Every finding on record at Masonicare Health Center

Based on staff interviews, review of the clinical record, facility documentation, and facility policy for 11 of 12 sampled residents (Resident #8, #17, #50, #53, #87, #97, #138, #234, #252, #254, and #255) reviewed for abuse, the facility failed to notify the State Agency in a timely manner of allegation of abuse/misappropriation of property. The findings include: 1.Resident #8 diagnoses included mixed anxiety and depression, difficulty in walking and muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 13 indicating intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. Additionally, the MDS identified Resident #8 did not exhibit delirium, delusions or hallucinations.The Resident Care Plan dated 10/21/25 identified Resident #8 was independent for meeting emotional, intellectual, physical and social needs relating to preference for self-directed activities. Interventions included establishing and recording the resident's prior activity involvement and interests by talking with the resident, caregivers and family on admission and as necessary.A Social Service (SS) interim note dated 12/10/25 at 11:52 AM identified Resident #8 asked about getting a haircut/shave but did not yet have a facility banking account set-up due to pending conservatorship. SS asked the Unit Secretary to set-up a haircut appointment which was scheduled for 12/11/25.A nursing note dated 12/30/25 at 12:53 PM identified Resident #8 stated he/she was missing $150.00, a room search was conducted, and no money was identified. The business office indicated that Resident #8 did not have an account set up with the facility.A Patient/Resident Grievance form dated 12/30/25 identified Resident #8 reported he/she was missing $150.00. Additionally, his/her wallet was empty, an account with the facility had not been established, and there was no locked drawer in Resident #8's room for him/her to secure money. A friend and former landlord confirmed he/she gave Resident #8 money ($154.00) on 12/8/26 and had a signed receipt to show it was received by the resident. The resolution to the grievance identified a locked drawer was to be provided to Resident #8 and to encourage him/her to set up an account with the facility. A SS note dated 12/31/25 at 10:23 AM identified Resident #8 was educated on the use of the lock on his/her nightstand to keep any money secured and he/she was agreeable to opening a resident account in the facility.Interview with Resident #8 on 7/30/26 at 11:04 AM identified he/she had $150.00 stolen about 7 months ago stating nobody helped to recover the loss even though he/she told a social worker and other people about the missing money.Interview with the Director of Social Work (SW) #1 on 8/3/26 at 2:54 PM identified that the facility's policy required staff to initiate a grievance form and investigate any reports of missing funds, then provide the residents with a locked drawer and encourage them to open a personal funds account. According to SW #1, missing funds were only reimbursed if theft was confirmed through an investigation in which case local police would be notified, and the Director of Nurses (DNS)/Administrator would be responsible for following through with reporting and obtaining interviews. SW #1 identified she had filled out the Patient/Resident Grievance form dated 12/30/25 after nursing had reported Resident #8's missing money. SW #1 indicated that she had then written the concern on the morning report board making staff aware and placed a notation at the top of the grievance form that the information was reviewed during morning report. Although the facility directed that she report all alleged violations including misappropriation of resident property immediately, but not less than 24 hours after an allegation was made, she could not confirm the DNS or Administrator were directly notified or if they were present when Resident #8's missing money was discussed during morning report. SW #1 stated the $150 was never located, and the resolution to the missing funds was to provide Resident #8 with a locked drawer and personal funds account, which she felt was appropriate. Interview with the Administrator on 8/3/26 at 3:27 PM identified the facility's policy directed to report grievances to the social worker, until a potential investigation was opened, if necessary, in which case the information would be reported to the State Agency. Review of Resident #8's grievance dated 12/30/25 identified that a report to the State Agency was not generated because Resident #8 stated the money was missing, not that anyone had taken his/her missing money and there was an understanding that Resident #8 misplaced the funds while out to the store, or out with recreation, or out to the hairdresser.Re-interview with Resident #8 on 8/5/26 at 9:07 AM identified he/she asked a landlord/friend to bring an envelope from his/her apartment that contained $154.00. Once delivered, he/she took $4.00 to the hairdresser as a tip and left the rest in a white envelope on the television stand of his/her room, under the impression that it would be safe. Resident #8 indicated that he/she just knew the money had been taken by someone. Additionally, Resident #8 stated no one had ever suggested reimbursement, he/she was only told money should be put somewhere safe, a lock drawer was provided, and he/she was assisted with an account for personal funds only after the money was taken from him/her. The Personal Funds of Resident Policy reviewed 12/3/25 directed in part that it was the policy to safeguard the assets of resident by maintaining sufficient internal and external controls over our cash maintained on hand, in bank accounts and held by investment managers.2. Resident #17's diagnoses included autistic disorder, depression, and unspecified joint pain. A Resident Care Plan dated 8/20/25 identified Resident #17 had a communication problem related to a cognitive deficit due to autism and intellectual disability. Interventions included to allow adequate time to respond, repeat as necessary , do not rush and use simple, brief, consistent words. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had intact cognition and required partial/moderate assistance with activities of daily living. The MDS further identified Resident #17 had no abnormal behaviors. A Social Worker (SW) note written by SW #5 on 12/29/25 at 11:23 AM noted the Unit Registered Nurse (RN) Manager reported that Resident #17 was missing $30.00. Resident #17 reported to SW #5 that he/she kept money in his/her locked drawer and the key to the drawer was in another dresser drawer. SW #5's note further identified Resident #17 was unable to tell SW #5 when the money went missing but believed it was sometime last week. SW #5 indicated she would follow up with the bank at the facility to see if the resident bought anything from the store and would report to the Administrator and Social Service Director. A social worker note written by SW #5 on 12/29/25 at 11:31 AM noted Resident #17's conservator was notified of the missing $30.00, and Resident #17 had not left his/her room during that time due to Covid-19 precautions. A Grievance form dated 12/29/25 also identified Resident #17 reported missing $30.00 from his/her locked drawer and stated he/she had $50.00 taken out but spent some of it, and had $30.00 remaining. On 8/4/26 at 2:45 PM and 8/5/26 at 11:31 AM, interview with the Administrator and SW #1 identified a Grievance form was initiated regarding the missing money, and Resident #17 was advised to keep the key to the locked drawer on him/her at all times. SW #1 could not recall what the outcome was when she inquired from the facility bank if Resident #17 had withdrawn money and both the Administrator and SW #1 noted the missing money was not reported to the State Agency because it was handled as a grievance. 3. Resident #50's diagnosis included congestive heart failure, need for assistance with personal care and depression.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status score of 15 indicating intact cognition, was independent with bed mobility, required substantial/maximal assistance with transfers, and was independent with wheelchair mobility.a. Review of the Patient/Resident Grievance dated 9/9/25 identified a self-reported complaint that $100.00 was missing from a drawer in his/her room that had been wrapped in a towel, that consisted of 5 $20.00 bills received for his/her birthday. The undated/unsigned investigation and resolution identified that the funds would be replaced as a customer service, Resident #50 was provided with a locked drawer the statement that the facility would not replace funds again, and the resident was encouraged to utilize the locked drawer and facility bank for safekeeping. Additionally, a request for petty cash was submitted and on 10/31/25, Resident #50 received cash.A nursing note dated 9/9/25 at 4:04 PM identified that a Nurse Aid (NA) had notified her that Resident #50 needed to urgently speak to her. Resident #50 reported that he/she misplaced 5 $20.00 bills and then some. The resident indicated where the money had been stored in his/her nightstand and the last time the money was seen was after the birthday party recreation activity and prior to dinner on 9/8/25. The resident indicated that he/she had not left the room on 9/9/25 and noted the missing money just prior to alerting the NA. Additionally, the Assistant Director of Nursing Services (ADON) was notified and was investigating, the family had already been notified by Resident #50.A Registered Nurse (RN) Supervisor note dated 9/9/25 at 4:11 PM indicated that she went to speak with Resident #50 who confirmed the information given at 4:04 PM.A RN Supervisor note dated 9/10/25 identified he followed up with Resident #50 and reassured the resident that an investigation was started, encouraged to be forthcoming with any additional information that could help with the investigation, and it was noted the resident was alert and oriented and recalled how the cash was acquired.Social Worker note dated 9/9/25 at 3:18 PM and 9/10/25 at 2:51 PM identified she met with the resident regarding the missing money, the team was notified for further follow-up, and the resident had a new locked drawer installed with a lanyard and educated to keep the key on his/herself at all times.b. Review of the Patient/Resident Grievance dated 2/4/26 identified a self-reported complaint that a Nurse Aid (NA) was rough while providing perineal care and hygiene. The unsigned investigation and resolution dated 2/4/26 identified that the CNM spoke to Resident #50 and was addressed with staff, as well as a second entry dated 2/4/26 indicating SWK spoke to staff, there was ongoing follow up with no other complaint 2/5, 2/7, 2/10, 2/19, 2/20, and 2/25, with 2 additional, illegible dates. A notation at the top of the form indicated that the concern was reported at AM meeting 2/6/26.A Social Service note dated 2/4/26 at 4:06 PM identified the Social Worker met with Resident #50 in regard to care concerns expressed on the previous shift, the resident was allowed to express his/her thought and concerns, reassurance and comfort was provided and the resident was thankful.A late entry CNM note dated 2/4/26 at 4:22 PM identified she had spoken to Resident #50 regarding care concerns the previous shift, the CNM apologized, offered supportive care and assured the resident that concerns would be addressed along with ensuring the resident was kept comfortable.Interview and review of facility documentation with the of Nursing Services (DNS) and Administrator on 8/5/26 at 11:31 AM identified the Administrator indicated she and the Interdisciplinary Team found out about the missing money on 9/10/26 (the following day) and that due to Resident #50 stating that the money was misplaced versus being stolen they did not complete a Reportable Event or report the missing money to the State Agency. The Administrator stated because Resident #50 did not state the money was stolen or that someone took the money, losing or misplacing his/her things was not considered to be a misappropriation. Additionally, regarding the complaint of rough treatment Resident #50 refused to indicate which NA provided him/her with rough personal care. Although the CNM note indicated she assured the resident that concerns would be addressed along with ensuring the resident was kept comfortable, there was no further documentation or a Reportable Event following up on the rough care allegation. The Administrator indicated the Social Worker was responsible to follow up on allegations, and it had been determined during the Interdisciplinary AM report on 2/5/26 next day, (the form indicated 2/6/26) that the incident was not abusive, mistreatment, or undignified treatment. Although the policy directed immediate notification to managerial staff of an allegation of mistreatment to determine if the incident was abusive, the Administrator indicated that the policy had not been followed. 4. Resident #53's diagnoses included hypertension, chronic obstructive pulmonary disease and peripheral vascular disease. A Resident Care Plan dated 11/3/25 identified Resident #53 had a communication problem related to cognitive deficits, and that he/she was very quiet and hesitates before responding. Interventions included to anticipate needs, be conscious of the resident's position when in groups and allowing adequate time to respond. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #53 had intact cognition and required substantial/maximal assistance with oral hygiene. The MDS also identified Resident #53 was dependent with toilet use, showering/bathing and upper/lower body dressing. A Grievance form dated 2/3/26 identified Resident #53 reported on 2/1/26 he/she did not receive any care from the Nurse Aide (NA) until 8:00 PM (but failed to identify the last time care was rendered). The Grievance form further noted that this was discussed in morning report (1 day after Resident #53 reported not receiving care on 2/1/26 until 8:00 PM). On 8/5/26 at 11:31 AM interview and review of the Grievance form with the DNS and Administrator noted they did not ascertain when the last time Resident #53 received care with the exception of being served his/her dinner at approximately 6:30 PM so therefore could not ensure the allegation did not occur and failed to identify the State Agency was notified of Resident #53's allegation of not receiving care on 2/1/26 until 8:00 PM. 5. Resident #87's diagnoses included Type 2 diabetes, depression and chronic kidney disease. A Resident Care Plan dated 6/4/26 identified problem with depression. Interventions included to assist the resident in developing a program of activities that was meaningful, encourage and provide opportunities for exercise and notify the provider of any risk for harm. An admission Minimum Data Set (MDS) assessment date 6/10/26 identified Resident #87 had intact cognition. On 8/4/26 at 2:45 PM a review of the Grievance log and interview with the DNS, Social Worker (SW) #1 and Administrator noted a Grievance form dated 2/3/26 that identified Resident #87 reported his/her wallet with money was missing. Additionally, the Administrator identified the wallet was not listed on the inventory of affects, only the wallet was found, but could not verify money was in it prior to the facility locating the wallet. Furthermore, the facility did not report to the State Agency when Resident #87 reported money/wallet was missing although a lock box was provided (7 days later) to the resident. Additionally, SW #1 identified she did not contact the family to inquire if Resident #87 had money in the wallet, or if it was possible the resident had access to money. (See F 610) 6. Resident #97s diagnoses chronic obstructive pulmonary disease, Parkinson's disease, and diabetes.The Resident Care Plan (RCP) dated 6/4/26 identified Resident #97 had a terminal prognosis related to end stage chronic obstructive pulmonary disease, and hospice was elected. Interventions included adjusting provision of activities of daily living to compensate for resident's changing abilities, encourage participation to the extent the resident wishes to participate, assessing the resident's coping strategies, respecting the resident's wishes, and to encourage Resident #97 to express feelings, listen with non-judgmental acceptance and compassion.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 was cognitively intact, required set-up assistance for eating, and substantial moderate assistance for transfers. Also, identified Resident #97 was dependent for toileting and required partial moderate assistance for bathing. Further, identifying Resident #97 used a manual wheelchair and was admitted to Hospice services.A nursing note dated 6/19/26 at 6:19 PM identified Resident #97 wanted to go back to bed but then refused when the Nurse Aid (NA) tried to help him/her. Resident #97 told the NA not to touch him/her when trying to help the resident back to bed. Resident #97 told the NA that they were cruel.A facility Reportable Event Form dated 6/20/26 identified that Resident #97 reported being punched in the stomach on 6/17/26 and was pulled from the wheelchair by his/her arms when the resident expressed he/she did not want to have an early bedtime. Also, identifying the resident had a history being accusatory prior to admission and since admission.An email to the Social Worker was sent on 6/20/26 by a family member who identified concerns that a NA was aggressive with Resident #97, and the resident had repeated the same statement several times to family members and friends regarding how this occurred. Resident #97 did not want to go to bed at 7:00PM, the NA tried pulling him/her out of the wheelchair to go to bed and then punched the resident in the stomach. Also, identifying the family member requested the altercation be reported and investigated.A Social Service note dated 6/22/26 at 3:49 PM identified Social Service met with Resident #97 regarding the nursing note dated 6/19/26, Resident #97 was confused and unable to provide details.A nursing note dated 6/23/26 at 2:14 PM identified staff spoke to Resident #97 regarding concerns of a staff interaction and the Resident #97 stated there was a bar brawl.A Social Service note dated 6/23/26 identified an email was sent by a family member and then a follow up phone call occurred identifying a concern with a NA punching Resident #97 in the stomach which was reported to have occurred on the 3:00 PM to 11:00 PM shift on 6/17/26. Also, the Social Worker (SW) identified the facility would get statements and follow up regarding care occurring on 6/17/26 although the family member did not feel it was indicated.Interview with SW #1 on 8/3/26 at 2:17 PM regarding a grievance form filled out by her on 6/20/26 identified she did not think the event ever transpired on 6/17/26 to warrant reporting to the State Agency. Also, the SW identified on 6/22/26 the occurrence from the weekend of 6/19/26 was not substantiated during morning report and the Director of Nursing Services (DNS) was in attendance. Further, identifying she knew the abuse policy, identifying the DNS would perform the investigation, reporting the incident to the State Agency and she would not perform that task.Interview on 8/3/26 at 2:22 PM with the DNS identified she was at morning report on 6/22/26 when SW #1 reported the grievance, but the DNS was not aware of the alleged physical abuse of Resident #97 being punched in the stomach. Also, identifying she had no minutes for morning reportInterview on 8/5/26 at 12:11 PM with SW #3 identified the family member sent her an email on 6/20/26 regarding the alleged altercation on 6/17/26.Interview on 8/5/26 at 12:38 PM with the DNS and the Administrator identified that they were not aware of the email sent by the family member on 6/20/26 which was received by the facility on 6/22/26. Also, identifying a grievance was completed but not reported to the State Agency.7. Resident #138 had diagnoses that included dementia, diabetes, anxiety, and chronic obstructive pulmonary disease.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 was moderately cognitively impaired, used a motorized wheelchair, was independent with wheelchair mobility, required setup or clean-up assistance with eating, required substantial/maximal assistance with bed mobility and personal hygiene, and was dependent for toileting hygiene, lower body dressing, bed/chair/toilet transfers.The Resident Care Plan (RCP) dated 2/10/26 identified Resident #138 had bowel and bladder incontinence related to impaired mobility. Interventions included checking 4 times per shift for incontinence, providing incontinence care with each incontinence episode (wash, rinse, and dry), and Resident #138 used disposable briefs. The RCP further indicated Resident #138 was at risk for self-care performance deficit related to impaired balance and activity intolerance. Interventions included providing assistance of 1 staff member for dressing, bathing/showering, and bed-level toileting.A note written by Social Worker (SW) #3 on 4/1/26 at 11:27 AM identified she met with Resident #138 in response to a reported care concern. The note indicated Resident #138 was given time to express his/her concern and that the nurse manager was aware of the concern. The note further identified Resident #138 was on the way downstairs to go to the library and had no current concerns. The note failed to identify when the concern was first reported, what the concern was, how SW #3 became aware of the concern, and what additional information, if any, Resident #138 provided about the concern. Additionally, the note failed to identify the Administrator and/or Director of Nursing Services (DNS) had been informed of an allegation of mistreatment reported by Resident #138, and what the plan of action was in relation to the reported concern.A nursing note written by Registered Nurse (RN) #3 on 4/1/26 at 3:15 PM identified she had spoken with Resident #138 regarding concerns he/she had reported about a staffing agency caregiver (Nurse Aide (NA) #21). The note indicated Resident #138 provided a description of the NA #21 as a black young guy with facial beard. The note indicated that Resident #138 had stated NA #21 was inappropriate with him/her while he provided care on Monday evening (3/30/26). The note indicated RN #3 reviewed the assignment for 3/30/26 evening shift and identified a female aide was assigned in the evening (however, NA #21 was a male with a female type name). The note further indicated Person #1 was updated on the concern from Resident #138. The note failed to identify the Administrator and/or Director of Nursing Services (DNS) had been informed within 2 hours of an allegation of mistreatment reported by Resident #138 related to a male NA who was inappropriate during care on Monday evening. Additionally, the note was written greater than 2 hours (3 hours and 48 minutes) after SW #3's note on 4/1/26 at 11:27 AM.A nursing note written by RN #3 on 4/1/26 at 3:50 PM identified it was an addendum to her previous note (4/1/26 at 3:15 PM) and indicated there was not a male NA that fit the description of Resident #138's concern and it's unsubstantiated. The note failed to identify the Administrator and/or DNS had been informed of the allegation of mistreatment reported by Resident #138.A follow- up nursing note dated 4/2/26 at 9:18 AM and written by RN #3 noted Resident #138 had identified NA #21 was a male NA, and when RN #3 reviewed the schedule, NA #21 had a female name so she had incorrectly documented in previous notes on 4/1/26 at 3:15 PM and 4/1/26 at 3:50 PM that there was not a male NA assigned to Resident #138 and/or matching that description. The note indicated a clarification that the male NA Resident #138 felt uncomfortable (with) had been assigned to him/her on the evening shift (on 3/30/26). The note indicated Resident #138 was informed he/she would no longer have male caregivers assigned. Additionally, the note failed to identify the Administrator and/or DNS had been informed of the clarification and identification that a male NA had in fact been assigned to Resident #138 on 3/30/26 as he/she had reported.A progress note written by the Psychiatric MD, (MD #2) on 4/2/26 (1 day after the reported allegation of mistreatment) identified he was requested to see Resident #138 related to an alleged interaction. The progress note indicated he had reviewed background information with RN #3 and the DNS extensively and that Resident #138 had reported he/she was made to feel uncomfortable by a NA but that there was no report of ethical misconduct, abuse, neglect, exploitation or abandonment. The progress note indicated the facility had conducted an internal investigation and did not determine a basis to make a report to the state. The progress note indicated when asked about the recent event, Resident #138 requested not to further elaborate on the topic again after having discussed it with the nursing staff. The progress note indicated Resident #138 did not give specific details of the inappropriate behavior on interview and the facility investigation did identify a report of physical contact or explicit misconduct, and that based on current information there did not appear to be grounds for reporting an allegation of abuse but the decision could be re-evaluated should new information become available.Interview with Resident #138 on 8/3/26 at 1:55 PM during a Resident Council meeting (Resident #138 had summoned the surveyor and had steered his/her motorized wheelchair to a private location in a separate area of the room) identified he/she was sexually assaulted about a month or so ago (he/she could not recall the specific date). He/she indicated that 1 or 2 days after the incident he/she told a fellow resident (Resident #50) about what happened and that Resident #50 instructed him/her to report it to the facility. Resident #138 indicated that he/she reported the allegation of abuse and was told by staff that going forward there would be no male NA providing care. Additionally, Resident #138 indicated the facility staff had suggested he/she was lying and that he/she should have reported the incident right away.Interview with Person #1 on 8/3/26 at 3:06 PM identified a while ago (unable to recall specific day or month) Resident #138 was abused by a male NA. He/she indicated the facility had called to inform him/her of the allegation made by Resident #138, and they had indicated there was no male NA working with him/her on that day (however NA #21 was a male NA with a female name). Person #1 indicated a couple days later the facility called back and said that they had determined that there was a male NA working that day caring for Resident #138, but he had a female name so they hadn't realized that it was in fact a male NA when they had called a couple days prior. Interview and clinical record review with the DNS on 8/4/26 at 9:20 AM identified she did not complete a Reportable Event (RE) form for 4/1/26, and she indicated at that time she was told Resident #138 was uncomfortable with male aides whether agency or facility staff. She indicated that the information in RN #3's nursing notes regarding a male NA being inappropriate while he provided care was not told to her and that she was only informed Resident #138 was uncomfortable with male aides. She indicated that if she had seen the nursing notes written by RN #3 on 4/1/26 and/or if RN #3 had informed her that the male NA was inappropriate with Resident #138 while he provided care she would have submitted a RE to the state agency because that verbiage rises to the level of abuse. She further indicated that 8/3/26 was the first day she was notified of any concerns related to abuse for Resident #138.Interview with SW #3 on 8/5/26 at 10:45 AM identified she had been informed by the nursing staff of Resident #138 reporting a concern related to a male NA. She further indicated RN #3 was already aware of the concern so she had not informed the DNS/Administrator.Interview with Person #1 and Person #4 on 8/6/26 at 12:47 PM identified RN #3 had called Person #1 and said Resident #138 reported sexual abuse and she looked at the list of staff working that shift and there was no male NA working, so maybe Resident #138 was mistaken or confused. Person #1 indicated that RN #3 had called back a day or 2 later and said she had looked again at the list of staff working on the day incident reported by Resident #138 and there was a male NA working but he had a female name so she hadn't realized that was a male NA when she first looked at the list. Person #1 indicated RN #3 said the facility would contact the staffing agency to ensure that NA #21 was not allowed to return to the facility, and that she said the facility was conducting their own investigation. Person #1 indicated he/she had spoken with the DNS 2 days ago when she called to inform him/her that a report was being done and that she had just been notified of the allegation of abuse. Additionally, Person #1 indicated he/she had asked the DNS why he/she wasn't notified months ago when the incident happened, but she would not provide an explanation. Although attempted, an interview with RN #3 was not obtained.8. Resident #234's diagnoses included depression, Type 2 diabetes and a Stage 3 pressure ulcer to the right heel. A Resident Care Plan dated 4/9/26 identified Resident #234 had an activities of daily living deficit related to limited mobility. Interventions included to provide assistance of 1 for bathing/showering, bed mobility, dressing and toilet use. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #234 was moderately cognitively impaired. On 8/4/26 at 2:45 PM review of the Grievance Log and interview with the DNS, Administrator and Social Worker (SW) #1 identified on 4/22/26 Resident #234 reported to SW #1 that peri-care was provided on 4/21/26 in a rough manner. SW #1 and the DNS identified that Resident #234 was not questioned as to who the Nurse Aide was (see F 610) and the allegation was not reported to the State Agency. 9. Resident #252's diagnoses included depression, psychosis, and pain syndrome. A Resident Care Plan dated 8/15/25 identified Resident #252 had an activities of daily living self-care performance deficit related to pain. Interventions included to apply splint/brace as ordered, put hair in ponytail each morning, and provide Resident #252 with a pitcher of ice, ice water in his/her personal water bottle. A Significant Change Minimum Data Set (MDS) dated [DATE] identified Resident #252 had intact cognition. A Social Service note written by SW #3 and dated 11/7/25 identified meeting with Resident #252 and discussed food and care. A review of a Grievance form dated 11/7/25 and interview with the DNS and Administrator on 8/5/26 at 11:31 AM identified Resident #252 reported on 11/6/25 that he/she was not provided care (on the night shift). Additionally, the Grievance form noted that this was discussed in morning report on 11/10/26 (3 days after Resident #252 reported not receiving care) which was when the DNS and Administrator became aware. Furthermore, the DNS identified nursing documents daily regarding Resident #252 related to resident having accusatory behavior but failed to identify any documentation related to the Grievance forms allegation of not providing care. Additionally, the DNS and Administrator identified they became aware of the allegation during morning report (3 days later) and should have been made aware on 11/6/25 when Resident #252 made the allegation. 10. Resident #254's diagnosis included neuromuscular dysfunction of bladder, history of urinary tract infections, and abnormalities of gait and posture.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #254 had a Brief Interview of Mental Status score of 15 indicating intact cognition and was dependent for bed mobility, transfers, upper and lower body dressing, toileting and was always incontinent of bowel.Review of the Patient/Resident Grievance dated 2/3/

