Every finding on record at Monsignor Bojnowski Manor, Inc

Based on interviews, record review, and review of facility policy for 1 of 5 sampled resident (Resident #13) observed during medication administration, the facility failed to ensure the nurse remained with Resident #13 while administering medication and for the only sampled resident (Resident #35) reviewed for abuse, the facility failed to ensure a Registered Nurse (RN) assessment was completed timely for a resident with an injury of unknown origin. Additionally, for 1 of 3 sampled residents (Resident #53) reviewed for accidents, the facility failed to initiate neurological (neuros) vital signs after Resident #53 hit his/her head. The findings include: 1. Resident #13's diagnoses included Alzheimer's disease, asthma, and constipation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had moderate cognitive impairment, requiring substantial to total assistance with activities of daily living (ADLs) cares/hygiene and partial/moderate assistance with mobility. A physician order dated 1/25/26 directed Miralax (Polyethlene Glycol) give 17 grams orally one time a day and a physician's order dated 5/4/26 directed Ipratropium-Albuterol Inhalation, 0.5-2.5 (3MG/3ML), 1 unit inhaled orally three times a day. Observation on 8/12/26 at 10:29 AM with Registered Nurse (RN) #1 identified Resident #13 was seated in an upright position in bed. RN #1 was observed to pour the nebulizer liquid (Ipratropium-Albuterol Inhalation Solution) into the nebulizer chamber. RN #1 applied the nebulizer mask to Resident #13 face and turned on the nebulizer machine. RN #1 indicated she needed to leave to go to the medication room to retrieve a medication ordered for Resident #13 that was not in the medication cart (Miralax). RN #1 left Resident #13 unattended in his/her room with the nebulizer mask in place on Resident #13's face, while the nebulizer treatment was running. The privacy curtain was partially pulled around Resident #13 rendering the resident not visible from the hallway. At 10:33 AM (4 minutes after RN #1 applied the nebulizer mask to Resident #13), RN #1 returned to Resident #13's room with Miralax retrieved from the med room. RN #1 poured a capful of Miralax powder into a cup of water at the med cart which was located outside the doorway of Resident #13's room with his/her back to the resident. RN #1 entered Resident #13's room, placed the cup of Miralax that was mixed with water on the bedside table and left the room to administer medication to another resident who was seated outside of Resident #13's room while Resident #13 continued with the nebulizer running. Resident #13 continued to self-administer the nebulizer treatment via mask. At 10:42 AM, RN #1 moved the med cart down the hallway approximately 30 feet away from Resident #13's room to wash his/her hands (still out of sight of Resident #13). The glass of water with the Miralax remained unsecured on Resident #13 's bedside table with Resident #13 continuing to self-administer the nebulizer treatment. Upon the surveyor re-entering the room, it was observed that Resident #13 self-removed the nebulizer mask. At 10:44 AM, RN #1 entered the resident's room, Resident #13 had already self-removed the mask. RN #1 confirmed that the nebulizer chamber was empty. At 10:46 AM, Miralax still remained untouched by Resident #13 and at the bedside on Resident #13's bedside table. RN#1 did not instruct Resident #13 to consume the Miralax upon leaving the room. Interview with RN #1 on 8/12/26 at 10:48 AM identified RN #1 usually stayed around the area during the med pass and poured medications for other residents while Resident #13 self-administered the nebulizer treatment and Miralax. (please refer to F 554) Interview and record review with the DNS on 8/14/26 at 10:05 AM identified that her/his expectation of the licensed nurses when administering medication would be to follow the facility's Medication Administration Policy. The DNS could not identify what the facility's policy was for Medication Administration. The DNS stated the Medication Administration Policy was lengthy and she/he would have to review it. The DNS stated RN #1 should have stayed with Resident #13 the entire time the nebulizer treatment and Miralax medication were being administered. Review of the facility's policy for Medication Administration identified that medications administered to a resident should be observed for the consumption of medication and administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 2.Resident #25's diagnoses included altered mental status, mild cognitive impairment of unknown etiology, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 was moderately cognitively impaired and required partial/moderate assistance with bed mobility and was dependent with toileting and transfers. The Resident Care Plan (RCP) dated 9/26/25 identified Resident #35 was at risk for alterations in skin integrity. Interventions included gentle handling during all transfers and care procedures and to inspect skin when providing care and report any issues as needed. A facility-initiated Accident and Incident report dated 11/2/25 (with no time indicated), identified the family of Resident #35 had reported to the charge nurse a bruise on the right eye of the resident. A nursing note written by Registered Nurse (RN) #1 and dated 11/2/25 at 7:00 PM (recorded as Late Entry on 11/3/25 at 12:22 PM) identified Resident #35's family member brought to the attention of the charge nurse about a discoloration above the resident's right eye. The nursing note failed to indicate a nursing assessment was completed when the injury was reported. A nursing note (RN #6) dated 11/3/25 at 10:12 AM (recorded as Late Entry on 11/5/26 at 10:15 AM) identified Resident #35 was alert and responsive with a discoloration to the right side of the right eye with skin intact and no swelling noted. The resident's family member had brought attention to the charge nurse about a discoloration above the resident's right eye. A nursing note dated 11/5/25 at 10:19 PM identified Resident #35 had black bruising to the right lateral orbital area and the resident had no grimacing or moaning. An update to Resident #35's RCP created on 11/6/26 identified an intervention which directed to educate the staff to report benign events to the charge nurse/supervisor. A nursing note dated 11/7/26 at 2:46 PM and 11/11/25 at 3:48 PM identified Resident #35 had bruising to the right eye which persisted with no signs or symptoms of infection. A facility Individual Staff Education form signed by RN #1 and dated 11/3/26 indicated bruising of unknown origin has to be reported immediately to the supervisor so an investigation can be initiated, and the charge nurse would report any bruising to the supervisor immediately. Interview and review of the clinical record with RN #1 on 8/17/26 at 11:23 AM identified she was the charge nurse working 11/2/25 on the 7:00 AM to 7:00 PM shift. RN #1 indicated Resident #35's family member informed her the resident had a bruised area on his/her face in the evening, but she failed to complete a nursing assessment of the resident or inform the nursing supervisor about the injury and stated she should have informed the nursing supervisor. Further stated that she was unsure why she did not do a nursing assessment of the resident but that she was a new nurse at the facility then and did not recall much about the incident with Resident #35. Interview and review of a written statement with the RN supervisor (RN #4) on 8/19/26 at 10:25 AM identified she was the RN supervisor working on 11/2/25 on the 7:00 AM to 7:00 PM shift. RN #4 indicated she was not informed of Resident #35's injury of unknown source (facial bruise) by RN #1 and should have been. RN #4 stated RN #1 could have completed a nursing assessment of the resident after the bruise was brought to her attention and she was unsure why that was not done, and further stated RN #1 was a new nurse. Interview and review of the clinical record with the RN supervisor (RN #6) on 8/19/26 at 10:43 AM identified she was the nursing supervisor who worked 11/3/25 on the 7:00 AM to 3:00 PM shift and completed a nursing assessment of Resident #35 the morning after the facial bruise was first reported. RN #6 indicated she was asked by RN #5 (the nursing supervisor who worked 11/2/25 from 7:00 PM to 7:00 AM) to complete a nursing assessment of the resident and stated her nursing note was put in as a late entry on 11/5/26 at 10:15 AM because she had failed to write a note when she completed her assessment of the resident on 11/3/25 (1 day after Resident #25's family reported the bruise). Further indicated she was unsure why a nursing assessment was not done by RN #1 of Resident #35's facial bruise when the injury was first reported. Interview and review of the clinical record and facility documents with the Director of Nursing (DNS) on 8/19/26 at 11:20 AM identified when RN #1 was notified by Resident #35's family member that the resident had a bruise on his/her face, the nursing supervisor (RN # 4) should have been notified, a nursing assessment should have been completed and an investigation should have been initiated. The DNS indicated Resident #35's injury was of unknown source and review of RN #4's written statement identified she was not made aware of the injury by RN #1. The DNS further stated RN #1 did not complete a nursing assessment of the resident after the facial bruise was reported to her and should have, but she was a new nurse and may not have known to do a nursing assessment. The DNS indicated that further education was provided to RN #1 after the incident. Attempts to contact RN #5 were unsuccessful. Review of facility policy, Abuse Prevention, undated, directed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Possible indicators of abuse include physical injury of a resident of unknown origin. The facility will make efforts to ensure all residents are protected during and after an investigation, examples include examining the alleged victim for any sign of injury, including a physical examination. 3. Resident #38's diagnoses included dementia without behaviors, insomnia, and restlessness and agitation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was severely cognitively impaired, required maximum assistance from 1 staff member for washing, dressing, toileting, transfers, and ambulation and moderate assistance from 1 staff member for bed mobility. The Resident Care Plan (RCP) dated 2/13/26 identified assistance with activities of daily living (ADLs) as an area of focus with interventions that included assistance of 1 staff for bed mobility, washing, dressing, stand/pivot, toileting and mouth care, provide incontinent care as needed, ensure glasses are available and are clean, honor refusals but remind of importance. Physician orders dated 3/19/26 directed, in part, activity level assist of 1 for bed mobility, stand/pivot to wheelchair (w/c), and assist of 1 wheelchair (w/c) level for toileting and ambulation assist of 1 using rolling walker and gait belt for 300 feet followed by w/c every day shift. A review of the Accident and Incident Report (A/I) dated 3/24/26 on 8/13/26 completed by Registered Nurse (RN) #6 identified that Resident #38 had a bruise to his/her forehead. The investigation concluded that Resident #38 hit his/her head on the side rail of the bed. A review of the clinical record on 8/14/26 failed to reflect that neurological assessments were initiated after Resident #38 hit his/her head on the side rail of the bed. Interview with the Director of Nursing (DNS) on 8/14/26 at 10:50 AM indicated that RN #6 should have initiated neurological checks on Resident #38 after the bruise on the forehead was identified. The DNS indicated that facility policy was that neurological checks were initiated whenever there was suspected injury to the head. The DNS could not explain why neurological checks were not initiated. Attempts to contact RN #6 were unsuccessful. The Observation of Neurological Signs Policy, not dated, directed, in part, observations are conducted to detect clinical manifestations of increased intercranial pressure. Observations are conducted, for example if a resident sustains a head injury. Neurological assessments are conducted every 15 minutes x4, then every 30 minutes x 2, then every hour x2, then every 4 hours x 5 unless otherwise indicated by the physician. Documentation will be completed on the Neurological Flowsheet.

