Every finding on record at Manchester Rehabilitation and Healthcare Center

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to ensure appropriate monitoring and implementation of interventions to prevent skin breakdown for a dependent resident who was identified as having a high risk for developing pressure sores (wound), including failure to ensure offloading boots were properly managed and failure to assess the skin under the boots every shift, resulting in the development of an avoidable pressure wound to the left dorsal foot that was not identified timely and progressed to a full thickness wound requiring ongoing treatment. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, Parkinson's disease (a progressive movement disorder of the nervous system), stage 3 chronic kidney disease (mild to moderate loss of kidney function), hypothyroidism, protein-calorie malnutrition and type 2 diabetes mellitus.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition with a staff assessment for mental status conducted which indicated short-term and long-term memory problems with no recall ability and was dependent on staff for personal hygiene, bed mobility and transfers. The MDS identified Resident #1 had three (3) unhealed stage four (4) pressure wounds (pressure ulcers involving full thickness tissue loss with exposed muscles, tendons or bone) that were present on admission.The Resident Care Plan (RCP) dated 8/19/25 identified Resident #1 had impaired skin integrity related to failure to thrive and immobility. Interventions included identifying risks for pressure wounds, turning and repositioning every two (2) hours, using proper positioning, transferring and turning techniques to minimize skin injury due to friction and shearing forces, a low air-loss mattress and offloading heels as tolerated.A Braden Scale for Predicting Pressure Sore Risk evaluation dated 9/16/25 identified Resident #1 was at high risk for acquiring pressure wounds.A Wound Care Specialist note by MD #2 dated 9/18/25 identified Resident #1 had been evaluated for stage 4 pressure wounds to his/her right hip, left hip and sacrum and the pressure wounds were largely stable. The note identified that a left medial foot wound (inner aspect extending from the heel to the big toe) resolved on 9/4/25.A Weekly Skin Check evaluation dated 9/21/25 by RN #4 identified no new skin issues were identified.An APRN note by APRN #2 dated 9/23/25 at 9:30 AM identified she was asked to see Resident #1, in part, for a wound to Resident #1's left foot. Resident #1 had a wound to his/her left dorsal foot and she ordered for the left dorsal foot to be cleansed with normal saline, the application of silver alginate (a highly absorbent antimicrobial wound dressing) daily to the wound bed and then covered with a clean dry dressing and changed every day shift. The note identified Resident #1 was to be seen and evaluated on Thursday by the wound team.A nurse's note by the ADON dated 9/23/25 at 12:19 PM identified she assessed Resident #1 and discovered an open area to the left dorsal foot measuring approximately 3 centimeters (cm) by 0.5 cm and reported the area was caused by Resident #1's skin rubbing against the heel booties (offloading boots). The ADON identified the offloading boots were removed, replaced with new offloading boots and Resident #1's responsible party was at the bedside and updated. The note identified RN #2 was updated and new dressing orders were obtained.A Wound Care Specialist note by MD #2 dated 9/25/25 identified Resident #1 was seen for evaluation of wounds to the right hip, left hip and sacrum in addition to a new wound to the left dorsal foot. The note identified the left dorsal foot had a full thickness wound measuring 1.1 cm by 0.9 cm by 0 cm and the wound bed was noted with 100 percent (%) slough (yellowish, soft and stringy material that forms in wounds as a result of dead or dying tissue, protein buildup and bacterial contamination and is a significant barrier to healing) and had a moderate amount of serosanguinous (appears pink or light red in color and consists of a mixture of serous fluid and small amounts of blood) drainage present. Treatment recommendations included cleansing the wound with normal saline, applying Santyl (an enzyme that removes dead tissue from skin ulcers and promotes healing) to the wound bed followed by calcium alginate and covered with a dry clean dressing and offloading heels per facility protocol.Review of the clinical record from 5/16/25 through 9/23/25 failed to identify an order to utilize offloading boots or for staff to check the skin under the offloading boots every shift.A physician's order dated 12/27/25 directed licensed nurses to complete diabetic foot care every day shift (3 months after the development of the left dorsal foot wound).Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from September 2025 to March 2026 failed to identify an order for offloading boots or that the skin under the offloading boots was checked every shift. A Wound Care Specialist note written by MD #2 dated 3/19/26 identified Resident #1's left dorsal foot wound was still present, classified as a stage 4 pressure wound and measured 1.3 cm by 1.9 cm by 0.1 cm. The note identified the left dorsal foot wound had one-hundred (100) % granulation tissue (new connective tissue with blood vessels and myofibroblasts that develop at the wound site in the process of healing) and a moderate amount of serous drainage (a thin, watery clear/pale yellow fluid that's normal during the inflammatory stage of wound healing). The note recommended offloading heels per facility protocol.Interview with APRN #2 on 3/25/26 at 11:39 AM identified the left dorsal foot wound that she first assessed on 9/23/25 was not identified timely and that the area would have been reddened and boggy (indicating tissue damage from excessive fluid content, inflammation or underlying pressure injury) before opening and expelling drainage. She identified Resident #1 should have had an order in place to offload both heels while in bed and that the offloading boots were a nursing measure, but, if used, should have been removed every shift to assess the skin under the offloading boots. She identified that if the skin had been assessed every shift, the wound could have been prevented or less severe.Interview with MD #2 on 3/25/26 at 12:35 PM identified when he assessed Resident #1's left dorsal foot wound on 9/25/25, he estimated the wound existed for at least a week prior and it was highly unlikely the area opened and slough developed from the last skin check on 9/21/25 to 9/25/25 when he assessed the wound. He identified he had seen Resident #1 since his/her admission to the facility and he knew Resident #1 to utilize offloading boots. He identified that if staff had been removing the offloading boots every shift and checking the skin, the area could have been identified sooner which could have prevented progression to a full thickness wound requiring Santyl.Interview with the ADON on 3/25/26 at 12:45 PM identified that when she assessed Resident #1 on 9/23/25, she realized the left dorsal foot wound was due to the strap from the offloading boot rubbing on the dorsal aspect of Resident #1's foot but reported there was no slough at that time. She identified there should have been an order in place directing staff to utilize the offloading boots and to remove the offloading boots every shift to perform a skin check. She identified if an order had been in place and completed, the affected area could have been identified prior to an open wound developing.Although attempted, an interview with RN #4 was not obtained.Review of the Pressure Injury Prevention and Management policy (undated) directed, in part, the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals and profession standards of practice, monitor and evaluate the impact of the interventions and revise the approaches as necessary. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of intervention and modifying the interventions as appropriate. Examples of risk factors include: impaired/decreased mobility and decreased functional ability, co-morbid conditions such as end-stage renal disease, thyroid disease or diabetes mellitus, cognitive impairment, under nutrition, malnutrition, and hydration deficits and the presence of previously healed pressure injuries. Interventions will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment. Basic or routine care interventions could include: providing non-irritative surfaces. Although requested, a facility policy for offloading boots was not available.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for allegations of neglect, the facility failed to notify a provider following a dental exam performed at the facility, which identified devastated dentition requiring further intervention, after the follow up visits were scheduled but not conducted or rescheduled at the facility, for six (6) consecutive visits over a period of 6 months. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, Parkinson's disease (a progressive movement disorder of the nervous system), stage 3 chronic kidney disease (mild to moderate loss of kidney function), hypothyroidism, protein-calorie malnutrition and type 2 diabetes mellitus.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition with a staff assessment for mental status conducted which indicated short-term and long-term memory problems with no recall ability and was dependent on staff for personal hygiene, bed mobility and transfers. The MDS identified Resident #1 had three (3) unhealed stage four (4) pressure wounds (pressure ulcers involving full thickness tissue loss with exposed muscles, tendons or bone) that were present on admission. The Resident Care Plan (RCP) dated 8/19/25 identified Resident #1 had oral/dental health problems related to functional impairment limiting the ability to perform oral hygiene and poor oral hygiene. Interventions included providing oral hygiene, inspecting the oral cavity for abscesses, sores, and/or signs and symptoms of infection, and monitoring/documenting/reporting to the provider signs and symptoms of oral/dental problems needing attention.Dental documentation dated 9/25/25 identified a dental cleaning every three (3) months was recommended due to poor oral health and Resident #1 had cavities on every tooth and should have all remaining teeth removed. The documentation identified the teeth were likely infected or a great source of bacteria, Resident #1 would be healthier without the devastated dentition and an FMX (a full mouth series that captures every tooth, root and surrounding bone structure in the mouth) was recommended as dentition was destroyed and x-rays would help in determining the best place to refer the resident.The Dental Group Schedule dated 10/10/25 for the dental hygienist identified Resident #1 was not treated because he/she was 'not on her list when she synced'.The Dental Group Schedule dated 11/13/25 for the dental hygienist identified Resident #1 was not treated because he/she was at the hospital.The Dental Group Schedule dated 1/21/26 for the dental hygienist identified Resident #1 was not treated because he/she was at the hospital.The Dental Group Schedule dated 2/12/26 for the dental hygienist identified Resident #1 was not treated because he/she was at the hospital.Review of the clinical record from 9/25/25 through 3/25/26 failed to identify progress notes regarding Resident #1's dental visit, need for x-rays or dentition, or that the provider was notified of the issues identified during the 9/25/25 visit.Interview with the Director of Social Services on 3/25/26 at 1:45 PM identified she was responsible for managing outside providers who provide services at the facility, including dental services. She reported she ensured residents were added to the list when needed and identified Resident #1 was on the list to be seen but was either at the hospital or the provider did not have time to see Resident #1. She identified Resident #1 was on the list for December 2025 but was not seen by the provider and dental did not go to the facility in March 2026. She reported she saw the 9/25/25 dental note for Resident #1 but did not ensure nursing was aware of the issues. She identified she should have notified nursing for additional follow-up. Interview with the DON on 3/25/26 at 2:14 PM identified she was not made aware of the 9/25/25 dental visit for Resident #1 or the missed hygienist visit on 10/10/25 and although the Dental Group Schedules for 11/13/25, 1/21/26 and 2/12/26 were addressed to her attention, she was unaware Resident #1 missed dental visits from 10/10/25 through 2/12/26. She reported that the Director of Social Services should have notified nursing and a provider of the missed dental visits. The DON identified the facility should have contacted the dental group for follow-up options or reached out to Resident #1's representative to see how he/she wanted to proceed.Interview with APRN #2 on 3/25/26 at 2:44 PM identified she was unaware of the 9/25/25 dental visit note for Resident #1 and should have been notified. She identified that if she were aware she would have evaluated the resident and provided treatment, if necessary, until the resident could be seen by dental. Additionally, she reported that once it was identified that Resident #1 missed the following appointment due to hospitalization, the facility should have followed up with the dental provider or spoken with Resident #1's representative to make alternative follow-up arrangements.Review of the Notification of Changes policy (undated) directed, in part, the facility must inform the resident, consult with the resident's provider and/or notify the resident's family member or legal representative when there's a change requiring such notification such as significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status or circumstances that require a need to alter treatment.Although requested, a facility policy for outside consults and follow-up was not available.

Based on observation, review of facility documentation and interviews, the facility failed to ensure the facility had a process for reconciliation of controlled medications. The findings include:Interview with the ADNS on 3/16/26 at 11:42 AM identified she was responsible for completing the bi-weekly (once every two weeks) controlled medication audits in the facility. Interview with the ADNS on 3/16/26 at 2:07 PM identified her process for the bi-weekly auditing consists of completing a controlled medication count at each of the medication carts with another nurse for verification. The ADNS indicated that when a controlled medication is received, the white controlled medication disposition record (CSDR) is placed with the medication cart with the medication and the yellow copy of the CSDR is placed in a binder located in the ADNS's office. The ADNS further noted that she does not take the binders with the yellow CSDRs with her for the audits. She indicated that she matched the white CSDRs with the yellow CSDRs when the medications are completed or destroyed. The ADNS identified that she was trained to do the audits by the previous DNS and could not identify if the facility had a policy addressing the reconciliation process for controlled medications. The process that the ADNS described does not address how the facility will monitor for the possibility of the diversion (theft) of controlled medications. Observation of the binders containing the yellow CSDRs on 3/16/26 at 2:15 PM identified yellow CSDRs that dated back to 11/21/23. 23 yellow CSDRs with dates from November 2023 through January 2026 were flagged for reconciliation. Interview with the DNS on 3/16/26 at 2:30 PM identified she was responsible for the controlled medication audits but that this process was delegated to the ADNS. The DNS indicated that the ADNS had the responsibility prior to her becoming the DNS and was not aware of the process that was being followed. Interview with the Corporate Representative for Clinical Services and the Administrator on 3/16/2026 at 3:10 PM identified the facility did not have a policy for the controlled medication audits and reconciliation or anything that directs how to do the audits. Interview with the ADNS on 3/16/26 at 4:15 PM identified she was able to reconcile 22 of the 23 flagged controlled medications and could not determine what happened to the Tramadol HCL 50mg (half tablets 25 mg) Quantity of 15 or 30 1/2 tablets received on 11/23/23. The facility did not have a policy that addressed the reconciliation of controlled medications to prevent the possibility of drug diversion.

