Every finding on record at Marlborough Health & Rehabilitation Center

Based on review of the clinical record, facility documentation/policies and interviews, for two (2) of four (4) sampled residents (Residents #1 and #4) who required staff assistance for personal care, the facility failed to ensure Residents #1 and #4 were protected from verbal abuse by a staff member when the staff member repeatedly made inappropriate, offensive comments. The findings include:1.Resident #1's diagnoses included Parkinsons Disease, mood disorder, psychotic disorder with hallucinations, anxiety, and depression.The annual Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of (15) and required moderate assistance from staff for personal care including incontinence care.The Resident Care Plan dated 5/13/26 identified Resident #1 was incontinent of bowel and bladder. Interventions directed personal care with each incontinent episode, ensure an unobstructed path to the bathroom, check every two (2) hours for incontinence and change clothing as needed.The nurse's note dated 5/24/26 at 4:51 PM by RN #1 identified Resident #1 made allegations of multiple accounts of verbal abuse. Resident #1 would not disclose specific details. Resident #1 denied physical abuse. Allegations were reported to the physician, police, administration and family and an investigation was initiated per facility protocol. Resident #1 was in no apparent distress and had no signs of injury.The nurse's note dated 5/24/26 at 7:18 PM by RN #1 identified Resident #1 reported allegations that a staff member (later identified as NA #1) made inappropriate comments during care. Resident #1 was unable to state an exact date of when the incidents occurred. The Social Work note dated 5/25/26 at 10:33 AM by the Director of Social Services (DSS) identified Resident #1 expressed concerns related to NA #1 making inappropriate comments. Resident #1 reported NA #1 made several inappropriate comments about Resident #1's body when assisting with care at night. Resident #1 identified he/she asked NA #1 to stop, informed NA #1 the comments were inappropriate and, in response, NA #1 stated the comments were not inappropriate in his culture. Resident #1 informed the DSS that he/she began avoiding assistance from NA #1, unless it was necessary and began using a different type of underwear to avoid interaction with NA #1. Resident #1 did not report the allegations because he/she did not want to get anyone in trouble and because he/she was uncomfortable.The physician's note dated 5/26/26 at 2:30 PM by the Advanced Practice Registered Nurse (APRN) #1 identified Resident #1 reported NA #1 made inappropriate sexual comments about Resident #1's body during care. Resident #1 asked for a medium-sized brief and NA #1 responded asking if Resident #1 needed a larger size because he/she had a big a** and on a separate occasion asked if Resident #1 needed an extra-large. Resident #1 felt uncomfortable and upset and avoided asking NA #1 for assistance. Resident #1 verbalized relief NA #1 was no longer providing care. Resident #1 denied trauma but stated comments were uncomfortable and he/she did not appreciate remarks about his/her body. Initially hesitant to report due to not wanting to get anyone in trouble. Resident #1 was psychiatrically stable, calm, cooperative, and in no acute distress during evaluation.Interview with the DSS on 6/23/26 at 2:35 PM identified she spoke with Resident #1 and Resident #1 identified NA #1 said something to the effect of Resident #1 had a big butt on more than one occasion when assisting Resident #1 with hygiene. Resident #1 identified he/she told NA #1 it was not appropriate and NA #1 proceeded to tell Resident #1 that it was an appropriate comment in his culture. Resident #1 further identified avoiding receiving care from NA #1 unless absolutely needed after the comments were made.Interview with Resident #1 on 6/24/26 at 10:40 AM identified when he/she asked NA #1 to get him/her a brief, NA #1 brought an extra-large and Resident #1 told NA #1 that he/she wore a size medium. NA #1 responded to Resident #1 that, you have a big a** on at least three (3) occasions. Resident #1 told NA #1 the comment was inappropriate to which NA #1 responded it would be considered a compliment in his country. Due to comments made, Resident #1 stopped wearing tabbed briefs at night which he/she required assistance with and began wearing pull-up briefs which he/she wore during the day and could manipulate independently, so that Resident #1 would not need to ask NA #1 for assistance.Interview with NA #1 on 6/24/26 at 1:15 PM identified he provided incontinence care for Resident #1 and initially assisted with tabbed briefs but the facility stopped providing the tabbed briefs and Resident #1 began wearing pull-up briefs which he/she no longer needed assistance with. NA #1 further identified an incident when he brought Resident #1 a large size brief and Resident #1 stated he/she wore a medium. NA #1 responded he thought his/her stomach was a size large to which Resident #1 stated, are you telling me I have a big butt?' At that point NA #1 told Resident #1 people where he is from see that as a compliment. NA #1 denied any further allegations.2.Resident #4's diagnoses included atrial fibrillation, anxiety, and depression.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required moderate assistance from staff for personal care including incontinence care.The Resident Care Plan dated 5/15/26 identified Resident #4 had a self-care deficit and was incontinent of bladder. Interventions directed assistance with personal care as needed and with each incontinent episode, ensure an unobstructed path to bathroom, check Resident #4 every two (2) hours for incontinence, and change clothing as needed.The nurse's note dated 5/24/26 at 7:19 PM by RN #1 identified Resident #4 reported an allegation that NA #1 made inappropriate comments during care. Emotional support was provided to Resident #4. There were no physical findings. The Director of Nursing (DON), Administrator, police, physician, and a family member were notifiedThe Social Work note dated 5/25/26 at 10:19 AM by the DSS identified Resident #4 expressed concerns related to NA #1 making inappropriate comments. Resident #4 informed the DSS that he/she told NA #1 that he/she did not like the language used. Resident #4 identified NA #1 continued making comments and Resident #4 did not feel comfortable repeating the comments. Resident #4 did not report the allegations to anyone because he/she felt shame and did not want to cause trouble.The physician's note dated 5/26/26 at 2:15 PM by APRN #1 identified Resident #4 was alert and oriented, with intermittent forgetfulness. No acute distress was observed. When asked about the allegation, Resident #4 reported that NA #1 made statements suggesting that when another male patient is done with Resident #4, he (NA #1) will take him/her (Resident #4) and made unsolicited comments about his/her breasts. Resident #4 stated he/she did not report this at the time, explaining that he/she feared others might think he/she was trying to get attention. Resident #4 further expressed that he/she perceived NA #1 as predatory and felt he should not be providing care to people with medical infirmities.Interview with the DSS on 6/23/26 at 2:35 PM identified she spoke with Resident #4 and Resident #4 identified that NA #1 used language he/she did not feel comfortable repeating on more than one occasion. Resident #4 had not reported anything in the past because he/she felt shame regarding the comments.Interview with Resident #4 on 6/24/26 at 10:00 AM identified NA #1 made him/her feel uncomfortable on several occasions. Resident #4 described one incident when he/she was in the bathroom and did not realize the door was not closed all the way. When Resident #4 looked up, he/she saw NA #1 staring through the door while Resident #4 was seated on the toilet. Resident #4 did not say anything because he/she was embarrassed that he/she did not close the door all the way.Resident #4 identified having a close male friend in the facility and on one occasion alleged NA #1 said, when the male resident is done f'ing you, I will take over. Resident #4 further identified NA #1 made other comments and said, you have nice tits. Resident #4 did not initially report the concerns but after overhearing others discussing concerns about the same NA felt empowered to come forward with the concerns. Resident #4 further identified she told LPN #1that she did not want NA #1 providing care for him/her but would not give LPN #1 a reason. Resident #4 told LPN #1 he/she did not like NA #1 and would prefer LPN #1 provide care as he/she felt more comfortable receiving care from LPN #1 who was kind. Resident #4 further identified he/she had a duck on his/her walker that squeaked when squeezed and whenever NA #1 would walk by Resident #4 he would squeeze the duck and say, I am going to get you making Resident #4 more uncomfortable. Resident #4 became teary eyed during the interview and voiced relief after sharing specifics of allegations. Throughout the interview, Resident #4 would not say the offensive/inappropriate words but rather spelled them. Resident #4 had not previously felt comfortable repeating the specific words NA #1 used because Resident #4 was embarrassed and ashamed by the encounters with NA #1.Interview with APRN #1 on 6/24/26 at 12:35 PM identified Resident #4 was unable to clarify if the comments NA #1 made to him/her were of a sexual nature. Resident #4 had some recent memory challenges following an episode of COVID but had no history of fabricating events. After informing APRN #1 of the interview conducted with Resident #4 and the further clarification of Resident #4's initial statements along with Resident #4's emotional reaction during the interview, APRN #1 identified she believed Resident #4 was negatively impacted from the actions of NA #1.Interview with NA #1 on 6/24/26 at 1:15 PM identified he did not provide personal care for Resident #4, and he denied all allegations made regarding care and comments to Resident #4.Interview with the DON on 6/24/26 at 2:15 PM identified on 5/24/26 the President of Resident Council brought three (3) written statements by Residents #1, #2, and #4 to RN #1 regarding allegations of abuse against NA #1. The facility immediately initiated an investigation and suspended NA #1 pending the outcome of the investigation. The facility determined NA #1 failed to follow facility expectations regarding customer care and made comments to residents that made them feel uncomfortable. NA #1 made the comments repeatedly despite being asked not to by the residents. NA #1 was terminated. The DON further identified the facility failed to follow the abuse policy because based on the facility abuse policy, the statements made by NA #1 to the residents was verbal abuse.Review of the facility Abuse Policy identified that each resident had the right to be free from abuse and that verbal abuse was defined, in part, as the use of oral language that willfully includes disparaging and derogatory terms to residents.Although attempted, an interview with LPN #1 was not obtained. Review of facility documentation identified that a Plan of Correction was initiated immediately: Staff training regarding Resident Rights and the Abuse Policy including investigating and reporting was initiated on 5/24/26. Residents were also educated on reporting allegations of mistreatment.Audits were scheduled to be completed weekly times four (4) weeks then monthly times three (3) months which included questions to determine if residents were treated inappropriately or had care concerns.Audits were to be reviewed at the monthly QAPI meetings.The Administrator and Director of Nursing were responsible for the Plan of Correction.Alleged compliance date of 6/22/26 The Plan of Correction was reviewed during an on-site visit on 6/24/26 and the facility met all components for past non-compliance.

Based on observation (video), interviews, and record/policy review, the facility failed to ensure Resident #1 remained free from abuse when Nurse Aide (NA) #1 deliberately struck the resident's head during transport to the resident's room on 03/12/2026 at ~5:51 PM, causing an actual psychosocial outcome (yelling with audible distress) to a severely cognitively impaired resident (BIMS=6). Specifically, the video shows NA #1 entering the room, striking the top of the resident's cap, then striking the left side of the resident's head with the left hand while passing the roommate's bed; a loud noise is heard immediately before the resident yells. The facility's Abuse Policy prohibits willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, yet NA #1's actions violated this requirement. While RN #1 assessed no physical injury and the facility notified the DNS and police and removed NA #1, the resident nonetheless experienced actual psychosocial harm under the reasonable person standard. The findings included:Resident #1 was admitted to the facility in December of 2024 and had diagnoses which included dementia, schizoaffective disorder, bipolar type, and anxiety disorder.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required supervision/touch assistance with toileting, dressing, and personal hygiene and use of a wheelchair for transport.The Resident Care Plan (RCP) dated 1/9/26 identified Resident #1 had the potential to be physically and verbally aggressive related to dementia with poor impulse control and psychotropic medication use related to posttraumatic stress disorder, major depressive disorder, and schizoaffective disorder. Interventions directed to provide physical and verbal cues to alleviate anxiety, give positive feedback, assist to set goals for more pleasant behavior, encourage seeking out staff members when agitated and to allow the resident to vent frustrations.Review of camera footage dated 3/12/26 at 5:51 PM identified NA #1 transporting Resident #1 into his/her room via wheelchair. After entering the room, NA #1 struck the top of the resident's baseball cap with his/her left hand and then struck the left side of the resident's head with his/her left hand while passing the roommate's bed. Resident #1's arms remained positioned on the wheelchair armrests during the incident. Camera visibility was partially obstructed beyond the roommate's bed area; however, a loud noise was heard, followed by Resident #1 yelling. NA #1 was then observed re-entering the camera's view and then re-approaching Resident #1's side of the room again before the footage ended.A nursing note by RN #1 on 3/12/26 at 8:00 PM identified Person #1 reported alleged abuse of a resident by a staff member. The Director of Nursing Services (DNS) and the police were notified. A Head to toe assessment was conducted, and no injury was noted. The resident was unable to give details of the incident due to dementia. The resident's sister was notified, the provider and APRN #1 were updated.A statement by NA #1 dated 3/12/26 identified he/she was helping Resident #1 back to his/her room when he/she noticed Resident #1's hat was coming off. NA #1 indicated he/she pushed it down to secure it, Resident #1 reached for the hat again, and NA #1 helped Resident #1 adjust it again. NA #1 further indicated Resident #1 got frustrated, tried to pick up the dinner tray (which made a loud noise), and after noticing Resident #1 was frustrated, NA #1 backed up and left the room. Interview with RN #1 on 4/8/26 at 10:38 AM identified he/she was informed of the 3/12/26 incident by Person #1 between 6:00 PM and 6:30 PM via phone call as Person #1 observed the incident in real time via the roommate's livestream camera. RN #1 indicated he/she reviewed the camera footage provided, immediately directed NA #1 to wait outside of the facility, notified appropriate staff and police, assessed Resident #1 and found him/her without injury. Interview with NA #1 on 4/8/26 at 11:36 AM failed to provide details of the 3/12/26 incident, however, indicated a statement provided to the facility was available for review. Interview with the DNS on 4/8/26 at 12:20 PM identified NA #1's actions were inappropriate and no resident was to be struck, at any time, regardless of the situation at hand. The DNS further identified the facility's standard of practice was that all residents were to always be kept safe and free from harm. The Abuse Policy and Procedure identified each resident has the right to be free from abuse, neglect, and misappropriation of resident property and exploitation and defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. PAST NON-COMPLIANCE The facility presented a corrective action plan dated 3/12/26 which included:-Body audits and nursing assessments performed to residents on 3/12/26 who may have received care from the alleged perpetrator.-Resident interviews and precautionary resident assessments completed by 3/13/26 for other facility residents.-Staff education dated 3/12/26 included: abuse prevention, including definitions of abuse, resident rights, mandatory reporting requirements, and the facility's zero tolerance policy.-Additional education provided included: staff burnout, stress management, and appropriate de-escalation techniques when caring for residents. -Residents on affected unit interviewed by social services to ensure residents felt safe and to identify any additional concerns.-Review of employee personnel files, including background checks, abuse registry verification, and required competencies to ensure compliance with hiring and training requirements.-Reinforcement of appropriate resident care, professional conduct, and reporting responsibilities during staff meetings and daily stand-up huddles.-Abuse prevention audits which included random resident interviews, staff interviews, and leadership observational rounds to evaluate staff interactions with residents.-Audits of staff performing care by nursing leadership to ensure appropriate resident interactions and adherence to abuse prevention policies to be conducted weekly for four (4) weeks, then monthly for three (3) months until substantial compliance is achieved.-Results will be reviewed by the QAPI committee to ensure sustained compliance and identify any additional opportunities for improvement.-Concerns identified through monitoring will result in immediate corrective action and additional staff education as needed.-The DNS was responsible for this corrective action plan.-The corrective action plan was accepted by the state agency during an onsite visit on 4/8/26.

