Every finding on record at Norwalk Care Center

Based on observation, review of the clinical record, facility documentation, facility policy, job descriptions, and interview, the facility failed to ensure the environment was maintained in good repair and a homelike manner and for 1 of 2 residents (Resident #89) reviewed as part of the environment task, the facility failed to ensure a non-functioning toilet and leaking bathroom sink were repaired in a timely manner and for (5 of 7) sampled resident bathrooms, the facility failed to ensure soap. The findings include: 1. Observations on 5/18/26 at 12:20 PM through 12:45 PM with the Maintenance Director and on 5/20/26 at 5:44 AM through 7:00 AM identified the following issues: a. Damaged, torn, stains, white speck, marred, and/or peeling wallpaper in the bedroom walls on 4 East wing in rooms 401, 402, 405, 406, 407, 408, 411, 413, and 414. b. Damaged, chipped, stains, and/or marred bathroom walls on 4 East wing in rooms 401, 402, 403, 404, 405, 406, 409, 410, 412, 413, and 414. c. Damaged and/or cracks between wall and floor in the bathroom on 4 East wing in rooms [ROOM NUMBERS]. d. Damaged, bent, and/or missing window blinds in bedroom on 4 East wing in rooms [ROOM NUMBERS]. e. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on 4 East wing in rooms [ROOM NUMBER]. f. Damaged, broken, and/or missing toilet bowl cover in bathroom on 4 East wing in rooms [ROOM NUMBER]. g. Stains, dirt, debris, spider webs, and/or wax build up on floors crevices and corners in the bedroom on 4 East wing in rooms 402, 405, 406, 409, 410, 411, and 412. h. Stains, dirt, debris, spider webs, and/or wax build up on floors crevices and corners in the bathroom on 4 East wing in rooms 405, 406, 411, 413, and 414. i. Damaged and/or missing bathroom floor tile on 4 East wing in rooms [ROOM NUMBERS]. j. Damaged and/or missing bedroom floor tile on 4 East wing in rooms [ROOM NUMBERS]. k. Winged flying black insects in bedroom and bathroom on 4 East wing in rooms 401, 402, 403, 404, 406, 407, 408, 409, 410, 411, and hallways. l. Damaged, chipped, marred, rusty and/or peeling door frame in the bathroom on 4 East wing in rooms 401, 403, 405, 409, and 410. m. Stains, dirt and/or brown spots on the privacy curtain in bedroom on 4 East in room [ROOM NUMBER]. Interview with the Director of Maintenance on 5/18/26 at 12:45 PM identified he was aware of some of the issues identified during the survey. The Director of Maintenance indicated that maintenance of the facility is ongoing. The Director of Maintenance indicated that staff are responsible to notify the maintenance department with issues or problems that require repair. The Director of Maintenance indicated he does perform environmental rounds. The Director of Maintenance indicated going forward the maintenance department will address the environmental issues in a timely manner. Interview with the Administrator on 5/18/23 at 1:20 PM identified she has been employed by the facility for approximately 7 months. The Administrator indicated she was aware of some of the issues identified with the environment during the survey. The Administrator indicated it is the responsibility of the maintenance department to oversee the repairing of any issues regarding the facility. The Administrator indicated she does do environmental rounds. The Administrator indicated she will be meeting with the Maintenance Director, maintenance department, Housekeeping Director, and housekeeping staff regarding the environment. Interview with the DNS on 5/19/26 at 2:25 PM identified she has been employed by the facility since 12/2025. The DNS indicated she was aware of some of the issues identified with the environment during the survey. The DNS indicated that the maintenance department is responsible to maintain the resident rooms in a homelike environment at all times. The DNS indicated she will have a meeting with the nursing staff regarding the environment. Interview with RN #1 on 5/20/26 at 10:30 AM identified she has been employed by the facility since 9/2025 in the Infection Preventionist (IP) position. RN #1 indicated she was aware of some of the issues identified on the 4 East wing. RN #1 indicated she performs environmental rounds once a month. RN #1 indicated she informed the Maintenance Director/Housekeeping Director with issues and findings. Review of the facility infection control rounds identified the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment in which patients live to help prevent the development and transmission of disease and infections. The maintenance director job description identified he/she is responsible for the overall maintenance operation of the facility, and he/she is responsible for performing repairs and maintenance on equipment. Maintains the building and grounds in compliance with Federal, State, and local laws. The director of housekeeper job description identified is responsible for efficiently managing the supervisor of housekeeping and the building housekeeping and laundry operations as well as staff. Manages department in order to maintain the master cleaning plan for the entire facility. 2. Resident #89 was admitted to the facility in August 2025 with diagnoses that included an encounter for orthopedic aftercare and difficulty in walking. The care plan dated 2/25/26 identified Resident #89 had a self-care performance deficit related to muscle weakness and difficulty walking, with interventions that included providing supervision or touching assistance to get on and off a bedside commode. Resident #89 had bladder incontinence related to decreased mobility and chronic kidney disease, with interventions that included ensuring he/she has an unobstructed path to the bathroom. The care plan further identified that Resident #89 expressed a desire to return to the community and was a good candidate to achieve this goal, with interventions that included staff assessments of support systems. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition, was frequently incontinent of bowel and bladder, and required supervision or touching assistance with toilet transfers. Interview with Resident #89 on 5/17/26 at 9:30 AM identified that it was his/her desire to return home and that he/she had been working with rehabilitation services to start using the toilet instead of the commode, as a goal towards discharge. Resident #89 indicated that the bathroom toilet had not been flushing for over a week and the bathroom sink had been leaking into a bucket on the floor. Resident #89 indicated he/she had reported the concerns to the Maintenance Director and the toilet and sink had been looked at but was still broken. Resident #89 identified that he/she was using the bedside commode since the toilet was broken, and that the nurse aide would put a bag in the commode and would dispose of the contents somewhere outside of the room. Observation of Resident #89's bathroom on 5/17/26 at 9:35 AM identified a toilet that did not flush, multiple basins under the sink drainage pipe, with one basin containing water, and 2 empty hand soap dispensers on the bathroom wall. Observation with the Infection Control Nurse (RN #1) on 5/17/26 at 2:12 PM identified that the toilet in Resident #89's bathroom was not flushing and the pipe under the sink was leaking water into a basin on the floor. RN #1 indicated that she was not aware of this issue, and that she would expect a flushing toilet in a resident bathroom, and that it appeared that someone had attempted to fix the pipe under the sink, but it was still leaking. Observation and interview with the Regional Clinical Director (RN #6) on 5/19/26 at 8:35 AM identified that Resident #89's bathroom toilet was still not flushing and the pipe under the sink was still leaking water into a basin on the floor. RN #6 indicated that she would expect the toilet and the sink to both have been repaired since it was brought to the facility's attention on 5/17/26. Observation and interview with the Maintenance/Housekeeping Director on 5/19/26 at 8:45 AM identified that he had put eyes on the toilet and the sink in Resident #89's bathroom on Saturday (5/16/26), and that the toilet needed new internal mechanicals and that the sink repair required changing the drainage pipe. The Maintenance/Housekeeping Director indicated that he was going to pick the parts up at any time, and due to the state survey, he did not have a chance to get to it. Subsequent to surveyor inquiry, the toilet mechanicals and the sink drainage pipe were replaced, and both were functioning. Interview with the DNS on 5/20/26 at 7:28 AM identified that she was unaware that Resident #89 did not have a functioning toilet, and that Resident #89 was working with PT towards discharge goals, including use of the toilet, as his/her family had been encouraging more independence with use of the toilet prior to discharging home. The DNS indicated that she would expect a non-functional toilet and leaking sink to be delt with immediately. Review of the Maintenance Director job description identified that the Maintenance Director was responsible for the overall maintenance operation of the center, and he/she was responsible for performing repairs and maintenance on equipment. 3. Interview with a resident, who wished to remain anonymous, on 5/17/26 at 8:46 AM identified that his/her bathroom, which was shared by his/her roommate and 2 other residents from an adjoining room, had been without hand soap for over 2 months, and when the resident's asked housekeeping for hand soap, they were was told that there was no hand soap. Observation with the Infection Control Nurse (RN #1) on 5/17/26 at 2:17 PM identified that the following resident bathrooms were without the benefit of hand soap: shared bathroom adjoining resident rooms #201and 202, shared bathroom adjoining #209 and 210, shared bathroom adjoining resident rooms #211 and 212, shared bathroom adjoining resident rooms #213 and 214, and bathroom [ROOM NUMBER]. Interview with RN #1 on 5/17/26 at 2:25 PM identified that she was unaware that some of the resident bathrooms did not have hand soap available, and that concern was not brought forth to her nor had it been identified during environmental rounds. RN #1 indicated that, in the last month or so, the facility had been in the process of changing the wall mounted hand soap pumps and there was an issue with the compatibility of the soap with the new pumps, however her expectation would be that if there was an issue causing the wall mounted pumps not to dispense soap, she would expect that individual hand soaps be placed in the bathroom. RN #1 indicated that residents and staff should have access to hand washing while in a room. Observation and interview with the Regional Clinical Director (RN #6) on 5/19/26 at 8:35 AM identified that the shared bathroom adjoining resident rooms #211 and 212, the shared bathroom adjoining resident rooms #213 and 214, and bathroom [ROOM NUMBER] remained without the benefit of hand soap. RN #6 identified that she would expect all resident bathrooms to have hand soap accessible for hand hygiene for residents and staff. Observation and interview with the Maintenance/Housekeeping Director on 5/19/26 at 8:45 AM identified that he was aware that there were not enough of the wall mounted soap dispensers and that they were supposed to be getting more on 5/15/26. Maintenance/Housekeeping Director indicated that the maintenance staff was supposed to put individual hand soaps in the bathrooms that did not have functional wall mounted soap dispensers. Interview with Housekeeper #1 on 5/19/26 at 10:15 AM identified that the facility had ordered new hand soap canisters for the resident bathrooms, but the straw inside the pump was not big enough for the soap that the facility had in stock, so some bathrooms were without soap, and that he was unaware that he could have stocked individual bottles of hand soap in the resident bathrooms. Interview with the DNS on 5/20/26 at 7:28 AM identified that soap for the benefit of hand hygiene should be in the bathroom at all times for staff and residents, and it was up to housekeeper to refill the soap. Review of the Housekeeping Aide job description identified that the housekeeping aid ensures the center is maintained in a clean and sanitary condition at all times; responsibilities included: following specific cleaning and service instructions, following cleaning procedures in a safe manner, checking stock and notifying the supervisor of supply needs, and maintaining equipment in good working condition. Review of the Housekeeping Director job description identified that the Director of Housekeeping was responsible for efficiently managing housekeeping and laundry operations as, well as staff. Responsibilities included: managing the master cleaning plan for the entire community, assuring that supplies were ordered on a timely basis, inventoried quarterly, and stored in a secure area, and ensuring that staff were fully trained on safety procedures for refilling self-dispensing chemicals. The Hand Hygiene policy directs the facility to follow a hand hygiene protocol in preventing the spread of potential pathogens on the hands. All personnel must perform hand hygiene as per standard guidelines. Guidelines for hand hygiene: before and after each resident contact, before placement of personal protective equipment and following removal, before, during, and after food preparation, before and after eating, after using tissues, resident hand hygiene should be performed after toileting and before meals, after touching inanimate sources that are likely to be contaminated with bodily fluid (i.e. a residence personal care item such as urinals), before handling a resident's food, before going home at the end of the day, as indicated in specific protocols, and when in doubt about the necessity for hand hygiene personnel are encouraged to wash hands.

Based on observation, review of facility documentation, facility policy and interviews the facility failed to ensure the kitchen surfaces and equipment were maintained in a clean and sanitary manner, failed to ensure infection control practices were followed for safe food handling, failed to ensure kitchen staff wore hair restraints, completed and recorded daily food and refrigerator temperatures, failed to date food and failed to store raw food in accordance with accepted standards. The findings include: Observations on 5/17/26 at 7:15 AM in the kitchen identified the following. a. Dietary Aide #1 was operating the dishwasher without the benefit of a hair restraint.Interview with Dietary Aide #1 on 5/17/26 at 7:15 AM identified she had just come on duty and should have been wearing a hair restraint when operating the dishwasher.Interview with the interim Food Service Director (FSD) on 5/17/26 at 12:30 PM identified all staff were expected to wear hair restraints when entering the kitchen.Review of the facility policy for Food Safety and Sanitation directed that hair restraints are required when working in the kitchen and should cover all hair on the head. b. The following food was observed uncovered on a large rack next to the oven defrosting at room temperature. A large tray of raw, partially frozen fish in water on a rack above another large rack of precooked partially frozen chicken strips and a large tray of precooked partially frozen meat patties. In the walk-in refrigerator there was a large tray of raw fish stacked in a rack above a large tray of precooked partially frozen French fries, both uncovered and without a date. Eleven plastic wrapped cheese and meat sandwiches in the reach in refrigerator without a date. Four large trays of pie wedges wrapped in plastic in the walk-in refrigerator without a date. One large box of lettuce in the walk-in refrigerator uncovered and without a date. One plate of meat, cheese and egg salad covered with plastic and without a date in the walk-in refrigerator. One large stainless-steel container of cut watermelon uncovered and without a date in the walk-in refrigerator. Interview with Dietary Staff #1 on 5/17/26 at 7:15 AM identified all food items in the refrigerator should be dated when prepared. Dietary Staff #1 indicated he/she believed the food was adequate to be maintained for one day. Interview with [NAME] #1 on 5/17/26 at 7:15 AM identified it was acceptable to have the raw fish thawing at room temperature in water and uncovered as the food was intended to be served at the next meal. [NAME] #1 was unable to explain policies related to thawing raw fish (on the bottom shelf) and covering food items. Interview and electronic image review with the FSD on 5/17/26 at 12:30 PM identified all food items in the refrigerator should be covered and dated when opened/prepared and maintained for three days. The FSD further identified all frozen raw meat and fish should be thawed in the refrigerator, covered and stored on the bottom rack. Interview with the Administrator on 5/18/26 at 1:10 PM identified she would expect kitchen staff to be dating, storing food in accordance with infection control standards and policy. Review of the facility policy for Food production and Food Safety directed that cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on the lower shelves of the refrigerator and in drip proof containers. For safe thawing of frozen meat, poultry and fish in refrigerator, allow a minimum of 24 to 48 hours and cook immediately after thawing. All foods should be labeled, dated and covered. c. Observation identified two large fans with a large buildup of grey fuzzy matter throughout the grill surface, one operating at high-speed pointing towards the food serving line. One large standing mixer (not in use) with a moderate amount of dried white buildup in the back plate and side grills. A large amount of white buildup with additional crusted yellow buildup located on the bottom shelf of the 'clean' side of the dishwasher shelf. A large glass pitcher and scoop ladle were set lip side down directly touching the surface. Moderate amounts of brown and yellow crusted build up along each side of the canned food rack. Interview with Dietary Staff #1 on 5/17/26 at 7:15 AM identified kitchen staff were responsible for cleaning kitchen surfaces and equipment but was unsure who was responsible for cleaning the fans. Dietary Staff #1 further identified the kitchen had been short staffed. Interview with the FSD on 5/17/26 at 12:30 PM identified kitchen staff were responsible for cleaning food surface areas and equipment after use. The FSD further identified he was unsure who was responsible for the cleaning of the fans between kitchen staff and maintenance. Interview with the Director of Maintenance on 5/17/26 at 12:30 PM identified maintenance was responsible for cleaning the fan grills on a weekly basis. The Director of Maintenance further identified the grills had not recently been cleaned as other maintenance check lists resulting from a change of ownership had been prioritized instead. Review of the facility policy for Food Storage directed racks and other storage surfaces will be clean and protected from splashes, overhead pipes or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc. Although requested, a policy for maintaining clean equipment or preventative maintenance logs for cleaning the fans were not provided. d. Observation identified the hot wash and rinse dishwasher temperature logs dated 5/1/26 - 5/17/26 identified no documented temperatures for 24 of 51 entries. Walk in refrigerator temperature logs dated 5/1/26 - 5/17/26 identified no documented temperature for 13 of 33 entries. Documented hot/cold food temperature logs were not available upon request. Interview with Dietary Staff #1 on 5/17/26 at 7:15 AM identified kitchen staff were responsible for obtaining refrigerator temperatures twice daily and dishwashing temperatures with each meal. Dietary Staff #1 further identified the kitchen had been short staffed. Interview with [NAME] #1 on 5/17/26 at 7:15 AM identified she was responsible for obtaining food temperatures prior to plating meals. [NAME] #1 indicated she had not been working the preceding days and was unable to locate the food temperature logs at that time for review. A subsequent observation on 5/17/26 at 8:20 AM identified the kitchen staff plating the breakfast meal with no documented meal temperatures for breakfast provided upon request Interview with [NAME] #1 on 5/17/26 at 8:20 AM identified she did not obtain meal temperatures prior to plating and was unable to provide an explanation. A third observation on 5/17/26 at 12:30 PM identified the kitchen staff plating the lunch meal with no documented meal temperatures for breakfast provided upon request. Interview with [NAME] #1 on 5/17/26 at 12:30 PM identified she did not obtain meal temperatures prior to plating and was unable to provide an explanation. Further, [NAME] #1 did not have a thermometer. Interview with the (interim) FSD on 5/17/2026 at 12:30 PM identified food temperatures should be recorded at every meal before plating. The FSD indicated he would locate and provide previously recorded food temperature logs. The FSD further identified the refrigerator and dishwasher temperature logs should be recorded three times daily with meals Subsequent interview and facility documentation review with the FSD on 5/18/26 at 7:02 AM identified hot/cold food temperature logs were provided for March 2026, April 2026 and through 5/17/26 dinner including recorded food temperatures for 5/17/26 breakfast and 5/17/26 lunch (this is in conflict with the interview with [NAME] #1 who stated she had not recorded breakfast or lunch food temperatures on 5/17/26). The FSD indicated [NAME] #1 had reported the food temperatures and he recorded them. Subsequent interview with [NAME] #1 on 5/18/26 at 7:02 AM he/she confirmed food temperatures were not taken or recorded on 5/17/26 for breakfast and lunch and she (guesstimated) instead and reported them to the FSD. Interview with the Administrator on 5/18/26 at 1:10 PM identified she would expect kitchen staff to be dating, storing and recording food temperatures in accordance with infection control standards and policy. Review of the facility policy for Food temperatures directed temperatures for all food items must be taken and recorded prior to service of each meal. Hot foods are to be cooked to 165 F - 180 F or higher when removed from the cooking heat source, held and served at a temperature of at least 135 F, cold served at temperatures below 41 F. Review of the facility policy for Food production and Food Safety directed that refrigerator temperatures were to be checked twice daily and (recorded) on a temperature form. Although requested a policy for monitoring dishwasher temperatures was not provided. e. Observation on 5/17/26 at 8:20 AM identified [NAME] #1 lifted the lid to the plate warmers with her right (gloved) hand, obtained several plates using both gloved hands, closed the lid using the left gloved hand, then returned to the food tray line where she used the same right gloved hand to pick up a hash brown cake and to place on a resident tray. The task was interrupted. Interview with [NAME] #1 on 5/17/26 at 8:20 AM identified she should have washed her hands after handling potentially contaminated surfaces and before handling food or used a utensil to handle the food when plating. Interview with the FSD on 5/18/26 at 7:02 AM staff should be washing hands after touching potentially contaminated surfaces or using a utensil if able when handling food. Interview with the Administrator on 5/18/26 at 1:10 PM identified she would expect kitchen staff to handle food in accordance with infection control standards and policy. Review of the facility policy for General Food Preparation and Handling directed that bare hands never touch ready made or raw food directly. Disposable gloves are single use and should be discarded after each use and hands washed prior to putting gloves on and after removing. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact with prepared foods. Review of the facility policy for Food Safety and Sanitation directed should wash their hands before working in the kitchen and after touching surfaces or items with potential for cross contamination.