Based on interviews, observations, review of clinical documentation, review of facility documentation and facility policy for 2 of 5 (Resident #5, and Resident #38) sampled residents reviewed for skin integrity and for 1 of 2 sampled residents (Resident #27) reviewed for abuse, the facility failed to ensure injuries of unknown origin (Resident #5 and Resident #38) were reported to the State Agency and for Resident #27, the facility failed to ensure the Nurse Aide (N/A) reported an allegation of involuntary seclusion timely to facility administration. The findings include: 1.Resident #5's diagnoses included dementia without behaviors, urinary tract infection (UTI), and diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 was severely cognitively impaired, was totally dependent on staff for activities of daily living (ADLs) and was a full mechanical lift for transfers. The Resident Care Plan (RCP) dated 6/21/26 identified needs assistance with ADLs as an area of focus related to cognitive deficits with interventions that included mechanical lift for transfers, bed pan for toileting, non-ambulatory, incontinent care per policy, mouth/denture care, at times refuses shower, fluctuates in ability to perform ADLS, assist with meals as needed, ensure hearing aids in daily, and transfers per MD orders. In addition, the RCP dated 6/21/26 identified skin as an area of focus with interventions that included arm sleeves as ordered due to purpura, dietary consult, follow facility skin protocol, incontinent care as need, inform responsible party of any new skin conditions, medications as ordered and monitor for any side effects and effectives, and weekly documentation on any skin alterations.Physician orders dated 7/4/26 directed to apply protective sleeves to bilateral arms for skin protection at all times, remove for care and apply to right hand petroleum jelly daily to maintain a moist healing environment for 3 days and cover with a non-adherent dressing.A facility Reportable Event (RE) form dated 7/4/26 identified that Resident #5 had bruising to both hands and a small 1-inch abrasion to the right hand. Only four statements were obtained from the 7:00 AM to 3:00 PM Nurse Aides (NA) who worked on 7/4/26 indicated they were unaware of how the bruising and abrasion occurred. The statements did not indicate if Resident #5 was wearing his/her protective sleeves. The investigation did not include statements from nursing staff from all shifts regarding the bruising to both hands and the abrasion to the right hand of unknown source. Furthermore, the bruises of unknown source were not reported to the Connecticut Department of Public Health (DPH) in the Facility and Licensing Investigation Section. (also refer to F 610).Interview and review of the RE with the Director of Nursing on 8/14/26 at 11:45 AM revealed that there was no conclusion on how Resident #5 obtained the injuries to his/her hands. The DNS stated injuries of unknown origin are reported to DPH if unable to determine how the injury occurred. Furthermore, the DNS indicated that the nursing supervisors were responsible for initiating an investigation, but she was responsible for ensuring a complete and thorough investigation is done. The DNS stated that the investigation lacked sufficient statements from nursing staff to determine how the injuries had occurred. Therefore, the bruises of unknown source should have been reported to DPH.2. Resident #38's diagnoses included dementia without behaviors, insomnia, and restlessness and agitation.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #38 was severely cognitively impaired and unable to participate in a Brief Interview of Mental Status (BIMS). Resident #38 required maximum assistance from 1 staff member for washing, dressing, toileting, transfers, and ambulation and moderate assistance from 1 staff member for bed mobility. Physician orders dated 5/6/26 directed to apply Geri-sleeves (a garment to protect fragile skin) on the upper extremities once a shift for bruising, activity level assist of 1 for bed mobility, stand/pivot to wheelchair (w/c), and assist of 1 w/c level for toileting and ambulation assist of 1 using rolling walker and gait belt for 300 feet followed by w/c every day shift.The Resident Care Plan (RCP) dated 5/14/26 identified assistance with activities of daily living (ADLs) as an area of focus with interventions that included assistance of 1 staff for bed mobility, washing, dressing, stand/pivot, toileting and mouth care, provide incontinent care as needed, ensure glasses are available and are clean, honor refusals but remind of importance. In addition, skin integrity was an area of focus with interventions that included Geri-sleeves or long sleeves, respect refusals, and follow facility protocols for treatment of injury.A facility Reportable Event (RE) form dated 6/18/26 identified that Resident #38 had a large bruise to his/her left arm. The investigation contained one statement from a Nurse Aide (N/A) who was not aware of the bruising to Resident #38's arm. The investigation contained no other statements from nursing staff from all shifts regarding the bruising to arm of unknown source. There was no conclusion on how Resident #38 might have obtained bruising to arm. Furthermore, the bruises of unknown source were not reported to the Connecticut Department of Public Health (DPH) in the Facility and Licensing Investigation Section. (also refer to F 610).Interview and review of the RE with the Director of Nursing (DNS) on 8/14/26 at 11:45 AM revealed the bruise of unknown origin was not reported to the State Agency and injuries of unknown origin were to be investigated and reported to the State Agency if unable to determine how injury occurred. The DNS stated that the investigation lacked sufficient statements from nursing staff to determine how the injuries had occurred and therefore, the bruises of unknown source should have been reported to the Stage Agency.3. Resident #27 diagnoses included dementia without behaviors, anxiety, and falls.The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #27 was severely cognitively impaired, was unable to participate in a Brief Interview of Mental Status (BIMS) and required moderate assistance of one staff member for washing, dressing, and toileting and was independent with walking, bed mobility, and eating. The physician orders dated 6/17/26 directed activity level was assist of 1 with transfers and ambulation with cane/walker every shift and a wanderguard check functioning, placed on left upper extremity (LUE) check every night shift for safety and check LUE every shift.The Resident Care Plan (RCP) dated 6/23/26 identified falls as an area of focus with interventions that included assist of 1 with ambulation, remind resident to use walker, ensure proper footwear, assist with toileting and ensure walker available. In addition, wandering was another area of focus with interventions that included wanderguard in place, check placement and functioning per facility policy, redirect resident as needed, and provide diversional activities.Observations on 8/13/26 at 11:30 AM, 8/14/26 at 9:30 AM and 1:00 PM noted Resident #27 was ambulating independently in the hallway with a rolling walker. A Reportable Event form dated 7/23/26 indicated Nurse Aide (NA #4) reported to nursing that on 7//8/26 on the 11:00 PM to 7:AM shift around 12:00 AM, NA #4 had observed NA #8 holding Resident #27's door closed so Resident #27 could not exit the room. NA #4 waited 5 days to report the alleged incident to the nursing administration. Once the incident was reported, the Administrator reported the alleged allegation of involuntary seclusion to the State Agency.Interview on 8/17/26 at 10:00 AM with NA #4 stated that she had witnessed NA #8 try to keep Resident #27's door shut when they heard Resident #27 trying to exit his/her bedroom. NA #4 stated she and NA #5 approached the door about the same time as NA #8 and immediately told NA #8 not to keep the door shut. NA #4 indicated that NA #8 let go of door handle right away and it was no more than a few seconds that the door was shut and that Resident #27 was not aware. NA #4 stated that she did not think too much of the incident but after discussing it with her family member, she decided it needed to be reported to nursing administration.Interview with NA #8 on 8/17/26 at 10:30 AM indicated that she worked Saturday evening on 7/18/26 doing 1:1 for another resident. NA #8 stated that Resident #27 had been wandering throughout the facility recently, had been going in and out of other residents' rooms and had a history of falls. NA #8 indicated that she was sitting in the hallway doing her 1:1 when Resident #27 attempted to exit the bedroom. NA #8 immediately responded and instinctively put her hands on the door to keep it shut so Resident #27 would not wander in the hallways. NA #8 stated that NA #4 and NA #5 responded at the same time to Resident #27 trying to exit the room and instruct NA #8 to let go of the door. NA #8 stated that she immediately let go of the door. NA #8 stated that Resident #27 exited the room and sat with NA #5.Interview with NA #5 on 8/17/26 at 3:30 PM indicated that Resident #27 attempted to exit his/her room on 7/18/26 when she and NA #4 were doing incontinent rounds around 12:00 AM. NA #8 put her hands on the door handle to keep the door closed. NA #4 an NA #5 immediately responded and told NA #8 that she could not keep the door closed to prevent Resident #27 from exiting the room. NA #5 stated that NA #8 immediately let go of the door and Resident #27 exited the room. NA #5 stated that they intervened before it became an issue, that was why she did not report what had occurred. Interview with the Director of Nursing (DNS) on 8/19/26 at 9:00 AM indicated that NA #4 did not report the incident immediately because she was unsure if it was an allegation of involuntary seclusion. The DNS stated that NA #4 told her that she had discussed her concerns with her mother regarding the observation of NA #8 holding the bedroom door shut when Resident #27 tried to exit the bedroom. NA #4 stated that her mother instructed her to report her concerns to administration at the facility. The DNS stated that abuse policy procedures direct staff to report any concerns of alleged abuse immediately. The DNS indicated that although NA #4 ultimately reported the incident, she should have reported immediately that evening to the nursing supervisor. Interview and review of facility documentation with Registered Nurse (RN) #9 on 8/19/26 at 11:00 AM indicated that NA #4 had reported to her the alleged incident that occurred involving Resident #27 and NA #8 on 7/23/26 around 12:00 PM. RN #9 stated the NA #5 said that NA #8 was doing 1:1 with another resident and sitting in the hallway, when Resident #27 was heard coming to the doorway to exit the room. NA #8 got up immediately and ran to the door holding the handle closed for a few seconds. NA #4 and NA #5 went to Resident #27's door at the same time and told NA #8 to let go of the handle as she could not force the door closed. NA #4 indicated that NA #8 immediately let go of the door handle and that if was not more than a few seconds to a minute that the door was closed. Interview with RN #7 on 8/19/26 at 8:30 AM indicated that she was the supervisor on 11-7 shift on 7/23/26 and that no staff reported any concerns regarding Resident #27 and if anything was reported, she would have contacted the DNS immediately. A review of the Abuse Prevention Policy, not dated, directed, in part, all new employees and existing employees will receive abuse training annually. Training will include prohibiting and preventing all forms of abuse, identifying what constitutes abuse, neglect, exploitation, and resident property, recognizing signs of abuse, reporting process of abuse.Provide residents, representatives, and staff information on how and when to report concerns, incidents, and grievances without the fear of retribution; and provide feedback regarding the concern.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure supervision to prevent a resident from leaving the facility without staff knowledge. The findings include: Resident #1's diagnoses included dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was severely cognitively impaired, had wandering behavior noted one (1) to three (3) of the prior seven (7) days that placed Resident #1 at significant risk of getting to a potentially dangerous place, and required supervision/touching assistance with transfers and ambulation with a walker. A physician order dated 6/28/2026 directed wander guard to the left ankle due to wandering, with check every shift for monitoring, and check function every night shift. Review of Physical Therapy Progress note dated 7/10/2026 identified Resident #1 transferred and ambulated with supervision or touching assistance. A facility Reportable Event (RE) Form identified on 7/12/2026 at 8:22 AM identified Resident #1 ambulated with one assist and a rolling walker, and at 3:52 AM Resident #1 was noted standing outside the door to the XXXXXX solarium at 3:52 AM. Resident #1 was redirected back inside the building. Additional RE information dated 7/13/2026 identified Resident #1 was previously identified as a wander/elopement risk and had a wander guard bracelet on the left ankle. Resident #1 was last observed about 3 AM in the hallway. Resident #1 exited from the dining room/recreation room, had walked approximately 300 feet from the door, was wearing night clothing: and non-skid slippers, and had no injuries noted. The RE Summary report dated 7/15/2026 identified on 7/12/2026 an alarm went off and staff identified the alarm was for dining room door and Resident #1 had exited building. A Dr. Hunt (search for a missing resident) was initiated and staff noted Resident #1 standing outside the XXXXXX solarium door. Resident #1 was returned to the building with no injuries identified and was placed on one-to-one (1:1) observation. Weather on-line search for Sunday, 7/12/2026 identified the weather between 2 AM and 4 AM was in the low 60's with zero precipitation. Record review identified nursing note dated 7/12/2026 at 8:49 AM by RN #1 (supervisor) identified Resident #1 was confused and wandered outside through a facility door. APRN note effective 7/12/2026 at 2 PM identified Resident #1 was seen for follow up and report of elopement. Resident #1 stated he/she did not know he/she could not go outside and thought a family member was waiting for him/her. Resident #1 was always confused, a PRN (as needed) Trazodone was given last night with no effect, previously with positive effect. Plan: schedule Trazodone 25 milligrams twice daily for anxiety and restlessness, and continue as needed Trazodone order, message left for responsible party. Review of RN #1 (supervisor) written statement dated 7/12/2026 identified at approximately 3:15 AM she was notified the exit door alarms were sounding. The statement indicated RN #1 was aware Resident #1 had been wandering during the shift and staff began searching. Resident #1 was located by LPN #1 and no injuries were identified. NA #2 written statement dated 7/13/2026 identified prior to providing other residents with care, she and NA #1 had asked LPN #1 to keep a close eye on Resident #1 who was wandering. Subsequently she noted the exit door alarms sounding. She notified LPN #1 of the alarm and that someone may have exited through one of the secured doors and stayed with another wandering resident while the search began. Although attempted, an interview with RN #1 and NA #2 were unable to be obtained during the survey. Interview and record review with NA #1 on 7/30/2026 at 10:53 AM identified on 7/12/2026 during the 11 PM to 7 AM shift, Resident #1 was not her resident, but she was familiar with him/her. Resident #1 had indicated he/she was looking for his/her spouse and NA #1 kept a close eye on the resident and frequently redirected him/her throughout the shift. NA #1 last saw Resident #1 at 3 AM. NA #1 indicated she and NA #2 were providing other residents with care and had asked LPN #1 to keep an eye on Resident #1 due to his/her wandering. Interview and record review on 7/30/2026 at 11:08 AM with LPN #1 identified he was the charge nurse on 7/12/2026 when Resident #1 was found outside. About 3 AM he was administered a resident medications when NA #1 and NA #2 asked him to keep an eye on Resident #1 who was wandering. LPN #1 stated he thought Resident #1 was in bed when he heard the alarms ringing about 10 minutes later. He and RN #1 began searching for Resident #1 and he saw Resident #1 standing outside looking through the glass doorway. He opened the door and let Resident #1 inside. Resident #1 does was not able to say what he/she was doing, and RN #1 assessed Resident #1 with no injury identified. RN #1 indicated Resident #1 apparently had gone out the dining room door. Interview and record review with the Administrator on 7/30/2026 at 11:55 AM with the Administrator identified he had watched a video recording of the 7/12/2026 incident. The Administrator indicated the video coverage did not cover the doorway or all the way down the (length of the) hall. The Administrator stated he viewed NA #2 looking at the alarm panel, with an alarm going off, and saw NA #2 turn it off and NA #2 did not leave area. The alarm went off again, and he then saw LPN #1 and RN #1 check the panel. The video showed a nurse go down the hall towards the dining room an appeared to initiate a Dr. Hunt (search for a missing resident) and staff began searching the building. On video footage LPN #1 was then seen bringing Resident #1 down the hall towards the nursing station. LPN #1 and RN #1 then brought Resident #1 to his/her room. Although requested, facility video surveillance of the hallways was no longer available. Interview and observation with Director of Maintenance and Administrator on 7/30/2026 at 12:18 PM identified the alarm indicated Resident #1 exited through the dining room door near a fenced area that surrounds most of the building. Interview and record review with the DNS on 7/30/2026 at 1:58 PM identified on 7/12/2026 identified Resident #1 was last seen by NA #1 at 3 AM, walking down the hallway towards the dining room. The DNS stated the investigation indicated Resident #1 crossed the dining room, opened the outside door, and went outdoors. DNS indicated video footage identified staff responded to the alarm and located Resident #1 outside, and since the incident Resident #1 will remain on one-to-one (1:1) monitoring. The DNS stated it was all staff's responsibility to monitor residents. Review of facility Elopements and Wandering Residents Policy directed in part; the facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Adequate supervision will be provided to prevent accidents or elopements.

