Every finding on record at Complete Care at Kimberly Hall North

Based on clinical record reviews, review of facility documentation, review of facility policy and staff interviews for 1 of 6 residents reviewed for abuse (Resident #87), the facility failed to ensure a resident was free from abuse, which resulted in a vulnerable resident being physically abused by a staff member and for (Resident #85) reviewed for abuse, the facility failed to prevent a physical injury during a resident-to-resident altercation. The findings included: 1.Resident #87's diagnoses included dementia, anxiety, muscle weakness, and cerebral vascular disease.The quarterly MDS assessment dated [DATE] identified Resident #87 had short-term and long-term memory problems. The MDS further indicated Resident #87 had not exhibited behavioral symptoms or rejection of care. The MDS also identified that Resident #87 was dependent for toileting and personal hygiene and required substantial to maximal assistance for bed mobility and transfers.A Resident Care Plan revised on 4/6/2026 identified Resident #87 had an impaired/decline in cognitive function related to dementia, interventions included: observing for changes in cognitive status and communicating with short phrases. The care plan also identified that Resident #87 was at risk for decreased ability to perform activities of daily living related to dementia. Interventions included: providing assistance from one staff member for bed mobility, eating, toileting, and bathing.A physician's order dated 6/15/2026 identified Resident #87 directed administration of the following medications: trazodone 100 mg by mouth once daily for anxiety; Aricept 10 mg by mouth at bedtime for dementia; Zoloft 100 mg by mouth at bedtime for anxiety; and buspirone 10 mg by mouth twice daily for anxiety.A nursing note by LPN#6 dated 6/24/2026 indicated that a Nurse Aide (NA # 6) approached the nurses' station to report an incident involving NA # 7 and a resident. The note also indicated that no visible injuries were noted.A nursing note by the nursing supervisor (RN#3) dated 6/24/2026 indicated the LPN # 6 had reported Resident #87 had been slapped by a nursing aide. The note indicated that an RN assessment had been completed, and no injuries had been noted.An Advanced Practice Registered Nurse (APRN) note dated 6/24/2026 identified Resident #87 had been involved in an altercation with a nursing aide during morning care. The note indicated that during the altercation Resident #87 had struck the nursing aide in the face and the nursing aide struck the resident back. Resident #87 remained confused at baseline, with stable vital signs and no visible or reported injuries.A facility Incident Report and investigation dated 6/24/2026 and a summary dated 6/26/2026 identified that on 6/24/2026, during morning care, NA#6 observed Resident #87 push NA#7 on her face, and then NA#7 slapped Resident #87 across the resident's face. The local police were called and made aware of the incident. During the facility investigation, NA#7 did not dispute the allegation and indicated that she reacted impulsively with no intent to harm the resident. NA#7 was placed on leave. Resident #87 was evaluated by psychiatry, who reported Resident #87 had no recollection of the incident.NA#7's written statement identified that after NA#6, an orientee, removed the pillows, Resident #87 became agitated. NA#7 then approached Resident #87's bedside and asked what the problem was. Resident #87 struck NA#7 in the face, after which NA#7 reactively hit Resident #87 back. NA#7's statement did not indicate where she had struck Resident #87.NA#6's written statement identified she was preparing to provide care to Resident #87 and Resident #87 did not want to take off her/his blanket. NA#7 then walked into the room and went to Resident #87's bedside and began wrestling Resident #87 for the blanket yelling at the resident and saying, what is your problem. Resident #87 then released the blanket, reached up, and pushed NA#7's face away. NA#7 then slapped Resident #87 hard across the resident's face and mouth. NA#7 then yelled at the resident, saying, Don't you dare touch my face and try to break my $500 glasses. NA#6 then walked out of the room and informed the nurse what had happened.RN#3's written statement identified he was the supervisor on duty in the morning of 6/24/2026. He was informed Resident #87 had slapped NA#7 across the face, and that NA#7 had retaliated, although the location of where NA#7 had slapped Resident #87 was not specified.A statement by the facility administrator dated 6/24/2026 indicated the administrator had spoken to NA#7, who indicated that she had struck Resident #87 back and she had reacted to being struck.A psychiatry note dated 6/24/2026 identified Resident #87 was oriented to self only, consistent with advanced dementia. The note identified that the resident's speech was clear, pleasant, and engaging, and the resident denied feelings of depression and anxiety. Additionally, the note indicated that Resident #87 had no agitation, aggression, emotional distress, or behavioral disturbance and appeared consistent with baseline.A local police report signed 7/2/2026 identified on 7/2/2026, the police had spoken to NA#7, who indicated that when she arrived in Resident #87's room, Resident #87 was awake and agitated. NA#7 walked over to Resident #87 and asked Resident # 87 what was wrong and tried to calm the resident down. Resident #87 swung at NA#7 and hit NA#7 on the left corner of the left eye at which time NA#7 slapped Resident #87 on the hand.t.A supplementary police report signed 7/11/2026 identified that NA#7 was arrested on 7/11/2026 for charges including breach of peace second degree and reckless endangerment second degree. On 7/15/2026 at 3:02 PM, an interview with NA#6 indicated she was on her first day of orientation and had started preparing Resident #87 for care by removing the pillows. When she attempted to remove the resident's blanket, the resident refused by saying no and holding on to the blanket with both hands. NA#6 then indicated she moved to the foot of the bed, and NA#7 walked in. NA#6 indicated that she told NA#7 Resident #87 was refusing care. NA#7 then went to the resident's left side of the bed and attempted to remove Resident #87's blanket. Resident #87 and NA#7 struggled with each other for the blanket while NA#7 was yelling at Resident #87, Why are you doing this? Resident #87 then released the blanket and pushed NA#7's face by the mouth and nose area using her/his palm. NA#7 then used both of her hands to push away Resident#87's hand and then slapped the resident across the right side of the face. From the slap, the resident's head went sideways towards the resident's left side towards NA#7. NA#6 indicated that the privacy curtain had been drawn closed, there was no other staff member in the room, and that Resident #87's roommate appeared to have been sleeping the whole time. NA#6 further indicated that she left the room and told the nurse about the incident.On 7/16/2026 at 10:32 AM, an interview with LPN#6 identified she was the first person to respond to the incident after NA#6 had told her about the incident. LPN#6 indicated she went to Resident #87's room and saw NA#7 still in the room finishing up care by putting sheets on Resident #87. LPN#6 indicated that NA#7 confirmed that she had slapped the resident, and LPN#6 asked NA#7 to stop what she was doing and leave. LPN#6 indicated she did not ask NA#7 where exactly she had slapped Resident #87 but indicated that NA#7 may have written it in her statement. LPN#6 further indicated she did not observe any injuries on Resident #87 and the resident appeared calm.On 7/16/2026 at 1:00 PM, attempts to interview Resident #87 and her/his roommate were unsuccessful due to both residents' severe cognitive impairment.On 7/16/2026 at 2:12 PM, an interview with the DNS, Administrator, RN#7, and Person #2 identified that the Administrator and Person #2 had spoken on the phone with NA#7 after the incident, and NA#7 indicated that she had struck Resident #87 back after getting hit in the face. Person #2 and the Administrator indicated that they could not recall if they had asked NA#7 where she had struck Resident #87. The DNS and RN#7 indicated after the incident, they initiated an investigation and substantiated the allegation. The facility also provided education on abuse prevention to staff and completed a facility-wide evaluation of residents via interviews or body audits to ensure no other resident had been affected.On 7/17/2026 at 1;53 PM, an interview with RN #3 indicated that he was the supervisor on the day of the incident. RN #3 indicated he was informed of the incident by the charge nurse, and he suspended NA#7 and assessed Resident #87, including a full skin audit, including hands and face. RN#3 indicated that Resident #87 had no injuries. Multiple attempts were made to interview NA#7 without success. A review of NA#7's employee record identified that she had been terminated from the facility on 6/30/2026. Additional information provided to the state agency on 7/28/26 and 7/29/26 identified the following for abuse prevention : The facility alleged Past Non- Compliance Daily audits to monitor and ensure that all staff are visible in hallways, dining room and activity area at peak behavior timeStaff to monitor any noise, clutter, crowding and to identify any additional triggersTo monitor residents with increased behaviors and interventions provided.Date of Compliance 6-26-26 A review of the facility policy titled Abuse, Neglect, and Exploitation, last reviewed on 6/17/2026, identified that abuse was defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Additionally, the policy indicated that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. 2.Resident #85's diagnoses included irritability and anger, visual hallucinations, and dementia with psychotic disturbance. The quarterly MDS assessment dated [DATE] identified Resident #85 was severely cognitively impaired, had the presence of physical and verbal behaviors directed towards others, and other behaviors not directed towards others. Resident #85 was independent with bed mobility, dependent with personal hygiene and dressing. The assessment further identified the resident ambulated independently. The care plan dated 6/4/26 identified Resident #85 was at risk for resident directed violence related to cognitive impairment or confusion. Interventions included: assessing possible triggers and offering diversional activities when restlessness. Resident #116's diagnoses included dementia with other behavioral disturbances, polyarthropathy (inflammation of the joints), and hypertension.The admission assessment dated [DATE] identified Resident #116 was severely cognitively impaired, noted the presence of physical and verbal behaviors directed towards others, and behaviors not directed towards others. Resident #116 was independent with bed mobility, supervision with personal hygiene and dressing. The assessment further identified the resident ambulated independently. The care plan dated 4/22/26 identified Resident #116 exhibits or has the potential to exhibit physical behaviors related to cognitive loss/dementia, physical aggression- striking out at staff. Interventions included : to bring resident to courtyard to de-escalate, offer and provide resident a cup of coffee, evaluate the nature and circumstances of behavior with resident/patient/or patient representative, evaluate need for psychiatric/behavioral health consult. The nurse's note for Resident #85 dated 6/26/26 at 12:17 PM from RN#6 identified Resident #85 was assessed following a resident-to-resident altercation where Resident #85 was pushed out of the door of the resident room where she/he hit his/her head on the door frame resulting in a skin tear to the right forehead. The social worker notes for Resident #116 dated 6/26/26 at 11:10AM identified Resident #116 pushed Resident #85 out of the room. Resident #116 was put on a 1:1 monitoring until cleared by psychiatry. The Reportable Event form dated 6/26/26 and an investigation identified Resident #116 pushed Resident #85 out of the resident's room resulting in a skin tear measuring 0.5 Centimeters (CM) x 0.5 CM to the forehead. Psychiatric evaluations were completed on both residents and Resident #85 was moved into a new room. Review of NA#5 statement dated 6/26/26 identified NA#5 was in the hallway witnessed Resident #116 opened the door and pushed Resident #85 out into the hallway. Review of the skin integrity report dated 6/26/26 identified a skin tear measuring 0.5CM x 0.5 CM resulting from the incident on Resident #85's forehead. Interview with NA#5 on 7/17/26 at 10:03AM identified she was the witness to the incident between the residents on 6/26/26. Resident #116 pushed Resident #85 out of the room with one hand and Resident #85 may have hit his/her head on the door jam. Resident #85 likes to organize her/his space and thinks the whole space is her/his. NA#5 identified she was in the hallway at the time of the incident. Per NA#5 Resident #85 did not fall. Interview with RN#6 on 7/17/26 at 11:15AM identified she was called to the area following the resident-to-resident altercation. At the time of assessment Resident #85 was noted with a skin tear above the right eyebrow with a small amount of blood present. RN#6 identified she was informed by NA#5 Resident #116 pushed Resident #85 out of the room and Resident #85 hit his/her head on the door jam. Neither Resident #85 nor Resident #116 could recall the incident. RN#6 notified the APRN and believes she/he placed some sort of dressing on the area. However, she could not recall specifically what was put on the forehead. Interview with the DNS on 7/17/26 at 2:00PM identified from her investigation Resident #116 pushed Resident #85 resulting in Resident #85 receiving a small area on the side of her/his head. The DNS further identified Resident #116 likes to organize her/his things and Resident #85 likes to walk around a lot. Resident #116 may have wanted Resident #85 out of her/his space. There was a room change made for Resident #116 following the incident. A review of the facility policy titled Abuse, Neglect, and Exploitation, last reviewed on 6/17/2026, identified abuse was defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Additionally, the policy indicated that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish.

Based on observations of the kitchen and dry storage area, review of facility policy and staff interview , the facility failed to ensure food was stored/labeled appropriately in the walk-in refrigerator and freezer, and dry storage area. The findings included: Observations of the kitchen with the Dietary Manager on 7/13/26 at 2:10PM identified in the walk-in refrigerator the following: A metal rectangular shaped pan of mushrooms covered in plastic wrap dated 7/7/26 1/4 full.A metal rectangular shaped pan containing rice mixed with peppers dated 7/9/26 full.Two packages of [NAME] O Turkey breast dated use of freeze by 6/15/26 one open with no dated opened and one closed.One package of Block and Barrel Ham opened in plastic wrap with no open date.One log of hard salami open to air 3/4 full and with no open date or expiration date.Two logs of pepperoni 1/4 full open to air with no open date or expiration date.One log of pepperoni 3/4 full wrapped in plastic wrap with no open date or expiration date. Sliced turkey lunch meat wrapped in plastic wrap with a date of 6/29 opened date with no expiration.Sliced turkey lunch meat wrapped in plastic wrap with a yellow and white substance on it with no open date or expiration date. Observation of the walk-in freezer with the Dietary Manager on 7/13/26 at 2:25PM identified the following:4 Hamburger patties opened to air with date of open or expiration.4 veggie patties in a plastic package opened with no open date or expiration date.Turkey lunch meat wrapped in plastic wrap with no label of open date or expiration date. 3 turkey burgers opened in plastic wrap with no opened date or expiration date. 4 omelets in a plastic bag with no open date or expiration date. [NAME] Spunkmeyer cookie dough in a plastic bag in a cardboard box open to air. Observation of the dry storage area with the Dietary Manager on 7/13/26 at 2:35PM identified:Spaghetti dried pasta opened in plastic wrap with no date opened and no expiration date. Interview with the Dietary Manager on 7/13/26 at 2:40PM identified food should be stored with an open date and an expiration date in the kitchen. The cooks and herself are responsible for labeling/dating items once they get used in the kitchen as well as throwing away expired foods. Once labeled the food should be used within 5 days or by the expiration date on the package. There is not a set schedule for one person to go through the food, however all the cooks when utilizing the food should label it when used and put it back. Review of the Food Safety Requirements policy reviewed on 6/17/26 directed food safety practices shall be followed throughout the entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to residents. Elements of the process include storage of food in a manner that helps prevent deterioration or contamination of the food including growth of microorganisms. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Labeling/dating and monitoring refrigerated food, including, but not limited to leftovers, use by its use by date, or frozen (where applicable)/discarded; and keeping food covered or in tight containers.

Based on observations, review of facility documentation, review of facility policy and staff interviews for 2 of 4 sampled units (Cambridge [NAME] and East) reviewed for wheelchair cleanliness for 5 residents (Resident #28, Resident #44, Resident #57, Resident #91, Resident #96 and Resident #118), the facility failed to ensure the residents' wheelchairs were kept in a sanitary manner. The findings included: A tour of the Cambridge [NAME] unit on 7/16/26 at 7:40 AM identified the following wheelchairs condition: 1.Resident #28's diagnoses included Alzheimer's disease, dementia, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #28 had severely impaired cognition, dependent on care for eating, personal hygiene, dressing, transfers, non-ambulatory and dependent on the use of a manual wheelchair as a mobility device. Observation on 7/16/26 at 7:40 AM identified Resident #28 lying in bed with her/his wheelchair next to the bed. Both arms of the wheelchair were noted with stained/water marks, build-up food like substance on the leg rest and footrest, and small amount of food particles along the sides of the wheelchair between the seat cushion and the side panel. Observation and interview on 7/16/26 at 9:45 AM with the Regional Director of Housekeeping identified Resident #28 was in his/her wheelchair next to the bed in his/her room. The Regional Director of Housekeeping also noted on both arms of Resident # 28's wheelchair stain marks, build-up of food -like substance on the leg rest and footrest, and small amount of food particles along the sides of the wheelchair between the seat cushion and the side panel. He further identified that the housekeeping supervisor was on leave and he was unable to locate the check-off sheet that indicated when the wheelchair was last cleaned. The Regional Director of Housekeeping further indicated wheelchairs are supposed to be cleaned monthly. Interview with the Infection Preventionist the Assistant Director of Nursing (ADNS) on 7/16/26 at 7:49 AM identified housekeeping is responsible for cleaning the wheelchairs and the schedule is created by their supervisor. The ADNS identified that she had observed the wheelchairs needed cleaning on 7/16/26 and indicated the nurse aide can wipe off spills on the wheelchairs. Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #28's wheelchair was not on the scheduled to be cleaned for the month of May 2026, for the month of June 2026 the wheelchair was however scheduled to be cleaned 2 days after the month ended, and for the month of July 2026 the resident's wheelchair was scheduled to be cleaned on 7/13/26. 2.Resident #44's diagnoses included dementia, cognitive communication deficit, and generalized muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #44 had severely impaired cognition, dependent on care for eating, personal hygiene, dressing, transfers, non-ambulatory and dependent on the use of a manual wheelchair as a mobility device. Observation on 7/16/26 at 7:35 AM identified Resident #44 lying in his/her bed with the wheelchair next to the bed. The wheelchair was noted with food particles along both sides between the cushion and the side panels, stains marks over the cushion seat, build- up of residues on the frame of the wheelchair and the wheel lock. Observation on 7/16/26 at 7:49 AM with the ADNS (Infection Preventionist) identified Resident #44 was lying in his/her bed with the wheelchair next to the bed. The ADNS also noted food particles along both sides between the cushion and the side panels, stains mark over the cushion seat, buildup of residues on the frame of the wheelchair and the wheel lock. Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #44's wheelchair was not on the scheduled to be cleaned for the month of May 2026 and June 2026. The wheelchair was scheduled to be cleaned on 6/22/26 and for the month of July/2026 the wheelchair was not on the schedule for cleaning. 3.Resident #57's diagnoses included Alzheimer's disease, dementia, and difficulty walking. The quarterly MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, dependent on care for eating, personal hygiene, dressing, transfers, and dependent on the use of a manual wheelchair as a mobility device. Observation on 7/16/26 at 7:36 AM identified Resident #57 lying in his/her bed with the wheelchair located towards the foot of the bed next to the window. The wheelchair was noted with food particles along both sides between the cushion and the side panels. Observation and interview on 7/16/26 at 9:48 AM with the Regional Director of Housekeeping identified Resident #57's wheelchair had food particles along both sides between the cushion and the side panels. He also identified the wheelchair needed to be cleaned.Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #57's wheelchair was not on the scheduled to be cleaned for the month of May 2026 and for the month of June 2026. The wheelchair was scheduled to be cleaned on 6/24/26 and for the month of July 2026 the wheelchair was scheduled to be cleaned on 7/9/26. 4. Resident #91's diagnoses included Alzheimer's disease, dementia, and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #91 had severely impaired cognition, dependent on care for eating, personal hygiene, dressing, transfers, and dependent on the use of a manual wheelchair as a mobility device. Observation on 7/16/26 at 7:37 AM identified Resident #91 lying in his/her bed with the wheelchair towards the foot of the bed in a corner next to the window. The wheelchair was noted with stain marks to both the armrest on the wheelchair and heavy coating of dust-like particles on the frame of the wheelchair on the sides and the cross brace underneath the wheelchair. Observation and interview on 7/16/26 at 9:49 AM with the Regional Director of Housekeeping identified Resident #91 was seated in his/her wheelchair in the hallway. The Regional Director of Housekeeping also noted stain marks to both armrest of the wheelchair and heavy coating of dust-like particles on the frame of the wheelchair on the sides and the cross brace underneath the wheelchair. He identified that the wheelchair had not being cleaned recently based on the accumulation of dust-like particles on the frame of the wheelchair. He further identified he would have to conduct a facility-wide audit of wheelchairs to identify which wheelchairs need cleaning. The Regional Director of Housekeeping identified the wheelchair did not appear to be cleaned recently. Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #91's wheelchair was not on the scheduled to be cleaned for the month of May 2026 and for the month of June 2026. The wheelchair was scheduled to be cleaned on 6/25/26 and for the month of July 2026 the wheelchair was not scheduled for cleaning. 5.Resident #96's diagnoses included dementia, muscle weakness, and bipolar disorder. The quarterly MDS assessment dated [DATE] identified Resident #96 had severely impaired cognition, required setup or clean-up assistance with eating, dependent on care for personal hygiene, dressing, transfers, did not ambulate and dependent on the use of a manual wheelchair as a mobility device. Observation on 7/16/26 at 7:35 AM identified a wheelchair in the hallway of the Cambridge East identified food particles along both sides between the cushion and the side panels, stains marks over the cushion seat and back support, buildup of residues on the frame of the wheelchair sides, cross brace, and the wheel lock area. Observation and interview with the charge nurse Licensed Practical Nurse (LPN #3) on 7/16/26 at 7:42 AM identified the wheelchair in the hallway belonging to Resident #96. LPN # 3 further indicated the wheelchair needed to be cleaned, and she would be notifying housekeeping. She further identified housekeeping is responsible for cleaning wheelchairs. LPN #3 identified housekeeping cleans wheelchairs, but she had not seen them cleaning the wheelchairs recently. Observation on 7/16/26 at 9:45 AM with the Regional Direction of Housekeeping identified food particles along both sides between the cushion and the side panels, stains marks over the cushion seat and back support, buildup of residues on the frame of the wheelchair sides, cross brace, and the wheel lock area. He identified the wheelchair had not been cleaned recently based on buildup of particles on the frame of the chair. Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #96's wheelchair was not on the scheduled to be cleaned for the month of May 2026 and for the month of June 2026. The wheelchair was scheduled to be cleaned on 6/23/26 and for the month of July 2026 the wheelchair was not scheduled for cleaning. 6.Resident #118's diagnoses included Alzheimer's disease, dementia, and generalized muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #118 had severely impaired cognition, required maximal assistance with eating, dependent on care for personal hygiene, dressing, transfers, did not ambulate and dependent on the use of a manual wheelchair as a mobility device.Observation on 7/13/26 at 2:56 PM identified Resident #118 seated in his/her wheelchair with food particles between the seat cushion and the side panel on both sides, food particles on the creases of both arm rest, build-up of food particles on the frame of the sides of the wheelchair and small pieces of food particles on the frame underneath the wheelchair on both sides. Observation on 7/16/26 at 7:35 AM with Nurse Aide (NA #3) identified Resident #118 was seated in his/her wheelchair with food particles between the seat cushion and the side panel on both sides, food particles between the creases on both arm rest, build-up of food particles on the frame of the sides of the wheelchair. Further observation identified small pieces of food particles and a small piece of tissue paper on the wheelchair frame located underneath the wheelchair on both sides. Interview with NA #3 at 7:35 AM identified housekeeping is responsible for cleaning wheelchairs, however if she identifies that a wheelchair has an odor, she will let housekeeping know and they would come and clean the wheelchair. NA #3 identified she was not sure if housekeeping had a cleaning schedule for the wheelchairs. Interview with NA #4 on 7/16/26 at 7:41 AM identified housekeeping is responsible for cleaning the wheelchairs and they are not being cleaned. Observation on 7/16/26 at 9:50 AM with the Regional Director for Housekeeping identified Resident #118 seated in his/her wheelchair with food particles between the seat cushion and the side panel on both sides, food particles between the creases on both arm rest, build-up of food particles on the frame of the sides of the wheelchair. Further observation identified small pieces of food particles and a small piece of tissue paper on the wheelchair frame located underneath the wheelchair on both sides. He identified Resident #118's wheelchair had not been cleaned recently based on the build-up of food particles on the frame on the sides and the buildup on food particles on the frame underneath the wheelchair. Review of the wheelchair cleaning schedule provided for May 2026 through July 2026 identified the following: Resident #118's wheelchair was not on the scheduled to be cleaned for the month of May 2026 and for the month of June 2026. The wheelchair was scheduled to be cleaned on 6/22/26 and for the month of July/2026 the wheelchair was scheduled to be cleaned on 7/8/26. Interview with the ADNS (Infection Preventionist) in the presence of the Regional Resource Nurse (RN #7) on 7/16/26 at 12:47 PM identified the housekeeping supervisor is responsible for the wheelchair cleaning schedule and to provide her with a copy of the wheelchair cleaning for the environmental rounds. She also indicated she had not received the copy of wheelchairs that require cleaning. The ADNS further observed and identified the resident's wheelchair needed cleaning. The ADNS further indicated wheelchairs should be cleaned to prevent infections and for cleanliness. Interview with the Housekeeper #2 and the Director of Housekeeping (Supervisor) on 7/17/26 at the time of the observations identified Housekeeper #2 was responsible for cleaning the wheelchairs. He identified that he uses the wheelchair cleaning schedule and collects the chairs to be cleaned for the day at 5:00 AM and returns them by 6:30 AM. He identified the facility had a machine to clean the wheelchair in which he uses and for larger wheelchairs he would bring them outside to clean. He also indicated when he cleans the wheelchair, he cleans the cushions, the frames and every area on the wheelchair. The supervisor identified she was responsible for posting the wheelchair schedule but had not posted the schedule last week, hence why Housekeeper #2 was just cleaning random wheelchairs. She further identified that she brings work home and she was unable to locate her check-off sheet where she documents when the wheelchairs are cleaned. The supervisor further identified that all wheelchairs are to be cleaned monthly. She also indicated staff had started to clean the wheelchairs on the Cambridge units now and had noticed that the wheelchairs had a lot of gunk (thick, sticky, oily, otherwise unpleasant substances that are dirty or grimy). She further identified that the cleaning of the wheelchairs on the Cambridge units fell behind, so the wheelchairs were not cleaned. Review of facility 2026 Wheelchair policy identified all wheelchairs will be completely cleaned once per month by the housekeeping department. Wheelchairs are cleaned between 5:00 AM and 6:30 AM (schedule posted). The policy further identified nursing staff is responsible for cleaning spills in between monthly cleaning.