Based on interviews, clinical record review, facility documentation and review of facility policies for 11 of 11 sampled residents (Resident #8, #17, #50, #53, #87, #97, #138, #234, #252, #254, and #255) reviewed for missing personal property/allegations of abuse, the facility failed to thoroughly investigate potential misappropriation of property/abuse. The findings include: 1. Resident #8 diagnoses included mixed anxiety and depression, difficulty in walking and muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 13 indicating intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. Additionally, the MDS identified Resident #8 did not exhibit delirium, delusions or hallucinations.The Resident Care Plan dated 10/21/25 identified Resident #8 was independent for meeting emotional, intellectual, physical and social needs relating to preference for self-directed activities. Interventions included establishing and recording the resident's prior activity involvement and interests by talking with the resident, caregivers and family on admission and as necessary.A Social Service (SS) interim note dated 12/10/25 at 11:52 AM identified Resident #8 asked about getting a haircut/shave but did not yet have a facility banking account set-up due to pending conservatorship. SS asked the Unit Secretary to set-up an appointment which was scheduled for 12/11/25.A nursing note dated 12/30/25 at 12:53 PM identified Resident #8 stated he/she was missing $150.00, a room search was conducted, and no money was identified. The business office indicated that Resident #8 did not have an account set up with the facility.A Patient/Resident Grievance form dated 12/30/25 identified Resident #8 reported he/she was missing $150.00. Additionally, his/her wallet was empty, an account with the facility had not been established, and there was no locked drawer in the room. A friend and former landlord confirmed he/she gave Resident #8 money ($154.00) on 12/8/26 and had a signed receipt to show it was received by the resident. The resolution to the grievance identified a locked drawer was to be provided to Resident #8 and to encourage him/her to set up an account with the facility. A SS note dated 12/31/25 at 10:23 AM identified Resident #8 was educated on the use of the lock on his/her nightstand to keep any money secured and he/she was agreeable to opening a resident account in the facility.Interview with Resident #8 on 7/30/26 at 11:04 AM identified he/she had $150.00 stolen about 7 months ago stating nobody helped to recover the loss even though he/she told a social worker and other people about the missing money.Interview with the Director of Social Work (SW) #1 on 8/3/26 at 2:54 PM identified that the facility's policy required staff to initiate a grievance form and investigate any reports of missing funds, then provide the residents with a locked drawer and encourage them to open a personal funds account. According to SW #1, missing funds were only reimbursed if theft was confirmed through an investigation in which case local police would be notified, and the Director of Nurses (DNS)/Administrator would be responsible for following through with reporting and obtaining interviews. She indicated that she had filled out the Patient/Resident Grievance form dated 12/30/25 after nursing had reported Resident #8's missing money. Additionally, SW #1 indicated that she had then written the concern on the morning report board making staff aware and placed a notation at the top of the grievance form that the information was reviewed during morning report. SW #1 stated the $150.00 was never located, and the resolution to the missing funds was to provide Resident #8 with a locked drawer and personal funds account, which she felt was appropriate. SW #1 added that no formal investigation was conducted because it was difficult to prove that Resident #8 had the money in the first place.Interview with the Administrator on 8/3/26 at 3:27 PM identified the facility's policy directed to report grievances to the social worker until a potential investigation was opened. A formal investigation had never been opened because Resident #8 had reported the money was missing, not stolen, and that due to the nature of the report it was understood the resident misplaced the money while out to the store, out with recreation, or while at a hairdresser appointment.Re-interview with Resident #8 on 8/5/26 at 9:07 AM identified he/she asked a landlord/friend to bring an envelope from his/her apartment that contained $154.00. Once delivered, he/she took $4.00 to the hairdresser as a tip and left the rest in a white envelope on the television stand of his/her room, under the impression that it would be safe. Resident #8 indicated that he/she just knew the money had been taken by someone. Additionally, Resident #8 stated no one had ever suggested reimbursement, he/she was only told money should be put somewhere safe, a lock drawer was provided, and he/she was assisted with an account for personal funds only after the money was taken from him/her. Interview with Therapeutic Recreation Assistant #1 on 8/5/26 at 1:09 PM identified that the Recreation Department kept track of any resident outings such as restaurants, shopping etc. Review of the facility December 2025 log failed to identify Resident #8 went out with the Recreation Department. 2. Resident #17's diagnoses included autistic disorder, depression, and unspecified joint pain. A Resident Care Plan dated 8/20/25 identified Resident #17 had a communication problem related to a cognitive deficit due to autism and intellectual disability. Interventions included allowing adequate time to respond, repeat as necessary , do not rush and use simple, brief, consistent words. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had intact cognition and required partial/moderate assistance with activities of daily living. The MDS further identified Resident #17 had no abnormal behaviors. A Social Worker (SW) note written by SW #5 on 12/29/25 at 11:23 AM noted the Unit Registered Nurse (RN) Manager reported that Resident #17 was missing $30.00. Resident #17 reported to SW #5 that he/she kept money in his/her locked drawer and the key to the drawer was in another dresser drawer. SW #5's note further identified Resident #17 was unable to tell SW #5 when the money went missing but believed it was sometime last week. SW #5 indicated she would follow up with the bank at the facility to see if the resident bought anything from the store and would report to the Administrator and Social Service Director. A note written by SW #5 on 12/29/25 at 11:31 AM noted Resident #17's conservator was notified of the missing $30.00, and Resident #17 had not left his/her room during that time due to Covid-19 precautions. A Grievance form dated 12/29/25 also identified Resident #17 reported missing $30.00 from his/her locked drawer and stated he/she had $50.00 taken out but spent some of it and had $30.00 remaining. On 8/4/26 at 2:45 PM and 8/5/26 at 11:31 AM, interview with the Administrator and SW #1 identified a Grievance form was initiated regarding the missing money, and Resident #17 was advised to keep the key to the locked drawer on him/her at all times. SW #1 could not recall what the outcome was when she inquired from the facility bank if Resident #17 had withdrawn money and both the Administrator and SW #1 noted the missing money was not investigated (interviews with family to inquire if resident had access to money, staff interviews, etc) because it was handled as a grievance and Resident #17 was advised to keep the key on his/her person. 3. Resident #50's diagnosis included congestive heart failure, need for assistance with personal care and depression.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status score of 15 indicating intact cognition, was independent with bed mobility, required substantial/maximal assistance with transfers, and was independent with wheelchair mobility.a. Review of the Patient/Resident Grievance dated 9/9/25 identified a self-reported complaint that $100.00 was missing from a drawer in his/her room that had been wrapped in a towel, that consisted of five $20.00 bills received for his/her birthday. The undated/unsigned investigation and resolution identified that the funds would be replaced as a customer service, Resident #50 was provided with a locked drawer the statement that the facility would not replace funds again, and the resident was encouraged to utilize the locked drawer and facility bank for safekeeping. Additionally, a request for petty cash was submitted and on 10/31/25, Resident #50 received cash.A nursing note dated 9/9/25 at 4:04 PM identified that a Nurse Aid (NA) had notified her that Resident #50 needed to urgently speak to her. Resident #50 reported that he/she misplaced five $20.00 bills and then some. The resident indicated where the money had been stored in his/her nightstand and the last time the money was seen was after the birthday party recreation activity and prior to dinner on 9/8/25. The resident indicated that he/she had not left the room on 9/9/25 and noted the missing money just prior to alerting the NA. Additionally, the Assistant Director of Nursing Services (ADON) was notified and was investigating, the family had already been notified by Resident #50.A Registered Nurse (RN) Supervisor note dated 9/9/25 at 4:11 PM indicated that she went to speak with Resident #50 who confirmed the information given at 4:04 PM.A RN Supervisor note dated 9/10/25 identified he followed up with Resident #50 and reassured the resident that an investigation was started, encouraged to be forthcoming with any additional information that could help with the investigation, and it was noted the resident was alert and oriented and recalled how the cash was acquired.A Social Worker note dated 9/9/25 at 3:18 PM and 9/10/25 at 2:51 PM identified she met with the resident regarding the missing money, the team was notified for further follow-up, and the resident had a new locked drawer installed with a lanyard and educated to keep the key on his/herself at all times.b. Review of the Patient/Resident Grievance dated 2/4/26 identified a self-reported complaint that a Nurse Aid (NA) was rough while providing perineal care and hygiene. The unsigned investigation and resolution dated 2/4/26 identified that the CNM spoke to Resident #50 and was addressed with staff, as well as a second entry dated 2/4/26 indicating SWK spoke to staff, there was ongoing follow up with no other complaints 2/5, 2/7, 2/10, 2/19, 2/20, and 2/25, with 2 additional, illegible dates.A Social Service note dated 2/4/26 at 4:06 PM identified the Social Worker met with Resident #50 regarding care concerns expressed on the previous shift, the resident was allowed to express his/her thoughts and concerns, reassurance and comfort was provided and the resident was thankful.A late entry CNM note dated 2/4/26 at 4:22 PM identified she had spoken to Resident #50 regarding care concerns the previous shift, the CNM apologized, offered supportive care and assured the resident that concerns would be addressed along with ensuring the resident was kept comfortable.Interview and review of facility documentation (Grievance forms) with the of Nursing Services (DNS) and Administrator on 8/5/26 at 11:31 AM identified that the Administrator indicated she and the Interdisciplinary Team found out about the missing money on 9/10/26 (the following day) and that due to Resident #50 stating that the money was misplaced versus being stolen they did not conduct an investigation. The Administrator stated because Resident #50 did not state the money was stolen or that someone took the money, losing or misplacing his/her things was not considered to be misappropriation. When the possibility, had an investigation been conducted into the missing money may have led the facility to check the laundry (as Resident #50 indicated he/she had wrapped the money in towels per his/her statement) the Administrator stated, I know for sure he/she didn't say someone took it (the money). Additionally, regarding the complaint of rough treatment Resident #50 refused to indicate which NA provided him/her with rough personal care due to not wanting to get the NA in trouble, and although the facility had tried, nothing more had been investigated (but there was no documentation related to an investigation). The CNM note indicated assurances that Resident #50 concerns would be addressed along with ensuring the resident was kept comfortable, there was no further documentation or investigation/interviews into the rough care allegation. The Administrator indicated the Social Worker was responsible to follow up on allegations, and it had been determined during the Interdisciplinary AM report on 2/5/26 next day, (the form indicated 2/6/26) that the incident was not abusive, mistreatment, or undignified treatment. Although the policy directed an investigation into an allegation of mistreatment, the Administrator indicated that the policy had not been followed. 4. Resident #53's diagnoses included hypertension, chronic obstructive pulmonary disease and peripheral vascular disease. A Resident Care Plan dated 11/3/25 identified Resident #53 had a communication problem related to cognitive deficits, and that he/she was very quiet and hesitates before responding. Interventions included to anticipate needs, be conscious of the resident's position when in groups and allowing adequate time to respond. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #53 had intact cognition and required substantial/maximal assistance with oral hygiene. The MDS also identified Resident #53 was dependent with toilet use, showering/bathing and upper/lower body dressing. A Grievance form dated 2/3/26 identified Resident #53 reported on 2/1/26 he/she did not receive any care from the Nurse Aide (NA) until 8:00 PM (but failed to identify the last time care was rendered). The Grievance form further noted that this was discussed in morning report (1 day after Resident #53 reported not receiving care on 2/1/26 until 8:00 PM). On 8/5/26 at 11:31 AM interview and review of the Grievance form with the DNS and Administrator noted they did not ascertain when the last time Resident #53 received care with the exception of being served his/her dinner at approximately 6:30 PM so therefore could not ensure the allegation did not occur and failed to identify the State Agency was notified of Resident #53's allegation of not receiving care on 2/1/26 until 8:00 PM. 5. Resident #87's diagnoses included Type 2 diabetes, depression and chronic kidney disease. A Resident Care Plan dated 6/4/26 identified problem with depression. Interventions included to assist the resident in developing a program of activities that was meaningful, encourage and provide opportunities for exercise and notify the provider of any risk for harm. An admission Minimum Data Set (MDS) assessment date 6/10/26 identified Resident #87 had intact cognition. On 8/4/26 at 2:45 PM a review of the Grievance log and interview with the DNS, Social Worker (SW) #1 and Administrator noted a Grievance form dated 2/3/26 that identified Resident #87 reported his/her wallet with money was missing. Additionally, the Administrator identified the wallet was not listed on the inventory of affects, only the wallet was found, but could not verify money was in it prior to the facility locating the wallet. Furthermore, the facility did not complete an investigation when Resident #87 reported money/wallet was missing although a lock box was provided (7 days later) to the resident. Additionally, SW #1 identified she did not contact the family to inquire if Resident #87 had money in the wallet, or if it was possible the resident had access to money. 6. Resident #97s diagnoses chronic obstructive pulmonary disease, Parkinson's disease, and diabetes.The Resident Care Plan (RCP) dated 6/4/26 identified Resident #97 had a terminal prognosis related to end stage chronic obstructive pulmonary disease, and hospice was elected. Interventions included to adjust provision of activities of daily living to compensate for resident's changing abilities, encourage participation to the extent the resident wishes to participate, assess the resident's coping strategies and respect the resident's wishes, and encourage Resident #97 to express feelings, listen with non-judgmental acceptance and compassion.A Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 was cognitively intact required set-up assistance for eating, and substantial moderate assistance for transfers. Also, identified Resident #97 was dependent for toileting and required partial moderate assistance for bathing. Further, identifying Resident #97 used a manual wheelchair and was admitted to Hospice services.A nursing note dated 6/19/26 at 6:19 PM identified Resident #97 wanted to go back to bed but then refused when the Nurse Aid (NA) tried to help him/her. Resident #97 told the NA not to touch him/her when trying to help the resident back to bed. Resident #97 told the NA that they were cruel.A facility Reportable Event Form dated 6/20/26 identified that Resident #97 reported being punched in the stomach on 6/17/26 and was pulled from the wheelchair by his/her arms when the resident expressed he/she did not want to have an early bedtime. Also, identifying the resident had a history of being accusatory prior to admission and since admission.An email to the Social Worker (SW) sent by a family member on 6/20/26 identified concerns that a NA was aggressive with Resident #97, and the resident had repeated the same statement several times regarding how this occurred to multiple family members and friends. Resident #97 did not want to go to bed at 7:00 PM, the NA tried pulling him/her out of the wheelchair to go to bed and then punched the resident in the stomach. Also, identifying a request that the altercation be reported and investigated. A Social Service note dated 6/22/26 at 3:49 PM identified Social Service met with Resident #97 regarding the Nurse's note dated 6/19/26, Resident #97 was confused and unable to provide details.A nursing note dated 6/23/26 at 2:14 PM identified staff spoke to Resident #97 regarding concerns of a staff interaction and that Resident #97 stated there was a bar brawl.A Social Service note dated 6/23/26 identified an email was sent by a family member and then a follow up phone call occurred identifying concern with a NA punching Resident #97 in the stomach which was reported to have occurred on 3:00 PM to 11:00 PM shift on 6/17/26. Also, the Social Worker identified the facility would get statements and follow up regarding care on 6/17/26 although the family member did not feel it was indicated.Interview with SW #1 on 8/3/26 at 2:17 PM regarding a grievance form filled out by her on 6/20/26 related to Resident #97's allegation identified she did not think the event ever transpired on 6/17/26 to warrant a Reportable Event form be started or reported to the state agency (see F 609). Also, SW #1 identified on 6/22/26 the occurrence from the weekend of the 6/19/26 was not substantiated during morning report and the Director of Nursing Services (DNS) was in attendance. Further, identifying she knew the abuse policy, identifying the DNS was responsible for performing the investigation and she would not perform that task.Interview on 8/3/26 at 2:20 PM with Registered Nurse (RN) #10 identified a Reportable Event form was not found for the dates of 6/17/26 through 6/20/26 for Resident #97.Interview on 8/3/26 at 2:22 PM with the DNS identified she was at morning report on 6/22/26 when SW #1 reported the grievance, but the DNS was not aware of the alleged physical abuse of Resident #97 being punched in the stomach. Also, identifying she had no minutes for morning reportInterview on 8/5/26 at 11:35 AM with SW #1 identified she did not obtain statements because the family did not want her to, the Administrator and DNS were responsible for the investigation, and she would do the follow-up after the investigation. Also, identifying the family member sent an email on 6/20/26 regarding the alleged altercation.Interview on 8/5/26 at 12:11 PM with SW #3 identified the family member sent her an email on 6/20/26 regarding the alleged altercation on 6/17/26.Interview on 8/5/26 at 12:38 PM with the DNS and the Administrator identified that they were not aware of the email sent by the family member on 6/20/26 which was received by the facility on 6/22/26. Also, identifying a grievance was completed.Interview on 8/6/26 at 9:07 AM with the DNS identified she was not at morning report on 6/22/26 and in her absence the Administrator or the Assistant Director of Nursing would complete a thorough investigation. Also, identifying if abuse was involved then a full investigation with statements should have been completed. Furthermore, she did not know why the incident from 6/17/26 was not investigated. 7. Resident #138 had diagnoses that included dementia, diabetes, anxiety, and chronic obstructive pulmonary disease.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 was moderately cognitively impaired, used a motorized wheelchair, was independent with wheelchair mobility, required setup or clean-up assistance with eating, required substantial/maximal assistance with bed mobility and personal hygiene, and was dependent for toileting hygiene, lower body dressing, bed/chair/toilet transfers.The Resident Care Plan (RCP) dated 2/10/26 identified Resident #138 had bowel and bladder incontinence related to impaired mobility. Interventions included checking 4 times per shift for incontinence, providing incontinence care with each incontinence episode (wash, rinse, and dry), and Resident #138 used disposable briefs. The RCP further indicated Resident #138 was at risk for self-care performance deficit related to impaired balance and activity intolerance. Interventions included assistance of 1 staff member for dressing, bathing/showering, and bed-level toileting.A Social Worker (SW) note written by SW #3 on 4/1/26 at 11:27 AM identified she met with Resident #138 in response to a reported care concern. The SW note indicated Resident #138 was given time to express his/her concern and that the nurse manager was aware of the concern. The note further identified Resident #138 was on the way downstairs to go to the library and had no current concerns. The SW note failed to identify when the concern was first reported, what the concern was, how SW #3 became aware of the concern, and what additional information, if any, Resident #138 provided about the concern. Additionally, the note failed to identify the Administrator and/or Director of Nursing Services (DNS) had been informed of an allegation of mistreatment (see below) reported by Resident #138, and what the plan of action was in relation to the reported concern.A nursing note written by Registered Nurse (RN) #3 on 4/1/26 at 3:15 PM identified she had spoken with Resident #138 regarding concerns he/she had reported about a staffing agency caregiver (Nurse aide (NA) #21). The note indicated Resident #138 provided a description of the NA #21 as a black young guy with a facial beard. The note indicated that Resident #138 had stated NA #21 was inappropriate with him/her while he provided care on Monday evening (3/30/26). The note indicated RN #3 reviewed the assignment for 3/30/26 evening shift and identified a female aide was assigned in the evening. The note further indicated Person #1 was updated on the concern from Resident #138. The note failed to identify what time Resident #138 had reported the concern, who he/she had initially reported the concern to, and what the plan of action was in relation to the reported concern. The note failed to identify the Administrator and/or Director of Nursing Services (DNS) had been informed within 2 hours of an allegation of mistreatment reported by Resident #138 related to a male NA who was inappropriate during care on Monday evening. Additionally, the note was written greater than 2 hours (3 hours and 48 minutes) after SW #3's note on 4/1/26 at 11:27 AM.A nursing note written by RN #3 on 4/1/26 at 3:50 PM identified it was an addendum to her previous note (4/1/26 at 3:15 PM) and she indicated there was no male NA that fit the description of Resident #138's concern and it's unsubstantiated. The note failed to identify the Administrator and/or DNS had been informed of the allegation of mistreatment reported by Resident #138.A follow-up nursing note written by RN #3 on 4/2/26 at 9:18 AM indicated a clarification that the male NA Resident #138 felt uncomfortable with had been assigned to the resident on the evening shift (on 3/30/26). The note indicated Resident #138 was informed he/she would no longer have male caregivers assigned. The Resident Care Plan (RCP) dated 4/1/26 identified Resident #138 had an accusatory behavior related to anxiety. Interventions included no male caregivers, anticipate and meet the needs of Resident #138, monitor episodes of behaviors and attempt to determine the underlying cause (location, time of day, person(s) involved, and the situation), and document behaviors and their potential causes.A progress note written by the Psychiatric MD, MD #2 on 4/2/26 (1 day after the reported allegation of mistreatment) identified he was requested to see Resident #138 related to an alleged interaction. The progress note indicated he had reviewed background information with RN #3 and the DNS extensively and that Resident #138 had reported he/she was made to feel uncomfortable by a NA but that there was no report of ethical misconduct, abuse, neglect, exploitation or abandonment. The progress note indicated the facility had conducted an internal investigation and did not determine a basis to make a report to the state. The progress note further indicated when asked about the recent event, Resident #138 requested not to further elaborate on the topic again after having discussed it with the nursing staff. The progress note indicated Resident #138 did not give specific details of the inappropriate behavior on interview and the facility investigation did identify a report of physical contact or explicit misconduct, and that based on current information there did not appear to be grounds for reporting an allegation of abuse but the decision could be re-evaluated should new information become available. Interview with Resident #138 on 8/3/26 at 1:55 PM identified he/she was sexually assaulted about a month or so ago (he/she could not recall the specific date). He/she indicated that 1 or 2 days after the incident he/she told a fellow resident (Resident #50) about what happened and that Resident #50 instructed him/her to report it to the facility. Resident #138 indicated that he/she reported the allegation of abuse and was told by staff that going forward there would be no male NA providing care. Additionally, Resident #138 indicated the facility staff had suggested he/she was lying and that he/she should have reported the incident right away.Interview with Resident #138 on 8/3/26 at 2:56 PM identified she had reported the allegation of abuse to the facility a while ago, and subsequent to that, Person #1 had attended his/her RCP meeting (5/12/26 most recent RCP meeting) and irate at the staff related to the allegation. She further identified that she thought it was SW #3 that he/she was told about the allegation and that it was a few days after it happened.Interview with Person #1 on 8/3/26 at 3:06 PM identified a while ago (unable to recall specific day or month) Resident #138 was abused by a male NA. He/she indicated the facility had called to inform him/her of the allegation made by Resident #138 and they had indicated there was no male NA working with him/her on that day. Person #1 indicated a couple days later the facility called back and said that they had determined that there was a male NA working that day caring for Resident #138 but he had a female name so they hadn't realized that it was in fact a male NA when they had called a couple days prior. Person #1 indicated he/she was informed the male NA was from an agency and would not be coming back to the facility, and that going forward Resident #138 would not have any male NA providing care. He/she further indicated the facility had told him/her an investigation was being conducted, so when he/she attended the last RCP meeting (5/12/26), he/she had inquired on what were the results of the investigation. He/she indicated that he/she was told due to Health Insurance Portability and Accountability Act (HIPAA) (federal law to protect patient privacy) the facility was unable to provide him/her with any information related to the investigation of the allegation of abuse for Resident #138. He/she further indicated there had been numerous attempts to contact the Administrator to go over concerns that he/she had for Resident #138 but that he/she had not received a call back even though there had been confirmation from facility staff that she had been notified of his/her request for a call.Interview and clinical record review with the DNS on 8/4/26 at 9:20 AM identified she did not complete a Reportable Event (RE) form for 4/1/26, and she indicated at that time she was told Resident #138 was uncomfortable with male aides whether agency or facility staff. She indicated that the information in RN #3's nursing notes regarding a male NA being inappropriate while he provided care was not told to her and that she was only informed Resident #138 was uncomfortable with male aides and an investigation was not completed.Interview with SW #3 on 8/5/26 at 10:45 AM identified she had been informed by the nursing staff of Resident #138 reporting a concern related to a male NA. She was unable to recall which nursing staff member had notified her of the concern or the specific details of what the concern was. She indicated when she went to discuss the concern about a male NA with Resident #138, he/she was in the hallway and on the way to the library. She indicated that Resident #138 did not provide any details because he/she was on the way to the library but that he/she did not verbalize that he/she was concerned or afraid. She further indicated RN #3 was already aware of the concern so she had collected any further information.Interview with the DNS on 8/5/26 at 1:40 PM identified when the surveyor had notified her on 8/3/26 of Resident #138's allegation of abuse from 4/1/26, she had immediately began an investigation. She indicated she had not asked Resident #138 why he/she did not want to receive care from a male NA, and she was unable to identify why after 3 years of being in the facility and receiving care from male NAs, Resident #138 no longer wanted to have a male NA. She was unable to identify why Resident #138 provided a description of a specific male NA when he/she reported being uncomfortable with a male NA, and why he/she was not asked what about that specific NA had made him/her feel uncomfortable. Additionally, she was unable to identify why Person #1 would be informed that an investigation was being conducted in relation to a report of alleged abuse but was unable to provide documentation of the investigation.Interview and facility documentation review with the DNS on 8/5/26 at 2:10 PM identified she did identify the name of the agency staff member who had cared for Resident #138 on 3/30/26, and that he/she had only worked in the facility that 1 shift. She indicated she did not have any investigation documentation to provide to the surveyor except for the statement from NA #21 because all remaining investigation was still pending (facility was notified of the allegation on 4/1/26). 8. Resident #234's diagnoses included depression, Type 2 diabetes and a Stage 3 pressure ulcer to the right heel. A Resident Care Plan dated 4/9/26 identified Resident #234 had an activities of daily living deficit related to limited mobility. Interventions included to provide assistance of 1 for bathing/showering, bed mobility, dressing and toilet use. An admission Minimum Data Set (MDS) dated [DATE][TRUNCATED]

Based on tour of the Dietary Department, staff interview, and facility policy, the facility failed to ensure Dietary Aide (DA) #1 wore an appropriate hair covering and beard covering while serving food to residents. Findings include: Observation and interview with DA #1 on 7/31/26 at 12:17 PM identified he was opening/uncovering and serving food to residents without the benefit of a full hair covering and beard restraint. DA #1 had a cap on his head with several inches of exposed hair coming out from under the cap. DA #1 also had facial hair/beard not covered. He indicated he forgot to cover his hair and facial hair and would go downstairs to put hair coverings on.Observation and interview with the Executive Chef on 7/31/26 at 12:15 PM indicated DA #1 should have had all his hair covered and should have had a beard restraint on when uncovering and serving food to residents. DA #1 had forgotten to put them on, and DA #1 went downstairs to put on the appropriate coverings.Interview with Food Service Director (FSD) on 8/3/26 at 7:47 AM identified DA #1 should have had all of his hair covered and had a beard restraint on when uncovering and serving food to the residents. She indicated DA #1 had been told before and would need to be reminded again of need to cover all exposed hair and to cover facial hair.Although a policy was requested regarding appropriate hair and beard coverings, one was not provided.

Based on review of facility documentation, facility policy and interviews for 9 of 20 Nurse Aide (NA) employee files reviewed (NA #21, NA #24, NA #27, NA #45, NA #46, NA #47, NA #48, NA #50, and NA #51), the facility failed to ensure that the required employee abuse training/in-services were completed. The findings include: 1. NA #21's date of hire was 4/15/24. Review of the facility documentation provided for NA #21 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed by NA #21. 2. NA #24's date of hire was 11/13/06. Review of the facility documentation provided for NA #24 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed by NA #24. 3. NA #27's date of hire was 4/5/22. Review of the facility documentation provided for NA #27 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #27. 4. NA #45's date of hire was 8/15/23. Review of the facility documentation provided for NA #45 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #45. 5. NA #46's date of hire was 5/21/24. Review of the facility documentation provided for NA #46 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #46. 6. NA #47's date of hire was 10/31/23. Review of the facility documentation provided for NA #47 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #47. 7. NA #48's date of hire was 12/4/19. Review of the facility documentation provided for NA #48 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #48. 8. NA #50's date of hire was 11/15/22. Review of the facility documentation provided for NA #50 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #50. 9. NA #51's date of hire was 6/20/23. Review of the facility documentation provided for NA #51 failed to identify that in-service training had been completed for Resident Rights and Abuse Prevention in 2025 (per the course completion documentation provided representing dates 1/1/25-12/31/25) and 2026 (per the course completion documentation provided representing dates 1/1/26-8/6/26). Although requested, the facility could not provide documentation that the required training had been completed for NA #51. Interview and review of training documentation with the Administrator and the Director of Nursing (DNS) on 8/6/26 at 4:04 PM identified the staff development nurse (who was on vacation) was responsible for ensuring the NA's annual education for Resident Rights and Abuse Prevention was completed. Review of the Course Completion History for 2025 (1/1/25-12/31/25) and 2026 (1/1/26-8/6/26) indicated the identified NAs had not completed the required annual training. The Administrator and the DNS stated they were unsure why the required annual training was not completed for NA #21, NA #24, NA #27, NA #45, NA #46, NA #47, NA #48, NA #50, and NA #51 in 2025 or 2026 and they would need to address the lack of training when the staff development nurse returned to the facility. Further indicated they were unable to provide additional training records for the identified NAs and the staff development nurse was new to her position at the facility. Review of the facility provided NA staff roster with the DNS confirmed the roster represented the currently employed and working NAs at the facility. Review of facility policy, Abuse and/or Crimes Committed Against Residents, Prevention, Reporting, and Investigation, dated 7/7/25, directed the facility staff would be trained to observe for, prevent and respond to, indicators of actual or potential resident abuse. Employees shall receive training during their orientation and annually on abuse, neglect, and/or potential crimes against residents and their reporting obligations as covered individuals.

Based on facility documentation, facility policy, review of personnel files and interviews, the facility failed to ensure 2 of 2 staffing agency Nurse Aides (NAs) (NA #1 and NA #8), and 1 of 1 staffing agency Licensed Practical Nurse (LPN) received training to orient them to the facility, ensure they were competent with necessary equipment, and ensure they were aware of facility policies and procedures while in the facility working and providing resident care. The findings include: Upon review of personnel records for 3 staffing agency employees (NA #1 and NA #8) and 1 LPN, the documents provided did not include facility documentation of education provided to agency staff on orientation to the facility, and review of facility policies and procedures, nor documentation which ensured staff caring for residents were competent to use the facility equipment.Interview with the Director of Nursing (DNS) on 8/5/26 at 1:40 PM identified the agency was responsible for ensuring their staff had all necessary education prior to acceptance of shifts at the facility. She was unable to identify what education was provided by the facility on an agency staff members prior to them working their first shift in the building. Additionally, she was unable to identify who at the facility was responsible to ensure the agency staff they contracted with were oriented to policies/procedures and general working practices of the facility.Although requested additional documentation was not received.Although requested a policy on use of agency staff was not provided.

