Every finding on record at Havencare at Valerie Manor

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure an adequate supply of oxygen was sent with a resident for a Leave of Absence (LOA) from the facility for a medical appointment, and failed to ensure a staff member accompanied a resident with a known cognitive impairment when on LOA to a medical appointment to ensure the oxygen remained at the prescribed liter flow. The findings include: Resident #1 had a diagnosis of acute respiratory failure, pulmonary embolism, plural effusion, heart failure, autism, intellectual disability, and displaced [NAME] fracture of the right tibia (break at the bottom of the shinbone/tibia) and a displaced fracture of the lateral malleolus right fibula (break in the prominent bony bump on the outside of ankle/leg bone). The admission Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of four (4) indicating severely impaired cognition, had no behaviors, and received no oxygen. Physician order dated 4/6/26 directed orthopedic follow up. Record review identified Resident #1 was transferred to the hospital on 4/16/26 for lethargy, hypotension, hypoxia with oxygen saturations in the 80's (normal 90% and above) on room air, and a temperature 100.6 degrees Fahrenheit. The readmission nursing assessment dated [DATE] identified Resident #1 returned from the hospital on oxygen. The Resident Care Plan (RCP) dated 3/18/26 identified autism, and alteration in respiratory status. Interventions directed to monitor for signs of respiratory distress, and administer oxygen per physician order. Physician order dated 4/24/26 directed oxygen at one (1) liter per minute via nasal canula, may titrate to four (4) liters to maintain PO greater than 90%. Physician order dated 4/27/26 directed oxygen via nasal cannula at one (1) to two (2) liters, may titrate as tolerated, may titrate as tolerated for ARFH (acute respiratory failure hypoxia). Nursing note dated 4/30/26 at 2:21 PM identified Resident #1 was sent from his/her appointment to the hospital due to a low oxygen saturation and the nursing supervisor was notified. Record review failed to identify the time Resident #1 left the facility for the medical appointment. Interview with the orthopedic office Administrator on 5/26/26 at 12:23 PM identified the office was not informed prior to Resident #1's arrival that he/she required use of oxygen. The office Administrator stated that a person that was with Resident #1 in the office, notified the office staff that Resident #1 had trouble breathing. Office staff then checked Resident #1's oxygen tank and identified it was empty, and the staff obtained one (1) of their office oxygen tanks. By the time the office staff obtained the tank, Emergency Medical Services (EMS) was already with Resident #1, and EMS transported the resident to the hospital. Emergency Medical Services (EMS) run sheet dated 4/30/26 identified dispatch was called at 10:26 AM and they arrived at the resident at 10:35 AM. The report indicated Resident #1 had a D oxygen tank cylinder that was empty and Resident #1's oxygen saturation level was at 80 % (normal 90 and above). EMS applied a new oxygen tank at four (4) liters per minute (LPM) which increased the oxygen saturation level to 91%. Bilateral lung wheezing was noted, and oxygen was increased to six (6) LPM and a nebulizer (breathing treatment) was administered. Resident #1 was then placed on 10 LPM of oxygen via a non-rebreather mask and his/her oxygen saturation level increased to 96%, and Resident #1 was transported to the hospital. Hospital record review identified chest CT Scan results dated 4/30/26 identified a near complete collapse (atelectasis)of the right lung with minimal aerated lung within the right upper and middle lobes. May represent a combination of atelectasis and infection/inflammation, and a large local right pleural effusion (excess fluid in the space between the lungs and the chest wall). Observation of the facility oxygen storage room on 5/26/26 at 11:30AM identified the facility had E-cylinder oxygen tanks (bigger tank) and D-cylinder oxygen tanks (smaller) tank in the oxygen storage tank room. Interview with LPN #1 on 5/26/26 at 10:51 AM identified she was the charge nurse when Resident #1 left about 9:30 AM for an orthopedic appointment and his/her pulse ox (oxygen saturation) was 96% at 7:30 AM. LPN #1 stated she sent Resident #1 with one (1) oxygen tank cylinder and indicated it was the bigger, E-tank). LPN #1 stated she switched Resident #1 from his/her oxygen concentrator to the E-cylinder oxygen tank right before he/she left the facility, and the cylinder was full. LPN #1 stated she placed the gauge on the tank it read a little past full and air was coming out of the tank, but she did not inform the orthopedic office that Resident #1 was on oxygen. LPN #1 further stated that Resident #1 was met at the medical office by a representative from Resident #1's prior living setting (Person #1). Interview with Person #1 on 5/26/26 at 11:57 AM identified he/she did not adjust the oxygen tank liter flow. Further, Person #1 stated Resident #1 was discharged from the hospital to another facility. Interview with APRN #1 on 5/26/26 at identified the atelectasis and pleural effusion would not be caused by the lack of oxygen in the oxygen cylinder. Interview with the facility oxygen vendor Director of Operations (DOO) on 5/26/26 at 11:47 AM identified the company supplies the facility with cylinder oxygen tanks. The oxygen DOO stated if an E-cylinder (larger tank) was set at three (3) liters, it would last approximately three (3) hours. The DOO did not provide information regarding how long the D-cylinder (smaller tank sent with Resident #1) would last. Interview with the Director of Nursing (DNS) on 5/26/26 at 2 PM identified Resident #1 left the facility with an oxygen tank, and she did not know if the oxygen tank level was checked prior to leaving, and she thought Resident #1 left with a large oxygen tank that would last about four (4) hours if full. The DNS stated the orthopedic office called and notified the facility the oxygen tank was empty, and he/she was transferred to the hospital. The DNS identified it was the nurse's responsibility to ensure the resident had enough oxygen prior to going out on appointments. The DNS stated the facility did not usually send a nurse with residents to appointments, and for Resident #1, a representative from Resident #1's prior living setting met Resident #1 at the appointment. Although Resident #1 had severe cognitive impairment, interview failed to identify why the facility did not provide a staff member to accompany Resident #1 in the transport vehicle to ensure the oxygen level remained at the ordered liter flow. Interview with the Director of Rehabilitation on 5/26/26 at 2:18 PM identified she did not think Resident #1 would have been able to change the oxygen liter flow. Review of Oxygen Administration Policy (no date) directed in part, when preparing to place the resident on oxygen to verify oxygen was flowing. No facility policy was provided for surveyor review regarding ensuring sufficient supply of oxygen on LOAs.

Based clinical record review, facility documentation review, facility policy review and interviews for three of four residents (Residents #2, #3 and #4) reviewed for misappropriation, the facility failed to assure adequate controls of narcotic medications leading to controlled substance medications misplacement and loss of medications. The findings include: Resident #2 was admitted with diagnoses that included fusion of the spine, Lumbar region, bipolar disorder and depression. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of no cognitive impairment and reported occasional pain in the last five (5) days. A physician order dated 8/31/2025 directed Oxycodone (a narcotic used for pain relief) five (5) milligrams (mg) by mouth, one (1) tablet every six (6) hours as needed for moderate pain and two (2) tablets for severe pain. The order directed an end date of 9/5/2025. The Resident Care Plan (RCP) dated 9/8/2025 identified pain due to lumbar spine surgery. Interventions included to administer pain medication as ordered. 2. Resident #3 was admitted with diagnoses that included dementia. Physician order dated 6/05/2025 directed Oxycodone five (5) milligrams (mg) by mouth, give 1 tablet by mouth every six (6) hours as needed for moderate pain and give two (2) tablets by mouth as needed for severe pain for fourteen days. The order was discontinued on 6/19/2025. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of three (3), indicative of severe cognitive impairment, and reported no pain in the last five (5) days. The Resident Care Plan (RCP) dated 9/25/2025 identified Resident #3 was at risk for pain. Interventions directed to administer pain medication as ordered. A review of the June Medication Administration Record (MAR) identified that Resident #2 did not receive the Oxycodone. 3. Resident #4 was admitted with diagnoses that included dementia and anxiety. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition. The Resident Care Plan (RCP) dated 10/1/2025 identified Resident #4 had anxiety. Interventions directed to administer anti-anxiety medication as ordered. A physician order dated 10/13/2025 directed to provide Lorazepam 0.5 mg, give one (1) tablet every six (6) hours as needed. The order was discontinued on 10/27/2025. A facility reportable event (RE) form dated 11/20/2025 identified discontinued medications that were scheduled to be destroyed appeared to be missing. Additional review of the form failed to identify the residents that were affected, and what the medications were. The form indicated the incident occurred on 11/10/2025 at 2 PM, and the Medical Director and Consumer Protection were notified on 11/10/2025, and the local law enforcement was not notified. Additional RE information provided on 12/2/2025 identified the local police were notified, and the disposition sheets (controlled medication administration documentation) were missing. The medications were last seen on 10/31/2025 during the 7 AM to 3 PM shift when an audit was conducted. Missing medications were identified as 37 tablets of Oxycodone (pain medication) 5 milligrams (mg) and 15 tablets of Lorazepam (used to treat anxiety) 0.5 mg. The facility RE summary dated 11/26/2025 identified on 11/9/2025 a drug audit identified missing narcotics scheduled for collection for discontinued medications. Missing medications were identified as discontinued, were all reported as last observed on 9/10/2025 by the nurse completing an audit and listed as: nine (9) tablets of Oxycodone for Resident #2; 28 tablets of Oxycodone for Resident #3; and 15 tablets of Lorazepam for Resident #4. The facility initiated an investigation, and the report failed to identify the person responsible for the missing medications. Review of the facility record of disposal for medications identified the last date of recorded medication disposal prior to 11/9/2025 was 10/8/2025. Interview and record review with LPN #3 on 3/24/2026 at 1:00 PM identified she completed a narcotic medication audit on 11/9/2025 and when she identified the discrepancy, she notified the DON. Interview and facility documentation review with the RN #1/Corporate Nurse on 3/24/2026 at 10:13 AM identified she and the DON conducted the investigation into the missing medications for Resident #2, Resident #3 and Resident #4. RN #1 stated she was notified on 11/9/2026 that the white control substance disposition record (proof of use sheets used to sign narcotic medication removed from the locked box and administered to the resident) located in the unit narcotic book and the matching medication packs were missing. RN #1 stated two (2) nurses complete an end-of shift count using the white proof of use sheets. RN #1 stated on 11/9/2025 the following were identified to be missing:Resident #2's proof of use sheet #173495 identified 30 tablets of Oxycodone 5 mg was delivered on 8/26/2025 and nine (9) tablets were missing and was discontinued on 9/10/2025 (62 days prior to identified missing). Resident #3's proof of use sheet #172617 identified 30 tablets of Oxycodone 5 mg was delivered on 6/7/2025 and 28 tablets were missing and was discontinued on 6/19/2025 (144 days prior to identified missing). Resident #4's proof of use sheet #186063 identified 30 tablets of Loazepam 0.5 mg was delivered on 10/22/2025 and 15 tablets were missing and was discontinued on 10/20/2025 (30 days prior to identified missing). RN #1 stated the medications had been moved to the back of the narcotic lock boxes in the two (2) unit medication carts for future removed for disposal/destruction. RN #1 stated that medications that required destruction should have been removed immediately from the narcotic lock boxes on the carts and placed in a secured lock box located in the nursing office, and it was the responsibility of the DON and/or ADNS to remove the drugs timely. RN #1 stated she did not know why the narcotics were not removed from the unit lock boxes when the medications were discontinued. Interview and documentation review with the Administrator on 3/24/2026 at 1:30 PM identified a Consumer Protection drug control division memo dated 12/4/2025 indicated there was a procedural lapse as discontinued medications were not segregated immediately upon discontinuation, and the facility was unable to locate the white proof of use sheets required for tracking movement and custody of the medications. The investigation confirmed that the narcotic loss occurred while the medications were under the security of the narcotic lock box enabled by procedural nonadherence concerning handling of discontinued stock and subsequent inability to reconcile inventory due to missing logs. Interview and review of the bimonthly audit results with LPN #3 on 3/24/2026 at 1:00 PM identified when she completed narcotic audits, and if she identified any discrepancy in the actual physical medication count compared to the proof of use sheet, she notified the ADNS and made a note on the yellow copy of the proof of use sheet identifying the reason for the discrepancy. LPN #3 stated her audits did not include review of the Medication Administration Record (MAR). Review of the 6/30 and 10/8/2025 audits completed by LPN identified a discrepancy for Resident #3's Oxycodone 5 mg; one extra tablet was listed on the white proof of use sheet than on the yellow master proof of use sheet, and she adjusted the audit count to match the white sheet. Review of the signatures for completion of the end-of-shift narcotic counts for August and September 2025 identified that the required two (2) nurse signatures were missing signatures on the following dates: 8/1, 8/30, 9/1, 9/3, 9/7 and 9/14/2025 for the on-coming and off-going nurses for the 7:00 AM to 3:00 PM shifts. Additional review identified signatures were missing for 8/18 and 8/22/2025 for the on-coming and off-going nurses for the 11:00PM to 7:00 AM shift. The facility failed to implement adequate narcotic control procedures to ensure adequate process controls were in place, to ensure discontinued medications were removed timely from the unit lock boxes, and to prevent the misappropriation narcotics. The DON was not available for interview during the survey. The facility Controlled Substance Handing Policy directed in part, when administering a controlled substance (Oxycodone and Lorazepam was considered a controlled substance), the nurse must document immediately in the controlled drug accountability. A physical inventory is completed at the change of shift by two (2) licensed nurses and was documented. Discontinued controlled drugs were returned to the nursing office after the count was verified. The drugs are stored in a double locked cabinet in the nursing office until permission to destroy has been obtained. Facility documentation review identified staff education was initiated on 11/13/2025 for licensed nurses regarding controlled substances handling including securing and reporting of discrepancies, loss of controlled substance, resident abuse and neglect policy and resident rights policy. A QAPI was developed and reviewed on 11/9/2025 and a house wide audit was completed. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, facility documentation review, facility policy review and interviews for three of four residents (Residents #2, #3 and #4) reviewed for abuse, the facility failed to ensure an incident report listed the residents affected, failed to ensure a reportable event was classified correctly, and failed to ensure the State Agency was notified timely after an allegation of misappropriation. The findings include: Resident #2 was admitted with diagnoses that included fusion of the spine, Lumbar region, bipolar disorder and depression. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of no cognitive impairment and reported occasional pain in the last five (5) days. A physician order dated 8/31/2025 directed Oxycodone (a narcotic used for pain relief) five (5) milligrams (mg) by mouth, one (1) tablet every six (6) hours as needed for moderate pain and two (2) tablets for severe pain. The order directed an end date of 9/5/2025. The Resident Care Plan (RCP) dated 9/8/2025 identified pain due to lumbar spine surgery. Interventions included to administer pain medication as ordered. 2. Resident #3 was admitted with diagnoses that included dementia. Physician order dated 6/05/2025 directed Oxycodone five (5) milligrams (mg) by mouth, give 1 tablet by mouth every six (6) hours as needed for moderate pain and give two (2) tablets by mouth as needed for severe pain for fourteen days. The order was discontinued on 6/19/2025. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of three (3), indicative of severe cognitive impairment, and reported no pain in the last five (5) days. The Resident Care Plan (RCP) dated 9/25/2025 identified Resident #3 was at risk for pain. Interventions directed to administer pain medication as ordered. A review of the June Medication Administration Record (MAR) identified that Resident #2 did not receive the Oxycodone. 3. Resident #4 had diagnoses that included anxiety. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition. The Resident Care Plan (RCP) dated 10/1/2025 identified Resident #4 had anxiety. Interventions directed to administer anti-anxiety medication as ordered. A physician order dated 10/13/2025 directed to provide Lorazepam 0.5 mg, give one (1) tablet every six (6) hours as needed. The order was discontinued on 10/27/2025. A facility reportable event (RE) form dated 11/20/2025 identified discontinued medications that were scheduled to be destroyed appeared to be missing. Additional review of the form failed to identify the residents that were affected, and what the medications were. The form indicated the incident occurred on 11/10/2025 at 2 PM (10 days prior to the report submitted to the State Agency). Additional RE information provided on 12/2/2025 identified the disposition sheets (controlled medication administration documentation) were missing and the medications were last seen on 10/31/2025 during the 7 AM to 3 PM shift when an audit was conducted. Missing medications were identified as 37 tablets of Oxycodone (pain medication) 5 milligrams (mg) and 15 tablets of Lorazepam (used to treat anxiety) 0.5 mg. The facility RE summary dated 11/26/2025 identified on 11/9/2025 a drug audit identified missing narcotics scheduled for collection for discontinued medications. Missing medications were identified as discontinued, were all reported as last observed on 9/10/2025 by the nurse completing an audit and listed as: nine (9) tablets of Oxycodone for Resident #2; 28 tablets of Oxycodone for Resident #3; and 15 tablets of Lorazepam for Resident #4. The facility initiated an investigation, and the report failed to identify the person responsible for the missing medications. A review of the facility incident report dated 11/9/2026 at 1:00 PM identified discontinued medication that were scheduled to be destroyed appear to missing, and did not list any of the affected residents. Review of the State Agency Reportable Events on-line portal identified the RE was submitted to the State Agency on 11/20/2025 at 1:51 PM for the incident identified on 11/10/2025 at 2 PM (10 days prior). The report was initially classified as a Class C (loss of heat/water/emergency systems or evacuation) and was changed to a Class B (abuse). Interview with the DON on 3/23/2026 at 9:30 AM identified although she submitted the RE to the State Agency as a Class B she did not classify the incident as a misappropriation; she classified it as other and it was submitted ten (10) days after the incident was identified. The DON stated she did not classify the RE as misappropriation because the medication orders were discontinued and the medications should have been destroyed. Interview failed to identify why the RE was not submitted to the State Agency timely and why the residents affected were not identified. Interview and documentation review with the Corporate RN #1 on 3/24/2026 at 10:13 AM identified the medications and related documentation were identified missing on 11/9/2025. RN #1 stated she did not notify the State Agency of the resident names, and she did not think it was a potential misappropriation because the physician orders had directed the medications were discontinued. The facility Abuse, Neglect and Exploitation Policy directed in part, misappropriation meant the deliberate misplace or use of a resident's belongings without the resident's consent. The facility will report all alleged violation to the State Agency immediately, but not later than 2 hours after the allegation is made if the allegation involves abuse. The facility Accident and Incident Policy directed in part, the accident and incident must include name of individuals involved, a detailed description of the event and condition of the residents involved.