Based on clinical record review, facility documentation, facility policies and interviews for one (1) of one (1) sampled resident (Resident #1) reviewed for an allegation of involuntary seclusion, the facility failed to report a change in behavior to the physician when facility staff were unable to de-escalate Resident #1's increased agitated behaviors which resulted in facility staff placing Resident #1 in the medication room with the door closed for one and one half (1 1/2) hours. The findings include: Resident #1's diagnoses included dementia, insomnia, end stage renal disease, failure to thrive, and depression.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 9), unable to make reasonable and consistent decisions regarding tasks of daily living, was dependent with all care including bed mobility and transfers, and was wheelchair bound. The Resident Care Plan (RCP) dated 12/23/25 identified Resident #1 had a self-care deficit. Interventions directed staff to assess the resident every shift and if Resident #1's mood was declining to order psychiatric services.Review of the nurse's notes from 2/9/26 to 2/21/26 identified Resident #1 often yelled out continuously throughout the shift. Resident #1 would decrease yelling when brought into the hallway near the nurse's station. The Family Nurse Practitioner (FNP) note dated 2/12/26 identified Resident #1 was seen after having two (2) falls over four (4) days with increased confusion with a dementia diagnosis and anxiety. The FNP discussed with family members starting low-dose Trazodone in the evening for increased anxiety and restlessness, but the family member declined at the time.The Nurse's note dated 2/26/26 at 11:53 AM, documented as an addendum note for 2/24/26, by the Director of Nursing (DON) identified on 2/21/26 on the 3:00 PM to 11:00 PM shift, Resident #1 was placed behind the nurse's station in the medication room for close observation. Resident #1's family member, law enforcement, and the Advanced Practice Registered Nurse (APRN) were notified.Review of the nurse's notes and clinical record from 2/20/26 to 2/21/26 failed to identify the physician was notified of Resident #1 exhibiting an increase in agitated behaviors in the twenty-four hours leading up to the 2/21/26 incident.A written statement by NA #1 dated 2/26/26 identified she brought Resident #1 to the nurse's station because Resident #1 was anxious and trying to get out of bed. RN #2 (the 7:00 PM to 7:00 AM Nursing Supervisor) placed Resident #1 in the medication room. NA #1 was surprised because she never saw this done in the eight (8) years she worked at the facility and identified RN #2 said she did this because it was easy to watch Resident #1. A written statement by LPN #1 (the 11:00 PM to 7:00 AM Charge Nurse) dated 2/26/26 identified when she arrived for work on 2/21/26 at about 11:00 PM she saw Resident #1 lying in his/her wheelchair in the medication room with the door shut. She asked RN #1 why Resident #1 was in solitary confinement. RN #1 responded, He/she won't stop screaming and he/she has been yelling all evening. LPN #1 then asked RN #2 the same question and RN #2 responded, I am the supervisor and decided to bring him/her out here so other residents could get some sleep. LPN #1 then went into the medication room to check on Resident #1. The medication room door was unlocked. Sometime after 12:10 AM, LPN #1 asked the NA to check a full set of vital signs on Resident #1 which were normal. The NA then brought Resident #1 back to his/her room and Resident #1 slept for the remainder of the night.Review of the facility Summary Report dated 3/2/26 at 12:00 AM by the Director of Nursing (DON), identified facility staff members were interviewed and it was noted on 2/21/26, Resident #1 exhibited increased agitation and restlessness beyond Resident #1's baseline. At the end of the 3:00 PM to 11:00 PM shift NA # 1 brought Resident #1 to the nurse's station area due to Resident #1's restlessness and high fall risk. RN #2 determined that, due to Resident #1's increased agitation, restlessness, and high fall risk, it would be safest to maintain Resident #1 under direct observation. When attempting to position Resident #1 behind the nursing station, it was determined that his/her custom wheelchair wound not fit in the space. RN #2 placed Resident #1 in the medication room located directly behind the nursing station.Interview with RN #1 on 3/2/26 at 12:55 PM identified on 2/21/26 she worked from 3:00 PM to 11:00 PM. Resident #1 was screaming throughout the entire shift. RN #1 could typically redirect the resident but was unable to on 2/21/26. NA #1 was getting ready to end her shift and RN #2 directed NA #1 to bring Resident #1 to the nurse's station. RN #2 attempted to bring Resident #1 close to her behind the nurse's station but was unable to fit the resident with his/her wheelchair so she placed Resident #1 in the medication room with the door shut. Interview with RN #2 on 3/2/26 at 1:15 PM identified she placed Resident #1 in the medication room with the door shut because the resident was screaming and was trying to climb out of bed. She called the family member around 4:30 AM but had not called the family member prior to that to see if the family member could help de-escalate the situation. Interview with the DON on 3/2/26 at 1:35 PM identified she first heard about Resident #1 being placed in the medication room when randomly speaking to staff about interactions with RN #2. At that time, LPN #1 identified witnessing Resident #1 being placed in the medication room on 2/21/26. The DON identified staff should not have placed Resident #1 in the medication room and should have made a better decision or called her for guidance. After completion of their investigation the facility identified they would no longer utilize RN #2, who was an agency nurse, to fill vacant shifts. Although attempted, a call was not returned by NA#1 and LPN #1.Review of the facility policy for Dementia Care, directed in part that appropriate referrals (physician/mental health provider) would be made if current interventions were ineffective or the resident showed a decline in psychosocial, mood or behavioral status.

Based on clinical record review, facility documentation, facility policies and interviews for one (1) of one (1) sampled resident (Resident #1) reviewed for an allegation of involuntary seclusion, the facility failed to timely report the allegation of involuntary seclusion. The findings include:Resident #1's diagnoses included dementia, insomnia, end stage renal disease, failure to thrive, and depression.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 9), unable to make reasonable and consistent decisions regarding tasks of daily living, was dependent with all care including bed mobility and transfers, and was wheelchair bound.The Resident Care Plan (RCP) dated 12/23/25 identified Resident #1 had a self-care deficit. Interventions directed staff to assess the resident every shift, administer medications as ordered, encourage the resident to participate in care, and if Resident #1's mood was declining or the resident was self-isolating, to order psychiatric services and encourage the resident to express his/her feelings. Review of the facility Reportable Event Form dated 2/25/26, identified a staff member reported that on 2/21/26 at 10:58 PM, Resident #1 was seen in the medication room with the door shut. The facility initiated an investigation and made proper notifications at that time.The Nurse's note dated 2/26/26 at 11:53 AM, documented as an addendum note for 2/24/26, by the Director of Nursing (DON) identified Resident #1 was placed behind the nurse's station in the medication room for close observation. A written statement by NA #1 dated 2/26/26 identified she brought Resident #1 to the nurse's station because Resident #1 was anxious and trying to get out of bed. RN #2 (the 7:00 PM to 7:00 AM Nursing Supervisor) placed Resident #1 in the medication room. NA #1 was surprised because she never saw this done in the eight (8) years she worked at the facility and identified RN #2 said she did this because it was easier to watch Resident #1. NA #1 further identified she did not report the incident as abuse because she did not know RN #2 had done something wrong.A written statement by LPN #1 (the 11:00 PM to 7:00 AM Charge Nurse) dated 2/26/26 identified when she arrived for work on 2/21/26 at about 11:00 PM she saw Resident #1 lying in his/her wheelchair in the medication room with the door shut. She asked RN #1 why Resident #1 was in solitary confinement. RN #1 responded, He/she won't stop screaming and he/she has been yelling all evening. LPN #1 then asked RN #2 the same question and RN #2 responded, I am the supervisor and decided to bring him/her out here so other residents could get some sleep. LPN #1 then went into the medication room to check on Resident #1. The medication room door was unlocked. Sometime after 12:10 AM, LPN #1 asked the NA to check a full set of vital signs on Resident #1 which were normal. The NA then brought Resident #1 back to his/her room and Resident #1 slept for the remainder of the night. Interview with LPN #2 (the 3:00 PM to 11:00 PM charge nurse) on 3/2/26 at 12:35 PM identified she was not working on Resident #1's unit on 2/21/26 but saw staff placed Resident #1 in the medication room. LPN #2 questioned RN #2 about Resident #1 being in the medication room because she had never seen a staff member do that, but she did not receive an answer from RN #2. LPN #2 identified the medication room door was shut. LPN #2 further identified she had been trained in Abuse and Neglect and was aware Involuntary Seclusion was a form of abuse. LPN #2 identified she did not report the incident because Resident #1 was not her patient.Interview with RN #1 on 3/2/26 at 12:55 PM identified on 2/21/26 she worked from 3:00 PM to 11:00 PM. Resident #1 was screaming throughout the entire shift. RN #2 directed NA #1 to bring Resident #1 to the nurse's station. RN #2 placed Resident #1 in the medication room with the door shut. RN #1 did not report this as suspected abuse because she felt they were preventing the resident from falling and from waking up other residents.Interview with RN #2 on 3/2/26 at 1:15 PM identified she placed Resident #1 in the medication room with the door shut because the resident was screaming and was trying to climb out of bed. She did not feel this was abuse because she was watching Resident #2 while he/she was in the medication room.Interview with the DON on 3/2/26 at 1:35 PM identified she first heard about Resident #1 being placed in the medication room when randomly speaking to staff about interactions with RN #2. At that time, LPN #1 identified witnessing Resident #1 being placed in the medication room on 2/21/26. The DON identified staff should not have placed Resident #1 in the medication room and should have made a better decision or called her for guidance. After completion of their investigation the facility identified they would no longer utilize RN #2, who was an agency nurse, to fill in vacant shifts.Although attempted, a call was not returned by NA #1 and LPN #1.Review of the facility policy for Abuse, directed in part that any suspected abuse was to be reported to the Administrator immediately, but no longer than two (2) hours after an allegation of abuse is made.

Based on clinical record review, facility documentation, facility policies and interviews for one (1) of one (1) sampled resident (Resident #1) reviewed for an allegation of involuntary seclusion, the facility failed to ensure Resident #1 was not separated from other residents or his/her room when they placed the resident in the medication room with the door closed for one and one half (1 1/2) hours when Resident #1 exhibited increased agitated behaviors. The findings include:Resident #1's diagnoses included dementia, insomnia, end stage renal disease, failure to thrive, and depression.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 9), unable to make reasonable and consistent decisions regarding tasks of daily living, was dependent with all care including bed mobility and transfers, and was wheelchair bound.The Resident Care Plan (RCP) dated 12/23/25 identified Resident #1 had a self-care deficit. Interventions directed staff to assess the resident every shift, administer medications as ordered, encourage the resident to participate in care, and if Resident #1's mood was declining or the resident was self-isolating, to order psychiatric services and encourage the resident to express his/her feelings.Review of the nurse's notes from 2/9/26 to 2/21/26 identified Resident #1 often yelled out continuously throughout the shift. Resident #1 would decrease yelling when brought into the hallway near the nurse's station.The Family Nurse Practitioner (FNP) note dated 2/12/26 identified Resident #1 was seen after having two (2) falls over four (4) days with increased confusion with a dementia diagnosis, anxiety and further decline of oral intake. Resident #1 was in consultation with palliative care at the VA; however, the family was continuing all treatment at the facility. The FNP discussed with family members starting low-dose Trazodone in the evening for increased anxiety and restlessness, but the family member declined at the time.Review of the facility Reportable Event Form dated 2/25/26, identified a staff member reported that on 2/21/26 at 10:58 PM, Resident #1 was seen in the medication room with the door shut. The facility initiated an investigation and made proper notifications at that time.The Nurse's note dated 2/26/26 at 11:53 AM, documented as an addendum note for 2/24/26, by the Director of Nursing (DON) identified on 2/21/26 on the 3:00 PM to 11:00 PM shift, Resident #1 was placed behind the nurse's station in the medication room for close observation. Resident #1's family member, law enforcement, and the Advanced Practice Registered Nurse (APRN) were notified.A written statement by NA #1 dated 2/26/26 identified she brought Resident #1 to the nurse's station because Resident #1 was anxious and trying to get out of bed. RN #2 (the 7:00 PM to 7:00 AM Nursing Supervisor) placed Resident #1 in the medication room. NA #1 was surprised because she never saw this done in the eight (8) years she worked at the facility and identified RN #2 said she did this because it was easy to watch Resident #1.A written statement by LPN #1 (the 11:00 PM to 7:00 AM Charge Nurse) dated 2/26/26 identified when she arrived for work on 2/21/26 at about 11:00 PM she saw Resident #1 lying in his/her wheelchair in the medication room with the door shut. She asked RN #1 why Resident #1 was in solitary confinement. RN #1 responded, He/she won't stop screaming and he/she has been yelling all evening. LPN #1 then asked RN #2 the same question and RN #2 responded, I am the supervisor and decided to bring him/her out here so other residents could get some sleep. LPN #1 then went into the medication room to check on Resident #1. The medication room door was unlocked. Sometime after 12:10 AM, LPN #1 asked the NA to check a full set of vital signs on Resident #1 which were normal. The NA then brought Resident #1 back to his/her room and Resident #1 slept for the remainder of the night.Interview with RN #1 on 3/2/26 at 12:55 PM identified on 2/21/26 she worked from 3:00 PM to 11:00 PM. Resident #1 was screaming throughout the entire shift. RN #1 could typically redirect the resident but was unable to on 2/21/26. NA #1 was getting ready to end her shift and RN #2 directed NA #1 to bring Resident #1 to the nurse's station. RN #2 attempted to bring Resident #1 close to her behind the nurse's station but was unable to fit the resident with his/her wheelchair so she placed Resident #1 in the medication room with the door shut. The medication room had clear glass panels and Resident #1 was visually seen while in the room.Interview with RN #2 on 3/2/26 at 1:15 PM identified she placed Resident #1 in the medication room with the door shut because the resident was screaming and was trying to climb out of bed. She called the family member around 4:30 AM but had not called the family member prior to that to see if the family member could help de-escalate the situation.Interview with the DON on 3/2/26 at 1:35 PM identified she first heard about Resident #1 being placed in the medication room when randomly speaking to staff about interactions with RN #2. At that time, LPN #1 identified witnessing Resident #1 being placed in the medication room on 2/21/26. The DON identified staff should not have placed Resident #1 in the medication room and should have made a better decision or called her for guidance. After completion of their investigation the facility identified they would no longer utilize RN #2, who was an agency nurse, to fill vacant shifts.Although attempted, a call was not returned by NA#1 and LPN #1.Review of the facility policy for Abuse, directed in part that it was the facility's policy to protect the health, welfare, and rights of each resident. The facility would protect residents from involuntary seclusion which referred to the separation of a resident from other residents or his/her room against the residents' will or the will of the residents' representatives.