Every finding on record at Complete Care at Meriden

Based on clinical record reviews, facility documentation, facility policies, and interviews for seven (7) of seven (7) sampled residents (Residents #1, #2, #3, #4, #5, #6 and #7) who received a controlled narcotic medication for pain management, the facility failed to ensure residents' controlled narcotic medications were not removed from the facility by a licensed staff member. The findings include: 1. Resident #1's diagnoses included left femur fracture, protein calorie malnutrition and polyneuropathy. The Advanced Practice Registered Nurse (APRN) progress note dated 5/6/26 at 1:00 PM identified Resident #1 was hospitalized for a left femoral neck fracture status post left total hip after a fall with associated pain, had impaired mobility, deconditioning and continued to report post operative pain with movement and weight bearing, and the pain was partially relieved with the current pain management regime. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicating Resident #1 was alert and oriented to person, place, and time and reported occasional pain in the last five (5) days. A physician's order dated 5/16/26 directed to administer Oxycodone HLI oral tablet 5 milligrams (mg), give 5 mg by mouth every eight (8) hours as needed for pain for fourteen (14) days. The Resident Care Plan (RCP) dated 5/18/26 identified Resident #1 had pain related to a recent fracture. Interventions directed to provide pain medication as ordered. The Facility Reported Incident form dated 5/23/26 identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, reported to the supervisor, Registered Nurse (RN) #1, that the shift inventory control sheet had one (1) card removed and one (1) count sheet removed for Resident #1, and there was no second signature to verify. The report indicated RN #1 reached out to the 7AM-3PM nurse, LPN #1, to ask what happened but she could not reach LPN #1. On 5/24/26 when LPN #1 came to work she asked a different supervisor, RN #2, on the day shift to sign the narcotic count sheet, and when RN #2 asked to see the medication card to verify, LPN #1 said the meds were damaged/melted after water spilled on them. RN #2 asked LPN #1 if anyone had witnessed the damaged medication, LPN #1 said no, at which time RN #2 refused to co-sign and notified the Director of Nursing (DON). The report identified the DON and Administrator came to the facility to meet with LPN #1 who admitted to taking the medication, LPN #1 was immediately suspended. The report indicated the medical director, police and state Consumer Protection Agency Drug Control Division and Haven program were notified. The summary report dated 5/29/26 identified during the interview LPN #1 admitted to removing the medication cards and LPN #1 turned over multiple medication sheets from discharged residents and admitted to taking those medications as well. A review was conducted to determine resident impact, and an additional seven (7) residents were identified as potentially affected. Of the seven residents, four (4) had already been discharged and the three (3) current residents were interviewed and hey indicated their pain was addressed appropriately, receiving medication and voiced no concerns. Review of residents receiving opioids for the past six (6) months was completed and no irregularities were found. 2. Resident #2's diagnoses included pelvis fracture, Large B cell lymphoma, agranulocytosis secondary to cancer chemotherapy and immunodeficiency. A physician's order dated 4/27/26 directed to administer Oxycodone HCI 5 mg, give 5 mg every three (3) hours as needed for moderate pain for fourteen (14) days. 3. Resident #3's diagnoses included fracture of upper and lower end of right fibula, fracture of right tibia and diabetes with diabetic neuropathy. A physician's order dated 5/11/26 directed to administer Oxycodone HCL tablet 5 mg, give 5 mg by mouth every four (4) hours as needed for pain for fourteen (14) days. 4. Resident #4's diagnoses included neoplasm of endocrine glands and other parts of nervous system, post procedural pain, surgical incision to back and neurogenic bladder. A physician's order dated 4/11/26 directed to administer Hydromorphone HCI oral tablet 2 mg, give 2 mg by mouth every four (4) hours as needed for moderate pain for 14 days and give 4 mg by mouth every four (4) hours as needed for severe pain for fourteen (14) days. 5. Resident #5's diagnoses included benign neoplasm of peripheral nerves and autonomic nervous system, osteonecrosis (the death of bone tissue due to a temporary or permanent loss of blood supply) and wound to right lower leg. A physician's order dated 5/10/26 directed to administer Oxycodone HCI oral tablet 5 mg, give 2 tablets by mouth every six (6) hours as needed for moderate pain for fourteen (14) days and give three (3) tablets by mouth every six (6) hours as needed for severe pain for fourteen (14) days. 6. Resident #6's diagnoses included surgical aftercare on skin and subcutaneous tissue, secondary malignant neoplasm of liver and intrahepatic bile duct and malignant neoplasm of rectum. A physician's order dated 4/13/26, directed to administer Hydromorphone 2 mg, give one (1) tablet by mouth every three (3) hours as needed for moderate pain for fourteen (14) days, and give 4 mg by mouth every three (3) hours as needed for severe pain. 7. Resident #7's diagnoses included effusion of the left knee and left knee pain. A physician's order dated 4/22/26 directed to administer Oxycodone HCI 5 mg, give 5 mg by mouth every four (4) hours as needed for moderate pain for 14 days and give 10 mg by mouth every four (4) hours as needed for severe pain for fourteen (14) days. Interview and record review on 8/17/26 at 1:32 PM with LPN #1 identified she was the 7AM-3PM charge nurse on 5/23/26 and Resident #1 was on her assignment. LPN #1 explained on 5/24/26 she asked the 7AM-3PM nursing supervisor, RN #2, to sign the narcotic record for Resident #1 because the record had been damaged on 5/23/26 after a water spill and the record identified there were nine (9) tablets remaining. RN #2 had asked her if anyone witnessed this and when she said, no, RN #2 would not co-sign. LPN #1 identified the DON, a human resources representative and the Administrator interviewed her, she informed them that she was aware a witness was needed for narcotic waste at the time, she indicated she put the Oxycodone HLI card in the shredder bin, and during the discussion provided an additional nine (9) other white narcotic count sheets of some discharged and some current residents from April and May. LPN #1 stated she admitted she took the narcotic medication. Interview and record review with the DON on 8/18/26 at 8:25 AM identified on 5/23/26 the 3-11PM charge nurse, LPN #2, noted a new medication card of Oxycodone HCI had been ordered and received for Resident #1, she questioned this as she knew there had been enough of the medication when she worked on 5/22/26 as she was Resident #1's regular nurse on the evening shift and an attempt to contact LPN #1 by the 3-11PM nursing supervisor was made on 5/23/26. The DON explained on 5/24/26 LPN #1 was asked what had happened to the Oxycodone HLI and LPN #1 indicated the card had gotten wet, so she destroyed the medication. The DON indicated on 5/24/26 LPN #1 had asked the 7AM-3PM nursing supervisor, RN #2, to co-sign the proof of use sheet, which he refused because he did not see the medication destroyed, LPN #1 later said she put the card in a shredder. The DON identified she and the Administrator checked the shredder bins, and when they interviewed LPN #1 who originally indicated Resident #1's card of Oxycodone HLI got wet, LPN #1 then confessed she took the medication. The DON explained that LPN #1 provided proof of use sheets for other residents, and LPN #1 reported when the residents' medication got low she would reorder the medication and then take some of the medication. Interview and record review with the Regional Corporate nurse, RN #3, on 8/18/26 at approximately 12:30 PM identified on 5/25/26 she investigated the additional residents potentially impacted by LPN #1's admission to taking medications. RN #3 indicated the DON had completed an audit to ensure no other residents were impacted and her focus was on identifying resident medications that were potentially taken by LPN #1. RN #3 indicated the additional sheets included four (4) discharged residents and three (3) active residents, which included Resident #1. Review of facility abuse policy directed in part; it is the policy of this facility to provide protection for the health, welfare and rights of each resident. Misappropriation of Resident Property means the deliberate exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without resident's consent. The facility developed and implemented a corrective action plan on 5/24/26:Immediate staff education/re-education on controlled substance count procedures at shift change, including requirement for a second nurse verification when medications or count sheets are added or removed.Re-education on discharge medication reconciliation and return of medications to the Supervisor and/or DON on the day of discharge; narcotics discharged home require the resident or family signature with two (2) nurse witnesses.Continue bi-monthly narcotic audits and monitoring of controlled substance documentation.Audit process implemented for medication destruction requiring two (2) signatures.Audit process is implemented for discharge medication reconciliation and return to DON.QAPI initiated and reviewed with the Medical Director on 5/26/26. The Plan of Correction compliance date was 5/29/26, therefore past non-compliance was identified.

Based on observations, review of the clinical record, facility policy, facility documentation, and interviews for 1 of 6 residents (Resident #127) observed for medication administration, the facility failed to ensure the medication error rate was not 5 percent (%) or greater (the error rate was 6.9%). The findings include: Resident #127 had diagnoses that included major depression, diabetes, heart failure, hypertension, and anemia. The quarterly MDS dated [DATE] identified Resident #127 had intact cognition. Resident #127 had pain occasionally on average 2 out of the last 5 days, and received antipsychotic, antidepressant, diuretic, opioid, antiplatelet, and hypoglycemic medications during the last 7 days or since admission.The RCP care plan dated 11/28/25 identified Resident #127 received psychotropic medications. Interventions directed to administer medications as ordered by the physician.The physician's order dated 2/9/26 directed to administer Aspirin (medication used to thin blood) 81 milligrams (mg) chewable daily, Plavix (prevents blood clots) 75 mg daily, Cymbalta (used to treat depression, anxiety, and chronic pain) 60 mg, Abilify (used to treat several mental health conditions) 10 mg daily, Losartan Potassium (lowers blood pressure) 25 mg daily, Singular (used to prevent asthma attacks and treat allergies) 10 mg daily, Steglatro (used to lower blood sugar) 15 mg daily, Torsemide (used to treat fluid retention) 20 mg twice a day, and Percocet (a narcotic pain medication) 10-325 mg tablet every 6 hours as needed. Observation of medication administration on 2/10/26 at 9:20 AM, for Resident #127 by LPN #6 removed the resident's medications, placed them into a plastic medication cup, approached the resident, and administered the following medications: Aspirin 81 mg chewable tablet (1 tablet), Plavix 75 mg (1 tablet), Losartan Potassium 25 mg (1 tablet), Steglatro 15 mg (1 tablet), Singulair 10 mg (1 tablet), and Torsemide 20 mg (1 tablet). LPN #6 asked Resident #127 if he/she was experiencing pain, Resident #127 stated yes and requested pain medication. LPN #6 searched the medication cart and stated that Abilify and Cymbalta were not available in the cart and that she would need to check the medication room. LPN #6 indicated she would go to the supervisor and check the emergency medication to obtain Percocet. At 9:40 AM LPN #6 and the supervisor removed one tablet of Percocet 5-325 mg. LPN #6 then approached Resident #127 and administered one tablet of Percocet 5-325 mg. LPN #6 stated she completed Resident #127 medication administration and was moving on to the next resident. Review of the Medication Administration Record (MAR) identified on 2/10/26 at 9:00 AM, LPN #6 signed off she administered Cymbalta 60 mg and Abilify 10 mg. Review of the MAR dated identified on 2/10/26 at 9:40 AM, LPN #6 did not sign off that she administered the Percocet 5-325 mg in accordance with physician orders. Interview and clinical record with LPN #6 on 2/10/26 at 10:00 AM revealed that she did not administer Cymbalta 60 mg or Abilify 10 mg to Resident #127 because they were not in the medication cart. After reviewing the MAR dated 2/10/26, LPN #6 stated that she had documented both medications as given but stated she should not have done so because they were not administered. LPN #6 stated that because she had already signed off the Cymbalta and Abilify as administered, she would not have returned to look for or give those medications if the surveyor had not reconciled the MAR and brought it to her attention. LPN #6 stated she had forgotten to go to the medication room to locate the Cymbalta and Abilify earlier in the medication pass. LPN #6 further stated that, had the surveyor not identified the discrepancy, she would not have returned to administer the medications.Subsequent to surveyor inquiry, on 2/10/26 at 10:05 AM LPN #6 administered Cymbalta 60 mg and Abilify 10 mg to Resident #127. Interview with the DNS on 2/10/26 at 10:08 AM identified nurses are required to prepare medications, administer them to the residents, and sign off only the medications actually given. The DNS stated that if medication is not available at the scheduled time, the charge nurse must notify the supervisor and must not document the medication as administered. The DNS identified that if a medication is not signed off, it appears highlighted in pink in the electronic MAR as a reminder that it remains unaddressed. The DNS also stated pain medication removed from the emergency box (e-box) must be documented on the MAR. The DNS identified that charge nurses are required to follow physician orders and notify the supervisor if unable to do so, so the provider can be contacted. The DNS stated that LPN #6 should have signed off only the medications she administered to Resident #127 on the MAR. The DNS stated that LPN #6 should have signed off only the medications she administered to Resident #127 and should have documented on the MAR when she administered Percocet to Resident #127. Review of the Medication Error Policy identified medication error means the observed or identified preparation or administered of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications regarding the preparation and administration of the medication; or accepted professional standards and principles which apply to professionals providing services. The facility shall ensure medications will be administered as follows: according to physician's orders and in accordance with standards and principles which apply to professionals providing services. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. To prevent medication errors the following procedures will be initiated: Right medication, dose, route, and time of administration and right resident and right documentation. The medication error rate was 6.9% based on the medication administration observation task.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 6 residents (Resident #2) reviewed for medication administration, the facility failed to ensure the clinical record was accurate to include timely documentation when medications were administered, and for 1 of 3 residents (Resident #42) reviewed for wound care, the facility failed to ensure the clinical record was complete and accurate to include documentation of wound care provided. The findings included:1.Resident #2 had diagnoses that included neuromuscular dysfunction of the bladder, osteoarthritis, deep vein chronic embolism and thrombosis, and diabetes. The RCP dated 12/5/25 identified Resident #2 has pain related to osteoarthritis with interventions that directed to administer pain medications per physician's orders. The physician's order dated 12/31/25 directed to administer Tylenol 1000 milligrams (mg) three times a day for pain, Eliquis (medication to prevent and treat blood clots) 5 mg twice a day, Vasotec (lowers blood pressure and treats heart failure) 20 mg daily, Atorvastatin Calcium (lowers cholesterol) 10 mg daily, Insulin Glargine (medication used to lower blood sugar) 100 units subcutaneously twice a day, Lispro (lowers blood sugar)100 units per 1ml sliding scale based on blood sugar taken before meals and bedtime, Pregabalin (used to treat seizure and nerve pain) 50 mg capsule three times a day, and Pro-stat (liquid protein supplement) 30 ml twice a day, and monitor pain on every shift. a. Review of the Medication Administration Record (MAR) identified on 1/6/26 at 9:00 AM, LPN #5 did not sign off that she administered Tylenol 1000 mg, Eliquis 5 mg, Vasotec 20 mg, Atorvastatin Calcium 10 mg daily, Insulin Glargine 100 units subcutaneously, Pregabalin 50 mg capsule, and Pro-stat 30 ml twice a day in accordance with physician's orders. b. Review of the MAR identified on 1/6/26 at 11:30 AM, LPN #5 did not sign off she administered Lispro (lowers blood sugar)100 units per 1ml sliding scale based on blood sugar reading in accordance with physician orders. c. Review of the Medication Administration Record (MAR) identified on 1/6/26 at 1:00 PM, LPN #5 did not sign off that she administered Tylenol 1000 mg in accordance with physician orders. d. Review of the MAR identified on 1/11/26 at 9:00 AM, LPN #5 did not sign off that she administered Tylenol 1000 mg, Eliquis 5 mg, Vasotec 20 mg, Atorvastatin Calcium 10 mg daily, Insulin Glargine 100 units subcutaneously, Pregabalin 50 mg capsule, and Pro-stat 30 ml twice a day in accordance with physician's orders. e. Review of the MAR identified on 1/11/26 at 11:30 AM, LPN #5 did not sign off she administered Lispro (lowers blood sugar)100 units per 1ml sliding scale based on blood sugar reading in accordance with physician orders. f. Review of the Medication Administration Record (MAR) identified on 1/11/26 at 1:00 PM, LPN #5 did not sign off that she administered Tylenol 1000 mg in accordance with physician orders. e. Review of the Medication Administration Record (MAR) identified on 2/8/26 at 9:00 AM, LPN #5 did not sign off that she administered Tylenol 1000 mg, Eliquis 5 mg, Vasotec 20 mg, Atorvastatin Calcium 10 mg daily, Insulin Glargine 100 units subcutaneously, Pregabalin 50 mg capsule, and Pro-stat 30 ml twice a day in accordance with physician's orders. f. Review of the MAR identified on 2/8/26 at 11:30 AM, LPN #5 did not sign off she administered Lispro (lowers blood sugar)100 units per 1ml sliding scale based on blood sugar reading in accordance with physician orders. g. Review of the Medication Administration Record (MAR) identified on 1/6/26 at 1:00 PM, LPN #5 did not sign off that she administered Tylenol 1000 mg in accordance with physician orders. A Disciplinary Action Form dated 1/13/26 identified LPN #5 was disciplined because she did not sign off on medications she had administered. Interview with APRN #1 on 2/10/26 at 2:14 PM identified Resident #2 has chronic pain and prescribed scheduled Tylenol. APRN #1 stated the nurses should sign the MAR/medical record when a medication was administered. Interview with LPN #5 on 2/11/26 at 12:40 PM, identified she was the assigned nurse for Resident #2 on 1/6/26, 1/11/26, and 2/8/26 during the 7 AM to 3 PM shifts. LPN #5 indicated on 1/6/26, 1/11/26, and 2/8/26 she thought she signed off the MARs after she administered Resident #2's medications per the physician's orders. LPN #5 stated the DNS disciplined her for not signing off Resident #2's MARs but does not recall when she received the education. LPN #5 stated she believes the issue may be computer-related, as the system sometimes logs her out during medication passes, and interruptions from residents contribute to missed signoffs on the MARs. LPN #5 indicated she requested IT assistance but has not met with anyone. LPN #5 stated that unlike previous places she had worked the supervisors at this facility do not verify end-of-day medication signoffs. Interview with the DNS on 2/11/26 at 1:33 PM identified nurses must sign the MAR/medical record when they administer any medication. The DNS could not explain why Resident #2's medications were not signed off as administered on 1/6/26, 1/11/26, and 2/8/26 by LPN #5. The DNS identified on 1/13/26 LPN #5 for failing to sign Resident #2's MAR on 1/6/26 and 1/11/26 after medication administration. The DNS stated LPN #5 should have signed the MAR immediately after administering the medications. The DNS further stated charge nurses are responsible at the end of each shift for ensuring all medications are administered and documented. Review of the facility Medication Administration Policy identified medications are administered as ordered by a licensed nurse in accordance with professional standards of practice, in a manner to prevent contamination or infection. Keep medication cart clean and adequately stocked. Ensure that the 6 rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation. Once medications are prepared observe resident consume the medications. Sign the MAR after administration. If the medication is a controlled substance (Percocet) sign the narcotic book. Correct any discrepancies and report to the nurse manager. 2. Resident #42 had diagnoses that included peripheral vascular disease, severe protein-calorie malnutrition, and generalized muscle weakness. The quarterly MDS dated [DATE] identified Resident #42 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15) indicative of intact cognition, was always incontinent of bowel, dependent on staff for all ADLs, including bed mobility, and transfers, non-ambulatory, at risk for developing pressure ulcers, and had one unhealed stage 4 pressure ulcer. The RCP dated 12/19/2025 identified Resident #42 was at risk for skin breakdown and had actual skin breakdown/wounds pressure ulcer to the left hip and discolored areas to the bilateral heels. Interventions directed to offload heels while in bed, place resident on pressure reducing air mattress, provide wound care per orders, and monitor closely for redness, warmth, swelling, drainage, or any other signs of infection. a. The physician orders dated 1/20/2026 directed to irrigate left heel with normal saline, apply Calcium Alginate AG (wound dressing containing silver), followed by a dry clean dressing (DCD), daily on every day shift and as needed for soiling , accidental removal, increased drainage and irrigate the left ischium with normal saline, apply collagen powder (medication used to promote tissue regeneration and accelerates healing), followed by Calcium Alginate AG, and DCD, daily on every day shift and as needed for soiling , accidental removal, and increased drainage. Review of the Treatment Administration Record (TAR) dated 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026, 2/2/2026, and 2/3/2026 on the 7 AM to 3 PM shift, identified LPN #5 did not sign off that she administered Resident #42's wound treatments to his/her left heel and left ischium in accordance with physician's orders. Interview with LPN #5 on 2/17/2026 at 1:00 P.M. identified she was the charge nurse for Resident #42 on 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026, 2/2/2026, and 2/3/2026, from 7:00 A.M. to 3:00 P.M. LPN #5 indicated she administered Resident #42's wound treatments to his/her left heel and left ischium per the physician's orders on 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026, 2/2/2026, and 2/3/2026. LPN #5 stated due to computer issues on 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026, 2/2/2026, and 2/3/2026 she was not successful in signing off on Resident #42's TARs to indicate she administered the wound treatments. b. The physician orders dated 1/20/2026 directed to irrigate left heel with normal saline, apply Calcium Alginate AG (wound dressing containing silver), followed by a dry clean dressing (DCD), daily on every day shift and as needed for soiling , accidental removal, increased drainage and irrigate the left ischium with normal saline, apply collagen powder (medication used to promote tissue regeneration and accelerates healing), followed by Calcium Alginate AG, and DCD, daily on every day shift and as needed for soiling , accidental removal, and increased drainage. Review of the Treatment Administration Record (TAR) dated 2/4/2026 for the 7 AM to 3 PM shift, identified LPN #3 did not sign off that she administered Resident #42's wound treatments to his/her left heel and left ischium in accordance with physician's orders. Interview with LPN #3 on 2/17/2026 at 1:08 P.M. identified she was the charge nurse for Resident #42 on 2/4/2026, from 7:00 A.M. to 3:00 P.M. LPN #3 indicated she administered Resident #42's wound treatments to his/her left heel and left ischium per the physician's orders on 2/4/2026. LPN #3 identified on 2/4/2026 she did not document on Resident # 42's TAR at the time she administered Resident #42's wound treatments because she left early on 2/4/2026. c. The physician orders dated 1/20/2026 directed to irrigate left heel with normal saline, apply Calcium Alginate AG (wound dressing containing silver), followed by a dry clean dressing (DCD), daily on every day shift and as needed for soiling , accidental removal, increased drainage and irrigate the left ischium with normal saline, apply collagen powder (medication used to promote tissue regeneration and accelerates healing), followed by Calcium Alginate AG, and DCD, daily on every day shift and as needed for soiling , accidental removal, and increased drainage. Review of the Treatment Administration Record (TAR) dated 2/5/2026 for the 7 AM to 3 PM shift, identified the ADNS did not sign off that she administered Resident #42's wound treatments to his/her left heel and left ischium in accordance with physician's orders. Interview with the ADNS on 2/17/2026 at 1:12 P.M. identified she was the charge nurse for Resident #42 on 2/5/2026, from 7:00 A.M. to 3:00 P.M. The ADNS indicated on 2/5/2026 she administered Resident #42's wound treatments to his/her left heel and left ischium per the physician's orders. The ADNS stated on 2/5/2026 she forgot to sign off on Resident #42's TAR to identify she administered the wound treatments. Interview with the DNS on 2/17/2026 at 1:25 P.M. identified she would expect that any wound treatment administered to a resident would be signed off in the TAR at the time the wound treatment was administered by the nurse. The DNS was unable to explain why on 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026, 2/2/2026, 2/3/2026, 2/4/2026, and 2/5/2026 the nurses did not sign off on Resident #42's TAR to reflect that his/her wound treatments were administered. Review of facility Documentation of Wound Treatment policy dated 9/1/2025 directed, in part, wound treatments are documented at the time of each treatment.