Based on clinical record review, facility documentation review, facility policy review and interviews for three of four residents (Residents #2, #3 and #4) reviewed for abuse, the facility failed to ensure the residents were free from misappropriation. The findings include: Resident #2 was admitted with diagnoses that included fusion of the spine, Lumbar region, bipolar disorder and depression. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of no cognitive impairment and reported occasional pain in the last five (5) days. A physician order dated 8/31/2025 directed Oxycodone (a narcotic used for pain relief) five (5) milligrams (mg) by mouth, one (1) tablet every six (6) hours as needed for moderate pain and two (2) tablets for severe pain. The order directed an end date of 9/5/2025. The Resident Care Plan (RCP) dated 9/8/2025 identified pain due to lumbar spine surgery. Interventions included to administer pain medication as ordered. 2. Resident #3 was admitted with diagnoses that included dementia. Physician order dated 6/05/2025 directed Oxycodone five (5) milligrams (mg) by mouth, give 1 tablet by mouth every six (6) hours as needed for moderate pain and give two (2) tablets by mouth as needed for severe pain for fourteen days. The order was discontinued on 6/19/2025. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of three (3), indicative of severe cognitive impairment, and reported no pain in the last five (5) days. The Resident Care Plan (RCP) dated 9/25/2025 identified Resident #3 was at risk for pain. Interventions directed to administer pain medication as ordered. A review of the June Medication Administration Record (MAR) identified that Resident #2 did not receive the Oxycodone. 3. Resident #4 was admitted with diagnoses that included dementia and anxiety. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition. The Resident Care Plan (RCP) dated 10/1/2025 identified Resident #4 had anxiety. Interventions directed to administer anti-anxiety medication as ordered. A physician order dated 10/13/2025 directed to provide Lorazepam 0.5 mg, give one (1) tablet every six (6) hours as needed. The order was discontinued on 10/27/2025. A facility reportable event (RE) form dated 11/20/2025 identified discontinued medications that were scheduled to be destroyed appeared to be missing. Additional review of the form failed to identify the residents that were affected, and what the medications were. The form indicated the incident occurred on 11/10/2025 at 2 PM, and the Medical Director and Consumer Protection were notified on 11/10/2025, and the local law enforcement was not notified. Additional RE information provided on 12/2/2025 identified the local police were notified, and the disposition sheets (controlled medication administration documentation) were missing. The medications were last seen on 10/31/2025 during the 7 AM to 3 PM shift when an audit was conducted. Missing medications were identified as 37 tablets of Oxycodone (pain medication) 5 milligrams (mg) and 15 tablets of Lorazepam (used to treat anxiety) 0.5 mg. The facility RE summary dated 11/26/2025 identified on 11/9/2025 a drug audit identified missing narcotics scheduled for collection for discontinued medications. Missing medications were identified as discontinued, were all reported as last observed on 9/10/2025 by the nurse completing an audit and listed as: nine (9) tablets of Oxycodone for Resident #2; 28 tablets of Oxycodone for Resident #3; and 15 tablets of Lorazepam for Resident #4. The facility initiated an investigation, and the report failed to identify the person responsible for the missing medications. Interview and facility documentation review with the RN #1/Corporate Nurse on 3/24/2026 at 10:13 AM identified she and the DON conducted the investigation into the missing medications for Resident #2, Resident #3 and Resident #4. RN #1 stated she was notified on 11/9/2026 that the white control substance disposition record (proof of use sheets used to sign narcotic medication removed from the locked box and administered to the resident) located in the unit narcotic book and the matching medication packs were missing. RN #1 stated two (2) nurses complete an end-of shift count using the white proof of use sheets. RN #1 stated on 11/9/2025 the following were identified to be missing:Resident #2's proof of use sheet #173495 identified 30 tablets of Oxycodone 5 mg was delivered on 8/26/2025 and nine (9) tablets were missing and was discontinued on 9/10/2025 (62 days prior to identified missing). Resident #3's proof of use sheet #172617 identified 30 tablets of Oxycodone 5 mg was delivered on 6/7/2025 and 28 tablets were missing and was discontinued on 6/19/2025 (144 days prior to identified missing). Resident #4's proof of use sheet #186063 identified 30 tablets of Loazepam 0.5 mg was delivered on 10/22/2025 and 15 tablets were missing and was discontinued on 10/20/2025 (30 days prior to identified missing). RN #1 stated the facility investigation identified the missing medications were from two (2) different units and 30 nurses had access to the locked narcotic storage boxes from the 10/31/2025 audit until the 11/9/2025 audit. RN #1 stated the medications had been moved to the back of the narcotic lock boxes in the two (2) unit medication carts for future removed for disposal/destruction. RN #1 stated the facility was unable to identify the nurse who removed the medications from the lock boxes. Interview and record review with LPN #3 on 3/24/2026 at 1:00 PM identified she completed a narcotic medication audits on 11/9/2025 and when she identified the discrepancy, she notified the DON. Interview and documentation review with the Administrator on 3/24/2026 at 1:30 PM identified a Consumer Protection drug control division memo dated 12/4/2025 indicated on 11/9/2025 there was a significant loss of controlled substances. The investigation confirmed there was a procedural lapse as discontinued medications were not segregated immediately upon discontinuation, and the facility was unable to locate the white proof of use sheets required for tracking movement and custody of the medications. The investigation confirmed that the narcotic loss occurred while the medications were under the security of the narcotic lock box enabled by procedural nonadherence concerning handling of discontinued stock and subsequent inability to reconcile inventory due to missing logs. Interview failed to identify who, or when, staff were able to remove the medications. The DON was not available for interview during the survey. The facility Abuse, Neglect and Exploitation Policy directed in part, to prohibit and prevent abuse. Misappropriation of Resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's property without the resident's consent. Facility documentation review identified staff education was initiated on 11/13/2025 for licensed nurses regarding controlled substances handling including securing and reporting of discrepancies, loss of controlled substance, resident abuse and neglect policy and resident rights policy. A QAPI was developed and meeting held on 11/9/2025 and audits were initiated on 11/14/2025. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, facility policy, facility documentation, and interviews for 3 of 5 residents (Resident #8, Resident #39, and Resident #48) reviewed for respiratory infections, the facility failed to implement droplet precautions prior to obtaining the results of nasal swabbing, and for 4 residents (Resident #17, Resident #29, and Resident #103, Resident #118) reviewed for transmission based precautions (TBP), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a room with requiring droplet/contact precautions per posted signage. Additionally, for 2 of 3 residents (Resident #122 and Resident #143) reviewed for pressure ulcers, the facility failed to ensure signage was posted regarding Enhanced Barrier Precautions (Resident #122) and failed to properly store indwelling catheter supplies (Resident #143). The facility also failed to ensure the Infection Control program maintained accurate and consistent documentation/information pertaining to a facility wide respiratory outbreak. The findings include: 1a. Resident #8's diagnoses included end stage renal disease, vascular dementia, diabetes, and influenza.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was cognitively intact, and was independent with eating, transfers, and walking.The Resident Care Plan (RCP) dated 10/22/25 identified Resident #8 had increased susceptibility to infection related to dialysis and the presence of a left upper extremity arteriovenous (AV) fistula (a connection between an artery and a vein surgically created for use in hemodialysis). Interventions included education of Resident #8 and family on the need for good hand hygiene, enhanced barrier precautions as ordered, and to notify the Medical Doctor (MD) on signs/symptoms of infection.A physician order dated 12/23/25 directed to administer Tamiflu 30 milligrams (mg) by mouth at bedtime every other day for 5 administrations related to flu exposure through 1/2/26.A physician order dated 1/5/26 directed to obtain a triple virus swab and COVID-19 swab.A nursing note dated 1/5/26 at 11:35 AM identified a swab was obtained for a respiratory panel and placed in the refrigerator for pickup by the lab.An Advanced Practice Registered Nurse (APRN) (late entry) progress note dated 1/5/26 at 12:24 PM identified Resident #8 was seen for a cough. The note identified Resident #8 complained of an infrequent non-productive cough and Resident #8 had been on Tamiflu prophylactively due to Influenza in the facility. The progress note identified related to influenza like symptoms: add cough medication (Tussin) as needed and await results of the respiratory viral swab due to no additional symptoms and renal impairment.A physician order dated 1/5/26 directed to administer 10 milliliters (ml) of Guaifenesin liquid 100 mg per 5 ml every 4 hours as needed (PRN) for cough for 7 days.Medication Administration Record (MAR) from 1/5/26 through 1/7/26 identified Resident #8 received Guaifenesin 10 ml by mouth for cough on 1/6/26 at 9:30 PM, 1/7/26 at 5:52 AM, and 1/7/26 at 11:49 AM.A nursing note dated 1/6/26 at 10:56 PM identified Resident #8 had no cough or shortness of breathA nursing note dated 1/7/26 at 4:04 PM identified Resident #8 was assessed for flu-like symptoms. The note identified Resident #8 had no complaints of body aches, chills, sore throat, or cough at that time and to continue to monitor the resident.A nursing note written by Registered Nurse (RN) #3 and dated 1/7/26 at 5:30 PM identified the APRN reviewed the results of the respiratory panel and Influenza A was detected. The note identified the responsible party and charge nurse were notified of the positive results.A physician order dated 1/7/26 directed to implement droplet precautions for positive Influenza every shift (7a-3p, 3p-11p, and 11p-7a) until 1/17/26 at 11:59 PM.A physician order dated 1/7/26 directed to evaluate and document: respiratory rate, oxygen saturation on room air, lung sounds, every shift for positive influenza until 1/17/26 at 11:59 PM.Nursing notes and health status report documentation dated 1/4/26 through 1/7/26 failed to identify droplet precautions were implemented on 1/5/26 when the APRN documented Resident #8 had flu like symptoms (and the facility was in a respiratory outbreak with COVID-19, RSV and Influenza A) until 1/7/26 on the 3:00 PM to 11:00 PM shift, when the results of the nasal swab confirmed Influenza A (48 hours after developing symptoms and the facility was in a respiratory outbreak). The RCP dated 1/9/26 identified Resident #8 had Influenza A. Interventions included measure intake and output, encourage good fluid intake, and give antipyretics (antifever medication) and analgesics (pain reliever medication) as ordered for fever and pain. Additionally, the RCP identified Resident #8 required isolation for positive Influenza test result. Interventions included maintain droplet/contact precautions as ordered, provide all services to the room as per isolation protocol, and follow Centers for Disease Control (CDC) guidelines for personal protective equipment. 1b. Resident #39 had diagnoses that included Alzheimer's disease, hypertension, and depression.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was severely cognitively impaired, used a wheelchair, and was dependent with eating and bed mobility, and required substantial/maximal assistance with transfers.The Resident Care Plan (RCP) dated 12/18/25 identified Resident #39 was at risk for dehydration related to chronic kidney disease, cognitive deficit from dementia, and advancing age. Interventions included to monitor intake and output as indicated, assist Resident #39 with intake of fluids, and Resident #39 may be dehydrated if he/she had a fever, decreased urinary output, changes in mental status, or concentrated urine. A nursing note dated 12/29/25 at 12:40 PM identified Resident #39 had a low-grade temperature of 99.1 F with occasional coughing. The note identified the Advanced Practice Registered Nurse (APRN) was notified and orders obtained for a respiratory virus panel, urine culture and sensitivity, and chest x-ray.A nursing note dated 12/29/25 at 2:29 PM identified Resident #39 felt warm to the touch, had an occasional non-productive cough, and had a chest x-ray obtained.A nursing note dated 12/29/25 at 4:05 pm identified a confirmation number for a respiratory viral panel.A physician order dated 12/29/25 directed to administer 10 milliliters (ml) of Dextromethorphan-Guaifenesin 20-200 milligrams (mg) per 10 ml by mouth every 4 hours as needed for cough for 7 days.An APRN progress note (late entry from 12/29/25) dated 12/30/25 at 12:22 PM identified Resident #39 was seen for congestion. The note identified Resident #39 had a new cough, had been afebrile, had a negative rapid COVID-19 swab and the chest x-ray was negative for pneumonia. The note identified Resident #39's Influenza swab was pending but there was a high likelihood of exposure due to other positive Influenza residents within the facility.A physician order dated 12/30/25 directed to obtain an Influenza/COVID-19 swab.A nursing note dated 12/30/25 at 3:39 PM identified Resident #39 had an occasional, non-productive cough and less appetite than usual. The note identified that an Influenza swab was obtained and was in the refrigerator for pickup by the lab. The note further identified the rapid COVID-19 swab was negative.A physician order dated 12/31/25 directed to administer Tamiflu 75 milligrams (mg) by mouth in the evening for 14 days related to Influenza exposure.An APRN progress note dated 1/1/26 at 8:38 PM identified Resident #39 was seen for Influenza exposure because Resident #39 was exposed to an Influenza positive resident in the facility. A physician order dated 1/2/26 directed to implement droplet precautions for positive influenza every shift (7a-3p, 3p-11p, and 11p-7a) for 14 days until 1/16/26. A nursing note dated 1/2/26 at 4:23 PM identified Resident #39 tested positive for Influenza and droplet precautions were initiated.A physician order dated 1/2/26 directed to evaluate and document: respiratory rate, oxygen saturation on room air, lung sounds, every shift for positive Influenza until 1/16/26. Nursing notes and health status report documentation dated 12/29/25 through 1/2/26 failed to identify droplet precautions were implemented on 12/29/25 when nursing documented Resident #39 had a low-grade temperature with occasional coughing (and the facility was in a respiratory outbreak with COVID-19, RSV and Influenza A) until 1/2/26 when the respiratory panel confirmed Resident #39 was positive for Influenza (greater than 96 hours). 1c. Resident #48 had diagnoses that included Alzheimer's disease, down syndrome, asthma, and influenza.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #48 had a short/long term memory problem and was dependent on staff for toilet/personal hygiene. The MDS further identified Resident #48 required partial/moderate assistance with oral hygiene and substantial/maximal assistance with upper/lower body dressing.The Resident Care Plan (RCP) dated 12/11/25 identified Resident #48 was at risk for altered respiratory status related to asthma. Interventions included elevating the head of the bed, provide oxygen as ordered, and monitor/report abnormal breathing (increased rate, decreased rate, use of accessory muscles, pursed-lip breathing, and nasal flaring) to the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) as needed.An Advanced Practice Registered Nurse (APRN) progress note dated 12/30/25 at 12:51 PM identified Resident #48 was seen for wheezing, Resident #48 had an expiratory wheeze and cough and he/she was in the common area eating lunch on the APRN's exam. The note identified Resident #48's lung sounds were rhonchorous (low-pitched rattling or snoring lung sounds) and a viral swab was ordered.A nursing note dated 12/30/25 at 2:36 PM identified Resident #48 was assessed related to report of wheezing and cough. The note identified Resident #48 was sitting in the common area when seen.A nursing note dated 12/31/25 at 5:09 AM identified Resident #48's chest x-ray results showed bilateral lung infiltrates (pneumonia) and antibiotics were ordered.A physician order dated 12/31/25 directed to implement droplet precautions for positive influenza every shift (7a-3p, 3p-11p, and 11p-7a) for 14 days until 1/14/26. Additionally, the physician order directed to evaluate and document: respiratory rate, oxygen saturation on room air, lung sounds, every shift for positive influenza until 1/14/26. A nursing note dated 12/31/25 at 6:02 PM identified the respiratory viral swab results showed Resident #39 was positive for Influenza A and Resident #48 was placed on droplet precautions. Nursing notes and health status report documentation dated 12/30/25 through 12/31/25 failed to identify droplet precautions were implemented on 12/29/25 when nursing identified sign and symptoms of respiratory illness (and the facility was in a respiratory outbreak with COVID-19, RSV and Influenza A) until 12/31/25 when the respiratory panel confirmed Resident #48 was positive for Influenza (24 hours after symptoms).The RCP dated 12/31/25 identified Resident #48 required isolation for infection of Influenza A. Interventions included maintain droplet/contact precautions as ordered, provide all services to the room as per isolation protocol, and follow Centers for Disease Control (CDC) guidelines for personal protective equipment. Interview with Licensed Practical Nurse (LPN) #3 (the Infection Preventionist) on 1/16/26 at 3:00 PM identified staff should notify the nursing Supervisor so that he/she can notify the APRN immediately when new respiratory symptoms were identified for a resident especially during a respiratory outbreak. LPN #3 identified those residents would be placed on droplet precautions immediately (before the results of any swabbing) and a respiratory viral panel would be obtained to rule out COVID-19, Influenza, and RSV. LPN #3 could not identify the reason there were multiple residents identified by surveyors who had symptoms and weren't placed on droplet precautions until their respiratory viral tests returned positive. LPN #3 further identified she was not aware of any symptomatic residents not being placed on droplet precautions immediately.Review of the Influenza Outbreak Management Plan policy directed, in part, the policy focused on the prompt identification, reporting, treatment, and control of a suspected or confirmed influenza outbreak within the facility. The policy directed that any resident with new onset of symptoms (fever, cough, sore throat) should be placed on droplet precautions and placed in a single room. The policy directed that a nasopharyngeal swab should be obtained immediately for symptomatic residents/staff. 2a. Resident #29 (roommate to Resident #103) had diagnoses that included dementia, chronic obstructive pulmonary disease, and asthma.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, and was dependent for transfers.A physician order dated 1/5/26 directed to implement droplet precautions for positive Respiratory Syncytial Virus (RSV) every shift (7a-3p, 3p-11p, and 11p-7a) for 8 days through 1/13/26.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #29 had a respiratory infection, (RSV). Interventions included emphasizing good hand-washing techniques to all direct care staff, encourage coughing and deep breathing, and monitor intake and output. The RCP failed to identify interventions related to transmission-based precautions (TBP) or wearing of appropriate PPE when inside Resident #29's room.Observation of posted signage located outside the doorframe of Resident #29's room indicated Resident #29 was on Transmission Based Precautions and directed staff to follow droplet/contact precautions which indicated PPE was required consisting of a gown, N95 mask, eye protection and gloves prior to entering the room. 2b. Resident #103 (roommate to Resident #29) had diagnoses that included history of a right femur fracture with repair, dementia, and heart disease.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was severely cognitively impaired, used a walker, required setup or clean-up assistance with eating, partial/moderate assistance with chair/bed transfers, and supervision or touching assistance with walking 10 feet and 50 feet with 2 turns.A physician order dated 1/7/26 directed to implement droplet precautions for positive RSV every shift (7a-3p, 3p-11p, and 11p-7a) until 1/17/26 at 11:59 PM.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #103 was at risk for malnutrition related to chronic diseases, therapeutic diet, cognitive impairment, and altered lab work values. Interventions included monitoring signs and symptoms of dehydration and to encourage intake of food and fluids. The RCP failed to identify Resident #103 was at risk for infection related to the current facility outbreak.Observation of posted signage located outside the doorframe of Resident #103's room indicated Resident #103 was on Transmission Based Precautions and directed staff to follow droplet/contact precautions which indicated PPE was required consisting of a gown, N95 mask, eye protection and gloves prior to entering the room. Observation on 1/14/26 at 9:21 AM identified Nurse Aide (NA) #1 entered Resident #29/Resident #103's room only wearing a surgical mask and gown (without the benefit of wearing an N95 mask/eye protection). NA #1 walked behind Resident #29's curtain, was speaking to the resident, then walked back to the front of the room, and exited. NA #1 was observed removing the gown, placing the gown in a bin located at the doorway within Resident #29/Resident #103's room and performed hand hygiene outside of the room using sanitizer located on the wall.Interview and review of the TBP sign posted outside Resident #29/Resident #103's room with NA #1 on 1/14/26 at 9:22 AM identified she should have worn a gown, gloves, and mask when entering the room. NA #1 identified the signage directed for her to wear an N-95 respirator mask and she was wearing a surgical mask. NA #1 identified her surgical mask was not the correct mask for her to have been wearing based on the signage, but she had forgotten to change to the N-95 mask from a surgical one. 2c. Resident #17 (roommate to Resident #118) had diagnoses that included dementia, malnutrition, and COVID-19.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was severely cognitively impaired, used a walker and wheelchair, required setup and clean-up assistance with eating, and substantial/maximal assistance with bed mobility and transfers.The Resident Care Plan (RCP) dated 12/12/25 identified Resident #17 was at risk for malnutrition related to significant weight changes and chronic diseases. Interventions included monitoring for signs and symptoms of dehydration and obtain and monitor blood work as needed.A physician order dated 1/10/26 directed to implement droplet precautions for positive COVID-19 every shift (7a-3p, 3p-11p, and 11p-7a) until 1/21/26 at 11:59 PM.Observation of posted signage located outside the doorframe of Resident #17's room indicated Resident #17 was on Transmission Based Precautions and directed staff to follow droplet/contact precautions which indicated PPE was required consisting of a gown, N95 mask, eye protection and gloves prior to entering the room. 2d. Resident #118 (roommate to Resident #17) had diagnoses that included hypertension, vascular dementia, and anxiety.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was severely cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent with bed/chair transfers.The Resident Care Plan (RCP) dated 12/29/25 identified Resident #118 was at risk for malnutrition related to significant weight changes, chronic diseases, difficulty self-feeding, and mechanically altered diet. Interventions included monitoring signs and symptoms of dehydration, obtain weights per physician order, and encourage the intake of food and fluids.Observation of posted signage located outside the doorframe of Resident #118's room indicated Resident #118 was on Transmission Based Precautions and directed staff to follow droplet/contact precautions which indicated PPE was required consisting of a gown, N95 mask, eye protection and gloves prior to entering the room. Observation on 1/14/26 at 9:12 AM identified Nurse Aide (NA) #2 entered Resident #17/Resident #118's room wearing only a surgical mask (without the benefit of wearing an N95 mask) she walked to Resident #118's side of the room (Resident ##17 and Resident #118 were in their bed) and exited the room with dishes which she carried 4 rooms down the hall and placed them into a black bin for transport to the kitchen. NA #2 was not observed changing her mask prior to or upon exiting Resident #17/Resident #118's room.Interview and review of the TBP sign posted outside Resident #17/Resident #118's room with NA #2 on 1/14/26 at 9:14 AM identified the sign was posted because at least 1 of the residents in that room had COVID-19 (Resident #17). NA #2 identified staff should wear a gown, gloves, and mask when entering that room and she should have been wearing all PPE items identified on the sign prior to entering the room, but she forgot.Subsequent to surveyor inquiry, observation of NA #2 on 1/14/26 at 9:18 AM noted she reentered Resident #17/Resident #118's room wearing a surgical mask (not an N95 mask) and had donned a gown and gloves. The observation identified NA #2 entered the room, conversed with the residents and upon exiting the room she removed the gown and gloves and performed hand hygiene. NA #2 was not observed changing her mask prior to or upon exiting the room.Interview and review of the TBP sign posted outside Resident #17/Resident #118's room with NA #2 on 1/14/26 at 9:20 AM identified that while the sign showed a picture of an N-95 mask with labeling underneath that read N-95 respirator, NA #2 identified still identified she should be wearing the surgical mask (despite the picture on the TBP sign directing an N95 mask) she currently had on when entering the room. NA #2 was unable to identify the difference between the N-95 mask and her surgical mask or why it was incorrect to wear only the surgical mask in that room.Interview with Licensed Practical Nurse (LPN) #3 (the Infection Preventionist) on 1/16/26 at 3:00 PM identified she used droplet/contact signage on resident rooms for residents that required TBP for COVID-19 to signify that the staff needed to wear an N-95 respirator mask in addition to the remaining posted PPE prior to entering that room.Review of the Infection Control Program policy included, in part, appropriate use of PPE (gloves, gowns, masks, and eye protection), implementation of contact, droplet, and airborne precautions as needed, implementation of enhanced barrier precautions where applicable.Review of current Centers for Disease Control (CDC) guidance last updated 1/23/26 directed that healthcare workers who enter the room of resident(s) with signs and symptoms of an unknown respiratory viral infection consistent with COVID-19 should use an N-95 respirator mask, gown, gloves, and eye protection. Further review of CDC guidance Appendix A (last updated 2/7/25): Type and duration of precautions recommended for selected infections and conditions recommends for COVID-19 that healthcare staff wear N-95 or higher protection, eye protection (goggles or face shield), and implement airborne plus droplet plus contact plus standard precautions (airborne preferred but if negative pressure room not available then droplet). 3. Resident #122 had diagnoses that included cellulitis, pressure ulcer of the sacral region, and adult failure to thrive.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #122 was moderately cognitively impaired, had 1 unhealed Stage 4 pressure ulcer, used a walker and wheelchair, was independent with eating, required supervision or touching assistance with bed mobility, and partial/moderate assistance with transfers.A physician order dated 12/30/25 directed to implement EBP related to wounds every shift (7AM-3PM, 3PM-11PM, and 11PM-7AM)The Resident Care Plan (RCP) dated 1/12/26 identified Resident #122 had an unstageable pressure ulcer to the sacrum. Interventions included to monitor impaired skin sites for healing/worsening per policy, provide treatments per physician orders, and provide pressure relieving devices as warranted. The RCP failed to identify Resident #122 required EBP precautions and the interventions associated with that such as use of PPE by staff during care.Review of the facility Residents on Precautions list updated 1/9/26 identified Resident #122 was on EBP for wounds.Observation of Resident #122's doorway to the room on 1/12/26 at 11:00 AM failed to identify EBP signage was posted that Resident #122 was on EBP. Interview at that time noted he was not wearing PPE because he was not aware Resident #122 was on EBP and PPE was required.Interview with Licensed Practical Nurse (LPN) #3 on 1/12/26 at 1:25 PM identified she checked posted transmission based precautions (TBP)/EBP signage on resident rooms at least daily and often multiple times a day and verified that the posted signage matched her line list. LPN #3 further identified that TBP/EBP orders were entered by either herself or a nursing supervisor. Observation of Resident #122's doorway to the room on 1/13/26 at 10:40 AM and 1/14/26 at 9:05 AM failed to identify EBP signage posted on the wall next to Resident #122's doorway near where his/her name was displayed.Observation on 1/14/26 at 12:10 PM noted an employee from rehabilitation was providing rehab services to Resident #122 (doing exercises) without wearing PPE.Interview with LPN #3 (the Infection Preventionist) on 1/15/26 at 12:22 PM identified residents with pressure ulcers should be on EBP with signage posted on the wall outside their room. LPN #3 was unable to identify why there was not an EBP sign posted on the wall outside Resident #122's room.Subsequent to surveyor inquiry observation of Resident #122's doorway to the room on 1/16/26 at 9:10 AM identified an EBP sign was posted on the wall to the left of Resident #122's doorway above where his/her name was displayed.Review of the Enhanced Barrier Precautions policy directed, in part, the purpose of EBP is to provide another layer of protection for higher risk residents. The policy directed EBP involved the consistent use of gowns and gloves by staff during high-contact resident care activities (dressing, bathing, wound care). The policy directed EBP would be implemented for residents with indwelling medical devices and the presence of a non-healing/chronic wound which included pressure ulcers. The policy directed residents that meet the criteria for EBP will have this documented within the medical record including the RCP. The policy directed that a sign may be placed outside the resident room as a reminder to staff and staff should be educated on EBP on orientation and ongoing. 4. Resident #143 had diagnoses that included Influenza, obstructive and reflux uropathy (blockage of the urinary tract), and benign prostatic hyperplasia (BPH) (enlarged prostate).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #143 was moderately cognitively impaired, had an indwelling catheter, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for bed/chair transfers.A physician order dated 1/6/26 directed to change the foley catheter leg bag daily on the 7:00 AM to 3:00 PM shift and to change the foley catheter drainage bag as needed for accumulation of sediment, discoloration of the bag, and for odor or leakage. Additionally, the physician order directed to check the foley to bedside drainage every shift (7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM) and place inside a privacy bag.The Resident Care Plan (RCP) dated 1/7/26 identified Resident #143 had a foley catheter related to diagnoses of obstructive uropathy and BPH. Interventions included to provide catheter care every shift and as needed, change foley bag per physician order, and foley catheter drainage bags would be changed as needed for accumulation of sediment, odor or leakage, and discoloration of the bag. The RCP further identified Resident #143 had an increased susceptibility to infection related to the foley catheter and history of extended-spectrum beta-lactamases (ESBL) (bacteria) in urine. Interventions included utilize enhanced barrier precautions (EBP) as ordered, and educate resident/family on need for good hand hygiene.Observation on 1/12/26 at 10:26 AM in Resident #143's bathroom identified 2 unlabeled, uncovered/unbagged urinary leg-bags were hanging off the right side of the towel rack and an unlabeled, uncovered/unbagged night time closed urine bag was hanging off the left side of the towel rack. The observation also identified an unlabeled, uncovered/unbagged graduated cylinder sitting on top of the toilet with crumpled paper towels inside it. Observation on 1/13/26 at 11:00 AM in Resident #143's bathroom identified 2 unlabeled, uncovered/bagged urinary leg-bags were hanging off the towel rack, and an unlabeled, uncovered/bagged graduated cylinder sitting on top of the toilet.Interview with Licensed Practical Nurse (LPN) #3 (the Infection Preventionist) on 1/14/26 at 2:28 PM identified foley bags, leg bags, and graduated cylinders were to be labeled with the resident name, date and stored in a bag when not in use. LPN #3 identified the nurse aides were aware these items were supposed to be labeled and stored in a bag when not in use. LPN #3 identified there had not been recent education on care and storage of foley bags, but that she would initiate education.Interview with Nurse Aide (NA) #8 on 1/16/26 at 1:00 PM identified Resident #143 was on his assignment on 1/12/26 from 7:00 AM to 3:00 PM. NA #8 identified he knew that the foley bag(s) and graduated cylinder were supposed to be rinsed out and placed in a bag for storage prior to hanging them in the bathroom. NA #8 further identified he had not been aware of the 2 unlabeled, uncovered/unbagged urinary leg-bags hanging off the right side of the towel rack, the unlabeled, uncovered/unbagged night time closed urine bag was hanging off the left side of the towel rack, or the unlabeled, uncovered/bagged graduated cylinder sitting on top of the toilet, and indicated those items must have been there prior to his shift.Review of the Urinary Catheter policy directed, in part, to regularly empty the drainage bag while ensuring to avoid contamination of the drainage spigot. The policy directed to change the catheter and drainage bags only when clinically indicated. The policy directed all nursing staff must receive training on proper catheter care and prevention of catheter related urinary tract infections, and the education must be documented and performed regularly. The policy directed that periodic audits of catheter care practices should be conducted. Review of the Urinary Catheter procedures (Appendix A) policy directed, in part, to connect the urinary drainage bag to the catheter, and to empty the bag at least every 8 hours using a clean container and while avoiding contamination of the drainage spigot.Review of both policies and procedures related to urinary catheters failed to identify directives for storage of drainage bags when not in use or storage of the graduated cylinders used for measuring the urine output. 5a. Review of the Master Line List regarding a respiratory outbreak of COVID-10, Influenza and Respiratory Syncytial Virus (RSV) onset date of 11/28/25 identified the name of the facility and included tables with the following columns: room/unit, resident (name), symptoms, date of onset, treatment, test performed, date tested, test results, and end date. The tables were organized according to the respiratory organism(s): Influenza and COVID-19. The document included the Medical Director (Medical Doctor (MD) #1) was notified on 11/28/25 and the Infection Preventionist was LPN #3. Additionally, the rows within each table listed the residents in a general order by date, it was not consistent, so entries did not facilitate a timeline of events. The line list identified 26 resident names within the Influenza table although none of the entries included a date of 11/28/25. Additionally, the line list identified 7 resident names within the COVID-19 table although none of the entries included a date of 11/28/25. The document failed to identify a table for RSV and the staff line list was not included.Interview, observation, and facility documentation review with LPN #3 (the Infection Preventionist) and RN #2 on 1/14/26 at 2:15 PM identified LPN #3 had contacted MD #1 to notify him of the outbreak on 11/28/25 as it was shown on the Master Line List with onset date of 11/28/25 document. LPN #3 was unable to identify the reason the date on the line list document was 11/28/25 when none of the residents had an onset date for symptoms or of a positive test dated 11/28/25. LPN #3 identified she thought it might have been a resident who had been sent to the hospital and the facility found out afterwards that the resident tested positive for Influenza. LPN #3 identified the staff line list was kept separate from the resident line list. Review of the resident line list on LPN #3's computer identified additional columns which weren't reflected on the printed line list which included resident age, sex, and if hospitalized . LPN #3 identified the line list on her computer couldn't be printed out due to the number of columns without making it so small it couldn't be easily read. A request was made on 1/14/26 at 2:20 PM for LPN #3 to send the current line list from her computer for viewing but one was not provided.Additionally, the updated Master Line List for Actual Outbreak with an onset date of 11[TRUNCATED]