Based on observation, review of facility documentations, job descriptions, and interviews for 2 of 5 wings, the facility failed to maintain an effective pest control program. The findings include:Tour of the facility on 5/17/26 from 9:00 AM - 1:00 PM, 5/18/26 from 8:00 AM - 12:30 PM, and 5/19/26 from 8:00 AM - 11:00 AM, and 5/20/26 from 8:00 - 9:00 AM identified numerous winged flying black insects were observed. Observation on 5/18/26 at 12:20 PM - 12:45 PM with the Maintenance Director and the pest control Supervisor identified numerous winged flying black insects were observed. Winged flying black insects were noted in the following areas on bedroom walls, bathrooms, hallways, and the shower room. Three East wing in resident rooms, bathrooms, and hallways. Four East wing in resident rooms, bathrooms, hallways, and shower room. Main floor hallways, and hallways by the elevator on the main floor.Review of the pest control invoices dated 8/5/25 - 12/22/25 identified pest control services were performed on a bi-weekly basis. Review of the pest control invoice dated 10/27/25 identified treatment was provided for gnats (small fly) activity in the kitchen, 1 East wing, and 3 East wing. Review of the pest control invoice dated 11/10/25 identified treatment was provided for gnats and flies activity in the 3 East floor pantry/nourishment room, resident rooms 405, 410, and the locker room. The pest control technician documented and informed facility staff that gnats and fly's activity was most likely related to sanitation and/or moisture issues in affected areas. During observation, a leak was noted in the nurse pantry area. The floor beneath the leak was covered with cloths in an apparent attempt to dry the wet floor. Documentation from the pest control technician recommended sealing/repairing the leak.The facility failed to ensure timely correction of environmental conditions contributing to pest activity.Review of the pest control invoice dated 1/5/26 - 5/11/26 identified pest control services were performed on a bi-weekly basis. However, the pest control invoices failed to reflect documentation of assessment and treatment measures were provided for winged flying black insects during the review period.Review of the environmental rounds worksheet for infection prevention dated 1/22/26 - 4/20/26 identified dirty resident bedroom and bathroom floors, food not stored properly in resident rooms. The environmental rounds worksheet for infection prevention failed to reflect documentation regarding the winged flying black insects during the review period.Interview with Housekeeper #2 on 5/18/26 at 11:04 AM identified she has been employed by the facility for approximately 30 years. Housekeeper #2 indicated she is the regular housekeeper for 4 East wing, and she has seen the winged flying black insects in the resident rooms and bathrooms. Housekeeper #2 indicated she had notified the Housekeeper Director who is also the Maintenance Director of the winged flying black insects. Housekeeper #2 indicated the pest control company comes to the facility every two weeks. Interview with the Pest Control Supervisor on 5/18/26 at 12:50 PM identified resident rooms [ROOM NUMBERS], which share a bathroom, has a sanitation issue. The yellow liquid in the crack between the wall and floor is a breeding source for the fruit flies to lay their eggs. The pest control Supervisor indicated that the winged flying black insects are fruit flies. The Pest Control Supervisor indicated he has observed the fruit flies in resident rooms, bathrooms, and other areas through the facility. The Pest Control Supervisor indicated sanitation is an issue in the residents' rooms and bathrooms. The Pest Control Supervisor indicated the facility has to implement a plan for food in resident rooms and sanitation and/or cleanliness program. Interview with the Maintenance Director on 5/18/26 at 1:00 PM identified he was not aware of the winged flying black insects issue in the residents rooms and bathrooms. The Maintenance Director indicated he will have a meeting with the Administrator and the DNS regarding the winged flying black insects in the resident rooms, bathrooms, and food being left out in resident rooms. Interview with the Administrator on 5/18/26 at 1:20 PM identified she was not aware of the issue with the winged flying black insects in resident rooms and bathrooms. The Administrator indicated the facility does have a pest control program. The Administrator indicated the facility will be educating the residents to discard or place any food items in a plastic container. The Administrator indicated the nursing staff, housekeeping, and the maintenance department will be educated. The Administrator indicated the Maintenance Director will address the crack between the wall and floor in the shared bathroom between rooms [ROOM NUMBERS] immediately.Interview with the DNS on 5/18/26 at 2:23 PM identified she was not aware of the issue with the winged flying black insects in resident rooms and bathrooms. The DNS indicated the facility does have a pest control program. The DNS indicated when she makes rounds, she has not been in all resident rooms and bathrooms. The DNS indicated the facility will educate the residents to discard or place any food items in a plastic container. The DNS indicated the nursing staff, and housekeeping will be educated on resident rooms cleanliness. Interview with the Contracted Pest Control Technician on 5/26/26 at 9:00 AM identified the he had serviced the facility since January 2026 for general pest control services. The Contracted Pest Control Technician indicated the facility had not verbally informed him of concerns related to winged flying black insects or fruit flies, and no documentation regarding such concerns had been recorded in the yellow pest control communication logs (yellow pest control books) located on the resident wings. The Contracted Pest Control Technician indicated the facility had ongoing sanitation concerns in resident rooms, bathrooms, and the other areas of the facility. The Contracted Pest Control Technician indicated he serviced the facility on Monday 5/25/26; however, no maintenance staff were present at the facility and nursing staff did not provide verbal or written reports regarding winged flying black insects or fruit flies activity. The Contracted Pest Control Technician indicated treatment was provided for other pest related concerns during the visit. Review of the pest control policy identified the facility to establish and maintain an integrated pest control program. To ensure a healthy clean and safe environment for our residents, families and staff. A service agreement shall be established with a licensed pest control company. Service shall include, at a minimum, weekly visits of the facility to address areas of concerns. Frequency of visits shall be increased depending on extent of needs. A log shall be maintained to record any pest/rodent complaints by residents, staff, visitors and any poor housekeeping and maintenance practices/situations. Housekeeping standards and practices shall be reviewed and modified, as needed, to incorporate procedures as they to pest control. Weekly environmental rounds shall be conducted by maintenance to identify any problems and determine corrective actions.The maintenance director job description identified heshe is responsible for the overall maintenance operation of the facility, and he/she is responsible for performing repairs and maintenance on equipment. Maintains the building and grounds in compliance with Federal, State, and local laws.The director of housekeeper job description identified is responsible for efficiently managing the supervisor of housekeeping and the building housekeeping and laundry operations as well as staff. Manages department in order to maintain the master cleaning plan for the entire facility.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #41) reviewed for notification of change, the facility failed to ensure the physician or APRN was notified when the resident missed 2 doses of Amiodarone and 3 doses of Furosemide because the medication was not available. The findings include:Resident #41 was admitted to the facility in April 2026 with diagnoses that included heart failure, bradycardia, atrial fibrillation, and hypertension. The admission MDS dated [DATE] identified Resident #41 had intact cognition and was taking medications from the following high-risk drug classes: anticoagulant, antibiotic, diuretic, and hypoglycemic. A physician's order dated 4/21/26 directed to administer Amiodarone HCL (antiarrhythmic medication) 200mg daily for atrial fibrillation with rapid ventricular response, and Furosemide (diuretic medication) 40mg daily for fluid retention; hold for systolic blood pressure below 90. The care plan dated 5/13/26 identified Resident #41 had the potential for dehydration and/or fluid deficit related to diuretic use. Interventions included administering medications as ordered and monitoring for side effects and effectiveness. The May 2026 MAR failed to identify the Amiodarone had been administered on 5/16/26 and 5/17/26, and failed to identify the Furosemide had been administered on 5/16/26, 5/17/26, and 5/18/26.The administration notes dated 5/16/26 at 9:31 AM and 9:32 AM identified the Amiodarone and Furosemide were on order.The administration notes dated 5/17/26 at 10:31 AM and 10:32 AM identified the Amiodarone and Furosemide were on order.The administration notes dated 5/18/26 at 9:30 AM and 9:30 AM identified the Amiodarone and Furosemide were on order.Review of the nurse's notes dated 5/16/26 through 5/18/26 failed to identify that the physician or APRN had been notified when the resident missed the ordered Amiodarone and Furosemide 5/16/26 through 5/18/26.Interview with LPN #2 on 5/18/26 at 10:51 AM identified that Resident #41's Amiodarone and Furosemide were not available for administration on 5/16/26 or 5/17/26 because they were on order from the pharmacy. LPN #2 indicated she did not notify the RN supervisor that the Amiodarone and Furosemide were not available nor was the physician or APRN notified. LPN #2 indicated that she did not follow-up with pharmacy on the status of the medications or notify the incoming nurse during the change of shift report that the Furosemide and Amiodarone were on order because it was documented in the administration notes. LPN #2 identified that she should have notified the RN supervisor, physician or APRN.Interview with LPN #1 on 5/18/26 at 11:20 AM identified that she notified the RN supervisor of the missing Amiodarone and Furosemide doses on 5/16/26 through 5/18/26, and the Medical APRN was also notified on 5/16/26 through 5/18/26; no new orders were obtained, and both medications would be administered once they arrived from pharmacy.Interview with the DNS on 5/18/26 at 12:50 PM identified that she would have expected the charge nurse to notify the RN supervisor that Resident #41's Amiodarone and Furosemide were not available for administration, as the RN supervisor could have looked to see if the medications were available in the pyxis (an automated medication dispensing cabinet). The DNS indicated that she would have expected the physician or medical APRN to have been notified of a missed medication dose, in case there was a need for monitoring or new orders, and she would expect licensed staff to document the notifications in a progress note. The DNS further indicated that she would have expected the charge nurse to follow up with the pharmacy to ensure they received the medication order request and/or the status of the delivery.Interview with MD #1 on 5/18/26 at 1:21 PM identified that he would have expected a medical provider to have been notified that Resident #41's missed the Furosemide and Amiodarone as they are important medications.The Physician Notification policy directs the medical provider to be notified for a change in the resident's condition (physical, mental, psychological, behavioral, etc). In the event that a licensed nurse recognizes a change in the resident's condition, the unit RN or supervisor completes an assessment of the resident and based upon the assessment the physician is notified. If there is no response within 30 minutes, a second call should be made. The RN who completed the assessment and notified the physician is responsible for reflecting all information in the progress notes.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for mood/behaviors, the facility failed to ensure that the resident's care plan was reviewed and revised following an identified plan to self-harm. The findings include:Resident #1 was admitted to the facility in October 2025 with diagnoses that included rhabdomyolysis, bipolar disorder, and depression.The care plan dated 10/15/25 identified Resident #1 had a mood state problem related to bipolar disorder. Interventions included to monitor/record/report to the physician mood patterns as needed and signs and symptoms of depression, anxiety, and sad mood as per facility behavior monitoring protocols.The admission MDS dated [DATE] identified Resident #1 had intact cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required supervision by staff with toileting, bathing, and dressing.Review of the clinical record identified Resident #1 had a history of suicidal ideation and suicidal gestures that required transfer to the hospital for evaluation on 11/20/25, 11/22/25, and 12/7/25. Further review of the clinical record also identified Resident #1 was admitted to the hospital from [DATE] - 1/9/26 for inpatient psychiatric treatment following an episode of self-harm.The nurse's note dated 1/22/26 at 5:48 PM by the prior ADNS identified that she was called by unit nurse and informed that Resident #1 verbalized to recreation staff that he/she wanted to overdose tonight and showed the recreation staff cups of medications that the resident had saved. The prior ADNS identified orders to monitor the resident every 15 minutes for 3 days until psychiatric re-evaluation is received and to check resident for possible medication pocketing.Review of the clinical record failed to identify physician's order related to 15-minute monitoring for Resident #1 following the 1/22/26 incident.A psychiatric note dated 1/23/26 identified Resident #1 had endorsed suicidal ideation with a plan to take stockpiled medications that the resident had not been taking for the past few days. The note identified that Resident #1 was placed on 1:1 monitoring until psychiatric evaluation and identified that Resident #1 reported no longer being suicidal. The note further identified the treatment plan included every 15-minute monitoring until next psychiatric evaluation on 1/27/26, check resident's mouth for pocketing during medication administration, and recommendation of crushing medications in apple sauce to decrease chance of medication pocketing by resident. Review of the clinical record failed to identify orders related to 1:1 monitoring for Resident #1 following the 1/22/26 incident. Further, the clinical record failed to identify documentation of monitoring the resident every 15 minute or 1:1 monitoring following the 1/22/26 incident. Additionally, the clinical record failed to identify documentation of what medications were identified at Resident #1's bedside that had been stockpiled. Review of facility accident and incident reports for Resident #1 failed to identify an investigation into what medications had been stockpiled at Resident #1's bedside. Review of Resident #1's care plan failed to identify any review or revisions related to the incident on 1/22/26 related to behaviors or medication stockpiling or medication pocketing, including the need for frequent observations of the resident, observation of medication administrations for medication pocketing, or the possible need to crush medications due to the 1/22/26 incident. Interview with Recreation Aide #1 on 5/19/26 at 11:36 AM identified that he was the recreation staff working with Resident #1 on 1/22/26. Recreation Aide #1 identified that he went to Resident #1's room to inquire about any interest in recreation activities during the 3:00 PM - 11:00 PM shift. Recreation Aide #1 identified that upon entering Resident #1's room, he observed a plastic medication cup with 5 tablets/pills of various colors and sizes. Recreation Aide #1 identified that he asked Resident #1 about the medication cup and Resident #1 identified that he/she was planning to use the medications in the cup to overdose and kill him/herself. Recreation Aide #1 identified he notified RN #13 who was the unit supervisor who came to Resident #1's room and addressed the situation from there. Interview with the prior ADNS on 5/19/26 at 12:45 PM identified she was notified by Recreation Aide #1 on 1/22/26 regarding pills at the Resident #1's bedside with a plan to overdose. The prior ADNS identified she was with MD #1 at the time of the notification, and they both went to Resident #1's room to speak to him/her about the incident, and upon arriving to the room, no medications were observed at the bedside. The prior ADNS identified that she recalled the medications had been removed by either RN #13 or Recreation Aide #1 prior to her arrival, however she could not recall the specifics regarding who removed the medications, the number of pills observed, what the medications were, or what was done with the medications following removal. The prior ADNS identified that Resident #1 declined transport to the hospital for evaluation following the incident, and that Resident #1 was placed on 1:1 monitoring following the incident. The prior ADNS identified she could not recall if Resident #1's care plan was reviewed or revised following the incident and identified she did not recall any investigation being done to identify what medications were at the bedside and not administered to Resident #1.Interview with the DNS on 5/19/26 at 1:28 PM identified that she was aware of the 1/22/26 incident with Resident #1 related to medication at the bedside with plans to overdose. The DNS identified she deferred the investigation and care plan review to the prior ADNS but did provide in servicing to nursing staff following the incident to ensure that no medications were left at the bedside. The DNS was unable to identify if any investigation regarding what medications were at the bedside and not administered to Resident #1. Review of the facility and service acknowledgement document dated 12/3/26 identified that the topic of medication administration was reviewed with nursing staff. The document further identified it was the expectation that nurses administering medications to residents adhere to best practice and nursing standards. Medications were not to be left with the resident, and medications must be observed being ingested by the resident and any exception to this must be documented in the residence care plan.Although attempted, an interview with RN #13 was not obtained. The facility policy for care planning process directed that the facility should have a care planning process that was person-centered and included integrating assessment findings and care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care, and documenting the care. The policy also directed that the resident's care plan would address issues and problems pertinent to the individual resident including but not limited to risk factors identified in risk observations, medical diagnoses, and conditions. The policy also directed that care plan meetings may be scheduled for reasons that included discussion of specific care issues or problems that might require more frequent monitoring. The policy also directed that it was the responsibility of the DNS and department heads of the included departments to ensure compliance in the care planning process.The facility policy regarding notification of significant changes in the residence medical condition and or status directed that in the event of a significant change in the residence condition or status new orders and interventions would be entered into the electronic medical record and the resident's care plan to reflect a change in treatment.The facility policy on reporting and investigation of resident abuse, neglect, misappropriation, exploitation, and mistreatment identified reportable events included adverse events which were untoward undesirable and usually unanticipated event that caused death or serious injury or risk thereof. The policy further directed that the interdisciplinary team would assess resident behavior and determine if the resident exhibited or had the potential to exhibit problem behaviors. The policy also directed that during care plan meetings, if and when necessary, care plans would be written and communicated to the care team to reduce the likelihood of the resident harming self or others.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 resident (Resident #1) reviewed for mood/behaviors, the facility failed to ensure that licensed staff administered medications according to professional standards to include observing the resident consume medications prior to leaving the resident. The findings include: Resident #1 was admitted to the facility in October 2025 with diagnoses that included rhabdomyolysis, bipolar disorder, and depression.The care plan dated 10/15/25 identified Resident #1 had a mood state problem related to bipolar disorder. Interventions included to monitor/record/report to the physican mood patterns as needed and signs and symptoms of depression, anxiety, and sad mood as per facility behavior monitoring protocols.The admission MDS dated [DATE] identified Resident #1 had intact cognition. Review of the clinical record identified Resident #1 had a history of suicidal ideation and suicidal gestures that required transfer to the hospital for evaluation on 11/20/25, 11/22/25, and 12/7/25. Further, the clinical record identified Resident #1 was admitted to the hospital from [DATE] - 1/9/26 for inpatient psychiatric treatment following an episode of self-harm after Resident #1 reported wrapping a call bell cord around his/her neck and stabbing him/herself with a fork.The nurse's note dated 1/22/26 at 5:48 PM by the prior ADNS identified that she was called by unit nurse and informed that Resident #1 verbalized to recreation staff that he/she wanted to overdose tonight and showed the recreation staff cups of medications that he/she had saved. The prior ADNS identified orders to monitor resident every 15 minutes for 3 days until psychiatric re-evaluation is completed and to check resident for possible medication pocketing.Review of the clinical record failed to identify any orders related to 15-minute monitoring for Resident #1 following the 1/22/26 incident.A psychiatric note dated 1/23/26 identified Resident #1 had endorsed suicidal ideation with a plan to take stockpiled medications that the resident had not been taking for the past few days. The note also identified that Resident #1 had a well-documented history of chronic suicidal ideation with suicidal gestures. The note identified that Resident #1 was placed on 1:1 monitoring until psychiatric evaluation and identified that Resident #1 reported no longer being suicidal. The note further identified the treatment plan included every 15-minute monitoring until next psychiatric evaluation on 1/27/26, check resident's mouth for pocketing during medication administration, and recommendation of crushing medications in apple sauce to decrease chance of medication pocketing by resident. Review of the clinical record failed to identify orders related to 1:1 monitoring for Resident #1 following the 1/22/26 incident. Further, the clinical record failed to identify monitoring documentation for every 15 minute or 1:1 monitoring for Resident #1 following the 1/22/26 incident. Review of the clinical record failed to identify documentation of what medications were identified at Resident #1's bedside. Review of facility accident and incident reports for Resident #1 failed to identify an investigation into what medications were identified at Resident 1's bedside after the resident showed the recreation staff stockpiled medications. Review of Resident #1's care plan failed to identify a review or revision after the incident on 1/22/26 related to behaviors and medication stockpiling or medication pocketing, including the need for frequent observations of the resident, observation of medication administrations for medication pocketing, or the possible need to crush medications due to the 1/22/26 incident. Interview with Recreation Aide #1 on 5/19/26 at 11:36 AM identified that he was the recreation staff working with Resident #1 on 1/22/26. Recreation Aide #1 identified that he went to Resident #1's room to inquire about any interest in recreation activities during the 3:00 PM - 11:00 PM shift. Recreation Aide #1 identified that upon entering Resident #1's room, he observed a plastic medication cup with 5 tablets/pills of various colors and sizes. Recreation Aide #1 identified that he asked Resident #1 about the medication cup and Resident #1 identified that he/she was planning to use the medications in the cup to overdose and kill him/herself. Recreation Aide #1 identified he notified RN #13 who was the unit supervisor who came to Resident #1's room and addressed the situation from there. Interview with the prior ADNS on 5/19/26 at 12:45 PM identified she was notified by Recreation Aide #1 on 1/22/26 regarding pills at the Resident #1's bedside with a plan to overdose. The prior ADNS identified she was with MD #1 at the time of the notification, and they both went to Resident #1's room to speak to him/her about the incident, and upon arriving to the room, no medications were observed at the bedside. The prior ADNS identified that she recalled the medications had been removed by either RN #13 or Recreation Aide #1 prior to her arrival, however she could not recall the specifics regarding who removed the medications, the number of pills observed, what the medications were, or what was done with the medications following removal. The prior ADNS identified that Resident #1 declined transport to the hospital for evaluation following the incident, and that Resident #1 was placed on 1:1 monitoring following the incident. The prior ADNS identified she could not recall if Resident #1's care plan was reviewed or revised following the incident and identified she did not recall any investigation being done to identify what medications were at the bedside and not administered to Resident #1.Interview with the DNS on 5/19/26 at 1:28 PM identified that she was aware of the 1/22/26 incident with Resident #1 related to medication at the bedside with plans to overdose. The DNS identified she deferred the investigation and care plan review to the prior ADNS but did provide in servicing to nursing staff following the incident to ensure that no medications were left at the bedside. The DNS was unable to identify if any investigation regarding what medications were at the bedside and not administered to Resident #1. Review of the facility and service acknowledgement document dated 1/23/26 identified that the topic of medication administration was reviewed with nursing staff. The document further identified it was the expectation that nurses administering medications to residents adhere to best practice and nursing standards. Medications were not to be left with the resident, and medications must be observed being ingested by the resident and any exception to this must be documented in the resident's care plan.Although attempted, an interview with RN #13 was not obtained. Although requested, the facility failed to provide a policy on accidents and incidents.The facility policy on reporting and investigation of resident abuse, neglect, misappropriation, exploitation, and mistreatment identified that adverse events included an untoward, undesirable and usually unanticipated event that caused death or serious injury, or risk thereof. The policy further directed that all staff who provided direct resident care were to carefully observe the resident during care and identify any changes. The policy further directed that the staff were to take note if the resident was articulating a problem, exhibiting any new behaviors, or making changes to their routine pattern of behavior. Upon identification of such a change, the staff member must report the finding to his or her supervisor to determine if a further investigation was warranted. The policy also directed that upon the identification of an incident, and the initiation of an investigation would include the nursing supervisor conducting a nursing assessment of the resident and documenting the finding in the resident's medical record and on an occurrence report form.The facility policy on suicide precautions identified that the facility was to evaluate residents with suicidal behaviors or ideation and that for residents who exhibited suicidal behavior facility staff were to ensure that the resident did not stockpile medication supplies or medications.The facility policy on common practices related to nursing documentation directed that the medical record was a communication tool and all documentation regarding care and services given to each resident became part of the legal medical record. The policy further directed that to avoid discrepancies that all documentation entries must be timely all fields must be completed and there should be timely completion of all accident and incident reports.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #10) reviewed for vision/hearing, the facility failed to ensure a referral to a Retina Specialist was completed in a timely manner. The findings include: Resident #10 was admitted to the facility in January 2026 with diagnoses that included type 2 diabetes mellitus and transient cerebral ischemic attack. The admission MDS dated [DATE] identified Resident #10 had intact cognition and had adequate vision and did not use corrective lenses. The care plan dated 2/5/26 identified Resident #10 had altered Endocrine/Metabolic Status related to type 2 diabetes mellitus, with interventions that included medical follow-up as necessary. The Consulting Optometry note dated 3/17/26 identified Resident #10 had Severe Non-Proliferative Diabetic Retinopathy to both eyes, Hypertension Retinopathy to both eyes, and age-related cataracts, with recommendations that included continuing blood sugar and blood pressure management/medication control and to refer to Retina Specialist. A physician's order dated 3/25/26 directed to refer Resident #10 to a Retina Specialist for a retina evaluation. Review of the clinical record dated 3/25/26 through 5/18/26 failed to identify that an appointment had been made with a Retina Specialist nor had a consultation been completed. Interview with the Medical Records/Transportation and Scheduling Coordinator on 5/18/26 at 11:57 AM identified that she was unaware that the physician referred Resident #10 to a Retina Specialist for a retina evaluation. The Medical Records/Transportation and Scheduling Coordinator indicated she would look for the recommendation in her bin of signed consults and schedule the appointment today. The Medical Records/Transportation and Scheduling Coordinator further indicated that she oversees 3 roles in the facility and that it was her goal to ensure resident appointments and transportation were scheduled as soon as possible. Subsequent to surveyor inquiry Resident #10 was scheduled for a Retina Evaluation on 6/12/26. Interview with the DNS on 5/20/26 at 7:45 AM identified that while there was no specific timeframe identified by Resident #10's provider to complete the Retina Specialist consult, she would expect an appointment of that nature to be scheduled within 1-2 weeks. The DNS further identified that in March other staff had been assisting with appointment scheduling so that was most likely why scheduling the appointment got missed. The Medical and Dental Consults policy directs the facility to arrange for the services of qualified personnel to render specific medical services.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #86) reviewed for indwelling urinary catheter, the facility failed to facilitate recommendations for Resident #86 to follow up with a urologist twice after a January 2026 and May 2026 hospitalization, and failed to monitor the resident's urinary output according to facility policy. The findings include: The hospital Discharge summary dated [DATE] identified Resident #86 was admitted to the hospital with diagnoses that included acute hematuria and prostate varices (dilated blood vessels in the prostate). An indwelling urinary catheter device was placed during hospitalization for continuous irrigation of the bladder to treat suspected clotted material within the lining of the bladder followed by antibiotic therapy. Two attempts were made to remove the indwelling urinary device during hospitalization but required replacement when voiding trails failed. Discharge recommendations included following up with urology services within three weeks of discharge. Resident #86 was admitted to the facility in January 2026 with diagnoses that included gross hematuria (blood in the urine), obstructive and reflux uropathy (blockage in the urinary tract impeding flow) and chronic kidney disease (CKD). The admission MDS dated [DATE] identified Resident #86 was admitted from the hospital, was cognitively intact, and had an indwelling urinary catheter. The care plan dated 1/27/26 identified Resident #86 required an indwelling catheter with interventions that included reporting to the physician any sediment, blood, cloudiness odor or fever to the physician and record output. a. A nurses note dated 4/19/26 at 11:22 AM identified bloody urine was observed in Resident #86's urine collection device. The APRN was notified and directed to obtain bloodwork, urinalysis and urine culture.The APRN progress note dated 4/21/26 at 5:10 PM identified Resident #86's urine culture results were still pending. Laboratory results obtained on 4/20/26 also noted an increase in creatinine (measures how well the kidney filters waste from the blood) of 1.81mg/dl (normal 0.7 to 1.2 milligrams per deciliter) with blood urea nitrogen or BUN (waste from protein breakdown filtered by the kidneys) of 44.3mg/dl (normal 8-24 milligrams per deciliter) and an eGFR (assesses kidney function) of 36.0 mL/min (normal levels 90 milliliters per minute per 1.73 square meters of body surface area or higher. Lower levels suggest a decrease in kidney function) raising concern for acute kidney injury in the setting of a suspected infection and ongoing diuretic use. Resident #86 was alert in no acute distress or signs of illness and denied acute pain. A plan was in place to start empiric antibiotic therapy based on preliminary results, hold diuretics (a medication used to remove excess salt and water from the kidneys) with repeat bloodwork to assess renal function.The APRN progress note dated 4/24/26 at 8:14 PM identified the urine culture was still pending. The urinalysis identified grossly bloody urine. An indwelling urinary catheter was in place and served as a potential contributing source. The urinalysis further identified findings consistent with a urinary tract infection in the setting of an indwelling catheter. Resident #86 was to be monitored for fever, mental status changes, and hemodynamic assessment. Escalation to higher care was warranted with signs of urosepsis including fever, hypotension and acute altered mention.Nurses note dated 4/25/26 at 2:59 PM identified Resident #86 had blood in the urine. The supervisor and APRN were notified and Resident #86 was transferred to the hospital for further evaluation. Vital signs were stable with no complaints of pain or discomfort.The hospital Discharge summary dated [DATE] identified Resident #86 was admitted with diagnoses that included gross hematuria, urinary tract infection, sepsis secondary to klebsiella, extended-spectrum beta-lactamases (ESBL) bacteremia (bacteria in the bloodstream) and sacral wound infection. Hospital course included antibiotic therapy, continuous bladder irrigation and wound management. Hematuria resolved and Resident #86 was cleared by urology with recommendations to be seen for urology follow up within one week following discharge to consider a voiding trial versus maintaining the indwelling urine device as Resident #86 had osteomyelitis of the coccyx/sacral decubitus ulcer.Review of the clinical record identified Resident #86 had not been evaluated by urology within three weeks of hospital discharge according to the 1/5/26 hospital discharge summary, 91 days beyond the recommended three-week timeframe. Further, Resident #86 had not been evaluated by urology within one week following hospital discharge according to the 5/5/26 hospital discharge summary, 8 days beyond the recommended one-week timeframe.Interview with Medical Records Staff #1 on 5/19/26 at 11:50 AM identified one of her responsibilities included scheduling medical appointments. Medical Records Staff #1 indicated the nursing staff were responsible for reviewing the hospital paperwork and notifying her of any specialty medical services that required a follow up appointment. The appointments would be scheduled within the recommended time frame. Medical Records Staff #1 further identified she had no record of a request made to schedule Resident #86 for a follow up urology appointment or that Resident #86 had not been evaluated by urology.Interview with APRN #2 on 5/19/26 at 12:02 PM identified he routinely reviewed the hospital discharge summaries for newly admitted /re-admitted residents to get information about the hospital course and medication review. APRN #2 indicated he relied on the nursing supervisor to review the discharge summary and schedule any follow up specialist medical appointments based on hospital recommendations. APRN #2 further identified that while it has never been the case, he would have included a documented rationale for any recommendation that had not been followed.Interview with the DNS on 5/19/26 at 2:30 PM identified she would expect nursing staff to follow hospital recommendations to ensure the timely scheduling for specialty services.Interview with RN #8 on 5/21/26 at 11:26 AM identified she was the assigned nursing supervisor on 5/5/26 when Resident #86 was readmitted back to the facility from the hospital. RN #8 indicated it was her responsibility to review the discharge paperwork and notify the scheduler (Medical appointment Scheduler #1) of any recommendations including for follow up specialist medical appointments following hospitalization. RN #8 further identified although she could not specifically recall conducting the admission or specifics about the hospital paperwork or recommendations, she would have electronically communicated any recommendations that required scheduling appointments to Medical Appointment Scheduler #1.Interview with MD #1, the Medical Director on 5/21/26 at 1:03 PM identified he was made aware that Resident #86 missed2 urology appointments subsequent to surveyor inquiry. MD #1 indicated that any resident with an indwelling urinary device was at risk for developing a urinary tract infection. Resident #86 was experiencing urinary retention therefore placing him/her at risk for other medical conditions, therefore he must balance the risk benefit. For Resident #86, the development of a urinary tract infection was unavoidable given the long-term need for the indwelling catheter. MD #1 further identified he would not remove the indwelling catheter without consulting with urology, and he would expect the nursing staff to ensure hospital recommendations were followed for any specialist medical follow up.Although requested, a policy for responding to hospital recommendations was not provided.Efforts to interview RN #14 were unsuccessful.b. Review of the census record identified Resident #86 was re-admitted to the facility on [DATE] and 5/14/26 following hospitalization with an indwelling urinary device.Physician's order dated 5/5/26 directed intake and output for three days with no further odors for monitoring indwelling catheter output.Physician's order dated 5/14/26 directed intake and output for three days with no further odors for monitoring indwelling catheter output.Interview with the DNS on 5/19/26 at 2:30 PM identified she would expect nursing staff to continue ongoing monitoring of urinary output for any resident with a urinary collection device.Interview with APRN #2 on 5/20/2026 at 7:54 AM identified while Resident #86 did not have medical issues related to fluid retention, he would expect nursing staff to follow the policy when managing a resident with an indwelling urinary device.Review of the facility policy for Measurement of Intake and Output directed the facility to monitor intake and output as ordered by a physician or when initiated by a licensed nurse. Urine output is to be measured for a resident with an indwelling catheter unless otherwise indicated.