Based on review of the clinical record, facility documentation, facility policy, observation, and interviews for 1 resident (Resident #2) reviewed for indwelling urinary catheter, the facility failed to ensure a urinary drainage bag was maintained in a manner that protected the resident's privacy and dignity. The findings include:Resident #2 had diagnoses that included urgency of urination, neuromuscular dysfunction of the bladder, and diabetes. The Resident Care Plan (RCP) dated 12/5/25 identified Resident #2 requires an indwelling catheter due to neurogenic bladder. Interventions included providing privacy and comfort, catheter care per physician orders and as needed, keeping catheter off floor, and providing a privacy bag.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition, was frequently incontinent of bowel, presence of an indwelling foley catheter, required moderate assistance with personal hygiene and dependent on staff for toileting, and dressing.The physician's order dated 1/15/26 directed a 16 French foley catheter with a 10 cubic centimeter (cc) balloon to bedside drainage, perform catheter care on every day shift, every evening shift, and as needed, and empty the catheter drainage system at least every 8 hours, when it is 1/4 to 2/3 full, and as needed. Observations on 2/5/26 at 11:00 AM and 2:20 PM identified Resident #2 was lying in bed with a urinary drainage bag attached to right side foot portion of the bed frame, visible from the hallway without a privacy cover. Observations on 2/9/26 at 10:30 AM and 1:05 PM identified Resident #2 was lying in bed with a urinary drainage bag attached to right side foot portion of the bed frame, visible from the hallway without a privacy cover.Observation on 2/10/26 at 10:30 AM identified Resident #2 was lying in bed with a urinary drainage bag attached to right side foot portion of the bed frame, visible from the hallway without a privacy cover. Observation on 2/10/26 at 2:30 PM identified Resident #2 was lying in bed with the urinary drainage bag attached to the foot portion of the bed frame, visible from the hallway without a privacy cover. The urinary drainage bag was approximately half full of yellow liquid.Interview and observation with the Assistant Director of Nurses (ADNS) on 2/10/26 at 2:41 PM identified Resident #2's urinary drainage bag, half full of a yellow liquid, was visible from the hallway. The ADNS identified that all urinary drainage bags must always be covered to protect the residents' dignity and privacy. The ADNS stated if a urinary drainage bag does not have a privacy cover, the nurse aide or charge nurse is responsible for obtaining a privacy cover immediately. The ADNS stated if she had been informed Resident #2 needed privacy cover, she would have obtained one immediately.Interview with the Director of Nurses (DNS) on 2/10/26 at 3:00 PM identified any residents with urinary drainage bags must always have a privacy cover in place to maintain the resident's dignity and privacy.Review of the facility Catheter policy identified it is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered while in use.Review of the facility Resident Rights policy identified, in part, the resident has the right to a dignified existence and self-determination.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 1 sampled resident identified to self-administer medication (Resident #91), the facility failed to assess Resident #91's ability to safely self-administer medication. The findings include:Resident #91 had diagnoses that included hypertension, hepatitis C, kidney disease, and pruritus (chronic itchiness). The RCP dated 2/3/26 identified Resident #91 had itching and was at risk for decreased ability to perform personal care tasks (ADL's). Interventions directed to administer medications as ordered, document effectiveness, and update the physician as necessary with any changes. The admission MDS dated [DATE], identified Resident #91 was cognitively intact, required the application of ointments/medications other than to his/her feet and was supervised or provided touching assistance for toileting, standing/transferring and bed mobility.Observation and interview on 2/5/26 at 10:38 AM identified Resident #91 was noted to have a 2-ounce tube of Hydrocortisone 1 % cream on the bedside table in his/her room. The tube was not in its original box and did not contain a pharmacy label or an opened dated indicating when the medication was dispensed or first opened.Interview with Resident #91 on 2/5/26 at 10:38 AM, identified Resident #91 indicated the Hydrocortisone 1 % cream was provided by the nursing staff and routinely left at the bedside. Resident #91 stated the cream does nothing to relieve the itch. A second observation on 2/9/2026 at 10:38 AM, Resident #91 was observed in his/her room with Person #1, and the 2-ounce tube of Hydrocortisone 1% cream was noted lying on Resident #91's bedside table. The tube was not in its original box and did not contain a pharmacy label or an opened date indicating when the medication was dispensed or first opened.Interview with Resident #91 and Person #1 on 2/9/26 at 10:38 AM identified Resident #91 and Person #1 both stated the Hydrocortisone 1% cream was provided by the facility. Person #1 stated that no medications or ointments had been brought from home for Resident #91. Person #1 identified he/she informed the facility Resident #91 had previously used another ointment at home. Resident #91 stated he/she was unable to recall which staff member provided him/her the Hydrocortisone cream and when he/she was provided with Hydrocortisone 1% cream.Review of the clinical record on 2/5/26 failed to identify Resident #91 had been assessed for self-administration of medication. Interview and clinical record review with the DNS on 2/9/26 at 11:08 AM, indicated that the DNS was not aware that Resident #91 was keeping Hydrocortisone 1% cream at the bedside or that he/she was self-administering. Additionally, review of the clinical record with the DNS failed to reflect that Resident #91 had been assessed for self-administration of medications. The DNS stated Resident #91 should have been assessed to identify if he/she could self-administer medication safely. Review of facility Resident Self-Administration of Medication policy dated 7/1/2024 directed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medication may be self-administered safely. Each resident is offered the opportunity to self-administer medications during routine assessments by the facilities interdisciplinary team. The residents' preferences will be documented on the appropriate form and placed in the medical record. Also, the care plan must reflect resident self-administration and storage arrangements for each such medication.

Based on review of the clinical record, facility documentation, facility policy, and interviews record review, interviews for 1 of 3 residents (Resident #127) reviewed for Advance Directives, the facility failed to ensure an advanced directives form was completed according to the resident's expressed wishes. The findings include:Resident #127 had diagnoses that included Type 2 Diabetes Meletus, congestive heart failure, and osteomyelitisThe Resident Care Plan (RCP) dated 11/20/2025 identified Resident #127 had established advanced directives and was a Full Code. Interventions directed to activate resident's advanced directive as indicated, inform resident and/or healthcare decision-makers of any changes in status or care needs, and allow opportunities for expression of feelings and ask questions.A physician's order dated 11/21/2025 directed a Full Code (all life saving measures).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #127 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. of intact cognition.Interview and clinical record review with Licensed Practical Nurse (LPN) #1 on 2/9/2026 at 11:41 AM identified an unsigned and incomplete advanced directives form in Resident #127's paper chart. Further clinical record review with LPN #1 identified there were no signed advanced directives in the paper chart or scanned into the Electronic Medical Record (EMR). LPN #1 stated the admitting nurse and Registered Nurse (RN) supervisor are responsible for ensuring advanced directive forms are completed during the admission process.Interview and clinical record review with RN #4 (nursing manager) on 2/9/2026 at 11:50 AM identified Resident #127 did not have completed advanced directives. RN #4 stated in the event of a code, staff must ensure the code status in the paper chart and EMR match; otherwise, staff would treat the resident as Full Code. RN #4 identified although Resident #127's EMR indicated he/she a Full Code, she could not confirm whether this reflected Resident #127's current wishes without a signed advanced directive. RN #4 stated she would need to verify with Resident #127 that he/she wished to be a Full Code. RN #4 could explain why Resident #127's advanced directives had not been completed. Interview with the DNS on 2/9/2026 at 2:15 PM identified nurses are responsible for ensuring advance directives are completed for every resident on day of admission. The DNS stated in the event of a code, nurses are expected to check both the paper chart and the EMR to verify the resident's code status. The DNS could not explain why Resident #127's advance directives had not been completed.Review of the facility Resident Rights Regarding Treatment and Advanced Directives policy identified, in part, upon admission the facility will determine if the resident has executed an advanced directive, and if not determine whether the resident would like to formulate an advanced directive. Upon admission, should the resident have an advanced directive, copies will be made and placed in the chart as well as communicated to staff.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #11) reviewed for dignity, the facility failed to ensure a resident with respiratory concerns had a clean and sanitary homelike environment. The findings include:Resident #11 had diagnoses that included chronic respiratory failure with hypoxia, tracheotomy, chronic obstructive pulmonary disease, stroke, and gastrostomy (g-tube) related to dysphagia. The quarterly MDS dated [DATE] identified Resident #11 had intact cognition and was independent with ADLs. The physician's order dated 1/8/26 directed to administrator eternal tube feeding of 474 milliliters via g-tube bolus twice a day, perform tracheostomy care twice a day and as needed, and enhanced barrier precautions related to Extended-Spectrum Beta-Lactamases (bacteria resistant to a variety of commonly used antibiotics) in the secretions of the tracheostomy. The RCP dated 2/4/26 identified Resident #11 had a tracheostomy in place. Interventions directed tracheostomy care twice a day and as needed for extra secretions and change the tracheostomy tube per physician's orders. Observation on 2/5/26 at 1:20 PM identified Resident #11 was seated in a standard wheelchair in his/her room. The wheelchair had visible dirt buildup on the seat, legs, and wheels; and the back right wheel was torn and shredded. The room only contained a bed for seating, and three rusty soiled overbed tables used for meals, respiratory equipment, and computers. The room walls and radiators had hardened brown drippings. The floor had brown spots and dirt built up along edges and corners. A red rolling walker near the doorway was soiled with brown debris.Observation on 2/9/26 at 2:00 PM identified Resident #11 was seated in a standard wheelchair in his/her room. The wheelchair had visible dirt buildup on the seat, legs, and wheels; and the back right wheel was torn and shredded. The room only contained a bed for seating, and three rusty soiled overbed tables used for meals, respiratory equipment, and computers. The room walls and radiators had hardened brown drippings. The floor had brown spots and dirt built up along edges and corners.Observation on 2/11/26 at 2:00 PM identified Resident #11 was seated in a standard wheelchair in his/her room. The wheelchair had visible dirt buildup on the seat, legs, and wheels; and the back right wheel was torn and shredded. The room only contained a bed for seating, and three rusty soiled overbed tables used for meals, respiratory equipment, and computers. The room walls and radiators had hardened brown drippings. The floor had brown spots and dirt built up along edges and corners. Interview and observations with the Administrator and DNS on 2/17/26 at 8:55 AM identified Resident #11 was lying on top of the bed in his/her room. The Administrator acknowledged dirt and food build on the room floor and Resident #11's wheelchair. The Administrator stated it took a long time for food and dirt to accumulate. The Administrator identified housekeeping follows a cleaning schedule, but Resident #11's wheelchair was not maintained. The Administrator stated Resident #11 needed a bedside chair. The Administrator indicated she was unaware of Resident #11's rusty overbed tables. The Administrator identified she would have expected staff to clean the wheelchair and floor. The Administrator stated Resident #11's room required deep cleaning. The Administrator was unable to explain why Resident #11's wheelchair and room had not been cleaned. Interview with the Director of Housekeeping on 2/17/26 at 11:50 AM identified he was the interim director from a contracted agency. The Director of Housekeeping stated Resident #11's room was scheduled for monthly deep cleaning, but he could not verify when or if it had been completed. The Director of Housekeeping identified on 2/16/26 Resident #11's room was scheduled for cleaning, but housekeeping staff did not complete it. The Director of Housekeeping indicated the wheelchair cleaning rotates weekly by unit. The Director of Housekeeping identified he was unable to locate the rosters for wheelchair cleaning. The Director of Housekeeping stated he Director of Housekeeping identified he was unable to locate the rosters for the wheelchairs on the 400-unit. The Director of Housekeeping stated he could not verify if Resident #11's wheelchair had been washed in the last 6 months. Review of the facility Safe and Homelike Environment policy identified in accordance with resident rights, the facility will provide a safe, clean, comfortable homelike environment. Sanitary means preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes equipment used in the completion of the activities of daily living. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Report any furniture in disrepair to maintenance promptly. Report any unresolved environmental concerns to the Administrator. Review of the facility Routine Cleaning and Disinfectant policy identified the facility was to ensure the provision of routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #96) reviewed for abuse, the facility failed to file a grievance for a resident who voiced concerns regarding treatment by a staff member. The findings include:Resident #96 had diagnoses that included overactive bladder, repeated falls, and congestive heart failure. Review of facility Grievance forms dated 1/1/2025 through 2/5/2026 failed to identify any grievances for Resident #96 regarding inappropriate staff behavior.The annual MDS assessment dated [DATE] identified Resident #96 had a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition, did not exhibit delusions or behavioral symptoms towards others, and was dependent with toileting hygiene and chair/bed-to-chair transfers.The RCP dated 11/4/2025 identified Resident #96 required assistance with activities of daily living. Interventions included assistance of two using a mechanical lift, assist of two for bed mobility, and dependent with toileting. The RCP further identified Resident #96 was resistive to care and fabricated stories. Interventions included providing consistent, trusted caregivers, and structured daily routine when possible.Interview with Resident #96 on 2/5/2026 at 10:16 AM identified he/she had experienced negative interactions with an aide on day shift. Resident #96 stated the aide does not treat me well and stated he/she felt humiliated when requesting assistance with toileting. Resident #96 indicated the aide spoke in a rude tone and had rolled her eyes at him/her from the hallway on multiple occasions. Resident #96 stated he/she had told several nurses about the aide's behavior, and the aide was not removed from his/her assignment. Resident #96 declined to identify the aide by name because he/she was afraid of retaliation.Interview with LPN #4 on 2/10/2026 at 12:57 PM, LPN #4 stated Resident #96 had voiced a grievance to her in the past about not being treated kindly by an aide. LPN #4 indicated Resident #96 had not voiced the name of the aide. LPN #4 stated she did not report Resident #96's complaint to her supervisor or anyone else because she believed Resident #96 wouldn't talk to her supervisor if the complaint were reported. LPN #4 stated Resident #96 acted like he/she wanted it dropped.On 2/10/2026 at 1:50 PM, the state surveyor notified the DNS of Resident #96's grievance.Review of Facility reportable event dated 2/10/2026 at 4:57 P.M. identified Nurse Aide (NA) #3 as the alleged perpetrator of Resident #96's grievance. Interview with NA #3 on 2/11/2026 at 9:32 AM identified she had cared for Resident #96 for several years and had not received any complaints about the care she provided. NA #3 stated she had never rolled her eyes at Resident #96 or made any negative comments to Resident #96 while providing care.Interview with the DNS on 2/11/2026 at 12:12 PM identified she was unaware of Resident #96's concerns regarding treatment prior to surveyor inquiry on 2/10/2026. The DNS identified her expectations are that staff report grievances as soon as the grievance is made. The DNS stated when Resident #96 initially voiced concerns related to treatment by a staff member a grievance should have been completed. Review of the facility's Resident and Family Grievances policy identified, in part, that a resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their facility stay. Grievances may be voiced as a verbal complaint to a staff member or Grievance Official. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form and forward the grievance form to the Grievance Official as soon as practicable. The facility will take appropriate action in accordance with State law if an alleged violation of resident's rights is confirmed by the facility or an outside agency, such as the State Survey Agency. The facility will make prompt efforts to resolve grievances.