Based on tour of the Dietary Department, staff interview and facility policy, the facility failed to ensure Dietary Aide (DA) #1's attire was clean and failed to ensure expiration dates were identified on various food items. The findings include: On 1/12/26 at 10:14 AM, tour of the Dietary Department with the Food Service Director (FSD) identified the following:a. Dietary Aide (DA) #1 was working in the dish room removing clean items from the dishwasher. She was wearing a black shirt with a heavy accumulation of fuzz/lint and animal hair on both sides of the shirt. Her shirt was not covered with any type of overshirt/apron which would contain the fuzz/lint/animal hair. Interview with DA #1 at that time identified that although she had a cat, she was unaware that her shirt had a heavy accumulation of fuzz/lint/animal hair.b. Observation of a cycle through the dish washing machine identified DA #1 removing 4 clean, mauve colored, plastic water pitchers from the dishwasher. The water pitchers were dripping wet with water and DA #1 stacked the water pitchers on the beverage station. Interview with DA #1 at that time identified that the water pitchers were clean and ready to be distributed to the units, however she did not have a dying rack to separate the water pitchers to air dry. Additionally, 17 clear dish covers/lids were observed to be located on the stainless-steel counter of the new tray line and stacked on top of one another, dripping wet with water. Interview with the FSD at that time identified the lids should be left to air dry, but there weren't enough drying racks to accommodate the items coming out of the dishwasher. c. Observation of the walk-in refrigerator identified a 128-ounce (oz) plastic container of Teriyaki sauce that was approximately 1/2 full, although the date opened (12/23/25) was noted, the expiration date located on the container was in a code, and the FSD was unable to decipher the actual expiration date. d. Observation of the walk-in freezer identified 20 pieces of French toast in a plastic bag, dated 1/6/26 (the date the French toast came in) but lacked an expiration date. Interview with the FSD at that time identified that the expiration date must have been located on the original box the French toast came in and when the item was removed from the box, the expiration date wasn't identified. The original box of French toast was not in the freezer for the expiration date to be referenced to. The FSD noted staff should have written the expiration date from the original box the items were taken from. Facility policy for the Dietary Department (undated) identified all Dietary employees will wear clean uniforms, rubber soled shoes, and restraints (long hair a hairnet is to be worn; for short hair, a cap). Facility policy for Dietary equipment (undated) identified all dishes, utensils and equipment will be air-dried after washing.