Based on observation, review of facility documentation, review of facility policy, and interviews during a review of the Infection Control Program, the facility failed to ensure that the laundry room had a cleaning schedule to protect linens from dust and soil, the facility failed to ensure infection surveillance data collection reports and analysis of infection trends within the facility were completed monthly, the facility failed to ensure the MDRO tracking sheet accurately reflects residents MDRO infection status, and the facility failed to ensure outbreaks were tracked and exposure investigations completed per facility policy. The findings include: During a tour of the laundry room on 3/10/26 at 10:30 AM with the Laundry Supervisor, Laundry Attendant #1 and Laundry Attendant #2 the following was identified: Three washers were noted to be heavily coated with greyish dust-like matter on the top and the sides.The walls behind the washers, pipes and plumbing fixtures connected to all three washers were noted to be heavily coated with greyish dust-like matter as the washers were in use.The laundry detergent system area with tubes connected and supplying the washers with detergent noted to be heavily coated with a whiteish dust-like matter while the washer was in use. Each of the three washers were in use and contained two filters locating on the left side and front facing towards the back of the washers, identified each filter to be covered with a thick coating of greyish dust-like matter, with a sign below each filter along with an arrow pointing towards the filter which read to clean filter daily.Four ceiling lights in the solid laundry area heavily coated with a thick coating of whiteish dust-like matter.Four ceiling lights in the clean area heavily coated with a thick coating of whiteish dust-like matter over uncovered clean linen A heating/cooling wall unit above the window heavily coated with a thick coating of whiteish dust-like matter over uncovered clean linen A metal fan which is extended down from the ceiling with the blades on the fan itself was coated with a greyish dust-like matter. Interview with the Laundry Attendant #1 and #2 on 3/10/26 on 10:30 AM identified they don't have a cleaning schedule for cleaning of the laundry room. Laundry Attendant #2 identified that she sanitizes the outside of the dryers, empty the lint trays in the dryer and clean the floor daily. Interview with the Laundry Supervisor on 3/10/26 at 10:35 AM identified she became the supervisor for the laundry three months ago and there is no actual cleaning schedule for the laundry room, their practice is to clean the laundry room daily. She further identified she was unable to locate any prior cleaning schedules before she started working as the supervisor. She identified there is another Laundry Attendant who is currently out who cleaned the filters on the washers, and she does not know how often it should be cleaned because it was done by the staff person who is current out of work for almost two weeks. She further identified that they should have a cleaning schedule but had not gotten around developing a cleaning schedule since she started working as the supervisor. The Laundry Supervisor identified the staff are responsible for the dusting as they have a duster with an extended head which can be used to clean the ceiling lights, pipes, fans, cooling system on the wall, but the metal fan is done by the maintenance department as it requires the use of a ladder in order to reach it for cleaning. Interview on 3/13/26 at 10:11 AM with the ADNS (overseeing the Infection Control Program) and RN #4 identified the laundry room, especially in the clean linen area, should not have dust as the dust particles could fall on the linens and could cause respiratory illnesses and allergies. A request for a laundry cleaning policy was made but not provided. In an interview with the Laundry Supervisor on 3/13/26 at 9:38 AM identified she does not have such a policy, but it is the practice that the laundry is cleaned daily and has created a laundry cleaning schedule subsequently to the inquiry and observations. Review of the infection control program for the period of June 2024 to February 2026 with the Infection Preventionist in training (RN #4), the ADNS who oversees the program and RN #5 (who is currently mentoring RN #4) on 3/11/26 at 1:09 PM failed to provide documentation that identifies monthly surveillance infection reports were completed for the period of June 2024 through April 2025 and for the period of January 2026 through February 2026. In addition, the facility failed provided documentation that identifies monthly analysis of infection trends/rates for the period of October 2024 through April 2025 and for the period of January 2026 through February 2026. Interview on 3/11/26 at 1:09 PM with RN #5 in the presence of the ADNS and RN #4 identified infection surveillance and analysis is completed monthly by the Infection Preventionist (IP) nurse. He identified that the IP nurse's role as it relates to the surveillance is to check if the nurse on the unit completes the infection screening in the evaluation section of the electronic medication records when an infection is suspected and if it is not completed the IP would then complete the screening. After the infection screening evaluation is completed, it will then trigger on the infection board for the IP nurse to review and complete any missing information. He further identified the facility uses McGeer's criteria (a standardized tool used to define an infection) which is automatically built into the computer system to identify if the infection meets criteria immediately. RN #5 identified that at the end of each month he obtains a report from the electronic medical record system, which provides numbers and percentages that he then reviews to check for accuracy and trends. After which, he completes a report which provides the rate of infection based on the type of infection, unit, how it was acquired, precautions, and antibiotics. He noted that he then uses a graph to show month to month trends, and when the trends are identified he figures out the cause of the trend to implement the appropriate interventions which are documented in the report along with the rates. He identified that he had RN #4 come to his facility where he showed her what needed to be completed. The ADNS and RN #4 identified that what RN #5 explained is what should be done; however, it is not being done. RN #4 identified she had printed the report for January 2026 and after visiting RN #5 in late February 2026 she had started to review the report as there was missing and incomplete information causing an inaccurate rate of infections. The ADNS identified that she is new to the role of overseeing RN #4 as she had only started in January of 2026 and is not familiar with the facility's infection practice and policies and is learning as well.Interview on 3/13/26 at 10:11 AM with the ADNS and RN #4 identified they were unable to locate any documentation of monthly infection surveillance that was completed for June 2024 through April 2025 and for the period of January 2026 through February 2026, and monthly analysis of infection trends/rates for the period of October 2024 through April 2025 and for the period of January 2026 through February 2026. Interview with the ADNS and RN #4 on 3/16/25 at 12:25 PM identifies RN #4 provided an Infection Surveillance Report obtained from the electronic medical record system for the period of March 13, 2024, through December 31, 2024, which was incomplete and only contained information from March 2024 through September 2024. RN #4 identified it had incomplete information in various columns such as: sign and symptoms, infection, pharmacy order, and comments, as it is not completed based on how RN #5 explained the reports should be completed. Review of the Infection Surveillance policy identifies the infection preventionist serve as the leader in surveillance activities. The policy further identifies the facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: the data to be collected, including how often and the type of data to be documented including: the infection site, pathogen (if available), signs and symptoms, residents location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections and the identification of unusual or unexpected outcomes, infection trends and patterns. The policy also identifies monthly time periods will be used for capturing and reporting data, line charts will be used to show data comparisons over time and will be monitored for trends. Review of the MDRO Tracking Sheet for the period of June 2024 to February 2026 with the Infection Preventionist in training (RN #4), the ADNS who oversees the program and RN #5 (who is currently mentoring RN #4) on 3/11/26 at 1:09 PM failed to identify the current MDRO infection status of residents within the facility. Reviewing the tracking sheet provided by the facility with the ADNS and RN #4 identified for the year 2026 the tracking sheet indicated that the facility only has 3 residents with MDRO, and the sheet also included each resident site of infection, type of MDRO, antibiotic treatment and isolation type. The ADNS identified the list provided are resident who had an MDRO that was treated in the facility. The ADNS identified there are at least 2 other residents that should have been added to the list who have a history of a MDRO. The ADNS identified that she was unable to locate a MDRO tracking sheet for 2024 and that the MDRO tracking sheet needed to include residents with both active and colonized MDRO infection, and the list should be updated when the resident status changes from active to colonized and whether the resident still resides in the facility. Review of the MDRO Infection policy identified the facility implements facility-wide strategies for preventing the spread of infections with multidrug-resistant organisms. Review of the State Survey Agency's reporting system identified the facility reported an influenza outbreak on 12/15/26. Further review of the outbreak reported identified on the line list identified one resident affected 1/13/26, another resident on 1/16/26 along with 3 staff members who tested positive for influenza on 1/16/26, 2/17/26 and 2/20/26. Review of the infection control program with the Infection Preventionist in training (RN #4), the ADNS who oversees the program and RN #5 (who is currently mentoring RN #4) on 3/11/26 at 1:09 PM identified the facility last outbreak was influenza which was initiated on January 19, 2026 involving one resident, as the other resident was community acquired and it was reported to the State Survey Agency by the DNS. RN #4 identified she was unaware of the staff members who were positive and the ADNS identified she was only aware of one staff member. They identified when a positive case is identified contact tracing or an exposure investigation should be initiated to prevent the spread, however it was not completed as they were not aware of the staff members who tested positive for the influenza virus. Interview with the DNS on 3/11/26 at 1:50 PM identified she was responsible for reporting outbreaks to the State Agency and updating the agency when there are new cases and when the outbreak is closed with a summary. The DNS identified she had kept adding the new cases to the already opened outbreak for influenza and could not recall informing the ADNS and RN #4 of the other positive cases. The DNS identified they should have been informed so that the exposure investigation could have been completed. Review of the Infection Outbreak Response and Investigation policy the facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. The policy further identified a line list about each person affected by the outbreak will be maintained.

Based on facility documentation, review of facility policy, and interviews, the facility failed to have a consistent designated Infection Preventionist (IP) with the required specialized training in infection control, that was responsible for the facility's Infection Control Program in 2024, 2025 and 2026. The findings include:Interview with the ADNS and RN #4 on [DATE] at 1:09 PM identified RN #4 was hired as the full time Infection Preventionist nurse for the facility in [DATE] and she is currently completing the specialized Infection Preventionist training course for nursing homes to receive her certification. The ADNS identified she had only been responsible for overseeing the infection control program in [DATE] and had completed all the modules for the Infection Preventionist specialized training in the year 2020 and will provide the certificate. A request was made on [DATE] for the previous Infection Preventionist (IP) nurse certification. The facility provided on [DATE] a list of IP nurses who worked as the IP in the building from [DATE] to [DATE]. The document identified LPN #11 had a certificate that indicated she had completed the IP training course on [DATE] and worked at the facility as the Infection Preventionist from [DATE] through [DATE]; RN #8 had a certificate that indicated she had completed the IP training course on [DATE] and worked at the facility as the IP nurse from [DATE] through [DATE] and RN #9 had a certificate that indicated she had completed the IP training course on [DATE] and worked as the IP nurse from [DATE] through [DATE]. The document provided failed to identify that the facility had an Infection Preventionist who had received specialized training certification working at the facility for the periods from [DATE] through April of 2025, and from [DATE] through [DATE]. Review of the infection control program on [DATE] at 10:11 AM with the ADNS and RN #4 failed to identify a MDRO tracking list for the year 2024, unable to provide any documentation that monthly infection surveillance and analysis of infections in the facility and antibiotic stewardship surveillance were completed for the period of [DATE] through [DATE], in complete documentation for [DATE], and for the period of [DATE] to February 2026. The ADNS identified the IP nurse was responsible for ensuring the infection surveillance and analysis was completed, however the facility had nobody working in the role of the IP nurse during some of the timeframe. Interview and review of the documents and certification on [DATE] at 3:30 PM with the Administrator identified the facility had gaps where the facility had no Infection Preventionist nurse and they were unable to find someone to fill the position. She further identified that the facility had job posting for the position and they were doing the best they can. She further identified the former DNS (RN #9) worked as the DNS and would also cover the IP nurse and will get her hire date of the DNS. Interview with the ADNS on [DATE] and RN #4 at 12:25 PM identified she had completed the modules but does not have the certificate of completion as she had done the modules a while now in 2020. The ADNS provided a document that indicated that the end of training plan verification and CE information expired since [DATE], at 11:59 PM. Review of the documents provided and interview with the Administrator on [DATE] at 1:00 PM identified a on the job posting document which indicated that the facility first posted an open position for the Infection Preventionist nurse on [DATE] and had made changes to the posting on various times. The Administrator further identified that the ADNS had completed her training and had the paperwork. The Administrator further identified that RN #9 worked as the DNS from [DATE] through [DATE]. However, the facility failed to provide the certificate that certifies that the ADNS had completed the Nursing Home Infection Preventionist training course, which would include the date the certificate was awarded and the number of contact hours. In addition, the documentation provided by the facility identified that RN #9 did not receive her infection preventionist certification until [DATE] and was working as the DNS prior and after, until [DATE] when she took on the role as the facility's infection preventionist nurse. A request for a policy regarding having a designated Infection Preventionist with specialized training was not provided.

Based on clinical record review, facility policy review and interviews for one of three sample residents (Resident #119) reviewed for resident-to-resident sexual abuse, the facility failed to ensure the resident was free from inappropriate sexual conduct. The findings include:Resident #119 had diagnoses that included dementia without behavioral disturbances, anxiety, and depression.The quarterly MDS assessment dated [DATE] identified Resident #119 had severe cognitive impairment, required extensive assistance with toileting, personal hygiene, dressing, and transfers, it further noted the resident utilized a rolling walker and a wheelchair for mobility.The Resident Care Plan (RCP) dated 12/19/25 identified Resident #119 verbalized the desire to be intimate with his/her partner as evidence by kissing and hand holding. The care plan interventions directed to provide psychiatric consultation as indicated, report any changes or concern to the physician, provide a safe and/or private are for intimacy, and one-to-one visits with social worker as needed.The psychiatrist progress note dated 2/19/26 identified Resident #119 was being followed for medication management and behavioral assessment in the context of the diagnoses of dementia and anxiety. The note further identified Resident #119's dementia was progressive but stable and he/she continues to have poor short-term memory, wanders around the facility but has not been exit seeking, is very social and pleasant toward other residents. There is no safety concerns reported.The late entry social worker progress note dated 3/1/26 at 11:30 AM identified that he/she was notified that a resident was observed displaying physical affection toward Resident #119 while in the recreation room. Staff immediately intervened and re-directed both residents. The note further identified that she (social worker) had assessed Resident #119's emotional status following the interaction, and Resident #119 had not exhibited any signs of distress at the time. A follow-up assessment was completed and reinforcement of appropriate boundaries and resident rights. The note further noted that social services would continue to monitor and provide support as needed.Interview with Person #1 (Resident #119's responsible party) on 3/11/26 at 12:10 PM identified that the nursing staff called on 3/1/26 to inform him/her that a resident had touched Resident #119's chest in the recreation room. Person #1 identified that Resident #119 has impaired cognition and often does not recognize him/her during visits. Person #1 described Resident #119 as very social and tactile but emphasized that Resident #119 did not give permission for inappropriate touching of his/her body. Resident #31 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, depression, and dysarthria.The annual MDS assessment dated [DATE] identified Resident #31 had intact cognition and required extensive assistance for toileting, personal hygiene, dressing, transfers, and ambulation.The care plan dated 12/6/25 identified Resident #31 had a behavioral problem as evidence by verbal outbursts, yelling at staff, accusatory toward staff, refusing food, medications and fluids. Care plan interventions directed to administer medication as ordered, analyze the key times, places, circumstances, triggers, de-escalate behavior, evaluate, review, and document behavior per protocol. Care plan interventions further noted that Resident #31 preferred to sit alone while in the dining room, and psychiatric follow up as needed.LPN #1's nursing note dated 3/1/26 at 9:04 PM identified that RA #1 reported Resident #31 was in the recreation room alone with Resident #119 while staff were transporting other residents to the recreation room. RA #1 observed Resident #31 touching the breast of Resident #119 when she entered the recreation room. Resident #119 was removed from the recreation room. Resident #31 confirmed that he/she touched Resident #119's breast and had stated that he/she was just an old man and laughed it off. She identified that she educated Resident #31 not to touch other residents because not all residents have the same understanding. The family, the APRN and the Nursing supervisor were made aware of the incident.A late entry social worker progress note written on 3/2/26 for 3/1/26 at 11:30 AM identified that Resident #31 perceived the interaction with Resident #119 as mutual. She provided education to Resident #31 regarding appropriate boundaries, consent, and the need to respect the rights and personal space of other residents. Resident #31 verbalized understanding, was receptive to redirection and apologized to SW #1 regarding the incident. The psychiatric progress note dated 3/3/26 identified Resident #31 acknowledged his/her behavior and reported that Resident #119 did not mind. Resident #31 stated it would not happen again and that this was the first such incident. A mental status exam identified Resident #31 was alert, pleasant and cooperative with speech and language within normal limits; thought process coherent, goal directed and insight and judgment fair.Interview with Resident #31 on 3/11/26 at 10:30 AM identified that while seated with Resident #119 in the recreation room, he/she touched Resident #119's breast. Resident #31 identified he/she told Resident #119 that he/she had nice breasts but could not recall whether Resident #119 had given permission to be touched. Interview with LPN #3 on 3/10/26 at 12:25 PM identified that Recreation Aide (RA #1) observed Resident #31 inappropriately touch Resident #119's breast while both residents were seated together in the recreation room on 3/1/26 and immediately reported the incident. She further noted that when questioned, Resident #31 admitted to touching Resident #119's breast. LPN #3 further noted that she provided education to Resident #31 about inappropriate touching and the need to respect boundaries, especially since not all residents can give consent. Additionally, she identified Resident #119 lacked the capacity to consent due to cognitive impairment. LPN #3 noted that she reported the incident to the nursing supervisor and was instructed not to initiate an Accident and Incident (A&I) report but to notify the APRN and the resident's family.Interview with SW #1 on 3/10/26 at 1:10 PM identified that RA #1 notified her via email about inappropriate touching between Resident #31 and Resident #119. SW #1 identified that on 3/1/26, RA #1 observed Resident #31 rubbing Resident #119's breast area in the recreation room and immediately removed Resident #119 from the area. SW #1 identified that she spoke with Resident #31, who believed Resident #119 had given permission to be touched. SW #1 provided education to Resident #31 about respecting personal boundaries and personal space. SW #1 further identified that Resident #119 could not give consent due to impaired cognition.Interview with RN #3 (weekend nursing supervisor) on 3/10/26 at 2:30 PM identified LPN #3 notified her of the incident of inappropriate touching involving Resident #31 and Resident #119. RN #3 identified she had not notified the nursing administration, nor initiated an investigation or filed an A&I report because she did not want to escalate the matter. Interview the Administrator in the presence of the DNS on 3/11/26 at 1:30 PM identified that they had not received any calls from nursing staff regarding a potential sexual abuse incident between Resident #31 and Resident #119 on 3/1/26. They were informed of the incident the next day. The Administrator indicated that when a potential reportable incident occurs, the nursing supervisor, DNS, and Administrator initiate an investigation, obtains statements from staff, and reports the incident to the state survey agency if required. The Administrator reported that she instructed the social worker to speak with both residents. The Administrator further identified that the facility had not investigated the alleged sexual contact between the two residents because Resident #119 has a documented history of seeking physical contact and relationships with other residents and had a care plan in place to address this behavior. She identified that Resident #119 can verbalize needs and wants, and it is the resident's right to decide whether he/she consents to being touched. She further identified that she was unsure whether Resident #119 had been evaluated by the psychiatrist to determine whether the resident could give consent to engage in sexual activity. Interview with RA #1 on 3/12/26 at 1:00 PM identified that on 3/1/26 she observed Resident #31's left hand beneath Resident #119's armpit, rubbing the chest/breast area while both were seated in the recreation room. She identified this was her first time witnessing such behavior and she immediately removed Resident #119 from the recreation room and reported the incident to LPN #3. RA#1 said she was transporting other residents to the recreation room when she observed the incident.The facility Abuse, Neglect and Exploitation policy states that the facility will establish and maintain a safe environment that, to the extent possible, supports residents' consensual sexual relationships while implementing policies and protocols to prevent sexual abuse. Policies will specify when, how, and by whom determinations of capacity to consent to sexual contact will be made and where those determinations will be documented. The policy will also affirm the resident's right to form and maintain relationships with other individuals.