Based on observations, interviews, facility documentation and review of facility policy for 6 of 8 sampled residents (Resident #8, #29, #52, #57, #168, and #224) reviewed for activities of daily living (ADLS), the facility failed to provide nail care and failed to shave Resident #244's facial hair. The findings include: 1. Resident #8's diagnoses included compartment syndrome of the left upper extremity, muscle weakness and depression.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition, required set up for eating, partial/moderate assistance for dressing and changing positions in bed and supervision/touching assistance for personal hygiene. Additionally, the MDS identified Resident #8 did not exhibit delirium, delusions or hallucinations. The Resident Care Plan dated 7/21/26 identified Resident #8 had a self-care performance deficit. Interventions included bathing/showering and dressing with the assistance of 1 staff member.Review of the Shower Task documentation identified Resident #8 received a shower on 7/29/25.The updated Resident Care Plan dated 8/3/26 identified Resident #8 had a self-care performance deficit. Interventions included education on left upper extremity orthotic use, and checking fingernails on shower days with cutting/ filing as necessary, Resident #8 may file fingernails on the left hand.Interview with Resident #8 on 8/3/26 at 9:14 AM identified he/she would like their fingernails to be clipped, had mentioned it to staff, but nothing had been done and was hoping staff would notice. Interview with Licensed Practical Nurse (LPN) #5 on 8/3/26 at 11:18 AM identified it was the facility's policy to trim/file resident's nails with the showering or when it was identified that fingernails needed to be trimmed.Interview and observation with Nurse Aid (NA) #7 on 8/3/26 at 11:22 AM identified that she was a regular NA in the facility but usually worked on another unit, and that it was the facility policy to cut and file resident's fingernails as needed. Observation of Resident #8 identified his/her nails were over 1/4 inch long over the nail bed, on both hands, with a black substance under the right-hand ring fingernail. NA #7 identified Resident #8's fingernails were in need of trimming and filing but could not identify why nail care had not been provided.Interview and observation with the Unit Manager Registered Nurse (RN) #8 on 8/3/26 at 1:36 PM identified it was the facility policy to provide nail care on shower days and as needed. Observation of Resident #8 with RN #8 identified his/her nails were over 1/4 inch long from the nail bed, on both hands, with a black substance under the right-hand ring finger. RN #8 stated they were long and would be taken care of right away but could not identify why they were not cut on Residents # 8's shower day on 7/29/25.Subsequent to surveyor inquiry Resident #8's fingernails were trimmed. 2.Resident #29 diagnoses included dementia with agitation and anxiety disorder.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #29 was unable to participate in a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs).The Resident Care Plan dated 6/3/26 identified activities of daily living (ADLs) as an area of focus with interventions that included providing assistance of 1 for bed mobility, dressing, eating, oral care, toilet use, and assist of 2 for transfers using Hoyer (mechanical lift) lift to custom wheelchair.Physician orders dated 6/9/26 directed weekly skin checks on shower day, document skin condition in skin observation tool evaluation on every Thursday and Sunday. Administer Trazadone (antidepressant used for anxiety) 50 milligrams (mg) give 0.5 mg daily for anxiety.Observation on 7/31/26 at 11:40 AM, 8/3/26 at 11:00 AM and 8/4/26 at 8:45 AM noted Resident #29 was dressed and sitting in a wheelchair (w/c) beside his/her bed. Resident #29's fingernails were observed to be long, with debris under the nailbed and yellow in color on both hands.Observation on 8/4/26 at 10:00 AM noted Resident #29 was dressed and sitting in a w/c beside his/her bed with Person #2 and his/her fingernails had been cleaned and trimmed. Interview with Person #2 on 8/4/26 at 10:00 AM stated, the resident's fingernails have been very long for a while, glad they are trimmed.Interview with Resident #29's primary Nurse Aide (NA) #20 on 8/4/26 at 10:05 AM indicated that she was not sure who trimmed and cleaned Resident #29's fingernails but they should not have been that long, and it was the responsibility of the NAs to trim resident's nails. NA #20 could not explain why Resident #29's nails were long and dirty. NA #20 stated that nails were trimmed and cleaned as needed and on shower days.Interview with the Unit Manager, Registered Nurse (RN) #1 on 8/4/26 at 11:30 AM indicated that she was not sure why Resident #29 did not have his/her fingernails cleaned and trimmed. RN #1 stated that it was the responsibility of the NAs on all shifts to ensure fingernails were cleaned and trimmed and indicated that NAs trim nails in shower days and as needed per facility policy. 3. Resident #52's diagnoses included stroke, bladder cancer, muscle wasting, heart attack, and respiratory failure.The Resident Care Plan dated 6/15/26 identified Resident #52 had a self-care deficit and required assistance with activities of daily living. Interventions included to assist with personal hygiene.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #52 had a moderate cognitive impairment and was dependent on staff for personal hygiene assistance.Observations on 7/31/26 at 9:32 AM, 8/3/26 at 12:41 PM, and 8/4/26 at 11:07 AM identified Resident #52 had long fingernails with brown debris underneath.A review of Resident #52's Treatment Administration Record and NA Personal Care Task Flowsheets for June through August 2026 failed to indicate Resident #52 had any refusals of care on shower days.Interview with Nurse Aide (NA) #9 on 8/3/26 at 1:57 PM identified nails should be cleaned and grooming of nails occurred once per week.Interview with Licensed Practical Nurse (LPN) #7 on 8/3/26 at 2:00 PM identified dirty nails should be cleaned.Interview and observation with LPN #10 on 8/4/26 at 12:00 PM identified Resident #52's nails were long and dirty and needed to be cleaned and trimmed.Interview and observation with NA #11 on 8/4/26 at 12:05 PM identified Resident #52's nails were long and dirty and should be cleaned. 4. Resident #57's diagnoses included dementia, major depressive disorder, and anxiety disorder.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 had severe cognitive impairment and required total assistance from staff for activities of daily living (ADLs) and mobility. Resident #57 was non-ambulatory.Observations on 7/30/26 at 1:40 PM, 7/31/26 at 10:00 AM and 8/3/26 at 11:40 AM identified Resident #57 fingernails were long, jagged, with black debris underneath his/her fingernails on both hands.Interview with Nurse's Aide (NA) #6 on 8/3/26 at 1:28 PM identified that NA #6 was unable to provide an answer on when the last time he/she gave Resident #57 a shower or provided nail care. NA #6 identified that nail care should be completed on shower/bath day and was unable to provide what the facility's policy was regarding bathing/showers or nail care.Interview with Licensed Practical Nurse (LPN) #4 on 8/3/26 at 12:05 PM identified that Resident #57 was scheduled for two showers a week on Friday 7:00 AM to 3:00 PM shift and on Monday 3:00 PM to 11:00 PM shift. LPN #4 was unable to identify when the last time Resident #57 was provided with a shower/bed bath and/or nail care and stated that the nurses and NAs were both responsible for providing nail care to the residents. LPN #4 did indicate that nail care should be provided on the resident's shower/bath day.Observation on 8/3/26 at 12:15 PM with LPN #4 identified that Resident #57 had long, jagged fingernails with black debris under all of her/his fingernails on both hands. LPN #4 stated that she/he would have Resident #57 fingernails cleaned and trimmed.Interview with the RN Supervisor, (RN #11) on 8/4/26 at 11:30 AM, identified that the facility's policy for providing the residents with nail care should be completed on Resident #57's bath/shower day. RN #11 stated that NAs were responsible for providing nail care to the residents.Interview with NA #14 on 8/5/26 at 3:00 PM identified that he/she gave Resident #57 a bed bath on the scheduled shower/bath day on 7/27/26 on the 3:00 PM to 11:00 PM shift but did not trim Resident #57 fingernails. NA #11 stated she/he intended to trim Resident #57 fingernails, but he/she didn't get back to do the fingernails because the facility was short staff on that day. NA #14 stated that there were only 4 [NAME] the entire unit and the unit usually had 5 NAs scheduled.Interview with NA #13 on 8/5/26 at 9:43AM identified that NA #13 provided Resident #57 with a bed bath on 7/31/26 on the 7:00 AM to 3:00 PM shift but did not provide nail care to Resident #57. NA #13 stated that Resident #57 fingernails didn't look bad when she provided the bed bath. NA #13 stated that he/she provided the bed bath by him/herself to Resident #57 and did not ask any other NA for assistance with the bed bath because they were all busy. NA #13 stated that the facility was short staff with only 4 NA on the 3:00 PM to 11:00 PM shift and usually there were 5 NAs scheduled.Interview with the DNS on 8/5/26 at 1:10 PM identified that the DNS expectations of the nursing staff when providing nail care to the residents, the nail care should be provided when the ADL care was being performed by the NAs. The DNS indicated that on the resident's shower/bath day, the resident would get a little more attention with ADL care, like the fingernails being trimmed if needed.5. Resident #168's diagnoses included Alzheimer's disease and arthritis.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #168 had a severe cognitive impairment and was dependent on staff for bathing and personal hygiene assistanceThe Resident Care Plan dated 6/19/26 identified Resident #168 required assistance with personal care, refused showers, and was prone to scratching. Interventions included providing assistance with bathing, giving clear explanations for care before it occurs, and keeping fingernails short.Observations on 7/30/26 at 11:04 AM and 8/3/26 at 12:14 PM identified Resident #168 had long fingernails with brown debris underneath.Interview and observation with Nurse Aide (NA) #9 on 8/3/26 at 1:55 PM identified Resident #168's fingernails nails should be cleaned and grooming of nails occurred once per week.Interview with the Director of Nursing Services (DNS) on 8/3/26 at 2:35 PM identified resident fingernails were inspected daily and should be trimmed and cleaned if jagged or dirty.For residents who refuse, staff should reapproach to provide the care. The DNS also stated the facility will also ask families to assist with care if there were multiple refusals for care.Observation on 8/4/26 at 10:26 AM with LPN #10 identified Resident #168's fingernails were cleaned and trimmed subsequent to surveyor inquiry. 6. Resident #244 diagnoses included skin graft, malignant and neoplasm (cancer) of scalp and neck.The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #244 was moderately cognitively impaired and required moderate assistance with washing, dressing, toileting, transfers and cueing/supervision for eating. Physician orders dated 7/16/26 directed to document skin integrity weekly on Friday on shower days and cleanse skin tear to the right side of face with Normal Saline, apply Xeroform (a sterile fine mesh gauze soaked in petrolatum and a deodorizing agent) followed by a dry, clean dressing change once a day and as needed. The Resident Care Plan (RCP) dated 7/30/26 identified actual impairment to skin of the left rib cage related to a surgical wound with 57 staples and the front of the left ear with 14 sutures as an area of focus with interventions that included avoid scratching and keep nails short. Additional interventions included to moisturize body, enhanced barrier precautions related to wounds, keep skin warm and dry, monitor of side effects of antibiotics, sutures and staples to be removed at oncologist office, monitor surgical site for 7 days, use caution for transfers to prevent skin injury to hands, legs, and arms, and weekly treatment documentation of each area of skin breakdown.Observation on 7/30/26 at 12:30 PM noted Resident #244 lying in bed attempting to eat his/her lunch. Resident #244 had long facial hair on his/her cheeks and chin. There was an electric razor on top of Resident #244's nightstand by the bed.Observation on 7/31/26 at 12:15 PM and 8/3/26 at 1:30 PM noted Resident #244 up in a wheelchair (w/c) in his/her bedroom with long facial hair on the cheeks and chin.Observation and interview with Nurse Aide (NA) #21 (from a staffing agency) on 8/4/26 at 11:00 AM identified that she had not provided care to Resident #244 yet as the 11:00 PM to 7:00 AM shift had gotten Resident #244 up that morning. NA #21 stated that she had never provided care to Resident #244 before and was not sure why he/she had not been shaven. NA #21 stated that she was aware that it wass the responsibility of NAs to shave residents if it wAs needed. Subsequent to surveyor inquiry, NA #21 shaved Resident #244. Interview with the Unit Manager, Registered Nurse (RN) #1 on 8/4/26 at 11:30 AM indicated that she was not sure why Resident #244 had not been shaved. RN #1 stated that it was the responsibility of the NAs on all shifts to ensure any resident that needs shaving was shaved and that NAs shave residents on shower days and as needed per facility policy. Although the facility did not provide a policy specifically for nail care, the facility did provide a policy for giving a bed bath. The Bed Bath Policy stated that a bed bath would be done by nursing personnel to cleanse the patient/resident and stimulate circulation. The bed bath policy stated to trim fingernails and/or toenails unless contraindicated and the bed bath would be done when needed and in between tub bath/shower or as requested.

Based on observations, review of the clinical record, facility policy and interviews for 2 of 5 sampled residents (Resident #29 and Resident #174) reviewed for position and mobility, for Resident #29 the facility failed to evaluate and document measurements of range of motion (ROM) for a decline of the right wrist and for Resident #174 the facility failed to document a baseline severity of foot drop, failed to ensure foot drop was evaluated for a decline from onset, and failed to ensure the resident was positioned optimally in a wheelchair in the presence of a contracture. The findings include: 1. Resident #29 diagnoses included right wrist fracture, osteoarthritis, and dementia with moderate agitation. The Quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified that Resident #29 was unable to participate in a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS further identified Resident #29 was dependent on staff for all activities of daily living (ADLS) and was transferred to a wheelchair (w/c) using a full mechanical lift. The Resident Care Plan (RCP) dated 6/3/26 identified ADL self-care deficit as an area of focus related to dementia and history of right wrist fracture. Interventions included total dependence on staff for all ADLs, splint/brace to right elbow on in AM and off in PM, transfer using Hoyer lift (a mechanical lift), out of bed into custom w/c per positioning plan and per patient tolerance, and PT/OT evaluation and treatment as per MD orders. Physician orders dated 7/5/26 directed to apply a right elbow splint daily at 9:00 AM and off at 5:00 PM and administer Extra Strength Tylenol tabs 500 milligrams (mg) give 2 tabs two times a day for pain to right wrist and Ibuprofen 400 mg give 1 tab every 12 hours as needed for arthritic pain to right hand. Observations on 7/30/26 at 12:00 PM and on 7/31/26 at 10:15 AM noted Resident #29 was seated in custom w/c in his/her room with both hands suspended in the air in front of Resident #29's face. Resident #29 had both hands in a curved/turned position with fingers turned inward towards palms of hands. Resident #29 had a splint in place on his/her right elbow. A review of Resident #29's diagnosis history identified Resident #29 had a fracture of his/her right wrist in July 2024. Interview with the Director of Rehabilitation Services (DRS) on 8/3/26 at 9:00 AM regarding Resident #29's contractures identified that the DRS would need to review Resident #29's therapy notes and speak to the occupational therapist (OT) as she was new to the facility, but she believed that Resident #29 came to the facility with hand contractures. Interview and clinical review with OT #1 on 8/3/26 at 12:15 PM identified that Resident #29 had chronic pain to his/her right wrist related to an old fracture and that Resident #29 had been on OT caseload a few times but had a low pain tolerance and became easily agitated when attempting any type range of motion (ROM) or splinting. OT #1 indicated that therapy was limited as Resident #29 was not cooperative regarding treatment. OT #1 indicated that Resident #29 received Tylenol for pain and was not on any type of muscle relaxants. A review of OT progress notes revealed Resident #29 had received OT from 12/29/24 through 1/27/25, 4/7/25 through 6/30/25, and 7/28/25 through 12/3/25. Resident #29 received a quarterly screen 4/25 which identified that Resident #29 had decreased ROM to the right shoulder and elbow and was referred to OT for further assessment and evaluation. Resident #29 received OT therapy from 4/7/25 through 6/30/25 for decreased ROM to the right elbow and shoulder. There was no treatment plan for Resident #29's right wrist or hands. Resident #29 received OT therapy from 7/28/25 through 12/3/25 for trial of right elbow splint. A review of OT notes from 7/28/25 through 8/26/25 identified that baseline measurements for the right wrist were 90 to 135 degrees and Resident #29's right wrist was impaired. Resident #29's wrist held in 95 degrees flexion, all digits in full extension and abduction other than thumb with no risk for skin breakdown at that time. Further, OT notes indicated that Resident #29 would yell out when attempting passive ROM to right wrist but would yell out less frequently when family was present. There were no further measurements of Resident #29's right wrist after 7/28/25. Interview and review of OT notes for Resident #29 with OT #1 on 8/4/26 at 8:45 AM indicated that the facility previously completed quarterly screens on residents, but residents were now reviewed at the interdisciplinary (IDT) care plan meetings for declines. OT #1 indicated that although they were reviewed at the IDT meetings, measurements were not conducted and that if measurements were to be obtained then an OT evaluation would need to occur. OT #1 could not locate any further measurements for Resident #29's wrist to determine if there was a decline in his/her ROM to right wrist. OT #1 indicated that measurements would be needed to determine if a decline had occurred. OT #1 could not explain why this had not been completed since 7/28/25. Interview and clinical record review with the DRS on 8/4/26 at 9:00 AM stated that all therapy notes related to Resident #29's right wrist would be in the progress note section of the electronic medical record. The DRS indicated that Resident #29 would have been reviewed at the last IDT meeting for a decline on 6/3/26; however, there were no signatures that therapy was in attendance. The DRS stated that measurements were not routinely done unless it was the goal of therapy. Furthermore, the DRS indicated that she was working on developing a new system for quarterly screens of residents. Currently, the MDS schedule was used to schedule screens but she also tracks this with a different schedule. 2. Resident #174's diagnoses included functional quadriplegia, Guillain-Barre Syndrome, and bipolar disorder The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #174 was cognitively intact and required total staff assistance with dressing, toileting, set up for hygiene, and remains on bedrest by choice. Additionally, the MDS identified Resident #174 was without a functional impairment limitation in range of motion of both upper and lower extremities. The Resident Care Plan (RCP) dated 6/23/26 identified limited physical mobility related to weakness, Guillan-Barre syndrome, neuralgia, compression of the brain due to hydrocephalus, does not want to get out of bed. Interventions included assistance of 1 staff for locomotion using a wheelchair, monitor/document/report any signs and symptoms of immobility as needed, contractures forming or worsening, provide gentle range of motion as tolerated with daily care. The Resident Care Plan failed to identify bilateral foot drop or interventions to manage foot drop (refer to observation of Resident #174 on 7/31/26). A physician order in effect 7/30/26 directed to administer baclofen 10 milligrams orally 3 times a day for neuralgia, physical therapy evaluation and treatment as indicated. The physician orders failed to include interventions/devices related to the resident's contractures. Observation on 7/31/26 at 10:33 AM identified Resident #174 in the resident lounge out of bed in a tilt in space wheelchair. The resident's legs were noted to be dangling unsupported, feet in the air, without the benefit of leg rests/footrests present on the wheelchair. Bilateral foot drop in plantar flexion (toes pointed downward away from the legs) was noted at the resident's ankles. Resident #174 was unable to dorsiflex (bring back to normal resting position) his/her bilateral feet. Interview with Nurse Aide (NA) #18 on 7/31/26 at 10:34 AM indicated that the wheelchair pedals were broken, which was the reason Resident #174's feet were dangling. NA #18 indicated that he would place this in the maintenance book for repair. An interview and clinical record review with the Director of Rehabilitation on 8/3/26 at 11:00 AM indicated that all the therapy notes related to Resident #174's contractures and wheelchair seating were located in the progress note section of the Electronic Medical Record (EMR). A review of Physical Therapy (PT) notes dated 7/28/20 through 11/22/23 identified that although bilateral fixed plantar contractures were present, no measurement of the degree of severity was noted, nor was there any indication that Resident #174 had been assessed for contracture improvement or decline as indicated on the RCP. The notes stated that Resident #174 declined the use of splints/multi-podus boots but failed to identify any further contracture management attempts had been made, such as a foot board or referral to a medical professional for treatment evaluation. Additionally, the Director of Rehabilitation identified that contractures were not measured by the Rehabilitation Department unless they were evaluating and treating the resident for a contracture. The Director of Rehabilitation could not identify if contracture measurements were a standard practice by the facility indicating Resident #174 had refused, however, no documentation of the attempt or refusal was noted in the clinical record. A re-interview with the Director of Rehabilitation and PT #1 on 8/5/26 at 12:10 PM identified that no measurements of the bilateral fixed plantar contractures were found in Resident #174's clinical record. She indicated Resident #174 was noted to have had full flexion contractures since 2019, however could not identify supporting documentation of this or documentation that the contractures/foot drop had not worsened. PT #1 indicated that Resident #174 only had pain when touching him/her but did not indicate the cause of the pain. The Director of Rehabilitation indicated that if Resident #174 had been seen by Physiatry (a doctor who manages skeletal and nervous systems using non-surgical treatment), it would be noted in the progress notes and nursing would be responsible for obtaining an order from Resident #174's physician. A nursing note dated 8/6/26 (subsequent to surveyor inquiry) indicated an assessment for contracture and limited mobility was completed and identified bilateral foot drop, Resident #147 was able to bend his/her knees and lift both legs off bed, and there was no limitation in mobility noted to the resident's hands and upper extremities. A review of the facility policy evaluation and treatment dated 11/14/25 directed, in part, to all residents identified as needing an assessment of functional status and potential to benefit from rehabilitation services were to be evaluated to determine appropriate plan of care. The scope of the evaluations includes case history, prior level of functioning, medical necessity, onset of functional decline, contraindications and precautions. A review of the facility policy splinting and positioning devices dated 5/20/26 directed, in part, to identify appropriate device and establish wearing schedule. Quarterly rounds/orthotic screens will be completed.

Based on in-service/education review, staff interview and review of facility policy for 7 of 20 Nurse Aides (NA) reviewed for mandatory education/training (NA #22, NA #27, NA #45, NA #46, NA #47, NA #48, and NA #49), the facility failed to provide the mandatory 12-hours of education. The findings include: 1. NA #22's date of hire was 7/11/23. Review of the facility documentation provided for NA #22 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26). Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #22. 2. NA #27's date of hire was 4/5/22. Review of the facility documentation provided for NA #27 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26). Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #27. 3. NA #45's date of hire was 8/15/23. Review of the facility documentation provided for NA #45 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26 Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #45. 4. NA #46's date of hire was 5/21/24. Review of the facility documentation provided for NA #46 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26). Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #46. 5. NA #47's date of hire was 10/31/23. Review of the facility documentation provided for NA #47 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26). Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #47. 6. NA #48's date of hire was 12/4/19. Review of the facility documentation provided for NA #48 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26 Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #48. 7. NA #49's date of hire was 4/16/24. Review of the facility documentation provided for NA #22 failed to identify that annual NA in-service training had been completed for 2025 or 2026 (per the course completion documentation provided representing dates 1/1/25-8/5/26). Although requested, the facility could not provide documentation that the required 12-hour NA training had been completed by NA #49. Interview and review of facility documentation with the Administrator and the Director of Nursing (DNS) on 8/6/26 at 4:04 PM identified the staff development nurse (who was on vacation) was responsible for ensuring the required 12-hour NA annual education was completed. Review of the Course Completion History for 2025 and 2026 (representing dates 1/1/25-8/5/26) indicated the identified NAs had not completed the required annual training. The Administrator and the DNS stated they were unsure why the required annual training was not completed for NA #22, NA #27, NA #45, NA #46, NA #47, NA #48, and NA #49 in 2025 or 2026 and they would need to address the lack of training when the staff development nurse returned to the facility. Further indicated they were unable to provide additional training records for the identified NAs and the staff development nurse was new to her position at the facility. Review of the facility provided NA staff roster with the DNS confirmed the roster represented the currently employed and working NAs at the facility. Although requested, a policy on required annual NA training was not provided.

