Every finding on record at Lord Chamberlain Nursing & Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #13 and Resident #126) reviewed for grievances, the facility failed to ensure the grievance procedure was followed. The findings include: 1. Resident #13 had diagnoses that included dementia, diabetes, chronic migraines.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #13 was severely cognitively impaired, did not use a mobility device, required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene and chair/bed transfers, substantial/maximal assistance with toileting hygiene, was independent with bed mobility and walking.The Resident Care Plan (RCP) dated 2/3/26 identified Resident #13 was at risk for impaired dentition or oral discomfort related to the need for assistance with oral hygiene. Interventions included coordinate arrangements for dental care, daily mouth care, monitor/document/report any signs/symptoms of oral/dental problems, and report to nurse if refusing oral care. The RCP further indicated Resident #13 was at risk for falls related to cognitive impairment, and unsteady gait. Interventions included use of proper footwear, provide needed assistance or supervision with mobility and toileting as needed, and transfer and ambulate per physician orders as recommended by therapy.Review of the Grievance book identified an entry in the grievance log for a grievance for Resident #13 dated 4/16/26 which indicated a concern had been received related to continence and falls.Review of the RCP failed to identify the care plan was updated with the grievance concerns or any interventions related to the 4/16/26 concerns listed on the Grievance log tracking sheet.A social service note written by Social Worker (SW) #2 on 4/21/26 at 9:20 AM identified a meeting had been held on 4/20/26 with Resident #13, 4 family members, the Unit Manager, Registered Nurse (RN) #1, the Administrator, the Assistant Director of Nursing (ADON), and SW #2. The note indicated the family and staff discussed concerns regarding hospitalizations, falls, laundry, shower schedule, and ability to contact the nursing floors on the weekends. The note identified SW #2 and RN #1 will meet with Resident #13's family member on 4/21/26 to review the care plan.Review of the clinical record failed to identify a follow-up progress note for 4/21/26 related to the planned meeting for 4/21/26 with SW #2, RN #1, and Resident #13's family member to review the care planReview of the Grievance book identified an entry in the grievance log for a grievance for Resident #13 dated 4/21/26 which indicated a concern had been received related to oral care and activities of daily living (ADLs). This grievance coincided with a family meeting documented by the social worker on 4/20/26 with an expected follow-up meeting on 4/21/26.Review of the RCP dated 4/28/26 identified the RCP was updated with an intervention that directed for staff to supervise or assist with oral care/tooth brushing in the morning and at bedtime and as needed after meals. The intervention further directed to document the (oral) care and any refusals. This RCP intervention coincided with the 4/21/26 grievance listed on the log in the Grievance book. The RCP failed to identify any updated intervention related to the concern for ADLs or any specific information related to what the ADLs concern was.A nursing note written by RN #9 on 5/5/26 at 1:46 PM identified a care conference was held via telephone with Resident #13's family member and that there were no changes made to the advanced directives. The note failed to identify what had been discussed at the meeting and if any concerns were expressed by the family member. Review of the Grievance book on 6/22/26 failed to identify the actual physical documents for the April grievances (4/16/26 and 4/21/26) listed on the grievance log.On 6/22/26 at 3:20 PM Resident #13's reportable event for 5/12/26 and 2 April grievances for 4/16/26 and 4/21/26 were requested from the Director of Nursing Services (DNS), and the surveyor was told they would be provided the following day.On 6/23/26 at 8:45 AM the reportable event for 5/12/26 and 2 April grievances for 4/16/26 and 4/21/26 were requested a 2nd time after the cart containing requested documents was checked.Interview and facility documentation review with the Director of Nursing Services (DNS) on 6/23/26 at 12:00 PM identified she was requested for the reportable event for 5/12/26 and 2 April grievances for 4/16/26 and 4/21/26 a 3rd time. The DNS then indicated she had brought them in and set them on the table near where the surveyor sat because the surveyor was not in the room when the documents were brought in. The table and all facility provided documentation was thoroughly checked in front of the DNS and only Resident #13's reportable event for 5/12/26 was located on the table. No April grievances for Resident #13 were located within the facility provided documentation. The DNS indicated that she would look in her office for the documents.Interview with the Director of Nursing Services on 6/23/26 at 3:30 PM identified that she was unable to locate the 4/16/26 and 4/21/26 grievances and their investigations for Resident #13 and she was unable to identify why the grievances had not been in the Grievance book on 6/22/26 when the surveyor first requested to see them. The DNS further indicated that she would continue to look for the 2 documents.An email to the DNS on 6/25/26 at 3:27 PM requested if the 2 April grievances for Resident #13 were located by the DNS, and if so that they be provided to the surveyor.An email response from the DNS on 6/26/26 at 12:22 PM identified she had been unable to locate the 2 April grievances for Resident #13.2. Resident #126 had diagnoses that included dementia, diabetes, and anxiety.The annual Minimum Data Set (MDS) dated [DATE] identified Resident #126 was cognitively intact, used a wheelchair, was dependent with eating, personal hygiene, bed mobility, and transfers. The Resident Care Plan (RCP) dated 3/10/26 identified Resident #126 had a self-care performance deficit. Interventions included Resident #126 requested to get out of bed after breakfast, encourage Resident #126 to self-feed, and educate staff on honoring Resident #126's requests.A Grievance Form dated 5/3/26 (date written on whiteout with date of 4/30/26 visible behind whiteout) identified on 4/30/26 Resident #126 reported a concern related to a Nurse Aide (NA). The form indicated Resident #126 stated at approximately 6:00 AM he/she had observed the NA opening his/her drawer and removing a soda from his/her belongings and that he/she had requested the NA return the soda. The form was completed by Registered Nurse (RN) #1. The form indicated the concern was reported to the Administrator for follow-up and investigation. The form identified a discrepancy between the date written on the whiteout and the description of events within the grievance. Additionally, the form failed to identify the location of the open drawer NA #16 was in.A Witness Statement form dated 5/3/26 (date written on white out with date of 4/30/26 visible behind whiteout) identified a handwritten statement from RN #1. The statement indicated on Thursday 4/30/26 Resident #126 informed her of an incident which involved NA #16. The statement indicated Resident #126 could not recall the exact day of the incident but indicated it had been over the weekend (4/25/26-4/26/26) or Friday (4/24/26). The statement indicated Resident #126 stated at approximately 6:00 AM he/she woke up and observed NA #16 opening his/her drawer and taking a soda. The statement indicated Resident #126 asked NA #16 what he was doing and that NA #16 had responded, I'm going to give it to you. The statement indicated Resident #126 then stated that he/she had replied to NA #16 I did not ask you for it. I just woke up. I'm not drinking and soda this early in the morning. Please put it back in my drawer. The statement identified a discrepancy between the date written on the whiteout and the description of events within the grievance.Review of the facility documentation for the grievance investigation failed to identify a statement from NA #16 or any of the other staff working 4/24/26-4/26/26 who cared for or were on the same unit as Resident #126 during the timing of the incident per Resident #126's statement to RN #1.Review of the facility documentation for the investigation for the Grievance form dated 5/3/26 for Resident #126 identified a Grievance Investigation Summary. The summary indicated the event occurred on 5/3/26 and NA #16 was the alleged perpetrator. The summary indicated a description of the incident and that an investigation was initiated immediately. The summary indicated that interviews were obtained with the resident, NA #16, and relevant staff members. The summary indicated Resident #126's account of the incident remained consistent, and that NA #16 provided a written statement which denied the allegation. The summary indicated the grievance was unable to be substantiated but that concerns related to inappropriate handling of resident belongings and professional boundaries were identified. The summary further indicated education was completed on resident rights, respect of personal property, and professional conduct. Interview with the DNS on 6/22/26 at 1:00 PM identified she was responsible for ensuring all grievances were thoroughly investigated and all documentation complete and with the grievance. Resident #126 initially reported the incident on 5/3/26 and that he/she had thought it occurred on 4/30/26 and that she had to go back to investigate that time period. She indicated Resident #126 had not identified NA #16 at the time of his/her grievance and had only said a male aide. She indicated on 4/30/26 there were 2 male aides working, 1 on the 3 PM-11 PM shift and 1 on the 11 PM-7 AM shift. She further indicated NA #16 was not assigned to Resident #126.Interview with RN #1 on 6/22/26 at 1:25 PM identified she received a statement from Resident #126 on 4/30/26 about NA #16 and that Resident #126 remembered the name of the aide and had specifically given it to her which and so she included it in the grievance. She indicated it was the responsibility of the Assistant Director of Nursing to obtain statements for grievances but she indicated she would obtain them herself from staff working on her shift if she knows the statements are needed. She indicated she then would give the completed statements to either the DNS or the ADNS. She indicated she had given them the grievance and statement from Resident #126 and no one had followed up with her after that regarding the grievance. She indicated that she specifically remembered Resident #126 gave her the statement on Thursday 4/30/26 and had indicated he/she couldn't remember the exact day of the incident but that it had been the previous weekend or Friday. She indicated this was why she had written On 4/30/26 resident reported a concern. She further indicated she did not know how or why the date was changed and whiteout was used and confirmed it was not her handwriting for the 5/3/26 date. Additionally, she had thought after the incident that NA #16 was no longer employed at the facility.Interview with the DNS on 6/22/26 at 2:00 PM identified she had changed the dates on the grievance with whiteout and that RN #1 had been aware, she indicated she had changed the date because Resident #126 had reported the incident on 5/3/26 and she was unable to offer an explanation for why she used whiteout on the grievance form and witness statement nor could she explain why RN #1 insisted the incident was reported on 4/30/26 and not 5/3/26. She indicated when she spoke with Resident #126 he/she had stated only that it had been a male aide and he/she had not given a name and she was unable to identify why she hadn't asked Resident #126 about NA #16 when that was the name he/she had provided to RN #1. She did not give a response to if she had been aware NA #16 had signed off care for Resident #126 on 4/24/26 which was consistent with Resident #126's timeline. She further indicated she had conducted interviews with staff and other residents to see if there were any similar concerns, but that she didn't write those down.Review of the Resident and Family Grievances policy directed, in part, the social worker was the grievance official and was responsible for overseeing the process. The policy directed the staff member receiving the grievance will document the information on a grievance form and take any necessary actions to prevent further potential violations. The policy directed any allegations of abuse, neglect, or misappropriation are to be reported immediately to the administrator. The policy directed all staff involved in the grievance investigation will make efforts to resolve the grievance promptly and the applicable department manager may receive the grievance for follow-up. The policy directed the resident will be apprised of progress during the investigation and will receive a written decision when the grievance is closed. The policy failed to identify directives on the process for thoroughly investigating the grievance and failed to identify directives to maintain documentation of the investigation that would be support the information within the summary statement for the grievance. ___________________________________________________________________TOMPKINS, [NAME] (172) Green, [NAME] (51183) - FTag Initiation F585 The facility failed to ensure thorough investigation of a grievance.[NAME], [NAME] G. (13) Green, [NAME] (51183) - FTag Initiation F585 The facility failed to ensure grievance procedure was followed.[NAME], [NAME] (126) Green, [NAME] (51183) - FTag Initiation F585 The facility failed to ensure thorough investigation of a grievance.[NAME], [NAME] (145) Green, [NAME] (51183) - FTag Initiation F585 The facility failed to ensure thorough investigation of a grievance. F842 The facility failed to ensure personal inventory form was completed on admission.[NAME], [NAME] (172) Green, [NAME] (51183) - RESIDENT NOTE No NotesSOTO, [NAME] G. (13) Green, [NAME] (51183) - RESIDENT NOTE No NotesMOORE, [NAME] (126) Green, [NAME] (51183) - RESIDENT NOTE No NotesPRETE, [NAME] (145) Green, [NAME] (51183) - RESIDENT NOTE No Notes

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #26) reviewed for abuse, and 1 of 4 residents (Resident #103) reviewed for misappropriation of property, the facility failed to ensure an injury of unknown origin, and an allegation of attempted misappropriation were reported timely to the State Agency. The findings include: 1. Resident #26 had diagnoses that included dementia, dysphagia, and chronic obstructive pulmonary disease.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, was dependent for personal hygiene, required supervision or touching assistance with bed mobility and substantial/maximal assistance with chair/bed transfers.The Resident Care Plan (RCP) dated 4/27/26 identified Resident #26 was at risk for alteration in skin integrity related to decreased mobility and cognitive impairment. Interventions included conducting a daily skin inspection during morning and evening care, turning and repositioning with rounds, and report any changes in skin integrity to the nurse.A nursing note written by RN #5 on 6/14/26 at 4:13 AM identified at 12:55 AM a Nurse Aide (NA) (NA #5) reported that during the dinner meal on 6/13/26 around 5:30 PM she had observed a bruise to Resident #26's right cheekbone. The note indicated RN #5 assessed Resident #26 who was lying supine in bed and had the following areas noted: a bruise measuring 2.0 centimeters (cm) length by 1.3 cm width (2.0 cm x 1.3 cm) to the right cheekbone, an area of discoloration measuring 1.5 cm x 1.5 cm to the right thenar web space (area between thumb and index finger), an area of discoloration measuring 4.0 cm x 3.0 cm to the back of the left wrist, and 2 areas of discoloration measuring 0.5 cm x 0.5 cm each to the left posterior compartment of the forearm. The note identified Resident #26 denied pain. The note further identified Resident #26 stated 2 names of people that were posing as a doctor and nurse. They dig into my skin with their fingernails. They live in Watertown and they keep breaking everything. This was the resident explanation.A nursing note written by RN #5 on 6/14/26 at 4:31 AM identified the on-call Advanced Practice Registered Nurse (APRN) was notified at 4:29 AM with no new orders and to follow-up with the facility APRN.A nursing note written by RN #5 on 6/14/26 at 8:26 AM identified the responsible party was notified of the bruising/discolorations.Review of the state agency Reportable Events tracking system on 6/18/26 failed to identify the injury of unknown origin was reported to the Stage Agency after identification of multiple areas of bruising/discoloration to Resident #26 on 6/14/26. Additionally, Resident #26 was moderately cognitively impaired and unable to identify the cause of the injuries. Interview with RN #5 on 6/18/26 at 12:53 PM identified NA #5 had told her that she saw bruising on Resident #26 and that it was her first time observing that bruising as she hadn't seen Resident #26 in over a week. She indicated that when she was notified of the bruising by NA #5, she had performed an assessment, Resident #26 denied pain and was unable to recall what happened due to confusion. Additionally, she indicated she had performed a full body audit and that's when she saw the additional areas of discoloration. She indicated she was unable to determine the cause of the bruising/discoloration, and that the bruise to the right eye was multi-colored suggesting it was beginning to heal which caused a change in the color. She indicated that she had spoken with the charge nurse who told her Resident #26 often removed his/her oxygen tubing on their own and maybe they had pulled too hard, but they could not determine any other potential root cause for the bruising/discoloration. She identified she filled out an Accident/Incident (A/I) report both electronically and on paper, obtained a statement from NA #5, and placed the A/I in the Assistant DNS mailbox. She further indicated that bruises/discoloration on a resident that she was unable to determine a root cause for was considered an injury of unknown origin (IUO) and by policy it required an investigation and notification to the DNS. She indicated she had initiated an investigation and had reported it directly to the DNS on Monday morning. She failed to identify the 2 hour window of time for reporting of an IOU to the State Agency.Interview with the DNS on 6/18/26 at 3:40 PM identified she could not recall being told about an A/I for Resident #26 by RN #5 on 6/15/26, that she did not have an A/I for that resident, and that she would have to look into it.Subsequent to surveyor inquiry an A/I for Resident #26 received on 6/22/26 was dated 6/13/26 at 5:30 PM and identified a Nurse Aide (NA) (NA #5) reported an unwitnessed bruise to Resident #26's right cheekbone, and on evaluation 4 additional unwitnessed areas of discoloration were noted. The report indicated the Advance Practice Registered Nurse (APRN) and responsible party were notified. The report further indicated to monitor the bruise and discolorations. The report was signed by RN #5 on 6/14/26 and signed by the Administrator on 6/22/26.Interview with the DNS on 6/22/26 at 2:10 PM identified she had investigated this incident as soon as she was notified by RN #5 and it was determined in less than 2 hours that the bruising was from Resident #26 holding his/her call bell up to their right ear as though it was a telephone, so she was able to identify the cause of the bruising and therefore did not notify the state agency. She was unable to identify how holding the call bell up to the right ear would also have resulted in bruising/discoloration to the left wrist, left forearm or right hand, she failed to identify why the incident hadn't been reported on 6/14/26 within 2 hours of NA #5 reporting the bruising/discoloration to RN #5.As of the survey exit from the facility on 6/23/26 the facility had not reported Resident #26's multiple areas of bruising/discoloration to the State Agency.2. Resident #103 had diagnoses that included a subarachnoid hemorrhage, dementia, and diabetes.The Nursing admission assessment dated [DATE] at 8:22 PM identified Resident #103 arrived to the facility by wheelchair transport accompanied by his/her spouse. The assessment identified Resident #103 was pleasant, and moderately cognitively impaired with clear speech. The assessment identified Resident #103 had unsteady gait with poor balance, and was a fall risk. The Resident Care Plan (RCP) dated 5/21/26 identified Resident #103 had potential for self-care deficit related to activities of daily living (ADLs). Interventions included to assist with bathing and dressing per physician orders and Resident #103 required assistance of 1 staff member for bed mobility.A facility initiated Reportable Event form dated 5/21/26 at 8:41 AM identified Licensed Practical Nurse (LPN) #10 heard a noise coming from Resident #103's room and entered the room to assess. The RE indicated upon entering the room LPN #10 observed Nurse Aide (NA) #16 standing near Resident #103 and Resident #103 then pointed at NA #16 and stated, he tried to take my wedding ring off my finger. The RE indicated that facility administration was immediately notified upon receipt of the allegation (This statement was a discrepancy from information within the investigation).Review of facility investigation documentation identified a typed Resident Interview Statement from Resident #103 dated 5/21/26 and signed by the DNS on 5/22/26. The statement indicated the interview was conducted on 5/21/26 (no time documented) by the DNS). The statement indicated Resident #103 confirmed that someone (NA #16) was trying to take his/her wedding ring and that he/she had reported it to the nurse. The statement indicated Resident #103 remained consistent during the interview. The statement further indicated that LPN #10 was notified of the allegation during the 11 PM-7 AM shift and that LPN #10 reported the allegation to RN #11 who immediately notified the DNS. This timeline of initial reporting of the allegation to the notification of the DNS is inaccurate and does not coincide with the LPN #10's statement that she became aware of the incident at 2:00 AM and the Reportable Event Report was submitted at 8:41 AM. This demonstrates the allegation was reported 6 hours and 41 minutes after the allegation was first reported.Interview with the DNS on 6/22/26 at 1:00 PM identified she had been notified of the allegation of attempted misappropriation for Resident #103 and had reported it to the State Agency immediately (she failed to identify the incident occurred at 2:00 AM and she had not reported it until 8:41 AM (6 hours and 41 minutes after the allegation occurred).Interview with RN #11 on 6/23/26 at 10:45 AM identified she was the nursing supervisor working at the time of the allegation of attempted misappropriation, and LPN #10 had told her about the incident later in the shift, around 6:00 AM, but she couldn't remember specifically. She indicated LPN #10 had told her that she went in the room to assist Resident #103 and saw NA #16 in the room, and then Resident #103 told LPN #10 that NA #16 tried to take his/her wedding ring. She indicated that because LPN #10 hadn't told her until near the end of the shift, she had not gone to the room to interview Resident #103 because she was really busy and it was close to the end of the shift so she knew the Director of Nursing Services (DNS) was coming in soon and that she would go see the resident. She indicated that she was aware of the policy for allegation of abuse and that misappropriation was considered abuse, but for some reason at the time she had not considered the incident as misappropriation. She further indicated that when the DNS arrived, her and LPN #10 notified the DNS of the incident.Interview with RN #10 on 6/23/26 at 4:00 PM identified allegations of abuse including misappropriation were supposed to be reported to the State Agency within 2 hours, and when a charge nurse was aware of an allegation at 2:00 AM, she should notify her nursing supervisor immediately so that the nursing supervisor can notify the DNS and receive instructions on how to proceed, and the allegation could have been reported promptly. She further identified it was not acceptable for the nursing supervisor to wait until the DNS arrived to the building to report the allegation of misappropriation.Interview with LPN #10 on 6/23/26 at 4:25 PM identified she was doing rounds at 2:00 AM, heard Resident #103 speaking and it sounded a little odd, so she went into the room to see if the resident was alright. She indicated upon entering the room NA #16 was standing on the right side of Resident #103's bed towards the center of the bed and his back was to the door. She indicated there wasn't any lighting in there when she opened the door so she couldn't see well, but that Resident #103 pointed to NA #16 and stated, he's trying to take my wedding ring. She indicated that she knew there was a 2 hour timeline for reporting allegations of abuse, so she had reported the incident to the nursing supervisor (RN #11) in less than 2 hours, but indicated she did not notify RN #11 immediately and instead finished her rounds first.Review of the Abuse, Neglect and Exploitation policy directed, in part, an immediate investigation is required upon suspicion of abuse, or when reports of abuse occur. The policy directed the facility will take efforts to ensure residents are protected from additional abuse by responding immediately to protect the alleged victim and the integrity of the investigation. The policy further directed all allegations of abuse are reported to the Administrator, the state agency, and all additional required agencies within 2 hours of when the allegation was reported.