Based on clinical record reviews, observations, facility policy and staff interviews for 1 of 4 residents (Resident # 52) observed for medication administration, the facility failed to ensure the resident was evaluated for self-administration of medication prior to being allowed to self-administer medication and for 1 of 2 residents (Resident #56) observed with medications at the bedside, the facility failed to ensure a resident with medication kept at bedside had a physician's order and an assessment for self-administration. The findings included: 1.Resident #52's diagnoses included cognitive communication deficit and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 was severely cognitively impaired and required supervision for bed mobility and transfers. A care plan dated 6/16/2026 indicated Resident #52 had the potential to demonstrate verbal behaviors related to cognitive loss/dementia, resistance to care, and not following directions. Intervention included: providing a consistent, trusted caregiver and a structured daily routine when possible. The care plan also indicated the resident had an impaired/decline in cognitive function or impaired thought process related to a condition other than delirium. Interventions included: allowing the resident to make daily decisions and to use verbal cues, gestures, and demonstrations to assist in decision-making if needed. The physician medication review dated 7/13/2026 directed to administer Diclofenac Sodium ( Non-Steroidal Anti- Inflammatory) External Gel 1 % to the bilateral knees four times a day. On 7/14/2026 at 9:35 AM, an observation with Licensed Practical Nurse ( LPN #3) during medication administration identified Resident #52 was self-administering diclofenac 1% gel to both knees. Resident #52 indicated that she/he started using the medication while at the facility and the medication tube was usually on the bedside table. Resident #52 further indicated that when the medication runs out, the facility orders a new tube for her/him. An interview and record review with LPN#3 indicated the Diclofenac gel tube was the same that the facility usually orders for residents. However, LPN # 3 did not know who had given the resident the Diclofenac tube of gel. LPN#3 further indicated when residents are determined about self-administering medications, the facility would evaluate the resident to see if they were able to self-administer safely. A review of the clinical record with LPN#3 failed to identify an evaluation for self-administration of medication was conducted for Resident # 52. On 7/16/2026 at 2:12 PM, an interview with the Director of Nursing Services (DNS) and Registered Nurse (RN #7) identified residents should be evaluated for self-administration of medications prior to self-administering. A review of the clinical record with the DNS and RN #7 failed to identify an evaluation for safe self-administration of medication. A review of the facility policy for Resident Self-Administration of Medication indicated each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. assessments of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form and filed in the resident's clinical record. 2.Resident #56's diagnoses included Parkinson's disease, Chronic Obstructive Pulmonary Disease (COPD), and cognitive communication deficit. The admission MDS assessment dated [DATE] identified Resident #56 had intact cognition, required moderate assistance with oral hygiene, set-up for eating and maximal assistance with personal hygiene. The care plan dated 6/9/26 identified Resident #56 was at risk for respiratory complications related to COPD. Interventions included: to medicate as ordered and monitor for effectiveness , to observe for signs/symptoms of side effects and report to physician as indicated. The care plan failed to identify an intervention for self-administration of medication and for any medication to be kept at the resident's bedside. The physician's order dated 6/9/26 directed Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) mcg/ACT to inhale one puff orally every six hours as needed for shortness of breath (SOB) or wheezing. Further review of the physician orders for the period of 6/16/26 through 7/14/26 failed to identify a physician's order for self-administration of Albuterol Sulfate HFA inhalation aerosol solution medication or a physician's order for the medication to be left at the resident's bedside. Observation on 7/13/26 at 4:00 PM identified Resident #56 sitting upright in his/her wheelchair with the overbed table positioned in front of the resident and Albuterol Sulfate inhalation aerosol solution 90 microgram (mcg) noted lying on the side among other personal items on the overbed table. Observation on 7/14/26 at 8:55 AM identified Resident #56 sitting upright in his/her wheelchair with the overbed table positioned in front of the resident and the Albuterol Sulfate 90 mcg inhalation aerosol solution lying on its side of the overbed table with personal items. Further observation on 7/14/26 identified Resident #56 shared a room with Resident #49, whose admission MDS assessment dated [DATE] identified Resident #49 had moderately impaired cognition, required set- up assistance for eating, supervision with oral hygiene and noted ambulation was not attempted due to medical condition or safety concern. Review of Resident #56's clinical record failed to identify a self-administration assessment completed for Albuterol Sulfate HFA inhalation aerosol solution medication. Observation on 7/14/26 at 12:11 PM identified Resident #56 was lying in bed with the overbed table near the bed and on top of the overbed table identified Albuterol Sulfate 90 mcg inhalation aerosol solution medication lying to the side with other personal items on the table. Observation on 7/14/26 at 12:32 PM with the charge nurse (LPN #3) identified the resident was seated upright in front of the overbed table and noted the lunch tray on the overbed table. Resident #56 was asked about the Albuterol Sulfate inhaler at which time he/she responded that he/she had just used the inhaler and placed it in his/her drawer in the nightstand near the bed. Resident #56 identified he/she administers the inhaler twice daily since at the facility by him/herself. When asked if he/she had made the facility aware he/she had the medication in his/her possession. Resident # 56 responded a nurse saw that he/she had the medication. However, Resident # 56 was unable to recall the name of the nurse or what time or when the nurse knew about the medication. Resident #56 further explained he/she told the nurse at the time he/she needed the medication and it was prescribed by his/her pulmonologist, and the nurse said to him/her the medication should be locked up. Interview on 7/14/26 at 12:34 PM with LPN #3 identified she was not aware the resident had the medication at bedside. On admission residents are checked for medication and if found with medication the nurse would remove the medication. LPN #3 further identified Resident #56 had no physician's orders for self-administration and for the medication to be kept at bedside. LPN # 3 identified the resident has a physician's order for the Albuterol Sulfate inhaler, but it is not scheduled to be administered during her shift, nor had she administered the medication to the resident. She further identified if a resident wanted to self-administer a medication, a self-administration assessment needed to be completed, and a physician's order should be obtained for self-administration. Interview with the nursing supervisor (RN #6) on 7/14/26 at 12:44 PM identified that a resident should not have medication brought in from home or dispensed by the facility left at the bedside without a self-administration assessment and a physician's order. RN #6 reviewed Resident #56's clinical record and was unable to locate a self-administration assessment and a physician's order for self-administration of the Albuterol Sulfate inhaler. Interview with charge nurse (LPN #4) on 7/14/26 at 3:49 PM identified she was the regular nurse on the unit, and she could not recall if she saw the resident with the inhaler on the overbed table. Interview with the Director of Nursing Services (DNS) in the presence of Person #2 on 7/14/26 at 4:22 PM identified a resident would need a physician's order and a self-administration assessment for medication to be left at the resident's bedside. The DNS further identified if the nurse knew about the medication at the bedside, she would expect that the nurse would get a physician's order and complete the self-administration assessment. When asked if the self-administration assessment is completed on admission, the DNS responded it is not completed on admission just when the resident asks to self-administer a medication. After surveyor's inquiry a Self-Administration of Medication Evaluation was completed on 7/14/26 indicating the resident is capable of independent self-administration of medications. Review of the Resident Self-Administration of Medication policy identified a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment form, which is placed in the resident's clinical record. The policy further identified all nurses, and nurse aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to charge nurses for return to the family or responsible party. In addition, the policy identified that the care plan must reflect resident self-administration and storage arrangements for such medications.

Based on observation, staff interviews, and review of facility policy for 1 of 3 medication carts reviewed (Cambridge South cart), the facility failed to ensure a multidose medication vial was appropriately labeled with the date opened. The findings include: On 7/14/2026 at 10:20 AM observation of the Cambridge South medication cart with LPN #5 identified on the top drawer of the cart a 10 milliliter (mL) multidose vial of lidocaine 1 % hydrochloride with an expiration date of 4/2027. The vial was opened and half full. There was no resident label or a date indicating when the vial had been opened. Additionally, the vial had a small rectangular sticker with a blue border and the characters /25 printed on it, positioned near the bottom edge of the glass. The sticker had a torn edge, indicating that only a portion of a larger label was present on the vial.An interview with LPN#5 indicated that multidose vials should have been labeled with the date opened. LPN#5 indicated she did not know how long the vial had been there or how long lidocaine should be kept after opening. On 7/17/2026 at 9:49 AM, an interview with the DNS and the Director of Resource Nurses (RN#7) identified multidose vials of medication should be labeled when they are opened and discarded 28 days later.A review of the facility policy for medication storage did not identify how a multidose vial should be labeled or how soon after opening it should be discarded.

Based on review of the clinical records, review of facility documentation, review of facility policy, and interviews for 2 of 5 sampled residents (Resident #1, and Resident #131) reviewed for immunizations, the facility failed to ensure that all doses of the COVID-19 vaccine were administered as requested by the resident/responsible party. The findings included:Facility 1.Resident #1's diagnoses included chronic obstructive pulmonary disease, sickle-cell disease, and type 2 diabetes mellitus.The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition. The assessment further identified Resident #1 was not up to date with the COVID-19 vaccination. Review of Resident #1 Informed Consent: COVID-19 Vaccine identified Resident #1's responsible party gave the facility permission on 11/11/2025 to administer the 2025-2026 Covid-19 vaccine, as well as any subsequent booster doses as recommended to stay up to date. Review of Resident #1 immunization record identified he/she received the first dose of the 2025 to 2026 Covid-19 vaccine (Moderna Spikevax) at age [AGE] years on 11/14/25. However, the records failed to identify Resident #1 had received/refused the second 2025 to 2026 COVID-19 vaccine dose six months after the first dose, which would be due after May 14, 2026. Review of the COVID-19 Vaccination policy identified the vaccination schedules for the 2025-2026 COVID-19 vaccines vary based on vaccination history, age group, and immune status. The policy identified for individuals who are not immunocompromised to refer to Table 1 for the 2025-2026 COVID-19 vaccination schedule details and for individuals 6months and older who are moderately or severely immunocompromised based on individual -based decision -making to refer to Table 2 for the 2025-2026 COVID-19 vaccination schedule details. Review of the Table 1 identified ages 65 years and older the number of 2025-2026 doses indicated is 2 doses for both previously vaccinated before 2025-2026 vaccine and unvaccinated, with the second dose to be given 6 months (minimum interval 2 months) after dose 1 of the moderna (Spikevax), Novavax, or Pfizer-BioNTech. Review of Table 2 identified for ages 12 years and older the number of 2025-2026 doses indicated is 2 doses for COVID-19 vaccination history before 2025-2026 and completed the initial series before 2025-2026, with the second dose to be given 6 months (minimum interval 2 months) after dose 1 of the moderna (Spikevax), Novavax, or Pfizer-BioNTech. 2.Resident #131's diagnoses included multiple sclerosis, chronic kidney disease and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #131 had intact cognition. The assessment further identified Resident #1 was not up to date with the COVID-19 vaccination. Review of Resident #131 Informed Consent: COVID-19 vaccine identified Resident #131's responsible party gave the facility permission on 11/11/2025 to administer the 2025-2026 Covid-19 vaccine, as well as any subsequent booster doses as recommended to stay up to date. Review of Resident #131 immunization record identified he/she received the first dose of the 2025 to 2026 COVID-19 vaccine (Moderna Spikevax) at age [AGE] years on 11/14/25. However, the records failed to identify Resident #131 had received/refused the second 2025 to 2026 COVID-19 vaccine six months after, which would be due after May 14, 2026. Interview with the Infection Preventionist (ADNS) and Regional Resource Nurse (RN #7) on 7/15/26 at 11:24 AM identified vaccine consent is obtained on admission and during the vaccine season for covid and influenza. They identified the 2025-2026 covid-19 vaccine consent provided and signed by resident/resident responsible party was inclusive of all required doses in which the resident is to receive, as residents who are over the age of 65 years is eligible to receive 2 doses of the 2025-2026 covid-19 vaccine within 6 months apart. The ADNS and RN #7 reviewed Resident # 1 and # 131 covid-19 vaccine records and consents and identified that residents were over the age of 65 years and was eligible to receive the second dose of the 2025-2026 covid-19 vaccine after May 14, 2026. RN #7 identified they would not need to obtain another consent from the resident/resident responsible party, but they would ask the resident/resident responsible prior to administering the second dose to ensure that they had not changed their mind. RN #7 and the ADNS further identified Resident #1 and Resident # 131 should have already received the vaccine as the facility uses a vaccine tracker to identify which resident is due for the second dose and it was the responsibility of the Infection Preventionist (IP) nurse to check the log/track to see which resident was due and administer the vaccine. The ADNS identified that she was new to the IP role and had only started working in the role in April 2026, hence why the residents had not received the second dose of the covid-19.Review of the COVID-19 Vaccination policy identified the vaccination schedules for the 2025-2026 COVID-19 vaccines vary based on vaccination history, age group, and immune status. The policy identified for individuals who are not immunocompromised to refer to Table 1 for the 2025-2026 COVID-19 vaccination schedule details and for individuals 6 months and older who are moderately or severely immunocompromised based on individual -based decision -making to refer to Table 2 for the 2025-2026 COVID-19 vaccination schedule details. Review of the Table 1 identified ages 65 years and older the number of 2025-2026 doses indicated is 2 doses for both previously vaccinated before 2025-2026 vaccine and unvaccinated, with the second dose to be given 6 months (minimum interval 2 months) after dose 1 of the moderna (Spikevax), Novavax, or Pfizer-BioNTech. Review of Table 2 identified for ages 12 years and older the number of 2025-2026 doses indicated is 2 doses for COVID-19 vaccination history before 2025-2026 and completed the initial series before 2025-2026, with the second dose to be given 6 months (minimum interval 2 months) after dose 1 of the moderna (Spikevax), Novavax, or Pfizer-BioNTech.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for neglect, the facility failed to ensure a severely cognitively impaired resident who was dependent on staff for hygiene care and was identified as at risk for pressure injuries received ongoing skin monitoring, hair care, thorough head to toe skin assessments (Weekly Skin Checks) and repositioning necessary to prevent pressure-related skin breakdown resulting in unrecognized posterior scalp pressure injuries progressing to necrotic wounds requiring an enzymatic debridement treatment after discovery by the resident representative when the residents head was shaved for closer observation due to odor and severely matted hair. The findings include:Resident #1's diagnoses included bilateral paralytic syndrome following cerebral infarction (a condition involving paralysis on both sides of the body due to stroke-related brain damage), type II diabetes mellitus with diabetic neuropathy (complication of diabetes, characterized by nerve damage), chronic pain syndrome, muscle weakness and anxiety disorder.A Nursing readmission assessment by RN #2 dated 3/10/26 identified a full body skin assessment was completed, skin was intact and no open areas were noted.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted which identified short-term and long-term memory problems and severely impaired cognition. The MDS identified Resident #1 required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers and was at risk for pressure injuries but had no current skin abnormalities.Weekly Skin Checks completed by RN #2 on 3/17/26 and 3/25/26 identified a skin check was performed and no skin injury/wounds were noted.The Resident Care Plan (RCP) dated 3/26/26 identified Resident #1 was at risk for skin breakdown related to quadriplegia (paralysis affecting all four limbs and the torso) with contractures, decreased activity, impaired cognition, bowel and bladder incontinence, dependence on staff for bed mobility, transfers, and toileting and had a history of healed pressure injuries. Interventions included the use of a low air loss mattress, turning and/or repositioning and checking the skin four (4) times per shift as determined by tissue tolerance, observing skin condition daily with care and reporting abnormalities and completing a Weekly Skin Check by a licensed nurse.A Braden Scale assessment dated [DATE] identified Resident #1 was at moderate risk for developing pressure injuries.The April 2026 Documentation Survey Report identified NA #1 gave Resident #1 a shower on 4/1/26 and documented the skin observation as Not Applicable (N/A).A Weekly Skin Check by RN #2 on 4/2/26 identified a skin check was performed and no skin injury/wounds were noted.Review of the Kardex in effect on 4/6/26 directed NA's to monitor for skin redness/irritation and report as indicated, observe skin condition daily with Activities of Daily Living (ADL) care and report abnormalities and continue to encourage every two (2) hour repositioning.A nurse's note by RN #1 dated 4/7/26 at 3:00 PM identified she assessed Resident #1 in response to a concern from the responsible party (Person #4) regarding a change in skin integrity to the scalp after Person #4 had Resident #1's head shaved due to severely matted hair. The back of Resident #1's head had a cluster of five (5) lesions, including two (2) distal (farther away from the midline) lesions that were closed/resolved and of the other three (3), 2 had adherent fibrinous tissue (a yellowish moist or dry layer of necrotic material composed of dead cells and debris) covering the wounds and the other lesion had a pink wound bed. The entire cluster measured 6 centimeters (cm) by 5 cm. The surrounding scalp was unremarkable and although the wound beds were moist, there was no active drainage and Resident #1 denied pain. The severely matted hair contributed to pressure on the scalp and Person #4 planned to keep the hair length short moving forward. RN #1 educated Person #4 on caring for ethnic hair and he/she verbalized understanding. The provider was notified and a new order for calcium alginate (a highly absorbent wound dressing used for managing moderate to heavily draining wounds) to be applied to the wound bed was obtained and Resident #1 would be followed during weekly wound rounds.Review of the RCP failed to identify a preference or request for Person #4 to provide care for Resident #1's hair or any identified abnormalities with Resident #1's hair.A facility Reportable Event (RE) dated 4/8/26 identified at 10:45 AM Person #4 reported a concern regarding Resident #1's hair hygiene and believed Resident #1 was neglected due to hair at the base of the scalp being knotted resulting in irritation to the scalp and back of the head. Resident #1 was a total assist of two (2) for care and transfers and a full body skin assessment was completed and no changes were noted to skin integrity. The provider and the police were notified, an investigation was initiated and an alternate style pillow was provided for better tissue tolerance.A note by APRN #1 dated 4/9/26 identified she was asked to see Resident #1 for reports of wounds to the back of the head. Resident #1 was awake and alert, had no indicators of pain, was afebrile (without a fever) and the wound dressing was in place with no drainage on the dressing. She ordered Santyl (enzymatic debriding agent) to the open clustered skin wounds to the back of head daily followed by a clean dry dressing. Staff were to monitor Resident #1's pain level and follow up with the wound physician for signs and symptoms of infection.The wound physician note by MD #2 dated 4/10/26 identified Resident #1 was seen and evaluated for a wound to the back of the head. The posterior scalp (back of the head) wound was a full thickness cluster wound measuring 4.5 cm by 3.5 cm by 0.1 cm with twenty (20) percent (%) thick adherent devitalized necrotic tissue (dead tissue that acts as a physical barrier to healing), with no drainage and no signs and symptoms of pain or infection although Resident #1 was anxious. The etiology (cause/reason) of the wounds were undetermined/unknown and the treatment plan included applying Santyl to the wound beds followed by a dry protective dressing once daily for thirty (30) days.A facility Grievance Form dated 4/12/26 by Person #4 identified there was a customer service concern regarding the repositioning and turning of Resident #1 and reported one-to-one education was provided to NA #4 for Resident #1's reposition plan of four (4) times per shift.Review of the April 2026 Documentation Survey Report identified all assigned tasks on the 11:00 PM to 7:00 AM shift on 4/11/26 were not documented, including the turning and repositioning of Resident #1.A Disciplinary Action Form identified from 4/11/26 to 4/12/26 NA #4 failed to complete assigned tasks including documentation and it was her responsibility to ensure all resident needs are met in a timely manner. NA #4 was re-educated to provide care per the RCP, frequent rounding, and completing required documentation of care provided.The wound physician note by MD #2 dated 5/4/26 identified the posterior scalp wound measured 4.8 cm by 1.2 cm by 0.1 cm and no longer required Santyl. The wound bed consisted of fifty (50) % granulation tissue (new connective tissue that forms on the surface of a wound during the healing process).Interview with Person #4 on 5/4/26 at 11:09 AM identified in 2024 he/she shaved Resident #1's head and discovered wounds