Based on clinical record review, facility documentation/policies, and staff interviews, for one (1) of one (1) sampled resident (Resident #6) reviewed for management and monitoring of hypertension, the facility failed to report elevated blood pressures to the physician and failed to establish clear parameters for reporting abnormal blood pressure readings in the absence of specific physician orders. The findings include:Resident #6's diagnoses included hypertension, intracerebral hemorrhage, acute respiratory failure hypoxia with tracheostomy, hemiplegia, and seizures.Physician's orders dated 4/9/25 directed all medications be administered through the gastrostomy tube (g-tube). Medications for hypertension included Amlodipine ten (10) milligrams (mg) one (1) tablet daily, carvedilol 6.25 mg every twelve (12) hours, clonidine HCl 0.2 mg every 12 hours, hydralazine 50 mg every four (4) hours, spironolactone 12.5 mg 1 tablet daily, and losartan potassium 100 mg 1 tablet daily.Documented blood pressures identified an admission blood pressure on 4/9/26 of 130/83 and elevated blood pressures on 4/10/26 (169/84); 4/11/26 (148/89 and 151/81); and 4/12/26 (188/100 and 192/98) with warning alerts generated on the vital sign report for systolic high of 139 exceeded.Review of the clinical record from 4/10/26 to 4/12/26 failed to identify the physician was notified of elevated blood pressures on 4/10/26 and 4/11/26.The admission Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 2), was dependent on all care including bed mobility and transfers.The Resident Care Plan (RCP) dated 4/12/25 identified Resident #6 had hypertension with interventions that directed to administer medications as ordered, monitor for abnormal cardiac symptoms, check vital signs per facility protocol, and monitor for change in lung sounds.The nurse's note dated 4/12/26 at 12:00 PM by RN #2 (the 7:00 AM to 3:00 PM supervisor) identified Resident #6 was assessed due to a change in condition. RN #2 identified Resident #6 as lethargic, warm, and clammy, and had vomited medication. The head of the bed was elevated at ninety (90 ) and Resident #6 was suctioned due to increased secretions. Resident #6's blood pressure was 188/100 manually. The physician was notified and Resident #6 was sent to the Emergency Department (ED) for possible aspiration or hypertension urgency due to elevated blood pressure and lethargy.The ED note dated 4/12/26 identified Resident #6 as a chronically ill-appearing resident distressed and diaphoretic. A CT scan of the head identified an acute intracranial hemorrhage involving the right temporal lobe with a small amount of subarachnoid and subdural blood. Resident #6 was started on nicardipine by intravenous route for elevated blood pressure and transferred to the hospital that had recently treated him/her for management of an intracranial hemorrhage. Interview with LPN #4 on 4/15/26 at 11:00 AM identified she provided care for Resident #6 on 4/11/26 and 4/12/26. She did not recall if Resident #6 had parameters in place for reporting elevated blood pressures and further identified the facility did not have parameters established for reporting elevated blood pressures. LPN #4 identified she would report an elevation in blood pressure if the systolic was over 160 or 170 or if the diastolic was over eighty. LPN #1 took Resident #6's blood pressure on 4/11/26 at 151/81 and failed to report the diastolic elevation based on her identified parameters.Interview with LPN # 3 on 4/15/26 at 1:30 PM identified she did not know if the facility had parameters in place for reporting elevated blood pressures and she would report to the supervisor if the systolic blood pressure was over 150 or 160 or if the diastolic blood pressure was over 90. LPN #3 took Resident #6's blood pressure on 4/10/26 at 169/84 and failed to report the systolic elevation based on her identified parameters. She further identified she rechecked the blood pressure but failed to document the results.Interview with the DON (Director of Nursing) on 4/15/26 at 2:45 PM identified that facility staff should report elevations in blood pressure based on the physician's orders, and in the absence of orders, should follow the Care Path Symptoms of Acute Mental Status Change that identified reporting a blood pressure elevation over 200 systolic. The DON further identified that all obtained vital signs should be documented. Interview with LPN #2 on 4/15/26 at 3:10 PM identified she would report elevations in blood pressure if the blood pressure was approaching 150/99 after checking the resident's baseline.Although attempted, a call was not returned by MD #1.Although requested, the facility did not have a policy for reporting abnormal vital signs in the absence of acute mental status changes.The facility Change in Condition Policy identified, in part, that when the staff identified the change of condition, they notify the licensed nurse, and the licensed nurse completes a physical evaluation and documents the findings in the medical record. The facility must inform the resident and consult with the resident's healthcare provider of significant change in the resident's physical condition.

Based on review of clinical records, interviews, video footage, and facility documentation/guidelines, for one (1) of three (3) sampled residents (Resident #1) reviewed for abuse, the facility failed to prevent unauthorized visual and audio access of Resident #1's care, interactions, and environment after the installation and use of video monitoring. The findings included:Resident #1 was admitted to the facility in December of 2024 and had diagnoses which included dementia, schizoaffective disorder, bipolar type, and anxiety disorder. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required supervision/touch assistance with toileting, dressing, and personal hygiene and use of a wheelchair for transport. The Resident Care Plan (RCP) dated 1/9/26 identified Resident #1 had the potential to be physically and verbally aggressive related to dementia with poor impulse control and psychotropic medication use related to post traumatic stress disorder, major depressive disorder, and schizoaffective disorder. Interventions directed to provide physical and verbal cues to alleviate anxiety, give positive feedback, assist to set goals for more pleasant behavior, encourage seeking out staff members when agitated and to allow the resident to vent frustrations. A nurse's note by LPN #8 on 3/10/26 at 11:59 AM identified he/she spoke with Resident #1's responsible party regarding the roommate's request to install a camera in the room to observe the roommate. LPN #8 assured the responsible party that the camera would not monitor Resident #1, the responsible party expressed understanding and verbal consent was obtained to install the camera. LPN #8 explained the policy and that the responsible party would need to sign consent. An email was sent to the responsible party as requested, awaiting return of signed paperwork. Interview with SW #1 on 4/9/26 at 2:32 PM identified the video camera was installed by the facility, on the roommate's side of the room, on 3/10/26. Review of video footage dated 3/12/26 at 5:51 PM identified Resident #1 received an assisted wheelchair transport into his/her room, was struck twice by a staff member, and captured audio of Resident #1's verbal outburst. The video footage further captured part of the hallway outside of Resident #1's room, the shared bathroom, all parties entering the room or walking by the doorway and enabled monitoring of the inside of the bathroom if the bathroom door was left open. Although verbal consent was received for the installation of the video camera on 3/10/26, the Roommate Virtual Monitoring Technology Consent Form was signed on 3/16/26 which agreed to virtual monitoring, with the understanding that Resident #1's roommate may begin using the electronic technology device. Although requested, the facility did not have a virtual monitoring policy. However, the facility provided the following guidelines regarding virtual connections: The State of Connecticut House of Representatives File #627, which both the Resident Virtual Monitoring Technology Consent Form and Instructions and Roommate Virtual Monitoring Technology Consent Form were modeled after. The Residents' [NAME] of Rights Policy identified a resident's right to privacy in accommodation, in receiving personal and medical care and treatment; in visits and in meetings with family and resident groups, in written, spoken, telephonic, and electronic communications, including email and video communications and in internet research; the right to associate and communicate privately with persons of your choice, including other residents.

Based on clinical record review, facility documentation, facility policy, and interviews, for one (1) of one (1) sampled resident (Resident #6) reviewed for an acute change in condition, the facility failed to provide adequate supervision and monitoring for a dependent resident experiencing an acute change in condition after Emergency Medical Services (EMS) was activated. This failure resulted in the resident being left unattended despite a compromised medical status, placing the resident at risk for aspiration and airway compromise. The findings include:Resident #6's diagnoses included hypertension, intracerebral hemorrhage, acute respiratory failure hypoxia with tracheostomy, hemiplegia, gastrostomy tube feed, and seizures.The admission Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 2), was dependent on all care including bed mobility and transfers.The Resident Care Plan (RCP) dated 4/12/25 identified Resident #6 had hypertension, a self-care deficit, a tracheostomy, and had a g-tube for feeding. Interventions directed to administer medications as ordered, monitor for abnormal cardiac symptoms, check vital signs per the facility protocol, provide complete care including repositioning, suction as needed, monitor respiratory and cardiac status.The nurse's note dated 4/12/26 at 12:00 PM by RN #2 (the 7:00 AM to 3:00 PM supervisor) identified Resident #6 was assessed due to a change in condition. RN #2 identified Resident #6 as lethargic, warm, and clammy, and had vomited medication. The head of the bed was elevated at ninety (90 ) and Resident #6 was suctioned due to increased secretions. Resident #6's blood pressure was 188/100 manually. The physician was notified and Resident #6 was sent to the Emergency Department (ED) for possible aspiration or hypertension urgency due to elevated blood pressure and lethargy. The nurse's note dated 4/12/26 at 12:05 PM by RN #2 identified at 11:30 AM after Resident #6 vomited, the tube feeding was turned off and the head of bed was elevated at 90 . Resident #6 vomited again. Lungs were clear and Resident #6 had positive bowel sounds. Skin was clammy and warm and Resident #6 was very lethargic. The family was called and was present during transfer to the ED. The ED note dated 4/12/26 identified Resident #6 as a chronically ill-appearing resident distressed and diaphoretic. A CT scan of the head identified an acute intracranial hemorrhage involving the right temporal lobe with a small amount of subarachnoid and subdural blood. Resident #6 was started on nicardipine by intravenous route for elevated blood pressure and transferred to the hospital that had recently treated him/her for management of an intracranial hemorrhage. Interview with LPN #4 on 4/15/26 at 11:00 AM identified she administered medications to Resident #6 the morning of 4/12/26 and Resident #6 was at baseline tracking with his/her eyes. Shortly after 11:00 AM, LPN #4 entered Resident #6's room to administer more medications and Resident #6 was less responsive, tracked with his/her eyes but did not hold a gaze. LPN #4 administered the medications and returned fifteen (15) minutes later to find Resident #6 had vomited, his/her skin was clammy, and blood pressure was elevated. LPN #4 turned off the tube feeding and called RN #2 to the room. After assessing Resident #6, RN #2 left his/her room to call 911, the family, and completed paperwork, LPN #4 proceeded to pass medications to other residents. LPN #4 further identified no one was in Resident #6's room until after Resident #6's family arrived at the facility. Once EMS arrived, LPN #4 had to suction Resident #6 again and the resident vomited during transfer to the ambulance stretcher. LPN #4 further identified someone should have stayed with the resident until EMS arrived on scene.Interview with NA #7 on 4/15/26 at 2:05 PM identified on 4/12/26 after 911 was called, she did not continuously stay with Resident #6 until EMS arrived and there was no nurse in the room during that time.Interview with the DON (Director of Nursing) on 4/15/26 at 2:45 PM identified that facility staff should provide supervision to any resident after 911 was called until the EMS arrived and due to the condition of Resident #6 it was a concern that no one stayed with him/her.Although requested, policies for Emergency Response, 911 Activation, Aspiration Precautions, and Supervision / Accident Prevention were not provided.

Based on review of clinical records, staff interviews, camera footage, and facility documentation, for one (1) of three (3) residents (Resident #1) reviewed for accident hazards, the facility failed to ensure leg rests were in place during an assisted wheelchair transport. This failure placed the resident at risk for injury. The findings included:Resident #1 was admitted to the facility in December 2024 and had diagnoses which included dementia, schizoaffective disorder, bipolar type, and anxiety disorder.Review of the Wheelchair Competency for NA #1 dated 7/29/25 identified he/she had successfully performed all competency elements, which included to ensure the resident's feet were placed safely on the footrests.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Mental Interview for Mental Status (BIMS) of 6), required supervision/touch assistance with toileting, dressing, and personal hygiene and use of a manual wheelchair for transport.The Resident Care Plan (RCP) dated 1/9/26 identified Resident #1 had a deficit in functional mobility. Interventions directed use of a standard wheelchair with anti-rollbacks due to Resident #1's inability to walk.Review of camera footage dated 3/12/26 at 5:51 PM identified NA #1 transporting Resident #1 into his/her room via wheelchair without attached leg rests and Resident #1 intermittently placing his/her feet on the floor while receiving assisted transport. Resident #1 presented agitated during the wheelchair transfer.Interview with PT #1 on 4/8/26 at 1:15 PM identified Resident #1 did not have the ability to raise his/her legs for an extended period while receiving assisted transport and required constant cueing/multiple reminders to raise his/her legs while receiving assisted transport as he/she would frequently rest his/her feet on the floor. PT #1 further indicated the risk for a resident who placed his/her feet on the floor while receiving assisted transport was injury and potential ejection from the wheelchair.Interview with NA #1 on 4/8/26 at 3:45 PM identified facility practice was to attach leg rests to a resident's wheelchair prior to assisted transport.Interview with the Director of Nursing Services (DNS) on 4/8/26 at 4:12 PM identified Resident #1 should have had leg rests attached to his/her wheelchair when he/she received assisted wheelchair transport on 3/12/26. The DNS further identified if leg rests were refused, the staff member should have sought an alternate means of transport to ensure the resident's safety and avoid the risk of injury. The DNS indicated staff received education in 2025 regarding assisted wheelchair transport which included the attachment of leg rests. Although requested, the facility did not have a policy for assisted wheelchair transport.

Based on clinical record review, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure an assessment was performed and a provider was notified of a change in condition after multiple reports of a change in condition was made by facility staff over an 11 day period of time. The findings include:Resident #1's diagnoses included dementia, abnormalities of gait, and muscle weakness. Physician's orders dated 5/21/25 directed Physical Therapy five (5) times per week for six (6) weeks and Occupational Therapy five (5) times per week for six (6) weeks.The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required maximum assistance for hygiene, showers, and bed mobility, was dependent on staff for dressing, toileting, transfers, and ambulation, and used a wheelchair for mobility. The Resident Care Plan (RCP) dated 5/24/25 identified Resident #1 had a self-care deficit and was at risk for falls. Interventions directed assistance with all care including transfers, wheelchair use for mobility, appropriate footwear, and for the resident to be in common areas while awake. The Physical Therapy (PT) note by Physical Therapist (PT) #1 dated 5/30/25 identified Resident #1 ambulated two (2) times forty (40) feet within his/her room and into the hallway using the two (2) wheeled walker with minimal assistance and verbal cues.The nurse's note dated 5/30/25 at 5:40 PM by RN #1 (3 PM to 11 PM supervisor) identified Resident #1 was observed sitting on the floor in his/her room at the bedside with his/her back resting on the bed frame. Resident #1 was unable to explain how he/she ended up on the floor, moved all extremities without issue, lower extremities were without deviation, rotation or shortness. Resident #1 was assisted to a standing position and took a few steps without issue. The Advanced Practice Registered Nurse (APRN) was updated and ordered monitoring per facility protocol for an unwitnessed fall. The PT note by PT #1 dated 6/2/25 identified Resident #1 was approached multiple times throughout the day but was too lethargic to safely perform PT activities.The PT note by PT #1 dated 6/5/25 identified once Resident #1 was standing, he/she was unable to tolerate single leg weight bearing to the left lower extremity. Upon palpation of the left hip, Resident #1 reported pain/wincing at the lateral aspect of the hip and reported pain when passively ranged into hip flexion while seated. Therapy was stopped and nursing staff were updated on left hip pain. The nurse's note dated 6/5/25 at 11:31 AM by LPN #3 (7 AM to 3 PM charge nurse) identified Resident #1 was out of bed in the wheelchair and a family member was visiting. The family member requested pain medication for left knee and left leg pain. Tylenol was administered with good relief.The PT note by PT #1 dated 6/9/25 identified Resident #1 had significant difficulty pivoting due to difficulty weight bearing through the left lower extremity and was unable to march in place due to inability to weight shift.The PT note by PT #1 dated 6/10/25 identified Resident #1 was having significant difficulty bearing full wight through the left lower extremity and unable to take a step forward with the left lower leg. When Resident #1 stepped forward with the right lower leg, the left lower leg buckled due to inability to weight bear and was unable to pivot feet during transfer. Recommeded transfer status be downgraded to use pivot transfer equipment to help ease pain. Nursing staff updated on decline and downgrade of transfer status from bed to chair.The PT note by the Rehabilitation Director (PTA #1) dated 6/12/25 identified Resident #1's sudden change had impacted functional status and safety.The nurse's note by LPN #2 (7 AM to 3 PM charge nurse) dated 6/16/25 at 9:40 AM identified she was called to Resident #1's room by the NA to observe Resident #1's left leg.The physician progress note dated 6/16/25 identified the APRN ordered an x-ray of the left hip which revealed an acute left hip fracture, with concern of an additional fall after the 5/30/25 fall due to a new skin tear to the left outer wrist. The x-ray identified an acute left hip fracture at the neck of the left femur with the left leg externally rotated. Resident #1 was sent to the Emergency Department for further evaluation and treatment. The x-ray of the left hip dated 6/16/25, identified an angulated and displaced intertrochanteric fracture of the left hip and severe osteopenia.Review of the nurse's notes from 6/5/25 to 6/16/25 failed to identify the APRN was notified of the change in condition reported by physical therapy to the nursing staff. The notes failed to identify an assessment after physical therapy reported their findings to the nursing staff. A statement dated 6/16/25 by PT #1 identified he/she reported concerns to nursing staff and requested the concerns be discussed during the facility Medicare meeting on 6/10/25. A statement dated 6/16/25 by OTA #1 identified he/she reported Resident #1's knee pain to the charge nurse. A statement dated 6/16/25 by PTA #1 identified he/she addressed mobility concerns throughout the prior week during morning meetings and discussed the change in Resident #1's mobility at the Medicare Meeting on 6/10/25. A statement dated 6/16/25 by OT #1 identified that on 6/12/25 he/she documented that Resident #1 continued to present with pain and decreased ability to weight bear on the left lower extremity but did not report the assessment to nursing staff because PT #1 had reported the left leg pain to nursing staff several times. Interview with PT #1 on 7/21/25 at 10:45 AM identified she was providing services to Resident #1 five (5) times per week. Prior to the fall on 5/30/25, Resident #1 was ambulating with PT staff and after the fall, he/she was unable to ambulate because he/she could not advance his/her feet and could not bear weight on the left lower extremity. PT #1 identified she downgraded Resident #1's transfer status which she communicated to the DON through the interagency communication system. PT #1 further identified Resident #1 did not have the ability to get up independently if he/she fell. Interview with the DON on 7/21/25 at 1:10 PM identified that if a resident had a change in condition the provider should be notified. The DON identified she was first notified of a change in condition for Resident #1 on 6/16/25 and the APRN was notified. The APRN was not made aware of any concerns or changes prior to 6/16/25. The DON did not recall any reports of concerns during the morning meeting or Medicare meeting and did not have minutes for those meetings. The DON further identified she had not reviewed the communication from PT #1 through the interagency communication system which was sent to her on 6/10/25 regarding the changed transfer status and indicated that the facility was going to stop using that practice since clinicians did not often look at the communication. Although attempted, interviews with LPN #1 and LPN #3 were not obtained. Review of the facility policy Change of Condition identified it was the facility's policy to notify the physician when the residents' condition changed. The policy further identified if a change in condition is identified the licensed nurse gets notified and completes a complete physical evaluation and documents the findings in the medical record. The licensed nurse notifies the physician of any change in condition.