Based on review of facility documentation, facility policy, facility assessment, and interviews, the facility failed to ensure licensed nurse and nurse aid annual competencies were completed in 2025 and to date in 2026. The findings include: Review of facility documentation identified NA #1 was hired on 11/19/2017, NA #7 was hired on 8/5/18, and NA #8 was hired on 2/2/21. Review of staff development documentation failed to identify NA's #1, 7, and 8 had completed annual nurse aide competencies, in 2025 or to date in 2026. Review of facility documentation identified LPN #2 was hired on 3/12/25.Review of staff development documentation failed to identify LPN #2 had completed annual competencies for licensed nurses in 2025 or to date in 2026. Review of facility documentation identified RN #8 was hired on 4/2/25 and RN #10 was hired on 5/29/07.Review of staff development documentation failed to identify RN #8 and RN #10 had completed annual competencies for licensed nurses in 2025 and to date in 2026. Review of the facility's documentation and interview with the Staff Development Nurse (RN #9) on 5/19/26 at 9:12 AM identified that the facility had undergone a change of ownership in June 2025, and that when she started working at the facility (hire date 12/8/25), she initiated and completed mandatory educational in-servicing for the entire facility staff, in December 2025. RN #9 identified that she was unable to locate documentation of nursing staff competencies prior to the change of ownership and prior to her role as the Staff Development Nurse. RN #9 further identified that she did not have evidence of nursing staff competencies being completed by the prior organization. RN #9 identified that setting up a system for annual nurse staffing competencies was a top priority, and that a whole house annual clinical skills fair was scheduled in 2 weeks. RN #9 further indicated that all new hires have completed clinical competency evaluations. Interview with the DNS on 5/20/26 at 7:14 AM identified that the need for completing annual nursing staff competencies had already been identified and discussed among the IDT. The DNS identified that a clinical skills fair for licensed nurses and nurse aides would be completed in the upcoming weeks. The Staff Development policy directs the staff development process to consist of orientation, in-service education, continuing education, and promoting the development of personnel, consistent with the goals and responsibilities of the employment. Based on the facility assessment, the facility will develop implement and maintain an effective training program for all new and existing staff and individuals providing services under a contractual arrangement. Licensed nurses should have the competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and as described in each resident's individual plan of care. The policy further directs that staff will receive regular in-service education appropriate to his/her individual educational level training, and experience, and continuing staff education programs will consist of planned formal education classes, as well as, informal learning experiences and/or unit or department-based conferences or educational sessions. The Facility assessment dated [DATE] directs that employees providing direct patient service are expected to fulfill core competencies that reflect their specialized role. Direct service core competencies include but are not limited to the following: medication pass audit, blood glucose monitoring, PPD administration, clean dressing change, t-tube, pleurex catheter, insulin pen, establishing a peripheral venous route, central line dressing changes, intermittent infusion via peripherally inserted catheter, point click care, preventing pressure sores, care of resident with a hip fracture, resident transfer with a lift, and terminal cleaning.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #146) reviewed for quality of care, the facility failed to administer medications according to professional standards which resulted in significant medication errors. The findings include:Resident #146 was admitted to the facility in May 2026 with diagnoses that included end stage renal disease, sepsis, pleural effusion, and pericardial effusion.The SBAR (Situation, Background, Assessment, Recommendation: a crucial communication technique in healthcare that helps health professionals communicate clear elements of a patient's condition) dated 5/18/26 (no time) identified Resident #146 was given the wrong medications (medications not prescribed for the resident) and experienced a change in condition, characterized by lethargy and complaints of shortness of breath. Vital signs included blood pressure 105/58, pulse 66, respiration rate 16, and blood glucose of 185. The physician was notified and Resident #146 was transferred to the hospital for further evaluation.A reportable event form dated 5/18/26 at 11:00 AM identified Resident #146 received another resident's medications (Resident #63) in error. Vital signs were obtained and Resident #146 was assessed by the RN supervisor and MD #1. Resident #146 was observed to be drowsy and lethargic, and complained of shortness of breath. Resident #146 was transferred to the hospital for further evaluation. Resident #63's physician's orders dated 5/1/26 directed to administer the following medications at 9:00 AM.Haloperidol (antipsychotic medication) 15mg for schizophrenia.Pregabalin 50mg (medication for nerve pain).Valproate Sodium 250mg/5ml give 15ml (mood stabilizer).Amlodipine Besylate 10mg (medication for high blood pressure).Miralax 17 grams (medication for constipation).Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg administer 2 puffs orally for asthma (side effects chest tightness, difficulty breathing, body aches, headache, tiredness and weakness).A written statement by LPN #3 (new nurse orientee) dated 5/18/26 (no time) indicated while she was working with LPN #4 (preceptor) medication intended for another resident was administered to the wrong resident. The medication error was identified shortly after administration. LPN #3 immediately notified LPN #4 and RN #11. A written statement by LPN #4 (preceptor) dated 5/18/26 (no time) indicated while working with LPN #3 (new nurse orientee), after LPN #3 administered the wrong medication to the wrong resident, Resident #146 reported shortness of breath. Resident #146 was assessed and oxygen was applied. RN #11 was notified immediately. The care plan dated 5/18/26 identified Resident #146 had a medication error. Resident #146 exhibited or is at risk for respiratory complications related to shortness of breath due to medication error. Interventions included monitoring and reporting oxygen saturation levels as ordered and as needed, and administer oxygen at 2 liters via nasal cannula. The resident was seen and assessed by the physician and transferred to the hospital for further evaluation. The nurse's note dated 5/18/26 at 3:36 PM identified that LPN #3 (new nurse orientee) while working under the supervision of LPN #4 (preceptor), administered a medication intended for another resident to Resident #146. The medication error was identified shortly after administration. The nurse's note dated 5/18/26 at 3:59 PM identified Resident #146 was alert and responsive and complaining of shortness of breath. The physician progress note dated 5/18/26 at 4:37 PM identified new admission evaluation and acute evaluation following medication error with complaint of shortness of breath and fatigue. MD #1 indicated he was notified by nursing of a medication administration error involving Resident #146. MD #1 indicated nursing reported, a newly hired nurse/orientee administered the wrong medications under direct supervision. MD #1 indicated Resident #146 was assessed by nursing, vital signs were obtained and stable, oxygen was applied per protocol, and fingerstick blood glucose was checked with result of 185. The nursing supervisor was notified and medication stopped. MD #1 evaluated Resident #146 immediately at bedside. Translation assistance was used. Resident #146 was alert and responsive, reported feeling fatigued, and appeared mildly somnolent but remained arousable, and able to answer questions appropriately. Resident #146 denied chest pain. MD #1 indicated after evaluation, given the medication administration error, given unclear medication exposure, resident is medically high-risk given recent complex hospitalization for flash pulmonary edema/respiratory failure, cardiopulmonary decompensation, renal failure, dialysis dependence, and concern for possible medication related adverse effect. MD #1 ordered Resident #146 to be transferred to the hospital for further evaluation and monitoring. The resident representative was notified in his/her native language regarding the medication error, resident's condition, and order to be transfer to the hospital. MD #1 diagnosed Resident #146 with accidental medication exposure/medication administration error, shortness of breath, fatigue, and somnolence.Interview with the ADNS on 5/19/26 at 1:29 PM identified she was called to the North wing and was informed that Resident #146 was lethargic. The ADNS indicated an assessment was performed. The ADNS indicated Resident #146 was alert and verbal at that time. The ADNS indicated LPN #4 informed her that Resident #146 was administered the wrong medications. The ADNS indicated she instructed LPN #4 to contact and notified MD #1 that Resident #146 received the wrong medications. The ADNS indicated MD #1 assessed Resident #146 and ordered for resident to be transferred to the hospital for further evaluation. Interview with the DNS on 5/19/26 at 2:09 PM identified she was notified by the ADNS after 11:00 AM on 5/18/26 that a medication error occurred on the North wing. The DNS indicated LPN #4 (preceptor) prepared medications intended for Resident #63 and handed the medication cup to LPN #3 (new nurse orientee) for administration. LPN #3 administered the medications to Resident #146. The DNS indicated LPN #4 was positioned down the hallway with the medication cart and was not present outside the resident's room during medication administration. The DNS indicated that is not the expectation of the facility regarding medication administration. The DNS indicated both licensed nurses are off the schedule pending investigation. The DNS indicated she will be re-educating the licensed nurses.Interview with MD #1 (Medical Director) on 5/21/26 at 9:29 AM identified the expectation is that licensed nurses administer medications according to physician orders and professional standards to prevent medication errors. MD #1 indicated the licensed nurses should have followed the physician's order. MD #1 indicated he was notified on 5/18/26 at the time of the medication error. MD #1 indicated he assessed Resident #146 while in the facility. MD #1 indicated Resident #146 complained of shortness of breath and he ordered the resident to be transferred to the hospital for further evaluation. MD #1 indicated he spoke to LPN #3 regarding the medication error.Interview with LPN #3 on 5/21/26 at 10:43 AM identified she has been employed at the facility since 5/6/26 and remained on orientation. LPN #3 indicated LPN #4 was her preceptor on 5/18/26 on the 7:00 AM - 3:00 PM shift. LPN #3 indicated LPN #4 prepared all of the 9:00 AM medications for Resident #63 and instructed her to administer the medications to Resident #63. LPN #3 indicated she was not provided the room number for Resident #63. LPN #3 indicated that she administered all of Resident #63's 9:00 AM medications to Resident #146 in error. LPN #3 indicated she immediately informed LPN #4 of the medication error. LPN #3 indicated that LPN #4 notified RN #11 of the medication error, RN #11 and RN #12 responded to the wing. LPN #3 indicated RN #11 instructed staff to hold Resident #146's medications and proceed with administering Resident #63's medications. LPN #3 indicated that the nurse aide assigned to the wing informed the ADNS that Resident #146 had received the wrong medications. LPN #3 indicated The ADNS then informed her she could no longer remain on the medication cart. LPN #3 indicated that the DNS contacted and interviewed her on 5/19/26 regarding the medication error.Interview with LPN #4 on 5/21/26 at 12:06 PM identified she was the preceptor to LPN #3 (new nurse orientee). LPN #4 indicated she took the medication cart from LPN #3 and prepared all of the 9:00 AM medications for Resident #63 and instructed LPN #3 to administer the medications to Resident #63. LPN #4 indicated LPN #3 administered all of Resident #63's 9:00 AM medications to Resident #146 in error. LPN #4 indicated she had informed LPN #3 of the resident name and room number. LPN #4 indicated the medication cart was not in front of Resident #63's room, the medication cart was down the hallway. LPN #4 indicated LPN #3 informed her that she had administered the medications to the wrong resident. LPN #4 indicated she notified RN #11 of the medication error. LPN #4 indicated she assessed Resident #146 and applied oxygen as protocol. LPN #4 indicated Resident #146 complained of shortness of breath. LPN #4 indicated she notified the physician and the APRN of the medication error and Resident #146's condition. LPN #4 indicated RN #11 instructed staff to hold Resident #146's medications and proceed with administering Resident #63's medications. LPN #4 indicated MD #1 was on the North wing and assessed the resident and ordered for resident to be transferred to the hospital for further evaluation.Based on interviews with LPN #3 and LPN #4, Resident #146 received the following medications in error that had been prescribed to Resident #63.Haloperidol (antipsychotic medication) 15mg.Pregabalin 50mg.Valproate Sodium 250mg/5ml give 15ml.Amlodipine Besylate 10mg.Miralax 17 grams.Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg administer 2 puffs orally.Interview with RN #12 on 5/26/26 at 2:56 PM identified she was currently on orientation. RN #12 indicated that on 5/18/26, RN #11 received a phone call from LPN #4 reporting a medication error on the North wing. RN #12 indicated LPN #4 reported that that LPN #3 administered medication to the wrong resident. RN #12 indicated she and RN #11 assessed Resident #146, and that the nurse aide had indicated to RN #11 that Resident #146 was lethargic. RN #12 indicated MD #1 had ordered the resident to be transferred to the hospital. RN #12 indicated LPN #4 prepared the medication and instructed LPN #3 to administer the medications. RN #12 indicated that this practice was not consistent with the expected medication administration procedures. The medication error summary report dated 5/27/26 identified a medication administration error involving Resident #146 was identified. It was determined that the preceptor prepared and dispensed the medications intended for Resident #63 and provided the medications to an orientee nurse for administration. The orientee nurse entered Resident #146's room and administered the medication to the wrong resident. The incident was determined to be related to failure to follow proper medication administration procedures, including resident identification and medication administration policy. The facility implemented a corrective action which included the following: The facility medication administration policy and procedures were reviewed with the two licensed nurses involved. On 5/26/26, both licensed nurses received medication administration education and in-service training conducted by the Staff Development Educator. Prior to resuming independent medication administration duties, each nurse will complete two supervised medication administration observations/medication passes with return demonstration of competency. Facility-wide re-education will be provided to all licensed nursing staff regarding medication administration policies and procedures, including resident identification and safe medication administration practices.Although attempted an interview with RN #11 was not obtained.Review of the medication error definition and reporting policy identified the facility will complete a medication error report for all medications errors. The DNS/designee is responsible for the investigation and review of medication errors. Significant Medication Error - means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided under significant and non-significant medication errors. Discomfort may be a subjective or relative term used in different ways depending on the individual situation.Review of the medication administration guidelines policy identified that licensed nurses shall administer medications in accordance with the physician orders. The nurse preparing any medication administers it and records it. Licensed staff will identify residents properly before administration. All medications administered are to be signed for in the EMAR/MAR. The individual administering the medication must use the five rights for medication administration.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for abuse, the facility failed to ensure adequate supervision was provided to prevent sexual abuse. The findings include: a. Resident #2 had diagnoses that included vascular dementia, psychotic disturbance, mood disturbance, aphasia, and anxiety. The quarterly [NAME] Data Set (MDS) dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition, with the presence of verbal behaviors directed towards others, was continent of bowel and bladder, independent with ADLs, bed mobility, transfers, and ambulation. The Resident Care Plan dated 2/19/2025 identified Resident #2 had behaviors of sexual expression and desire with interventions that directed to encourage Resident #2 to talk about h/her feelings, missing h/her significant other, as well as feelings h/she may have for any of the male or female residents on h/her unit, and psychology consult as needed. b. Resident #3 had diagnoses that included anxiety, depression, and dementia. The quarterly MDS dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, required supervision with ambulation, set-up for ADLs, and was independent with bed mobility and transfers. The Resident Care Plan dated 2/18/2025 identified Resident #3 was at risk of being a victim of abuse, neglect, and/or mistreatment, sexual risk due to congregate living with interventions that directed to advise Resident #3 to seek out staff if having difficulty with others, assess medical status and provide appropriate care, and counsel resident to avoid contact with the aggressor. A nurse's note dated 2/22/2025 at 5:22 A.M. (late entry) by Registered Nurse (RN) #2 identified she was notified by Licensed Practical Nurse (LPN) #2 that an incident occurred on the unit. RN #2 identified LPN #2 reported that Nurse Aide (NA) #1 observed Resident #2 in Resident #3's room, Resident #2 was lying on top of Resident #3 with h/her pants down and Resident #2's diaper was shifted to the side. RN #2 identified that NA #1 believed that Resident #2 and Resident #3 were having intercourse. RN #2 indicated that Resident #3 was escorted back to h/her room. RN #2 identified during an interview with Resident #3 h/she stated, we were having sex. RN #2 indicated she and LPN #2 assessed Resident #3, and no signs of trauma were observed. RN #2 indicated interviews with Resident #2 and Resident #3 were completed and both residents stated that the sexual act was consensual. RN #2 identified Resident #3 was transferred to the hospital for further evaluation and Resident #2 was on a one-to-one observation. Review of the facility's accident and incident report dated 2/22/2025 at 6:33 A.M. identified on 2/22/2025 at approximately 4:30 A.M. NA #1 observed Resident #2 lying in the bed with Resident #3, Resident #3 did not have h/her pants on, Resident #2 's johnny coat was slightly pulled up, and h/her brief was opened. Resident #3 verbalized h/she gave consent to Resident #2 to have sex with h/her. Resident #3's Power of Attorney was notified and h/she mentioned that h/she was aware that Resident #2 and Resident #3 liked each other. Resident #2 was placed on one-to-one monitoring and Resident #3 was transferred to the hospital for further evaluation. The facility's investigation summary dated 2/25/2025 identified both Resident #2 and Resident #3 had a diagnosis of dementia and Resident #3's Power of Attorney knew that Resident #2 and Resident #3 liked each other. Per an interview with Resident #3 h/she stated that h/she gave permission to Resident #2 to touch h/her and they had sex. Per an interview with Resident #2 h/she verbalized that h/she was not doing anything, that nothing happened between h/her and Resident #3. The summary indicated the facility could not substantiate any wrongdoing, and the facility initiated education on Dementia and sexual desires, and how to care for residents who are expressing needs of sexual encounters. Interview with LPN #2 on 3/18/2025 at 9:00 A.M. identified that the 11:00 P.M. to 7:00 A.M. shift staff are assigned break times at the start of the shift, to ensure when a staff member takes a break there are always two staff on the unit. LPN #2 identified on 2/22/2025 at approximately 4:00 A.M. she was going on her break and told NA #1 who was sitting in a chair in the doorway of the dining room and that if she needed anything she would be in the unit break room. LPN #2 identified although she did not see NA #2 on the unit before she left for break, she assumed NA #2 was on the unit in a resident's room. LPN #2 identified at approximately 4:30 A.M., towards the end of her break, NA #1 came to her to report that Resident #2 and Resident #3 may have had sexual intercourse because she observed Resident #2 in Resident #3's room, Resident #2 had h/her pants off lying on top of Resident #3, and Resident #3's brief was undone and opened. LPN #2 indicated NA #1 immediately separated the residents and Resident #2 was back in h/her room. LPN #2 indicated she immediately went down to assess Resident #3 who stated h/she gave Resident #2 permission, and that they were having sex. LPN #2 identified Resident #2 was placed on one-to-one monitoring and Resident #3 was sent out to the hospital. LPN #2 identified after the incident she became aware that when NA #1 found Resident #2 in Resident #3's room, NA #1 was alone on the unit, because she (LPN #2) and NA #2 were on break at the same time. LPN #2 identified she should have ensured NA #2 was on the unit prior to taking her break and not assumed NA #2 was in a resident's room. Interview MD #2 (psychiatrist) on 3/18/2025 at 10:20 A.M. identified following the sexual encounter between Resident #2 and Resident #3 she was asked by the facility to urgently see Resident #3 to evaluate h/her capacity to consent. MD #2 identified Resident #3 lacked the capacity to consent to sexual activity and relationships. Interview with RN #2 on 3/18/2025 at 10:55 AM identified prior to 2/22/2025 that she was not aware of any episodes, sexual in nature, between Resident #2 and Resident #3. RN #2 identified by the time she went to Resident #3's room, the residents were already separated. RN #2 identified she and LPN #2 assessed Resident #3's genital areas and no injuries or abnormalities were noted. RN #2 indicated Resident #3 stated it was consensual and that h/her gave Resident #2 permission, and Resident #2 stated that they were both consenting adults. RN #2 identified Resident #2 was placed on one-to-one monitoring and Resident #3 was transferred to the hospital. Interview with NA #1 on 3/18/2025 at 11:31 A.M. identified on 2/22/2025 at approximately 3:50 A.M., she was seated in a chair in the doorway of the dining room, unable to visualize the unit hallway. NA #1 identified LPN #2 told her she was taking a break and to call her if she needed anything. NA #1 identified, although she did not see NA #2, she thought NA #2 was on the unit when LPN #2 went on break. NA #1 identified on 2/22/2025 at approximately 4:20 A.M. when she went to start rounds alone, Resident #2 was not in h/her room. NA #1 identified while was looking for Resident #2 she noticed that Resident #3's room door was closed. NA #1 identified when she opened Resident #3's room door she observed Resident #2 with h/her pants off lying on top of Resident #3 with a johnny coat on. NA #1 identified she directed Resident #2 to get off Resident #3 and when Resident #3 got up she observed Resident #3's legs wide open with h/her brief opened and pushed to the side. NA #1 indicated she directed Resident #2 back to h/her room, then went to get LPN #2, and reported what happened. NA #1 identified that after the incident, NA #2 returned to the unit and identified she had been on break. Interview with NA #2 on 3/19/2025 at 11:00 A.M. identified on 2/22/2025 at approximately 3:50 A.M. when she went on her scheduled break NA #1 and LPN #2 were on the unit. NA #2 identified between 4:15 A.M. and 4:30 A.M. when she returned from her break NA #1, LPN #2, and RN #2 told her that Resident #2 was found lying on top of Resident #3 in h/her room. NA #2 identified on the 11:00 P.M. to 7:00 A.M. shift when a staff member goes on break it is one staff per break time because there always has to be two staff members on the unit. Interviews with Director of Nurses (DNS) on 3/18/2025 at 12:00 P.M. and on 3/19/2025 at 11:10 A.M. identified on 2/22/2025 at approximately 4:15 A.M. NA #1 observed Resident #2 lying on top of Resident #3 without h/her pants on and not wearing a brief, Resident #3 was on h/her back lying in the bed with a johnny coat, with h/her brief opened and pushed to the side exposing h/her genital area. The DNS indicated the residents were immediately separated by NA #1, Resident #2 was placed on one-to-one monitoring, and Resident #3 was sent to the hospital for further evaluation. The DNS indicated following the incident Resident #2 continued to deny any type of sexual activity occurred and remained on one-to-one monitoring until h/she was discharged per h/her request. The DNS identified at that start of each shift staff discuss break times with each other, break times are then assigned so that only one staff member is on break at a time to ensure that there are always two staff on the unit. The DNS identified her expectations are prior to the staff taking a break the charge nurse should ensure that there are two other staff on the unit and the 11:00 P.M. to 7:00 A.M. staff should not be in the dining room unless they are on a break. The DNS identified on 2/22/2025 that there should have been two staff on the unit when the sexual encounter happened between Resident #2 and Resident #3 and NA #1 should not have been sitting in the doorway of the dining room where she was unable to observe the unit or the residents. Review of the facility's reporting and investigation of resident abuse/neglect, or mistreatment policy dated 11/2016, in part; identified that the purpose of the policy is to ensure every resident has the right to free from abuse, neglect, misappropriation of resident property and exploitation.

Based on review of the clinical record, review facility documentation, review of facility policy and interviews for one sampled resident (Resident #94) reviewed for abuse, the facility failed to ensure the resident was provided adequate supervision to prevent abuse that resulted in an injury. The findings included: Resident #29 diagnoses included dementia, anxiety, schizophrenia and bipolar disorder. A quarterly MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment, no behaviors, no range of motion deficits, and was independent with ambulation. Resident #94's diagnoses included dementia, anxiety, restlessness and agitation. The quarterly MDS assessment dated [DATE] identified Resident #94 was severely cognitively impaired, had no behaviors, no range of motion deficits, and was independent with ambulation. Resident #94's care plan in place in May 2024 identified Resident #94 was at risk to be a victim of abuse, neglect, and/or mistreatment in congregate living and is vulnerable due to cognitive deficits with interventions that included: calmly redirect resident away from areas of potential harm and intervene as necessary to ensure safety. The care plan further identified Resident #94 had the behavior of wandering related to dementia and wanders into other residents' rooms with interventions that included: encourage attendance in activities as a constructive use of free time, engage in diversional activities, redirect as needed. The care plan also identified the resident had impaired visual function related to having a cataract, with an intervention to orient resident to environment. Social Worker #1's progress note dated 4/12/24 identified Residents #29 and #94 were roommates on the secured unit and were not getting along. Resident #94's family agreed to a room change and Resident #94 was moved to a different room on the secured unit. The Reportable Event report dated 5/4/24 identified that at 10:30 AM Resident #94 was observed by the charge nurse with a small amount of blood on the face, the resident was unable to verbalize what occurred. The charge nurse followed the blood trail on the floor, and it led to Resident #29's room. When asked what occurred Resident #29 verbalized that he/she had hit Resident #94 because he/she had touched his/her private area. The report further identified Resident #94 sustained an open area to the left side of the head that measured 1.0 centimeter (cm) by 0.5 cm. Resident #94 was sent to the hospital emergency department. The report further identified Resident #29 was also sent out to the emergency department for a psychiatric evaluation. The report further identified Resident #29 was admitted to an psychiatric hospital subsequent to this incident. The hospital Discharge summary dated [DATE] identified Resident #94 had a hematoma (a solid swelling of clotted blood within the tissues). and was treated for a 2.5 cm forehead laceration with three sutures. The facility's investigation dated 5/8/24 identified that during the time of the incident between Resident #29 and Resident #94, the nurses' aides on the unit were providing care to other residents and had not witnessed the altercation between the residents. The Reportable Event report summary further identified that as a result of the incident between Resident #94 and Resident #29, the facility implemented every thirty-minute checks on the unit to check residents' whereabouts and activity. It further noted that education would be provided to the staff on how to conduct every 30 thirty-minute checks. A physician's order dated 5/6/24 for Resident #94 directed the performance of a psychiatric consult. The psychiatric evaluation and consultation dated 5/6/24 identified Resident #94 appeared calm and in no obvious physical distress, and no indication of behavioral changes. It also identified the resident's language was significantly impaired but noted that during the interaction the resident appeared pleasant and cooperative and did not appear frustrated. A physician's order dated 5/6/24 directed to monitor sutures to the left side of Resident #94's head, for swelling, drainage, warmth or changes, and to provide incisional care every shift for 14 days. Social Worker #1's progress note dated 5/6/24 identified Resident #94 had been involved in a resident-to-resident physical altercation on 5/4/24, sent to the hospital and returned to the facility. In addition, the note identified Resident #94 was transferred to another unit and was being monitored for any adjustment concerns. Interview with the DNS on 10/9/24 at 7:20 AM identified staff are trained on deescalating any resident-to-resident altercations by separating the residents, moving the residents to different rooms, and decreasing any excess stimulus. She further noted that the staff go through training for dementia, which includes all the forementioned interventions as well as being aware of any triggers residents may have due to their medical history. Observation on 10/9/24 at 7:40 AM identified Resident #94 in his/her room resting in bed and attempts to interact with the resident identified he/she was not communicative. Interview with LPN #2 (charge nurse on East 1 unit) on 10/9/24 at 11:40 AM identified that on 5/4/24, Resident #94 approached the nurses' station and was noted to be bleeding from a wound on the forehead. She noted that she followed the drops of blood on the floor to Resident #29's room and observed the resident holding a cup that appeared to have blood on it. Resident #29 conveyed that Resident #94 had touched his/her private parts. LPN #2 further identified the incident was unwitnessed by any of the staff on the unit. Additionally, LPN #2 identified that she had not observed any negative interactions between the two residents prior to the incident. The Reporting and Investigation of Resident Abuse, Neglect, Misappropriation, Exploitation and Mistreatment policy identified that the facility does not permit verbal, mental, sexual, or physical abuse, including corporal punishment and involuntary seclusion of residents or other mistreatment or neglect by anyone, including, but not limited to, other residents, staff, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends or other individuals.