Based on clinical record review, facility policy review and interviews for one of three sample residents (Resident #119) reviewed for sexual abuse, the facility failed to report allegation of sexually inappropriate behavior between two residents to the state survey agency. The findings include:Resident #119 had diagnoses that included dementia without behavioral disturbances, anxiety, and depression.The quarterly MDS assessment dated [DATE] identified Resident #119 had severe cognitive impairment, required extensive assistance with toileting, personal hygiene, dressing, and transfers, it further noted the resident utilized a rolling walker and a wheelchair for mobility.The Resident Care Plan (RCP) dated 12/19/25 identified Resident #119 verbalized the desire to be intimate with his/her partner as evidence by kissing and hand holding. The care plan interventions directed to provide psychiatric consultation as indicated, report any changes or concern to the physician, provide a safe and/or private are for intimacy, and one-to-one visits with social worker as needed.The psychiatrist progress note dated 2/19/26 identified Resident #119 was being followed for medication management and behavioral assessment in the context of the diagnoses of dementia and anxiety. The note further identified Resident #119's dementia was progressive but stable and he/she continues to have poor short-term memory, wanders around the facility but has not been exit seeking, is very social and pleasant toward other residents. There is no safety concerns reported.The late entry social worker progress note dated 3/1/26 at 11:30 AM identified that he/she was notified that a resident was observed displaying physical affection toward Resident #119 while in the recreation room. Staff immediately intervened and re-directed both residents. The note further identified that she (social worker) had assessed Resident #119's emotional status following the interaction, and Resident #119 had not exhibited any signs of distress at the time. A follow-up assessment was completed and reinforcement of appropriate boundaries and resident rights. The note further noted that social services would continue to monitor and provide support as needed.Interview with Person #1 (Resident #119's responsible party) on 3/11/26 at 12:10 PM identified that the nursing staff called on 3/1/26 to inform him/her that a resident had touched Resident #119's chest in the recreation room. Person #1 identified that Resident #119 has impaired cognition and often does not recognize him/her during visits. Person #1 described Resident #119 as very social and tactile but emphasized that Resident #119 did not give permission for inappropriate touching of his/her body. Resident #31 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, depression, and dysarthria.The annual MDS assessment dated [DATE] identified Resident #31 had intact cognition and required extensive assistance for toileting, personal hygiene, dressing, transfers, and ambulation.The care plan dated 12/6/25 identified Resident #31 had a behavioral problem as evidence by verbal outbursts, yelling at staff, accusatory toward staff, refusing food, medications and fluids. Care plan interventions directed to administer medication as ordered, analyze the key times, places, circumstances, triggers, de-escalate behavior, evaluate, review, and document behavior per protocol. Care plan interventions further noted that Resident #31 preferred to sit alone while in the dining room, and psychiatric follow up as needed.LPN #1's nursing note dated 3/1/26 at 9:04 PM identified that RA #1 reported Resident #31 was in the recreation room alone with Resident #119 while staff were transporting other residents to the recreation room. RA #1 observed Resident #31 touching the breast of Resident #119 when she entered the recreation room. Resident #119 was removed from the recreation room. Resident #31 confirmed that he/she touched Resident #119's breast and had stated that he/she was just an old man and laughed it off. She identified that she educated Resident #31 not to touch other residents because not all residents have the same understanding. The family, the APRN and the Nursing supervisor were made aware of the incident.A late entry social worker progress note written on 3/2/26 for 3/1/26 at 11:30 AM identified that Resident #31 perceived the interaction with Resident #119 as mutual. She provided education to Resident #31 regarding appropriate boundaries, consent, and the need to respect the rights and personal space of other residents. Resident #31 verbalized understanding, was receptive to redirection and apologized to SW #1 regarding the incident. The psychiatric progress note dated 3/3/26 identified Resident #31 acknowledged his/her behavior and reported that Resident #119 did not mind. Resident #31 stated it would not happen again and that this was the first such incident. A mental status exam identified Resident #31 was alert, pleasant and cooperative with speech and language within normal limits; thought process coherent, goal directed and insight and judgment fair.Interview with Resident #31 on 3/11/26 at 10:30 AM identified that while seated with Resident #119 in the recreation room, he/she touched Resident #119's breast. Resident #31 identified he/she told Resident #119 that he/she had nice breasts but could not recall whether Resident #119 had given permission to be touched. Review of the state survey agency's online reporting portal on 3/10/26 at 10:30 AM failed to identify that the facility submitted a reportable event involving inappropriate touching behavior between Resident #31 and Resident #119. The facility failed to report the incident within two hours of the allegation of abuse. Interview with LPN #3 on 3/10/26 at 12:25 PM identified that Recreation Aide (RA #1) observed Resident #31 inappropriately touch Resident #119's breast while both residents were seated together in the recreation room on 3/1/26 and immediately reported the incident. She further noted that when questioned, Resident #31 admitted to touching Resident #119's breast. LPN #3 further noted that she provided education to Resident #31 about inappropriate touching and the need to respect boundaries, especially since not all residents can give consent. Additionally, she identified Resident #119 lacked the capacity to consent due to cognitive impairment. LPN #3 noted that she reported the incident to the nursing supervisor and was instructed not to initiate an Accident and Incident (A&I) report but to notify the APRN and the resident's family.Interview with SW #1 on 3/10/26 at 1:10 PM identified that RA #1 notified her via email about inappropriate touching between Resident #31 and Resident #119. SW #1 identified that on 3/1/26, RA #1 observed Resident #31 rubbing Resident #119's breast area in the recreation room and immediately removed Resident #119 from the area. SW #1 identified that she spoke with Resident #31, who believed Resident #119 had given permission to be touched. SW #1 provided education to Resident #31 about respecting personal boundaries and personal space. SW #1 further identified that Resident #119 could not give consent due to impaired cognition.Interview with RN #3 (weekend nursing supervisor) on 3/10/26 at 2:30 PM identified LPN #3 notified her of the incident of inappropriate touching involving Resident #31 and Resident #119. RN #3 identified she had not notified the nursing administration, nor initiated an investigation or filed an A&I report because she did not want to escalate the matter. Interview the Administrator in the presence of the DNS on 3/11/26 at 1:30 PM identified that they had not received any calls from nursing staff regarding a potential sexual abuse incident between Resident #31 and Resident #119 on 3/1/26. They were informed of the incident the next day. The Administrator indicated that when a potential reportable incident occurs, the nursing supervisor, DNS, and Administrator initiate an investigation, obtains statements from staff, and reports the incident to the state survey agency if required. The Administrator reported that she instructed the social worker to speak with both residents. The Administrator further identified that the facility had not investigated the alleged sexual contact between the two residents because Resident #119 has a documented history of seeking physical contact and relationships with other residents and had a care plan in place to address this behavior. She identified that Resident #119 can verbalize needs and wants, and it is the resident's right to decide whether he/she consents to being touched. She further identified that she was unsure whether Resident #119 had been evaluated by the psychiatrist to determine whether the resident could give consent to engage in sexual activity. After surveyor inquiry regarding the reportable event on 03/11/26, the facility still had not submitted a reportable event through the FLIS online reporting portal, as the Administrator indicated that the incident was not considered a reportable event.Interview with RA #1 on 3/12/26 at 1:00 PM identified that on 3/1/26 she observed Resident #31's left hand beneath Resident #119's armpit, rubbing the chest/breast area while both were seated in the recreation room. She identified this was her first time witnessing such behavior and she immediately removed Resident #119 from the recreation room and reported the incident to LPN #3. RA#1 said she was transporting other residents to the recreation room when she observed the incident.The facility Abuse, Neglect, and Exploitation policy requires that all alleged violations be reported to the administrator, state agency, Adult Protective Services, and other required agencies (including law enforcement when applicable) within specified timeframes. Reports must be made immediately but no later than 2 hours after the allegation if the event involves abuse or results in serious bodily injury. If the event does not involve abuse and does not result in serious bodily injury, the report must be made no later than 24 hours after the allegation. The administrator and/or DNS must follow up with the government agency during business hours to confirm receipt of the initial report and must report the final investigation results to the agency within 5 working days of the incident, as required by state agencies.

Based on clinical record review, facility policy review and interviews for one of three sample residents (Resident #119) reviewed for sexual abuse, the facility failed to conduct a timely and comprehensive investigation involving an inappropriate sexual behavior between two residents and failed to put measures in place to prevent the recurrence of the inappropriate behavior with Resident #119 and other residents. The findings include: Resident #119 had diagnoses that included dementia without behavioral disturbances, anxiety, and depression.The quarterly MDS assessment dated [DATE] identified Resident #119 had severe cognitive impairment, required extensive assistance with toileting, personal hygiene, dressing, and transfers, it further noted the resident utilized a rolling walker and a wheelchair for mobility.The Resident Care Plan (RCP) dated 12/19/25 identified Resident #119 verbalized the desire to be intimate with his/her partner as evidence by kissing and hand holding. The care plan interventions directed to provide psychiatric consultation as indicated, report any changes or concern to the physician, provide a safe and/or private are for intimacy, and one-to-one visits with social worker as needed.The psychiatrist progress note dated 2/19/26 identified Resident #119 was being followed for medication management and behavioral assessment in the context of the diagnoses of dementia and anxiety. The note further identified Resident #119's dementia was progressive but stable and he/she continues to have poor short-term memory, wanders around the facility but has not been exit seeking, is very social and pleasant toward other residents. There is no safety concerns reported.The late entry social worker progress note dated 3/1/26 at 11:30 AM identified that he/she was notified that a resident was observed displaying physical affection toward Resident #119 while in the recreation room. Staff immediately intervened and re-directed both residents. The note further identified that she (social worker) had assessed Resident #119's emotional status following the interaction, and Resident #119 had not exhibited any signs of distress at the time. A follow-up assessment was completed and reinforcement of appropriate boundaries and resident rights. The note further noted that social services would continue to monitor and provide support as needed.Interview with Person #1 (Resident #119's responsible party) on 3/11/26 at 12:10 PM identified that the nursing staff called on 3/1/26 to inform him/her that a resident had touched Resident #119's chest in the recreation room. Person #1 identified that Resident #119 has impaired cognition and often does not recognize him/her during visits. Person #1 described Resident #119 as very social and tactile but emphasized that Resident #119 did not give permission for inappropriate touching of his/her body. Resident #31 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, depression, and dysarthria.The annual MDS assessment dated [DATE] identified Resident #31 had intact cognition and required extensive assistance for toileting, personal hygiene, dressing, transfers, and ambulation.The care plan dated 12/6/25 identified Resident #31 had a behavioral problem as evidence by verbal outbursts, yelling at staff, accusatory toward staff, refusing food, medications and fluids. Care plan interventions directed to administer medication as ordered, analyze the key times, places, circumstances, triggers, de-escalate behavior, evaluate, review, and document behavior per protocol. Care plan interventions further noted that Resident #31 preferred to sit alone while in the dining room, and psychiatric follow up as needed.LPN #1's nursing note dated 3/1/26 at 9:04 PM identified that RA #1 reported Resident #31 was in the recreation room alone with Resident #119 while staff were transporting other residents to the recreation room. RA #1 observed Resident #31 touching the breast of Resident #119 when she entered the recreation room. Resident #119 was removed from the recreation room. Resident #31 confirmed that he/she touched Resident #119's breast and had stated that he/she was just an old man and laughed it off. She identified that she educated Resident #31 not to touch other residents because not all residents have the same understanding. The family, the APRN and the Nursing supervisor were made aware of the incident.A late entry social worker progress note written on 3/2/26 for 3/1/26 at 11:30 AM identified that Resident #31 perceived the interaction with Resident #119 as mutual. She provided education to Resident #31 regarding appropriate boundaries, consent, and the need to respect the rights and personal space of other residents. Resident #31 verbalized understanding, was receptive to redirection and apologized to SW #1 regarding the incident. The psychiatric progress note dated 3/3/26 identified Resident #31 acknowledged his/her behavior and reported that Resident #119 did not mind. Resident #31 stated it would not happen again and that this was the first such incident. A mental status exam identified Resident #31 was alert, pleasant and cooperative with speech and language within normal limits; thought process coherent, goal directed and insight and judgment fair.Interview with Resident #31 on 3/11/26 at 10:30 AM identified that while seated with Resident #119 in the recreation room, he/she touched Resident #119's breast. Resident #31 identified he/she told Resident #119 that he/she had nice breasts but could not recall whether Resident #119 had given permission to be touched. Review of the facility's investigation records identified that, although a reportable event investigation was requested on 3/10/26, the facility did not initiate or begin an investigation into the reportable event that occurred on 3/1/26. The facility failed to follow its own abuse policy, which states that the facility will immediately investigate when there is a report of sexual abuse. The policy requires the investigation to include interviews with all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with relevant information, and must include complete and thorough documentation of findings and actions taken. Review of Resident #31's care plan failed to identify that the care plan had been updated to address the newly developed behavior to ensure other residents were protected from inappropriate touching. Interview with LPN #3 on 3/10/26 at 12:25 PM identified that Recreation Aide (RA #1) observed Resident #31 inappropriately touch Resident #119's breast while both residents were seated together in the recreation room on 3/1/26 and immediately reported the incident. She further noted that when questioned, Resident #31 admitted to touching Resident #119's breast. LPN #3 further noted that she provided education to Resident #31 about inappropriate touching and the need to respect boundaries, especially since not all residents can give consent. Additionally, she identified Resident #119 lacked the capacity to consent due to cognitive impairment. LPN #3 noted that she reported the incident to the nursing supervisor and was instructed not to initiate an Accident and Incident (A&I) report but to notify the APRN and the resident's family.Interview with SW #1 on 3/10/26 at 1:10 PM identified that RA #1 notified her via email about inappropriate touching between Resident #31 and Resident #119. SW #1 identified that on 3/1/26, RA #1 observed Resident #31 rubbing Resident #119's breast area in the recreation room and immediately removed Resident #119 from the area. SW #1 identified that she spoke with Resident #31, who believed Resident #119 had given permission to be touched. SW #1 provided education to Resident #31 about respecting personal boundaries and personal space. SW #1 further identified that Resident #119 could not give consent due to impaired cognition.Interview with RN #3 (weekend nursing supervisor) on 3/10/26 at 2:30 PM identified LPN #3 notified her of the incident of inappropriate touching involving Resident #31 and Resident #119. RN #3 identified she had not notified the nursing administration, nor initiated an investigation or filed an A&I report because she did not want to escalate the matter. Interview the Administrator in the presence of the DNS on 3/11/26 at 1:30 PM identified that they had not received any calls from nursing staff regarding a potential sexual abuse incident between Resident #31 and Resident #119 on 3/1/26. They were informed of the incident the next day. The Administrator indicated that when a potential reportable incident occurs, the nursing supervisor, DNS, and Administrator initiate an investigation, obtains statements from staff, and reports the incident to the state survey agency if required. The Administrator reported that she instructed the social worker to speak with both residents. The Administrator further identified that the facility had not investigated the alleged sexual contact between the two residents because Resident #119 has a documented history of seeking physical contact and relationships with other residents and had a care plan in place to address this behavior. She identified that Resident #119 can verbalize needs and wants, and it is the resident's right to decide whether he/she consents to being touched. She further identified that she was unsure whether Resident #119 had been evaluated by the psychiatrist to determine whether the resident could give consent to engage in sexual activity. After the surveyor inquiry regarding the reportable event investigation on 3/11/26, the facility did not initiate an investigation, as the Administrator indicated that the incident was not considered a reportable event. Further, the Administrator and the DNS could not identify what measures were put in place to prevent this behavior from recurring with Resident #119 and/or to protect other residents from this behavior. Interview with RA #1 on 3/12/26 at 1:00 PM identified that on 3/1/26 she observed Resident #31's left hand beneath Resident #119's armpit, rubbing the chest/breast area while both were seated in the recreation room. She identified this was her first time witnessing such behavior and she immediately removed Resident #119 from the recreation room and reported the incident to LPN #3. RA#1 said she was transporting other residents to the recreation room when she observed the incident.The facility Abuse, Neglect and Exploitation policy requires an immediate investigation when there is suspicion or a report of abuse, neglect, or exploitation. The investigation must identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and any others with relevant knowledge, and must include complete, thorough documentation of findings and actions taken.