Based on clinical record review, facility documentation, facility policy and interviews for two of three sampled residents (Residents #2 and Resident #3) who were reviewed for an allegation of resident-to-resident sexual abuse, the facility failed to provide adequate monitoring for a resident who had a history of wandering and was observed by facility staff wandering into other resident rooms. The findings include:1. Resident #2's diagnoses included dementia, anxiety, and difficulty ambulating. The Resident Care Plan (RCP) dated 5/13/25 identified Resident #2 had a self-care deficit and wandered throughout the unit and in and out of other residents' rooms. Interventions directed to offer structured activities, comfort support and redirection when wandering into other residents' rooms. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had severe memory recall deficits (Brief Interview for Mental Status (BIMS) score of 2), required maximum assistance from staff for eating, hygiene, showers, toileting, and dressing and was independent with mobility. 2. Resident #3's diagnoses included dementia and an unsteady gait. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had severe memory recall deficits (Brief Interview for Mental Status (BIMS) score of 5), required touching assistance for all care and was independent with mobility. The Resident Care Plan dated 6/13/25 identified Resident #3 had a self-care deficit, and interventions directed to provide set-up assistance for care as needed. The nurse's note dated 7/4/25 at 10:17 PM by RN #1 (3 PM to 11 PM supervisor) identified Resident #2 went in and out of other residents' rooms before dinner with frequent redirection. Resident #2 did not exhibit signs of discomfort, was alert and confused per baseline, and was placed on one (1) to one (1) supervision after dinner. Review of the clinical record failed to identify implementation of increased monitoring and care-planned interventions, including structured activities and comfort support, to address Resident #2's wandering behaviors observed prior to dinner. The nurse's note dated 7/4/25 at 10:56 PM by RN #1 identified Resident #2 was found in Resident #3's room. NA #1 witnessed Resident #2 lying in a supine position in the bed belonging to Resident #3's roommate. Resident #2's pants were down, and the incontinence brief was open on one side. Resident #3 was observed partially undressed attempting to initiate sexual contact. The incident was immediately stopped, and Resident #2 was removed from the room. No physical injuries were noted, the Director of Nursing (DON), family members, police, and physician were notified, and psychology and social work referrals were made. Both residents were placed on one (1) to one (1) observation for safety. A written statement by NA #1 dated 7/4/25 identified she observed Resident #2 lying in the bed of Resident #3's roommate. NA #1 noted that Resident #2 frequently wandered into other residents' rooms and had a particular interest in that specific bed, for unknown reasons. At the time of observation, Resident #2's pants were lowered to the right calf, and the incontinence brief was open on the right side. Resident #3 was observed with a hand on his/her own genitalia and was attempting to engage in sexual contact with Resident #2. The behavior ceased immediately upon NA #1 entering the room. The Facility Accident and Incident Report dated 7/4/25 identified there was an incident between Resident #2 and Resident #3 that occurred at 6:45 PM. One (1) to one (1) monitoring was initiated because of the incident. The Director of Social Services (DSS) note dated 7/7/25 at 11:10 AM identified Resident #3 reported, we almost did it when asked about the incident on 7/4/25. When the DSS inquired what it meant Resident #3 responded, having sex, but it didn't happen because the nurse stopped us. Resident #3 further identified both residents talked about it and agreed. Resident #3 denied physical touch and identified him/her and Resident #2 were undressing themselves and Resident #2 was lying in the bed while Resident #3 was standing next to the bed when the nurse came in. The Psychiatric Evaluation note dated 7/8/25 identified Resident #3 was seen as follow up by the Advanced Practice Registered Nurse (APRN). Resident #3 was seen partially undressed with apparent intent to engage in inappropriate behavior with another cognitively impaired, partially undressed resident who had wandered into his/her room. Resident #3 appeared guarded on the discussion around the incident with Resident #2 on 7/4/25. He/she perseverated on the incident and identified feeling staff and the resident's roommate set him/her up and that Resident #2 told him/her to do it. The APRN further identified that while no physical contact occurred due to staff intervention, the behavior raised concern regarding judgement, insight and impulse control. Interview with RN #1 on 7/21/25 at 10:35 AM identified he was in the dining room with the residents during dinner on 7/4/25 and saw Resident #2 ten (10) minutes before NA # 1 requested he go to Resident #3's room. Upon entering Resident 3's room, Resident #3 was on his/her side of the room fully dressed and on the phone, and Resident #2 was still lying in the roommate's bed partially undressed. Attempts to interview NA #1 were unsuccessful. Review of the facility policy for Abuse and Neglect, identified that residents had the right to be free from abuse. Sexual abuse was defined as non-consensual sexual contact of any type and a resident-to-resident altercation was defined as a physical or verbal act between two (2) residents with or without injury.

Based on observation, review of facility policy/procedures and interviews during the kitchen tour, the facility failed to ensure the 3-day emergency water supply was available and not expired. The findings include: Initial tour of the kitchen on 6/22/25 at 8:18 AM found no expired foods in the refrigerator, or freezer, or in the dry storage area. Reviewed the 3-day emergency food supply. No expired foods noted. 3-day menu in place. Foods are rotated monthly per the Food Service Director (FSD). Water in the dry storage area/3-day emergency food closet, observed with no expiration dates (3 cases of water 32 ounces each, with no expiration dates). According to the FSD, that water was extra, in addition to the 3-day water supply kept in the garage (off the basement) at the facility. Water in the garage designated for the 3-day emergency supply, approximately 60 gallons, had an expiration date of 9/24/24. Observation on 6/22/25 at 10:15 AM of the Administrator of the facility, indicated the administrator was talking on the phone and was heard inquiring about the 3-day emergency water supply. Observation on 6/22/25 at 2:50 PM with the Food Service Director (FSD), in the 3-day emergency closet/storage room, identified approximately 60 gallons (3-gallon jugs per case) of expired water dated 9/24/24. Observation on 6/22/25 at 2:52 PM with the FSD, identified the 3-day emergency water had expired on 9/24/24 and the extra water located in the 3-day emergency food closet, had no expiration date on them (3-cases-32-ounce bottles-18 gallons). Interview on 6/22/25 at 2:54 PM with the FSD indicated the water indeed was expired and would be removed, thrown out and new water would be purchased. Not sure why it had expired and had not been removed already, as it expired back in 2024. Interview on 6/23/25 at 9:42 AM with the FSD indicated the fault for having expired water was the FSD's as the expiration date was not checked. A new order of water was placed by the facility for the 3-day emergency water supply. Interview on 6/24/25 at 7:52 AM with the administrator, indicated the emergency water supply was the responsibility of the food service director to audit when it expired. Recently we had no water for some time and had plenty of emergency water on hand. I understand, the water was expired. Can you accept a plan of correction, oh never mind. I know, it had expired. Review of the Water Supplies policy dated 11/11/2024 directed, to maintain a drinkable water supply of 1 gallon per resident per day, plus an additional 1 gallon per staff member and volunteer(s) (minimum of 50 additional gallons) for the 3-day inventory on hand. It is the responsibility of each National facility location to order sufficient water products to maintain its emergency water inventory.

Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for 4 of 6 sampled residents (Residents #24, #90, #91 and #93) reviewed for involuntary seclusion, the facility failed to ensure the residents' responsible party was involved in care planning, including the decision for placement in a secured/locked area and the development of interventions, failed to ensure that documentation in the clinical record included clinical criteria met for placement, failed to reflect the responsible party involvement in the decision for placement, failed to reflect involvement of the MD in deciding that the placement in the secured/locked area was the least restrictive approach that is reasonable to protect the resident and assure safety and ensured that ongoing documentation illustrated the impact of placement on the unit and whether the resident continued to meet the criteria for remaining in the secured/locked area and if the interventions continue to meet the needs of the resident. The findings included:Observation on 6/22/25 at 11:00 AM identified a secured designated memory care unit. The main entrance to the unit is accessible by a button that unlocks the door to the unit. Once in the unit, a code must be entered into a key pad, or a key fob must be used to exit the unit. The unit consists of a North wing, and a South wing. The North wing of the unit is able to house 32 and had a census of 30. The other doors on the unit were also secured. The South wing is able to house 30 residents and had a census of 30. The South unit also contained secured doors, which required a code to unlock the doors in order to exit the secured unit. admission criteria for the memory care unit identified placement was reviewed by the admissions team consisting of the Director of Admissions, Director of Nursing, and the Memory Care Community Program Director. The policy indicated the Administrator, Medical Director and psychiatrist can assist in the evaluation of information when necessary. admission criteria identified residents with a primary diagnoses of mental illness will not be considered for admission and that individuals admitted to the unit must be diagnosed with Alzheimer's disease, dementia, or a similar cognitive disorder or confusion that is not a result of a reversible medical or psychological condition, have behavioral expressions that can be managed in the community and be able to participate in the specialized programming designed for their stage of dementia. The regulation guidance regarding involuntary seclusion includes a resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. The regulation indicated that criteria for placing a resident in the secured/locked area would not:1. Used for staff convenience or discipline.2. Based on the resident's diagnosis alone since the determination for placement in the area must be made on an individualized basis; and/or3. Based on a request from the resident's representative or family member without clinical justification.Additionally, the regulation identified items that are expected in the resident's record to include: Documentation of the clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by the interdisciplinary team. Documentation reflects the resident/representative's involvement in the decision for placement in the secured/locked area. Documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety. Documentation by the interdisciplinary team of the impact and/or reaction of the resident regarding placement on the unit; and Ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. The memory care unit guidelines/policy identified the unit is equipped with a security system that prevents residents from eloping while staff and visitors discretely use a code entered on keypads to enter and exit the unit. The policy indicated that the Medical Director collaborates with the IDT to approve admissions to the unit. Resident #24 was admitted to the facility September 2022. Diagnoses included mild neurocognitive disorder due to known physiological condition without behavioral disturbances, chronic post-traumatic stress disorder and obsessive-compulsive disorder. The quarterly MDS assessment dated [DATE] identified Resident #24 had intact cognition, required partial/moderate assistance with toileting and showering hygiene, bed mobility and transfers, did not exhibit inattention, disorganized thinking or altered level of consciousness and did not exhibit rejection of care or wandering and did not utilize alarms. Physician's orders dated 5/23/25 directed behavior monitoring of verbal outbursts and refusal of Geri-sleeves when in wheelchair. The physician's orders did not contain orders directing residence on a secured unit. Resident #24's care plan dated in effect for May 2025 identified the resident would attend activities off the secured unit with interventions that included: escort on and off secured unit by staff and monitor while off the secured unit. The memory care secured unit disclosure and waiver documentation dated September 26, 2023, identified Resident #24 did not meet the criteria for placement and indicated that instructions would be provided on how to leave the unit. Review of social work progress notes from 12/20/23 through 6/11/25 failed to identify Resident #24 or resided on the secured unit or that he/she continued to meet the criteria. Physician's notes reviewed from 1/2/25 through 6/22/25 failed to identify Resident #24 resided on a secured unit and failed to document whether the secured unit placement was the least restrictive for the resident or that the resident continued to meet the criteria for the placement. The elopement risk evaluations dated 4/12/25, 5/14/25 and 6/13/25 identified Resident #24 did not have the physical ability to leave the facility and did not have the capacity to make informed decisions about leaving and was identified as not at risk for elopement. The nurse aide care card dated June 2025 identified Resident #24 is to be escorted on and off the secured unit by staff and would be monitored by staff while off the unit. Observation on 6/22/25 at 11:19 PM identified Resident #24, in the resident room on the North hallway of the unit in the wheelchair eating lunch. Resident #24 was independent in eating and was able to self-propel in the wheelchair. Interview on 6/22/25 at 11:21 AM with Resident #24 identified he/she has intact cognition, lives on a secured memory care unit and is not able to leave the unit independently. Interview on 6/24/25 at 11:06 AM with LPN #6 (memory care unit director) identified Resident #24 resided on the unit prior to it becoming a secured unit and chose to stay. LPN #6 indicated the secured doors can be unlocked with a key fob. She further identified that but Resident #24 had been assessed for the ability to use the key fob but was physically unable to utilize the fob and open the door in his/her wheelchair. LPN #6 was unable to provide documentation for this assessment. Additionally, LPN #6 could not identify why Resident #24 required monitoring off of the unit and indicated the interdisciplinary team (IDT) makes the decision for placement, but there is no documentation to support the reasons for decisions made. Resident #90 was admitted to the facility May 2024. Diagnoses included Dementia in other diseases severe with agitation. Unspecified dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The Quarterly MDS dated [DATE] identified Resident #90 had severely impaired cognition, did not utilize any alarms, identified Resident #90 had impairment on one side of the lower extremities, was dependent with bed mobility and transfers. Physician's orders dated 6/20/25 directed Q15 min checks every shift until further notice, monitoring of behaviors to include refusing medication, combative, impulsivity, restlessness, entering peers room, removing items from cart, verbal outburst and unprovoked crying but failed to identify Resident #90 resided on a secured unit. The care plan dated 5/14/25 identified Resident #90 was at risk for elopement due to past history of attempts to leave premises prior to admission but then indicated Resident #90 was not currently an elopement risk due to inability for independent ambulation and identified that when Resident #90 was able to ambulate the status would become an elopement risk with interventions to include repeat elopement risk assessment, Resident #90 not to go outside without constant supervision and secured unit. Observation on 6/22/25 at 11:00 AM identified Resident #90 in the resident room on the south hallway. Resident #90 remained in bed. Social services notes dated 5/3/24 through 6/23/25 identified Resident #90 adjusted well to the facility but failed to identify placement on a secured unit. Provider progress notes dated 1/2/25 through 6/23/25 failed to identify Resident #90 resided on a secured unit and failed to document whether the secured unit placement was the least restrictive for the resident or that the resident continued to meet the criteria for the placement. Elopement risk assessment dated [DATE] identified Resident #90 was an elopement risk and indicated the resident wanders r/t dementia and will wander into other resident room and lay on their bed with task identified as Monitor every 15-minute checks for safety. Nurse aide care card dated June 2025 identified Resident #90 had a bed/exit alert system in use and indicated staff should distract Resident from wandering, 15 checks for safety and indicated Resident #90 would not go outside without constant supervision. Subsequent to surveyor inquiry, a memory care secured unit notice and disclosure was provided for Resident #90 with a signature. The signature does not include whose signature it is. Resident #91 was admitted to the facility May 2024. Diagnoses included Unspecified dementia, unspecified severity with agitation, severe with agitation, with mood disturbance, major depressive disorder recurrent. The Annual MDS dated [DATE] identified Resident #91 had severely impaired cognition, did not exhibit rejection of care or wandering or any physical or verbal behavioral symptoms directed toward self or others. Physician's orders dated 5/4/25 directed monitoring of behaviors to include withdrawn, agitation, anxiousness, yelling, and screaming. The orders indicated the MD had participated in and discussed the current interdisciplinary care plan and approved its implementation. The care plan dated 6/13/25 identified Resident #91 was at risk for elopement related to dementia/wandering and indicated Resident #91 dressed like a visitor with interventions to provide structured activities, be safely housed on designated unit over the next review without incident, had a wanderguard placed on the left ankle, would not go outside without constant supervision and secured unit. Observation on 6/22/25 at 9:00 AM identified Resident #91 ambulating on the South hallway of the unit independently. Provider progress notes dated 12/11/24 identified Resident #91 was currently residing in the facility but failed to identify Resident #91 resided on a secured unit. Social services progress notes dated 5/31/24 through 6/23/25 failed to identify Resident #91 resided on a secured unit. All other provider progress notes dated 8/30/24 through 6/23/25 failed to identify Resident #90 resided on a secured unit and failed to document whether the secured unit placement was the least restrictive for the resident or that the resident continued to meet the criteria for the placement. Psychiatric note dated 5/3/25 at 11:28 AM identified Resident #91 does not present as a danger to self or others, had no indications of distress and failed to identify Resident #91 resided on a secured unit or that it was the least restrictive placement. Nurse aide care card dated June 2025 identified Resident #91 would not go outside without constant supervision and required wanderguard monitoring. Resident #93 was admitted to the facility May 2025. Diagnoses included encephalopathy and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admission MDS dated [DATE] identified Resident #93 had severely impaired cognition, did not exhibit inattention, disorganized thinking, hallucinations, delusions, altered level of consciousness or wandering and indicated Resident #93 did not utilize any type of alarm, including a wander alarm. Physician's orders dated 5/23/25 directed to check functioning of wander guard on right wrist every night shift, check location of wanderguard on right wrist every shift, check location of wander guard on right wrist every shift for monitoring, and check expiration date every day shift every 7 days for monitoring but failed to direct placement on a secured unit. The care plan dated 5/21/25 identified Resident #93 would participate in activities and dining off of secured unit with interventions to be monitored by staff while off secure unit, be escorted on and off secure unit by staff and elopement evaluations per facility policy. Additionally, the care plan indicated Resident #93 was a risk for elopement with interventions to include placement of a wanderguard, constant supervision if outside, secured unit placement with IDT evaluation of appropriate placement. Observation on 6/24/25 at 8:30 AM identified Resident #93 in the resident room on the South hallway. Resident #93 was independently ambulating and able to communicate needs to staff without difficulty. Elopement risk evaluation dated 5/16/25 identified Resident #93 had the physical ability to leave the facility and did not have the capacity to make informed decisions about leaving, had a history of wandering/elopement, hallucinations and was deemed an elopement risk with wander device monitoring. Physician's progress notes dated 5/18/25 at 6:35 PM failed to identify Resident #93's placement on a secured unit or that it was the least restrictive housing. Nursing progress note dated 5/20/25 at 11:11 AM identified Resident #93 was in the hall agitated and threatening to call police because of being held against his/her will. APRN progress note dated 5/22/25 at 10:15 AM identified Resident #93 was noted to have altered mental status, memory impairment and wandering behavior while in the hospital prior to admission and directed monitoring for continued signs of elopement risk. Care conference documentation dated 6/5/25 identified acclimation to the facility was addressed but failed to identify Resident #93's placement on a secured unit. APRN progress note dated 6/20/25 at 12:00 PM identified Resident #93 was considered high risk for elopement and continued to require frequent redirection and was refusing monitoring in the form of ankle bracelet. The note indicated Resident #93 did not exhibit symptoms of depression or psychosis and did not present as a danger to self or others but failed to identify Resident #93 resided on a secured unit. Interview on 6/24/25 at 10:06 AM with Person#4, conservator for Resident #93 identified that Resident #93 had been confused and Person#4 indicated that placement in the facility was temporary until they are able to secure a safe discharge plan. Person#4 indicated that she was not aware that Resident#93 was placed on a secured unit, as she could not find anything specific in her notes, and did not recall consenting. Person#4 identified that Resident #93 had been approved for a community money program and community housing was being looked into. Person#4 indicated that in the last care conference it was discussed that Resident #93 needed monitoring and that a wanderguard was being discussed. Interview on 6/24/25 at 10:20 AM with Person #5, office care manager for Person#4, identified that when in the hospital, Resident #93 had tried to leave several times and that possibly Resident #93 was on the secured unit for that reason. Interview on 6/23/25 at 11:19 AM with LPN#5 identified there were no residents who resided on the secured unit who were able to leave the unit independently. Interview on 6/23/25 at 11:31 AM with RN#2, supervisor, identified secured unit admissions are usually completed by the RN supervisor. RN#2 indicated that social work and the memory care director reviewed all of the admissions prior to admission for appropriateness. RN#2 identified that none of the residents on the unit have the code for egress and indicated she was not involved in ongoing assessments of the residents. Interview on 6/23/25 at 11:44 AM with LPN#6, memory care director, identified the admission criteria for the secured unit was a corporate decision. LPN#6 indicated that placement was dependent on diagnosis, which needed to be Alzheimer's or dementia. LPN#6 identified that medications are reviewed for medications that manage behaviors and identify whether these behaviors can be managed on the unit. Interview on 6/24/25 at 9:42 AM with SW#1 identified she oversees the care conference meetings to make sure that everything that is supposed to be discussed is discussed to include labs, weights, rehab, goals, dc planning, advocacy or additional supports. SW#1 indicated that if there is a patient on the dementia unit, the family/representative is asked if they want the resident to remain on the unit. SW#1 identified she was not overly familiar with admission criteria and indicated that elopement was a consideration for placement and that the placement is individual and specific to the resident. SW#1 identified that when a resident resides on the secured unit, they should be care planned for that placement and that all residents/representatives sign a consent for placement and that these consents should be signed annually but reviewed quarterly and indicated that family members were able to give consent for placement. SW#1 identified that placement should be based on the resident's assessment and not what happened at the hospital. Interview on 6/24/25 at 10:34 AM with LPN#6, Administrator and Person #3 (Director of operations) identified that there are consents for all residents on the secured unit although LPN#6 was not able to locate the consents. LPN#6 indicated that residents who chose to stay on the unit signed waivers to remain there. They identified the secured unit was established in Nov. 2023 and resident admissions are individualized based on whether they need a secured unit, including elopement evals. Additionally, it was indicated that the admission discussion for admission was not documented in the clinical chart and that it was unclear if the medical director documented the need or ongoing need for placement on the unit. Interview on 6/24/25 at 12:49 with the Medical Director, MD#1, identified the facility had its own protocol for admission on to the secured unit. MD#1 indicated that he is informed if a resident is placed on the unit after the nursing assessment is completed and the facility decides what is needed for the resident. MD#1 identified placement had a behavioral component but was not aware of the regulation for the secured unit. MD#1 indicated he does an assessment of the resident during the required visits and reviewed the social worker documentation but doesn't order the placement and doesn't necessarily document anything about the resident placement on a secured unit.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #107) reviewed for urinary catheter, the facility failed to ensure a resident utilizing a urinary catheter had a clinical condition which demonstrated the need for catheterization and that an assessment was completed for the removal of the catheter. The findings include: Resident #107 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, diastolic congestive heart failure, and acute kidney failure. Review of the Inter-Agency Patient Referral Report (W-10) dated 6/16/25 identified in the genitourinary system (GU) Resident #59 had a foley catheter. The Nursing admission Evaluation dated 6/16/25 identified Resident #107 was oriented to person, place, time and situation, and had an indwelling urinary catheter. The physician's orders for June/2025 failed to identify Resident #107 had an indwelling urinary catheter and failed to identify how to care for the catheter (inclusive of type of catheter, size of catheter, indication for the use of the catheter and care instructions). Review the Resident #107's clinical records with the Regional Director of Clinical Operations (RN #1) and the MDS Coordinator (RN #3) on 6/23/25 at 9:47 AM failed to identify a diagnose or clinical condition for the need of an indwelling urinary catheter or that an assessment was completed for the removal of the urinary catheter. Interview with the RN #1 and RN #3 on 6/23/25 at 9:32 AM identified resident should have had a diagnosis indicating the need for the indwelling urinary catheter. They further identified if when the resident was admitted there was no diagnoses for the urinary catheter it should have been addressed for its removal and the resident placed on a voiding trial to further assess the need for the indwelling urinary catheter. Interview with the Nursing Supervisor (RN #4) on 6/23/25 at 3:57 PM identified after reviewing the resident's record, Resident #107 did not have a diagnosis, and it should have been assessed for its removal. He further identified it was an oversight as on the day of the resident's admission he was busy with admissions, and he had only reviewed the medication reconciliation and the care plan for the resident had come in on the day shift. Observation and interview with the Nursing Supervisor (RN #2) on 6/23/25 at 8:24 AM identified Resident #107 lying in bed with an indwelling urinary catheter connected to a drain bag hung on the left side of the bed draining yellow urine. RN #2 was asked should the resident have a physician's order for the use of an indwelling urinary catheter, which she responded yes. She proceeded to her office to find the order but there was no physician's order for the use of the indwelling urinary catheter. She identified it was the responsibility of the admitting nurse to ensure there was an order in place. She further identified she was unaware that the resident had an indwelling urinary catheter. Interview with the Charge Nurse (LPN #3) on 6/23/24 at 9:17 AM identified she had completed the nursing admission evaluation form and failed to check off under the device and treatment section that the resident had a Foley catheter, which should have been selected. Interview with the Regional Director of Clinical Operations (RN #1) and the MDS Coordinator (RN #3) on 6/23/25 at 9:47 AM identified Resident #59 should have a physician's order for the indwelling urinary catheter which would include the type of device, size of the foley, balloon, and changing of the catheter. RN #3 identified that because on the nursing admission evaluation form the foley catheter was not checked off it did not prompt the nursing supervisor to obtain an order. Interview with the evening shift Nursing Supervisor (RN #4) on 6/23/25 at 3:57 PM identified he was aware that the resident had a foley catheter but did not check to see if the resident had an order, as the resident came in on the day shift and he was only reconciling the medication and completing the baseline care plan. He further indicated that the resident should have a physician's order for the urinary catheter and care of the catheter. Review of the Urinary Catheterization policy identified urinary catheter should be placed only under the direction of a physician's order. The policy further identified that the physician order to include catheter type and size, diagnosis for use, irrigation if indicated and drainage collection type and urinary catheters should be evaluated for need and removed promptly when no longer necessary.