to the back of the head. At that time the facility contributed the wounds to barrettes that he/she put in Resident #1's hair and was told to no longer do so. Person #4 identified on or around 4/6/26, LPN #1 asked if Person #4 was going to shave Resident #1's head again. He/she thought the request was odd because the hair was only about three (3) inches long and Resident #1 always wore a hair cover. Person #4 identified he/she then noticed blood on Resident #1's pillow and reported the hair had an odor. On 4/7/26, Person #4 brought clippers to shave Resident #1's head. Upon inspection of the hair, the back of the head was severely matted. Person #4 reported he/she requested NA #2's assistance with shaving and when they shaved the hair, multiple pink areas and scabbed areas were observed to the back of the head. Person #4 identified he/she never had Resident #1 go to the hairdresser because staff reported they washed the hair weekly and never reported issues with the hair. Person #4 reported there was a live camera in the room and numerous times where no one entered the room to reposition Resident #1 for over four (4) hours. Person #4 filed a grievance 4/12/26 which reported no staff entered the room to turn and reposition Resident #1 from around 9:20 PM on 4/11/26 until around 5:20 AM on 4/12/26 (eight hours) and suspected the wounds were caused from pressure related to Resident #1 not being repositioned.Interview with LPN #1 on 5/4/26 at 12:03 PM identified she frequently provided care for Resident #1 on the 7:00 AM to 3:00 PM shift and had not noticed matted hair to the back of the head, scabbing, wounds or drainage. LPN #1 reported she asked Person #4 if he/she was going to shave Resident #1's head because the weather was getting warmer.Interview with NA #1 on 5/4/26 at 12:59 PM identified she frequently provided care for Resident #1 on the 3:00 PM to 11:00 PM shift. On 4/1/26 she gave Resident #1 a shower but did not notice matted hair and did not look at the scalp. She identified Resident #1 usually wore a hair cover but after a full bed bath or shower, she would comb Resident #1's hair, including the back. She was unable to identify if she combed from the base of the scalp outwards and identified the hair to the back of the head was thicker, but she did not think it was matted.Interview with RN #2 on 5/5/26 at 8:37 AM identified she normally worked the 3:00 PM to 11:00 PM shift and completed the Weekly Skin Checks for Resident #1 while in bed on 3/10/26, 3/17/26, 3/25/26 accompanied by an NA, but the back of the head was difficult to see, even with two (2) staff. She identified she did the best assessment she could and did not notice matted hair to the back of the head or skin abnormalities to the scalp. RN #2 identified that on 4/2/26, she performed the Weekly Skin Check independently and did her best to check the head but may have missed an area. She identified she should have had another staff present for assistance. She was unable to identify why the Weekly Skin Check had not occurred the previous day (4/1/26) when NA #1 documented a shower.Observation of Resident #1 on 5/5/26 at 8:45 AM identified Resident #1 turned to the right side with a positioning wedge in place to the right and the head of bed elevated to approximately forty-five (45) degrees. The touch pad call-bell was hanging on the back wall, out of reach.Interview and observation of Resident #1 with NA #1 on 5/5/26 at 8:46 AM identified Resident #1's call bell hanging on the back wall out of reach. NA #1 reported she had not yet been in the room since the start of her shift because there was no help and ignored the request to place the call-bell within reach of Resident #1. NA #1 continued to pass drinks for breakfast in the hallway and did not go into Resident #1's room to replace the call-bell or reposition Resident #1.Subsequent to surveyor inquiry, at 9:08 AM (20-minutes after notification to NA #1), LPN #1 and RN #1 placed Resident #1's call bell within reach and turned and repositioned Resident #1 in bed.Interview with MD #2 on 5/5/26 at 10:24 AM identified he was initially unsure of the etiology of the wounds to the back of Resident #1's head during his 4/10/26 visit and thought they could have been malignant (chronic, non-healing skin lesions caused by cancer cells in the skin) so documented them as non-pressure wounds. Since 4/10/26 the wounds improved. The wounds would not have improved if they were malignant, therefore, there was no need to biopsy the wounds and he determined they were caused by pressure due to the back of the head location. MD #2 reported if the back of the head been offloaded consistently, the area most likely would not have developed. He identified that when he first evaluated the areas, they did not appear new and appeared to have been existing at least one (1) to two (2) weeks or longer. He identified the wounds should have been discovered and reported immediately before becoming necrotic. Interview with RN #1 on 5/5/26 at 11:08 AM reported she had not seen the back of Resident #1's hair or head prior to being shaved on 4/7/26 but all the wounds were open or necrotic which identified they were not new wounds and were existing prior to being first discovered. She identified the wounds appeared to have been caused by matted hair which created a solid mass and caused pressure to the back of the head. RN #1 identified staff should have identified the matted hair while providing hair care and Weekly Skin Checks. She reported if the hair was not matted, the wounds to Resident #1's head could have been identified by NA's and licensed nursing staff before becoming necrotic.Interview with the Rehab Director on 5/5/26 at 11:38 AM identified she evaluated Resident #1 following the discovery of the wounds and determined the wounds were not caused from the wheelchair headrest and Resident #1 was never in the wheelchair longer than three (3) hours at a time daily. Following the evaluation, the wheelchair headrest was removed and Resident #1's positioning was still aligned. Resident #1 reported being comfortable without the headrest, so it was left off to allow time to heal. She reported the wounds were most likely due to positioning in bed but was unable to identify an exact cause. A contouring pillow was ordered to relieve pressure.Interview with the DON on 5/5/26 at 12:45 PM identified licensed nurses are expected to perform complete head to toe skin checks (Weekly Skin Checks) at least weekly and Resident #1 was a two (2) person assist for care so the Weekly Skin Check should not have been performed without assistance. She reported NA's should have brushed/combed Resident #1's hair at least daily with care and observed the skin every shift with care. She identified if staff removed Resident #1's hair cover, provided hair care, checked the skin every shift, and turned and repositioned Resident #1 four (4) times every shift per the plan of care, the matted hair and/or wounds could have been identified timely.Interview with NA #2 on 5/5/26 at 1:19 PM identified on 4/7/26, she provided care to Resident #1 in bed, not including hair care and once she assisted Resident #1 out of bed and into the wheelchair, she braided the top portion of Resident #1's hair. NA #2 reported she did not inspect the bottom portion of Resident #1's hair nor braid the bottom portion of the hair because Resident #1's head was too close to the headrest on the wheelchair, and she could not see it. She identified later in the day, Person #4 came to her requesting assistance with shaving Resident #1's head. She reported Resident #1 was not usually on her assignment so was unsure of what Resident #1's hair usually looked like. Person #4 removed the headrest on the wheelchair and the back of Resident #1's head had an area that was much thicker than the rest of the hair. She reported she gently shaved the hair to that area, which revealed several dark, scabbed areas and identified she notified LPN #1 immediately, and RN #1 assessed the area. Review of in-room camera footage with Person #4 on 5/5/26 at 1:57 PM identified staff last repositioned Resident #1 on 5/5/26 at 5:18 AM and Resident #1 was not again turned and repositioned until 9:08 AM by LPN #1 and RN #1 subsequent to surveyor inquiry (almost 4 hours later) despite the plan of care directing Resident #1 be turned and repositioned at least four (4) times per shift (every 2-hours). Although attempted, an interview with NA #4 was not obtained.Review of the Pressure Injury Prevention and Management policy dated 7/1/25 directed, in part, the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed.Review of the Turning and Repositioning policy dated 7/1/24 directed, in part, all residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. Turning and repositioning is a primary responsibility of nursing assistants, however, all nursing staff are expected to assist with turning and repositioning. The frequency of turning and repositioning will be documented in the resident's plan of care and will be determined by the resident's: tissue tolerance, level of activity and mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution support surface in use, comfort levels and resident preferences. Use the appropriate number of staff to perform the tasks safely.Review of the Activities of Daily Living (ADLs) policy dated 7/1/24 directed, in part, a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for neglect, the facility failed to notify the State Agency (SA) of an allegation of neglect related to the turning and repositioning of a dependent resident with existing facility acquired pressure injuries to the posterior scalp (back of head) within two (2) hours as required. The findings include:Resident #1's diagnoses included bilateral paralytic syndrome following cerebral infarction (a condition involving paralysis on both sides of the body due to stroke-related brain damage), type II diabetes mellitus with diabetic neuropathy (complication of diabetes, characterized by nerve damage), chronic pain syndrome, muscle weakness and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted which identified short-term and long-term memory problems and severely impaired cognition. The MDS identified Resident #1 required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers and was at risk for pressure injuries but had no current skin abnormalities.The Resident Care Plan (RCP) dated 3/26/26 identified Resident #1 was at risk for skin breakdown related to quadriplegia (paralysis affecting all four limbs and the torso) with contractures, decreased activity, impaired cognition, bowel and bladder incontinence, dependence on staff for bed mobility, transfers, and toileting and had a history of healed pressure injuries. Interventions included the use of a low air loss mattress, turning and/or repositioning and checking the skin four (4) times per shift as determined by tissue tolerance, observing skin condition daily with care and reporting abnormalities and completing a Weekly Skin Check by a licensed nurse.A nurse's note by RN #1 dated 4/7/26 at 3:00 PM identified she assessed Resident #1 in response to a concern from the responsible party (Person #4) regarding a change in skin integrity to the scalp after Person #4 had Resident #1's head shaved due to severely matted hair. The back of Resident #1's head had a cluster of five (5) lesions, including two (2) distal (farther away from the midline) lesions that were closed/resolved and of the other three (3), 2 had adherent fibrinous tissue (a yellowish moist or dry layer of necrotic material composed of dead cells and debris) covering the wounds and the other lesion had a pink wound bed. The entire cluster measured 6 centimeters (cm) by 5 cm. The surrounding scalp was unremarkable and although the wound beds were moist, there was no active drainage and Resident #1 denied pain. The severely matted hair contributed to pressure on the scalp and Person #4 planned to keep the hair length short moving forward. RN #1 educated Person #4 on caring for ethnic hair and he/she verbalized understanding. The provider was notified and a new order for calcium alginate (a highly absorbent wound dressing used for managing moderate to heavily draining wounds) to be applied to the wound bed was obtained and Resident #1 would be followed during weekly wound rounds.The wound physician note by MD #2 dated 4/10/26 identified Resident #1 was seen and evaluated for a wound to the back of the head. The posterior scalp (back of the head) wound was a full thickness cluster wound measuring 4.5 cm by 3.5 cm by 0.1 cm with twenty (20) percent (%) thick adherent devitalized necrotic tissue (dead tissue that acts as a physical barrier to healing), with no drainage and no signs and symptoms of pain or infection although Resident #1 was anxious. The etiology (cause/reason) of the wounds were undetermined/unknown and the treatment plan included applying Santyl to the wound beds followed by a dry protective dressing once daily for thirty (30) days. A facility Grievance Form dated 4/12/26 by Person #4 identified there was a customer service concern regarding the repositioning and turning of Resident #1 and reported one-to-one education was provided to NA #4 for Resident #1's reposition plan of four (4) times per shift.Review of the April 2026 Documentation Survey Report identified all assigned tasks on the 11:00 PM to 7:00 AM shift on 4/11/26 were not documented, including the turning and repositioning of Resident #1.A Disciplinary Action Form identified from 4/11/26 to 4/12/26 NA #4 failed to complete assigned tasks including documentation and it was her responsibility to ensure all resident needs are met in a timely manner. NA #4 was re-educated to provide care per the RCP, frequent rounding, and completing required documentation of care provided.The wound physician note by MD #2 dated 5/4/26 identified the posterior scalp wound measured 4.8 cm by 1.2 cm by 0.1 cm and no longer required Santyl. The wound bed consisted of fifty (50) % granulation tissue (new connective tissue that forms on the surface of a wound during the healing process). Interview with Person #4 on 5/4/26 at 11:09 AM identified in 2024 he/she shaved Resident #1's head and discovered wounds to the back of the head. At that time the facility contributed the wounds to barrettes that he/she put in Resident #1's hair and was told to no longer do so. Person #4 reported there was a live camera in the room and numerous times where no one entered the room to reposition Resident #1 for over four (4) hours and suspected the wounds were caused from pressure related to Resident #1 no being repositioned.Observation of Resident #1 on 5/5/26 at 8:45 AM identified Resident #1 turned to the right side with a positioning wedge in place to the right and the head of bed elevated to approximately forty-five (45) degrees. The touch pad call-bell was hanging on the back wall, out of reach.Interview and observation of Resident #1 with NA #1 on 5/5/26 at 8:46 AM identified Resident #1's call bell hanging on the back wall out of reach. NA #1 reported she had not yet been in the room since the start of her shift because there was no help and ignored the request to place the call-bell within reach of Resident #1. NA #1 continued to pass drinks for breakfast in the hallway and did not go into Resident #1's room to replace the call-bell or reposition Resident #1.Subsequent to surveyor inquiry, at 9:08 AM (20-minutes after notification to NA #1), LPN #1 and RN #1 placed Resident #1's call bell within reach and turned and repositioned Resident #1 in bed.Interview with MD #2 on 5/5/26 at 10:24 AM identified he was initially unsure of the etiology of the wounds to the back of Resident #1's head during his 4/10/26 visit and thought they could have been malignant (chronic, non-healing skin lesions caused by cancer cells in the skin) so documented them as non-pressure wounds. Since 4/10/26 the wounds improved. The wounds would not have improved if they were malignant, therefore, there was no need to biopsy the wounds and he determined they were caused by pressure due to the back of the head location. Review of in-room camera footage with Person #4 on 5/5/26 at 1:57 PM identified staff last repositioned Resident #1 on 5/5/26 at 5:18 AM and Resident #1 was not again turned and repositioned until 9:08 AM by LPN #1 and RN #1 subsequent to surveyor inquiry (almost 4 hours later) despite the plan of care directing Resident #1 be turned and repositioned at least four (4) times per shift (every 2-hours). Person #4 reported he/she was going to immediately show the DON the 5/5/26 camera footage.Interview with the DON on 5/5/26 at 2:27 PM identified Person #4 showed her the camera footage which identified Resident #1 had not been turned or repositioned from 5:18 AM until 9:08 AM.Subsequent to surveyor inquiry, review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/6/26 failed to identify the 5/5/26 allegation of neglect by Person #4 was reported to the SA as required.Review of the Abuse, Neglect and Exploitation policy dated 7/1/24 directed, in part, the facility is to report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies ( e.g., law enforcement when applicable) within specified timeframes: immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for neglect, the facility failed to ensure an allegation of neglect related to the discovery of several pressure injuries to the posterior scalp (back of head) of a dependent resident was thoroughly investigated and statements were obtained from all staff who were in contact with the resident for the prior 72 hours after the discovery of the pressure injuries. The findings include:Resident #1's diagnoses included bilateral paralytic syndrome following cerebral infarction (a condition involving paralysis on both sides of the body due to stroke-related brain damage), type II diabetes mellitus with diabetic neuropathy (complication of diabetes, characterized by nerve damage), chronic pain syndrome, muscle weakness and anxiety disorder.A Nursing readmission assessment by RN #2 dated 3/10/26 identified a full body skin assessment was completed, skin was intact and no open areas were noted.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted which identified short-term and long-term memory problems and severely impaired cognition. The MDS identified Resident #1 required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers and was at risk for pressure injuries but had no current skin abnormalities.Weekly Skin Checks completed by RN #2 on 3/17/26 and 3/25/26 identified a skin check was performed and no skin injury/wounds were noted.The Resident Care Plan (RCP) dated 3/26/26 identified Resident #1 was at risk for skin breakdown related to quadriplegia (paralysis affecting all four limbs and the torso) with contractures, decreased activity, impaired cognition, bowel and bladder incontinence, dependence on staff for bed mobility, transfers, and toileting and had a history of healed pressure injuries. Interventions included the use of a low air loss mattress, turning and/or repositioning and checking the skin four (4) times per shift as determined by tissue tolerance, observing skin condition daily with care and reporting abnormalities and completing a Weekly Skin Check by a licensed nurse.A Weekly Skin Check by RN #2 on 4/2/26 identified a skin check was performed and no skin injury/wounds were noted.A nurse's note by RN #1 dated 4/7/26 at 3:00 PM identified she assessed Resident #1 in response to a concern from the responsible party (Person #4) regarding a change in skin integrity to the scalp after Person #4 had Resident #1's head shaved due to severely matted hair. The back of Resident #1's head had a cluster of five (5) lesions, including two (2) distal (farther away from the midline) lesions that were closed/resolved and of the other three (3), 2 had adherent fibrinous tissue (a yellowish moist or dry layer of necrotic material composed of dead cells and debris) covering the wounds and the other lesion had a pink wound bed. The entire cluster measured 6 centimeters (cm) by 5 cm. The surrounding scalp was unremarkable and although the wound beds were moist, there was no active drainage and Resident #1 denied pain. The severely matted hair contributed to pressure on the scalp and Person #4 planned to keep the hair length short moving forward. RN #1 educated Person #4 on caring for ethnic hair and he/she verbalized understanding. The provider was notified and a new order for calcium alginate (a highly absorbent wound dressing used for managing moderate to heavily draining wounds) to be applied to the wound bed was obtained and Resident #1 would be followed during weekly wound rounds.A facility Reportable Event (RE) dated 4/8/26 identified at 10:45 AM Person #4 reported a concern regarding Resident #1's hair hygiene and believed Resident #1 was neglected due to hair at the base of the scalp being knotted resulting in irritation to the scalp and back of the head. Resident #1 was a total assist of two (2) for care and transfers and a full body skin assessment was completed and no changes were noted to skin integrity. The provider and the police were notified, an investigation was initiated and an alternate style pillow was provided for better tissue tolerance.Review of the facility schedules dated 4/5/26, 4/6/26 and 4/7/26 identified RN #2, RN #4, LPN #1, LPN #4, NA #1, NA #2, NA #3, NA #4, NA #5, NA #9, NA #10, NA #11 and NA #12 had been assigned to work on Resident #1's unit.Review of the facility Accident and Investigation / Incident (A & I) documents for Resident #1 failed to identify statements were obtained from RN #2, RN #4, LPN #4, NA #4 and NA #10.Interview with the DON on 5/4/26 at 1:49 PM identified the wounds discovered to the back of the head should have been investigated as an injury of unknown origin and statements should have been obtained from all staff who worked with Resident #1 and on Resident #1's unit for at least the prior 72-hours from the discovery of the wounds. She reported she reviewed the schedules and put each staff members name on blank statement sheets going back beyond 72-hours but then went on vacation, and the nursing supervisors should have ensured the statements were obtained. The DON identified she should have ensured all the statements were obtained when she returned from vacation to ensure a complete investigation, especially from RN #2 who was the nurse that completed all Weekly Skin Checks leading up to the incident. The DON was unable to produce statements from RN #2, RN #4, LPN #4, NA #4 and NA #10.Review of the Abuse, Neglect and Exploitation policy dated 7/1/24 directed, in part, an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: Identifying staff responsible for the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to ensure Resident #1 was turned and repositioned per the plan of care to prevent pressure-related skin breakdown, resulting in the development of several posterior scalp (back of head) pressure injuries. The findings include:Resident #1's diagnoses included bilateral paralytic syndrome following cerebral infarction (a condition involving paralysis on both sides of the body due to stroke-related brain damage), type II diabetes mellitus with diabetic neuropathy (complication of diabetes, characterized by nerve damage), chronic pain syndrome, muscle weakness and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted which identified short-term and long-term memory problems and severely impaired cognition. The MDS identified Resident #1 required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers and was at risk for pressure injuries but had no current skin abnormalities.Weekly Skin Checks completed by RN #2 on 3/17/26 and 3/25/26 identified a skin check was performed and no skin injury/wounds were noted.The Resident Care Plan (RCP) dated 3/26/26 identified Resident #1 was at risk for skin breakdown related to quadriplegia (paralysis affecting all four limbs and the torso) with contractures, decreased activity, impaired cognition, bowel and bladder incontinence, dependence on staff for bed mobility, transfers, and toileting and had a history of healed pressure injuries. Interventions included the use of a low air loss mattress, turning and/or repositioning and checking the skin four (4) times per shift as determined by tissue tolerance, observing skin condition daily with care and reporting abnormalities and completing a