Based on staff interview, record review and review of facility policy for 6 sampled residents (Resident #29, #41, #122, #139, #233 and #244), the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to reflect Resident #29 refusing showers and only allowing bed baths and that Resident #139 required a certain approach to accept taking a shower. Additionally, the RCP did not reflect Resident #41 was hard of hearing and family requests of not turning the call light off at the nurse's desk (answer call light in person). Also, for Resident #122, the RCP was not comprehensive to include the use of anticoagulant medication with interventions to identify the risk for bleeding, prevention of bruising, handling with care, etc. Also, for Resident #233, the RCP was not comprehensive to include his/her strict religious beliefs and Resident #244's presence of surgical drains and drain site locations. The findings include: 1. Resident #29 was admitted to the facility in May 2024 with diagnoses that included dementia with agitation and anxiety disorder.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #29 was unable to participate in a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs) such as eating, washing, dressing, toileting, and transfers.The Resident Care Plan dated 6/3/26 identified activities of daily living (ADLs) as an area of focus with interventions that included assistance of 1 for bed mobility, dressing, eating, oral care, toilet use, and assist of 2 for transfers using Hoyer (mechanical lift) lift to custom wheelchair.Physician orders dated 6/9/26 directed weekly skin checks on shower day, document skin condition in skin observation tool evaluation on every Thursday and Sunday, apply Ketoconazole external shampoo 1% (dandruff/seborrheic dermatitis) every Thursday and administer Trazodone (antidepressant used for anxiety) 50 milligrams (mg) give 0.5 mg daily for anxiety.Nurse Aide (NA) flow sheets revealed that not applicable (N/A) was documented for Resident #29's showers for the entire month of July 2026 (31 days). Indicating that out of 10 opportunities for scheduled showers (Thursday and Sunday) Resident #29 did not receive a shower.Interview and review of the clinical record with Registered Nurse (RN) #1 on 8/5/26 at 8:53 AM identified that Resident #29's RCP did not address showers, nor did the care card indicate that Resident #29 did not take a shower. RN #1 indicated that she believed Resident #29 no longer took a shower and received a bed bath because he/she became extremely agitated (yelling out) when given a shower. RN #1could not explain why Nurse Aides (NA) would be documenting N/A on the Resident #29's flowsheet and that bed bath should be documented. RN #1 stated that the electronic medical record will default to N/A if the NA does not document. RN #1 indicated that if Resident #29 took a bed bath because became agitated in the shower then it should be in the care plan.Interview NA #20 on 8/5/26 at 9:10 AM who was Resident #29's primary NA on the 7:00 AM to 3:00 PM shift indicated that Resident #29 had not taken a shower for over a year and took a bed bath. NA #20 indicated that she had informed the charge nurse, Licensed Practical Nurse (LPN) #10 a long time ago but could not recall when she had informed him that Resident #29 did not like to take a shower. A review of Resident #29's RCP on 8/5/26 failed to reflect Resident #29's shower status or that Resident #29 no longer took showers as he/she would yell out and become very agitated in the shower.Interview with LPN #10 at 9:45 AM indicated that NA #20 had informed him a while ago that Resident #29 became agitated in the shower, but he was not sure who he should tell. LPN #10 indicated that he should have informed someone for the RCP and care card to be updated.Interview with RN #7 (the MDS nurse) on 8/5/26 at 11:30 AM indicated that Resident #29's care plan should have been updated to reflect no showers due to agitation and that it was either the responsibility of the unit manager or the MDS nurse to ensure the care plan was updated and accurate. RN #7 indicated that it was the facility's policy to ensure care plans were individualized and reflect the care provided to a resident. After surveyor inquiry, Resident #29's RCP and care card was updated to reflect no showers. 2. Resident #41 was admitted to the facility in July 2026 with diagnoses that included fracture of right femur, blindness in right eye, anxiety, bilateral impact cerumen (earwax) and Presbycusis of both ears (age related hearing loss). The Nursing admission assessment dated [DATE] identified that Resident #41 was alert to person, place and time with some confusion but able to make self-understood and understood staff. Resident #41 required assistance of 1 staff member for activities of daily living (ADLs) (washing, dressing, toileting and transferring and cueing/supervision for eating). Resident #41 had moderate difficulty with hearing. The Resident Care Plan (RCP) dated 7/28/26 identified ADLs as an area of focus with interventions that included providing assist of 1 for showers, bathing, dressing, personal hygiene and supervision with meals.Physician orders dated 7/29/26 indicated physical/occupational therapy (PT/OT) 5 to 6 times a week for self-care, gait training, neuromuscular reeducation and group therapy.Interview with Person #6 on 7/29/26 at 10:30 AM identified that Resident #41 was hard of hearing and that sometimes staff would talk into the intercom instead of answering Resident #41's call bell. Person #6 stated that he/she was concerned as Resident #41 could not hear staff over the intercom. Person #41 indicated that staff knew Resident #41 had difficulty hearing as Resident #41 was at the facility previously on the same unit. In addition, Person #6 stated he/she had spoken to a staff member at the desk recently but could not recall who he/she spoke with to inform staff that Resident #41 was hard of hearing and that staff needed to go to the room when responding to the call bell.The RCP failed to reflect Resident #41 was hard of hearing and that staff needed to respond to the call bell in person. Interview with the Assistant Director of Nursing (ADNS) on 8/5/26 at 10:15 AM indicated that Resident #41's RCP should have addressed that Resident #41 was hard of hearing. The ADNS stated that she was responsible along with the charge nurses to ensure the RCP was individualized and accurate. In addition, the facility policy was the care plans needed to be individualized to meet the needs of the residents.Interview with RN #7 (the MDS nurse) on 8/5/26 at 11:30 AM indicated that Resident #41's care plan should have included difficulty in hearing and that nursing was responsible for updating the RCP. 3. Resident #122 had diagnosis of cerebral infarction (stroke), hypertension (high blood pressure), and intracranial and intraspinal phlebitis and thrombophlebitis (inflammation of the veins in the brain and spinal cord, often associated with blood clots).A physician order dated 5/21/26 directed to administer Heparin (an anticoagulant/blood thinner injected under the skin) 5000 units per (/) milliliter (ml), inject 1 ml under the skin every 8 hours.A Resident Care Plan dated 5/21/26 failed to identify Resident #122 had been taking an anticoagulant medication despite a physician's order directing the administration of an anticoagulation medication.A physician order dated 5/22/26 directed to administer Aspirin (an antiplatelet medication) 81 milligrams (mg) by mouth daily. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #122 was dependent on staff for personal hygiene, oral hygiene, toileting, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and transferring between surfaces. The MDS assessment indicated Resident #122 was taking antiplatelet medication (a medication that prevents platelets from clumping together, reducing the risk of blood clots). A physician order dated 6/2/26 directed to discontinue Heparin and directed to administer Eliquis (an anticoagulant/blood thinner taken by mouth) 2.5 mg tablet by mouth every 12 hours.A review of Resident #122's Medication Administration Record (MAR) indicated Resident #122 had received Heparin 5000 units/ml, give 1 ml under the skin every 8 hours from 5/21/26 through 6/2/26. The MAR indicated Aspirin had been given 5/22/26 through 6/2/26. On 6/2/26 the order for heparin was discontinued and changed to Eliquis 2.5 mg and indicates the first dose of Eliquis 2.5 mg was given on 6/2/26 and remained an active order. An interview and record review with the unit nurse Licensed Practical Nurse (LPN) #6 on 8/3/26 at 11:59 AM indicated Resident #122 was on an anticoagulation medication and had been since admission on [DATE]. She was unable to locate any care plan or interventions for monitoring for Resident #122 related to the anticoagulation medication. She indicated there should be a care plan and monitoring in place for Resident #122 related to anticoagulant medication. She stated the unit managers were responsible for updating resident care plans. An interview and record review on 8/3/26 at 12:09 PM with the unit manager, RN #6, indicated she was responsible for the care plans for residents on her assigned unit. She indicated Resident #122 should have had a care plan in place for their anticoagulant and staff should have been monitoring Resident #122 for potential bleeding and bruising associated with anticoagulant therapy.An interview with the Director of Nursing Services (DNS) on 8/3/26 at 12:25 PM indicated the facility should have had a care plan related to anticoagulation therapy.An interview and record review on 8/4/26 at 10:00 AM with an MDS nurse identified the facility failed to accurately assess and document Resident #122's medication list identifying the anticoagulation medication. She indicated a per diem nurse had assisted with the MDS assessment however, she had signed off on it. She indicated the anticoagulant should have been captured and documented in the assessment. Subsequent to surveyor inquiry the care plan for anticoagulant therapy with interventions was added on 8/4/26. 4. Resident #139 was admitted to the facility in December 2024 with diagnoses that included dementia without behaviors, muscle weakness, and abnormalities of gait and mobility.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #139 was moderately cognitively impaired, required total assistance for bathing and dressing and supervision for toilet use and ambulation. The Resident Care Plan (RCP) dated 6/10/26 identified activities of daily living (ADLs) as an area of focus with interventions that included providing assistance of 1 for bathing, bed mobility, personal hygiene, toilet use and transfers and set up for eating, discuss with resident/family/POA care concerns related to loss of independence, and PT/OT evaluation and treatment as indicated.Physician orders dated 7/11/26 directed Trazodone (an antidepressant) 150 milligrams (mg) at bedtime for depression/insomnia. A review of Resident #139's flowsheets (documentation of care provided by Nurse Aides) indicated that Resident #139 refused a shower on the 7:00 AM to 3:00 PM shift on 7/7/26, received a shower on 7/21/26 on the 7:00 AM to 3:00 PM shift, and refused a shower on 7/31/26 on the 3:00 PM to 11:00 PM shift. The remainder of the days on the flowsheet was documented as not applicable (N/A), indicating that out of 10 opportunities for scheduled showers (2 times a week), one shower was given, 2 refusals, 54 N/As, and 5 left blank (on 3:00 PM to 11:00 PM on 7/8/26, on 3:00 PM to 11:00 PM on 7/10/26, on 7:00 AM to 3:00 PM on 7/18/26, on 3:00 PM to 11:00 PM on 7/23/26, and on 3:00 PM to 11:00 PM on 7/28/26).Interview and review of the clinical record with Registered Nurse (RN) #1 on 8/5/26 at 8:53 AM indicated that Resident #139 required a certain approach for him/her to shower. The NA would ask Resident #139 to go for a walk and ambulate towards the shower room. The NA then gently would mention taking a shower. RN #1 indicated that sometimes Resident #139 would agree and sometimes Resident #139 would refuse a shower. RN #1 indicated that Resident #139's RCP or care card did not indicate that Resident #139 required a certain approach for showersOn 8/5/26 at 9:15 AM, interview with NA #11 (who was Resident #139's primary NA on the 7:00 AM to 3:00 PM shift) indicated that Resident #139 required that you walk with him/her slowly and address a shower with him/her very gently. NA #11 indicated that sometimes Resident #139 would take a shower and sometimes would refuse. NA #11 was not sure why there were so many N/As documented on Resident #139's flowsheets.On 8/5/26 at 9:45 AM, interview with LPN #10 (who was Resident #139's primary charge nurse on the 7:00 AM to 3:00 PM shift) indicated that he was aware that Resident #139 required a certain approach for showers but was unsure who he should make that awareness to so that it could be documented on the RCP.A review of Resident #139's RCP on 8/5/26 did not reflect any type of individualized approaches for Resident #139's showers.Interview with RN #7 (the MDS nurse) on 8/5/26 at 11:30 AM indicated that Resident #139's RCP should have been updated with interventions related to showers and it was the responsibility of nursing to ensure the care plan was updated.Subsequent to surveyor inquiry, Resident #139's RCP was updated to include individualized interventions for showers. 5. Resident #233 was admitted to the facility in July 2026 with diagnoses that included fracture of left femur with prosthetic hip joint repair, anemia, and cognitive communication deficits. A hospital Discharge summary dated [DATE] noted that Resident #233 underwent surgical revision of the left hip and courses were complicated by expected surgical loss anemia. For religious reasons, Resident #233 refused blood transfusions.Resident #233's clinical record (Face Sheet) identified Resident #233 practiced a restorationist Christian denomination.Physician orders date 7/1/26 directed physical/occupational/speech (PT/OT/ST) evaluation and treatment as indicated. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #233 was cognitively intact, required maximum assistance for showering and dressing, total dependence for transfers and toileting and supervision for meals. The MDS further identified that participation in religious activities and services was somewhat important to Resident #233. The Resident Care Plan (RCP) dated 7/17/26 identified emotional, intellectual, physical, and social needs as an area of focus with interventions that included encourage ongoing family involvement, invite resident's family to attend special events, activities, and meals, invite resident to scheduled activities, provide activities of interest and empowers the resident, thank resident for attendance to activities, and provide 1:1 visit if unable to attend activities. Interview with Advance Practice Registered Nurse (APRN) #2 on 8/5/26 at 10:45 AM identified that Resident #233 was self-limiting related to treatments due to certain religious beliefs. APRN #2 indicated that Resident #233 refused blood work, blood products, certain medications, and psychiatric services. APRN #2 indicated that Resident #233's religious beliefs had a significant impact on the care provided to Resident #233. Interview and review of the clinical record with the Assistant Director of Nursing (ADNS) on 8/5/26 at 11:00 AM identified that she was aware that Resident #233 practiced a certain religion and that his/her religious beliefs directed much of the care provided to Resident #233. The ADNS was unable to locate an RCP related to Resident #233's religion and strict religious beliefs. The ADNs indicated that the Social Worker (SW) was usually responsible for updating religious, ethnic and/or cultural preferences in the RCP; however, the ADNs did indicate that since Resident #233's medical and nursing care was significantly impacted due to religious beliefs that nursing should have ensured that it was included within the RCP.A review of SW #4's notes from 7/1/26 through 8/5/26 failed to identify that Resident #233's religious beliefs had a significant impact on Resident #233's care. Interview with SW #4 on 8/5/26 at 2:00 PM identified that she was aware that Resident #233 practiced a specific religion with strict beliefs regarding limiting certain treatments/care but did not update the RCP as she believed nursing or recreation would have updated the RCP.Interview with RN #7 (the MDS nurse) on 8/5/26 at 11:30 AM indicated that she was not aware that Resident #233 was of a specific strict religion and that she was responsible for sending updates to Resident #233's insurance company and if she was aware she would have included this information with his/her weekly updates as it impacted the care the facility was able to provide to Resident #233. RN #7 indicated that Resident #233's RCP should have included that Resident #233 was unable to receive certain care/treatment based on his/her religion and either nursing or the SW should have ensured that it was in Resident #233's RCP. 6. Resident #244 was admitted to the facility in July 2026 with diagnoses that included skin graft, malignant and neoplasm (cancer) of the scalp and neck.The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #244 was moderately cognitively impaired and required moderate assistance with washing, dressing, toileting, transfers and cueing/supervision for eating. Physician orders dated 7/16/26 directed to empty the JP drain (Jackson Pratt a closed suction surgical drain after surgery to remove blood, fluids, and other drainage) every shift and record output for drain #2 and #3.The Resident Care Plan (RCP) dated 7/30/26 identified actual impairment to skin of the left rib cage related to surgical wound with 57 staples and the front of the left ear with 14 sutures as an area of focus. Interventions included to avoid scratching and keep nails short and moisturize body, enhanced barrier precautions related to wounds, keep skin warm and dry, monitor of side effects of antibiotics, sutures and staples to be removed at oncologist office on 7/20/26, monitor surgical site for 7 days, use caution for transfers to prevent skin injury to hands, legs, and arms, and weekly treatment documentation of each area of skin breakdown.Observation on 8/3/26 at 7:30 AM noted Resident #244 was sitting in a wheelchair and staff were assisting with repositioning and preparing for transfer when the bulb of JP drain came undone from the tubing and fell onto the floor. The bulb was retrieved by staff and Resident #244 was brought in the room for nursing staff to reconnect the drainage bulb.A review of nursing progress notes for 8/3/26 through 8/5/26 failed to reflect documentation that the JP drain had come off the tubing and fell to the floor.Interview and review of the clinical record with Registered Nurse (RN) #1 on 8/5/26 at 8:53 AM identified that the JP drain bulb was easily reconnected to the tubing. RN #1 was not aware of any special procedures that needed to be done when reconnecting the JP drain bulb to the tubing such as needing a new JP bulb if disconnects. RN #1 stated that although the physician's orders addressed the emptying of the JP drains, the RCP failed to identify that Resident #244 had JP drains in place. There were no interventions related to the care of drains or instructions for the procedure if the drain bulbs became detached. RN #1 indicated that Resident #244's JP drains should have been addressed/included in Resident #244's RCP and that it was nursing's responsibility to ensure that the JP drains were in the RCP. RN #1 could not explain why the JP drains were not included in the RCP.Interview with RN #7 (the MDS nurse) on 8/5/26 at 11:30AM indicated that Resident #244's JP drains and the care of the drains should have been included in Resident #244's RCP and that it was nursing's responsibility to ensure it was in the RCP.After surveyor inquiry, Resident #244's RCP was updated to include the JP drains.A facility policy Patient/Resident Care Plan dated 7/29/26 directed Policy: Masonicare Health Care Center shall assure that a patient specific care plan developed for all patients/residents. Procedure: 1. Each level of care shall maintain a level-specific procedure on development of patient/resident care plan. 2. The patient/resident care planning process shall be implemented by members of the interdisciplinary team in a manner that assures coordinated participation of all appropriate health care individuals. 3. Based on findings of the interdisciplinary assessment, realistic and measurable goals shall be identified for each patient/resident based on his or her unique needs. The patient/resident and/or family, when appropriate, shall participate in the goal setting process.

Based on observations, interviews, review of the clinical record and facility policy for 1 of 3 residents (Resident #54) reviewed for pressure ulcers/injury, the facility failed to ensure Resident #54 who had a pressure ulcer was on Enhanced Barrier Precautions (EBP) and failed to ensure appropriate infection control practices during a dressing change. Additionally for the only resident (Resident #96) reviewed for a supra-pubic tube (SP) (a tube placed directly into the bladder through the abdomen for the drainage of urine), the facility failed to ensure personal protective equipment (PPE) was donned (placed on) prior to providing personal/hygiene care, mechanical lift transfer and a bed linen change for a resident on Enhanced Barrier Precautions (EBP) with a SP tube. The findings include: 1. Resident #54 had diagnoses that included Alzheimer's disease, muscle wasting and atrophy, and moderate protein-calorie malnutrition. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was severely cognitively impaired, was at risk for pressure ulcers/injuries, and had moisture associated skin damage which required application of a nonsurgical dressing. The MDS assessment further indicated Resident #54 used a walker and wheelchair and was dependent with eating, bed mobility, and chair/bed transfers. A Skin/Tissue Event dated 6/14/26 identified a new Stage 2 pressure ulcer was identified on Resident #54's coccyx/buttocks. The Resident Care Plan (RCP) dated 7/20/26 identified Resident #54 was at risk for impaired skin integrity related to fragile skin and bowl and bladder incontinence. Interventions included to be mindful of excess moisture to bony prominences, check function and setting of specialty air mattress every shift, and provide incontinence care as needed for prevention of skin breakdown. A physician order dated 7/23/26 directed for wound care to the left buttock open area: cleanse wound with wound cleanser or Normal Saline (NS), apply Plurogel (topical wound treatment gel) with Calcium Alginate (topical wound treatment) and cover with a dry clean dressing daily on the day shift and as needed for a dressing that is soiled/not intact. Observation on 8/3/26 at 8:33 AM, 8/4/26 at 8:30 AM and 8/4/26 at 10:35 AM identified no EBP signage on the doorway of Resident #54's room or any other means to notify staff Resident #54 was on EBP. Review of the clinical record physician orders failed to identify an order for EBP. Observation of a pressure ulcer dressing change for Resident #54 performed by Licensed Practical Nurse (LPN) #5 on 8/4/26 at 10:35 AM identified she cleansed her hands with soap and water, then dried them and then applied clean gloves. She entered the room without wearing a gown as part of their personal protective equipment (PPE) protocol. She explained the procedure to Resident #54 then turned him/her in the bed and after unhooking the incontinence brief she noted Resident #54 had urinated and required incontinent care. She exited the room and returned with Nurse Aide (NA) #4. Both LPN #5 and NA #4 entered the room to provide incontinence care to Resident #54 without donning a gown (PPE). Following the incontinence care NA #4 remained in the room to assist with positioning of Resident #54. Neither staff member wore a gown (PPE). LPN #5 was observed to remove her gloves and performed hand hygiene with soap and water, dried her hands and donned clean gloves. She removed the old dressing from Resident #54, discarded it, removed her gloves and discarded them. She then donned clean gloves without performing hand hygiene in between glove changes and applied the new dressing to Resident #54's left buttock area. After LPN #5 performed the dressing change NA #4 then assisted Resident #54 with reapplication of an incontinence brief, re-dressed and repositioned Resident #54 while wearing gloves but without wearing a gown (PPE) while LPN #5 removed the dressing supplies. Interview and facility documentation review with Licensed Practical Nurse (LPN) #9 on 8/4/26 at 10:16 AM identified the EBP policy directed EBP would be initiated for any resident with a chronic wound. She indicated when EBP was in place there was a PPE cart outside the door and EBP signage on the doorway directing staff on what PPE to wear, there would be an orange dot next to the resident name if not in a private room, EBP would be identified in the RCP, and on the Nurse Aide care card (Kardex), and a physician order in the medical record. She indicated Resident #54 was not on EBP, but that he/she should be. She further indicated while it was an expectation that the unit managers put residents with new pressure ulcers on EBP, it was ultimately her responsibility to double-check and ensure the list was up to date. She was unable to identify the reason Resident #54 was not on EBP, indicated she would add the resident to the list and update the orders and RCP. Interview with LPN #5 on 8/4/26 at 10:48 AM identified she had not performed hand hygiene prior to donning new gloves after removal of the soiled dressing during the pressure ulcer dressing change. She indicated that she was not aware that hand hygiene was required with glove changes and indicated she thought the glove changes themselves were adequate for infection prevention. Additionally, she indicated that she was not aware that the gloves worn during care were not 100% impervious and therefore hand hygiene was required with glove changes. LPN #5 further indicated that residents who required EBP had signage posted at the doorway, were listed on the EBP roster, and/or had a physician order for EBP. She indicated that she was not aware all residents with pressure ulcers required EBP. She further indicated she had not realized she should have donned a gown as part of her PPE when doing the dressing change and incontinence care for Resident #54 because there was no signage posted and he/she did not have an order for EBP. Interview with the DNS on 8/5/26 at 1:40 PM identified that nursing staff should be performing hand hygiene with glove changes while performing resident dressing changes. Review of the Hand Hygiene policy, dated as reviewed on 1/29/26, directed, in part, ABHR use is promoted as infection prevention except for a resident with spore forming bacteria where hand hygiene with soap and water must be used. The policy directed hand hygiene must be performed before donning and after removing gloves. Review of the Standard/Transmission Precautions policy, dated as reviewed 4/6/26, directed, in part, standard and transmission based precautions were needed to prevent transmission of infection by direct or indirect contact. The policy directed that every resident was a possible carrier of pathogens and required standard precautions and additional levels as needed. The policy directed EBP was used when appropriate. The policy directed EBP was the use of a gown and gloves during high-contact resident activities which included changing of briefs, assisting with toileting, and wound care. The policy directed that appropriate signage will be posted on the door of the resident's room which indicates what type of precaution was required. 2. Resident #96's diagnosis included multiple sclerosis, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. A physician order dated 7/6/26 directed Enhanced Barrier Precautions (EBP) related to supra-pubic (SP) tube every shift. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #96 was cognitively intact and was dependent with bed mobility, toileting and transfers. The MDS identified Resident #96 had a diagnosis of obstructive uropathy and had an indwelling catheter. The Resident Care Plan (RCP) dated 7/28/26 identified Resident #96 had a SP Tube in place due to obstructive uropathy and benign prostatic hypertrophy (BPH) with interventions that included EBP was in place related to an SP tube. The facility bedside kardex report (Nurse Aide care card) directed EBP was in place related to an SP tube. Observation and interview with NA# 3 and NA #4 on 7/31/26 at 9:55 AM identified NA #3 had just provided Resident #96 with incontinent care, a bed bath, clothing change and with NA #4's assistance, completed a mechanical lift transfer of the resident into a wheelchair. NA #3 was also changing the linens on the resident's bed and both NA #3 and NA #4 indicated they had provided the high contact care of Resident #96 without the benefit of an isolation gown and gloves. NA #3 and NA #4 stated they were aware the resident was on EBP but thought that only meant they had to wear PPE when emptying the resident's urine bag. Review of the EBP signage outside of Resident #96's room with NA #3 and NA #4 identified donning of gown and gloves was required for dressing, bathing, transferring, changing briefs or linens and providing hygiene. NA #3 and NA #4 further indicated although they had received education on EBP, they had made an error by not donning the required PPE (isolation gown and gloves) when providing care for Resident #96. Interview with LPN #1 on 7/31/26 at 10:00 AM identified she was the charge nurse for Resident #96 and when NA #3 and NA #4 provided personal/hygiene care, a mechanical lift transfer and a bed linen change and should have donned an isolation gown and gloves because the resident was on EBP. LPN #1 indicated she was unsure why NA #3 and NA #4 did not put on PPE because the EBP signage and cart with available PPE was right outside of Resident #96's room. LPN #1 stated NA #3 and NA #4 should have known about the PPE requirement for Resident #96 and that she needed to let the unit manager know to provide the NA's further education. Interview with the DNS on 8/5/26 at 9:30 AM identified NA #3 and NA #4 should have donned isolation gowns and gloves when they provided personal/hygiene care, a mechanical lift transfer, and a bed linen change for Resident #96 and she was unsure why that was not done. The DNS indicated the NAs were provided education on EBP and Resident #96 had signage posted and PPE available outside of the room. Review of the facility policy, Standard/Transmission Precautions, dated 11/1/88, directed standard and transmission precautions are necessary to prevent transmission of infections by direct or indirect contact. Enhanced Barrier Precautions (EBP) required use of gown and gloves during high-contact care activities that provide opportunities for transfer of MDRO's (multi-drug resistant organisms) to staff hands and clothing. EBP was indicated for the following high contact resident care activities such as dressing, bathing, providing hygiene, changing briefs or linens and transferring. EBP was indicated for residents with use of an indwelling device such as a urinary catheter.

Based on observations, interviews and review of the facility policy for 1 of 4 medication rooms, the facility failed to ensure medication refrigerators were monitored and maintained within required temperature limits. Additionally, the facility failed to ensure the medication cart was locked when unattended and not visible to the nurse. The findings include: 1. Observation, interview and review of facility documentation with Registered Nurse (RN) #2 on 7/30/26 at 11:33 AM identified that temperatures from the Ramage 2 Unit medication refrigerator were documented between -20 degrees ( ) Fahrenheit (F) and -18 F from 7/1/26 to 7/30/26. Additionally, there were no temperatures documented for 18 out of 30 days for that time. RN #2 indicated that it was the responsibility of the night shift (11:00 PM to 7:00 AM) nurse to document the refrigerator temperatures. RN #2 indicated that for temperatures documented out of range, between 34 F and 41 F, the supervisor should be notified. The refrigerator thermometer was observed at 38 F. The following medications were present and not frozen: 9 Acetaminophen 650 milligram (mg) suppositories 45 Bisacodyl 10 mg suppositories 1 prefilled Insulin Glargine injection pen 4 prefilled Kwik Lispro Humalog injection pens 4 prefilled Ozempic injection pens 2 unopened Humalog 1 milliliter (ml) vials 1 unopened Epogen 1 ml vial Observation, interview and review of facility documentation with the Unit Manager, Registered Nurse (RN) #3 on 7/30/26 at 11:45 AM identified that refrigeration temperatures were monitored nightly by the night shift nurse and if they were noted to be out of range, between 34 F to 41 F, the Unit Manager should be notified. RN #3 indicated that at the end of each month, she would review the temperature logs for any discrepancies which she didn't remember there being any recently. Review of Ramage 2 Unit medication refrigerator logs identified that all temperatures documented for 5/1/26 to 5/31/26 were between 26 F to 34 F, 6/1/26 to 6/30/26 were between 26 F to 28 F and 7/1/26 to 7/30/26 were between -20 F to -18 F with no documented temperature for 18 out of 30 days. RN #3 indicated that the temperatures documented were out of range, there were numerous days in July 2026 with no documentation and did not remember being notified or reviewing which she should have. RN #3 identified that staff were not recording temperatures or notifying the supervisor as they should have been and would reeducate staff. Interview and review of facility documentation with the Director of Nursing (DON) on 7/30/26 at 2:13 PM identified that it was the responsibility of the night nurse to observe and document medication refrigeration temperatures. She indicated that if temperatures were observed as out of range that the supervisor should be notified. After review of Ramage 2 Unit medication refrigerator temperature logs from 5/1/26 to 7/30/26, the DON identified that the temperatures documented were out of range, a supervisor should have been notified, and there should have be documentation of what was done. The DON indicated that she believed RN #4 was documenting the temperatures of the freezer and not the refrigerator and that she would in-service staff to the proper procedure. Interview with the Pharmacist on 7/31/26 at 1:05 PM identified that she did not expect the facility to call her if the medication refrigerator was observed out of range, but that they should call the manufacturers as each medication may have different parameters for when they can no longer be used. After review of the medications that were in Ramge 2 Unit medication refrigerator, she indicated that they were probably still usable since they were not frozen. Interview with the RN #4 on 7/31/26 at 1:41 PM identified that it was his responsibility as the night nurse to observe and document the medication refrigeration temperature. RN #4 indicated that refrigerator temperatures must be between 34 F to 41 F and that he would notify the supervisor if they were outside of that range. RN #4 indicated that he documented the freezer temperatures instead of the refrigerator temperatures and that was why he did not notify the supervisor. RN #4 could not identify why he did not notice the documented temperature discrepancies from 5/1/26 to 7/30/26. Review of the Medication Storage policy, undated, directed in part that medications must be stored in accordance with manufacturer's specifications. Additionally, it indicated that refrigerated medications must be stored in a separate medication refrigerator with temperatures maintained at 36 F to 46 F. 2. Observation on 8/3/26 at 6:24 AM noted Licensed Practical Nurse (LPN) #3's medication cart was unlocked in the hallway. LPN #3 was in a resident room, and medication cart was outside the doorway but not visible to LPN #3. Further observation at 6:27 AM on 8/3/26 noted there were several residents awake and out of bed in their rooms and 3 residents in wheelchairs self-propelling up and down the hallway. LPN #3 was observed exiting a resident room at 6:30 AM (the medication cart was unlocked, accessible to others and unattended for 7 minutes). Interview with LPN #3 at 6:35 AM indicated that she should have locked the cart as it was not in her view and that she always locks the medication cart. LPN #3 was unable to explain why she forgot to lock the medication cart and that it was her responsibility to ensure the medication cart was locked when unattended and not in her view. LPN #3 indicated that she was sure the facility policy was that the medication cart must be locked when unattended or not in view as it was a standard of practice. Interview with Registered Nurse (RN) #5 the 11:00 PM to 7:00 AM shift supervisor for 8/2/26 into 8/3/26 indicated that the facility policy was the medication cart must be locked when unattended or not in view of the nurse. RN #7 indicated that the nurse who had the keys to the medication cart was responsible for ensuring the medication cart was locked. Although requested, a policy on medication carts was not provided,