Based on observations, review of clinical records, review of facility policy and interviews for five of six sampled residents (Residents #1, #9, #21, #33 and #82) who resided on a secured unit, the facility failed to ensure there was documentation of the clinical criteria met for placement in the unit and that the secured unit was the least restrictive setting for the residents. The findings include: Observation of the East 1 Unit on 10/07/24 at 11:14 PM identified that to enter and/or exit the unit through the doors to the unit required a code (sequence of numbers) be entered into a keypad located on the wall by the doors. The doors at the end of the hallways (both left and right) were also secured and required code entry into a keypad. Further observation on the unit identified two closed doors that opened to stairwells, which were identified as the fire exits and contained wanderguard alarm sensors. Interview with the DNS on 10/7/24 at 3:37 PM identified the 1 East unit is a secured unit and placement on the unit is dependent on the resident's history of dementia and wandering. Interview with the Administrator on 10/7/24 at 3:47 PM identified the secured unit is a memory care unit. He further identified that he was unfamiliar with the criteria for placement on the unit but indicated that each resident is assessed for placement on the unit. Interview with the Corporate Social Worker on 10/7/24 at 4:02 PM identified she could not identify the criteria for placement on the secured unit but indicated that residents residing on the unit had been assessed appropriately for placement on the unit. Resident #1's diagnoses included dementia with behavioral disturbances, and monoplegia affecting the right lower limb. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition, exhibited physical and verbal behavioral symptoms, was totally dependent for transfers, hygiene and toileting. The assessment further identified the resident did not ambulate and utilized a wheelchair for mobility. The Care plan dated 7/16/24 identified Resident #1 had problems related to behavior, inappropriate/harmful agitation and combative behaviors with an intervention to provide a calm structured environment. The monthly physician's orders for October/2024 directed to monitor for behaviors including agitation, hitting, kicking, spitting, delusions, hallucinations, psychosis, aggression, and refusals of care. Review of the clinical record identified a special care unit (secured unit) consent form dated 4/2/24 that identified the resident's conservator agreed to Resident #1's placement on the unit. Further review of the clinical record identified a form titled Interdisciplinary Team Preference to Leave Unit Independently dated 7/3/2024 at 4:56 PM and indicated the Resident #1 had problems with communication, memory, mobility, and inability to navigate the elevator that interfered with independent function. The assessment further noted Resident #1 was not safe to leave the unit independently. The form was signed by the Social Worker, dietary representative, Recreation, Rehabilitation Director; However, the form failed to include required signatures from nursing, psychiatric provider, or the attending physician. The Social Services Care meeting note dated 7/16/24 at 10:27 PM identified Resident #1 continued to reside on the behavioral/dementia unit. Review of the Behavior Monitoring and Interventions Report from 8/1/24 through 10/9/24 identified Resident #1 exhibited behaviors of grabbing others 5 days, cursing at others 9 days, agitated 1 day, screaming at others 1 day, and repetitive motions 1 day. Psychiatry notes dated 9/10/24 identified Resident #1 was not currently a danger to self and not currently a danger to others and had a history of behavioral disturbance. The record failed to include documentation by the physician of the clinical criteria met for placement on the secured unit and it failed to identify that the secured unit was the least restrictive setting/approach for the resident. Resident #9's diagnoses included muscular dystrophy, schizoaffective disorder, mild intellectual disabilities, and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition, did not exhibit wandering behaviors, did not use assistive devices, was independent withal transfers, mobility, and personal care. The care plan dated 7/30/24 identified Resident #9 was at risk for leaving the unit (does not specify the unit) independently related to safety with interventions that included: escort resident to and from activities of choice and to therapy or facility programs. The physician's orders for October 2024 directed behavior monitoring for agitation, hitting, kicking, spitting, delusion, hallucinations, psychosis, aggression, and refusing care. Review of the Interdisciplinary Team (IDT) Assessment for Preference to Leave Unit Independently forms dated 1/19/24, 4/16/24, and 7/17/24 identified Resident #9 voiced a preference to leave the unit on 2 of the assessments. All three assessments identified the resident had the capacity to leave the unit, was independent or required supervision with mobility and could communicate a destination but identified the outcome of the assessments as not safe to leave the unit independently. These assessments were signed by the Social Worker, Dietician, Recreation and Rehabilitation. The designated area for the nurse to sign was not signed. Review of the physician's progress notes from 6/1/24 through 10/9/24 failed to address the resident's placement in the secured unit. Review of psychiatric progress notes dated 7/17/24, 8/13/24, 9/5/24, and 10/01/24 identified Resident #1 exhibited anxiety and delusions and was not a danger to self or others. Recommendations were to monitor behaviors. The notes did not address Resident #9's placement on the secured unit The Special Care unit consent form dated 8/17/21 identified the resident's conservator had consented for the resident to be placed on the secured unit. Review of the Behavior Monitoring and Interventions Report from 8/1/24 through 10/9/24 identified Resident #9 was monitored for physical and verbal behaviors directed at others, socially inappropriate behaviors, and other behaviors not directed at others. The documentation identified Resident #9 had not exhibited any of the identified behaviors. Interview with Resident #9 on 10/7/24 at 11:34 AM identified the resident referred to living on the secured unit as a prison and indicated he/she was not able to make independent choices to sit outside or attend programs in other areas of the building. The record failed to include documentation by the physician of the clinical criteria met for placement on the secured unit and it failed to identify that the secured unit was the least restrictive setting/approach for the resident. Resident #21 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, rhabdomyolysis, schizoaffective disorder, major depressive disorder, and a history of substance abuse. The admission MDS assessment dated [DATE] identified Resident #21 had moderately impaired cognition, did not exhibit hallucinations, delusions, or physical or verbal behavioral symptoms, nor had the resident exhibited wandering behaviors. The MDS indicated the resident was dependent with toileting, showering, and upper and lower body dressing. The Care Plan dated 8/28/24 identified Resident #21 could not safely leave the unit independently with interventions that included: escort the resident to and from activities of choice, to therapy or facility programs. The physician's orders for October 2024 did not identify an order for placement on a secured unit. Review of Nursing Progress Notes from 8/8/24 through 10/10/24 identified Resident #21 was alert and oriented to person, place, and time, was able to communicate verbally with clear speech, and able to be understood. Additionally, Resident #21 consistently had pleasant mood with no unwanted behaviors displayed. The review further identified Resident #21had difficulty with decision making, showed poor decision making, and needed cues or supervision. The physician's progress note dated 8/26/24 at 11:20 AM identified Resident #21 was alert and at baseline and indicated the resident's behavior was normal and directed to continue to monitor mood and behavior related to schizoaffective disorder. The psychiatric progress note dated 9/10/24 identified Resident #21 was alert and oriented to person, place, time and situation, was not currently a danger to self or others, had a complex pharmacological regimen and required behavioral monitoring for medications. The Special Care unit consent form dated 8/13/24 identified that due to present status with Alzheimer's/Dementia/Schizophrenia/Bi-Polar disorder, the resident shall be evaluated quarterly as needed according to facility policy for continued stay if the evaluation finds the continued stay on the unit is no longer appropriate, the resident or designee shall be informed. The record failed to include documentation by the physician of the clinical criteria met for placement on the secured unit and it failed to identify that the secured unit was the least restrictive setting/approach for the resident. Resident #33's diagnoses included heart failure, dementia, anxiety disorder and visual loss. The quarterly MDS assessment dated [DATE] identified Resident #33 was cognitively intact, had not exhibited physical and verbal behavioral symptoms directed to others and no other behavioral symptoms not directed towards others, had rejection of care behavior type that occurred 1 to 3 days. The assessment further identified Resident #33 required limited assistance with personal hygiene, upper body dressing, transfers, ambulation and utilized a wheelchair and walker for mobility. The care plan dated 9/26/24 identified Resident #33 could not leave the unit independently with an interventions to assess for safety to leave the unit. Review of the physician's orders for September 2024 thru October 9, 2024, did not address Resident #3's placement on a secure/special care unit. The record failed to include documentation by the physician of the clinical criteria met for placement on the secured unit and it failed to identify that the secured unit was the least restrictive setting/approach for the resident. Resident #82 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, dementia, anxiety, bipolar disorder, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #82 had severely impaired cognition, did not exhibit hallucinations, Delusion, physical or verbal behavioral symptoms directed toward others, did not wander, and did not refuse care. The MDS identified the resident required partial/moderate assistance with position changes and used a wheelchair for mobility. The Care Plan dated 7/9/24 identified Resident #82 was appropriate for long term placement but failed to identify housing placement on a secured unit. The Special Care Unit consent form dated 12/21/23 was signed by the resident's Power of Attorney (POA). The physician's progress note dated 2/7/24 identified the resident's mentation/behavior was at baseline without specifics, and that in the judgment of the physician, the resident did not have the capacity to make health care decisions. The physician's progress note did not identify an assessment or review for placement on a secured unit. Review of nursing progress notes from 3/20/24 through 10/7/24 identified weekly behavior Progress notes that indicated Resident #82 did not have abnormal behavior that was observed and indicated the resident was calm and cooperative. Review of Social services care plan meeting notes dated 3/20/24, 4/9/24, 7/9/24, and 10/8/24 identified Resident #82 continued in the behavioral unit with family in agreement with placement. Review of psychiatric progress notes from 6/27/24 through 10/9/24 identified Resident #82 had intermittent anxiety, structure, and treatment of unpredictable agitation, anxiety, depression and confusion. Additionally, the psychiatric notes indicated that the resident's present medications were effective in managing behavior and mood, and that the resident was not a danger to self or others. Review of the facility Interdisciplinary team (IDT) Assessment form for Preference to Leave Unit Independently dated 9/24/24 identified Resident #82 had not voiced a preference to leave the unit. The assessment identified the resident did not have the capacity to leave the unit, was not independent or did not require supervision with mobility and could not communicate a destination and identified the outcome as not safe to leave the unit independently. This assessment was signed by social work, dietician, Recreation, and Rehabilitation. There is also a spot for a nursing signature which was not signed. The Social Services note dated 10/8/24 at 2:40 PM as a late entry identified Resident #82 could not safely leave the unit independently and directed to continue with goals and interventions. The record failed to include documentation by the physician of the clinical criteria met for placement on the secured unit and it failed to identify that the secured unit was the least restrictive setting/approach for the resident. Interview with LPN #20 on 10/8/24 at 10:41 AM identified that if a resident wants to go outside or leave the unit, staff would redirect and assure the resident that the unit was their home. LPN #20 indicated she might take the resident for a walk on the unit, and that the residents residing on the unit do not go outside. She further identified that some residents were able to attend other activities in other parts of the facility if there is enough staff to escort the resident(s). Interview with APRN #1 on 10/8/24 at 10:45 AM identified she does not take part in the assessment or review for placement on the secured unit. Interview with Social Worker #1 on 10/8/24 at 11:20 AM identified that residents were referred for placement on the secured unit based on hospital discharge recommendations, and behavior reviews by the admission nurse. The Interdisciplinary team responsible for the assessment included recreation, social services, nursing, dietary, and therapy. SW #1 indicated they would only consult with the psychiatric physician for placement on the unit for appropriateness and did not know if the doctor documented the consultation. Interview with the Medical Director (MD#1) on 10/9/24 at 12:53 PM identified that he does not review the documentation, nor does he provide input or an order for placement on the secured unit. MD#1 identified that placement on a secured unit would be a psychiatric determination and that as the Medical Director, he reviews the medical conditions. Interview with the Corporate Medical Director on 10/9/24 at 1:35 PM identified that evaluation for placement on the secured unit would be the responsibility of the attending of record for the resident. He indicated that recognition of the placement should be made by the attending physician of record and placed as an order in the resident's clinical record with the criteria for placement. The policy for the secured unit Titled: 1 East Criteria and identified the purpose of the unit was to provide a safe and appropriate placement for those residents whose needs would best be met in a Special Care Unit as it relates to their safety, security, and individualized plan of care. The policy indicated the interdisciplinary team and the resident and/or their representative shall identify those who present with needs to be placed within the secure unit. This included, but was not limited to diagnoses, cognitive status, functional status, behavioral health needs and/or individual request. The policy further directed that the social worker completes quarterly assessments that includes the review of the resident's plan of care and preference to leave the unit. 47900

Based on observations, review of the clinical records, review of facility policy and interviews for five of six sampled residents (Resident #1, #9, #21, #33 and #82) who resided on a secured unit, the facility failed to ensure the residents' care plans reflected the residents' placement on a secured unit. The findings include: Observation of the East 1 Unit on 10/7/24 at 11:14 PM identified that to enter and/or exit the unit through the doors to the unit required a code (sequence of numbers) be entered into a keypad located on the wall by the doors. The doors at the end of the hallways (both left and right) were also secured and required code entry into a keypad. Further observation on the unit identified two closed doors that opened to stairwells, which were identified as the fire exits and contained wanderguard alarm sensors. 1. Resident #1's diagnoses included dementia with behavioral disturbances, and monoplegia affecting the right lower limb. The facility Special Care Unit Consent dated 4/2/24 identified verbal consent for placement on the Special Care Unit for safety and security due to present status with Alzheimer's/Dementia/Schizophrenia/Bi-Polar disorder from the resident's Conservator. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition, exhibited physical and verbal ( (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)e.g., threatening others, screaming at others, cursing at others)behavioral symptoms directed toward others and behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 to 3 days out of 7 days, and was totally dependent for transfers using mechanical lift. Additionally, the MDS identified Resident #1 did not exhibit wandering behavior, had impairment of the upper and lower extremities on both sides and used a wheelchair for all mobility. The care plan dated 7/16/24 identified Resident #1 had problems related to behavior, inappropriate/harmful agitation and combative behaviors with interventions to provide calm structural environment and provide a calm, safe environment to decrease stress, and to remove hazards. The care plan failed to identify the resident resided on a secured unit, failed to identify criteria for resident to be on the unit and failed to identify that the secured unit was the least restrictive setting. 2. Resident #9 was admitted to the facility on [DATE]. Diagnoses included muscular dystrophy, schizoaffective disorder, mild intellectual disabilities, and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition, did not exhibit wandering behaviors, did not use and assistive devices, was independent withal transfers, mobility, and personal care. The care plan dated 7/30/24 identified Resident #9 was at risk for leaving the unit independently related to safety with interventions that included to escort resident to and from activities of choice and to therapy or facility programs with a goal that the resident will not leave the unit independently through next review period. Additionally, the care plan identified the resident had been assessed for discharge and it was determined that long-term placement was appropriate with interventions to involve resident in activities of interest and psychological consultation, or treatment as needed. Review of Physician's progress notes from 6/1/24 through 10/9/24 failed to identify any mention of review of resident for placement on a secured unit. Interview with Resident #9 on 10/7/24 at 11:34 AM identified the resident referred to the housing as a prison and indicated the resident was not able to make independent choices to sit outside or attend programs in other parts of the building. The care plan failed to identify the resident resided on a secured unit, failed to identify criteria for resident to be on the unit and failed to identify that the secured unit was the least restrictive setting. 3. Resident #21 was admitted to the facility 8/8/2024. Diagnoses included metabolic encephalopathy, Rhabdomyolysis, schizoaffective disorder, major depressive disorder, single episode, other psychoactive substance abuse. The admission MDS assessment dated [DATE] identified Resident #21 had moderately impaired cognition, did not exhibit hallucinations, delusions, or physical or verbal behavioral symptoms, nor had the resident exhibited wandering behaviors. The MDS indicated the resident was dependent with toileting, showering, upper and lower body dressing. The care plan dated 8/28/24 identified the resident cannot safely leave the unit independently with interventions to escort the resident to and from activities of choice and to therapy or facility programs. Review of Nursing Progress Notes from 8/8/24 through 10/10/24 identified Resident #21 was alert and oriented to person, place, and time, was able to communicate verbally with clear speech, and able to be understood. Additionally, Resident #21 consistently had pleasant mood with no unwanted behaviors displayed. But was noted to have difficulty with decision making, showed poor decisions, and needed cues or supervision. Review of Physician's Progress Notes dated 8/26/24 at 11:20 AM identified the resident's mental status is alert and at baseline and indicated the resident's behavior was normal and directed to continue to monitor mood and behavior related to schizoaffective disorder. Psychiatric Progress notes dated 9/10/24 identified Resident #21 was alert and oriented to person, place, time and situation, was not currently a danger to self or others, had a complex pharmacological regimen and required behavioral monitoring for medications. The care plan failed to identify the resident resided on a secured unit, failed to identify criteria for resident to be on the unit and failed to identify that the secured unit was the least restrictive setting. 4. Resident #33's diagnoses included heart failure, dementia, anxiety disorder and visual loss. The quarterly MDS assessment dated [DATE] identified Resident #33 was cognitively intact, had not exhibited physical and verbal behavioral symptoms directed to others and no other behavioral symptoms not directed towards others, had rejection of care behavior type that occurred 1 to 3 days. The assessment further identified that Resident #33 required limited assistance with personal hygiene, upper body dressing, transfers, ambulation and utilized a wheelchair and walker for mobility. The care plan dated 9/26/24 failed to identify that Resident #33 resided on a secured/special care unit along with the reason for placement. The physician's order for the month September 2024 thru October 9, 2024, failed to identify a physician's order directing Resident #33 placement on a secure/special care unit. 5. Resident #82 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, Unspecified dementia, unspecified severity without behavioral disturbance, mood disturbance and anxiety, bipolar disorder, difficulty in walking and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #82 had severely impaired cognition, did not exhibit hallucinations, Delusion, physical or verbal behavioral symptoms directed toward others, did not wander, and did not refuse care. The MDS identified the resident required partial/moderate assistance with position changes and used a wheelchair for mobility. The care plan dated 7/9/24 identified Resident #82 was appropriate for long term placement. Physician's orders dated October 2024 failed to identify any orders for monitoring behaviors and failed to identify an order for resident placement on a secured unit. Review of Nursing progress notes dated 3/20/24 through 10/7/24 identified weekly behavior Progress notes that indicated Resident #82 did not have abnormal behavior that was observed and indicated the resident was calm and cooperative. Review of psychiatric progress notes from 6/27/24 through 10/9/24 identified Resident #82 had intermittent anxiety, required SNF care for safety, structure, and treatment of unpredictable agitation, anxiety, depression and confusion. Additionally, the psychiatric notes indicated that the resident's present medications were effective in managing behavior and mood, and that the resident was not a danger to self or others. Social Services note dated 10/8/24 at 2:40 PM as a late entry identified Resident #82 could not safely leave the unit independently and directed to continue with goals and interventions. The care plan failed to identify the resident resided on a secured unit, failed to identify criteria for resident to be on the unit and failed to identify that the secured unit was the least restrictive setting. Interview with the DNS on 10/9/24 at 9:12 AM identified that care plans should be individualized, and special circumstances should be reflected in the plan of care so that care could be directed appropriately. Interview with MD#1, the Medical Director, on 10/9/24 at 12:53 PM identified that he would expect the secured unit placement to be reflected somewhere and indicated it should probably be in the care plan although he had not seen it there before. Facility policy for the secured unit was Titled: 1 East Criteria and identified the purpose of the unit policy was to provide a safe and appropriate placement for those residents whose needs would best be met in a Special Care Unit as it related to their safety, security, and individualized plan of care. The policy indicated the interdisciplinary team and the resident and/or their representative shall identify those who present with needs to be placed within the secure unit. This included, but was not limited to diagnoses, cognitive status, functional status, behavioral health needs and/or individual request. The facility care planning process policy identified that Comprehensive Care plans would include the services that are provided to maintain the resident's highest practicable physical, mental and psychosocial wellbeing. The policy indicated that the care plan shall describe the services that are being provided and are created to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psych-social well-being. The care plan should address risk factors identified in the screens and shall address the triggered Care areas to include, but not limited to, special care needs, medical diagnoses/condition, ADL functional ability, Resident strengths, socialization patterns, daily customary routine, strengths and needs, and personal preferences. 47900

Based on observations, review of facility policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. The findings include: Observations during a tour of the kitchen on 10/7/24 from 9:40 AM to 10:20 AM with the Corporate Food Service Director (FSD) identified the following: The kitchen floor was sticky and had scattered food debris and water was noted on the floor under the 3-bay sink near the cooking area. One ceiling vent cover and ceiling in the 3 bay sink area had a moderate amount of black dusty buildup. Multiple vent covers near the coffee station were noted to have black dusty buildup. The side and the front of the stove oven had a buildup of brownish/grey matter. The ice machine metal piece inside the machine was covered with brown stains that appeared to be rusted areas. The ice cream freezer plastic covering inside the freezer had cracks and there was a black stain noted inside the plastic cover. The prep counter had scattered food debris and was smeared with white stains, papers, and pens were on top of the counter. Interview with Dietary Aide #1 on 10/7/24 at 9:35 AM identified the kitchen staff is responsible for ensuring the cleanliness of the kitchen. She identified that the floor was cleaned after each meal, equipment is cleaned after each use. She was not sure who was responsible for cleaning the ceiling and/or vents in the kitchen. Interview with corporate FSD on 10/7/24 at 10:35 AM identified he was not sure of the cleaning schedule for the kitchen but would provide a cleaning schedule if available. He identified that the kitchen staff are responsible for the cleanliness of the kitchen. He could not identify when the last time the vent or ceiling was cleaned. A cleaning log was requested but no documentation was provided during the survey. An interview with the facility's Food Service Director (FSD) was not available during the survey. The policy for the cleaning schedule identified vent and ceiling would be cleaned monthly, the oven cleaned weekly and as needed, and the floor and counters cleaned after each use and as needed.

Based on review of facility documentation, review of facility policy/procedures, and interviews, the facility failed to ensure the infection prevention and control program policies and procedures were reviewed at least annually, and the facility failed to provide documentation that monthly infection surveillance reports and analysis of the infection trends within the facility were completed, and the facility failed to provide documentation that the Infection Control Surveillance report analysis of trends were completed quarterly, and failed to ensure that a positive legionella water sampling test result was reported to the State Agency. The findings include: 1. Review of the facility's Infection Control Program Policies and Procedure manual for the past two and half years with the Infection Preventionist Nurse (RN #1) on 10/9/24 at 10:30 AM identified that the policies and procedures manual was reviewed and approved in July of 2022 and on July 5, 2023, but the facility failed to provide any documentation that the Infection Control Program Policies and Procedure manual was reviewed in 2024. Interview with RN #1 on 10/9/24 at 10:30 AM identified that she was recently hired in July of 2024 as the Infection Preventionist nurse and was unable to locate the signature page that the Infection Control policies and procedure manual was reviewed and approved for 2024. RN #1 identified that the infection control manual is usually reviewed and approved annual at the quarterly meeting. Interview with the DNS on 10/9/24 at 12:38 PM identified that the facility reviews the infection control policies and procedure manual annually at the quarterly meeting but was unable to locate the documentation that it was completed for 2024. Review of the Infection Prevention Control Program policy identified that the program would be reviewed and updated/revised yearly to include additional requirement. 2. Review of the Infection Control Surveillance documentation for the past two and half years with the Infection Preventionist (RN #1) on 10/8/24 at 2:30 PM and on 10/9/24 at 10:30 AM identified that the monthly infection surveillance analysis of infections trends within the facility were not completed for April 2022 thru September of 2024. Interview with the Infection Preventionist nurse (RN #1) on 10/8/24 at 2:31 PM identified that it was the responsibility of the Infection Preventionist (IP) nurse to complete the monthly infection report analysis of the various infections within the facility. RN #1 indicated that she had only started working as the IP in July of 2024 and was provided training on completing the monthly statistical reports. RN #1 indicated that she had completed it a different way, however failed to provide documentation as to how she did the report. Interview with RN #1 on 10/9/24 at 10:30 AM identified she was unable to locate the monthly report analysis reports for 2022, 2023 and 2024 after searching through the binders and the previous IP office that was located upstairs. RN #1 identified that they were a new team and had not read through the facility's infection control policies and procedures in its entirety. Review of the Surveillance of Infection policy and procedures identified that the IP programs investigate, controls and prevents infections, decides what precautionary measures are to be instituted and enables the facility to analyze clusters and/or significant increases in the rates of infection. The policy and procedure further identified the surveillance monthly form shall be maintained by each unit by the infection control nurse listing all infections: nosocomial infection surveillance form, a monthly report is to be compiled to help pinpoint areas of high incidences. The policy further identifies that the nosocomial rates are calculated by the number of healthcare associated infections divided by population at risk multiplied by 100. 3. Review of the Infection Control Surveillance documentation for the past two and half years with the Infection Preventionist (RN #1) on and 10/8/24 at 2:3:30 PM and 10/9/24 at 10:30 AM failed to identified that quarterly infection statistical report/analysis were completed for January of 2024, April of 2022; April of 2023, April of 2024; July of 2022,2023, and 2024; and October of 2022, and 2023. Interview with RN #1 on 10/8/24 at 2:31 PM identified that the Infection Preventionist (IP) nurse was responsible for completing the quarterly statistical report/analysis of the infection trends within the facility. RN #1 indicated that she had only started working as the IP in July of 2024. Interview with RN #1 on 10/9/24 at 10:30 AM identified that they were only able to locate the quarterly meeting infection control rate for January 23, 2023, after they had searched through the binders and the previous IP office that was located upstairs. RN #1 identified that the quarterly reports are due in January, April, July and October of each year. RN #1 identified that she had just started in July of 2024 when a quarterly meeting was scheduled and was currently focused on wounds. Interview with the DNS on 10/9/24 at 12:38 PM identified that the infection control nurse would present at the quarterly meeting but was unable to locate the reports. The DNS added that they were a new team, and the IP had recently started working as the IP nurse and her herself had started working as the DNS since February of 2024. Review of the Surveillance of Infection policy and procedures identified that a quarterly statistical report would be completed by the IP nurse and submitted to the infection control committee for its review and discussion at the quarterly infection control meeting. 4. Review of the facility's Water Management plan identified positive water sampling results of Legionella that the facility failed to report to the State Agency: A water sample collected from the kitchen sink dated 3/23/23 with a final result date of 4/3/23 identified a positive test result with a concentration of 760.0 colony forming per milliliter or swab (CFU/mL) of species L. pneumophilia, not serogroups 1-6. A water sample collected from the HW Recri Loop dated 3/23/23 with a final result date of 4/3/23 identified a positive test result with a concentration of 5.0 CFU/mL of species L. pneumophilia, not serogroups 1-6. A water sample collected from the Basement sink dated 3/23/23 with a final result date of 4/3/23 identified a positive test result with a concentration of 5.0 CFU/mL of species L. pneumophilia, not serogroups 1-6. A water sample collected from the Basement sink dated 10/10/23 with a final result date of 10/18/23 identified a positive test result with a concentration of 5.0 CFU/mL of species L. pneumophilia, not serogroups 1-6. A water sample collected from room [ROOM NUMBER] sink north wing dated 3/6/24 with a final result date of 3/14/24 identified a positive test result with a concentration of 35.0 CFU/mL of species L. pneumophilia, serogroup 1. Review of the facility's interventions for the positive legionella testing with a result date of 4/3/23 identified the kitchen faucet was removed soaked in bleach and the other identified positive areas (HW recri loop, kitchen sink, basement sink) aerators were cleaned and flushed for 3 times per day for 4/4/23, 4/5/23, and 4/6/23. Review of the facility's interventions for the positive legionella testing with a result date of 10/18/23 identified the basement sink faucet was change and flushed 3 times per day for 10/18/23, 10/19/23 and 10/20/23. Review of the facility's interventions for the positive legionella testing with a result date of 3/14/24 identified the facility had a water management meeting to review report, and a legionella test was reorder for 3/21/24 and completed which showed a not detected result for the previously positive sampled location on 3/14/24. Interview with the RN #1 and the DNS on 10/8/24 at 4:00 PM identified that the facility did not have a positive human case of Legionaries Disease within the facility. Interview with the Director of Maintenance on 10/9/24 at 1:30 PM identified that the cooperate office would notify the facility regarding when to flush based on the test result. He identified that he was responsible for flushing the areas when identified but does not keep a log. Interview with the Administrator and the Regional Administrator (Person #1) on 10/9/24 at 2:43 PM identified that it was the responsibility of the Administrator to notify the State Agency regarding the positive result, however the current Administrator was not the Administrator at the facility during the times when the water sample had tested positive for Legionella. Person #1 identified that the previous Administrator indicated that the facilities consultant for the water management informed the facility that the State Agency was not needed to be notified. Person #1 indicated that the water management consultant was familiar with the neighboring state laws which had required reporting to the state agency when the number of positive sites were greater than 30%. Person #1 further identified that the facility should have reported the positive result, however, it was not done. Attempts to contact the former Administrator for an interview were unsuccessful Review of the Prevention and Remediation policy identified that the facility reports any positive Legionella testing results to the Connecticut Department of Public Health.