Based on review of the clinical record, facility policy, facility documentation, and interviews for 1 of 5 residents (Resident #8) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to submit a request for a Level II screen subsequent to Resident #8's new psychiatric diagnoses. The findings include:Resident #8 had diagnoses that included paranoid personality disorder, anxiety, depression, and dementia.A PASRR Level 1 Screen dated 5/24/24 identified Resident #8 had no diagnosis of any mental illness and no diagnosis of dementia. The Level 1 screen indicated Resident #8 was approved for long term care.Review of Resident #8's clinical record identified on 6/24/24 diagnosis of paranoid personality disorder was added.A PASRR Level 1 Screen outcome dated 6/26/24 submitted by SW #2 dated identified Resident #8 had diagnoses of anxiety and dementia. The Level 1 outcome did not identify Resident #8's diagnoses of paranoid personality disorder and depression. The outcome from the assessment indicated long term care for a nursing facility level of care with no status change. The PASRR Level 1 Screen further identified Resident #8's approval remained valid for the duration of his/her stay and that no additional screening was required unless Resident #8 was suspected of having a serious mental illness or an intellectual or developmental disability and exhibited a significant change in treatment needs.Review of Resident #8's clinical record identified on 6/27/24 diagnosis of anxiety disorder was added.The admission MDS dated [DATE] identified Resident #8 had severely impaired cognition, diagnoses of paranoid personality disorder, anxiety, depression, and dementia. The MDS further identified antipsychotic and antidepressant medications were administered. The physician's order dated 6/27/24 directed to administer Lexapro (antidepressant) 5 mg at bedtime, Trazodone (for anxiety) 50 mg every 8 hours as needed for agitation, and Risperidone (antipsychotic) 0.25 mg every 12 hours as needed for behavioral disturbances. A Psychiatric Evaluation and Consultation note dated 6/27/24 identified Resident #8 was seen for evaluation of his/her mood and behaviors related to insomnia, anxiety, depression, agitation, dementia, and paranoid personality disorder.The RCP dated 6/28/24 identified Resident #8 had a mood problem related to agitation, anxiety, depression, insomnia, paranoia and confusion. Interventions directed to administer medications as ordered.A Psychiatric Evaluation and Consultation note dated 7/8/24 identified Resident #8 was seen for evaluation of his/her mood and behaviors related to insomnia, anxiety, depression, agitation, dementia, and paranoid personality disorder.A Psychiatric Evaluation and Consultation note dated 7/17/24 identified Resident #8 was seen for evaluation of his/her mood and behaviors related to insomnia, anxiety, depression, agitation, dementia, and paranoid personality disorder.Review of the clinical record failed to identify the PASSR contracted agency was notified of the new psychiatric diagnoses of paranoid personality disorder and anxiety disorder from 6/27/24 through 2/9/26 in order to conduct an additional Level 1 and Level 2 screen.Interview with SW #1 (Director of Social Services) on 2/9/26 at 12:24 PM identified he was responsible for updating the PASRR contracted agency when there is a new psychiatric diagnosis. Subsequent to surveyor inquiry, SW #1 reviewed the clinical record, identified Resident #8 had diagnoses of paranoid personality disorder, anxiety, and dementia which occurred after Resident #8's admission to the facility and had not been communicated to the PASRR contracted agency. SW #1 indicated it had been missed by SW #2 and was unable to identify the reason SW #2 had not updated the PASRR contracted agency with the new diagnoses of paranoid personality disorder, anxiety, and dementia. SW #1 stated Resident #8's PASRR should have been resubmitted at the time of the new psychiatric diagnoses.Interview with SW #2 on 2/9/26 at 12:45 PM identified she submitted Resident #8's PASRR on 6/21/24 with and received the outcome on 6/26/24. SW #2 indicated when she reviewed Resident #8's psychiatric notes she just looked at the diagnosis in bold type and did not read all the diagnosis. SW #2 stated she missed Resident #8's diagnoses of depression and paranoid personality disorder.Subsequent to surveyor inquiry, a PASRR submission request dated 2/10/26 was made to the PASSR contracted agency to report that Resident #8 had a new diagnosis of paranoid personality disorder which may trigger a Level II PASRR. Review of the Resident Assessment Coordination with PASRR Program policy directed, in part, the facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental health disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The facility will only admit residents with a mental health disorder or intellectual disability who the state mental health authority has determined as appropriate for admission. The social services director will be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. The policy further identified any resident who exhibits a newly evident or possible serious mental health disorder or related condition will be referred promptly to the state mental health authority for a Level 2 review.

Based on the observation, review of the clinical record review, facility documentation, facility policy, and interviews for 1 of 1 sampled resident (Resident #91) reviewed for medication storage, the facility failed to properly secure medication, and for 1 of 1 sampled resident (Resident #91) reviewed for medication administration the facility to ensure obtain physician's order prior to providing a resident with medication. The findings included:Resident #91 had diagnoses that included hypertension, hepatitis C, kidney disease, and pruritus (chronic itchiness). The RCP dated 2/3/26 identified Resident #91 had itching and was at risk for decreased ability to perform personal care tasks (ADL's). Interventions directed to administer medications as ordered, document effectiveness, and update the physician as necessary with any changes. The admission MDS dated [DATE], identified Resident #91 was cognitively intact, required the application of ointments/medications other than to his/her feet and was supervised or provided touching assistance for toileting, standing/transferring and bed mobility.a. Observation and interview on 2/5/26 at 10:38 AM identified Resident #91 was noted to have a 2-ounce tube of Hydrocortisone 1 % cream on the bedside table in his/her room. The tube was not in its original box and did not contain a pharmacy label or an opened dated indicating when the medication was dispensed or first opened.Interview with Resident #91 on 2/5/26 at 10:38 AM, identified Resident #91 indicated the Hydrocortisone 1 % cream was provided by the nursing staff and routinely left at the bedside. Resident #91 stated the cream does nothing to relieve the itch. A second observation on 2/9/2026 at 10:38 AM, Resident #91 was observed in his/her room with Person #1, and the 2-ounce tube of Hydrocortisone 1% cream was noted lying on Resident #91's bedside table. The tube was not in its original box and did not contain a pharmacy label or an opened date indicating when the medication was dispensed or first opened.Interview with Resident #91 and Person #1 on 2/9/26 at 10:38 AM identified both Resident #91 and Person #1 stated the Hydrocortisone cream was provided by the facility. Person #1 stated that no medications or ointments had been brought from home for Resident #91. Person #1 identified he/she informed the facility Resident #91 had previously used another ointment at home. Resident #91 stated he/she was unable to recall which staff member provided him/her the Hydrocortisone cream.b. Review of Resident #91's clinical record on 2/5/26 failed to identify a physician's order for Hydrocortisone 1% cream. Subsequent to surveyor inquiry on 2/5/26, a physician's order was obtained directing to apply hydrocortisone 1% cream topically to trunk and bilateral arms every day and night shift for itch, for 14 days. An interview and observation on 2/9/2026 at 11:08 AM with the DNS identified a tube of Hydrocortisone 1 % cream was noted on Resident #91's bedside table. The DNS stated that the Hydrocortisone 1% cream should not have been left at the resident's bedside. The DNS stated the Hydrocortisone 1% cream was facility house stock and removed it from Resident #91's bedside table at that time. The DNS stated a physician order is required prior to administering any medications including house stock. Review of facility Medication Storage policy dated 7/1/2024, directed in part, it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Review of facility Medication Orders policy dated 7/1/2024, directed in part, directed medications should be administered only upon the signed order from a person lawfully authorized to prescribe.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #42) reviewed for pressure ulcers, the facility failed to maintain proper infection control during wound care and perform hand hygiene between glove changes and for 2 of 3 residents (Resident #53 and Resident #127) reviewed Enhanced Barrier Precautions (EBP) the facility to wear appropriate Personal Protective Equipment (PPE) during care. The findings include:1.Resident #42 had diagnoses that included severe protein-calorie malnutrition, osteoarthritis, colonized MRSA, and peripheral vascular disease. The quarterly MDS assessment dated [DATE] identified Resident #42 had intact cognition, dependent on staff for all ADLs including bed mobility and transfers. The MDS identified a stage 4 pressure ulcer was present. The RCP dated 12/26/25 identified Resident #42 was non complaint with offloading heels, had a stage 4 pressure ulcer to the left hip, and discolored areas to the bilateral heels. Interventions directed to educate resident on why heels must be elevated to prevent pressure injury and maintain skin integrity and provide wound care per physician's orders. The physician's order dated 2/8/26 directed to apply Dakins 1/4 strength solution to left heel topically once a day for a deep tissue injury and irrigate the left heel with Dakins 1/4 strength solution, apply calcium alginate with silver (AG) followed by a dry clean dressing daily and as needed, and irrigate the left ischium with normal saline followed by calcium alginate and dry clean dressing daily and as needed. Observation of Resident #42's wound care on 2/11/26 at 2:30 PM with the ADNS (wound nurse) and LPN #5 identified LPN #5 collected all the necessary supplies for the dressing changes before entering the room. LPN #5 and the ADNS donned PPE (gown and gloves) before entering the resident's room. LPN #5 placed a box of gloves and a bottle of hand sanitizer on the foot of Resident #42's bed. LPN #5 poured Dakins 1/4 solution into a plastic cup and placed it on Resident #42's bedside table without the benefit of cleansing the tabletop or placing a barrier on the tabletop surface. LPN #5 removed the dressing from Resident #42's left hip and discarded it into the garbage. LPN #5 removed the soiled gloves and without performing hand hygiene donned a new pair of gloves. LPN #5 poured Dakins 1/4 strength solution from the plastic cup on to gauze pads, cleansed the wound, and packed the wound with the Dakins 1/4 strength gauze pads she used to cleanse. LPN #5 removed the soiled gloves and without performing hand hygiene donned a new pair of gloves. LPN #5 then placed a piece of calcium alginate with silver over the Dakins 1/4 strength gauze pads. The ADNS intervened and directed LPN #5 to remove the gauze pads from the wound bed and then apply the calcium alginate with silver to the wound bed. LPN #5 removed the calcium alginate with silver and Dakins 1/4 solution gauze pads packing form the wound. LPN #5 removed the soiled gloves and without performing hand hygiene donned a new pair of gloves. LPN #5 took the same piece of calcium alginate with silver that she removed, placed it over the wound, and followed by a bordered gauze dressing . LPN #5 removed the soiled gloves and without performing hand hygiene donned a new pair of gloves. LPN #5 removed the dressing from the left heel, discarded the dressing, removed her gloves, and without performing hand hygiene, donned a new pair of gloves. Following this LPN #5 poured Dakins 1/4 strength solution from the plastic cup on to gauze pads, cleansed the left heel wound and discarded the gauze pad, and with the same gloves on she applied a piece of calcium alginate with silver to the wound bed, and placed bordered gauze dressing over the wound. LPN #5 removed the soiled gloves and without performing hand hygiene, donned a new pair of gloves. LPN #5 proceeded to apply skin prep to the right heel and placed a bordered gauze dressing over the heel. LPN #5 removed her soiled gloves and discarded them in the waste bin. LPN #5 then washed her hands in the resident bathroom. Interview with the DNS on 2/11/26 at 3:11 PM identified that for all wound care, nurses should ensure a clean environment for use as a surface for supplies, such as a bedside table, and not place supplies on a resident's bed. The DNS stated that all nurses are to perform hand hygiene before initiating a dressing change and between all glove changes. Interview with the ADNS (wound nurse) on 2/17/26 at 10:30 AM identified during dressing changes all nurses are to perform hand hygiene between all glove changes. Review of the facility Hand Hygiene Policy identified all staff will perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene will be performed by washing your hands vigorously for at least 20 seconds or alcohol-based hand rub for 20 seconds covering all surfaces of hands and fingers. The use of gloves does not replace hand hygiene. If your task requires glove perform hand hygiene before you put gloves on and after you remove the gloves. Hand hygiene table identifies hand hygiene must be done before and after handling clean or soiled dressings. Review of the facility Clean Dressing Change Policy identified it is the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes. Wound care supplies will be dated and initialed when they are opened. Each wound will be treated individually. When multiple wounds are being addressed, the dressings will be changed in the order of least contaminated to most contaminated. The dressing with infected wounds will be changed last. Set up the field on the overbed table with needed supplies for wound cleaning and dressing applications, wash hands and put on gloves once wound supplies are prepared. Loosen the dressing and remove the existing dressing. Remove gloves by pulling the glove inside out over the old dressing Discard into receptacle. Wash hands and put on clean gloves. Cleanse the wound as ordered and pat dry with gauze. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound per physician order. Secure dressing and mark with initials and date. Discard disposable items and gloves into appropriate trash receptacles and wash hands. 2. Resident #53's had diagnoses that included dementia, Diabetes Meletus, and a Stage 2 pressure ulcer. The annual MDS assessment dated [DATE] identified Resident #53 had a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment, was dependent on staff with personal hygiene and required maximal assistance with rolling left and right. The RCP dated 1/21/2026 identified Resident #53 had a stage 2 pressure ulcer. Interventions included provide turning and repositioning as tolerated, apply treatment as ordered, and monitor for signs and symptoms of infection. The RCP failed to include that he/she was on EBP. A review of Physician's orders on 2/05/2026 failed to identify an order directing EBP. Observation of Resident #53's room on 2/09/2026 at 1:27 PM identified an Enhanced Barrier Precautions (EBP) sign posted outside Resident #53's door directing providers and staff gown and gloves must be worn for high contact activities. Observation and interview with NA #2 on 2/09/2026 at 1:27 PM identified NA #2 started to roll Resident #53 from his/her back to his/her side in preparation to receive wound care and provide incontinent care without the benefit of wearing a gown or gloves. NA #2 stated when providing care to a resident on EBP she should have donned a gown and gloves, but she did not think of it. Observation of wound care on 2/09/2026 at 1:29 PM with LPN #1 identified an open wound Resident #53's coccyx that measured 1 centimeter (cm) X 1.5 cm with a medium pink colored base. Subsequent to surveyor inquiry, a physician's order dated 2/09/2026 at 3:00 PM directed Enhanced Barrier Precautions related to increased risk of transmission to/from due to a chronic wound. 3. Resident #127 had diagnoses that included Type 2 Diabetes Meletus, congestive heart failure, and osteomyelitis. The quarterly MDS assessment dated [DATE] identified Resident #127 had a Brief Interview of Mental Status (BIMS) score of 15 indicative of intact cognitive, and required supervision with personal hygiene, rolling left and right and chair/bed to chair transfers. The RCP dated 12/15/2025 identified Resident #127 was at risk for skin breakdown and had moisture-associated skin damage (MASD) to the bilateral buttocks. Interventions directed to provide treatment per medical doctor order, weekly wound assessments, and observe skin for signs/symptoms of skin breakdown. The RCP failed to identify that he/she was on EBP. The Wound care provider notes dated 1/30/2026 through 2/2/2026 identified Resident #127 had a stage 2 pressure ulcer on the left buttock with partial thickness skin loss. A review of Physician's orders on 2/05/2026 failed to identify an order directing EBP. Observation of Resident #127's room on 2/09/2026 at 12:59 PM identified an Enhanced Barrier Precautions (EBP) sign posted outside Resident #127's door directing providers and staff gown and gloves must be worn for high contact activities. Observation and interview with the ADNS on 2/09/2026 at 12:59 PM identified the ADNS administered Resident #127's wound care without the benefit of wearing a gown. The ADNS identified she did not put a gown on prior to administering wound care because she felt very rushed and had a lot of medications to pass. The ADNS stated she should have put a gown on according to the facility policy. Interview on 2/09/2026 at 1:51 PM with Registered Nurse (RN) #4 (nursing manager) staff should wear appropriate PPE when providing care to residents on EBP residents, including during incontinence care and wound care. RN #4 stated NA #2 and the ADNS should have worn PPE when providing care to the residents on EBP. RN #4 could not explain why NA #2 and the ADNS failed to don appropriate PPE. Interview on 2/09/2026 at 2:15 PM with the Director of Nursing Services (DNS) identified all staff should wear a gown and gloves when providing hands on care to any residents on EBP. The DNS stated NA #2 and the ADNS should have donned the appropriate PPE prior to providing the residents with care. Review of the facility Enhanced Barrier Precautions policy identified in part an order for EBP will be obtained for residents with wounds (e.g. Chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) even if the resident is not known to be infected or colonized with a Multi Drug Resistant Organism. PPE for EBP is necessary when performing high-contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, and wound care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was treated with respect and dignity. The findings include: Resident #1's diagnoses included depressive episodes, anxiety, delusional disorders and auditory hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, required assistance with ADLs, and had no behaviors. The Resident Care Plan (RCP) dated 2/22/2025 or last CP review completed dated 3/11/2025 identified a decreased ability to perform ADLs. Interventions directed to assist with ADLs. Review of Facility Reportable Events form dated 3/15/2025 at 1:30 PM identified according to witnesses (LPN #1 and Dietary Aide #1) Resident #1 and Nurse Aide (NA) #1 exchanged harsh words, Resident #1 became upset, claiming NA #1 had yelled at him/her first which and then Resident #1 shouted back, and used foul language directed at NA #1 (told NA #1 to shut the ***k up. The form indicated witnesses reported NA #1 responded to Resident #1 using foul language and repeated the same phrase to Resident #1. Resident #1 reported the exchange to RN #1. Interview and witness statement review with Dietary Aide #1 on 4/8/2025 at 11:48 AM identified she was standing in the hall directly across from Resident #1's room when she heard a NA saying in a loud voice to Resident #1, how do you not know how to clean yourself up and not know how to use a ***king napkin. Dietary Aide #1 stated LPN #1 was in the same hallway, she notified LPN #1 and LPN #1 went into the resident's room. Dietary Aide #1 stated she did not hear Resident #1 speaking, and she spoke to LPN #1 and LPN #1 entered Resident #1's room. Interview and review of witness statement on 4/8/2025 at 12:07 PM with LPN #1 identified Dietary Aide #1 did not notify her; she was standing at the medication cart in the nearby (lateral) hallway when she heard Resident #1 and NA #1 talking in loud voices that she described as screaming at each other. When she arrived at the room, NA #1 told her the kitchen always gives Resident #1 too much ice cream and pudding. LPN #1 reported there was pudding and ice cream on the resident and on the floor and NA #1 stated Resident #1 does that all the time. NA #1 said she was trying to give Resident #1 a wash cloth to wash his/her hands and face, and the resident did not want to do it. NA #1 indicated Resident #1 said it's your ***king job to do it, so you clean it up, and NA #1 responded yes, I clean up everything else, we are trying to get you to . but Resident #1 interrupted and told NA #1 to shut the ***k up. LPN #1 stated NA #1 spoke to Resident #1 in a raised tone, a raised voice volume and said right back at you to Resident #1, but NA #1 did not use foul language; did not use the f-word. On 4/8/2025 at 12:59 PM interview, review of clinical record and facility documentation with RN #1/RN supervisor identified Dietary Aide #1 notified him that she overheard a verbal exchange between a resident and a NA. RN #1 began an investigation, spoke with Resident #1, LPN #1, Dietary Aide #1, and NA #1. RN #1 stated NA #1 may have been offended by comments the resident made, however, NA #1 should not have behaved in that manner and it was unprofessional. Interview and review of witness statement on 4/8/2025 at 1:16 PM with NA #1 indicated Resident #1 had never spoken to her like that before, ice cream was everywhere and Resident #1 started swearing at her and said, shut the ***k up. NA #1 stated she did not swear back at the resident, but repeated back to the resident asking, why did you tell me to shut the *** up? NA #1 indicated that she did not swear at the resident and denied speaking in a loud volume level or raised voice. Interview, clinical record and facility documentation review on 4/8/2025 at 2:22 PM with the DNS identified Dietary Aide #1 and LPN #1 both overheard NA #1 speaking with Resident #1, and when LPN #1 entered the room, he observed spilled yogurt and ice cream on the resident's clothes. NA #1 handed a towel to Resident #1 to clean up the food, the resident became upset and told NA #1 shut the ***k up. NA #1 responded by saying why did you say shut the ***k up to me? NA #1's voice was overheard as she was speaking too loud to Resident #1. The DNS stated that NA #1 should not have spoken loudly, in that tone or volume or repeated the sentence back to the resident. NA #1 should not have asked the resident why he/she said it, and NA #1 should have just gone about doing what she needed to do. Review of the facility Resident Rights Policy directed in part, the resident has a right to be treated with respect and dignity. Review of Employee Relations, code of conduct directed in part the Company considers professional conduct and compliance with Company's policies and procedures to be an essential responsibility of an employee's job.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to provide the necessary supervision to prevent elopement. As a result, Resident #1 who had cognitive impairment and was at risk for elopement was able to exit the building unsupervised, resulting in a finding of Immediate Jeopardy, past non-compliance. The finding includes: Resident #1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, alcohol induced dementia and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of seven (7) indicative of moderate cognitive impairment and required supervision with Activities of Daily Living (ADLs) including ambulation. A Social Work (SW) note dated 8/15/24 identified a family meeting was held due to Resident #1 walking all over the building and going into other resident's rooms. The interdisciplinary team and family agreed that the resident would need to be transferred to a facility with a secured dementia unit for his/her safety. The referral process was started on 8/16/24. The care plan dated 8/25/24 identified Resident #1 had the potential for impaired cognitive function related to metabolic encephalopathy with interventions that included to cue, reorient and supervise as needed. Psychiatric notes dated 8/15, 8/28, 9/5 and 9/9/24 identified Resident #1 was seen due to concerns of wandering behaviors. Resident #1 presented with significant cognitive impairment, almost manic-like, confused, poor executive functioning, very poor impulse control with cognitive deficits quite evident, the resident would benefit from a secured dementia unit. Medication adjustments were made to prevent psychiatric hospitalization . A nurse's note dated 9/9/24 at 12:03 PM written by Registered Nurse (RN) #1 identified that Resident #1 was wandering and restless. An elopement risk assessment was completed. The assessment identified Resident #1 had short- and long-term memory loss, was confused, had impaired decision-making ability and delusions and hallucinations which could contribute to an elopement risk. The elopement risk assessment dated [DATE] identified Resident #1 scored a nine (9) which identified a moderate risk for elopement. An interim care plan dated 9/9/25 identified Resident #1 was at risk for an elopement related to cognitive loss/dementia/wandering behavior and a wander guard (a bracelet placed on a resident to alert staff when a resident approaches an exit door) was in place with interventions that directed to monitor the resident's location with visual checks at least every 1-2 hours as needed. A reportable event form dated 9/10/24 identified at approximately 4:30 PM Resident #1 was observed sitting in the hallway of the 300 unit. Around 4:45 PM, Resident #1 could not be located, and the charge nurse (LPN#1) began to search for the resident. The charge nurse alerted the nursing supervisor who instructed all staff to begin searching for the resident. The supervisor notified the Director of Nursing Services, Administrator, Resident #1's family and the police department. The reportable event summary identified that #1 was found wandering next to a nearby facility (0.3 miles away), had complaints of chest pain and was sent to the emergency department where police later located Resident #1 around 6:45 PM. Around 9:00 PM the hospital called to report Resident #1 would return to the facility. Observation and interview with the Director of Maintenance on of the 300-unit emergency exit door on 10/1/24 at 10:00 AM identified that the emergency door was not equipped with a wander guard alert system. When the door is opened, an alarm will immediately sound to alert the staff the door has been opened, a numeric code must be placed into the keypad by staff to silence and reset the alarm. Interview with Nurse Aide (NA) #1 on 10/1/24 at 12:52 PM identified on 9/10/24 she last saw Resident #1 sitting in the hallway around 3:30 PM. NA #1 identified sometime prior to dinner being served (4:30 PM), the emergency door in unit 300 alarmed, she responded, the door was closed, so she entered the numeric code to reset and silence the alarm and continued providing care to her assigned residents. NA #1 identified she became aware that Resident #1 was missing, although could not state the time or how she became aware the resident was missing. NA #1 then informed the nursing supervisor, RN #1, that she could not find Resident #1. NA #1 identified that she was unaware that when the door alarm sounded, she needed to