Based on review of the clinical record, review of facility policy/procedures and interviews for 1 of 6 sampled residents (Resident #91) reviewed for Advanced Directives, the facility failed to ensure Do Not Resuscitate advanced directives were physically signed by the resident representative and witnessed by 2 facility nurses. The findings included: Resident #91 was admitted to the facility on [DATE]. Diagnoses included dementia, and major depressive disorder recurrent. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 had severely impaired cognition, was taking antipsychotics and antidepressant medications and did not exhibit rejection of care or wandering behaviors. Physician's orders dated 11/19/24 directed do not hospitalize except for trauma, do not intubate, do not resuscitate, no intravenous fluids, no tube feeding and RN may pronounce. Prior to this, orders directed Resident #91 was a Full Code. The care plan dated 9/10/24 identified Resident #91 was a Full Code with interventions to honor advanced directives as directed by resident/responsible party for guidance and to provide information to resident/responsible party to complete Advance Directives and assist as necessary. Social Services note dated 5/25/24 at 11:46 AM identified Resident #91's son indicated Resident #91 had a living will and had elected to be a DNR at a past facility and identified he would bring the paperwork and sign the facility documentation. Social Services note dated 9/10/24 at 10:18 AM identified Resident #91 remained a Full Code. Social Services note dated 9/11/24 at 10:58 AM identified Resident #91's conservator verified the DNR, DNI, no tube feed, no IV hydration, and send to ED/hospital for trauma only as a verbal confirmation over the phone. Advance Directive Consent/acknowledgement and release form dated 11/19/24 identified Do not administer cardiopulmonary resuscitation, artificial respiration, artificial nutrition, IV hydration and do not hospitalize except for trauma. This form indicated a verbal consent from Resident #91's conservator and with a witness signature from one LPN. Social Services note dated 11/22/24 at 11:31 AM identified Resident #91 remained a DNR. Interview on 6/23/25 at 11:37 AM with RN#2, nursing supervisor for the shift, identified advance directives are established on admission and indicated that confirmation of the status can be obtained over the phone and should be witnessed by two people. Additionally, it is expected that there be a hard signature on it and is usually followed up by the unit director or the social worker. The residents that need to be followed up on are passed on in morning meeting. Interview on 6/24/25 at 9:42 AM with SW#1 identified that she was responsible for double checking that the advance directive consent sheets were signed and witnessed with two people and reviewed to ensure the signed elections matched the code status order and the care plan. Interview on 6/24/25 at 7:01 AM with RN#5 identified that she conducted the company's education on advance directives and indicated that the consent must be signed by the conservator or designee and be witnessed by two nurses. The facility policy for Advanced care planning code status identified surrogate decision making/healthcare proxy consent for a DNR order must be in writing, signed in the presence of two witnesses [AGE] years of age or older, who must sign the consent form. The policy did not allow a verbal agreement with a surrogate decision making/healthcare proxy consent.

Based on clinical record reviews, facility policy review, and interviews for two of five sampled residents (Residents # 91 & #102) reviewed for unnecessary medications, the facility failed to ensure the Risperdal (anti-psychotic medication) that was ordered as needed was limited to 14 days unless the prescribing physician evaluates the resident for appropriateness of the medication and failed to ensure the resident's drug regimen was free from administration in excessive dose, for excessive duration, without adequate monitoring or without adequate indications for use. The findings include: Resident #91 was admitted to the facility June 2024. Diagnoses included dementia and major depressive disorder recurrent. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 had severely impaired cognition, exhibited physical and verbal behavioral symptoms directed toward others, was a partial/moderate assist with activities of daily living and mobility, was administered antipsychotic and antidepressant medications and exhibited rejection of care or wandering behaviors with the last the 7 days. Physician's orders dated 8/24/24 directed to administer Vitamin D3 Oral capsule 1.25 mg (50,000 units) 1 capsule 1 time weekly. The care plan dated 6/5/24 identified Resident #91 was resistive to care related to dementia with interventions to encourage participation and give clear explanations of all care activities and indicated Resident #91 was taking psychotropic medication but failed to identify Vitamin D, a medication that required monitoring. Drug Regimen Review dated 8/27/24 identified Resident #91 was receiving Vitamin D 50,000IU once weekly. Please evaluate continued need for high dose. Consider ordering a follow-up 25 hydroxyvitamin D level and taper to maintenance dose of Vitamin D3 50,000 IU once monthly, if appropriate. This review was reviewed and agreed to recommendations by an APRN. Physician's orders dated 8/31/24 directed to obtain a 25-hydroxyvitamin D level. This order was marked as completed on 8/31/24 but the facility failed to provide proof of lab results. Drug Regimen Review dated 9/26/24 identified Vitamin D was ordered on 8/31/24, results not located on chart. Please follow up and obtain a duplicate copy or consider reordering, if necessary. This recommendation was not signed or acknowledged by the facility provider. Physician's order dated 11/29/24 directed administration of Vitamin D 50,000 unit given every 1 month starting on 1st for 28 days. Medication administration record for December 2024 identified Resident #91 received Vitamin D 50,000 units daily from 12/1/24 through 12/24/24. Medication Regimen review dated 12/24/24 identified the order for Vitamin D on 11/29/24 appeared to be mis-transcribed on the current Medication Administration Record and indicated the facility should investigate and initiate a medication incident report, if necessary. Additionally, the review identified Vitamin D 50,000-unit order entered as every 1 month starting on 1st for 28 days, created administration for 50,000 units daily and recommendations were to change schedule to starting on 1st and ending on 1st to create 1 administration per month. Physician's orders dated 1/25/25 directed administration of Vitamin D 50,000 units one time monthly on the 10th of the month. The clinical chart dated 5/24/24 through 6/20/25 failed to identify any lab results related to vitamin D levels for Resident #91. Nurses' notes reviewed from 8/1/24 through 11/1/24 failed to identify any patient refusals for blood draws. Interview on 6/23/25 at 7:40 AM with MDS coordinator identified that medications that require monitoring should be identified in the care plan. Interview on 6/24/25 at 7:01 AM with RN#5 identified the labs for Resident#91 were never obtained and were never followed up with. Additionally, the order was put in incorrectly and RN#5 indicated she did not know why no one realized it was wrong, nor was there any incident report started or report of a medication error. Interview on 6/24/25 at 10:35 AM with LPN#6 identified that nurses are responsible for checking the orders for lab orders and put the resident's name in the lab book so they can have blood drawn. LPN#6 indicated patient refusals should be documented, reattempted and the supervisor should be notified. LPN#6 identified that in the event of a medication error or over administration there should have been an incident form completed, and the resident should have been monitored for side effects. LPN#6 could not identify why this wasn't completed. Interview on 6/24/25 at 11:21 AM with RN#2 identified that if a resident refused care, there should be a note identifying the refusal. Additionally, RN#2 indicated that the supervisor and the APRN should be notified of the refusal. RN#2 identified that if an order was written incorrectly, and a medication administered incorrectly, an incident report should have been started and medications that require monitoring should be included in the care plan. Interview on 6/24/25 at 11:36 AM with Pharmacist #1 identified normal guidelines for administration of the Vitamin D 50,000 units is to be taken weekly and then monthly. Pharmacist #1 indicated that the dose and frequency of the Vitamin D depends on the resident lab values because the levels are pliable and each patient is different. Pharmacist #1 indicated the administration should have a stop date so the dose could be reviewed. Interview with 6/24/25 at 12:46 PM with RN#1, Regional Director of Clinical Operations, identified that the order placed 11/29/24 should have been questioned because a dose that high is not usually administered daily Interview on 6/24/25 at 12:49 PM with MD#1 identified Vitamin D should be routinely monitored every 6 months. MD#1 indicated he reviews all pharmacy recommendations and identified that elevated vitamin D levels do cause hypercalcemia, high calcium blood levels, among other issues. MD#1 could not identify why the monitoring of the Vitamin D, or the pharmacy recommendation was not followed up. Although requested, the facility failed to provide any documentation outlining investigation of improper medication administration or follow up of monitoring after pharmacy recommendation to obtain labs, and monitoring of resident after improper medication administration. Subsequent to surveyor inquiry on 6/25/25 the facility provided lab results for Resident #91's Vitamin D levels, obtained 6/24/25, which were 37.7 ng/ml with a normal reference range of 30-100 ng/ml. The facility policy for Drug regimen review identified the prescriber/licensed designee shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. The facility policy for charting and documentation identified that licensed staff and interdisciplinary team members shall document all assessments, observations, evaluations, and services provided in the patient's medical record in accordance with state law and should document all pertinent changes in the patient's condition, reaction to treatment, medication etc. and shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. The facility policy for accidents/incidents identified the Risk Management System (RMS) is used to document Medication errors. Resident #102's with diagnoses included Alzheimer's disease, obsessive compulsive disorder, insomnia, and adjustment disorder with anxiety. The quarterly MDS assessment dated [DATE] identified Resident #102 had moderate cognitive impairment and independent with toileting, transfer, and ambulation and received anti-psychotic, anti-anxiety, and anti-depressant medications in the previous 7 days. The resident care plan dated 6/4/25 identified Resident #102 had been receiving psychotropic medications related to obsessive compulsive disorder and adjustment disorder with anxiety. The care plan interventions directed to administered medications per physician order, review medications for gradual dose reduction as indicated, monitor for targeted behavior symptoms, and psychiatrist follow-up as needed. The current physician's orders identified Resident #102 directed to administered Risperdal 0.5 mg (anti-psychotic medication) by mouth twice per days and at bedtime with origination date order of 4/16/25, to administered Risperdal 0.5mg by mouth as needed every 12 hours with no end date, to administered fluvoxamine maleate 50 mg (anti-depressant medication) by mouth every morning (both medications had origination date of 5/27/25), and to administered Ativan 0.5 mg (anti-anxiety medication) by mouth every 8 hours as needed for pacing and irritability for 30 days (had origination date of 5/29/25). Review Medication Administration Record (MAR) record from 5/27/25 to 6/23/25 identified Resident #52 had received 1 doses of as needed Risperdal 0.5 mg on 6/16/25. The Risperdal 0.5 mg as needed medication usage should have been evaluated on 6/10/25 (past due for 13 days). Review of APRN #1 psychiatrist progress note dated 5/27/25 identified Resident #102 was evaluated for psychiatric follow-up related to reported increase in wandering behavior and food seeking behavior and nursing staff had reported that Resident #102 was seen following the staff and other residents and repeatedly requesting snacks. The progress note also identified that Resident #102 had a documented history of dementia with progressive cognitive decline. The APRN #1 treatment plan was to include adding as needed of Risperdal to the schedule Risperdal dosage. The Ativan medication as needed would be utilized for anxiety as needed as well. Supportive care to the resident would continue which includes calm re-direction, offering finger foods during periods of food seeking behavior as alternative to the traditional meal setting. Review of APRN #1 psychiatrist progress note dated 6/12/25 identified Resident #102 was evaluated for increase restlessness and fixation on food. The note's also identified that Resident 102 was previously evaluated for worsening targeted behavior related to food seeking behavior. At the time of evaluation, Resident #102 was not in any acute distress, denied any current complaints and no overt signs of restlessness or agitation were observed. The treatment plan to continue the current medications of Risperdal and fluvoxamine and continue to use as needed Ativan for irritability and restlessness and re-enforced non-pharmacological interventions such as re-direction, re-assurance, supportive care, and encouraging participation with recreational activities. The APRN #1 progress notes dated 6/12/25 failed to re-evaluated the use of as needed Risperdal 0.5 mg that was started on 5/27/25 and remain an active physician's order as 6/23/25. Interview with RN #2 (7-3 shift nursing supervisor) on 6/23/25 at 10:05 AM identified any residents with order as needed anti-psychotic medication be limited to 14 days and the physician needs to re-evaluate the use of anti-psychotic medication past 14 days. She identified APRN #1 was responsible for transcribing her physician orders in the electronic record and the nursing staff to review and acknowledge the physician order in the electronic record. She identified the nursing staff would verify with the physician when there is a physician orders for anti-psychotic medication without a duration of 14 days. She identified that she was not aware of Resident #102 as needed Risperdal was ordered since 5/27/25 and was not evaluated for continue use of the as needed Risperdal. Interview with RN #1 (Regional nurse) on 6/23/25 at 11:15 AM identified she was aware of any as needed physician's orders for anti-psychotics medication would be limited to 14 days and was also aware that it cannot be ordered for indefinitely without re-evaluation of the use of anti-psychotic medications. She also identified that the physician and the nursing staff would be responsible for ensuring the anti-psychotic medications was not ordered for indefinitely and ensuring the as needed anti-psychotic was limited to use for 14 days and will need to be reassessed by the physician if needed to continue past 14 days. Review of the psychiatrist progress notes dated 6/12/25 with RN #1 identified that Resident #102 was re-evaluated for behavior and medication regimen; however, the psychiatrist progress notes did not identify for continue use of the as needed Risperdal 0.5 mg that was started on 5/27/25. She further identified that Resident #102 as needed Risperdal should have been discontinued or renewed for additional 14 days when Resident #102 was re-evaluated on 6/12/25. Attempted to interview APRN #1 was not successful during the survey period. The DNS was not available for interview during the survey period. The facility policy as needed Psychotropic Medications identified that all as needed physician's orders for psychotropic medications will not exceed 14 days. The as needed physician's orders for as needed psychotropic medications cannot be extended unless the healthcare provider believes that it is appropriate for the as needed psychotropic medications extended beyond the 14-day duration.