Based on review of clinical records, review of facility policy, review of facility documentation, and interview for two of five sampled residents (Resident #26 and Resident #87), reviewed for immunizations, the facility failed to administer the pneumococcal and influenza vaccine as requested by the resident upon admission and failed to offer and/or assess for the pneumococcal vaccine upon admission. The findings include: 1. Resident #26 was admitted to the facility in the month of September of 2023 with diagnoses that included anemia, end stage renal disease and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition and had not received the pneumococcal vaccine as it was not offered. Review of the electronic medical record system under the immunization tab identified that Resident #26 required the pneumococcal vaccine (PCV20) but failed to identify that the vaccine was administered. A request was made on 10/8/24 at 2:31 PM and on 10/9/24 at 10:30 AM to the Infection Preventionist Nurse (RN#1) for Resident #26 pneumococcal vaccine consent form and proof of administration of the vaccine in which the facility failed to provide the surveyor. Review of Resident #26 clinical records failed to identify that he/she had received the vaccination historically or at the facility. Interview with the Infection Preventionist (IP) nurse RN #1 on 10/8/24 at 2:31 PM identified when asked about the process of obtaining and assessing vaccination history and consent, she responded that the supervisor at the time of the resident's admission was responsible to assess and obtain vaccination consent and status from the resident. RN #1 further added that the infection control nurse would follow up on the vaccine consent documentation and if it was not done by the admitting supervisor, the night shift nurse would notify the DON and the IP nurse via email. RN #1 further identified she had only started working as the IP in July of 2024, as Resident #26's vaccination assessment and consent should have been obtained on admission. RN #1 identified that when the vaccine was administered to the resident, the proof of administration would have been located under the immunization tab in the electronic medical record. RN #1 further indicated that she is currently in the process of reviewing the resident's vaccination information. Review of the Pneumococcal Vaccine Program policy identified that each resident is offered a pneumococcal immunization unless medically contraindicated or the resident/representative refused or already received the immunization. The policy further identified that all new admissions are to be assessed for the need for these vaccines as part of the admission medical work-up and documentation regarding administration of the pneumovax vaccine must be made on the immunization record. 2. Resident #87 was admitted to the facility in the month of November of 2022 with diagnoses that included chronic obstructive pulmonary diseases (COPD), hypertension and pulmonary nodule. The quarterly MDS assessment dated [DATE] identified Resident #87 was cognitively intact, had not received the pneumococcal vaccine. Review of the Immunization Consent form for pneumococcal vaccination identified that Resident #87 gave the facility permission to administer the pneumococcal vaccine on 11/7/22. Review of the electronic medical record system under the immunization report identified that Resident #87 required the pneumococcal vaccine (PCV20), gave consent on 11/7/22 but failed to identify that the vaccine was administered. Interview with the Infection Preventionist (IP) nurse RN #1 on 10/8/24 at 2:31 PM identified that the infection control nurse would follow up on the vaccine consent documentation and obtained a physician's order to administer the vaccine. RN #1 further identified she had only started working as the IP in July of 2024, as Resident #87's vaccination assessment and consent should have been obtained on admission. RN #1 identified that when the vaccine was administered to the resident, the administration record would be located under the immunization tab in the electronic medical record. RN #1 further indicated that she is currently in the process of reviewing the resident's vaccination information. Review of the Pneumococcal Vaccine Program policy identified that each resident is offered a pneumococcal immunization unless medically contraindicated or the resident/representative refused or already received the immunization. The policy further identified that all new admissions are to be assessed for the need for these vaccines as part of the admission medical work-up and documentation regarding administration of the pneumovax vaccine must be made on the immunization record. 3. Resident #87 was admitted to the facility in the month of November of 2022 with diagnoses that included chronic obstructive pulmonary diseases (COPD), hypertension and pulmonary nodule. The quarterly MDS assessment dated [DATE] identified Resident #87 was cognitively intact. Review of the Immunization Consent form for influenza vaccination identified that Resident #87 gave the facility permission to administer the influenza vaccine on 11/7/22. Review of the electronic medical record system under the immunization report identified that Resident #87 required the influenza vaccine and gave consent on 11/7/22 but failed to identify that the vaccine was administered. Review of Resident #87's clinical records failed to identify that he/she had received the vaccination historically or at the facility. Interview with the Infection Preventionist (IP) nurse RN #1 on 10/8/24 at 2:31 PM identified that the infection control nurse would follow up on the vaccine consent documentation and obtained a physician's order to administer the vaccine. RN #1 further identified she had only started working as the IP in July of 2024, as Resident #87's vaccination assessment and consent should have been obtained on admission. RN #1 identified that when the vaccine was administered to the resident, the administration record would be located under the immunization tab in the electronic medical record. RN #1 further indicated that she is currently in the process of reviewing the resident's vaccination information. Review of the Influenza Vaccination Program identified that all residents are to receive the influence vaccine on a yearly basis unless medically contraindicated, or the resident/representative refuse or was already immunized. The policy further identified that all residents admitted to the facility during the influenza season shall be offered the influenza vaccine and administration of the vaccine and refusal are to be reflected as permanent entry in the electric medical record.

Based on review of the clinical records, review of the facility policy, review of the facility documentation, and interview for two of five sampled residents (Resident #26 and Resident #52) reviewed for immunizations, the facility failed to ensure the COVID-19 vaccine was administered as requested by the resident upon admission and failed to offer and/or assess for COVID-19 immunizations upon admission. The findings include: 1. Resident #26 was admitted to the facility in the month of September of 2023 with diagnoses that included anemia, end stage renal disease and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition. Review of the Immunization Consent form for COVID-19 vaccination identified that Resident #26 gave the facility permission to administer the COVID-19 vaccine on 9/20/23. Review of Resident #26 clinical records failed to identify that he/she had received the vaccination historically or at the facility. Review of the electronic medical record system under the immunization tab identified that Resident #26 had refused the COVID-19 vaccine. A requested was made on 10/8/24 at 2:31 PM and on 10/9/24 at 10:30 AM to the facility and the Infection Preventionist Nurse (RN#1) for Resident #26's COVID-19 vaccine consent form where he/she declined the vaccine which the facility provided a consent dated 9/20/23 consenting for the administration of the COVID-19 vaccine. The facility failed to provide a COVID-19 consent form identifying that the Resident #26 had refused the vaccine. Interview with RN #1 on 10/8/24 at 2:31 PM identified that Resident #26 had declined the COVID-19 vaccine on 6/7/24 but was unable to locate the consent form. RN #1 further identified she had only started working as the IP in July of 2024, as Resident #26's vaccination assessment and consent should have been obtained on admission and administered if requested. RN #1 further indicated that she was currently in the process of reviewing and obtaining consent for the newly updated COVID-19 vaccine for residents. Review of the regulations for COVID-19 Vaccination Program policy identified that the facility shall ensure that every new resident admitted /readmitted to the facility had an opportunity to receive the first or any required next dose of the COVID-19 vaccine within 14 days of having been admitted to the facility. The policy further identified that for residents who are vaccinated, the nurse admitting the resident will update the resident's care plan and immunization tab in Point click Care (PCC) to reflect receipt of the COVID-19 vaccine. 2. Resident #52 was admitted to the facility in the month of October of 2022 with diagnoses that included chronic kidney disease, type 2 diabetes mellitus, and legal blindness. The quarterly MDS assessment dated [DATE] identified Resident #52 had moderate impaired cognition. Review of the immunization records in the paper chart of Resident #52 on 10/9/24 at 12:30 PM failed to identify that the COVID-19 vaccine was offered and/or assessed for past immunization. A requested was made on 10/8/24 at 2:31 PM and on 10/9/24 at 10:30 AM to the facility and the Infection Preventionist Nurse (RN#1) for Resident #52's COVID-19 vaccine consent form where he/she declined the vaccine, and the facility failed to provide a consent form/documentation that Resident #52 was offered and/or assessed for COVID-19 vaccine wherein he/she had declined. Interview with the Infection Preventionist Nurse (RN #1) on 10/8/24 at 2:31 PM identified when asked about the process of obtaining and assessing vaccination history and consent, she responded that the supervisor at the time of the resident's admission was responsible to assess and obtain vaccination consent and status from the resident. RN #1 further added that the infection control nurse would follow up on the vaccine consent documentation and if it was not done by the admitting supervisor, the night shift nurse would notify the DON and the IP nurse via email. RN #1 further identified she had only started working as the IP in July of 2024, as Resident #52's vaccination assessment and consent should have been obtained on admission. RN #1 identified that when the vaccine was administered to the resident, the proof of administration would have been located under the immunization tab in the electronic medical record. RN #1 further indicated that she is currently in the process of reviewing the resident's vaccination information Review of the regulations for COVID-19 Vaccination Program policy identified that the facility shall ensure that every new resident admitted /readmitted to the facility had an opportunity to receive the first or any required next dose of the COVID-19 vaccine within 14 days of having been admitted to the facility. The policy further identified that for residents who are vaccinated, the nurse admitting the resident will update the resident's care plan and immunization tab in Point click Care (PCC) to reflect receipt of the COVID-19 vaccine.

Based on observations and interviews, the facility failed to ensure kitchen equipment was maintained in a safe and functional manner. The findings include: Observation on 10/7/24 at 8:15 AM identified the facility used disposable plates and cups to serve breakfast to all of the residents. An observation during a tour of the kitchen on 10/7/24 from 9:20 AM to 9:35 AM with Dietary Aide #1 identified the following: 1. The kitchen dishwasher was not functional. 2. The 3-bay sink near the oven area had continuous leak of water onto the floor. 3. Two of four ovens were not functional. Interview with Dietary Aide #1 on 10/7/24 at 9:30 AM identified that the dishwasher had been broken for months. She also identified that the dishwasher could no longer be repaired, and a new dishwasher is needed. She identified that the facility was using paper plates and cups for all meals. She further identified that the Maintenance Director, and Administrator are aware of the dishwasher not functioning. Interview with the Maintenance Director on 10/8/24 at 11:00 AM identified that he just started his position a month ago. He identified that the dishwasher was already not functional when he started his position and had been told that a new dishwasher was being ordered. He could not identify whether a new dishwasher had already been ordered or the timeline of when the new dishwasher would be installed. He identified that he was not aware of the 2 ovens not working and the continuous water leak in the 3-bay sink. He further identified that he would reach out to the vendor to check the ovens and check the water leak. Interview with [NAME] #1 on 10/8/24 at 11:10 AM identified the dishwasher and 2 ovens were not functional for months. He could not identify the exact date when the dishwasher and ovens were broken. He identified that the Maintenance and Administration were aware of the broken equipment in the kitchen. Interview with Vendor Representative #1 on 10/9/24 at 1:30 PM identified that the facility had obtain a price quote for a new dishwasher machine on 10/2/24, but the facility had not paid a deposit to in order for them to process the order of the new dishwashing machine.

Based on review of the clinical record, review of facility policy, and interviews for one sampled resident (Resident #62) reviewed for pre-admission screening and resident review (PASARR), the facility failed to ensure that a resident with a qualifying diagnosis was referred to the state-designated authority for the consideration for a level II assessment. The findings include: Resident #62's diagnoses included major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #62 was cognitively intact, had no behaviors, required supervision or touching assistance with eating, and oral hygiene, required total assistance for toileting, showers, and moderate to maximal assistance with dressing and transfers. The assessment further identified the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 7/17/24 identified Resident #62 was at risk for psychotropic drug use complications related to the use of antidepressant medication with interventions that included: behavior monitoring and interventions, monitor and evaluate for signs and symptoms of confusion, change in activities of daily living (ADL) functioning, monitor for decreased nutrition/hydration/weight, difficulty in communication, and medication side effects. Social Worker #2's (SW #2) progress note dated 9/17/24 at 5:53 PM identified Resident #62 had the new diagnosis of major depressive disorder with an onset date of 9/18/24. Interview with SW#1 on 10/8/24 at 1:50 PM identified major depressive disorder would be a qualifying diagnosis that would trigger a referral to the state-designated authority responsible for conducting the PASARR level II assessment. SW#1 identified that information is relayed to their office through the MDS Coordinator, and once the diagnosis is received, she is responsible for submitting the referral to the state-designated authority to see if the resident qualifies for a level II screening. SW#1 further identified she was unaware of Resident #62's new diagnosis. Interview with SW#2 on 10/8/24 at 2:05 PM identified she wrote the note on 9/17/24 and should have notified SW#1 of the new diagnosis so that the referral for the level II assessment could have been made to the state-designated authority. Interview with the Regional MDS Coordinator on 10/8/24 at 2:30 PM identified that there is a weekly meeting with the psychiatric provider(s) that the Social Worker attends. She further noted that at the meeting the Social Worker is made aware of any new psychiatric diagnoses that would require a referral to the state-designated authority for a level II PASARR assessment. The Pre-Admission Screen and Annual Resident Review (PASRR) policy directs that a resident who has not been previously identified as having a serious mental disorder (SMI) will require a level II assessment if a new diagnosis of mental illness is identified during the stay or during hospitalization .

Based on observations, clinical record reviews, facility documentation review and interviews for one (1) of five (5) residents, (Resident #2), reviewed for abuse, the facility failed to ensure adequate supervision was provided for a resident who was known to wander into other resident's rooms and who sustained significant injuries following multiple resident to resident altercations, resulting in a finding of Immediate Jeopardy, and for Resident #18, the facility failed to ensure that the resident did not leave the building unattended. The findings include: 1. Resident #1 had diagnoses that included dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, was independent with transfers and required limited assist with ambulation in h/her room with a wheelchair or walker. A Resident Care Plan dated 9/20/23 identified Resident #1 had a diagnosis of dementia, was resistive to care at times, and was at risk for falls with interventions which directed to anticipate needs, allow space, and maintain a safe environment. 2. Resident #2 had diagnoses that included dementia and schizoaffective disorder. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was independent with self-care and mobility. A Resident Care Plan (RCP) dated 11/30/22 identified Resident #2 as an elopement risk due to wandering behaviors with interventions that included reorienting and redirecting as needed, maintain a wandering device, anticipate needs/provide assist as needed and provide hourly checks. 3)Resident #3 had diagnoses that included dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment and was independent with activities of daily living (ADL's). A RCP dated 1/14/23 identified Resident #3 had a psychiatric diagnosis of Schizophrenia with a history of past resident to resident altercations with interventions that directed to redirect immediately when starting to show inappropriate behavior and make room changes to ensure the most appropriate room placement in the facility. a) A review of the clinical record identified Resident #2 had wandered into Resident 3#'s room several times and was involved in three (3) separate resident to resident altercations that occurred on 2/12/23, 5/27/23 and 8/29/23. These altercations resulted in Resident #2 sustaining injuries to the facial area that required a transport to the hospital with suture placement. A Physician note written by the Medical Director dated 5/30/23 identified the case was discussed with administrative staff to increase monitoring and add staffing to monitor the hallway on the unit until definitive plan is carried out. Although the facility placed interventions into place for Resident #2 in the plan of care after the aforementioned incidents, these interventions did not address the wandering behaviors that put Resident #2 at risk for injury. Subsequent to the incidents on 2/12/23, 5/27/23, or 8/29/23, there were no changes in staffing patterns to monitor the hallway after the 5/27/23 incident as addressed in the Medical Director's note on 5/30/23. Subsequent to the third incident (8/29/23) between Resident #2 and Resident #3, Resident #3 was moved to another room on another unit. b) Resident #1's nurse's note dated 9/25/23 at 4:40 PM identified Resident #1 was found sitting on the floor in h/her room after being pushed to the ground by Resident #2. Resident #2's nurse's note dated 9/25/23 at 4:20 PM identified Resident #2 entered Resident #1's room on multiple occasions, and when Resident #1 asked Resident #2 to leave, Resident #2 pushed Resident #1 to the floor. Resident #2 was subsequently transferred to the emergency room for an evaluation. Resident #1's hospital documentation dated 9/25/23 identified Resident #1 was evaluated after being pushed to the floor by another resident. X-rays of the right hip, right pelvis and right knee were obtained that identified no fractures/ dislocation and returned to the facility. Resident #2's hospital documentation dated 9/26/23 identified Resident #2 was seen in the hospital on three other occasions previously for being a victim of assault. On this occasion s/he pushed a resident at the facility. Resident #2 was evaluated, received Haldol (a medication used to treat psychiatric disorders and Ativan (a medication used to treat anxiety) parenterally. Resident #2 was psychiatry cleared and returned to the facility with recommendation for medication adjustments. Resident #2's care plan was updated to include intervening before agitation escalates, guide away from stress and engage calmly in conversation. Resident #1 was subsequently moved to another unit, and received psychiatric and social service support. A Reportable Event Summary dated 9/29/23 identified on 9/25/23 at 3:45 PM, Resident #2 was walking around the unit, a typical behavior. Resident #2 walked into Resident #1's room multiple times and was redirected out twice by the aide, NA #6 within 30 minutes. The third time, Resident #1 and Resident #2 were heard arguing and when NA #6 entered the room, Resident #1 was on the floor. The residents were separated, and Resident #1 was noted to have back discomfort and right knee pain. Interview with Licensed Practical Nurse #4 on 10/18/23 at 1:48 PM identified Resident #2 currently wanders into other resident's rooms and when this occurs staff will redirect h/her out, offer a nap or escort to the dining area when Resident #2 exhibits wandering behaviors. An interview with Nurse Aide, NA #7 on 10/18/23 at 1:48 PM identified Resident #2 often wanders into other resident's rooms. If redirected, Resident #2 will be non-compliant and return to the resident's room after redirection. Interview with the Administrator on 10/18/23 at 1:14 PM and on 10/23/23 at 10:00 AM identified that Resident #2 was known to wander into other resident's rooms but was easily redirected. The Administrator stated that it was the Director of Nursing's (DNS's) responsibility to ensure the appropriate interventions were put in place following a resident-to-resident altercations. The Administrator identified that although enhanced monitoring was put in place for Resident #2 following all three events (2/12/23, 5/27/23 and 8/29/23), when Resident #2 was injured by Resident #3 for entering h/her room, she was unable to provide documentation to support that Resident #2 received enhanced supervision or that the schedule was adjusted to accommodate Resident #2's monitoring. An interview with Registered Nurse, RN #2 on 10/19/23 at 1: 39 PM identified she was the assigned Nursing Supervisor on 9/25/23 during the 3:00 PM- 11:00 PM shift when the resident-to-resident altercation took place. RN #2 indicated that although she did not hear or observe anything leading up to the incident, she later learned the assigned nurse aide, NA #6 had redirected Resident #2 out of another resident's rooms on three occasions that shift before a resident-to-resident altercation took place. An interview with the current DNS on 10/23/23 at 11:11 AM identified she had been employed at the facility since July 2023. The DNS stated that although she was not the DNS on 2/12/23 and 5/27/23 when the first two events occurred, she would have ensured both residents were safe with interventions that included 1:1 supervision and move one resident off the floor to ensure no further interaction as she did with subsequent resident to resident altercations involving Resident #2. The DNS indicated Resident #2's wandering behaviors were difficult to manage as preventing h/her from entering other resident's rooms was not always possible and that she did not want to prevent Resident #2 from the ability to walk freely on the unit. On 8/29/23 The DNS #1 provided education for staff to monitor the halls for resident's whereabouts, but that staff may not always know to do that. The facility failed to provide adequate supervision to a resident with known wandering behaviors resulting in resident to resident altercations resulting in the finding of Immediate Jeopardy. Attempts to interview NA #6 were unsuccessful. Although a policy on supervision was requested, none was provided. 4) Resident #18 had diagnoses that included adjustment disorder with anxiety and cerebral infarction. A 5 day Minimum Data Set, dated dated dated [DATE] identified that the resident had moderate cognitive impairment, was independent with activities of daily living including ambulation, and locomotion required supervision when off of the unit. A care plan dated 8/5/23 identified that the resident was a fall risk and could not safely leave the nursing unit independently with interventions that included to anticipate needs and escort the resident off of the nursing unit to activities. A progress note written by APRN #15 on 9/27/23 identified that she was asked to see the resident because the resident was found roaming the neighborhood streets and attempting to cross the street by another provider last week. The resident stated that she left the facility without permission because she needed toiletries and food. The provider will consider a wander guard if another incident occurs. Interview with the receptionist on 10/24/23 at 1:35 PM identified that to exit the facility the receptionist presses a button to let people in and out of the building. On 9/22/23 Resident #18 had walked by the desk and said have a nice day and the receptionist hit the button and let the resident out of the facility. The receptionist identified that she let Resident #18 out of the facility because she was not aware h/she was a resident. Interview with APRN #15 on 10/24/23 at 3:00 PM identified that she had written the note about Resident #18 leaving the building, however, she had been told by APRN # 16 about the incident and had no involvement. Interview with APRN #16 on 10/24/23 at 1:56 PM identified that she was leaving work on 9/22/23 and headed to the parking lot in the back of the building and she saw the resident crossing the street adjacent to the parking lot. APRN #16 called the social worker and inquired if Resident #18 was allowed to be out of the building unsupervised. The social worker stated that the resident needed to be brought back to the building. Interview with both facility Social Workers on 10/24/23 at 2:34 PM identified that they did not recall getting a phone call from APRN #16 on 9/22/23 about Resident #18 being outside Interview with the 7:00 AM to 3:00 PM supervisor who worked 9/22/23 on 10/24/23 at 9:45 AM identified that she was told that the resident was outside, however, she thought she was found on facility property in front of the building. Interview with the DON and Administrator on 10/24/23 at 4:05 PM identified that although they were aware that the resident had exited the building, they were not aware, nor believed that the resident had been found in the street behind the building. They identified that the resident was found on facility property in the front of the building. The DON identified that the receptionist should not have let the resident out of the facility, and if she wasn't sure if the resident could go out, she should have checked with another staff member. A notice of disciplinary action dated 9/22/23 identified that the receptionist was disciplined for allowing a resident outside unsupervised which violated facility policy.

Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of five (5) sampled residents, (Resident #1, Resident #2, and Resident #3) who were reviewed for abuse, the facility failed to ensure residents were free from physical abuse resulting from multiple resident to resident altercations resulting in multiple significant injuries for Resident #2. The findings include: 1. Resident #2 had diagnoses that included dementia and schizoaffective disorder. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was independent with self-care and mobility. The Resident Care Plan (RCP) dated 11/30/22 identified Resident #2 as an elopement risk due to wandering behaviors with interventions that included to re-orient and redirect as needed, maintain a wandering device, anticipate needs/provide assist as needed and provide hourly checks. 2. Resident #3 had diagnoses that included dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment and was independent with activities of daily living (ADL's). The RCP dated 1/14/23 identified Resident #3 had a psychiatric diagnosis of Schizophrenia with a history of past resident to resident altercations with interventions that directed to re-direct immediately when starting to show inappropriate behavior and make room changes to ensure the most appropriate room placement in the facility. 3. Resident #1 had diagnoses that included unspecified dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment, was independent with bed mobility, transfers and required limited assist with ambulation in h/her room with a wheelchair or walker. The RCP dated 9/20/23 identified Resident #1 had a diagnosis of dementia, was resistive to care at times, was at risk for falls and received anticoagulant therapy with interventions that directed to anticipate needs, allow space, monitor for bleeding, and maintain a safe environment. a) Resident #2's nurse's note dated 2/12/23 at 11:13 PM identified at 4:45 PM, Resident #2 had altercation with another resident, Resident #3, and Resident #2 was punched in the face and sustained a bruise to the right eye and skin lacerations to left chin. Resident #2 was transferred to the hospital for evaluation and received five sutures for a 2.8 cm facial laceration. b) Resident #2's nurse's note dated 5/27/23 at 4:45 PM identified that Resident #2 was walking down hall with blood all over h/her face. The housekeeper stated that Resident #3 entered Resident #2's room into another and he noticed blood on the floor. Resident #3 stated s/he had a fight with Resident #2 because h/she was in Resident #3's room. Resident #2 sustained two lumps on the left side of the face and a laceration to the side of left eye. 911 was called, and Resident #2 was transferred to the hospital for further evaluation. The hospital Emergency Documentation dated 5/27/23 identified Resident #2 had wandered into another resident's room and was assaulted. Resident #2 sustained an abrasion and laceration to the face above the left temple that was closed with sutures. A physician's note for Resident #2 dated 5/30/23 identified the case between Resident #3 and Resident #2 was discussed with administrative staff to increase monitoring and add staffing to monitor the hallway on the unit until definitive plan is carried out. Resident #3's nurses note dated 5/27/2023 at 3:59 PM identified at 2:45 PM, Resident #3 stated to housekeeper that S/he had a fight with another resident because the resident was in h/her room. The Supervisor notified. 911 notified regarding the incident and Resident #3 was transferred to hospital for further evaluation. The responsible party was notified. A hospital discharge summary for Resident #3 dated 5/29/23 identified that the resident received treatment for exacerbation of schizophrenia and diagnostic workup for a facial abrasion. A referral was made to a geriatric psychiatric facility. However, there were no beds and Resident #3 was transferred back to the unit with medication adjustments and was determined not to be a harm to self or others. A physician note for Resident #3 dated 5/30/23 identified the case discussed with administration due to Resident #3's repetitive aggression towards other residents, more monitoring would be needed on the unit until Resident #3 was able to be transferred to inpatient psychiatric treating facility. There was no documented increase in monitoring for Resident #3 or adjustments to the nursing schedule to address the need for increased monitoring and Resident #3 remained in the building. c) A Reportable Event dated 8/29/23 identified at 4:45 PM, Resident #2 was observed laying on Resident #3's bed with a laceration to the left forehead. Resident #2 was transferred to the hospital for evaluation. A hospital Emergency Documentation for Resident #2 identified that h/she was assaulted by another resident, A laceration to the left eyebrow was closed with (6) sutures and Resident #2 returned to the facility. Resident #3's nurse's note dated 8/30/23 at 9:47 PM identified Resident #3 returned to facility at 7:30 PM with a diagnosis of aggressive behavior. 1:1 monitoring was initiated, and a wandering device placed. A physician note for Resident #3 dated 8/31/2023 at 7:06 PM identified Resident #3 was involved in another resident-to-resident altercation on 8/29/2023, and was subsequently transferred to an inpatient psychiatric facility. Subsequent to the third incident (8/29/23) between Resident #2 and Resident #3, Resident #3 was moved to another room on another unit. Subsequent to the incidents on 2/12/23, 5/27/23, or 8/29/23, there were no changes in staffing patterns to monitor the hallway after the 5/27/23 incident as addressed in the Medical Director's note on 5/30/23. An interview with the former Director of Nursing, DNS #2 on 10/23/23 at 10:27 AM identified he was the DNS during the resident-to-resident altercation that took place on 2/12/23 and 5/27/23. DNS #2 was unable to recall the (2) incidences involving Resident #2 and Resident #3 but indicated both should have been placed on 1:1 supervision until cleared by psychiatry and then look at changes in the overall care of the two residents to ensure future incidents do not occur. d) Resident #1's nurse's note dated 9/25/23 at 4:40 PM identified Resident #1 was found sitting on the floor in h/her room after being pushed to the ground by Resident #2. The hospital Emergency Documentation notes dated 9/25/23 identified Resident #1 was evaluated after being pushed by another resident, X-rays of the right hip, right pelvis and right knee were obtained that identified no fractures or dislocations and Resident #1 returned to the facility. Resident #1 was subsequently moved to another unit on 9/27/23. Resident #2's nurse's note dated 9/25/23 at 4:20 PM identified Resident #2 entered Resident #1's room on multiple occasions. When asked to leave, Resident #2 pushed Resident #1 to the floor. Resident #2 was subsequently transferred to the hospital for further evaluation. A Reportable Event Summary dated 9/29/23 identified on 9/25/23 at 3:45 PM, Resident #2 was walking around the unit, which is a typical behavior. Resident #2 walked into Resident #1's room multiple times and was redirected out twice by the aide, Nurse Aide, NA #6 within 30 minutes. The third time, Resident #1 and Resident #2 were heard arguing, when NA #6 entered the room, Resident #1 was on the floor. The residents were separated. Resident #2 was noted to have back discomfort and right knee pain. Resident #1 was transferred to the Emergency Department (ED) for evaluation where X-rays were negative. Resident #1 was subsequently moved to another unit. The hospital Emergency Department (ED) documentation for Resident #2 dated 9/26/23 identified Resident #2 was seen in the ED on three other occasions previously for being a victim of assault. On this occasion s/he pushed a resident at the facility. Resident #2 was evaluated, received Haldol (a medication used to treat psychiatric disorders and Ativan (a medication used to treat anxiety) parenterally. Resident #2 was psychiatry cleared and returned to the facility with recommendations for medication adjustments. An interview with the Administrator on 10/18/23 at 1:14 PM and on 10/23/23 at 10:00 AM identified Resident #2 was known to wander into other resident's rooms but was easily redirected. The Administrator indicated it was the Director of Nursing's (DNS's) responsibility to ensure the appropriate interventions were put in place following a resident-to-resident altercation. The Administrator identified that although she alleged additional enhanced monitoring was put in place for Resident #2 following all three events, she was unable to provide documentation to support that Resident #2 received enhanced supervision or that the schedule was adjusted to accommodate Resident #2's needs. An interview with Registered Nurse, RN #2 on 10/19/23 at 1:39 PM identified she was the assigned Nursing Supervisor on 9/25/23 during the 3:00 PM to 11:00 PM shift when the resident-to-resident altercation took place. RN #2 indicated that although she did not hear or observe anything leading up to the incident, she later learned the assigned nurse aide, NA #6 had redirected Resident #2 out of another resident's rooms on three occasions that shift before a resident-to-resident altercation took place. Interview with the current DNS on 10/23/23 at 11:11 AM identified she has been employed at the facility since July 2023. The current DNS stated that although she was not the DNS on 2/12/23 and 5/27/23 when the first two events occurred, she would have ensured both residents were safe with interventions that included 1:1 supervision and move one resident off the floor to ensure no further interaction. The DNS indicated Resident #2's wandering behaviors were difficult to manage as preventing h/her from entering other resident's rooms was not always possible and that she did not want to prevent Resident #2 from walking around. The current DNS indicated education was provided to staff after the 8/29/23 incident to monitor the halls for all resident's whereabouts but that staff may not always know to do that. Review of the abuse policy identified that all residents at the facility have a right to be free from abuse.