Weekly Skin Check by a licensed nurse.A Braden Scale assessment dated [DATE] identified Resident #1 was at moderate risk for developing pressure injuries.The April 2026 Documentation Survey Report identified NA #1 gave Resident #1 a shower on 4/1/26 and documented the skin observation as Not Applicable (N/A).A Weekly Skin Check by RN #2 on 4/2/26 identified a skin check was performed and no skin injury/wounds were noted. Review of the Kardex in effect on 4/6/26 directed NA's to monitor for skin redness/irritation and report as indicated, observe skin condition daily with Activities of Daily Living (ADL) care and report abnormalities and continue to encourage every two (2) hour repositioning. A nurse's note by RN #1 dated 4/7/26 at 3:00 PM identified she assessed Resident #1 in response to a concern from the responsible party (Person #4) regarding a change in skin integrity to the scalp after Person #4 had Resident #1's head shaved due to severely matted hair. The back of Resident #1's head had a cluster of five (5) lesions, including two (2) distal (farther away from the midline) lesions that were closed/resolved and of the other three (3), 2 had adherent fibrinous tissue (a yellowish moist or dry layer of necrotic material composed of dead cells and debris) covering the wounds and the other lesion had a pink wound bed. The entire cluster measured 6 centimeters (cm) by 5 cm. The surrounding scalp was unremarkable and although the wound beds were moist, there was no active drainage and Resident #1 denied pain. The severely matted hair contributed to pressure on the scalp and Person #4 planned to keep the hair length short moving forward. RN #1 educated Person #4 on caring for ethnic hair and he/she verbalized understanding. The provider was notified and a new order for calcium alginate (a highly absorbent wound dressing used for managing moderate to heavily draining wounds) to be applied to the wound bed was obtained and Resident #1 would be followed during weekly wound rounds.A facility Reportable Event (RE) dated 4/8/26 identified at 10:45 AM Person #4 reported a concern regarding Resident #1's hair hygiene and believed Resident #1 was neglected due to hair at the base of the scalp being knotted resulting in irritation to the scalp and back of the head. Resident #1 was a total assist of two (2) for care and transfers and a full body skin assessment was completed and no changes were noted to skin integrity. The provider and the police were notified, an investigation was initiated and an alternate style pillow was provided for better tissue tolerance. The wound physician note by MD #2 dated 4/10/26 identified Resident #1 was seen and evaluated for a wound to the back of the head. The posterior scalp (back of the head) wound was a full thickness cluster wound measuring 4.5 cm by 3.5 cm by 0.1 cm with twenty (20) percent (%) thick adherent devitalized necrotic tissue (dead tissue that acts as a physical barrier to healing), with no drainage and no signs and symptoms of pain or infection although Resident #1 was anxious. The etiology (cause/reason) of the wounds were undetermined/unknown and the treatment plan included applying Santyl to the wound beds followed by a dry protective dressing once daily for thirty (30) days. A facility Grievance Form dated 4/12/26 by Person #4 identified there was a customer service concern regarding the repositioning and turning of Resident #1 and reported one-to-one education was provided to NA #4 for Resident #1's reposition plan of four (4) times per shift.Review of the April 2026 Documentation Survey Report identified all assigned tasks on the 11:00 PM to 7:00 AM shift on 4/11/26 were not documented, including the turning and repositioning of Resident #1.A Disciplinary Action Form identified from 4/11/26 to 4/12/26 NA #4 failed to complete assigned tasks including documentation and it was her responsibility to ensure all resident needs are met in a timely manner. NA #4 was re-educated to provide care per the RCP, frequent rounding, and completing required documentation of care provided. Interview with Person #4 on 5/4/26 at 11:09 AM identified in 2024 he/she shaved Resident #1's head and discovered wounds to the back of the head. At that time the facility contributed the wounds to barrettes that he/she put in Resident #1's hair and was told to no longer do so. Person #4 identified on or around 4/6/26, LPN #1 asked if Person #4 was going to shave Resident #1's head again. He/she thought the request was odd because the hair was only about three (3) inches long and Resident #1 always wore a hair cover. Person #4 identified he/she then noticed blood on Resident #1's pillow and reported the hair had an odor. On 4/7/26, Person #4 brought clippers to shave Resident #1's head. Upon inspection of the hair, the back of the head was severely matted. Person #4 reported he/she requested NA #2's assistance with shaving and when they shaved the hair, multiple pink areas and scabbed areas were observed to the back of the head. Person #4 identified he/she never had Resident #1 go to the hairdresser because staff reported they washed the hair weekly and never reported issues with the hair. Person #4 reported there was a live camera in the room and numerous times where no one entered the room to reposition Resident #1 for over four (4) hours. Person #4 filed a grievance 4/12/26 which reported no staff entered the room to turn and reposition Resident #1 from around 9:20 PM on 4/11/26 until around 5:20 AM on 4/12/26 (eight hours) and suspected the wounds were caused from pressure related to Resident #1 not being repositioned. Observation of Resident #1 on 5/5/26 at 8:45 AM identified Resident #1 turned to the right side with a positioning wedge in place to the right and the head of bed elevated to approximately forty-five (45) degrees. The touch pad call-bell was hanging on the back wall, out of reach.Interview and observation of Resident #1 with NA #1 on 5/5/26 at 8:46 AM identified Resident #1's call bell hanging on the back wall out of reach. NA #1 reported she had not yet been in the room since the start of her shift because there was no help and ignored the request to place the call-bell within reach of Resident #1. NA #1 continued to pass drinks for breakfast in the hallway and did not go into Resident #1's room to replace the call-bell or reposition Resident #1.Subsequent to surveyor inquiry, at 9:08 AM (20-minutes after notification to NA #1), LPN #1 and RN #1 placed Resident #1's call bell within reach and turned and repositioned Resident #1 in bed. Interview with MD #2 on 5/5/26 at 10:24 AM identified he was initially unsure of the etiology of the wounds to the back of Resident #1's head during his 4/10/26 visit and thought they could have been malignant (chronic, non-healing skin lesions caused by cancer cells in the skin) so documented them as non-pressure wounds. Since 4/10/26 the wounds improved. The wounds would not have improved if they were malignant, therefore, there was no need to biopsy the wounds and he determined they were caused by pressure due to the back of the head location. MD #2 reported if the back of the head been offloaded consistently, the area most likely would not have developed. Interview with the Rehab Director on 5/5/26 at 11:38 AM identified she evaluated Resident #1 following the discovery of the wounds and determined the wounds were not caused from the wheelchair headrest and Resident #1 was never in the wheelchair longer than three (3) hours at a time daily. Following the evaluation, the wheelchair headrest was removed and Resident #1's positioning was still aligned. Resident #1 reported being comfortable without the headrest, so it was left off to allow time to heal. She reported the wounds were most likely due to positioning in bed but was unable to identify an exact cause. A contouring pillow was ordered to relieve pressure.Interview with the DON on 5/5/26 at 12:45 PM identified NA staff were responsible for turning and repositioning residents per their plan of care and Resident #1 was to be turned and repositioned four (4) times every shift per the plan of care.Review of in-room camera footage with Person #4 on 5/5/26 at 1:57 PM identified staff last repositioned Resident #1 on 5/5/26 at 5:18 AM and Resident #1 was not again turned and repositioned until 9:08 AM by LPN #1 and RN #1 subsequent to surveyor inquiry (almost 4 hours later) despite the plan of care directing Resident #1 be turned and repositioned at least four (4) times per shift (every 2-hours). Although attempted, an interview with NA #4 was not obtained.Review of the Turning and Repositioning policy dated 7/1/24 directed, in part, all residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. Turning and repositioning is a primary responsibility of nursing assistants, however, all nursing staff are expected to assist with turning and repositioning. The frequency of turning and repositioning will be documented in the resident's plan of care and will be determined by the resident's: tissue tolerance, level of activity and mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution support surface in use, comfort levels and resident preferences. Use the appropriate number of staff to perform the tasks safely.Review of the Comprehensive Care Plan policy dated 4/1/25 directed, in part, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to ensure Resident #1's call bell was consistently accessible and within reach, resulting in a dependent resident with limited verbal communication being unable to independently request assistance. The findings include:Resident #1's diagnoses included bilateral paralytic syndrome following cerebral infarction (a condition involving paralysis on both sides of the body due to stroke-related brain damage), type II diabetes mellitus with diabetic neuropathy (complication of diabetes, characterized by nerve damage), chronic pain syndrome, muscle weakness and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted which identified short-term and long-term memory problems and severely impaired cognition. The MDS identified Resident #1 required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers and was at risk for pressure injuries but had no current skin abnormalities.The Resident Care Plan (RCP) dated 3/26/26 identified Resident #1 was dependent for Activities of Daily Living (ADL) care in all ADL's related to history of a stroke, spasticity, cognitive impairment, limited range of motion and limited mobility, was at risk for falls and was at risk for respiratory complications related to Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, shortness of breath and had a tracheotomy with increased respiratory secretions putting the resident at risk for aspiration of enteral feeding. Interventions included anticipating and meeting the resident's needs, being sure the resident's call light was within reach and encouraging the resident to use the call light for assistance as needed. The RCP further indicated Resident #1 needed prompt response to all requests for assistance.A facility Reportable Event (RE) dated 4/8/26 identified at 10:45 AM Person #4 reported a concern regarding Resident #1's hair hygiene and believed Resident #1 was neglected due to hair at the base of the scalp being knotted resulting in irritation to the scalp and back of the head. Resident #1 was a total assist of two (2) for care and transfers and a full body skin assessment was completed and no changes were noted to skin integrity. The provider and the police were notified, an investigation was initiated and an alternate style pillow was provided for better tissue tolerance.A nurse's note by the DON dated 4/8/26 at 12:16 PM identified Resident #1's responsible party (Person #4) reported a concern regarding hair hygiene. The APRN and police were notified, a skin assessment was completed and no changes to skin integrity were noted. An alternate style pillow was provided for better tissue tolerance and Person #4 was updated.A. Observations on 5/4/26 at 11:33 AM identified Resident #1 in bed, on his/her back with tears running down his/her face. Resident #1 was unable to verbally communicate but when asked if he/she was okay, Resident #1 shook his/her head no. A moderate amount of pink secretions were noted to the gauze under Resident #1's tracheostomy site and the touch pad call bell was noted to be hanging on the oxygen concentrator that was against the back wall about three (3) feet away from the head of Resident #1's bed, not within reach of Resident #1.Observation and interview with LPN #1 on 5/4/26 at 11:37 AM identified the touch pad call bell to not be within reach of Resident #1. LPN #1 performed tracheostomy care for Resident #1, changed the dressing to the back of Resident #1's head as ordered and then at 12:03 PM placed the call bell on the bed next to Resident #1's right hand and clipped it to the bed. LPN #1 identified she was unsure why the call bell was not in place and within reach of Resident #1, as Resident #1 had recently received personal care from NA #3. She reported Resident #1 had use of his/her right hand and was able to use the call bell and the call bell should have been within reach to utilize as needed. Moments later, the call system was noted to be lit up outside of Resident #1's room and LPN #1 responded.Interview with NA #3 on 5/4/26 at 12:20 PM identified after performing personal care for Resident #1 approximately one (1) hour earlier, she forgot to place the call bell back in Resident #1's reach, and she should have ensured the call bell was within reach prior to leaving the room.B. Observation of Resident #1 on 5/5/26 at 8:45 AM identified Resident #1 turned to the right side with the positioning wedge in place to the right and the head of bed elevated to approximately forty-five (45) degrees. The touch pad call bell was noted to be hanging on the back wall, not within reach of Resident #1. Resident #1 was noted with a minimal amount of pink secretions to the gauze under the tracheostomy site but did not appear to be in distress but when asked if he/she was okay, Resident #1 did not shake his/her yes or no but instead raised his/her right fist in the air.Interview and observation of Resident #1 with NA #1 on 5/5/26 at 8:46 AM identified Resident #1's call bell hanging on the back wall out of reach. NA #1 reported she had not yet been in the room since the start of her shift because there was no help and ignored the request to place the call-bell within reach of Resident #1. NA #1 continued to pass drinks for breakfast in the hallway and did not go into Resident #1's room to replace the call-bell or reposition Resident #1. Subsequent to surveyor inquiry, at 9:08 AM (20-minutes after notification to NA #1), LPN #1 and RN #1 placed Resident #1's call bell within reach and turned and repositioned Resident #1 in bed. Interview with the DON on 5/5/26 at 9:11 AM identified after providing care for residents, both NA's and licensed nurses should ensure the call bell is within reach of the resident prior to leaving the room. She reported if NA #1 was not providing care to another resident at the time she was notified the call bell was not within reach for Resident #1, she should have responded immediately when notified, and placed the call bell within reach of Resident #1.Review of the Call Lights: Accessibility and Timely Response policy dated 9/1/24 directed, in part, all staff will be educated in the proper use of the resident call system, including how the system works and ensuring residents have access to the call light. Staff will ensure the call light is within reach of each resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of two (2) sampled residents (Residents #4 and #5) reviewed for abuse, the facility failed to ensure residents were protected from sexual abuse. Both residents had cognitive impairment which limited their ability to consent to or understand the interaction, and the facility failed to implement adequate supervision and interventions to prevent the incident. The findings include:1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia and dementia with behavioral disturbance. Resident #4's family member was Resident #4's responsible party for medical care. The Nursing admission assessment dated [DATE] identified Resident #4 was independent with bed mobility, transfers and required supervision for dressing. The Physician's orders dated 3/28/26 directed Donepezil 10 mg at bedtime for dementia, Quetiapine Fumarate 100 mg in the evening for agitation and Sertraline 150 mg once a day for depression.The Brief Mental Interview for Mental Status (BIMS) interview dated 3/30/26 identified Resident #4 scored five (5), indicative of severely impaired cognition.The Resident Care Plan (RCP) dated 3/30/36 identified Resident #4 had impaired/decline in cognitive function and impaired thought processes related to dementia. Interventions included to allow Resident #4 to make daily decisions, use verbal cues, gestures and demonstrations to assist in decision making, break down tasks to support short-term memory deficits and re-direct Resident #4 using external cues as needed.The Psychiatric Evaluation dated 3/31/26 identified Resident #4 was alert and orientated to self only with cognitive deficits evident. The Physician's order dated 4/1/26 directed Lorazepam 0.5 mg in the morning for anxiety.2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder and dementia. The Court of Probate document dated 4/24/25 identified Resident #5 had a conservator of person.The Physician's order dated 1/29/26 directed Venlafaxine 100 mg once a day for anxiety.The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #5 had a Brief Mental Interview for Mental Status (BIMS) of six (6) indicative of severely impaired cognition. The Quarterly Nursing admission assessment dated [DATE] identified Resident #5 was independent with bed mobility, transfers, dressing and toileting. The Brief Mental Interview for Mental Status (BIMS) interview dated 3/30/26 identified Resident #4 scored five (5), indicative of severely impaired cognition.The Resident Care Plan (RCP) dated 2/23/26 identified Resident #5 was at risk for elopement and wandering related to cognitive impairments. Interventions included to engage Resident #5 with tailored recreation activities based on his/her interests, intervene and re-direct when wandering, exit seeking or behaviors become intrusive or affect peers, monitor and document target behaviors and divert Resident #5 by giving alternative objects or activities. The care plan further identified Resident #5 had impaired/decline in cognitive function and impaired thought processes related to dementia. Interventions included to observe and evaluate the types of changes in cognitive status and notify the physician as needed, speak in a normal-tones voice, clearly and slowly while making eye contact, stress key words and present just one thought at a time and use short phrases that require yes or no answers.The Psychiatric Evaluation dated 4/3/26 identified Resident #5 was alert to self only and was unable to accurately state day, month, year. Resident #5 previously was without mood or behavior concerns since the last evaluation (3/17/26) but nursing reports increased anxiety. She identified to renew Clonazepam 0.5 mg every twelve (12) hours as needed for anxiety for fourteen days.The Physician's order dated 4/4/26 directed Clonazepam 0.5 mg every eight (8) hours as needed for increased anxiety, agitated behaviors for fourteen (14) days. The Reportable Event form by the DNS dated 4/7/26 at 10:00 AM identified Resident #4 and #5 reside on a locked dementia unit and are not responsible for themselves. Resident #5 was observed in Resident #4's room and Resident #4 and Resident #5 were lying prone in bed partially clothed. The residents were immediately separated. Skin checks were completed for both residents with no injuries noted. Resident #4 was placed on every 15-minute checks and currently remains on every 15-minute checks. Resident #5 was placed on 1:1 observation and currently remains on 1:1 observation. Resident #5's room was moved further away as they previously had close proximity to each other.Resident #4's Assessment of Resident Capacity to Consent to Sexual Activity form dated 4/7/26 identified the Social Worker and DNS met with Resident #4's family member who is Resident #4's emergency contact. Resident #4's family member did not consent to sexual activity for Resident #4 with other residents.Resident #5's Assessment of Resident Capacity to Consent to Sexual Activity form dated 4/7/26 identified the Social Worker and DNS met with Resident #5's conservator of person via the phone. No consent was given for Resident #5 to participate in sexual activity with other residents.NA #2's statement dated 4/7/26 identified on 4/7/26 she entered into Resident #4's room to feed the resident and saw Resident #4 on top of Resident #5. Resident #5's pants and undergarments were on the bottom of the bed. Resident #4's pants were open and unzipped. NA #2 immediately called for the nurse.Interview with COTA #1 on 4/9/26 at 12:18 PM identified on 4/7/26 during breakfast time, she was next door to Resident #4's room feeding a resident who just received breakfast. She could not identify the estimated time. She identified she heard ruckus in the hallway and it appeared like NA #2 needed assistance. She then went into Resident #4's room and observed Resident #4 in Resident #5's bedroom. Resident #4 had a shirt on but no pants or underwear. Resident #5 had a shirt on and his/her pants and underwear were pulled down. She identified Resident #4 was on top of Resident #5. She identified she pulled Resident #4 off Resident #5 with his/her belt on his/her pants and Resident #5 sat in his/her room chair. Resident #4 proceeded to dress him/herself and more staff arrived in the room.Interview with RN #1 on 4/9/26 at 2:30 PM identified she was the RN on the dementia unit on 4/7/26 during the 7:00 AM - 3:00 PM shift. She identified she last saw Resident #4 in the dining room for breakfast around 8:30 AM. She identified Resident #5 ate breakfast in his/her room. She identified a page was announced for the RN supervisor to the floor and went to Resident #4's room. She identified Resident #4 and Resident #5 were already separated. Resident #4 and Resident #5's were assessed and no injuries were found. Resident #4 was placed on every 15-minute checks and Resident #5 was placed on 1:1 observation.Interview with APRN #3 on 4/9/26 at 12:30 PM identified Resident #4 was alert and orientated to self but not the day, time or place. Resident #4 had no previous behavioral concerns. She identified Resident #4 did not recall the incident on 4/7/26. Resident #5 was alert and orientated to self, day, place but had severe cognitive impairments. Resident #5 had recent previous behaviors of refusal of care but no sexual disinhibition behaviors. She identified Resident #5 thought Resident #4 was someone from his/her past and they were rekindling a relationship.Interview with the Regional Clinical Nurse and DNS on 4/9/26 at 12:00 PM identified the incident occurred after breakfast, which is served from 8:30 AM - 9:00 AM. Resident #4's and Resident #5's breakfast trays were already picked up (around 9:15 AM - 9:30 AM) when NA #2 was assisting with feeding another resident when she identified Resident #4's door was closed. The estimated time between when the residents were last observed to the time of the incident (9:50 AM) is 15 - 20 minutes.Review of the Sexual Expression of Residents policy directed to respect the right of residents to express themselves sexually, as long as it does not violate the rights of other residents. The policy applies to individuals who exhibit intact cognitive decision-making capacity. PAST NON-COMPLIANCE The facility presented a corrective action plan dated 4/7/26 which included:Staff education dated 4/7/26 to include: Policies on sexual expression, resident's rights and reporting requirements.Audits of residents on the dementia unit evaluated for any behaviors of inappropriate affection towards other residents. Audits of staff knowledge on what to do if they observe residents displaying inappropriate affection towards each other and what steps they should takeQAPI meeting was held reviewing the event and the plan of correction.The corrective action plan for past noncompliance was accepted by the state agency during an onsite visit on 4/9/26.