investigate why the alarm sounded which included looking outside to see if a resident exited. Facility documentation identified that NA #1 was educated in 2023 on the elopement and door alarm policy. Interview with Licensed Practical Nurse (LPN) #1 on 10/1/24 at 11:22 AM identified on 9/10/24 around 4:20 PM, NA #1 informed her that Resident #1 was missing. At 4:30 PM LPN #1 informed Registered Nurse (RN) #2 that she could not locate Resident #1, they both began to search the facility. LPN #1 identified she did not page for a Dr. Hunt when the resident could not be located and was not aware that a Dr. Hunt needed to be called because she was not given education on the elopement policy. Facility documentation identified that LPN#1 was educated on the elopement policy in 2023. Interview with RN #2 on 10/2/24 at 10:15 AM identified on 9/10/24 at 4:30 PM LPN #1 informed him she could not locate Resident #1. RN #2 identified he stopped his medication pass and started looking for Resident #1 and did not tell the supervisor that Resident #1 was missing or page Dr. Hunt because he was busy trying to locate Resident #1. Interview with RN #1 on 10/2/24 at 2:22 PM identified on 9/10/24 she was working the floor in the 400 unit and supervising the building. RN #1 identified around 5:00 PM, NA #1 called her from the 300 unit and asked if she had seen Resident #1. RN #1 stated she paged Dr. Hunt overhead, but the page was unclear, so she went to each department and unit to tell them Resident #1 was missing. A search of the facility and facility grounds was conducted, and Resident #1 could not be located, and the police were notified. Interview with the DNS on 10/1/24 at 1:48 PM identified when a door alarm goes off, all staff are to investigate why the door is alarming, and step outside to ensure a resident has not exited. The DNS identified NA #1 should have looked outside when the emergency door alarmed, and LPN #1 and RN #2 should have called a Dr. Hunt and notified the nursing supervisor when the resident was first identified as missing. The DNS identified that Dr. Hunt was paged around 5:00 PM by RN #1 (approximately 40 minutes after Resident #1 was first identified as missing). Review of the elopement prevention and management policy identified the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. It further identified an elopement as defined by when a resident leaves the physical structure of the facility unattended and without staff knowledge. Review of the elopements and wandering resident's policy directed alarms are not a replacement for necessary supervision and staff are to be vigilant in responding to alarms in a timely manner. It further directed the procedure for locating a missing resident is as follows: any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code), the designated facility staff will look for the resident, if the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department, DNS or designee shall notify the physician and family member or legal representative.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to ensure the resident who was a known to wander, had physician's orders and a care plan in place for a wanderguard in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included metabolic encephalopathy, alcohol induced dementia and anxiety. The nursing admission assessment dated [DATE] identified Resident #1 was not able to ambulate, or self propel a wheelchair independently, therefore Resident #1 was not at risk for an elopement. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition and requires assistance with ADLs. A nurses note dated 8/12/24 at 5:18 AM written by LPN #2 identified Resident #1 slept partially that shift and a wanderguard was in place. Psychiatric notes dated 8/15/24 , 8/25, 8/28, 9/5/24 and 9/9/24 identified per staff report Resident #1 wandered and went into other resident's rooms. Resident #1 was forgetful with chronic confusion however re-directable. . A SW note dated 8/15/24 identified a family meeting was held due to Resident #1 walking all over the building and going into other resident's belongings and rooms. The team and family agreed that the resident needed to be placed in a locked dementia unit for his/her safety due to dementia. On 8/16/24 a referral was made to another nursing facility. The care plan dated 8/25/24 identified Resident #1 was at risk for decreased ability to perform ADL's. Interventions included assist of one staff for transfers and ambulation with rolling walker as tolerated. The care plan further identified Resident #1 had the potential for impaired cognitive function related to metabolic encephalopathy. Interventions included to cue, reorient and supervise as needed. A nursing note dated 8/27/24 at 6:13 AM identified Resident #1's wandering occurred daily or almost daily and posed a significant risk and/or is intruding on others. A nursing note dated 8/31/24 at 2:16 PM identified Resident #1 was wandering at times and a wanderguard was in place and functioning. Review of Resident #1's medical record failed to identify an elopement assessment, progress note and care plan was in place for Resident #1's wanderguard. RN #1 nursing note dated 9/9/24 at 12:03 PM identified an elopement risk assessment was completed. It identified Resident #1 had short and long term memory loss, was disorientated, had impaired decision making ability and delusions and hallucinations which could contribute to an elopement risk. Resident #1 was wandering and restless. The elopement risk assessment dated [DATE] identified Resident #1 scored a nine (9) which identified he/she was a moderate risk for elopement. The care plan dated 9/9/25 identified Resident #1 was at risk for an elopement related to cognitive loss/dementia/wandering behavior and a wanderguard was in place. Interventions included to monitor the resident's location with visual checks at least every 1-2 hours as needed. The accident and incident form dated 9/10/24 identified around 4:30 PM Resident #1 was observed sitting in the hallway of the 300 unit. Around 4:45 PM, Resident #1 was identified not in his/her room and the charge nuse began to search for him/her. The charge nurse alerted the supervisor who instructed all staff to begin searching for the resident. The supervisor notified the DNS, Administrator, Resident #1's family and the police. A few hours later, the facility received notice that Resident #1 was found wandering near a nearby facility (0.3 miles away) and an ambulance was dispatched. Around 9:00 PM the hospital called to report Resident #1 would return to the facility. Review of the physician's orders failed to identify wanderguard orders were in place prior to Resident #1's elopement on 9/10/24. A physician's order dated 9/10/24 directed wanderguard elopement device to right ankle due to poor safety awareness, expiration date of 10/2027 and check the function every night shift. Interview with LPN #2 on 10/1/24 at 11:30 AM identified Resident #1 had a wanderguard on his/her left ankle. She identified she did not place the wanderguard on Resident #1 but identified he/she already had it on. She identified she would not test the wanderguard for function but the 11:00 PM - 7:00 AM shift would check for functioning. Interview with RN #3 (11:00 PM - 7:00 AM supervisor) on 10/1/24 at 11:55 AM identified Resident #1 had a history of wandering into other resident's rooms. She identified she could not remember if Resident #1 had a wanderguard on previous to 9/10/24. She identified she did not place a wanderguard on Resident #1 prior to 9/10/24. She further identified for resident's with a wanderguard, the placement and function checks should be put in as a physician's order. Interview with RN #1 (3:00 PM - 11:00 PM supervisor) on 10/1/24 at 12:43 PM identified Resident #1 would wander aimlessly. She did not know when Resident #1's wanderguard was placed. She identified any nurse can put a wanderguard on a resident but needs to complete an elopement assessment, get a physician's order, write a progress note, update the care plan and . Interview with the DNS on 10/1/24 at 1:00 PM identified she did not know who put on Resident #1's initial wanderguard. She identified any nurse can put a wanderguard on a resident if the elopement assessment deemed them at risk for if a resident was attempting to leave. She identified the following should occur; an elopement assessment, physician orders received, tell the family/appointed person, put in orders for the wanderguard including expiration date, nursing note as to why the wanderguard was placed and update the care plan, however none was evident prior to 9/10/24. Review of the wandering policy directed the resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the elopements and wandering residents policy identified the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk.

Based on tour of the kitchen, observations, facility policy and interviews, the facility failed to ensure food items in the dry storage were kept sealed from the environment and non-food items (detergent and open box of unused scrub pads) were not stored in the dry food storage and failed to ensure that daily food meal temperatures were consistently documented and failed to ensure the cook during plating food properly handle hamburger roll and the nourishment room ice machines was free from build up and pink build up on the ice outlet and the one machine was free from water overflow dish that overflowed onto the floor. The findings included: 1. Observation of the kitchen during the survey 4/1/24 with the Food Service Director of the dry storage area identified a large box with a bag of chocolate chips left open. The Food Service Director at the time of the observation indicated brownies were made 2 days ago, and immediately closed and knotted the bag while stating the bag should have been closed after use. Further observation of the kitchen identified 2 bottles of dishwashing detergent and an open box of new green scrub pads were found on a shelf in the dry food storage in the presence of the Dietary Manger who indicated which the items should not be there, immediately removed and could not explain the items were in the dry storage area. 2. A kitchen review on 4/1/2024 at 9:15 AM with the Food Service Director identified the March food temperature log kept by the cook had no breakfast temperatures logged for 3/3/2024 and on 3/11 and 3/31/2024 no food temperatures were documented on the temperature log for dinner The Food Service Manager indicated temperature should have been taken and recorded and there was no other location where the temperatures could have been written. 3, On 4/1/2024 while arriving on the 300/400 unit with the steam table observation identified with the Dietary Manager the nourishment room ice machine tray was full of water which dripped onto the floor. The Dietary Manager removed the catch tray from the ice machine, emptied the water from the tray and returned the tray to the machine. 4. Observation 4/1/2024 at 11:40 AM while plating food from the steam table on the 300/400 unit Cook #2 reached into the hamburger roll bag with bare hands (not utilizing gloves or utensil) and plated a hamburger roll open to accept a hamburger handing to Cook #1. The Dietary Manager indicated the staff was told not to use gloves while serving on the units and went to the kitchen and returned with a pair of tongs and directed Cook #2 to use the tongs to pick up the rolls out of the bag to plate the roll. Cook #2 repeated what the Dietary Manger said to him/her and proceeded to access the hamburger rolls out of the bag and plate it with the use of the tongs. Cook #1 who plated the hamburger on the roll utilized tongs to hold the hamburger and roll while slicing it into quarters with a knife. The Dietary Manager further indicated he/she would expect tongs to be used when handling hamburger rolls. 5. Observations and interview on 4/02/24 at 12:30 PM with the Maintenance Director and review of the facility logs for cleaning noted completed monthly and noted no indication of any scale or buildup of pink debris on the ice outlet. The Maintenance Director further indicated the last cleaning was mid-March about 2 weeks ago. Observation of the 100/200-unit ice machine revealed a thick pink buildup of debris on the ice outlet which the Maintenance Director indicated was due to obtaining ice in cups and pitchers that already had juice in them. The Maintenance Director further indicated the cleaning schedule could be adjusted and proceeded to the 300/400 unit with the surveyor to observe the ice machine. Observation of the nourishment room revealed wet floor signs and water on the floor in the nourishment room and foot tracks from the nourishment room into the hallway. The Maintenance Director indicated the ice machine catch tray needs to be manually emptied or it overflows as this ice machine also gives water. After asking 2 nurse aids in the nourishment room if they called housekeeping to mop the water on the floor both (indicted no). The Maintenance Director indicated he/she would empty the catch tray as it was everyone's responsibility and would call housekeeping. On 4/2/2024 at 12:40 PM an interview and observation with Housekeeper #1 with (Maintenance Director in attendance) indicated his/her job duties in the 300/400 nourishment room is to wipe down the areas and ice machine, mop the floors and empty the collection tray further indicated he/she empties 3 times herself during the shift and does not know how many times other staff empty it during the shift. An observation on 4/03/24 at 12:49 PM identified the ice machine on 300/400 out of order/service and the tray removed from the machine. The facility policy labeled Food Storage: Dry Goods dated as revised 2/2023 indicated in part all packaged and canned food items will be kept clean, dry, and properly sealed, and date marked as appropriate. The facility policy labeled Storage: Chemicals dated 2/2023 indicated in part all chemicals will be in a separate/secure area labeled and in original containers. The facility policy labeled Meal Distribution dated revised on 2/2023 indicated in part meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and delivered in a timely and accurate manner with proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point of service dining.