Based on interviews, review of the clinical record, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #17) reviewed for an allegation of rough care and for 7 of 9 sampled residents (Resident #39, Resident #103, Resident #112, Resident #138, Resident #145, Resident #169 and Resident #172) reviewed for missing items, the facility to ensure missing property was thoroughly investigated. The findings include: 1. Resident #17's diagnoses included dysphagia, dementia, and cardiomyopathy.The Resident Care Plan (RCP) dated 4/20/26 identified Resident #17 had impaired cognitive function or impaired thought process, not always able to think of words or to understand due to cognitive loss. Interventions included keeping routine consistent and providing consistent care givers as much as possible in order to decrease confusion, engage in simple, structured activities that avoid overly demanding tasks, and speak slowly, clearly repeating information as needed.The Re-entry Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was severely cognitively impaired and dependent for showering, dressing, and toileting. Also, identified Resident #17 required substantial maximal assistance for eating.A nursing note dated 5/28/26 at 2:35 PM, written by Registered Nurse (RN) #4 identified that Resident #17 reported at 4:00 AM a Nurse Aid (NA) came into his/her room and handled him/her roughly while giving the resident care, grabbing Resident #17's left wrist and hand. Resident #17 complained of pain to the left hand and wrist. On assessment a bruise was observed on the left dorsal hand measuring 1.0 centimeters by (x) 0.7 cm, slight deformity to the left wrist, and skin intact. The right forearm was noted to have 2 bruises, measuring 9.0 cm x 6.5 cm and 4.0 x 9.0 cm yellowish/blue in color, flat, healing, and upper arm bruise measuring 2.0 cm x 3.4 cm blue/purple in color, flat and skin intact. The Advanced Practice Registered Nurse (APRN) was updated, and a stat order directed an X-Ray to the left wrist and hand to rule out fracture or dislocation.A Social Worker note dated 5/28/26 at 3:19 PM identified Resident #17 felt safe and presented at baseline of being friendly and pleasant.A grievance form dated 5/28/26, filed by RN #4, identified an incident in which Resident #17 alleged that staff were being abusive. Three statements obtained were individually signed by NA #6, NA #15 and Licensed Practical Nurse (LPN) #4. The statements indicated that Resident #17 alleged a staff member with a specific name had provided rough care with him/her hurting the resident's left hand. Resident #17 stated she/he did not feel comfortable with this specific staff member and was oriented to person at the time. Also, identifying the X-Ray to the left hand was negative for fracture or dislocation. Interview on 6/18/26 at 11:45 AM with LPN #4 identified Resident #17 identified a NA with a similar name to NA #7, had provided rough care. Also, identified Resident #17 had stated this name to her and the 2 NAs that worked 11PM-7 AM on 5/28/26. Further, identifying NA #7 worked on the same unit as Resident #17 and worked the 3 PM-11 PM shift.Interview on 6/18/26 at 12:59 PM with NA #7 (who had a similar name to the name Resident #17 identified on 5/28/26) noted that she worked on 5/27/26 on the 3 PM-11 PM shift and was assigned to Resident #17. Also, identified NA #7 denied being rough with Resident #17 on 5/27/26 and Resident #17 had bruising noted. NA #7 identified she provided care on her own for Resident #17.Interview on 6/18/26 at 1:13 PM with the Director of Nursing Services (DNS) identified NA # 7, worked on 5/27/26 from 3 PM-11PM. Also, reviewed the staff statements with the DNS who identified Resident #17 stated a similar name to the one provided by the staff statements but Resident #17 stated the incident transpired on 5/28/26 in the early morning. Further, identifying NA #7 was questioned but her statement was missing from the file, then stating NA #7 should have been interviewedInterview on 6/18/26 at 1:33 PM with RN #4 (who called the blood draw lab on speaker phone to ascertain if Resident #17 had a blood draw to the left wrist/hand) identified the Lab Representative stated Resident #17's last blood draw was performed on 4/22/26 on her/his right hand.Interview 6/18/26 at 2:48 PM with NA #7 identified that she was never questioned about an incident on 5/27/26 or 5/28/26 with Resident #17.Interview on 6/22/26 at 9:16 AM with NA #6 identified that she was working with Resident #17 who stated a NA with a similar name to NA #7 was not nice to him/her. Also, identifying she reported the incident to LPN #4 and Resident #17 spoke in Spanish to LPN #4 when interviewed. NA #6 identified she does not understand Spanish. 2. Resident #39 had diagnoses that included end stage renal disease, diabetes, and transient ischemic attack (TIA) (temporary blockage of blood flow to the brain causing stroke-like symptoms).The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was moderately cognitively impaired, required dialysis, used a wheelchair, was independent with eating and bed mobility, required supervision or touching assistance for bed/chair and toilet transfers and was dependent for wheelchair mobility.The Resident Care Plan (RCP) in effect on 3/1/26 identified Resident #39 was at risk for falls related to cognitive impairment, decreased neuromuscular coordination, and impaired balance. Interventions included placing the call light within reach at all times, orienting to surroundings, and encouraging to ask for assistance prior to transfers.A Grievance Form dated 3/2/26 indicated Resident #39 reported upon returning from an appointment that the drawer of his/her nightstand was open, his/her wallet was inside and open and $60 was missing. The form indicated that a room search was conducted, the money was not found, and statements were obtained from the resident and care staff.A statement from Resident #39 and written by Registered Nurse (RN) #4 (dated 3/2/26 at 3:00 PM) identified he/she had put $60 in their wallet on Friday (2/27/26) after giving a family member $40 and that there had been three $20 bills placed in the black wallet. Resident #39 stated the black wallet was placed inside the nightstand drawer on top of another wallet (light in color) and had closed the drawer. Resident #39 indicated that the morning of 3/2/26 before going to an appointment he/she had visualized the wallet in the same place as it was placed on 2/27/26. The statement indicated upon return from the appointment around 2:00 PM Resident #39 had found the drawer of the nightstand open, and the wallet (black) was open with $60 missing, and he/she had immediately reported the missing money to the nurse and nurse aide (NA).Review of the facility documentation for the grievance dated 3/2/26 for Resident #39 identified 1 staff statement (NA #4) was obtained on 2 separate witness statement sheets. The statement indicated she had provided morning care to Resident #39 to prepare for the appointment and Resident #39 was ready to leave at 9:00 AM. The statement indicated upon returning from the appointment after lunch Resident #39 had reported to her that he/she was missing $60 from their wallet and it was immediately reported to the nurse. The statement further indicated that in the morning while providing care to Resident #39 the orientee NA #16 was making the beds for Resident #39 and his/her roommate. The statement failed to identify any other staff members observed in Resident #39's room. Additionally, the facility documentation failed to identify any additional staff interviews/statements.Review of the facility documentation for investigation of the 3/3/26 misappropriation failed to identify the full interview with NA #16, on what date that occurred, and failed to identify a statement other than from NA #4 of staff members working during the timeframe of the missing money such as housekeeping, charge nurse, unit manager, additional NAs not assigned to Resident #39.Interview with the DNS on 6/22/26 at 1:00 PM identified she was responsible for ensuring all grievances were thoroughly investigated and any grievance that was reported as an allegation of abuse would also be her responsibility to ensure it was thoroughly investigated. She indicated that for missing items/money the facility usually obtained statements from the main aide for the resident on each shift and she was unable to identify why there had only been 1 staff statement obtained for Resident #39's investigation. 3. Resident #103 had diagnoses that included a subarachnoid hemorrhage, dementia, and diabetes.The Nursing admission assessment dated [DATE] at 8:22 PM identified Resident #103 arrived to the facility by wheelchair transport accompanied by his/her spouse. The assessment identified Resident #103 was pleasant, and moderately cognitively impaired with clear speech. The assessment identified Resident #103 had unsteady gait with poor balance and was a fall risk. The Resident Care Plan (RCP) dated 5/21/26 identified Resident #103 had potential for self-care deficit related to activities of daily living (ADLs). Interventions included to assist with bathing and dressing per physician orders and Resident #103 required assistance of 1 staff member for bed mobility.A nursing note written by Licensed Practical Nurse (LPN) #10 on 5/21/26 at 6:28 AM identified Resident #103 was put to bed at midnight and then monitored for safety throughout the shift. The note failed to identify Resident #103 had reported an allegation of attempted misappropriation by Nurse Aide (NA) #16 to LPN #10 at 2:00 AM on 5/21/26.A facility initiated Reportable Event (RE) form dated 5/21/26 at 8:41 AM identified Licensed Practical Nurse (LPN) #10 heard a noise coming from Resident #103's room and entered the room to assess. The RE indicated upon entering the room LPN #10 observed Nurse Aide (NA) #16 standing near Resident #103 and Resident #103 pointed at NA #16 and stated, he tried to take my wedding ring off my finger. The RE indicated the resident was immediately assessed and had no visible injury however his/her wedding ring was observed to be half off Resident #103's finger. The RE further indicated that administration was notified and an immediate investigation was started. (This was a discrepancy from the timing of the witness statement by LPN #10 who indicated the event occurred at 2:00 AM and from the statement of RN #10 who indicated she waited for the Director of Nursing Services (DNS) to arrive and begin the investigation). Review of the facility documentation for the investigation of the 5/21/26 allegation of NA #16 attempting to remove Resident #103's ring identified an unsigned written statement from LPN #10 dated 5/21/26 which indicated during the 11 PM-7 AM shift she was doing 2:00 AM rounds when she entered Resident #103's room and observed NA #16 in the room. The statement indicated that Resident #103 pointed at NA #16 and stated he was trying to take my wedding band off my finger. The statement indicated that she reported the allegation to the nursing supervisor. Review of the facility-initiated investigation identified a typed Resident Interview Statement from Resident #103, dated 5/21/26 and signed by the DNS on 5/22/26. The statement indicated the interview was conducted on 5/21/26 (no time documented) by the DNS and noted Resident #103 confirmed that someone (NA #16) was trying to take his/her wedding ring and that he/she had reported it to the nurse. The statement indicated Resident #103 remained consistent during the interview and further indicated that LPN #10 was notified of the allegation during the 11 PM-7 AM shift and that LPN #10 reported the allegation to RN #11.A statement obtained by the facility from NA #16 (alleged perpetrator) dated 5/20/26 for an incident dated 5/20/26 (this was discrepancy from the date of the incident on 5/21/26) which indicated he did not have any knowledge of anything LPN #10 said. The statement indicated Resident #103 was saying things that made no sense and that Resident #103 asked the nurse repeatedly to leave the room because they were trying to take wedding band. The statement failed to identify why NA #16 had been in the room and what he was doing with Resident #103 when the nurse entered the room.Review of the facility documentation for investigation of the 5/21/26 attempted misappropriation failed to identify a statement from RN #10, or any other staff (including Resident #103's assigned NA) working on the unit for the 11 PM-7 AM shift.Interview with the DNS on 6/22/26 at 1:00 PM identified NA #16 was not assigned to Resident #103 on 5/21/26 when he was in Resident #103's room, and that she had interviewed NA #16 after the incident, but she was unable to identify why NA #16 was in the room. Interview with RN #11 on 6/23/26 at 10:45 AM identified she was the nursing supervisor working at the time of the allegation of attempted misappropriation, and LPN #10 had told her about the incident later in the shift. She indicated LPN #10 had told her that she went in the room to assist Resident #103 and saw NA #16 in the room, and then Resident #103 told LPN #10 that NA #16 tried to take his/her wedding ring. She indicated that she was unable to recall if the ring was partially off the resident's finger. She indicated that because LPN #10 hadn't told her until near the end of the shift, she had not gone to the room to interview Resident #103 nor did she assess him/her because she was really busy and it was close to the end of the shift so she knew the Director of Nursing Services (DNS) was coming in soon and that she would go see the resident. Additionally, because it was near the end of the shift she indicated she did not send NA #16 home and instead told LPN #10 not to let NA #16 enter Resident #103's room. She further indicated that when the DNS arrived, her and LPN #10 notified the DNS of the incident and she thought LPN #10 was asked for a statement, but wasn't sure about anyone else's statement.Interview with RN #10 on 6/23/26 at 4:00 PM identified allegations of abuse including misappropriation are supposed to be reported to the nursing supervisor immediately so that the nursing supervisor can notify the DNS and obtain a statement. She further identified it was not acceptable for the nursing supervisor to wait until the DNS arrived to the building to initiate an investigation.4. Resident #112 had diagnoses that included autistic disorder, diabetes, and Tourette's disorder.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #112 was cognitively intact, used a walker and wheelchair, was independent with eating, required partial/moderate assistance with bed mobility and bed/chair transfers and was independent for wheelchair mobility.The Resident Care Plan (RCP) in effect on 1/21/26 identified Resident #112 had a self-care performance deficit. Interventions included determining the aspects of self-care that are problematic and providing assistance per physician orders, do not overwhelm the resident with multiple step directions, and side rails up at the top portion of the bed to assist with mobility.A Grievance Form dated 3/2/26 indicated Resident #112 reported putting $20.00 into his/her pouch on 3/1/26 and was now missing. The form indicated when Resident #112 went to buy lunch on 3/2/26 the money was missing from the pouch, a room search was conducted, the money was not found, and statements were obtained from the resident and care staff.A statement from Resident #112 and written by Registered Nurse (RN) #4 (undated) identified the resident had put a $20 bill in their pouch on 3/1/26, the pouch was in the nightstand drawer, and when he/she went to take money out of the pouch to pay for lunch on 3/2/26 the money was missing. Resident #112 stated that he/she looked everywhere in the room and was unable to find the missing money. The statement further identified he/she had not seen anyone in his/her room today because he/she wasn't consistently in the room the whole day.Review of the facility documentation for the grievance dated 3/2/26 identified 1 staff statement (NA #16) (undated and unsigned) was obtained. The statement indicated he was unaware of missing money, and that a false report had been made against him stating that he was seen in Resident #112's drawer which was absurd. The statement indicated that he had not been spoken to about the matter, and that there wouldn't be a reason for him to go in a resident's drawer. The statement indicated NA #16 felt he was being targeted and that there was no time when he was in the room by himself. The statement failed to identify the staff member who would have been with him in Resident #112's room. Additionally, the facility documentation failed to identify any additional staff interviews/statements.Review of the facility investigation of the 3/3/26 reportable event of missing money failed to identify a statement other than from NA #16 of staff members working during the timeframe of the missing money such as housekeeping, charge nurse, unit manager, additional NAs not assigned to Resident #112. Additionally, the investigation failed to identify the statement from the individual who had reported seeing NA #16 inside Resident #112's drawer as indicated in his statement.Interview with the DNS on 6/22/26 at 1:00 PM identified she was responsible for ensuring all grievances were thoroughly investigated and any grievance that was reported as an allegation of abuse would also be her responsibility to ensure it was thoroughly investigated. She indicated that for missing items/money the facility usually obtained statements from the main aide for the resident on each shift and she was unable to identify why there had only been 1 staff statement obtained for Resident #112's investigation.5. Resident #138 had diagnoses that included vascular dementia, chronic obstructive pulmonary disease, and anxiety.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 was cognitively intact, used a wheelchair, required setup or clean-up assistance with eating, supervision or touching assistance with bed mobility, bed/chair/toilet transfers, and wheelchair mobility.The Resident Care Plan (RCP) dated 2/18/26 identified Resident #138 required assistance with activities of daily living related to a history of polio. Interventions included to determine the aspects of self-care that are problematic and providing assistance per physician orders, do not overwhelm the resident with multiple step directions, and refer to rehabilitation therapy for changes in self-care abilities.A Grievance Form dated 3/2/26 indicated he/she reported missing $30 (3 $10 bills) from his/her wallet that was in the bedside drawer.A statement from Resident #138 and written by Registered Nurse (RN) #4 on 3/2/26 identified the resident had noticed around 3:30 PM on 3/2/26 that his/her wallet was moved inside the bedside drawer, and that there was $30 missing from his/her wallet. The statement indicated Resident #138 last saw the money the morning of 3/2/26 when he/she put the money in the wallet and put the wallet in the drawer of the bedside table where he/she has always kept the wallet. The statement indicated Resident #138 stated he/she always kept the wallet in that drawer and that he/she had been there for 15 years and never lost his/her money. The statement indicated that he had been provided care by a female NA after a male NA (NA #16) had tried to help him/her. The statement further indicated that Resident #138 had gone to the bathroom after lunch, had been in the bathroom for more than 30 minutes, and that while he/she was in the bathroom, he/she saw NA #16 come to the room and he/she didn't know why NA #16 was there because he/she was in the bathroom.A statement from Resident #182 (Resident #138's roommate) written by RN #4 on 3/2/26 identified he/she had seen a male NA (NA #16) in his/her room that morning when he/she was providing care to Resident #138, then after lunch, and again in the early afternoon. The statement indicated Resident #182 had rung the call light and that NA #16 had answered the call light. The statement indicated that Resident #182 did not see NA #16 go to Resident #138's bed or nightstand, but that he/she did see NA #16 go to his/her nightstand and open the drawer and check inside. The statement further indicated that he/she did not know why NA #16 opened the drawer of his/her nightstand because NA #16 had not requested to open the drawer, and that Resident #182 had not told anyone what he/she saw at the time.Review of the facility documentation for the grievance dated 3/2/26 identified 2 staff statements (NA #10 and NA #16) were obtained. The statement from NA #10 (undated) indicated on 3/2/26 she provided care to Resident #182 when she saw NA #16 who was training with NA #4 going through and searching the drawers of Resident #138. The statement from NA #16 dated 3/3/2023 indicated he was unaware of missing money, and that a false report had been made against him stating that he was seen in a resident's drawer which was absurd. The statement failed to identify the staff member who would have been with him in Resident #138's room. The statement from NA #16 for Resident #138 was the exact same statement included within the investigation documentation for the missing money grievance/reportable event for Resident #112. The documentation failed to identify a statement from NA #4 who was training with NA #16.Review of the facility investigation of the 3/2/26 grievance for missing money identified a phone interview with NA #16 signed by the DNS on 3/3/26. The interview indicated NA #16 was assigned to care for Resident #138 on 3/2/26 and that he was unaware of any missing money, and he denied taking, touching, or looking at any money that belonged to Resident #138. The interview indicated NA #16 stated he did not go in Resident #138's wallet, nor remove any money from the room, and he did not know where the missing money was. The interview indicated NA #16 did not observe anyone else going in Resident #138's belongings or acting suspicious in the room.Review of the facility documentation for investigation of the 3/3/26 reportable event of misappropriation failed to identify a statement from NA #10 and staff members workingInterview with the DNS on 6/22/26 at 1:00 PM identified she was responsible for ensuring all grievances were thoroughly investigated and any grievance that was reported as an allegation of abuse would also be her responsibility to ensure it was thoroughly investigated. She indicated that for missing items/money the facility usually obtained statements from the main aide for the resident on each shift and she was unable to identify why there had only been 2 staff statements obtained for Resident #138's investigation.Although attempted, an interview with NA #10 was not obtained. 6. Resident #145 had diagnoses that included Alzheimer's disease, diabetes, and hypothyroidism.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #145 was severely cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, supervision or touching assistance with personal hygiene, partial/moderate assistance with chair/bed transfers, and was dependent for upper body dressing. The Resident Care Plan (RCP) dated 4/27/26 identified Resident #145 had impaired cognitive function related to Alzheimer's disease. Interventions included identifying yourself at each interaction with Resident #145, providing a homelike environment with consistent care routines and familiar objects, and provide activities that accommodate Resident #145's abilities.A nursing note written by Registered Nurse (RN) #1 on 5/7/26 at 3:59 PM identified Resident #145's family member reported a missing silver ring with a tiny diamond that was missing for a month. The note indicated the family member was unable to identify an exact day and time the ring was last seen. The note indicated the Assistant Director of Nursing was updated, the family member was informed the facility would continue to investigate and update him/her as needed.A Grievance Form dated 5/7/26 identified Resident #145's family member reported a concern related to a missing silver ring with a tiny diamond that had been missing for approximately 1 month. The form indicated that the family member could not provide a more specific timeline for when the ring had last been seen. The form indicated the grievance form was filled out by Registered Nurse (RN) #1 and was investigated by RN #1 and the Director of Nursing Services (DNS). The form indicated the grievance was documented on 5/20/26 and did not indicate a resolution date.Review of the facility documentation for the grievance follow-up/investigation attached to the Grievance Form dated 5/7/26 identified 2 staff interviews were obtained and typed by RN #1 on 5/7/26. The 1st interview was identified as Resident #145's regular day shift (7AM-3PM) Nurse Aide (NA) #15. The interview summary for NA #15 indicated that she was not aware of the ring being missing, and that she denied seeing, handling, removing, or possessing Resident #145's ring at any time. The interview further indicated that NA #15 had not observed the ring in the resident's room or on the resident recently. The typed interview for NA #15 obtained by RN #1 was not signed by either RN #1 or NA #15. The 2nd interview was identified as Regular Assigned CNA and did not indicate an actual NA name or shift. The interview indicated the NA reported she had not seen Resident #145 wearing the ring for an extended period of time and was unable to recall the last time the ring was observed in Resident #145's possession. The interview indicated the NA denied removing, handling, or having knowledge of the location of the ring. Review of the facility investigation for the Grievance form dated 5/7/26 identified an Investigation Summary by the DNS which indicated a resident interview had been obtained regarding the missing item. The facility documentation failed to identify a resident interview.Review of the facility investigation for the Grievance form dated 5/7/26 for Resident #145 identified an Investigation Summary by the DNS which indicated nursing staff from all shifts were interviewed. Review of the facility documentation identified only 2 nursing staff interviews, with only 1 of the 2 staff members identified by name and shift. No additional staff interviews were identified.Additionally, the Grievance form noted housekeeping and laundry departments were notified and interviewed and the staff were reminded to report any found personal belongings immediately. The facility documentation failed to identify any housekeeping or laundry department interviews.Interview with the 4th floor Unit Manager, RN #1, on 6/23/26 at 12:30 PM identified she was unaware Resident #145 had a ring and had not seen it herself. RN #1 indicated that when she had become aware of the missing item, she had asked NA #15 for a statement which she then typed up, she indicated that she had only obtained 1 statement for the investigation of the Grievance and she did not know why the typed statements showed 2 separate interviews when she had only interviewed NA #15. RN #1 indicated that she had not been requested to obtain any staff statements and had taken the initiative to interview NA #15 because she was the regular 7:00 AM-3:00 PM nurse aide for Resident #145, and that she had not obtained any other statements related to the grievance. Additionally, she indicated she had submitted NA #15's statement to the DNS. 7a. Resident #169 was admitted to the facility in July 2025 with diagnoses that included dementia with mood disturbances, chronic obstructive pulmonary disease (COPD), and anxiety disorder.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #169 was severely cognitively impaired and required maximum assistance from staff for all activities of daily living (ADLs).A review of a Grievance Form dated 5/1/26 completed by Registered Nurse (RN) #1 indicated that Resident #169 was missing a gold necklace, reported by Person #3. Person #3 indicated that Resident #169 was wearing the necklace about a week ago. There were no statements attached to the grievance form except for a typed note (not dated or signed) indicating that the primary Nurse Aide (NA) was not aware of the necklace missing and did not know what happened to the necklace. There was no other investigation attached to the grievance. The grievance was signed by the Assistant Administrator with no date.The Resident Care Plan (RCP) dated 5/8/26 identified a self-care deficit as an area of focus with interventions that included assist of 1 for ADLS, provide positive reinforcement for all activities attempted, refer to rehab for changes in self-care abilities, side rails up on top portion of bed to aid with mobility, assist of 2 for transfers out of bed to wheelchair per positioning plan, and no male NAs. The RCP did not include mention of Person #3's allegation of Resident #169's missing necklace. Interview with the Director of Social Work (DOS) on 6/22/26 at 1:05 PM indicated that she was not aware of the grievance as it was still opened and she signs off on the grievance once it is completed. The DOS indicated that she is the designated Grievance Officer. The DOS stated that she would need to inquire further about Person #3's grievance. Interview with the Assistant Administrator on 6/22/26 at 2:05 PM indicated that the grievance was still opened because the necklace may appear and they did not know what happened to the necklace (53 days after the grievance was written). The Assistant Administrator indicated that the facility cannot assume that the necklace was stolen. He indicated that staff were questioned about the missing necklace but could not provide any statements from staff indicating that there was an investigation. He indicated that he would need to check to find out about the investigation and statements from staff. Interview with RN #1 on 6/22/26 at 2:15 PM indicated that Person #3 had reported the missing gold necklace on 5/1/26 and that it was religious with praying hands and catholic pendent. RN #1 indicated that Person #3 stated that it was given to Resident #169 by his/her significant other and it had never been removed since it was given to Resident #169. RN #1 indicated that Person #3 informed her that Resident #169 wanted to be buried with the necklace. RN #1 stated she had obtained 2 statements from NAs regarding the necklace on 5/1/26. RN #1 stated that she did not obtain a statement from Resident #149, who was Resident #7's roommate (moderate cognitive impairment/interviewable). RN #1 stated she submitted the grievance and 2 statements to the DNS.Interview with the Director of Nursing (DNS) on 6/22/26 at 2:30 PM noted she was unsure about further statements regarding the necklace and would need to investigate. The DNS was unaware that the necklace was religious in nature and that Resident #169 wanted to be buried with the necklace. In addition, the DNS stated that she would need to look to see if an inventory of personal effects was completed on admission for Resident #169.Interview with Social Worker (SW) #2 on 6/23/26 at 9:00 AM indicated that she was never informed of a missing necklace for Resident #169, that she was usually updated on missing items and that normally she was involved in the investigation and following up with the responsible party. SW #2 could not explain why she was not updated regarding the missing necklace or why it was not thoroughly investigated. Interview with Person #2 on (another family member) 6/23/26 at 9:20 AM indicated that he/she never received an update about the missing necklace from anyone at the facility. Person #2 stated that the necklace was religious in nature and had a lot of sentimental value. Person #2 indicated that Resident #169 had never removed the necklace since given to him/her and Resident #169 could not remove the necklace by him/herself. Person #2 indicated that Resident # 169 had the necklace since he/she was admitted to the facility and was very upset that the necklace had just disappeared. Person # 2 indicated that Resident #169's laundry was done by the facility. Interview with the Director of Housekeeping (DOH) indicated she[TRUNCATED]