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure medications designated for destruction and/or return to pharmacy were secured. The findings include: Observation on 1/30/25 at 10:28 AM identified the DNS office door opened and unoccupied with a yellow basket located on top of the medication safe that contained several blister packs containing medications. The office is located on a nursing unit and opens to the resident corridor. There was one resident seated in a chair located next to the nurses' station approximately 20 feet from the opened door/office. Observation on 1/31/25 at 1:18 PM identified the DNS office door open with medications in sight. The office was unoccupied, and four residents were seated in wheelchairs outside of the unoccupied office. There was no facility staff present in the area. Observation on 2/3/25 at 12:07 PM noted the office door opened with medications in sight and unsecured. Interview on 2/3/25 at 12:39 PM with RN#2 identified discontinued and expired medications are stored in a cabinet in the medication storage room. RN#2 indicated that the medications are kept there until taken by the DNS for destruction or return to pharmacy. Interview on 2/3/25 at 1:00 PM with the DNS identified that on a biweekly basis, medications that belonged to discharged or expired residents are removed from circulation and kept in a locked box in the DNS office. Some medications that need to be returned to pharmacy or destroyed are kept in the medication room. The DNS further identified that the medications in the DNS office are supposed to be destroyed; however, they had not yet been destroyed. Observation of the open office on 2/3/25 from 2:00 PM to 2:20 PM identified several ambulatory residents, and visitors in the corridor near the opened office. Interview on 2/3/25 at 2:22 PM with the DNS identified she did not secure the office door because she did not feel residents and visitors would enter the office. Medications present and unsecured in the yellow basket included: 1. Eliquis 2.5 mg tablet 5 tablets 2. Eliquis 2.5 mg tablet (6 pills) 3. Eliquis 2.5 mg tablet (22 pills left) 4. Amox-Clav 500-125mg (7 pills) 5. Cephalexin 500 mg capsule (14 pills) 6. Cephalexin 500mg capsule (30 pills) 7. Ciprofloxacin HCL (1 pill) 8. Cephalexin 500mg capsule (2 pills) 9. Ciprofloxacin HCL 250 mg (2pills) 10. Ciprofloxacin HCL 250 mg (1 pill) 11. Eliquis 2.5 mg tablet (22 pills) 12. Smz/TMP DS DS 800-160 mg (3 pills) 13. Cephalexin 500 mg (2 pills) 14. Prednisone 5mg (30 pills) 15. Minocycline HCL 100mg (4 pills) 16. Prednisone 5mg (22 pills) 17. Levofloxacin 500 mg tablet (1 pill) 18. Ciprofloxacin HCL f/c 250 mg (1 pill) 19. Midodrine HCL 10 mg (11 pills) 20. Eliquis 5 mg (22 pills) 21. Levofloxacin f/c 750 mg (2 pills) 22. Smz/TMP DS 800-160 mg tab (2 pills) 23. Cephalexin 500 mg (4 pills) 24. Cefuroxime f/c 500 mg (5 pills) 25. Levofloxacin 500 mg (2 Pills) 26. Levofloxacin 500 mg (1 pill) 27. Baclofen 5mg tab (30 pills) 28. Cefuroxime 500mg (3 pills) The facility policy for medication storage identified that all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security and indicated that the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for five of five sampled residents (Resident #12, Resident #31, Resident #43, Resident #46, and Resident #49) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed/and administered and failed to offer the influenza vaccine to residents (Resident #12 and Resident #31). The findings include: Resident #12's diagnoses included hypertension, osteoarthritis, and hypercholesterolemia. Review of the Resident Vaccine Consent form which consists of the pneumococcal vaccine consent identified Resident #12 gave the facility permission to administer the pneumococcal vaccine on 4/21/24 and on 7/7/24. Review of Resident #12's vaccination report failed a history of receiving the pneumococcal vaccine(s) or that he/she had been administered the vaccine while at the facility. Interview with the DNS (who is an Infection Preventionist (IP) and is covering for the IP) on 2/3/25 at 2:15 PM identified Resident #12 should have been offered and given the PCV 20 vaccine based on the resident's pneumococcal history. Resident #31's diagnoses included dementia, depressive disorder, and gastrointestinal hemorrhage. Review of the Resident Vaccine Consent form which consists of the Pneumococcal vaccine consent dated 4/21/24 identified Resident #31 indicated that he/she had received the PCV 13 vaccine in the past in the month of October of 2023. Review of Resident #31's clinical records failed to identify that he/she had received any of the pneumococcal vaccines while at the facility or documentation of having received them prior to being admitted to the facility. It also did not contain documentation that the resident had refused the vaccine. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 2/3/25 at 2:15 PM identified Resident #31 should have been offered and given the PCV 20 vaccine based on the resident's pneumococcal history. Resident #43's diagnoses included type 2 diabetes mellitus, peripheral vascular disease, and spinal stenosis. Review of the Resident Vaccine Consent form which consist for Pneumococcal vaccine consent identified Resident #43 gave the facility permission to administer the pneumococcal vaccine on 7/25/24. Review of Resident #43 vaccination report failed to identify any history obtained or inoculation of pneumococcal vaccine for the resident. Review of Resident #43's clinical records failed to identify that he/she had received any of the pneumococcal vaccines at the facility. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 2/3/25 at 2:15 PM identified Resident #43 should have been offered and given the PCV 20 vaccine based on the resident's pneumococcal history. Resident #46's diagnoses included sepsis, sleep apnea, chronic obstructive pyelonephritis and gout. Review of the Resident Vaccine Consent form which consist for Pneumococcal vaccine consent identified Resident #46 gave the facility permission to administer the pneumococcal vaccine on 10/30/24. Review of Resident #46 vaccination report failed to identify any history obtained or inoculation of pneumococcal vaccine for the resident. Review of Resident #46 clinical records failed to identify that he/she had received any of the pneumococcal vaccine at the facility. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 2/3/25 at 2:15 PM identified Resident #46 should have been offered and given the PCV 20 vaccine based on the resident's pneumococcal history. Resident # 49's diagnoses included dementia, hypercholesterolemia and psychotic disorder. The quarterly MDS assessment dated [DATE] identified Resident #49 had severely impaired cognition, and resident pneumococcal vaccine was up to date. Review of the Resident Vaccine Consent form which consist for Pneumococcal vaccine consent identified Resident #46 gave the facility permission to administer the pneumococcal vaccine on 9/27/24. Review of Resident #49's vaccination report failed to identify any history obtained or inoculation of pneumococcal vaccine for the resident. Review of Resident #49's clinical records failed to identify that he/she had received any of the pneumococcal vaccines at the facility. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 2/3/25 at 2:15 PM identified Resident #49 should have been offered and given the PCV 20 vaccine based on the resident's pneumococcal history. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine timing for adults identified that adults 65years or older have an option to receive the pneumococcal vaccine 20 (PVC 20) if they had already received both Prevnar 13 (PCV 13) at any age and/ pneumococcal vaccine (PPSV23) at or after age [AGE] years old and are eligible to receive after 5 years the PCV20 or another dose of the PPSV23 after shared decision with the provider and the patient. CDC also identify that an adult over the age of [AGE] years and had no prior vaccination of the pneumococcal vaccine are eligible for receiving the PCV20 vaccine or the PCV15 then after one year the PPSV23 vaccine. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 2/3/25 at 2:15 PM identified it is the responsibility of the infection control nurse on admission to review and assess vaccination status and obtain consents from residents. The DNS further identified the IP nurse is also responsible for obtaining the physician's order for the appropriate vaccine and input the order for the nurses on the unit or the IP nurse to administer the vaccine. The DNS identified she expects residents to receive the pneumococcal vaccine within 30 days of giving consents and for historically vaccine information to be documented in the preventative care section of the electronic medical record system. Review of the Pneumococcal Vaccination policy identified each resident would be assessed for pneumococcal immunization upon admission, self-reporting of immunization will be accepted. Any additional efforts to obtain information will be documented, including efforts to determine fate of immunization or type of vaccine received. Resident #12's diagnoses included hypertension, osteoarthritis, and hypercholesterolemia. Review of the Resident Vaccine Consent form which consist of the Influenza vaccine consent identified Resident #12 had signed the consent on 7/7/24 without selecting an option to receive, refuse, or provided vaccination history of receiving the vaccine. Review of Resident #12 vaccination report identified on 11/15/24 that the influenza consent was not obtained and was not on record for the resident to receive the annual flu vaccine. Review of Resident #12 clinical records failed to identify that he/she had received the influenza vaccination at the facility or had refused in the fall when the facility hosted the influenza vaccination clinic for the residents. Interview with Resident #12 on 2/14/25 at 2:08 PM identified he/she could not recall the facility offering or administering the influenza vaccine to him/her in the fall of 2024. Resident #12 identified if it was offered, he/she would have accepted as the providers encourage him/her to receive the influenza vaccine. Resident #31's diagnoses included dementia, depressive disorder, and gastrointestinal hemorrhage. Review of the Resident Vaccine Consent form which consist of the Influenza vaccine consent identified Resident #31 had signed the consent on 4/20/24 indicating that he/she had already received the influenza vaccine in October of 2023. Review of Resident #31 vaccination report identified on 11/15/24 that the influenza consent was not obtained and was not on record for the resident to receive the annual flu vaccine. Review of Resident #31 clinical records failed to identify that he/she had received the influenza vaccination at the facility or had refused in the fall when the facility hosted the influenza vaccination clinic for the residents. Interview with Person #3 identified he/she could not recall the facility offering or signing any consent for Resident #31 to receive the influenza vaccine. Person #3 identified the only vaccine offered he/she recalled was the COVID -19 which consent was signed, and Resident #31 received the COVID-19 vaccine. Interview with the DNS (who is also an Infection Preventionist (IP) covering for the IP in her absence) on 1/31/25 at 1:30 PM identified Resident #12 and Resident #31 should have been offered and given the influenza vaccine as the resident was in the facility during the time the vaccine was being administered to all residents. The DNS indicated the IP nurse was out on leave at the moment who would be better able to answer why the resident did not receive the vaccine as she was only aware of this when she host the COVID-19 clinic on 1/21/25 that some residents who were in the building did not receive the vaccine. Review of the Influenza Vaccination Program policy identified to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza.

Based on review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #52) reviewed for hospice care and had the behavior of refusing care and medications, the facility failed to ensure the resident's care plan addressed the refusals of care and medication. The findings include: Resident #52 was admitted to the facility in October of 2024. Diagnoses included vascular dementia with agitation, anxiety disorder due to known physiological condition, open wound of unspecified front wall of thorax without penetration into thoracic cavity, disorientation and insomnia. The admission MDS assessment dated [DATE] identified the resident had intact cognition, required supervision or touching assistance with toileting, showering, and personal hygiene, independent with position changes and required supervision/touching assistance with transfers and walking. The assessment further indicated Resident #52 exhibited delusions, but did not exhibit physical or verbal behavioral symptoms directed toward others and did not exhibit rejection of care or wandering. The significant change MDS assessment dated [DATE] identified Resident #52 had intact cognition, was experiencing delusions, and did not exhibit rejection of care or wandering. The care plan dated 1/3/25 identified the problem of end-of-life requiring Hospice services, pain, and the risk for potential adverse effects of psychotropic medication. Physician's orders dated 1/12/25 directed an assist of one for transfers and ambulation with a rolling walker, monitor for side effects of medication and monitor target behaviors. The orders further identified the following medication orders: 1. Administer Lorazepam 0.5 mg 1 tab by mouth every six hours for anxiety 2. Administer Morphine Concentrate 20mg sublingually every three hours as needed for pain or shortness of breath 3. Administer Prochlorperazine Maleate 10mg by mouth every six hours as needed for nausea and/or vomiting. 4. Administer Seroquel 12.5mg by mouth twice per day 5. Administer Trazadone 25mg by mouth twice per day for anxiety, insomnia, and delusions. Review of nursing notes from 11/1/24 through 2/3/25 identified Refusals of care as listed below with no indication of re-approach or redirection: 11/17/24: Refused Trazodone this evening 11/18/24: Continues to refuse scheduled Trazodone 11/19/24: Continues to refuse scheduled Trazodone 11/23/24: Continued to refuse scheduled Trazodone 12/9/24: Refused scheduled Trazodone stating there was no need for sleeping aid 12/15/24: Refused HS Trazodone 12/16/24: Refused HS Trazodone 12/17/24: Refused HS Trazodone 12/23/24: Refused HS Trazodone 12/24/24: refused HS Trazodone 12/25/24: Refused HS Trazodone 12/28/24: Refused HS Trazodone 12/30/24: Refused Trazodone 12/31/25: Refused scheduled Trazodone 1/1/25: Refused Trazodone 1/15/25: Refused body check so post fall assessment not completed. 1/15/25: Refused vitals and remains combative 1/16/25: Refused medications and treatment to chest 1/22/25: Refused scheduled Trazodone 1/24/25: Refused Hospice assessment and was not cooperative. 1/25/25: Refused am medications, refused dressing change 1/28/25: Confused and non-cooperative with care. The medication administration record (MAR) for December 2024 identified Resident #52 refused Trazodone at bedtime 26 times out of 31 attempted administrations. The MAR for January 2025 identified Resident #52 refused 23 out of 31 attempted administrations at bedtime. The nurse's progress note dated 1/23/25 identified Resident #52 opted to discontinue radiation treatments for cancer and was placed on Hospice. The nurse's progress note dated 1/28/25 at 10:32 PM identified Resident #52 refused care by the hospice and identified he/she was able to manage. Interview on 2/4/25 at 10:50 AM with LPN#6 identified Resident #52 is redirectable but often refuses care and medications depending on the staff and the resident's mood. LPN#6 indicated that he reapproaches the resident with a good outcome usually. Interview on 2/4/25 at 11:07 AM with the DNS identified that when a resident has consistent refusals of care or medications, the supervisor and the provider should be notified. The DNS further identified the facility did not have a policy regarding refusals of care or refusals of medications, but she would expect refusals to be addressed in the resident's care plan. Interview on 2/4/25 at 11:29 AM with RN#2 regarding resident refusals identified that the RN Supervisor and the APRN should be notified, and the type and frequency of refusals should be identified. She further noted that when Resident #52 refuses, the staff should reapproach and if the resident still does not allow the treatment/care/medication, then the APRN should be notified. Additionally, RN #2 identified the care plan should have been updated to include interventions such as reapproach, etc. and indicated the MDS coordinator is responsible for making care plan changes. Further review of the care plan dated 1/3/25 failed to address Resident #52's behavior of refusing care, treatments and medications. Interview on 2/4/25 at 11:48 AM with LPN#4 (MDS Coordinator) identified he looks at the morning report/24-hour report and run reports back to the last time he reviewed the chart. When asked about refusals being reflected in the care plan LPN #4 indicated that the change in condition was reflected in the transition to Hospice Care. Additionally, LPN #4 indicated that there was a care plan that addressed refusal of showers and directed staff to redirect and honor resident's right to refuse. The care planning policy identified that the facility ensures residents have a comprehensive and individualized plan of care that will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing. The policy indicated that the care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status.

Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #16) reviewed for accidents, the facility failed to ensure the resident was provided accurate supervision to prevent an elopement and failed to ensure staff responded to the door alarm when the resident exited the building. The findings include: Resident # 16 's diagnoses included dementia, poly-osteoarthritis, restlessness and agitation. The elopement evaluation dated 6/24/24 identified Resident #16 was at risk for elopement. A physician's order dated 6/24/24 identified Resident #16 wander guard on right wrist and check bracelet application every shift, check function once a shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had severe cognitive impairment, required supervision with transfers and ambulation and had a wander guard (monitoring device that triggers an alarm) in place. The care plan dated 9/13/24 identified Resident #16 frequently wandered and was at risk for elopement from the building. The care plan interventions directed to offer and engage resident in an activity, apply wander guard and check function when resident is seen heading toward or lingering near an exit door, and offer to escort to another area of the building. The nurse's note dated 11/17/24 at 7:34 PM identified Resident #16 had eloped to the courtyard patio outside of the facility at approximately 5:50 PM and Resident #16 returned into the facility at 6:00 PM. Resident #16 was independent with ambulation and the wander guard was noted to the right wrist. Resident #16 was in the dining room which ended approximately at 5:30PM and he/she was noted ambulating back and forth in the St. [NAME] hallway. A body audit was completed with no noted injuries. The physician, responsible party and DNS were notified of the elopement. Review of facility Accident and Incident (A & I) report dated 11/17/24 identified Resident #16 had eloped outside to the courtyard patio, and he/she was seen knocking on the window outside the building at the end of the St [NAME] hallway. Further review of facility (A &I) report identified the timeline of events based on the facility cameras identified the following: 5:14 PM: Resident #16 was sitting in the dining room on the St. [NAME] unit. 5:35 PM: Resident #16 finished dinner and left the dining room. 5:39 PM: Resident #16 was noted sitting on a chair in the St [NAME] hallway near the nurses' station. 5:50 PM: The dining room was cleared from all residents, tables were cleaned, and lights were turned off and the door to the recreation room was closed but not locked. 5:55 PM: Resident #16 walked toward the dining room located on St [NAME] and there was no staff present in the St [NAME] hallway. Resident #16 opened the door that led to the dining room and closed the door behind him/her. The nursing supervisor was on the phone with a family member sitting at the nurses' station and was facing the St, [NAME] hallway. 5:56 PM: Resident #16 opened the door and walked out to the courtyard patio. 6:00 PM: LPN #2 walked out of a resident's room and walked toward the medication cart located near the St [NAME] lounge door, LPN #2 heard a knock on the window and saw Resident #16 knocking on the windows from outside in the courtyard. LPN #2 opened the door and brought Resident #16 back inside the building from the courtyard. 6:05 PM: Resident #16 was inside the facility and the St [NAME] rear door and St [NAME] lounge door were both alarming when resident brought into the facility. Observation on 1/29/25 at 10:30 AM identified Resident #16 was pacing back and forth without assistive device in the St. [NAME] hallway. A tour of the building with the DNS on 2/3/25 at 9:40 AM identified all doors that could lead to outside the facility are equipped with an alarm. The St [NAME] rear door where Resident #16 went out to the courtyard patio was equipped with a door alarm when opened and also the St [NAME] lounge area door was also equipped with a door alarm where Resident #16 was seen knocking on the window. The DNS identified that when a door is opened, there is an audible alarm and blinking red light at the alarm panel near the nurses' station. The alarm panel is labelled and will identify the door that has been opened. The tour further identified that the patio is enclosed but is not secure (a resident can exit the patio area through a gate). Interview and review of the facility timeline of events with the DNS on 2/3/25 at 9:30 AM identified Resident #16 was a high risk for elopement because of his/her independent ambulation and frequently wandering throughout the facility hallway. She identified that she received a call from her nursing staff because Resident #16 went out to the courtyard on 11/17/24. She also identified that she reviewed the facility camera the next day to review how Resident #16 accessed the courtyard without staff's knowledge. She identified that Resident #16 was seen walking in St [NAME] hallway and there was no staff at St [NAME] because they were taking care of other resident. Furthe, the recreation room leading to the St [NAME] dining room was closed but it was not locked. Resident #16 was able to open and exit the recreation door. She identified that all facility doors that lead to the outside are equipped with an alarm, and it will show an alert at the alarm panel near the nurses' station when a door is opened. She also identified that after this incident, the recreation door is now locked after dinner time. She identified that the courtyard patio was for resident use; however, any resident in the courtyard patio would need staff supervision. Interview with NA #2 on 2/3/25 at 3:20 PM identified that she was not the assigned nursing aide for Resident #16. She identified that she did not observe Resident #16 elope to the courtyard patio. She noted that she heard the door alarm at the alarm panel at the nurses' station, but she did not stop to investigate which door alarm was activated and noted that when the facility investigated the facility camera, she was seen walking by the alarm panel approximately three times without stopping to investigate which door alarm was activated. NA #2 further identified that she was given a verbal warning and education was provided regarding responding to the alarm. Interview with LPN #2 on 2/4/25 at 12:30 PM identified she saw Resident #16 knocking on the window in the courtyard patio at St [NAME] lounge door when she came out from a resident room, and she had not heard the alarm. She further identified that the St [NAME] rear door and St [NAME] lounge door were both active at the alarm panel when she brought Resident #16 back inside the facility. The Elopement and Wandering Resident's policy identified that the facility would ensure that residents who exhibit wandering behavior and/or at risk of elopement will receive adequate supervision to prevent accidents. The policy also indicated that the alarms are not a replacement for necessary supervision and staffs will be vigilant in responding to the alarms in a timely manner.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact. The findings include: Continuous observations of medication administration on 1/30/25 at 9:21 AM identified LPN#5 took Resident #34's blood pressure and then exited the room without performing hand hygiene. LPN #5 then preceded to the medication cart, prepared Resident #34's medications, and re-entered the resident's room and administered the medications. LPN#5 spoon fed the resident a few medications at a time and assisted the resident with drinking the water. LPN#5 then returned to the med cart and prepared an additional medication that Resident #34 had requested. It was noted that Resident #34 had a new complaint of rash to bilateral arms. At 9:45 AM, LPN#5 exited Resident #34's room, retrieved the blood pressure machine (which had been wiped down by the NA) and entered Resident 50's room and obtained a blood pressure. LPN#5 exited the room without performing hand hygiene, and did not sanitize the blood pressure machine. LPN#5 prepared Resident #50's medications. A NA took Resident #50 to the bathroom to wash up. LPN#5 was then asked by another NA to obtain supplies for another resident. LPN#5 labelled and taped up Resident #50's medications and placed them in the top drawer of the medication cart and went down the hallway. At 9:58 AM, LPN #5 walked away from the medication cart and entered Resident #46's room, donned gloves, provided care to Resident #46 then exited the room and discarded the gloves. LPN #5 did not perform hand hygiene after discarding the gloves. He then obtained foley bags from a hall closet and brought them into Resident #46's room. LPN#5 exited Resident #46's room and returned to the medication cart. At 10:11 AM LPN#5 poured juice for Resident #50 and entered Resident #50's room to administer medications. While in Resident #50's room LPN#5 handed the medication cup to Resident #50, grabbed a paper towel from the bathroom and picked something up off of the floor. He discarded whatever he picked up into the trash, poured more juice for the resident continued observing the resident take medication and then performed hand hygiene as he exited the room. Interview on 1/30/25 at 10:20 AM with LPN #5 identified he is from the agency but has worked at the facility regularly for the past two months. LPN#5 identified he was unfamiliar with the facility's hand hygiene policy and indicated that when performing medication administration, he should perform hand hygiene every couple of rooms by using the hand sanitizer or washing his hands. Interview on 1/30/25 at 10:24 AM with RN#2 identified that hand hygiene should be completed by sanitizing after every care, or in between each patient and before and after glove use. Additionally, staff should wash hands with soap and water if visibly soiled. The facility policy for hand hygiene identified hand hygiene as a general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub, and indicated alcohol-based hand rub with 60 - 95% alcohol is the preferred method for cleaning hands in most clinical situations. Additionally, the policy identified to wash hands with soap and water whenever they are visibly dirty, before eating and after using the restroom. Additionally, the policy identified the use of gloves does not replace hand hygiene and indicated to perform hand hygiene prior to donning gloves, and immediately after removing gloves. The policy identified hand hygiene is indicated and will be performed under the conditions listed in the attached hand hygiene table which indicated alcohol-based hand rub should be used: between resident contacts, before applying and after removing personal protective equipment, including gloves, before preparing or handling medications, and before providing resident care procedures

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of two sampled residents (Resident #35) reviewed for hospitalization, the facility failed to ensure medication was administered as ordered. The findings include: Resident #35's diagnoses included epilepsy, dementia and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #35 was moderately cognitively impaired, had no behaviors, required max assistance for bed mobility, dressing, and hygiene, was dependent for transfers, utilized a mechanical lift and utilized a wheelchair for mobility. The physician's orders for June/July 2024 (original order dated 10/5/22) directed to administer Clobazam (benzodiazepine/used to treat seizures) 10mg orally once a day in the evening. The Controlled Substance Disposition Record dated 6/14/24 indicated a 30-day supply (30 tabs) of Clobazam 10mg tablets were delivered to the facility on 6/14/24. The disposition record identified that the last dose administered was on 7/13/24. Review of the medication administration record (MAR) for the month of July/2024 identified the Clobazam was not administered on 7/14, 7/15, & 7/16/24. The nurse's note, dated 7/16/24 at 10:31 PM written by RN #3 identified Resident #35 was not feeling well, had difficulty pronouncing words, and had labored breathing with an expiratory wheeze. The advanced practice registered nurse (APRN) and family were notified and the family wanted Resident #35 to be sent out to the hospital to be evaluated A medication error report dated 7/17/24 indicated that Clobazam 10mg was not administered as ordered on 7/14/24 resulting in Resident #52 being hospitalized for 24 hours. The report further indicated that the evaluation at the hospital was negative. The nurses note dated 7/17/24 at 4:13 AM written LPN #1 indicated a call was received from the hospital physician inquiring about the last administration of Clobazam. Per the MAR, it was last administered on 7/13/24. There were missed doses on 7/14-7/16/24 as the medication was not available. A Reportable Event report dated 7/17/24 indicated Resident #35 missed 3 doses of Clobazam medication due to the medication not being available and Resident #35 was sent to the hospital to be evaluated for shortness of breath. The blood serum laboratory results for Resident #35 dated 7/17/24 indicated Clobazam was at a level of 202 with the normal range noted as 30-300 nanograms per milliliter (ng/ml). Interview on 1/30/25 at 12:15 PM with the DNS identified that the pharmacy requested a prescription to refill the Clobazam and APRN #1 wrote the prescription electronically. The medication was still not refilled by the pharmacy so LPN #3 cancelled the original order for the Clobazam, hoping a new order would expedite getting the medication but it did not. The pharmacy was contacted and indicated the medication had been discontinued, which was not the case. A new order was sent to the pharmacy. DNS further identified that when a medication is not received from the pharmacy within 24-48 hours, a call needs to be placed to the pharmacy. Interview on 1/30/25 at 12:32 PM with RN #2 (day supervisor) indicated the medication refills and orders are completed through the electronic medical record (EMR) system. There is a button in the EMR for refilling medications and it shows the date of the last request/refill. All staff are responsible for reordering medications. Medications are re-ordered when a 5-day supply is remaining. When a controlled medication is ordered, a prescription is required, unless it is a previous order with refills on it. If there were refills on it, then a prescription is not required. The APRN and or MD can call the pharmacy to order or refill a controlled medication and can fax or order electronically through the EMR. Any new controlled medications require a prescription. RN #2 was unable to recall any issue with Resident #35's seizure medication in July of 2024. Interview on 1/30/25 at 12:45 PM with the Pharmacist associated with the pharmacy identified that a 30-day supply of Clobazam was filled on 6/13/24 with an additional 3 refills remaining. He noted that the medication was refilled on 7/17/25. The Pharmacist could not identify any issues related to the refilling of the Clobazam in July 2024 because a new prescription was not needed in order for the medication to be refilled. The Pharmacist further noted that there were no notes related to the refilling of the medication from July 2024. He further noted that he found no billing issues that would have affected the medication being refilled and he noted that not receiving three doses of an antiseizure medication, may increase the risk of having seizures. Interview on 1/31/25 at 9:17 AM with Person #1 identified Resident #35 was evaluated for a stroke at the hospital and noted that while the resident was at the hospital, the emergency room physician notified him/her that Resident # 35 had not received 3 doses of the Clobazam. Person #1 identified that the facility did not notify him/her that the medication had not been administered for three days. Interview on 2/3/25 at 2:31 PM with APRN #1identified the DNS notified her that Resident #35 had missed doses of Clobazam. She further noted that Resident #35 was at a higher risk for having a seizure with the missed doses. APRN #1 identified that she had contacted the resident's Neurologist (MD #1) and after he viewed a video (the resident had a camera with a video feed installed in his/her room) of the incident with the Resident, he noted non-rhythmic shaking of the right hand only and identified that he suspected that changes in the resident and the shaking of the right hand were not related to the resident experiencing a seizure because Resident #35 had a structural abnormality on the right frontotemporal and parietal lobes of the brain. Interview on 2/4/25 at 11:44 AM with LPN #2 indicated the clobazam was not available from the pharmacy. There were refills remaining, yet the pharmacy showed no refills available. That incident was a pharmacy error. That's why the medication was not delivered. The EMR showed refills remaining. When the pharmacy was contacted, they did not show or see any refills remaining. The pharmacy had incorrect data regarding the refills. The pharmacy was contacted multiple times to refill the Clobazam. LPN #2 was re-educated on contacting the pharmacy, APRN and DNS, if or when a medication is unavailable in order to escalate a solution. Review of the Medication Administration policy directed, in part, that medications were administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice. To report and document any adverse side effects or refusals, and to correct any discrepancies and report to the nurse manager.