Based on clinical record reviews, facility documentation, facility policy and interviews for 6 of 6 residents, (Residents # 27, # 28 , # 34, # 87 # 212 and # 215) reviewed for bed rails, the facility failed to acquire consent and physician's orders prior to the initiation of a bed rails, explain risk and benefits and failed to assess the function and perform maintenance to the bed rail according to facility policy. The findings included: 1. Resident #27 was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), dementia, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 was cognitively intact and dependent for personal hygiene, bathing, and toileting. The nursing quarterly assessment dated [DATE] identified Resident #27 had side rails on each side of the bed which were indicated for safety and to promote independence with bed mobility. After surveyor inquiry, a consent for use of bed rails dated 4/4/24 identified the use and risk of bed rails and the resident has the right to refuse them. Additionally, an order for bed rails dated 4/4/24 directed the use of bed rails as an enabler for turning and repositioning in bed. An interview on 4/4/24 at 12:47 PM with the DNS and the Director of Operations indicated consents and physician's orders for side rails were obtained on 4/4/24 and that the nursing staff should have obtained them on admission to the facility. The DNS and Director of Operations further indicated they were educating staff on this requirement at the time of the interview. 2. Resident #28's diagnosis included dementia and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had cognitive loss. Resident #28's care plan dated 3/11/2024 indicated Resident # 28 was at risk for falls due to impaired mobility, cognitive loss, and lack of safety awareness. Interventions included, in part to keep the bed in a low position and to tie the side rails in the down position to prevent Resident #28 from putting arms through the rails. An observation on 4/3/204 at 2:40 PM identified 2 half siderails on Resident #28's bed. An observation with RN #7 on 4/4/2024 at 10:40 AM identified 2 half side rails up on the sides of Resident#28's bed which was in the low position. After surveyor inquiry on 4/4/2024 at 11:23 AM a physician's order was obtained for 1/4 bedrails as an enabler for turning and repositioning in bed and verbal consent for use was obtained on 4/4/2024 from the responsible party/family. 3. Resident #34's diagnoses included Type 1 diabetes mellitus, falls, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #34 as severely cognitively impaired and required maximum assistance with toileting, showering and dressing. The Resident Care Plan with a revision date of 3/19/24 identified Resident #34 had an actual fall with no injury. Interventions included toileting the resident on last rounds, offering a snack followed by toileting when awake on the 11;00 PM - 7:00 AM shift. Further the Resident Care Plan identified Resident #34 at risk for falls. Interventions included reinforcing call bell use, placing call light within reach, and monitoring for and assisting with toileting needs. A quarterly nursing assessment dated [DATE] at 12:40 PM indicated Resident #34 had bed rails. On 4/3/24 at 2:00 PM an interview with the Director of Maintenance identified bed rails should be inspected annually. The Director of Maintenance identified that he had a log, and the Bed Rail Inspection Report for Resident #34 was dated 1/21/22. He indicated the last time the rails were inspected was 1/21/22. Further, The Director of Maintenance stated that he has not gotten a chance to inspect them. After surveyor inquiry a Bed Rail Inspection Report was produced on 4/4/24 with the inspection date of 2/16/23. A physician's order dated 4/4/24, after surveyor inquiry, directed for use of 1/4 bed rails as an enabler for turning and repositioning in bed. A consent for use of bed rails, dated 4/4/24, after surveyor inquiry, identified the use, risk, and benefits for use of bed rails. 4. Resident #87's diagnoses included end stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity. A bed rail inspection dated 1/21/22 identified the bed designated for room [ROOM NUMBER] A as a 'Passed' inspection. A quarterly Nursing assessment dated [DATE] identified two half side rails were in place for safety and to promote independence with bed mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 as cognitively intact, required substantial maximal assist with bed mobility, total two person assist with transfers and had no reported falls. The Resident Care Plan (RCP) dated 3/14/24 identified Resident #87 was at risk for decreased ability to perform activities of daily living (ADL) and at risk for falls. Interventions directed Resident #87 was dependent with bed, assist with morning and evening care and arrange resident environment as much as possible to facilitate ADL performance. A review of the facility resident obtained consents and physician's orders identified there was no documented consent or physician's order for the use of the resident bed rails. Further, there was no documented updated annual bed rail inspection completed for Resident #87's bed. An interview with the Director of Maintenance on 4/3/24 at 2:05 PM identified he had not completed a bed rail inspection for Resident #87's bed since 1/21/22 because he had not yet gotten around to it. After surveyor inquiry, a Bed Rail Inspection dated 2/16/23 was provided. An interview with the Director of Nursing on 4/3/24 at 2:56 PM identified she would expect bed rail assessment to be performed according to policy. An interview with the Medical Director on 4/9/24 at 11:07 AM identified he was not aware that consents and physician's orders were not being obtained for the use of bed rails and their use should be implemented according to policy. A review of the facility policy for Side Rails directed upon admission, each resident will be assessed for the need of either half side rails or bed bars, consent /education will be obtained prior to installation and maintenance staff will complete an annual review of the condition and conduct any necessary maintenance. Consent for the use of bed rails and physician orders dated 4/4/24 were obtained after surveyor inquiry. 5. Resident #212's diagnosis included heart failure and diabetes mellitus. The Nursing Admission/Readmission/Annual/Significant Change assessment-V7 dated 3/21/2024 at 11:17 PM indicated half side rails on both sides of the bed were in place with no indication for use and no consent obtained. The care plan dated 3/22/2024 indicated Resident #212 was at risk of falling due to cognitive loss. Interventions included in part to provide verbal cues for safety. 6. Resident #215 diagnosis included fracture of the proximal phalanx of the left great toe, fall and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #212 was severely cognitively impaired. The Nursing quarterly assessment-V5 dated 11/16/2023 indicated both half side rails were in place to promote independence with bed mobility but no consent for use. The care plan dated 11/28/2023 indicated Resident #215 was at risk for falls. Interventions include in part to provide verbal cues for safety and to place call bell in reach. An interview and review of facility documentation on 4/3/2024 at 2:10 PM indicated the last side rail inspection completed on the bed in room [ROOM NUMBER]-B (Resident #215's bed) was completed on 1/20/2022. The Maintenance Director further indicated side rail inspections should be completed annually but he/she has not been able to complete that task since. An interview with the DNS on 4/4/2024 at 11:14 AM indicated she and the Regional Nurse were currently completing an audit of all residents for side rail use and consent. Interview on 4/4/2024 at 12:10 AM with the DNS indicated unable to find physician's orders, siderail assessments and consent with indication for use of side rails on all residents including Resident #28, #212 and #215. 46046 48792 48880

Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 4 sampled residents, (Resident #156 and Resident #159) reviewed for abuse, the facility failed ensure social service support was provided following an allegation of physical mistreatment within accordance to facility policy. The findings included: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to the wheelchair using a mechanical lift and to allow the resident to choose when to go to bed. 2. Resident #159's diagnoses included aneurysm of the artery of the lower extremity. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #159 as moderately cognitively impaired and required one person assist with bed mobility, transfers, and locomotion on the unit. The Resident care Plan dated 11/8/22 identified Resident #159 was at risk for experiencing adjustment issues related to change in lifestyle /routines and difficulty accepting placement. Interventions directed to encourage the resident to make independent decisions and encourage expression of feelings related to change in routines. A facility Reportable Event dated 11/3/22 at 9:30 AM identified on 11/2/22 between 8:45 PM and 9:00 PM, the roommate of Resident #156, Resident #159 allegedly heard Resident #156 tell the nurse aide, NA #3 that s/he did not want to go to bed. Resident #159 pulled the curtain back and observed NA #3 with both hands-on Resident #156's johnny telling Resident #156 s/he was going to bed while overhearing Resident #156 stating, You are hurting me. The Advanced Practice Registered Nurse, responsible party and police were notified. NA #3 would remain out of work pending investigation. A Reportable Event Summary dated 11/7/22 identified the allegation was unable to be substantiated as Resident #159 provided a different account of what occurred and that observations of staff members identified NA #3 was physically attacked by Resident #159 after being overheard to please turn h/her music down so Resident #156 could sleep. Resident #156 denied anyone hurting h/her and had no signs of injury. A review of Resident #156's clinical record failed to identify any social service support following the allegation of staff to resident psychological mistreatment. A review of Resident #159's clinical record failed to identify any social service support following the witnessed resident to staff physical mistreatment. An interview with the Director of Nursing, DNS on 4/01/24 at 10:47 AM identified social services should have followed up with Resident #156 and Resident #159 for three days after the alleged event and documented their interaction in the clinical record. An interview with the Director of Social Services on 4/01/24 at 3:16 PM identified any resident involved in an allegation of mistreatment would be provided emotional support for three days following the alleged incident and documented in the clinical record. A review of the facility policy for Abuse dated 7/1/23 directs that emotional support and counseling will be provided to the resident during and after an abuse investigation, as needed. A review of the Social Services job description dated 7/5/23 identified the Social Worker was responsible for providing and arranging needed mental and psychosocial counseling sessions, assuring notes were informative and descriptive of services provided and resident response, and provide individual/group help for family and residents at all times of adjustment, crisis, or need.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 4 sampled residents, (Resident #156) reviewed for abuse, the facility failed ensure an allegation of staff to resident physical mistreatment was reported to the state agency within required time frames. The findings include: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to the wheelchair using a mechanical lift and to allow the resident to choose when to go to bed. 2. Resident #159's diagnoses included aneurysm of the artery of the lower extremity. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #159 as moderately cognitively impaired and required one person assist with bed mobility, transfers, and locomotion on the unit. The Resident care Plan dated 11/8/22 identified Resident #159 was at risk for experiencing adjustment issues related to change in lifestyle /routines and difficulty accepting placement. Interventions directed to encourage the resident to make independent decisions and encourage expression of feelings related to change in routines. A facility Reportable Event dated 11/3/22 at 9:30 AM identified on 11/2/22 between 8:45 PM and 9:00 PM, the roommate of Resident #156, Resident #159 allegedly heard Resident #156 tell the nurse aide, NA #3 that s/he did not want to go to bed. Resident #159 pulled the curtain back and observed NA #3 with both hands-on Resident #156's johnny telling Resident #156 s/he was going to bed while overhearing Resident #156 stating, You are hurting me. The Advanced Practice Registered Nurse, responsible party and police were notified. NA #3 would remain out of work pending investigation. A Reportable Event Summary dated 11/7/22 identified the allegation was unable to be substantiated as Resident #159 provided a different account of what occurred and that observations of staff members identified NA #3 was physically attacked by Resident #159 after being overheard to please turn h/her music down so Resident #156 could sleep. Resident #156 denied anyone hurting h/her and had no signs of injury. An interview with Registered Nurse, (RN #2) on 4/01/24 9:49 AM identified she was the assigned nursing supervisor on 11/2/22 during the 3:00 PM to 11:00 PM shift. RN #2 had heard there was an altercation on the unit. Upon arrival, RN #2 observed Resident #159 kicking NA #3 who was attempting to hold Resident #159's wrists to prevent further assault. RN #2 intervened to allow NA #3 to get out of the room. RN #2 identified she learned that Resident #159 had expressed concerns Resident #156 was not cared for properly. A skin check was completed for Resident #156 due to the concern of abuse and the Director of Nursing Services was notified. RN #2 further identified any allegation for reporting to the state agency was the responsibility of the DNS. An interview with the Director of Nursing, DNS on 4/01/24 at 10:47 AM identified she was contacted on the evening of 11/2/22 with a report of resident to staff physical mistreatment. The initial report of the incident did not involve alleged mistreatment of another resident. Rather, Resident #159 became upset that NA #3 asked h/her to turn h/her music down so residents could sleep. The DNS was not fully informed of all the details until the following morning during report and then initiated the notification to the state agency. The DNS further identified in her absence, the nursing supervisor could initiate a Reportable Event and that RN #2 should have reported the allegation to the state agency at the time of the incident. A review of the facility policies for Abuse dated 7/1/23 directed that all alleged violations are to be reported to the state agency immediately or within 2 hours after the allegation is made.

Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 4 sampled residents, reviewed for abuse for (Resident # 156 and Resident # 159), the facility failed ensure the protection of other residents following an allegation of staff to resident physical mistreatment and the facility failed to ensure the protection of other residents following a witnessed resident to staff assault. The findings include: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to the wheelchair using a mechanical lift and to allow the resident to choose when to go to bed. 2. Resident #159's diagnoses included aneurysm of the artery of the lower extremity. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #159 as moderately cognitively impaired and required one person assist with bed mobility, transfers, and locomotion on the unit. The Resident care Plan dated 11/8/22 identified Resident #159 was at risk for experiencing adjustment issues related to change in lifestyle /routines and difficulty accepting placement. Interventions directed to encourage the resident to make independent decisions and encourage expression of feelings related to change in routines. A facility Reportable Event dated 11/3/22 at 9:30 AM identified on 11/2/22 between 8:45 PM and 9:00 PM, the roommate of Resident #156, Resident #159 allegedly heard Resident #156 tell the nurse aide, NA #3 that s/he did not want to go to bed. Resident #159 pulled the curtain back and observed NA #3 with both hands-on Resident #156's johnny telling Resident #156 s/he was going to bed while overhearing Resident #156 stating, You are hurting me. The Advanced Practice Registered Nurse, responsible party and police were notified. NA #3 would remain out of work pending investigation. A Reportable Event Summary dated 11/7/22 identified the allegation was unable to be substantiated as Resident #159 provided a different account of what occurred and that observations of staff members identified NA #3 was physically attacked by Resident #159 after being overheard to please turn h/her music down so Resident #156 could sleep. Resident #156 denied anyone hurting h/her and had no signs of injury. An interview with Registered Nurse, RN #2 on 04/01/24 9:49 AM identified she was the assigned nursing supervisor on 11/2/22 during the 3:00 PM to 11:00 PM shift. RN #2 had heard of the altercation on the unit. Upon arrival, RN #2 observed Resident #159 kicking NA #3 who was attempting to hold Resident #159's wrists to prevent further assault. RN #2 intervened to allow NA #3 to get out of the room. RN #2 identified that she learned Resident #159 had expressed concerns that Resident #156 was not cared for properly. A skin check was completed for Resident #156 after the concern of abuse and the Director of Nursing Services was notified. Although RN #2 identified staff were to be immediately removed from the schedule following an allegation of staff to resident physical abuse, she was unable to explain why she allowed NA #3 to remain on duty for the remainder of the shift only requiring him/her to stay away from Resident #159. An interview with the Director of Nursing Services on 4/01/24 at 10:47 AM identified she was contacted on the evening of 11/2/22 with a report of resident to staff physical mistreatment. The initial reporting of the incident did not involve alleged mistreatment of another resident. Rather, Resident #159 became upset that NA #3 asked h/her to turn h/her music down so residents could sleep. The DNS was not fully informed of all the details until the following morning during report and then initiated the notification. Once aware, NA #3 was removed from the schedule and did not return until the investigation was completed. A review of the facility policy for abuse dated 7/1/23 directed that the facility makes efforts to ensure the protection of resident(s) from the alleged perpetrator including staffing changes during the investigation.