Based on observation, interviews and review of facility policy, the facility failed to ensure the medication cart was secured prior to licensed staff leaving the cart unattended. The findings include: Medication Administration observation with Licensed Practical Nurse (LPN) #3 on 6/18/26 at 7:38 AM noted she dispensed medications then left the medication cart unlocked. The medication cart was unattended and out of sight of LPN #3 in the hallway of the second-floor unit. During that time LPN #3 was in a resident's room, behind a curtain administering eye drops and by mouth medications to the resident next to the window. The surveyor was able to open the drawers to the cart that contained blister packs and house stock bottles of medication.Observation and interview on 6/18/26 at 7:47 AM with LPN #3 identified she should not have walked away from the medication cart and left it unattended and out of her sight. LPN #3 indicated she forgot to lock the medication cart and identified it was her responsibility, but she had made a mistake and forgot.Interview on 6/18/26 at 8:10 AM with the second-floor unit manager (RN #4) identified the medication cart should have been locked and indicated LPN #3 was responsible but she must have been nervous and forgot. Interview with the DNS on 6/22/26 at 1:55 PM indicated while LPN #3 was administering medications on 6/18/26, she should have locked the medication cart. The DNS indicated LPN #3 was responsible, but she must have been nervous and forgot. The DNS further identified she would need to provide further education to LPN #3. Review of facility policy, Medication Storage, dated 11/25, directed all drugs and biologicals will be stored in locked compartments of medication carts and during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on facility documentation, facility policy and interviews for review of the infection prevention program, for 1 of 4 residents (Resident #94) reviewed for respiratory care, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a multi-drug-resistant organism (MDRO) and for 2 of 4 residents (Resident #18 and #102) observed during a wound treatment, the facility failed to ensure hand hygiene between glove changes and prevent a treatment container coming in contact with the resident's sacral area. Additionally, the facility failed to thoroughly track the surveillance of infections. The findings include: 1. Resident # 18's diagnoses included abnormal posture, other atrophic disorders of skin, muscle weakness and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 had moderately impaired cognition and was dependent on assistance with putting on/taking off footwear, lower body dressing, upper body dressing, and bathing. The MDS also indicated the resident was at risk for developing pressure ulcers. The Resident Care Plan dated 4/18/26 identified Resident #18 was on Enhanced Barrier Precautions (an infection control intervention designed to reduce infection that requires gown and glove use for high contact resident care). Interventions included directing care staff to utilize gowns and gloves for all personal care of the resident. A physician order dated 6/15/26 directed Enhanced Barrier Precautions (EBP) for Resident #18. Observation of wound care performed by the wound nurse, Licensed Practical Nurse (LPN) #11 on 6/18/26 at 8:40 AM identified LPN #11 entered Resident #18's room, carrying treatment supplies, and although there was a sign posted on the door frame indicating staff must wear a gown and gloves to provide personal care for resident, LPN #11 failed to don (put on) a gown. Observation of wound care at that time identified LPN #11 then changed her gloves without the benefit of performing hand hygiene between glove changes. Interview with LPN #11 on 6/18/26 at 8:50 AM indicated she failed to wear proper PPE including a gown and failed to perform hand hygiene between glove changes. Resident #18's room had a sign in place for EBP and an equipment cart containing gowns and gloves was outside of the resident room. LPN #11 confirmed Resident #18 was on EBP and stated she should have worn a gown and gloves and performed hand hygiene between glove use but forgot. Interview with the DNS on 6/22/26 at 2:00 PM indicated she would expect the nurse to have worn proper PPE including a gown for a resident on EBP and to have performed hand hygiene between glove changes. Review of the facility policy Clean Dressing Change Policy directed hand hygiene be performed between glove changes. Review of the facility policy Enhanced Barrier Precautions dated 10/16/2023 directed: 2(b)i order for enhanced barrier precautions will be obtained for residents with wounds. 3(a) make gowns and gloves available immediately neat or outside the residents' room. 2.Resident #94 was admitted to the facility in March 2026 with diagnoses that included pneumonia and carrier of Carbapenem-Resistant Acinetobacter Baumannii (CRAB a multi-drug-resistant organism/ MDRO), acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). A physician order dated 3/14/26 directed Enhanced Barrier Precautions (EBP) for Acinetobacter bacteria history. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #94 was moderately cognitively impaired and was dependent with transfers and toileting and required substantial/maximal assistance with bed mobility. The MDS indicated Resident #94 had an MDRO and was a carrier of CRAB. The Resident Care Plan (RCP) dated 4/21/26 identified Resident #94 had a risk for respiratory distress and infections related to COPD and respiratory failure. Interventions included administering medications and monitor/document/report any signs of symptoms of respiratory infection or change in respiratory status. The RCP failed to indicate Resident #94 had an MDRO or CRAB and required EBP. On 5/5/26 the physician's order for EBP was discontinued for Resident #94. Review of the progress notes failed to indicate a reason why EBP was discontinued. Review of the clinical record with Licensed Practical Nurse (LPN #9) on 6/15/26 at 1:30 PM identified Resident #94 had a diagnosis of the MDRO CRAB however review of the physician's orders failed to indicate the resident had an order for EBP and observation of Resident #94's room failed to indicate signage for EBP was present. LPN #9 indicated she would need to follow-up with the Infection Preventionist (IP) (RN #6) about this. Subsequent to surveyor inquiry, a physician's order dated 6/16/26 directed Enhanced Barrier Precautions every shift for CRAB history. Subsequent to surveyor inquiry, the RCP was updated on 6/16/26 and directed a need for Enhanced Barrier Precautions related to targeted MDRO (CRAB). Interventions included direct care staff and visitors to follow EBP and utilize gowns and gloves for all personal care, to educate the resident and staff on EBP precautions and to monitor Resident #94 for signs or symptoms of infection. Interview with the IP nurse (RN #6) on 6/18/26 at 11:45 AM identified Resident #94 should have had EBP in place at all times because the resident recently had pneumonia and was a carrier of a targeted MDRO (CRAB). RN #6 indicated he was unsure why the EBP order for Resident #94 was discontinued in error on 5/5/26. RN #6 stated after he completed an audit on 6/16/26 he obtained a physician's order for Resident #94 to be put back on EBP, ensured EBP signage was placed outside of the resident's room and the RCP was updated. RN #6 identified although it would have been his responsibility to ensure the resident remained on EBP while at the facility, he failed to notice that Resident #94's EBP order had been discontinued on 5/5/26 and it was not put back in place until 6/16/26 (6 weeks later). Interview with the DNS on 6/22/26 at 1:45PM identified Resident #94 should have been on EBP since admission, and she was unsure why the order was discontinued and the resident was taken off EBP on 5/5/26. The DNS indicated that due to the resident being a carrier of a targeted MDRO (CRAB) he/she needed to remain on EBP while at the facility and the IP nurse would have been responsible to ensure that EBP had continued. The DNS stated although the resident was taken off EBP in error on 5/5/26, she was aware the IP nurse had completed an audit and Resident #94 was placed back on EBP on 6/16/26 (6 weeks later). Review of the facility policy, Enhanced Barrier Precautions, dated 10/16/25, directed it was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with infection or colonization with a CDC targeted MDRO when Contact Precautions do not otherwise apply. Examples of MDRO's targeted by CDC include: Carbapenemase-producing carbapenem-resistant Acinetobacter baumanii. Additionally, enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility. 3.Resident #102 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, spinal stenosis, and osteoarthritis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was severely cognitively impaired and utilized a wheelchair or walker and needed assistance for toileting and personal hygiene. Additionally, the MDS identified Resident #102 remained at risk for pressure ulcer/injury and had a Stage 3 pressure ulcer requiring the use of pressure reducing device for bed, applications of ointments/medications, and pressure ulcer/injury care. The Resident Care Plan dated 3/30/26 identified Resident #102 was at risk for skin integrity with interventions that included the need for daily skin inspections during am and pm care, repositioning and offloading pressure, moisture barrier per protocol, and the need to report any skin breakdown to the nurse. A physician progress note written by the Wound Care Specialist and dated 6/16/26 noted a right sacrum Stage 3 pressure ulcer measuring 0.6 centimeters (cm) by ( x) 0.6 cm x 0.5 cm, 100% granulation, with moderate amount of serous exudate. Recommendations included: rinse with Normal Saline, apply Calcium Alginate with Silver (a highly absorbent, antimicrobial wound dressing) to the base of the wound, secure with dry clean dressing and change as needed. A physician order dated 6/2/26 directed a right sacral Normal Saline cleanse followed by Calcium Alginate rope and dry clean dressing every day shift for wound. Observation of the dressing change to Resident #102's coccyx on 6/18/26 at 9:21 AM by Licensed Practical Nurse (LPN) #11 noted LPN #11 brought the treatment cart to the door of Resident #102's room with the supplies for the dressing change on top of the treatment cart. LPN #11 donned a gown, sanitized her hands and applied gloves. LPN #11 noted that Resident #102 was incontinent of urine, then raised the bed and turned Resident #102 onto his/her left side and proceeded to remove the dressing from Resident #102's sacral area. LPN #11 removed her gloves, put on a new set of gloves but did not perform hand hygiene in between glove changes. LPN #11 began cleaning the open area to the sacral area by spraying Normal Saline onto Resident #102's sacral area with a spray bottle in her right hand. While using her right hand to reposition Resident #102 slightly more on the left side, LPN #11 laid the bottle directly onto the skin of Residents #102's right buttock. LPN#11 finished cleaning the wound and then packed the wound with Calcium Alginate (and not Calcium Alginate rope as the physician orders directed) and covered the wound with a clean dressing without the benefit of a glove change or hand hygiene. LPN #11 then dated the dressing, brought the Normal Saline spray bottle to the cart and removed her gloves and washed her hands in Resident 102's bathroom sink. LPN #11 returned the spray bottle into the compartment of the cart (which was previously resting on Resident #102's right buttocks) without the benefit of properly disinfection. (Please also refer to F 686) Interview with LPN #11 on 6/18/26 at 9:30 AM indicated she should have performed hand hygiene after each glove change and but did not because she forgot the hand sanitizer bottle on the cart located at the resident doorway. LPN #11 indicated that she should have changed gloves after cleaning the wound and before applying a clean dressing but forgot. LPN #11 indicated she wiped the Normal Saline bottle with hand sanitizer wipes but should have wiped it with disinfecting wipes and not put it away while still wet. Review of Clean Dressing Change policy dated 2024 directed to use no-touch techniques to remove ointments and creams from their containers. Hands will be washed when gloves are changed and gloves will be changed when going from a contaminated area to a clean area. 4. Interview and review of facility documentation related to the Infection Prevention Program with the Infection Preventionist, Registered Nurse (RN) #6 on 6/18/26 at 11:20 AM identified RN #6 had a Monthly Infection Surveillance Log. The information on the log identified the resident name, resident location, resident admission date, type of infection, signs and symptoms, date of onset of symptoms, whether the infection met criteria (McGeer's criteria-surveillance and data collection tool used for tracking of infections in long term care). Additionally, the log identified the name of the antibiotic, length of treatment, ordering provider, and the date of infection resolution. RN #6 indicated the Monthly Infection Surveillance Log was used for Antibiotic Stewardship and for creating the Monthly Infection Surveillance Summary Report. Interview with RN #6 at 11:50 AM identified he was unable to identify a tracking mechanism used for tracking of all signs and symptoms of infection for residents which included those residents that did not require initiation of an antibiotic. He indicated that he attended morning report and reviewed the 24-hour report (compilation of nursing notes) each day he worked to identify residents with symptoms of infection, but that he did not document his daily surveillance anywhere for tracking purposes. He indicated the only residents added to the Monthly Infection Surveillance Log were those residents who required an antibiotic. RN #6 was unable to identify why there was not a tracking system in place to track all residents with signs and symptoms of infection including those that did not require treatment with an antibiotic as this would capture those residents with viral respiratory signs/symptoms that wouldn't have antibiotics prescribed, those residents with gastrointestinal (GI) symptoms (not classified as an outbreak), residents with increased wound drainage or wound changes (that required addition of silver impregnated treatments or Dakins treatment for decreasing bioburden), residents with eye redness or drainage that had warm soaks ordered without initiation of antibiotics. RN #6 indicated that he sometimes jotted down notes for residents he was following to see if their signs/symptoms progressed to where an antibiotic was needed, but that he did not keep a formal or consistent tracking of those residents, so when he was on vacation or ill the staff member covering would not know he was following those residents. He indicated that residents with signs/symptoms of urinary tract infections (UTI) had a 3-day UTI diary but there was not a list to go to of residents currently being monitored with a UTI diary. Additionally, RN #6 indicated he did not have a tracking mechanism for including residents with infections that did not require treatment with antibiotics in the Monthly Infection Surveillance Summary Report, but that if he suspected an outbreak he would initiate a line list for tracking. Review of the Monthly Infection Surveillance Log for May 2026 identified 30 residents were listed on the log with infections which included pneumonia, asthma exacerbation, urinary tract infection with and without an indwelling catheter, dental procedure, eye infection, cellulitis, and gastroenteritis. Every resident listed on the log had an antibiotic ordered. The log failed to include documentation of residents with sign/symptoms of infection that did not require treatment with an antibiotic. Review of the May Monthly Infection Surveillance Summary Report for 2026 identified the average daily census was 184, there were 5 community acquired infections for the month and 16 facility acquired infections for a total of 21 infections for the month of May 2026. The report further identified the infection rate was 8.7% or 2.81 per 1,000 patient days. The report failed to identify 30 infections for May as identified in the monthly surveillance log (the 21 infections on the report coincided with the 21 infections that met McGeer's criteria on the Monthly Infection Surveillance Log for May 2026). Although requested, an Infection Surveillance policy was not received. Core practices for infection prevention and control recommended by the Center for Disease Control and Prevention (CDC) recommends monitoring for the incidence of infections potentially related to care provided in the facility by data and information collected through surveillance.

Based on review of the clinical record, facility policy and interviews for 5 of 5 residents (Resident #1, Resident #6, Resident #91, Resident #94, and Resident #115) reviewed for pneumococcal and influenza immunizations, the facility failed to offer a pneumococcal and influenza vaccine or document a refusal and/or proof of prior immunization. The findings include: 1. Resident #1 was admitted to the facility on [DATE].a. Review of the clinical record failed to identify a vaccine consent form for an influenza vaccine had been completed.Review of the immunization section of the electronic medical record (EMR) identified Resident #1 had received an influenza vaccine on 10/2/24. The EMR failed to identify Resident #1 or the resident representative had been offered, had given consent or refused consent for an influenza vaccine for the 2025-2026 season.b. Review of the clinical record failed to identify a vaccine consent form for a pneumococcal vaccine.Review of the immunization section of the EMR failed to identify that Resident #1 had received any pneumococcal vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #1 or the resident representative had been offered, given consent or refused consent for a pneumococcal vaccine since admission.2. Resident #6 was admitted to the facility on [DATE].a. Review of the clinical record identified an unsigned influenza vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #6 had received any influenza vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #6 or the resident representative had been offered, given consent or refused consent of an influenza vaccine since admission.b. Review of the clinical record identified an unsigned pneumococcal vaccine consent form.Review of the immunization section of the EMR identified Resident #6 had a history of receipt of a Pneumovax 23 pneumococcal vaccine on 10/17/13 and a Prevnar 13 pneumococcal vaccine on 12/6/19. The EMR failed to identify Resident #6 or the resident representative had been offered, given consent or refused consent of a Prevnar 20 pneumococcal vaccine which was the current pneumococcal vaccine offered by the facility.3. Resident #91 was admitted to the facility on [DATE].Review of the clinical record identified an unsigned pneumococcal vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #91 had received any pneumococcal vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #91 or the resident representative had been offered, given consent or refused consent of a pneumococcal vaccine since admission.4. Resident #94 was admitted to the facility on [DATE].a. Review of the clinical record identified an unsigned influenza vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #94 had received any influenza vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #94 or the resident representative had been offered, given consent or refused consent of an influenza vaccine since admission.b. Review of the clinical record identified an unsigned pneumococcal vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #94 had received any pneumococcal vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #94 or the resident representative had given consent or refused consent of a pneumococcal vaccine since admission.5. Resident #115 was admitted to the facility on [DATE].a. Review of the clinical record identified an unsigned influenza vaccine consent form.Review of the immunization section of the EMR identified Resident #115 had received an influenza vaccine on 10/25/24. The EMR failed to identify Resident #115 or the resident representative had given consent or refused consent of an influenza vaccine for the 2025-2026 season.b. Review of the clinical record identified an unsigned pneumococcal vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #115 had received any pneumococcal vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #115 or the resident representative had given consent or refused consent of a pneumococcal vaccine since admission.Interview, clinical record review, and facility documentation review with the Infection Preventionist (IP), Registered Nurse (RN) #6, on 6/23/26 at 12:00 PM identified the charge nurse was responsible for obtaining vaccine consent forms signed by the resident or the resident representative, and then he was responsible for ensuring the residents received any vaccine they provided consent for. He indicated that he had started in the Infection Preventionist position in December 2025, and he was currently making his way through all the residents to ensure they had been offered the influenza and pneumococcal vaccines, and if they consented that the vaccines were received. He indicated that he was going floor by floor to ensure all residents vaccines were up-to-date and all consents signed and current. He was unable to identify why the residents were not up-to-date with their vaccines prior to him starting in IP position, nor why the EMR didn't reflect that the residents had been offered an influenza and pneumococcal vaccine and whether they refused or consented. He further indicated that he was not currently using the CT Wiz (public portal for accessing immunization records) for identifying which vaccines the residents needed and which they were up-to-date with. Additionally, he indicated that he did not have a current mechanism in place for identifying when the charge nurses failed to get the consent forms for the vaccinations signed.Interview with RN #1 on 6/23/26 at 12:30 PM identified the admission nurse was responsible for obtaining consents for vaccinations (influenza and pneumococcal) on admission, and RN #6 was responsible for following up and administering vaccines to those residents who consented to receive the vaccination. Review of the Influenza, Prevention and Control of Seasonal policy directed, in part, the facility followed current guidelines for prevent and control of influenza. The policy directed the IP will promote and administer the seasonal influenza vaccine. The policy further indicated a key aspect of influenza prevention was administrative controls such as vaccination.Review of the Pneumococcal Vaccine (Series) policy directed, in part, it was facility policy to offer residents and staff immunization from pneumococcal disease according to current guidelines. The policy directed each admission was assessed for pneumococcal immunization, that self-report of immunization was accepted, and all information to determine date and type of vaccine shall be documented. The policy directed that all eligible residents will be offered the pneumococcal vaccination after receipt of vaccine education, and that residents have a right to refuse. The policy directed refusals will be documented in the clinical record with reason of refusal, and a consent form will be signed and filed in the medical record prior to receipt of a vaccine.

Based on review of the clinical record, facility policy and interviews for 3 of 5 residents (Resident #1, Resident #6, and Resident #91) reviewed for COVID-19 vaccines, the facility failed to offer a COVID-19 vaccine or document a refusal and/or proof of prior immunization. The findings include:1. Resident #1 was admitted to the facility on [DATE] and the clinical record face sheet identified Resident #1 as [AGE] years of age.Review of the clinical record failed to identify a vaccine consent form for a COVID-19 vaccine.Review of the immunization section of the electronic medical record (EMR) failed to identify that Resident #1 had received any COVID-19 vaccines prior to admission or since admission. The EMR failed to identify Resident #1 or the resident representative had been offered, given consent or refused consent of a COVID-19 vaccine for the 2025-2026 season.2. Resident #6 was admitted to the facility on [DATE] and the clinical record face sheet identified Resident #6 as [AGE] years of age.a. Review of the clinical record identified an unsigned COVID-19 vaccine consent form.Review of the immunization section of the EMR failed to identify that Resident #6 had received any COVID-19 vaccines prior to admission or since admission. Additionally, the EMR failed to identify Resident #6 or the resident representative had given consent or refused consent of a COVID-19 vaccine for the 2025-2026 season.3. Resident #91 was admitted to the facility on [DATE] and the clinical record face sheet identified Resident #91 as [AGE] years of age.Review of the clinical record identified an unsigned COVID-19 vaccine consent form.Review of the immunization section of the EMR identified Resident #91 had received a COVID-19 vaccine on 6/11/24. The EMR failed to identify Resident #91 or the resident representative had given consent or refused consent of a COVID-19 vaccine for the 2025-2026 season.Interview with Registered Nurse (RN) #6 on 6/16/26 at 12:30 PM identified he had a COVID-19 vaccine clinic scheduled for 6/19/26 and there were approximately 40 residents scheduled to receive vaccines.Interview, clinical record review, and facility documentation review with the Infection Preventionist (IP), Registered Nurse (RN) #6, on 6/23/26 at 12:00 PM identified the charge nurse was responsible for obtaining vaccine consent forms signed by the resident or the resident representative, and then he was responsible for ensuring the residents received any vaccine they provided consent for. He indicated that he had started in the Infection Preventionist position in December 2025, and he was currently making his way through all the residents to ensure they had been offered the COVID-19 vaccine which was how he had the vaccine clinic on 6/19/26. He indicated when a resident consented to receipt of the COVID-19 vaccine, that the vaccines were administered by him. He indicated that he was going floor by floor to ensure all residents vaccines were up-to-date and all consents signed and current. He was unable to identify why the residents were not up-to-date with their vaccines prior to him starting in the IP position, nor why the EMR didn't reflect that the residents had been offered a COVID-19 vaccine and that they refused even though he had just had a COVID-19 vaccine clinic for those who had consented. He further indicated that he was not currently using the CT Wiz (public portal for accessing immunization records) for identifying which vaccines the residents needed and which they were up-to-date with. Additionally, he indicated that he did not have a current mechanism in place for identifying when the charge nurses failed to get the consent forms for the vaccinations signed.Interview with RN #1 on 6/23/26 at 12:30 PM identified the admission nurse was responsible for obtaining consents for vaccinations (COVID-19) on admission, and RN #6 was responsible for following up and administering vaccines to those residents who consented to receive the vaccination.Although requested, a facility policy for COVID-19 vaccinations was not provided.Per recommendations by the Centers for Disease Control and Prevention (CDC) all residents residing in a long term care facility over the age of 65 or who are immunocompromised are recommended to receive COVID-19 vaccination.