Based on observations, facility policy and interviews, the facility failed to label/cover food in the refrigerator, freezer, and dry storage as well as wear proper hair/beard coverings while preparing food in the kitchen. Observation on 1/29/25 at 10:30 AM with [NAME] Supervisor #1 during the initial brief tour identified bologna wrapped in plastic wrap in the reach in fridge with no label of date opened or discard date. Interview on 1/29/25 at 10:30 AM with [NAME] Supervisor #1 identified the bologna should have been labeled when it was opened and he was unsure when it was opened and will discard. Observation on 1/29/25 at 10:42 AM with [NAME] Supervisor #2 identified a tray of pasta with meat sauce in a metal tray covered with foil with the lower right corner of the tray opened exposing the food to open air in the walk-in freezer. Interview on 1/29/25 at 10:42 AM with [NAME] Supervisor #2 identified the food should not have been opened to air in the freezer and it should have been properly covered. Observation on 1/29/25 at 10:45 AM with [NAME] Supervisor #2 identified 2 bags of fish squares opened and tied at the top of the bag in the walk-in freezer with no open label date and no date of expiration. Interview on 1/29/25 at 10:45 AM with [NAME] Supervisor #2 identified that food should be labeled with an open date and a date of expiration while stored in the freezer. Observation on 1/29/25 at 10:50 AM with [NAME] Supervisor #2 identified two bags opened and tied at the top of yellow cake mix with no open date and no expiration date. Interview on 1/29/25 at 10:50 AM with [NAME] Supervisor #2 identified the cake mix should have been labeled with an open date and a expiration date. Observation on 1/29/25 at 10:52 AM with [NAME] Supervisor #1 identified Dietary Aide #1 preparing pears into individual servings from a can. Dietary Aide #1 was not wearing a beard guard and had a full beard that was approximately 1 inch in length. Interview on 1/29/25 at 10:52 with Dietary Aide #1 identified he does not typically wear a beard covering and did not believe it was required. Observation on 1/31/25 at 11:20 AM identified [NAME] Supervisor #2 was not wearing a head covering and was placing food into the steam table. After seeing the surveyor, [NAME] Supervisor #2 walked over to the far side of the kitchen to place his hat on. Interview on 1/31/25 at 11:22 AM with [NAME] Supervisor #2 identified he should have been wearing a hair guard. Interview on 1/31/25 at 11:30 AM with the Dietary Manager identified food should be labeled with date prepared or when opened in the refrigerator/freezer and food should also be labeled with an expiration date on it. The facility policy directs the staff to wear hair guards and beard guards while preparing food in the kitchen. Review of facility Food Storage Policy directed the facility to utilize a date marking system. Dry storage items will be required to have a date (including month/date/year) in which product was delivered or a manufacturer printed Best By/use by date. A product still within its delivered box with a visible food distributor shipping label with date is acceptable. Review of the facility policy Hair Restraint directed anyone within the kitchen, who will have close contact with the preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include a facial hair.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for five of five sampled residents (Residents #12, #31, #43, #46, and #49) reviewed for immunizations, the facility failed to ensure the MDS assessments were accurately encoded. The findings include: 1. Resident #12's diagnoses included hypertension, osteoarthritis, and hypercholesterolemia. The quarterly MDS assessment dated [DATE] identified Resident #12 was cognitively intact, and noted the influenza vaccine was received on 11/15/24 and the pneumococcal vaccination was up to date. Review of the clinical record with LPN #4 (MDS Coordinator) identified a hospital discharge summary dated 7/7/24 that identified Resident #12 received PPSV23(PPSV23 stands for pneumococcal polysaccharide vaccine 23. It is a vaccine that helps protect against pneumococcal disease, which is caused by bacteria called Streptococcus Pneumoniae) on 8/14/2014. Further review of the clinical record failed to identify that the resident was offered and/or received an up-to-date pneumococcal vaccine (administered within the past five years). There was also no documentation to support the resident being administered the influenza vaccine. Interview with Resident #12 on 2/14/25 at 2:08 PM identified he/she did not recall receiving the influenza vaccine in the fall of 2024. Interview with LPN #4 (MDS Coordinator) on 2/3/25 at 12:23 PM identified Resident #12's pneumococcal vaccine was not up to date and the resident had not been administered the influenza vaccine. 2. Resident #31's diagnoses included dementia, depressive disorder, and gastrointestinal hemorrhage. The quarterly MDS assessment dated [DATE] identified Resident #31 had severe cognitive impairment, had an up-to-date pneumococcal vaccine, and noted the influenza vaccine was not administered in the facility Review of the clinical record with LPN #4 (MDS Coordinator) on 2/3/25 at 12:23 PM identified Resident #31 had not been administered the pneumococcal vaccine within the past five years, and there was also no documentation to support the resident being administered the influenza vaccine. Interview with LPN #4 (MDS Coordinator) on 2/3/25 at 12:23 PM identified Resident #31's pneumococcal vaccine was not up to date and the resident had not been administered the influenza vaccine. 3. Resident #43's diagnoses included type 2 diabetes mellitus, peripheral vascular disease, and spinal stenosis. The quarterly MDS assessment dated [DATE] identified Resident #43 was cognitively intact and had an up-to-date pneumococcal vaccine. Review of the clinical record with the MDS coordinator (LPN #4) on 2/3/25 at 12:23 PM failed to identify Resident #43 had been administered the pneumococcal vaccine within the past five years. Interview with LPN #4 on 2/3/25 at 12:23 PM identified Resident #43 had not been administered the pneumococcal vaccine within the past five years. 4. Resident #46's diagnoses included sepsis, sleep apnea, chronic obstructive pyelonephritis and gout. The quarterly MDS assessment dated [DATE] identified Resident #46 had moderately impaired cognition and was up to date with the pneumococcal vaccine. Review of the clinical record with LPN #4 on 2/3/25 at 12:23 PM failed to identify Resident #46 had received the pneumococcal vaccine within the past five years. Interview with LPN #4 on 2/3/25 at 12:23 PM identified Resident #46 had not been administered the pneumococcal vaccine within the past five years. 5. Resident # 49's diagnoses included dementia, hypercholesterolemia and psychotic disorder. The quarterly MDS assessment dated [DATE] identified Resident #49 had severely impaired cognition and was up to date with the pneumococcal vaccine. Review of the clinical record with LPN #4 on 2/3/25 at 12:23 PM identified Resident #49 had received the Prevnar 13 (PCV13/a type of pneumococcal vaccine) on 9/22/2019. Further review of the record failed to identify any other pneumococcal vaccines administered or offered within the past five `years. Interview with LPN #4 on 2/3/25 at 12:23 PM identified Resident #49 had not been administered the pneumococcal vaccine within the past five years. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine timing for adults identified that adults 65years or older have the option to receive the pneumococcal vaccine 20 (PVC 20) if they have already received both Prevnar 13 (PCV 13) at any age and/ pneumococcal vaccine (PPSV23) at or after age [AGE] years old and are eligible to receive after 5 years the PCV20 or another dose of the PPSV23. The CDC also identified that an adult over the age of [AGE] years and have no prior vaccination of the pneumococcal vaccine are eligible for receiving the PCV20 vaccine or the PCV15 then after one year the PPSV23 vaccine. Interview with LPN #4 on 2/3/25 at 12:23 PM identified that when completing the immunization section of the MDS, he reviews the resident's hospital discharge documentation, and immunization consent forms. LPN #4 further identified that he is responsibility for the accurate coding of the MDS assessments and noted that he had not coded the assessments for Resident's #12, #31, #43, #46 and #49 accurately. In addition, he did not explain why the MDS assessments had been inaccurately coded when the clinical records did not contain the information necessary for what was indicated in the MDS assessments. Interview with the DNS on 2/3/25 at 2:15 PM identified she was responsible for signing off on the resident assessments. The DNS identified she signs the MDS assessments to indicate the completion of the assessment, but noted it is the MDS Coordinator's responsibility to ensure the assessments accurately reflect the resident's status. Review of the MDS 3.0 Completion policy identified the facility conducts an initial and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity using the RAI specified by the state. The policy further identified that persons completing part of the assessment must attest to the accuracy of the section they complete by signature and indication of the relevant sections. The R.N. Coordinator signs, dates and attests to the timely completion of the RAI once all other disciplines have completed their sections.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of two sampled residents (Resident #34) reviewed for hospitalization , the facility failed to ensure the Ombudsman's office was provided with the required notification of the transfer. The findings included: Resident #34's diagnoses included osteomyelitis, anemia, and osteoarthritis of the knee. The quarterly assessment dated [DATE] identified Resident #34 had moderate cognitive impairment, required maximal assistance with personal hygiene, toileting hygiene and was non-ambulatory. LPN #6's progress note dated 11/29/24 at 2:44 PM identified the nurse aide reported Resident #34 was unresponsive and LPN #6 and the Nursing Supervisor entered the Resident #34's room and found the resident slumped over in the wheelchair and was unresponsive to the administration of sternal rub. The APRN was notified and ordered Resident #34 be sent to the emergency room for evaluation. The DNS's note dated 11/29/24 at 2:44 PM identified Resident #34 was admitted to the hospital with osteomyelitis and syncope. A request for the monthly Ombudsman's report for transfers and discharges for the last 4 months was made on 2/3/25 at 9:00 AM. A copy of the report was not provided. Review of the facility's admission/discharge reports for the past six months identified the following: For the month of September, there were sixteen residents discharged and/or transferred from the facility. For the month of October 2024, there were twenty-one residents discharged and/or transferred from the facility. For the month of November 2024, there were seventeen residents discharged and/or transferred from the facility. For the month of December 2024, there were twelve residents discharged and/or transferred from the facility. For the month of January 2025, there were fifteen residents discharged and/or transferred from the facility. Interview with the Administrator on 2/3/25 at 1:04 PM identified the Social Worker is responsible for sending the monthly report of transfers and discharges to the Ombudsman's office. The Administrator further identified that the Social Worker was out on leave, and he did not have access to the Ombudsman's reporting portal. Interview with the Social Worker (SW #1) on 2/4/25 at 10:25 AM identified she was responsible for completing the monthly transfer and discharge report; however, it was not completed. SW #1 identified she started working at the facility in September of 2024 and was unaware that she was responsible for completing the report. She further identified the report should include all discharges and/or transfers to the hospital, home, deaths in the facility, and admission. On 2/4/25 (after surveyor inquiry) the facility updated the Ombudsman's office of all discharges and transfers that occurred during the period of September/2024 through January/2025. Review of the Transfer and Discharge (including AMA-against medical advice) policy identified the facility would maintain evidence that the notices were sent to the Ombudsman. The policy further identified the Social Services Director would provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notice.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1, #2) reviewed for accidents, the facility failed to ensure the residents were transferred in accordance with the plan of care to prevent an injury. The findings include: a. Resident #1's diagnoses included osteoarthritis, non-thrombocytopenia purpura, and dermatitis. Review of the Nurse Aide (NA) care card dated 7/23/2024 directed transfers with assist of one (1), device needed walker. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment and required partial/moderate assistance with transfers. The Resident Care Plan (RCP) dated 10/24/2024 identified Resident #1 had arthritis and required assistance with transfers. Interventions directed to transfer per MD orders and use of supportive devices as recommended. Physician order dated 12/2/2024 assist of one (1) with rolling walker and gait belt. Review of facility Reportable Event Form dated 12/28/2024 at 8:30 PM identified Resident #1 was alert and oriented, and transferred with one staff assist and a rolling walker. Resident #1 was being transferred from the wheelchair to bed and during the transfer his/her leg grazed over the metal part of the wheelchair for the attachment of the leg rest. Resident #1 sustained a right shin laceration measuring 6.5 by 3.5 centimeters (cm), was transferred to the hospital and required seven (7) sutures. Review of facility Summary Report dated 1/3/2025 identified NA #1 did not use the proper transfer and use of a rolling walker. The Summary indicated NA #1 did not use a walker for the transfer and the resident's feet were placed slightly under the wheelchair (not in front of the wheelchair) near the chair's metal bars when NA #1 stood the resident for the transfer. The Summary indicated use of a rolling walker and proper foot placement would have prevented the injury. During an interview and observation on 1/14/2025 at 10:45 AM with Resident #1 identified his/her wheelchair had detachable leg/footrests. Resident #1 stated the area that caught and injured his/her leg was the upper thin metal flange on the inner side of the wheelchair that the detachable footrest (when attached) glides along when the leg rest is put in place for resident leg rest use. Resident #1 stated as the NA assisted with the transfer, his/her leg got caught on the area. Interview and record review with NA #1 on 1/14/2025 at 11:02 AM identified when she attempted to transfer Resident #1 from the chair to bed, Resident #1 yelled my foot, my foot. NA #1 stated Resident #1's legs were under the chair in a bended position when she started the transfer. NA #1 further stated she did not know Resident #1 required use of a walker, and she did not look at the NA care card for any needs Resident #1 may have required. NA #1 stated Resident #1 was calm during the transfer and did not direct NA #1 to use a walker. NA #1 stated after the transfer she learned she should have used a walker (stated it was the second time she worked at the facility). Interview, clinical record review and facility documentation review with the DNS and Administrator on 1/14/2025 at 1:51 PM identified on 12/28/2024 when NA #1 transferred Resident #1 from the wheelchair to bed she did not follow the care card. The DON stated the injury could have been prevented, and NA #1 should have used a rolling walker for the transfer as directed on the NA care card. b. Resident #2's diagnoses included Alzheimer's disease. The admission MDS assessment dated [DATE] identified that Resident #2 had a BIMS score of ten out of fifteen, indicative of moderate cognitive impairment and required substantial/maximal assistance with transfers. The RCP dated 8/21/2023 identified cognitive loss/dementia, and arthritis. Interventions directed offer one step at a time directions and consult with PT/OT as needed for any changes in transfer ability, positioning needs and use of supportive devices as recommended, transfer with caution, per transfer status and remind to use caution and be aware of the position of extremities when transferring and ambulating. Review of the NA care card dated 8/21/2023 directed transfer assist of two (2), device needed walker. Review of facility Reportable Event Form dated 9/2/2023 at 9 PM indicated Resident #2 was alert, confused and required two (2) staff for transfers with rolling walker/grab bar. Two (2) NAs were transferring Resident #2 from the chair to bed when Resident #2 sustained a skin cut to the left lower leg and was sent to the hospital. Resident #2 returned with stitches. Review of facility Summary Report dated 9/8/2023 identified Resident #2 had frail skin with purpuras (reddish - purple skin discoloration caused by bleeding under the skin). The Summary indicated the NAs failed to use the rolling walker per the physical therapy orders, and while the resident was pivoting for the transfer, his/her leg got caught in the side rail and caused a laceration. Both NAs were provided education regarding how to properly transfer Resident #2. Interview and observation on 1/16/2025 at 9:59 AM with DNS identified Resident #2 sustained a left leg injury on 9/2/2023 during the transfer with NA #2 and #3. The injury was caused from the release button on the side rail attached to the resident's hospital bed. Interview and record review with NA #2 on 1/16/2025 at 10:21 AM identified the NA care card was not located on the closet door so she asked the nurse how to transfer Resident #2 and was told transfer with assist of two (2) staff. NA #2 stated she stood to the side of Resident #2 during the transfer with NA #3, and then Resident #2's leg got caught on the bed railing. NA #2 further stated she did not know she should have used a walker for the transfer. Interview and record review with NA #3 on 1/16/2025 at 10:54 AM identified she assisted NA #2 to transfer Resident #2. NA #3 stated she stood behind the wheelchair and after Resident #2 was standing, she moved to the side of Resident #2 and he/she shuffled and pulled himself, and plopped down on the bed. NA #3 stated she and NA #2 did not actually have hands on to assist Resident #2 with the transfer. NA #3 further stated she and NA #2 did not use a walker for the transfer, and the walker was not listed on the care card. NA #3 further clarified, both NAs were present for the transfer but did not give any physical assistance; Resident #2 transferred him/herself. During an interview, clinical record and facility documentation review with the DNS on 1/16/2025 at 1:29 PM with DNS stated the facility investigation identified NA #2 and #3 did an incorrect transfer; the NAs should have followed the care plan/care card as directed and should have used the rolling walker to transfer Resident #2. Review of the facility Safe Resident Handling/Transfers policy directed in part, to ensure that residents are handled and transferred safely to prevent or minimize risks for injury. Handling aids may include rolling walkers and other devices.