Based on observation, review of clinical records, review of facility policy review, and staff interviews for two of three sampled residents (Resident #20 and #115) reviewed for facility acquired pressure ulcers, the facility failed to ensure that Braden Scale assessments were completed in accordance with the facility's policy, documentation of turning and repositioning, failed to ensure that a comprehensive pressure ulcer assessment was completed once the pressure ulcer was identified and failed to ensure timely treatment orders were put in place. The findings include:Resident #115 was re-admitted to the facility on [DATE] with diagnoses that included peripheral venous insufficiency, pneumonia, anemia, chronic venous hypertension with other complication of bilateral lower extremity. The Braden Scale assessment (used to predict the risk of pressure ulcer development) dated 8/5/25 identified Resident #115 had a score of 16 which indicate a low risk to develop a pressure ulcer. The physician's order dated 8/5/25 directed staff to apply skin prep to both heels twice daily, with instructions to observe for discoloration, pain, or any open areas, and to notify the physician of any changes. The order also directed staff to ensure the resident was turned and repositioned every two hours and that a pressure reducing mattress was in place whenever the resident was lying in bed. The Resident Care Plan (RCP) dated 9/2/25 identified that Resident #115 had an alteration in skin integrity related to moisture associated skin damage. The care plan interventions included repositioning the resident every two hours, administering treatments as ordered by the physician, providing incontinence care every two hours, and applying barrier cream as needed. The quarterly MDS assessment dated [DATE] identified that Resident #115 had severe cognitive impairment and required extensive assistance with toileting, personal hygiene, dressing, and transfers, and was non ambulatory. The assessment further indicated that the resident had an indwelling catheter, was always incontinent of bowel, and was at risk for the development of pressure ulcers but had no pressure ulcers at that time. Review of Resident #115's clinical record identified that the required quarterly Braden Scale assessment had not been completed. The Braden Scale assessment should have been completed prior to the quarterly MDS assessment dated [DATE]. The quarterly MDS assessment dated [DATE] identified that Resident #115 had severe cognitive impairment and required extensive assistance with toileting, personal hygiene, dressing, and transfers, and was non ambulatory. The assessment further indicated that the resident had an indwelling catheter, was always incontinent of bowel, and was at risk for the development of pressure ulcers but had no pressure ulcers at that time. Review of Resident #115's clinical record identified that the required quarterly Braden Scale assessment had not been completed. The Braden Scale assessment should have been completed prior to the quarterly MDS assessment dated [DATE]. The nurse's notes dated 1/15/26 at 5:30 PM identified that Resident #115 was noted to have an open wound on the left heel. The resident denied pain or discomfort. The APRN and the resident's family were notified of the open wound. The physician's orders dated 1/15/26 directed staff to cleanse the left heel with normal saline, applied calcium alginate to the wound bed and cover with dry clean dressing daily and as needed when soiled and/or dislodged. Staff had also been directed to offload both heels. The RN #2 (wound nurse) wound assessment dated [DATE] identified that Resident #115 had an open wound to the left heel, which had been classified as a pressure wound. The treatment plan directed staff to cleanse the left heel with normal saline, apply calcium alginate, cover with a dry clean dressing daily, and off load the heels. The wound assessment failed to identify the wound measurement, a description of the wound bed, and/or the stage of the left heel pressure injury. The initial physician's wound consultation dated 1/22/26 identified that Resident #115's left heel wound was evaluated and identified as a Stage 3 pressure injury. The wound was measured as 3.5 centimeters in length, 3.0 centimeters in width, and 0.1 centimeters in depth. The wound base was described as consisting of 25% epithelial tissue, 25% granulation tissue, and 50% eschar. The treatment plan directed staff to cleanse the wound with normal saline, apply Santyl (a chemical debridement agent), followed by calcium alginate to the wound base, and secure with a dry, clean dressing twice daily. The weekly wound physician's progress notes dated 1/29/26 indicated that Resident #115's left heel wound was reclassified as an unstageable pressure injury. The wound measured 4.4 centimeters in length and 4.0 centimeters in width. The wound base was described as consisting of 50% slough and 50% eschar. The treatment plan directed staff to cleanse the wound with normal saline, apply Santyl (a chemical debridement agent), followed by calcium alginate to the wound base, and secure with a dry, clean dressing twice daily. The nurse's notes dated 2/13/26 at 9:39 PM identified that Resident #115 had an X ray of the left foot, which showed no evidence of osteomyelitis or fracture. Arthritis was noted in the left foot. The duplex scan of the left lower extremity, dated 2/28/26, showed decreased velocity in the left dorsalis pedis artery and moderate stenosis in the left lower extremity. This test is a non invasive diagnostic procedure used to visualize blood vessels and measure blood flow. The vascular consultation dated 3/5/26 indicated that Resident #115 had a left heel wound and hazy plaque throughout the arteries of the left leg. The consultation recommended that the resident undergo an angioplasty procedure (a minimally invasive, non surgical procedure used to open a narrowed or blocked blood vessel to restore proper blood flow) and continue offloading the heels. The weekly wound physician's progress notes dated 3/12/26 identified that Resident #115's left heel wound was reclassified as an arterial, full thickness wound. The wound measured 4.5 centimeters in length and 4.5 centimeters in width. The wound base was described as consisting of 25% to 49% granulation tissue, 25% to 49% slough, and 24% eschar. The treatment plan directed staff to cleanse the wound with normal saline, apply Santyl (a chemical debridement agent), followed by calcium alginate to the wound base, and secure with a dry, clean dressing twice daily. The vascular consultation dated 3/13/26 indicated that Resident #115 underwent a left superficial femoral artery angioplasty due to stenosis of the left femoral and tibial arteries. Observation on 3/16/26 at 8:35 AM identified Resident #115 was observed lying in bed on a low air loss mattress with both heels floated using a blue foam heel offloading device. Observation of wound care with LPN #2 and RN #2 on 3/16/26 at 10:40 AM identified Resident #115 was observed lying in bed on a low air loss mattress with both heels floated using a blue foam heel offloading device. The resident had an open wound on the left heel. The wound bed contained black necrotic (dead) tissue and yellow slough (dead) tissue. Interview with RN #2 (wound nurse) on 3/11/26 at 2:45 PM identified that she had been responsible for monitoring all residents' wounds on a weekly basis and for assisting the wound specialist physician during weekly wound rounds. She reported that the charge nurse had notified her on 1/16/26, that Resident #115 had developed an open wound on the left heel. She identified that she had assessed the resident's left heel wound, obtained a treatment order from the APRN, and added the resident to the list for the next wound round with the wound specialist. She acknowledged that she had forgotten to measure the wound and to provide a description of the wound at the time it was reported. She further identified that she does not stage any open wounds until the wound specialist has evaluated and staged them Interview with the DNS on 3/16/26 at 9:00 AM identified that the charge nurse and/or the nursing supervisor is responsible for assessing residents for risk of pressure ulcers. She explained that the facility uses the Braden Scale to determine whether a resident is at risk for pressure ulcer development. She reported that, per facility policy, Braden Scale assessments must be completed upon admission or admission, weekly for four weeks following admission/readmission, quarterly, and whenever a resident experiences a significant change in condition. The DNS identified that when a resident is identified as being at risk for pressure ulcers, the facility initiates interventions such as barrier cream, skin prep, pressure reducing mattresses, and a two hour turning and positioning schedule, depending on the location and nature of the risk. She reported that she could not attest to whether Resident #115's Braden Scale assessments were accurate because the scoring depends on the resident's clinical presentation at the time each question on the Braden Scale is answered. Interview with MD #1 (wound specialist) on 3/16/26 at 11:55 AM identified that he evaluated Resident #115's left heel wound on 1/22/26 during his scheduled wound consultation visit. He reported that, at the time of his initial assessment, the left heel wound was pressure related. He further explained that the resident's left leg arterial stenosis, which was confirmed by a duplex scan and subsequently treated with an angioplasty procedure, contributed to the rapid deterioration and/or delayed healing of the wound. He identified that Resident #115's left heel wound may have a mixed etiology, related both to pressure and to the arterial stenosis of the left leg. The facility Pressure Injury Prevention and Management policy identified the facility's commitment to preventing avoidable pressure injuries unless clinically unavoidable and to providing treatment and services aimed at healing existing pressure injuries, preventing infection, and preventing the development of additional pressure injuries. The policy directed licensed nurses to conduct a pressure injury risk assessment using the Braden Scale upon admission or readmission, weekly for four weeks thereafter, quarterly, and whenever the resident experienced a change in condition. The policy also indicated that the facility would complete a thorough assessment and evaluation of the wound, and that the interdisciplinary team would develop a relevant care plan with appropriate interventions Resident #20's diagnoses include vascular dementia without behavioral disturbance, cachexia, non-thrombocytopenic purpura, osteoarthritis and left artificial hip joint. The quarterly MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition, was incontinent of bowel and bladder, was at risk for developing pressure ulcers/injuries, had a skin tear and was receiving hospice care. The care plan dated 11/18/25 identified Resident #20 had the potential for alteration in skin integrity related to decreased mobility, incontinence, and diagnosis of purpura, with interventions that include: incontinent care every two hours and as needed, pressure redistribution device to seat of device when out of bed and pressure redistribution mattress and repositioning every two hours The active monthly physician's orders for December 2025 identified Resident #20 was non-ambulatory and directed weekly skin checks every Tuesday, apply moisture barrier cream to bilateral buttocks and coccyx every shift for breakdown prevention, monitor buttocks for skin breakdown and apply Desitin every shift. The weekly skin check documentation dated 1/6/26 identified a new skin impairment located on the left gluteal fold. It further noted that the nursing supervisor and the wound care nurse were notified. A review of the clinical record failed to identify that the newly found skin wound was assessed by a registered nurse when the skin impairment was noted on 1/6/26. According to the National Institute of Health, a comprehensive assessment of a pressure wound should include staging with the depth, length and width noted along with the notation of location, any exudate, a description of what the tissue looks like, any odors and if any undermining or tunneling is present. This documentation should be conducted on at least a weekly basis in long-term care. The physician's order dated 1/10/26 directed to apply Triad to the left buttock open area every shift. Review of the clinical record failed to identify a nurse's note or assessment dated [DATE] that addressed the resident's newly identified skin impairment to the buttock. The care plan dated 1/10/26 identified Resident #20 had a left buttock stage 2 pressure injury with interventions provide incontinent care every two hours and as needed and to reposition every two hours. The Wound nurse note dated 1/13/26 identified Resident #20's buttocks area with MASD with treatment to cleanse with soap and water, apply triad paste twice daily and prn with incontinent care. Add nutritional supplements and specific turning/repositioning program. 1.5 cm in length by 0.7 cm in width with a depth of 0.1 cm. The Wound MD documentation dated 1/15/26 identified Resident #20 was evaluated for new stage 2 pressure ulcer to the left buttock and indicated there was no peri wound erythema, induration, or fluctuance and no drainage noted from the wound bed on exam today. Wound MD note directed to begin triad for management and identified if wound appears to be worsening, will recommend back to bed schedule as resident would benefit from being on air mattress more frequently and from not sitting for hours in the wheelchair. Observation of Resident #20 on 3/13/26 at 9:04 AM in the dining room/lounge. Observation on 3/13/26 at 11:14 AM identified Resident #20 was in the dining room/lounge seated in the custom wheelchair leaning on the left hip with a travel pillow under the left side of the neck. Observation of Resident #20 indicated that Resident #20 had not changed position since previous observation. Review of the clinical record failed to identify documentation of the implementation of turning and repositioning. Interview with NA#4 on 3/13/26 at 11:50 AM identified she was caring for Resident #20 and brought the resident into the resident lounge in the morning after care was provided in the resident room. NA#4 indicated she did not know the time Resident #20 was placed in the lounge but identified that Resident #20 had been sleeping in the lounge with no care provided. Interview with RN#2 (Wound RN) on 3/16/26 at 9:46 AM identified when Resident #20's skin was noted to have blanchable redness on 12/9/25, the area should have been assessed to determine the cause, whether moisture or pressure. RN#2 indicated that on admission each resident should have some sort of barrier cream use in place and turning and repositioning every 2 hours if the resident is not able to do it themselves. RN#2 identified that she took over the wound RN position in December 2025 and had not been made aware of Resident #20's reddened area until notified of a wound 1/13/26. Interview with MD#1 (Wound MD) on 3/16/26 at 12:07 PM identified that Resident #20 had a lot of co-morbidities including bedbound, dementia, cachectic and should have been monitored more closely. MD#1 indicated that wounds are referred to the wound MD when they are non-blanchable. MD#1 identified that a blanchable area warranted interventions of aggressively offloading, ordering an air mattress but indicated that when he first saw Resident #20 the area was a stage II pressure with an open area. MD#1 identified that it would be highly unlikely that the turning and repositioning and care was being completed appropriately and that if the area had been monitored appropriately, Resident #20 should have been referred when the area was non-blanchable, which would have been the next progression after blanchable. Interview with the DNS on 3/16/26 at 1:59 PM identified skin checks should be completed weekly with baths and indicated that when a document is opened it should be completed and signed on the date of service. The DNS identified that the new skin findings documented on 12/9/25 and 12/23/25 should have been followed up with a nursing assessment. The DNS indicated that she did not find a nursing assessment to correspond with the notes. Interview with LPN#5 on 3/16/26 at 3:07PM identified when an issue with a resident's skin is found, the supervisor should be notified to do an assessment. LPN#5 reviewed Resident #20's clinical chart and indicated that documentation on 12/9/25 was correct and LPN#5 identified she had notified RN #4 who was the nursing supervisor on that date. LPN#5 reviewed the documentation dated 12/23/25 and indicated that this documentation was from 1/6/26 and could not identify if there was skin documentation made on 12/23/25. Interview with RN#4, nursing supervisor on 3/16/26 at 3:43 PM identified that although she could not remember the particular day, indicated that had she been told about Resident #20's skin, she would have addressed the resident and put a note in the clinical chart based on the assessment. RN#4 identified that she had no recollection of being told about redness to Resident #20's skin. Facility policy for wound treatment management identified wound treatments would be provided in accordance with physician's orders. Facility policy for skin assessment identified a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The policy identified this as part of the systematic approach to pressure injury prevention. The policy indicated the assessment would include the general status of the resident's skin to include color, temperature, moisture status, sensory perception, skin texture, turgor and perfusion and should be documented along with description of the wound to include measurements, color, type of tissue in wound bed, drainage, odor, pain.