Based on observation, interviews, and review of the clinical record for 2 of 3 residents (Resident #5 and Resident #190) reviewed for dignity and for 12 of 15 residents (Resident #9, Resident #20, Resident #23, Resident #25, Resident #75, Resident #91, Resident #93, Resident #102, Resident #117, Resident #123, Resident #129, and Resident #168) reviewed for breakfast dining, the facility failed to provide a dignified dining experience. The findings include: 1a. Resident #5 was admitted to the facility in March 2023 with diagnoses that included dementia with agitation, dysphagia (difficulty swallowing), and Parkinson's disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 was severely cognitively impaired, required moderate assistance of 1 staff member for eating, and had a 10% weight loss in 6 months. Physician orders dated 6/4/26 directed a mechanical soft diet with thin liquids, Ensure plus (high calorie supplement drink) 240 milliliters (ml) 3 times a day, Magic Cup (high calorie ice cream) 2 times a day, Prostat (protein supplement) 30 ml 3 times a day and Mirtazapine (antidepressant used as an appetite stimulant) 15 milligrams (mg) at bedtime. The Resident Care Plan (RCP) dated 6/12/26 identified nutrition risk due to dementia/weight loss with poor appetite as an area of focus with interventions that included encouraging supplements if Resident #5 will not eat/attempt to feed/offer alternatives for meals/likes sweets, Ensure plus supplement 240 ml three times a day, monitor intake and weights, Magic Cup 2 times a day, Prostat 30 ml 3 times a day, mechanical soft diet with thin liquids, and provide set up and assistance with meals as needed. On 6/15/26 at 12:15 PM, Resident #5 was observed in the dining room, seated in a wheelchair at the dining room table with two other residents. One resident was sitting beside Resident #5 and one resident across the table. Resident #5 was provided a mechanical soft meal along with a cup of coffee. Resident #5 independently ate a spoonful of the meal and then placed the spoon on the table. At 12:23 PM Nurse Aide (NA) #2 was observed to stand behind Resident #5, picked up the spoon and placed a small amount of food from Resident #5's plate and then from behind Resident #5 placed the spoon in front of Resident #5's mouth and stated, come on eat something. Resident #5 became agitated and stated No in an angry tone. NA #2 proceeded to say, eat something (still standing behind Resident #5) and Resident #5 continued to refuse stating No. NA #2 left Resident #5 and proceeded to assist other residents. On 6/15/26 at 12:40 PM, NA #1 was noted to stand behind Resident #5, picked up the spoon with a small amount of food on the spoon and then from behind Resident #5 placed the spoon in front of Resident #5's mouth, stated Resident #5's name and said eat. Resident #5 stated No. NA #1 then left the spoon on Resident #5's plate and walked away. Resident #5 did not consume anymore of his/her meal except for the initial bite when the meal was delivered. Resident #5 was not offered any alternative meal from NA #1 or NA #2. NA #1 or NA #2 did not explain to the resident that they were attempting to assist Resident #5's with his/her meal when they approached Resident #5 from behind with the spoonful of food nor did they try to sit down next to Resident #5 to encourage him/her to eat. A review of Resident #5's meal intake flowsheet for 6/15/26 completed by NA #3 who was not in the dining room but was assigned to care for Resident #5 on 6/15/26 documented that Resident #5 consumed 50% of lunch meal (however Resident #5 was observed to only consume 3 bites of food (less than 5%). Interview with NA #2 on 6/17/26 at 2:30 PM indicated that she was attempting to encourage Resident #5 to eat his/her meal when she stood behind Resident #5. NA #2 indicated that Resident #5 recognized her voice, so she did not think it was necessary to identify herself or sit down next to Resident #5. In addition, NA #2 stated that Resident #5 liked to feed him/herself. NA #2 stated that an alternative meal should have been offered when it was noted that Resident #5 was not eating the main lunch meal. NA #2 stated it was the policy of the facility to sit down next to a resident when feeding and an alternative meal should be offered if a resident does not eat. Interview with NA #3 on 6/17/26 at 2:45 PM indicated that she had not obtained information from the NAs in the dining room regarding the amount of lunch Resident #5 had eaten and just documented Resident #5's normal intake for meals. NA #3 stated that she should have not just assumed that Resident #5 consumed 50% of his/her meal and she should have obtained the information regarding Resident #5's meal intake. NA # stated that it was not the policy to just document an amount without obtaining accurate information and stated, I will never do that again, I promise. Interview with NA #1 on 6/17/26 at 3:00 PM identified that it was the policy of the facility to sit down when attempting to feed a resident and that an alternative meal should be offered to a resident if he/she did not eat. NA #1 could not explain why she did not sit down next to Resident #5 or why she approached Resident #5 from behind when attempting to give Resident #5 a bite of food. Additionally, NA #1 stated that she should have offered Resident #5 an alternative meal, but she did not because Resident #5 was refusing to eat his/her meal. Interview with the DNS on 6/18/26 at 8:45 AM stated that NA #1 and NA #2 should not have stood behind Resident #5 and attempt to feed him/her from behind. The NAs should have sat down next to Resident #5 and when Resident #5 did not eat, an alternative meal should have been given to Resident #5. Furthermore, the DNS indicated that it was the policy for the NAs to document on the residents' meal tickets and provide the information to the primary aide for documentation. b. Resident #190 was admitted to the facility in June 2026 with diagnosis that included fracture right femur, dementia, Type 2 diabetes with retinopathy (damage to the retina of the eye causing difficulty with vision) and cerebral vascular accident (CVA) with visual deficit. The Nursing admission assessment dated [DATE] identified that Resident #190 was alert and oriented and was able to make needs known some of the time due to a language barrier (Spanish primary language). Resident #190 required assistance of 1 for activities of daily living (ADLs) and wheelchair (w/c) was the primary mode of transportation. Physician orders dated 6/15/26 directed a no added salt and no concentrated sweets with regular consistency diet and physical, occupational and speech therapy (PT/OT/ST) evaluation and treatment as indicated. The admission Resident Care Plan date 6/16/26 identified a self-care deficit/communication as an area of focus with inability to always think of words or understand due to cognitive loss. Interventions included assessing the ability to carry out ADLs, determining the aspects that are problematic and getting PT/OT evaluations, assessing the need for assistive devices, reinforce safety, and orient to surroundings. A Nutritional assessment dated [DATE] and completed by the Dietician identified Resident #190's weight on admission was 99 pounds and height was 59 inches (4 feet and 11 inches). The Dietitian identified that Resident #190 was underweight and meal intake was 25%-50% per Nurse Aide (NA) documentation. The Dietitian recommended 240 milliliters (ml) of Glucerna (diabetic supplement) 3 times a day and continue to monitor meal intake, fluids, weights and labs. Observation on 6/17/26 at 12:15 PM noted Resident #190 was transported by w/c into the dining room by the Rehabilitation Technician. Resident #190 was placed at small round table in his/her w/c the w/c was low in height and wide (larger than standard size w/c which measures 26 inches wide and 42 inches long). Resident #190 was provided with his/her meal by NA #1. Resident #190 had to lean forward in his/her w/c and extend his/her arms in an attempt to reach the plate on the table. Resident #190 was having difficulty reaching the lunch plate on the table due to the w/c being much lower than the table height. Observation and interview with OT #1 on 6/17/26 at 1:05 PM identified that Resident #190 was not at the proper height in the w/c to eat his/her meal. OT #1 stated that the positioning of Resident #190's arms was not ideal for him/her to reach the food on the table, and that Resident #190 needed a different w/c or needed to have an over the bed table for the meal for the proper height. Observation and interview with NA #1 on 6/17/26 at 1:15 PM identified that NA #1 stood on the side of Resident #190 and gave him/her a spoonful of food. NA #1 then provided Resident #190 with another beverage and continued to observe Resident #190 unsuccessfully attempting to eat. NA #1 stated that Resident #190 was not at the proper height at the table to easily eat by him/herself and that an over the bed table would be better. Observation on 6/17/26 at 1:25 PM noted Resident #190 had only eaten about 25% of his/her meal. There was no attempt by OT #1 or NA #1 to provide Resident #190 with an over the bed table, change w/c or relocate Resident #190 to a table that would be easier for Resident #190 to reach to eat his/her meal. Furthermore, no substitute meal was offered to Resident #190. Interview with the DNS on 6/18/26 at 8:45 AM stated that NA #1 or OT #1 should have provided Resident #190 with an over the bed table in order to easily eat his/her lunch. Furthermore, the DNS indicated that it was the policy for the NAs to document on the residents' meal tickets the amount consumed and provide the information to the primary aide. Interview with Director of Rehabilitation Services (DRS) on 6/22/26 at 10:00 AM identified that the w/c that was in place on 6/17/26 for Resident #190 was not provided by the therapy department and that nursing had provided Resident #190 the w/c when the resident was admitted on [DATE]. The DRS indicated that PT/OT was aware that the w/c was not appropriate and had been working on providing a different w/c. The DRS indicated that she was unsure why nursing had given Resident #190 that w/c as there were w/c's available that were more appropriate. Furthermore, the DRS stated that OT #1 or NA #1 should have provided Resident #190 an over the bed table to eat his/her lunch meal on 6/17/26. The DRS indicated that Resident #190 had received a new w/c from therapy on 6/18/26. Observation of Resident #190 on 6/22/26 at 10:15 AM in the therapy room, noted Resident #190 working with PT and was in a different w/c that was more suitable in size for Resident #190. The Activities of Daily Living (ADLs) Supporting policy dated 11/2025 directed, in part, appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including support and assistance with hygiene, mobility, elimination, dining and communication. If residents with cognitive impairment or dementia resist care, staff will attempt to identify underlying cause if problem and not just assume resident is declining or refusing care. Approaching the resident in a different way or have another staff member speak with the resident may be appropriate. The Promoting/Maintaining Dignity During Mealtime policy (not dated) directed, in part, treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances quality of life, recognizing each individuality and protecting the rights of each resident. Focus on the resident while talking to him/her and address individually, staff will be seated, if possible while facing the resident, and offer substitutes if applicable. 2a. Resident #9 had diagnoses that included stroke, dementia, and dysphagia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was severely cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, was dependent with eating, oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 6/11/26 identified Resident #9 had potential for inadequate nutrition related to dementia. Interventions included to provide Resident #9 with 1 to 1 feeding assistance (total feed) using a slow rate and small bites. The RCP further indicated Resident #9 had a self-care performance deficit related to a stroke with hemiparesis. Interventions included for feeding to assist with feeding, encourage Resident #9 to self-feed, consider the appropriate setting for feeding where Resident #9 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. b. Resident #20 had diagnoses that included vascular dementia, hemiplegia and hemiparesis (weakness) affecting the right side following a stroke, and dysphagia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired, was on a mechanically altered therapeutic diet, used a manual wheelchair, required supervision or touching assistance with eating, and substantial/maximal assistance with oral hygiene and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 4/27/26 identified Resident #20 was at risk for aspiration with dysphagia and difficulty chewing and swallowing. Interventions included observe Resident #20 during mealtimes for signs/symptoms of aspiration or difficulty swallowing and staff to provide distant supervision in hallway or dining room for meals. The RCP further indicated Resident #20 had a self-care performance deficit related to a stroke with hemiparesis. Interventions included for feeding to encourage Resident #20 to self-feed, consider the appropriate setting for feeding where Resident #20 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. Observation of Resident #20 on 6/17/26 at 8:55 AM identified he/she was sitting in the hallway directly behind Resident #9 at the end of the hallway. He/she was the last resident a line of residents eating in the hallway. Resident #20's wheelchair was facing the center of the hallway and the right wheel was approximately 12 inches from the back of Resident #9's wheelchair. Although Resident #20 faced the center of the hallway providing a more open view there were no residents positioned in the same way next to him/her so if he/she turned their head to the right they would be looking at the back of Resident #9's head. c. Resident #23 had diagnoses that included dementia, dysphagia, and hypothyroidism. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired, was on a mechanically altered therapeutic diet, used a manual wheelchair, required setup or clean-up assistance with eating, and was dependent with oral hygiene, and required substantial/maximal assistance with wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 6/12/26 identified Resident #23 was at risk for aspiration due to difficulty chewing and swallowing and the need for a mechanically altered diet. Interventions included observe Resident #23 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. The RCP further indicated Resident #23 had a self-care performance deficit related to history of transient ischemic attack (TIA). Interventions included for feeding to encourage Resident #23 to self-feed, consider the appropriate setting for feeding where Resident #23 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. d. Resident #25 had diagnoses that included dysphagia, stroke, and hypothyroidism. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 was severely cognitively impaired, was on a mechanically altered therapeutic diet, used a manual wheelchair, was dependent with eating, oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 5/26/26 identified Resident #25 was at risk for aspiration due to difficulty chewing and swallowing and the need for a mechanically altered diet. Interventions included observe Resident #25 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. The RCP further indicated Resident #25 had a self-care performance deficit related to history of stroke. Interventions included for feeding to encourage Resident #25 to self-feed, consider the appropriate setting for feeding where Resident #25 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. e. Resident #75 had diagnoses that included Lewy body dementia, diabetes, and adult failure to thrive. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #75 was severely cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, was dependent with eating, oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 4/27/26 identified Resident #75 was at risk for aspiration due to difficulty chewing and swallowing and the need for a mechanically altered diet. Interventions included observing Resident #75 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. The RCP further indicated Resident #75 had a self-care performance deficit. Interventions included for feeding to encourage Resident #75 to self-feed, consider the appropriate setting for feeding where Resident #75 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. f. Resident #91 had diagnoses that included Alzheimer's disease, diabetes and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 was severely cognitively impaired, was on a mechanically altered therapeutic diet, used a manual wheelchair, required substantial/maximal assistance with eating, and was dependent with oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 4/19/26 identified Resident #91 was at risk for aspiration due to dysphagia and difficulty chewing and swallowing. Interventions included observe Resident #75 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. The RCP further indicated Resident #75 had a self-care performance deficit. Interventions included for feeding to encourage Resident #75 to self-feed, consider the appropriate setting for feeding where Resident #75 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. g. Resident #93 had diagnoses that included stroke, Alzheimer's disease, and congestive heart failure (CHF). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 was severely cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, required supervision or touching assistance with eating, and was dependent with oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 4/19/26 identified Resident #93 had potential for inadequate nutrition related to Alzheimer's disease and CHF. Interventions included to set up and assist with meals as needed. The RCP further indicated Resident #93 had a self-care performance deficit. Interventions included for feeding to encourage Resident #93 to self-feed, consider the appropriate setting for feeding where Resident #93 has supportive assistance. h. Resident #102 had diagnoses that included Alzheimer's disease, dysphagia, and hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was severely cognitively impaired, was on a regular diet, used a manual wheelchair, required setup or clean-up assistance with eating, was dependent with oral hygiene, and required substantial/maximal assistance with wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 3/30/26 identified Resident #102 had a self-care performance deficit. Interventions included for feeding to encourage Resident #102 to self-feed, consider the appropriate setting for feeding where Resident #102 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. The RCP further indicated Resident #102 was at risk for aspiration due to dysphagia. Interventions included observe Resident #102 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. i. Resident #117 had diagnoses that included traumatic hemorrhage of the right cerebrum (section of brain), diabetes, and Alzheimer's disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #117 was severely cognitively impaired, was on a therapeutic diet, used a manual wheelchair, required supervision or touching assistance with eating, and substantial/maximal assistance with oral hygiene and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 6/18/26 identified Resident #117 had a risk for inadequate nutrition related to diabetes and dementia. Interventions included monitor oral intake and set up and assist with meals as needed. The RCP further indicated Resident #117 had a self-care performance deficit. Interventions included for feeding to encourage Resident #117 to self-feed, consider the appropriate setting for feeding where Resident #117 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. j. Resident #123 had diagnoses that included Alzheimer's disease, stroke, and diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 was severely cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, required setup or clean-up assistance with eating, and was dependent with oral hygiene, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 6/12/26 identified Resident #123 had a self-care performance deficit. Interventions included for feeding to encourage Resident #123 to self-feed, consider the appropriate setting for feeding where Resident #123 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. The RCP further indicated Resident #123 was at risk for aspiration due to due to difficulty chewing and swallowing and the need for a mechanically altered diet. Interventions included to encourage Resident #123 to chew thoroughly and eat slowly during meals. k. Resident #129 had diagnoses that included dysphagia, right eye blindness, and glaucoma. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #129 was moderately cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, was independent with eating, required substantial/maximal assistance with oral hygiene, and partial/moderate assistance with transfers, walking, and wheeling 50 feet with 2 turns. The Resident Care Plan (RCP) dated 6/18/26 identified Resident #129 had a self-care performance deficit. Interventions included for feeding to encourage Resident #129 to self-feed, consider the appropriate setting for feeding where Resident #129 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. The RCP further indicated Resident #129 was at risk for aspiration due to due to difficulty chewing and swallowing and the need for a mechanically altered diet. Interventions included observe Resident #129 during mealtimes for signs/symptoms of aspiration or difficulty swallowing. l. Resident #168 had diagnoses that included stroke, dysphagia, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #168 was severely cognitively impaired, was on a mechanically altered diet, used a manual wheelchair, required setup or clean-up assistance with eating, was dependent with oral hygiene and wheeling 50 feet with 2 turns, and required partial/moderate assistance with transfers. The Resident Care Plan (RCP) dated 6/5/26 identified Resident #168 had a self-care performance deficit. Interventions included for feeding to encourage Resident #168 to self-feed, consider the appropriate setting for feeding where Resident #168 has supportive assistance, and offer to eat lunch in the dining room versus meals in their own room or in the hallways to interact and socialize with others. Observation on 6/17/26 at 8:55 AM of the 4th floor [NAME] hallway identified 15 residents (Resident #9, Resident #20, Resident #23, Resident #25, Resident #53, Resident #75, Resident #91, Resident #93, Resident #102, Resident #107, Resident #117, Resident #123, Resident #129, Resident #145, and Resident #168) eating outside of their rooms in the hallway along the left side of the hallway. 11 out of 15 residents were observed to be eating with their wheelchairs facing forward in the direction of the nursing station and lined up one resident directly behind another with each resident sitting with their overbed table in front of them. 3 out of 15 residents (Resident #53, Resident #107, and Resident #145) were observed sitting along the left side of the hallway facing the center of the hallway side by side with their tray tables in front of them and they were observed talking and socializing with each other throughout the meal. Interview with Unit Secretary (US) #1 on 6/17/26 at 9:26 AM identified the residents ate in the hallway about 1 time a week. She indicated that the kitchen was finished with meal service and had brought all the meals up to the floor before the staff member arrived to open the dining room, and they had decided to serve the residents in the hallway so the food didn't get cold. Interview and observation with Licensed Practical Nurse (LPN) #1 and US #1 on 6/17/26 at 9:28 AM identified that several residents were sitting one directly behind the other, and very close together leaving minimal room between each resident. Specific observation of Resident #25, Resident #91, Resident #93, and Resident #102 identified they were sitting very close together such that Resident #102's feet were positioned underneath the back of Resident #93's wheelchair and a large handle on the back of Resident #93's wheelchair protruded halfway over the overbed table for Resident #102 and subsequently was positioned directly above the plate of Resident #102. Additionally, Resident #25 was positioned directedly behind Resident #102, and his/her feet were positioned under the back of Resident #102's wheelchair with the overbed table approximately 2 inches from the back of Resident #102's wheelchair. Further observed, Resident #91 was positioned directedly behind Resident #25 and his/her feet were positioned under the back of Resident #25's wheelchair with the overbed table approximately 2 inches from the back of Resident #25's wheelchair. The positioning of the residents was such that Resident #102 and Resident #25 could not be taken out of the hallway and brought to their room without first moving Resident #93 and Resident #91. Both LPN #1 and US #1 indicated that it was not dignified to be sitting that close to the back of another resident while eating and that Resident #102 should not be expected to eat with someone's handle for their wheelchair protruding into their personal space and over their plate of food. Additionally, LPN #1 and US #1 did not recall receiving education related to residents eating in the hallway following the previous re-certification survey findings of the same issue. Interview and observation with the 4th floor Unit Manager, Registered Nurse (RN) #1, on 6/17/26 at 9:30 AM identified the residents ate in the hallway almost every day. She indicated that sometimes they have a staff member come in to open the dining room so that the residents can have breakfast in the dining room but that most days they do not have the available staffing to permit opening of the dining room for the breakfast meal, and so the residents ate in the hallway. She indicated that she was not aware that eating back to back in a line down the hallway was undignified and after observation of the close proximity of the residents to the back of the person sitting in front of them, she indicated that it was not dignified and she would ensure the residents did not eat that way going forward. Additionally, she did not recall receiving education related to residents eating in the hallway following the previous survey. Interview with LPN #1 on 6/17/26 at 11:45 AM identified the residents observed eating in the hallway, while she was completing her morning medication administration, frequently ate in the hallway in the same manner (lined up on the left side of the hallway with their wheelchairs positioned one behind the other and facing the direction of the nursing station). She indicated that it wasn't a dignified way to eat and stated she hadn't thought about whether the morning breakfast routine of eating in the hallway was dignified until questioned by the surveyor. Additionally, she indicated that now that she was aware it wasn't dignified she (and RN #1) would make changes going forward. She further identified that having that many wheelchairs lined up along the hall along with the beverage cart, and cart with meal trays for those residents eating in their rooms caused the hallway to be congested and cramped as she navigated her medication cart down the hallway. Interview with the Director of Nursing Services (DNS) on 6/22/26 at 12:00 PM identified some residents were care planned to eat in the hallway. She was unable to identify if those specific residents were care planned to eat in the hallway and positioned so that they were seated directly behind another resident with only a couple inches of space between their table and the back of the other resident's wheelchair. Additionally, she was unable to identify if it was dignified to eat a meal in the hallway lined up wheelchair behind wheelchair against a wall with no interaction or socialization. Review of the Promoting/Maintaining Resident Dignity During Mealtimes policy directed, in part, it is the practice of the facility to treat each resident with dignity and respect. The policy directs staff involved in feeding assistance are to promote and maintain resident dignity at mealtimes. The policy directs if the resident is in the dining room, assist them back to their room as needed, and if the resident is in their room to position per orders or as resident desires. The policy failed to identify directives for residents eating in the hallway or maintaining dignity if a resident does not eat in their room or in the dining room.

Based on clinical record review, facility documentation, facility policies, and interviews for 1 of 7 residents (Resident #26) reviewed for nutrition, the facility notify the physician/APRN of intermittent refusals of nutritional supplements and medication for weight gain, which potentially resulted in additional weight loss and for 1 of 5 residents (Resident #78) reviewed for hospitalizations, the facility failed to notify the physician of a change in condition for a resident with symptoms of infection. The findings include: 1.Resident #26 had diagnoses that included dementia, dysphagia, and chronic obstructive pulmonary disease.A Dietician Nutrition assessment dated [DATE] at 3:52 PM identified Resident #26 current weight was 74 pounds (lbs.), he/she was on a regular, mechanical soft diet with thin liquids, and his/her average oral intake was 0-50 % of meals. The assessment indicated Resident #26 had a supplement of Hi-cal 240 milliliters (ml) ordered 3 times a day, and Remeron 15 milligrams (mg) (medication used for appetite stimulation) ordered. The assessment indicated Resident #26 had dysphagia and indicated Resident #26 had a nutritional risk due to dysphagia, poor oral intake and was underweight. The assessment further indicated there were no significant weight changes noted, indicated Resident #26 had dementia, further weight loss was anticipated and may be unavoidable.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, had no behaviors of rejection of care, required setup or clean-up assistance with eating, was dependent for personal hygiene, required supervision or touching assistance with bed mobility and substantial/maximal assistance with chair/bed transfers. The MDS assessment further indicated Resident #26 weighed 74 pounds (lbs.), was on a mechanically altered therapeutic diet, and had no weight loss.A physician progress note dated 4/2/26 at 7:47 AM identified Resident #26 was seen for a monthly evaluation. The note did not indicate Resident #26's current weight or speak to his/her nutritional status.Review of the clinical record identified Resident #26 weight on 4/3/26 at 2:38 PM was 63.2 lbs. (a 10.8 lbs./14.59% weight loss in 9 days). Review of the clinical record failed to identify a re-weight was obtained to verify the weight.Review of the clinical record failed to identify a nursing note stating the APRN/MD and/or Dietician were notified of Resident #26's significant weight loss noted on 4/3/26.Review of the clinical record identified Resident #26 weight on 4/8/26 at 3:54 PM, 4/15/26 at 3:54 PM was 63.2 lbs. (unchanged from 4/3/26) and on 4/22/26 at 3:08 PM was 64.0 lbs.A dietary note written by Dietician #1 on 4/23/26 at 7:59 AM identified Resident #26 had a significant weight loss and was underweight. The note indicated Resident #26's oral intake was 25-100% for meals and noted Resident #26 received oral nutritional supplements of 120 ml house milkshake 4 times a day, 240 ml of Hi-Cal 3 times a day, and received Remeron 15 mg daily for appetite stimulation. The note indicated she recommended addition of a Magic Cup (a fortified nutritional dessert) 2 times a day to provide additional calories.A physician order dated 4/23/26 directed to provide a Magic Cup 2 times a day for promoting weight gain and oral intake.The Resident Care Plan (RCP) dated 4/27/26 identified Resident #26 was at risk for inadequate nutrition related to dysphagia and poor oral intake. Interventions included to monitor oral intake, monitor weight and report significant weight changes to the Medical Doctor (MD) and the dietician, provide a regular, mechanical soft diet with thin liquids. Additionally, interventions included to provide 240 milliliters (ml) of Hi-Cal 3 times a day, 120 ml of house milkshake (oral nutritional supplement) 4 times a day, and a magic cup (frozen oral nutritional supplement) 2 times a day. The RCP failed to identify Resident #26 had a significant weight loss.a. Review of the Medication Administration Record (MAR) from 4/1/26-4/30/26 identified Resident #26 refused Remeron 15 19 out of 30 opportunities (63.3%), refused Hi-Cal 240 ml 21 out of 90 opportunities (23.3%), and refused House Milkshake 41 out of 120 opportunities (34.2%).Review of nursing notes in the clinical record from 4/1/26 to 4/30/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or Dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Review of the clinical record identified Resident #26 weight on 5/1/26 at 1:54 PM was 62.8 lbs.(a continued weight loss).A physician note dated 5/3/26 at 7:36 AM identified Resident #26 was seen for a monthly evaluation and that little had changed since the last visit (4/2/26). The note did not indicate Resident #26's current weight or identify his/her nutritional status/refusals of supplements.An APRN progress note written by APRN #1 and dated 5/4/26 identified Resident #26 was seen for status post leukocytosis. The note indicated that his/her weight was 62.8 lbs. and Resident #26 had dysphagia. The note failed to address Resident #26's weight loss, did not identify he/she was on any oral nutritional supplements or intermittent refusals of supplements.Review of the clinical record identified Resident #26 weight on 5/27/26 at 2:54 PM was 63.0 lbs.A dietary note written by Dietician #1 on 5/27/26 at 12:23 PM identified Resident #26 was seen for follow-up for a significant weight loss. The note indicated that his/her weight had remained stable for the past month. The note indicated his/her oral intake was 25-100% for meals and noted Resident #26 received oral nutritional supplements of 120 ml house milkshake 4 times a day, 240 ml of Hi-Cal 3 times a day, Magic Cup 2 times a day, and received Remeron 15 mg daily for appetite stimulation. The note indicated there were no new recommendations at this time but failed to identify Resident #26 was frequently refusing the Remeron 15 mg daily, was refusing the Hi-cal supplement at least once a day most days, refused the house milkshakes 2 times a day most days, and refused Magic Cups at least once a day most days.b.Review of the MAR from 5/1/26-5/31/26 identified Resident #26 refused Remeron 15 mg 19 out of 31 opportunities (61.3%). Additionally, the MAR indicated that LPN #5 documented the medication refusal 18 out of 19 refusals. Resident #26 consumed 0% or refused 9 out of 62 opportunities (14.5%) of Magic Cup, refused Hi-Cal 240 ml supplement 20 out of 93 opportunities (21.5%) and refused House Milkshake 41 out of 124 opportunities (33.0%).Review of nursing notes in the clinical record from 5/1/26 to 5/31/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Review of the clinical record identified Resident #26 weight on 6/10/26 at 2:58 PM was 63.0 lbs.Interview and observation of Resident #26 on 6/15/26 at 11:03 AM identified Resident #26 appeared thin with bones of the arms and face easily visible and prominent through the skin. Resident #26 indicated that the food in the facility was okay, but he/she didn't always get what he/she wanted to eat so he/she would have to ask the staff for something different.An APRN progress note written by APRN #2 and dated 6/15/26 identified Resident #26 was seen for evaluation of multiple bruises and discolorations noted on the resident with no recent fall and weighed 63.0 lbs. The note identified a diagnosis of poor appetite and indicated the plan was Remeron 15 mg daily and to continue the Hi-cal supplement. The note failed to identify Resident #26 was frequently refusing the Remeron 15 mg daily and also was refusing the Hi-cal supplement at least once a day most days. Additionally, the note failed to identify Resident #26 was also on house milkshakes and Magic Cups for oral nutritional supplements and that he/she frequently refused those supplements also.c. Review of the MAR from 6/1/26-6/22/26 identified Resident #26 refused Remeron 15 mg 11 out of 21 opportunities (52.3%), refused Majic Cup 24 out of 43 opportunities (55.8%), refused Hi-Cal 240 ml 10 out of 65 opportunities (15.3%), and refused House Milkshake 21 out of 86 opportunities (24.4%).Review of nursing notes in the clinical record from 6/1/26 to 6/22/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or Dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Interview with LPN #5 on 6/22/26 at 10:56 AM identified Resident #26 often refused medications and often drank only about 50% of the supplements. She indicated that Resident #26 often did not drink the Hi-Cal supplement and would leave it on overbed table without drinking any of it. She indicated that Resident #26 liked the house milkshakes and Magic Cups but did not take the ordered Remeron 15mg. LPN #5 further identified she put the refusals of medication in the APRN book to notify them but could not identify how often. She indicated that she had notified the nursing supervisor of Resident #26's refusals, and that she had written a note about the refusals 1 or 2 times but could not recall if she had ever told the family. She indicated it was the policy for refusals to write it in the APRN book to notify them. Additionally, she indicated that she reported Resident #26's refusals of supplements to RN #1, and that she had notified the Dietician by submitting a communication form to them in their mailbox.Interview with Dietician #1 on 6/22/26 at 11:30 AM identified she had not been notified by nursing of the weight loss for Resident #26 first documented in the electronic medical record on 4/3/26, and that she had identified the weight loss on her own when she was monitoring his/her nutritional status on 4/23/26. She indicated that the nursing staff were supposed to notify her when there were weight losses so she could complete an evaluation and that she usually completed them within a day or 2 when she was notified of a weight loss. She indicated that nursing could update her by phone, email, or in person. She indicated that for her follow-up on 5/27/26 she had asked the nursing staff how Resident #26 was doing with the oral nutritional supplements and Remeron and she had been told that Resident #26 was taking them all well (no refusals were reported). Additionally, she indicated that she had not recommended any changes but had wondered why Resident #26 wasn't gaining weight with all the supplements he/she had in place. She indicated that she did not look at the MAR to see Resident #26's acceptance of supplements and Remeron, and that now that she was aware of the frequent refusals she would make changes to the current supplements to try to increase Resident #26's acceptance of them. She further indicated that Resident #26's frequent refusals of the supplements and Remeron had contributed to his/her lack of weight gain.Interview with APRN #1 on 6/22/26 at 11:45 PM identified that she had likely been notified of Resident #26 refusing Remeron and/or oral nutritional supplements, but that she definitely was certain she had not been notified the refusals were as frequent as they were. Had she been aware of the frequency of the refusals she would have requested a dietary evaluation to see what adjustments could be made to the current regimen. She further indicated that she wouldn't discontinue the Remeron even with the frequent refusals but would ask nursing to evaluate what they could do differently to encourage him/her to take it more frequently.Interview with the Director of Nursing Services (DNS) on 6/22/26 at 12:00 PM identified medication refusals were to be documented and after a few days the APRN should be updated on the medication refusal. She indicated that supplement refusals should be reported to the dietician so that they can be evaluated and changed if needed. She indicated that weight loss should be verified and reported immediately. She further identified the means of notification for the APRN was by phone or email and that an APRN was available all hours by phone through the on-call service. She was unable to identify why the APRN and dietician were not notified of multiple refusals of medication or supplements for a resident with weight loss.Review of the Nutritional Management policy directed, in part, the facility provides services to ensure the resident maintains acceptable parameters of nutritional status. The policy directed systematic approaches to optimize nutritional status were assessments to determine risk factors, development and implementation of pertinent nutritional interventions, and monitoring of the effectiveness of interventions and revising as indicated. The policy directed ongoing monitoring will be done through direct observations, interviews with direct care staff, and review of the care plan to ensure interventions are implemented and effective. The policy directed the physician will be updated of significant changes in weight, intake, and nutritional status. The policy further indicated the care plan should describe any nutritional interventions offered, but declined by the resident.Review of the Weight Monitoring policy directed, in part, the facility will ensure all residents maintain acceptable parameters of nutritional status and their usual body weight. The policy directed weight was an indicator of nutritional status, and a weight monitoring schedule is developed for all residents on admission. The policy directed weights should be recorded at the time obtained. The policy directed residents with weight loss are monitored weekly, and all new weights should be compared with the previous weight. The policy directed a significant weight change is a 5% change in a month, 7.5% change in 3 months, and 10% change in 6 months. The policy directed the physician be updated of significant weight changes so nutritional interventions can be ordered if needed and the physician should document the diagnosis and clinical conditions contributing to the weight loss. The policy directed observations of the resident's weight status should be documented in the clinical record and the dietitian should be consulted to assist with interventions and actions documented in a progress note.2.Resident #78's diagnosis included acute respiratory failure, dependance on renal dialysis, and a history of venous thrombosis and embolism.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 had intact cognition and was dependent with putting on/taking off footwear, lower body dressing, showers and toileting. The MDS further indicated Resident #78 had no current shortness of breath, fever, or use of oxygen.The Resident Care Plan dated 4/8/26 identified Resident #78 required hemodialysis for Stage 4 kidney disease and Enhanced Barrier Precautions (an infection control intervention designed to reduce infection that requires gown and glove use for high contact resident care). Interventions included monitor/document/report to medical doctor (MD)/ Advanced Practice Registered Nurse (APRN) for signs and symptoms of the following: bleeding, hemorrhage, bacteremia (an infection with bacteria in the blood), and septic shock (a life-threatening infection). Additionally, the RCP interventions included monitor/document/report to MD/APRN the following symptoms: weight gain of 2 or more pounds in 1 day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, elevated skin temperature, change in level of consciousness, abnormal breath sounds. Monitor for signs and symptoms of infections, document, and properly report signs and symptoms of potential infections.A nursing note dated 4/19/26 at 10:50 PM and written by Licensed Practical Nurse (LPN) #8 on the 3:00 PM to 11:00 PM shift identified Resident #78 had a temperature of 103.4 degrees Fahrenheit (F), was coughing, sneezing, and screaming loudly. The nursing note further identified Resident #78's oxygen (O2) level went down to 89% requiring LPN #8 to place O2 on the resident to maintain his/her O2 level at a normal volume (greater than 90). Resident #78's oxygen level increased to 94% on 2 liters of O2 via nasal cannula (through his/her nose). LPN #8 administered the resident cough medicine at 6:00 PM, Tylenol (a pain reliever and fever reducing medication) at 7:00 PM, and documented it was effective. The clinical record failed to reflect the MD/APRN were notified regarding Resident #78's change in condition. A nursing assessment dated [DATE] at 9:42 AM from the Registered Nurse (RN) #5, the supervisor for the 11:00 PM to 7:00 AM shift, indicated on 4/20/26 at 5:35 AM the charge nurse for the 11:00 PM to 7:00 AM shift called her to evaluate Resident #78 (14 hours and 42 minutes after Resident #78 was administered cough medication by LPN #8 for low O2 saturation, cough, sneezing and screaming). The RN assessment identified blood pressure 167/100, pulse 100, respiration count 28, temperature 97.8 F, O2 level of 95% on 2 liters of O2. Resident #78 was noted to be shaking, feeling cold, and cyanotic (a blue or purplish color to the skin) to the bilateral upper extremities (both arms). RN #5 notified the primary care who directed resident to be sent to the emergency room for evaluation. A nursing note dated 5/12/26 indicated that Resident #78 returned from hospital stay with a new diagnosis of sepsis and Methicillin Resistant Staphylococcus Aureus (MRSA), and infection and inflammatory reaction due to cardiac and other vascular devices, implants, or grafts.Interview with the DNS on 6/22/26 at 2:00 PM indicated the MD/APRN should have been notified timely of a resident change in condition. Interview with APRN #2 on 6/22/26 at 1:00 PM indicated she had not been notified of Resident #78 change in condition on 4/19/2026. She indicated both the 103.4 F fever and the new need for O2 would be considered a change in condition and the APRN/MD and should have been notified of the change in condition. She indicated she would have ordered labs and a chest Xray for a resident who presented with these symptoms. She indicated the potential for pneumonia or another infectious process.Review of facility policy Notification Change in Condition, Change in Treatment/ Services undated, directed the facility to report to resident, physician, and resident family/legal representative when there is a change in condition. General Information: 1. Facility must immediately inform resident, consult with physician, and if known the residents' legal representative or an interested family member when there is a significant change in the residents physical, mental, or psychosocial status (that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). Procedure: 1. Changes in condition when identified by staff are brought to the charge nurse, or the charge nurse identifies a change of condition, and notifies RN Supervisor/Nurse Manager immediately and completes Situation Background Assessment Recommendation (SBAR) assessment in Point Click Care (PCC), (the facilities electronic medical record). 2. RN Supervisor/Nurse Manager conducts a complete physical/mental assessment and documents finding in PCC. The residents' reactions to symptoms, for example, pain, anxiety, or discomfort must be documented. 3. When assessment is completed, the Nurse Manager notifies the resident, attending physician, and residents' legal representative. The nurse will have completed the SBAR with all of the pertinent information when calling the physician (vital signs, current medications, presenting symptoms, pertinent lab work, etc), 9. Physician/Resident representative notification must be documented in PCC. If the nurse was unable to reach either the MD or the patient representative this must be documented in PCC. The following are examples of a change in condition but not limited to: 1. Temperature elevation of 101 degrees or above, 3. Respiratory, cardiac symptoms, chest pain, signs and symptoms of a heart attack or stroke, 8. Behavioral changes- agitation, confusion.