Based on review of the clinical record, review of facility policy/procedures and interviews for one of six residents (Resident #91 reviewed for unnecessary medications, the facility failed to ensure that recommendations from the consultant pharmacist regarding getting a vitamin D level was reviewed and acted upon. The findings include: Resident #91 was admitted to the facility June 2024. Diagnoses included dementia, and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 had severely impaired cognition, exhibited physical and verbal behavioral symptoms directed toward others, was a partial/moderate assist with activities of daily living and mobility, was administered antipsychotic and antidepressant medications and exhibited rejection of care or wandering behaviors with the last the 7 days. The care plan dated 6/5/24 identified Resident #91 was resistive to care related to dementia with interventions to encourage participation and give clear explanations of all care activities. Physician's order dated 8/24/24 directed to administer Vitamin D3 Oral capsule 1.25 mg (50,000 units) 1 capsule 1 time weekly. Drug Regimen Review dated 8/27/24 identified Resident #91 was receiving Vitamin D 50,000IU once weekly with a recommendation to please evaluate continued need for high dose, consider ordering a follow-up 25 hydroxyvitamin D level and taper to maintenance dose of Vitamin D3 50,000 IU once monthly, if appropriate. The recommendation was reviewed by the APRN with the indication that she/he was in agreement with the recommendation. Physician's order dated 8/30/24 directed to obtain a 25-hydroxyvitamin D level. This order was marked as completed on 8/31/24. Drug Regimen Review dated 9/26/24 identified Vitamin D level was ordered on 8/31/24, and results were not located in the chart. A recommendation was made to please follow up and obtain a duplicate copy or consider reordering, if necessary. This recommendation was not signed or acknowledged by the facility provider. Nurses' notes reviewed from 8/1/24 through 11/1/24 failed to identify any patient refusals for blood draws. Review of the clinical record, failed to reflect laboratory test results for vitamin D level and failed to identify nurses' notes regarding Resident #91 refusing lab work. Interview on 6/24/25 at 10:35 AM with LPN #6 identified that nurses check the orders every shift and look for pending orders and confirm the orders. LPN#6 indicated any labs ordered would require a lab sheet that is put it in the lab book. There is a sign in sheet in the front of the book and that is signed off by the phlebotomist who draws the labs. Resident refusals are documented and the physician/APRN is notified. LPN#6 was unable to locate lab results, resident refusals or documentation that the Vitamin D level was drawn. Interview on 6/24/25 at 11:21 AM with RN#2 identified that if a resident refuses care, there should be a note identifying the refusal. Additionally, RN#2 indicated that the supervisor and the APRN should be notified of the refusal. Interview on 6/24/25 at 12:49 PM with MD#1 identified Vitamin D should be routinely monitored every 6 months. MD#1 indicated he reviews all pharmacy recommendations and identified that elevated vitamin D levels do cause hypercalcemia, high calcium blood levels, among other issues. MD#1 could not identify why the monitoring of the Vitamin D, or the pharmacy recommendation was not followed up. Although requested, the facility failed to provide any documentation detailing attempts at drawing blood or resident refusals. Additionally, the facility failed to identify that the order for the Vitamin D level was reordered or the blood draw re-attempted. The facility policy for drug regimen review identified the prescriber/licensed designee shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. The facility policy for charting and documentation identified that licensed staff and interdisciplinary team members shall document all assessments, observations, evaluations, and services provided in the patient's medical record in accordance with state law and should document all pertinent changes in the patient's condition, reaction to treatment, medication etc. and shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observations, review of clinical records, review of facility documentation, review of facility policy and procedure, and interviews, for one sampled resident (Resident #14) the facility failed to ensure the nebulizer face mask and tubing in use by the resident was dated and stored appropriately. The findings include: Resident #14's diagnoses included acute respiratory failure with hypoxia, congestive heart failure, and nondisplaced fracture of acromial process of left shoulder. The admission MDS assessment dated [DATE] identified Resident #14 had moderately impaired cognition (BIMS of 12), required moderate assistance with oral hygiene, dressing, personal hygiene, bed mobility and for ambulation. The physician's order dated 6/17/25 directed Ipratropium-Albuterol Solution 0.5-2.5miligram (mg)/3 milliliter (ml) to inhale orally four times a day for shortness of breath or wheezing for 7 days and lung sounds pre and post nebulization treatment. Observation on 6/22/25 at 8:00 AM identified a night stand located to the right of the bed, which held a nebulizer face mask along with the tubing connected to the nebulizer machine/compressor without the benefit of a label on the tubing that consisted of the date, time, and the nurse's initial nor was the nebulizer mask covered or placed in a plastic bag. Observation on 6/23/25 at 8:24 AM with the day shift Nursing Supervisor (RN #2) identified the same as noted above. Interview with RN #2 on 6/23/25 at 8:26 AM identified the nebulizer face mask should be placed in a bag and the tubing should be label with the date changed. She identified it was everyone's responsibility to ensure the mask was covered and tubing label, but it was mainly the night nurse's responsibility to label and date the tubing. Interview with the night shift Charge Nurse (LPN #4) on 6/23/25 at 8:30 AM identified the nebulizer face mask and tubing should be placed in a bag and the tubing should be labelled with the date. She identified it was her responsibility, but it was an oversight as to why it was not completed. Interview and observation with the day shift Charge Nurse (LPN #3) on 6/23/25 at 8:18 AM identified the nebulizer face mask and tubing was not covered and was without a label of the date on the tubing. She identified that she had used the nebulizer face mask in the morning to administer the resident's medication and had left it on the nightstand. LPN #3 further identified the nebulizer mask should have been stored in a bag and the tubing should been labelled with the date. Interview with the Regional Director of Clinical Operations (RN #1) on 6/23/25 at 9:32 AM identified nebulizer tubing should be labelled with the date and the nebulizer face mask is to be stored in a plastic bag. Review of the Nebulizer Treatments policy and procedure identified when the treatment is completed to turn off the compressor, disconnect the reservoir from the compressor and clean per manufacture's instruction and place reservoir in a plastic bag.

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews, reviewed for Intravenous (IV) therapy, for two sampled residents (Resident #110 and Resident #366), the facility failed to ensure intravenous medications were administered in accordance with professional standards of practice. The findings include: 1. Resident #110's diagnoses included non-pressure chronic ulcer of left foot with necrosis of muscle, bacterial infections of unspecified site, and infection of left ankle and foot in infectious and parasitic disease. The quarterly MDS assessment dated [DATE] identified Resident #110 was cognitively intact, required maximal assistance with toileting hygiene, dressing, personal hygiene, bed mobility, transfers and was non-ambulatory. The care plan dated 5/30/25 identified Resident #110 was on IV medication for infection with interventions which included observe dressing routinely for sign and symptom of leaking/bleeding, observed, document and report as needed sign and symptom of edema at the insertion site, taut, shiny or stretched skin, whitening or blanching of coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid at the insertion site. A request was made on 6/23/24 for the Licensed Nurse (LPN #4) IV certification, education and/ competencies and the facility failed to provide any documentation on IV education and that she had attended a basic comprehensive infusion therapy class prior to administering IV medication and caring for a resident receiving infusion therapy. The physician's order dated 5/29/25 directed Unasyn Injection Solution 3 (2-1) gram (GM) use 3gm intravenously every six hours for wound infection; to monitor Peripherally Inserted Central Catheter (PICC) for redness, swelling, drainage, any signs of infection every shift for prophylaxis and Normal Saline flush use 10 milliliters (ml) intravenously every 6 hours for patency and flush PICC line with 10 ml of normal saline before and after each medication administration. Review of May 2025 and June 2025 electronic Medication Administration Record (EMAR) identified Licensed Practical Nurse (LPN #4) signing off the EMAR indicating that she had administered Unasyn Injection solution 3 gram IV medication on 5/30/25, 6/3-66/6/25, 6/8-6/9/25, 6/11-6/13/25, 6/17-6/23/25.; monitored the IV PICC site for redness, swelling, drainage, any signs of infection on 5/30/25, 6/3-66/6/25, 6/8-6/9/25, 6/11-6/13/25, 6/17-6/23/25., changed the IV tubing on 5/30/25, 6/3-66/6/25, 6/8-6/9/25, 6/11-6/13/25, 6/17-6/23/25, and administered Normal Saline flush of 10ml intravenously every 6 hours for patency and flush PICC line with 10 ml of normal saline before and after each medication administration on 5/30/25, 6/3-66/6/25, 6/8-6/9/25, 6/11-6/13/25, 6/17-6/23/25. 2. Resident #366's diagnoses included sepsis, pneumonia due to pseudomonas, and chronic obstructive pulmonary disease. The Nursing admission Evaluation dated 6/20/25 identified Resident #366 was alert and oriented to situation and person, required maximal assistance with dressing, personal hygiene, transfers, toileting and moderate assistance with bed mobility. A request was made on 6/23/24 for the Licensed Nurse (LPN #4) IV certification, education and/ competencies and the facility failed to provide any documentation on IV education and that she had attended a basic comprehensive infusion therapy class prior to administering IV medication and caring for a resident receiving infusion therapy. The physician's order for the month of June/2025 directed Cefepime HCl Intravenous Solution 2 GM/100ml use 2 gram intravenously every 12 hours for pneumonia for 3 days; change intermittent peripheral IV tubing one time a day for routine; change needleless connector one time a day every 7 days; evaluate peripheral IV site before, during and after medication administration for redness, tenderness, swelling, drainage, leaking, and dislodgement two times daily and every two hours for routine care, Saline flush intravenous solution (Sodium Chloride flush) use 10ml intravenously two a day for patency and after medication administration and every 8 hours to maintain patency. Review of the June 2025 electronic Medication Administration Record (EMAR) identified Licensed Practical Nurse (LPN #4) signing off the EMAR indicating that she had administered Cefepime HCl Intravenous Solution 2-gram medication intravenously on 6/22/25 and 6/23/25; had changed the intermittent peripheral IV tubing and needless connector on 6/23/25; and administered Saline flush intravenous solution (Sodium Chloride flush) uses 10ml intravenously on 6/23/25; and had evaluate the peripheral IV site on 6/23/25. Interview with the Regional Director of Clinical Operations and Infection Preventionist (RN #5) on 6/24/25 at 7:10 AM identified LPN #4 does not have an IV certification of infusion therapy basics which includes IV management and IV medication administration. She further identified without this certification LPN #4 should not be signing off the medication administration record regarding any IV medication and any orders related to IV therapy. RN #5 identified it was the nursing supervisor who had administered the medication and not LPN #4, however if she did not administer the medication she should not have signed the EMAR. Interview with the Charge Nurse (LPN #4) on 6/24/25 at 7:55 AM identified when she signs the EMAR, it indicates that she had administered the medication, but she did not administer any IV medication to any resident with IV as she had not attended any IV certification class and was not certified. She indicated that it was the nursing supervisor on duty who administered the medication, however she would sign the EMAR instead of the nursing supervisor. LPN #4 identified she only monitor the IV site by herself without the nursing supervisor, gathers the supplies for the infusion for the nursing supervisor but does not change the dressing, disconnect the tubing, nor flush the site. She identified she had started working at the facility on June 4, 2024, and the DNS is aware that she had not attended any IV certification class and stated they would schedule her to attend a class. Interview with the Regional Director of Clinical Operations (RN #1) on 6/24/25 at 8:15 AM identified the person who signs the EMAR indicates that they had administered the medication. She further identified if the nurse did not administer the medication, she should not sign the EMAR nor monitor the IV sites. RN #1 identified that IV certification is check on hired and if the nurse does not have a certification the nurse would be scheduled to attend a class. She added that she does not know why LPN #4 did not attend a class, and it was an oversight due to not having a consistent Staff Development nurse. Review of the Education Requirements for Licensed Staff policy identified all licensed staff will complete and provide documentation of attending a basic comprehensive infusion therapy class consisting of the following, at minimum: anatomy and physiology, regulatory guidelines, legal issues, device selection, review of venous access devices including appropriate care and maintenance, potential complications and interventions, infection prevention, documentation and passing a written exam with a score of at least 80%. The policy further identified that prior to caring for the infusion resident, the licensed nurse will have competency validated according to organization policy. Review of the Initiation of IV Therapy Policy identified all licensed staff and supportive staff assigned to care for the resident will have documented infusion therapy education and all licensed staff and have documented competency prior to delivering care to the resident receiving infusion therapy services.