Based on review of the clinical record, facility policy, facility documentation, and interviews for 2 of 3 residents (Resident #78 and Resident #84) reviewed for dental, the facility failed to develop a dental care plan. The findings include: 1.Resident #78's diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, required a therapeutic diet, had no natural teeth or tooth fragments, and was independent with eating, oral hygiene, transfers, and ambulation. The Resident Care Plan (RCP) dated 12/21/22 identified Resident #78 required a therapeutic diet related to morbid obesity and poorly controlled diabetes. Interventions included to provide a consistent carbohydrate diet and monitor oral intake. The RCP failed to identify Resident #78's dental status and that Resident #78 had no natural teeth or tooth fragments, and no dentures. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, required a therapeutic diet, and was independent with eating, oral hygiene, transfers, and ambulation. The RCP dated 12/3/25 identified Resident #78 was at risk for malnutrition related to obesity, COPD, diabetes, dementia, bipolar disorder, depression, gastroesophageal reflux disease (GERD), hypothyroidism, disorder of bone density, peptic ulcer, psychosis, and a therapeutic diet. Interventions included providing a consistent carbohydrate diet, encourage diet compliance, and encourage the intake of food and fluids. The RCP failed to identify Resident #78's dental status and that Resident #78 had no natural teeth or tooth fragments, and no dentures. Interview with Resident #78 on 1/13/26 at 11:02 AM identified he/she had difficulty chewing meats because they are too hard to chew. Resident #78 identified he/she had no teeth and was waiting for dentures to be made. Resident #78 further identified he/she had not told staff about the difficulty with chewing meats. Interview with Person #1 on 1/16/26 at 9:19 AM identified Resident #78 had been without teeth and dentures for a long time. Person #1 identified Resident #78 had lost his/her dentures prior to admission to the facility and insurance wouldn't cover replacement of the dentures at first, but that Resident #78 was now in the process of getting new dentures made. Interview with Licensed Practical Nurse (LPN) #9, who was the Care Plan Coordinator on 1/16/26 at 12:07 PM identified Resident #78 should have a care plan related to oral health and condition of teeth/dentures. LPN #9 identified the RCP should reflect when a resident doesn't have teeth and/or dentures and that it would often be reflected in the RCP related to diet. LPN #9 identified she had just recently become responsible for Resident #78's care plan and that the previous nurse had not completed the care plan as expected. LPN #9 further indicated that she would be implementing a dental focus in Resident #78's RCP. Subsequent to surveyor inquiry the RCP dated 1/16/26 identified Resident #78 was edentulous (no natural teeth) on both upper and lower and was in the process of getting dentures. Interventions included obtaining a dental consult as needed and monitor for complaints of difficulty chewing or swallowing. Subsequent to surveyor inquiry facility education titled Oral Health identified education on the policy for oral health was initiated by the DNS on 1/16/26. There are 42 staff member signatures identified. Review of this education and the Oral Health policy failed to identify directives within the policy to ensure the RCP was updated accordingly. Interview with the Director of Nursing Services (DNS) on 1/20/26 at 1:15 PM identified that Resident #78 should have a care plan that reflected his/her dental status. The DNS identified that there was an MDS nurse who was no longer employed at the facility that was not updating care plans appropriately and the current MDS nurse (LPN #9) was in the process of fixing those care plans. Interview and review of facility documentation for Quality Assurance and Performance Improvement (QAPI) with the Administrator on 1/21/26 at 3:31 PM failed to identify implementation of a QAPI plan prior to survey related to resident care plans and the need to review and update all care plans overseen by the former MDS nurse. 2. Resident #84 was admitted to the facility in March 2021 with diagnoses that included dementia, anxiety, and depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #84 had intact cognition, was independent with activities of daily living and had obvious or likely cavities or broken natural teeth. Advanced Practice Registered Nurse (APRN) # 1's progress note dated 4/11/25 identified that Resident #84 agreed to see an oral surgeon for teeth extractions and dentures but did not want to see the same oral surgeon that he/she saw on 10/16/24. Physician's orders dated 4/18/25 directed dental consults as needed, a no added salt diet with regular liquids and meats hand cut into small pieces A nursing note dated 4/19/25 at 2:47 PM identified Resident #84 was complaining of pain to his/her first molar on the left mandibular jaw and the resident was added to the dental list to be seen in the facility. The Resident Care Pan (RCP) dated 4/24/25 indicated that Resident #84 was on a mechanically altered diet, Resident #84 needed to eat well and maintain good nutrition. Interventions included to monitor and report weight changes, encourage foods and liquids, offer snacks 3 times a day, and give no added salt diet with thin liquids and meats hand cut into small pieces. APRN #1's progress note dated 5/9/25 identified Resident #84 was seen by APRN #1 due to his/her multiple refusals to see a dentist/oral surgeon for needed extractions and dentures. Resident #84 expressed that he/she felt fine and did not need to go to the dentist. A dental consultant at the facility on 8/20/25 identified that Resident #84 was missing 12 teeth in total and had 13 fractured teeth with severe demineralization and gingivitis. An Oral Health Assessment conducted at the facility by licensed nursing staff on 12/2/25 identified Resident #84 had 4 or more decaying or broken teeth, pink gums, no pain, no swallowing difficulties and had food particles/tartar/plaque in areas of the mouth. A review of Resident #84's care plan and interview with LPN #9 (Resident Care Plan Coordinator) on 1/15/26 at 10:30 AM identified the RCP lacked a dental care plan and the care plan did not address Resident #84's missing and fractured teeth, the need for extractions and dentures, and Resident #84's refusal to follow up with the dentist/oral surgeon. LPN #9 indicated that nursing was responsible for initiating a dental care plan that was individualized related to Resident #84's dental needs. LPN #9 could not explain the reason Resident #84's dental care plan was not in place and that Resident #84 should have had a dental care plan. LPN #9 indicated that she had initiated an audit for all residents' care plans related to dental needs to ensure a dental care plan was in place and was in the process of updating everyone's care plan. A review of the Care Plan Policy directed, in part, the facility is committed to providing residents/patients with all necessary care and services. Recognizing each resident/patient as an individual, we clarify and meet these needs in a resident centered environment. Assessments and care plans are oriented toward preventing avoidable decline in functional levels and reflect resident/patient right to refuse certain services and treatments. The care plan is evaluated and revised quarterly and as needed.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 7 residents (Resident #31) reviewed for nutrition, the facility failed to provide supervision during a meal per the physician's order for a resident with dysphagia (swallowing difficulty). The findings include: Resident #31's diagnoses include type 2 Diabetes, dysphagia (difficulty swallowing), transient ischemic attack (mini-stroke) and having a PEG tube (abdominal feeding tube). A Nutritional assessment dated [DATE] at 2:11 PM and written by the Dietician identified Resident #31 required mechanically altered food and nectar thick liquids. A physician's order dated 12/16/25 directed a mechanically altered texture, nectar thick consistency diet for risk of choking and directed staff to provide constant and individual (1 to 1) supervision with Resident #31's meals. The Resident Care Plan (RCP) dated 12/17/25 identified Resident #31 was at risk for aspiration related to dysphagia with interventions that included providing a regular, soft diet, with thickened liquids as well as encouraging Resident #31 to take small sips, bites, and allow for adequate swallow time and cue as needed. The RCP dated 12/17/25 also identified Resident #31 was at risk for malnutrition and directed staff to observe/ document/ report any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow, refusing to eat, and appearing concerned during meals. A dietary note dated 12/17/25 at 2:10 PM and written by the Dietitian identified Resident #31's diet recommendations included a mechanically altered and nectar thick liquids as part of aspiration precautions.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition and was independent with most activities of daily living. Additionally, the MDS identified Resident #31 required set up/ clean up for eating and had symptoms of a possible swallowing disorder that included loss of liquid/solids from mouth when eating or drinking and coughing or choking during meals or when swallowing medication. On 12/30/25, a swallow evaluation completed by the Speech Therapist indicated that Resident #31 retained food in the mouth and cheeks after meals, exhibited coughing or choking during meals or when swallowing medications, and had food or liquid residue on or around the tongue, cheeks, and gums indicating the resident required a mechanically altered diet and nectar-thickened liquids. A dietary note dated 1/13/26 at 11:04 AM and written by the Dietician identified Resident #31 was able to feed him/herself however still required 1 to 1 supervision due a risk of choking. An observation 1/13/26 at 12:42 PM noted Resident #31 eating grilled cheese for lunch alone in his/her room without supervision. Observation on 1/14/26 at 12:06 PM noted Resident #31 to be eating alone in his/her room without supervision. Interview with Nurse Aide (NA) #4 on 1/14/26 at 12:22 PM indicated that she did not provide supervision to Resident #31 during the meal and was unaware that Resident #31 required supervision because it was not reflected on the care card. Interview with Speech Therapist # 1 (Speech Regional Director) on 1/16/26 at 9:45 AM identified that the active physician order of 1 to 1 meal supervision should have been followed during mealtime. An interview with the DNS on 1/16/26 at 12:57 PM also identified that the physician order for Resident #31 to be supervised during meals should have been followed although she was unaware there was an active order for 1 to 1 supervision. Review of the facility's Meal Service/Tray Service policy, dated July 2025, directed staff to verify any special meal-related instructions for each resident prior to meal delivery and to monitor residents during the meals, providing assistance as needed.

Based on observations, review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #119) reviewed for edema, the facility failed to follow a physician's order for the application of compression stocking for a resident with edema. The findings include:Resident #119's diagnoses included Type 2 Diabetes Mellitus, chronic kidney disease and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 was moderately cognitively impaired and required substantial/maximal assistance for bed mobility, toileting, and transfers. The Resident Care Plan (RCP) dated 1/7/26 identified a risk for skin breakdown. Interventions included compression stockings on in AM off at HS (hour of sleep) and may use Ace wraps to bilateral lower extremities if resident refuses compression stockings. A physician's order dated 1/12/26 directed to apply TED (compression stockings) stocking daily (on in AM and off at HS) to bilateral lower extremities and may use Ace wraps to bilateral lower extremities if resident refuses compression stockings. Observations on 1/13/26 at 10:30 AM and 1/14/26 at 11:44 AM identified Resident #119 was seated in a wheelchair without the benefit of compression stockings applied to his/her bilateral lower extremities. Observation, interview, and review of facility documents with Nurse Aide (NA) #5 on 1/13/26 at 12:11 PM identified Resident #119 was seated in a bedside chair without the benefit of compression stockings to his/her bilateral lower extremities. NA #5 indicated she could not locate the resident's compressions stockings and they must have been in the laundry department. NA #5 further identified she had not reviewed Resident #119's NA care card before providing the resident care and had not informed the charge nurse she was unable to locate the resident's compression stockings. Review of the NA care card with NA #5 indicated Resident #119 was to have compression stockings applied in the AM to his/her bilateral lower extremities. NA #5 identified she wound need to check with the charge nurse. Observation and interview with Licensed Practical Nurse (LPN) #5 and Resident #119 on 1/13/26 at 12:13 PM identified Resident #119 was seated in a bedside chair without the benefit of compression stockings to his/her bilateral lower extremities. LPN #5 indicated Resident #119 should have had the compression stockings on and proceeded to locate the compression stockings in the top drawer of the resident's dresser. LPN #5 identified it was the responsibility of the NA to apply the compressions stockings and if NA #5 was unable to locate the compression stockings she should have let her know. LPN #5 proceeded to apply the compression stockings to Resident #119's bilateral lower extremities. Resident #119 indicated he/she was not refusing to wear the compression stockings, had not had the stockings applied in a few days and was unsure of the reason. An Advanced Practice Registered Nurse (APRN) progress note dated 1/13/25 at 3:59 PM identified Resident #119 had weight gain and +2 (moderate pitting) edema to his/her bilateral lower extremities. An additional observation, interview, and review of facility documents with NA #6 on 1/15/26 at 12:06 PM identified Resident #119 was seated in a wheelchair without the benefit of compressions stockings applied to his/her bilateral lower extremities. NA #6 indicated she was unaware Resident #119 was supposed to have compression stockings applied and stated she had failed to review the NA care card prior to providing Resident #119 care. Review of the NA care card with NA #6 identified Resident #119 was to have compression stockings applied to his/her bilateral lower extremities in the AM. Another observation and interview with LPN #6 on 1/15/26 at 12:11 PM identified Resident #119 was seated in a wheelchair without the benefit of compression stockings applied to his/her bilateral lower extremities. LPN #6 indicated she had forgotten to tell NA #6 to apply the compression stockings, NA #6 should have reviewed the NA care card and applied the stockings for the resident. LPN #6 proceeded to locate the compression stockings in the top drawer of the resident's dresser, transferred Resident #119 to the bedside recliner and applied the compression stockings. LPN #6 indicated she should have checked earlier to ensure Resident #119 had the compression stockings applied with AM care. Resident #119 was agreeable with having the compression stockings applied by LPN #6 and the resident indicated he/she also wanted to elevate his/her legs. Interview and review of the clinical record with the DNS on 1/16/26 at 12:39 PM identified she would have expected Resident #119's compression stockings to be applied to his/her bilateral lower extremities per the physician's order. The DNS indicated it would have been the responsibility of the NA or charge nurse to apply the compression stockings and identified the NA's should be checking the NA care cards prior to providing care. Additionally, the DNS noted the charge nurses should have checked the resident and directed the NA to apply the compression stockings. The DNS indicated she would need to provide further education to the NA's and charge nurses. Review of the facility policy, Anti-Embolic Stockings, dated 7/2025, directed stockings were provided to support and aid return circulation for lower extremities and to reduce edema. The policy further directed to apply and remove stockings per the physician's order.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 6 residents (Resident #126, and Resident #143) reviewed for pneumococcal immunization, the facility failed to ensure that pneumococcal vaccines were administered when Resident #126 consented to receive and failed to offer or obtain a history of receiving the pneumococcal vaccine on admission (Resident #143). The findings include:1. Resident #126 was admitted to the facility on [DATE] on the short-term rehabilitation unit with diagnoses that included hypertension, dementia, and depression.A Resident admission Vaccination Education form dated 1/2/26 and signed by Resident #126 identified consent to receive the Pneumococcal conjugate vaccine (PCV20).Additionally, Resident #126's electronic medical record did not reflect any historical pneumococcal vaccinations nor indicate a pending pneumococcal vaccine order. 2. Resident #143 was admitted to the facility on [DATE] on the short-term rehabilitation unit.A Resident admission Vaccination Education form was located in the paper chart and blank (not filled out), indicating that the resident's vaccination status had not been reviewed with him/her and the pneumococcal vaccine was not offered.Interview with Licensed Practical Nurse (LPN) #3 (the Infection Preventionist) on 1/20/26 at 3:10 PM identified that she had not reviewed or administered any pneumococcal vaccines for residents since assuming the role of Infection Preventionist in October 2025. She explained that, as a new employee she was focused on managing the current facility outbreak, was unable to complete this responsibility despite being aware of the facility's policy requiring pneumococcal vaccine review and offering upon admission. LPN #3 stated that each resident should receive a vaccination consent form in their admission packet, which was placed in the paper chart by the admission nurse and later collected by her for review, tracking, ordering, administration, and documentation. However, due to time constraints related to a facility respiratory outbreak, these tasks were not completed. She acknowledged the expectation that residents who consent to pneumococcal vaccination should receive the vaccine within one to two weeks of consent, typically obtained during admission. LPN #3 described methods for obtaining vaccine history, including verbal reports from residents or families, previous health records, and the State of Connecticut resource CT Wiz. She confirmed that any history of pneumococcal vaccination or refusal should be documented under the immunization tab in the electronic medical record. When documentation is absent, it indicates the resident's vaccination status was not formally reviewed and the vaccine was not administered. An interview with the Director of Nursing Services (DNS) on 1/21/26 at 12:48 PM indicated her expectation was that residents' pneumococcal vaccination status would be reviewed, documented in the electronic medical record, and administered when consent had been obtained, in accordance with facility policy. She further indicated that all residents, including short-term residents who may stay for only one to two weeks, should have the opportunity to receive the pneumococcal vaccine. The DNS confirmed that LPN #3's expectation of administering the vaccine within one to two weeks of obtaining consent is reasonable. A review of the facility's undated policy, Procedure for Pneumococcal Vaccination of Residents, undated, directs that upon admission, each resident should be asked whether they have previously received any pneumococcal vaccines and at what age. The policy further states that if a resident's vaccination status is unknown, the pneumococcal vaccine should be offered and administered to those who consent. Additionally, the policy specifies that adults aged 65 or older who have not previously received a pneumococcal vaccine, or whose vaccination history is unknown, should receive a pneumococcal conjugate vaccine (PCV20 or PCV15). If PCV15 is administered, a dose of PPSV23 should be given within one year of the PCV15 administration.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 7 residents (Resident #106) reviewed for nutrition, the facility failed to provide adaptive equipment at mealtime per the physician's order. The findings include:Resident #106's diagnoses included dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #106 required setup or clean-up assistance with eating and was receiving a therapeutic diet. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #106 had oropharyngeal dysphagia (difficulty swallowing) and was an aspiration risk with a risk for malnutrition. Interventions included aspiration precautions and safe swallowing strategies and to provide an inner lip plate at meals. A physician's order dated 11/8/25 and currently in effect, directed adaptive equipment of an inner lip plate at meals. Observation on 1/13/26 at 12:10 PM noted Resident #106 in bed and eating his/her lunch meal without the benefit of an inner lip plate on his/her tray table. Observation, interview, and review of Resident #106's meal ticket with Nurse Aide (NA) #7 on 1/15/26 at 12:19 PM identified she served and set up Resident #106 for lunch without the benefit of an inner lip plate on the meal tray. NA #7 indicated she made a mistake and served Resident #106 lunch without ensuring the kitchen had plated the resident's lunch on an inner lip plate. NA #7 did not notify the kitchen and Resident #106 continued to eat from a regular plate. Review of the resident's meal ticket with NA #7 identified Resident #106 required adaptive equipment of a Kennedy cup and inner lip plate at meals. Observation, interview, and review of the meal ticket with LPN #6 on 1/15/26 at 12:26 PM identified Resident #106 was in bed eating lunch without the benefit of an inner lip plate. LPN #6 indicated the resident's adaptive equipment should have come up from the kitchen and been served on an inner lip plate from the steam table in the dining room. LPN #6 stated NA #7 should have ensured Resident #106's meal was on an inner lip plate before she provided the tray and set up the resident's lunch. LPN #6 indicated she was going to call the kitchen and get it corrected. Interview and review of the clinical record with Occupational Therapist (OT) #1 on 1/16/26 at 10:51 AM identified Resident #106 had weakness and hand tremors which can affect the resident's nutrition and dignity. OT #1 indicated an inner lip plate provided Resident #106 with better nutrition because Resident #106 was able to get more food on the spoon and into his/her mouth. OT #1 further stated due to Resident #106's tremoring, decreased strength and fine motor function he/she required the inner lip plate (which provided an edge) to prevent spillage. OT #1 identified it was the responsibility of the kitchen to provide adaptive equipment and the dietary staff should have served the resident's meal on an inner lip plate. Additionally, the nursing staff was responsible to ensure the meal was plated on an inner lip plate before serving the meal to the resident. Interview and review of facility documents with the DNS on 1/16/26 at 12:36 PM identified Resident #106's meals should be plated on an inner lip plate by the dietary staff and served by the nursing staff according to the resident's meal ticket. The DNS indicated adaptive equipment should be sent up from the kitchen on the dietary cart and provided to the resident per the physician's order. The DNS stated she would need to speak to the Dietary Director and provide further education to the nursing staff regarding Resident #106's adaptive equipment. Interview and review of the clinical record with the Dietary Director on 1/16/26 at 2:21 PM identified dietary staff should have read Resident #106's meal ticket and accurately served the resident's meal on an inner lip plate. The Dietary Director indicated adaptive equipment came up to the unit with the steam table and Dietary staff should have cross checked the meal ticket and plated the resident's meal accordingly. The Dietary Director identified Dietary staff should have provided Resident #106 with adaptive equipment per the physician's order and the NA should have ensured the inner lip plate was present before serving the resident's meal. The Dietary Director indicated he would need to provide further education to the Dietary staff regarding Resident #106's adaptive equipment. Review of facility policy, Nutrition, dated 07/2025, directed it is the policy of the facility to provide appropriate interventions according to the physical and mental abilities of the resident. Meals will be placed in front of the resident with all equipment/assistive devices and assistance required.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 7 residents (Resident #106) reviewed for nutrition, the facility failed to provide the appropriate consistency meal per the physician's order for a resident with dysphagia (difficulty swallowing). The findings include: Resident #106's diagnoses included dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #106 required setup or clean-up assistance with eating and was receiving a therapeutic diet. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #106 had oropharyngeal dysphagia (difficulty swallowing) and was an aspiration risk with a risk for malnutrition. Interventions included to provide aspiration precautions and safe swallowing strategies. A physician's order dated 11/8/25 and currently in effect, directed a low-fat diet, puree texture with thin liquid consistency. Observation on 1/13/26 at 12:10 PM identified Resident #106 was alone, in bed and eating a peanut butter and jelly sandwich on white bread with crusts. The sandwich was served on white plate with plastic wrap still on and covering the plate with a small opening noted in the plastic wrap on one edge of the plate. The resident had 1/2 of the sandwich in his/her right hand and was taking small bites from one end of the sandwich. The resident's eyes were closed, and he/she was coughing at times. Subsequent to this observation, a record review indicated Resident #106 had dysphagia and a physician's order for a puree diet. Observation, interview, and review of Resident #106's meal ticket with Occupational Therapist (OT) #1 on 1/14/26 at 8:45 AM identified Resident #106 was served hash brown potatoes which were cubed for breakfast. Review of the resident's meal ticket with OT #1 indicated Resident #106 was on a pureed diet, OT #1 identified the resident should not have been served hash brown potatoes which were cubed for breakfast and proceeded to remove them from Resident #106's tray table. Interview and review of the clinical record with Speech Therapist (ST) #1 on 1/16/26 at 9:30 AM identified Resident #106 had dysphagia and was downgraded to a puree diet on 1/7/26. ST #1 indicated he would not have expected Resident #106 to be alone in his/her room eating a peanut butter and jelly sandwich and should not have been served hash brown potatoes which were cubed if he/she was on a puree diet. ST #1 identified a peanut butter and jelly sandwich and hash brown potatoes which were cubed were out of the scope of a puree diet and put the resident at risk for choking and aspiration (food going into the lungs). ST #1 indicated he would have expected Resident #106 to be served the correct diet and to be supervised if he/she was going to eat food other than what was supposed to be on a puree diet. Interview and review of facility documents with the DNS on 1/16/26 at 12:36 PM identified Resident #106's meals should have been plated by the dietary staff and served by the nursing staff according to the resident's meal ticket (which noted a puree diet). The DNS indicated Resident #106 should not have been served a peanut butter and jelly sandwich and hash brown potatoes which were cubed as those were not considered part of a puree diet. The DNS identified Resident #106 had dysphagia and would be at risk of choking and aspiration if not served a pureed diet. The DNS stated she would need to speak to the dietary director and provide further education to the nursing staff regarding Resident #106's pureed diet. Interview and review of facility documents with the Dietary Director on 1/16/26 at 2:21 PM identified dietary staff should have read Resident #106's meal ticket and accurately plated/served the resident's meal as puree per the physician's order. The Dietary Director indicated a peanut butter and jelly sandwich and hash brown potatoes which were cubed were not part of a puree diet and should not have been served to Resident #106. The Dietary Director identified it was the Dietary Aide's (DA) responsibility to serve the resident's meal according to the meal ticket and there were pureed options for starch servings (pureed danish, cream of rice or mashed potato) available on the steam table that the DA should have served instead. The Dietary Director indicated he would need to provide further education to the Dietary staff regarding Resident #106's puree diet. Review of facility policy, Food and Dining Service, dated 07/2025, directed the objective of food service is to supply the resident with a diet that is comparable to the individual's needs and therapeutic diets are to be to be prepared and served as prescribed by the attending physician. Review of the facility policy, Meal Service Tray Service, dated 07/2025, directed the policy of the facility was to provide the correct meal for the right resident and the diet card should be checked for the resident's diet order and any special instructions. Before serving the meal, staff should verify the residents name and ensure that the right diet is being served to the right resident and if differences are found between what the diet card says and what is served, the charge nurse should be notified, or the kitchen should be called.