Based on interviews, review of the clinical record, facility documentation and facility policy for 1 of 4 residents (Resident #3) reviewed for mistreatment, the facility failed to follow the care plan for a resident who required 2 staff for care. The findings include: Resident #3's diagnoses included schizoaffective disorder, bipolar disorder, and major depressive disorder. A physician order dated 11/25/25 and currently in effect directed that Resident #3 was to have 2 Nurse Aides (NAs) with all care every shift due to accusatory behavior.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had serious mental illness and was cognitively intact. The MDS indicated Resident #3 was dependent with toileting and required substantial/maximal assistance with transfers and bed mobility.The Resident Care Plan (RCP) dated 4/16/26 identified Resident #3 had a mood problem with agitation manifested by direct conflict with staff and accusatory behavior with confabulation (an unconscious memory error resulting in fabricated, misinterpreted or distorted information). The RCP indicated on 5/13/26 Resident #3 had alleged staff was abusive with him/her. Interventions included to have 2 persons assist Resident #3 for all care. Additionally, on 5/13/26 the NA was removed from the schedule pending investigation, the NA was disciplined and educated to follow the care card when caring for the resident. The RCP further indicated social service would continue to meet with the resident for emotional support and to address any issues or concerns.Review of facility Reportable Event form dated 5/13/26 indicated Resident #3 alleged that during care NA #8 had forcibly removed the bed remote control from his/her hand and the resident later reported his/her hand hurt. The resident's family and the police were notified and an investigation was initiated.Review of NA #8's witness statement identified that she pulled the curtain for privacy and provided the resident with incontinent care. Before leaving the room she opened the resident's hand to get the remote control and adjusted the bed to prevent the resident from falling.Interview with the DNS on 6/23/26 at 11:00 AM identified on 5/13/26, NA #8 was providing care alone to Resident #3 and should not have been. The DNS indicated due to the residents accusatory behavior, NA #8 should have had another staff with her when providing care. The DNS stated NA #8 was aware that Resident #3 required 2 staff for all care and NA #8 would have been responsible to ensure another staff was with her. The DNS further indicated she provided verbal education to NA #8 after the incident on 5/13/26 and she was unsure why NA #8 did not follow Resident #3's care plan.Interview and review of a witness statement with Registered Nurse Supervisor (RN # 7) on 6/23/36 at 12:42 PM identified she was the supervisor working when the incident with Resident #3 occurred on 5/13/26. RN #7 indicated NA #8 was in the room by herself providing care to the resident and should not have been. RN #7 stated NA #8 was knowledgeable and would have been responsible to ensure she had provided care with another staff present and she was unsure why that was not done. RN #7 further indicated she provided verbal education to NA #8, removed her from the schedule and sent her home after the incident with Resident #3 on 5/13/26.Interview and review of a witness statement with Licensed Practical Nurse (LPN #6) on 6/23/26 at 12:52 PM identified she was the charge nurse working when the incident with Resident #3 occurred on 5/13/26. LPN #6 indicated NA #8 had provided care to Resident #3 by herself and should not have been. LPN #6 stated although she was administering medications at the time of the incident, NA #8 would have been responsible to ensure Resident #3 had 2 staff for all care and she was unsure why that was not done. Further, indicated NA #8 should have referenced the care/task section of the resident's electronic health record before providing care and there were additional staff on the floor at the time who would have helped NA #8 with Resident #3.Multiple attempts to contact NA #8 were unsuccessful.Review of facility policy, Care Planning, dated 11/25, directed the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Personnel included in the development of the resident's care plan include the attending physician, registered nurse, social services, director or nurses, charge nurse, nursing assistants and others as appropriate including the resident and residents family. Ongoing changes in the resident's status shall be updated in the care plan by nursing and or the interdisciplinary team as needed.

Based on interviews, review of clinical record and facility documentation for 1 of 6 sampled residents (Resident #7) reviewed for accidents, the facility failed to ensure the care plan was reviewed and revised after a fall with a major injury to attempt alternative and additional interventions to prevent a further fall. The findings include: Resident #7 was admitted to the facility in December 2022 with diagnoses that included dementia with agitation, Type 2 diabetes with neurological complications, spondylopathies, cervical region (degenerative and inflammatory disease affecting bones of the spine) and cerebral vascular accident (CVA).The Resident Care Plan (RCP) dated 5/15/25 identified falls as an area of focus with interventions that included toilet on first rounds, Physical therapy referral for sit cushion on wheelchair, keep lid on all drinks, neurological checks per protocol, check and toilet after breakfast, increase safety awareness, monitor frequently outside of rounds resident impulsive, offer toileting after meals, and place a table in front of resident while sitting in hallway/wheelchair with folding clothes to occupy resident. An Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #7 was severely cognitively impaired and was totally dependent on staff for activities of daily living (ADLs) except requiring maximum assist with eating and had one fall without injury. A Facility Reportable Event form dated 6/26/25 at 3:00 PM noted Resident #7 had an unwitnessed fall from the w/c by the nursing station which resulted in a laceration to Resident #7's left eyebrow area measuring 4.0 centimeters. Resident #7 was sent to ER for an evaluation of laceration. Nursing notes dated 6/26/25 at 3:30 PM identified that Resident #7 was seated in his/her wheelchair (w/c) by the nursing station and had an unwitnessed fall. Resident #7 was found on the floor beside his/her w/c with a laceration to the left side of his/her head by the eyebrow area. A physician order was obtained to send Resident #7 to the emergency room (ER) for evaluation, and the responsible party was notified.Physician orders dated 6/26/25 directed to provide assistance of 2 out of bed to wheelchair, send to emergency room for evaluation of laceration to forehead.The Resident Care Plan failed to reflect any new interventions were initiated for the fall on 6/26/25 requiring 6 sutures to Resident # 7's eyebrow. Subsequently, Resident #7 had a fall on 7/25/25 with no injuryInterview and review of the RCP with the MDS Coordinator, Registered Nurse (RN) #10 on 6/22/26 at 9:50 AM identified that Resident #7 did not have alternative fall interventions initiated after Resident #7 was sent to the hospital for his/her laceration on 6/26/25. RN #7 stated that the unit manager or the nursing supervisor usually updates the RCP. The fall incident report is brought to morning report and reviewed by the Assistant Director of Nursing (ADNS) and the interdisciplinary team (IDT). The intervention for the fall is reviewed for changes and to ensure an appropriate intervention was put in place. RN #10 could not explain why Resident #7 did not have an intervention after his/her fall requiring sutures to his/her forehead as it is the facility policy to update the RCP with a new intervention after a fall. RN #10 stated it is the responsibility of all licensed nursing staff that care for Resident #7 to ensure an intervention was put in place after a fall.Interview and review of the Accident Incident Report for Resident #7 with the ADNS on 6/23/26 at 11:40AM identified that a new intervention for the fall on 6/26/25 was not put in place. The fall and injury was reported to the Connecticut Department of Public Health on 6/27/25 per regulations. The ADNS stated she could not explain why the RCP was not updated with a new intervention as she was not working at the facility at that time. The ADNS indicated that it is the responsibility of the IDT to ensure an RCP is updated with a new intervention after a fall. The Fall Prevention Policy, not dated, directed, in part, after a fall the resident is assessed, a post-fall assessment and incident report is completed, the physician and family are notified, the RCP is reviewed and update as indicated, documented all assessments and actions and obtain statements on the case of injury.The Care Planning Policy dated 11/25 directed, in part, the facility's care plan/IDT responsible for the development of an individualized comprehensive care plan for each resident. Ongoing changes in residents' status shall be updated by nursing or IDT as needed.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #78) reviewed for hospitalization and for 1 of 3 residents (Resident #79) reviewed for a non-pressure skin condition, the facility failed to complete an assessment by a Registered Nurse (RN) upon Resident #78's developing a change/decline in respiratory status and upon Resident #79 sustaining an abrasion/laceration to the chin. The findings include: 1.Resident #78's diagnosis included acute respiratory failure, dependance on renal dialysis, and personal history of venous thrombosis and embolism. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 had intact cognition and was dependent with putting on/taking off footwear, lower body dressing, showers, and toileting. The MDS further indicated Resident #78 had no current shortness of breath, fever, or use of oxygen. The Resident Care Plan dated 4/8/26 identified Resident #78 as requiring hemodialysis for Stage 4 kidney disease and Enhanced Barrier Precautions (an infection control intervention designed to reduce infection that requires gown and glove use for high contact resident care). Interventions included to monitor/document/report to medical doctor (MD)/ Advanced Practice Registered Nurse (APRN) for signs and symptoms of the following: bleeding, hemorrhage, bacteremia (an infection with bacteria in the blood), and septic shock (a life-threatening infection). Monitor/document/report to MD/APRN the following symptoms, weight gain of 2 or more pounds in 1 day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, elevated skin temperature, change in level of consciousness, abnormal breath sounds, monitor for signs and symptoms of infections, document and properly report signs and symptoms of potential infections. A nursing note dated 4/19/26 at 10:50 PM written by Licensed Practical Nurse (LPN) #8 identified Resident #78 had a temperature of 103.4 degrees Fahrenheit (F), was coughing, sneezing, and screaming loudly. Noted oxygen (O2) level went down to 89% requiring her to place O2 on the resident to maintain his/her O2 level at a normal volume. Resident #78's oxygen level increased to 94% on 2 liters of O2 via nasal cannula (through the nose). LPN #8 gave the resident cough medicine at 6:00 PM and Tylenol (a pain reliever and fever reducing medication) at 7:00 PM, and documented it was effective. The clinical record failed to reflect the resident's temperature was retaken to verify effectiveness of the Tylenol administration and failed to reflect the Registered Nurse (RN) Supervisor/ Manager was notified in order to complete an RN assessment (including a full set of vital signs). A nursing assessment dated [DATE] at 9:42 AM from RN supervisor (14 hours and 42 minutes after LPN #8 administered cough medication to Resident #78 for a cough, low O2 saturation, sneezing and screaming) indicated on 4/20/26 at 5:35 AM the charge nurse notified her Resident #78 needed to be evaluated by an RN. The RN assessment identified a blood pressure of 167/100, pulse 100, respiration count 28, temperature 97.8 F, O2 level of 95% on 2 liters of O2. Resident #78 was noted to be shaking, feeling cold, and cyanosis (a blue or purplish color to the skin) to bilateral upper extremities (both arms). Nurse contacted primary care provider who ordered resident to be sent to the emergency room for evaluation. A nursing note dated 5/12/26 indicated that Resident #78 returned from hospital stay with a new diagnoses of sepsis and Methicillin Resistant Staphylococcus Aurous (MRSA). Interview with the DNS on 6/22/26 at 2:00 PM indicated the RN supervisor should have been notified of a resident change in condition and subsequently a MD/APRN. The nurse should have retaken the residents' temperature and document after administration of a fever reducing medication to verify effectiveness. The nurse should have obtained and recorded a full set of vital signs for a resident who had a fever of 103.4 F and a new need for O2. Interview with APRN #2 on 6/22/26 at 1:00 PM indicated both the 103.4 F fever and the new need for O2 would be considered changes in condition. She indicated an RN and APRN/MD should have been notified of the change in condition. The nurse should have retaken the residents' temperature and documented after the administration of a fever reducing medication. She indicated she would have ordered labs and a chest Xray for a resident who presented with these symptoms and the potential for pneumonia or another infectious process. Interview with LPN #8 on 6/23/26 at 12:05 PM indicated she had been the charge nurse for the 3:00 PM to 11:00 PM shift on 4/19/26 and failed to complete documentation (vital signs, RN notification and Resident #78's temperature post administration of Tylenol) in the resident chart. She stated she administered cough medicine, a breathing treatment, and Tylenol to the resident, took a full set of vital signs including blood pressure, pulse, and respirations. She stated she retook the resident's temperature to verify the Tylenol was effective. She stated she notified the Nursing Supervisor. She stated she would consider the residents presentation a change in condition and that she should take a full set of vital signs, notify the RN on duty, and document. The clinical chart failed to reflect a full set of vital signs, a follow up temperature to verify effectiveness of Tylenol, documentation of notification to RN Supervisor/Manager on duty or a MD/APRN, and RN assessment with documentation Interview with RN #8 on 6/23/26 at 1:29 PM indicated she was the RN supervisor for the 3:00 PM to 11:00 PM shift on 4/19/26. She indicated she was not notified of a change in condition for Resident #78. She indicated she should have been notified of a resident who had presented with a 103.4 F fever and a new need for O2 and that these symptoms would be a change in condition. The clinical chart failed to reflect RN notification in order to complete an assessment and documentation on 4/19/26 for a change in condition. Review of facility policy Notification Change in Condition, Change in Treatment/ Services undated, directed changes in condition when identified by staff are brought to the charge nurse, or the charge nurse identifies a change of condition, and notifies RN Supervisor/Nurse Manager immediately and completes Situation Background Assessment Recommendation (SBAR) assessment in Point Click Care (PCC), (the facilities electronic medical record). 2. RN Supervisor/Nurse Manager conducts a complete physical/mental assessment and documents finding in PCC. The residents' reactions to symptoms, for example, pain, anxiety, or discomfort must be documented. 3. When assessment is completed, the Nurse Manager notifies the resident, attending physician, and residents' legal representative. The nurse will have completed the SBAR with all of the pertinent information when calling the physician (vital signs, current medications, presenting symptoms, pertinent lab work, etc.). 2. Resident #79 had diagnoses that included aphasia, stroke, and diabetes. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #79 was severely cognitively impaired, used a wheelchair, and was dependent for eating, personal hygiene, bed mobility, and transfers. The Resident Care Plan (RCP) dated 1/20/26 identified Resident #79 was at risk for alteration in skin integrity related to decreased mobility and decreased sensation. Interventions included daily skin inspection during morning and evening care and report any skin integrity changes to the nurse. A physician order currently in effect directed to obtain a weekly skin check on bath day on the Tuesday 3:00 PM to 11:00 PM shift with directions for the nurse to assess the skin and document the skin condition in a weekly skin note and if there were new finding, notify the RN for assessment. Review of the Medication Administration Record (MAR) from 3/1/26 to 3/31/26 identified the weekly skin check order was only signed off by Licensed Practical Nurse (LPN) #5 on 3/10/26 and 3/17/26 as completed but failed to identify results of the skin check. Review of nursing progress notes for 3/10/26 failed to identify a nursing note written by LPN #5 with documentation of Resident #79's skin condition. A Skin Check evaluation dated 3/15/26 at 2:26 PM and completed by Licensed Practical Nurse (LPN) #16 identified Resident #79's skin was warm, dry, normal skin tone, with normal skin turgor (elasticity). The evaluation indicated that Resident #79 had a new facility acquired linear abrasion to the middle of the chin which measured 2.5 centimeters (cm). A nursing note dated 3/15/26 at 2:30 PM written by LPN #16 identified Resident #79 was noted to have a linear abrasion to the chin that measured 2.5 cm. The note indicated the Advanced Practice Registered Nurse (APRN) had been updated and a new order to cleanse the abrasion with normal saline followed by application of bacitracin daily and leave open to air for 3 days was ordered. Additionally, the note identified a message was left for the responsible party to update, and the nursing supervisor was notified. An APRN order dated 3/15/26 directed to cleanse the linear abrasion to the chin with normal saline then apply bacitracin and leave open to air daily for 3 days. A nursing note written by LPN #5 on 3/15/26 at 8:20 PM identified Resident #79 had a laceration to the chin with a treatment in place for 3 days. A nursing note written by LPN #5 on 3/17/26 at 8:35 PM identified Resident #79 was alert, non-verbal, and had an intact gastrostomy tube with an insertion site that had no signs/symptoms of infection. The note failed to identify the findings from the weekly skin check performed by LPN #5 including the current status of the linear chin abrasion first identified on 3/15/26. Review of the clinical record nursing notes failed to identify any further documentation of the linear chin abrasion after 3/15/26. Review of the Treatment Administration Record (TAR) for March 2026 for dates 3/1/26-3/31/26 identified the nurses signed off the treatment order for Bacitracin for Resident #79's chin on 3/16/26, 3/17/26, and 3/18/26. Review of the clinical record failed to identify an RN nursing note or RN assessment of the linear chin abrasion identified 3/15/26 for Resident #79. Interview with the Director of Nursing Services (DNS) on 6/22/26 at 2:10 PM identified any skin impairment documented in nursing notes or on a skin check should be identified in follow-up weekly skin checks. Interview with the Director of Nursing Services on 6/23/26 at 9:15 AM identified she did not have an A&I for Resident #79 for an abrasion on 3/15/26. Interview and clinical record review with RN #1 on 6/23/26 at 1:40 PM identified there should be an A&I for any newly identified skin impairment. Additionally, all newly identified skin impairments should have an RN assessment done and documented. She indicated the RN supervisor notified of the chin abrasion for Resident #79 on 3/15/26 should have done and assessment and filled out an A&I. She further indicated it was the responsibility of the Assistant Director of Nursing to follow-up on documentation for all newly identified skin impairments to ensure an RN assessment was done and an A&I was completed. She was unable to identify why the RN supervisor did not do an assessment and write a note, nor why there was not an A&I completed for Resident #79's linear chin abrasion on 3/15/26. Interview with the DNS on 6/23/26 at 2:00 PM identified an abrasion for a non-verbal resident documented in a progress note should have an A&I with an investigation completed to determine the cause of the skin impairment. She was unable to identify why an A&I wasn't done for Resident #79's linear chin abrasion on 3/15/26 and indicated that all progress notes are reviewed in morning report and this abrasion must have been missed in the review. Additionally, she indicated that all skin impairments should have an RN assessment. Review of the Incidents and Accidents policy directed, in part, staff are to report, investigate and review and accidents or incidents that may involve a resident. The policy directed an accident is any unexpected or unintentional incident which results in resident injury or illness. The policy directed the purpose of incident reporting was assuring implementation of appropriate interventions to prevent recurrence and improve care. The policy directed incident reporting is to be completed within 5 working days. The policy directed incidents which require an A&I report include observed accidents/incidents, resident injuries due to staff handling, self-inflicted injuries, and unobserved injuries. The policy directed any injuries are to be assessed by the licensed nurse or practitioner, reported to the supervisor, notification to the responsible party, and an A&I completed. The policy further directed documentation should include the incident date and time, location, nature of the incident and initial findings, immediate interventions and new orders, and notifications made. Review of the Weekly Skin Audits policy directed, in part, the purpose was to identify changes in skin integrity through weekly head to toe skin audits on all residents. The policy directed the licensed nurse completes a skin audit weekly on shower day and as needed, and initials the task on the administration record and in a skin evaluation under the assessments. The policy directed the RN supervisor will be notified of all new area of skin impairments and will assess. The policy further directed the APRN and responsible party are notified of new skin impairments and new orders obtained and put in the medical record.