Based on review of clinical records, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered within acceptable time frames and documented at the time of administration, resulting in a pattern of medication administration errors, including the administration of time-sensitive medications outside the facility's established one (1) hour before to one (1) hour after window. The findings included:Resident #1 was admitted to the facility in February 2024 with diagnoses which included seizure disorder, anxiety, and dementia.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Mental Interview for Mental Status (BIMS) score of 3) and required moderate assistance with toileting, bathing, and personal hygiene. The Resident Care Plan (RCP) dated 1/2/26 identified Resident #2 as at risk for seizure activity related to a history of seizure disorder. Interventions directed to medicate as ordered and monitor for effectiveness and side effects, and report to the physician as needed.1.A physician's order directed two (2) tablets of gabapentin, 100 milligrams, to be administered every eight (8) hours for neuropathy.A physician's order directed two (2) tablets of acetaminophen, 500 milligrams, to be administered every eight (8) hours for pain management.The March 2026 Medication Administration Report identified Resident #2 was not given his/her 2:00 PM scheduled 200 milligrams of gabapentin and 1000 milligrams of acetaminophen on 3/2/26.Interview with RN #1 (nurse supervisor of the 7:00 AM to 3:00 PM shift on 3/2/26) on 4/6/26 at 2:26 PM identified he/she administered Resident #2's 200 milligrams of gabapentin and 1000 milligrams of acetaminophen at 2:00 PM on 3/2/26, however, failed to document the medications were administered. RN #1 further identified facility policy directed staff to document medications were administered at the time they were administered.2.The following 9:00 AM scheduled medications were documented as administered to Resident #1 by RN #2 on 3/1/26 at 1:32 PM (four (4) hours and thirty-two (32) minutes past the scheduled time):-Brivaracetam Oral Solution, 10 milligrams/milliliter (for seizures)-Ferrous Sulfate, 325 milligrams (for anemia)-Baclofen, 5 milligrams (for muscle spasms)-Carvedilol, 12.5 milligrams (for hypertension)-Losartan Potassium, 50 milligrams (for hypertension)-Apixaban, 2.5 milligrams (for atrial fibrillation)-Amlodipine, 10 milligrams (for hypertension)-Duloxetine, 20 milligrams (for depression)-Senna, 8.6/50 milligrams (for constipation)-Lorazepam, 0.5 milligrams (for seizure disorder)The following 9:00 PM scheduled medications were administered to Resident #1 by RN #3 on 3/1/26 at 6:32 PM (two (2) hours and twenty-eight (28) minutes before schedule):-Brivaracetam Oral Solution, 10 milligrams/milliliter (for seizures)-Diclofenac Sodium External Gel, 1% ointment (for pain)-Baclofen, 5 milligrams (for muscle spasms)The following 9:00 PM scheduled medications were administered to resident #1 by RN #3 on 3/1/26 at 6:33 PM (two (2) hours and twenty-seven (27) minutes before schedule):-Melatonin, 5 milligrams (for insomnia)-Apixaban. 2.5 milligrams (for atrial fibrillation)-Mirtazapine, 7.5 milligrams (for depression)-Lorazepam, 0.5 milligrams (for seizure disorder)-Acetaminophen, 1000 milligrams (for pain management)The following 10:00 PM scheduled medications were administered to resident #1 by RN #3 on 3/1/26 at 6:34 PM (three (3) hours and twenty-six (26) minutes before schedule):-Gabapentin, 200 milligrams (for neuropathy)Interview with RN #2 on 4/7/26 at 10:29 AM identified he/she documented medications were administered after all his/her assigned residents were administered their medications due to issues with uploading data into the electronic medical record, requiring him/her to restart his/her computer and wait for the system to reload. RN #2 further indicated he/she would also wait until all his/her assigned residents were administered their medications before documenting they were given to avoid delayed administration due to a challenging workload. Although attempted, an interview with RN #3 was not obtained.Interview with the Director of Nursing Services (DNS) on 4/7/26 at 11:08 AM identified the facility's standard of practice was for medications to be administered up to one hour before to one hour after the scheduled medication administration time. The DNS further identified once medication(s) were administered to a resident, the nurse was to immediately document the administration in the resident's medical record. The Medication Administration policy directed to ensure the six rights of medication administration were followed, which included right documentation, and to sign the medication administration record after medication(s) were administered.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for ADL's, the facility failed to ensure a resident who was dependent on staff for feeding was fed in a dignified manner. The findings include:Resident #1 had diagnoses that included dementia, dysphagia oropharyngeal phase, mood disorder, lack of coordination, and difficulty walking.Physician's orders dated 5/9/2025 directed to provide a regular dysphagia puree texture diet with nectar thick liquids.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had short-term and long-term memory impairment, severely impaired cognitive skills for daily decision making, was frequently incontinent of bowel and bladder, dependent on staff for all ADLs including eating, bed mobility, transfers, was non ambulatory, dependent on staff for mobility in the wheelchair, and on a mechanically altered diet.The Resident Care Plan (RCP) dated 5/30/2025 identified Resident #1 was at risk for impaired swallowing related to dementia. Interventions directed to provide dysphagia puree consistency diet as ordered, sit upright for all oral intake and medications, feed slowly, small bites/sips via cup, alternate liquids and solids, if coughing occurs no food/liquids until coughing resolves, and monitor for signs and symptoms of aspiration coughing during/after meals, watery eyes, choking, moist sounding voice, or increased temperature.The Resident Care Card directed to assist or feed Resident #1 at mealtimes, provide slow approach and cues while feeding, provide a dysphagia puree consistency diet with nectar thick liquids, if coughing occurs no food/liquids until coughing resolves, and monitor for signs and symptoms of aspiration, coughing during/after meals, watery eyes, choking, moist sounding voice, feed slowly small bites/sips, alternate liquids and solids.Review of the documentation survey report dated 7/12/2025 for the 7:00 A.M. to 3:00 P.M. shift identified NA #1 signed off the eating task at 1:00 P.M. indicating the task was completed.Interview with Person #2 on 7/12/2025 at 9:56 A.M. identified video footage dated 7/12/2025 at approximately 9:40 A.M. captured Resident #1 being fed breakfast by NA #1. Person #2 identified h/she sent the video footage to the facility on 7/13/2025. Review of the one-minute video footage on 7/29/2025 identified the video was dated 7/12/2025 during the breakfast meal. NA #1 was sitting in a chair spoon feeding Resident #1. NA #1 proceeded to place a full spoonful of oatmeal with a piece of scrambled egg to Resident #1's lips then partially inserted the spoon into Resident #1's mouth. NA #1 stated to Resident #1 open with the spoon still at Resident #1's mouth, Resident #1 lifted h/her left hand and moved it towards h/her mouth. NA #1 took the spoon away from Resident #1's mouth. NA #1 then opened a sugar packet, added it to the oatmeal, and stirred it slightly. NA #1 took the bowl of oatmeal placed it under Resident #1's chin and stated to Resident #1 try this one. NA #1 proceeded to put two heaping spoonful's of oatmeal into Resident #1's mouth with oatmeal dripping off the spoon onto Resident #1's chin. NA #1 used the spoon to remove the oatmeal from Resident #1's chin and stated, you doing good, then proceeded to place another heaping spoonful of oatmeal into Resident #1's mouth.Interview with NA #1 on 7/29/2025 at 11:16 A.M. identified prior to 7/12/2025 she received education on feeding residents and passed the competency titled Feeding the Resident. NA #1 identified that on 7/12/2025 she was aware Resident #1 needed to be fed slowly and did not realize how fast she was feeding Resident #1. NA #1 identified she should have ensured Resident #1 swallowed each spoonful of oatmeal before inserting an additional spoonful into Resident #1's mouth.Interview with the DNS on 7/29/2025 at 12:35 P.M. identified that based on video footage dated 7/12/2025, NA #1 was feeding Resident #1 too fast. The DNS identified that staff should feed residents slowly and ensure the resident swallows food in their mouth before feeding another spoonful of food. The DNS identified that NA #1 should have paused between each spoonful of oatmeal and not fed Resident #1 one spoonful after another.Review of the facility's Resident Rights policy dated 7/1/2024; in part, identified the resident has the right to a dignified experience.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for ADL's, the facility failed to ensure a resident who was dependent on staff for feeding, was fed using the proper feeding technique. The findings included:Resident #1 had diagnoses that included dementia, dysphagia oropharyngeal phase, mood disorder, lack of coordination, and difficulty walking.Physician's orders dated 5/9/2025 directed to provide a regular dysphagia puree texture diet with nectar thick liquids.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had short-term and long-term memory impairment, severely impaired cognitive skills for daily decision making, was frequently incontinent of bowel and bladder, dependent on staff for all ADLs including eating, bed mobility, transfers, was non ambulatory, dependent on staff for mobility in the wheelchair, and on a mechanically altered diet.The Resident Care Plan (RCP) dated 5/30/2025 identified Resident #1 was at risk for impaired swallowing related to dementia. Interventions directed to provide dysphagia puree consistency diet as ordered, sit upright for all oral intake and medications, feed slowly, small bites/sips via cup, alternate liquids and solids, if coughing occurs no food/liquids until coughing resolves, and monitor for signs and symptoms of aspiration coughing during/after meals, watery eyes, choking, moist sounding voice, or increased temperature.The Resident Care Card directed to assist or feed Resident #1 at mealtimes, provide slow approach and cues while feeding, provide a dysphagia puree consistency diet with nectar thick liquids, if coughing occurs no food/liquids until coughing resolves, and monitor for signs and symptoms of aspiration, coughing during/after meals, watery eyes, choking, moist sounding voice, feed slowly small bites/sips, alternate liquids and solids.Review of NA #1's clinical competency validation dated 6/27/2025 on Feeding the Resident identified that NA #1 passed the Feeding the Resident competency.Review of the documentation survey report dated 7/12/2025 for the 7:00 A.M. to 3:00 P.M. shift identified NA #1 signed off the eating task at 1:00 P.M. indicating the task was completed.Interview with Person #2 on 7/12/2025 at 9:56 A.M. identified video footage dated 7/12/2025 at approximately 9:40 A.M. captured Resident #1 being fed breakfast by NA #1. Person #2 identified h/she sent the video footage to the facility on 7/13/2025. Review of the one-minute video footage on 7/29/2025 identified the video was dated 7/12/2025 during the breakfast meal. NA #1 was sitting in a chair spoon feeding Resident #1. NA #1 proceeded to place a full spoonful of oatmeal with a piece of scrambled egg to Resident #1's lips then partially inserted the spoon into Resident #1's mouth. NA #1 stated to Resident #1 open with the spoon still at Resident #1's mouth, Resident #1 lifted h/her left hand and moved it towards h/her mouth. NA #1 took the spoon away from Resident #1's mouth. NA #1 then opened a sugar packet, added it to the oatmeal, and stirred it slightly. NA #1 took the bowl of oatmeal placed it under Resident #1's chin and stated to Resident #1 try this one. NA #1 proceeded to put two heaping spoonful's of oatmeal into Resident #1's mouth with oatmeal dripping off the spoon onto Resident #1's chin. NA #1 used the spoon to remove the oatmeal from Resident #1's chin and stated, you doing good, then proceeded to place another heaping spoonful of oatmeal into Resident #1's mouth.Interview with NA #1 on 7/29/2025 at 11:16 A.M. identified prior to 7/12/2025 she received education on feeding residents and passed the competency titled Feeding the Resident. NA #1 identified that on 7/12/2025 she was aware Resident #1 needed to be fed slowly and did not realize how fast she was feeding Resident #1. NA #1 identified she should have ensured Resident #1 swallowed each spoonful of oatmeal before inserting an additional spoonful into Resident #1's mouth.Interview and review of the video footage with Speech and Language Pathologist (SLP) #1 on 7/29/2025 at 11:30 A.M. identified based on the video footage dated 7/12/2025, NA #1 was feeding Resident #1 too fast. SLP #1 identified that Resident #1 needed to be fed slowly, and NA #1 should have paused between each bite of oatmeal.Interview with the DNS on 7/29/2025 at 12:35 P.M. identified that based on video footage dated 7/12/2025, NA #1 was feeding Resident #1 too fast. The DNS identified that staff should feed residents slowly and ensure the resident swallows food in their mouth before feeding another spoonful of food. The DNS identified that NA #1 should have paused between each spoonful of oatmeal and not fed Resident #1 one spoonful after another.Review of the facility's Feeding the Resident clinical competency validation form identified; in part, the critical elements directed to offer the food in bite-size pieces, make sure the resident's mouth is empty before the next bite, and wipe food from the resident's mouth and hands as necessary.Although requested, a facility policy for feeding residents was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure that a resident, who was being fed by facility staff, was free from abuse. The findings include:Resident #1 had diagnoses that included dementia, dysphagia oropharyngeal phase, mood disorder, lack of coordination, and difficulty walking.The Resident Care Card dated 5/1/2025 directed to assist or feed Resident #1 at mealtimes as needed, provide slow approach and cues while feeding, encourage Resident #1 to consume all fluids during meals, and if Resident #1 becomes combative or resistive, postpone care/activity and allow h/her time to regain composure, and redirect as necessary. Physician's orders dated 5/9/2025 directed to provide a regular dysphagia puree texture diet with nectar thick liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had short-term and long-term memory impairment, severely impaired cognitive skills for daily decision making, was frequently incontinent of bowel and bladder, dependent on staff for all ADLs including eating, bed mobility, and transfers, was non ambulatory and dependent on staff for mobility in the wheelchair.The Resident Care Plan (RCP) dated 5/30/2025 identified Resident #1 was at risk for a decreased ability to perform ADLs. Interventions directed to provide assistance for eating as needed, provide slow approach and cues while feeding, Resident #1 could be resistive to care at times and nursing staff should re-approach Resident #1 for breakfast and dinner after 1st attempt. Review of the documentation survey report dated 6/3/2025 for the 7:00 A.M. to 3:00 P.M. shift identified NA #1 signed off the eating task at 8:00 A.M. and at 12:00 P.M. indicating the tasks were completed. Interview with Person #1 on 6/27/2025 identified video footage dated 6/3/2025 at approximately 9:30 A.M. identified Resident #1 being fed breakfast by NA #1. Person #1 gave consent for the video footage to be viewed by facility staff. Interview and review of the video footage on 6/27/2025 at 9:50 A.M. with the Director of Nursing (DNS), Administrator, RN #1 (regional nurse), and RN #4 (Regional Director of Clinical) identified during the breakfast meal NA #1 was sitting in a chair spoon feeding Resident #1, and as NA #1 puts the spoon towards Resident #1's mouth, Resident #1 put h/her hands up in attempt to block h/her face. NA #1 moved Resident #1's hands away and proceeded to place a spoonful of oatmeal into Resident #1's mouth. NA #1 stood up with the spoon still in the Resident #1's mouth while pushing the spoon further into Resident #1's mouth causing Resident #1's head to jerk to the right. NA #1 stated to Resident #1 stop kicking, I am done, although in the video footage, Resident #1 was not kicking. NA #1 then threw the spoon on the meal tray, placed the plastic cover on the oatmeal, and left the room. The DNS identified that when NA #1 started to feed Resident #1 and Resident #1 put h/her hands up, NA #1 should have stopped feeding Resident #1, tried to redirect Resident #1, gave Resident #1 time, and then reapproached Resident #1. An interview with RN #1 (regional nurse) on 6/27/2025 at 11:01 A.M. identified that based on the video footage dated 6/3/2025, NA #1's actions toward Resident #1 could not be rebutted. RN #1 indicated NA #1 would be terminated for mistreating Resident #1. Subsequent to viewing the video footage dated 6/3/2025 the DNS and Administrator identified they would initiate a class B accident and incident report with an event type of staff to resident abuse without injury and NA #1 was suspended pending the outcome of the investigation. Although attempted, interviews with LPN #1 and NA #1 were not obtained. Review of facility Abuse, Neglect, and Exploitation policy dated 7/1/2024; in part, identified the facility will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, abuse means the willful infliction of injury, intimidation resulting in physical harm, pain or mental anguish which can include staff to resident abuse, and employees receive annual training through planned in-services and as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure interventions were implemented for a resident who is dependent on staff for eating. The findings include:Resident #1 had diagnoses that included dementia, dysphagia oropharyngeal phase, mood disorder, lack of coordination, and difficulty waking.The Kardex Report dated 5/1/2025 directed to assist or feed Resident #1 at mealtimes as needed, provide slow approach and cues while feeding, encourage Resident #1 to consume all fluids during meals, and if Resident #1 becomes combative or resistive, postpone care/activity and allow h/her time to regain composure, and redirect as necessary. The physician's orders dated 5/9/2025 directed to provide a regular dysphagia puree texture diet with nectar thick liquids. The quarterly [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had short-term and long-term memory impairment (not capable of completing a brief interview for mental status exam), severely impaired cognitive skills for daily decision making, was frequently incontinent of bowel and bladder, dependent on staff for all ADLs, including eating, bed mobility, and transfers, was non ambulatory and dependent on staff for mobility in the wheelchair.The Resident Care Plan dated 5/30/2025 identified Resident #1 at risk for decreased ability to perform ADLs. Interventions directed to provide assist for eating as needed, provide slow approach and cues while feeding, Resident #1 can be resistive at care at times, nursing should re-approach Resident #1 for breakfast and dinner after 1st attempt. Interview and review of the video footage on 6/27/2025 at 9:50 A.M. with the Director of Nursing (DNS), Administrator, Registered Nurse (RN#1 regional nurse), and RN #4 (Regional Director of Clinical) identified the date of the video was 6/3/2025 which showed NA #1 sitting in a chair feeding Resident #1 with a spoon as NA #1 puts the spoon towards Resident #1's mouth Resident #1 put h/her hands up in attempt to block h/her face, NA #1 moved Resident #1's hands away, proceeded to place a spoonful of oatmeal into Resident #1's mouth, NA #1 stood up with the spoon still in the Resident #1's mouth pushing the spoon further into Resident #1's mouth causing Resident #1's head to jerk to the right NA #1 stated to Resident #1 stop kicking I am done, although in the video footage Resident #1 was not kicking, NA #1 then throws the spoon on the meal tray, places the plastic cover on the oatmeal, and leaves the room. The DNS identified on 6/3/2025 when NA #1 started to feed Resident #1 the resident put h/her hands up NA #1 should have stopped feeding Resident #1, tried to redirect Resident #1, and gave Resident #1 time, and then reapproached Resident #1. Although attempted, interviews with LPN #1 and NA #1 were not obtained. Review of the facility Comprehensive Care plan policy dated 4/1/2025; in part, identified the facility will develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental psychosocial needs to meet professional standards of quality.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for a fall, the facility failed to ensure the hallway was free of environmental hazards to prevent a resident from tripping which resulted in the resident falling and sustaining a laceration to the lip. The findings include: Resident #1's diagnoses included Alzheimer's Disease and abnormal gait and mobility. The physical therapy discharge summary dated 7/13/24 identified Resident #1 was independent with transfers and ambulating. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was unable to complete the Brief Interview for Mental Status indicating poor memory recall and was independent with transfers and ambulating. The Resident Care Plan dated 10/22/24 identified Resident #1 was at risk for falls due to dementia. Interventions directed to keep areas clutter free and provide handheld assistance of one (1) when redirecting. The nurse's note dated 1/14/25 at 1:45 PM identified the Unit Manager, Registered Nurse (RN) #1, assessed Resident #1 in response to a staff member's observation at 11:30 AM on 1/14/25 of Resident #1 tripping on a cord in the hallway and falling forward. The note identified Resident #1 had a moderate amount of bleeding from the inner lower lip and gums which stopped when pressure was applied. The Advanced Practice Registered Nurse (APRN) was present to assess Resident #1 and directed to transfer Resident #1 to the Emergency Department (ED) for further evaluation and treatment. The nurse's note dated 1/16/25 at 3:30 PM identified Resident #1 returned to the facility with three (3) dissolvable sutures to the inner lip, a CT scan of the head and spine and an x-ray of the pelvis and bilateral femurs were conducted and were negative and a physical therapy evaluation was ordered. The hospital record dated 1/16/25 identified Resident #1's lower lip laceration measured two (2) centimeters (cm) long by three (3) cm deep and was repaired with three (3) sutures and a physical therapy evaluation identified Resident #1 initially ambulated with handheld assistance and then progressed to stand by assist only. Review of the summary report dated 1/17/25 indicated on 1/14/25 a 7AM-3PM nurse aide witnessed Resident #1 ambulating independently in the hallway and although there were caution signs placed around the electrical cord Resident #1 tripped over the cord falling forward. Interview with the Unit Manager, RN #1, on 2/4/25 at 11:40 AM identified she responded when Resident #1 had fallen on 1/14/25. RN #1 identified she noted there were four (4) wet floor caution signs placed in the hallway, an electrical cord was running across the hall in the vicinity of where Resident #1 fell and housekeeping staff (Housekeeper #1) was in the vicinity of the area. RN #1 identified Resident #1 was independent with ambulating and staff would hold Resident #1's hand if the resident needed redirection. Interview with the housekeeper, Housekeeper #1, on 2/4/25 at 12:15 PM identified on 1/14/25 he was buffing individual resident rooms and had plugged the cord to the machine in a hallway outlet, he had placed four (4) wet floor signs in the hallway and was going back and forth across the hall to the different rooms. Housekeeper #1 indicated the electrical cord was running across the hallway and when he was in one of the rooms, he heard one of the signs fall, he proceeded to go out into the hall and found Resident #1 lying on the ground. Housekeeper #1 indicated going forward the cord will be plugged in an outlet in the individual resident rooms. An interview with the Director of Housekeeping on 2/4/25 at 12:20 PM identified the facility safety policy for floor cleaning directed to keep machines that are required to be plugged into an outlet on the side of the hallway the staff is working on to prevent a tripping hazard. The Director of Housekeeping indicated Resident #1 tripped and fell over the cord because the cord was running across the hall. The Director of Housekeeping identified she provided an in-service to staff on 6/11/24 on this topic and Housekeeper #1 was present at that in-service. Review of facility policy for Floor Care identified, in part, not to stretch any equipment cords across any open common areas in a manner that creates an unnecessary trip hazard.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure assistance was provided in accordance with the resident plan of care. The findings include: Resident #1's diagnoses included dementia, osteoarthritis and osteoporosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment and required total care for ADLs. The Resident Care Plan (RCP) dated 11/15/2024 identified Resident #1 required assistance with ADLs. Interventions directed two (2) staff to assist with bed mobility. The nurse aide care card/Kardex dated 11/26/2024 directed Resident #1 required assist of two (2) for bed mobility. Facility incident report dated 11/30/2024 at 7 AM identified Resident #1 required two (2) staff assist for bed mobility. The report indicated on 11/29/2024 at 10:15 PM Resident #1 was noted with facial grimacing with new orders obtained for a right shoulder x-ray. X-ray results identified a right subcoracoid dislocation of the humeral head. Review of facility Summary Report dated 12/5/2024 identified Resident #1 required two (2) staff for bed mobility and Hoyer lift transfers, used a wheelchair and was unable to self-propel, had no falls, and was unable to verbalize what occurred due to his/her cognition. Resident #1 was identified on 1/27/2024 to have right shoulder pain, and x-ray results identified a dislocation of the right shoulder. Interview and review of facility documentation on 12/23/2024 at 11:32 AM with NA #6 identified that Resident #1 was on her assignment on the 11 PM to 7 AM shift on 11/26/2024 (three days before the dislocation was identified). NA #6 indicated that Resident #1 said ow briefly when she turned the resident in bed, and she indicated that Resident #1 did that as a routine behavior at times. NA #1 further indicated that she provided care to Resident #1 without the assistance of a second staff member. NA #6 stated she was aware that Resident #1's aide care card/Kardex directed two (2) staff assist for bed mobility, and stated there was only one aide on the 11 PM to 7 AM shift on that unit; she had no second NA to assist her. Interview on 12/23/2024 at 12:16 PM with LPN #5 indicated he worked the 11 PM to 7 AM shift on 11/26/2024 and Resident #1 was his resident. LPN #5 stated he did not assist NA #6 with any care or repositioning, and he was not aware of any reports of pain or discomfort - none were reported by NA #6 regarding Resident #1. Interview, clinical record review and facility documentation review with the DNS on 12/23/2024 at 12:33 PM identified when NA #6 was interviewed, NA #6 did not indicate any new complaints. Further, ow was typical verbalization for the resident and he/she is care planned for alteration in comfort. The DNS further stated that there should have been two (2) staff members assisting with bed mobility as directed per Resident #1's care card/Kardex on 11/26/2024 when NA #6 provided Resident #1's care alone on the 11 PM to 7 AM shift. Review of facility Care Plan, Comprehensive Person-Centered Policy directed in part, the comprehensive, person-centered care plan will describe the services that are to be furnished to the resident.