Based on observations, review of facility documentation, review of facility policy and interviews, the facility failed to ensure expired medications were removed from active use. The findings include: Observation of the North 1 medication cart on 3/16/26 at 10:21 AM with LPN #8 identified Meclizine tab 12.5 mg with an expiration date of 12/31/25 with 29 tablets remaining in the bubble pack.Interview with LPN #8 on 3/16/26 at 10:25 AM identified that expired or discontinued medications should be removed from the medication carts. LPN#8 indicated that all nurses are responsible for ensuring the medication cart does not have expired or discontinued medications. Observation of the North 2 medication cart with LPN #10 identified the following expired medications: two blister packs of Ondansetron tab 4 mg with an expiration date of 1/12/26 and Meclizine 12.5 mg (24 tablets) with expiration date 12/30/25 Observation of the North unit medication room with LPN#10 on 3/16/26 at 11:03 AM identified a box of Duoneb (Ipratropium Bromide and Albuterol) solution that contained 3 sealed multi packs and 3 single use vials with an expiration date of January 2026 on a shelf containing active use overflow medications. Interview with LPN#10 on 3/16/26 at 11:05 AM identified that expired or discontinued medications should be removed from active use, the medication cart or active use medication area in the medication storage room and placed in a bag to be sent to pharmacy or destroyed. Interview with the ADNS on 3/16/26 at 11:40 AM identified that expired medications should be removed from the medication carts to be returned to pharmacy. The ADNS indicated that all nurses are responsible for the medication carts and that the night shift nurses usually go through the medication carts. The facility policy for medication storage identified medications must be stored in accordance with manufacturer's specifications and in compliance with state and federal requirements and accepted professional standards of practice. The policy further identified prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #27) reviewed for dental, the facility failed to ensure dental services were provided. The findings include: Resident #27 was admitted to the facility in July of 2022 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left side, hypertension, gastro-esophageal reflux disease without esophagitis. The quarterly MDS assessment dated [DATE] identified Resident #27 had intact cognition. The care plan dated 1/26/24 identified Resident #27 had an oral/dental problem related to complaints due to a history of peri-oral skin lesions with interventions to be free of infection, pain or bleeding, to receive a dental consultation annually/as needed, and to monitor for signs or symptoms of dental problems needing attention. Review of care conference notes dated 4/7/25 identified Person #3 reiterated Resident #27 has limited funds and is not interested in pursuing dentures as Person #3 felt most likely the resident will not be able to manage them. Interview on 3/9/26 at 10:30AM with Resident #27 identified she/he was edentulous since admission and wanted dentures but noted Person #3 (family member who handles resident's finances) would not pay for the dentures. Resident #27 identified that she/he had not received dental services for the duration of her/his time in the facility and no one had reached out to a dentist or dental service to identify if there would be an out of the pocket cost for services. Resident #27 has further stated the process was in the works prior to coming into the facility for her/him to get dentures however Person #3 canceled the order once admitted into the facility. Review of the clinical record identified Resident #27 had not been seen by dental for the past two years. Review of the clinical record failed to identify that the resident had elected to be provided with dental services through the facility's contracted dental provider. APRN#2's progress note dated 1/30/25 identified Resident #27 reported a desire to be seen by the dentist and evaluated for dentures. The resident reported that Person #3 canceled a denture order. APRN#2 requested nursing staff to place the resident in the Health Drive book for evaluation. (Not seen by health drive, no evaluation found.)Interview with MDS Coordinator #1 on 3/11/26 at 1:40PM identified Health Drive services are available for the residents if they don't have an outside dentist that they see. An oral exam is done on admission by the nurse and quarterly. Interview with the Administrator on 3/11/26 at 2:15PM identified Health Drive is available for residents who don't have an outside dentist and if they want an outside dentist they can help them obtain one. The Administrator further identified Resident #27 had been requesting dentures for a while, but Person #3 had stated they would not pay for them, so it had not been pursued. The Administrator further could not identify if Person #3 was the power of attorney or conservator for Resident #27 and able to make those decisions. Interview with the Administrator on 3/12/26 at 8:40AM identified that when Resident #27 was admitted , Person #3 was deemed the decision maker for Resident #27 due to the cognitive status at that time. Person #3 was responsible for finances for Resident #27 and listed as the emergency contact. The Administrator identified that she spoke with Resident #27 a few weeks back and she had spoken again about wanting dentures and she let the social worker know. Interview with the Social Worker #1 on 3/12/26 at 10:30AM identified Resident #27 had been talking for several months about getting/wanting dentures and had been involved with the Administrator. Resident #27 has always said she/he wanted dentures, but Person #3 would not buy them. Social Worker #1 identified she had not reached out to Health Drive to find out if there would be any associated cost for Resident #27 to be seen or for dentures nor has Social Worker #1 reached out to Person #3 regarding dental. Interview with Social Worker #2 on 3/13/26 at 10:05AM identified Resident #27 wanted to follow up with Person #3 and then about a week ago the Administrator spoke with Resident #27 and Social Worker #2 went down to bring the paperwork to sign up and spoke to the admission director to have Resident #27 be seen. Social Worker #2 identified she had multiple discussions with the resident that are not documented about his/her desire to get dentures. Social Worker #2 identified she had not spoken to Person#3 to clarify any information regarding the services offered. Interview on 3/13/26 at 10:30AM with Scheduler #1 identified she was not aware of Resident #27 signing up for services and did not have any documentation regarding it. Nor had Resident #27 been included in the upcoming schedule yet dated 3/16/26. Review of the quarterly audit report from Health Drive provided by the administrator identified Resident #27 was on dental services on the report dated 8/29/25. However, then dropped off the report. Interview with Health Drive #1 on 3/13/26 at 12:29PM identified Resident #27 was enrolled the previous day 3/12/26 for dental services. Resident #27 was enrolled on 4/2/25 for dental, however on 4/3/25 the service was cancelled. Prior to that there was no enrollment in dental services. Following the 4/2/25 enrollment and the 4/3/25 cancellation Resident #27 was put in a Do not treat status. This was why the resident came up enrolled in dental on the quarterly audit report. Health Drive #1 further identified there is not typically an out-of-pocket cost for dentures for a resident on Medicare and Medicaid insurance if they have not received dentures before. Interview on 3/16/26 at 8:42 AM with Person#3 identified the dentures have been a discussion ever since Resident #27 was at the facility, however Person #3 identified if Medicare won't pay for the dentures, then Medicaid won't pay for the dentures. Person #3 further identified that he/she is not paying for dentures. Person #3 identified the facility had never reached out to Health Drive to find out if there would be an estimated cost for Resident #27. Interview on 3/16/26 at 10:47AM with APRN#2 identified she knew about Resident #27 wanting dentures and has been trying to get them for a while however each time APRN#2 brings it up with Resident #27, the resident responds that Person #3 isn't going to pay for it. APRN#2 identified that the resident is not seen by the APRN for routine visits only the acute issues. APRN #2 identified that at a minimum she would expect Resident #27 to be seen at least annually by the dentist. APRN#2 further identified that although she was aware of the denture issue she assumed that Resident #27 was being seen by dental and was unaware that there were no services provided by the dentist to the resident. APRN#2 identified that there is an order set typically put in on admission for dental by the MD. Review of the Dental Services Policy identified the dental needs of each resident are identified through the physical assessment and MDS assessment processes and are addressed in each resident's plan of care. Residents and/or representatives are notified of dental services available under the State plan and of the potential charges that may apply in the case of routine or emergency dental care provided by outside resources.Although a policy was requested regarding next of kin/responsible party one was not received.

Based on review of clinical records, review of facility documentation, facility policy and interviews, for one of three residents (Resident #94) reviewed during a review of the antibiotic stewardship program, the facility failed to ensure that an antibiotic time out was completed for a resident on an antibiotic and the facility failed to provide documentation of antibiotic usage, patterns and resistant trends. The findings include: Resident #94's diagnoses included Parkinson's disease, atrial fibrillation, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #94 had severely impaired cognition and was dependent for personal hygiene. The physician's order with an origination order date of 8/15/25 directed Erythromycin Ophthalmic ointment 5 milligram/gram to instill one ribbon in both eyes at bedtime for eye infection and to continue until seen by ophthalmologists. Review and interview on 3/13/26 at 10:11 AM with the ADNS and RN #4 of Resident #94 clinical records failed to identify an antibiotic time out that was completed within 48 to 72 hours of the resident starting the antibiotic. RN #4 and the ADNS identified that the antibiotic time out is located in the evaluation section of the electronic medical records and is completed within 48 to 72 hours and should have been completed by the Infection Preventionist with feedback from the provider after the start of an antibiotic to identify if the antibiotic is working, to review the laboratory result to see if the antibiotic needs to continue or change. RN #4 and the ADNS identified it was the responsibility of the then IP nurse at the time to complete the antibiotic time out with the provider and document the feedback provided by the provider and are not sure if the resident has been seen by the eye provider. Review of the Antibiotic Stewardship Program policy identifies to monitor response to antibiotics, and laboratory results when available to determine if the antibiotic is still indicated or adjustment should be made. The policy further identified nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic time out within 48-72 of antibiotic therapy to monitor with response on response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustment needs to be made based on the findings. A request was made on 3/11/26 for the quarterly infection control reports presented at medical staff meetings for the period of June 2024 through March 2026. The reports provided were dated 7/17/24, 10/16/24, 1/22/25, and 7/16/25. A review of the Antibiotic Stewardship program, monthly infection surveillance reports and quarterly infection control reports for the period of June 2024 through March 2026 with the ADNS and RN #4 on 3/13/26 at 10:11 AM failed to identify the number of antibiotic usages for the period of June 2025 through April of 2025 and for January to February 2026. The ADNS identified that she was not working as the IP nurse during that period, and it was the IP nurse's responsibility at the time to present the information at the quarterly medical staff meeting and maintain monthly tracking as seen in the other months that were completed. The ADNS identified just started to oversee the IP program in January of 2026 and was not familiar with the facility's IP program and is currently the facility's practice. RN #4 identified she had started recently to track the antibiotic usage in the facility but has not completed the reports. Review of the Antibiotic Stewardship Program policy identifies the Infection Preventionist utilizes expertise and data to inform strategies to improve antibiotics use to include tracking of antibiotics starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistance organism. The program includes antibiotic use protocols and a system to monitor antibiotic use. The policy further identifies at least annually or per facility policy feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, and QAA committee. Based on review of clinical records, review of facility documentation, facility policy and interviews, for one of three residents (Resident #94) reviewed during a review of the antibiotic stewardship program, the facility failed to ensure that an antibiotic time out was completed for a resident on an antibiotic and the facility failed to provide documentation of antibiotic usage, patterns and resistant trends. The findings include:

NMBased on review of clinical records, review of facility documentation, and interviews for one of three sampled residents (Resident #36) reviewed for pressure injury, the facility failed to ensure the comprehensive MDS assessment was accurately coded to reflect the resident was admitted with pressure injuries and for one of four sampled residents (Resident #61) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the MDS accurately reflected the resident's status. The findings include: 1. Resident #61's diagnoses included bipolar disorder, and schizophrenia. A positive PASRR level II assessment dated [DATE] was completed for Resident #61. The annual MDS assessment dated [DATE] identified Resident #61 was cognitively intact and did not display behaviors. The assessment further reflected that the resident did not have a positive level 2 PASRR. Interview with the MDS Coordinator (LPN#4) on 3/13/26 at 1:30PM identified that he was responsible for completing the section of the MDS that addressed PASRR level 2 status for Resident #61 on the most recent annual assessment. He noted that when making the determination of status, he checks the medical record and looks for the level 2 PASRR assessment. LPN#4 further identified that if he does not see a PASRR level 2 he would further verify with social work if the person had a positive PASRR level 2 assessment. He recalled checking the clinical record, however, did not recall verifying with social work. LPN#4 identified the annual MDS assessment for Resident #61 should have been coded positive for a level 2 PASRR. The MDS 3.0 Completion policy directed all disciplines to follow guidelines in Chapter 3 of the current RAI manual for coding each assessment. The Resident Assessment Instrument (RAI) manual provides guidance on how to complete the MDS assessment. And it notes that a positive PASRR screen indicates the resident has a mental illness, intellectual disability, or a related condition and should be coded in section A1500 as yes. 2. Resident #36's diagnoses include type 2 diabetes mellitus, anemia, and pneumonia. Resident #36 was readmitted to the facility on [DATE] and the weekly wound evaluation dated 2/19/26 at 7:00 PM identified the resident had a suspected deep tissue injury to the right heel, the left heel, stage 2 pressure injury to the right elbow, right outer ankle, and to the coccyx. The admission MDS assessment dated [DATE] identified Resident #36 was at risk for developing pressure ulcer/injuries but noted that the resident did not have any pressure ulcers present. Interview on 3/13/26 at 1:23 PM with MDS Coordinator (LPN #1) identified there are two MDS Coordinators and they are responsible for completing section M (skin condition) of the MDS assessment. LPN #1 identified that information is retrieved from the resident's admission assessment/evaluation, skin/wound document, and the wound provider notes to complete section M of the assessment. LPN #1 reviewed Resident #36's wound provider notes, the admission assessment/evaluation, the weekly wound evaluation and identified Resident #36 had a total of 4 pressure injuries when she completed the MDS assessment dated [DATE]. She noted that the assessment should have reflected the presence of the pressure ulcers/injuries. Interview on 3/13/26 at 2:09 PM with the other MDS Coordinator (LPN #4) in the presence of LPN #1 and the DNS identified that he was responsible for completing Resident #36's admission MDS assessment dated [DATE] and thought that he had captured the pressure injuries/ulcers on the assessment. LPN #1 and LPN #4 identified that when completing the MDS assessments, it is their responsibility to ensure that the assessment is completed accurately and not the responsibility of the ADNS because when she signs the MDS assessment it is only to indicate that the assessment was completed. Review of the MDS 3.0 Completion policy identified that according to federal regulations, the facility conducts initially and periodically a comprehensive and standardized assessment of each resident's functional capacity, using the RAI specified by the state. The policy further identified in the section Care Plan Team Responsibility for Assessment Completion that persons completing part of the assessment must attest to the accuracy of the section they complete by signature and indication of the relevant section.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure neurological monitoring was completed timely after an unwitnessed fall and the facility failed to ensure the facility policy directed staff when to conduct neurological monitoring after an unwitnessed fall. The findings include: Resident #1's diagnoses included Parkinson's, cervicalgia (neck pain), and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicative of no cognitive impairment and ambulated independently with a rolling walker. The Resident Care Plan (RCP) dated 8/20/2025 identified ADL self-care deficit. Interventions directed independent with bed mobility, transfers, toilet use with use of grab bars, and independent ambulation up to 250 feet as tolerated. Review of physical therapy Discharge summary dated [DATE] identified Resident #1 was able to ambulate 300 feet safely on level surfaces with supervision using rolling walker. Review of facility reportable event dated 11/10/1025 at 10:30 AM identified on 11/9/2025 at approximately 3:40 AM Resident #1 was observed on the ground outside of his/her bedroom window and stated he/she wanted to leave to gain his/her independence. Assessment identified Resident #1 was able to move all extremities without difficulty, denied hitting his/her head and pain, and was noted to have skin tears to his/her bilateral hands. Neurological assessment was within normal limits. The report further identified Resident #1 had a recent psychiatric evaluation that identified he/she has full decisional capacity, was self-responsible and the facility was planning his/her discharge to the community. Resident #1 was transferred to the hospital and returned the same day with no new orders. On 11/9/2025 at approximately 4:20 PM, Resident #1 complained of right side and midback pain and was transferred to the hospital for evaluation, and hospital imaging revealed fractures of right ribs 10 and 11. Nursing note dated 11/9/2025 at 4:56 AM (written by RN #1) identified pupil reactions were equal and reactive to light, had equal strong hand grasps, and Resident #1 was transferred to the hospital at approximately 4:40 AM. Review of the facility Head Injury Observation dated 11/9/2025 identified neurological monitoring was completed at 3:45 AM, 4 AM, 4:30 AM and beginning at 5 AM indicated Resident #1 was hospitalized . Nurses note dated 11/9/2025 by RN supervisor indicated resident returned from emergency room at 8:45 AM, RN and was placed on every 15-minute checks. Record review and review of the facility Head Injury Observation dated 11/9/2025 identified neurological monitoring indicated resident was hospitalized and failed to identify neurological monitoring/assessments were completed or documented upon Resident #1's return to the facility at approximately 8:45 AM. Review identified hourly neurological monitoring was due every hour at 9 AM, 10 AM, 11 AM, and then every four (4) hour assessments were due to begin at 3 PM. The Head Injury Observation form indicated the resident was hospitalized at 9 AM (when he/she had returned at 8:45 AM), at 10 AM and at 11 AM. Further, LPN #2 documented that a neurological assessment was completed at 1 PM, five (5) hours after Resident #1 was due to be re-assessed. Nursing note dated 11/9/2025 at 4:45 PM indicated Resident #1 was heard yelling and cursing in the hallway near the recreation room, and stated, I can't breathe, I think I broke my ribs, I think I punctured something. Resident #1 was transferred to the hospital. Additional record review failed to identify Resident #1 refused any neurological assessments after his/her return from the hospital at 8:45 AM. Review of hospital paperwork dated 11/9/2025 at 8:55 PM identified C-2 (cervical vertebra number 2) fracture verses chronic non-union of prior C-2 fracture noted on 1/2025, and right number 10 and 11 rib fractures. Facility reportable event summary dated 11/14/2025 identified Resident #1 did not return from the hospital. Prior to the incident Resident #1 learned that a long-awaited discharge to an assisted living facility had fallen through and had agreed to remain at the facility and work with social services for an alternate placement. Resident #1 expressed the desire to be discharged from the hospital to community and was discharge to a different facility. Interview, clinical record and facility documentation review with LPN #2 on 11/19/2025 at 8:32 AM identified she assessed Resident #1's vital signs (blood pressure, pulse and respirations) at 9 AM upon return from the hospital and Resident #1 refused neurological monitoring at that time, however. LPN #2 stated she did not document Resident #1's refusal and she should have. LPN #2 initially indicated resident's neurological monitoring was due every four (4) hours after his/her return from the hospital, and stated she next completed neurological checks at 1 PM. Further, LPN #2 stated she did not recall completing, or attempting to complete the neurological assessments at 10 AM, 11 AM or 3 PM, and was unable explain why the Head Injury Observation documentation at 10 AM, 11 AM indicated resident was hospitalized when he/she had returned to the facility previously. Interview, clinical record and facility documentation review on 11/19/2025 at 8:36 AM with the DNS identified Resident #1 had no prior elopement attempts and had no wandering or exit seeking behaviors prior to the incident. Resident #1 wanted to be discharged to the community and lost an assisted living placement due to decisions made by a family member. Resident #1 had expressed that he/she wanted to be discharged and expressed a desire to go to a hotel. On 11/5/2025 Resident #1 had a psychiatric evaluation for competency and was deemed as able to make his/her own decisions, and social services was working with Resident #1 on discharge plans. On 11/9/2025 LPN #1 felt a breeze when completing shift rounds, noted the window was open and saw Resident #1 on ground. An RN assessment with a neurological assessment was completed, and staff remained with Resident #1 until transfer to the hospital. Resident #1 returned from the hospital at 8:45 AM and the DNS was unable to provide documentation that the neurological assessments resumed. The DNS stated LPN #2 should have resumed and completed neurological monitoring upon resident's return as per standards (for 72 hours). Per the fall protocol policy: when any resident experiences a fall the facility will monitor for head injury for all unwitnessed falls regardless of head strike. The DNS stated LPN #2 should have completed and documented neurological assessments at 9 AM, 10 AM, 11 AM and 3 PM. Further, if Resident #1 refused the neurological assessment at 9 AM, LPN #2 should have documented the refusal in the clinical record. The DNS stated the facility did not have a policy and/or procedure that directed staff when to complete post fall neurological monitoring, and that staff relied on the electronic medical record (EMR) software to direct them. Review of the facility Fall Protocol directed in part, when a resident experiences a fall, the facility will: assess the resident, document assessments, monitor for head injury for all unwitnessed falls regardless of head strike. Review of facility Position Description, Title: LPN directed in part, to provide optimal quality of care for residents, documents, and to maintain all pertinent records in a timely, efficient, and confidential manner. Although requested, a neurological monitoring policy and/or procedure was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for wound care, the facility failed to moisten the adhered dressing prior to removing the dressing to ensure the Stravix skin graft that was sutured to the right Achilles Stage 4 pressure ulcer was not removed. The findings include: Resident #2's diagnoses included Stage 4 pressure ulcer of the right heel, paraplegia, chronic pain syndrome, and anxiety. The hospital Discharge summary dated [DATE] identified the right heel dressing was intact, the dressing was changed on 7/24/24 and the Stravix graft was adhered to the wound bed. The nursing admission or readmission evaluation dated 7/25/24 identified Resident #1 was oriented to person, place, time, and situation, experienced frequent pain due to the right heel wound and received pain medications. A physician's order from the hospital discharge paperwork dated 7/25/24 directed to cleanse the right heel with normal saline, apply hydrogel followed by Adaptic, cover with an ABD pad, secure loosely with kerlix wrap followed by an ace wrap, every other day, last change was done in the hospital on 7/24/24. The admission Resident Care Plan dated 7/26/24 identified Resident #2 had a pressure ulcer to the right heel. Interventions directed to offload heels while in bed, observe for signs of infection or wound deterioration and provide wound care as ordered. The nurse's weekly wound evaluation note dated 7/26/24 at 10:22 AM identified the wound care nurse, Registered Nurse (RN) #1, changed the dressing to the right foot and there was a moderate amount of serosanguineous drainage. The nurse's noted dated 7/26/24 at 11:35 AM identified a call was placed to the podiatrist to inform to update on the wound status. The note at 12:57 PM identified the treatment order frequency was changed to daily. A document provided by Resident #2 dated 7/26/24 identified he/she took pictures of the right foot ulcer and sent a message to the podiatrist regarding the wound care he/she received on 7/26/24. Resident #2 identified in the note the wound nurse commented the dressing was dry, it was stuck, she did not soak it with saline to get it off and just pulled the dressing off. The nurse's weekly wound evaluation note dated 7/29/24 at 1:09 PM identified RN #1 provided wound care and Resident #2 stated the graft was ripped off. RN #1 contacted the wound clinic and sent photos of the wound to the wound center. A telephone encounter by the wound care center dated 7/29/24 at 3:48 PM identified the wound center staff spoke with RN #1 and RN #1 confirmed the Stravix was gone, and it was likely removed over the weekend. The note indicated the podiatrist was notified and ordered adaptic and hydrogel. The podiatrist's progress note dated 8/1/24 identified Resident #2 was seen for surgical follow-up after the right heel debridement and the application of Stravix. The note indicated the Stravix was inadvertently removed by someone at the nursing facility despite the Stravix graft being sutured in with 3-0 chromic sutures. The note identified the wound had a fair amount of granulation and did not look terrible. The recommendation was to continue to dress the wound with hydrogel and Adaptic three (3) times a week until the wound vac is approved. Interview with the AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 9/30/24 at 11:45 AM identified he had changed the resident's dressing on 7/28/24 and did not recall seeing a skin graft. LPN #1 indicated Resident #2 thought the graft had come off, so he reported Resident #1's concern to the supervisor. Interview with Resident #2 on 10/1/24 at 1:45 PM identified on 7/26/24 RN #1 changed the dressing. Resident #2 indicated he/she could feel that the dressing was stuck. Resident #1 stated after the dressing change, he/she was in a lot of pain and noted a large amount of blood on the pillow. Review of the facility policy Pressure Injury Prevention and Management identified the facility is committed to provide treatment and services to heal the pressure ulcer. The policy further identified they should utilize a systematic approach for management including prompt assessment and treatment and notify the physician of any complications.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #2) who required wound care, after Resident #2 developed a breakdown in skin integrity, the facility failed to inform the resident's representative of the worsening progression, for eight (8) days, to discuss additional treatment options to prevent a further decline of the skin. The findings include: Resident #2's diagnoses included dementia, bullous pemphigoid, restlessness and agitation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or [NAME] made decisions regarding tasks of daily life, was dependent on staff for hygiene, toileting, bathing, dressing, bed mobility, and transfers and there was no identified skin breakdown. The Resident Care Plan dated 7/10/24 identified Resident #2 had the potential for skin breakdown, related to dementia and a self-care deficit. Interventions directed padded wheelchair, lotion to both arms twice per day, geri-sleeves all day, incontinent care every two (2) hours, to assist with activities of daily living and monitor for decline, allow for sufficient time to accomplish tasks, and encourage resident participation as much as possible. The nurse's note dated 7/28/24 at 9:41 PM identified a new skin impairment was noted on the right and left thighs and the Nursing Supervisor and wound care nurse were notified. The Nurse Practitioner's progress note dated 7/29/24 identified Resident #2 had multiple blisters on the hands, fingers, and legs with edema to the right hand. The resident also had multiple old scratches on the hands, chest, and leg areas. The note indicated the fluid filled blisters were identified as bullous pemphigoid which was an auto immune condition, and orders directed to elevate the right hand for seven (7) days, Hydrocortisone cream 2 % to the hands twice a day and Prednisone (a steroid) 10 milligrams (mg) one (1) daily for five (5) days. The Nurse Practitioner's progress note dated 8/2/24 identified Resident #2 was seen due to worsening blisters that spread to various areas of the body. The Nurse Practitioner directed to start cortisol cream to the hands and thighs daily, Hydroxyzine HCL 25 mg daily for itch and Prednisone taper 40 mg one (1) daily for three (3) days. The wound care Nurse Practitioner's progress note dated 8/5/24 at 12:13 PM identified she was asked to see the resident for wound evaluation. The note indicated there were painful blisters to bilateral hands and thigh areas, possibly bullous pemphigoid and directed to begin Clobetasol cream (topical corticosteroid) twice a day, obtain a dermatology consult, and the plan of care was coordinated with the resident, staff and Assistant Director of Nursing. The Nurse Practitioner's progress note dated 8/5/24 identified the Nurse Practitioner was asked by nursing staff to speak with Resident #2's responsible party (Person #2). Person #2 inquired about the blisters and treatment and was informed that a dermatology referral had been made. Resident #2's condition was worsening, and the Nurse Practitioner directed to continue with current treatment and to add Trazadone 25 mg every twelve (12) hours for agitation. Review of the nurse's notes and physician progress notes from 7/28/24 through 8/5/24 failed to identify Resident #2's responsible party was notified of the significant change in condition. Interview with the Assistant Director of Nursing (ADON) on 8/26/24 at 2:30 PM identified the facility is supposed to notify the responsible party of any change in condition and the facility failed to notify the responsible party of the change in condition and prescribed treatment for Resident #2. The facility did not follow their policy on Notification of Changes. Review of the facility policy for Notification of Changes directed the facility to promptly inform the resident's representative when there is a change in condition requiring notification which included the need to start a new treatment regimen. Review of the facility policy for Resident Rights identified the resident (or representative) had the right to be fully informed about his/her health status and to participate in planning care and treatment.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 residents (Resident #48) reviewed for advanced directives, the facility failed to ensure advanced directive choices were reviewed with the resident/resident representative to ensure their choices were honored. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included dementia, femur fracture, and pneumonia. The hospital discharge paperwork dated 4/11/24 directed Resident #48 was a do not resuscitate (DNR). A physician's order dated 4/11/24 directed Resident #48 to be a do not resuscitate (DNR), do not intubate (DNI), and a registered nurse may pronounce (RNP). The Advanced Directive form in the clinical record dated 4/11/24 identified Resident #48 (with severe cognitive impairment) had signed him/herself as a full code. Additionally, the form had not been signed by a witness/nurse or the physician. The admission MDS assessment dated [DATE] identified Resident #48 had severely impaired cognition. The care plan dated 4/29/24 identified impaired cognition due to dementia. Interventions included discussing and educating the advanced directives with resident and/or resident responsible party and notifying physician of residents wishes regarding advanced directives. Follow the physicians order for advanced directive. Review of the clinical record dated 4/11/24-5/6/24 did not identify that Resident #48's resident representative was contacted, educated, and offered to make wishes known regarding the advanced directives for Resident #48. Interview with the Resident Representative on 5/6/24 at 8:46 AM indicated that no one at the facility has spoken to him/her regarding Resident #48's wishes for the code status since admission to the facility on [DATE] (26 days later). The Resident Representative indicated that he/she would speak with Resident #48 but was sure Resident #48 wishes were to be a DNR. S/he also indicated s/he visits daily. Interview with the DNS on 5/6/24 at 8:51 AM indicated that the hospital code status is used for the first 24 hours, and she would expect the charge nurse or supervisor to get the wishes for the code status from the resident or resident representative within the first 24 hours. The DNS indicated that on admission if the resident was not cognitively intact like Resident #48 that two nurses, one nurse and a social worker, or the APRN/MD would call the resident representative, and both would sign the advance directive form. The DNS indicated if unable to reach the resident representative she would expect a note in the progress section stating that they tried to reach the resident representative to discuss legal matters. The DNS indicated if unable to reach resident representative within 24 hours the resident would then become a full code until the resident representative was reached to decide. The DNS indicated that after 24 hours if nursing cannot reach the resident representative, then social services would be asked to help. S/he indicated that Resident #48 had a BIMS of 2 meaning severe cognitive impairment and the resident representative would have to be called. The DNS indicated that the nurse should call the resident representative for resident ID #48 on the day of admission. After review of the clinical record, the DNS indicated she did not see a progress note that someone called the resident representative regarding their wishes for the advanced directive. The DNS indicated that the advanced directive form was signed by Resident #48 who was not the decision maker. The DNS indicated that the current code status form signed by the resident is not valid because he was not cognitively intact. The DNS indicated that Resident #48 was a full code from 24 hours after admission until the resident representative signs the advanced directive form. Interview with case manager (LPN #1) on 5/6/24 at 10:04 AM indicated that she was responsible to coordinate the care conferences. LPN #1 indicated that she had conducted the first care conference for Resident #48 on 4/25/24 with Resident #48, resident representative, and another family member. LPN #1 indicated that she does not bring the paper chart into the conference she just goes by the physician orders in the electronic medical record to review at the meeting. LPN #1 indicated she nor anyone else asked the resident representative to sign any forms although the resident's representative was responsible to sign all legal forms. Resident #48 was not able to sign any legal forms with a BIMS of 2. LPN #1 indicated that the code status should be signed at admission and that her first care conference was held between day 14-21 from admission. LPN #1 indicated that she sees the resident representative in the facility visiting every day that she works. Review of the facility Advanced Directive Policy identified it was the policy of the facility to provide each resident with appropriate high quality medical and nursing care. The facility recognizes the right of each resident, if capable, to make decisions regarding his/her treatment and to execute advanced directives. The resident who is not capable to make decisions will have a resident representative on their behalf make the decision for the advanced directive. At the time of admission, the facility will provide each resident or resident representative with a copy of the policy regarding advanced directives. The facility will abide by the decision made by the resident or resident representative with the respect to order a do not resuscitate and the withholding and withdrawal of life sustaining measures. Such decisions made, and consent documented in accordance with facility procedures.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #118) reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The findings include: Resident #118's diagnoses included degenerative disease of the nervous system, obesity, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 had severe cognitive impairment and required extensive assistance of two (2) for ADLs. The Resident Care Plan (RCP) dated 2/11/2024 identified Resident #118 had a self-care deficit. Interventions directed maximum assist of two (2) with ADLs and one-quarter bedrails for enabler. The nurse aide care card directed Resident #118 required assist of two (2) staff with ADLs. Facility incident report dated 3/11/2024 at 10:15 PM identified Resident #118 rolled or slid out of bed and was observed lying on the floor next to his/her bed. Investigation completed by the DNS identified Resident #118 had been attempting to raise the head of the bed. Review identified NA #5's written statement indicated she had provided care for Resident #118, left the room to obtain additional supplies and upon return observed Resident #118 on the floor. Review failed to identify any additional NA statements. Facility documentation review identified LPN #5 was the charge nurse and there were four (4) NAs (NA #5, #6, #7 and #8) working on Resident #118's unit during the evening shift on 3/11/2024. Interview, clinical record and facility documentation review with LPN #5 (charge nurse) on 5/8/2024 at 3:02 PM identified she did not assist NA #5 with any care for Resident #118 prior to the fall. Interview on 5/22/2024 at 11:31 AM with NA #8 identified that she did not provide any care for Resident #118 and had not seen the resident during the 3 PM to 11 PM shift on 3/11/2024. Interview on 5/22/2024 at 11:42 AM with NA #7 identified she did not provide any care for Resident #118 during the 3 PM to 11 PM shift on 3/11/2024 except to deliver the dinner meal and collect the tray after the meal. Interview on 5/22/2024 at 12:59 PM with NA #6 identified that she did not provide any care for Resident #118 during the 3 PM to 11 PM shift on 3/11/2024. Although attempted, an interview with NA #5 was not obtained during survey. Interviews and facility documentation review failed to identify NA #5 had a second NA with her when providing Resident #118's care, in accordance with the plan of care. During an interview and facility documentation review with the DNS on 5/22/2024 at 3:16 PM, the DNS was unable to identify a second staff member who assisted with providing care on 3/11/2024 for Resident #118 prior to the fall. The DNS indicated a second staff member should have assisted with care, in accordance with the plan of care. Review of facility Comprehensive Care Plans Policy directed in part, to implement a comprehensive plan of care.