Based on review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #26) reviewed for a decline in activities of daily living (ADLs), the facility failed to intervene when Resident #26 had a decline in functional ability. The findings include: Resident #26 had diagnoses that included dementia, dysphagia, and chronic obstructive pulmonary disease.A Therapy Referral Form dated 5/1/25 indicated a therapy screen was requested related to a recent fall. The form indicated a physical therapy evaluation was completed on 5/14/25 which demonstrated Resident #26 was at his/her baseline level of functioning and further physical therapy services were not indicated. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, required partial/moderate assistance with upper body dressing, putting on/taking off footwear, sit to lying on bed, lying to sitting on bed, and chair/bed transfers. The MDS assessment further indicated Resident #26 required substantial/maximal assistance with lower body dressing, sit to stand, and toilet transfers, weighed 75 lbs., had no weight loss, and had received no physical therapy or occupational therapy. This MDS assessment reflected a decrease in functional status in 3 areas of Section GG-functional abilities.The Quarterly MDS assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, required substantial/maximal assistance with upper/lower body dressing, putting on/taking off footwear, sit to lying on bed, lying to sitting on bed, sit to stand, chair/bed transfers, and toilet transfers. The MDS assessment further indicated Resident #26 weighed 74 lbs., had no weight loss, and had received no physical therapy or occupational therapy. This MDS assessment reflected a decline in functional status in 5 areas of Section GG-functional abilities with no change in functional status for the 3 areas of decline from the 1/7/26 MDS assessment.The Resident Care Plan (RCP) dated 4/27/26 identified Resident #26 had a self-care performance deficit related to dementia. Interventions included to encourage Resident #26 to self-feed and assist with set-up as needed, provide assistance of 1 staff member with activities of daily living (ADLs), and refer to rehabilitation therapy for changes in self-care abilities.Interview with the Director of Nursing Services (DNS) on 6/22/26 at 12:00 PM identified it was the responsibility of the unit managers to request resident screens for occupational or physical therapy with a decline in function. She indicated these would be requested for any change in mobility or for a post fall assessment. Interview with the Rehabilitation (Rehab) Director on 6/22/26 at 1:00 PM identified Resident #26 had not received rehabilitation services since May 2025. She indicated a Therapy Referral Form had been submitted in May 2025 following a fall and a physical therapy evaluation was completed which indicated Resident #26 was at his/her baseline level of functioning so did not require full physical therapy services. She indicated that the Rehab department only performed resident screening when a Therapy Referral Form was submitted, or when Rehab concerns were brought forward in morning report, risk meetings, or care plan meetings. She indicated that the Rehab department had not received any Therapy Referral Forms for Resident #26 since 5/1/25, and she was unaware of any concerns related to his/her mobility being discussed in any meetings. She was not aware of Resident #26 having a decline in multiple areas of functional ability of Section GG of the last 2 MDS assessments. She further identified the Rehab department should have been given a Therapy Referral Form to request a screen for Resident #26, and that she would initiate a screen now that she was aware there had been a decline in functional status.Review of the clinical record failed to identify Therapy Referral Forms dated after 5/1/25. Interview and clinical record review with the MDS Coordinator (RN #9) on 6/23/26 at 11:40 AM identified that Resident #26 had a significant weight loss in April 2026 and had more than 2 areas of functional decline on the last 2 MDS assessments. She indicated she was responsible for submitting Therapy Referral Forms when she identified a decline in functional ability, but that any staff member could submit a form if they identified a concern related to functional ability. She further indicated that she hadn't submitted any Therapy Referral Forms and was unable to identify why she had failed to do so.Review of the Activities of Daily Living (ADLs), Supporting policy directed, in part, residents will be provided care, treatment, and services to maintain their ability to carry out ADLs. The policy directed the existence of a clinical diagnosis does not justify the decline of a resident's ADL performance ability. The policy directed unavoidable decline may occur due to a debilitating disease, onset of an acute condition causing physical or mental decline in which care to restore or maintain services was received, and if the resident refuses care or treatment. The policy directed a resident's ability to perform ADLs will be measured using tools including the MDS The policy further directed interventions to improve a resident's functional abilities will be monitored and evaluated.

Based on observations, interviews, review of the clinical record and facility policy for 1 of 7 sampled residents (Resident #7) reviewed for activities of daily living (ADLs), the facility failed to ensure Resident #7's hair was clean and nails were clean and trimmed. The findings include: Resident #7 was admitted to the facility in December 2022 with diagnoses that included dementia with agitation, Type 2 diabetes with neurological complications, spondylopathies, cervical region (degenerative and inflammatory disease affecting bones of the spine) and cerebral vascular accident (CVA)The Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #7 was severely cognitively impaired and was totally dependent on staff for ADLS except requiring maximum assist with eating.The Resident Care Plan (RCP) dated 5/15/26 identified ADL Self Care Performance Deficit related to CVA as an area of focus with interventions that included side rails up at the top portion of bed, provide privacy while resident is toileting, keep light within reach and instruct resident to call as early as possible , assist resident to remove or replace clothing, use consistent routines and allow time to complete tasks, offer special shampoo, and offer to eat lunch in dining room vs. meals in their own room or in hallways. Also, behaviors as an area of focus with interventions that included resistance to care at times, throwing coffee/liquids at staff and other residents. Interventions included accept right to refuse and show respect taking into consideration safety and risk for self-harm, administer medications as ordered, and attempting to identify sources of anxiety and assist to resolve as appropriate. The care plan failed to reflect Resident #7 eats with hand at times. Physician orders dated 6/2/26 directed to administer Morphine Sulfate 20 milligrams (mg)/1 milliliter (ml) give 5 mg every 4 hours as needed for pain and shortness of breath, Tylenol 650 mg every 6 hours as needed, Hyoscyamine Sulfate 0.125 mg sublingually (under the tongue) every 4 hours as needed for excessive secretions, Humalog insulin 7 units subcutaneous (under the skin) 3 times a day with meals and Lantus insulin 15 units subcutaneously at bedtime.Observations on 6/16/26 at 1:14 PM, 6/18/26 at 2:20 PM and 6/23/26 at 10:00 AM noted Resident #7's hair was uncombed and greasy, and his/her fingernails had a yellow/brown substance under right 3rd and 4th finger and left 2nd finger. In addition, Resident #7's nails were chipped and uneven.Review of nursing notes from 6/1/26 through 6/22/26 identified that Resident #7 was compliant with care and taking medications and had no refusals of care. Interview and observation on 6/23/26 at 10:00 AM with Nurse Aide (NA) #9 indicated that Resident #7's nails were dirty and that the resident eats with his/her hands at times. In addition, NA #9 indicated that Resident #7 hair was oily and he/she was not sure last time Resident #7's hair was washed. NA #9 stated that Resident #7 goes to the hairdresser but not every week. NA #9 indicated that Resident #7's nails needed to be filed and cleaned and hair needed to be washed if Resident #7 would allow care as sometimes Resident #7 refused. NA #9 was unsure if Resident #7 had refused nail and hair care. Interview with the Infection Control Nurse (IC) on 6/23/26 at 11:30 AM indicated that the NAs were responsible for washing residents' hair and cleaning and trimming fingernails. This was usually done on a resident's shower day or when needed. The Activities of Daily Living (ADLs) Supporting policy dated 11/2025 directed, in part, appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including support and assistance with hygiene, mobility, elimination, dining and communication. If residents with cognitive impairment or dementia resist care, staff will attempt to identify underlying cause if problem and not just assume resident is declining or refusing care. Approaching the resident in a different way or have another staff member speak with the resident may be appropriate.The Nail Care Policy dated 11/2025 directed, in part, routine inspection and cleaning of nails will be provided during ADL care on an ongoing basis.Routine nail care to include trimming and filing will be provided on a regular schedule if needed for resident. Nails should be kept smooth to avoid skin injury.

Based on interviews, review of the clinical record, review of facility documentation and facility policy for 3 of 5 sampled residents (Resident #18, Resident #102 and Resident #169) reviewed for pressure ulcers, the facility failed to ensure wound measurements were obtained and an order for a treatment was obtained when the pressure ulcer was identified (Resident #18 and Resident #169), the dietitian was notified timely of the pressure ulcer and recommendations were implemented, and skin assessments and Braden Scales were completed (Resident #169). Additionally, the facility failed to ensure the correct treatment was completed per physician orders for Resident #102. The findings include: 1. Resident #18's diagnoses included peripheral vascular disease, abnormal posture, other atrophic disorders of skin, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 had moderately impaired cognition and was dependent on assistance with putting on/taking off footwear, lower body dressing, upper body dressing, and bathing. The MDS also indicated Resident #18 did not have a pressure ulcer but was at risk for developing pressure ulcers. The Resident Care Plan dated February 2026 identified Resident #18 had a risk of alteration to skin integrity with interventions that included to float heels off bed surface if indicated, pressure reducing cushion to chair/wheelchair, turning and positioning on rounds and as needed (PRN) if indicated. A nursing note dated 3/6/26 at 11:46 AM and written by Registered Nurse (RN) #6 indicated Resident #18 had a pressure ulcer to the left heel that measured 0.6 centimeters (cm) by (x) 0.8 cm x 0.2 cm. RN #6 documented he cleansed the pressure ulcer and applied Calcium Alginate with Silver to the wound bed followed by a dry clean dressing (DCD) (although no physician order was obtained for a treatment to the left heel). A wound assessment completed by the wound care specialist (APRN #3) on 3/12/26 indicated the left heel wound measured 0.7 cm x 0.7 cm x 0.3 cm with a wound base of 100% granulation tissue (the clinical record failed to identify the left heel wound was treated and monitored from 3/6/26). A physician's order dated 3/12/26 (obtained 6 days after the left heel pressure ulcer was identified) directed to cleanse the left heel pressure ulcer followed by Calcium Alginate to the wound bed followed by a DCD daily and PRN. A physician's order dated 5/5/26 directed to cleanse the wound with Normal Saline and apply Calcium Alginate with Silver to the wound bed followed by DCD daily and PRN. A wound assessment dated [DATE] completed by the wound care specialist (MD #1) indicated the left heel wound measured 1.9 (cm) x 1.5 cm x 0.1 cm with a wound base of 25% fibrin (tissue that helps wound heal) and 75% granulation tissue (healthy, healing tissue). No change in wound treatment was recommended. A nursing note dated 5/15/26 at 1:26 PM and written by RN #12 identified Resident #18 was complaining of abdominal pain, altered level of consciousness and a distended abdomen. Resident #18 was lethargic, non-verbal and not eating. Additionally, the nursing note identified the MD/APRN was notified and directed to send Resident #18 to the Emergency Department. A nursing note dated 5/20/26 and written by Licensed Practical Nurse (LPN) #9 identified Resident #18 returned from a hospital stay with no new skin issues and treatment continued to the right heel (a discrepancy with Resident #18's wound to the left heel). The clinical record failed to reflect an assessment was completed by a Registered Nurse regarding a pressure ulcer to left heel upon return from hospital. A physician order dated 5/20/26 directed to cleanse the left heel wound with Normal Saline and apply Calcium Alginate with Silver to the wound bed followed by a DCD daily and PRN. A nursing note dated 5/21/26 and written by wound nurse (LPN #10) indicated Resident #18 had returned to the facility from a hospital stay from 5/15/26 through 5/20/26 and the dressing on the left heel was dated 5/14/26. The clinical record failed to reflect any wound assessment had been completed (measurements and descriptions). A wound assessment dated [DATE] (6 days after Resident #18 was re-admitted to the facility) and written by the wound doctor (MD #1) identified the left heel wound had deteriorated and measured 2.4 cm x 1.6 cm x 0.1 cm with a wound base of 75% granulation tissue (healthy, healing tissue) and 25% slough (dead tissue that accumulates on the surface of a wound). No change to wound treatment was recommended. Interview and clinical record review with LPN #9 on 6/17/26 at 11:15 AM identified Resident #18 went to the hospital on 5/15/26 and upon return on 5/20/26 the wound nurse or admission nurse was responsible for assessing and documenting the wound. LPN #9 was the admission nurse on 5/20/26 but was unable to identify an assessment to Resident #18's left heel wound was completed by a Registered Nurse when the resident was re-admitted from the hospital on 5/20/26 (although an assessment was completed on 5/26/26 which was 6 days post re-admission). Interview with wound doctor (MD #1) on 6/17/26 at 2:11 PM indicated a wound assessment should have been completed and documented by the facility after hospitalization. He did not indicate any negative outcomes for the wound not being documented as long as a treatment was in place. Interview with the DNS on 6/22/26 at 10:00 AM indicated the admitting nurse or RN on duty should have assessed and documented a pressure ulcer, with measurements, when a resident returns from a hospital leave. Although requested, she was unable to identify and provide clinical documentation within the record to support a wound assessment when the resident returned from his/her hospital stay. 2. Resident #102 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, spinal stenosis, and osteoarthritis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was severely cognitively impaired, utilized a wheelchair or walker and needed assistance for toileting and personal hygiene. Additionally, the MDS identified Resident #102 remained at risk for pressure ulcer/injury and had a Stage 3 pressure ulcer requiring the use of pressure reducing device for bed, applications of ointments/medications, and pressure ulcer/injury care. The Resident Care Plan dated 3/30/26 identified Resident #102 was at risk for impaired skin integrity with interventions that included the need for daily skin inspections during am and pm care, repositioning and offloading pressure, moisture barrier per protocol, and the need to report any skin breakdown to the nurse. A physician progress note written by the Wound Care Specialist and dated 6/16/26 noted a right sacrum Stage 3 pressure ulcer measuring 0.6 centimeters (cm) by (x) 0.6 cm x 0.5 cm, 100% granulation, with moderate amount of serous exudate. Recommendations included: rinse with Normal Saline, apply Calcium Alginate with Silver (a highly absorbent, antimicrobial wound dressing) to the base of the wound, secure with dry clean dressing and change as needed. A physician order dated 6/2/26 directed a right sacral Normal Saline cleanse followed by Calcium Alginate rope and dry clean dressing everyday shift for wound. Observation of the dressing change to Resident #102's coccyx on 6/18/26 at 9:21 AM by Licensed Practical Nurse (LPN) #11 noted LPN #11 brought the treatment cart to the door of Resident #102's room with the supplies for the dressing change located on top of the treatment cart. LPN #11 donned a gown, sanitized her hands and applied gloves. LPN #11 noted that Resident #102 was incontinent of urine, then raised the bed and turned Resident #102 onto his/her left side and proceeded to remove the dressing from Resident #102's sacral area. LPN #11 removed her gloves, put on a new set of gloves but did not perform hand hygiene in between glove changes. LPN #11 began cleaning the open area to the sacral area by spraying Normal Saline onto Resident #102's sacral area with a spray bottle in her right hand. While using her right hand to reposition Resident #102 slightly more on the left side, LPN #11 laid the bottle directly onto the skin of Residents #102's right buttock. LPN #11 finished cleaning the wound and then packed the wound with Calcium Alginate (and not Calcium Alginate rope as the physician orders directed) and covered the wound with a clean dressing without the benefit of a glove change or hand hygiene. Interview with MD #1 on 6/22/26 at 12:09 PM indicated that he would expect the nurses to follow his orders for the residents and that he ordered the Calcium Alginate rope rather than the pack because it was generally easier for the nurses and less likely to cause minor peri-wound trauma or deterioration. Review of Wound Treatment Management Policy dated 10/16/2025 stated in #1, that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 3. Resident #169 was admitted to the facility in July 2025 with diagnoses that included dementia with mood disorder, chronic pulmonary disease (COPD), and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #169 was moderately cognitively impaired and required maximum assistance with activities of daily living (ADLs). Additionally, the MDS noted Resident #169 was at high risk for developing a pressure ulcer and did not have a pressure ulcer at the time of the MDS assessment. Nursing notes dated 2/16/26 at 4:13 PM and written by Licensed Practical Nurse (LPN) #7 noted that during AM care the Nurse Aide (NA) noted Resident #169 had an open area to the coccyx area, the head nurse and Infection Control nurse aware and assessed, treatment in progress, the wound MD to look at it tomorrow and the responsible party was made aware. The clinical record failed to reflect that a physician's order was obtained, the wound was measured or a Registered Nurse (RN) documented on the coccyx wound on 2/16/26. a. Physician orders dated 2/17/26 (the day after the open area was identified) directed to cleanse blister area to the sacrum with wound cleaner or Normal Saline followed by a dry, clean dressing daily (DCD) and as needed (1 day after wound was identified), provide a mechanical soft diet, house milk shake 240 milliliters (ml) 3 times a day. The Resident Care Plan (RCP) dated 2/25/26 identified a blister to the sacrum as an area of concern with interventions that included, treatment as ordered, followed by the wound MD, alternating pressure mattress, avoid uninterrupted sitting in chair, and daily skin inspections during care in am and pm and report any changes. The pressure ulcer was assessed by MD #1 (wound physician) on 2/17/26 and was identified as a blister to the sacrum measuring 1.1 centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth. MD #1 recommended a DCD daily and as needed. MD #1 assessed the sacrum wound on 2/24/26 and documented that the sacral wound had deteriorated and presented as 100% slough (dead tissue). The wound measurements were 2.5 cm in length by 4.0 cm in width (wound more than doubled in size in one week) MD #1 recommended to irrigate the sacral wound with Dakins solution (antiseptic wound cleaner used for infected/foul smelling wounds), apply crushed Flagyl (antibiotic) to the wound followed by Calcium Alginate (highly absorbent seaweed dressing) to wound bed. Interview with RN #6 (Infection Preventionist) IP on 6/18/26 at 9:50AM identified that he could not find any measurements or a treatment order for Resident #169 when the pressure ulcer was identified on 2/16/26. RN #6 stated that the wound should have been measured and a treatment order obtained when Resident #169 pressure ulcer was identified on 2/16/26. b. A review of Dietitian notes dated 2/26/26 noted she recommended adding Ensure Plus (high calorie/protein supplement drink) 240 milliliters (ml) 3 times a day in addition to the already prescribed supplements Resident #169 was receiving. Resident #169's weight was 105 pounds. Interview and review of the clinical record with the Dietitian on 6/17/26 at 11:30 AM noted that she was notified of the sacral wound on 2/26/26 (10 days after the wound developed). The Dietitian indicated that she was normally made aware the same day or the next when a new wound develops. She recommended Ensure plus as it would increase Resident #169's caloric and protein intake as Resident #169 had previously triggered for a significant weight loss and was at high risk for further weight loss. The clinical record failed to identify that Ensure Plus was ordered for Resident #169. The Dietitian stated she was unaware that Ensure Plus was not ordered and that the charge nurse or supervisor was responsible for following up on her recommendations with the practitioner. Interview with RN #6 (Infection Preventionist) IP on 6/18/26 at 9:50 AM identified that he could not locate a physician order for Ensure Plus and the charge nurse or supervisor should have followed up in obtaining an order for Ensure Plus after the Dietitian made the recommendation on 2/26/26. Interview and review of nursing notes with RN #1 on 6/18/26 at 12:15 PM identified she was aware of Resident #169's pressure ulcer but could not recall if the charge nurse made her aware on 2/16/26. She recalled assessing the pressure ulcer with RN #6 but was unsure if it was on 2/16/26 or at a later date. She indicated that if she had assessed the pressure ulcer, she would have written a nursing note at that time. RN #1 could not locate a nursing note written by her on 2/16/26. c. Physician orders dated 2/25/26 directed weekly skin evaluations on shower day, document in Point Click Care (electronic medical record) on the skin evaluation form. A review of Resident #169's weekly skin assessments and Braden scales revealed that skin assessments were not completed per physician's orders, and Braden scales were not completed quarterly. The last Braden Scale was completed 11/7/25 and weekly skin assessment sheet was completed on 3/24/26 and 3/25/26. Interview with the Assistant Director of Nursing (ADN) on 6/22/26 at 2:05 PM identified that she was not sure how it was handled but Braden Scales were usually done quarterly unless the resident was in the hospital. Further, the skin evaluations should be completed on the skin evaluation form. The ADN indicated that the unit manager and/or Infection Preventionist was responsible to oversee that the Braden Scales and weekly skin evaluations are completed. Review of the Prevention of Pressure Ulcers/Injuries/Skin Assessment policy directed: Risk Assessment 2. Conduct a comprehensive skin assessment upon admission including, a. any evidence of existing or developing pressure ulcers or injuries b. the ability of the skin to endure effects of pressure and c. areas of impaired circulation due to pressure from positioning or medical devices. Review of the facility policy Documentation of Wound Treatments directed 1.wound assessments are documented upon admission, weekly , and as needed if the resident or wound deteriorates, 2. the following elements are documented as a complete wound assessment: a. type of wound (pressure, injury, surgical), b. stage of the wound if pressure injury, c. measurements height, width, depth, undermining, tunneling, d. description of wound characteristics including color of the wound bed, type of tissue in the wound bed. The Weekly Skin Checks Policy, not dated, directed, in part, the facility will identify changes in skin integrity through weekly skin audits. The nurse will initiate on the Treatment admission Record as task completion and initiate skin evaluation under assessments in PCC. The Braden Scale Policy, not dated, directed, in part, the Braden Scale will be the standard method of classifying resident's risk factors for the development of pressure ulcers and/or skin integrity. The Braden Scale will be done by the Licensed Nurse for all admissions and readmissions on the day admitted and for all residents on a regular basis in conjunction with their MDS (quarterly and annually).