Based on review of the clinical record, facility policy and interviews for 4 of 24 sampled residents (Resident #128, Resident #130, Resident #132, Resident #135) reviewed for physician visits, the facility failed to ensure physician visits were alternated with Advanced Practice Registered Nurse (APRN). The findings include: 1.Resident #128's diagnoses include essential hypertension, malnutrition, and dementia.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #128 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 and required partial assistance with toileting and dressing. Clinical record review indicated Resident #128 was admitted to the facility on [DATE], was seen and orders were signed by a physician on 12/18/24. Further review of the medical record identified no documented physician or APRN visit during the month of March 2025 and no physician visit until 6/4/25. Although Resident #128 was seen by the APRN on 1/16/25, 2/13/25, 2/28/25, 4/10/25, 4/14/25, and 6/3/25 there were no alternating visits with the physician.2. Resident #130's diagnoses include coronary heart disease, hypertension and diabetes.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #130 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11, required maximum assistance with bathing and moderate assistance with toileting and dressing. Clinical record review indicated Resident #130 was seen by a physician on 12/23/24 and then on 5/19/25. Although Resident #130 was seen by the APRN on 1/27/25, 2/20/25, 2/21/25, 2/25/25, 2/27/25, 3/10/25, 3/14/25, and 5/5/25, there were no alternating visits with the physician.3. Resident #132's diagnoses include Vascular dementia, dysphagia, and diabetes.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #132 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 8, was dependent with toileting and bathing and required moderate assistance with personal hygiene.Clinical record review indicated Resident #132 was seen by a physician on 12/2/24, 5/5/25, 7/26/25 and then again on 12/21/25. Resident #132 was seen by the APRN on 6/9/25, 7/10/25, 7/21/25, 7/26/25, and 11/3/25. There were no visits from the physician/APRN from 12/2/24 through 5/5/25 and from 7/21/25 to 12/21/25. 4. Resident #135's diagnoses include diabetes, major depressive disorder, and obesity. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #135 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and was dependent for toileting, bathing and personal hygiene.Clinical record review indicated Resident #135 was only seen by a physician on 10/17/24 and 9/25/25, all other visits were by the APRN on 11/19/24, 11/27/24, 12/18/24, 1/8/25, 1/16/25, 1/22/25, 1/29/25, 2/13/25, 3/12/25, 4/8/25, 4/16/25, 4/22/25, 6/16/25, 7/14/25, 8/12/25, 8/27/25, and 9/11/25.Interview and record review with the Medical Director (MD #1) on 8/6/26 at 11:45 AM identified there was a gap in physician visits in these residents. MD #1 further explained that he had to hire another physician because he was aware there was a gap in coverage during this timeframe.Review of the Alternate Schedule of Physician Visits policy dated 1/1/2018 directed, in #1, dictates that the Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) may see the resident for clinical review in an alternating pattern with a physician clinical review. In #2 the policy further dictates that residents may not be placed on a 60-day visit schedule until after the first 90 days following admission. The policy further states at no time may an alternate schedule of visits exceed 60 days.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 sampled residents (Resident #143) reviewed for pain management, the facility failed to routinely monitor for pain and failed to report and treat a new onset of back pain. The findings include:Resident #143's diagnoses included osteomyelitis of the spine (site unspecified), osteoarthritis, and Type 2 diabetes.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #143 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment and required set up assistance for eating, substantial assistance for dressing, personal hygiene and moving in bed. Additionally, the MDS noted Resident #143 did not indicate he/she was having any pain.The Resident Care Plan (RCP) dated 5/13/26 identified Resident #143 denied pain on admission and would not have interruption in normal activities due to pain. Interventions included to administer Tylenol (acetaminophen) per the physician orders, give 1/2 hour before treatments or care, and to evaluate effectiveness of pain interventions before and after receiving the medication. A physician order in effect on 7/27/26 directed to give 2 tablets of acetaminophen 500 milligrams (mg) every 6 hours as needed for pain. A Pain Interview assessment dated [DATE] identified Resident #143 reported pain occurring occasionally in the previous 5 days and the pain occasionally interrupted his/her sleep and day-to-day activities. Additionally, the pain was reported to be in his/her back. A review of the Electronic Medication Administration Record (EMAR) and Weights and Vitals Summary, from 7/1/26 to 7/24/26 failed to identify routine monitoring of pain. Additionally, from 7/24/26 to 7/31/26 the clinical record failed to identify Resident #143 was being routinely monitored for pain, had received acetaminophen for pain, or had pain as indicated during the Pain Interview assessment dated [DATE].Interview with Resident #143 on 7/31/26 at 10:19 AM identified he/she had not been getting out of bed due to back pain on and off for about a week and stated it felt like something is in my back.Observation on 8/3/26 at 11:30 AM during morning care with Nurse Aide (NA) #10 identified Resident #143 was able to assist with bed mobility by holding the bed rails to turn on his/her side. Resident #143 was in good spirits, joking and laughing with NA #10, but stated he/she had back pain and that it felt like something is in my back. Interview with NA #10 on 8/3/26 at 11:45 AM identified although Resident #143 had reported back pain during the observation, she had stated the resident had not reported pain to her and if pain had been reported she would have notified the nurse immediately.Interview with Licensed Practical Nurse (LPN) #8 on 8/3/26 at 12:05 PM following Resident #143's report of back pain on 8/3/26 at 11:30 AM identified he would typically treat pain for one occurrence and that if it occurred more than once he would notify a provider to see if other measures could be implemented to treat the resident's pain. He indicated that Resident #143's pain when reported was usually around his/her indwelling urinary catheter site, at the bottom of his/her feet, and that when Resident #143 reported back pain, it went away after a cup of coffee was provided. LPN #8 was unable to state the facility policy/practice for pain monitoring indicating he would follow up with Resident #143 regarding his/her reported back pain. Follow-up observation and interview with Resident #143 on 8/3/26 at 1:55 PM identified him/her in bed, thrashing his/her arms attempting to put a straw in a cup of coffee with a lid. Resident #143's voice was noted to be tense stating he/she had back pain and no staff had come in to inquire about his/her pain. Resident #143 requested Can you tell someone to come in?On 8/3/26 at 2:05 PM Resident #143's back pain was again reported to LPN #8. LPN #8 stated he had gone into Resident #143's room but that the resident did not complain about pain. LPN #8 indicated that when a resident complained of pain, it would be documented in the Electronic Medication Administration Record (EMAR), however, on review, LPN #8 identified that Resident #143 failed to have an area prompting him to ask if the resident was having any pain. Further, LPN #8 stated that other residents have an area prompting nurses to ask residents if they were in pain, but he could not explain why Resident #143's pain prompt was missing.Review of the EMAR identified that on 8/3/26 at 2:10 PM LPN #8 had documented a pain level to be 9 out of 10, where 0 was no pain and 10 was severe pain and that he (LPN #8) had administered 2 tablets of acetaminophen 500 mg.Interview with the Director of MDS Registered Nurse (RN) #7 on 8/3/26 at 2:45 PM identified it was her expectation that the person completing the Pain Interview assessment should have communicated to nursing staff when Resident #143's pain was identified. Review of the RCP and nurse's notes with RN #7 failed to identify the nurse completing the Pain Interview assessment had notified any nursing staff that Resident #143 reported a new onset pain during the 5-day look back assessment conducted on 7/29/26 (5 days earlier).Interview with Director of Nursing (DON) on 8/3/26 at 3:00 PM identified it was her expectation that the nurse who completed the Pain Interview assessment should have updated the nursing staff immediately for follow-up when Resident #143 reported a new onset of pain.A nursing note dated 8/3/26 at 3:29 PM identified Resident #143 denied having back pain following the administration of acetaminophen on 8/3/26 at 2:10 PM.Subsequent to surveyor inquiry, a physician order dated 8/3/26 was obtained to monitor every shift for painA review of the Pain Assessment Policy dated 10/1/99 stated pain management was a high priority and an essential aspect of living and integrated life at Masonicare and directed, in part, to conduct a pain data collection on admission and readmission, quarterly, with change of condition, and with new onset of pain. The policy failed to identify routine daily monitoring for pain.

Based on interviews, review of the clinical record and facility policy for 1 of 3 sampled residents (Resident #233) reviewed for bowel and bladder, the facility failed to ensure bladder incontinence was evaluated in order to maintain the highest level of functioning. The findings include: Resident #233 diagnoses included fracture of left femur with prosthetic hip joint repair, anemia, and cognitive communication deficits. A review of Resident #233's Nursing admission Screening/History dated 7/1/26 identified that Resident #233 had mixed incontinence (stress/urgency incontinence).The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #233 was cognitively intact, required maximum assistance for showering and dressing, total dependence for transfers and toileting and supervision for meals. The MDS further identified Resident #233 was occasionally incontinent of urine (less than 7 episodes of incontinence) and was not on a trial training program for urinary incontinence.Physician orders dated 7/1/26 directed physical/occupational/speech therapy (PT/OT/ST) evaluation and treatment as indicated. The Resident Care Plan (RCP) dated 7/17/26 identified that Resident #233 required assist with toileting related to impaired mobility as an area of focus with interventions that included clean peri-area with each incontinence episode and monitor/document signs and symptoms of urinary tract infection. The goal was to maintain continence during waking hours and remain free from skin breakdown related to incontinence. A review of Resident #233's Care Card (directs Nurse Aides (NAs) on care needed to be provided) directed that Resident #233 required the use of a bed pan for toileting. A review of Resident #233's care flowsheets (documented care provided by NAs) for July and August 2026 revealed that NAs documented Resident #233 was not transferred to the toilet (not applicable documented) and was incontinent of urine.Resident #233 did not have an admission Bowel and Bladder Evaluation completed.Interview with Resident #233 on 8/4/26 at 9:15 AM noted that Resident #233 was continent of urine prior to admission to the facility. Resident #233 stated that he/she would walk to the bathroom to use the toilet with supervision from his/her caretaker. Resident #233 stated that it was somewhat difficult now as he/she had only been walking with therapy sometimes. In addition, Resident #233 indicated that he/she could use the bed pan but it was a bit painful to roll on his/her side due to hip surgery and that staff had been using an incontinent brief instead. Resident #233 stated that he/she did not want to be incontinent of urine but was not sure what he/she could do to prevent incontinence due to mobility challenges. Interview with Advanced Practice Registered Nurse (APRN) #2 on 8/5/26 at 10:45 AM indicated that she was not aware Resident #233 was incontinent of urine since admission and that prior to admission that Resident #233 was continent of urine. APRN #2 indicated although Resident #233 could be self-limiting related to his/her care at times that the facility should have initiated some type of training program to attempt to restore Resident #233's urinary continence. Interview and review of the clinical record with the Assistant Director of Nursing (ADNS) on 8/5/26 at 10:55 AM indicated that a bowel and bladder training program had not been attempted with Resident #233 and that a 3-day voiding log to determine voiding patterns had not been completed. The ADNS stated that a check and change was the current plan of care for Resident #233. The ADNS stated that a Bowel and Bladder Evaluation should have been completed.The Bowel and Bladder Policy reviewed on 10/7/26 directed, in part, all patients/residents will have a continence evaluation done on admission and with any change in continent status. Continent residents do not require further evaluation.The continence management program is designed to provide each resident who is incontinent of bowel or bladder with appropriate assessment and interventions to restore as much normal bladder and bowel function as possible and achieve his/her highest practicable level of independence and dignity. Indwelling catheters should not be used unless medical diagnoses justification. A voiding log will be initiated for a minimum of 3 days to establish a voiding pattern and the need for bladder retraining program at the discretion of the clinical nurse.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #3) reviewed for positioning and mobility, the facility failed to correctly set an air mattress and offload heels for Resident #3 who had a risk of developing pressure ulcers. The findings include: Resident #3's diagnoses included dementia, metabolic encephalopathy, and history of pressure ulcers. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #3 was at risk of developing pressure ulcers/injuries based on formal and clinical assessments and had a pressure reducing device to the bed and chair with application of ointments/medications. The Resident Care Plan (RCP) dated 7/23/26 identified Resident #3 was at risk for skin impairment related to incontinence. Interventions included daily skin checks, and weekly skin evaluations and to report to nurse or provider any new skin impairments.A physician order dated 7/1/26 and currently in effect directed to check function and weight setting of the specialty air mattress every shift with setting at 150 pounds and to off-load heels while in bed every shift.Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/2/26 identified Resident #3 was at risk for the development of pressure injuries.The Nurse aide (NA) care card failed to indicate the residents air mattress was in place or the setting and that the resident's heels should be offloaded when in bed.Observations on 7/30/26 at 10:45 AM and 7/31/26 at 9:40 AM noted Resident #3 in bed without the benefit of having his/her heels offloaded and with the air mattress set at 250 pounds (label on unit indicated setting should be at 150 pounds).Observation, interview and review of the clinical record with LPN #2 on 8/3/26 at 7:15 AM identified Resident #3 was in bed without the benefit of having his/her heels offloaded and with the air mattress set at 250 pounds (sticker on unit indicated setting should be at 150 pounds). LPN #2 stated although she checked Resident #3's air mattress overnight, she was unsure why the air mattress was set so high when the physician's order and label on the unit indicated it should be set at 150 pounds. LPN #2 proceeded to reset the air mattress to 150 pounds and indicated she would have been responsible for ensuring the air mattress was set correctly because there was a physician's order and she signs off on that in the treatment administration record. LPN #2 further identified Resident #3's heels were not offloaded and she was unable to locate a pillow for offloading in the resident's room and would need to obtain one. LPN #2 indicated it would have been her responsibility to ensure the resident's heels were offloaded when in bed, again because there was a physician's order and she signs off on that in the treatment administration record. Interview and review of the clinical record with the unit manager (RN #6) on 8/3/26 at 8:07 AM identified the nursing staff were responsible to ensure Resident #3's air mattress was on the correct setting and that the resident had his/her heels offloaded when in bed. RN #6 indicated the physician's order directed a setting of 150 pounds for the air mattress for Resident #3 and she was unsure why the mattress was on an incorrect setting of 250 pounds. Review of the NA care card for Resident #3 with RN #6 failed to indicate the residents air mattress or setting and that the resident's heels should be offloaded when in bed. RN #6 stated the NA care card should have been updated and further identified it would have been the responsibility of the charge nurse to follow the physician's orders and ensure the air mattress was set correctly and that the resident's heels were offloaded when in bed and she was unsure why that was not done. Interview with the DNS on 8/5/26 at 9:40 AM identified the charge nurse should have made rounds overnight and ensured Resident #3's air mattress was on the correct setting, and she was unsure why that was not done. Further, the DNS indicated it was her expectation that the charge nurse followed the physicians' order and should have offloaded the resident's heels when in bed. The DNS stated she would need to provide further education to the nursing staff. Review of the facility policy, Air Mattress Use, dated 4/17/26, directed the use of an air mattress required a physician's order specifying an appropriate setting for the resident.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #2) reviewed for unnecessary medications, the facility failed to ensure physician orders were followed for a medication with administration parameters. Additionally, for 1 of 5 residents (Resident #140) reviewed for skin issues, the facility failed to ensure Geri-sleeves (a protective garment used to shield fragile skin) were applied per physician orders and for 1 of 3 residents (Resident #232) reviewed for positioning and mobility, the facility failed to implement floor mats and offloading of the heels per the physician's order and plan of care. The findings include: 1. Resident #2 had diagnoses that included hypertensive heart disease, dementia, and diabetes.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired, used a walker and wheelchair, required setup and clean-up assistance with eating, required substantial/maximal assistance with bed/chair transfers, and was dependent with bed mobility and toilet transfers.The Resident Care Plan (RCP) dated 4/28/26 identified Resident #2 had potential for alteration in cardiovascular status related to atrial fibrillation and presence of pacemaker. Interventions included monitoring for chest pain, monitor for shortness of breath and/or cyanosis, and obtaining a diet consult as needed. A physician order dated 5/11/26 directed to administer Metoprolol Tartrate 12.5 milligram (mg) tablet by mouth 2 times a day for hypertensive heart disease with administration times of 9:00 AM and 5:00 PM. The physician order had additional directions to hold the medication for a systolic blood pressure (SBP) less than 100 millimeters of mercury (mmHg) or a heart rate (HR) less than 60 beats per minute (bpm).Review of the Medication Administration Record (MAR) for July 2026 from 7/1/26 to 7/31/26 identified Metoprolol Tartrate 12.5 mg tablet was administered on 7/1/26 at 9:00 AM and indicated a HR of 56 ( per physician orders, the medication was to have been held for a HR less than 60 bpm); on 7/1/26 at 5:00 PM and indicated a HR of 56 (less than 60 bpm); on 7/11/26 at 9:00 AM and indicated a HR of 58; and 7/31/26 at 5:00 PM and indicated a HR of 59 (less than 60 bpm).Interview and clinical record review with Registered Nurse (RN) #12 on 8/4/26 identified that Resident #138's should not have received Metoprolol Tartrate 12.5 mg medication on 7/1/26 at 9:00 AM and 5:00 PM, 7/11/26 at 9:00 AM, and 7/31/26 at 5:00 PM based on the physician order to hold the medication for a systolic blood pressure (SBP) less than 100 millimeters of mercury (mmHg) or a heart rate (HR) less than 60 beats per minute (bpm). She further indicated she would provide education with the staff on following medication parameters per physician orders when administering Resident #138's medication.Review of the Physician Orders for Patient Care in Long Term policy directed, in part, the electronic medical record (EMR) contains physician orders for medication. The policy directed physician orders entered into the EMR must contain all pertinent information required for the staff to carry out the order. 2. Resident #140 diagnoses included dementia, atherosclerotic heart disease, and anxiety.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #140 was severely cognitively impaired, required total assistance with activities of daily living (ADLs) and substantial to total assistance with mobility. Resident #140 was non-ambulatory.The Resident Care Plan dated 5/21/26 identified Resident#140 had a skin impairment care plan in place indicating Resident #140 had fragile skin. Interventions included providing assistance with needs to apply protective garments, Geri sleeves (a protective garment to shield fragile skin), and remove for skin checks and/or providing care.A physician order dated 5/28/26 directed Geri sleeves to be worn every shift, remove for personal care, and skin checks every shift.Observation on 7/30/26 at 2:37 PM noted Resident #140 seated in a wheelchair in his/her room wearing a short sleeve shirt exposing the skin on both arms from just above the elbows to his/her fingers and was not wearing Geri sleeves on his/her arms.Observation on 7/31/26 at 11:20 AM and 8/3/26 at 11:35 AM noted Resident #140 seated in a wheelchair in the dining room wearing a short sleeve shirt exposing the skin on both arms from just above the elbows to his/her fingers and was not wearing Geri sleeves on his/her arms.Interview with the License Practical Nurse (LPN) #4 on 8/3/26 at 12:10 PM identified that the nurses were responsible for ensuring that Resident #140 was wearing Geri sleeves. LPN #4 identified that Resident #140 had a physician's order for Geri sleeves to be worn and that the order was transcribed onto the Treatment Administration Kardex (TAR) for the nurses to sign off on every shift. LPN #4 stated that Resident #140 had fragile skin and was prone to skin tears and that Resident #140 should be wearing Geri sleeves on both of his/her arms and removed for care. LPN #4 was not aware of a facility policy on Geri sleeves and could not provide an explanation why Resident #140 was not wearing Geri sleeves. LPN #4 stated she/he would apply Geri sleeves to Resident #140 arms.Interview and record review with the Unit Manager, Registered Nurse (RN #11) on 8/4/26 at 3:00 PM identified that the nurse and the Nurse Aides (NAs) were both responsible for applying Geri sleeves. RN #11 stated that the NAs should be putting on Geri sleeves to Resident #140's arms and the nurses should be overseeing that the NAs were applying them. RN #11 identified that Resident #140 had a physician's order for Geri sleeves and they should have been applied to both of Resident #140 arms. RN #11 identified that the issue was related to when the Geri sleeves intervention was added into Resident #140's care plan on 5/21/26, the intervention was not linked to the NA Kardex in the computer. RN #11 stated she/he would update the care plan intervention, and the intervention would now appear on the NA Kardex.Interview with the DNS on 8/5/26 at 1:10 PM identified that when a resident had a physician's order for Geri sleeves to be worn every shift, remove for personal care, and skin checks every shift the expectation of the nurses and NAs would be that Geri sleeves were being applied as orderedThe facility did not provide a policy for the application of Geri sleeves.Review of the Skin Assessment and Surveillance Policy identified that all residents would receive weekly skin evaluations to prevent the development of skin impairments and any resident at risk for or with an actual skin impairment will have a care plan individualized with interventions to promote prevention and/or healing of any skin impairments. 3.Resident #232's diagnoses included hemiparesis (weakness) and hemiplegia (paralysis) of the left side after cerebral infarction (stroke), cognitive communication deficit and rheumatoid arthritis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #232 was severely cognitively impaired and required total assistance with bed mobility, toileting and transfers. The Resident Care Plan (RCP) dated 6/23/26 identified Resident #232 was at risk for falls related to impaired mobility, hemiparesis/hemiplegia and use of psychotropic medications. The RCP indicated the resident had a potential for skin impairment related to immobility. Interventions included when in bed, floor mats were to be placed on both sides of the bed and to administer treatments as ordered and follow protocols for the prevention of skin breakdown.A Braden Scale for Predicting Pressure Sore Risk dated 6/8/26 identified Resident #232 was at moderate risk for pressure sore development. A physician's order dated 6/29/26 and currently in effect directed to offload heels while in bed every shift.A fall risk evaluation dated 6/18/26 identified Resident #232 was at risk for falls. The Nurse Aide (NA) care card (bedside kardex report) for Resident #232 directed when in bed, floor mats were to be placed on both sides of the bed.Observation on 7/31/26 at 9:47 AM noted Resident #232 in bed and without the benefit of having his /her heels offloaded and without floor mats placed on both sides of the bed. Interview, observation and review of facility documents with NA #1 on 8/3/26 at 6:47 AM found Resident #232 in bed and without the benefit of having his/her heels offloaded and without floor mats placed on both sides of the bed. NA #1 indicated she was not aware the resident needed floor mats or his/her heels offloaded and she would need to check with the charge nurse. Review of the NA care card with NA #1 identified floor mats were to be in place on both sides of the bed when the resident was in bed. NA #1 stated she did not check the NA care card for Resident #232 before providing care. NA #1 attempted to locate floor mats and a pillow in the resident's room (to offload the resident's heels), but she was unable to locate either one.Interview, observation review of the clinical record with the Registered Nurse supervisor (RN #5) on 8/3/26 at 7:10 AM identified Resident #232 was in bed and without the benefit of having his/her heels offloaded and without floor mats placed on both sides of the bed. RN #5 indicated she was unsure if the need for floor mats was included on the kardex or if the resident had a physician's order to have his/her heels offloaded. Review of the NA care card and the physician's orders with RN #5 identified the floor mats and heels offloaded were identified in the resident's plan of care. RN #5 stated it would have been the responsibility of the charge nurse and NA to ensure the floor mats were in place to both sides of the bed and the resident's heels were offloaded when in bed, and she was unsure why that was not done. RN #5 attempted to locate floor mats and a pillow in the resident's room (to offload the resident's heels), but she was unable to locate either one. Further indicated if she had been made aware by the charge nurse or NA that floor mats were needed, she could have obtained them from the storage room downstairs. Interview with the DNS on 8/5/26 at 9:34 AM identified it was her expectation that Resident #232 would have had floor mats in place and his/her heels offloaded when in bed per the physician's orders and plan of care. The DNS indicated it would have been the responsibility of the charge nurse and the NA to ensure the floor mats were in place and the resident's heels were offloaded and she was unsure why that was not done. Further stated the NA should have reviewed the residents NA care card and when she was unable to locate floor mats, she should have informed the charge nurse or RN supervisor. Review of facility policy, Fall Prevention Program Policy, dated 1/25/26, directed a resident deemed to be at risk for falls will have a person-centered care plan initiated with interventions appropriate for that resident. Review of facility policy, Physician's Orders for Patient Care in Long Term, dated 10/31/25, directed the electronic medical record is the standard for processing and transmitting physician orders and orders are legally placed in the computer system. The receiving staff are to carry out the orders and telephone and verbal orders can be utilized.

Based on interviews, review of the clinical records and facility policy for 1 of 3 sampled residents (Resident #139) reviewed for respiratory care, the facility failed to ensure there was a Registered Nurse (RN) assessment when Resident #139 had a change in respiratory status and failed to ensure there were follow up nursing assessments and documentation. The findings include: Resident #139's diagnosis included acute cough, chronic obstructive pulmonary disease (COPD), and dementia without behavior disturbances. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #139 was moderately cognitively impaired and required total assistance for washing and dressing and supervision for toileting, transfers and eating. The Resident Care Plan (RCP) dated 6/10/26 identified COPD as an area of focus with interventions that included to monitor for signs and symptoms of respiratory distress, administer medications as ordered and effectiveness, keep head of bed elevated, monitor for signs and symptoms of respiratory infection and notify MD, and administer oxygen therapy as needed per MD orders. Physician orders dated 7/11/26 directed to administer Guaifenesin (cough syrup) oral syrup 100 milligrams (mg)/5 milliliters (ml), give 10 ml every 4 hours as needed for cough/congestion, Ipratropium-Albuterol (bronchodilator) inhalation solution 0.5-2.5 (3) mg/3ml, give 3 ml via inhalation (nebulizer) every 4 hours as needed for wheezing or SOB. A review of nursing notes revealed LPN #9 completed a Situational Background Assessment Recommendation (SBAR) Form on 7/29/26 at 6:45 AM indicating that Resident #139 had a blood pressure of 130/70 (normal), pulse of 105 beats per minute (normal 60 to 100), temperature of 98.1 Fahrenheit, pulse oximetry (oxygen saturation) 94% (normal), respirations 19 breaths per minute (normal 12-20), abnormal lung sounds of wheezing heard and a nonproductive cough. A nebulizer treatment and cough syrup were administered with good effect, and a COVID-19 antigen test was completed with negative results. The Advanced Practice Nurse Practitioner (APRN) was notified of the change in condition. The nursing notes failed to identify documentation that a Registered Nurse (RN) assessment was conducted when Resident #139 had a change in condition of his/her respiratory status on 7/29/26 at 6:45 AM or later in the day on the 7:00 AM to 3:00 PM shift. Furthermore, there were no nursing follow-up notes on 7/29/26 on the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts. APRN #1's progress note dated 7/29/26 at 4:18 PM revealed nursing staff reported that Resident #139 had a bad cough overnight. Resident #139 was assessed by APRN #1 (9 hours and 38 minutes after Resident #139's change in respiratory status) and identified that Resident #139 had an acute cough, unstable with decreased breath sounds with no SOB. An order was placed for stat 2 view chest x-ray and a completed blood count (CBC) and basic metabolic panel (BMP), continue with nebulizer treatments and Guaifenesin every 4 hours as needed for cough and monitor vital signs and for new or worsening symptoms. APRN #1's follow up progress note dated 7/30/26 identified that Resident #139 continued with ongoing cough with leukocytosis (elevated white blood cell/WBC), no respiratory distress and WBC count of 15.2 thousand (normal WBC is 4,000 to 11,000 per microliter of blood) with a upper respiratory infection. A new physician order was placed for Augmentin (antibiotic) 500-125 mg, give one tab every 12 hours and acidophilus (probiotic) 1 capsule two times a day for 7 days by APRN #1.Interview and review of nursing notes with RN #1 on 8/5/26 at 8:53 AM indicated that an RN assessment was completed when there was a change in condition from a resident's baseline. RN #1 indicated that an RN assessment probably should have been completed in the AM on 7/29/26 and that there should have been nursing follow up notes on the 3-11/11-7. Furthermore, RN #1 stated that the policy was that RN assessments were completed for changes in condition and follow up nursing notes. Although requested, a policy on RN assessment was not provided. The Change in Condition policy reviewed 12/25/26 directed, in part, when there is a change in a resident's condition, a change in condition evaluation will be completed by a licensed nurse. As part of the change in condition the licensed nurse should notify the medical provider and resident's family. The Declaratory Ruling by the Connecticut State Board of Examiners dated 1989, directs, in part, the LPN may participate in the nursing process by collecting, reporting, and recording subjective and objective data, but may not perform the nursing assessment independently.

