Every finding on record at Notre Dame Health and Rehabilitation Center

Based on review of facility documentation and interviews, the facility failed to ensure accurate staffing data was entered in the Payroll Based Journal (PBJ) during FY Quarter 3 2025 (April 1 -June 30). The findings include: Review of the PBJ Staffing Data Report dated FY Quarter 3 2025 (April 1 -June 30) submitted to Center for Medicare and Medicaid (CMS) identified the facility triggered no RN hours and no licensed nurse coverage 24 hours/day from 4/1/25 through 6/30/25 Review of the Daily Staffing dated 4/1/25 through 6/30/25 identified the facility did have RN coverage and licensed nurse coverage 24 hours a day. Interview with the Administrator on 4/19/26 at 12:35 PM identified that the PBJ data submitted for FY Quarter 3 2025 was completed by the former business office manager, who is no longer at the facility and was the only assigned employee who maintained ongoing correspondence with CMS related to PBJ submissions. The Administrator further identified the facility had since acquired a new payroll service for calculating hours and no longer had access to information related to past submissions. The Administrator indicated she would review past submissions that may have been retained by the facility and provide any additional information.Interview and facility documentation review with the (current) Business office Manager on 4/20/26 at 12:15 PM, identified, subsequent to surveyor inquiry, FY Quarter 3 2025 PBJ was submitted to CMS by the former Business Office Manager on the 8/14/25 deadline and was returned 'Rejected' with instructions to make the necessary corrections. Subsequent correspondence dated 8/20/25 identified the issue regarding PBJ submission as closed for the FY Quarter 3 2025 (April 1 - June 30) Instructions were provided converting an Excel document for submission with no further documentation or follow up. Subsequent interview with the Administrator on 4/21/26 at 8:52 AM identified the former Business Office Manager had submitted the PBJ timely. However, she did not inform anyone once it was rejected. The Administrator identified that although she had overall responsibility to ensure accurate PBJ submissions, the former Business Office Manager was the only person communicating with CMS, so any action required after the rejection of PBJ submission was not addressed. Interview with Business Office Staff #1 on 4/21/2026 at 8:52 AM identified she assisted in creating an Excel document that included all the nursing hours with Business Office Staff #2. Business Office Staff #1indicated that although she also had oversight of PBJ submissions, she could not confirm its submission as the former Business Office Manager was the only employee communicating with CMS during that time. Interview with Business Office Staff #2 on 4/21/2026 at 8:52 AM identified she assisted in creating an Excel document with all the nursing hours and sent it electronically to the former Business Office Manager on 8/14/25 who later confirmed the hours were submitted on 8/14/25. Business Office Staff #2 could not confirm its submission as the former Business Office Manager was the only employee communicating with CMS during that time. Review of the facility electronic communication dated 8/14/25 did not include transmission of information from Business office Manager #2 to the former Business Office manager. The Payroll Based Journal Manual directs that direct care and census dates will be collected quarterly and are required to be timely, complete and accurate when submitting the facility's staffing records. Facilities should run the staffing, and census reports available in CASPER (reporting provider user guide) to verify accuracy and completeness of their final submission and the accuracy of their resident census prior to submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement.

Based on review of the clinical record, facility documentation, facility policies, and interviews the facility failed to ensure the infection surveillance system tool (McGeer Criteria) was utilized prior to initiating antibiotics and failed to ensure antibiotic time outs were completed 72 hours after the initiation of antibiotics, per the facility policy for 3 of 3 resident (Residents #1, 15, and 46), and failed to ensure a system was in place to monitor antibiotic usage data. The findings include: 1a. Resident #1 was admitted to the facility in May 2025 with diagnoses that included hydronephrosis and a history of other infectious and parasitic diseases. The nurse's note dated 10/2/25 at 6:09 PM identified Resident #1 remained within normal baseline, alert and oriented, denied pain or discomfort. However, Resident #1 reported to the charge nurse episodes of discomfort in the abdominal/pelvic area, upon interviewing the resident, he/she stated that he/she had pain all over the lower abdomen, specifically in the pelvic region and was relieved by an OTC medication but had returned. The physician was made aware of the symptoms and when this writer spoke with the Resident #1's responsible party, it was verbalized that he/she had concerns about a UTI, stating, whenever Resident #1 had these symptoms at home it was usually a UTI. The physician ordered a urinalysis and empirical treatment of suspected UTI with Nitrofurantoin 100 mg, twice daily for five days, to start after the urine collection for laboratory analysis. Review of Resident #1's Individual Infection Report dated 10/2/25 identified Resident #1 had the following diagnosis or risk factors, acute kidney failure, UTI, and hydronephrosis, and on 10/2/25, Resident #1 had the following signs and symptoms, pain to lower abdomen