Based on observations, review of the clinical record, and interviews for 1 of 8 residents sampled residents (Resident #9) reviewed for dining, the facility failed to follow physician orders for providing 1 to 1 (1:1) supervision at mealtimes. The findings include: Resident #9's diagnoses included cerebral infarction, dysphagia, and unspecified dementia. A physician order dated 2/10/26 and currently in effect directed aspiration precautions and directed staff to provide 1:1 feeding assistance with use of slow rate, small bites/sips and alternation of solids/liquids and check for pocketing at end of meals and medication pass. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 was dependent for eating and hygiene, required completed assistance and was on a mechanically altered diet. The Resident Care Plan dated 6/11/26 identified a nutrition risk related to dementia with interventions that included providing a regular puree and honey thick liquid diet, monitor by mouth (PO) intake, aspiration precautions, 1:1 feeding assistance with use of slow rate, small bites/sips and alternation of solids and liquids and to check for pocketing at end of meals and medication pass. Observation of lunch served on 6/15/26 at 12:34 PM noted Resident #9 sitting in a wheelchair, alone at a table in the dining room self-feeding a meal of puree food (mashed potatoes, fish, vegetables, applesauce). Although staff were present in the dining room, they were passing trays and feeding other residents and not providing 1:1 supervision per physician orders. There were no staff present at Resident #9's table while he/she was self-feeding. Resident #9 had consumed about 50% of his/her meal. At 1:04 PM, a Nurse Aide (NA) was observed to begin to assist Resident #9 with eating (30 minutes after the meal tray was placed in front of Resident #9). Observation during lunch on 6/16/26 at 12:33 PM noted Resident #9 sitting in a wheelchair, alone at a table in the dining room self-feeding a puree meal, unassisted by staff (no staff were providing 1:1 supervision). At 12:48 Registered Nurse (RN) #1 was observed bringing Resident #9 a cup of coffee and prompted him/her to feed him/herself and then left Resident #9 unattended. Interview with RN #1 on 6/16/26 at 12:50 PM indicated that a resident on aspiration precautions requiring 1:1 feeding assistance should be observed at all times during meals. RN #1 identified Resident #9 was no longer a 1:1 supervision with feeding, however upon review of the clinic record with RN #1, an active current physician order was still in place for aspiration precautions and 1:1 supervision. RN #1 stated she should not have left the resident alone. Observation of breakfast on 6/17/26 at 9:20 AM noted Resident #9 sitting in a wheelchair in the hallway outside of his/her room with a tray table and breakfast tray in front of him/her eating independently without being provided 1:1 supervision. Resident #9 continued to eat independently until 9:25 AM when a nurse aide sat in a chair across the hallway to observe Resident #9. Interview with Speech Therapist #1 on 6/22/26 at 8:55 AM indicated that a resident with an order for aspiration precautions and 1:1 feeding assistance should be observed during the entire meal and risks include airway obstruction, aspiration, and weight loss. She also stated that Resident #9 was on her current case load, completed a fiberoptic endoscopic evaluation of swallowing (FEES) test on 6/18/26 and was upgraded to mechanical soft solids and thin liquids.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 7 residents (Resident #26) reviewed for nutrition, the facility failed to address/notify the Dietician of inconsistent administration of oral nutritional supplements for a resident with significant weight loss and failed to identify a weight loss timely. The findings include: Resident #26 had diagnoses that included dementia, dysphagia, and chronic obstructive pulmonary disease.A Dietician Nutrition assessment dated [DATE] at 3:52 PM identified Resident #26 current weight was 74 pounds (lbs.), he/she was on a regular, mechanical soft diet with thin liquids, and his/her average oral intake was 0-50 % of meals. The assessment indicated Resident #26 had a supplement of Hi-cal 240 milliliters (ml) ordered 3 times a day, and Remeron 15 milligrams (mg) (medication used for appetite stimulation) ordered. The assessment indicated Resident #26 had dysphagia and indicated Resident #26 had a nutritional risk due to dysphagia, poor oral intake and was underweight. The assessment further indicated there were no significant weight changes noted, indicated Resident #26 had dementia, further weight loss was anticipated and may be unavoidable.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, had no behaviors of rejection of care, required setup or clean-up assistance with eating, was dependent for personal hygiene, required supervision or touching assistance with bed mobility and substantial/maximal assistance with chair/bed transfers. The MDS assessment further indicated Resident #26 weighed 74 pounds (lbs.), was on a mechanically altered therapeutic diet, and had no weight loss.A physician progress note dated 4/2/26 at 7:47 AM identified Resident #26 was seen for a monthly evaluation. The note did not indicate Resident #26's current weight or speak to his/her nutritional status.Review of the clinical record identified Resident #26 weight on 4/3/26 at 2:38 PM was 63.2 lbs. (a 10.8 lbs./14.59% weight loss in 9 days). Review of the clinical record failed to identify a re-weight was obtained to verify the weight.Review of the clinical record failed to identify a nursing note stating the APRN/MD and/or Dietician were notified of Resident #26's significant weight loss noted on 4/3/26.Review of the clinical record identified Resident #26 weight on 4/8/26 at 3:54 PM, 4/15/26 at 3:54 PM was 63.2 lbs. (unchanged from 4/3/26) and on 4/22/26 at 3:08 PM was 64.0 lbs.A dietary note written by Dietician #1 on 4/23/26 at 7:59 AM identified Resident #26 had a significant weight loss and was underweight. The note indicated Resident #26's oral intake was 25-100% for meals and noted Resident #26 received oral nutritional supplements of 120 ml house milkshake 4 times a day, 240 ml of Hi-Cal 3 times a day, and received Remeron 15 mg daily for appetite stimulation. The note indicated she recommended addition of a Magic Cup (a fortified nutritional dessert) 2 times a day to provide additional calories.A physician order dated 4/23/26 directed to provide a Magic Cup 2 times a day for promoting weight gain and oral intake.The Resident Care Plan (RCP) dated 4/27/26 identified Resident #26 was at risk for inadequate nutrition related to dysphagia and poor oral intake. Interventions included to monitor oral intake, monitor weight and report significant weight changes to the Medical Doctor (MD) and the dietician, provide a regular, mechanical soft diet with thin liquids. Additionally, interventions included to provide 240 milliliters (ml) of Hi-Cal 3 times a day, 120 ml of house milkshake (oral nutritional supplement) 4 times a day, and a magic cup (frozen oral nutritional supplement) 2 times a day. The RCP failed to identify Resident #26 had a significant weight loss.a. Review of the Medication Administration Record (MAR) from 4/1/26-4/30/26 identified Resident #26 refused Remeron 15 19 out of 30 opportunities (63.3%), refused Hi-Cal 240 ml 21 out of 90 opportunities (23.3%), and refused House Milkshake 41 out of 120 opportunities (34.2%).Review of nursing notes in the clinical record from 4/1/26 to 4/30/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or Dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Review of the clinical record identified Resident #26 weight on 5/1/26 at 1:54 PM was 62.8 lbs.(a continued weight loss).A physician note dated 5/3/26 at 7:36 AM identified Resident #26 was seen for a monthly evaluation and that little had changed since the last visit (4/2/26). The note did not indicate Resident #26's current weight or identify his/her nutritional status/refusals of supplements.An APRN progress note written by APRN #1 and dated 5/4/26 identified Resident #26 was seen for status post leukocytosis. The note indicated that his/her weight was 62.8 lbs. and Resident #26 had dysphagia. The note failed to address Resident #26's weight loss, did not identify he/she was on any oral nutritional supplements or intermittent refusals of supplements.Review of the clinical record identified Resident #26 weight on 5/27/26 at 2:54 PM was 63.0 lbs.A dietary note written by Dietician #1 on 5/27/26 at 12:23 PM identified Resident #26 was seen for follow-up for a significant weight loss. The note indicated that his/her weight had remained stable for the past month. The note indicated his/her oral intake was 25-100% for meals and noted Resident #26 received oral nutritional supplements of 120 ml house milkshake 4 times a day, 240 ml of Hi-Cal 3 times a day, Magic Cup 2 times a day, and received Remeron 15 mg daily for appetite stimulation. The note indicated there were no new recommendations at this time but failed to identify Resident #26 was frequently refusing the Remeron 15 mg daily, was refusing the Hi-cal supplement at least once a day most days, refused the house milkshakes 2 times a day most days, and refused Magic Cups at least once a day most days.b.Review of the MAR from 5/1/26-5/31/26 identified Resident #26 refused Remeron 15 mg 19 out of 31 opportunities (61.3%). Additionally, the MAR indicated that LPN #5 documented the medication refusal 18 out of 19 refusals. Resident #26 consumed 0% or refused 9 out of 62 opportunities (14.5%) of Magic Cup, refused Hi-Cal 240 ml supplement 20 out of 93 opportunities (21.5%) and refused House Milkshake 41 out of 124 opportunities (33.0%).Review of nursing notes in the clinical record from 5/1/26 to 5/31/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Review of the clinical record identified Resident #26 weight on 6/10/26 at 2:58 PM was 63.0 lbs.Interview and observation of Resident #26 on 6/15/26 at 11:03 AM identified Resident #26 appeared thin with bones of the arms and face easily visible and prominent through the skin. Resident #26 indicated that the food in the facility was okay, but he/she didn't always get what he/she wanted to eat so he/she would have to ask the staff for something different.An APRN progress note written by APRN #2 and dated 6/15/26 identified Resident #26 was seen for evaluation of multiple bruises and discolorations noted on the resident with no recent fall and weighed 63.0 lbs. The note identified a diagnosis of poor appetite and indicated the plan was Remeron 15 mg daily and to continue the Hi-cal supplement. The note failed to identify Resident #26 was frequently refusing the Remeron 15 mg daily and was also refusing the Hi-cal supplement at least once a day most days. Additionally, the note failed to identify Resident #26 was also on house milkshakes and Magic Cups for oral nutritional supplements and that he/she frequently refused those supplements also.c. Review of the MAR from 6/1/26-6/22/26 identified Resident #26 refused Remeron 15 mg 11 out of 21 opportunities (52.3%), refused Majic Cup 24 out of 43 opportunities (55.8%), refused Hi-Cal 240 ml 10 out of 65 opportunities (15.3%), and refused House Milkshake 21 out of 86 opportunities (24.4%).Review of nursing notes in the clinical record from 6/1/26 to 6/22/26 failed to identify a nursing note written by LPN #5 which indicated the APRN/MD or Dietician was notified of frequent refusals of oral nutritional supplements and Remeron 15 mg.Interview with LPN #5 on 6/22/26 at 10:56 AM identified Resident #26 often refused medications and often drank only about 50% of the supplements. She indicated that Resident #26 often did not drink the Hi-Cal supplement and would leave it on overbed table without drinking any of it. She indicated that Resident #26 liked the house milkshakes and Magic Cups but did not take the ordered Remeron 15mg. LPN #5 further identified she put the refusals of medication in the APRN book to notify them but could not identify how often. She indicated that she had notified the nursing supervisor of Resident #26's refusals, and that she had written a note about the refusals 1 or 2 times but could not recall if she had ever told the family. She indicated it was the policy for refusals to write it in the APRN book to notify them. Additionally, she indicated that she reported Resident #26's refusals of supplements to RN #1, and that she had notified the Dietician by submitting a communication form to them in their mailbox.Interview with Dietician #1 on 6/22/26 at 11:30 AM identified she had not been notified by nursing of the weight loss for Resident #26 first documented in the electronic medical record on 4/3/26, and that she had identified the weight loss on her own when she was monitoring his/her nutritional status on 4/23/26. She indicated that the nursing staff were supposed to notify her when there were weight losses so she could complete an evaluation and that she usually completed them within a day or 2 when she was notified of a weight loss. She indicated that nursing could update her by phone, email, or in person. She indicated that for her follow-up on 5/27/26 she had asked the nursing staff how Resident #26 was doing with the oral nutritional supplements and Remeron and she had been told that Resident #26 was taking them all well (no refusals were reported). Additionally, she indicated that she had not recommended any changes but had wondered why Resident #26 wasn't gaining weight with all the supplements he/she had in place. She indicated that she did not look at the MAR to see Resident #26's acceptance of supplements and Remeron, and that now that she was aware of the frequent refusals she would make changes to the current supplements to try to increase Resident #26's acceptance of them. She further indicated that Resident #26's frequent refusals of the supplements and Remeron had contributed to his/her lack of weight gain.Interview with the Director of Nursing Services (DNS) on 6/22/26 at 12:00 PM identified that supplement refusals should be reported to the dietician so that they can be evaluated and changed if needed. She indicated that weight loss should be verified and reported immediately. She was unable to identify why the APRN and dietician were not notified of multiple refusals of medication or supplements for a resident with weight loss. Review of the Weight Monitoring policy directed, in part, the facility will ensure all residents maintain acceptable parameters of nutritional status and their usual body weight. The policy directed weight was an indicator of nutritional status, and a weight monitoring schedule is developed for all residents on admission. The policy directed weights should be recorded at the time obtained. The policy directed residents with weight loss are monitored weekly, and all new weights should be compared with the previous weight. The policy directed a significant weight change is a 5% change in a month, 7.5% change in 3 months, and 10% change in 6 months. The policy directed the physician be updated of significant weight changes so nutritional interventions can be ordered if needed and the physician should document the diagnosis and clinical conditions contributing to the weight loss. The policy directed observations of the resident's weight status should be documented in the clinical record and the dietitian should be consulted to assist with interventions and actions documented in a progress note.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #1 and Resident #115) reviewed for respiratory therapy, the facility failed to ensure oxygen tubing was dated per facility policy. The findings include: 1. Resident #1 had diagnoses that included acute respiratory failure with hypoxia, acute pulmonary edema, and end stage renal disease.A physician order dated 3/11/26 directed may apply Oxygen at 0-15 liters per minute via nasal cannula or non-rebreather mask prn if oxygen saturation was below 90%.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, dependent on transfers, showering and toileting. Also, identifying Resident #1 required substantial maximal assistance for personal hygiene and was independent for eating. Further, identifying Resident #1 required continuous oxygen therapy.The Resident Care Plan (RCP) dated 6/12/26 identified Resident #1 was at risk of alterations in cardiac/circulatory status. Interventions included oxygen as indicated, promoted rest periods as needed, and monitor for dyspnea.The Advanced Practice Registered Nurse (APRN) progress note dated 6/13/26 at 7:48 PM identified Resident #1's lung sounds were diminished, and the resident was receiving 2 liters of oxygen.Observation on 6/16/26 at 2:28 PM with Registered Nurse (RN) #4 identified Resident #1 was out of bed in his/her room wearing oxygen via a nasal cannula, set at 2 liters. The oxygen tubing failed to have a label/date identifying when it was last changed.A second observation on 6/18/26 at 9:27 AM identified Resident #1 was out of bed in his/her room wearing oxygen via a nasal cannula, set at 2 liters. The oxygen tubing failed to have a label/date identifying when it was last changed.Subsequent to surveyors' inquiry, a physician order was obtained on 6/22/26 directing to oxygen tubing to be changed and labeled weekly on Sundays, on the 11:00 PM-7:00 AM shift.2. Resident #115's diagnosis included asthma, sleep apnea, and hypertension.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #115 was severely cognitively impaired and was dependent on toileting, dressing, bathing and transfers. Also, identifying Resident #115 was independent for eating and was utilizing a non-invasive mechanical ventilator.A physician's order dated 6/2/26 directed to apply CPAP (Continuous Positive Airway Pressure) at bedtime with full mask with 2 liters of oxygen, use distilled water in the water chamber every evening and night shift for sleep apnea.A Resident Care Plan (RCP) dated 6/9/26 identified Resident #115 had a sleep disorder that requires the use of positive airway pressure (PAP)device for the management of sleep apnea. Interventions included supplement oxygen via the PAP device as ordered, consulting with respiratory therapy as needed, and ensuring humidifier chamber is filled with distilled water or saline.Observation on 6/15/26 at 12:00 PM noted Resident #115 was out of bed in a wheelchair wearing oxygen via a nasal cannula, set at 2 liters. The oxygen tubing failed to have a label/date identifying when it was last changed.Observation on 6/16/26 at 11:27 AM with Registered Nurse (RN) #4 noted Resident #115 was in his/her room wearing oxygen via nasal cannula, set at 2 liters. The oxygen tubing failed to have a label/date identifying when it was last changed.Interview with RN #4 on 6/18/26 at 1:53 PM identified both Resident #1 and Resident #115 should have the tubing dated and labeled as per the facility policy.Interview on 6/22/26 at 1:42 PM with the Respiratory Therapist/DNS identified the oxygen tubing was to be changed weekly as per the facility policy with a label that was dated. Also, identifying nursing staff was responsible for ensuring the oxygen tubing was changed and dated weekly. Further, identifying the standard batch order for oxygen would contain changing and labeling the oxygen tubing weekly but there was no order for Resident #1 to have the oxygen tubing changed weekly.Subsequent to surveyor inquiry the oxygen tubing for Resident #1 and Resident #115 was labeled and dated. Also, an order was obtained for Resident #1 on 6/22/26 for oxygen tubing to be changed and labeled weekly on Sundays the 11:00 PM to 7:00 AM shift. Review of the Oxygen Administration Policy dated 10/2025 directed, in part, oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on observation, interviews, and facility documentation for 1 of 7 sampled residents (Resident #7) reviewed for activities of daily living (ADLS), the facility failed to ensure Resident #7's wheelchair (w/c) was clean and armrest was not damaged.Resident #7 was admitted to the facility in December 2022 with diagnoses that included dementia with agitation, Type 2 diabetes with neurological complications, spondylopathies, cervical region (degenerative and inflammatory disease affecting bones of the spine) and cerebral vascular accident (CVA)The Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #7 was severely cognitively impaired and was totally dependent on staff for activities of daily living (ADLs) except requiring maximum assistance with eating.The Resident Care Plan (RCP) dated 5/15/26 identified ADL Self Care Performance Deficit related to CVA as an area of focus with interventions that included side rails up at the top portion of bed, provide privacy while resident is toileting, keep light within reach and instruct resident to call as early as possible , assist resident to remove or replace clothing, use consistent routines and allow time to complete tasks, offer special shampoo, and offer to eat lunch in dining room vs. meals in their own room or in hallways.Physician orders dated 6/1/26 directed, in part, out of bed to wheelchair (w/c) and hospice services.Observations on 6/15/26 at 11:00 AM, 6/18/26 at 2:30 PM, 6/22/26 at 10:30 AM, and 6/23/26 at 9:15 AM noted Resident #7's w/c was noted to have food debris on the seat of the w/c and on the footbox of the footrests and the right piece of the rear armrest support was missing. Interview and observation with Nurse Aide (NA) #9 on 6/23/26 at 10:00 AM identified that Resident #7's w/c was dirty and needed to be cleaned. NA #9 indicated that housekeeping usually cleans the w/c early in the morning around 5:00 AM or 6:00 AM before residents get up for the day. NA #9 stated that Resident #7 eats with his/her hands a lot and food drops into the w/c. In addition, NA #9 stated that she had not noticed the piece of the armrest was missing and she thought that the w/c was provided to Resident #7 from hospice and would communicate with hospice regarding the broken armrest.Interview and review of the w/c cleaning documentation with the Director of Housekeeping (DOH) on 6/23/26 at 11:30 AM indicated that wheelchairs get cleaned quarterly. Review of the cleaning schedule with the DOH noted the last time wheelchairs were cleaned on Resident #7's unit was 4/2/26 but the DOH was unable to provide any documentation that Resident #7's w/c was cleaned on 4/2/26 as part of that units cleaning.Interview with Housekeeper #1 on 6/23/26 at 11:45 AM indicated that he was aware that Resident #7's w/c gets dirty with food and that the NAs usually ask for the w/c to be cleaned more frequently but they have not asked recently. HK #1 indicated that Resident #7 's w/c should be on a more frequent routine w/c cleaning schedule and that he would clean Resident #7's w/c immediately and place the w/c on a new cleaning schedule.Although requested, a policy for cleaning resident w/c was not provided.

Based on review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #26) reviewed for a decline in activities of daily living (ADLs), the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident with functional decline and weight loss. The findings include: Resident #26's diagnoses included dementia, dysphagia, and chronic obstructive pulmonary disease.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, required partial/moderate assistance with upper/lower body dressing, putting on/taking off footwear, sit to lying on bed, lying to sitting on bed, sit to stand, chair/bed transfers, and toilet transfers. The MDS assessment further indicated Resident #26 weighed 74 pounds (lbs.) and had weight loss.The Quarterly MDS assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, required partial/moderate assistance with upper body dressing, putting on/taking off footwear, sit to lying on bed, lying to sitting on bed, and chair/bed transfers. The MDS assessment further indicated Resident #26 required substantial/maximal assistance with lower body dressing (a decline from the 10/14/25 MDS which identified Resident #26 required partial/moderate assistance), sit to stand dressing (a decline from the 10/14/25 MDS which identified Resident #26 required partial/moderate assistance), and toilet transfers dressing (a decline from the 10/14/25 MDS which identified Resident #26 required partial/moderate assistance), weighed 75 lbs., had no weight loss, and had received no physical therapy or occupational therapy. This MDS assessment reflected a change in functional status in 3 areas of Section GG-functional abilities.The Quarterly MDS assessment dated [DATE] identified Resident #26 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, required substantial/maximal assistance with upper/lower body dressing, putting on/taking off footwear, sit to lying on bed, lying to sitting on bed, sit to stand, chair/bed transfers, and toilet transfers. The MDS assessment further indicated Resident #26 weighed 74 lbs., had no weight loss, and had received no physical therapy or occupational therapy. This MDS assessment reflected a change in functional status in 5 areas of Section GG-functional abilities with no change in functional status for the 3 areas of decline from the 1/7/26 MDS assessment.A dietary note written by Dietician #1 on 4/23/26 at 7:59 AM identified Resident #26 had a significant weight loss and was underweight.The Resident Care Plan (RCP) dated 4/27/26 identified Resident #26 had a self-care performance deficit related to dementia. Interventions included to encourage Resident #103 to self-feed and assist with set-up as needed, providing assistance of 1 staff member with activities of daily living (ADLs), and refer to rehabilitation therapy for changes in self-care abilities. Interview with the Rehabilitation (Rehab) Director on 6/22/26 at 1:00 PM identified Resident #26 had not received rehabilitation services since May 2025. She was not aware of Resident #26 having a decline in multiple areas of functional ability of Section GG of the last 2 MDS assessments.Interview and clinical record review with RN #9 on 6/23/26 at 11:40 AM identified that Resident #26 had a significant weight loss in April 2026 and had more than 2 areas of functional decline on the last 2 MDS assessments but there had not been a significant change in status MDS assessment completed. RN #9 indicated that her department had recently identified significant change in status MDS was an area that they had identified as needing improvement. She further indicated that she wasn't sure why she hadn't put Resident #26 in for a significant change in status MDS assessment, and further indicated he/she was due for an MDS assessment so she would complete the assessment as a significant change in status MDS.Review of the Policy for MDS-Significant Change Assessment directed, in part, within 14 days after the facility has or should have determined there's been a significant change in a resident's physical or mental condition that is not self-limiting and therefore will not resolve itself without intervention from staff or clinical interventions, and which impacts more than 1 area of the resident's health a significant change in status will be comprehensively assessed.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for a change in condition, the facility failed to ensure the physician/APRN was notified of the unavailability of a medication resulting in hospitalization , and for 2 of 2 residents (Resident #33 and Resident #38) reviewed for edema, the facility failed to notify the physician of weight increase of 5 pounds (lbs.) in one week for a resident with diagnosis of Congestive Heart Failure (CHF). The findings included: 1. Resident #42's diagnoses included Chronic inflammatory demyelinating polyneuritis (disorder of the autonomic nervous system), and dysarthria and anarthria.( a condition that results in complete or partial loss of speech due to a severe motor speech impairment). A physician's order date 7/25/24 directed to administer immunoglobulin 10% every 4 weeks. An Inter-Agency Referral Report dated 7/25/24 indicated the resident was to receive immunoglobulin 10% every 4 weeks intravenously. The admission Minimum Data Set assessment dated [DATE] identified Resident #42 was cognitively intact and required maximum assistance for toileting, showering, and personal hygiene. The Resident Care Plan dated 10/15/24 identified Resident #42 as a paraplegic related to a spinal injury. Interventions included to medicate the resident as ordered. A nurse's note dated 10/5/24 at 7:50 PM identified Resident #42 requested to go to the hospital because she/he had not received her/his immunoglobulin in 3 months and felt she/he was having an immune response. Furthermore, the resident reported stiffness and pain in his/her hands, and a burning sensation in his/her chest. Resident #42 was sent to the emergency room (ER) for an evaluation. A nurse's noted dated 10/10/24 at 12:37 PM identified the resident returned from hospital at 10:20 AM and identified the resident received 3 immunoglobulin infusions: 1 per day for 3 days while in the hospital. An interview and record review on 10/24/24 at 10:30 AM with Unit Manager RN#4 identified the hospital discharge summary and/or the Inter-Agency Referral Report were reviewed for physician's orders and the Medical Director also reviews the documents and writes physician's orders based on the facility's recommendations. Review of the clinical record indicated an order was written on 7/25/24 for the administration of IV Immunoglobulin every 4 weeks, however the clinical record identified the medication was not administered until October 2024 when Resident #42 requested to go to the hospital. RN#4 indicated she was aware of the situation with the IV Immunoglobulin. The facility was unable to administer IV Immunoglobulin because the facility could not find an infusion center that would administer the medication. RN #4 called the resident's oncologist at the end of August 2024; however, they were unable to administer the IV Immunoglobulin due to insurance restrictions. RN #4 further stated that she did not document her efforts, nor did she recall notifying the Advanced Practice Registered Nurse (APRN)/MD that she was having difficulty finding a clinic to administer the IV Immunoglobulin medication. In an interview on 10/25/24 at 9:30 AM with APRN #1 s/he identified s/he was aware Resident #42 had an order for monthly infusions of immunoglobulin. APRN #1 indicated s/he was aware Resident # 42 went to theER on [DATE], but was unsure of the details in-between 7/25/24 and 10/5/24. APRN #1 also identified she asked nursing at the end of August 2024 the status of scheduling the infusion and was told they were working on getting it scheduled. The next time she was updated was on October 5, 2024, when the resident was sent out to an acute care facility. APRN #1 identified s/he would have sent the resident to the ED if s/he was aware that the staff was having difficulty scheduling the infusion. Review of the Policy for Medication Errors dated 8/23/2005 and currently active directs, in part, that an omission of a medication is an error. Further it defines that when a medication error has occurred the physician and the supervisor are notified immediately. According to Drug. Com Intravenous Immunoglobulin is used for treatment of primary immunodeficiency. 2. Resident #33's diagnoses included CHF, diabetes, and peripheral vascular disease. The Resident Care Plan dated 7/17/24 identified Resident #33 had potential for alterations in cardiac output related to CHF. Interventions included to monitor, document and report to the MD/APRN, as needed, any signs or symptoms of CHF (dependent edema of legs and feet, periorbital edema, weight gain unrelated to nutritional intake, and crackles or wheezes upon listening to the lungs) and weight monitoring per the facility policy. The admission Minimum Data Set assessment dated [DATE] identified Resident #33 was cognitively intact and required supervision or touching assistance with eating, was dependent with lower body dressing, and required partial/moderate assistance with rolling left and right. A physician's order dated 7/24/24 directed to obtain weights weekly every Friday before breakfast. Physician's order in effect from 8/1/24 through 8/13/24 directed to notify the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) if there was a weight gain of 2 lbs. or more in 1 day or 5 lbs. or more in 1 week. Resident #33 was admitted to the hospital from 8/13/24 through 8/26/24. Physician's orders dated 8/26/24 directed to obtain a daily weight before breakfast and notify the MD/APRN if there was a weight gain of 2 lbs. or more in 1 day or 5 lbs. or more in 1 week. Physician's orders dated 9/4/24 directed to discontinue the daily weight before breakfast and a new order directed to obtain a weight weekly on Friday. Review of weight documentation in Resident #33's clinical record for 7/16/24 through 10/18/24 identified 3 occurrences of weight gain of 5 lbs. or more in 1 week. Between 7/26/24 (231 lbs.) and 8/2/24 (241 lbs.) a gain of 10 lbs. was noted. Between 9/1/24 (225.4 lbs.) and 9/6/24 (236.6 lbs.) a gain of 11.2 lbs. Between 9/13/24 (230 lbs.) and 9/20/24 (235 lbs.) a gain of 5 lbs. Although a review of the Medication Administration Records for August 2024 and September 2024 identified the MD/APRN was notified of the weight gains, a review of nurses' progress notes between 8/2/24 and 9/20/24 failed to identify documentation of MD/APRN notification of a weight gain of 5 lbs. or more in 1 week. Interview with APRN #1 on 10/25/24 at 12:00 PM identified that she had not been notified by the nurses of a 5 lbs. or more weight gain for Resident #33 on 8/2/24, 9/6/24 and 9/20/24, and that if she had been notified she would have evaluated Resident #33's lungs, checked for edema, looked for a trend for weight gain, evaluated Resident #33's current medications, and she would have looked at documentation of Resident #33's ejection fraction (amount of blood pumped out with each heart beat) and if stable would have considered medication changes. 3. Resident #38's diagnoses included CHF, diabetes, and aphasia following a stroke. The annual Minimum Data Set assessment dated [DATE] identified Resident #38 was severely cognitively impaired and was dependent for eating, oral hygiene, and rolling left and right. The Resident Care Plan in effect from 5/1/24 through 5/31/24 identified Resident #38 had potential for alterations in cardiac status related to CHF. Interventions included to monitor, document and report to the MD/APRN as needed any signs or symptoms of CHF (dependent edema of legs and feet, periorbital edema, weight gain unrelated to nutritional intake, and crackles or wheezes upon listening to the lungs) and weight monitoring per policy. Physician's orders dated 5/1/24 directed to obtain weights weekly every Monday and notify the MD/APRN if there is a weight gain of 2 lbs. or more in 1 day or 5 lbs. or more in 1 week. Review of weight documentation in Resident #38's clinical record for 5/1/24 through 5/31/24 identified 2 occurrences of weight gain of 2 or more lbs. in 1 day or 5 lbs. or more in 1 week. Between 5/13/24 (215.0 lbs.) and 5/13/24 (218.0 lbs.) gain of 3 lbs. in the same day. Between 5/17/24 (217.6 lbs.) and 5/20/24 (228.5 lbs.) a gain of 10.8 lbs. in 3 days was noted. Although a review of the Medication Administration Record for May 2024 identified the MD/APRN was notified of the weight gains, a review of the nurses' progress notes between 5/13/24 through 5/27/24 failed to identify documentation of MD/APRN notification of a weight gain of 2 or more lbs. in 1 day or 5 lbs. or more in 1 week. Interview with APRN #3 on 10/25/24 at 10:15 AM identified he could not recall being updated by nurses of a weight gain of 2 or more lbs. in 1 day or 5 lbs. or more in 1 week for Resident #38 and if he had been updated, he would have requested for the nurse to provide him with information about Resident #38's lung sounds and any presence of edema. He further stated that if the information the nurse provided revealed acute signs or symptoms of CHF, he would have provided orders to the nurse right away and he would have visited the resident the next day. If the information provided by the nurse revealed non-acute signs or symptoms of CHF there wouldn't have been a need for immediate orders, but Resident #38 would have received an APRN visit the next day. Review of APRN #3's progress notes from 5/13/24 to 5/27/24 failed to identify a visit for follow-up related to a notification of weight gain of 2 or more lbs. in 1 day or 5 lbs. or more in 1 week. Although attempted, interviews with nursing staff from 5/13/24 and 5/20/24 were unable to be obtained. Review of the CHF policy directed, in part, that residents with a diagnosis of congestive heart failure would be managed according to physician recommendations and weights would be taken as prescribed per physician orders. Review of the Weight Assessment and Intervention policy failed to identify directives for management of weight gain related to a resident disease process. ___________________________________ 51183