Based on a record reviews, review of policy and interviews for 1 of 1 resident (Resident # 28) reviewed for dementia care, the facility failed to ensure a resident with a diagnosis of dementia was reflected in the resident care plan and for 1 of 6 residents (Resident #212) reviewed for accidents, the facility failed to ensure a care plan was developed to include a facial hematoma present on admission. The findings included. 1. Resident #28's diagnosis included dementia and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had cognitive loss. The care plan dated 3/11/2024 indicated in part Resident #28 had behaviors such as yelling and striking out at staff, resistant to care. Interventions included: to have two staff members at all times while providing care, explaining all care before initiating and providing psychiatric consult/care as needed. The care plan did not mention dementia or Alzheimer's disease. An interview and record review with RN#4 on 4/02/24 at 8:50 AM indicated Resident #28's care plan did not reflect the diagnosis of dementia or Alzheimer's disease and further indicated the MDS Coordinator is responsible for adding care plans on admission and the ADNS or nurses add any care plans if there are changes. An interview on 4/2/2024 at 9:50 AM with RN #3 indicated there was no care plan for Resident #28 regarding dementia and s/he would add one at this time to the care plan. Subsequent inquiry on 4/2/2024 a care plan was written indicating Resident #28 had impaired cognitive function. Dementia or impaired thought processes related to Alzheimer's disease with interventions inducing in part to administer medications as ordered, communicate with the resident/family/caregivers regarding the resident's needs and capabilities, to provide communication techniques including using preferred name, identify self with interactions and face the resident when speaking and make eye contact., reduce distractions and to provide any necessary cues and to stop if resident becomes agitated .Additionally, interventions also included to keep routine and care givers consistent. The facility policy labeled Care Plan Comprehensive, Person Centered indicated in part the facility will develop and implement a care plan for each resident including measurable objectives and timetables to meet each resident's physical, psychological and functional needs. The policy further indicated the care plan is derived by a thorough analysis of the information gathered as part of the comprehensive assessment (which included diagnosis). 2. Resident #212's diagnosis included heart failure and diabetes mellitus. The Nursing Admission/Readmission/Annual/Significant Change assessment-V7 dated 3/21/2024 at 11:17 PM indicated the only skin impairment on admission was a Stage 2 pressure ulcer of the coccyx. The assessment also noted Resident #212 had a fall with a fracture in the last 6 months. A physician's order dated 3/22/2024 at 3:00PM directed to monitor hematoma on the left temporal area status post fall every shift. The care plan dated 3/22/2024 indicated Resident #212 was at risk for falls related to cognitive loss, lack of safety awareness impaired mobility and history of falls. Interventions included in part to assess for changes in medical status, provide verbal cues, assist with toileting needs, remind to use call light, and report any changes to the physician. On 4/1/2024 at 3:06 PM an interview and record review with the ADNS and RN # 4 indicated Resident #212 was admitted with facial hematoma as seen in the identification picture in the electronic record. RN#4 was able to locate results of a scan done while in the hospital which indicated Resident #212 had a soft tissue hematoma overlying the frontal bone of the face with a mildly displaced nasal fracture. An interview and record review on 4/02/24 at 8:45 with the ADNS and RN #4 indicated Resident #212's care plan should have reflected the facial hematoma/bruising since a physician order was in place to monitor the area. The ADNS further indicated the Minimum Data set (MDS) Coordinator, and the nurses write the baseline care plans on admission and if there are any changes to the care plan nursing, MDS or the ADNS would add as needed. Although a facility policy for baseline care plans was requested one was not provided.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #7) who was totally dependent on staff for personal hygiene, the facility failed to ensure two (2) staff members provided care to prevent the resident from rolling roll out of the bed and sustaining a fracture and.the facility failed to ensure an extension cord was not utilized to power thescreening device. The findings include: Resident #7's diagnoses included anxiety disorder, [CONDITION(S)], and obstructive sleep apnea. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 made poor decisions regarding tasks of daily life, was totally dependent on two (2) staff with turning and repositioning while in the bed, personal hygiene, and transfers in and out of the bed and chair, was non-ambulatory and had no history of falls in the past ninety (90) days. The Resident Care Plan dated 7/9/21 identified the resident made false statements about care that was provided Interventions directed assist of two (2) for toileting and activities of daily living which include personal hygiene, dressing, and turning and repositioning, and handle gently, do not rush. The resident care card indicated Resident #7 required an assist of two (2) for toileting and activities of daily living which include personal hygiene, dressing, and turning and repositioning. The nurse's note dated 9/6/21 at 9:15 PM identified Resident #7 fell out of bed, was complaining of right leg pain, and the nurse was unable to assess range of motion to right lower extremity. The Facility Reported Incident dated 9/6/21 indicated Resident #7 fell out of the bed while the nurse aide was providing care. The report identified Resident #7's lower extremity propelled off the bed when resident #7 rolled over onto the right side and landed on the floor in a sitting position, Resident #7 complained of right leg pain and was transferred to the emergency room . In a written statement dated 9/6/21 the 3-11PM nurse aide indicated during care Resident #7 was positioned on his/her right side and Resident #7's lower extremities rolled off the air mattress and the resident landed on the floor in a sitting position. The identified one-on-one in-service was provided to NA #1 instructing the aide to review the care card prior to care to provide optimum care to residents. The acute care hospital documentation dated 9/6/21 indicated Resident #7 had a comminuted fracture to distal femoral metaphysis of the right knee, given Resident #7 was bedbound status at baseline, Resident #7 opted for conservative management, a right knee immobilizer was applied, and Resident #7 was discharged on [MEDICATION(S)] for pain control. Interview with the 3-11PM nurse aide, Nurse Aide (NA) #1, on 10/13/21 at 9:24 AM identified she was providing incontinent care, when Resident #7 rolled over Resident #7 slide out of the bed. NA #1 stated when Resident #7 turned the legs were off the bed too much therefore Resident #7 slid off and there was nothing I could do. NA #1 identified this was the first time she was caring for Resident #7 and did not know an assist of two (2) was required. NA #7 identified prior to care she pushed the button at the bottom of the bed to make the mattress firm. In an interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/13/21 at 12:27 PM, she indicated she was informed Resident #7 fell out of bed and upon entering the room Resident #7 was observed on the floor with his/her back against the bed. LPN #1 identified Resident #7 required assistance of two (22) staff for care and NA #1 did not ask for assistance. In an interview with the Director of Nursing (DON) on 10/13/21 at 12:50 PM she indicated that Resident #7's care plan identified two (2) persons for care, however NA #1 did not follow the plan of care and Resident #7 fell out of bed sustaining a fracture. In an interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 10/13/21 at 4:43 PM she indicated Resident #7's care card directed two (2) persons assist for care, however NA #1 did not ask for assistance while providing care to Resident #7. RN #1 indicated that after the incident education was provided to NA #1. 2. Observations on 10/20/21 at 4:35 P.M. identified the facility screening device for COVID -19 for visitors plugged into an extension cord near Receptionist #2's desk. Interview with Receptionist #2 on 10/20//21 at the time of the observation identified she was unaware of the extension cord and would contact the Director of Maintenance to follow up. Interview with the RN Supervisor on 10/20/21 at 4:35 P.M. identified she was unaware the facility screening device was plugged into an extension cord and would follow up with the Director of Maintenance and the Director of Nursing . Subsequent to inquiry the Director of Maintenance on 10/21/21 removed the extension cord from the facility screening machine.

Based on review of the clinical record, review of facility documentation, review of policy and/or procedures and interviews for one of three sampled resident reviewed for falls (Resident # 400), the facility failed to follow the plan of care and /or ensure the resident received the necessary assistive device to prevent an accident. The finding include: Resident # 400 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An admission assessment dated [DATE] identified the resident as cognitively intact, without behaviors and requiring extensive assistance of two staff for transfers, bed mobility and/or for toileting, unsteady balance and requiring staff's assistance with transitioning. The RCP dated 12/4/17 identified risk for injury related to anticoagulant therapy as the focus. Interventions included to observe for active bleeding and directed to utilize caution during mobility to avoid trauma. A Reportable Event dated 12/23/17 at 6:00 P.M. identified in part, Resident # 400 sustained laceration to his/her left lower leg during a stand-pivot transfer while being transferred by Nurse Aide (NA#3) from the wheelchair to the bed. A review of wound documentation dated 12/24/17 identified Resident # 400's left leg wound was assessed upon his/her return and was noted to measure 16.0 Centimeters (Cm) by 0.2 CM. On 6/13/18 at 2:00 P.M. during an interview and review of the Reportable Event with NA#3 indicated while performing a stand-and-pivot transfer with Resident #400, the resident was noted to be agitated and confused, was pulling on NA #3's clothing and screaming throughout the transfer. Although, the NA#3 tried to calm the resident down, Resident #400 remained agitated as NA# 3 continued to provide care by transferring the resident from his/her wheelchair to bed while he/she was agitated and confused. On 6/18/18 at 10:40 A.M. an interview and review of the clinical record and staff in-service education dated 12/24/17 with the DNS indicated in part, NA# 3 failed to re-approach Resident # 400 when the resident was noted with agitation. On 6/18/18 at 10: 58 A.M. an interview and review of the clinical record with the former DNS (RN#3) indicated the laceration to the left leg was large in size and due to the inability of staff to control the bleeding in spite of applying pressure the resident was transferred to an acute care setting for an evaluation and received sutures to the left leg wound. On 6/13/18 at 2:00 P.M. during an interview and review of the Reportable Event with NA# 3 indicated while performing a stand-and-pivot transfer with R#400, the resident's sustained a laceration to the left leg after his/her leg became caught under the bed without the benefit of transferring the resident with a gait belt. NA#3 further indicated that during the transfer, he/she was wearing a gait belt around his/her waist, but declined to utilize it. On 6/13/18 at 2:22 P.M. during an interview and review of the clinical record with the Director of Rehabilitation (DOR) identified he/she was not aware if the facility had a policy for gait belts during transfers. The DOR also indicate there are times when clothing can be used to grip the resident during transfer maneuvers. An interview and review of the clinical record, facility documentation and facility policy and/or procedures with the DNS on 6/18/18 at 10:40 A.M. indicated the gait belt should have been utilized by NA # 3 during her/his transfer with Resident # 400 on 12/23/17.

Based on review of the clinical record review, facility documentation, facility policy and interview for one of four sampled residents reviewed for accidents (Resident #22), the facility failed to perform a safe transfer to prevent an accident. The findings include: Resident #22's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, total dependence for bed mobility, transfers and all activities of daily living (ADLs), nonambulatory, impairment of both the upper and lower extremities and no falls in the last 90 days. The care plan dated 6/29/11 identified dependence for ADLs with interventions that included using a Hoyer (mechanical) lift for transfers from the bed to the chair with the assistance of two staff. The July 2011 physician's orders [REDACTED]. The Accident & Incident (A&I) report dated 7/7/11 at 7:25 PM indicated Resident #22 sustained a fall during a Hoyer lift transfer. The nurse's note dated 7/7/11 at 7:25 PM identified that during a Hoyer lift transfer from the wheelchair to the bed, one side of the lift pad slipped out of the hooks and the resident was lowered to the floor with the resident's head resting on the wheelchair cushion. The nurse's note further indicated a skin tear was noted to the right arm 2.0 centimeters (cm) by 2.0 cm and the resident complained of right hip and leg pain. The physician was notified and directed to transfer the resident to the emergency department for an evaluation. The radiology report from the acute care facility dated 7/8/11 identified a fracture of the right femoral neck with superior displacement of the distal fracture fragment and diffuse osteopenia. Interview with Nurse Aide (NA) #1 on 10/6/11 at 3:00 PM identified he received education in June 2011 on the proper procedure for use of a Hoyer lift transfer. NA #1 indicated he was aware the facility Hoyer lift policy required two staff members to perform a safe transfer, however, on 7/7/11 he transferred Resident #22 by himself. NA #1 indicated the upper loops of the Hoyer lift pad slipped from the hooks during the transfer and the resident fell backwards onto the wheelchair. The Total Lift policy identified a total lift is used for residents who are dependent and non-weight bearing and require a minimum of two persons to perform the lift. One person stands next to the resident to ensure the hanger bar does not hit the resident and to provide assistance in guiding the resident. The other person stands next to the lift and uses the hand controls to slowly raise the resident to a height necessary for the transfer.