Based on observations, a review of clinical records, facility documentation, and interviews for two of three residents reviewed for care and services (Resident#1 R#2), the facility failed to ensure that the hydrocullator temperature was being maintained as per the facility's policy and/or the facility failed to provide adequate supervision to prevent a fall. The findings include: 1. R#1 [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified that R#1 was moderately cognitively impaired and required 1-2 staff to provide extensive physical assistance with ADL tasks. Review of the care plan dated 8/3/18 identified that R#1 was a diabetic with interventions that included avoid direct and/ or extreme cold and or heat. Review of a physician's orders [REDACTED]. Review of the nursing notes dated 9/19/18 at 2:33 PM indicated that an intact blister measuring 5 centimeters (cm) by 2.2 cm was identified on R#1's right knee. An assessment dated [DATE] at 12:58 PM indicated that the intact blister measured 8.1cm x 2.7 cm x 4.4cm; there was no pain and that a Xeroform dressing was applied. On 10/26/18 the wound was identified as completely healed. A review of the facility's investigation indicated that the blister was identified the day after Physical Therapy Assistant (PTA) #1 applied a hot pack to R#1's right knee. Interview with PTA #1 on 11/26/18 at 1:40PM indicated that s/he recalls applying 4 layers to the resident's affected area. PTA #1 indicated that s/he recalls using a hot pack cover (which is equivalent to 2 towels) and 2 towels. Tour of the rehabilitation unit on 11/26/18 at 10:10 AM with Regional Director of Rehabilitation (RDPT) identified that the hydrocullator appliance had a 4 cm x 4 cm dark brown (rust like) area inside the left posterior section of the hydrocullator. The inside of the hydrocullator was full with hot water and the hot pads were observed as being store in the pool of hot water. Further observation with RDPT on 11/26/18 at 10:10 AM identified that outside of the hydrocullator had a posting that directed the staff that the pool temperature should not exceed 165° Fahrenheit (F). Observation of a temperature reading of the hydrocullator pool with the facility's (Ace Cooper dial) thermometer was identified as 164° F. An additional observation with RDPT and the Director of Maintenance (DM) on 11/26/18 at 10:15 AM indicated that the temperature of the hydrocullator pool was 169° F when measured (using facility's digital thermometer #2). A third observation with DM at 12:45 PM identified that the temperature of the hydrocullator was 169° F (using a third thermometer from the facility) and 164° F when the Ace Cooper dial thermometer (used to monitor the hydrocullator) daily) simultaneously. Interview with the RDPT on 11/26/18 at 12:50 PM indicated that the rehabilitation unit has been using the Ace Cooper thermometer prior to the incident, however, was unable to identify a specific date. The RDPT indicated that the maintenance staff would be responsible for calibrating the thermometer. Interview with DM on 11/27/18 at 11AM indicated that the facility does not calibrate the thermometers. Interview with Product Support Person #1 on 11/27/18 at 11:30AM indicated that it is recommended that the Ace Cooper thermometer is calibrated routinely to ensure the accuracy of the thermometer. 2. R# 2 [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that R#2 was intact cognitively and that s/he required the assistance of one staff to provide extensive physical assistance with ADL tasks. A review of the resident's care plan dated 8/7/18 identified that R#2 was at risk for falls due to poor safety awareness. Interventions included maintain a safe environment and anticipate the needs of the resident. Additional review of the resident's care plan dated 9/10/18 identified that R#2 had an actual fall. Interventions included always keep in a high visibility area, offer toileting on first rounds during 11-7 shift, and monitor the resident every thirty (30) minutes. Review of the clinical record and the facility's investigations identified that the resident fell on [DATE], 7/31/18, 8/6/19, 9/7/18 (care plan was revised to keep the resident in an area were s/he could be visualized by the staff), 9/10/18, 9/14/18 at 3:00 AM, 9/14/18 at 1:40PM (record reflected resident being treated for [REDACTED]. On 9/22/18 the resident fell in the dining room without sustaining any injuries and the care plan was updated to reflect staff ensure that the resident is clean and dry. Review of facility documentation dated 9/23/18 identified that the resident was found on the floor across from the nursing station at 6:45 PM and sustained a [MEDICAL CONDITION] that required an open reduction and internal fixation (ORIF) with IM nailing. Interview with NA #5 on 11/27/18 at 2PM indicated that R#2 was always busy and that the staff could not keep eyes on the resident constantly as the resident needed. NA indicated that the resident was re-directed on 9/23/18 however it was with limited success. NA indicated that even though the resident was on 30 min checks R#2 needed additional supervision. Interview with LPN#3 indicated that s/he recalls assisting another resident with his/her meal while in the dining room on 9/23/18 and during the meal R#2 attempted several times to get up from the table without assistance and was re-directed with limited success. LPN #3 stated that the resident remained seated for a period of time however, did leave the dining room as staff were attending to other residents. R#2 subsequently fell in the hallway and sustained a fracture to the left hip. LPN #3 further indicated that prior to the fracture, the supervisor and DNS were informed by the staff that R#2 needed more supervision due to the resident's poor safety awareness and frequent falls. An attempt to interview RN#2 on 11/27/18 2:45 PM was unsuccessful. Interview with DNS on 11/28/18 at 10AM indicated that the staff did inform him/her of the resident's need for increased supervision. The DNS indicated that s/he did not provide 1:1 for R#2 because if s/he did it for one resident s/he would have to implement with others. The DNS indicated that s/he attempted to attain a psych referral for the resident however the family declined.

Based on a review of the clinical record, staff interviews, a review of the facility documentation for one of three sampled residents reviewed for risk of elopement (Resident #1), the facility failed to ensure that the resident was supervised appropriately and/or failed to ensure that the resident did not exit the facility which resulted in Immediate Jeopardy. The finding includes: Review of the clinical record identified Resident #1 was admitted to the facility on [DATE] from the hospital after being found searching for his/her GED (General Education Development), while wandering near a local high school. Resident #1 had a recent placement of a ventriculoperitoneal (VP) shunt for NPH (normal pressure [DIAGNOSES REDACTED]) which was complicated by an [MEDICATION NAME] bleed and a [MEDICAL CONDITION] disorder. Resident #1's [DIAGNOSES REDACTED]. The hospital discharge summary dated 3/8/18 identified Resident #1 demonstrated a lack of insight, poor memory, intermittent disorientation, and confused behavior, therefore, discharge to a chronic dementia unit was recommended as the resident required twenty four hour supervision. An elopement risk assessment dated [DATE] identified Resident #1 was at high risk for elopement. Review of the nurse's notes dated 3/8/18 indicated a wanderguard was placed to the residents arm as Resident #1 had a history of [REDACTED]. Review of the physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified severe cognitive impairment (BIMS score of 5), and supervision with ambulation, transfers, personal hygiene and bed mobility. The nursing care plan dated 3/16/18 identified impaired safety awareness, non-compliance with the use of the wander guard, elopement as a problem, with interventions that included conducting quarterly risks assessments, in addition to a significant change in condition, or with an elopement attempt. Further interventions directed to check for wander guard placement every shift, avoid events that lead to wandering, a photo of the resident to be maintained at the front desk for identification related to elopement risk and to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. Further review of the nurse's notes dated 3/8/17 through 3/24/18 indicated the resident had demonstrated exit seeking behaviors that included the resident banging on doors requesting to leave the facility and pacing the halls. Resident #1 was found checking doors to exit while dressed in his/her coat with belonging on his/her person. Further review of the nurse's notes identified the resident was severely agitated due to the inability to leave the unit, and did not respond to multiple interventions, resulting in a transfer to an acute care setting for an evaluation. Additional behaviors included attempts to open locked doors with metal utensils and on one occasion the resident was found in the front lobby stating he/she was leaving the premise which ultimately requiring police intervention to return the resident to the unit. Review of the psychiatric consult dated 3/20/18 identified Resident #1 was evaluated secondary to elopement risk with aggressive behaviors. It was noted that the resident was severely confused with a BIMS score of zero. Irritability, significant memory loss, lack of insight and judgement were identified. Review of the facility documentation dated 3/24/18 indicated Resident #1 was found missing from the facility at 11:30 AM. Interview with LPN #1 on 4/9/18 at 1:30 PM identified NA #1 notified LPN #1 that while he/she was conducting the residents fifteen minute checks at 11:30 AM he/she realized Resident #1 was missing. LPN #1 notified the nursing supervisor, an immediate sweep of the facility was completed which was unsuccessful in locating the resident. The local police department, the attending physician, and the family was notified. On 3/24/18, at approximately 3:00 PM, a family member located Resident #1 and returned him/her to the facility. According to the family member, Resident #1 was a half a mile from the facility at a shopping center. Review of video tape from the camera located in the hallway of the resident's room identified on 3/24/18 at 8:32 AM, the resident was seen surveying the unit and peeking from his/her doorway watching LPN #1 administer medications. Resident #1 walked toward the door with his/her belongings wrapped in a pillowcase. At 8:33 AM, Resident #1 left his room and exited the hall door immediately following a dietary staff member who was pushing a food cart. Further review of the video tape dated 3/24/18 at 8:37 AM identified Resident #1 walked to the front of the building where Receptionist #1 was located. The receptionist unlocked the door and allowed the resident to exit the facility without checking the elopement risk notebook at the desk, which was not according to facility policy. Interview and review of the fifteen minute observation sheet dated 3/24/18 with the facility Administrator and Director of Nursing on 4/9/18 at 1:45 PM identified that although checks wer documented by NA #1 from 845am-10:00am that the resident was visually present, the resident had already exited the building. In addition, fifteen minute checks were doucmented from 10:15am-11:30am. Further interview with LPN #1 indicated he/she was assigned to Resident #1 and did not check the observation sheet to ensure the checks were completed and documented and/or failed to ensure the wanderguard was checked every shift for functionality and placement. Further interview with the Administrator and the Director of Nurses identified the facility failed to conduct fifteen minute checks, and ensure the wanderguard device was being utilized in accordance with facility policies and procedures. Furthermore, the staff did not ensure that the hall door was closed after exiting the unit, and although an elopement book with the resident's picture was kept at the entrance of the building, the staff failed to utilize the book to identify that Resident #1 was a patient of the facility, and unlocked the front entrance door allowing the resident to exit the building. Moreover, the facility failed to recognize that Resident #1 who was at risk for elopement, had left the facility three hours before it was identified the resident was missing. Subsequent to the elopement on 3/24/18, Resident #1 was sent to the hospital for an evaluation where no injuries were noted. Resident #1 was placed on 1:1 observation. NA #1 and Receptionist #1 were terminated and employees were re-in serviced on the facilities policies and procedures regarding wandering behavior, elopement prevention and observational checks. The facility policy entitled visual checks in part directed that visual checks are to be performed by the nursing assistant assigned to the resident. The policy directed the visual checks would be documented on the check flow sheet by the certified nurse assistant and the licensed nurse would review the visual check list and ensure documentation was completed. The facility policy entitled elopement policy and procedure directed in part the resident would have an elopement risk assessment completed on admission. If the resident was deemed at risk for elopement the wandering device would be placed on the resident, checked for functionality, and documented on the treatment assessment record on each shift.

Based on observations, clinical record reviews, review of reportable event documentation, review of facility policy, and interviews for three of seven resident's reviewed for accidents, (R#9, #37, and #139), the facility failed to initiate interventions and/or increased supervision for confused residents with repeated falls, and/or failed to ensure that staff transferred and handled a resident appropriately during a mechanical lift transfer to prevent injuries, and/or failed to ensure that hazardous materials were stored out of reach of confused residents. The findings include: 1. Resident # 37's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had severe cognitive impairment, required extensive assistance with ADL's including transfers and bed mobility, and was non-ambulatory. The RCP dated 11/24/16 identified a self-care performance deficit and risk for injury related to impaired mobility, contractures, weakness, musculoskeletal impairment, impaired balance and non-ambulatory status. Interventions directed extensive assistance of two for bed mobility and two person assistance and mechanical lift for transfers. Nurse's notes dated 11/28/16 identified that an 11:00 PM to 7:00 AM shift NA reported finding a 9 cm by 3 cm skin tear on the resident's lower right leg. The wound was actively bleeding and had had a dressing applied prior to the discovery which was saturated with blood. A towel was found wrapped around the leg wound and dressing. The APRN was notified and an order was obtained to apply a wet/dry dressing to the wound followed by a kling dressing. The APRN also directed a wound consult with the wound doctor in the morning. Nurse's notes dated 11/28/16 identified MD #1 assessed the wound and identified a full thickness wound that measured 9 cm by 3 cm by 0.2 cm deep, with a light amount of serous drainage. The resident was transferred to the ED for evaluation and returned to the facility at 5:30 PM with 10 sutures in the lower right leg and an order to administer the antibiotic, Keflex 500 mg 4 times a day for 7 days. A Reportable Event form and investigation dated 11/28/16 identified that on 11/27/16 around 9:00 PM, NA #2 and NA#3 transferred the resident from a wheelchair to bed with the use of a Sara lift. Once in bed, they pulled off the resident's pants and found a large bleeding laceration on the resident's lower right leg. They reported it to LPN#1 who proceeded to put a dressing and towel on the wound. At 12:30 AM, a NA found the leg wound and informed the charge nurse. The investigation identified that LPN#1 failed to notify the supervisor of the incident, document a full assessment of the wound, notify the physician of the injury, obtain a treatment order, and/or initiate a reportable event form and investigation. LPN #1 failed to report the incident and injury to the on-coming shift. Facility Notice of Disciplinary Action forms dated 12/12/16 and 12/13/16 identified NA# 2 and NA# 3 received two weeks unpaid suspension for failure to provide a proper transfer. Interview and review of facility documentation on 7/11/17 at 9:45 AM with Person #4 identified LPN was an agency nurse and after the incident the facility no longer booked LPN#1. Interview, review of the clinical record, and review of the facility's investigation of the incident on 7/13/17 at 12:00 PM with the DNS noted that the injury happened during the mechanical lift transfer. 2. Resident #9's [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #9 had severe cognitive impairment, difficulty focusing attention, exhibited no behavioral symptoms, required 2 person assistance with transfers, did not walk in room/corridor, and had a history of [REDACTED]. The resident care plan dated 3/15/17 identified a risk for falls related to poor safety awareness, cognitive impairment, balance/transfer impairment and a history of falls. Interventions included dycem in wheelchair, safe environment, ensure wheelchair was locked before transferring, toilet resident every 2-3 hours, every fifteen (15) minute checks, increased monitoring due to increased number of falls and noncompliance with care plan, and offer and assist back to bed after breakfast. The fall risk assessment dated [DATE] identified the resident was a high fall risk. Review of facility documentation for identified Resident #9 sustained twenty-two (22) falls between 9/22/16 through 6/30/17: 9/22/16 at 8:45 PM the resident was found half way out of bed with hands on the floor and the legs still on the bed. The interventions implemented were to continue to monitor, educate on using the call bell for assistance. 11/9/16 at 4:30 PM identified the resident was found lying on the right side in front of the wheelchair. Interventions implemented after the fall included placing a Dycem in the wheelchair to prevent the resident from sliding out. 11/13/16 at 10:00 AM the resident had an unwitnessed fall in his/her room. The interventions implemented after the fall were to do vital signs and neuro checks and the resident was placed back into bed. 12/1/16 at 9:00 AM identified the resident was found on the floor next to the bed. Interventions included to assess resident needs and frequently offer to transfer the resident back to bed after breakfast. 12/1/16 at 11:00 AM identified the resident was found on the floor next to the bed. Interventions implemented included place resident back to bed, rehab evaluation and hospice to perform a medication review. 12/3/16 at 9:35 AM identified the resident was found sitting on the floor with his/her back leaning against the bed. The resident was placed on every fifteen minute monitoring. 12/13/16 at 9:15 AM the resident was found with his/her upper half of body on the floor. Interventions included to reassess side rails for positioning and turning. 12/20/16 at 5:00 PM identified the resident was found lying on the floor in his/her room. Interventions included to educate resident about use of call bell, bed in low position, toilet every 2 hours, and floor mats and a referral to rehab. 12/21/16 at 9:50 AM identified that when a nurse aide was providing care to the resident, the nurse aide left the resident and upon return, the resident was found on the floor next to the bed. The resident sustained [REDACTED]. Interventions included a treatment to the wounds. Review of the Hospice provider supplemental interdisciplinary note dated 12/21/16 noted recommendations for safety to initiate frequent visual checks, every 15/30 minutes and initiate constant observation in form of one (1) to one (1) for safety. 1/9/17 at 2:30 PM identified the resident was observed on the floor next to the bed. Interventions directed to offer resident a nap after lunch. 2/4/17 at 2:30 PM identified the resident was found on the floor next to the bed. Interventions included to lock wheelchair, and provide education/reminders. 2/10/17 at 9:00 PM identified the resident was found on the floor next to the wheelchair. Interventions included to assist the resident back to bed, check the resident every fifteen minutes, and to put the resident out of bed sitting at nursing station. 2/19/17 at 5:10 PM identified the resident was found on the floor sitting on the buttocks. The documentation lacked any new interventions implemented. 2/26/17 at 10:55 AM identified the resident sitting on the floor. The documentation lacked any new interventions implemented. 2/28/17 at 3:15 PM identified the resident was found lying on the floor with blood on his/her forehead. A laceration to the forehead measuring 0.5 cm by 0.3 cm. was noted. Interventions included rehab to assess and a medical work up and medication review. 3/2/17 at 11:30 AM identified the resident was observed on the floor next to the bed. No preventative long term action was identified. 4/14/17 at 9:05 AM identified the resident on the floor next to the bed. Interventions included neuro checks and to continue to prevent injuries when falls occur. 4/21/17 at 6:10 PM identified the resident was found lying on the right side in the bathroom bleeding from the head. The documentation noted the resident was non-compliant with plan of care, uncooperative and forgetful. The resident was transferred to the hospital and received five (5) sutures to the right lateral eyebrow. 5/22/17 at 11:00 AM identified the resident was found sitting on the floor mat in the room. Interventions included offer toilet prior to lunch. 5/27/17 at 10:30 PM the resident attempted to transfer self rom the bed to wheelchair and fell . The wheelchair was not locked. The documentation also identified the resident was non-compliant at times. Interventions included remind resident to call for help, provide anti-roll back brakes to wheelchair. 5/30/17 at 11:00 AM identified the resident was on the floor against the wall in the bathroom. Interventions included to offer recreation after breakfast. 6/30/17 at 10:30 AM identified the resident was found on the floor on his/her buttocks on the floor mat. Interventions included to provide a weighted blanket. Interview with NA #7 on 7/12/17 at 3:15 PM identified they were told to watch the resident more frequently but they were not told that the resident was on every fifteen minute checks and did not document on the residents whereabouts. NA #7 further stated that they were told to bring the resident out to common areas in the past, but the resident would self-propel around and they were busy assisting other residents to be able to watch him/her. Interview with NA #8 on 7/12/17 at 3:40 PM identified that no matter how many times you reminded the resident to not get up, he/she would get up on their own. NA #8 further stated that s/he had been directed in the past to watch the resident more closely, but they had other residents to care for and couldn't always do that. Interview with RN #5 on 7/13/17 at 11:15 AM identified that Resident #9 would get up on his/her own frequently and s/he had instructed staff to watch the resident closely. Interview and review of the clinical record with the Director of Nursing (DON) on 7/13/17 at 12:00 PM identified the resident had twenty-two (22) falls from 9/22/16 through 6/30/17, some resulting in injury. The DON stated the resident was to be monitored with every fifteen minute checks, but the clinical record failed to reflect documentation that the checks were ever initiated and/or completed and the record failed to reflect that new interventions directed at providing increased supervision to the resident to prevent further falls were ever implemented. 3. Resident #139's [DIAGNOSES REDACTED]. The resident care plan dated 5/19/17 identified the resident was a risk for falls related to difficulty walking, lack of coordination, history of falls, poor safety awareness, and psychotropic medication use. Interventions directed to offer rest periods and maintain a safe environment. The fall risk assessment dated [DATE] identified the resident was at high risk for falls. The physical therapy evaluation dated 5/20/17 identified the resident was capable of independent ambulation with supervision and/or touching assistance. The Minimum Data Set assessment dated [DATE] identified Resident #139 had severe cognitive impairment, required limited one person assistance with ambulation, was at risk for falls, and had one (1) fall in the past ninety (90) days. The Reportable Event Form dated 6/2/17 identified the resident was observed in the dining room in a kneeling position with no injuries noted. Interventions included physical therapy to focus on balance, and gait training with emphasis on cueing to promote redirection. The Reportable Event Form dated 6/5/17 identified the resident was observed in a seated position in the hallway with no injuries noted. Prevention recommendations were to obtain a hospice evaluation. Review of the fall care plan interventions dated 6/5/17 identified that a pharmacy consult would be conducted to evaluate medications, visual checks would be done on the resident every fifteen (15) minutes, and a hospice evaluation would be completed. Review of the clinical record failed to reflect documentation that fifteen (15) minute visual checks were completed and/or any new interventions were added to the plan of care after the fall of 6/2/17 (resident was already working with PT). A physician's orders [REDACTED]. The nurse's note dated 6/11/17 at 7:36 AM identified the resident had an unwitnessed fall and was observed on the floor in the hallway, face down, was unresponsive and bloody drainage was noted from a laceration on the forehead. The resident's hands and body started to shake, and his/her tongue was protruding and the eyes were rolled back into his/her head. Emergency services were called and the resident was transported to the hospital. Review of the hospital discharge summary dated 6/11/17 identified Resident #139 had sustained a sinus fracture and a skull fracture. Interview with Physical Therapist (PT) #1 on 7/1/17 identified that the resident was a supervision and contact guard with ambulation from the evaluation on 5/20/17, and was capable of independent ambulation with distant supervision of the staff on the unit, he/she was treated by her for balance, and transfer training. On 6/6/17, PT #1 made the resident independent with ambulation, because although the resident had poor safety awareness he/she was able to manage obstacles and navigate without difficulty. Interview and review with the Director of Rehabilitation on 7/11/17 at 12:30 PM identified all therapy notes from evaluation on 5/20/17 to discharge on 6/6/17 failed to identify that any increase in focus of on balance and gait training with emphasis on cueing to promote redirection was initiated by PT as indicated on the reportable event dated 6/2/17. The Director of Rehabilitation identified that balance, gait training, cueing and redirection were included within Resident #139's plan of care since start of treatment on 5/20/17. The Director of Rehabilitation identified s/he was unable to find any documentation from nursing regarding the fall of 6/2/17. Interview with the Director of Nurses (DNS) on 7/11/17 at 10:30 AM identified that she had reviewed the fall on 6/2/17 and felt the intervention to have PT focus on balance/gait and increase emphasis on cueing to promote redirection was appropriate because although he/she was on the PT caseload already, they may be able to cue him/her to independently ambulate to prevent him from falling, although, he/she was unable to find any documentation that this recommendation was communicated to PT. The DNS further identified that for the fall that occurred on 6/5/17 s/he was unable to find documentation that observational checks (every 15 minute checks) were completed as entered into the care plan as a fall intervention. Additionally, for the fall on 6/5/17 s/he had decided that a hospice evaluation was appropriate because the resident had a [DIAGNOSES REDACTED]. Review of the falls policy identified that after a fall has occurred, the licensed nurse will establish new interventions to prevent re-occurrence of a fall and/or the prevention of injury. 4. Observations on 7/10/17 at 6:30 AM and 7/11/17 at 8:30 AM identified a recreation cart located on the fourth floor in an unlocked closet across from Room 402 which contained the following potentially hazardous items: nail polish nail polish remover wooden sticks for manicures two aromatherapy machines beads string In an interview with RN#2 on 7/11/17 at 8:30 AM identified the potentially hazardous items as belonging to Recreation Therapy. Review of facility Hazardous Materials and Waste Storage Policy identified in part, that the facility will provide safe storage of hazardous materials and wastes to prevent injury to residents and that storage areas are secure.