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for 4 of 4 residents (Resident #3, Resident #106, Resident #114 and Resident #119) reviewed for oxygen use, the facility failed to label and date oxygen tubing and failed to appropriately store nebulizer tubing for a resident with chronic obstructive pulmonary disease (COPD) (Resident #114) and pneumonia (Resident #119). The findings include:1. Resident #3's diagnosis included COPD, asthma, and obstructive sleep apnea. A physician's order dated 11/8/25 and currently in effect, directed oxygen via nasal cannula at 2 liters/minute and to change oxygen tubing every week on the Sunday 11:00 PM to 7:00 AM shift. The Resident Care Plan (RCP) dated 12/4/25 identified Resident #3 had an altered respiratory status and difficulty breathing with a diagnosis of COPD. Interventions included oxygen at 3 liters/minute via nasal cannula continuously and to administer oxygen and nebulizer treatments as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was cognitively intact and required partial/moderate assistance with bed mobility and transfers and was dependent with toileting. The MDS indicated Resident #3 received continuous oxygen therapy. Observations on 1/13/26 at 11:36 AM and 1/14/26 at 12:01 PM identified Resident #3 was seated in a bedside chair and was receiving continuous oxygen via nasal cannula. The oxygen tubing was unlabeled and undated. Observation and interview with Licensed Practical Nurse (LPN) #6 on 1/15/26 at 12:00 PM identified Resident #3 was receiving oxygen via a nasal cannula and the oxygen tubing was undated. LPN #6 indicated Resident #3 was on continuous oxygen due to a diagnosis of COPD. LPN #6 identified it was the responsibility of the Sunday 11:00 PM to 7:00 AM nurse to change, label and date respiratory equipment weekly and she was unable to indicate why the appropriate tube change/labeling/dating was not done. 2. Resident #106's diagnosis included COPD, moderate persistent asthma, and dependence on supplemental oxygen. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #106 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #106 received continuous oxygen therapy. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #106 had respiratory disease related to a diagnosis of COPD. Interventions included to administer oxygen via nasal cannula as ordered. A physician's order dated 11/8/25 and currently in effect, directed to administer oxygen via nasal cannula at 1 liter per minute continuous every shift and to change oxygen tubing every Sunday on the 11:00 PM to 7:00 AM shift. Observations on 1/13/26 at 11:35 AM and 1/14/26 at 12:00 PM identified Resident #106 was seated in a wheelchair and was receiving continuous oxygen via nasal cannula. The oxygen tubing was unlabeled and undated. Observation and interview with LPN #6 on 1/15/26 at 12:02 PM identified Resident #106's oxygen tubing was unlabeled and undated. LPN #6 indicated Resident #106 was on continuous oxygen due to a diagnosis of COPD. LPN #1 identified it was the responsibility of the Sunday 11:00 PM to 7:00 AM nurse to change, label and date respiratory equipment weekly and she was unable to indicate why appropriate tube change/labeling/dating was not done. 3. Resident #114's diagnoses included COPD, acquired absence of part of the lung and a personal history of tuberculosis. A physician's order dated 11/8/25 and currently in effect, directed oxygen via nasal cannula at 2 liters/minute and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml inhale orally every 4 hours as needed for shortness of breath. The physician's orders further directed to change oxygen and nebulizer tubing every week on the Sunday 11:00 PM to 7:00 AM shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #114 was cognitively intact and required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. The MDS failed to indicate Resident #114 received oxygen therapy. The Resident Care Plan (RCP) dated 12/11/25 identified Resident #114 had a diagnosis of COPD and acute respiratory failure with a history of a partial lobectomy (removal of the left lower lobe of the lung). Interventions included oxygen via nasal cannula at 2 liters/minute and to administer oxygen and nebulizer treatments as ordered. Observations on 1/13/26 at 11:37 AM and 1/14/26 at 12:02 PM identified Resident #114 was seated in a wheelchair and was receiving continuous oxygen via nasal cannula. The oxygen tubing was not labeled and undated. There was a nebulizer mask that was stored uncovered, placed on top of the bedside table with undated tubing attached. Observation and interview with Licensed Practical Nurse (LPN) #6 on 1/15/26 at 12:03 PM identified Resident #114's oxygen and nebulizer tubing were not labeled and undated and the nebulizer mask was stored uncovered and placed on top of the bedside table. LPN #1 indicated Resident #114 was on continuous oxygen due to a diagnosis of COPD and was utilizing the nebulizer on a regular basis. LPN #1 identified it was the responsibility of the 11:00 PM to 7:00 AM nurse to change and date respiratory equipment weekly and she was unable to indicate why the nebulizer mask was uncovered. 4. Resident #119's diagnoses included pneumonia, dyspnea, and pulmonary hypertension. A physician's order dated 12/6/26 and currently in effect, directed oxygen via nasal cannula at 2 liters/minute and Ipratropium-Albuterol Inhalation Solution 0.5/2.5 (3) mg/3ml inhale orally every 6 hours as needed for wheezing and shortness of breath. The physician's orders further directed to change oxygen and nebulizer tubing every week on the Sunday 11:00 PM to 7:00 AM shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 was moderately cognitively impaired and required substantial/maximal assistance with bed mobility, toileting, and transfers. The MDS indicated Resident #119 required oxygen therapy. The Resident Care Plan (RCP) dated 1/7/26 identified Resident #119 had a risk of altered respiratory status related to dyspnea (shortness of breath) and cough. Interventions included to provide oxygen and medications/inhalers as ordered. Observations on 1/13/26 at 10:29 AM and 1/14/26 at 11:44 AM identified Resident #119 was seated in a wheelchair and was receiving continuous oxygen via nasal cannula. The oxygen tubing was unlabeled and undated. There was a nebulizer mask that was stored uncovered, placed on top of the bedside table with undated tubing attached. Observation and interview with Licensed Practical Nurse (LPN) #6 on 1/15/26 at 12:04 PM identified Resident #119's oxygen and nebulizer tubing was undated, and the nebulizer mask was stored uncovered and placed on top of the bedside table. LPN #6 indicated Resident #119 was on continuous oxygen due to a recent diagnosis of pneumonia and the resident was utilizing the nebulizer on a regular basis. LPN #6 identified it was the responsibility of the 11:00 PM to 7:00 AM nurse to change and date oxygen/nebulizer tubing and was unable to indicate the reason the nebulizer mask was not covered. Subsequent to surveyor inquiry an observation on 1/16/25 at 11:04 AM identified Resident #3, Resident #106, Resident #114 and Resident #119's oxygen tubing was labeled/dated 1/15/26 and Resident #114 and Resident #119's nebulizer tubing was labeled/dated 1/15/26, and the nebulizer masks were bagged and being stored on top of the bedside table. Interview with the DNS on 1/16/26 at 12:39 PM identified oxygen and nebulizer tubing should be changed weekly and as needed, should be dated, and stored appropriately. The DNS indicated it was the responsibility of the nurse on the Sunday 11:00 PM to 7:00 AM shift and the nurse should have made sure the oxygen and nebulizer tubing was changed and dated and nebulizer masks were bagged. Review of the facility policy, Oxygen Administration, undated, directed to replace and date masks, cannula and tubing weekly or sooner if visibly soiled or damaged. When not in use, masks and nasal cannulas must be stored in a plastic bag and kept off the floor. Review of the facility policy, Medication Administration Nebulizers, dated 7/2025, directed to change the nebulizer cup and tubing according to facility policy.

Based on review of facility policy, facility documentation, and interview for the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) programs, the facility failed to implement a QAPI plan related to management of the infection prevention and control program . The findings include: Interview and review of facility documentation with the Administrator on 1/21/26 at 3:31 PM identified the QAA committee met monthly to review current QAPI plans and needs for additional quality improvement. The Administrator identified 12 current QAPI plans located within the QAPI binder, but the 12 QAPI plans did not include the additional QAPI plans initiated prior to the start of the survey in response to infection prevention concerns identified by surveyors during interviews with facility staff. (Refer to F 880 and F 883)Interview with the Administrator on 1/21/26 at 3:43 PM identified she was unaware of a QAPI related to the facility outbreak which Registered Nurse (RN) # 2 had indicated was implemented in December 2025. Although the re-certification survey had identified several areas of deficient practice (refer to F 880 and F 883), the Administrator identified she was not specifically aware of concerns related to the infection prevention and control program. The Administrator identified that she was not the only staff member who could initiate a QAPI plan, and that depending on the department affected, the DNS could initiate a plan. The Administrator was unable to identify why the facility had not implemented a QAPI plan for the management of the infection prevention and control program (IPCP) due to her not being aware that there were concerns related to the IPCP.Review of facility documentation received 2/4/26 identified a Performance Improvement Project (PIP) worksheet dated 12/29/25 which indicated the problem was rapid transmission of respiratory viruses (COVID-19 and Influenza A) among residents on 2 units. Inservice education provided by Licensed Practical Nurse (LPN) #3 titled Outbreak Management and QAPI identified 15 of 16 staff signatures were obtained on 12/29/25, and 1 of 16 staff signatures was obtained on 1/14/26 (the facility had 180 staff members).Review of the Quality Assurance and Performance Improvement (QAPI) Plan policy directed, in part, all staff are engaged in the QAPI process. The policy directed the QAPI program was ongoing and addressed all systems of care including infection control under clinical care. The policy directed that the administration is responsible for the QAPI program. The policy directed the Administrator monitors the effectiveness of the QAPI program through regular reports from the QAPI committee. The policy directed the QAPI coordinator (DNS) supports the development and implementation of performance and improvement projects (PIPs). The policy directed that information/data is collected from a variety of sources including, in part, staff feedback from department meetings, infection control surveillance data, and incident reports. The policy directed that PIPs will focus on high risk, high problem areas. The policy directed the facility will use the Plan-Do-Study-Act cycle for all PIPs. The policy directed the facility will use a structured approach to analyze the root causes of identified concerns. The policy directed root cause analysis will be conducted for all adverse events (facility outbreaks). The policy further directed that all QAPI activities, including meeting minutes, data collection tools, reports, PIPs, RCA reports, and action plans will be documented and maintained in a secure accessible location.

Based on observations, interviews, and facility policy for 1 of 2 (Skyview Medication Room) medication rooms observed for medication storage, the facility failed to ensure that items were not stored under the sink in the medication room. The findings included: Observation of the Skyview Medication Room on 1/16/26 at 10:30 AM identified that items were stored under the sink cabinet. The items included: Bottle of Harvey's Bristol Cream 750ml that was 3/4 full33 Empty various assorted size containers(7) 3M masks1 full box of black KN95 masks3 VHS tapes2 plastic wash basins1 phone charger labeled BB [NAME] R4 boards 1 stack of sports cards1 empty notebook binderInterview and observation of the cabinet under the sink in the medication room with the DNS on 1/16/26 at 10:40 AM identified that the cabinet under the sink should be locked and no items should be stored under the sink. The DNS stated she was unsure why items were stored under the sink and that nursing staff must have put them there. She indicated that it was facility policy that no items should be stored under the sink in the medication room. She indicated that it was nursing's and maintenance's responsibility to ensure items were not stored under the sink. Interview with Director of Environmental Services on 1/16/26 at 12:00 PM identified that he was unaware that items were being stored under the sink. Subsequent to surveyor inquiry, the Director of Environmental Services removed the items from under the sink and locked the cabinet. A review of Environmental Rounds that were conducted by LPN #9 on 12/26/25 identified all medication rooms on 12/26/25 and noted that no items were stored under the sinks in the medication rooms. The Medication Storage Policy (undated), directed, in part, medications must be stored in accordance with manufacturer's specifications and secured in locked storage area in compliance with state and federal requirements and acceptable standards of practice.

Based on observations, interviews and facility documentation for 1 of 4 residents (Resident #66) reviewed for environment, the facility failed to ensure Resident #66's room was free from insects, and in good repair. The findings include: Resident #66 was admitted to the facility in December 2023 with diagnoses that included paranoid schizophrenia, dementia, and intellectual disabilities. An annual Minimum Data Assessment (MDS) assessment dated [DATE] identified Resident #66 was severely cognitively impaired and required moderate assistance of 1 staff member for activities of daily living (ADLs).The Resident Care Plan (RCP) dated 12/18/25 identified an ADL deficient due to cognitive loss, dementia, paranoid schizophrenia, and intellectual disabilities. Interventions included to assist with gathering and setting up clothing, toiletries, and equipment. Additionally, the RCP noted to encourage self-performance and praise all attempts and allow sufficient time for task completion, occupational evaluation and treatment as needed and provide assist of 1 and cueing to maximize current level of functioning.Physician orders dated 1/12/26 directed independent with bed mobility, transfers and supervision with ambulation off unit and assist with self-care. Observations on 1/12/26 at 11:00 AM, 1/15/26 at 3:20 PM and 1/16/26 at 9:00 AM and 11:10 AM noted Resident #66 to have a private room and be seated in his/her recliner chair that was located in proximity to the windowsill. The windowsill on the inside to the room, was observed to have a white towel rolled up and laying on the right side of the windowsill up against the bottom of the window and ledge. The rolled towel was noted to have a heavy accumulation of small black insects with wings that were dead. Additionally, on 1/12/26 at 11:00 AM and 1/16/26 at 9:00 AM identified the radiator cover below the window was falling off, and an approximate 6 foot section of wallpaper below the window ledge was marred and in disrepair. The toilet seat in Resident #66's bathroom was visibly discolored with an orange/rust color stain.Interview with Resident #66 on 1/16/26 at 11:10 AM identified that he/she was unaware of the towel with the insects and did not know who put the towel on the windowsill (despite 3 observations made by the surveyor).Interview with the Administrator on 1/16/26 at 11:14 AM noted she was unaware of the towel containing the dead bugs in Resident #66's room and she had not received any concerns from staff or residents regarding any insects.Interview with the Director of Housekeeping Services on 1/16/26 at 11:30 AM indicated he was unaware of who put the towel on the windowsill and that there were dead insects on the towel. He indicated that basic cleaning was completed daily by the assigned housekeeper and consisted of emptying the garbage, wiping down over the bed tables and any visible dirty areas in the room, and light sweeping of the floor. He indicated that the housekeeper was not aware of the towel having dead insects on it.Interview with the Director of Environmental Services indicated that he was unaware of the insects on the towel in Resident #66's room. He indicated that pest control did not visit the facility in December, however; were in the facility on 1/13/26 with no indication of insects/bugs in the facility. Furthermore, he indicated that there were no reports from staff that there was an issue with bug/insects in Resident #66's room. The Director of Environmental Services indicated that staff should have reported the bugs/insects on the towel. Subsequent to survey inquiry, the Director of Environmental Services and his assistant installed an insulation weather strip in windowsill of Resident #66's room on 1/16/25. The housekeeper cleaned the windowsill prior to the installation of the weatherstripping. In addition, pest control was notified on 1/16/26 and a visit was conducted on 1/18/26. Resident #66's room was checked along with 2 adjacent resident rooms with no pest activity identified.A second interview with the Director of Housekeeping on 1/20/26 at 1:00 PM identified that a complete cleaning of Resident #66's room had taken place on 1/8/26 and no insects were noted in the room at that time. A review of the housekeeping cleaning checklist form for Resident #66's room completed on 1/8/26 failed to identify that windowsills were part of the cleaning of a room. The Director of Housekeeping indicated that it was an error in the form, and a new form would be developed containing windowsills. A review of the Environmental Services Room Cleaning Policy and Disinfection dated July 2025 directed, in part that standard procedures for environmental sanitation to provide a safe, sanitary and comfortable environment for residents and staff while preventing the transmission of infectious agents.Routine daily cleaning focuses on removing soil and minimizing the microbial load in the resident's environment. Daily cleaning involves the cleaning of high touch surfaces, horizontal surfaces and floors.