Based on interviews, clinical record review and review of facility policies for 2 of 2 sampled residents (Resident #8 and Resident #138) reviewed for personal property, the facility failed to exercise reasonable care to protect a resident's property from loss or theft. The findings include: 1.Resident #8's diagnoses included mixed anxiety and depression, difficulty in walking and muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 8 had intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. Additionally, the MDS identified Resident #8 did not exhibit delirium, delusions or hallucinations.The Resident Care Plan dated 10/21/25 identified Resident #8 was independent for meeting emotional, intellectual, physical and social needs relating to preference for self-directed activities. Interventions included establishing and recording the resident's prior activity involvement and interests by talking with the resident, caregivers and family on admission and as necessary.A Social Service (SS) note dated 12/2/25 at 11:30 AM identified Resident #8 had an upcoming voluntary conservatorship Probate Court hearing on 12/5/25.A SS interim note dated 12/10/25 at 11:52 AM identified Resident #8 asked about getting a haircut/shave but did not yet have a facility account set-up due to pending conservatorship. SS asked the Unit Secretary to set-up a haircut and shave, which was scheduled for 12/11/25.A nursing note dated 12/30/25 at 12:53 PM identified Resident #8 stated he/she was missing $150.00, a room search was conducted and no money was identified, checked with the business office and Resident #8 did not have an account set up in the facility.A Patient/Resident Grievance form dated 12/30/25 identified Resident #8 reported he/she was missing $150.00. Additionally, the grievance form identified his/her wallet was empty but did not have an account in the facility and did not have a locked drawer in the room. A friend and former landlord confirmed he gave Resident #8 money ($154.00) on 12/8/26 and had a signed receipt for the delivery of the money. The resolution to the grievance was identified as providing Resident #8 with a locked drawer and encouraging him/her to set up an account in the facility. A SS note dated 12/31/25 at 10:23 AM identified Resident #8 was educated on the use of the lock on his/her nightstand to keep his/her money secured, and agreeable to opening a resident account in the facility.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. Additionally, the MDS identified Resident #8 did not exhibit delirium, delusions or hallucinations.Interview with Resident # 8 on 7/30/26 at 11:04 AM identified he/she had $150.00 stolen about 7 months ago stating nobody helped recover it even though he/she told a social worker and other people about the missing money.Interview with Resident #8 on 8/5/26 at 9:07 AM identified he/she asked a landlord/friend to bring an envelope from his/her apartment that contained $154.00. Once delivered, he/she took $4.00 to the hairdresser as a tip and left the rest in a white envelope on the television stand of his/her room, under the impression that it would be safe. However, the money went missing, and he/she just knew someone took it. Additionally, Resident #8 stated no one ever suggested reimbursement, and he/she was only told money should be put somewhere safe, provided with a lock box and assisted with an account for funds after the incident. Interview with Social Worker (SW) #1 on 8/4/26 at 1:52 PM identified that it was the facility's policy to provide lock boxes/locked drawers for residents that expressed wanting to keep anything of value safe and it was not routine to provide that to all residents. Additionally, SW #1 identified that although the business office and admission office offers residents the opportunity to open a facility bank account it was not offered to Resident #8 until he/she had money (after it went missing).The Personal Funds of Resident Policy reviewed 12/3/25 directed in part that it was the policy to safeguard the assets of resident by maintaining sufficient internal and external controls over our cash maintained on hand, in bank accounts and held by investment managers.2. Resident #138's diagnoses included dementia, diabetes, anxiety, and chronic obstructive pulmonary disease.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 was moderately cognitively impaired, used a motorized wheelchair, was independent with wheelchair mobility, required setup or clean-up assistance with eating, required substantial/maximal assistance with bed mobility and personal hygiene, and was dependent for toileting hygiene, lower body dressing, bed/chair/toilet transfers.The Resident Care Plan (RCP) dated 2/10/26 identified Resident #138 had a self-care performance deficit related to activity intolerance. Interventions included assistance of 1 staff member for dressing, and Resident #138 preferred to get up in the morning after breakfast.During a Resident Council meeting on 8/3/26 at 1:30 PM it was identified Resident #138 voiced concerns there was often no facility follow through for missing items and/or no reimbursement for lost items.Interview with Resident #138 on 8/3/26 at 2:30 PM identified that he/she was missing many clothing items including socks, pants and tops. He/she indicated the current outfit that he/she was wearing did not belong to him/her but was brought up from the laundry unclaimed items area because there were none of his/her own clothes available to wear. He/she further indicated that the missing clothing items were labeled, and his/her family had indicated they were not going to supply anymore clothing because he/she had missing clothing items so frequently.Interview with Person #1 on 8/3/26 at 3:06 PM identified Resident #138 was missing approximately 18 pairs of pants and tops to go with them. He/she indicated that the clothing was always labeled with Resident #138's name and that there was frequently no clothing inside his/her closet resulting in the need for him/her to wear other people's clothing that the staff bring up from the laundry area. He/she indicated that the missing clothing issue had been brought forward to the nursing and social worker staff and that Social Worker (SW) #1 and SW #3 have personally told him/her that they do not know where the clothes were. He/she further indicated that the social work department had indicated they would be purchasing Resident #138 new clothes about 1.5 months ago but he/she hadn't heard anything since and hadn't seen any new clothing. He/she further indicated that he/she had left multiple messages both by phone and through facility staff for the Administrator to call him/her to discuss concerns related to Resident #138, but the Administrator had not called him/her back.Interview with SW #3 on 8/5/26 at 10:45 AM identified she had lots of conversations with Person #1 and/or Resident #138 about missing clothing. She indicated that the most recent conversation about missing clothing was about 2 weeks ago and that Resident #138 had reported missing 11 pair of socks and lots of pants (12 pair). She indicated that her, RN #12, and a laundry staff member went to Resident #138's room to verify the missing clothing. She indicated that they found 11 pair of socks in Resident #138's drawer along with 4 pair of pants not including the ones he/she was wearing (5 total pair of pants). SW #3 indicated that Resident #138 had a big issue for a long time with pants going missing and that SW#1 had recently ordered 4 pair of pants. SW #3 indicated that Person #4 would bring new clothes to Resident #138 before they were labeled so that could contribute to them going missing. She indicated that although there was a section in the laundry area down in the basement for unlabeled clothing Resident #138 was not allowed in the basement so he/she could not go through those clothes to see if any belonged to him/her. Additionally, she indicated that she had not brought any of the unlabeled clothes up from the basement for Resident #138 to see if any of them belonged to Resident #138. SW #3 further indicated that she thought there were numerous grievances for Resident #138 for missing clothes. Interview and facility documentation review with SW #1 on 8/5/26 at 12:25 PM identified she had recently purchased 4 new pairs of sweatpants which had arrived earlier in the week for Resident #138 because he/she reported not having clothing. She indicated that she was aware Person #1 and/or Resident #138 had reported missing clothing on multiple occasions, but that she had spoken with Person #4 about the missing clothing. She indicated that she had filled out grievances for Resident #138's missing clothing many times. She was unable to identify what the difficulty was in preventing Resident #138's clothing from being lost but indicated that it was important that the family ensure everything was labeled. Additionally, she indicated there was an area in the basement where unlabeled clothing was kept, but that she had never brought any of those clothes up to Resident #138 to see if they belonged to him/her and stated that Resident #138 was not allowed down in the basement. Review of the undated Resident Rights directed for a safe environment and in part that the facility must take reasonable care in protecting property from loss or theft. Additionally, residents had the right to have prompt efforts made by the facility to resolve grievances residents may have.Review of the undated Resident admission Agreement directed in part that although the facility will work to see that misplaced belongings are recovered, the facility will not be responsible for any personal effects, valuables or money left in possession of the Resident.

Based on facility documentation, and staff interview for 30 of 40 employee files reviewed (Nurse Aide (NA) #2, NA #6, NA #8, NA #9, NA #11, NA #17, NA #21, NA #22, NA #23, NA #24, NA #25, NA #26, NA #27, Na #28, NA #29, NA #30, NA #31, NA #32, NA #33, NA #34, NA #35, NA #36, NA #37, NA #38, NA #39, NA #40, NA #41, NA #42, NA #43, and NA #44), the facility failed to ensure the required annual performance evaluations were completed. The findings include: 1. NA #2's date of hire was 12/7/10. A performance evaluation dated 4/16/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #2. 2. NA #6's date of hire was 1/13/20. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #6. 3. NA #8's date of hire was 3/5/24. A performance evaluation dated 3/5/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #8. 4. NA #9's date of hire was 8/2/22. A performance evaluation dated 4/13/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #9. 5. NA #11's date of hire was 1/12/09. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #11. 6. NA #17's date of hire was 9/6/22. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #17. 7. NA #21's date of hire was 4/15/24. A performance evaluation with a target completion date of 4/15/26 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #21. 8. NA #22's date of hire was 7/11/23. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #22. 9. NA #23's date of hire was 2/7/23. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #23. 10. NA #24's date of hire was 11/13/06. A performance evaluation dated 12/19/24 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #24. 11. NA #25's date of hire was 9/5/23. A performance evaluation dated 12/16/24 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #25. 12. NA #26's date of hire was 5/18/21. A performance evaluation dated 3/6/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #26. 13. NA #27's date of hire was 4/5/22. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #27. 14. NA #28's date of hire was 3/10/03. A performance evaluation dated 3/2/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #28. 15. NA #29's date of hire was 4/13/15. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #29. 16. NA #30's date of hire was 6/23/08. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #30. 17. NA #31's date of hire was 3/19/24. A performance evaluation with a target completion date of 3/19/25 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #31. 18. NA #32's date of hire was 7/20/21. A performance evaluation dated 3/25/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #32. 19. NA #33's date of hire was 3/7/23. A performance evaluation dated 2/25/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #33. 20. NA #34's date of hire was 5/13/29. A performance evaluation with a target completion date of 5/13/26 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #34. 21. NA #35's date of hire was 8/9/84. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #35. 22. NA #36's date of hire was 11/19/24. A performance evaluation with a target completion date of 11/19/25 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #36. 23. NA #37's date of hire was 5/5/03. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #37. 24. NA #38's date of hire was 11/19/07. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #38.25. NA #39's date of hire was 2/6/24. A performance evaluation with a target completion date of 2/6/25 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #39. 26. NA #40's date of hire was 12/7/21. A performance evaluation dated 4/22/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #40. 27. NA #41's date of hire was 10/28/19. A performance evaluation dated 7/2/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #41. 28. NA #42's date of hire was 11/9/92. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #42. 29. NA #43's date of hire was 3/10/14. A performance evaluation with a target completion date of 12/31/24 was provided by the facility but it was unsigned. Although requested, the facility could not provide a signed or current annual evaluation for NA #42. 30. NA #44's date of hire was 7/11/11. A performance evaluation dated 4/17/25 was provided by the facility. Although requested, the facility could not provide a current annual evaluation for NA #44. An interview and review of facility documentation with the Administrator on 8/6/26 at 1:55 PM identified the unit managers were responsible for ensuring the required annual performance evaluations for NA's were completed timely. Review of the performance evaluations provided by the facility with the Administrator indicated she was unable to provide more up to date or signed performance evaluations for the NA's identified and she was unsure why they were not done annually as required. An interview and review of facility documentation with the Director of Nursing (DNS) on 8/6/26 at 3:15 PM identified the unit managers were responsible for ensuring the required annual performance evaluations for NA's were completed timely. Review of the performance evaluations provided by the facility with the DNS indicated she was unable to provide more up to date or signed performance evaluations for the NA's identified and she was unsure why they were not done. Review of the facility provided NA staff roster with the DNS confirmed the roster represented the currently employed and working NA's at the facility. The DNS indicated that it was the policy of the facility that performance evaluations be completed annually and that she would work with the unit managers on getting them completed. Review of facility policy, Performance Evaluation Policy, dated 12/31/24, directed that all employees would receive regular and constructive feedback on their performance and performance appraisals would be completed annually on the employee's anniversary date. Managers are expected to complete all assigned responsibilities, including conducting performance evaluations, within designated timelines. The annual review will evaluate the employee's performance over the last year and reviews would be stored electronically inside the Human Resources Information Systems. All performance evaluations should be documented and signed by both the supervisor and the employee, and a copy of the completed appraisal form would be placed in the employee's electronic personnel file.

Based on review of facility documentation and interviews, the facility failed to provide follow-up to residents in attendance at Resident Council meetings related to resident concerns and failed to attempt alternative measures with a re-occurring issue. The findings include: A Resident Council meeting was conducted as part of the re-certification survey on 8/3/26 at 1:30 PM and attended by 7 residents (Resident #7, Resident #38, Resident #50, Resident #85, Resident #130, Resident #136, and Resident #138). Interviews with the residents in attendance at the meeting on 8/3/26 at 1:30 PM identified consistent complaints regarding missing laundry items with no resolution, poor food quality, delayed or absent response to call bells, and reports of being short staffed. Multiple residents complained that aides often appeared stressed out and had attitudes while caring for them. The residents reported that despite bringing these issues up during previous resident council and/or town meetings they have not seen any attempts by the facility to address them. Review of Resident Council minutes from September 2025 through July 2026 identified multiple concerns related to Nurse Aides (NAs) being rushed and not providing care timely that had been brought forth in Resident Council in September 2025, October 2025, November 2025, February 2026, and March 2026. Additionally, complaints regarding food were identified in August 2025, September 2025, October 2025, and January 2026. Review of the Resident Council meeting minutes for 9/29/25 identified 6 residents were in attendance. The minutes identified multiple staffing concerns from residents including, large caseloads and working their tails off and getting burnt out, when staff were hurrying, they don't take the time residents need and our bones hurt if you move them too fast. Residents further shared that staff members did not support each other and could be short and rude when answering a call bell despite residents seeing staff on their phones or chatting with each other at the nursing stations. Review of the Resident Council meeting minutes for 10/21/2025 identified 4 residents were present and indicated that minutes were accepted. The minutes failed to identify discussion of the actions taken by the facility to address the concerns brought forth by the residents at the September 2025 meeting regarding staffing concerns. Additionally, a resident residing on Ramage 2 identified that during mealtimes there was a delay in receiving lunch trays for residents who eat in their rooms because staff were pulled to the dining room. Review of the Resident Council meeting minutes for 11/19/25 identified 5 residents were in attendance and indicated that minutes were accepted. The minutes failed to identify discussion of the actions taken by the facility to address the concerns brought forth by the residents at the October 2025 meeting regarding staffing concerns. Additionally, residents from Ramage 2 and Ramage 4 had concerns regarding lack of staff, especially on weekends, and frequently pulling staff to other floors for call outs resulting in staff not familiar with their care needs.No Resident Council meeting was held in December 2025 Review of the Resident Council meeting minutes for 1/21/26 identified 4 residents were in attendance and indicated that minutes were accepted. The minutes failed to identify discussion of the actions taken by the facility to address the concerns brought forth by the residents at the November 2025 meeting regarding staffing concerns. Additionally, resident voices concerns again about inconsistency with NAs and that staff was noisy at night. Review of the Resident Council meeting minutes for 2/18/26 identified 5 residents were in attendance and indicated that minutes were accepted. The minutes failed to identify discussion of the actions taken by the facility to address the concerns brought forth by the residents at the January 2026 meeting regarding any of the concerns brought forward including staffing. Additionally, residents reported long wait times for call bells. Review of the Resident Council meeting minutes for 3/12/26 identified 3 residents were in attendance and indicated that minutes were accepted. The minutes failed to identify discussion of the actions taken by the facility to address the concerns brought forth by the residents at the February 2026 meeting regarding any of the concerns brought forward including staffing. Additionally, residents continue to share concerns regarding cold food, inconsistency with staff, staff rushing during care, call bells not answered timely, and staff talking loudly after 10 PM. Interview and observation with the Resident #7 on 8/5/26 at 9:30 AM indicated that he/she doesn't always see the minutes from the resident council meetings and that when he/she does, he/she puts them in his/her binder. He/she further indicated that they don't always include everything discussed at the meetings and didn't feel as though concerns were always resolved. Review of Resident #7 Resident Council meeting minutes binder identified the last minutes were from November 2025. Interview with the Director of Recreation (Dir Rec) on 8/5/26 at 11:45 AM indicated that it was the responsibility of both her and the Director of Social Services to take notes during meetings and every concern should be written down. The Dir Rec then takes both notes, types up the minutes, and hands them out, but admits she may have missed printing them for a few months. The Dir Rec further explained the residents are invited to a Town Meeting and then one representative from each unit meet monthly in Resident Council to bring forth the concerns. She indicates that they discuss the concerns but don't include them in the minutes. The Dir Rec stated there is no formal process to communicate out the concerns when the head of a department is not present during the meeting, she just types them up and leaves them in a book. She has no cadence to share the concerns with the Administrator. Additionally, in March she created a Follow Up Action Report to develop a response to concerns by appropriate department head, but they haven't been completed since March. Interview with the Director of Social Services (SW #1) on 8/5/26 at 11:56 AM indicated that she runs the meetings with the Dir Rec and leaves the notes with her to type up. SW #1 indicated that the concerns from the town meeting should be discussed and included in the Resident Council minutes but doesn't see them. SW #1 further stated that she was not responsible for any follow up with the department heads or the Administrator. Interview with the Administrator on 8/5/26 at 1:00 PM identified that she was aware of the Resident Council meeting schedule and pops into some of the meetings when she can. The Administrator indicated she does not review the minutes or meet regularly to review resident council concerns. The Administrator indicated there were some recurring concerns brought up but believe some residents bring up issues that are already addressed. Although requested, a policy with guidelines for resident council was never provided.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to properly transfer a resident which ultimately resulted in a fall with a laceration to the head and subdural hematoma. The findings include: Resident #1's diagnoses included dementia, difficulty walking, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a BIMS score of two (2) indicating short and long-term memory recall deficits and was dependent on staff for turning and repositioning when in bed and transfers getting in and out of the bed and chair. The Resident Care Plan dated 8/3/24 identified Resident #1 had a self-care deficit and was at risk for falls due to impaired balance, dementia, and poor safety awareness. Interventions directed assistance of two (2) with bed mobility and mechanical lift transfers. The nurse's note dated 10/16/24 at 12:00 PM identified the Nursing Supervisor, Registered Nurse (RN) #1, heard a loud noise from Resident #1's room at approximately 11:30 AM. The note indicated while Resident #1 was being transferred from the bed to the wheelchair the Hoyer lift strap disconnected, and Resident #1 fell to the ground striking their head on the Hoyer lift. The note identified the physician assistant was at the bedside to evaluate, Resident #1 had an open area to the back of the head and a bump on the head, there was a moderate amount of blood from the site, 911 was called and Resident #1 was sent to the hospital. The nurse's note dated 10/16/24 at 4:13 PM identified the charge nurse, Licensed Practical Nurse, (LPN) #1, was positioning the wheelchair about three (3) feet from the bed and as the nurse aide, Nurse Aide (NA) #1, was in the process of turning the Hoyer lift to place Resident #1 in the wheelchair, the back strap to the Hoyer lift pad came off the lift causing Resident #1 to fall out of the pad and hit his/her head on the Hoyer lift. The hospital record dated 10/16/24 identified Resident #1 sustained a scalp hematoma and a three (3) cm laceration to the right inferior occiput which was repaired with three (3) staples. A CT scan identified bifrontal petechial hemorrhage and a subdural hematoma. The resident was admitted for treatment and neurological monitoring due to multiple comorbidities. The nurse's note dated 10/21/24 at 9:26 PM identified Resident #1 was readmitted . A physician's progress noted dated 10/22/24 identified Resident #1 was stable with serial CT scans, was diagnosed with bifrontal petechial hemorrhages and subdural hematoma, was at baseline and directed to continue to monitor for worsening symptoms. Review of the facility's summary report dated 10/22/24 indicated Resident #1 was being transferred out of the bed to the wheelchair to go to the dining room. According to staff interviews and return demonstration utilizing the hoyer lift, the nurse aide, (NA) #1 holding the remote in her hand while maneuvering the mechanical lift, inadvertently hit the remote button which caused the sling to recline back which caused the strap to come off the hook. Interview with the Nurse Educator, RN #2, on 11/13/24 at 12:25 PM identified Resident #1's transfer was to be done with two (2) staff using a Hoyer Lift. RN #2 identified the proper transfer technique was to be done by two (2) staff working together as a team. A staff member stands on either side of the bed and assists the resident onto the lift pad and then the staff attach the top and bottom straps to the lift and ensure they are secure. Next, one (1) person assumes the role of the machine operator and the other person assumes the role of the guide or spotter of the resident's body. The guide would place their hands on the resident or sling during the transfer to ensure the resident remains in the proper position while the lift is being moved. The operator controls the machine by manipulating the machine up and off one surface and then moves to the proper position to the next surface and then lowers the resident. RN #2 identified NA #1 had been retrained on 3/15/24 and 4/16/24 for improper transfers prior to the incident on 10/16/24. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse, (LPN) #1, on 11/13/24 at 1:25 PM identified on 10/16/24, NA #1 asked her to assist in the transfer of Resident #1 and when she entered the room Resident #1 was already positioned on the lift sling and the straps were attached to the lift. The staff utilized the correct sling size for Resident #1. LPN #1 indicated while she was positioning and holding onto the wheelchair, NA #1 began operating the lift and Resident #1 fell on to the floor. LPN #1 identified the expectation would have been for her to have had her hands on Resident #1 to assist in guiding the resident to the chair, but NA #1 moved Resident #1 too fast before she could get into the position to assist Resident #1. Interview with the Administrator and Director of Nursing (DON) on 11/13/24 at 2:00 PM identified that if a lift pad were to start to slide the staff responsible to guide the resident would be responsible to assist the resident. Both the Administrator and Director of Nursing identified the facility's investigation determined the cause of the fall was when NA #1 continued to hold the remote-controlled device in her hand while maneuvering the mechanical lift, inadvertently hit the remote button which caused the sling to recline back, and this caused the strap to come off the hook. The DON stated NA #1 was no longer employed at the facility due to ongoing issues with proper transfer techniques. Attempts to interview NA #1 were unsuccessful.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident environment remained as free of accident hazards as possible to ensure a resident with dementia and exit seeking behaviors did not have free access to a stairwell that resulted in a resident fall with polytrauma injuries which resulted in a hospital admission, and Resident #1 expired the following day. The failures resulted in a finding of Immediate Jeopardy for Resident #1. The findings include: The Administrator was notified of the Immediate Jeopardy on [DATE] at 3 PM. The immediate jeopardy was not removed by the exit date of the survey ([DATE]). Resident #1 was admitted on [DATE] with diagnoses that included Alzheimer's dementia, history of falls and anxiety. Review of the clinical record identified Resident #1 had a Power of Attorney (POA), and was admitted to a short-term unit (not secured unit). admission nursing assessment dated [DATE] identified Resident #1 was alert, confused, and not able to determine place, time, or situation. The assessment further identified Resident #1 required one staff assistance for toileting, was incontinent, and used a walker and wheelchair for mobility. Fall risk assessment dated [DATE] identified Resident #1 was at high risk for falls, and an intervention was initiated for intermittent checks between meals for safety. APRN note dated [DATE] identified Resident #1 was admitted after a fall at home and was disoriented. Review of the nurse's notes identified the following: note dated ,d+[DATE] at 5:50 PM and [DATE] at 7:16 PM identified Resident #1 was attempting to get out of bed independently and staff provided redirection. Note dated [DATE] at 7:07 PM identified Resident #1 was confused, agitated, complained of being confined and the facility was taking away his/her liberty, staff were unable to redirect, and Resident #1 ambulated in the hallway with a rolling walker with staff following. Note dated [DATE] at 5:58 PM identified Resident #1 was agitated, argued with staff, stated he/she was going to leave, put on his/her shoes and walking independently, and multiple attempts by staff to redirect were unsuccessful. Resident #1 spoke with family by phone, walked unassisted, and then was redirected to bed. Note dated [DATE] at 11:32 PM indicated Resident #1 was confused, was transferring and walking unassisted, and refused all medications. A Wanderguard bracelet was offered multiple times and Resident #1 refused. Resident #1 was continually exit seeking from 3:30 to 7:15 PM and staff provided redirection as Resident #1 self-propelled on the unit. The Resident Care Plan (RCP) dated [DATE] identified impaired cognitive function and risk for falls. Interventions directed to cue, re-orient and supervise as needed, to anticipate/meet needs, and intermittent checks in between meals for safety. Nurse's notes on ,d+[DATE] at 3:17 and 11:25 PM and [DATE] at 11:52 PM identified Resident #1 was self-transferring, walking unassisted, and was confused and education was provided. Note dated [DATE] at 4:08 AM identified Resident #1 was confused, blocked the door to his/her room, refused staff assistance and began walking in the hall barefoot stating he/she was looking to go to work, and staff provided redirection. Additional record review identified that although Resident #1 was identified to have confusion, wandering, and exit seeking behaviors (stating he/she was going to leave, donning shoes, stating he/she was going to work, stating he/she was being confined), the clinical record failed to reflect safety interventions were instituted when the wandering/exit seeking behaviors were identified. Review of the facility reportable event form dated [DATE] at 3:30 AM identified Resident #1 had an unwitnessed fall in a stairwell with complaints of rib pain and was transferred to the hospital. Facility investigation identified during the ,d+[DATE] shift Resident #1 refused to get undressed. NA #2 written statement dated [DATE] indicated she was assigned to provide care on the 11 PM to 7 AM shift. Her statement indicated that the 3 to 11 PM shift NA had informed her Resident #1 refused care and had refused to get undressed. NA #2 observed Resident #1 ambulating from his/her room to the nurse's desk and back to his/her room, and repeatedly opening/closing his/her room door. She offered care, Resident #1 accepted incontinent care and refused to change his/her clothes (remained in daytime clothes) and she left the room about 1:30 AM. NA #1's written statement dated [DATE] indicated at approximately 2 AM (3 AM due to the Daylight Savings Time change) she identified Resident #1 was not in his/her room. She notified LPN #1 (charge nurse) and NA #2, and a search of the unit was conducted with Resident #1 not located. NA #1 indicated that she and LPN #1 left the unit through the closed double doors at the north end of the unit and searched the adjacent area (clinic area). NA #1 indicated that upon looking through the window of a stairwell door, they saw Resident #1's walker and hat at the top of the stairs. They walked down the stairs and saw Resident #1 on the second (2nd) landing of the stairwell. LPN #1's written statement dated [DATE] identified when she searched the clinic area (adjacent to the nursing unit) with NA #1, she looked though the stairwell door window and saw Resident #1's walker and hat at the top of the stairs, and she opened the door, walked down the first (1st) set of stairs and observed Resident #1 lying on his/her left side on the second landing. LPN #1 notified the supervisor, called 911 and Resident #1 was transfered to the hospital. Nurse's note dated [DATE] at 3:46 AM identified Resident #1 was found in the [NAME] stairwell, level 1, lying on his/her left side. Resident #1 was awake, alert, had no head trauma. The APRN was notified, 911 was called and Resident #1 was transferred to the hospital. Review of the Emergency Medical Services (EMS) documentation dated [DATE] at 4:02 AM identified EMS was notified at 3:22 AM. Upon arrival EMS observed Resident #1 prone (face down) at the bottom of the stairs, and were informed by staff that Resident #1 broke out of the dementia unit on the second floor and unknown length of time ago and they just found Resident #1 at the bottom of the stairs. EMS estimated Resident #1 fell approximately 12 to 24 feet, anywhere between 10 to 20 steps as there was a landing that split the staircase in half. Resident #1 was alert, confused and crying but consolable. Resident #1 complained of left flank pain, had a left elbow skin tear, noted swelling of the left shoulder and left elbow, and had no neurological deficits. A cervical collar was placed, 02 was administered, IV access established and EKG was unremarkable. EMS departed the facility at 3:45 AM to transfer Resident #1 to the hospital. Review of the hospital discharge summary dated [DATE] at 2:26 PM identified Resident #1 was admitted to the Surgical Intensive Care Unit (SICU) for polytrauma after an unwitnessed fall, with a history of dementia, not on blood thinners and staff had found Resident #1 at the bottom of 10 stairs. Diagnoses included traumatic pneumothorax, left temporal bone fracture, left parietal subgaleal hematoma, right parieto-occipital SAH (subarachnoid hemorrhage), moderate left and trace right pneumohemothoraces, left side one through nine rib fractures, sternal fracture, left lateral clavicular fracture, left flank and posterior chest wall hematoma. Further, hospital CT imaging identified C7 and T1 fractures and left posterior neck hematoma. Resident #1 was placed on oxygen (02) at two (2) liters via nasal canula. Per family discussions Resident #1 was made Do Not Resuscitate/Do Not Intubate (DNR/DNI) and no painful interventions such as chest tubes, central line or blood draws. Resident #1 received Haldol (antipsychotic used to treat hallucinations and delusions) for agitation one to two times (dates/times not indicated). On [DATE] Resident #1's blood pressure decreased, and oxygenation worsened requiring use of a non-rebreather aerosol mask. Family was present, Resident #1 was made Comfort Measures Only (CMO) and treated with Morphine (for pain relief and to treat respiratory distress) for fractures and tachypnea (rapid breathing). Asystole (no heart movement) was noted at 12:39 PM, and death was pronounced at 12:50 PM. Interview, clinical record review and facility documentation review with the DON on [DATE] at 10 AM identified any resident who is exit seeking should be evaluated for a Wanderguard and have an intervention that is appropriate. The DON indicated Resident #1 should not have had independent access to the door to access the stairs. She further indicated that staff should have put specific interventions into place to keep Resident #1 safe when Resident #1 was observed to have exit seeking behaviors. Interview, clinical record review and facility documentation review with LPN #1 on [DATE] at 10 AM identified she was the charge nurse on [DATE] when Resident #1 was found at the bottom of the stairs. LPN #1 indicated she observed Resident #1 in hallway outside his/her room at 11:30 PM. She indicated that at approximately 2 AM (3 AM due to time change) she was notified Resident #1 was not in his/her room and a search was conducted. She indicated when Resident #1 was not found on the unit, she searched the adjacent area, looked though a stairwell door window, and saw Resident #1's walker and hat at the top of the stairs. She opened the door, walked down the first (1st) set of stairs and observed Resident #1 lying on his/her left side on the second landing. The supervisor was notified, and Resident #1 was transferred to the hospital. LPN #1 indicated Resident # 1 should not have been unattended and should not have been in the stairwell alone. Interview, clinical record review and facility documentation review with the Director of Rehab on [DATE] at 12:05 PM identified Resident #1 should not have had independent access to the stairwell. No facility policy was provided for surveyor review. IJ was not removed at exit on [DATE] because the facility failed to provide staff education regarding resident access to an unsecured door and interventions for wandering/exit seeking residents, and no audits and QA review was completed. A review of the facility Action Plan submitted [DATE] identified staff will be educated on residents with exit seeking behaviors, the appropriate interventions to be implemented immediately and the need for a hall monitor for continual monitoring ,d+[DATE] to limit access to stairwell doors. A house-wide audit has been initiated to identify any residents with exit seeking behaviors. Audits have been initiated to be completed every shift by the nursing supervisor or hall monitor presence. Audits will be conducted weekly for four (4) weeks and then monthly for three (3) months. Audits will be reported to the QAPI committed for review. A review of the facility ' s corrective action plan during an onsite visit on [DATE] identified facility staff education was initiated to ensure residents with exit seeking behaviors had appropriate interventions to be implemented immediately and the need for continual monitoring ,d+[DATE] to limit access to stairwell doors. A house-wide audit was initiated to identify any residents with exit seeking behaviors. Audits have been initiated to be completed every shift by the nursing supervisor or hall monitor presence. Jeopardy was identified to be removed on [DATE].