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for change in condition, the facility failed to administer the resident's medication as prescribed to ensure the resident was free of a significant medication error. The findings include Resident #42's diagnoses included Chronic inflammatory demyelinating polyneuritis (disorder of the autonomic nervous system), and dysarthria and anarthria.( a condition that results in complete or partial loss of speech due to a severe motor speech impairment). A physician's order date 7/25/24 directed to administer immunoglobulin 10% every 4 weeks via intravenously. An Inter-Agency Referral Report and hospital Discharge summary dated [DATE] indicated the resident was to receive immunoglobulin 10% every 4 weeks intravenously. The admission Minimum Data Set assessment dated [DATE] identified Resident #42 was cognitively intact and required maximum assistance for toileting, showering, and personal hygiene. The Resident Care Plan dated 10/15/24 identified Resident #42 as a paraplegic related to a spinal injury. Interventions included to medicate the resident as ordered. A nurse's note dated 10/5/24 at 7:50 PM identified Resident #42 requested to go to the hospital because she/he had not received her/his immunoglobulin in 3 months and felt she/he was having an immune response. Furthermore, the resident reported stiffness and pain in his/her hands, and a burning sensation in his/her chest. Resident # 42 was sent to emergency room (ER) for an evaluation. A nurse's noted dated 10/10/24 at 12:37 PM identified the resident returned from hospital at 10:20 AM and identified the resident received 3 immunoglobulin infusions: 1 per day for 3 days while in the hospital. An interview and record review on 10/24/24 at 10:30 AM with Unit Manager RN#4 identified the hospital discharge summary and/or the Inter-Agency Referral Report are reviewed for physician's orders and the Medical Director also review the documents and write physician's orders based on the facility's recommendations. Review of the clinical record indicated an order was written on 7/25/24 for the administration of IV Immunoglobulin every 4 weeks, however the clinical record identified the medication was not administered until October 2024 when Resident #42 requested to go to the hospital. RN#4 indicated she was aware of the situation with the IV Immunoglobulin. The facility was unable to administer IV Immunoglobulin because the facility could not find an infusion center that would administer the medication. RN # 4 called the resident's oncologist the end of August 2024; however, they were unable to administer the IV Immunoglobulin due to insurance restrictions. RN # 4 further stated that she did not document her efforts, nor did she recall notifying the Advanced Practice Registered Nurse (APRN)/MD that she was having difficulty finding a clinic to administer the IV Immunoglobulin medication. In an interview on 10/25/24 at 9:30 AM with APRN #1 s/he identified s/he was aware Resident #42 had an order for monthly infusions of immunoglobulin. APRN #1 indicated s/he was aware Resident # 42 went to the ER on [DATE], but was unsure of the details in-between 7/25/24 and 10/5/24. APRN #1 also identified she asked nursing at the end of August 2024 the status of scheduling the infusion and was told they were working on getting it scheduled. The next time she was updated was on October 5, 2024, when the resident was sent out to an acute care facility. APRN # 1 identified s/he would have sent the resident to the ED if s/he was aware that the staff was having difficulty scheduling the infusion. Review of the Policy for Medication Errors dated 8/23/2005 and currently active directs, in part, that an omission of a medication is an error. Further it defines that when a medication error has occurred the physician and the supervisor are notified immediately. According to Drug. Com Intravenous Immunoglobulin is used for treatment of primary immunodeficiency

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for change in condition, the facility failed to ensure the resident was free of a significant medication error. The findings include: .Resident #42's diagnoses included Chronic inflammatory demyelinating polyneuritis (disorder of the autonomic nervous system), and dysarthria and anarthria. A physician's order date 7/25/24 directed to administer immunoglobulin 10% every 4 weeks. An Inter-Agency Referral Report dated 7/25/24 indicated the resident was to receive immunoglobulin 10% every 4 weeks intravenously. The admission Minimum Data Set assessment dated [DATE] identified Resident #42 was cognitively intact and required maximum assistance for toileting, showering, and personal hygiene. The Resident Care Plan dated 10/15/24 identified Resident #42 as a paraplegic related to a spinal injury. Interventions included to medicate the resident as ordered. A nurse's note dated 10/5/24 at 7:50 PM identified Resident #42 requested to go to the hospital because she/he had not received her/his immunoglobulin in 3 months and felt she/he was having an immune response. Furthermore, the resident reported stiffness and pain in his/her hands, and a burning sensation in his/her chest. Resident # 42 was sent to emergency room (ER) for an evaluation. A nurse's noted dated 10/10/24 at 12:37 PM identified the resident returned from hospital at 10:20 AM and identified the resident received 3 immunoglobulin infusions: 1 per day for 3 days while in the hospital. An interview and record review on 10/24/24 at 10:30 AM with Unit Manager RN#4 identified the hospital discharge summary and/or the Inter-Agency Referral Report are reviewed for physician's orders and the Medical Director also review the documents and write physician's orders based on the facility's recommendations. Review of the clinical record indicated an order was written on 7/25/24 for the administration of IV Immunoglobulin every 4 weeks, however the clinical record identified the medication was not administered until October 2024 when Resident #42 requested to go to the hospital. RN#4 indicated she was aware of the situation with the IV Immunoglobulin. The facility was unable to administer IV Immunoglobulin because the facility could not find an infusion center that would administer the medication. RN # 4 called the resident's oncologist the end of August 2024; however, they were unable to administer the IV Immunoglobulin due to insurance restrictions. RN # 4 further stated that she did not document her efforts, nor did she recall notifying the Advanced Practice Registered Nurse (APRN)/MD that she was having difficulty finding a clinic to administer the IV Immunoglobulin medication. In an interview on 10/25/24 at 9:30 AM with APRN #1 s/he identified s/he was aware Resident #42 had an order for monthly infusions of immunoglobulin. APRN #1 indicated s/he was aware Resident # 42 went to the ER on [DATE], but was unsure of the details in-between 7/25/24 and 10/5/24. APRN #1 also identified she asked nursing at the end of August 2024 the status of scheduling the infusion and was told they were working on getting it scheduled. The next time she was updated was on October 5, 2024, when the resident was sent out to an acute care facility. APRN # 1 identified s/he would have sent the resident to the ED if s/he was aware that the staff was having difficulty scheduling the infusion. Review of the Policy for Medication Errors dated 8/23/2005 and currently active directs, in part, that an omission of a medication is an error.

Based on record reviews and staff interviews for one of three sampled residents (Resident #1) who required two (2) person assistance with turning and repositioning when in bed, the facility failed to ensure two (2) staff members were present at the bedside when the resident was turned onto a side to prevent the resident from sliding off the bed and sustaining a fracture of the right tibia and fibula. The findings include: Resident #1's diagnoses included abnormality of gait and mobility, dementia, and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had short- and long-term memory recall deficits, required extensive two (2) person assistance with turning and repositioning when in bed, and extensive one (1) person assistance with dressing and personal hygiene. A physician's orders dated 11/23/23 directed two (2) nurse aides to provide care every shift. Review of the Resident Care Card in place on 11/30/23 directed two (2) staff members to provide care to Resident #1. The nurse's note dated 11/30/23 at 6:44 PM identified the 11 PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, was called into Resident #1's room by the 11 PM-7AM nurse aide, Nurse Aide (NA) #1, to evaluate Resident #1's coccyx pressure ulcer. The note indicated Resident #1 was lying on his/her left side and slid off the bed sheets. LPN #1 helped Resident #1 to the ground, Resident #1's knees landed on top of the base of the bedside table, Resident #1 was assisted onto his/her back by LPN #1 and the nurse aide, and after being evaluated by the Nursing Supervisor, Resident #1 was assisted back into bed. The note identified Resident #1 complained of bilateral knee pain, the right knee pain was greater than the left which increased with movement and a 1.5 centimeter (cm) x 0.5 cm skin tear to the left front shin was noted. The note indicated a physician's order directed to obtain an X-ray and wound care. The Facility Reported Incident dated 11/30/23 identified on 11/30/23 at 5:45 AM Resident #1 slid off the bed and his/her knees landed on top the base of the bedside table. The report identified at 8:00 AM, the right knee was noted to be swollen, Resident #1 complained of increased pain, and was transferred to the Emergency Department for an orthopedic evaluation and treatment. The Hospital Discharge Summary dated 12/2/23 identified Resident #1 was admitted on [DATE] after sustaining a fall and the X-ray identified a right tibial plateau and fibular neck fracture. Physician orders directed pain medications and a blood thinner Lovenox and an orthopedic follow up in one (1) week. The summary indicated the orthopedic consultant recommended conservative management of a knee immobilizer for full leg extension and non-weight bearing status, and Resident #1 was discharged back to the facility on [DATE]. Interview with the Director of Nursing (DON) on 12/22/23 at 10:00 AM identified NA #1 was providing care to Resident #1 alone and was not following the care plan and physician's order that directed two (2) nurse aides to provide care. Interview with NA #1 on 12/22/23 at 12:45 PM identified that she provided care to Resident #1 on 11/30/23 and she provided care for him/her on a regular basis. NA #1 identified she was providing hygiene care alone and after she finished providing care, she called LPN #1 to come into room to provide wound care. NA #1 explained while waiting for the LPN, she assisted Resident #1 to roll onto his/her left side. NA #1 indicated she was standing on the right side of the bed and rolled the resident away from her. NA #1 identified when LPN #1 came into the room she went to the left side of the bed and noticed Resident #1 was sliding off the bed. NA #1 identified she tried to help LPN #1 keep Resident #1 on the bed but the resident was too heavy, so they assisted Resident #1 to slide onto the floor. NA #1 indicated although the nurse aide care card directed two (2) staff to provide all care to Resident #1, she felt Resident #1 only needed the assistance of one (1) person because Resident #1 was able to hold onto the bed rail when being turned. NA #1 identified she did not follow the directions on Resident #1's care card. An attempt to interview LPN #1 on 12/22/23 was unsuccessful.

Based on clinical record reviews, observation and interviews for one of four sampled residents resident in survey sample reviewed for accidents (Resident # 168) and/or for one of three sampled residents reviewed for transfers (Resident # 317), facility failed to provide/ensure a safe transfer utilizing a mechanical lift (Hoyer). Findings include: 1. Resident #168's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident as severe cognitive impairment, required extensive assistance with Activities of Daily Living and transfers between surfaces such as chair to bed. The Resident Care Plan (RCP) dated 12/2/15 and 4/23/15 identified a problem with osteoporosis. Interventions included to encourage physical activity and daily ambulation, use rolling walker to transfer, encourage weight bearing, exercise as tolerated to help maintain bone mass and to monitor /document risk for falls and to educate resident, family/care givers on safety measures that need to be taken in order to reduce the risk for falls. Physician's orders dated 5/31/15 identified Resident #168's mobility was bed to chair with use of a Hoyer lift (mechanical lifting device) with assistance of two (2) staff. The facility Accident & Incident Report documentation dated 6/5/15 identified on evening shift at 4:40 P.M. Licensed Practical Nurse (LPN) #1 was notified by (NA) #1 and (NA) #2 that Resident #168 fell out of the Hoyer lift during a transfer. Resident #168 sustained a laceration to the back of the neck and the resident was sent to the hospital emergency room for an evaluation. Treatment included a head/neck Computed Tomography (CT) and two (2) staples were required to approximate the laceration to the back of the head. A written statement from LPN #1 dated 6/515 at 4:40 P.M. identified when she/he entered Resident #168's room Resident #168 was laying between the legs of the Hoyer lift on the floor. The Hoyer pad was dangling on one side from the Hoyer cradle with only one side of the upper Hoyer pad attached to the metal hooks. Further review of facility investigation dated 6/5/15 and 6/12/15 identified NA #1 and NA #2 guided the resident and operated the Hoyer lift/transfer device in accordance to facility practice. However, when NA #1 and NA #2 proceeded to transfer Resident #168 to the bed, the resident slid out of Hoyer pad causing the resident to fall to the floor. Interview with the DNS on 9/15/15 at 12:24 P.M. identified that although the resident's door was closed LPN #1 was outside in the hallway at the medication cart when the incident occurred and was the first licensed person to assess the event. NA#1 on 9/16/15 at 8:43 A.M. during an interview indicated on 6/5/15 NA #2 assisted in the transfer. NA #1 and NA #2 placed the Hoyer pad under Resident #168 and attached the pad to the Hoyer lift. NA #1 indicated that while guiding the resident suspended in the air, she/he lowered the bed and NA #2 operated the Hoyer device. When attempting to move the resident to the bed, Resident #168 began to slip and the resident's buttocks came out of the Hoyer pad. NA #1 indicated she/he attempted to catch the resident; however, Resident #168 hit the side of the bed and fell on to the floor. Interview with NA #2 on 9/16/15 at 9:22 A.M. and at 9:34 A.M. with the DNS present identified NA# 1 requested assistance with Resident #168's transfer to bed. NA #2 indicated upon entrance to the resident's room the Hoyer pad was already in place under the resident and attached to the Hoyer cradle. During the transfer, NA#1 was operating the lift and she/he held/guided the resident. NA #2 further indicated and demonstrated with the DNS present that as the transfer proceeded one of the pad/sling loops detached from the cradle hook and Resident #168 slipped out of the Hoyer pad on to the floor. Interview and review of Resident #168's clinical record and facility documentation with RN #4 on 9/16/15 at 12:31 P.M.identified the facilities investigation failed to come to a conclusion, and indicated she/he was not present when the incident occurred. Interview with the representative (Person #1) of the Mechanical Lift manufacturer on 9/16/15 at 2:24 P.M. identified a fall from a Hoyer lift and/or failure of a lift sling to support a patient during a transfer would involve either the utilization of an incorrect size sling and/or failure to properly attach sling loops to hooks located on the cradle. Facility Hoyer lift policy procedure identified the goal to safely and comfortable transfer residents and to prevent resident and caregiver injuries. Procedure identified in part to ensure resident's safety included attaching shoulder and hip loops to the lift. Attempts to contact and interview LPN #1 on 9/15/15 and 9/16/15 were unsuccessful due to the unavailable. 2. Resident #317 [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident without cognitive impairment and requiring extensive assistance from staff for most activities of daily living. Review of the clinical record identified an Advance Practical Nurse ( APRN) note dated 9/14/15 identified in part although there was no ecchymosis or increase in pain as a result of the resident's left hand being struck by the mechanical lift, the resident had left hand pain in the past and left sided [DIAGNOSES REDACTED]. A review of facility documentation dated 9/14/15 at 6:30 A.M. identified in part that as NA# 5 and NA#3 were utilizing a mechanical lift to weigh the resident, while the resident hands were across his/her chest, the resident suddenly moved his/her left hand without warning and the scale on the mechanical lift bumped the resident's left hand as it was being lowered. The nurse's note dated 9/14/15 identified the resident complained of left arm and dorsal left hand pain secondary to his/her arm hit by scale and indicated the resident receive Tylenol for the pain with good effect. An x-ray was obtained of the resident left hand on 9/15/15 due to the resident's complaints of left hand pain, results identified the resident as having osteoarthritis and no fracture to the extremity. On 9/16/15 at 10:03 A.M. during an interview with R#317, the resident was observed sitting in his/her wheelchair with his/her left hand resting on his/her lap. The resident indicated at the time that while being weighed on the night shift (11:00 P.M. - 7 :00 A.M.) the scale on mechanical lift struck the resident left hand. The resident verbalized the pain was so intense he/she saw stars . A review of facility documentation dated 9/14/15 at 6:30 A.M. identified in part that as NA# 5 and NA#3 were utilizing a mechanical lift to weigh the resident, while the resident hands were across his/her chest, the resident suddenly moved his/her left hand without warning and the scale on the mechanical lift bumped the resident's left hand as it was being lowered. On 9/18/15 at 6:10 A.M. an interview and review of facility documentation with NA#3 indicated when NA# 5 lowered the scale it somehow accidentally bumped against Resident # 317's hand NA #3 further indicated the resident did not complain of pain and there was no visible injury noted therefore she/he NA # 5 decided to proceed with care and not report the incident to the nurse. An interview and review of the clinical record and facility documentation with LPN #2 on 9/17/15 at 2:40 P.M. indicated that although NA #3 and NA # 5 should have reported the incident to him/her the resident bumped his/her hand during care and indicated she/he was not notified of the incident. On 9/18/15 at 2:10 P.M. an interview and review of the clinical record and facility documentation with the DNS indicated that although the resident did not sustain a fracture when struck by the scale of the mechanical lift, the aides were to have reported the event to the charge nurse immediately. The RCP updated on 9/15/15 identified the resident with a history for falls with an actual fall on 8/30/15. Interventions included obtain and use proper foot wear, keep area clutter free, well lit, bed and chair alarms, check placement and functioning. Review of facility documentation identified in part that on 8/30/15 at 4:15 A.M. Resident #317 was observed on the floor after sliding out of bed. The resident's bed was in low position and no injuries were identified at the time of the fall. On 9/17/15 at 2:40 P.M. an interview and review of facility documentation and the clinical record with LPN#2 indicated that upon finding the resident on the floor it was determined that as the resident was turning his/herself in bed, the side rail was broke so when the resident turned his/herself in bed, the side rail went down and the resident fell out of bed onto the floor. The nurse further noted that the bed was old and was switch out for a new one. On 9/17/15 at 1:20 P.M. an interview and review of facility documentation with NA #4 indicated that during rounds he/she found the resident lying on the right side of the bed on the floor. The aide further noted when he/she checked the resident's side rail by putting pressure on it. The rail went straight down and could not support the resident when he/she turned in bed. NA #4 indicated that the resident's bed was in its lowest position. On 9/18/15 at 9:40 A.M., an interview and review of monthly environmental rounds for side rails with the Physical Plant Manager (PPM) indicated he/she checked all the side rails in the facility at some point in the month of August 2015 but indicated he/ she could not give a definitive date the siderails were checked by maintenance. Subsequent to surveyor inquiry identified the resident's siderails had not been check by PPM as of 9/18/15. On 9/18/15 at 2:10 P.M. an interview and review of the facility policy and/or procedure and facility documentation related preventive maintenance and/or inventory and/or the environmental rounds indicated that he/she would have expected the PPM to have a start date for each month when checking for the safety of the residents ' side rails.

Based on clinical record reviews, review of facility documentation, facility policy and interviews for two of six sampled residents ( Residents #91 and #288) reviewed for accident, the facility failed to transfer residents with the appropriate assistive device and/or according to facility policy and procedures to prevent an accident. The finding included: 1. Resident #91 [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified resident with some cognitive impairment, memory problems and that the resident required extensive assistance of two people for all transfers. The Resident Care Plan dated 12/9/13 indicated Resident #91 had fragile skin and interventions included bumper guard placement to bilateral sides when in bed, staff to be instructed in skin protection technique for repositioning and transferring residents. A Review of facility A/I report dated 5/1/14 indicated that Resident # 91 obtained a laceration that measured 5 Centimeter (CM) x 2 CM on left shin during transfer from the bed to the chair. The nurse's notes dated 5/1/14 indicated deep laceration 5 CM x 2 CM on anterior aspect of left lower extremity after assisted transfer into wheelchair, pressure applied to injury, intact hematoma 3 CM x 2 CM above laceration. During an interview with NA #2 on 10/7/14 at 11:40 A.M. indicated that she assisted with transferring Resident # 91 from the bed to chair on 5/1/14 and indicated that a gait belt was not utilized during the transferred. During an interview with Licensed Practical Nurse(LPN) #2 on 10/8/14 at 11:10 A.M. identified Resident #91 sustained a bumped and a laceration to his/her left shin during a transfer. LPN#2 indicated that the resident was transferred to the emergency room for an evaluation and returned to the facility with five sutures to the left shin. An interview with NA#3 on 10/9/14 at 9:50 A.M. indicated that on 5/1/14 she transferred resident #91 out of bed with the assistance of NA#2 , the resident refused to twice have staff use the gait belt. Additionally, NA#3 indicated that she did not inform the charge nurse or the supervisor of the resident's refusal and indicated that she transferred the resident out of bed to wheelchair " with one aide holding the resident under the arm and the other aide held Resident # 91's waist by using his/her pants. NA# 3 indicated that she was aware that the resident had fragile skin and staff needed to be careful with transfer. Interview with the Director of Nursing ( DNS) on 10/9/14 at 11:50 A.M. indicated that the facility policy require nurse aides to utilize a gait belt with all transfers per facility policy and when the resident refuse the gait belt, NA#3 should have reported incident to charge nurse prior to transferring resident out of bed. During an interview with RN #4 on 10/9/14 at 12:10 P.M. indicated that all nurses aides are educated on gait belt transfer and whenever a resident refused care, the charge nurse need to be updated. Review of facility gait belt policy indicated a gait belt is to be used for assisted transfer requiring contact guard assist or greater, or ambulation of a resident. The use of gait belts is mandatory for all staff members to use. Review of facility transfer technique policy indicated that all residents who require assistance in transferring will be transferred using a gait belt or with a mechanical lift. 2. Resident # 288 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A quarterly MDS dated [DATE] indicated moderate impaired cognition, required extensive assistance with ADL including transfers. Facility Accident /Incident Report dated 12/25/13 identified Resident #288 was alert and confused required assistance of two staff for transfers and assist of one for incontinent care. Additionally, the A/I report identified that at 8:25 P.M. during P.M. care Resident #288 was attempting to sit during toileting and hit his/her head on the bathroom wall, the resident was very upset over the incident and that Resident #288 sustained a laceration to the left forehead that measured 31.5 Centimeters (CM) by 1.5 CM, Resident # 288 complained of pain to the area , received Tylenol ( Pain Reliever ) when needed and indicated that the resident was transferred out to the emergency room for an evaluation. The A/I report noted that Resident # 288 returned from the emergency room with 5 sutures. A written statement from( NA# 4) dated 12/25/13 at 8:30 P.M. indicated that Resident # 288 was a one person physical assistance , that during the transfer of Resident # 288 from the toilet to the wheelchair, the resident stood near the wall held onto the grab bar, while she/he placed the wheelchair behind the resident at which time she/ he stood behind the chair holding the resident's waist, when she /he asked Resident # 288 to sit she/he heard a bump, saw blood on the wall and directed Resident # 288 to sit in the chair. Interview with Registered Nurse ( RN #3) on 10/9/14 at 2:45 P.M. identified that NA#4 failed to follow Resident # 288's transfer status in accordance to the plan of care and that NA#4 transferred the resident independently. Interview with NA #4 on 10/9/14 at 3:10 P.M. identified that the resident's transfer status was one or two during a transfer and indicated that the transfer was performed without another staff, the resident hit his/her head on the bathroom grab bar and sustained a laceration. Further interview with NA #4 indicated that the resident can be " floppy " at times. Review of NA# 4's personnel record identified that the aide received a corrective action for not providing two staff members for Resident # 288's transfer.