and a burning sensation when urinating. The Individual Infection Report failed to identify a urine culture was completed and the organism(s) isolated field was incomplete; the October 2025 Monthly Infection Log identified Resident #1's culture results/date (pathogen) was NA. Review of facility documentation failed to identify the McGeer Criteria for Infection Surveillance Checklist was completed prior to the initiation of antibiotics. A physician's order dated 10/2/25 directed for the administration of Macrobid 100mg (antibiotic), give 1 capsule by mouth every 12 hours for abdominal/pelvic pain/discomfort for 5 days, start after urine collection. Review of the October 2025 Medication Administration Record identified Macrobid 100mg was administered from 10/3/25 through 10/7/25 at 8:00 AM and 8:00 PM. Review of Resident #1's laboratory report dated 10/5/25 identified a reflexive urine culture was collected on 10/2/25 and the specimen result identified isolated mixed genital flora. These superficial bacteria were not indicative of a urinary tract infection. No further organism identification was warranted on this specimen. The laboratory report further identified Resident #1's complete urinalysis identified the following out of range measurements: appearance was cloudy (reference range-clear), protein was trace (reference range-negative), Leukocyte Esterase was trace (reference range-negative), WBC was 6-10 (reference range-less than or equal to 5/HPF), squamous epithelial cells were 6-10 (reference range-less than or equal to 5/HPF), and bacteria was moderate (reference range-none seen). Review of Resident #1's clinical record failed to identify an antibiotic timeout was completed 72 hours after the initiation of the antibiotic. b. Resident #15 was admitted to the facility in October 2025 with diagnoses that included chronic kidney disease and a history of UTI. The nurse's note dated 12/26/25 at 6:08 PM identified Resident #15 complained of pain and discomfort when urinating, oral fluid intake and proper perineal care was encouraged. The physician was notified and a new order was given for Macrobid 100 mg, twice daily by mouth, for 5 days and collect a urinalysis and culture and sensitivity. Review of Resident #15's clinical record failed to identify the McGeer Criteria for Infection Surveillance Checklist was completed prior to the initiation of antibiotics. A physician's order dated 12/26/25 directed for the administration of Macrobid 100mg, give 1 capsule by mouth every 12 hours for UTI for 5 days. Review of Resident #15's Individual Infection Report dated 12/27/25 identified Resident #15 had the following diagnosis or risk factors, COPD with acute exacerbation, hypoxemia, and heart failure, and on 12/26/25, Resident #15 had the following signs and symptoms, burning sensation when urinating. The Individual Infection Report failed to identify a urine culture was completed and the organism(s) isolated field was incomplete; the December 2025 Monthly Infection Log identified Resident #15's culture results/date (pathogen) was NA. The nurse's note dated 12/27/25 at 9:00 AM identified that Resident #15 was alert and oriented, a urine specimen was collected, the laboratory was called and pick up was confirmed; the urine specimen was placed in the refrigerator, and the lab was aware of the location. Resident #15 had no burning sensation, at the present time, but did report spasms with the start of the urine stream and in between, pain medication was offered and refused. Resident #15's urine did not have a foul odor and was clear with no sediment. Review of the December 2025 Medication Administration Record identified Resident #15 was administered Macrobid 100mg from 12/27/25 through 12/31/25 at 9:00 AM and 5:00 PM. Review of Resident #15's laboratory report dated 12/30/25 identified a routine urine culture was collected on 12/27/25 and the specimen result identified 50,000-99,000 CFU/ml of Pseudomonas aeruginosa with susceptibility to Amikacin, Cefepime, Ceftazidime, Ciprofloxacin, Gentamicin, Imipenem, Levofloxacin, Meropenem, and Tazobactam (Macrobid/Nitrofurantoin was not listed). The laboratory report further identified Resident #15's complete urinalysis identified the following out of range measurements: occult blood was 2+ (reference range-negative) protein was 1+ (reference range-negative), Leukocyte Esterase was trace (reference range-negative), WBC was 6-10 (reference range-less than or equal to 5/HPF), RBC was 10-20 (reference range-less than or equal to 2/HPF ), and squamous epithelial cells were 6-10 (reference range-less than or equal to 5/HPF). Review of Resident #15's clinical record failed to identify an antibiotic timeout was completed 72 hours after the initiation of the antibiotic. c. Resident #46 was admitted to the facility in May 2024 with diagnoses that included dementia and chronic kidney disease. The nurse's note dated 4/7/26 at 1:51 PM identified that Resident #46 was noted to be very confused and talkative. Fluids were encouraged, offered, and accepted. The Psychiatric APRN note dated 4/7/25 identified Resident #46 was seen and evaluated per facility request; staff endorsed a sudden increase in restlessness and difficulty redirecting and calming. Resident #1 was seen in the halls, affect was anxious and was difficult to calm and redirect, will order labs to rule out medical cause, and will continue to monitor. The nurse's note dated 4/7/26 at 9:57 PM identified that the psychiatric APRN (APRN #1) was in to see Resident #46 and an order was written for a urinalysis (UA), culture and sensitivity (C&S), complete blood count with differential (CBC with diff), and comprehensive metabolic panel (CMP), and