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #59) reviewed for foot care, the facility failed to ensure the resident follow-up podiatry appointment was scheduled as recommended by the podiatrist. The findings include:Resident #59's diagnoses included peripheral vascular disease, type 2 diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The quarterly MDS assessment dated [DATE] identified Resident #59 was cognitively intact, required maximal assistance with putting on and taking off footwear, dressing, personal hygiene, rolling from left to right and dependent for transfers. The assessment further identified the resident was non-ambulatory and dependent on staff with the utilization of a wheelchair for locomotion. The care plan dated 4/21/25 identified Resident #59 had ADL self-care performance deficit related to weakness, hemiplegia chronic pain with interventions that directed for extensive assistance of one staff for bathing/showering and dressing. The care plan further identified the potential for skin breakdown related to the resident requiring assistance with bed mobility, toileting and peripheral vascular disease with interventions that directed for skin checks with care for changes and weekly skin evaluations. Review of the monthly physician's orders for June/2025 identified an order that directed to monitor diabetic feet every shift. Observation on 6/22/25 at 8:30 AM identified Resident #59 was lying in bed and his/her feet uncovered and noted his/her toenails on the right and left foot needed trimming. Review of the resident clinical records identified Resident #59 was last seen by the podiatrist on 11/13/24 with the report indicating all the resident's nail was debrided and recommended a follow-up visit in 3 months. The nurse's progress note dated 11/13/24 at 1:31 PM written by RN #2 identified Resident #59 returned from podiatry, all nails were debrided and follow-up in 3 months. The note further identified that an appointment needed to be made for the resident. Interview with the day shift Nursing Supervisor (RN #2) on 6/23/25 at 8:35 AM identified Resident #59 was last seen by the podiatrist in November/2024 with a recommendation for a follow-up visit. She identified that when a resident returns from a consultation visit the paperwork returned with the resident is reviewed by the nursing supervisor and if appointments need to be made the supervisor sometimes would make the appointment and/or notify the unit secretary that the resident needed the appointment. RN #2 identified she did not see any other podiatry appointment schedule for the resident or that the resident had seen a podiatrist since November 13, 2024, as the resident does not see the in-house podiatrist. She added that she was not aware that the resident toenails needed trimming or to be seen by the podiatrist. Observation with the day shift Nursing Supervisor (RN #2) on 6/23/25 at 8:55 AM identified Resident #59 was lying in bed. RN #2 let the resident know what she was about to do prior to removing the blanket and the following was noted: On the right foot the 1st toenail tip measured 0.5 centimeter (cm), 3rd toenail tip measured 0.5cm, the 4th toenail tip measured 0.8 cm, and the 5th toenail tip measured 0.5cm. On the left foot the 3rd toenail tip measured 0.5 cm and 4th toenail tip measured 0.5cm. Interview with the night shift Charge Nurse (LPN #4) on 6/23/25 at 8:40 AM identified she had noted the toenails being long when she had completed the resident diabetic feet check but forget to notify anyone regarding the resident's toenail. Interview with the day shift Charge Nurse (LPN #3) on 6/23/25 at 9:17 AM identified she had noticed the length of the resident's toenail during foot checks as the checking toenails, skin for any redness and pain are included in the diabetic feet checks, however she did not notify the supervisor. A call was made to Resident #59's podiatrist for an interview on 6/23/25 but they did not return the call. Interview with the Unit Secretary on 6/23/25 at 9:00 AM identified she was responsible for scheduling resident appointments and transportation. She identified that she did not recall making any podiatry appointment for Resident #59. She later identified that after calling the podiatry office the resident had an appointment on 2/14/25 which was cancelled, however, she could not recall rescheduling the appointment or why the appointment was cancelled. The Unit Secretary identified the resident does not usually refuse to go to his/her appointment. Interview with the Regional Director of Clinical Operations (RN #1) and the MDS Coordinator (RN #3) on 6/23/25 at 9:32 AM identified the unit secretary was responsible for scheduling appointments and transportation. They identified that Resident #59 would have an appointment schedule in February 2025 but failed to identify that an appointment was made, or the resident had refused. RN #1 identified if the charge nurse identified a change in the resident's feet that he/she would report it to the supervisor. They identified that the diabetic foot checks included inspecting the resident toenails, skin and any deterioration in the feet. RN #1 later then interviewed the resident who identified he/she had no issues with his/her nails being trimmed and that they could be trimmed. Review of the Diabetes Management Protocol policy identified in the complication prevention section for foot care to perform daily foot inspections for wounds, redness, or swelling and refer to a podiatrist for nail care or any foot abnormalities.