Based on clinical record review, facility documentation review, facility policy review, and agency staff file review for three of three agency NAs (NA #1, 2 and 3), the facility failed to ensure agency staff received facility orientation to include emergency procedures and abuse training prior to working in the facility. The findings include: A. Agency NA #1 file review identified NA #1 worked at the facility on 12/28/2024 during the 3 to 11 PM shift. File review for NA #1 failed to identify a general orientation to include facility emergency procedures and abuse training. B. Agency NA #2 file review identified NA #2 worked at the facility on 9/2/2023 during the 3 to 11 PM shift. File review for NA #2 failed to identify a general orientation to include facility emergency procedures and abuse training. C. Agency NA #3 file review identified NA #3 worked at the facility on 9/2/2023 during the 3 to 11 PM shift. File review for NA #3 failed to identify a general orientation to include facility emergency procedures and abuse training. Interview, facility documentation review and facility policy review with the Administrator on 1/16/2025 at 1:08 PM identified the medical records/scheduler orients agency/pool staff. The medical records/scheduler provides agency staff with a tour of the facility and includes emergency procedures and abuse training for agency staff, which was located in a facility binder. The Administrator stated the facility did not have documentation that education, including facility emergency procedures and abuse training were provided for Agency NA #1, 2 and 3 and was unable to explain why. Review of facility Orientation Policy directed in part, to develop, implement, and maintain and effective orientation process for all new staff, individuals providing services under a contractual agreement, consistent with their expected roles. Orientation consists of in-depth review of resident population, policies and procedures (including emergency procedures, care procedures). General orientation must be completed prior to the employee's formal contact with facility residents.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for wound care, the facility failed to ensure hand hygiene was performed during a dressing change in accordance with accepted infection control practices. The findings include: Resident #1's diagnoses included an open knee wound and osteomyelitis of the knee. The admission assessment dated [DATE] identified Resident #1 was alert and oriented, had a left shin surgical incision with a surgical dressing and Jackson Pratt drain in place. The physician order dated 8/17/2024 directed left anterior knee wound: apply skin prep, allow to dry, cut a thin strip of Alginate AG with silver and gently pack into the wound bed using a cotton tipped applicator leaving the end exposed, apply Aquacel AG over the wound bed and cover with an adhesive foam dressing, change daily and as needed. The Resident Care Plan (RCP) dated 8/6/2024 identified chronic antibiotic use due to chronic osteomyelitis and a pressure ulcer/injury. Interventions directed to administer antibiotic per MD order, follow up with infectious disease specialist as ordered. The physician order dated 9/5/2024 directed to cleanse left knee wound with dial soap and water, apply calcium alginate lay on top of wound followed by drawtex or a highly absorbent dressing, followed an abdominal pad dressing and roll gauze, change daily and as needed. Observation of wound care provided on 9/18/2024 at 10:15 AM with LPN #1 identified LPN #1 removed the soiled dressing, and then while wearing the same gloves, LPN #1 cleansed the wound. LPN #1 further applied the clean dressing while wearing the same soiled gloves. LPN #1 failed to remove the soiled gloves, perform hand hygiene and don new gloves after removing the soiled dressing and after cleansing the wound, prior to applying the clean dressing. Interview with LPN #1 on 9/18/2024 at 10:31 AM identified that she should have removed the soiled gloves and washed her hands after removing the soiled dressing and then and donned clean gloves before applying Resident #1's clean dressing. LPN #1 further indicated she had been trained on the wound care treatment procedure, that she forgot and did not know why she didn't follow the wound care procedure. Interview, clinical record review, and facility documentation review with RN #1 on 9/18/2024 at 11:14 AM identified when a nurse performs wound care, he/she should remove dirty gloves, wash their hands, and apply new gloves before proceeding with a dressing change/applying the clean dressing. Review of facility Policy and Procedure for Clean Dressing Technique directed in part, it is the policy of this facility that all clean dressing changes and treatments to be performed by the Treatment or Charge Nurse in a manner that maintain skin integrity and prevents infection by maintaining a clean working environment and following clean nursing technique. Wash Hands, apply clean gloves, remove old dressing and discard in plastic bag, remove gloves, wash hands, apply clean gloves, cleanse wound with solution ordered, observe wound, remove gloves, wash hands apply clean gloves, apply any medication ordered and dress wound.

Based on clinical record review, observations, facility documentation, facility policy and interviews for one of three residents (Resident #3), reviewed for abuse, the facility failed to ensure the resident was treated in a dignified manner. The findings include: Resident #3's diagnoses included sepsis, fracture of T9-T10 vertebra, moderate protein-calorie malnutrition, osteoarthritis, and acute/chronic pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 as alert and oriented, and required extensive assistance of one (1) person with bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 1/19/2024 identified Resident #3 had a diagnosis of arthritis and may be prone to fractures. Interventions directed to monitor for pain/discomfort, and assist with care. The facility incident report dated 2/1/2024 at 9:00 PM identified Resident #3 reported NA #1 was verbally abusive during care. Resident #1 alleged that NA #1 used a loud voice while taking care of him/her, verbally abused him/her, took Resident #3's shoes off without unlacing them and was rough while providing care. Resident #3 explained NA #1 took off the resident clothes so fast and rough, that made the resident have shoulder pain. Further, NA #1 refused to use Resident #3's walker for transfers. NA #1 was removed from the schedule, and Resident #3 was assessed to have no injury. Facility summary dated 2/5/2024 identified NA #1 was an agency staff and was on her cell phone while she simultaneously provided care to Resident #3 on 2/1/2024. NA #1 became loud while on the phone, was not paying attention to Resident #3 and quickly removed Resident #3's clothing and shoes. The RN #2 (supervisor) heard loud voices and responded to the room, identified the situation and immediately removed NA #1 from the room, assessed Resident #3 for any injury (none identified), and provided emotional support. Although attempted, an interview with RN #2 was unable to be obtained during survey. Interview with NA #1 on 3/6/2024 at 1:00 PM identified on 2/1/2024, she answered Resident #3's call bell and assisted with PM care. NA #1 indicated as she began to help, Resident #3 indicated he/she can take care of him/herself and began to self-transfer back to bed. NA #1 identified she asked if Resident #3 needed assistance with his/her clothes, but Resident #3 stated, I can't hear you and NA #1 indicated she increased her tone throughout the interaction. After Resident #3 was in bed and settled, a nurse came into the room and assisted with finishing PM care. Approximately 5 minutes later, the nurse requested I leave the building due to Resident #3 alleged abuse concerns. NA #1 identified she had not returned to the facility and was unaware of the outcome of the investigation. NA #1 identified during the interaction with Resident #3, she never touched the resident's arm during care and resident was able to self-transfer to bed. NA #1 indicated she spoke loudly because Resident #3 was unable to hear what she was saying. Interview with the DON on 3/07/2024 at 10:00 AM identified the facility concluded NA #1 should not have been on the phone, and should have treated Resident #3 with care. The DON indicated NA #1 did not respond to Resident #3's care in a dignified manner. Review of the facility Dignity Policy directed in part, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Speak respectfully to residents; avoid discussions about residents that may be overheard.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Resident #1's diagnoses included Alzheimer's dementia, peripheral vascular disease, non-pressure chronic ulcers, urinary tract infection, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had significantly impaired cognition and required extensive assistance with assist of one (1) with bed mobility and transfers. The Resident Care Plan (RCP) dated 12/22/2023 identified Resident #1 was sometimes confused and forgetful due to age-related forgetfulness/dementia. Intervention directed to allow resident time to respond when speaking to resident, offer one step at a time directions, if the resident does not seem to understand what you are saying, please restate using simpler terms, and if the resident is confused or forgetful, offer gentle reminders. Clinical record review identified Resident #1's primary language was not English. The facility incident report dated 1/30/2024 at 8 AM identified Resident #1 alleged emotional distress with a sexual accusation occured at 2 AM by a male staff member. Review of the nursing note dated 1/30/2024 at 6:37 AM identified Resident #1 had increased confusion with several attempts to get out of bed from 2 AM. Assisted out of bed at 4 AM, dressed and in wheelchair. Resident #1 requested to spend some time with Resident #2, and visited and after a few minutes Resident #1 started to scream and Resident #2 asked for staff to remove Resident #1 from the room. Resident #1 was kept at the nurse's station for close monitoring. NA #3 started her shift at 6 AM and spoke with Resident #1 in the resident's primary language. Resident #1 then related to NA #3 an allegation of sexual abuse that was alleged to have occurred to him/her and to Resident #2 during the night of 1/30/2024. LPN #1 notified the supervisor. Review of the nursing note dated 1/30/2024 at 10:07 AM identified the DON was reviewing the 24-hour report and noted the incident from the night shift about Resident #1. APRN #1 and SW #1 were fluent in Resident #1's primary language, and along with DON, interviewed Resident #1 and Resident #2 together. Resident #1 alleged an assault on him/her by a male staff member during the night. A body assessment identified no injury, and support was provided. Review of facility cameras identified no males entered the room (no males were working), and the accused male had not worked with Resident #1 or Resident #2 for several weeks. Resident #1's responsible party (Power of Attorney - POA) was updated and indicated Resident #1 was probably recalling a past trauma from many years ago. Interview with the DON on 3/07/2024 at 10:00 AM identified the allegation of abuse was not reported to the State Agency, due to the DON completing the investigation within the two hours. The DON identified upon notification of the incident, she, APRN #1 and SW #1 immediately initiated an investigation. The DON indicated both APRN #1 and SW #1 were fluent in Resident #1's language and were able to interview Resident #1. Resident #1 indicated Resident #2 was raped by a male Physical Therapy Aide (PTA #1). Resident #2 was interviewed and denied the allegations occurred, and indicated it was most likely Resident #1 who was raped. The DON indicated the facility cameras were reviewed and no male staff members entered Resident #1 and #2's room during the night shift. The DON identified Resident #1's Power of Attorney (POA) (responsible party) was contacted, who identified Resident #1 possibly was re-living a traumatic event from many years ago, and Resident #1 had made similar accusations in the past. Interview identified although all allegations of abuse are required to be reported to the State Agency, the DON indicated she thought if she investigated and resolved the allegation within two (2) hours that she did not need to report the allegation. Review of the State Public Health Code (PHC) directed in part, Class B reportable events are a complaint of patient abuse. The PHC further directed a Class B event requires immediate notification to the State Agency with a written report within seventy-two (72) hours. Review of the facility Abuse Prevention Policy directed in part, allegations of abuse are a Class B State Reportable Event. The Administrator is responsible for ensuring that proper notification is done in accordance with applicable state regulations. Class B incidents require immediate notification of the state.