Based on clinical record reviews, review of facility documentation, and interviews for two of six sampled residents (Resident #1 and Resident #4) who were at risk for falls, the facility failed to provide supervision when the resident was off the unit, and/or use the appropriate assistive device (a gait belt) when ambulating the resident with a rolling walker and/or failed to complete a quarterly and/or change of condition fall risk assessment per the facility's policy and/or failed to have a nurse assess a resident prior to moving the resident after a fall. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. A quarterly minimum (MDS) data set [DATE] identified that the resident had severe cognitive impairment, severely impaired decision making skills, other behavioral symptoms that were not directed towards others, required extensive assistance with activities of daily living including transfers, non-ambulatory, and had difficulty with balance during position transitions. A care plan dated 7/25/18 identified that the resident was at risk for falls related to impaired mobility and severe cognitive loss from dementia with interventions that included to maintain a safe environment at all times. a. Review of the physician's progress note dated 8/22/18 at 11:43 AM identified that the resident had left foot bruising and a left foot x-ray was ordered. Review of a nurse's note dated 8/22/18 at 3:05 PM identified that the resident was laying on his/her right side on the x-ray table when she was noted to roll off the x-ray table and fell approximately 2 ½ feet onto the floor. Subsequently, Resident #1 did not have a loss of consciousness, but did suffer a [MEDICAL CONDITION] with moderate bleeding. Resident #1 was sent to the Emergency Department for an evaluation. Review of a hospital inter-agency report dated 8/22/18 identified that the resident was seen in the emergency department where sutures were placed for a [MEDICAL CONDITION]. Review of the nurses note dated 8/22/18 at 10:32 PM identified that the resident had returned to the facility from the emergency department at 6:30 PM with a [MEDICAL CONDITION] measuring 1.5 inches in length with 5 sutures in place. Interview with Nurse Aide (NA) # 2 on 1/15/19 at 10:23 AM identified that her and Registered Nurse (RN) #4 had taken Resident #1 down to the radiology department for an x-ray of the foot. They lifted the resident onto the table, and the radiology technician told her and RN#4 that they had to leave the room while the x-ray was taken. NA#2 further stated that RN#2 identified as they left the x-ray room, that she was nervous leaving the patient unattended on the x-ray table because of her cognitive status and that she looked unstable on the x-ray table. Interview with RN #4 on 1/15/19 at 1:00 PM identified that she and NA #2 had lifted the resident onto the x-ray table, and at that time she questioned the x-ray technician about placing straps on the resident. RN #4 identified she inquired about the straps because she was concerned about the resident's safety on the table because of the residents confusion, and positioning because his/her head was not flat on the x-ray table, and the resident looked uncomfortable, but was told that there were no straps on the x-ray table. RN #4 was then asked to leave the room by the x-ray technician and then asked to stand behind an adjacent door while the x-rays were taken, and although she had concerns about the resident's safety on the table when left unattended, she left the room because she was told to do so by the radiology technician. RN #4 stated that she went to the adjacent room, but was able to visualize the resident through a window in the door. RN #4 stated that she watched the resident through the window, the x-ray technician then changed the resident's position to get another view of the left foot, and then the x-ray technician left the room to take the x-ray (leaving the resident unattended in the x-ray room). Resident #1 slid off the x-ray table and fall to the floor sustaining a [MEDICAL CONDITION]. RN # 4 indicated that she could have called the nursing supervisor if she was concerned about the resident's safety on the x-ray table, but did not because she did not want to question another department. Interview with the Supervisor of Radiology on 1/15/19 at 1:40 PM identified that it was the facility policy that the resident should not have been left unattended on the x-ray table. Interview with the Director of Nurses on 1/15/19 at 1:30 PM identified that it was RN #4's responsibility to ensure the safety of Resident #1 while in the x-ray room, she should have called the nursing supervisor and the supervisor could have addressed the issue. The DON further stated that after the incident, the facility purchased safety straps for the x-ray table as an added safety measure. Attempts to interview the x-ray technician were unsuccessful. Review of the facility policy for radiology patient safety dated 7/25/16 identified that the resident should never be left unattended on the x-ray table. b. Review of the clinical record identified that the last fall assessment that was completed for Resident #1 was on 8/17/17 (1 year and 5 months ago) and identified that the resident was a high risk for falls. No further fall risk assessments were completed for Resident #1. Interview with the Director of Nurses on 1/15/19 at 1:30 PM identified that the fall risk assessment for Resident #1 had not been completed since 8/17/17, the assessments should have been completed quarterly, but there was confusion in the nursing department as to whose responsibility it was. Review of the Facility's Policy on Fall Prevention program directed that a fall risk documentation will be completed annually and quarterly with the MDS process, and with any noted significant change in condition by the Resident Assessment Coordinator/designee. 2. Resident #4's [DIAGNOSES REDACTED]. The Resident Care Plan dated 9/27/18 identified the resident was at risk for injury related to cognitive impairment, poor safety awareness secondary to the dementia, the resident needed reminders to ask for assistance and utilized a walker. Upon further review, the care plan identified Resident #4 had unwitnessed falls ambulating to the bathroom on 3/14/18 and 6/14/18 and on 9/19/18 ambulating in his/her room which resulted in an injury. Interventions directed to maintain a safe environment, to encourage the resident to call for staff assistance, non-slip and/or appropriate footwear to be worn, to keep the call bell in reach, and maintain the bed at the lowest position for safety. The quarterly Minimum Data Set ((MDS) dated [DATE] identified Resident #4 had some memory deficits, some difficulty with making decisions regarding tasks of daily life therefore requiring cues and supervision, required supervision of one (1) person when ambulating and limited one (1) person assistance with transfers, walking in the room, and toilet use, had utilized a walker and/or wheelchair for mobility and the resident's balance during transitions and walking was not steady, the resident was only able to stabilize with staff assistance. The Reportable Event Form dated 11/14/18 at 10:00 AM identified Resident #4 complained of right rib pain after losing his/her balance in the bathroom and leaning against the right handrail in the presence of a nurse aide. The summary of findings dated 11/16/18 identified Resident #4 was in the bathroom and during the process of undressing to use the toilet, the resident lost his/her balance, made contact with right handrail adjacent to the toilet, before sitting down on the toilet. Per the nurse aide, Resident #4's knees had buckled, causing the resident to become off-balance and clutch to the handrail, leaning against the rail with the right side. The summary indicated the nurse aide reported the incident to the charge nurse, Resident #4 was immediately assessed by the Advanced Practice Registered nurse (APRN) and an order was placed to obtain a chest x-ray secondary to the resident complaining of right sided pain. The x-ray was completed and showed multiple right side rib fractures. Upon notification of the x-ray results, the APRN ordered as needed pain medication, respiratory therapy [MEDICATION NAME], physical therapy, bloodwork and a urinalysis and a follow up appointment was made with the orthopedic physician for 11/20/18. Interview with the 7AM-3PM nurse aide assigned to Resident #4 on 11/14/18, Nurse Aide (NA) #3, on 1/14/19 at 3:20 PM she indicated that she was assisting Resident #4 to the bathroom to complete morning care and to use the toilet. NA #3 stated once in the bathroom, Resident #4 turned placing his/her back to the toilet and was holding onto the walker. NA #3 identified she assisted Resident #4 by pulling down the resident's pants at which time the resident lost his/her balance and fell to the right side hitting the metal handrail and then Resident #4 sat on the toilet. NA #3 stated she does not usually use a gait belt with Resident #4 because the resident starts to walk on his/her own with a walker most of the time and on 11/14/18 she did not utilize a gait belt when ambulating Resident #4 to the bathroom and assisting the resident onto the toilet. Interview with the Director of Nursing Services (DNS) on 1/15/19 at 2:00 PM identified that NA #3 should have used a gait belt to assist with and ambulate Resident #4 on the morning of 11/14/18. The DNS stated that gait belts must be used for all resident who are identified as supervision which consists of ambulating with walker with the assist of one and/or contact guard. Review of the facility's policy on Gait Belt Use directs that gait belts with be used to transfer and ambulate all residents who needs hands on or assistance in moving from one place to another. Review of the clinical record identified a fall risk assessment was completed on 3/14/18 which indicated a score of nine (9) therefore Resident #4 was a low risk for falls. Upon further review, the clinical record failed to reflect documentation that quarterly and/or change of condition fall risk assessments were completed after 3/14/18. Interview with the DNS on 1/15/19 at 2:00 PM indicated that the fall risk assessment should have been completed by the nurse after every fall and quarterly. The DNS identified the clinical record failed to reflect fall risk assessments were completed with each fall and/or quarterly after 3/14/18. Review of the Facility's Policy on Fall Prevention program directed that a fall risk documentation will be completed annually and quarterly with the MDS process, and with any noted significant change in condition by the Resident Assessment Coordinator/designee. The Reportable Event Form dated 11/21/18 at 3:00 AM identified Resident #4 was heard calling out for help and was found in the bathroom on the floor with his/her back facing the wall. The report identified the resident stated he/she was attempting to use the bathroom by him/herself, slipped and he/she hit his/her head. The nursing assessment completed identified the resident did not sustain any injuries from the fall. Review of the facility's investigation in a written a statement NA #4 indicated she heard a loud scream from Resident #4's room, she went into the resident's bathroom and found the resident on the bathroom floor with the his/her back facing the wall. The statement indicated NA #4 got the nurse aide assigned to the resident who then called the Nursing Supervisor. NA #4 wrote she stayed with Resident #4 and assisted the resident up off the floor and onto the toilet before the Nursing Supervisor came to the room and assessed Resident #4 and was not aware she should not move a resident before a nurse completes an assessment. Interview with NA #4 on 1/15/18 at 9:55 AM, she identified she heard a loud noise of someone calling for help coming from Resident #4's room and she went into the room and found the resident on the bathroom floor. NA #4 stated that he/she called for the resident's assigned aide and that aide went to get the Nursing Supervisor. NA #4 identified she moved Resident #4 from the bathroom floor to the toilet seat before the Nursing Supervisor came to assess the resident because the resident was independent with walking and could move on his/her own. Interview with the DNS on 1/15/19 at 2:00 PM indicated that regardless of a resident's ambulatory status, if a resident has a fall, the Registered Nurse needs to assess the resident before the resident is moved.

Based on clinical record review, review of facility documentation, and interviews for two of four sampled residents (Residents #24 and #245) reviewed for pressure ulcers, the facility failed to ensure measures were in place for the treatment and/or prevention of a pressure ulcer. The findings include: a. Resident #24's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified Resident #24's skin was intact on admission to the skilled nursing facility. A Braden assessment dated [DATE] identified Resident #24 was at moderate risk for breakdown. The admission Minimum Data Set ((MDS) dated [DATE] identified Resident #24 with severely impaired cognition, required extensive assistance with bed mobility, personal hygiene, and toileting, and was occasionally incontinent of urine and continent of bowel. The Resident Care Plan dated 3/29/17 identified Resident #24 was at risk for skin breakdown related to occasional urinary incontinence with interventions including to turn and reposition the resident every two hours. The Nurse's note dated 5/8/17 identified Resident #24 developed incontinence associated [MEDICAL CONDITION] to the coccyx and the bilateral buttocks. The physician's orders [REDACTED].#24 was provided with a low air loss mattress. The Nurse's note dated 6/12/17 identified Resident #24 developed an unstageable pressure ulcer to the coccyx, measuring 7.5 CM x 5 CM. The Wound Nurse (Advanced Practice Registered Nurse (APRN) #1) consult dated 6/26/17 identified Resident #24 with an unstageable deep tissue injury to the sacrum measuring 9.7 cm x 6 cm x 2 cm with 1.7 cm undermining. The same consult identified Resident #24 was on an alternating pressure mattress as well as a static air cushion for positioning out of bed, with documentation identifying the cushion has air pockets and the resident bottoms out. APRN #1 recommended an OT consult for the use of a ROHO pressure reducing cushion. The Wound Nurse (APRN #1) consult dated 8/15/17 identified Resident #24 was observed with the ROHO cushion, however it was under inflated. Consult identified the wound was a Stage 4 (following debridement) pressure ulcer measuring 6.8 cm x 5.2 cm x 0.9 cm with undermining. Review of the clinical record and interview with Licensed Practical Nurse (LPN) #1 on 1/8/17 at 11:00 AM identified that although there was no documentation in the clinical record to identify the use of a pressure reducing cushion, LPN #1 identified Resident #24 was utilizing an air cushion in the wheelchair and was able to recall the resident had been out of his/her bed in the wheelchair and when the aides returned Resident #24 to bed it was noted that the air cushion was deflated and the area to the sacrum was identified. A review of the Treatment Administration Record (TAR) for the months of (MONTH) and (MONTH) (YEAR) failed to reflect documentation to support the staff was monitoring the air cushion for inflation. Further review of the June, (MONTH) and (MONTH) (YEAR) TAR's failed to reflect that the staff was monitoring the inflation of the ROHO cushion. Interview with the Director of Nursing Services on 1/18/18 at 2:30 PM identified that there is no place for the staff to sign off on the monitoring of chair cushions, however the expectation was for the staff to check for inflation and identify when the cushion was not inflated. Interview with APRN #1 on 1/9/18 at 7:57 AM identified that he/she was able to recall Resident #24's wound and the circumstances surrounding the wound, including the deflated air cushion prior to the development of the deep tissue injury to the sacrum. APRN #1 further indicated that in the case of a resident with incontinence associated [MEDICAL CONDITION] the resident is at greater risk for breakdown and the pressure reducing cushion being deflated or under inflated absolutely contributed to the wound on the resident's sacrum. APRN #1 further identified he/she was able to recall finding the ROHO cushion under deflated as well indicating that staff should be routinely checking/monitoring the cushions for inflation. Review of the Skin Documentation and Surveillance policy and procedure identified that if the resident is considered to be at risk for skin breakdown or has skin breakdown, appropriate prevention measures will be initiated and the care plan will be updated to include these interventions. Prevention measures include, but are not limited to pressure reducing devices including wheelchair cushions. b. Resident #245's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #245 with impaired cognitive skills, required extensive assistance for bed mobility and transfers, with the absence of a pressure ulcer, and was at risk for developing a pressure ulcer. A care plan dated 11/27/172 identified Resident #245 was at risk for impaired skin integrity with interventions that included to turn and reposition every two hours and as needed, elevate heels off of bed, pressure relieving devices and check skin daily and report changes. Nurse notes dated 11/30/17 indicated that an open blister was noted on the right heel that measured 2 x 4 x 0,125 cm with a small amount of serosanguinous drainage. The APRN directed to cleanse the area with wound wash, apply [MEDICATION NAME] and cover with dry clean dressing. Review of the weekly wound assessment dated [DATE] indicated the area was now an unstageable pressure ulcer that measured 2 x 3 cm with a dry and boggy periwound after mechanical debridement. Clinical record review and interview with Dietitian #1 on 1/9/18 at 12:00pm identified that a dietary assessment was not completed until 12/14/17 (two weeks after the identification of the wound) with recommendations to initiate Promod 30ml twice a day, a nutritional supplement to aid in wound healing. Further interview indicated that a previous assessment was completed on 11/20/17 due to an erroneous entry of a blister of the left foot that was intact. Dietitian #1 indicated that an assessment was not completed due to this previous assessment. Review of the facility's policy on skin surveillance protocol indicated that if the resident has a skin breakdown, prevention measures will be initiated and the care plan updated to include interventions that included monitoring for adequate nutrition and hydration.

Based on clinical record reviews, review of facility documentation, and interviews for one of six sampled residents (Resident #1) who was reviewed for pressure ulcers and/or alterations in skin integrity, the facility failed to ensure a treatment was in place and/or that a wound was monitored to promote healing and prevent a decline. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified Resident #1 had some memory loss, required assistance with mobility, was incontinent of bowel and bladder, and was a moderate risk for skin breakdown and had moisture associated skin damage on the buttock. The nurse's note dated 9/18/17 identified Resident #1 had a macerated area in between the buttocks, the area was cleaned, dried thoroughly and Z-guard ointment was applied. A physician's orders [REDACTED]. The attending physician's progress notes dated 9/22/17 identified that she had reviewed the moisture associated skin damage with nursing and the area was improving with the use of the barrier cream and sealing agents. Review of the September and October 2017 Treatment Administration Record (TAR) failed to reflect documentation a treatment was administered to the macerated open area on the buttocks and although the TAR had a pre-printed order for the use of [REDACTED]. The physician's progress note dated 10/9/17 identified Resident #1's buttocks was assessed and the buttocks wound was a Stage 2, most likely due to a shear injury with surrounding moisture associated skin damage. The note identified there were several small one millimeter (mm) open areas to the superior arc around the larger area, distal to the Stage 2, and a small open area approximately 0.25 centimeter (cm) with 3 mm or less satellite area. Review of the clinical record failed to reflect documentation a treatment was put into place on 10/9/17 to address the Stage 2 and surrounding open area on the buttocks. The physician's progress note dated 10/12/17 identified a family member had asked if a wound care specialist had assessed the coccyx wound, the family member was told the facility did not have a wound specialist on site. The note indicated the nurses were tracking the wound on the wound tracking reports. Review of the clinical record failed to reflect documentation of wound tracking from admission on 9/18/17 until 10/13/17, the day before discharge. The nurse's note dated 10/13/17 at 3:45 PM identified that the moisture associated skin damage area had opened more, measured 7.0 centimeters (cm) by 1.0 cm in total, the entire area was not open, there were scattered small areas within the measurement, the coccyx area has a 2.5 cm by 1.0 cm open area, the areas were cleansed, and hydrogel and [MEDICATION NAME] were applied. The nurse's note dated 10/14/17 at 2:29 PM identified that the coccyx moisture associated skin damage area measured 2.0 cm by 1.0 cm by 0.125 cm and alongside of the right buttock fold the moisture associated skin damage area measured 5.5 cm by 1.5 cm by 0.125 cm in total with multiple small areas noted within that space, the area was cleansed and hydrogel and [MEDICATION NAME] were applied. The note identified a family member was at the bedside and was walked through the wound care. Resident was the discharged home on[DATE] at 12:10 PM. Review of the hospital clinical record identified Resident #1 was admitted to the hospital on [DATE] for a worsening Stage 3 pressure ulcer that measured 13.0 cm by 5.0 cm with a depth of 0.3 cm, purulent drainage was noted, the wound culture grew streptococcus and a seven (7) day course of Keflex, an antibiotic, was started, the Z-guard twice a day and as needed was continue and Xeroform cover was added to the treatment. Interview with Person #1 on 10/16/17 at 9:30 AM identified that when Resident #1 was discharged from the facility on 10/14/17, he/she was uncomfortable with the wounds appearance and his/her ability to care for the wound at home, therefore, he/she took Resident #1 directly from the facility to the hospital emergency department. Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #1, on 10/18/17 at 8:30 AM identified that she was Resident #1's charge nurse five (5) days a week, had received education on wound care through the facility, and it was her responsibility to assess her assigned residents. RN #1 stated that initially the treatment for [REDACTED]. RN #1 stated that initially the wound was identified as moisture associated skin damage. RN #1 identified that she had noted the wound to be bigger on 10/13/17 and although she changed the treatment to hydrogel and [MEDICATION NAME], she did not notify the physician of the deterioration in the wound. RN #1 stated that on 10/14/17, the day Resident #1 was discharged , she assessed the wound to be a Stage 2 and she did not notify the physician of the wounds decline. Interview with the Wound Nurse, Registered Nurse (RN #2), on 10/18/17 at 11:00 AM identified that when a wound was identified, a wound tracking from is filled out, and when the form is completed a report was generated, and this is how she would become aware of wounds in the building. RN #2 stated that she was unaware Resident #1 had wounds and was unable to locate any wound tracking sheets on Resident #1 and/or documented treatments to the wound on the Treatment Administration Record (TAR). RN #2 stated that if a resident was admitted with moisture associated skin damage she would expect a wound tracking form to be filled out and thereafter completed on a weekly basis, which would include measurements, general appearance, interventions and treatments. RN #2 identified that when the physician documented on 10/9/17 that the area was a Stage 2, the treatment should have been changed, and the clinical record failed to reflect documentation of a change in and/or any treatment to the area. Interview with the attending physician, MD #2, on 10/18/17 at 11:29 AM identified when Resident #1 was admitted to the facility, the resident had moisture associated skin damage on the buttocks, and a barrier cream would have been the appropriate treatment. MD #2 stated when she evaluated the area on 10/9/17 to be a Stage 2, she would expect the facility to monitor the wound and change the treatment order according to the facility wound protocol. MD #2 identified when wound had deteriorated on 10/13/17, she would have expected to be notified, and if she had been notified, she would have changed the treatment, possibly referred the resident to the wound care clinic, and/or may have postponed the resident's discharge on 10/14/17. Interview and review of the September and October 2017 Treatment Administration Records (TAR) with the Director of Nurses (DON) on 10/19/17 at 12:00 PM failed to reflect documentation treatments to Resident #1's buttocks were conducted from admission on 9/18/17 until discharge on [DATE]. The DON stated all wound treatments should be placed on the TAR, and signed off accordingly, and any area of moisture associated skin damage, and/or pressure are to be assessed weekly. The facility policy on the management of moisture associated skin damage identified that the nurse will document skin breakdown observations on the nursing admission data tool, appropriate interventions including incontinent care, skin barrier every shift and as needed will be implemented. The skin documentation and surveillance protocol identified that once a wound is identified and weekly thereafter, documentation will include the type of ulcer, location, color, drainage color, wound bed and appearance of surrounding tissue and be added to the wound tracking tool, and the physician will be notified to obtain a treatment order.

Based on a review of clinical records, facility documentation, and interview, and policies, for one of three resident's who sustained an injury (Resident #551), the facility failed to prevent a nephrostomy tube dislodgement during a transfer resulting in subsequent procedures. The finding includes: Resident #551's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition with a BIMS of 15. The MDS identified that the resident was dependent on two staff for transfer and had an indwelling catheter (nephrostomy tube). A care plan dated 1/26/16 identified that the resident was unable to ambulate and required a stand (Sara) lift with the assistance of two staff for transfers. A nurse's note dated 2/2/16 at 2:05 PM identified that RN #6 was called to the resident's room by a NA because the resident's nephrostomy tube became dislodged and completely removed from site during a transfer to the commode via Sara Lift. The record identified that the resident was transferred to the acute care hospital at 1:45 PM for replacement of the nephrostomy tube. The nurse's note dated 2/2/16 at 10:05 PM identified that a new nephrostomy tube was placed in the same incision with bloody urine draining in the bag. The family member stated the resident needed to return to the hospital for a subsequent procedure on 2/4/16 to remove some pieces left from the old tube. A nurse's note dated 2/15/16 identified that the resident had an impending surgery to remove the remaining pieces of the nephrostomy tube when unable to retrieve via cystoscopy on two (2) occasions (2/4/16 and 2/9/16). Record review and interview with the DON on 1/27/17 at 11:00 AM identified that she was unable to identify the specific staff involved in the transfer and/or the details of the transfer as the resident's ADL flow sheet was not completed by the NA as expected on 2/2/16 during the 7:00 AM to 3:00 PM shift and an investigation into the incident was not initiated. Review of the staffing schedule identified that RN #6 and NA #6 were assigned to care for the resident on 2/2/16. Attempts to contact NA#6 were unsuccessful at the time of the onsite investigation. During an interview on 1/27/17 at 1:45 PM, RN #6 identified that she unable to recall the specific details of the event but did recall that she was informed that the resident's nephrostomy tube got caught on something when the staff was transferring him/her with a mechanical lift. RN #6 was unable to specify which NA informed her but thought it was NA #7. During an interview on 1/27/16 at 2:35 PM, NA#7 was unable to recall the event and/or if she was involved in the transfer of Resident #551 on 2/2/16.