the order was approved by the Medical Director (MD #1). Review of Resident #46's Individual Infection Report dated 4/8/26 identified Resident #46 had the following diagnosis or risk factors, chronic deficiency anemia, muscle weakness, anxiety disorder, and dysphagia, and on 4/8/26 Resident #46 had the following signs and symptoms, confusion and urinary frequency. The Individual Infection Report further identified the criteria had been met, the following treatment was initiated, Augmentin oral tablet, twice daily for 5 days, for UTI, and the UTI resolution date was 4/16/26.The laboratory diagnostic report dated 4/10/26, initialed but not date or time stamped, identified Resident #46's complete urinalysis identified the following out of range measurements: appearance was turbid (cloudy reference range-clear), occult blood was 2+ (reference range-negative), protein was 1+ (reference range-negative), Leukocyte Esterase was 2+ (reference range-negative), WBC was packed (reference range-less than or equal to 5/HPF), RBC was 20-40 (reference range-less than or equal to 2/HPF), and bacteria was many (reference range-none seen). The laboratory diagnostic report dated 4/11/26 identified Resident #46's final urine culture results identified 10,000-49,000 CTU/ml of E.coli, with susceptibility to Amoxicillin/Clavulanate, Ampicillin, Cefazolin, Cefepime, Ceftazidime, Ceftriaxone, Ciprofloxacin, Gentamycin, Imipenem, Levofloxacin, Meropenem, and Trimethoprim/sulfa. additional non-predominating organisms were isolated. These organisms were commonly found on external and internal genitals and considered colonizers. Review of Resident #46's clinical record failed to identify the McGeer Criteria for Infection Surveillance Checklist was completed prior to the initiation of antibiotics. Review of Resident #46's clinical record identified a physician's order dated 4/15/26 (8 days after the initial report of symptoms and 4 days after the final urine culture results were reported) directed to administer Augmentin 500/125mg, 1 tablet by mouth, twice daily for 5 days. The April 2026 Medication Administration Record identified Resident #46 received Augmentin 500-125 mg, 1 tablet on 4/16/26 at 5:00 PM, 4/17/26 through 4/20/26 at 9:00 AM and 5:00 PM, and on 4/21/26 at 9:00 AM. Review of Resident #46's clinical record failed to identify an antibiotic timeout was completed 72 hours after the initiation of the antibiotic. Interview with the Infection Preventionist (LPN #1) on 4/20/26 at 11:00 AM identified that the facility does not use McGeer criteria or a specific standardized tool/criteria for infection surveillance. LPN #1 indicated that if a resident was suspected of having an infection, the resident would be assessed by the nursing supervisor, the findings would be reported to the physician, any orders placed would be followed, and documentation would be completed in the resident's clinical record and tracked on the Individual Infection Report. Interview with the DNS on 4/21/26 at 7:00 AM identified that the facility does use McGeer Criteria for their surveillance tool, and that licensed nurses were expected to initiate an Individual Infection Report when a resident was in question of having an infection, notify the physician, and write a progress note in the clinical record. The DNS indicated that upon further review of the Individual Infection Report, the report did not entirely reflect the same criteria as the McGeer Criteria for Infection Surveillance. The DNS indicated that the current form would be updated and she would work with the facility's Administrator to see if the McGeer Criteria infection surveillance tool could be added into the electronic health record, allowing the nurses to complete on-going surveillance in the resident's electronic health record. The DNS further indicated that it was her expectation to ensure an antibiotic time-out was completed 72 hours after antibiotic initiation and documentation should be completed in a progress note in the resident's clinical record. The DNS identified that she would expect to see a progress note that Resident #1's urine culture was not indicative of a urinary tract infection and that the physician was made aware, and all ordered antibiotics were to be reviewed for appropriateness after the lab results were reported. The facility's Antibiotic Stewardship policy identified antibiotic stewardship actions were conducted to enable or to measure key elements of care, knowing when to be concerned about an infection in a resident, what clinical and historical information to gather for the provider, when to submit diagnostic specimens to the laboratory, how to quantify and assess appropriateness of antibiotics prescribed, and how to identify adverse outcomes that might be associated with antibiotics. The policy directs providers to utilize the McGeer criteria when considering initiation of antibiotics. Consistent with this criteria, the standardized suspected UTI SBAR form should be used for all residents suspected of having a UTI. The completed form should be provided to, or information communicated with, the provider. It is encouraged that McGeer criteria be used for other suspected infections, including lower respiratory tract infections, skin and soft tissue infections, and fever of unknown focus, when considering antibiotic prescription. At 72 hours after antibiotic initiation or first dose in the facility, each resident would be reassessed for consideration of antibiotic need, duration, selection, and deescalation potential. At this time, laboratory testing results, response to therapy, resident condition, and facility needs (e.g. outbreak situation) would be considered. Completion of an antibiotic timeout must be recorded in the resident record. 