Based on review of the clinical record, facility documentation and facility policy, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to provide adequate supervision to prevent a resident-to-resident incident. The findings include: 1. Resident #1 had diagnoses that included dementia with agitation and adjustment disorder with mixed anxiety and depressed mood. Record review identified Resident #1 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicative of severely impaired cognition, and was independent with ambulation. The Resident Care Plan (RCP) dated 7/24/2025 identified Resident #1 had a history of inappropriate sexual behaviors and seeking out residents of the opposite sex, and observed on 2/26/2025 rubbing a Resident #2's thighs with his/her hand near or on Resident #1's breasts. Further the RCP identified the COP consented Resident #1 can spend time with Resident #2 in the common area holding his/her hands, but the resident cannot kiss other residents. Interventions directed to report inappropriate sexual behaviors, administer medications as ordered, offer diversional activities, encourage the resident to verbalize feelings and concerns, and attempt to identify sources of mood and behavior. 2. Resident #2 had diagnoses that included vascular dementia, depression, anxiety. Record review identified Resident #2 had a court appointed Conservator of Person (COP). The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of three (3), indicative of severely impaired cognition, and was independent with ambulation.The RCP dated 10/2/2025 identified Resident #2 exhibited sexually inappropriate behavior, had a potential for anxiety related to Resident #1 rubbing his/her thigh and was observed with his/her hand near Resident #1's breast on 2/26/2025. Further review identified the COP gave consent for Resident #2 to spend time with Resident #1 in a common area holding hands and did not consent to the residents being alone in a room or kissing. Interventions directed to encourage to attend communal activities, social services support, and encourage to verbalize thoughts and feelings. Record review and observation identified Resident #1 and Resident #2 resided on the same unit in the facility. Facility reportable event dated 10/5/2025 at 7:19 PM identified NA #1 observed Resident #2 with his/her chest exposed, and Resident #1 was in contact with it. The residents were separated and Resident #1 was placed on one-to-one (1:1) supervision pending psychiatry evaluation with plan for Resident #1 to be transferred to the hospital as a Physician Emergency Certificate (PEC). A facility written statement by NA #1 dated 10/5/2025 at 6:45 P.M. identified he witnessed Resident #1 and Resident #2 sitting at a table in the common area, Resident #2's chest and left breast were exposed, and Resident #1 was touching Resident #2's left chest and breasts. NA #1 indicated he intervened, and Resident #1 immediately became aggressive and threatened NA #1 with violence, and the nurse escorted the residents to their respective rooms. MD #2 (psychiatry) note dated 10/6/2025 identified Resident #1 was evaluated after the resident-to-resident incident occurred on 10/5/2025. The note indicated when staff redirected Resident #1, he/she became very agitated, threatening, and combative and Resident #1 was on 1:1 observation. A PEC was completed for transfer to the hospital due to exacerbation of symptoms. Facility reportable event summary dated 10/10/2025 identified when staff separated Resident #1 and Resident #2 on 10/5/2025, Resident #1 became agitated, combative, and used threatening language directed toward staff. Due to Resident #1's behavior, new orders were obtained to transfer Resident #1 to the hospital with a PEC for evaluation, and was subsequently admitted to the hospital. Record review identified Resident #1 was not re-admitted to the facility at the time of the survey. Interviews with NA#3, NA #4, NA #5, and NA #6 on 10/28/2025 at various times identified that they cared for Resident #1 and Resident #2, and they were aware that Resident #1 and Resident #2 had a friendly relationship. NA #3, NA #4, NA #5, and NA #6 stated Resident #1 and Resident #2 would spend time together holding hands, conversing, or just hanging out in the common area. Further, NA #4 stated Resident #1 and Resident #2 were both care planned to hold hands. Interview with Licensed Practical Nurse (LPN) #1 on 10/28/2025 at 11:15 A.M. identified she was aware Resident #1 and Resident #2 had a friendly relationship and often sat together in the common area. LPN #1 stated she observed Resident #1 at the nursing station and Resident #2 in his/her room at 6:40 PM. When the incident was reported by NA #1, she assisted to separate the residents and placed Resident #1 on 1:1 observation. Interview with APRN #2 (psychiatry) on 10/28/2025 at 11:52 A.M. identified Resident #1 and Resident #2 were allowed to spend time together in the common area and hold hands per their COP. APRN #2 stated she was aware Resident #1 had a previous history of inappropriately touching Resident #2 and was receiving Medroxyprogesterone (hormone medication used to treat hypersexual behaviors). APRN #2 stated that both Resident #1 and Resident #2 had cognitive impairment and were unable to give consent to an intimate relationship. Interview with the Director of Nurses (DNS) on 10/28/2025 at 1:15 P.M. identified both Resident #1 and Resident #2 had the same COP, the residents had a friendly relationship, and their COP was aware and consented to hand holding. The DNS stated due to cognitive impairment, Resident #2 was not able to give consent to intimate contact. The DNS identified that the behaviors observed by staff on 10/5/2025 were not consented to by the residents (due to cognitive impairment) and not consented to by the COP. Although attempted, an interview with NA #1 was not obtained during the survey. Review of the undated facility Abuse, Neglect, and Exploitation Policy, directed in part, the facility policy was to protect residents from abuse. The Policy further directed sexual abuse is non-consensual sexual contact of any type with a resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for four (4) of four (4) residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for medication administration, the facility failed to ensure the clinical records were accurate to reflect when medications were administrated. The findings include:1. Resident #3 had diagnoses that included adult failure to thrive, weakness, and dementia.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of two (2) indicative of severely impaired cognition, was always incontinent of bowel and bladder, dependent on staff for all ADLs, including bed mobility, and transfers, was non ambulatory, and dependent on staff for mobility in the wheelchair. The physician's orders dated 7/17/2025 directed to administer liquid protein supplement 30 milliliters once per day at 9:00 A.M., magic cup twice per day at 9:00 A.M. and 5:00 P.M, and supplemental house milkshake 120 cubic centimeter (cc) twice per day at 9:00 A.M. and 5:00 P.M. Review of the facility's accident and incident report dated 7/28/2025 identified on 7/28/2025 an internal medication administration audit report was generated that flagged late medication administrations of one hour or more which revealed a consistent pattern where the scheduled medications times predominantly around 9:00 A.M. were documented later often between 10:00 A.M. and 2:00 P.M. affecting approximately 80 residents on various units.The facility's Medication Administration Audit report dated 7/28/2025 identified Licensed Practical Nurse (LPN) #3 documented at 11:30 A.M. she administered Resident #3's supplemental house milkshake 120 cc's (2 hours and 30 minutes late), at 11:57 A.M. LPN #3 documented she administered Resident #3's liquid protein supplement (2 hours and 57 minutes late), and at 2:17 P.M. LPN #3 documented she administered Resident #3's magic cup (4 hours and 17 minutes late).Review of the facility's accident and incident summary dated 8/2/2025 identified that no residents were negatively affected by the delay in documentation, medications were administered on time, but the documentation of the administration was delayed.Interview with Registered Nurse (RN) #1 (Regional Nurse) on 8/19/2025 at 11:00 A.M. identified on 7/28/2025 Resident #3's medications were administered per the physician's orders at 9:00 A.M. RN #1 indicated LPN #3 documented late in Resident #3's MAR not at the time she administered the medications. RN #1 identified her expectations are when the nurse administers any medication to a resident the nurse documents at the time of administration in the resident's MAR. RN #1 identified on 7/28/2025 LPN #3 should have documented in Resident #3's MAR at the time medications are administered.Interview with LPN #3 on 8/19/2025 at 1:12 P.M. identified on 7/28/2025 at 9:00 A.M. she administered 30 ml's of liquid protein supplement, magic cup, and supplemental house milkshake to Resident #3. LPN #3 identified she did not document Resident #3's MAR at time she administered Resident #3's medications. LPN #3 was unable to document because all the residents on her assignment had medications ordered to be administered at 9:00 A.M. LPN #3 signed off in the medication administration records for all the residents on her assignment after she finished administering the morning medications. Interview with the Director of Nursing (DNS) on 8/19/2025 at 2:00 P.M. identified that she would expect that any medication given to a resident would be signed off in the MAR at the time the medication was administered. The DNS identified the documentation needs to be completed in actual time not later. 2. Resident #4 had diagnoses that included dementia with behavioral disturbance, delusional disorder, anxiety, and depressive episodes.The quarterly MDS dated [DATE] identified Resident #4 had short-term and long-term memory impairment (not capable of completing a brief interview for mental status exam), severely impaired cognitive skills for daily decision making, was always incontinent of bowel and bladder, and dependent on staff for all ADLs, including bed mobility, and transfers, was non ambulatory, and dependent on staff for mobility in the wheelchair.The physician's orders dated 7/17/2025 directed to administer Ativan 0.5 mg twice per day at 8:00 A.M. and 8:00 P.M., acetaminophen 500 mg twice per day at 9:00 A.M. and 9:00 P.M, and Lexapro 10 mg one time per day at 9:00 A.M.Review of the facility's accident and incident report dated 7/28/2025 identified on 7/28/2025 an internal medication administration audit report was generated that flagged late medication administrations of one hour or more which revealed a consistent pattern where the scheduled medications times predominantly around 9:00 A.M. were documented later often between 10:00 A.M. and 2:00 P.M. affecting approximately 80 residents on various units.The facility's Medication Administration Audit report dated 7/28/2025 identified LPN #3 documented at 11:58 A.M. that she administered Resident #4's Ativan 0.5 mg (3 hours and 58 minutes late) acetaminophen 500 mg (2 hours and 58 minutes late, and Lexapro 10 mg (2 hours and 58 minutes late). Review of the facility's accident and incident summary dated 8/2/2025 identified that no residents were negatively affected by the delay in documentation, medications were administered on time, but the documentation of the administration was delayed.Interview with Registered Nurse (RN) #1 (Regional Nurse) on 8/19/2025 at 11:00 A.M. identified on 7/28/2025 Resident #4's medications were administered per the physician's orders. RN #1 indicated that LPN #3 documented late in Resident #4's MAR not at the time she administered the medications. RN #1 identified her expectation is when the nurse administers any medication to a resident the nurse documents at the time of administration in the resident's MAR. RN #1 identified on 7/28/2025 LPN #3 should have documented in Resident #4's MAR at the time she administered the medications not later.Interview with LPN #3 on 8/19/2025 at 1:12 P.M. identified on 7/28/2025 at approximately 9:15 A.M. she administered Ativan 0.5 mg, acetaminophen 500 mg, and Lexapro 10 mg to Resident #4. LPN #3 did not document on Resident #4's MAR at the time she administered the medications. LPN #3 was unable to document because all the residents on her assignment had medications ordered to be administered at 9:00 A.M. LPN #3 signed off in the medication administration records for all the residents on her assignment after she finished administering the morning medications. Interview with the Director of Nursing (DNS) on 8/19/2025 at 2:00 P.M. identified that she would expect that any medication given to a resident would be signed off in the MAR at the time the medication was administered. The DNS identified that the documentation needs to be completed in actual time not later. 3. Resident #5 had diagnoses that included dementia with behavioral disturbance, glaucoma, adult failure to thrive, and anxiety. The quarterly MDS dated [DATE] identified Resident #5 had short-term and long-term memory impairment (not capable of completing a brief interview for mental status exam), severely impaired cognitive skills for daily decision making, was always occasional incontinent of bowel, always continent of bladder, independent with ambulation and bed mobility, required substantial assistance with transfers and ADLs. The physician's orders dated 7/17/2025 directed to administer Lexapro 10 mg one time per day at 9:00 A.M., Ensure Clear 240 ml one time per day at 9:00 A.M., Namenda 5 mg twice per day at 9:00 A.M. and 9:00 P.M., and Combigan solution 0.2-5% instill 1 drop in both eyes twice per day at 9:00 A.M. and 5:00 P.M.Review of the facility's accident and incident report dated 7/28/2025 identified on 7/28/2025 an internal medication administration audit report was generated that flagged late medication administrations of one hour or more which revealed a consistent pattern where the scheduled medications times predominantly around 9:00 A.M. were documented later often between 10:00 A.M. and 2:00 P.M. affecting approximately 80 residents on various units.The facility's Medication Administration Audit report dated 7/28/2025 identified LPN #2 documented at 11:44 A.M. that she administered Resident #5's Lexapro 10 mg and Combigan solution 0.2-5% (2 hours and 44 minutes late). LPN #2 documented at 11:45 A.M. that she administered Resident #5's Ensure Clear 240 ml's and Namenda 5 mg (2 hours and 45 minutes late).Review of the facility's accident and incident summary dated 8/2/2025 identified that no residents were negatively affected by the delay in documentation, medications were administered on time, but the documentation of the administration was delayed.Interview with Registered Nurse (RN) #1 (Regional Nurse) on 8/19/2025 at 11:00 A.M. identified on 7/28/2025 Resident #5's medications were administered per the physician's orders on time. RN #1 indicated that LPN #2 documented in Resident #5's MAR late and not at the time LPN #2 administered the medications. RN #1 identified her expectation is when the nurse administers any medication to a resident the nurse documents at the time of administration in the resident's MAR. RN #1 identified on 7/28/2025 LPN #2 should have documented in Resident #5's MAR at the time she administered the medications not later. Interview with LPN #2 on 8/19/2025 at 1:12 P.M. identified on 7/28/2025 that she administered Resident #5's Lexapro 10 mg, Ensure Clear liquid, Namenda 5 mg, and Combigan solution 0.2-5% per the physician's orders on time. LPN #2 did not document in Resident #5's MAR at the time she administered the medications because she was helping provide care to the residents. LPN #2 signed off Resident #5's MAR when she had time. Interview with the Director of Nursing (DNS) on 8/19/2025 at 2:00 P.M. identified that she would expect that any medication given to a resident would be signed off in the MAR at the time the medication was administered. The DNS identified that the documentation needs to be completed in actual time not later. 4. Resident #6 had diagnoses that included hypertension, chronic diastolic heart failure, gastric bleed, and type 2 diabetes mellitus. The quarterly MDS dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of eight (8) indicative of moderately impaired cognition, was occasionally incontinent of bowel, always continent of bladder, required set-up with ADLs, supervision with transfers and ambulation, and independent with bed mobility.The physician's orders dated 7/17/2025 directed to administer pantoprazole 40 mg twice per day at 8:00 A.M. and 4:00 P.M., Klor-Con extended-release tablet 10 MEQ, give 2 tablets (20 MEQ), twice per day at 9:00 A.M. and 9:00 P.M., metformin 500 mg twice per day at 9:00 A.M. and 5:00 P.M., and bumetanide 1 mg tablet give 2 tablets one time per day at 9:00 A.M.Review of the facility's accident and incident report dated 7/28/2025 identified on 7/28/2025 an internal medication administration audit report was generated that flagged late medication administrations of one hour or more which revealed a consistent pattern where the scheduled medications times predominantly around 9:00 A.M. were documented later often between 10:00 A.M. and 2:00 P.M. affecting approximately 80 residents on various units.The facility's Medication Administration Audit report dated 7/28/2025 identified LPN #2 documented at 9:34 A.M. she administered Resident #6's pantoprazole 40 mg (1 hour and 34 minutes late), and at 10:20 A.M. she administered metformin 500 mg ( 1 hour and 20 minutes late), at 10:21 A.M. she administered bumetanide 2 mg and Klor-Con 10 MEQ two tablets (1 hour and 21 minutes late). Review of the facility's accident and incident summary dated 8/2/2025 identified that no residents were negatively affected by the delay in documentation, medications were administered on time, but the documentation of the administration was delayed.Interview with Registered Nurse (RN) #1 (Regional Nurse) on 8/19/2025 at 11:00 A.M. identified on 7/28/2025 Resident #6's medications were administered per the physician's orders on time. RN #1 indicated that LPN #2 documented in Resident #6's MAR late and not at the time she administered the medications. RN #1 identified her expectation is when the nurse administers any medication to a resident the nurse documents at the time of administration in the resident's MAR. RN #1 identified on 7/28/2025 LPN #2 should have documented in Resident #6's MAR at the time she administered the medications not later. Interview with LPN #2 on 8/19/2025 at 1:12 P.M. identified on 7/28/2025 that she administered Resident #6's pantoprazole 40 mg, Klor-Con 10 MEQ, 2 tablets, metformin 500 mg, and bumetanide 2 mg on time per the physician's orders. LPN #2 did not document in Resident 6's MAR at the time she administered the medications because she was helping provide care to the residents. LPN #2 signed off Resident #6's MAR when she had time. Interview with the MD #1 (Medical Director) on 8/19/2025 at 1:40 P.M. identified on 7/28/2025 he reviewed the medication administration audit that indicated multiple medications were administered late to various residents throughout the facility. MD #1 indicated that on 7/28/2025 there were not any significant medication errors, no adverse or negative outcomes, and no omissions of medications. MD #1 indicated it appeared the issues were related to late documentation in the residents MAR's not late medication administration. Interview with the Director of Nursing (DNS) on 8/19/2025 at 2:00 P.M. identified that she would expect that any medication given to a resident would be signed off in the MAR at the time the medication was administered. The DNS identified that the documentation needs to be completed in actual time not later. Review of the facility medication administration and documentation policy directed, in part, the medication administration record (MAR) is the form onto which all medication orders are transcribed, from which medications are poured and administered, and which medication doses are charted. Documentation administration of medication on the MAR immediately following administration.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the care plan intervention was implemented timely after a fall with an injury. The findings include: Resident #1 had a diagnosis of anxiety, dementia, history of falls, weakness, and insomnia. The quarterly Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition, Resident #1 had no behaviors, and was required one (1) staff assistance for mobility. The Resident Care Plan (RCP) dated 4/23/2025 identified an alteration in mobility and a risk for falls. Interventions directed to place call bell within reach and assist of one (1) with bed mobility. The nursing note written by RN #2, dated 6/23/2025 at 2:03 AM identified the charge nurse reported Resident #1 was noted screaming and was found on floor at 1 AM. Resident #1 was lying in the prone position, partially on his/her left side next to the bed and had his/her left arm behind his/her torso, and screaming my legs. Resident #1's right leg was observed over the left leg and yelled when his/her legs were touched. 911 was called and Resident #1 was transferred to the hospital. The hospital x-ray report dated 6/23/2025 identified an oblique (slanting) distal (lower part of the femur) left femoral shaft fracture with moderate displacement, and an oblique moderately displaced fractured deformity distal femoral metadiaphysis of the right femur. Further, the x-ray results identified osteopenia (bone loss). The physician note dated 6/23/2025 at 2:47 PM identified Resident #1 had severe dementia, and a family decision to treat Resident #1 conservatively, without surgery. Resident #1 was discharged back to the skilled nursing facility. Nursing note dated 6/23/2025 at 9:10 PM identified Resident #1 was readmitted to the facility from the hospital on 6/23/2025 at 8:15 PM with orders for a hospice consult. The nursing note dated 6/25/2025 at 2:39 PM identified Resident #1 was admitted to hospice services. Additional record review identified the care plan dated 6/25/2025 directed use of a bolster mattress. Facility incident summary dated 6/27/2025 identified a new intervention was for a bolster mattress to be applied to the bed. The summary indicated the bolster mattress was to be delivered by hospice. Although record review identified the care plan was updated to include pain management after the fall, the review failed to identify the care plan was updated to include an intervention to prevent another fall, prior to 6/25/2025. Further the care plan intervention for the bolster mattress was not implemented until 6/27/2025 (four days after the fall with injury). Interview and record review with the Director of Nursing (DNS), Administrator and RN #1/corporate representative on 7/16/2025 at 1:40 PM identified Resident #1 had an unwitnessed fall on 6/23/2025 at 1 AM, was transferred to the hospital and diagnosed with femur fractures to both legs. Resident #1 returned from the hospital on 6/23/2025. Interview identified although the care plan was updated on 6/25/2025 to direct use of a bolster mattress, the mattress was not applied to the bed until 6/27/2025 (four days after the fall). The DNS stated the care plan should have been updated with interventions prior to 6/25/2025 and the interventions (bolster mattress) should have been implemented prior to 6/27/2025. Interview failed to identify why interventions were not implemented until 6/27/2025.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from abuse by a staff member. The findings include: Resident #1's diagnoses included dementia, depression, adjustment disorder and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, required moderate assistance for personal hygiene. Resident Care Plan (RCP) dated 3/26/2025 identified Resident #1 had episodes of anxiety. The RCP directed to encourage resident to verbalize feelings, use a calm, gentle approach to quiet Resident and monitor for triggers and avoid them. A Facility Reportable Event (RE) report dated 4/12/2025 at 9:05 AM identified nursing and dietary staff in the dining room observed Nurse Aide (NA) #1 be verbally rude to Resident #1 and Resident #1 had emotional distress. NA #2 was removed from the dining room, an investigation was initiated, and NA #2 was sent home pending investigation. Facility statements provided by NA #1, #3 and #4 identified they witnessed NA #2 using inappropriate language and tone, and state loudly near Resident #1's face, I am going to tell my supervisor for you to leave me the hell alone. A facility interview completed by NA #2 as part of the 4/12/2025 investigation identified she had had it with Resident #1 as Resident #1 targeted her since Resident #1 came to the floor. NA #2 continued she ignored Resident #1 all the time when Resident #1 picked on her, called her names and sometimes followed NA #2 around. The facility interview identified on 4/12/2025, NA #2 had to say something for Resident #1 to stop. NA #2 identified she told Resident #1 she was going to speak to her supervisor for Resident #1 to leave her the hell alone noting that Resident #1 targeted her all the time. The facility summary dated 4/17/2025 identified three (3) NAs in the dining room on 4/12/2025 observed Resident #1 tell NA #2 to get back to work. NA #2 responded to Resident #1's comment by saying I am going to tell my supervisor to tell you to leave me the hell alone. Facility investigation substantiated NA #2 made the comments, and NA #2's employment was terminated. Resident #1 was initially upset, but then had no recollection of the event later in the day. Interview and facility documentation review with NA #3 on 5/6/2025 at 9:55 AM identified she was in the dining room on 4/12/2025 and witnessed Resident #1 said something to NA #2 who was standing outside the dining room. NA #2 then aggressively marched over to Resident #1 yelling with her finger pointed at Resident #1 standing in front of Resident #1 and telling Resident #1 that she was tired of the way Resident #1 talked to her, she had enough, and she was going to tell the supervisor to tell Resident #1 to leave her the hell alone. Then NA #2 left the dining room, and NA #1, #3 and #4 notified the supervisor. Interview and facility documentation review with NA #1 on 5/6/2025 at 10:06 AM identified on 4/12/2025 at around 9:00 AM while she was in the dining room she observed NA #2 suddenly walk fast from the hallway to Resident #1 who was sitting at a table. NA #2 was standing, leaning in close, and pointed her finger at Resident #1 and yelling loud enough for the whole dining room to hear said that she was going to tell the supervisor to tell Resident #1 to leave her the hell alone. Interview with NA #4 on 5/6/2025 at 1:45 PM identified on 4/12/2025 at breakfast time she observed NA #2 march from the doorway to Resident #1 and while pointing her finger at the resident and loudly telling him/her she was going to tell the supervisor to tell Resident #1 to leave her the hell alone. Attempts to interview NA #2 were unsuccessful during survey. Interview with RN #2, nursing supervisor on 4/12/2025 on the 7:00 AM to 3:00 PM shift, staff notified her of the allegation of verbal abuse directed at Resident #1 in the dining room by NA #2. RN #2 indicated she thought it was abuse and NA #2 should not have acted in that manner toward any resident. After the incident was reported, she took Resident #1 back to his/her room to speak with the resident, and Resident #1 was not upset about the incident at that time. Interview and facility documentation review with RN #1/acting DON on 5/6/2025 at 12:00 PM identified NA #2 should not have behaved that way. The DON indicated the allegation of abuse was substantiated and NA #2's employment was terminated due to resident abuse. The facility Abuse, Neglect and Exploitation policy, dated 2/2023, directed in part The facility prohibits (resident) abuse. The policy defined abuse as the will infliction of injury, intimidation with resulting physical harm, pain or mental anguish. Verbal abuse was the use of oral, written or gestured communication that willfully includes disparaging or derogatory terms to a resident or within hearing distance. Mental Abuse includes but is not limited to harassment or threats of punishment. The facility Resident Rights policy, dated July 2021, directed in part that residents have the right to be free from abuse. Facility documentation review identified staff education was initiated on 4/14/2025 for all staff, and included review of facility abuse policy. Audits were initiated on 4/16, and a QAPI meeting was held on 4/12/2025. Past non-compliance was identified as of 4/16/2025.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) who was a recent admission, the facility failed to verify the resident's identity prior to administering medication which resulted in a significant medication error and a hospital admission. The findings include: Resident #1 was a recent admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life and was independent with eating and drinking. The Facility Incident Report and Investigation dated [DATE] identified at approximately 9:15 AM, the charge nurse notified the Director of Nursing (DON) she had mistakenly given Resident #1 another resident's morning medications. Resident #1 was assessed by the DON and at the time was alert and oriented to person, place, and time, and vital signs and neurological checks performed were within normal limits for the resident. The report indicated the Advanced Practice Registered Nurse (APRN) and Medical Director were notified of the medication error and after their assessment gave orders to transfer Resident #1 to the local acute care facility for cardiac and respiratory monitoring. The Nursing Progress Note dated [DATE] at 9:16 AM identified the charge nurse approached this writer to report she had inadvertently given another resident's medications to Resident #1. The note indicated Resident #1 was assessed by the DON, was alert and oriented x 3, denied dizziness or shortness of breath, an identification bracelet was in place on the right arm. The note identified Resident #1's Blood pressure was ,d+[DATE], pulse 88 and regular, respirations 18, temperature 97.6 and oxygen saturation was 94%, APRN #1 was updated and directed to check Resident #1's vital signs every fifteen (15) minutes and when MD #1 arrived later at the facility she was made aware. The note indicated MD #1 ordered Resident #1 to be sent to the Emergency Department (ED) for an evaluation and monitoring. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Admission History and Physical Summary dated [DATE] identified Resident #1 arrived at the emergency department after accidently receiving the wrong set of medications that included [MEDICATION(S)] 10mg, [MEDICATION(S)] 20mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 225mg, [MEDICATION(S)] 6mg, [MEDICATION(S)] ER 150mg, [MEDICATION(S)] ER 50mg, [MEDICATION(S)] 300mg, [MEDICATION(S)] 10mg and [MEDICATION(S)] 300mg. Upon evaluation in the ED, resident was noted to have a blood pressure of ,d+[DATE], was given two (2) liters of intravenous fluids, the oxygen saturation level was 94% on two (2) liters of oxygen, Resident #1 received three (3) liters of fluid in total. The hospital record identified around 2:00 PM, Resident #1 started having worsening [CONDITION(S)], oxygen requirement went from two (2) liters to fifteen (15) liters via a non-rebreather. The hospital record dated [DATE] identified Resident #1 was admitted for [CONDITION(S)] secondary to medication and found to have acute respiratory failure with [CONDITION(S)] and hypercapnia secondary to [CONDITION(S)] and congestive heart failure exacerbation, and acute kidney injury. The Discharge Summary dated [DATE] identified the discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #1 on [DATE] at 11:50 AM identified at the time of the incident, Resident #1 and Resident #2 were next to the medication cart in the hallway with a physical therapist and occupational therapist behind each resident waiting for their medications prior to going to therapy. RN #1 indicated as she was preparing Resident #2's medication, she was mentally preparing and planning how to handle Resident #1's medication afterwards. RN #1 identified once she finished preparing Resident #2's medication, she turned towards Resident #1 and administered the medications. RN #1 stated as soon as the medications were administered, she realized she gave the wrong medications to the wrong resident. RN #1 indicated she immediately reported the incident to the supervisor, DON and notified APRN #1 and MD #1 as well. RN #1 identified although she performed the five (5) rights of medication at the beginning process, she did not check the identification bracelet prior to handing the medication to Resident #1. Interview with APRN #1 on [DATE] at 12:05 PM identified on [DATE], she was notified of a medication error that occurred with Resident #1 and at the time of her assessment, Resident #1 was at his/her baseline with blood pressure and all other vital signs stable. APRN #1 identified she discussed the case with MD #1, and they determined that due to the cardiac medications Resident #1 received, it would be best to transfer Resident #1 to the hospital in the event Resident #1's blood pressure drops. APRN #1 identified the facility would not be able to timely treat the resident if this were to occur, as they would need to order and wait for outside resources to place an intravenous line, not to mention they are not equipped with cardiac monitoring as a hospital would utilize. Interview with MD #1 on [DATE] at 2:35 PM identified on [DATE], she was notified of the medication error that occurred with Resident #1. MD #1 indicated she performed an assessment on Resident #1 and noted at the time the resident was at baseline and all vital signs stable. MD #1's identified her main concern from the medication error was the cardiac medications administered. MD #1 verified [CONDITION(S)] was the main concern and Resident #1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #1 verified treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #1 identified respiratory failure would not have been a side effect from the medication error, as all the medications would have a very low impact on the respiratory system. MD #1 noted with the residents past medical history [CONDITION(S)] and [CONDITION(S)] with maybe underlying heart failure, fluid overload would much be the likelier candidate that caused the respiratory failure. Interview with DON on [DATE] at 12:40 PM identified it's her expectation and facility policy that the nursing staff perform the five (5) rights of medication prior to medication administration. DON verified RN #1 failed to perform the five (5) rights of medication administration check to ensure the right resident which resulted in a significant medication error. Review of the Medication Administration Policy identified to verify medication order on MAR. Check against physician order. Identify resident, explain procedure and provide privacy. Perform hand hygiene. Avoid distractions and interruptions when preparing and administering medications (to reduce the risk of medication errors). Only prepare one resident medications at a time. Compare the medication label to the resident's MAR. Verify medication hasn't expired and that no contraindications exist. Visually inspect the medication for any loss of integrity. Verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route (to reduce the risk of medication errors). If the resident is receiving medication for the first time, educate about significant adverse reactions. Assess the resident's condition. Check for allergies to the medications. If necessary, obtain vital signs. Do not touch the medication when opening the bottle or unit dose packaging. Give the resident his/her medication and an appropriate vehicle or liquid as needed. Document medication administration.