Based on clinical record reviews, observation, facility documentation, facility policy and interviews for 2 of 6 sampled residents (Resident #76) reviewed for abuse, the facility failed to ensure a resident was free from physical mistreatment by another resident (Resident #139) and for Resident # 122 , the facility failed to ensure the resident was free from physical abuse by Resident # 10. The findings included: 1. Resident #76's diagnoses included Alzheimer's disease and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #76 as severely cognitively impaired, required assistance with activities of daily living (ADL), and was independent with ambulation. The Resident Care Plan (RCP) dated 7/1/24 identified Resident #76 at risk for elopement, wandering/pacing and tended to ambulate quickly. Interventions directed to reside on a secured unit and, redirect near exits/doorways and encourage resident to slow down when ambulating. 2. Resident #139's diagnoses that included Alzheimer's disease, depression and aphasia. The quarterly MDS assessment dated [DATE] identified Resident #139 required assistance with Activities of Daily Living ( ADL) skills and was independent with ambulation. The RCP dated 7/22/24 identified Resident #139 exhibited wandering behaviors, had the potential to exhibit physical behaviors such as biting, aggression, grabbing related to dementia and had a history of past resident mistreatment. Interventions directed to divert to alternate activities, redirect from peers if observed to be agitated and ambulating in the hallway. An observation on 9/17/24 at 2:07 PM identified Resident #139 pacing up and down the halls on a secured memory care unit. Resident #139 went into a resident room that two residents were occupying at the time and where s/he did not reside. Nurse Aide, NA #4 who was standing just outside the dining common area, immediately attempted to redirect Resident #139 out of the room who was initially resistive but eventually exited into the hallway. Resident #139 then grabbed a hair product from NA #4's hand and threw it on the floor before continuing to quickly resume pacing down the hall. NA #4 then returned to the dining/common area and stood just outside the door. At 2:15 PM Resident #139 was observed pacing the hallway along with other residents that included Resident #76. Both Resident #76 and Resident #139 were ambulating in the same direction down the hall walking past the medication cart at the same time. NA #4 stated, S/he (Resident #139) just hit (Resident #76) in the back!. Registered Nurse, RN #5, who was with the medication cart at the time immediately directed staff to take Resident #76 to her/his room, called for assistance and remained with Resident #139. A facility Reportable Event dated 9/17/24 at 3:41 PM on 9/17/24 at 2:15 PM identified staff, (NA #4) reported observing Resident #139 hit Resident #76 in the back while walking by in the hallway on unit. Staff immediately intervened and separated both residents. Both residents were ambulating independently in the hallway on unit. Resident #139 was immediately placed on 1:1 observation. The physician, family and local police were notified. A body audit was completed for Resident #76 no injury noted. An interview with RN #5 on 9/18/24 10:16 AM identified she was administering medications when she observed Resident #139 walk up to Resident #76 and then walk side by side. RN #5 looked away momentarily and then heard NA #4 say Resident #76 was hit in the back by Resident #139. RN #5 immediately separated the two residents, called for another nurse and initiate 1:1 supervision for Resident #139. RN #5 further identified Resident #139, had aphasia, any speech was disorganized, and staff had to anticipate her/his needs. Resident #139 was agitated earlier in the shift before lunch, ambulating quickly in the hall. RN #5 called in Resident #139's family member who came to the facility to assist and bring her/his outside and Resident #139 seemed calm when returning to the unit. RN #5 identified she was not aware Resident #139 was agitated and was throwing objects just prior to the event and would have had staff well known to Resident #139 intervene or provided a medication used as needed for agitation. An interview with NA #4 on 9/18/24 11:00 AM identified she was routinely assigned to the unit and was familiar with Resident #139's behavior. NA #4 identified minutes before the incident, Resident #139 was observed entering another resident(s) room and was redirected out. Resident #139 was agitated and grabbed a hair product NA #4 was holding and threw it on the floor before continuing down the hall. NA #4 identified that when Resident #139 begins throwing things, she notifies the nurse but did not during this occasion as the nurse was nearby and NA #4 thought she would have observed the incident. NA #4 identified minutes later, Resident #139 was ambulating down the hall behind, and then alongside Resident #76 who both were walking around the medication cart. Resident #139 hit Resident #76 in the back before continuing down the hall. RN #5 intervened and separated the residents. NA #4 further identified that although Resident #139 had previously been the alleged aggressor in a previous resident to resident altercation, s/he did not normally attack other residents. An interview with the Director of Nursing Services, DNS on 9/18/24 at 12:18 PM identified Resident #139 was involved in a separate resident to resident altercation where s/he was the aggressor and had difficulty being redirected at times when agitated. Resident #139's family member was occasionally called in to assist by removing Resident #139 from the unit which had been effective in the past. The DNS identified she would expect staff to inform the nurse right away if efforts to redirect were ineffective and expect that residents be free from any mistreatment. A review of the facility policy for Abuse given during the survey for the incident directs the facility to provide protections for the health welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation including physical abuse. 3. Resident #122's diagnoses included dementia, anxiety, and depression. The admission MDS assessment dated [DATE] identified Resident #122 as severely cognitively impaired and exhibited wandering behaviors. Additionally, the MDS assessment noted wandering behavior that significantly intruded on privacy or activities of others. A care plan dated 9/24/2023 identified Resident #122 had the potential to exhibit behaviors such as entering others' rooms, making beds, and attempting to help residents. Interventions included: to provide activities to keep the resident occupied, such as a cleaning kit, a duster, and items to fold and sort. An Accident and Incident (A&I) Report dated 6/13/2023 indicated Resident #122 was in the hallway by a rest bench. Resident #122 was observed by NA # 14 holding on to Resident #10's wheelchair. Resident #10 turned around, held Resident #122's right hand, and bit Resident #122's right forearm. A nursing note dated 6/13/2023 identified Resident #122 was bitten on the right forearm by Resident # 10 and both residents were immediately separated. A care plan dated 6/16/2023 identified Resident #122 as a recipient of a resident-resident altercation and at risk for mood alteration. Interventions included redirecting the resident away from other residents when seen wandering in the hallway and gently guiding the resident away from potential conflict. An A&I Report dated 6/25/2023 identified staff observed Resident #10 on top of Resident #122 on the floor in the doorway of Resident #10's room. The A&I also indicated Resident #10 reported to staff Resident #122 had come into Resident #10's room and refused to leave. Resident #10 indicated s/he then hit Resident #122 when the resident refused to leave. A nursing note dated 6/25/2023 indicated Resident #122 was knocked down by Resident #10 and developed a bruise on the right forearm. The note also indicated Resident #122 did not remember what happened. 4. Resident #10's diagnoses included dementia, schizoaffective disorder, and impulse disorder. The MDS assessment dated [DATE] indicated Resident #10 with moderate cognitive impairment and noted the resident did not exhibit physical or verbal behaviors directed toward others. A nursing note dated 6/13/2024 indicated that Resident #10 bit Resident #122 on the right arm after Resident #122 touched Resident #10 on the arm. A psychiatric evaluation dated 6/15/2023 identified the resident was oriented to self, place, and time. The evaluation further indicated facility staff had reported that Resident #10 had bitten their peer when the peer entered Resident #10's room. Additionally, the evaluation indicated the resident expressed frustration with fell ow residents on the nursing unit. The evaluation also identified the resident was easily frustrated by dementia-associated behaviors. A nursing note dated 6/25/2023 indicated Resident #122 walked by Resident #10's room. The nursing notes further indicated Resident #10 transferred from the bed to a wheelchair, rolled over to the doorway, got out of the wheelchair, and jumped on Resident #122, knocking both to the ground. On 9/17/2024 at 1:21 PM an interview with NA #2 identified s/he could not recall the 6/13/2023 or 6/25/2023 incidents. NA #2 indicated Resident #122 walked around the unit going into other residents' rooms and making the beds. NA #2 also indicated many residents would attempt to go to Resident #10's room, but as soon as a resident was in the doorway, Resident #10 would tell them to go away. In an interview on 9/18/2024 at 11:28 AM, NA #1 indicated she could not recall the details of the incident on 6/25/2023 but indicated Resident #122 liked going into other residents' rooms to fold clothes. NA #1 identified Resident #10 was oriented and made her/his needs known in 2023. NA #1 indicated Resident #10 may have complained about residents going into his/her room and thought that was why Resident #10 was in a private room. NA #1 further indicated there were no stop signs in use for Resident #10's room at the time of the incident. On 9/18/2024 at 11:59 AM, an interview with the Director of Nursing Services (DNS) indicated the incident on 6/25/2023 occurred at the doorway of Resident #10's room; the DNS indicated that when the residents were found, they were half in the hallway and half in the room. The DNS indicated stop signs used to deter wandering residents were not in use at the time because Resident #122 would remove the signs and still go into other residents' room. The facility believed supervising and redirecting Resident #122 was the most effective intervention. The DNS also indicated the incident occurred at 2:14 PM, which is close to the change of shift, and that staff did not witness the incident because staff were probably in other rooms providing care. 48880

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure a comprehensive care plan was developed timely for a resident with dysphagia and who required staff assistance with meals, which resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with behavioral disturbance (impaired ability to think with behaviors). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, had no swallowing disorder, and required total assistance with eating. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 required assistance/was dependent for ADL care related to cognitive loss from dementia. Interventions directed to assist with feeding. The RCP note dated [DATE] identified Resident #1 required some assistance and cueing with eating, was pocketing some food, was seen by Speech Therapy and the diet was changed to Dysphagia Advanced diet. The Speech Therapy (ST) Evaluation dated [DATE] identified Resident #1 was previously on a regular diet. Resident #1 presented with mild oropharyngeal phase dysphagia (difficulty swallowing), characterized by increased oral phase of swallow with dysphagia advanced solid foods, lingual (near the tongue) residue post swallowing which required an extended time to clear the food, and had a decreased attention to task. The evaluation further identified Resident #1 demonstrated poor insight into deficits (stated had no difficulty with current diet), and desired to return to regular solids, despite education provided. Resident #1 demonstrated holding food in his/her mouth/cheeks or had residual food in his/her mouth after meals. Review of ST Treatment Encounter Note dated [DATE] identified nursing reported the resident pocketing and coughing with a hot dog at meal time. Resident #1 had difficulty consuming a hot dog and had shoveling-like behavior resulting in the inability to clear a food bolus (small round mass of food), had a recent decrease in function, was unable to self-feed and currently required total staff assistance for meals/eating. Review of MD #1 Progress Note dated [DATE] identified Resident #1 had bilateral hand contractures and recent discontinuation of splints. The resident had an overall decline in her/his dementia and required to be fed by staff. The ST Discharge Summary and note dated [DATE] identified Resident #1 tolerated a regular diet with use of strategies that directed to alternate solid and liquid foods, a small bolus, use a slow rate and upright position for eating, and direct feeding assistance. Staff training was provided for carryover of strategies. Further review identified Resident #1 required supervision and assistance due to swallowing safety at mealtime. The NA Bedside Kardex Report dated [DATE] directed staff to assist the resident with feeding. A physician's order dated [DATE] directed regular texture diet. Review of facility incident report dated [DATE] at 8:50 AM identified Resident #1 was observed unresponsive, no apical pulse and no respirations (cessation of breath). Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. Review of Emergency Medical Services (EMS) Prehospital Care Report dated [DATE] identified Emergency Management Team (EMTs) arrived in Resident #1's room on [DATE] at 9:03 AM and staff were providing chest compressions with a bag valve mask (BMV) for ventilations (breathing). The report indicated, per staff, Resident #1 was given food by a NA in the morning at approximately 8:45 AM, then the NA left the room and returned approximately 5 minutes later to find the resident unresponsive and not breathing. CPR was initiated and 911 was called. Upon direct laryngoscopy by EMS, a foreign object was noted in Resident #1's oropharynx. The object was retrieved using [NAME] forceps and was found to be approximately a 1-inch piece of sausage, which the NA stated she fed Resident #1. CPR was continued and the resident received additional doses of Epi with no change, unable to revive pulse and respiration. Further review identified that Medical Control was consulted via triage call, resuscitation was ceased, and Resident #1's death was pronounced at 9:28 AM. Record review and facility documentation review identified NA #1 did not remain with Resident #1 during the meal to supervise chewing and swallowing. Interview with the DON on [DATE] at 9:50 AM identified that NA #1 should have stayed with Resident #1 during the meal on [DATE] to ensure that Resident #1 was safe, without aspiration or choking while eating. Interview with NA #1 on [DATE] at 10:55 AM identified that on [DATE], Resident #1 was sitting in her/his bed for breakfast with head of bed elevated and NA #1 cut a sausage link into three pieces. NA #1 indicated she fed Resident #1 two (2) pieces of the sausage (separately) and did not give Resident #1 anything to drink in the pieces of meat. Then, NA #1 put a third piece of sausage into the Resident #1's mouth and left the room before the resident chewed and swallowed the food. NA #1 explained that it took Resident #1 too long to chew her/his food and she wanted to give Resident #1 time to chew, so she went to serve a breakfast tray to another resident. NA #1 returned to the room approximately five (5) minutes later and noticed Resident #1 was pale and was leaning to one side in her/his bed. NA #1 further indicated Resident #1 took one or two breaths, stopped breathing, was not responding and she called for help. NA #1 further identified that she was unaware Resident was to be supervised for meals and required to alternate solid food and liquids. NA #1 identified that NA Bedside Kardex Report (NA care card) directed only to assist the resident with feeding and no feeding strategies or directions to supervise were identified. Interview with Speech-Language Pathologist (SLP #1) on [DATE] at 12:30 PM identified Resident #1 required direct assist during meals, and staff was to stay with Resident #1 during the entire meal to ensure safety. SLP #1 indicated staff feeding Resident #1 were responsible to provide a drink of thin liquids after each solid food bite and liquids should have been alternating through the meal, otherwise there was a risk of some food remaining in Resident #1's mouth, which caused a potential for aspiration and/or choking. SLP #1 indicated she provided education verbally to a nurse regarding the precautions and strategies required for Resident #1 to eat safety. Interview with APRN #1 on [DATE] at 3:30 PM identified recommendations related strategies for safe eating provided by SLP #1 should have been implemented, and staff should had stayed with Resident #1 during the meal. Interview with RN #4 on [DATE] at 4:30 PM identified when SLP #1 notified nursing of the new feeding interventions for Resident #1, nursing staff were responsible to update the resident's care plan and NA Bedside Kardex Report with the new directions. Review of facility Person Center Care Plan Policy directed in part; a comprehensive person-center care plan must be developed for each patient and must be customized to each individual patient's preferences and needs.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff education was provided timely for a resident at risk of aspiration when discharged from Speech Therapy, which resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with behavioral disturbance (impaired ability to think with behaviors). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, had no swallowing disorder, and required total assistance with eating. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 required assistance/was dependent for ADL care related to cognitive loss from dementia. Interventions directed to assist with feeding. The RCP note dated [DATE] identified Resident #1 required some assistance and cueing with eating, was pocketing some food, was seen by Speech Therapy and the diet (texture) was changed to Dysphagia Advanced. The Speech Therapy (ST) Evaluation dated [DATE] identified Resident #1 was previously on a regular diet. Resident #1 presented with mild oropharyngeal phase dysphagia (difficulty swallowing), characterized by increased oral phase of swallow with dysphagia advanced solid foods, lingual (near the tongue) residue post swallowing which required an extended time to clear the food, and had a decreased attention to task. The evaluation further identified Resident #1 demonstrated poor insight into deficits (stated had no difficulty with current diet), and desired to return to regular solids, despite education provided. Resident #1 demonstrated holding food in his/her mouth/cheeks or had residual food in his/her mouth after meals. Review of ST Treatment Encounter Note dated [DATE] identified nursing reported the resident pocketing and coughing with a hot dog meal. Resident #1 had difficulty consuming a hot dog and had shoveling-like behavior resulting in the inability to clear a food bolus (small round mass of food), had a recent decrease in function, was unable to self-feed and currently required total staff assistance for meals/eating. Review of MD #1 Progress Note dated [DATE] identified Resident #1 had bilateral hand contractures and recent discontinuation of splints. The resident had an overall decline in her/his dementia and required to be fed by staff. The ST Discharge Summary and note dated [DATE] identified Resident #1 tolerated a regular diet with use of strategies that directed to alternate solid and liquid foods, a small bolus, use a slow rate and upright position for eating, and direct feeding assistance. Staff training was provided for carryover of strategies. Further review identified Resident #1 required supervision and assistance due to swallowing safety at mealtime. The NA Bedside Kardex Report dated [DATE] directed staff to assist the resident with feeding. A physician's order dated [DATE] directed regular texture diet. Review of facility incident report dated [DATE] at 8:50 AM identified Resident #1 was observed unresponsive, no apical pulse and no respirations (cessation of breath). Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. Review of Emergency Medical Services (EMS) Prehospital Care Report dated [DATE] identified Emergency Management Team (EMTs) arrived in Resident #1's room on [DATE] at 9:03 AM and staff were providing chest compressions with a bag valve mask (BMV) for ventilations (breathing). The report indicated, per staff, Resident #1 was given food by a NA in the morning at approximately 8:45 AM, then the NA left the room and returned approximately 5 minutes later to find the resident unresponsive and not breathing. CPR was initiated and 911 was called. Upon direct laryngoscopy by EMS, a foreign object was noted in Resident #1's oropharynx. The object was retrieved using [NAME] forceps and was found to be approximately a 1-inch piece of sausage, which the NA stated she fed Resident #1. CPR was continued and the resident received additional doses of Epi with no change, unable to revive pulse and respiration. Further review identified that Medical Control was consulted via triage call, resuscitation was ceased, and Resident #1's death was pronounced at 9:28 AM. Record review and facility documentation review identified NA #1 did not remain with Resident #1 during the meal to supervise chewing and swallowing. Interview with the DON on [DATE] at 9:50 AM identified she was unable to provide documentation that the staff providing care for Resident #1 were provided education regarding Speech Therapy recommendations. The DON indicated the nursing staff should have been provided with education regarding Speech Therapy recommendations for feeding Resident #1, and she did not know why it was not done. Interview with NA #1 on [DATE] at 10:55 AM identified that on [DATE], Resident #1 was sitting in her/his bed for breakfast with head of bed elevated and NA #1 cut a sausage link into three pieces. NA #1 indicated she fed Resident #1 two (2) pieces of the sausage (separately) and did not give Resident #1 anything to drink in the pieces of meat. Then, NA #1 put a third piece of sausage into the Resident #1's mouth and left the room before the resident chewed and swallowed the food. NA #1 explained that it took Resident #1 too long to chew her/his food and she wanted to give Resident #1 time to chew, so she left the room and went to serve a breakfast tray to another resident. NA #1 returned to the room approximately five (5) minutes later and noticed Resident #1 was pale and was leaning to one side in her/his bed. NA #1 further indicated Resident #1 took one or two breaths, stopped breathing, was not responding and she called for help. NA #1 further identified that she was unaware Resident was to be supervised for meals and required to alternate solid food and liquids. NA #1 identified that NA Bedside Kardex Report (NA care card) directed only to assist the resident with feeding and no feeding strategies or directions to supervise were identified. Interview with Speech-Language Pathologist (SLP #1) on [DATE] at 12:30 PM identified Resident #1 required direct assist during meals, and staff was to stay with Resident #1 during the entire meal to ensure safety. SLP #1 indicated staff feeding Resident #1 were responsible to provide a drink of thin liquids after each solid food bite and liquids should have been alternating through the meal, otherwise there was a risk of some food remaining in Resident #1's mouth, which caused a potential for aspiration and/or choking. SLP #1 indicated Resident #1 had oropharyngeal phase dysphagia, required dysphagia precautions, and was not safe to eat unsupervised. SLP #1 further indicated the precautions and specific strategies to prevent aspiration and choking were communicated verbally to a nurse at the time of discharge from ST therapy. SLP #1 further identified that she was not aware of any other way to communicate her recommendations to staff to be implemented other than verbal communication while at the facility. Interview with APRN #1 on [DATE] at 3:30 PM identified recommendations related strategies for safe eating provided by SLP #1 should have been implemented, and staff should had stayed with Resident #1 during the meal. Interview with RN #4 on [DATE] at 4:30 PM identified when SLP #1 notified nursing of the new feeding interventions for Resident #1, nursing staff were responsible to update the resident's care plan and NA Bedside Kardex Report with the new directions, and he did not know why it was not done. RN #4 further indicated therapy staff were responsible to communicate all recommendations to nursing staff and nursing was responsible to update the resident's care plan and NA Bedside Kardex Report with new directions, and the information should be shared with nursing staff during shift reports. Clinical record review, facility documentation review and interviews failed to identify Speech Therapy recommendations were acted upon by facility staff timely. In addition, the facility was unable to provide documentation the recommendations were communicated to staff that provide care for Resident #1. Review of facility Person Center Care Plan Policy directed in part, Care Plans will be communicated to appropriate staff, patient, resident representative, family. The Policy further directed the care plan will be reviewed and revised as needed to reflect changing resident needs. Review of facility documentation identified on [DATE] the facility provided education for nursing staff related to feeding residents and directed staff to remain with a resident who was a total feed until all food items were swallowed (not to leave when the resident had food in their mouth). The facility completed an audit, identified thirty-four residents that required assistance with eating and four residents that required total feeding and were at risk for choking and/or aspiration, and ensured that staff was supervising and assisting as required. Further, on [DATE], the facility completed audits of staff feeding residents.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision was provided for a resident with dysphagia and who required staff assistance with meals. The resident was left unattended during a meal and was found unresponsive. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with behavioral disturbance (impaired ability to think with behaviors). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, had no swallowing disorder, and required total assistance with eating. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 required assistance/was dependent for ADL care related to cognitive loss from dementia. Interventions directed to assist with feeding. The RCP note dated [DATE] identified Resident #1 required some assistance and cueing with eating, was pocketing some food, was seen by Speech Therapy and the diet was changed to Dysphagia Advanced. The Speech Therapy (ST) Evaluation dated [DATE] identified Resident #1 was previously on a regular diet. Resident #1 presented with mild oropharyngeal phase dysphagia (difficulty swallowing), characterized by increased oral phase of swallow with dysphagia advanced solid foods, lingual (near the tongue) residue post swallowing which required an extended time to clear the food, and had a decreased attention to task. The evaluation further identified Resident #1 demonstrated poor insight into deficits (stated had no difficulty with current diet), and desired to return to regular solids, despite education provided. Resident #1 demonstrated holding food in his/her mouth/cheeks or had residual food in his/her mouth after meals. Review of ST Treatment Encounter Note dated [DATE] identified nursing reported the resident pocketing and coughing with a hot dog meal. Resident #1 had difficulty consuming a hot dog and had shoveling-like behavior resulting in the inability to clear a food bolus (small round mass of food), had a recent decrease in function, was unable to self-feed and currently required total staff assistance for meals/eating. Review of MD #1 Progress Note dated [DATE] identified Resident #1 had bilateral hand contractures and recent discontinuation of splints. The resident had an overall decline in her/his dementia and required to be fed by staff. The ST Discharge Summary and note dated [DATE] identified Resident #1 tolerated a regular diet with use of strategies that directed to alternate solid and liquid foods, a small bolus, use a slow rate and upright position for eating, and direct feeding assistance. Staff training was provided for carryover of strategies. Further review identified Resident #1 required supervision and assistance due to swallowing safety at mealtime. The NA Bedside Kardex Report dated [DATE] directed staff to assist the resident with feeding. A physician's order dated [DATE] directed regular texture diet. Review of facility incident report dated [DATE] at 8:50 AM identified Resident #1 was observed unresponsive, no apical pulse and no respirations (cessation of breath). Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. Review of Emergency Medical Services (EMS) Prehospital Care Report dated [DATE] identified Emergency Management Team (EMTs) arrived in Resident #1's room on [DATE] at 9:03 AM and staff were providing chest compressions with a bag valve mask (BMV) for ventilations (breathing). The report indicated, per staff, Resident #1 was given food by a NA in the morning at approximately 8:45 AM, then the NA left the room and returned approximately 5 minutes later to find the resident unresponsive and not breathing. CPR was initiated and 911 was called. Upon direct laryngoscopy by EMS, a foreign object was noted in Resident #1's oropharynx. The object was retrieved using [NAME] forceps and was found to be approximately a 1-inch piece of sausage, which the NA stated she fed Resident #1. CPR was continued and the resident received additional doses of Epi with no change, unable to revive pulse and respiration. Further review identified that Medical Control was consulted via triage call, resuscitation was ceased, and Resident #1's death was pronounced at 9:28 AM. Record review and facility documentation review identified NA #1 did not remain with Resident #1 during the meal to supervise chewing and swallowing. Interview with the DON on [DATE] at 9:50 AM identified that NA #1 should have stayed with Resident #1 during the meal to ensure that Resident #1 was safe, without aspiration or choking while eating. Interview with NA #1 on [DATE] at 10:55 AM identified that on [DATE], Resident #1 was sitting in her/his bed for breakfast with head of bed elevated and NA #1 cut a sausage link into three pieces. NA #1 indicated she fed Resident #1 two (2) pieces of the sausage (separately) and did not give Resident #1 anything to drink in the pieces of meat. Then, NA #1 put a third piece of sausage into the Resident #1's mouth and left the room before the resident chewed and swallowed the food. NA #1 explained that it took Resident #1 too long to chew her/his food and she wanted to give Resident #1 time to chew, so she left the room and went to serve a breakfast tray to another resident. NA #1 returned to the room approximately five (5) minutes later and noticed Resident #1 was pale and was leaning to one side in her/his bed. NA #1 further indicated Resident #1 took one or two breaths, stopped breathing, was not responding and she called for help. NA #1 further identified that she was unaware Resident was to be supervised for meals and required to alternate solid food and liquids. NA #1 identified that NA Bedside Kardex Report (NA care card) directed only to assist the resident with feeding and no feeding strategies or directions to supervise were identified. Interview with Speech-Language Pathologist (SLP #1) on [DATE] at 12:30 PM identified Resident #1 required direct assist during meals, and staff was to stay with Resident #1 during the entire meal to ensure safety. SLP #1 indicated staff feeding Resident #1 were responsible to provide a drink of thin liquids after each solid food bite and liquids should have been alternating through the meal, otherwise there was a risk of some food remaining in Resident #1's mouth, which caused a potential for aspiration and/or choking, and Resident #1 was not safe to eat without supervision. Interview with RN #1 on [DATE] at 1:15 PM identified, she responded to the code on [DATE]. RN #1 indicated Resident #1 was identified with no pulse and no respiration on [DATE] at breakfast time and CPR was initiated; staff were not aware at the time the code was called that Resident #1 had choked on food. RN #1 indicated she was squeezing the Ambu bag to provide ventilation (breaths) during CPR while other nurses were performing chest compressions. RN #1 indicated that she had a hard time to get air in and at first, she saw Resident #1's throat getting puffy but then the residents chest started rising slightly. RN #1 also repositioned Resident #1 ' s head multiple times while APRN #1 was holding the Ambu mask with both hands and indicated finally it seemed like some of the air was going in but not a full breath. Further interview identified NA #1 should not have walked away from Resident #1 during the meal, before Resident #1 swallowed the food in his/her mouth due to the risk for aspiration related to diagnosis of dysphagia. Review of facility Assistance with Meals Policy directed in part, residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example keeping interactions with other staff to a minimum while assisting residents with meals. Although requested, a facility policy related dysphagia precautions was not provided for surveyor review. Review of facility documentation identified staff education was provided on [DATE] (the day of the incident) regarding feeding residents meals and directed staff to remain with a resident who was a total feed until all food items were swallowed. The facility completed an audit, identified thirty-four residents that required assistance with eating and four residents that required total feeding and at risk for choking and/or aspiration and ensured that staff was supervising and assisting the residents as required. Further, on [DATE] the facility-initiated Clinical Competency Validations related to feeding residents and QA oversight of the education and audits was completed.

Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #127) who experienced a change in condition that required a hospitalization , the facility failed to ensure that readmission physician's orders were transcribed accurately resulting in the resident missing 12 doses of medications (6 days) and not receiving the accurate dosages of another medication culminating in the resident being re-hospitalized . These failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #127 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, chronic bronchitis, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, chronic kidney disease (stage 3) and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #127 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use and personal hygiene, was independent with eating, had no range of motion deficits, utilized a wheelchair and walker as mobility devices and received anticoagulant medication. The MDS further noted the resident's diagnoses included coronary artery disease, pulmonary embolism and respiratory failure. The care plan initiated in February of 2022 identified Resident #127 had impaired cognitive function related to dementia with interventions that included observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed A reportable event report dated 4/28/22 identified that upon Resident #127's re-admission to the facility on [DATE] the following medications were not transcribed into the electronic medical record and thus not included on the medication administration record (MAR): Eliquis, Metformin, and Metoprolol Tartrate and Prednisone was not transcribed properly. The report identified the event type as a medication error of clinical significance and noted the resident had been hospitalized on [DATE] and was expected to return to the facility on [DATE]. The hospital discharge summary dated 4/19/22 identified Resident #127 was admitted to the hospital on 4/15/22 for the chief complaint of shortness of breath (sudden onset of respiratory distress and change in mental status after receiving Rocephin (antibiotic) for cellulites. The discharge summary contained a medication list with all current and recommended medications. The list included an order for Prednisone (steroid) 20 mg by mouth every morning with breakfast for two days and then 10 mg by mouth for three days, Metformin (anti-diabetic medication) 500mg by mouth two times per day with meals, Metoprolol Tartrate (beta blocker used to treat high blood pressure, angina, heart failure and it may lower the risk of death after a heart attack) 25 mg by mouth every twelve hours and Eliquis (used to prevent serious blood clots from forming due to atrial fibrillation or surgery) 5mg twice per day. Review of the admission physician's orders located in the electronic medical record dated 4/19/22 failed to reflect that the orders for Metoprolol Tartrate, Metformin, and Eliquis were transcribed (entered into the electronic medical record system). Further review identified the order for Prednisone was entered incorrectly. The order was written as Prednisone 20mg once per day for three days then stop until 4/25/22 and Prednisone 10mg give two tablets by mouth one time per day for SOB (shortness of breath) for two days. Review of the medication administration record (MAR) for April identified Resident #127 was administered 20 mg of Prednisone on the 20, 21, 23, 24 and 25th. The MAR indicated that Prednisone was not administered on the 22nd. According to the hospital discharge summary Resident #127 should have received 10mg on April 22, 23 and 24th. The MAR did not contain the orders for the Metformin, Metoprolol Tartrate or the Eliquis resulting in the medications not being administered between 4/19/22 and 4/25/22. The nurse's note dated 4/19/22 at 6:11 PM written by RN #4 identified that Resident #127 arrived at the facility a little after 5:00 PM and medications were reviewed and verified with Physician #1. The nurse's note dated 4/21/22 at 3:51 PM identified Resident #127 was alert and confused per baseline. It further noted he/she was on 3 liters of oxygen via nasal cannula, lung sounds clear to auscultation, no cardiac or respiratory distress and no indication of pain or discomfort. The nurse's note dated 4/22/22 at 9:52 PM identified Resident #127 was on the 3rd day post readmission, denied pain, appetite good, blood pressure: 138/70, pulse: 76, respirations: 20, oxygen saturation level noted to be 98% on oxygen. The nurse's note dated 4/25/22 at 9:00 AM written by RN #5 identified Resident #127 had altered mental status with response to painful stimuli. The DNS was immediately notified, and a full body audit was completed. Vital signs were taken and reported to Physician #1 who ordered that the resident be sent to the hospital. The hospital discharge summary dated 4/29/22 identified that that the resident was admitted to the hospital on 4/25/22 with the chief complaint of unresponsiveness. It further noted the final diagnoses on discharge as acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation with lots of artifact, hypomagnesemia and hypokalemia likely diuresis related, history of bilateral pulmonary embolism with secondary hypercoagulable state on Eliquis, COPD on 2 to 3 liters admitted on 6 liters and back down to 3 liters, diabetes mellitus type 2, hypertension, hypothyroidism and dementia. The summary also noted that the resident had a moderate left pleural effusion. Further review of the discharge summary identified that during the hospital course the resident was diuresed with intravenous Lasix (diuretic) 40 mg twice daily for the heart failure. The resident was admitted to the telemetry unit. Interview on 5/10/22 at 9:30 AM with the DNS, Corporate Clinical Director and MDS nurse identified that during a record review the MDS nurse identified that the resident was not receiving Eliquis, which the resident had been taking prior to 4/19/22, this discrepancy prompted an overall medication review which resulted in the discovery that the Eliquis along with the Metformin and the Metoprolol Tartrate had been missed for 6 days for a total of 12 missed doses of each medication. The review also identified that the incorrect dose of Prednisone had been administered for three days with one missed dose (4/22/22). Interview on 5/11/2022 at 12:40 PM with RN# 5 identified that on 4/25/22 she greeted Resident #127 and the resident only opened his/her eyes when normally he/she would respond verbally. RN# 5 identified that she performed a mild sternal rub and the resident mildly groaned and turned away from the nurse. She further identified that since the resident is always engaging, she notified the DNS who assessed Resident #127, Physician #1 was notified, and an order given to send the resident to the hospital to be evaluated. The clinical hospital transfer form also completed by RN# 5 identified the resident's vital signs as follows, blood pressure 156/70, respirations 26, temperature 98.2, oxygen saturation 99% on 3liters of oxygen per minute, heart rate 50 and blood glucose level 134 mg/dl (levels of 80mg/dl to 130mg/dl is the normal range for a type 2 diabetic before the consumption of a meal). Interview on 5/11/2022 at 2:00 PM with RN #4 identified upon Resident #127's readmission on 4/19/22, she reviewed and verified the medication orders with Physician #1. RN #4 further identified that she worked 7:00 AM to 7:00 PM on 4/19/22 and although she confirmed the orders with Physician #1, she noted that the orders were electronically entered into the resident's electronic medical record by RN #7 (RN #7 worked 7:00 PM to 7:00 AM on 4/19/22). Interview on 5/11/2022 at 2:34 PM with Physician #1 identified that upon Resident #127's readmission to the facility, medications were approved as recommended by the hospital. He further noted that it was unfortunate that the resident had not received all of the ordered medications and was upset that the medication errors occurred. In addition, he indicated that he did not feel that the failure to administer the ordered medications for six days contributed to the resident being re-hospitalized on [DATE]. Physician #1 noted that the resident had a COPD exacerbation and the Metformin has been known to have a lasting effect, the resident's blood pressures were normal and there was no evidence of clotting. In addition, he acknowledged that Resident #127 was administered higher doses of Prednisone than he/she should have but also felt that this did not have an adverse effect on the resident. Physician #1 noted that any medications that are ordered should be administered. Interview on 5/11/2022 at 3:00 PM with the DNS identified that prior to the discovery of the medication errors/omissions, the facility did not have a policy in place that addressed the admission/readmission process but noted that the practice involves the orders being entered into the EMR and a chart check completed to confirm the orders. The DNS further identified that the unit manager/nursing supervisor or RN on duty on the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts perform the chart check. The DNS could not provide any documentation that a chart check had been performed for Resident #127 when he/she was readmitted to the facility on [DATE]. Interview on 5/12/2022 at 7:40 AM with RN #7 identified she could not recall entering the physician's orders into the EMR on the evening of 4/19/2022, but review of the electronic medical record identified that RN #7 entered the medications into the system. A second interview on 5/12/2022 at 12:55 PM with RN #4 identified that she utilized a cell phone to scan the discharge medication summary forms to Physician #1 and received a text message back from Physician #1 that read meds look good. In addition, RN #4 was able to indicate on her cell phone what she had sent to the physician and the message that he sent to her indicating an approval of the orders. A review of the scanned forms matched the discharge medication summary forms. Following the discovery of the medication errors, the facility initiated a new protocol dated 4/29/2022 that identified the following: * Upon admission and readmission, the discharge summary and W-10 will be compared for any discrepancies. If it is a readmission, the orders will also be compared to the resident's orders form the prior admission. All orders will then be reviewed with the MD or APRN with discrepancies noted and clarified and documented in a nurses note. * Once medications are reconciled and orders obtained, orders are to be transcribed into the point click care (PCC . electronic medical record system) and checked by a second nurse immediately following transcription. * The process is to be documented on the Admission Checklist * The admission Checklist will be completed for all new admissions/ readmissions and verified by a second nurse. * The resident's record will be reviewed again by Nursing Management and documented on the admission checklist. * When transcribing orders, be sure to verify the correct medication, dose, route and frequency as well as ensuring that it is transcribed into PCC in a manner that displays on the MAR or TAR (treatment administration record) and has a schedule A review of the facility's corrective action plan on 5/12/22 at 4:00 PM included a review of the records of all twelve residents admitted to the facility since 4/19/22. Licensed staff were educated and re-educated on the protocol to have two nurses review the medication reconciliation and transcription process for new admissions and readmissions with an administrative nurse performing a third check of the records. An audit of the newly admitted and readmitted resident records from 4/19/22 identified no other irregularities. The facility failed to ensure critical medications were transcribed correctly and administered to Resident #127 as ordered for a period of six days resulting in the omission of a total of 36 doses of the combined omitted medications of Metoprolol Tartrate, Metformin, and Eliquis, in addition, the wrong Prednisone dose was administered for three days and one day it was omitted all together. These failures resulted in a finding of Immediate Jeopardy

Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled resident (Resident #127) reviewed for a change in condition, the facility failed to ensure the resident was free of significant medication errors related to critical medications (Metformin, Metoprolol, Eliquis) not administered for six days for a total of 36 mixed doses as well as the incorrect dosage of Prednisone administered for a total of three days. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #127 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, chronic bronchitis, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, chronic kidney disease (stage 3) and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #127 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use and personal hygiene, was independent with eating, had no range of motion deficits, utilized a wheelchair and walker as mobility devices and received anticoagulant medication. The MDS further noted the resident's diagnoses included coronary artery disease, pulmonary embolism and respiratory failure. The care plan initiated in February of 2022 identified Resident #127 had impaired cognitive function related to dementia with interventions that included observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed A reportable event report dated 4/28/22 identified that upon Resident #127's re-admission to the facility on [DATE] the following medications were not transcribed into the electronic medical record and thus not included on the medication administration record (MAR): Eliquis, Metformin, and Metoprolol Tartrate and Prednisone was not transcribed properly. The report identified the event type as a medication error of clinical significance and noted the resident had been hospitalized on [DATE] and was expected to return to the facility on [DATE]. The hospital discharge summary dated 4/19/22 identified Resident #127 was admitted to the hospital on 4/15/22 for the chief complaint of shortness of breath (sudden onset of respiratory distress and change in mental status after receiving Rocephin (antibiotic) for cellulites. The discharge summary contained a medication list with all current and recommended medications. The list included an order for Prednisone (steroid) 20 mg by mouth every morning with breakfast for two days and then 10 mg by mouth for three days, Metformin (anti-diabetic medication) 500mg by mouth two times per day with meals, Metoprolol Tartrate (beta blocker used to treat high blood pressure, angina, heart failure and it may lower the risk of death after a heart attack) 25 mg by mouth every twelve hours and Eliquis (used to prevent serious blood clots from forming due to atrial fibrillation or surgery) 5mg twice per day. Review of the admission physician's orders located in the electronic medical record dated 4/19/22 failed to reflect that the orders for Metoprolol Tartrate, Metformin, and Eliquis were transcribed (entered into the electronic medical record system). Further review identified the order for Prednisone was entered incorrectly. The order was written as Prednisone 20mg once per day for three days then stop until 4/25/22 and Prednisone 10mg give two tablets by mouth one time per day for SOB (shortness of breath) for two days. Review of the medication administration record (MAR) for April identified Resident #127 was administered 20 mg of Prednisone on the 20, 21, 23, 24 and 25th. The MAR indicated that Prednisone was not administered on the 22nd. According to the hospital discharge summary Resident #127 should have received 10mg on April 22, 23 and 24th. The MAR did not contain the orders for the Metformin, Metoprolol Tartrate or the Eliquis resulting in the medications not being administered between 4/19/22 and 4/25/22. The nurse's note dated 4/19/22 at 6:11 PM written by RN #4 identified that Resident #127 arrived at the facility at 5:00 PM and medications were reviewed and verified with Physician #1. The nurse's note dated 4/21/22 at 3:51 PM identified Resident #127 was alert and confused per baseline. It further noted he/she was on 3 liters of oxygen via nasal cannula, lung sounds clear to auscultation, no cardiac or respiratory distress and no indication of pain or discomfort. The nurse's note dated 4/22/22 at 9:52 PM identified Resident #127 was on the 3rd day post readmission, denied pain, appetite good, blood pressure: 138/70, pulse: 76, respirations: 20, oxygen saturation level noted to be 98% on oxygen. The nurse's note dated 4/25/22 at 9:00 AM written by RN #5 identified Resident #127 had altered mental status with response to painful stimuli. The DNS was immediately notified, and a full body audit was completed. Vital signs were taken and reported to Physician #1 who ordered that the resident be sent to the hospital. The hospital discharge summary dated 4/29/22 identified that that the resident was admitted to the hospital on 4/25/22 with the chief complaint of unresponsiveness. It further noted the final diagnoses on discharge as acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation with lots of artifact, hypomagnesemia and hypokalemia likely diuresis related, history of bilateral pulmonary embolism with secondary hypercoagulable state on Eliquis, COPD on 2 to 3 liters admitted on 6 liters and back down to 3 liters, diabetes mellitus type 2, hypertension, hypothyroidism and dementia. The summary also noted that the resident had a moderate left pleural effusion. Further review of the discharge summary identified that during the hospital course the resident was diuresed with intravenous Lasix (diuretic) 40 mg twice daily for the heart failure. The resident was admitted to the telemetry unit (patients who suffer from heart disease, heart failure and complications associated with cardiac conditions are placed on the telemetry unit for close monitoring). Interview on 5/10/22 at 9:30 AM with the DNS, Corporate Clinical Director and MDS nurse identified that during a record review the MDS nurse identified that the resident was not receiving Eliquis, which the resident had been taking prior to 4/19/22.This discrepancy prompted an overall medication review which resulted in the discovery that the Eliquis along with the Metformin and the Metoprolol Tartrate had been missed for 6 days for a total of 12 missed doses of each medication. The review also identified that the incorrect dose of Prednisone had been administered for three days with one missed dose (4/22/22). Interview on 5/11/2022 at 12:40 PM with RN# 5 identified that on 4/25/22 she greeted Resident #127 and the resident only opened his/her eyes when normally he/she would respond verbally. RN# 5 identified that she performed a mild sternal rub and the resident mildly groaned and turned away from the nurse. She further identified that since the resident is always engaging, she notified the DNS who assessed Resident #127, Physician #1 was notified, and an order given to send the resident to the hospital to be evaluated. The clinical hospital transfer form also completed by RN# 5 identified the resident's vital signs as follows, blood pressure 156/70, respirations 26, temperature 98.2, oxygen saturation 99% on 3liters of oxygen per minute, heart rate 50 and blood glucose level 134 mg/dl (levels of 80mg/dl to 130mg/dl is the normal range for a type 2 diabetic before the consumption of a meal). Interview on 5/11/2022 at 2:00 PM with RN #4 identified upon Resident #127's readmission on 4/19/22, she reviewed and verified the medication orders with Physician #1. RN #4 further identified that she worked 7:00 AM to 7:00 PM on 4/19/22 and although she confirmed the orders with Physician #1, she noted that the orders were electronically entered into the resident's electronic medical record by RN #7 (RN #7 worked 7:00 PM to 7:00 AM on 4/19/22). Interview on 5/11/2022 at 2:34 PM with Physician #1 identified that upon Resident #127's readmission to the facility, medications were approved as recommended by the hospital. He further noted that it was unfortunate that the resident had not received all of the ordered medications and was upset that the medication errors occurred. In addition, he indicated that he did not feel that the failure to administer the ordered medications for six days contributed to the resident being re-hospitalized on [DATE]. Physician #1 noted that the resident had a COPD exacerbation and the Metformin has been known to have a lasting effect, the resident's blood pressures were normal and there was no evidence of clotting. In addition, he acknowledged that Resident #127 was administered higher doses of Prednisone than he/she should have but also felt that this did not have an adverse effect on the resident. Physician #1 noted that any medications that are ordered should be administered. Interview on 5/11/2022 at 3:00 PM with the DNS identified that prior to the discovery of the medication errors/omissions, the facility did not have a policy in place that addressed the admission/readmission process but noted that the practice involves the orders being entered into the EMR and a chart check completed to confirm the orders. The DNS further identified that the unit manager/nursing supervisor or RN on duty on the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts perform the chart check. The DNS could not provide any documentation that a chart check had been performed for Resident #127 when he/she was readmitted to the facility on [DATE]. Interview on 5/12/2022 at 7:40 AM with RN #7 identified she could not recall entering the physician's orders into the EMR on the evening of 4/19/2022, but review of the electronic medical record identified that RN #7 entered the medications into the system. A second interview on 5/12/2022 at 12:55 PM with RN #4 identified that she utilized a cell phone to scan the discharge medication summary forms to Physician #1 and received a text message back from Physician #1 that read meds look good. In addition, RN #4 was able to indicate on her cell phone what she had sent to the physician and the message that he sent to her indicating an approval of the orders. A review of the scanned forms matched the discharge medication summary forms. Interview on 5/12/2022 at 3:20 PM with the Pharmacy Consultant indicated Eliquis has a half-life of 12 hours resulting in the medication having cleared Resident #127's system in a 48 hour period, meaning after 4/21/22 there was no anticoagulant in the resident's system, which could have resulted in the resident forming a blood clot/pulmonary embolism. According to information contained on the website healthfully.com once a diabetic stops taking Metformin, the blood glucose levels will increase which can have an adverse impact on overall health. According to the website Drugs.com abrupt discontinuation of Metoprolol Tartrate can exacerbate angina and may increase the risk of a heart attack; it notes that the dose should be reduce gradually over a few weeks as instructed by a physician. The Drugs.com website further identified that the lowest effective dose should always be used because it can increase the blood pressure. Following the discovery of the medication errors, the facility initiated a new protocol dated 4/29/2022 that identified the following: * Upon admission and readmission, the discharge summary and W-10 will be compared for any discrepancies. If it is a readmission, the orders will also be compared to the resident's orders from the prior admission. All orders will then be reviewed with the MD or APRN with discrepancies noted and clarified and documented in a nurses note. * Once medications are reconciled and orders obtained, orders are to be transcribed into the point click care (PCC . electronic medical record system) and checked by a second nurse immediately following transcription. * The process is to be documented on the Admission Checklist * The admission Checklist will be completed for all new admissions/ readmissions and verified by a second nurse. * The resident's record will be reviewed again by Nursing Management and documented on the admission checklist. * When transcribing orders, be sure to verify the correct medication, dose, route and frequency as well as ensuring that it is transcribed into PCC in a manner that displays on the MAR or TAR (treatment administration record) and has a schedule The facility failed to ensure critical medications were administered to Resident #127 as ordered for a period of six days resulting in the omission of a total of 36 doses of the combined omitted medications of Metoprolol Tartrate, Metformin, and Eliquis, in addition, the wrong Prednisone dose was administered for three days and one day it was omitted all together culminating in the resident being hospitalized for acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation as well as a moderate left pleural effusion. These failures resulted in a finding of Immediate Jeopardy A review of the facility's corrective action plan on 5/12/22 at 4:00 PM included a review of the records of all twelve residents admitted to the facility since 4/19/22. Licensed staff were educated and re-educated on the protocol to have two nurses review the medication reconciliation and transcription process for new admissions and readmissions with an administrative nurse performing a third check of the records. An audit of the newly admitted and readmitted resident records from 4/19/22 identified no other irregularities. The Immediate Jeopardy was removed on 5/12/22.