Based on review of clinical records, review of facility policy/procedures and interviews for one of six sampled residents (Resident #90) reviewed for unnecessary medications and for one sampled resident (Resident #107) reviewed for urinary catheter, the facility failed to ensure ordered laboratory blood work was completed and failed to ensure a Registered Nurse (RN) assessment documentation was completed for a newly admitted resident in accordance with professional standards of practice. The findings include: Resident #90 was admitted to the facility 5/2/24. Diagnoses included dementia with agitation and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #90 had severely impaired cognition, did not utilize alarms, had functional limitation s in range of motion to one side affecting the lower extremity, and was dependent with bed mobility and transfers. The physician's orders dated 6/20/25 directed Resident #90 be checked every fifteen minutes until further notice, monitor behaviors: refusing medication, combative, impulsivity, restlessness, entering peers room, removing items from cart, verbal outbursts and unprovoked crying. The care plan dated 5/14/25 identified Resident #90 had a behavior problem related to hugging staff and residents, stroking staff and residents on their arms and kissing staff and residents on their hands and removing brief and putting it wherever it is removed; interventions included 15-minute checks. Elopement risk evaluation dated 2/6/25 identified Resident #90 was an elopement risk and indicated Resident#90 wanders r/t dementia and will wander into other resident room and lay on their bed with the task identified as monitor Q15 checks for safety. The resident care card as of 6/23/25 identified Resident #90 was on 15-minute checks every shift until further notice. Interview on 6/23/25 at 7:38 AM with MDS Coordinator identified the facility did not have a policy regarding the 15-minute checks for the residents. The MDS Coordinator indicated that the facility had a policy for 1:1 observation and identified a resident on 15-minute checks would have a care plan intervention for the checks. Interview on 6/23/25 at 11:19 AM with LPN#5 identified 15-minute check are documented in the NA flowsheet in the computer and there is also a paper sheet that should be on the counter for residents being observed, although LPN#5 was unsure if the paper was required for the 15-minute checks. LPN#5 identified she did not have any residents on 15 minutes checks but after checking Resident#90's clinical record, she noted he/she was on 15-minute checks and that the NA's would document them. Interview on 6/23/25 at 11:27 AM with NA#5 identified 15-minute checks were documented in the computer. NA#5 indicated the NAs are responsible to document on the residents they were responsible for. NA#5 identified that all staff are responsible to visualize the patient and that NAs were supposed to document in real time, throughout the day but also indicated that is sometimes not possible and it is documented all at once. Additionally, NA#5 identified that although she may document all of the observations, there are other staff who visualize the resident but could not identify how she would confirm Resident #90 was visualized every 15 minutes if NA#5 did not actually do the visualizations. Interview on 6/23/25 at 11:31 AM with RN#2 (RN supervisor) identified for 15-minute checks the expectation is that staff put their eyes on the resident, physically see them. RN#2 indicated that all staff are responsible or can make the visualization but that it is mainly the NAs and the nursing department. RN#5 identified the NAs document in the electronically when they do their charting RN#2 indicated that the supervisors do rounds and make sure the visualizations are being completed and that Resident#90 was being monitored because of a fall. Review of the clinical record on 6/23/25 at 12:00 PM identified LPN#5 documented in the clinical record at 11:27 AM that the 15-minute checks on Resident #90 were completed for the entirety of the shift. Treatment administration record (TAR) dated June 2025 identified Resident#90 did not receive 15-minute observations on 6/3/25, 6/9/25 and 6/20/25 between the hours of 7:00 AM and 3:00 PM. Additionally, the TAR indicated that observations were being documented prior to the scheduled time. As an example on 6/1/25, the TAR documentation indicated that the checks scheduled for 2:15 AM, 2:30 AM, 2:45 AM and 3:00 AM were all documented as completed at 2:03 AM. Pre-emptive documentation like this occurred every day during the month of June. Additionally, some documentation indicated the NA documents most of the checks at the same time or at the end of the shift. For example: On 6/23/25 the Q15 minute checks from 7:00 AM through 3:00 PM were documented between 2:39 PM and 2:41PM. Although requested, the facility failed to provide a policy for 15-minute checks. Resident #107 was admitted to the facility 6/16/25 with diagnoses that included atrial fibrillation, diastolic congestive heart failure, and acute kidney failure. The Nursing admission Evaluation dated 6/16/25 completed by the Licensed Practical Nurse (LPN #3) identified Resident #107 was oriented to person, place, time and situation, urinary status indicated a urinary catheter indwelling. The evaluation further identified under the mobility section that gait disturbance or unsteady gait was unable to be determined at this time. Review of June/2025 clinical records of the progress note failed to identify an RN assessment admission note completed for Resident #107 upon admission. Interview with the Charge Nurse (LPN #3) on 6/23/25 at 9:17 AM identified she completed the Nursing admission Evaluation. She further noted that the RN on duty is supposed to review the evaluation and sign it. Additionally, she noted that the RN normally writes a note. Interview with the evening shift Nursing Supervisor (RN #4) on 6/23/25 at 3:57 PM identified that when a resident is admitted the LPN assigned assesses the resident with the RN or if he/she goes by themselves then the RN supervisor would then go after, review the evaluation and write the RN assessment note. However, he noted that he had assessed the resident, but did not write a note. Interview with the Regional Director of Clinical Operations (RN #1) and the MDS Coordinator (RN #3) on 6/23/25 at 9:47 AM identified that when a resident is admitted to the facility that both the LPN and RN would complete the admission nursing assessment. They identified it was the practice and expectation of the facility that the RN goes in and evaluate and assess the resident upon admission and write a note. Interview with the day shift Nursing Supervisor (RN#2) on 6/24/25 at 8:35 AM identified that the LPN would go into the room and complete the nursing evaluation form and she would write an admission nursing note, however she did not for Resident #107, which she or the evening shift nursing supervisor should had completed a note as both completed the admission. The Connecticut LPN Practice Act dated 7/22/2003 identifies that an LPN can contribute to the nursing assessment by collecting, reporting, and recording subjective and objective patient-related data in an accurate and timely manner, but an LPN cannot perform the assessment independently. Review of the Charting and Documentation policy identified licensed staff and interdisciplinary team members shall document all assessments, observations, evaluations, and services provided in the patient's medical records in accordance with state law. The policy further identified documentation shall be competed at the time of service but no later than the shift in which the assessment, observation, or care service occurred.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #6) reviewed for a resident-to-resident altercation, the facility failed to ensure Resident #6 was free from physical abuse. The findings include:Resident #6's diagnoses included post-traumatic stress disorder, anxiety disorder, major depressive disorder, dementia, psychotic disorder with delusions, and moderate intellectual disabilities. The RCP dated 7/4/24 identified Resident #6 is selective with leisure time pursuits and needs moderate encouragement. Interventions identified: provide in room activities to promote mental stimulation and added socialization, resident may have childlike personality, may be attention seeking, and likes to hold stuffed animals/toys. The quarterly MDS assessment dated [DATE] identified Resident #6 had severe cognitive impairment and required supervision or touching assistance for bed mobility and transfers, required substantial/maximal assistance with toileting and hygiene, partial to moderate assistance with dressing, transfers and ambulation. The nurse's note dated 10/15/24 at 2:32 PM identified Resident #6 had been hit on the cheek by Resident #74. Resident #6 let out a yell but was easily calmed. The residents were separated and notifications made to the psychiatric provider, APRN, police, family and social worker. The note further identified Resident #6 was assessed and noted no redness, bruising or open areas to the face. A Reportable Event report dated 10/15/24 identified Resident #6 was in the doorway to his/her room when Resident #74 was walking by and slapped him/her on the cheek. The incident was witnessed by the Recreation Director Resident #74's diagnoses included adjustment disorder with anxiety, unspecified dementia without behavioral disturbance, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #74 had severe cognitive impairment, was independent with bed mobility, toileting, dressing, hygiene, transfer, and ambulation. The Resident Care Plan (RCP) dated 10/4/24 identified Resident #74 had the potential to be physically aggressive scratching pinching related to being angry. Interventions directed to evaluate and address for contributing sensory deficits, when the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff is to walk calmly away and approach later. The nurse's note dated 10/15/24 at 2:07 PM identified that around 10:55 AM the Recreation Director notified the nurse that Resident #74 was walking past Resident #6 who was standing in the doorway to his/her room when Resident #74 slapped him/her on the cheek. The residents were separated, and Resident #74 was placed on 1:1 observation. The psychiatric provider, APRN, police, family, and social work were notified. Resident assessed. An investigation statement dated 10/15/24 at 10:55 AM by Recreation Aide #1 identified Resident #74 was agitated, aggressive, impulsive, and continued to grab residents/items and not let go. Interview on 6/24/25 at 7:30 AM with the Recreation Director identified she witnessed Resident #74 trying to go into Resident #6's room. Resident #6 is very protective of her room and all of her stuff and does not like people in his/her room. Resident #6 was standing in the doorway when Resident #74 tried to enter the room and Resident #74 slapped Resident #6 on the cheek. Resident #6 was crying following the incident and was upset at what had transpired, she needed to be calmed down. Both residents were separated, and the supervisor was contacted. No marks were noticed at the time of the incident. Although she saw what transpired she did not intervene at the time of the incident as she was down the hall. Interview on 6/24/25 at 9:30 AM with Regional Nurse #1 identified that every resident in the facility has the right to be free from abuse. The facility failed to protect Resident #6 from physical abuse by Resident #74. A review of facility Abuse Policy each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for 2 of 4 sampled residents (Resident #4, and #85) reviewed for preadmission screening and resident review (PASRR), for one sampled resident (Resident #24) who received a diuretic medication and for two sampled residents (Residents #91 and #93) who utilized wanderguard alarms, the facility failed to ensure the MDS was coded appropriately for residents with a positive level II screening and failed to ensure the assessments were coded correctly for the use of a diuretic. The findings include: 1. Resident #4's diagnoses included schizoaffective disorder and bipolar disorder. A level II PASRR assessment dated [DATE] identified Resident #4 was approved for long term placement without specialized services. The significant change MDS assessment dated [DATE] and annual MDS dated [DATE] identified Resident #4 was moderately cognitively impaired, had no behaviors, needed substantial/maximal assistance with bed mobility, transfers, dressing and personal hygiene. The assessment further identified Resident #4 had psychiatric mood disorder of depression, bipolar disorder, and schizophrenia. The MDS did not identify that the resident had a positive level II PASRR. The care plan dated 5/12/25 identified Resident #4 had mental health diagnoses with interventions that directed PASSR recommendations mental health counseling and supportive counseling from nursing staff, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. 2. Resident #85's diagnoses included Major depressive disorder and schizophrenia. The admission MDS dated [DATE] and annual assessment dated [DATE] identified Resident #85 had intact cognition, had no behaviors, needed substantial/maximal assist with bed mobility, dependent for transfers, partial to substantial/maximal assistance with dressing, and substantial/maximal assistance with personal hygiene. The assessment further identified Resident #85 had active psychiatric/mood disorder diagnoses of anxiety disorder, depression, and schizophrenia. The MDS did not identify that the resident had a positive level II PASRR. The care plan dated 4/3/25 identified Resident #85 had a psychosocial wellbeing problem related to the diagnoses with interventions that directed PASRR screen recommendations approved without specialized services rehabilitative recommendations of family involvement, minimum of yearly comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis. Review of the Level II PASRR screen completed on 3/19/24 identified Resident #85 was approved for long term care without specialized services. Interview with RN#3 MDS Coordinator on 6/23/25 at 2:00 PM identified that although she is the MDS Coordinator certain areas are responsible for certain sections of the MDS, such as PASRR is completed by social work. Although the end of the assessment is signed off on by her she is signing stating that the assessment was completed not signing off on accuracy. Interview with Social Worker #2 on 6/23/25 at 2:15 PM identified that she is responsible for coding the long-term care MDS's, however could not identify why the MDS's were coded incorrectly and that it must have been an error and that if someone has a positive level II PASRR then there should be a yes next to question A1500. Interview with the Director of Social Work #1 on 6/24/25 at 10:30AM identified that she and Social Worker #1 share the responsibility of entering information in for the MDS. However, any work entered by Social Worker #1 is checked by the MDS Coordinator. 1. Resident #24 was admitted to the facility in September 2022. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease and hyperlipidemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had intact cognition, and was taking antidepressant, antiplatelet and hypoglycemic medications but failed to identify Resident #24 was receiving diuretic medication. Physician's orders dated 6/9/25 directed administration of Bumex (diuretic medication) 2 mg, 1 tablet by mouth in the morning for fluid retention. The care plan dated 6/11/25 identified Resident #24 had the potential for constipation related to diuretic use with interventions to monitor signs and symptoms of constipation and follow facility bowel protocol. In addition, the care plan identified the resident was on diuretic therapy related to fluid retention and hypertension with interventions that included: administer diuretic medications as ordered, monitor for side effects/effectiveness, monitor, document, and report adverse reactions. The physician progress note dated 6/9/25 at 8:03 PM identified Resident #24's blood pressure was well-controlled with current dose of losartan (antihypertensive medication) and indicated the Bumex may result in lowering of the blood pressure. Interview on 6/23/35 at 7:34 AM with the MDS Coordinator identified Resident #24 was taking a diuretic in the seven day look back period captured on the MDS but noted it was an error that the assessment reflected that the resident was not taking a diuretic. 2. Resident #91 was admitted to the facility on [DATE]. Diagnoses included dementia with mood disturbance, and major depressive disorder. The annual MDS assessment dated [DATE] identified Resident #91 had severely impaired cognition, did not exhibit rejection of care or wandering or any physical or verbal behavioral symptoms directed toward self or others and did not utilize an alarm. The care plan dated 5/30/25 identified Resident #91 was at risk for elopement and wandering with interventions to include wanderguard placement on the left ankle, can go outside with constant supervision only. The physician's orders for May2025 and June 2025 directed: check expiration date of wanderguard every 7 days on day shift, check functioning of wanderguard every night shift, and as needed and check location of wanderguard every shift for monitoring. The treatment administration record (TAR) for May 2025 identified Resident #91's wanderguard was checked daily and noted to be in place without functional issues. Observation on 6/23/25 at 11:15 AM identified Resident #91 ambulating in the hallway with a noted bulge on the left ankle under his/her sweatpants. Interview on 6/23/25 at 7:36 AM with LPN #3 (MDS Coordinator) identified Resident #91 should have been coded for use of an alarm (wanderguard) and that the error was an oversight. The wanderguard/secure care alarm policy identified residents that have been identified as an elopement risk will have a wanderguard/secure care device applied to ensure safety and indicated the device will be checked for placement every shift and documented on the TAR and checked for function once daily and documented on the TAR. 3. Resident #93 was admitted to the facility in May 2025. Diagnoses included encephalopathy, dementia without behavioral disturbance, and anxiety. The admission MDS assessment dated [DATE] identified Resident #93 had severely impaired cognition, did not exhibit inattention, disorganized thinking, hallucinations, delusions or altered level of consciousness or wandering and indicated Resident #93 did not utilize any type of alarm, including a wanderguard alarm. The physician's orders dated 5/23/25 directed to check the functioning of the wanderguard on the right wrist every night shift, check location of wanderguard on right wrist every shift, and check expiration date every 7 days. The care plan dated 5/21/25 identified Resident #93 had the behavior of removing the wanderguard with interventions that included: monitor behavior episodes and attempt to determine underlying cause and conduct checks every fifteen minutes. Additionally, the care plan indicated Resident #93 was at risk for elopement with interventions to check wanderguard location, and function per schedule. The admission evaluation dated 5/16/25 identified Resident #93 needed behavior monitoring and was an elopement risk. Elopement risk evaluation dated 5/16/25 identified Resident #93 had a history of wandering/elopement, was hallucinating or delusional, anxious/agitated, disoriented, had not expressed a desire to leave the facility and did not have easy access to unsecured exits. The evaluation further indicated Resident #93 was to be monitored with wander device placement, be safely housed on designated secured unit and was rated a score of 4 which indicated Resident #93 was at risk for elopement. The TAR for May 2025 identified Resident #93 had a wanderguard in place. Interview on 6/23/25 at 7:38 AM with LPN #3, (MDS Coordinator) identified Resident #93 had the wanderguard in place during the MDS look back period and the MDS was coded incorrectly. It should have reflected the use of alarms. Facility policy for wanderguard/secure care alarm identified that resident that have been identified as an elopement risk will have a wander guard/secure care device applied to ensure safety and indicated the device will be checked for placement every shift and documented on the TAR and checked for function once daily and documented on the TAR. Although requested, the facility did not provide an MDS policy.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure that a resident was properly positioned in a wheelchair while being transported by staff. The resident fell from the wheelchair and suffered multiple serious injuries including a fractured tibia and fibula. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, difficulty in walking, abnormalities of gait (walking) and mobility (the ability to move or be moved from one place to another) and muscle weakness. A Fall Evaluation dated 8/5/23 identified that although Resident #1 was not a fall risk, he/she had the potential for a fall with/without injury. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), required substantial assistance for toileting, personal hygiene and transfers and required partial assistance for bed mobility. The MDS identified Resident #1 did not exhibit behaviors. The Resident Care Plan (RCP) dated 5/31/25 identified Resident #1 was at risk for falls related to increased weakness to the lower extremities and a history of falls. Interventions included encouraging Resident #1 to be out of his/her room when awake for socialization and/or recreation and applying Dycem (a plastic silicone mat that creates a non-slip surface) under the wheelchair cushion to prevent sliding. The facility Reportable Event (RE) dated 5/31/25 identified that at 8:30 PM Resident #1 had a witnessed fall (by NA #1) out of the wheelchair, landing in a prone position (face first) on the floor of the bedroom and resulting in a contusion to the right forehead, a bruise to the right arm and pain to the right ankle. The RE identified the family was notified, the provider was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED) for evaluation. A Situation, Background, Assessment and Recommendation (SBAR) note dated 5/31/25 at 9:16 PM by RN #1 identified Resident #1 was observed on the floor of his/her bedroom. Resident #1 reported sliding out of the wheelchair resulting in the fall. A bump was noted to Resident #1's right forehead, a bruise to the right arm and Resident #1 complained of pain to the right ankle on assessment. A Fall Evaluation dated 5/31/25 at 9:51 PM identified Resident #1 was a low fall risk. Review of the Prehospital Care Report (ambulance run sheet) dated 5/31/25 identified Emergency Medical Services (EMS) was called by the facility at 9:27 PM (57-minutes after the fall) and responded to the facility at 9:45 PM. The report indicated that the facility reported Resident #1 was being helped from the bathroom when he/she fell, and hit his/her right forehead, right forearm and lower right leg on a dresser. It identified that when EMS arrived Resident #1 was in bed, was oriented to person, place, time and event and was observed with a one (1) inch by two (2) inch raised contusion (bruise) to the right forehead that stopped bleeding, as well as a 1 inch by 2 inch raised contusion to the right forearm, and Resident #1 complained of right lower leg pain. Review of hospital ED documentation dated 5/31/25 identified Resident #1 was seen subsequent to a witnessed fall where Resident #1 hit a dresser with his/her head but did not lose consciousness and was complaining of right arm and right lower leg pain that was worse on palpation. It identified that an abrasion (a superficial skin injury caused by scraping or rubbing) was noted to Resident #1's right forehead, swelling, tenderness and bruising was noted to the right forearm and tenderness was noted to the right lower leg. It identified that imaging was completed of the head, right forearm and right tibia fibula (lower leg bones) which identified small right frontal scalp soft tissue swelling and hematoma (a closed wound where blood pools and fills a space at a point of injury because it cannot flow or drain out) as well as acute displaced oblique fractures of the distal shaft of the tibia and fibula (a broken shinbone and calf bone near the ankle, with the break occurring at an angle and the bone fragments are slightly out of alignment). The note identified that due to Resident #1 being non-ambulatory, surgery was not an option, Resident #1 was placed in a splint, and was to be non-weightbearing until he/she followed up with outpatient orthopedics. Interview and observation of Resident #1 on 6/20/25 at 10:21 AM identified that on 5/31/25, NA #1 was assisting him/her to get ready for bed in the bedroom bathroom. Resident #1 identified that NA #1 was rushed and indicated he did not assist him/her into the wheelchair correctly, as he/she was on the edge of the seat and not positioned back. NA #1 then started to push Resident #1 too fast into the room. Resident #1 reported that he/she told NA #1 to stop because he/she felt like he/she was going to fall, but NA #1 did not listen and Resident #1 fell forward out of the wheelchair. Resident #1 indicated the next thing he/she remembered was being on the floor in pain. Resident #1 identified Resident #2 (roommate) was sitting on his/her bed and witnessed the fall as the fall occurred right next to Resident #2's bed. Resident #1 was observed with a bump to his/her right mid forehead, bruising to the right mid-arm and a pink cast was in place from below the knee to above the toes. Interview with Resident #2 (intact cognition: BIMS score of 15 on 3/20/25 and 6/20/25) on 6/20/25 at 10:32 AM identified he/she was sitting on the edge of his/her bed facing the bathroom door when he/she observed NA #1 pushing Resident #1 in his/her wheelchair out of the bathroom. Resident #2 identified Resident #1 was on the edge of the wheelchair and yelled, stop, stop but NA #1 did not stop, and Resident #1 fell forward out of the wheelchair, hit his/her head on Resident #2's dresser and the wheelchair fell on top of Resident #1. Resident #2 reported that the bedroom door was closed at the time of the fall and NA #1 pushed the wheelchair aside and attempted to lift Resident #1 up from the floor, as Resident #1 yelled in pain, but was unsuccessful, so he sat Resident #1 up and Resident #2 started to yell for help. Resident #2 identified that NA #1 did not use the call bell or attempt to get staff assistance following the fall, but staff responded after Resident #2 yelled for help. Three (3) staff members stood Resident #1 up and assisted him/her into bed. Resident #2 identified that OTA #1 (Rehab Manager) spoke with him/her and Resident #1 regarding the incident but neither the DNS nor any nursing staff interviewed him/her as a witness to the incident. Interview with NA #1 on 6/20/25 at 11:12 AM identified that on 5/31/25, he brought Resident #1 into the bathroom to get him/her ready for bed and when he was finished, assisted Resident #1 back into the wheelchair and was not certain if Resident #1 was positioned all the way back in the wheelchair. He started to push Resident #1 in the wheelchair and identified Resident #1 yelled, stop, so he stopped, and thinks Resident #1 then self-propelled and quickly fell forward out of the wheelchair and hit his/her head on something. He identified the incident happened fast and he was unsure of what had happened. NA #1 identified the wheelchair fell on top of Resident #1 and he pushed it aside and moved Resident #1 onto his/her back because his/her face was pushed into the floor. He denied attempting to pick Resident #1 up but was unable to explain how Resident #1 got into a sitting position. NA #1 identified that Resident #1 was moaning in pain following the fall. Interview with OTA #1 (Rehab Director) on 6/20/25 at 12:20 PM identified Resident #1 was discharged from Physical Therapy (PT) services on 4/9/25 and, at that time, there were no safety concerns. He indicated therapy worked with Resident #1 in the wheelchair and if there were concerns of the cushion sliding, that would have been addressed prior to discharging Resident #1 from services. OTA #1 identified Resident #1 was safe to self-propel in the wheelchair, and if Resident #1 was positioned upright and all the way back in the wheelchair with his/her hips positioned correctly, it would be unlikely for Resident #1 to slip off the edge of the wheelchair if self-propelling from the doorway of the bathroom to the roommates dresser (five (5) to ten (10) feet away). OTA #1 identified Resident #1 did not have a history of slipping out of the wheelchair. OTA #1 further identified Resident #1 had overall decreased strength and he did not believe Resident #1 had the ability of moving from a stomach or back lying position to sitting up at 90 degrees independently, especially following a fall. Resident #1 required partial to moderate assistance at the time of therapy discharge on [DATE]. OTA #1 identified that following any resident fall, he speaks with the resident, and identified he spoke with both Resident #1 and Resident #2 after Resident #1's fall out of the wheelchair. He identified that both Resident #1 and Resident #2 reported Resident #1 was on the edge of the wheelchair seat while NA #1 was pushing him/her and that Resident #1 requested NA #1 stop pushing him/her but NA #1 continued to push Resident #1 which resulted in the fall. OTA #1 identified he reported both Resident #1 and Resident #2's account of the incident to the DNS and also spoke about it in morning report the following day and thought the information he provided should have been investigated. An Occupational Therapy Evaluation & Plan of Treatment note dated 6/3/25 identified Resident #1 was referred following a witnessed fall out of his/her wheelchair. The note identified that per Resident #1 and Resident #2, a Nurse Aide (NA #1) was assisting Resident #1 out of the bathroom in his/her wheelchair, but Resident #1 was sitting at the edge of the wheelchair, the Nurse Aide went too fast, and Resident #1 fell out of the wheelchair and hit his/her head on a dresser. The note identified that on evaluation, Resident #1 presented below his/her baseline and required a Hoyer lift assist of two (2) staff for transfers out of bed and bed level Activities of Daily Living (ADLs) and Resident #1 was previously an assist of one (1) for toileting and ADLs at the wheelchair level. Interview with LPN #1 and review of statement dated 5/31/25 on 6/20/25 at 12:40 PM identified he was the first licensed nurse on scene following the incident. He reported that when he entered the room, Resident #1 was sitting on the floor in an upright position between the bathroom door and Resident #2's dresser, with a bleeding area to his/her right forehead and Resident #1's wheelchair was on its side next to Resident #1. He identified that NA #1 reported Resident #1 slid out of his/her wheelchair and hit his/her head and he (LPN #1) did not think Resident #1 had the ability to move from a lying to sitting position independently. He identified that after an RN assessment, NA #1, himself and a third staff member stood Resident #1 and assisted him/her into the wheelchair and then into bed. He reported he did not know how long Resident #1 was in bed prior to EMS arriving. Review of NA #2's statement dated 5/31/25 identified that on 5/31/25, she was in the hallway when she heard Resident #2 screaming for help. She identified she knocked on the door and when she opened it, Resident #1 was on the ground accompanied by NA #1. Interview with the DNS on 6/20/25 at 1:05 PM identified her investigation revealed Resident #1 told NA #1 to stop while he was pushing him/her in the wheelchair out of the bathroom, and she thought he stopped and Resident #1 self-propelled prior to sliding out of the wheelchair. She identified it was reported by OTA #1 that Resident #1 and Resident #2 reported Resident #1 was on the edge of the wheelchair and NA #1 continued pushing Resident #1 after he/she told him to stop. She identified she spoke with OTA #1 about the incident and spoke with Resident #2, but could not recall the specifics except that Resident #2 reported he/she was in bed at the time of the incident. The DNS indicated she did not believe Resident #2 could see the fall from where he/she (Resident #2) was positioned so did not further investigate. The DNS was unable to provide documentation of the conversation with Resident #2 or a statement from Resident #2 which she indicated should have been documented as part of the investigation. The DNS identified she did not question NA #1 on whether he moved Resident #1 after the fall and was unaware that staff transferred Resident #1 into the wheelchair and then into the bed following the fall. She reported that when she conducted her interviews staff reported Resident #1 was never moved. The DNS identified she was unsure why EMS was not called until 57-minutes after the fall. Although attempted, interviews with RN #1 and NA #2 were not obtained. Review of the Accident/Incident policy dated 6/2024 directed, in part, that staff will notify the nursing supervisor /licensed nurse when an incident occurs. The licensed nurse or the nursing supervisor will complete and document the evaluation of the resident's condition. The licensed nurse will complete an investigation for accidents/incidents. The investigation will include written statements from staff members caring for the resident and from people having knowledge of the event. If the resident makes a statement, their statement is to be included. The licensed nurse or nursing supervisor records their investigative findings and conclusions in RMS. The DNS reviews RMS events to ensure accurate and complete documentation of the incident, and to determine if there is credible evidence to substantiate the allegations of abuse, neglect or mistreatment. The RMS and investigation will be reviewed by the Administrator, DNS and the Medical Director when completed. Review of the Fall Prevention Program policy dated 3/2023 directed, in part, that if a fall occurs, keep the resident immobile until the resident is examined and determined to be free from fractures.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure that a cognitively impaired resident who had wandering behaviors that included wandering into other resident's rooms, and laying in other residents beds had interventions in place to ensure the resident was free from sexual abuse. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #2 had diagnoses including vascular dementia with anxiety, major depressive disorder and post-traumatic stress disorder. A care plan dated 11/6/24 identified that the resident had a behavior problem because of using sexual language at times with interventions that directed to encourage the resident to express feelings appropriately, monitor behavioral episodes and determine underlying cause, administer medications as ordered, and psychiatric consults as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of ten (10) indicative of moderately impaired cognition and was independent with bed mobility and transfers and utilized a wheelchair independently for mobility. 2. Resident #1 had diagnoses including dementia with agitation, anxiety and restlessness with agitation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and was independent with ambulation. Review of an undated facility face sheet identified Person #1 as the resident's next of kin and health care proxy (court appointed to make health care decisions). The Resident Care Plan (RCP) dated 11/6/24 identified that Resident #2 was at risk for wandering and entering other resident's rooms and lying in other resident's beds due to a diagnosis of dementia with interventions to distract the resident by providing diversional activities, and a wander alert bracelet (a bracelet worn to alert staff when the resident is near an exit). The care plan further identified that the resident hugs, strokes hands and arms and kisses staff and other residents with interventions that included medications as ordered, provide baby doll to hold, encourage the resident to express feelings, and if attempts to kiss other male residents, redirect. Review of the facility Reportable Event (RE) dated 12/14/24 identified that Resident #1 was observed in Resident #2's bed, under the covers. The nurse removed the covers and noted that Resident #1 did not have his/her brief on, and his/her gown was pulled up to the chest. Resident #2's hand was noted between Resident #1's legs just above his/her knees, and Resident #2 quickly removed his/her hand once uncovered. The residents were separated, Resident #1 was placed on every fifteen (15) minute checks, Resident #2 was placed on one-to-one staff observation. The RE further identified that Resident #1 reported no pain, and a body audit was completed with no injuries noted. The RE summary identified that Resident #1 has severe A psychiatric Advanced Practice Registered Nurse (APRN) note dated 12/15/24 at 6:15 PM identified Resident #1 was involved in a resident-to-resident inappropriate interaction. Recommendations included continuing every fifteen (15) minute checks due to potential wandering into other residents' rooms which may increase the risk of altercation and inappropriate interaction due to the resident's poor insight and judgement related to dementia. A nurse's note dated 12/15/24 at 10:22 PM identified that Resident #1 remained on every 15-minute checks with attempts to enter other residents' rooms but was redirected. The Resident Care Plan (RCP) update on 12/16/24 identified that Resident #1 has a history of hugging, stroking and kissing other staff and residents on the hands and face and that the resident is approved by the Power of Attorney (POA) to have intimate relationships with peers with interventions that included to encourage the resident to express feelings appropriately, staff is to complete every fifteen (15) minute checks, and that family consented to initiation and acceptance of affection and intimate relationships. A nurse's note dated 12/17/24 at 10:12 PM identified that Resident #1 was attempting to enter other residents' rooms and was redirected multiple times. A nurse's note dated 12/19/24 at 10:52 PM identified that Resident #1 attempted to enter other residents' rooms and was redirected. Review of the December 2024 and January 2025 Medication Administration Record (MAR) for Resident #1 identified that Resident #1 was being monitored for impulsivity, restlessness, entering peers' rooms, removing items from carts, verbal outbursts and unprovoked crying but did not differentiate each behavior. The charting identified that these behaviors were observed intermittently on all shifts. Interview with Registered Nurse (RN) #4 (Regional Nurse) on 1/7/25 at 12:10 PM identified that the facility was unable to locate healthcare proxy paperwork for Resident #1 and placed a follow-up call to Person #1 (Resident #1's listed health care proxy on the face sheet) and it was reported by Person #1 that there was no legal paperwork and that Person #1 was the next of kin, not the healthcare proxy, therefore, it should not have been documented in Resident #1's clinical record that Person #1 could make decisions regarding Resident #1's intimate relationships within the facility. Interview with the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) on 1/7/24 at 9:02 AM identified that Resident #2 had a doorway stop sign as a deterrent to keep wandering residents out of specific rooms that were identified as frequently visited by wandering residents. The stop signs do not require a physician's order, as they are a nursing measure, and they do not input their use into the plan of care for specific residents. Interview and Observation with Nurse Aide (NA) #2 on 1/6/25 at 12:50 PM identified that Resident #1 will often enter Resident #2's room, reporting that there is supposed to be a stop sign at the doorway to prevent wandering residents, however, upon observation with the surveyor the stop sign was not in place to Resident #2 ' s doorway. Interview with Licensed Practical Nurse (LPN) #2 on 1/6/25 at 12:09 PM identified that on 12/14/24 she observed Resident #1 in Resident #2's bed both covered with a sheet. She reported that when she entered, the stop sign was not in place at the doorway. She identified that she observed Resident #2's hand under the sheet move from between Resident #1's legs to visible above the sheet and Resident #1 was naked from the waist down. LPN #2 identified that Resident #1 had a history of wandering into other residents' rooms. Interview with LPN #1 on 1/6/25 at 10:50 AM identified that Resident #1 had a history of entering Resident #2's room prior to the incident on 12/14/24, as well as other residents' rooms, Resident #1 would either push through or crawl under the stop sign on the doorways and lay down on other residents' beds when he/she gets tired. LPN #1 identified that on 12/14/24 at 9:45 PM she entered Resident #2's room and observed Resident #1 in Resident #2's bed under the sheet. LPN #1 stated that she observed Resident #2's arm movement under the sheet move from Resident #1's groin area to out from under the sheet, Resident #2 stated Am I in trouble? Resident #1 was noted with his/her gown lifted to the chest area and was naked from the waist down, Resident #2 had underwear on, but no shirt. LPN #1 further identified that since the 12/14/24 incident, she has observed Resident #1 crawl under the stop sign to Resident #2's room and she has had to remove Resident #1 from Resident #2's bathroom one time that she could recall. LPN #1 further identified that she did not report Resident #1's behaviors both prior to and after the incident on 12/14/24 because all staff were aware. Interview with Registered Nurse (RN) #1 (3:00 PM to 11:00 PM nursing supervisor) on 1/6/25 at 2:19 PM identified that on 12/14/24 Resident #1 and Resident #2 were observed in Resident #2's bed and when the sheet was removed Resident #1 was without a brief or clothing from the waist down. When Resident #2 was questioned he/she stated that Resident #1 had gotten into his/her bed while he/she was sleeping. RN #1 stated that prior to the 12/14/24 incident, she had seen Resident #1 crawl under the stop sign at the doorway of Resident #2's room and other residents who have a stop sign at the doorway, reporting that the stop sign is an ineffective intervention at keeping Resident #1 out of other residents' rooms, however, did not report this to the DNS. Interview with NA #1 on 1/6/25 at 11:25 AM identified that Resident #1 had always wandered into Resident #2's room prior to the incident on 12/14/24. NA #1 identified that subsequent to the incident between Resident #1 and Resident #2 on 12/14/24, Resident #1 continues to crawl under the stop sign at Resident #2's door and he has found Resident #1 in Resident #2's room numerous times and had to redirect him/her out of the room. NA#1 identified that he didn't report these behaviors to anyone prior to or subsequent to the incident because all licensed nurses and NAs had also observed Resident #1 going under the stop sign and have found the resident in Resident #2's room. Interview with Social Worker #1 on 1/6/25 at 11:36 AM identified that Resident #1 had a history of wandering throughout the unit and when he/she would get tired, he/she would lay down in other residents' beds. Social Worker #1 identified that due to Resident #1's cognition, it was unknown if he/she consented to any intimacy with other residents within the facility. She reported that the staff continued to redirect the resident out of rooms as needed and continued to utilize the stop sign in Resident #2's doorway to deter the resident from entering Resident #2's room but identified that it wasn't effective in keeping Resident #1 out of Resident #2's room but would slow him/her down. Interview with the DNS on 1/6/25 at 1:04 PM identified that the 12/14/24 incident involving both Resident #1 and Resident #2 were found to be unsubstantiated following the investigation, as Resident #1 had a history of becoming aggressive and agitated when he/she didn't want to do something and stated he/she was calm on assessment, had no injuries and could not prove that intimate relations took place as the sheet was covering the residents on initial observation. The DNS identified that she was unaware prior to the incident that Resident #1 was going under the stop sign and entering Resident #2's room frequently. Subsequent to 12/14/24, the resident was placed on every fifteen (15) minute observations which she believed to be effective, as staff had not reported to her that Resident #1 had been continuing to go into Resident #2's room and that the stop sign in Resident #2's doorway was ineffective. She identified that if she had been aware she was unsure of what interventions she would have put into place, stating that she would have to do an investigation to determine the best interventions to implement. Additionally, she identified that although not reflected in the Plan of Care (POC) the doorway stop sign should have been in place to Resident #2's doorway to prevent wandering residents from entering Resident #2's room but she was unsure why it was not in place on observation on 1/6/24 or on 12/14/24 when the incident occurred, however stated they do their best to reapply the stop sign as soon as it's identified that it's not in place. Review of the Abuse policy dated 01/2023 directed, in part, that each resident has the right to be free from abuse. Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Staff training should include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, what constitutes abuse, that abuse allegations require immediate action and how to identify residents who have the potential for becoming victims of abuse. The facility will continue to provide individualized care plans that identify risk factors of residents as well as plans for protecting their rights. After the incident occurs the interdisciplinary team will update the person-centered care plan with appropriate interventions.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for accidents, (Resident #1), the facility failed to implement the plan of care for a resident who was identified as high fall risk and had a fall with an injury. The findings include: Resident #1 was admitted to the facility with diagnoses that included stroke, chronic heart failure, major depressive disorder, and myocardial infarction (heart attack). The care plan dated 2/10/23 identified Resident #1 was at risk for falls related to increased weakness and advanced age with interventions that included for Resident #1 to wear appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating. Resident #1's undated Nurse Aide (NA) [NAME] identified for the category safety to have appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating. A fall risk assessment dated [DATE] identified Resident #1 was at risk for falls and identified when Resident #1 walked forward he/she has loss of balance while standing, balance problems when walking, decrease in muscular coordination and use of assistive device. The admission Minimum Data Set, dated [DATE] identified Resident #1 had no impairments in cognition, was occasionally incontinent of urine and always continent of bowel, was an extensive assistance of one staff for toilet use. A Nursing note dated 3/2/23 at 3:02 AM identified she was called in to assess Resident #1 at 4:15 AM for a witnessed fall in the room. Resident #1 was coming out of the bathroom and NA #4 was to the right of the walker and Resident #1 fell towards his/her left into the wall and then to floor, the resident had tripped on his/her slippers. Resident #1's legs were equal and symmetrical with no shortening or lengthening of limbs, however the resident complained of pain. The APRN was notified with new order for stat (immediate) x-ray of left hip/pelvis and bilateral wrists. Resident #1's daughter was updated and agreed with the plan of care. The accident & incident report dated 3/2/23 identified Resident #1 had a witnessed fall in his/her room. Nurse Aide (NA) #4's investigation statement identified at 4:00 AM she assisted Resident #1 to the bathroom, NA #4 transferred Resident #1 with the use of Resident #1's walker. When Resident #1 was leaving the bathroom, he/she slipped on his/her slippers and fell forward on his/her left side hitting the wall and floor. A Physician's order dated 3/2/23 directed stat X-ray to left hip/pelvis. A Radiology report dated 3/2/23 identified Resident #1 had an X-ray of left hip and unilateral pelvis with 2-3 views due to pain. A total his prosthesis was in place without fracture or loosening and no acute process demonstrated. An APRN note dated 3/2/23 identified she assessed Resident #1 following a fall in the bathroom and Resident #1 thought his/her walker got caught on a slight elevation on the floor that separated the bathroom from the room. Resident #1 complained of intense pain in left hip, X-rays of left hip were done and unremarkable with no fractures or dislocations. Resident #1 reported 10/10 pain and acetaminophen was given with no effect, and a new order for Tramadol 25 mg every 4 hours as needed for pain for two weeks. Physician's order dated 3/2/23 directed Tramadol 25 mg every 4 hours as needed for pain for fourteen (14) days. Review of the medication administration record from 3/2/23 through 3/8/23 identified Resident #1 was medicated with tramadol for hip pain eight (8) times on the 7:00 AM to 3:00 PM shift, two (2) times on the 3:00 PM to 11:00 PM shift and one (1) time on the 11:00 PM to 7:00 AM shift, all with good effect. An APRN note dated 3/8/23 identified that the resident was noted with increased confusion and increased pain in the Left hip, repeat X-rays and blood work were ordered. A Physician's order dated 3/8/23 directed repeat the Left hip X -ray. A radiology reported dated 3/8/23 identified Resident #1 had an x-ray of left hip and unilateral pelvis with 2-3 views due to pain. No acute fracture of focal osseous lesion observed, diffuse osteopenia seen with no dislocation of joints A SBAR note dated 3/9/23 identified Resident #1 had worsening pain in the Left hip, the physician was notified at 8:30 AM with a new order to send Resident #1 to the emergency room. Review of hospital paperwork dated 3/9/23 identified that the resident had a fall at the skilled nursing facility approximately ten (10) days prior and had been complaining of left hip pain, two (2) X-rays were ordered with no acute findings, the resident continued to complain of pain and was therefore sent to the emergency department. A computed tomography (CT) scan at the hospital identified an overlapping displaced fracture of the Left inferior ramus and two (2) fractures of the superior ramus (pelvic fractures), the resident was managed with oral pain medication and discharged with an order for physical therapy. Interview with APRN #2 on 4/6/23 at 1:53 PM identified Resident #1's X-ray completed on 3/2/23 after the fall had no findings, and tramadol was ordered for pain. She further identified that a repeat X-ray was ordered on 3/8/23 due to Resident #1's complaint of increasing pain, which also had no findings. She identified she was not the practitioner that received the call on 3/9/23 for Resident #1's worsening pain, but assumed she was sent to the ED for further imaging due to the increase in pain. Interview with the facility contracted radiology company radiologist on 4/6/23 at 2:30 PM identified although portable x-rays are usually accurate, due to Resident #1's osteopenia, hardware in hips, and limited positioning, small fractures may not have been identified on the previous portable X-rays taken at the facility. Interview with Maintenance Person #1 on 3/28/23 at 10:00 AM identified he assessed Resident #1's room after the fall occurred on 3/2/23 and identified there were no raised structures from the threshold of the room to the bathroom and no maintenance work had to be done. Interview with the DNS on 3/28/23 at 11:00 AM identified Resident #1 was care planned to have non-skid socks on for ambulation prior to the fall on 3/2/23. Resident #1 was not wearing non-skid socks at the time of the fall, the slippers that the resident was wearing had no grip on them, therefore they were removed from Resident #1's room after the fall. She identified Resident #1's care plan was updated after the fall to remove Resident #1's slippers from his/her room, and the resident is to wear non-skid socks at all times even when not ambulating. Multiple attempts were made to contact NA #4 without success. Review of the fall prevention program policy directed for residents at risk for falls to develop interventions and incorporate them into the resident's care plan.