Based on review of the clinical records, review of facility documentation, review of facility policies and/or procedures, and interviews for two of five residents, (Resident #144 and Resident #147), reviewed for accidents, the facility failed provide adequate supervision to prevent an accident and/or failed to provide services to prevent an accident during transport. The findings include: a. Resident #144's [DIAGNOSES REDACTED]. An annual assessment dated [DATE] identified Resident #144 as severely impaired for cognitive status, requiring extensive assistance from staff for most activities of daily living, had unsteady balance with standing, walking and with transfers, utilized a walker and/or wheelchair, was frequently incontinent for bladder status and always incontinent for bowels status, and as having no falls prior to previous assessment. The Resident Care Plan (RCP) updated on 4/27/19 identified a risk for falls as the focus due to cognitive impairment and previous history of falls. Interventions included, keep resident in staff's view when out of bed, place call light within reach and orient to surrounding, assist of one for transfers, and offer to sit in common area in stationary chair. A review of nursing progress notes dated 5/15/19 at 11:35 A.M. identified in part, the nurse aide saw the resident stand up, caught the resident, and assisted and/or lowered Resident #144 to his/her buttocks to the floor. Upon the writer entering the TV room, Resident #144 was noted to be sitting on the floor in the TV room/rec room with a nurse aide. The resident's skin was intact, had mobility of upper and lower extremities without difficulty, and bilateral hand grasp firm and equal. Reportable event (RE) dated 5/19/19 at 7:00 P.M. noted Resident #144 was found lying on his/her right side on the floor in the television room. The fall was unwitnessed and the resident sustained [REDACTED]. A description of the fall noted Resident #144 stated he/she was going to see his/her neighbor. Review of nursing progress notes dated 5/19/19 at 11:32 P.M. identified in part, that at 7:00 P.M. Resident #144 was found on the floor of the TV room in the common area in front of his/her wheelchair (w/c) which was noted to be off to the left. Resident #144 had previously been noted to be watching TV without anxiety and/or restlessness prior to fall. The resident sustained [REDACTED]. The resident demonstrated full Range of Motion (ROM) to both the upper and lower extremities without complaints of pain. Neuro checks initiated, Advanced Practice Registered Nurse (APRN) and family notified. Orders included obtaining an x-ray of the right shoulder. Subsequent to the resident's fall, Resident #144 was transferred to the emergency Department (ED) on 5/20/19 and was diagnosed with [REDACTED]. On 6/13/19 at 9:55 A.M. an interview and review of the RE and clinical record with Nurse Aide (NA) #3 indicated while on his/her way to the shower room, and/or while the other staff on the unit were at the nurse's station, he/she recalled hearing a loud noise and when NA #3 went to see the source of the noise, NA #3 saw other nurse's aides jump up to see what had happened. NA #3 further indicated he/she had arrived to the TV room first and found the resident on the floor in front of his/her w/c. The resident was quite, confused and kept touching his/her head with his/her left hand stating, It hurts while the resident's right arm was tucked beneath him/her. An interview with NA #2 on 6/13/19 at 10:15 A.M indicated he/she was assigned to provide care to Resident #144 on the evening shift (3:00 P.M.-11:00 PM.) of 5/19/19 and after dinner NA #2 placed Resident #144 next to the red chairs in the front row of the television room to watch television with other residents. The resident also had a tray table positioned to the left side of the resident to hold his/her soft drink. NA #2 indicated Resident #144 was placed in the television room with other residents who could be trusted not to stand and/or make attempts at getting out of their wheelchairs (w/c). NA #2 further noted, he/she last assisted Resident #144 with toileting needs during first rounds (between 3 P.M. and 5 P.M.) prior to dinner. Interview with Registered Nurse (RN) #6 on 6/13/19 at 1:10 P.M. indicated he/she documented his/her assessment in the nursing progress note of Resident #144's record on 5/15/19 at 11:35 A.M. He/she further noted that he/she updated the resident's plan of care and/or nursing care card to include the following interventions: Following breakfast and ambulation, offer to sit in common area in a stationary chair. On 6/13/19 at 1:20 P.M. observation of the TV/room from the nurse's station with the Director of Nurses (DNS) identified the TV room is adjacent and/or side by side and/or next to the dining room on the unit. A view from the nurse's station into the TV/room identified an enclosure and/or partial wall located to the far right of the dining room with one large window. In utilizing the large window to look into the TV room from the nurse's station it was noted that the window provided only a partial view of the television room and not a full view from the nurse's station. An interview with the DNS at the time indicated Resident #144 was not to have been left without a staff person in the television room and subsequent to the resident's falls and attempts at standing up (per progress note dated 5/15/19 at 11:35 A.M.), the facility is now requiring staff to monitor both the television room and dining room every 15 minutes to ensure that all residents are supervised as well. The facility was not able to demonstrate that the Resident was in view of the staff when he/she was in the TV room. b. Resident #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly fall risk assessment dated [DATE] indicated Resident #147 was at risk for falls. The annual Minimum Data Set ((MDS) dated [DATE] identified Resident #147 had severely impaired cognition, had limited energy, exhibited no behavioral symptoms, and required extensive assistance of two for bed mobility, transfers, personal hygiene, and toilet use. The Resident Care Plan care plan dated 7/12/18 identified Resident #147 was at risk for falls and was known to stand up unassisted at times. Interventions directed to assist with mobility per physical therapy recommendations and to use an anti-roll back device on wheelchair. The nurse's note dated 8/27/18 at 6:54 PM identified that Resident #147 had a witnessed fall and was found on the floor with a nurse aide and the charge nurse in attendance. Resident #147 was alert and awake, and noted to have a moderate amount of blood on his/her mid forehead. The Advanced Practice Registered Nurse (APRN) was updated and the resident's family was notified. Resident #147 transported by ambulance to hospital. A physician's orders [REDACTED].#147 to ER for evaluation. The nurse's note dated 8/28/18 at 1:33 AM indicated Resident #147 returned from the emergency department with 4 staples to his/her forehead. The hospital discharge note dated 8/27/18 indicated 4 cm laceration on scalp, 4 staples placed for primary closure, no loss of consciousness, no other acute injuries or changes from baseline state of health. The facility policy titled Wheelchair Use instructed when a wheelchair is used to transport any resident, the leg rests must be used. Interview and clinical record review with Physical Therapist (PT) #1 on 6/11/19 at 11:42 AM, identified he/she would expect leg rests to be used on Resident #147's wheelchair when transporting the resident. Interview with NA #1 on 6/11/19 at 3:13PM identified that NA #1 was transporting Resident #147 to the bathroom in his/her wheelchair without the leg rests on the wheelchair. NA #1 indicated Resident #147 suddenly put his/her foot down which cause Resident #147 to topple forward out of the wheelchair landing on the floor. NA #1 identified that Resident #147 was lying on the floor with bleeding noted from his/her head. NA #1 immediately went to get the floor nurse. NA #1 indicated that he/she was trained to use leg rests for all residents in a wheelchair during transport, but did not use leg rests because he/she felt the transport to the bathroom was for a short distance.