Based on clinical record review and staff interviews for one of three sampled residents ( Resident # 40) who required anti-[MEDICAL CONDITION] medication , the facility failed to administer the medications in accordance to physician's orders [REDACTED]. The findings include: Resident # 40's [DIAGNOSES REDACTED]. The quarterly MDS assesment dated 4/5/16 identified the resident's cognition and memory were impaired and noted the resident required one person physical extensive assistance for bed mobility. The quarterly MDS assesment dated 6/29/16 identified the resident's cognition and memory were intact and the resident required an extensive assistance of one person for bed mobility and transfers. The physician's orders [REDACTED].Additionally, directed to administer [MEDICATION NAME] 500mg daily by mouth and [MEDICATION NAME] 750 mg by mouth at bed time. A review of the MAR for August 2016 and interview with the DNS on 9/13/16 at 12:36 P.M. in the presence of the Administrator noted Resident # 40's [MEDICATION NAME] 500 mg was not administered on August 5, and 6,2016 and noted the medication lacked facility code of a check to identify the medication was administered by staff. Further review of the August 2016 Medication Administration Record [REDACTED]. The nurse's note dated 8/30/16 recorded at 8:05 A.M. identified Resident # 40 was noted with [MEDICAL CONDITION] activity by staff around 6:20 A.M. , the APRN was notified and ordered an one time dose of [MEDICATION NAME] ( Anti-Anxiety) 2 MG and indicated the resident received the medication at 6:35 A.M The nurse's note dated 8/30/16 at 8:05 A.M. also noted staff was directed to send the resident to an acute care facility for an evaluation. Interview with MD # 1 on 9/15/16 at 11:15 A.M. identified he/she was informed by the acute care facility staff on 8/30/16 that the resident had an undectable [MEDICATION NAME] and [MEDICATION NAME] Level . Further interview with MD # 1 on 9/15/16 identified when the facility informed him/her on 8/30/16 Resident # 40 had not received his/her [MEDICATION NAME] and [MEDICATION NAME] per physician's orders [REDACTED]. Interview with the DNS on 9/13/16 and 9/15/16 identified staff failed to administer Resident # 40's [MEDICATION NAME] (Anti-[MEDICAL CONDITION]) chewable 100 MG ( 3.5) tablet by mouth every 24 hours, [MEDICATION NAME] chewable 100 MG ( 4 tablets) by mouth two times a day for [MEDICATION NAME] 500mg daily by mouth and [MEDICATION NAME] 750 mg by mouth at bed time on 8/26, 27, 28, 29, and 30, 2016 in accordance to physician's orders [REDACTED]. Attempts were made to interview RN # 15 but were unsuccessful due to out of country status.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had a history of [REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. [DIAGNOSES REDACTED]. The interim Resident Care Plan dated 10/1/15 identified actual fall on 10/1/15. Interventions directed if restless to place the resident in a visible area for monitoring, neurological assessment for seventy-two (72) hours and behavioral monitoring for seventy-two (72) hours. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, symptoms of [MEDICAL CONDITION], required limited to extensive assistance with activities of daily living and a history of falls before and since admission. The 7-3PM charge nurse, Registered Nurse (RN) #1, nurse's note dated 10/9/15 at 3:15 PM identified on first rounds Resident #1 was at baseline functioning, alert and oriented to self and able to follow direction. The note indicated the resident was noted to have tremors and the psychiatric Advanced Practice Registered Nurse (APRN) #2 was notified and ordered STAT (statim, meaning immediately) bloodwork to be drawn to check the [MEDICATION NAME], an anticonvulsant medication, level. The note further identified that the resident wanted to stay in bed after breakfast and sleep. At 1:00 PM the resident refused to eat lunch. At 2:00 PM the resident was noted to be more lethargic and difficult to arouse. The medical APRN, APRN #1, was notified and the resident was continued to be monitored. The note identified at 3:00 PM the resident was arousable but with difficulty, followed minimal command, had loose hand grips and the RN Supervisor and APRN #1 were again notified. The Nursing Supervisor's (RN #2) note dated 10/9/15 written at 10:15 PM, identified the resident was assessed at 1:45 PM for the lethargy that was noted by the charge nurse, RN #1. The assessment indicated a sternal rub was done, the resident woke up, was able to follow simple commands and answer simple questions. APRN #1 was updated and ordered to continue to monitor the resident and to update the on-call APRN if any further changes occurred. The Nursing Supervisor's note dated 10/10/15 at 3:22 PM identified at 10:00 AM Resident #1 was seated in a wheelchair, noted to be very lethargic, no answer, but was trying to squeeze the writer's hands. The resident was assisted back to bed and an assessment completed which revealed the resident could not open his/her eyes. The resident was monitored closely. At 1:30 PM the resident started shaking his/her hands and was seen by the attending physician, MD #1, who sent the resident to the hospital for further evaluation. The nurse's note dated 10/10/15 at 2:49 PM identified Resident #1 was transferred to the hospital for evaluation related to change in mental status, lethargy and unable to open eyes. Review of the physician's orders [REDACTED]. The Inter-Agency Referral Report (W-10) completed on 10/9/15 by RN #1 identified Resident #1 had a change in mental status, refused to open eyes, was lethargic but could follow direction. Review of the Emergency Medical Services call dated 10/9/15 identified RN #1 called 911 to transfer Resident #1 to the hospital. RN #1 explained to the 911 dispatcher Resident #1 needed to be transferred to the hospital for altered mental status, lethargy and difficulty to arouse. The dispatcher was heard to say we will send an ambulance. RN #1 was then heard speaking to someone who was in the background and stating they were not sending Resident #1 out, the transfer was canceled. RN #1 informed the dispatcher they would not be sending the resident out. Interview and in a sworn statement with RN #1, the 7-3PM charge nurse, on 3/29/16 at 12:35 PM identified that Resident #1 had a change in his/her mental status. The resident was lethargic, difficult to arouse, and had difficulty following directions. RN #1 stated that at first she notified APRN #2, the psychiatric APRN, who was in the facility and STAT bloodwork was ordered. But when the resident continued to have mental status changes she notified APRN #1, the covering medical APRN. RN #1 stated that the APRN #1 directed her to send the resident to the hospital for an evaluation. RN #1 identified that she initiated the 911 call, started to complete an Inter-Agency Referral Report, W-10, and while she was on the phone with 911 she was directed from the RN Supervisor, RN #2, not to send Resident #1 out to the hospital per the direction of the now former Director of Nursing. RN #1 stated that she did not write the order to transfer to the hospital on [DATE] because she forgot at the time. Interview with the RN Supervisor, RN #2, on 3/28/16 at 12:10 PM identified she was asked to assess the resident and could not fully recall if the now former Director of Nursing had told her not to send the resident to the hospital. RN #2 stated that the now former Director of Nursing had directed the Nursing Supervisors to reassess residents before they are transferred to the hospital to see if they can stay at the facility to maintain the census. RN #2 identified that she could not recall if she notified the physician of not sending the resident out per APRN #1's order. RN #2 stated that she thinks she told RN #1 while on the phone with 911, to stop the transfer to the hospital per the now former Director of Nursing. Interview and in a sworn statement with APRN #1 on 3/29/16 at 1:24 PM identified that the RN Supervisor notified him of Resident #1 having acute mentation changes, weakness and confusion. APRN #1 stated that he gave a telephone order to send the resident to the hospital for an evaluation related to the resident having a history of subdural hematomas and a change in mental status functioning. APRN #1 indicated later that day he received a call from RN #1, the charge nurse, who informed him that she was told by the RN Supervisor that the now former Director of Nursing refused to send the resident to the hospital. Although APRN #1 directed RN #1 to again send the resident to the hospital and if there was an issue related to not sending the resident to the hospital from the now former Director, APRN #1 was to be called. APRN #1 stated that he sent a text message to both medical doctors to alert them that he gave an order to transfer Resident #1 to the hospital and had received a phone call from the charge nurse stating they will not be sending the resident out because the now former Director of Nursing refused. APRN #1 stated that he did not receive another phone call from the facility that Resident #1 had not been transferred to the hospital. Interview with MD #1 on 3/29/16 at 12:05 PM identified that when he was at the facility on 10/10/15 he was asked to see Resident #1. MD #1 stated he noted a change in the resident's mental status and ordered Resident #1 to be transferred to the hospital. MD #1 stated that he did receive a text message on 10/9/15 from APRN #1 explaining how APRN #1 directed two (2) nurses to send the resident to the hospital on [DATE] related to mental status changes but the now former Director Nursing refused the transfer. MD #1 identified he did not follow up with APRN #1 and/or the facility because he thought the resident was sent to the hospital. Interview with APRN #1 on 3/29/16 at 1:40 PM identified on 10/10/15 Resident #1 had emergency cranial surgery where burr holes were inserted and post operatively the resident was placed on hospice care.

Based on clinical record reviews, review of facility documentation and interviews of one of three sampled residents (Resident #1) who had a change in condition, the licensed staff failed to follow the physician's orders [REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. [DIAGNOSES REDACTED]. The interim Resident Care Plan dated 10/1/15 identified actual fall on 10/1/15. Interventions directed if restless to place the resident in a visible area for monitoring, neurological assessment for seventy-two (72) hours and behavioral monitoring for seventy-two (72) hours. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, symptoms of [MEDICAL CONDITION], required limited to extensive assistance with activities of daily living and a history of falls before and since admission. The 7-3PM charge nurse, Registered Nurse (RN) #1, nurse's note dated 10/9/15 at 3:15 PM identified on first rounds Resident #1 was at baseline functioning, alert and oriented to self and able to follow direction. The note indicated the resident was noted to have tremors and the psychiatric Advanced Practice Registered Nurse (APRN) #2 was notified and ordered STAT (statim, meaning immediately) bloodwork to be drawn to check the level of the anticonvulsant medication, [MEDICATION NAME]. The note further identified that the resident wanted to stay in bed after breakfast and sleep. At 1:00 PM the resident refused to eat lunch. At 2:00 PM the resident was noted to be more lethargic and difficult to arouse. The medical APRN, APRN #1, was notified and the resident was continued to be monitored. The note identified at 3:00 PM the resident was arousable but with difficulty, followed minimal command, had loose hand grips and the RN Supervisor and APRN #1 were again notified. The Nursing Supervisor's (RN #2) note dated 10/9/15 written at 10:15 PM, identified the resident was assessed at 1:45 PM for the lethargy that was noted by the charge nurse, RN #1. The assessment indicated a sternal rub was done, the resident woke up, was able to follow simple commands and answer simple questions. APRN #1 was updated and ordered to continue to monitor the resident and to update the on-call APRN if any further changes occurred. The Nursing Supervisor's note dated 10/10/15 at 3:22 PM identified at 10:00 AM Resident #1 was seated in a wheelchair, noted to be very lethargic, no answer, but was trying to squeeze the writer's hands and the resident was assisted back to bed. At 1:30 PM the resident was seen by the attending physician, MD #1, who sent the resident to the hospital for further evaluation. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED].#1 to the emergency department for an evaluation and treatment. The Inter-Agency Referral Report (W-10) completed on 10/9/15 by RN #1 identified Resident #1 had a change in mental status, refused to open his/her eyes, was lethargic but could follow direction. Review of the Emergency Medical Services call dated 10/9/15 identified RN #1 called 911 to transfer Resident #1 to the hospital. RN #1 explained to the 911 dispatcher Resident #1 needed to be transferred to the hospital for altered mental status, lethargy and difficulty to arouse. The dispatcher was heard to say we will send an ambulance. RN #1 was then heard speaking to someone who was in the background and stating they were not sending Resident #1 out, the transfer was canceled. RN #1 informs the dispatcher they would not be sending the resident out. Interview and in a sworn statement with RN #1, the 7-3PM charge nurse, on 3/29/16 at 12:35 PM identified that Resident #1 had a change in his/her mental status. The resident was lethargic, difficult to arouse, and had difficulty following directions. RN #1 stated that at first she notified APRN #2, the psychiatric APRN, who was in the facility and STAT bloodwork was ordered. But when the resident continued to have mental status changes she notified APRN #1, the covering medical APRN. RN #1 stated that the APRN #1 directed her to send the resident to the hospital for an evaluation. RN #1 identified that she initiated the 911 call, started to complete a W-10 and while she was on the phone with 911 she was directed from the RN Supervisor, RN #2, not to send Resident #1 out to the hospital per the direction of the now former Director of Nursing. RN #1 stated that she did not write the order to transfer to the hospital because she forgot at the time. Interview with the RN Supervisor, RN #2, on 3/28/16 at 12:10 PM identified she was asked to assess the resident and could not fully recall if the now former Director of Nursing had told her not to send the resident to the hospital. RN #2 identified that she could not recall if she notified the physician of not sending the resident out per APRN #1's order. RN #2 stated that she thinks she told RN #1 while on the phone with 911, to stop the transfer to the hospital per the now former Director of Nursing. Interview and in a sworn statement with APRN #1 on 3/29/16 at 1:24 PM identified that the RN Supervisor notified him of Resident #1 having acute mentation changes, weakness and confusion. APRN #1 stated that he gave a telephone order to send the resident to the hospital for an evaluation related to the resident having a history of subdural hematomas and a change in mental status functioning. APRN #1 indicated later that day he received a call from RN #1, the charge nurse, who informed him that she was told by the RN Supervisor that the now former Director of Nursing refused to send the resident to the hospital. Although APRN #1 directed RN #1 to again send the resident to the hospital and if there was an issue related to not sending the resident to the hospital from the now former Director of Nursing, APRN #1 was to be called. APRN #1 stated that he sent a text message to both medical doctors to alert them that he gave an order to transfer Resident #1 to the hospital and had received a phone call from the charge nurse stating they will not be sending the resident out because the now former Director of Nursing refused. APRN #1 stated that he did not receive another phone call from the facility that Resident #1 had not been transferred to the hospital. Interview with MD #1 on 3/29/16 at 12:05 PM identified that when he was at the facility on 10/10/15 he was asked to see Resident #1. MD #1 stated he noted a change in the resident's mental status and ordered Resident #1 to be transferred to the hospital. MD #1 stated that he did receive a text message from APRN #1 explaining how he directed two (2) nurses to send the resident to the hospital on [DATE] related to mental status changes. Interview with APRN #1 on 3/29/16 at 1:40 PM identified on 10/10/15 Resident #1 had emergency cranial surgery where burr holes were inserted and post operatively was placed on hospice.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had a change in mental status, the licensed staff failed to notify the attending physician and/or the Advanced Practice Registered Nurse the resident was not transferred to the hospital as ordered and/or update the medical staff when the resident's mental status changes continued. The findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. [DIAGNOSES REDACTED]. The interim Resident Care Plan dated 10/1/15 identified actual fall on 10/1/15. Interventions directed if restless to place the resident in a visible area for monitoring, neurological assessment for seventy-two (72) hours and behavioral monitoring for seventy-two (72) hours. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, symptoms of [MEDICAL CONDITION], required limited to extensive assistance with activities of daily living and a history of falls before and since admission. 1. The 7-3PM charge nurse, Registered Nurse (RN) #1, nurse's note dated 10/9/15 at 3:15 PM identified on first rounds Resident #1 was at baseline functioning, alert and oriented to self and able to follow direction. The note indicated the resident was noted to have tremors and the psychiatric Advanced Practice Registered Nurse (APRN) #2 was notified and ordered STAT (statim meaning immediately) an anticonvulsant medication, [MEDICATION NAME] blood levels to be drawn. At 2:00 PM, the resident was noted to be more lethargic and difficult to arouse. The medical APRN, APRN #1, was notified and the resident was continued to be monitored. The note identified at 3:00 PM the resident was arousable but with difficulty, followed minimal command, had loose hand grips and the RN Supervisor and APRN #1 were again notified. The Nursing Supervisor's (RN #2) note dated 10/9/15 written at 10:15 PM, identified the resident was assessed at 1:45 PM for the lethargy that was noted by the charge nurse, RN #1. The assessment indicated a sternal rub was done, the resident woke up, was able to follow simple commands and answer simple questions. APRN #1 was updated and ordered to continue to monitor the resident and to update the on-call APRN if any further changes occurred. Interview and in a sworn statement with RN #1, the 7-3PM charge nurse, on 3/29/16 at 12:35 PM identified that Resident #1 had a change in his/her mental status. The resident was lethargic, difficult to arouse, and had difficulty following directions. RN #1 stated that at first she notified APRN #2, the psychiatric APRN, who was in the facility and STAT bloodwork was ordered. But when the resident continued to have mental status changes she notified APRN #1, the medical APRN. RN #1 stated that the APRN #1 directed her to send the resident to the hospital for an evaluation. RN #1 identified that she initiated the 911 call, started to complete an Inter-Agency Referral Report, W-10, and while she was on the phone with 911 she was directed from the RN Supervisor, RN #2, not to send Resident #1 out to the hospital per the direction of the now former Director of Nursing. RN #1 stated that she did not notify APRN #1 and/or the attending physician, MD #1, that Resident #1 was not transferred to the hospital as the medical APRN had directed. Interview with the RN Supervisor, RN #2, on 3/28/16 at 12:10 PM identified she was asked to assess the resident and could not fully recall if the now former Director of Nursing had told her not to send the resident to the hospital. RN #2 stated that the now former Director of Nursing had directed the Nursing Supervisors to reassess residents before they are transferred to the hospital to see if they can stay at the facility to maintain the census. RN #2 identified that she could not recall if she notified the physician of not sending the resident out per APRN #1's order. Interview and in a sworn statement with APRN #1 on 3/29/16 at 1:24 PM identified that the RN Supervisor notified him of Resident #1 having acute mentation changes, weakness and confusion. APRN #1 stated that he gave a telephone order to send the resident to the hospital for an evaluation related to the resident's history of subdural hematomas and a now change in mental status function. APRN #1 indicated later that day he received a call from RN #1, the charge nurse, who informed him that she was told by the RN Supervisor that the now former Director of Nursing refused to send the resident to the hospital. APRN #1 directed RN #1 to again send the resident to the hospital and if there was an issue related to not sending the resident from the now former Director of Nursing, APRN #1 was to be called. Interview with MD #1 on 3/29/16 at 12:05 PM identified he had received a text message on 10/9/15 from APRN #1 who explained how he directed two (2) nurses to send the resident to the hospital on [DATE] related to mental status changes but the now former Director of Nursing refused the transfer. MD #1 identified he did not follow up with APRN #1 and/or the facility because he thought the resident was sent to the hospital. 2. The Nursing Supervisor's note dated 10/10/15 at 3:22 PM identified at 10:00 AM Resident #1 was seated in a wheelchair, noted to be very lethargic, no answer, but was trying to squeeze the writer's hands. The resident was assisted back to bed and an assessment completed which revealed the resident could not open his/her eyes. The resident was monitored closely. The nurse's note indicated that at 1:30 PM, three and one-half hours later, the resident started shaking his/her hands, the resident was seen by the attending physician, MD #1, who sent the resident to the hospital for further evaluation. Interview with MD #1 on 3/29/16 at 12:05 PM identified that when he was at the facility on 10/10/15 he was asked to see Resident #1. MD #1 stated that he was unaware that they did not send the resident out as ordered on [DATE]. MD #1 identified he assessed a change in Resident #1's mental status, the resident was lethargic, not really responding and was not as his/her baseline functioning therefore he ordered Resident #1 to be transferred to the hospital. MD #1 stated that when the resident was noted with a change of mental status at 10:00 AM, he should have been made notified at that time. Interview with APRN #1 on 3/29/16 at 1:40 PM identified on 10/10/15 Resident #1 had emergency cranial surgery where burr holes were inserted and post operatively the resident was placed on hospice care. Several attempts made to interview RN #3 and RN #4 were unsuccessful.

Based on clinical record reviews, review of facility documentation and interviews for 4 of 4 sampled residents (Residents #1, #4, #5, and #6) who required supervision when smoking, the facility failed to provide the appropriate supervision during a smoking session which resulted in immediate jeopardy. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had short and long term memory impairment, moderate cognitive impairment, rejection of care, and was independent with ambulating. The Resident Care Plan (RCP) dated 11/16/15 identified the resident was at risk for injury related to smoking. Interventions directed the smoking contract would be reviewed and completed by the resident and facility indicating when and where smoking was permitted. The Smoking Screen assessment dated [DATE] identified Resident #1 was to be supervised when smoking. 2. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #4 had no cognitive impairments, required one person assistance for locomotion on and off unit and a wheelchair was the primary mode of transportation. The RCP dated 11/8/15 identified the resident was at risk for injury due to smoking and had a history of [REDACTED]. Interventions directed to wear driving gloves to prevent excoriation during smoking, observe during smoking to ensure resident does not put cigarette butts in mouth, smoking apron to be worn, smoking contract will be reviewed and completed by the resident and facility indicating when and where smoking was permitted and smoking materials to be kept at the nurse's station. Review of the Smoking Screen assessment dated [DATE] identified Resident #4 was to be supervised when smoking. 3. Resident #5's [DIAGNOSES REDACTED].#5 was alert, oriented, and required supervision to limited assistance with activities of daily living. The RCP dated 11/17/15 identified Resident #5 was at risk for injury related to smoking and non-compliant with smoking policy at times. Interventions directed the smoking contract will be reviewed and completed by the resident and facility indicating when and where smoking was permitted and smoking materials to be kept at nurse's station. Review of the Smoking Screen assessment dated [DATE] identified Resident #5 was to be supervised when smoking. 4. Resident #6's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #6 had severe cognitive impairment and required supervision to limited assistance activities of daily living. The RCP dated 11/17/15 identified Resident #6 was at risk for injury related to smoking. Interventions directed the smoking contract will be reviewed and completed by the resident and facility indicating when and where smoking was permitted and smoking materials were to be kept at nurse's station. The Smoking Screen assessment dated [DATE] identified Resident #6 was to be supervised when smoking. The Reportable Event Form dated 12/30/15 at 7:30 PM identified Resident #1 had been accompanied outside by a Nurse Aide (NA) to the fenced in smoking courtyard and around 8:00 PM Resident #1 was unable to be located within the unit and/or courtyard. The investigation identified the Nurse Aide (NA #3) failed to remain with Resident #1 to provide supervision during the smoking session and Resident #1 used his/her lit cigarette to melt through the plastic zip ties that secured a gate and Resident #1 was able to exit the courtyard and facility grounds. The investigation identified that NA #3 had accompanied not only Resident #1 but Resident #4, #5, and #6 to the smoking courtyard therefore, four (4) residents were left unattended while smoking. Review of the facility's documentation dated 1/4/16, the charge nurse, Registered Nurse (RN) #1 in a written statement identified that at approximately 7:30 PM he gave NA #3 the residents' smoking material and instructed NA #3 to supervise the smoking break. The statement indicated approximately five (5) minutes later NA #3 returned the smoking material to RN #1 and RN #1 told NA #3 she needed to stay with the residents while they were smoking. NA #3 was interviewed by facility staff and stated that she lights the cigarettes and usually stands inside at the door inside to observe the residents. NA #3 stated that on 12/30/15 she may have gone from the door for approximately ten (10) minutes to assist another staff person. NA #3 stated she was aware the residents were to be supervised during smoking and she didn't know why she left them alone. Review of the facility's time line from the surveillance cameras identified that on 12/30/15 at 7:43:59 PM Resident #1 was observed walking up the facility driveway smoking a cigarette. Upon further review of the time line from the surveillance cameras the following events were noted: -7:39:04 PM, the door to the resident smoking area opens and NA #3 accompanied four (4) residents (Resident #1, #4, #5, and #6) outside. -7:39:24 PM, NA #3 re-enters the building without the residents and goes into the last room on the right at the end of the hallway. -7:40:08 PM, NA #3 opens the door to the courtyard, looks out and closes the door at 7:40:13 PM. -From 7:40:46 PM to 8:00:53 PM NA #3 was noted to be at the nursing station, in the dirty utility room and in a resident's room. During that time, at 7:44:00 PM Resident #6 entered the facility from the smoking area and the hallway was empty. At 7:48:24 PM Resident #4 in from the smoking break, no staff were visible, the resident wheeled down to the nurse's station and goes into his/her room. At 7:52:33 PM Resident #5 entered the facility. -8:12:54 PM, NA #3 was observed to exit a resident room and at 8:13:01 opens the back door and sticks her head out. The facility's investigation dated 1/5/16 identified Resident #1 was located at a nearby bus station by the facility staff and was transferred to the hospital by the local authorities. Review of the clinical record identified Resident #1 was readmitted to the facility on [DATE] after the hospitalization in the behavioral health unit. In an interview on 1/12/16 at 11:25 AM, RN #1 stated that he gave NA #3 the residents' smoking material and told NA #3 to stay with and supervise the residents while they smoked. RN #1 stated that approximately twenty (20) minutes later NA #3 reported to him that all the residents were back inside. RN #1 identified that around 8:00 PM he went to give Resident #1 his/her medications and he could not locate the resident. RN #1 stated he began searching for the resident per facility policy. RN #1 identified he asked NA #3 when Resident #1 could not be found if the resident came back in after smoking and NA #3 told him the resident did. Interview with the Administrator on 1/12/16 at 10:40 AM identified that he reviewed the video surveillance tape the following day on 12/31/15 and noted that NA #3 brought four (4) residents outside for a smoking break, light the cigarettes and then NA #3 returned inside the building two (2) minutes later. The Administrator stated the residents were left outside smoking, unsupervised for approximately one half hour. The Administrator stated that Resident #1 was observed on camera to be walking up the driveway away from the facility smoking a cigarette. Interview with the Director of Nursing (DON) on 1/12/16 at 10:50 AM identified that when she spoke with NA #3 on the day of the incident, NA #3 stated that she stayed with the residents during the entire smoking time. The DON identified that after the tapes were reviewed NA #3 was re-interviewed and admitted to not staying with the residents while they were smoking. The DON stated that supervised smoking had been in place and NA #3 was recently educated on supervised smoking. Subsequent to the incident an action plan was developed and implemented. Two nurse aides will accompany the residents of the behavioral unit to the smoking area for one week. The managers will conduct audits for compliance. The fence company was contacted and will check the gate. No further incidences occurred after 12/30/15. Review of facility documentation dated 10/9/15 identified NA #3 received inservice education on the facility's smoking policy. Review of the facility policy and procedure for smoking identified residents are assessed by the interdisciplinary team to determine if they are able to smoke independently in a designated smoking area under the direct supervision of staff. Several attempts made to contact NA #3 were unsuccessful.