2. During a review of the facility's infection control program with the Infection Preventionist (LPN #1) on 4/20/26 at 2:00 PM, the facility documentation failed to identify that a system was in place to provide feedback to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols. LPN #1 indicated that the consulting pharmacy tracked antibiotic use data and sent it to the facility, but she was unable to access the information at this time. LPN #1 identified that antibiotic data was shared with the IDT during QAPI, quarterly. Review of the Quality Assessment and Performance Improvement 7/30/25 through 10/28/25 document identified the following data about antibiotic usage: there was a total of 16 residents on antibiotic usage for this quarter. Breakdown was as follows for infection: UTI (9) all being health care acquired infection (HAI), eyes (1), skin (3), oral (1), pneumonia (PNA)/upper respiratory infection (URI) (2) both HAI. Continued working close with facility prescribers to monitor antibiotic usage, monitoring length of therapy, and appropriate use of antibiotics is ongoing. Review of the Quality Assessment and Performance Improvement 10/30/25 through 12/31/25 document identified the following data about antibiotic usage: there was a total of ten residents on antibiotic usage for this quarter. Breakdown was as follows for infection: UTI (5), eyes (1), oral (2), PNA/URI (2) both HAI. Continued working close with facility prescribers to monitor antibiotic usage, monitoring length of therapy, and appropriate use of antibiotics is ongoing.Interview with LPN #1 on 4/21/26 at 7:40 AM identified that she was not receiving the monthly antibiotic reports, so she had not been reviewing the monthly pharmacy report data with the IDT, including prescribing providers, but she was sharing data that was manually calculated from her monthly surveillance tracking, with the IDT during the quarterly QAPI meetings; LPN #1 could not provide documentation of the data that was shared during the QAPI meetings.Interview with the DNS on 4/21/26 at 7:45 AM identified that she thought that LPN #1 was receiving the antibiotic reports from the pharmacy, and that she received the monthly medication regimen from the Consultant Pharmacist, for each resident, but could not find the monthly antibiotic reports in her email. Interview with LPN #1 and the Staff Development Nurse (RN #5) on 4/21/26 at 2:55 PM identified that RN #5, who served as the interim-Infection Preventionist had been receiving the monthly pharmacy reports and was unaware the LPN #1 was not receiving them; subsequent to surveyor inquiry the monthly pharmacy reports dated January 2025 through March 2026 were provided to LPN #1. The facility's Antibiotic Stewardship Policy and Procedure directs for monthly Antibiotic Stewardship Program (ASP) tracking report to complete and report the following calculations: total number of antibiotic starts, number and percentage of antibiotic starts by antibiotic name and class, and the number and percentage of antibiotic starts originating from facility providers and outside providers.

Based on observation, review of the clinical record, facility documentation, facility policy, facility assessment and interviews for 1 resident (Resident #6) reviewed for pressure ulcers, the facility failed to ensure personal protective equipment (PPE) was worn while providing care in accordance with infection control standards for a resident on enhanced barrier precautions (EBP), failed to ensure monthly infection surveillance data was tracked from 1/1/26 through 4/19/26 and failed to ensure complete and accurate clinical data was included in 2 of 3 residents (Residents #1 and 46) Individual Infection Reports that were reviewed. The findings include: 1. Resident #6 was admitted to the facility in May 2019 with diagnoses that included osteoarthritis and dementia. The quarterly MDS dated [DATE] identified Resident #6 required two person assist with bed mobility, transfers, at risk for the development of pressure ulcers and had no unhealed pressure ulcers. The care plan dated 4/15/26 identified Resident #6 was dependent with ADL's, at risk for pressure ulcers and had developed a stage II pressure ulcer to the right ischium. Physician orders dated 4/19/26 directed EBP. Observation on 4/20/26 at 10:55 AM identified NA #3 and another nurse aide in the provision of incontinent care for Resident #6, without the benefit of PPE, specifically an isolation gown. Interview with NA #3 on 4/20/26 at 10:55 AM identified she had only intended on assisting with a resident transfer and did not expect Resident #6 to need incontinent care. NA #3 further identified she should have been wearing PPE while providing direct care. Interview with the DNS on 4/21/26 at 10:05 AM identified she would expect PPE to be worn while providing direct care for a resident on EBP. Review of the facility policy for Enhanced barrier Precautions directed PPE to be worn, specifically gowns and gloves during high contact resident care (dressing, bathing, transfers) for residents that include wounds. 