Based on record review and interview for 1 of 1 residents (Resident #80) reviewed for Activities of daily living, the facility failed to provide the necessary care and services to maintain or improve mobility. The findings include: Resident #80 was admitted to the facility with diagnoses that included falls, hip replacement, and chronic pain. The care plan dated 12/12/23 identified decreased functional activity. Interventions included to ambulate Resident #80 150 feet with rolling walker and minimal assistance. The annual MDS assessment dated [DATE] identified Resident #80 had intact cognition and needs assistance for transfers and ambulation with a walker. Review of the physician orders dated 3/1/24-5/5/24 directed to ambulate Resident #80 150 feet with rolling walker with assist x 1 twice a day with a wheelchair to follow. Review of the progress notes dated 3/1/24-5/5/24 did not reflect Resident #80 had refused to ambulate or that the APRN /physician were notified that Resident #80 was not being ambulated per physician orders. Review of the 3/1/24 to 3/31/24 nursing assistant flow sheets for Resident #80 identified there were 34 out of 62 opportunities that Resident #80 was not ambulated. Six (6) opportunities for ambulation were not documented, and 28 out of 62 opportunities identified Resident #80 did not ambulate with no rational. Review of the 4/1/24 to 4/30/24 nursing assistant flow sheets for Resident #80 identified there were 25 out of 60 opportunities that Resident #80 was not ambulated. Eleven (11) opportunities for ambulation were not documented, and 14 out of 60 opportunities identified Resident #80 did not ambulate with no rational. Review of the 5/1/24 to 5/5/24 nursing assistant flow sheets for Resident #80 identified there were 7 out of 12 opportunities that Resident #80 was not ambulated. One (1) opportunity for ambulation that was not documented, and 6 out of 12 opportunities that identified Resident #80 did not ambulate with no rational. During an interview on 5/5/24 at 12:36 PM Resident #80 indicated the nursing staff are supposed to walk him/her in the hallway every day twice a day, but that does not happen. Resident #80 indicated that sometimes the therapist will walk him/her to the recreation room for a program, but they are not walking me every day. Resident #80 indicated that he/she was supposed to ambulate two times a day with staff, and it does not occur. Resident #80 indicated that the nursing staff are in a hurry and don't have time to ambulate him/her all the time. Resident #80 indicated that he/she has brought this concern to nursing staff, but nothing has changed. Resident #80 indicated that he/she really wants to be ambulated 2 times a day so he/she can get stronger to be independent and go home. Interview with Director of Rehabilitation Department on 5/6/24 at 3:10 PM indicated that each therapist puts in a physician order for nursing to continue with ambulating the residents while on therapy or when coming off therapy. The Director of Rehab indicated that Resident #80 is being seen by therapy 3 times a week privately. The Director of Rehab indicated that therapy had put in a physician's order for the physician to sign off on and the order for Resident #80 was to ambulate with someone from nursing 2 times a day up to 150 feet with a rolling walker and the wheelchair to follow. S/he indicated that nursing was responsible to document how far and how many times Resident #80 ambulates and that no one had reported to her that Resident #80 was not being ambulated by nursing twice a day as ordered by the physician. Interview with NA #2 on 5/7/24 at 8:16 AM indicated that she works 6:00 AM to 2:00 PM full time 4 days a week and she was Resident #80's regular nursing assistant. NA #2 indicated that when she gets done washing Resident #80 in the morning the therapy people take Resident #80 for a couple of hours to therapy. NA #2 indicated after lunch Resident #80 usually goes to recreation, so she does not offer to ambulate Resident #80. NA #2 indicate that she does not inform the charge nurses that he does not ambulate Resident #80 on the days that she works. Interview with the DNS and Administrator on 5/7/24 at 9:23 AM indicated if there was a physician order to ambulate Resident #80 twice a day their expectation was that the nursing staff would ambulate Resident #80 twice a day. The DNS indicated that the nursing assistants would document if they ambulate Resident #80 and document the number of feet ambulated. The DNS expectation is if a resident refuses or does not get walked the nursing assistant must tell the charge nurse. The DNS indicated that if the nursing staff are not following the physician's order the physician must be notified. The Administrator indicated that the resident should ambulate per the physician's order. Interview with APRN #2 on 5/7/24 at 11:15 AM indicated that Resident #80 has a physician order to ambulate two times a day and that her expectation was if Resident #80 was not walked for one day she would want to be notified. APRN #2 indicated she would expect to be notified because she would be able to monitor if there were refusals versus if the nursing staff just were not ambulating Resident #80 and to see if the resident had a decline. APRN #2 indicated that no one had notified her since she started in February 2024 that Resident #80 had not been ambulated.