Based on clinical record review, review of facility documentation and interviews for one of three residents reviewed for accidents, (Resident#59), the facility failed to ensure the resident received the necessary assistive device to prevent an accident. The finding include: Resident#59's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified short and long term memory impairments, severe impairment in cognition, requiring total assistance of one to two staff for ADL and no falls since last assessment. The RCP dated 9/12/17 for assistance with ADLs. Interventions directed to transfer the resident via Hoyer lift with the assist of two staff to an adaptive wheelchair with bilateral legs rests and lap tray. The nurse's note dated 11/27/17 recorded at 10:06 P.M. identified RN#1 was called to the resident's room about 7:00 P.M. secondary to Resident # 59's left swollen leg and the resident screaming secondary to pain. Additionally, the nurse's note indicated NA #5 noted a different shape in Resident # 59's left leg compared to the right leg. Upon RN #1 assessment on 11/27/17 identified that Resident # 59's left leg was swollen and the resident was screaming in pain upon palpation. The nurse's note also indicated the APRN was notified. The Reportable Event dated 11/27/17 at 7:20 PM identified Resident #59 was found with a left swollen thigh and discomfort with palpation. An X-ray was performed at the facility of the left femur which identified diffuse [MEDICAL CONDITION] and an acute comminuted [MEDICAL CONDITION] femur with significant displacement. Resident#59 family was updated and the resident was transferred to the hospital for treatment. A progress note dated 11/29/17 by MD#1 indicated displaced left distal femur fracture, no known trauma. Fracture most likely secondary to osteopenia and normal activity. Facility documentation dated 11/30/17 and the Inter-Agency Patient Referral report dated 12/1/17 indicated on follow-up exam and imaging done at the hospital, the resident was also found to have a right distal femur fracture. A review of the facility investigation dated 12/1/17 regarding an re-enactment of the incident identified the facility's investigation revealed that NA # 2 failed to follow the resident's care plan and initiated a mechanical lift transfer without the benefit of two assistance. The facility's investigation on 12/1/17 identified NA # 2 during the investigation admitted when she/he transferred Resident # 59 the resident's legs swung against the dresser. In a statement obtained during the investigation by NA#2 (assigned to Resident #59 on 11/27/17 on the 7-3 shift), indicated he/she prepared the resident for a Hoyer transfer and went to look for someone to help but no one was around so she/he (NA #2) Hoyer lift the resident by herself/ himself and in the process of the transfer the resident's legs swung against the dresser. Subsequent to the incident NA # 2 was terminated for violation of policy and procedure. NA # 5 failed to transfer Resident # 59 with a Hoyer lift with two staff members in accordance to the plan of care resulting in the resident sustaining right and left femur fractures. The resident was evaluated at the hospital and diagnosed with [REDACTED]. Review of facility investigation and interview with the DNS on 2/22/18 at 2:00 P.M. identified when the [MEDICAL CONDITION] femur was diagnosed on [DATE] and based on MD#1's review of the x-ray, the focus of the investigation was on a possible pathological event on the evening shift. The DNS indicated, however, when the right femur fracture was identified, the investigation included re-interviews and focus on the day shift on 11/27/17. Interview with NA#2 on 2/22/18 at 12:15 P.M. identified she/he could not recall the event. Facility policy for Resident Transfers indicated the nurse aide will check the assignment to ensure the proper transfer is performed. Further review of the policy identified the policy did not indicate two staff members were required for the transfer as directed in the care plan. The facility does not have a specific Hoyer lift policy.

Based on clinical record reviews, review of facility policies/documentation, observations and interviews for two of three residents who had a fall (Residents #1, #2) the facility failed to provide a positioning device per the physician's orders [REDACTED]. The findings include: Resident #1 had a [DIAGNOSES REDACTED]. The assessment dated [DATE] identified that the resident had cognitive impairment with memory loss, required extensive assistance from staff for transfers/ambulation and was unsteady when moving from seated to standing position. The fall risk assessment dated [DATE] indicated that the resident was a moderate risk for falls. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Nursing narratives and/or facility documentation dated 4/2/11 noted that the resident was in the wheelchair without the lap tray, fell and was found on the floor at 7:20 PM. Although the resident initially sustained a skin tear to the right elbow, the resident complained of pain, had decreased range of motion and bruising on 4/4/11 and was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 5/10/11 at 10:05 AM identified that the NA assignment reflected both "lap tray only with meals," and "lap tray at all times." H/she further indicated that nursing did not ensure the accuracy of the NA assignment by erasing old interventions when new interventions were ordered and nurse aides did not clarify the NA assignment discrepancy regarding lap tray use. Resident #2 had [DIAGNOSES REDACTED]. The assessment dated [DATE] identified that the resident had cognitive impairment with memory loss, required assistance from staff for transfers/ambulation, was unsteady when moving from seated to standing position and did not utilize restraints. The fall risk assessment dated [DATE] indicated that the resident was at moderate risk for falls. The plan of care dated 1/20/11 directed continued use of an alarming self- release seatbelt in the wheelchair (seatbelt for positioning). Physician orders [REDACTED]. The OT evaluation from 2/16/11 to 2/13/11 noted no further need of pelvic positioning belt and directed the use of a Philly Slide. An alternate w/c alarm device was not addressed. Nursing narratives dated 2/19/11 identified that the resident fell out of bed at 3:40 PM, the alarm did not sound and the battery was changed. Nursing narratives and/or facility documentation dated 2/23/11 noted that the resident attempted to assist self to stand by holding onto the gate at the nursing station, the gate opened widely, the resident fell while the NA was at the desk and was observed in a medium pool of blood. The resident was sent to the emergency department and the x-ray dated 2/23/11 identified nasal bone fracture. The resident returned to the facility on [DATE] and the alarming seatbelt was reordered on [DATE].Observation during tour on 5/6/11 noted four units and 2 of the units had large nursing stations with swinging gates for entry. Interview with the DON on 5/10/11 at 3:05 PM indicated that the gates on the nursing stations do not have the ability to lock and or remain closed tightly. The gates at the nursing stations provided an unsafe environment for residents who may attempt to hold onto the gates for support. The facility submitted a written action plan dated 5/10/11 to include immediate removal of both nursing station gates and the future installation of self latching doors.