Based on review of the clinical records, review of facility documentation and interviews for one of three sampled residents (Resident #2) with a history of sexually inappropriate behavior, the facility failed to ensure that a resident was free from sexual misconduct. The findings include: Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had no cognitive impairments, ambulated independently and had not exhibited any behavioral symptoms. The Resident Care Plan (RCP) initiated on 8/8/15 identified Resident #3 had a behavior related to making false statements regarding staff, not being aware of or concerns with physical or personal boundaries (entering other resident rooms without knocking. Interventions directed to administer medications as ordered, remove resident from public area when behavior is disruptive or inappropriate, monitor behavior episodes and document and psychiatry consultation as ordered. The psychiatry follow up visit dated 9/2/15 identified Resident #3 was seen for increased weepiness. The assessment indicated Resident #3 had a history of [REDACTED]. The psychiatry follow up visit dated 9/11/15 identified Resident #3 was seen for increasing disinhibition with female residents. The plan was to increase the [MEDICATION NAME] from 50 mg to 75 mg at bedtime for one (1) week and then increase the dose to 100 mg at bedtime. The psychiatry follow up visit dated 9/13/15 identified Resident #3 was seen for blood work results of the [MEDICATION NAME] level. The assessment indicated there had been no behavioral issues since the transfer from the second floor; there was a question of previous inappropriate touching another resident. Review of the care plan and the behavioral monitoring sheets from 9/1/15 through 11/29/15 that Resident #3 had a history of [REDACTED].#3 was observed by a nurse aide in a female room. Resident #3 was next to Resident #2 and noted to be inappropriately touching himself while touching Resident #2's upper thigh and genital area. While the nurse aide was redirecting Resident #3 out of the room, Resident #3 struck the nurse aide on her back. The investigation identified that Resident #3 and #2 were interviewed. Resident #3 denied touching Resident #2 and stated the staff were a bunch of liars. Resident #2 stated that Resident #3 came into the, sat down in a chair next to the wheelchair. Resident #2 identified Resident #3 placed his hand between her legs and staff had intervened immediately. Resident #2 denied any distress and stated Resident #3 did not hurt her and had touched her on the outside of her clothes. Resident #2's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairments and required one to two person extensive assistance with activities of daily living. Review of the December 2015 behavior monthly flow sheet identified the targeted behaviors were depression and withdrawn, wandering and mood changes. The flow sheets failed to reflect the specific of inappropriate sexual behavior. The nurse's note dated 12/1/15 identified that the Social Worker spoke with Resident #3 regarding the 11/29/15 incident and Resident #3 continued to deny the event. The note indicated that Resident #3 had agreed to a room change on another unit and was encouraged not to enter female resident rooms. Interview with the Nurse Aide (NA) who witnessed the event, NA #2, on 1/2/16 at 11:00 AM identified that she observed Resident #3 sitting next to Resident #2 on 11/29/15 at 11:40 AM in Resident #2's room. NA #2 stated Resident #3 was noted to be inappropriately touching himself and had his hand on Resident #2's clothed thigh. NA #2 stated she immediately redirected Resident #3 at which time Resident #3 struck her on the back. Review of the Resident Rights and Organizational Ethics, Abuse Policy indicated that every resident had the right to be free from sexual and/or physical abuse.

Based on clinical record reviews, observations and interview for the only resident in the survey sample reviewed with a fecal impaction (R #19), the facility failed to monitor the resident's constipation, administer as needed laxatives as directed by the physician, and/or assess the resident when signs of constipation occurred resulting in hospitalization for fecal impaction, and/or for the only resident in the survey sample reviewed for pain management (R#50), the facility failed to provide pain medication as directed by the physician prior to a painful wound treatment. The findings include: 1. Resident #19's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated the resident was cognitively intact, required extensive assist with transfer, did not walk in the room, and was occasionally incontinent of bowel. A constipation assessment dated [DATE] identified the resident had mild to moderate constipation. A care plan dated 1/15/14 identified a problem with constipation and incontinence of bowel at times related to impaired mobility. Interventions included administer medications as ordered and monitor for effectiveness, and report if no bowel movement in 48 to 72 hours. A physician's orders [REDACTED]. Review of a medication record dated January 2013 indicated the resident received milk of magnesia 30 cc by mouth on 1/11/13 for complaints of constipation. The record lacked documentation for a response to the laxative. Review of a resident personal care record dated January 25, 26, and 27, 2014 noted the resident had no bowel movements. No documentation was noted related to notification and/or assessment of no bowel movement and /or administration of an as needed laxative as ordered by the physician. The personal care record dated 1/31/14 noted the resident had a loose stool. The record lacked documentation that the nurse was notified and/or an assessment completed. On 2/3/14, the record indicated the resident had a loose stool. The record lacked documentation that the nurse was notified and/or an assessment completed. A nurse's note dated 2/5/14 indicated the resident complained of generalized weakness. The physician was notified and the resident sent to the emergency room for evaluation. Review of a hospital history and physical dated 2/5/14 indicated patient reports lower abdominal discomfort as well as some bladder pain. Patient states last bowel movement was yesterday and can not recall when last urinated. Abdomen moderately distended. A CT scan of the abdomen noted a large amount of stool within the rectum measuring 10 cm in diameter with displacement of the bladder superiorly to the right as well as left-sided hydro[DIAGNOSES REDACTED] and hydroureter of unclear etiology. It is possible that resident's symptoms of lethargy, poor po intake and increased in terms of baseline dysarthria may be secondary to GI and GU issues as detailed above. A hospital discharge summary dated 2/9/14 indicated the resident was given multiple enemas and rectal suppository. At time of discharge the resident has been started on a bowel regime. Close attention needs to be paid to his/her bowel movement frequency and consider enema or suppositories as needed. An interview on 2/27/14 at 11:45 AM with LPN # 1 indicated he/she was not aware of any bowel issues, including loose stools with R #19 prior to hospitalization on [DATE]. He/she indicated when the resident returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. A review of a facility policy on assessment of residents with an impaction indicated loose bowel movements are to be reported to the nurse, and the nurse shall assess for bowel sounds, distention, and/or discomfort. 2. Resident # 50's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] indicated the resident had short and long term memory problems, required total care with all ADL's and did not walk. A resident care plan dated 2/6/14 identified a pressure ulcer on the sacrum. Interventions included treat pain per orders. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. An observation of R #50's wound on 2/27/14 at 10:00 AM with RN #1 noted a 6.5 cm x 6 cm (measured by RN #1) open wound on the resident's coccyx. The wound bed was noted to have a large amount of slough. The resident was not verbally responsive but did moan x 2 during the observed dressing change. Review of a treatment kardex dated 2/24/14 through 2/27/14 noted the resident received a dressing change daily. Review of the Medication Administration Record [REDACTED]. Review of the clinical record and interview on 2/27/14 at 10:50 AM with RN #1 (wound nurse) indicated the resident had not received [MEDICATION NAME] sulfate prior to the dressing changes on 2/24/14 and 2/25/14 because the route of the medication had to be clarified. He/she was not aware of why the resident did not receive the [MEDICATION NAME] on 2/26/14 and 2/27/14. At that time the medication cart was observed. No [MEDICATION NAME] was available for the resident.

Based on observation, clinical record review, and staff interview for one of three residents in the survey sample reviewed for pressure ulcers (R # 50), the facility failed to provide an appropriate treatment to promote the healing of a pressure ulcer. The findings include: Resident # 50's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] indicated the resident had short and long term memory problems, required total care with all ADLs, did not walk, and was always incontinent of urine and stool. A resident care plan dated 1/6/14 identified a problem with potential for impairment in skin integrity. Interventions included keep skin clean and dry, pressure relief devices and turn and position measures. A nurse's note dated 2/2/14 indicated that upon applying Calazyme cream to coccyx, a superficial opening was noted on the coccyx. Measured approximately 4 cm x 3 cm. Physician was notified and ordered to cover with a dry dressing until the wound nurse could examine in the morning. Review of a physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. A wound assessment dated [DATE] noted the stage 2 pressure ulcer measured 6 cm x 6 cm with the wound bed 100% of [MEDICATION NAME] tissue. An observation of R #50's wound on 2/27/14 at 10:00 AM with RN # 1 noted a 6.5 cm x 6 cm (measured by RN #1) open wound on the resident's coccyx. The wound bed was noted to to be covered in slough. Review of the clinical record and interview on 2/27/14 at 10:33 AM with RN #1 (wound nurse) indicated the resident was not seen by the wound nurse on 2/3/14 as directed by the physician on 2/2/14. The resident continued to have Calazyme and [MEDICATION NAME] applied to his/her pressure ulcer on the coccyx for 24 hours (2/3/14- 2/4/14) until he/she saw the wound on 2/4/14. Although the Calazyme and [MEDICATION NAME] were applied every shift from 2/3/14 to 2/4/14 he/she was unable to provide documentation that the Calazyme and [MEDICATION NAME] were applied after each incontinent episode during that 24 hours. RN # 1 (wound nurse) further indicated since the resident was incontinent of bowel and bladder the open area should have been covered with a dressing from the day it was identified.

Based on clinical record review, observation and interview for one (R#1) of three residents reviewed for the provision of care and services of a resident with dementia, the facility failed to ensure that the resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social well-being and failed to develop a resident centered care plan with interventions to maintain a hazard free environment for a resident who had a history of [REDACTED]. The findings include: R#1's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified severely impaired cognition, behavioral symptoms directed toward others and self, wandering, independent ambulation and used a feeding tube. The resident care plan dated 3/14/13 identified R#1 with behavioral issues which included constant wandering, yelling, randomly entering other resident's rooms and taking items off the nurses desk, medication cart and meal trucks. Interventions included fifteen-minute checks and psychiatric interventions which included medication changes. An MDS dated [DATE] identified severely impaired cognition, behavioral symptoms directed toward others and self, wandering, independent ambulation and used a feeding tube. The nursing care plan dated 6/27/13 identified that R#1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's Dementia with interventions to administer medications as ordered, anticipate needs and provide care, and keep resident's routine consistent. The 6/27/13 care plan failed to identify the resident's behavioral issues identified in the 3/14/13 care plan which included constant wandering, yelling, randomly entering other resident's rooms and taking items off the nurses desk, medication cart and meal carts. Review of the nurse's notes identified the following: On 3/18/13 it was documented that a mouth sweep was performed but the documentation did not indicate why. On 3/19/13 R#1 was observed with foam on his/her lips, the mouth was cleaned and a mouth sweep was performed with no findings, but the documentation did not indicate the source of the foam. On 3/20/13, R#1 was observed putting wet paper towels in his/her mouth obtained from the dispenser in the shower room. A team meeting was held and R#1 was determined to have no insight into his/her safety needs. A decision was made to place a lock on the shower room door. At that time, R#1 had a [MEDICAL CONDITION] feeding tube to provide for nourishment, was NPO and unable to swallow. On 3/23/13 something red was observed in R#1's mouth, a mouth sweep was performed, and an item was removed from R#1's mouth, but the documentation did not indicate the item. On 4/13/13 R#1 was observed with plastic flowers in his/her mouth requiring a mouth sweep to remove the flowers. The five (5) instances where R#1 was identified as placing inanimate objects in his/her mouth were known to facility staff and staff failed to address this hazardous behavior in the resident's care plan. Nurse's notes dated 8/8/13 identified that R#1 vomited brown emesis at 5:30 AM. The physician was notified, an X-ray identified the possibility of an early or partial small bowel obstruction, and R#1 was transferred to an acute care hospital. Review of the inter-agency report from the facility to the hospital dated 8/8/13 identified to monitor the resident closely, as the resident places thing in his/her mouth. Radiological imaging (CT scan) of R#1's abdomen dated 8/8/13 identified a high-grade bowel obstruction at the level of the mid-ileum and a markedly distended stomach containing large globular ingested material, and the imaging had the appearance of a bezoar (a hard mass of material). R#1 remained hospitalized and on 8/13/14, underwent an medical procedure which identified a large [MEDICAL CONDITION] bezoar in the stomach. Attempts were made to cut up the bezoar but were unsuccessful. On 8/14/13, R#1 underwent an exploratory laparotomy during which seven (7) examination gloves were removed from the resident's stomach and another one (1) removed from the jejunum (further down in the gastrointestinal tract). A surgical pathology report dated 8/14/13 identified that 8 tan/yellow discolored foreign bodies consistent with rubber gloves. R#1 was transferred back to the facility on [DATE]. Review of the interagency communication (W 10) dated 8/23/13 identified R#1's discharge [DIAGNOSES REDACTED]. The W 10 identified that R#1 could ambulate with assistance and directed that all unnecessary objects be kept out of the resident's room and other areas including gloves and unattended food. It further stated that R#1 needed to be watched closely. Surveyor observation on 8/26/13 at 9:00 AM, identified that R#1 was pacing up and down the facility hallway and in and out of his/her room. In R#1's room, a box of latex gloves were observed on top of the wardrobe with a chair along the side. This surveyor called the nursing supervisor and the gloves were immediately removed. An interview and review of R#1's interim care plan dated 8/23/13 was conducted with the MDS Coordinator on 8/26/13 at 12:00 PM. It was identified that R#1's care plan failed to address R#1's recent history of ingesting inanimate objects and failed to identify interventions to keep the resident safe from future hazards. The MDS coordinator further stated that it would have been the admitting supervisor's responsibility to address the behavior of ingesting inanimate objects upon return from the hospital and to address it in the interim care plan. Interview with NA#1 on 8/26/13 at 1:50 PM identified that R#1 had a history of [REDACTED]. He/she further stated that staff attempted to watch R#1 and try to get the items out in time. Interview with the Speech Therapist on 8/26/13 at 2:10 PM identified that a resident screen had been requested by nursing for R#1's possible return to mouth (PO) intake (i.e. pleasure foods) on 7/3/13. Given R#1's impulsive behavior and decreased cognitive function, R#1 remained at high risk for aspiration and PO trials were not recommended. R#1 was capable of swallowing but had poor oral control and delayed swallowing. Review of facility policy identified that the facility shall have a care planning process which included: integrating assessment findings in care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care and documenting the care. The purpose is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social well-being.

Based on clinical record review, interview and observation for one (R#1) of three residents reviewed for accident hazards, the facility failed to ensure that a resident with dementia who was known to swallow examination gloves had an environment that was free of accident hazards which resulted in a finding of immediate jeopardy. The findings include: R#1's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified severely impaired cognition, behavioral symptoms directed toward others and self, wandering, independent ambulation and used a feeding tube. The resident care plan dated 3/14/13 identified R#1 with behavioral issues which included constant wandering, yelling, randomly entering other resident's rooms and taking items off the nurses desk, medication cart and meal trucks. Interventions included fifteen-minute checks and psychiatric interventions which included medication changes. An MDS dated [DATE] identified severely impaired cognition, behavioral symptoms directed toward others and self, wandering, independent ambulation and used a feeding tube. The nursing care plan dated 6/27/13 identified that R#1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's Dementia with interventions to administer medications as ordered, anticipate needs and provide care, and keep resident's routine consistent. The 6/27/13 care plan failed to identify the resident's behavioral issues identified in the 3/14/13 care plan which included constant wandering, yelling, randomly entering other resident's rooms and taking items off the nurses desk, medication cart and meal carts. On 8/8/13 R#1 was transferred to an acute care hospital, identified with a high-grade bowel obstruction, and on 8/14/13, R#1 underwent an exploratory laparotomy during which seven (7) examination gloves were removed from the resident's stomach and another one (1) removed from the jejunum. A surgical pathology report dated 8/14/13 identified that 8 tan/yellow discolored foreign bodies consistent with rubber gloves. R#1 was transferred back to the facility on [DATE]. Review of the interagency communication (W 10) dated 8/23/13 identified R#1's discharge [DIAGNOSES REDACTED]. The W 10 identified that R#1 could ambulate with assistance and directed that all unnecessary objects be kept out of the resident's room and other areas including gloves and unattended food, and that R#1 needed to be watched closely. Surveyor observation on 8/26/13 at 9:00 AM, identified that R#1 was pacing up and down the facility hallway and in and out of his/her room. In R#1's room, a box of latex gloves were observed on top of the wardrobe with a chair along the side. This surveyor called the nursing supervisor and the gloves were immediately removed. An interview and review of R#1's interim care plan dated 8/23/13 was conducted with the MDS Coordinator on 8/26/13 at 12:00 PM. It was identified that R#1's care plan failed to address R#1's recent history of ingesting inanimate objects and failed to identify interventions to keep the resident safe from future hazards. The MDS coordinator further stated that it would have been the admitting supervisor's responsibility to address the behavior of ingesting inanimate objects upon return from the hospital and to address it in the interim care plan. Review of facility policy identifies that the facility shall have a care planning process which includes: integrating assessment findings in care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care and documenting the care. The purpose is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social well-being.

Based on clinical record review, review of facility documentation, observations and interviews for one of two residents who exhibited non-adherent behavior to dietary restrictions (Resident #1) and/or for 11 of 21 residents who currently resided on the East 1 unit and required a special diet or no oral nutrition (Residents #3 through #13), the facility failed to ensure a safe environment regarding food accessibility. The finding includes: a. Resident #1 resided on the behavior/dementia unit with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified that the resident had severe cognitive impairment with behaviors to include wandering, required a mechanically altered diet and utilized a wheelchair for mobility. The RCP dated [DATE] indicated that the resident was non-compliant with dietary orders (takes drinks off other residents' trays that are not thickened) with a goal to prevent choking from non-diet consistency. Interventions to address this problem included in part, observe resident for noncompliance to diet and redirect when noncompliant. Physician orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 1:12 PM and review of nursing narratives and/or the facility investigation noted that, on [DATE] at 5:30 PM, Resident #2 opened the nursing station gate granting access for Resident #1 to retrieve food items from a partially eaten tray of food leftover from the noon meal. R#1 was observed by numerous staff members to have food in his/her mouth and although staff requested R #1 remove the food from his/her mouth, the resident refused. The resident's airway became compromised with the Heimlich maneuver and cardiopulmonary resuscitative efforts administered to the resident without success. EMS was activated and transferred the resident to the hospital. Review of the acute care hospital record dated [DATE] identified that the resident was found with copious amounts of food obstructing the airway with CPR initiated. The resident sustained [REDACTED]. On [DATE], life support was discontinued and the resident expired. Interview with RN #2 on [DATE] at 12:15 PM identified that the lunch tray should have been cleared of remaining food when the food cart left the unit. Although the facility did not have a current policy regarding trays after meals, facility documentation dated [DATE] identfied staff were directed that no tray is allowed in the unit after each meal. The facility failed to ensure that facility practices were followed on the behavior/dementia unit for environmental food safety. Subsequent to this incident, the facility installed an alarm to the nursing station gate with a mechanism to self-lock and staff were educated regarding food safety. b. Resident #2 resided on the behavior/dementia unit on [DATE] and had a [DIAGNOSES REDACTED]. The RCP dated [DATE] indicated that the resident offered other residents foods/snacks with interventions that included staff observance for behavior of offering food/fluids to other residents and education/reminders not to offer peers anything. Resident #3 resided on the behavior/dementia unit on [DATE] and had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified that the resident had severely impaired cognition and had a feeding tube (GT). Physician orders [REDACTED]. The RCP dated [DATE] noted a problem of food seeking with an entry dated [DATE] that the resident was found with soda, a [DATE] entry that the resident asked a peer for soda with interventions that included to redirect and monitor. Review of the clinical records and/or review of facility documentation identified that Resident #4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 resided on the behavior/dementia unit on [DATE] and required diets of altered consistency (soft/ground/puree). In addition, Resident #5 and #6 required thickened liquids. Observation on [DATE] at 8:40 AM noted that Resident #2 sat next to Resident #6 in the dining room and verbalized that if Resident #6 were hungry, s/he would feed the resident. Observation on [DATE] at 12:30 PM identified that the East 1 nursing station gate was opened and a box of snacks were on the nursing station counter closest to the hall. Although a staff member was at the nursing station when the observations were made, interview with LPN #1 on [DATE] at 12:30 PM indicated that the box of snacks had been there since approximately 9:30 AM. The nursing station gate was immediately closed by RN #2. Interview with the DON on [DATE] at 1:28 PM noted that although the facility did not have a specific policy, staff were previously in-serviced to close the nursing station gate and to place snacks in the locked refrigerator or medication room. The in-services dated [DATE] and ,[DATE] identified that nursing must ensure that the nursing station gate is locked at all times, however, lacked direction for storage of resident snacks. The facility submitted an immediate action plan dated [DATE] that included a protocol for food-truck and snack storage with staff education/reeducation to ensure a safe environment.

Based on clinical record reviews, interviews and review of facility policies for one resident (R#112) who sustained a fall, the facility failed to ensure that the resident was free from injury and/or for one of three residents observed for smoking (R#4, R#10, R#54) the facility failed to provide a smoking apron and/or ensure ashtrays were accessible to extinguish cigarettes and/or the facility failed to ensure disposable razors were stored in a secure location. The finding include: 1. Resident #112's (R#112) [DIAGNOSES REDACTED]. A care plan dated 4/9/11 identified that the resident had the potential for falls related to impaired physical mobility and impaired cognition. Interventions included to transfer the resident with a Hoyer (mechanical) lift with assistance of 2 staff and a nurse to supervise. Review of a nurse's note dated 4/24/11 at 8:30 AM identified that LPN#3 was called to the resident's room when the resident fell while being transferred with the Hoyer lift. The resident was observed in a supine position, bleeding from the occipital area and was transferred to the Emergency Department for evaluation. The resident subsequently required three staples to left occipital scalp. Review of facility documentation dated 4/24/11 identified that when NA#1 and NA#2 transferred R#112, via the Hoyer lift, a hook came off of the sling which caused the resident to fall to the floor. The documentation identified that NA#1 and NA#2 transferred the resident without supervision of the nurse, as directed in the resident's plan of care. Interview with NA#1 on 5/26/11 at 10:00 AM identified that on 4/24/11 she prepared R#112 for transfer. NA#1 stated that she put the pad under the resident and hooked the pad to the lift machine then called for NA#2 for assistance. NA#1 stated that she didn't know what happened but the lower part of the pad unhooked and the resident slid out of the sling, landing on the floor. NA#1 stated that she did not inform the charge nurse that the resident was ready to be transferred and proceeded to transfer the resident without the nurse present. Attempts to contact NA#2 were unsuccessful. During an interview on 5/25/11 at 10:30 AM, LPN#3 identified that she was the charge nurse on 4/24/11 and was called to the resident's room after the resident had fallen. LPN#3 stated that she did not oversee R#112's transfer because the NA's did not notify her prior to transferring the resident. Review of the facility's mechanical lift policy identified in part, that two people are required to perform a mechanical lift transfer and the charge nurse will oversee the procedure. NA#1 and NA#2 were suspended during the facility's investigation. At the conclusion of the investigation, NA#1 and NA#2 were terminated on 5/11/11 for failure to complete a resident transfer safely. 2. Resident #54's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as moderately cognitively impaired, required total assistance with transfers and did not ambulate. A smoking assessment dated [DATE] identified the resident could smoke independently during supervised smoking. A smoking risk assessment dated [DATE] identified the resident's risk at a 4 (0 -13 = safe smoker-develop standard smoking care plan). A resident care plan dated 2/24/11 identified the resident required supervised smoking. Interventions included wear apron during smoking to prevent cigarette ash falling on resident. An Advanced Practice Registered Nurse (APRN) note dated 3/22/11 indicated, in part that the resident reported dropping a cigarette on the left leg resulting in a 1.0 centimeter (cm) by 1.0 burn with a current treatment of [REDACTED]. R#54 indicated that he/she was burned by a cigarette. The resident indicated that he/she did not have his/her smoking apron on when he/she was burned because someone had taken it. Review of a reportable event (RE) and investigation dated 3/20/11 and interview with RN#1 on 5/25/11 at 11:50 AM indicated R # 54 had been wearing a smoking apron for at least one year. RN#1 indicated that during the investigation she was informed that the resident's smoking apron was missing. A statement dated 3/20/11 signed by NA # 7 indicated the resident usually puts her apron on and off independently. RN # 1 indicated that although the resident could apply the apron independently, she would have expected NA # 7 to ensure the smoking apron was in place while the resident was smoking. Review of a facility policy and procedure on smoking, in part, indicated only a nursing staff member may assist a resident with any smoking appliances, such as a smoking apron. 3. Observation during a smoking session on 5/25/11 at 11:00 AM on the second floor identified R # 54, R #4 and R #10 smoking independently with smoking aprons in place. Two ashtrays were noted across the patio and out of reach of the residents. Although no resident were observed flicking and/or dropping ashes on themselves, ashes were observed being flicked on the ground. At no time did NA # 3 attempt to move the residents closer to the ashtray and/or move the ashtray within their reach. Subsequent to surveyor inquiry and interview with the Administrator on 5/25/11 at 12 noon three ashtrays were added to the smoking area. Review of the facility smoking policy indicated that cigarettes must be extinguished in the appropriate receptacle. 4. During tour of the 1st floor psychiatric unit and the second floor East Unit on 5/23/11 at 10:00 AM, disposable razor blades were found to be located in an unlocked area in the utility room. Interview with the DNS at the time identified that disposable razor should have been stored in the locked medication room. Subsequent to inquiry, the razors were immediately secured and staff inservice education was provided. .

Based on review of the clinical record, facility documentation and interviews for 1 sampled resident reviewed for pressure ulcers (Resident #1), the facility failed to provide appropriate treatment and services to promote healing of a pressure ulcer. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Braden Scale (pressure risk assessment) dated 4/21/10 identified a score of 14 indicating a moderate risk for skin breakdown. The care plan dated 4/20/10 identified a risk for skin breakdown with interventions that included pressure relief mattress and chair pad, use of barrier skin protection and repositioning every two hours. The Treatment Administration Record dated 6/23/10 identified " the coccyx looks red with no open areas". The medical Advanced Practice Registered Nurse (APRN) progress note dated 6/26/10 identified a 3.0 centimeter (cm) x 3.3 cm x 0.6 cm stage 4 coccyx pressure ulcer with tunneling. The area was dry and without slough. The medical APRN's order dated 6/26/10 directed to cleanse the area with Normal Saline followed by a [MEDICATION NAME] dressing, change every 3 days for 14 days then reassess the wound. The wound APRN progress note dated 7/6/10 (11 days later) identified the coccyx pressure ulcer was unstageable with an area of black slough and had deteriorated. The wound APRN's order dated 7/6/10 directed to cleanse the coccyx wound with Normal Saline, apply Santyl to the wound bed, pack lightly with Calcium Alginate and cover with border gauze, turn and reposition every half hour to 2 hours, and not to be out of bed greater than one and a half hours. The nurse ' s note dated 7/8/10 noted the pressure ulcer had an increase in foul odor extreme brown drainage and was deeper. The physician's orders [REDACTED]. Interview and review of the clinical record with Registered Nurse (RN) #1 (facility wound nurse) on 11/1/10 at 12:25 PM indicated that when a wound is identified an assessment is completed describing the area with specific interventions implemented according to the identified risk factors. RN #1 indicated she is notified when a new pressure ulcer is identified and/or a change is noted in a wound. RN #1 indicated the treatment ordered on [DATE] by the Medical APRN was not an appropriate treatment for [REDACTED]. RN #1 further noted she was unaware of the pressure ulcer until 7/6/10. RN #1 noted she reviews the 24 hour nursing reports and attends morning report and the resident's pressure ulcer was not discussed and/or noted on the 24 hour nursing report.