2a. During a review of the facility's infection control program with the Infection Preventionist (LPN #1) on 4/20/26 at 11:30 AM, the facility documentation identified that Individual Infection Reports were completed from 1/1/26 through 4/19/26 but failed to identify documentation that Monthly Infection Logs were completed from 1/1/26 through 4/19/26. Interview with LPN #1 on 4/20/26 at 11:30 AM identified that she had not yet completed the January 2026, February 2026, or March 2026 Monthly Infection Logs nor had she initiated an April 2026 Monthly Infection Log, and that her plan was to complete them all this week. During an interview with LPN #1 and the DNS on 4/20/26 at 12:16 PM, the DNS identified that LPN #1 was newer to the Infection Preventionist role and her learning was on-going, but that she would expect that in addition to completing the Individual Infection Reports; she would expect LPN #1 to initiate Monthly Infection Logs and to update the logs on an ongoing basis, as the logs serve the line list for infection surveillance. b. Resident #1 was admitted to the facility in May 2025 with diagnoses that included hydronephrosis and a history of other infectious and parasitic diseases. Review of Resident #1's Individual Infection Report dated 10/2/25 identified Resident #1 had the following diagnosis or risk factors, acute kidney failure, UTI, and hydronephrosis, and on 10/2/25, Resident #1 had the following signs and symptoms; pain to lower abdomen and a burning sensation when urinating. The Individual Infection Report failed to identify a urine culture was completed and the organism(s) isolated field was incomplete; the October 2025 Monthly Infection Log identified Resident #1's culture results/date (pathogen) was NA. Review of Resident #1's clinical record identified a reflexive urine culture was collected on 10/2/26 and the specimen result identified mixed genital flora isolated; these superficial bacteria were not indicative of a urinary tract infection (UTI). c. Resident #46 was admitted to the facility in May 2024 with diagnoses that included dementia and chronic kidney disease. Review of Resident #46's Individual Infection Report dated 4/8/26 identified Resident #46 had the following diagnosis or risk factors, chronic deficiency anemia, muscle weakness, anxiety disorder, and dysphagia. On 4/8/26 Resident #46 had the following signs and symptoms; confusion and urinary frequency. The Individual Infection Report further identified the criteria had been met, the following treatment was initiated, Augmentin oral tablet, twice daily for 5 days, for UTI, and the UTI resolution date was 4/16/26. Review of Resident #46's clinical record identified a physician's order dated 4/15/26 (1 day prior to the resolution date) directed to administer Augmentin 500/125mg, 1 tablet by mouth, twice daily for 5 days. The April 2026 Medication Administration Record identified Resident #46 received Augmentin 500-125 mg, 1 tablet on 4/16/26 at 5:00 PM, 4/17/26 through 4/20/26 at 9:00 AM and 5:00 PM, and on 4/21/26 at 9:00 AM. During an interview with LPN #1 and the DNS on 4/20/26 at 12:16 PM, LPN #1 was unable to identify why there were inaccuracies on the Individual Infection Reports; the DNS identified that LPN #1 was newer to the Infection Preventionist role and that she would continue to provide on-going education to ensure LPN #1 was documenting accurate clinical information on the Individual Infection Reports. The Infection Prevention and Control Program policy directs that surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Data gathered during surveillance is used to oversee infections and spot trends. The Facility Assessment directs that the facility must establish an infection prevention and control program that must include, at a minimum, the following elements: a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon the facility assessment conducted according to accepted national standards.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that the temperature logs for the sanitizing solution, refrigerators and freezers were documented accurately for November 2025 and December 2025; and failed to ensure that food temperatures were monitored and documented; and failed to ensure that tracking logs for the sanitizing solution, refrigerators, and freezers, and resident meals were completed in their entirety and daily. The findings include:a. Observation and interview on 4/18/26 at 7:15 AM with the Dietary Director identified an issue with the sanitizing solution strips used to check the quaternary sanitizing solution concentrations. Observations identified that the facility used individual white plastic test strips, and following 3 attempts to check the red sanitizing bucket, the strip failed to indicate any color change to confirm the concentration levels of the sanitizing solution. The Dietary Director attempted to check the sanitizing solution in a basin at the 3-bay sink, which also failed to identify any color change. The Dietary Director attempted to check the sanitizing solution dispenser over the sink, which also failed to identify any color change. The Dietary Director identified that the plastic strips had been recently sent for use and thought they may have been a bad batch. The Dietary Director identified he also had paper testing strip rolls and would attempt to check the solutions again using those. b. Observation and interview on 4/18/26 at 10:00 AM with the Dietary Director identified that the quaternary sanitizing solutions for the red sanitizing bucket, 3 bay sink, and sanitizing solution dispenser all measured between 200-400 PPM (per the manufacturer instructions) with use of the paper testing strip roll. The Dietary Director identified that he was unsure how long the individual plastic strips had been in use, but they were fairly new. A request was made to the Dietary Director to provide all temperature (meal/refrigerator/freezer/dishwasher) logs and all sanitizing solution testing strip logs for the kitchen for the last 6 months (11/2025 - 4/2026), and the date the individual plastic test strips were received and put into use at the facility.Review of the kitchen logs identified the following: c. The freezer temperature log identified the freezer