Based on observation, clinical record review, and staff interview, for two of four residents in the survey sample reviewed for pressure ulcers (Residents #30 and #37), the facility failed to implement ongoing interventions to prevent a pressure ulcer. The findings include: a. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 had no cognitive deficits, required extensive assist of two people for bed mobility and transfer, did not walk, was at risk for developing pressure ulcers, and had no pressure ulcers. A Braden scale for predicting pressure sore risk dated 1/29/18 indicated Resident #30 was not at risk (score = 19). A subsequent Braden scale for predicting pressure sore risk dated 2/5/18 indicated Resident #30 was at risk (score = 15). A resident care plan dated 2/6/18 identified a problem with risk for pressure ulcers. Interventions included assist with incontinence care after each incontinent episode, weekly skin inspection, minimize exposure to moisture, offer and assist to turn and reposition at least every 2 hours, report signs of breakdown, use moisture barrier as needed, and utilize seat cushion for pressure reduction in the wheelchair. A physician's orders [REDACTED]. Review of physical therapy notes dated 1/31/18, 2/6/18, and 2/13/18 indicated Resident #30 was walking 0 feet and was totally dependent without attempts to initiate. A physical therapy discharge summary dated 2/20/18 indicated Resident #30 was totally dependent with hoyer lift for transfer, and did not walk without attempts to initiate. A skin integrity condition form dated 2/11/18 indicated Resident #30 had a deep tissue injury on the left heel that measured 4.0 cm x 3.5 cm. The area was described as dark purple/maroon with blanchable redness that measured 1.0 cm around the perimeter. A physician's orders [REDACTED]. A skin integrity condition form dated 2/21/18 indicated the right heel had a deep tissue injury on the right heel that measured by 2.9 cm x 1.3 cm. The area was purplish/red. A skin integrity condition form dated 3/15/18 indicated the deep tissue injury on the left heel that measured 2.9 cm x 3.0 cm of necrotic tissue. A skin integrity condition form dated 3/15/18 indicated the deep tissue injury on the right heel measured 2.5 cm x 1.0 cm with 0.4 cm x 1.5 cm of dry brown eschar. The tissue was described as necrotic. An observation on 03/19/18 10:04 AM with Licensed Practical Nurse (LPN) # 1 noted a linear dark brown/black area on the left heel and a round dark brown/black area on the right heel. An interview on 3/20/18 at 9:34 AM with Registered Nurse (RN) #1 indicated preventative measures for resident's at risk for skin breakdown include skin prep to the heels for 7 days and off loading heels every shift. Although he/she was able to provide documentation that Resident #30 had skin prep applied to his/her heels for 7 days (discontinued on 2/5/18), he/she was unable to provide documentation that the resident's heels were off-loaded every shift until 2/11/18 when the deep tissue injury was identified on the left heel. An interview on 3/21/18 at 9:43 AM with the Director of Nursing (DNS) indicated prior to discontinuing skin prep to heels and off-loading heels preventatively, the resident should be assessed to determine if the resident is still at risk for skin breakdown. The Braden scale risk, weekly skin checks, and mobility status should be considered prior to discontinuing a preventative intervention. Although Resident #30's pressure ulcer risk increased from no risk to risk on 2/5/18 and Resident #30 was non-ambulatory, the preventative skin prep was discontinued on on 2/5/18. Additionally, review of the heel float manufacture informational sheet indicated Important- Remove the Heel float every 8 to 12 hours and check the patient's skin for ischemia or discoloration. An interview on 3/21/18 at 10:45 AM with RN #1 indicated he/she was unable to provide documentation that the heel float (boot) was removed and the skin checked every 8 to 12 hours when it was used preventatively on Resident #30's right heel from 2/11/18 and 2/21/18. b. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden scale for Predicting Pressure Sore risk dated 1/18/18 indicated Resident #37 was at risk. An admission resident careplan dated 1/18/18 identified a problem that Resident #37 was at risk for altered skin integrity. Interventions included hip precautions and pillow between legs and against outside of left leg when in bed. A physician's orders [REDACTED]. An admission MDS assessment dated [DATE] indicated Resident #37 had severe cognitive impairment, required extensive assist with two people for bed mobility and transfer, did not walk, was at risk for developing pressures, and had no pressure ulcers. Review of a nurse's note dated 1/26/18 indicated Resident #37 was readmitted to the hospital on [DATE] for [MEDICAL CONDITION] and blood [MEDICAL CONDITION]. Resident #37 returned to the facility on [DATE]. A Braden scale for Predicting Pressure Sore risk dated 1/28/18 indicated Resident #37 was at risk. A resident care plan dated 1/31/18 identified a problem with risk for skin breakdown. Interventions included assist with turning and positioning at least every 2 hours, weekly skin checks, keep clean and dry, incontinent care, moisture barrier to perineal area, and seat cushion for pressure reduction when resident in the wheelchair. A nurse's note dated 2/16/18 indicated there was a dark area noted on Resident #37's heel that measured 1cm x 1cm. The Physician was notified. Heel lift boots were placed on Resident #37, skin prep to heels every shift, and air mattress was initiated. A skin integrity documentation form dated 2/22/18 indicated Resident #37 had a 1.0 cm x 0.9 cm deep tissue injury pressure sore on the left heel. A skin integrity report dated 2/28/18 indicated a pressure ulcer measured 0.8 cm x 0.6 cm irregularly shaped. An observation on 3/19/18 at 12:45 PM with LPN #1 noted a brown discolored area on the bottom of Resident #37's left heel. Resident #37 indicated the heel continued to hurt when touched. An interview on 3/20/18 at 9:34 AM with RN #1 indicated preventative measures for resident's at risk for skin breakdown include skin prep to the heels for 7 days and off-loading heels every shift. Although he/she was able to provide documentation that Resident #37 had skin prep applied to his/her heels for 7 days (discontinued on 1/25/18) when Resident #37 was first admitted on [DATE], he/she was unable to provide documentation that the skin prep to the heels was reinstituted when the resident returned from the hospital on [DATE]. He/she was also unable to provide documentation that Resident #37's heels were off-loaded every shift until 2/16/18 when the deep tissue injury was identified on the resident's left heel. An interview on 3/21/18 at 9:43 AM with the the DNS indicated prior to discontinuing skin prep to heels and off-loading heels preventatively, the resident should be assessed to determine if the resident is still at risk for skin breakdown. The Braden scale risk, weekly skin checks, and mobility status should be considered prior to discontinuing a preventative intervention. Although Resident #37's pressure ulcer risk continued after his/her return from the hospital on [DATE] and the resident continued to require extensive assist with bed mobility, the preventative skin prep to the heels was not restarted when the resident returned from the hospial on 1/28/18.

Based on review of the clinical record, review of facility documentation, and interviews for one of four residents reviewed for accidents, (Resident #36), the facility failed to ensure that the resident's splint was applied in a manner to prevent an injury. The findings include: 1. Resident #36 (R #36) had [DIAGNOSES REDACTED]. The care plan dated 7/29/14 identified that R #36 had limited range of motion to his/her bilateral hands with interventions that included to apply a right wrist splint and a left resting hand splint after morning care and to remove the splints at bedtime. In addition, the care plan directed that staff apply a rolled washcloth to the resident's bilateral hands after the right and left hand splints were removed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #36 had cognitive deficits and was totally dependent on staff for personal hygiene. Review of facility accident/incident report dated 12/8/14 identified that R #36 was observed to have sustained a skin tear after the right splint was removed and that the resident's thumb had rubbed beneath on the right middle finger. Review of supervisor summary/conclusion indicated that R #36 had sustained a skin tear after splint was applied and that his/her thumb rubbed beneath right middle finger. Nursing notes dated 12/8/14 identified that R #36 sustained a 2.0 centimeter (cm) beefy red gash between the first and second fingers of right hand. The documentation identified that the resident's first finger was swollen and that a pressure dressing was applied. The nursing notes further indicated that the physician was updated and would be in to assess the resident in the morning. Nursing notes dated 12/9/14 indicated that R #36 was seen by the physician who recommended that the resident be seen by a hand surgeon. Review of a written statement and subsequent interview with Nursing Assistant #1 (NA) #1 on 6/30/15 at 12:30PM, NA#1 indicated that on 12/8/14, he/she removed R #36 splints and noted dried blood on the splint. NA #1 indicated that R #36's fingernails were observed to be long and sharp at that time. Interview with Licensed Practical Nurse #1 (LPN #1) on 6/30/15 at 3:15 PM identified that R #36 was observed with a skin tear that measured approximately 3.0 cm by 0.1 cm on the right hand. LPN #1 indicated that area on R #36's hand was deep, not superficial, and that R #36 seemed a little bit uncomfortable but did not seem to be in severe pain. Interview with NA #2 on 7/1/15 at 10:50 AM identified that he/she applied R #36's splint on the morning of 12/8/14. NA #2 stated that he/she had checked the resident's care card before providing care to the resident, that there was nothing wrong with the resident's hands when he/she applied the splints, and that he/she was sure that he/she had applied the splints correctly. Review of R #36's clinical record and subsequent interview with Occupational Therapist #1 (OT #1) on 7/1/15 at 2:10 PM identified that R #36 had a deep laceration at the base of his/her right finger extending distally along the medial anterior aspect of the phalanx. OT #1 indicated that R #36's splints were inspected after the injury and that the splint covers were observed to have been placed backwards. OT #1 indicated that R #36's hands were totally contracted and that the resident had no motion in his/her hands prior to the injury occurring. OT #1 indicated that splint on R #36's hand may have been applied incorrectly. Interview with RN #1 on 7/2/15 at 2:15 PM identified that one of R #36's fingers was noted underneath the splint and that the laceration was observed upon removal of splint. RN #1 indicated that based on the facility's investigation, it was identified that splints were applied incorrectly to R #36's right hand. Interview with LPN #2 on 7/1/15 at 10:35 AM identified that R #36 was transferred to Acute Care Hospital #1 on 12/9/15 after a physician evaluation. LPN #2 indicated area observed between the resident's right hand and right index finger was an evulsion indicating that the area was pulled back, exposing white area, possibly tendons. Review of documentation dated 12/9/14 from Acute Care Hospital #1 indicated that R #36's hand laceration was likely from thumbnail, that the resident was given a tetanus shot. In addition, the documentation identified that care provided included: one suture gaped, one continuous suture applied, and that the resident's 2nd and 3rd fingers were buddy taped. The documentation further recommended monitoring the resident for infection over the next few days.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of six sampled residents, Resident #21, who sustained a fracture of the right humerus subsequent to a transfer by two staff members and/or Resident #30, who sustained a hip fracture subsequent to a fall, the facility failed to ensure that an appropriate transfer and/or supervision was provided. The findings included: 1. Resident #21 (R #21) was admitted to the facility with [DIAGNOSES REDACTED]. The admission assessment dated [DATE] identified that R #21 was severely cognitively impaired, had range of motion impairment of the bilateral upper extremities, and required extensive assistance by two staff persons for transfers. The fall risk assessment dated [DATE] identified that R #21 was at high risk for falls. The nursing care plan updated on 4/28/12 identified that R #21 was at high risk for falls due his/her right hemiparesis and impaired transfer/ambulation difficulties with interventions that included to transfer the resident with the assistance of two persons utilizing a gait belt and a right ankle air splint. R #21's care plan goals included safe transfers to his/her left side. Physician orders [REDACTED]. Review of a nursing note dated 4/30/12 at 1:30 PM identified that R #21 complained of right shoulder pain after transfer from the wheelchair to the bed by two staff persons. The documentation identified that during the transfer, staff reported hearing a "pop" at the resident's right shoulder. Nursing assessment at that time identified that R #21's right shoulder was in a contracted position at the right elbow. The physician was notified and an x-ray of the resident's right arm was obtained. Review of the radiology report dated 4/30/12 identified that R #21 had sustained an acute fracture of the humeral neck without displacement. Interview with and subsequent demonstration of the transfer by Nursing Assistant #2 (NA #2) on 7/23/12 at 2:00 PM identified that during the transfer, NA #2 reported that R #21's legs buckled and that the gait belt slid underneath the resident's arm. NA #2 stated that he/she pulled up and underneath R #21's arm with the gait belt and then heard a "pop" noise. Interview with and subsequent demonstration by NA#1 on 7/23/12 at 2:15 PM identified that NA#1 reported that he/she went under the resident's arm pit to hold the gait belt in place during the transfer. NA #1 stated that when the resident's legs buckled, "we jerked (her /him) up." Review of facility documentation identified that the facility conducted an investigation beginning 4/30/12 and identified that staff utilized R #21's appendages to lift the resident into bed after the resident's legs buckled during transfer. The documentation identified that facility staff was reeducated to the appropriate use of the gait belt. Interview with the Staff Development Nurse, RN #2, on 7/25/12 at 2:45 PM identified that the proper use of the gait belt with a two person transfer included to hold the gait belt at the side of the resident and not from underneath the arm. Facility policy on the use of gait belts directed that during transfer/ambulation with a gait belt, the belt should be worn around the resident's waist, to grasp the gait belt from underneath the front when assisting a resident to stand or sit, and to grasp the gait belt in the back putting a free hand on the resident's shoulder to guide the resident when ambulating the resident. 2. Resident #30 (R #30) was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that R #30 was severely cognitively impaired with delusions and behavioral symptoms. The assessment further identified that R #30 was non ambulatory, totally dependent on staff for transfers, and had experienced a fall since the last assessment. The fall risk assessment dated [DATE] identified that R #30 was at high risk for falls. Review of the nursing care plan dated 5/8/12 identified the problem of high risk for falls due to dementia with interventions that included to transfer the resident via Hoyer lift and to utilize right and left foot rests on the resident's wheelchair when out of bed. Review of a nursing note dated 5/25/12 at 10:45 AM identified that R #30 was found lying on his/her left side on the floor of his/her room by a housekeeping staff member who responded to R #30's room after hearing a "boom." The documentation identified that R #30 was complaining of left hip pain and was subsequently transferred to the Emergency Department (ED). Review of the hospital radiology report dated 5/25/12 identified that R #30 had sustained an impacted and slightly displaced subcapital fracture of the left proximal femur. Interview with Nursing Assistant #2 (NA#2) on 7/25/12 at 11:30 AM identified that he/she provided morning care to R #30. NA #2 reported that R #30 was very agitated while in bed and wanted to get up. NA #2 stated that he/she and another NA used the Hoyer lift to transfer R #30 to the wheelchair. NA #2 reported that the resident was combative and kept moving his/her legs, and didn't want to be touched. NA #2 stated that after R #30 was in the wheelchair, she/she heard another resident's alarm sounding and left R #30 to respond to the other resident ' s alarm before completing the care and/or placing the leg rests on R #30's wheelchair. Review of the Supervisor ' s investigation report dated 5/25/12 identified that R #30's leg rests were not placed on the wheelchair and the resident was left unattended by NA #2 who went to assist another resident who was at risk of falling. Review of the care plan, facility investigation, and subsequent interview with RN#2 on 7/25/12 at 1:45 PM identified that R #30 should have had the leg rests in place when up in the wheelchair in accordance with the resident's care plan related to his/her risk to fall. Subsequent to event, the care plan was revised to reflect that the staff must ensure the foot pedals are on R #30's wheelchair prior to leaving the resident unattended.