Based on review of the clinical record, review of facility documentation, review of facility policies, and interviews for two of four residents reviewed for accidents, (Residents #78 and #519), the facility failed to ensure that the resident's difficulty in transfers was addressed in order to ensure that care and services were provided to prevent an accident and/or failed to ensure that resident equipment was in safe working condition prior to resident use. The findings include: 1. Resident #78 (R #78) had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The annual MDS assessment dated [DATE] identified that R #78 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen, indicative of moderate cognitive impairment and required extensive assistance of one person for bed mobility, transfers and toilet use. The Resident Care Plan (RCP) dated 10/12/15 identified R #78's risk for injury due to impaired physical mobility and dementia with interventions that included to maintain a safe environment, use gait belt for transfers and OT and PT evaluations as ordered. Review of the clinical record identified an addendum nursing note entry dated 12/3/15 at 2238 (10:38 PM), identified that R #78 was very unsteady (that) evening, sat on the arm of the recliner when transferred, needed hands on guidance to sit on seat of recliner, had difficult following directions, and attempted to sit down multiple times before in position. An addendum nursing note entry dated 12/4/15 at 1353 (1:52 PM) identified that R #78 was found to be hard to transfer with the assistance of one person from the chair to the toilet. The nursing note identified that the resident complained of bilateral hip pain at the beginning of the shift but that the resident did not complain after breakfast. A nursing note dated 12/4/15 at 22:37 (10:37 PM) identified that R #78 had refused both breakfast and lunch on 12/4/15, that the resident was assessed by the Physician Assistant, and that a Physical Therapy order was obtained. Review of facility documentation that included an Reportable Event Form dated 12/7/15 identified a nurse reported that on 12/3/15, R #78 had sat down hard on the commode and subsequently complained of right sided hip and leg pain. Nursing notes dated 12/4/15 through 12/7/15 identified that R #78 continued to complain of pain when turning, was observed by staff to be grimacing during care, and was medicated on 12/5/15 for pain reported at a seven out of ten (zero being no pain and ten being the worst pain). Although an initial right hip x-ray obtained on 12/5/15 was reported as negative for a hip fracture, a pelvic x-ray was subsequently ordered on [DATE] based on the resident's continued complaints of pain and the need for analgesic medications. Review of the clinical record dated 12/7/15 identified that R #78 had sustained a minimal fracture of the right superior pubic ramus. Telephone interview with radiologist, MD #1, on 12/10/15 at 12:26 PM, MD #1 stated that he/she believed the fracture would have been caused by an impacting trauma, by bumping against something. Review of the facility's investigation included written statements from NA #6, RN #7, LPN #3, and NA #8 who all reported via written statements, that R #78 was known to them to sit hard and/or flop when transferring the resident from seat to seat. Interview and review of clinical record with RN #5 on 12/10/15 at 12:36 PM identified that R #78 had been assessed to required one person assistance for transfers but was unable to provide documentation/evidence that R #78 had difficulty with transfers, sat down hard or flopped in chair as reported via written statements by multiple staff members, prior to the identification of the resident's pelvic fracture. RN #5 stated that he/she was unable to locate any information in the record that indicated R #78's history of flopping/sitting hard when transferred was reported. The clinical record lacked documentation to reflect that R #78 was evaluated by Physical Therapy (PT) and/or Occupational Therapy (OT) since 2014. RN #5 further stated that NA #7 had assisted R #78 on 12/3/15 when it was reported that R #78 sat on the arm of the recliner but was unable to provide documentation of a statement by NA #7. NA # 7 was not available for interview. Interview and review of facility documentation with NA #6 on 12/10/15 at 1:04 PM, identified that he/she was the regular NA who provided care for R #78. NA #6 indicated that R #78 would always start to sit too soon when transferred, would end up sitting on the arm of the recliner or the commode handrails, and staff would have to guide R #78 onto the chair seat/toilet seat. NA #6 stated R #78 often sat hard or flopped into the chair or onto the toilet seat and that it was discussed with the nurses at shift report. Interview with LPN # 3 on 12/10/15 at 1:24 PM identified that he/she was the regular nurse on the unit and familiar with R #78. LPN # 3 stated he/she was aware that staff needed to guide R #78's bottom to sit on the chair/toilet seat as the resident sat down hard or flopped onto the seat. LPN # 3 stated he/she did not notify the nursing supervisor and/or rehab, and felt it was not really a big issue, that it was just how R #78 transferred. Interview with the Nurse Manager, RN #6, on 12/10/15 at 1:57 PM indicated that he/she was not aware of R #78's transfer issues that included attempts to sit down before he/she was over the chair or toilet seat and/or that the resident would sit down hard/flop into chair. RN # 6 further indicated that he/she would have wanted to know so that he/she could speak with the physician and obtain an order for [REDACTED].#78 was transferred properly. Interview with the DNS on 12/10/15 at 1:59 PM identified that he/she would have expected staff to obtain a physician's orders [REDACTED].#78 for transfers if R #78 had difficulty sitting down/sitting down hard or was attempting to sit down before he/she was over the seat. Review of facility policy on Physical Transfer directed in part, that residents would be transferred safely and that proper technique would be be utilized when moving residents from bed to chair and vice versa in order to avoid injuries. 2. Resident # 519 (R #519) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R #519 had a BIMS score of thirteen out of fifteen, indicative of intact cognition, and required extensive assistance of one person for transfer, bed mobility and toileting. Physician orders [REDACTED].#519 could ambulate ad lib with assistance. Review of facility documentation dated 11/19/15 identified that R #519 complained that a nurse aide was rough during care and had dropped the resident hard onto the toilet seat causing the toilet seat to break. Interview with NA #3 on 12/9/15 at 10:40 AM identified that on the night of 11/19/15, he/she arrived to assist NA #4 with R #519's care and that upon arrival, the resident was very restless. NA #3 stated that R #519 and NA #4 were standing at bathroom door and that he/she did not provide any care to resident at that time. NA #3 stated that at that time, R # 519 reported that the raised toilet seat was broken. Review of written statement and subsequent interview with NA # 4 on 12/9/15 at 11:45 AM, NA #4 stated that R #519 was restless, combative and had hit him/her several times during the shift. NA #4 indicated that he/she reported to the charge nurse R #519 was restless at about 1:00 AM on 11/19/15. NA #4 indicated that he/she was aware that the toilet seat was broken at the beginning of the shift. NA #4's written statement indicated that he/she assisted R #519 onto the toilet during his/her shift, even after he/she was aware that the toilet seat was broken. Review of written documentation and subsequent interview with RN #1 on 12/9/15 at 12:20 PM identified that R #519 reported that NA #4 was rough during care and had dropped him/her onto the toilet seat very hard causing the toilet seat to break. RN #1 indicated that NA # 4 did not report the broken toilet seat until after resident reported the allegation of mistreatment by NA #4. RN #1 further stated that upon inspection during the 7-3 shift on 11/19/15, the raised toiled seat was observed to be cracked and was removed from bathroom. RN #1 indicated that facility policy directed staff to report broken equipment immediately for removal and/or replacement. Nursing notes dated 11/19/15 identified that R #519 complained of testicular discomfort and that a testicular ultrasound was scheduled. During an interview with R #519 on 12/9/15 at 2:05 PM, the resident indicated that although he/she could not clearly recall incident, he/she might have pinched his testicle on the toilet seat. Review of facility documentation that included an investigation of R #519's allegation identified that NA #4 failed to report a broken raised toilet seat at the time he/she noticed it was broken and that education was provided to NA #4 with instruction to report broken equipment immediately for resident safety.

Based on clinical record reviews, review of facility documentation and interviews for two of six sampled residents (Resident #3 and #2) who were reviewed for falls, the facility failed to ensure the appropriate number of staff assisted with a transfer and/or failed to utilize an appropriate approach for a resident who was resistive to care to prevent an accident. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The care plan revision dated 2/11/15 identified that Resident #3 had a fall while ambulating with a nurse aide and rolling walker. Interventions directed an assist of two with ambulating, staff to utilize a gait belt, to utilize a rolling walker and one staff to guide the resident while the other follows closely behind with the wheelchair. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had moderate cognitive impairment, required extensive two person assistance for toileting, utilized a wheelchair for mobility, was occasionally incontinent of urine, always continent of bowel and a history of falls. The nurse's note dated 3/28/15 identified that the nurse aide reported Resident #3 was complaining of left knee pain. The nurse aide stated while being toileted Resident #3 felt weak and went down on one knee. The resident insisted on getting up, was able to grasp the side bars and assisted to pull him/herself up. The resident was transferred to the wheelchair and to bed with no issues. The note identified that the Advanced Practice Registered Nurse (APRN) assessed the resident and swelling was noted just below the left knee. Resident #3 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The Reportable Event Form dated 3/28/15 at 4:15 PM identified Resident #3 fell in the bathroom after being toileted. The investigation indicated that Resident #3 was yelling for assistance and attempting to get out of bed when Nurse Aide (NA) #5 was walking by the room. NA #5 went into the room, the resident was agitated and noted that the resident had a large bowel movement in the bed. In a written statement NA #5 identified that she placed the gait belt on Resident #3 and transferred the resident from the bed to the wheelchair and from the wheelchair to the toilet with no problem. The statement indicated Resident #3 stood so NA #5 could provide peri-care and apply a new incontinent brief. When NA #5 went to transfer the resident from the toilet to the wheelchair Resident #3's knees started to give out and the resident went down on one knee. NA #3 stated that Resident #3 was eager to get up and get to bed and was able to stand with guidance. After being assisted back to bed Resident #3 complained of left knee pain which was reported to the charge nurse immediately. Interview and review of the clinical record with the Acting Director of Nursing and the Acting Assistant Director of Nursing on 9/3/15 at 1:00 PM identified Resident #3 was an assist of two for transfers with a care plan change. Interview with NA #5 on 9/3/15 at 2:10 PM identified that as she was walking by Resident #3's room, the resident was calling out for assistance to the bathroom and appeared to be attempting to transfer independently out of bed. NA #5 stated that she transferred Resident #3 to the wheelchair into the bathroom and onto the toilet. NA #5 identified that she assisted Resident #3 to stand to provide peri-care and then Resident #3 sat down on the toilet. NA #5 stated that when she transferred Resident #3 to the wheelchair the resident lost his/her balance and fell on to one knee. Resident #3 refused to wait and NA #5 proceeded to assist the resident up and into the wheelchair. NA #5 stated that she was a float aide and had not gotten report but the unit manager directed her to review the resident care cards that on the inside of the resident's closet. NA #5 stated that she assisted the resident without the assistance of another staff member because the resident was already attempting to transfer and she did not use the call light and/or call for help. Review of the Nurse Aide job description directed that the nurse aide is responsible for following the treatment plan that was designed to meet the appropriate age, needs and abilities of each resident/patient including assisting with meals and nourishment's and transferring using proper body mechanics and appropriate assistive devices. 2. Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had moderate cognitive impairment, difficulty focusing attention, easily distracted, difficulty following what was said, required extensive one person assistance for transfer and personal hygiene, exhibited no behavior symptoms and/or rejection of care and utilized a wheelchair for mobility. The resident care plan dated 7/1/15 identified a problem of impaired physical mobility with need for assistance with transfers. Interventions directed an assist of one for transfers with gait belt. The Reportable Event Form dated 7/11/15 at 6:30 AM identified that Resident #2 was being transferred from the bed to wheelchair when the resident attempted to place him/herself on the floor while standing, the Nurse Aide (NA) was able to get assistance and lower Resident #2 to the floor to prevent an injury. The investigation indicated that Resident #2 did not sustain an injury, the resident denied pain, a fall analysis was conducted and the care plan updated. The nurse's note dated 7/11/15 at 6:47 AM identified that Resident #2 was difficult with morning care, crossing his/her legs and holding onto the johnny. The nurse aide was able to wash and dress the resident despite resistance. While being transferred Resident #2 attempted to throw him/herself down onto the floor and the nurse aide was able to lower the resident safely to the floor. Resident #2 was sitting in the wheelchair outside the room at 6:47 AM, will continue to monitor. The nurse's note dated 7/13/15 at 3:50 AM identified Resident #2 had facial grimacing while being checked for incontinence, the resident was sleeping on the right side and will continue to monitor. The note at 3:15 PM identified the resident continued with pain to the left leg, the resident was medicated with Tylenol at 8:50 AM, was seen by the Physician's Assistant and an x-ray of the left leg was obtained. At 9:59 PM Resident #2 continued with pain to the left leg with activity and the x-ray results were pending. The nurse's note dated 7/14/15 at 2:59 PM identified that Resident #2 continued with pain to the left lower extremity, mainly the hip and had some relief with medications, facial grimacing noted. The Physician's Assistant progress note dated 7/14/15 at 1:07 PM identified that Resident #2 had persistent left lower extremity discomfort and facial grimacing with range of motion and an x-ray of the left hip and ankle was ordered. The nurse's note identified Resident #2 had a left hip subcapital fracture and was transferred to the hospital at 2:55 PM. Interview with NA #2 on 9/1/15 at 2:25 PM identified she responded to NA #1 calling for assistance who had informed her that Resident #2 was combative during care. Upon entering the room, the resident was sitting on the side of the bed and NA #1 was positioned at one side of the resident. Resident #3 the reached out to NA #1's arm and slide of the bed, NA #2 indicated that she and NA #3 lowered the resident to the floor. NA #2 notified RN #1 of the resident's behavior. Interview with NA #1 on 9/1/15 at 2:4 PM identified that Resident #2 was typically quiet and an assist of one for transfer. NA #1 indicated on the morning of 7/11/15 although the resident was resistive to care she continued to provide care. NA #1 stated that she sat the resident up on the side of the bed and placed a locked wheel chair adjacent to him/her for transfer. When NA #1 asked the resident to stand for the transfer Resident #2 did not respond, at this point NA #1 laid the resident down in the bed and called for assistance, both NA #2 and NA #3 responded. NA #1 identified that Resident #2 was assisted to the side of the bed, held NA #1's hands, then suddenly grabbed NA #1's right arm and went down towards the floor. NA #1 indicated NA #2 and #3 grabbed the resident and lowered him/her to the floor. Interview with Registered Nurse (RN) #1 on 9/2/15 at 1:20 PM identified she was notified by NA #2 that Resident #2 was being resistant to care. Upon entering the room RN #1 noted the resident was dressed and sitting on the side of the bed. RN #1 stated that she was informed Resident #2 was lowered to the floor and then returned to bed. RN #1 indicated the resident was transferred to the wheelchair and brought out to the hallway by the nurse's station. Interview with NA #3 on 9/2/15 at 1:35 PM identified she responded to NA #1 calling for assistance to transfer Resident #2. Upon entering the room NA #3 observed Resident #2 was standing next to the bed and then the resident leaned forward. NA #3 indicated she assisted with lowering the resident to the floor and then putting him/her back to bed. Interview with the Acting Director of Nurses on 9/2/15 at 2:45 PM identified if a resident was resistive to care a nurse aide should leave the resident, return to resume care and report the behavior to the charge nurse.

Based on clinical record reviews, review of facility documentation and interviews for one of four sampled residents (Resident #129) who were reviewed for accidents, the facility failed to transfer the resident with the assistance of two staff using a Sara lift as outlined in the physician's order to prevent an injury. The findings include: Resident #129's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #129 had moderate cognitive impairments, physical behavioral symptoms exhibited through hitting, kicking, pushing, required extensive two person assistance with transfers in and/or out of the bed and chair, was non-ambulatory and a wheelchair was the mode of transport. The resident care plan dated 3/19/14 identified an activity of daily living deficit. Interventions directed assist of two for transfer with Sara lift. A physician's order dated 4/4/14 directed out of bed to the wheelchair assist of two staff. The Reportable Event Form dated 4/24/14 at 7:20 AM identified Resident #129 fell to floor in the room and sustained a right humeral neck fracture. The nurse's note dated 4/24/14 at 7:50 AM identified that Registered Nurse (RN) #2 responded to Resident #129's room and observed the resident lying on the floor, a pillow was under the resident's head, and the resident was gripping his/her right arm. The Nurse Aide reported that she had attempted to transfer Resident #129 from the bed to the wheelchair, the resident was unable to remain standing and she lowered Resident #129 to the floor. Resident #129 was weeping, guarding the right arm and would call out when the arm was touched. Resident #129 was transferred back to bed via the maxi lift. Subsequent to physician notification an x-ray was conducted which identified an acute right humeral neck fracture with medial and anterior displacement of the humeral shaft and mild overriding of the fracture fragments. Resident #129 was transferred to the hospital for an evaluation, the right arm was set and the resident returned back to the facility on the 3-11 PM shift with a sling and swath. The investigation indicated that during care Resident #129 began to lean forward when attempting to transfer and began to push him/herself forward holding onto the rail. The nurse aide was unable to support the resident and lowered Resident #129 to the floor. Interview with NA #3 on 1/21/15 at 3:00 PM identified that she was normally assigned to the dining room four days a week and would pick up a day a week on the unit. NA #3 indicated that she had not cared for Resident #129 in two to three weeks, was unaware that the care plan had changed and did not check the care card prior to providing care. NA #3 identified that when she attempted to stand and pivot Resident #129, the resident was unable to stand and she had to lower the resident to the floor. NA #3 heard a snapping noise as Resident #129 was lowered to the floor. NA #3 was aware that she should have checked the care plan prior to rendering care. NA #3 transferred Resident #129 alone and not using the Sara lift with another staff member as directed in the physician's order and the resident care plan. Review of the facility policy identified that all patient transfers and/or lifting is done safely and appropriate to protect the employee and patient from injury.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of five residents (R#7), who required [MEDICAL CONDITION], the facility failed to ensure that the resident received Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) as ordered on admission and/or for three of five resident's, failed to ensure physicians' orders were reflective of the residents' respiratory needs. The findings include: 1a. Resident #7's admitting [DIAGNOSES REDACTED]. Review of the interagency referral report dated [DATE] identified that the resident was to have [MEDICAL CONDITION] ,[DATE] every night. Review of the nurses' notes dated [DATE]-[DATE] identified that the resident was alert, orientated and on 3 liters of oxygen. Further review identified that the resident became easily short of breath and desaturated into the 70's with exertion,while her saturation levels returning to ,[DATE]%, while resting in bed. Further review failed to identify that the resident received her [MEDICAL CONDITION] from ,[DATE]-[DATE] (2 days). On [DATE] at 5:31 PM, Person #2 had indicated to the facility that the resident had not received his/her [MEDICAL CONDITION] for two days while the resident's home [MEDICAL CONDITION] machine was at the facility since admission. Review of nurse's notes dated [DATE] at 11:12 AM identified that the resident was not feeling well, and was unable to participate in occupational therapy. Resident #7's eyes were closed, appeared significantly short of breath and complained of nausea and being tired. Resident #7's oxygen saturation level was 75%-87% on four liters of oxygen. At 12:30 PM, Resident #7 was transferred to the hospital with respiratory difficulty and [MEDICAL CONDITION]. Subsequently, Resident #7 was discharged to home with Hospice services and expired on [DATE]. Review of facility policy identified that all physician orders [REDACTED]. Interview with the Nurse Manager on [DATE] identified that the admitting nurse did not follow up with the resident's [MEDICAL CONDITION]. b. Resident #10's [DIAGNOSES REDACTED]. Review of the nursing care plan dated [DATE] identified that although the resident was on [MEDICAL CONDITION], the plan of care identfied that the resident was to have [MEDICAL CONDITION] nightly this quarter. Review of the physician orders [REDACTED]. Subsequent to surveryor inquiry on [DATE], the Nurse Practitioner updated the physician order [REDACTED]. c.. Resident #11's [DIAGNOSES REDACTED]. Review of the nursing care plan dated [DATE] identified that the resident was to have oxygen along with [MEDICAL CONDITION]. Review of the physician orders [REDACTED]. Subsequent to surveyor inquiry on [DATE], the Nurse Practitioner updated the physician order [REDACTED]. d. Resident #13's [DIAGNOSES REDACTED]. Review of the interagency referral report dated [DATE] identified that the resident was to have [MEDICAL CONDITION] set at 16 with a FiO2 at 30. Review of the history and physicial dated [DATE] identified that the resident was to receive [MEDICAL CONDITION] at a rate of 16. Review of the nursing care plan dated [DATE] identified that the resident had obstructive sleep apnea with [MEDICAL CONDITION] with no interventions noted. Review of the physician orders [REDACTED]. Further review failed to identify that the physician's orders [REDACTED]. Review of facility policy identified that the physician order [REDACTED].

Based on clinical record review and staff interview for two of five sampled residents reviewed for accidents ( R#81, R#182), the facility failed to ensure the residents were transported in a safe manner. The findings include: 1. Resident #81's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as moderately cognitively impaired, required extensive assistance with transfer and nonambulatory. A RCP dated 3/29/11 identified a problem with impaired physical mobility. Interventions included to use assistive device, observe for safety awareness and teach and reinforce safety precautions. A nurses note dated 6/06/11 identified that while R #81 was being transferred via a wheelchair to the dining room for supper, the resident placed a foot on floor while wheelchair was in motion. The resident screamed and the foot slightly twisted under wheelchair. No visible injuries were identified at the time. Fifteen minutes after the incident swelling was noted. The APRN was notified and an X-ray of right foot and ankle were obtained. An x-ray report dated 6/06/11 noted no evidence of fracture or dislocation. An APRN note dated 6/23/11 identified that R#81 complained of persistent right ankle pain and due to a [DIAGNOSES REDACTED]. A repeat X-ray of the right ankle was ordered. A subsequent x-ray report dated 6/24/11 identified a nondisplaced fracture through the tip of the lateral malleolus. A RE dated 6/06/11 identified that when the resident was being pushed in his/her wheelchair, the resident placed her right foot on floor while the wheelchair was in motion. An investigation was initiated and concluded that NA # 1 pushed the wheelchair which was without benefit of foot pedals, a standard practice at the facility. Interview with NA #1 on 2/15/12 at 1:30 PM indicated that on 6/06/11 she transported R#81 from his/her room to the dining room. She was unable to find the footrests in the resident's room and/or closet. NA#1 indicated that she instructed the resident to lift her legs during the transport and half-way to the dining room she felt resistance, and the resident yelled. NA#1 indicated that she stopped the wheelchair and noted the resident's right foot was twisted under the wheelchair. NA #1 further indicated she did not inform the nurse that she could not find the foot rests because she was in a hurry to get the resident to the dining room for the evening meal. Interview on 2/16/12 at 8:35 AM with the Director of Nursing indicated the expectation is the nurse aide should have applied the footrests to the resident's wheelchair prior to transport. She further indicated the nurse aide should have notified the nurse if unable to find the footrests so an alternate plan could have been implemented. 2. Resident #182 was admitted to the facility on [DATE], with a past medical history that included cerebrovascular accident (CVA), left-sided hemiparesis, and atrial fibrillation. An MDS dated [DATE] identified the resident as totally dependent for locomotion on and off the unit with one person physical assist. In addition, mobility devices used were a wheelchair or walker. A review of the hospital discharge summary identified that on 11/14/11 at approximately 6:40 PM, R#182 was being pushed down the hallway in a wheelchair by NA#8. The wheelchair foot pedal hit a shower chair that had been placed in the hallway which caused a sudden stop and resulted in R#182 to fall out of the chair onto the floor. An x-ray of the left shoulder dated 11/15/2011 identified a non-displaced distal clavicular fracture. Interview with NA# 8 on 2/16/12 at 2:45 PM identified that although she felt there was enough clearance in the hallway, P#182's wheelchair foot rest bumped the shower chair. In addition, NA#8 indicated that the wheelchair foot rest may have become improperly positioned while the patient was being wheeled down the hallway.

Based on clinical record review and interviews for two of three sampled residents identified with a significant weight loss ( R#6, R#42) the facility failed to provide care and services to prevent a weight loss. The findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s plan of care dated 9/16/11 identified a problem with nutrition with interventions that included obtaining weekly weights. Review of the clinical record identified that on 9/16/11 the resident weight was 181 pounds (lbs), on 9/20/11 - 170 lbs, on 9/23/11 - 169 lbs and on 9/27/11 164 lbs. A nutrition note dated 9/20/11 identified in part, that although the resident weight was 170 lbs on 9/20/11 via wheelchair (scale) and 181.1 lbs on 9/6/11 via bed scale sling, noting a significant weight loss of 6.1 % times 4 days, the Registered Dietician #2 identified that she didn't believe the significant weight loss was accurate as weights were obtained via different weight scales. It was further noted that the Resident was receiving [MEDICATION NAME] 40 mg daily, and was consuming 50 to 100% intake by mouth . It was further noted that the resident indicated that he/she was a fussy eater and reported that his/her usual body weight was 175 to 180 lbs. The resident ' s body mass index was identified as 28.4 and was further identified by the dietician as an overweight score. Although it was further noted that no nutritional recommendations were made at the time of the note, due to the question of the accuracy of the weights and indicated that the dietician would monitor the resident's weights with recommendations as needed, documentation was lacking to reflect that the resident's weight loss was addressed when an additional decline was noted Interview with RD #1 on 2/17/12 at 12:00 P.M. and review of the clinical record identified that the previous dietician was no longer employed at the facility, and so she was to have followed up with recommendations regarding the resident's weight loss. She further indicated that it was also nursing responsibility to address the weight loss as well. RD #1 indicated that there is a problem with the communication between the nursing and the dietary department and that she is presently working to resolve the problems. Interview with RN#2 on 2/17/12 at 1:15 P.M. and review of the clinical record identified that although the resident resided on her unit and was identified with a decline in weight, she believed that it was RD #1's responsibility to monitor the resident's weight. 2. Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#42's weight every week. A nutritional assessment dated [DATE] identified that the resident reported having poor appetite over past month with a 7 lb. (3.6%) weight loss. The assessment further identified the resident as having a weight loss trend for past 6 months and was at risk for unintended weight loss. A RCP dated 9/29/11 identified a problem with nutrition due to involuntary/unintentional weight loss of seven (7) pounds in past month and poor appetitive as per resident report, related to unknown etiology. Interventions included to obtain weights as ordered by the physician. An initial admission assessment dated [DATE] identified the resident as having no cognitive impairments and nutritional status as weight of 193 lbs and previous weight loss as unknown. Review of R#42's nutritional assessment and weight documentation as well as facility documentation identified that weights were obtained and documented on 9/28/11 as 193 lbs, on 11/08/11 as 174.2 lbs (loss of 18.8 lbs or a 9.8% weight loss) and on 12/8/11 as 175 lbs. Interview and review of R#42's clinical record with RD #1 on 2/17/12 at 12:15 PM identified that R#42's weights were not obtained weekly as directed by the physician . Additionally the RD#1 indicated that when there is a weight change of plus or minus 3 lbs. the resident must be reweigh. Review of the clinical record failed to reflect that weekly weights were obtained as per physician order [REDACTED].

Based on clinical record reviews, review of facility documentation and interviews for two of five residents reviewed for accidents (Residents #239 and #413), the facility failed to provide adequate supervision and/or follow the plan of care to prevent an accident with injury. The findings include: 1. Resident #239's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified short term memory deficit, some difficulty with decision making, total dependence for bed mobility and a history of falls. The care plan dated 9/10/10 identified a history of falls with interventions that included using two staff for turning and repositioning in bed and a landing matt on the door side of the bed. The resident profile dated 9/25/10 identified a history of falls with interventions that included providing one staff member on each side of the bed and all bed rails elevated on the side of the bed the resident is turning towards. The nurse's note dated 10/9/10 identified Resident #239 fell out of bed when Nurse Aide (NA) #3 turned the resident to apply a brief without the benefit of assistance. The nurse's note dated 10/10/10 identified the resident reported pain upon movement and the physician ordered an x-ray. The x-ray report dated 10/10/10 identified no fracture, however, directed to obtain an MRI if pain persisted. A subsequent x-ray report dated 10/11/10 identified a minimal impacted femoral neck fracture was hard to exclude and recommended to obtain an MRI. The MRI report dated 10/15/10 identified a right sub capital femoral neck fracture with minimal impaction and the resident was admitted to the hospital for surgical repair. Interview with NA #3 on 1/24/11 at 11:45 am identified she was aware two staff were required to provide care to the resident in bed, but on 10/9/10 she could not find assistance and proceeded to provide care without assistance. NA #3 further noted the resident fell on the side of the bed without the benefit of a floor matt. Interview with Unit Manager (UM) #1 on 1/24/11 at 11:00 am identified the resident had a history of [REDACTED]. UM #1 indicated NA #3 did not follow the plan of care on 10/9/10, which resulted in the resident falling out of bed and subsequently sustaining a fracture of the right femur. 2. Resident #413's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified short and long term memory deficits, moderate cognitive impairment, extensive assist for transfer with a mechanical lift, partial physical support needed for sitting balance and a fall in the past 31-180 days. The care plan dated 8/15/10 identified a risk for falls and dependence for transfers with interventions that included using assistance of two for transfer with a mechanical lift. The nurse's note dated 10/18/10 at 7:30 pm indicated at 6:50 pm the nurse was called to the resident's room by the nurse aide. The resident was noted hanging in the maxi lift in front of the wheelchair slipping through the maxi lift pad and the resident was assisted to the floor. Vital signs were within normal range and no injuries were noted on the initial assessment. The nurse's note dated 10/21/10 at 2:17 pm identified the resident complained of pain in the right shoulder with repositioning and range of motion was decreased. The physician was and notified and directed to obtain an x-ray of the right shoulder. The x-ray report dated 10/21/10 identified a dislocation of the right shoulder. The Orthopedic Consultation dated 10/22/10 identified a right shoulder dislocation that required manual manipulation to approximate. Interview with Nurse Aide (NA) #1 on 1/20/11 at 8:45 am identified NA #2 called her to assist with the transfer of the resident on 10/18/10. The resident was already in the wheelchair and the lift pad was underneath the resident when she entered the room. NA #1 indicated she did not check to ensure the clips were in place prior to initiating the transfer. NA #2 started the mechanical lift and the resident started to slide out of the lift pad. LPN #1 was notified and the resident was lowered to the floor. Interview with NA #2 on 1/20/11 at 9:30 am identified she placed the maxi lift pad under the resident and attached the clips by herself. NA #2 then went to seek assistance to conduct the transfer. NA #2 indicated she did not check to ensure the clips were still in place prior to attempting to transfer the resident with the mechanical lift. NA #2 further indicated she was unable to return the resident to a sitting position in the wheelchair and the resident slid down eventually resting with the upper body between the armrests of the wheelchair. Review of the facility mechanical lift policy and procedure identified two staff are required to prepare the resident for transfer with a mechanical lift and the clips are to be checked prior to conducting the transfer.