as NOT WORKING for the 6:30 AM and 10:30 AM from 11/12/25 - 11/17/25, 6 days. Further review identified that for 2:30 PM and 6:30 PM, freezer temperatures documented and initialed by Dietary [NAME] #3 were as follows:11/12/25 2:30 PM: -1211/12/25 6:30 PM: -611/13/25 2:30 PM: -811/13/25 6:30 PM: -211/14/25 2:30 PM: -1211/14/25 6:30 PM: -811/15/25 2:30 PM: -1011/15/25 6:30 PM: -611/16/25 2:30 PM: -1211/16/25 6:30 PM: -4Review of Dietary [NAME] #3's punch detail identified that although he did not work on 11/14/25, he documented freezer temperatures for 2:30 PM and 6:30 PM.Review of a handwritten undated unsigned note at the top of the log identified; (talking to my night cook regarding putting numbers and not really reading the temp). d. Review of the sanitizing test strip log for November 2025 identified from 11/1/25 - 11/19/25 19 days, and from 11/24/25 - 11/30/25, 7 days, failed to identify which staff performed the testing before and after each meal (a total of 6 tests daily). Further review of the log identified that the handwritten results for these dates were all written in the same fashion, with the same pen ink and in similar handwriting.Review of the sanitizing test strip log for December 2025 identified sanitizing solution tests were documented and initialed by Dietary [NAME] #1 for all breakfast and lunch meals (4 total per day). From 12/3/25 - 12/29/25, a total of 26 consecutive days worked.Review of Dietary [NAME] #1's punch detail for December 2025 identified although he documented all breakfast and lunch meals for 26 consecutive days, he did not work on the following dates: 12/3, 12/7, 12/8, 12/10, 12/16, 12/20, 12/24, 12/26, and 12/30/25. Further review of the sanitizing test strip log for December 2025 identified sanitizing solution tests were documented and initialed by Dietary [NAME] #3 for all dinner checks (2 total per day) from 12/10/25 - 12/30/25, a total of 20 consecutive days worked. Review of Dietary [NAME] #3's punch detail for December 2025 identified although he documented sanitizing solution tests for all dinner checks for 20 consecutive days, he did not work on the following dates: 12/12, 12/15, 12/20, 12/21, 12/26, and 12/29/25. e. Review of the dish machine temperature logs for November 2025 identified that dishwasher temperatures for wash and rinse temperature logs failed to identify which staff monitored and documented the temperatures from 11/20/25 - 11/30/25. Further review of the log identified that the handwritten results for these dates were all written in the same fashion, with the same pen ink and in similar handwriting.Although requested, the facility failed to provide any documentation of dish temperature logs for December 2025. f. Review of the meal temperature logs failed to identify any monitoring or documentation of food temperatures for any meals (breakfast, lunch, dinner) from 11/1/25 - 11/3/2025, 11/11/25 - 11/15/25, and 11/24/25 - 11/26/25. Further review of the food temperature logs identified the log dated 11/4/25 failed to identify lunch food temperatures and which staff monitored and documented the breakfast food temperatures. Dinner food temperatures were dated for 10/4/25 as well the bottom of the log which was also dated 10/4/25 (one month prior).The log dated 11/6/25 identified that the dinner food temperatures were dated for 10/6/25 as well the bottom of the log which was also dated 10/6/25 (one month prior).The log dated 11/7/25 failed to identify any dinner food temperatures and failed to identify which staff monitored and documented the temperatures for breakfast and lunch.The log dated 11/10/25 failed to identify any dinner food temperatures and failed to identify which staff monitored and documented the temperatures for breakfast and lunch.A weekly food temperature log dated 11/16/25 failed to identify any dinner food temperatures for 11/20/25 - 11/22/25 and failed to identify which staff monitored and documented any of the food temperatures. A weekly food temperature log dated 11/23/25 failed to identify any dinner food temperatures for 11/23, 11/27, and 11/29/25 and failed to identify which staff monitored and documented any of the food temperatures.A weekly food temperature log dated 11/30/25 failed to identify any dinner food temperatures for 11/30, 12/2, 12/4, 12/5 and 12/6/25 and failed to identify which staff monitored and documented any of the food temperatures. Review of the December 2025 meal temperature logs failed to identify any monitoring or documentation of food temperatures for any meals (breakfast, lunch, dinner) from 12/14/25 - 12/18/2025, 12/24/24, and 12/26/25 - 12/31/25. Further review of the food temperature logs identified the following.The weekly food temperature log dated 12/7/25 identified conflicting dates for the actual food documented. The log also identified a date of 11/10/25 in different area of the log, and the dates on the log identified that after 12/9/25 (Tuesday), the subsequent dates for meals and the log included 11/10/25 (outlined on the log as Wednesday, however this date was a Monday); 11/11/25 (outlined on the log as Thursday, however this date was a Tuesday) and 11/12/25 (outlined on the log as Friday, this date was a Wednesday) and 11/13/25 (outlined on the log as Saturday, this date was a Thursday). Further review also failed to identify any dinner food temperatures documented on 12/8 and 12/9/25 and failed to identify which staff monitored and documented the food temperatures.The log dated 12/19/25 failed to identify which staff monitored and documented the temperatures for breakfast and lunch.The logs dated 12/20, 12/21, 12/23 and 12/25/25 failed to identify any dinner food temperatures and failed to