2) Resident #37 was admitted to the facility in March 2021 with diagnoses that included dementia, schizophrenia, and muscle weakness. Review of the clinical record identified Resident #37 had a weight of 173.4 lbs on 10/11/23. The clinical record also identified Resident #37 was placed on hospice from 10/11/23-1/8/24, and then had a change in status to comfort measures only (CMO). Further review of the clinical record failed to identify any additional weights recorded for Resident #37. The quarterly MDS assessment dated [DATE] identified Resident #37 had severely impaired cognition, was always incontinent of bowel, utilized a urinary catheter, and was dependent on staff assistance with bathing, dressing, and eating. The care plan dated 4/18/24 identified Resident #37 had a history of skin growths and bowel incontinence. Interventions included use of a low air loss mattress, and that the mattress should be checked for placement, settings (set to weight) and function every shift, and adjust for comfort as needed. A physician's order dated 4/23/24 directed Resident #37 required a low air loss mattress. The order further identified that the placement, settings (set to weight) and function were to be checked every shift and may be adjusted to resident's comfort as needed. Observations on 5/5-5/6/24 identified Resident #37's low air loss mattress was not set to his/her last recorded weight. Observation on 5/5/24 at 8:10AM identified the low air loss mattress was set at the midpoint of the 240-279 lb setting ( approximately 260 lbs), 86.6 lbs above Resident #37's last recorded weight of 173.4 lbs. A follow up observation on 5/6/24 at 1:08 PM identified the low air loss mattress setting was unchanged. 3) Resident # 47 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, dementia, and cardiomegaly. Review of the clinical record identified that Resident #47 had a weight of 196 lbs on 6/14/23. The clinical record also identified that Resident #47 was placed on comfort measures only (CMO) on 7/19/23. Further review of the clinical record failed to identify any additional weights recorded for Resident #47. The care plan dated 4/17/24 identified Resident #47 was at risk for alteration in skin integrity related to decreased mobility. Interventions included use of a low air loss mattress. The quarterly MDS assessment dated [DATE] identified Resident #47 had moderately impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with bathing, dressing, and toileting. A physician's order dated 4/23/24 directed Resident #47 required a low air loss mattress. The order further identified that the placement, settings (set to weight) and function were to be checked very shift and may be adjusted to resident's comfort as needed. Observations on 5/6/24 identified Resident #47's low air loss mattress was not set to his/her last recorded weight. Observation on 5/6/24 at 8:26 AM identified the low air loss mattress was set at the midpoint of the 200-239 lb setting (approximately 220 lbs), 24 lbs above Resident #47's last recorded weight of 196 lbs. A follow up observation on 5/6/24 at 1:08 PM identified the low air loss mattress setting was unchanged. Review of the operation manual for the Emerald Supply low air loss mattress, the air mattress in place for Resident #37 and #47, identified the setting for the pressure adjustment knob included adjustment to the mattress by weight, with lower weight settings increasing softness and higher weight settings increasing firmness. Additional information received from Emerald Supply identified that the knob on the pump would be set to the resident's weight, and once the resident was on the mattress, the weight setting could be adjusted to allow for additional firmness or softness but should be kept around the resident's weight level. Interview with RN #1 (IP/wound nurse) on 5/6/24 at 1:00 PM identified that the facility had recently started using new low air loss mattresses with weight settings. RN #1 identified that the facility had recently done audits of all the air mattresses in the last 2 weeks and based on the audits, the residents with the low air loss mattresses that required weight settings had orders added to their clinical records. RN #1 identified that the low air loss mattresses with weight setting were supposed to be set to the resident's weight and not to softness or firmness. Interview with APRN #2 and LPN #3 on 5/6/24 at 1:27 PM identified that the facility had recently changed the low air loss mattresses used for residents which may have been the issue identified with the mattress settings. APRN #2 identified that if the orders included setting the mattress to the resident's weight, she would expect that order directions would be followed. APRN #2 also identified that Resident #37 and #47 were both on CMO, and this typically included no longer checking weights or vital signs as part of the treatment plan for the resident, but given how long it had been since the residents had been weighed, it may be a good idea to obtain a reweigh of the residents to ensure that the mattress settings were correct. LPN #3 identified that the low air loss mattresses that included the weight setting were new equipment to the facility in the past couple of months, and that the facility previously used a low air loss mattress that was set to firmness or softness only and did not have any settings related to weight. The facility policy on use of supportive surfaces directed that a support surface included specialized mattresses designed to manage pressure, shear, or friction forces on tissues. The policy also directed that support surfaces were chosen by matching the potential therapeutic benefits with the resident's specific situation and consideration would for utilizing specialized support surfaces would include the resident's size and weight. The policy further directed that any guidelines for support surfaces did not supersede the physician's orders. 4) Resident # 79 was admitted to the facility on [DATE] with diagnoses that included dementia, heart failure, and venous hypertension. Review of the clinical record identified that Resident #79 was placed on comfort measures only (CMO) on 5/17/23. The quarterly MDS dated [DATE] identified Resident # 79 had severely impaired cognition. The care plan dated 4/1/24 identified Resident #79 was receiving comfort measures. Interventions included to administer medications as ordered. A physician's order dated 4/2/24 directed to administer Lasix (a diuretic medication used for fluid retention) 20 mg by mouth one time daily for edema. The order further directed to check blood pressure with administration. Review of the clinical record failed to identify any blood pressures obtained on documented on Resident #79 on or after 4/2/24. Interview with APRN #2 and LPN #3 on 5/6/24 at 1:27 PM identified that residents on CMO did not typically have vital signs monitored unless it was included for a specific medication. APRN #2 identified that Resident #79 should have had his/her blood pressure monitored with administration of Lasix as this was part of the order, however Resident #79's CMO status may have caused confusion as residents on CMO did not have vital sign monitoring. LPN #3 identified that while CMO residents did not have vital sign monitoring, if there was a specific order in place for monitoring, it was supposed to be done regardless of CMO status. Interview with the DNS on 5/7/24 at 11 AM identified that Resident #79 should have had blood pressure monitoring with his/her Lasix administration. The facility policy on vital signs directed that vital signs would be obtained by a nurse or therapist as indicated when administering certain medications or when monitoring for effectiveness of medications or therapies. Based on record review and interviews for 1 of 3 residents (Resident #80 ) reviewed for Activities of daily living, the facility failed to follow the physician order for ambulation, and for 2 of 2 sampled residents (Resident #37 and 47) reviewed for mobility, the facility failed to ensure that a low air loss mattress was set to resident's weight per physician's order and manufacturer recommendations; and for 1 of 25 residents (Resident #79) reviewed for medication administration, the facility failed to ensure blood pressures were monitored per the physician's order with administration of a prescribed medication. The findings include: 1. Resident #80 was admitted to the facility with diagnoses that included falls, hip replacement, and chronic pain. The care plan dated 12/12/23 identified decreased functional activity. Interventions included ambulating Resident #80 150 feet with rolling walker and minimal assistance. The annual MDS assessment dated [DATE] identified Resident #80 had intact cognition and requires touching assistance for transfers and ambulation with a walker. Review of the physician orders dated 3/1/24-5/5/24 reflected Resident #80 to ambulate 150 feet with rolling walker with assist x 1 twice a day with a wheelchair to follow. Review of the progress notes dated 3/1/24-5/5/24 did not reflect Resident #80 had refused to ambulate. Review of the 3/1/24 to 3/31/24 nursing assistant flow sheets for Resident #80 identified there were 34 out of 62 opportunities that Resident #80 was not ambulated. Six (6) opportunities for ambulation were not documented, and 28 out of 62 opportunities identified Resident #80 did not ambulate with no rational. Review of the 4/1/24 to 4/30/24 nursing assistant flow sheets for Resident #80 identified there were 25 out of 60 opportunities that Resident #80 was not ambulated. Eleven (11) opportunities for ambulation were not documented, and 14 out of 60 opportunities identified Resident #80 did not ambulate with no rational. Review of the 5/1/24 to 5/5/24 nursing assistant flow sheets for Resident #80 identified there were 7 out of 12 opportunities that Resident #80 was not ambulated. One (1) opportunity for ambulation that was not documented, and 6 out of 12 opportunities that identified Resident #80 did not ambulate with no rational. The Grievance Form dated 3/19/24 identified that Resident #80 would like to be walked two times a day. Resident #80's goal was to be ambulated with walker independently. The follow up plan was Resident #80 will continue to work with therapy and the floor staff will ambulate Resident #80 to and from activities or in the hallway on the other days. During an interview on 5/5/24 at 12:36 PM with Resident #80 indicated the nursing staff are supposed to walk him/her in the hallway every day twice a day, but that does not happen. Resident #80 indicated that sometimes the therapist will walk him/her to the recreation room for a program, but they are not walking him/her every day. Resident #80 indicated that he/she was to ambulate two times a day with staff, and it does not occur. Resident #80 indicated that the nursing staff are in a hurry and don't have time to ambulate him/her all the time. Resident #80 indicated that he/she has brought this concern to nursing staff, but nothing has changed. Resident #80 indicated that he/she really wants to be ambulated two times a day so he/she can get stronger to be independent and go home. Interview with Resident Representative on 5/5/24 at 12:45 PM indicated that when he/she visits the staff do not ambulate Resident #80 and he/she had written a grievance on Resident #80's behalf and had met with staff about Resident #80 needing to be ambulated twice a day in the hallway. The Resident Representative indicated that things have not gotten any better since they wrote the grievance about Resident ID#80's ambulation. Interview with Director of Rehabilitation Department on 5/6/24 at 3:10 PM indicated that each therapist puts in a physician order for nursing to continue with ambulating the residents while on therapy or when coming off therapy. The Director of Rehab indicated that Resident #80 is being seen by therapy 3 times a week privately. The Director of Rehab indicated that therapy had put in a physician's order for the physician to sign off on and the order for Resident #80 was to ambulate with someone from nursing 2 times a day up to 150 feet with a rolling walker and the wheelchair to follow. S/he indicated that nursing was responsible to document how far and how many times Resident #80 ambulates and that no one had reported to her that Resident #80 was not being ambulated by nursing twice a day as ordered by the physician. Interview with NA #2 on 5/7/24 at 8:16 AM indicated that she works 6:00 AM to 2:00 PM full time 4 days a week and she was Resident #80's regular nursing assistant. NA #2 indicated that when she gets done washing Resident #80 in the morning the therapy people take Resident #80 for a couple of hours to therapy. NA #2 indicated after lunch Resident #80 usually goes to recreation, so she does not offer to ambulate Resident #80. NA #2 indicate that she does not inform the charge nurses that he does not ambulate Resident #80 on the days that she works. Interview with the DNS and Administrator on 5/7/24 at 9:23 AM indicated if there was a physician order to ambulate Resident #80 twice a day their expectation was that the nursing staff would ambulate Resident #80 twice a day. The DNS indicated that the nursing assistants document if they ambulate Resident #80 and document the number of feet ambulated. The DNS expectation is if a resident refuses or does not get walked the nursing assistant must tell the charge nurse. The Administrator indicated that Resident #80 is on and off therapy, and that therapy ambulates Resident #80 on those days. The DNS indicated that if the nursing staff are not following the physician's order the physician must be notified. The Administrator indicated that the resident should ambulate per the physician's order. Interview with APRN #2 on 5/7/24 at 11:15 AM indicated that Resident #80 has a physician order to ambulate two times a day and that her expectation was if Resident #80 was not walked for one (1) day she would want to be notified. APRN #2 indicated she would expect to be notified because she would be able to monitor if there were refusals versus if the nursing staff just were not ambulating Resident #80 and to see if the resident had a decline. APRN #2 indicated that no one had notified her since she started in February 2024 that Resident #80 had not been ambulated.

Based on clinical record review, review of facility documentation, review of facility policy, observations and interviews for one of three sampled residents reviewed for bed mobility (Residents #2), the facility failed to ensure that the resident was protected from injury during the provision of care. The finding includes: Resident #2's [DIAGNOSES REDACTED]. The annual MDS (minimum data set) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and required extensive assistance of one with bed mobility. The RCP (Resident Care Plan) in place on 1/11/17 noted alteration in ADLs self-care deficit related to [DIAGNOSES REDACTED]. Facility documentation dated 1/11/17 indicated at approximately 7:20 AM, R #2 sustained a 2.5cm x 0.5cm laceration to the left forehead during bed repositioning (by NA #4). Nursing narratives and/or transfer documentation dated 1/11/17 noted the resident was transferred to the hospital and the laceration was closed with six sutures. Nursing narratives by RN #3 dated 1/11/17 at 10:31 PM identified that the resident had returned to the facility with left eye/periorbital bruise, bruise to right side of nose and left eyebrow sutures. Observation on 6/5/17 at 9:41 AM noted R #2 in the wheelchair with a roll device positioned in the Resident's contracted right hand. Interview with NA #4 on 6/5/17 at 3:11 PM noted that R #2 was positioned in bed on a pad, he/she tucked and bunched the pad under the Resident's left side to remove the pad. NA #4 noted that when he/she attempted to remove the pad from under the Resident's right side, the Resident flipped quickly striking his/her head hard on the bed's left side rail and was injured. NA #4 indicated the resident had a stiff contracted body positron and was unable to assist with repositioning. The facility NA job description technical competencies included to properly utilize techniques in performing activities of daily living. Subsequent to the event, the facility revised the Resident's plan of care to include the assist of two for bed repositioning and the use of lamb's wool to cover (pad) both side rails. In addition, Occupational Therapy provided nursing staff with education related to safety during bed mobility for R #2.

Based on review of the clinical record, review of facility documentation, staff interview and observations for one of one sampled resident with a potential for accidents, (R#33), one of two sampled residents with a history of falls, (R#169), the facility failed to provide the necessary equipment according to the plan of care and/or provide the appropriate supervision resulting in a fall, and/or ensure safe water temperatures. The findings include: 1. Resident #33's [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident with no cognitive impairments and requiring limited assistance and one person physical assist for eating. A RCP dated 9/30/13 identified a potential for inadequate intake. Interventions included to encourage and assist with intake, common dining room, and an added intervention dated 10/3/13 included sip lid with all hot beverages. Observation on 10/30/13 at 8:45 AM identified RN#2 in bed with a blanket wrapped around him/her. The bedside table was observed close to the window away from resident and two glasses of milk and a cup of coffee were also noted on the bedside table which were all uncovered. During observation with RN#2, she reviewed R#33's dietary slip which indicated that the resident was OK to have an open coffee cup and no adaptive equipment was required. Interview with R#33 identified he/she did not want to get out of bed because the room was too cold. RN#2 identified that R#33's window was open, then closed it and gave the resident a sweatshirt and assisted him/her to the side of the bed. RN#2 then placed the overbed table close to resident, gave Resident#33 the coffee, who then proceeded to take two sips. Upon surveyor inquiry RN#2 indicated that although R#33's meal ticket indicated an EZ lip for all hot beverages she had not provided one. Interview with NA#3 on 10/30/13 identified that an EZ lid was provided for the resident after RN#2 brought to it to her attention that resident coffee cup required one. Review of a RE dated 8/02/13 indicated R#33 spilled hot coffee on him/her while eating in room. Facility investigation further indicated that after removing the resident's pants, redness was noted to the resident's upper thighs especially the right side and ice was applied. A area of peeling skin on right side was noted measuring 12.0 cm x 8.0 cm x 12.0 cm, and left measuring 10.0 cm x 10.0 cm noted. A RE dated 10/02/13 indicated R#33 again spilled hot coffee on the right side of abdomen and a 5.0 cm x 2.0 cm reddened area was noted. Facility investigation indicated that the resident was evaluated by the physician and directed to apply ice for 20-30 minutes and with new interventions that included to provide a sip lid cup for all hot beverages. Observation on 10/31/13 identified R#33 in the dining room eating breakfast. Interview with NA#2 on 10/31/13 indicated that the resident was now placed in dining room for supervision and assistance. 2. Resident #169's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as moderately cognitively impaired, requiring extensive assistance for toilet use and personal hygiene, and impaired balance during transitions and walking. A RCP dated 5/16/13 identified a potential for falls related to decreased mobility and poor safety awareness. Interventions included the assistance of one for transfers and ambulation, and the use of a chair and bed alarm. Additionally the RCP identified an alteration in behavior related to frequent attempts to transfer and/or toilet independently. Nurse's Note dated 5/29/13 identified that at 7:45 AM the resident was found on his/her knees in the bathroom. A deep laceration was noted on the residents forehead, a compression dressing was applied, and the resident was transferred to the ED for evaluation and treatment. At 12:15 PM with the resident returned to the facility with 5 sutures on the forehead. An Emergency Department Discharge Summary dated 5/29/13 identified a [DIAGNOSES REDACTED]. Interview with the DNS at 1:00 PM and review of the clinical record identified the NA left the resident unattended on the toilet to retrieve the resident's clothing on the bed. The NA heard a thump, turned around and found the resident kneeling on the floor. A Facility Record of Corrective Action identified a violation of the facility's safety rule. Residents with dementia and/or who required the use of alarms should not be left unattended in the bathroom. Attempts to contact NA#1 were unsuccessful. 3. Observations on 10/29/30 at 11:00 AM with the Director of Maintenance identified water temperature in resident room 2009 as 130.4 degrees Fahrenheit (F) and at 11:10 AM in resident room 1022 the temp was 125.1 degrees F. Interview with the Director of Maintenance on 10/29/13 at 11:15 AM indicated that the water mixing valve on the hot water system required frequent adjustments related to hot water demand usage. Furthermore the facility water temps are tested at 5 AM, 12 PM and 2 PM with frequent adjustments required to the mixing valve throughout the day. The only daily hot water temp recorded by the facility was a reading taken at 2:00 PM. Subsequent to surveyor inquiry the Director of Maintenance adjusted the mixing valve and arranged for heating repair services. Interview with the facility administrator, DNS and Director of Maintenance on 10/30/13 at 8:52 AM identified the facility was aware.