Based on clinical record review, review of facility documentation, staff interview and observation for three of seven residents reviewed for accidents, (Residents #100, #151, and #220), the facility failed to provide supervision to prevent and accident and/or failed to ensure that the resident was transferred in a manner to prevent injury and/or failed to ensure that a resident had access to the call bell when left on a commode. The findings include: 1. Resident #220 (R #220) had [DIAGNOSES REDACTED]. The nursing notes dated 5/1/14 indicated that R #220 was alert with confusion, was admitted to facility after fall at home in which he/she sustained left hip displaced femoral neck fracture. The nursing admission care plan dated 5/1/14 identified that R #220 was at risk for falls related to decreased mobility and poor safety awareness with interventions that included to assist with two persons for transfer. Review of facility accident/incident report dated 5/9/14 indicated that R #220 was found lying on floor in room next to the bed and was transferred to the acute care hospital secondary to a right proximal hip fracture. The revised care plan dated 5/10/14 identified that R #220 had a [DIAGNOSES REDACTED]. In addition, the care plan dated 5/10/14 identified that R #220 was at risk for falls related to decrease mobility, poor safety awareness and history of falls. Resident #220 was readmitted to the facility on [DATE] after undergoing right hip hemiarthroplasty. The 14 day schedule assessment dated [DATE] identified that R #220 had moderate cognitive impairment and required extensive assistance of two persons for transfers and toilet use. Review of the facility accident/incident report dated 6/12/14 identified that R #220 was assisted to the bathroom by NA #7 and NA #8. The documentation identified that NA #7 and NA #8 left R #220 unattended in the bathroom. The documentation indicated that R #220 subsequently attempted to stand without assistance, lost his/her balance and landed on his/her right side on the bathroom floor. A registered nurse (RN) injury assessment notes dated 6/12/14 indicated that R #220's right thumb appeared injured and that the resident reported pain to the right hand. The documentation identified that R #220's right leg was tucked under the left leg, that the resident's legs were crossed, and that the resident reported pain when the right leg was moved. R #220 was subsequently transferred to the acute care hospital. Interview with NA #7 on 3/25/15 at 10:53 AM identified that after assisting R #220 into the bathroom on 6/12/14, he/she and NA#8 placed the call light into R #220's hand and stepped out of the bathroom with the door slightly ajar. NA#7 indicated that both he/she and NA#8 proceeded to assist R #220's roommate with care when he/she heard a loud thud. NA #7 stated that upon reentering the bathroom, he/she found R #220 lying on the bathroom floor. NA#7 indicated that he/she was aware that R #220 had a history of [REDACTED]. Interview and review of a written statement with NA #8 on 3/25/15 at 2:55 PM identified after assisting R #220 to the bathroom on 6/12/14, he/she left R #220 unattended in the bathroom with the call light in his/her hand. NA #8 indicated that he/she and NA #7 were assisting R #220's roommate with the stand lift when he/she heard a loud bang from the bathroom. Upon entering the bathroom, R #220 was observed on the floor. NA#8 indicated that he/she was aware that R #220 had a history of [REDACTED]. Interview and review of facility documentation with the Director of Nursing (DON) on 3/25/15 at 12:00 PM identified that R #220 should not have been left in the bathroom unattended based on the resident's history of falls and [DIAGNOSES REDACTED]. Review of R #220's acute care hospital discharge summary dated 6/16/14 identified that a CT scan of the right hip demonstrated a minimally displaced right hip fracture, mild femur fracture, primarily involving the greater trochanter with minimal extension into the proximal right lateral femur. The CT scan further indicated that R #220 had sustained a subluxation of the right first metacarpophalangeal joint and a displaced right ulnar fracture. Review of facility safety standard policy indicated that resident who have poor safety awareness and/or who do not have trunk control should not be left unattended in the bathroom. 2. Resident #100 (R #100) had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that R #100 was cognitively impaired and required extensive assistance of two persons for transfer. Physician orders [REDACTED]. The care plan dated 7/20/14 identified that R #100 required extensive assistance for transfers out of bed. The care plan further directed transfer out of bed via mechanical lift with the assistance of two person to a customized wheel chair as per the twenty four hour positioning plan. The care plan updated on 7/29/14 identified that R #100 had a history of [REDACTED]. Review of the facility accident/incident report dated 9/3/14 identified that R #100 had sustained a skin tear to the left leg at 6:00 AM. The nursing note dated 9/3/14 at 6:40 AM indicated that R #100 had sustained a skin tear to the left leg that measured 0.1 centimeters (cm) by 3.5 cm and a bruise that measured 6.0 cm by 3.5 cm. The nursing note dated 9/3/14 at 10:51 AM identified that the initial skin tear area was now noted to have progressed to a large hematoma that measured 11.0 cm by 4.0 cm by 2.0 cm was raised, pale blue/purple and that the resident complained of increased pain at the site described by the resident as excruciating and pulsating in waves. R #100 was transferred to the acute care hospital on [DATE]. Review of the hospital discharge summary dated 9/15/14 indicated that R #100 was admitted to the acute care facility on 9/3/14 with a 5.0 by 5.0 cm left leg hematoma, that the resident's INR was 6.7 (Normal 2.5 to 3.5) and that a surgical consult was obtained. The documentation identified that R #100 had a surgical procedure for a left leg hematoma on 9/4/14. The discharge summary indicated that on 9/9/14, the resident's hematoma worsened and the resident was brought to the operation room for continued cleaning. Physician orders [REDACTED]. Interview with the Director of Nursing (DNS) on 3/25/15 at 12:05 PM identified that R #100 sustained a skin tear to the left lower extremity during a transfer from wheelchair to bed. The DNS identified that although the resident required transfer via a Hoyer lift, R #100 was transferred to bed without the Hoyer lift. The DNS stated that the facility investigation identified that the two nursing assistants reported that they had difficulty with R #100's transfer and so pivoted the resident back into bed without utilizing the Hoyer lift. The DNS stated secondary to R #100's high risk for skin tears, when the transfer became difficult for NA #9 and NA#10, the NAs should have informed the nurse and used a team approach to get the resident safely into bed. Interview with NA#10 on 3/26/15 at 12:25 PM identified that on the morning of 9/3/14, R #100 was initially being transferred from the wheelchair to the bed via the Hoyer lift but that while lifting resident up, the Hoyer pad was observed to be improperly positioned for a safe transfer to bed. NA #10 stated that R #100 was placed back into the chair and at that time, NA #9 indicated that they (both NA #9 and NA #10) should just put the resident in bed without using the Hoyer lift. NA #10 indicated that R #100's chair was positioned facing the head of the bed and that NA #9 proceeded to stand and pivot R #100 by grabbing the resident by the waist and placing him/her on the side of the bed. NA #10 further indicated that at that time, R #100's feet were dangling and that he/she then held onto R #100's ankles and proceeded to place both legs on the bed. NA #10 stated that after placing R #100's feet on the bed, a skin tear to the resident's left lower extremity was observed. NA #10 stated that although he/she was aware that R #100 required a Hoyer lift for all transfers, one was not utilized to transfer R #100 from the chair to bed on 9/3/14. Multiple attempts to interview NA#9 were unsuccessful. Review of facility safety standard policy indicated that if a mechanical lift or sit-stand lift is used to transfer a resident, two staff members must assist with transfer. If other than a mechanical lift or sit-stand lift transfer, nurse aides are required to use gait belts to transfer any resident who requires physical assistance to avoid injury to both resident and the staff person. 3. Resident #151 (R #151) had [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] at 3:14 PM identified that R #151 was alert and oriented and required staff assistance with toileting. The Resident Care Plan (RCP) dated 2/22/15 identified that R #151 was at risk to fall with interventions that included to orient the resident to surroundings and to allow weight bearing as ordered. Review of the nursing note dated 2/23/15 identified that R #151 was found on the floor in front of the commode and observed to have a skin tear that measured 1.5 cm by 0.5 cm on the right shin. Review of the facility accident and incident investigation dated 2/23/15 identified R #151 was on the commode and was reaching for call bell when the fall occurred. Facility investigation included a written statement by NA #5 that identified that NA #5 transferred R #151 onto the commode with NA #4, that the resident's call bell was not within in reach when resident was left on the commode, and that R #151 fell from the commode when trying to reach call bell. Interview & record review on 3/25/2015 at 11:02 AM with the DNS identified that R #151 was alert and oriented and able to use the call bell. The DNS further stated that NA #4 and NA #5 transferred R # 151 onto the commode, left R #151 alone for privacy, and that R #151 fell when he/she tried to reach for the call bell. The DNS stated that the call bell should have been within the resident's reach. During a phone interview with LPN #4 on 3/25/15 at 11:15 AM in the presence of the DNS, LPN #4 stated that R #151 was positioned on the commode next to the window, between the window and his/her bed, and that the call bell was tied to the side rail closest to the door which was on the opposite side of the bed. LPN # 4 stated that R #151 fell when trying to reach across the bed for the call bell. Interview and record review with RN # 2 on 3/26/15 at 10:58 AM identified that R #151 was transferred onto the commode and the call bell was not moved from the opposite side of the bed to be within R #151's reach. RN #2 further stated that R #151 fell when he/she stood up to try to reach the call bell. RN #2 indicated that one staff person should have stayed with R #151 or moved the call bell within reach of the resident. NA #4 and NA #5 were not available for interview during survey. The care plan was updated subsequent to the fall on 2/23/15 to ensure that the resident's call bell was within reach when on commode Review of the facility's Certified Nurse Aide job description directed in part, that the nursing assistant ensure that all call bells are placed within the reach of the resident.

Based on clinical record review, observations and interviews for two of five residents reviewed for accidents (R#77 and R#239), the facility failed to ensure that the residents receive adequate supervision and/or failed to provide care and services to prevent an accident. The findings include: 1. Resident #77's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as severely cognitively impaired, long and short-term memory problems, rarely understood in ability to express ideas and wants, with physical symptoms like screaming, extensive assistance for all activities of daily living, and incontinent of bowel and bladder. A RCP dated 2/22/12 identified a problem with falls, with interventions that included transfer with mechanical lift with assistance of three to a Broda wheelchair with thigh belt and padded sides and anti-tippers, stay with resident if observed rocking Broda chair, out of bed if observed awake on first rounds on the 3-11 shift, keep immediate surroundings clear and free of obstacles, place Broda chair in bathroom when resident in bed, place mats at the foot of the bed from window wall to bathroom wall and do not leave unattended in wheelchair while being transferred. Nurse's note dated 2/09/12 identified the resident was found lying on his/her face on the floor, mild bleeding and a hematoma was noted on the right forehead, with a small amount of undigested food. The resident was then transferred to the emergency room for further evaluation. Review of nurse's note dated 2/20/12 identified the resident was found on the floor. Review of the facility investigation indicated the resident leaned forward while seated in the Broda chair, fell forward landing on the knees, and hitting head on the mechanical lift, sustaining a bump. Interview with NA#6 on 3/13/13 at 3:30 PM who witnessed the incident, indicated the resident rocks her pelvis most of the time while in the Broda chair, and some of the movements include bending forward from the hips. NA#6 indicated that the movements intensify and become forceful if R#77 wants something, is agitated or is frustrated about something. NA#6 further indicated that at the time of the fall, despite R#77 being buckled at the thighs at the back of the chair, he/she fell forward. NA#6 indicated that additional details could not be provided due to the span of time. Nurse's notes dated 3/14/12 identified the resident was found on the floor lying on his/her left side in front of the wheelchair with no apparent injuries. Facility investigation indicated the resident wanted to go to bed and was provided incontinent care thirty minutes earlier. Nurse's note dated 3/22/12 further indicated that the resident was found on the floor face down in front of Broda chair. Further review indicated the resident sustained [REDACTED]. Interview with NA#7 on 3/14/13 at 10:00 AM identified lack of memory on details of incident but indicated that R#77 lunges forward when agitated and that the Broda chair goes with the resident at the time of falls. NA#7 further indicated that the legs straps were on at the time of the fall. Clinical record review and interview with the DNS on 3/14/13 at 9:00 AM indicated that although causal factors related to care that contributed to the falls were reviewed and corrected, assessment of the Broda chair and its integrity were not a part of the investigation. The DNS indicated that the Director of Rehabilitation (DPT) was part of the interdisciplinary team that reviewed the falls, however, the clinical record and the facility investigation related to the falls failed to provide assessments of the Broda chair post fall. The DNS could not explain how R#77 was found on the floor when the resident was attached to the Broda chair with a thigh belt clipped at the back of the wheelchair. Review of the clinical record and interview with the OT on 3/13/13 at 1:00 PM indicated that a PT post fall assessment was completed on 2/22/12 (after second fall off Broda chair) indicating that the Broda chair and it's components were frankly intact. However, the chair vendor would be called to check the chair and replace any broken parts. Additionally, the OT indicated other post fall assessments related to the falls on 2/09/12, 3/13/12 and 3/22/12 were not in the clinical record. Interview with the DPT on 3/13/13 at 5:15 PM indicated that PT screens were at her desk and stated the chair vendor was called to look at the chair. Although the DPT indicated communication with the chair vendor was completed, the details and progress of the interactions were not documented. Additionally, further review of PT notes failed to provide alternative/additional measures to provide enhancements to increase the chair's stability. However, interview with the chair vendor's representative on 3/14/13 at 10:00 AM indicated that she could not recall being called to assess the stability of the chair and/or offer enhancements to the chair to prevent the resident from falling and sustaining head/facial injuries. The vendor representative further indicated that if she had known earlier, a Broda chest belt would be provided as an initial step. Facility documentation review indicated that a chest harness was provided to R#77 on 4/04/12 (22 days after the fourth fall). 2. Resident #239's [DIAGNOSES REDACTED]. An Elopement/Wandering risk evaluation completed on 2/28/12 at 12:34 AM identified the resident was not a risk for elopement. An admission nurse's note dated 2/27/12 identified the resident was admitted from the hospital and transported to the facility via ambulance. The nurse's note further identified the resident as alert, oriented, and cooperative, with a question of occasional confusion. The nurse's notes further indicated the resident was friendly, appears to have a well adjusted personality. Nurse's note dated 2/28/12 identified that when the resident was not found during checks at 3:15 AM, the facility's missing person protocol was initiated that included a search of all the units in the building, a search outside the building, notification of the Administrator and the DNS, including the police. At 4:00 AM the resident was found by the police walking down the road beyond the facility premises and then sent to the emergency room for evaluation. Interview with the 11 PM to 7 AM RN Supervisor #1 (RNS#1) on 3/12/13 at 3:10 PM indicated that it was part of her duties to ensure the front door of the building was locked. RNS#1 indicated that she locked the front door after the change of shift at 11:00 PM on 2/28/12 however failed to lock it again after the 3-11 Supervisor left the building at 1:00 AM.

Based on record review and staff interview for one of three residents reviewed for pressure ulcers (R#146) the facility failed to provide care and services to prevent the development of a pressure ulcer and/or promote healing. The findings include: Resident #146's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as having long and short term memory problems and requiring extensive assistance of two staff members for bed mobility and toileting. The MDS identified R#146 as totally dependent on two staff members for transfers. A RCP dated 2/01/13 identified the resident required assistance with activities of daily living related to dementia. Interventions included to utilize bilateral knee orthosis', to apply on last rounds on the 3:00 PM to 11:00 PM shift and to remove in the morning on the 7:00 AM to 3:00 PM shift. Physician orders [REDACTED]. A weekly body audit dated 2/14/13 and 2/21/13 and completed by the charge nurse identified no pressure ulcers, non-pressure ulcers, skin tears, ecchymosis, rash and/or abrasions. Nurse's note dated 2/22/13 at 11:51 PM identified that during hours of sleep (hs) care, an open area to the posterior right knee was identified and reported to the RN Supervisor by the NA. The open area appeared to be a Stage 3 pressure ulcer, 75% of the wound bed appeared white with folded edges and with eschar noted to the center of the wound bed. The area measured 2.0 cm by 2.0 cm. Tunneling and undermining was difficult to assess due to R#146's leg contracture. On 2/23/13 the physician directed to hold application of the bilateral knee orthosis related to the pressure ulcer to the right posterior knee. Facility investigation dated 3/08/13 identified the pressure ulcer was a result of the resident's knee orthosis. Interview with the Registered Physical Therapist on 3/14/13 at 1:02 PM identified the pressure ulcer was at an area of the posterior knee that was probably caused by the knee splint. Although the facility lacked a policy for checking skin integrity prior to and after splint application, facility investigation dated 3/07/13 noted that although the right leg orthosis was written in the treatment kardex, there was no area to document skin checks. Facility investigation dated 3/07/13 further identified that although body audits were completed on 2/14/13 and 2/21/13 that failed to identify the pressure ulcer, the resident had severe contractures of the right knee and not one staff member could have assessed the areas alone. Facility investigation further noted that the pressure ulcer to the right posterior knee could not have developed within 24-hours of the negative body audit completed on 2/21/13. Interview with RN#3 on 3/14/13 at 1:10 PM identified that she completed the body audit on 2/21/13 and she always has someone with her when she completes a body audit. However she could not recall accompanied her on 2/21/13. Interview with the ADNS on 3/14/13 at 10:35 AM identified that body audits are completed on the resident's shower day. The NA checks the skin, but the nurse is responsible for completing the actual body audit.

Based on a review of facility documentation, clinical record review, and staff interviews, for two of four residents reviewed for range of motion (Residents #122 and #154), the facility failed to provide treatment and services to prevent further decreases in range of motion. The findings include: 1. Resident #122's [DIAGNOSES REDACTED]. The Care Plan dated 7/1/11 identified a deficit in activities of daily living with interventions that included to provide assistance with ADL'S, transfer via hoyer lift with assist of two staff to wheelchair and assist with turning and positioning in bed every two hours and as needed. Facility documentation and clinical record review dated 7/2/11 identified bruising was noted on the whole perineal area that extended to the lower buttocks towards the anus. The right side of the labia was swollen 12 cm in length and 7 cm in width and the right thigh was very hard on palpation. Hospital emergency report dated 7/3/11 ruled out sexual abuse , absence of fracture (though the X-ray was limited due to the resident's sub-optimal positioning and problem with cooperation) and identified contusion. Follow-up X-ray completed on 7/5/11 indicated no evidence of pelvic fracture or obvious [MEDICAL CONDITION] right and left femur. Clinical record review with RNS #1 on 2/1/12 at 10:30AM indicated the absence of trauma and/or fall prior to the bruising being noted. Clinical record review and interview with the Director of Rehabilitation (DOR) on 2/1/12 at 10:00AM indicated that an annual rehabilitation screen completed on 1/28/11 identified absence of limitation in range of motion for the upper and lower extremity. Interview however with NA#2 on 2/1/12 at 4:15PM indicated that the resident preferred to lay on his/her side curled up, knees bent with the feet towards the thighs. NA#2 further indicated that Resident #122 resisted attempts to loosen the legs and that as time went on, the curling became worse. In addition, NA#2 stated that at times after eating in bed,with the head of the bed up and Resident #122 seated on the mattress with the knees drawn to the chest, Resident #122 would press his/her head against the mattress and siderail and then grab feet tightly towards self with the heels hitting the perineal area. Further interview with LPN#2 and NA#3 on 2/1/12 at 1:35PM identified that Resident #122's legs were always drawn up against the body laying on her side as if in a fetal position since long before the bruising occurred. Review of facility documentation and further interview with the DOR on 2/1/12 at 12:30PM indicated that screens are completed annually and upon request by staff for identified concerns and that screens are done by interviewing staff, clinical record review and direct observation. Additionally the DOR indicated that weekly chat rounds are conducted with nursing staff while on the units to discuss residents' problems and staff concerns and documented on weekly check-up list. Review however of the check-up list failed to identify concerns for Resident #122 for the month of January through June 2011. The DOR indicated that she was not made aware of the resident's problems of positioning while in bed until after the bruising and when made aware a recommendation to place a pillow between the resident's bent knees and perineum as well as splinting was initiated. Rehabilitation notes dated 7/8/11 identified severely limited bilateral lower extremity passive range of motion and a treatment plan that included therapeutic exercise and orthotics. Further review of discharge rehabilitation notes dated 8/11/11 identified that nurse aides reported providing morning care was easier because Resident #122's legs were more flexible and relaxed and that the knee orthotics provided actually assist with positioning during care. The DOR identified that the knee foot orthotics (KFO) were provided in order to extend the knee and prevent further contractures. Interview and review of facility documentation with the DNS on 2/2/12 indicated that since the use of knee orthotics and placement of pillow between the perineal area and legs, the resident has not had vaginal bruising. The facility failed to assess the resident for a change in range of motion and/or implement measures to address such in a timely manner. 2. Resident # 154's [DIAGNOSES REDACTED]. Occupational Therapy discharge summary dated 11/18/11 identified the resident with worsening of bilateral hand contractures and due to elbow contractures the resident also demonstrated skin maceration to the anterior aspect of the elbow with [MEDICAL CONDITION] to the bicep. Therefore staff was instructed on placement of hand roll and washcloth to elbows to maintain range and extension. Recommendations included, and staff made aware, once open area to thumb was healed, the carrot will be resumed. Review of nurse's notes dated 11/20/11 noted that the open area on left thumb had healed. Review of a physician's orders [REDACTED].#2-#3) to left hand, on after am care at 10:00 AM and remove at 4:00 PM; Check skin every 2 hours; rolled up wash cloth to right hand and bilateral elbows on the 7-3 shift and 3-11 shift. The quarterly MDS dated [DATE] identified that Resident #154 had severe cognition impairments, required total assistance with ADL's and had bilateral impairments of upper and lower extremity. Observation of the resident on 1/30/12 at 11:00 AM and 2:30 PM identified that Resident #154 had a contracture of bilateral upper extremities and no adaptive equipment was being utilized. Interview with NA #1 on 1/30/12 at 2:35 PM indicated that she usually does not work on the unit and she was unaware that resident require the carrot and/or rolled up washcloths to bilateral hands and elbows. A review of the NA's care card failed to address resident's contractures and treatment. Although documented in the Treatment Administration Record on 1/30/12 at 2:45 PM as being in place, the carrot to the left hand and rolled up washcloths to the right hand and bilateral elbows were not in place. In an interview at that time, RN #1 could not find the carrot and stated that she had forgotten to check if devices were in place. Additional observation on 2/1/12 at 3:00 PM identified the resident in bed without the benefit of a rolled up washcloth in the right elbow. Interview with DON on 2/1/12 at 3:40 PM identified that it is the responsibility of the charge nurse to monitor that treatment to prevent contractures is implemented.