Based on observations, review of the clinical record, review of facility documentation and interviews for one of three sampled residents (Resident #96) reviewed for pain management, the facility failed to provide requested pain medication in a timely manner. The findings include: Resident #96's diagnoses included malignant neoplasm of bronchus or lung, malignant neoplasm of vertebral column, malignant neoplasm of other parts of the nervous system, chronic obstructive pulmonary disease, anxiety disorder, generalized muscle weakness and depression. The quarterly MDS assessment dated [DATE] identified Resident #96 was cognitively intact, required limited assistance with ambulation, was independent with transfers, bed mobility, dressing, eating, personal hygiene and toilet use. The assessment further noted that the resident received opioid medication every day for the past seven days. The care plan dated 4/15/22 identified Resident #96 exhibited or was at risk for alterations in comfort related to bone cancer and neuropathy with interventions that included, medicate Resident #96 as ordered for pain and monitor for effectiveness, complete pain assessment- evaluate pain characteristics; quality, severity, location, precipitating/relieving factors, encourage resident to request pain medication before pain becomes severe, and monitor for non-verbal signs or symptoms of pain medicate as ordered. A physician's order dated 4/26/22 directed to monitor for pain and complete pain evaluation; Oxycodone HCL 10 MG every 4 hours by mouth as needed for breakthrough pain and Oxycontin ER 20 MG every 12 hours by mouth for moderate to severe pain (scheduled for 8 AM and 8 PM). Observation and interview on 5/2/22 at 12:00 PM identified Resident #96 seated in a standard wheelchair in his/her room with oxygen in place via nasal cannula. Resident #96 was alert and rationale and identified that that he/she was in pain and was waiting for his/her pain medication that was due at 8:00 AM. Resident #96 reported that when the nurse came to his/her room around 9:00 AM to assess pain he/she told the nurse that the severity of his/her pain was 8 out of 10 but had increased to 9 out of 10 since that time and now he/she was very uncomfortable. In addition, Resident #96 identified that this was not the first time he/ she had to wait to receive pain medication and noted that at times he/she had waited a whole day. Resident #96 further identified that he/she would be told by the nurse that the medication had 'ran out' and had to be reordered or there was no one to help retrieve medication from the pyxis machine. Interview on 5/2/22 at 12:09 PM with RN #3 identified Resident #96's Oxycontin (pain medication) had run out and she needed to retrieve it from the Pyxis. Interview on 5/4/22 at 9:37 AM with RN #3 identified that Resident #96's Oxycontin ER 20 MG had 'ran out' in the cart and had to be retrieved from the emergency supply in the Pyxis and identified that it required two nurses to retrieve narcotic medication from the emergency supply in the Pyxis. She further identified that she asked RN #4 to assist but she was still performing medication administration on her unit and was unable to assist. RN #3 noted that she went back to Resident #96 to tell him/her that she was waiting for someone to help with the Pyxis and noted the resident said OK. In addition, RN #3 identified that she thought Resident #96 could bare the pain and did not feel it was emergent for him/her to be administered the pain medication. Further interview identified that RN #3 noted that any pain score over a 7 was indicative of moderate to severe pain. She also noted that it had not occurred to her to administer the resident the as needed pain medication (Oxycodone HCL) and acknowledged that the scheduled Oxycontin was not administered to the resident until 2:00 PM on 5/2/22 (six hours after the scheduled time). Interview on 5/3/22 at 9:00 AM with Resident #96 identified that he/she was administered the requested pain medication at 2:00 PM and noted that he/she had to endure pain for that duration and had to try sleeping and resting to alleviate his/her severe pain. Interview on 5/12/22 at 1:00 PM with RN #6 (corporate nurse) identified that nurses are expected to reorder medications for the medication cart via electronic service and must obtain physician's orders for narcotics. She identified that emergency supplies for narcotics were kept in the Pyxis. She further noted that the DNS was not able to help RN #3 retrieve Resident #96 on that day because the DNS was new to the facility (since January 2022) and did not have access to the Pyxis. A review of the facility's pain management policy identified that residents will be evaluated as part of the nursing assessment process for the presence of pain or change in pain status. Pain management will be consistent with professional standards of practice to maintain the highest possible level of comfort for residents. By providing a system to identify, assess, treat, and evaluate pain.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was totally dependent on staff for personal hygiene and dressing and had contractures of both upper and lower extremities, the nurse aide failed to provide care when the resident was resistive to prevent injuries and fractures of the right upper extremity. The finding include: Resident #1's [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had short and long term memory recall deficits, was unable to make decisions regarding tasks of daily life, and required total one (1) person assistance with personal hygiene and dressing. Upon further review, Section G0400 of the MDS assessment did not reflect that Resident #1 had functional limitation in range of motion to the upper and lower extremities. The revised care plan dated 8/29/19 identified Resident #1 was dependent on staff for activities of daily living. The occupational therapy initial evaluation dated 11/4/19 identified the Range of Motion (ROM) of Resident #1's right shoulder was impaired with only approximately thirty (30) degrees of flexion, the right elbow, forearm, and right wrist ROM were impaired, and the right hand ROM was impaired, the resident held the hand in a tight fist and measurements were unable to be obtained. The evaluation identified Resident #1's left shoulder ROM was impaired with approximately 30 degrees of flexion, and the left elbow, forearm, wrist and hand ROM were also impaired. The nurse's note dated 11/8/19 at 6:58 PM identified a skin check was performed and Resident #1's skin was intact, no injuries or wounds were noted. The nurse's note dated 11/15/19 at 10:23 PM identified the charge nurse was notified that during evening care Resident #1 had sustained a skin tear to the right elbow that measured 1.5 centimeters (cm) by 2cm, there was scant serosanguineous drainage, no pain or discomfort was noted and the physician was notified. The note indicated the physician directed to cleanse the area with normal saline, followed by xeroform gauze, followed by a clean dressing and to change every three (3) days and as needed. The Reportable Event Form dated 11/15/29 identified that during evening care Resident #1 was noted with a skin tear to the right elbow. Review of facility investigation identified that Resident #1 sustained a skin tear while the nurse aide was providing care, the nurse aides was educated regarding clothing management for residents with contractures and two (2) caregivers were to provide assistance with activities of daily living. The nurse's note dated 11/16/19 at 2:41 PM identified Resident #1 was noted to have a large purple discoloration to the right upper arm and an open area to the right upper back with surrounding skin ecchymosis. The Reportable Event Form dated 11/16/19 identified during morning care a large purple discoloration was observed to the resident's right upper back and an open area to the right upper back with surrounding skin ecchymosis. The investigation identified that Resident #1 sustained a skin tear while the nurse aide was providing care, the nurse aides was educated regarding clothing management for residents with contractures and two (2) caregivers were to provide assistance with activities of daily living. A physician's orders [REDACTED]. The nurse's note dated 11/16/19 at 6:16 PM identified that Resident #1 was alert, nonverbal per baseline and confused, the right upper extremity remained discolored and during evening care the right shoulder was observed to be swollen and Resident #1 was guarding the right shoulder. The note indicated the physician was notified and a new order was obtained for x-ray of the right upper extremity. A physician's orders [REDACTED]. The radiology report dated 11/16/19 at 10:19 PM identified a fracture involving the neck of the humerus with mild callus, modest displacement and a non-acute appearing right humerus fracture as described. A physician's orders [REDACTED].#1 to the hospital for an evaluation of the abnormal x-ray results to the right shoulder and right humerus. The nurse's note dated 11/16/19 at 11:18 PM identified Resident #1 had an unplanned transfer to the hospital. The hospital documentation dated 11/17/19 identified that Resident #1 presented to the hospital with right arm pain likely secondary to an acute proximal humerus fracture. The x-ray report indicated the results were extremely limited and the orthopedic physician recommended pursuing a CT scan. The CT scan confirmed the presence of a minimally displaced surgical neck [MEDICAL CONDITION] humerus with no dislocation and also a comminuted nondisplaced [MEDICAL CONDITION] right clavicle (a comminuted fracture is a break or splinter of the bone into more than two fragments, since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma). The note identified the injuries were unlikely to be atraumatic in origin as was reported to the Emergency Medical Service by the facility, therefore, there were concerns for either neglect or non-accidental trauma. The hospital documentation identified Resident #1 would be discharged to another long term care facility per the request of the Conservator of Person. Interview with the Occupational Therapist (OT) #1, on 12/9/19 at 10:48 AM identified Resident #1's hands, elbows, shoulders, knees, hips, ankles were contracted and the resident had very limited range of motion. OT #1 stated that nursing did not request to screen Resident #1 for dressing. OT #1 indicated that both of Resident #1's elbows and hands were contracted and if there was an issue with dressing she would have suggested she would suggest adaptive clothing, such as looser fitting clothing and clothing that closed in the back. OT #1 indicated when putting a t-shirt on, to start with the arm that had least ROM first, then over the head and opposite arm. OT #1 stated that to remove the shirt off, the nursing staff should start with the arm that moves the most, pull the back of the shirt up as much as possible, take that arm out, then pull the shirt over the head, and the arm that moves the least should come off easily. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 12/9/19 at 1:50 PM identified that she was about to provide morning care on 11/16/19 when she noticed a discoloration on Resident #1's right upper arm. NA #1 stated she reported the discoloration to the charge nurse, Licensed Practical nurse (LPN) #3. NA #1 indicated that after LPN #3 assessed the resident she turned Resident #1 over on his/her side and noticed the discoloration on the resident's back close to the collarbone, the discoloration was dark black and blue in color. NA #1 stated she also noticed an abrasion on Resident #1's upper back, the same area where the discoloration was. Interview with the 7AM-3PM charge nurse, LPN #3, on 12/9/19 at 2:32 PM identified that at 8:00 AM, NA #1 reported to her that Resident #1 had a large bruise on his/her right inner upper arm and five (5) minutes later NA #1 reported a small abrasion on Resident #1's back with redness surrounding the abrasion. LPN #3 indicated that when she saw Resident #1 the resident had a tee shirt on. LPN #3 stated that the 3-11PM nurse aide, NA #4, reported to her around 6:00 PM that Resident #1 had swelling to the right arm. LPN #3 indicated she notified a physician regarding the bruising and swelling to right arm and an order was obtained to x-ray right arm. LPN #3 identified that she received x-ray report at 10:40 PM, notified a physician and the responsible party and Resident #1 was sent to the hospital for an evaluation. Interview with the 3-11PM nurse aide, NA #3, on 12/9/19 at 3:26 PM identified that she provided evening care and changed Resident #1 to pajamas on 11/15/19. NA #3 identified that she rolled Resident #1 to the side lifted the shirt up, then proceeded to take the right arm out first, and as she was taking the shirt off of the right arm, Resident #1 sustained a skin tear to the right elbow. NA #1 stated Resident #1's shirt was tight that when she was taking the shirt off of the right arm, the resident sustained [REDACTED].#3 indicated as she was trying to remove the shirt over the right elbow, she primed the right elbow and lifted the arm a little to get the elbow out of the shirt. NA #3 identified that she did not stop when she met resistance removing the shirt over the elbow or notify the charge nurse she was having difficult removing the shirt. Interview with NA #4 on 12/9/19 at 4:00 PM identified she cared for Resident #1 during the day shift. NA #4 indicated that Resident #4 was contracted and although it was always difficult to dress him/her, she never reported this to a charge nurse. NA #4 stated that Resident #1 was so contracted that she would put the arms in first then go over the head with the tee shirt. Interview and clinical record review with the Director of Nursing (DON) on 12/10/19 at 11:15 AM identified that NA #3 should have stopped undressing Resident #1 when she met resistance removing the shirt and informed the charge nurse. The DON indicated that nursing staff was educated for that reason. Interview with the attending physician on 12/20/19 identified the cause of the fracture was the clothing being tight mixed with the contractures. The attending physician stated Resident #1 had very limited movement of the both arms due to the contractures and her thought was the fracture happened when the resident was dressed, either putting on or removing the clothing. The attending physician indicated she discussed the case with the Emergency Department (ED) physician and the ED physician thought it was quite possible that the fracture occurred during the dressing. Interview with the Director of Nursing (DON) on 1/15/20 identified that the fracture occurred when the nurse aide removed clothing and met resistance. The DON stated from her investigation the nurse aide, NA #3, had indicated Resident #1's arms were tight and at times it was hard to remove the clothing. The DON identified NA #3 was unable to recall if she had stopped when she met resistance. Review of the in-service documentation identified the nursing staff was educated on dressing and grooming residents with contractures. Review of the care plan failed to address Resident #1's contractures and that interventions were implemented which directed the care of a resident with contractures.

Based on clinical record review, facility documentation, observations and interviews, for one of five sampled residents ( Resident # 98) reviewed for accidents, the facility failed to keep the resident's assistive device (wheelchair brake handle) protected and/or secured during a transfer from the wheelchair to the bed to prevent an accident .The findings include : Resident #98's [DIAGNOSES REDACTED]. Resident #98's Quarterly MDS dated [DATE] identified that the resident was severely cognitively impaired , had memory problems and required extensive assistance with one person physical assistance for all transfers. The RCP dated 1/21/15 identified that Resident #98 required extensive assistance with one person for all transfers from the wheelchair to the bed with the use of a gait belt. In addition, the resident was also care planned for risk of bruising and skin tears as evidenced by aspirin treatment. Review of the Facility's Accident and Injury Report (A&I) of Resident #98 dated 2/19/15 identified that Resident #98 sustained a skin tear while being transferred from his/her wheelchair to bed on 2/17/15 in the presence of a Nurse Aide (NA). NA#1 who assisted Resident #98 after the transfer from wheelchair to bed observed blood on the floor next to the resident's wheelchair. NA#1 noticed bleeding from the resident's left lower leg and immediately informed Registered Nurse ( RN#1) of the incident. Further Review of the A& I indicated that blood was noted on the handle of the wheelchair brake and that the rubber handle that protects the surface of the handle of the wheelchair brake was missing. RN#1 assessed Resident #98 and identified a 8 CM X 2 CM laceration to the left lower leg. RN#1 cleansed the area and applied a dry dressing and notified the Advanced Practice Nurse (APRN) who recommended that Resident #98 be sent to the emergency room . At the acute care facility , Resident # 98 received 11 sutures and the area was covered with a dry sterile dressing. Resident #98 returned to the facility. RN#1 began an investigation and identified that the initial possible cause of the skin tear was the side rail on the left side of the bed. The left side rail was padded by the RN#1. Further investigation by DNS#2 on 2/19/15 and interview with the DNS # 2 on 5/13/15 at 12:05 P.M. during a reenactment of the incident with NA# identified that dried red blood was observed on the right wheelchair brake handle and an investigation by DNS # 2 identified that the padding covering the handle was missing. After the reenactment was completed, DNS#2 identified that the cause of the injury was the right brake handle which was missing the padded covering and not due to the siderail on the bed. Interview with NA#1 on 5/12/15 at 1:55 P.M. identified that he/she transferred Resident # 98 on 2/17/15 the day in question with the gait belt and after the transfer from the wheelchair to the bed she/he noticed blood on the floor and near the resident's leg rest which was on the floor. NA#1 notified RN#1 who came and assessed the resident after the incident. NA#1 further stated that he/she usually look at the floor to see if there are any obstacles in the way before transferring the resident and usually check the equipment( such as the wheelchair or bed) for any potential problems or defects, but did not identify the missing padding on the right brake handle on 2/17/15. Further interview and observation of the reenactment of the incident with NA#1 on 5/13/15 at 3:35 P.M. identified that he/she could not remember if the wheelchair brakes were sharp before locking the wheelchair brakes for Resident #98 on 2/17/15 and indicated that at times other residents in the facility do not have protective coverings on their wheelchair brakes and that the metal pieces can be sharp on some wheelchairs. Review of the facility's Maintenance Work Order log on 5/13/15 for February 19, 2015 after the incident identified an issue with Resident #98's wheelchair brakes and the work order request was to file for the resident's wheelchair brakes. Maintenance documentation dated 2/19/15 reflected that all sharp edges on the brakes of Resident #98 were filed and brake grips were installed on the right handle. Interview with The Director of Nursing Services (DNS#2) who was the DNS at the time of the incident on 5/13/15 at 12:05 P.M. stated that the incident occurred on 2/17/15 in the evening at around 9:00 P.M. and on 2/19/15 he/she was reviewing the investigation done by RN#1 on 2/17/15 which identified that the cause of the injury was possibly due to the side rails on Resident #98 bed. DNS#2 further stated that he/she completed a reenactment because the injury did not appear to be caused by the side rails. In addition, before the reenactment was completed, DNS#2 noticed dried blood to the right wheelchair brake handle and identified that the rubber piece that protects the brake handle was missing. DNS#2 stated that during the reenactment on 2/19/15, NA#1 was transferring the resident with a gait belt and during the pivot to the bed Resident #98 sustained a left lower extremity laceration which aligned with the right wheelchair brake handle. The DNS#2 further stated that the brake handle was " very sharp " and that he/she immediately had a work order placed via The Maintenance Order log and temporarily covered the right brake handle to prevent any further issues. A re-education on transferring was completed with NA#1 immediately and a sweep of the entire building with maintenance to check all wheelchairs for any equipment defects was completed immediately on 2/19/15. DNS#2 stated that NA#1 performed the transfer correctly but that NA#1 should have noticed the missing rubber over the wheelchair brake and covered it with a protective device before transferring the resident. Several attempts were made to contact RN#1 but was unavailable for an interview. Interview with DNS#1 on 5/13/15 at 3:30 P.M. . identified that there was no specific policy on Wheelchairs Maintenance but that all departments are responsible for checking the wheelchairs for any defects and/or problems. She/he further stated that the Nursing Assistants and the Registered Nurses will take a wheelchair out of services immediately, when a problem is identified and a work order is than placed to maintenance.