identify which staff monitored and documented the temperatures for breakfast and lunch.Review of the January 2026 food temperature logs failed to identify any monitoring or documentation of food temperatures for any meals (breakfast, lunch, dinner) from 1/1/26 - 1/17/26. g. Review of the freezer (small and walk in) temperature logs from November 2025 - March 2026 identified that for all months, the temperature of the freezers were documented as minus zero (-0) as the actual temperature, a temperature value that does not exist, for at least 50 % of the months, > 15 days. Further review of the logs identified multiple dates which failed to identify which staff monitored and documented the temperatures.h. Review of the refrigerator (small and walk in) temperature logs from November 2025 - March 2026 identified multiple dates which failed to identify which staff monitored and documented the temperatures.Review of the kitchen logs and interview with the Dietary Director on 4/20/26 at identified he was aware there were issues with misrepresentation of the documentation as well as filling the logs out in their entirety, including all food temperatures for meals. The Dietary Director identified he did an informal in-service with the dietary staff regarding documenting on the logs shortly after he began in the role sometime in November 2025 but did not have any documentation of the education. The Dietary Director also identified he wrote the note on the November 2025 freezer temperature log regarding Dietary [NAME] #3 and documentation of temperatures on dates that the freezer was not functioning and that he had been providing informal education regarding complete and accurate logs, however he also did not document any of the in-service education and could not provide the specific topics reviewed. The Dietary Director also identified following review of the November 2025 sanitizing logs while there were no initials that identified the staff member who completed the log, the log was completed by Dietary [NAME] #1. The Dietary Director identified that he did not believe Dietary [NAME] #1 or Dietary [NAME] #3 worked all the days documented on the December 2025 logs but could not identify the specific days they worked.Review of kitchen documentation and interview with Dietary [NAME] #1 on 4/20/26 at 9:16 AM initially identified that while he did not complete any of the sanitizing logs for November 2025, he did complete and confirmed he signed off on the kitchen logs for December 2025. Dietary [NAME] #1 identified he was sure he worked the entire month of December 2025 with no time off, however upon notification that his punch detail for December 2025 was being reviewed, Dietary [NAME] #1 then identified he did not sign off on all of the dates for the logs for December 2025, and then subsequently identified he did not complete any of the logs for December 2025 and that someone must have filled it out for him.Interview with the Dietary Director regarding the sanitizing bucket policy on 4/21/26 at 11:47 AM directed that the changing frequency and testing of solutions would occur every 2-4 hours and would be tracked on the sanitizing solution log.Although requested, the facility failed to provide any kitchen logs for April 2026 for review.Although attempted, an interview with Dietary [NAME] #3 was not obtained.The facility policy on taking food temperatures directed it was the policy of the facility to ensure that all food prepared and served in the facility met all applicable food safety standards. The policy further directed that at each meal i.e. breakfast, lunch, and dinner, all foods which have been prepared would be tested prior to being served by each crook and or her their designee in accordance with food safety standards. The policy further directed that all food temperatures would be taken and documented by each cook at each meal on the appropriate food temperature log and there were no exceptions.The facility policy on food storage directed that it was the policy of the facility that food would be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. The policy further directed that foods that required refrigeration should be in refrigerators between 35 and 40 F and that the thermometers of the refrigerators should be checked at least three to four times a day and to see the freezer and refrigerator temperature form. The policy further directed that for frozen foods the temperature of the freezers should be at 0 F or below and should be checked at least twice each day.The facility policy on sanitizing buckets required keeping, labeling, and storing buckets filled with typically a 200-400 PPM quat solution changed every 2-4 hours or when visibly soiled. The policy further directed that sanitizer solution would be tested regularly with appropriate test strips to ensure the proper strength as overconcentration could be toxic.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for change of condition, the facility failed to notify the physician and resident representative on multiple occasions when the residents blood pressure and blood sugar were outside the normal range. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included diabetes, congestive heart failure, and dementia. A physician's order dated 1/3/26 directed to administer regular Insulin three times daily (8:00 AM, 11:30 AM and 9:00 PM) by sliding scale parameters: inject 5 units if blood glucose between 200-240 and 7 units if 251-300. Call MD if blood glucose less than 100 or greater than 300. The orders also directed to administer Diltiazem 180 mg extended-release capsule at 9:00 AM daily with parameters to hold medication for systolic blood pressure less than 100 and to call MD for systolic blood pressure greater than 160. The quarterly MDS dated [DATE] identified Resident #30 had severely impaired cognition, was always incontinent of bowel and bladder, required substantial assistance from staff with eating, and was dependent on staff to assist with toileting and bathing.The care plan dated 1/21/26 identified Resident #30 had diabetes. Interventions included to administer diabetic medication per MD current orders and note the parameters for the medications. The care plan also identified Resident #30 had cardiac diagnoses which included congestive heart failure. Interventions included to monitor vital signs for any changes in condition, administer medications as ordered, and report any signs or symptoms of cardiac or respiratory distress. a. Review of the January 2026 MAR identified LPN #2 documented a blood pressure of 162/91 prior to Diltiazem administration on 1/28/26.Review of the clinical record failed to identify the physician was notified, per the physician's order, of the systolic blood pressure that was out of range at 162.Review of the February 2026 MAR identified LPN #2 documented a blood pressure of 176/88 prior to Diltiazem administration on 2/27/26.Review of the clinical record failed to identify the physician was notified, per the physician's order, of the systolic blood pressure that was out of range at 176.Review of the March 2026 MAR identified LPN #2 documented the following blood pressures prior to Diltiazem administration: 3/6/26 - 174/86.3/28/26 - 170/90.3/29/26 - 168/87. Review of the clinical record failed to identify the physician was notified, per the physician's order, of the systolic blood pressure that was out of range.Review of the April 2026 MAR identified LPN #2 documented the following blood pressures prior to Diltiazem administration: 4/8/26 - 164/76.4/11/26 - 170/81.Review of the clinical record failed to identify the physician was notified, per the physician's order, of the systolic blood pressure that was out of range.Review of the clinical record and interview with LPN #2 on 4/21/26 at 9:07 AM identified she was unsure if she had notified the physician on 1/28, 2/27, 3/6, 3/28, 3/29, 4/8, or 4/11/26 of the systolic blood pressures that were out of range. LPN #2 identified she believed she had discussed the blood pressures with MD #1 (Medical Director) sometime in the last week but was unable to provide information or documentation of when the discussion occurred, the specific blood pressures discussed, or the outcome of the discussion. LPN #2 was also unable to identify what she did regarding reporting and documentation to the RN supervisor for each incident but identified the facility policy regarding a change of condition would require a nursing assessment and physician and resident representative notification. LPN #2 identified that sometimes, if Resident #3 had an elevated blood pressure, she would recheck the blood pressure but did not document the results and did not report the repeat blood pressures to any physician or provider. Review of the nurse staffing schedules identified RN #10 was the RN supervisor on duty with LPN #2 on 4/11/26Interview with RN #10 on 4/21/26 at 9:40 AM identified she was not aware of any issues related to Resident #30's blood pressure on that date, and that LPN #2 did not communicate any issues related to the resident. b. A nurse's note dated 3/9/26 at 12:49 PM by RN #9 identified Resident #3 had issues with elevated blood glucose levels on that date. The note identified that Resident #3 had a blood glucose of 341 at 8:00 AM and 477 at 11:45 AM. The note identified MD #3, Resident #3's attending physician, was notified and new orders were given to administer 3 additional units of regular Insulin (for a total of 10 units) and to obtain blood work on 3/10/26 to include CBC, CMP, UA culture and sensitivity. The note also identified Resident #3's resident representative was notified, that Resident #3 had a good appetite and tolerated lunch well. Review of the March 2026 MAR also identified LPN #3 documented a blood glucose of 434 at 9:00 PM on 3/11/26 as part of the resident's sliding scale Insulin administration at that time. Review of the MAR identified LPN #3 annotated the Insulin administration as Other/See Nurse's Notes. Review of the nurse's notes failed to identify Insulin had been administered at that time. Further review of the clinical record failed to identify that the physician was notified of the blood glucose reading of 434, despite the Insulin order parameters to notify if greater than 300.Review of the March 2026 MAR also identified LPN #3 documented a blood glucose of 422 at 9:00 PM on 3/13/26 as part of the resident's sliding scale Insulin administration. Review of the MAR identified LPN #3 annotated the Insulin administration as MD notified/7 units given.Review of the clinical record failed to identify that Resident #3's resident representative was notified regarding the blood glucose levels outside of order parameters on 3/11 and 3/13/26.Review of the clinical record and interview with LPN #3 on 4/20/26 at 3:28 PM identified she could not initially recall what steps she took following the identification of Resident #3's elevated blood glucose levels on 3/11 and 3/13/26. LPN #3 identified on 3/11/26, she notified the RN supervisor, who would have then assessed the resident and notified the MD. LPN #3 was unable to identify who the charge nurse was, which MD was notified, and what instructions were given regarding Resident #3's condition and Insulin orders and identified her normal practice was to notify the RN supervisor regarding the situation and then wait for instructions. LPN #3 identified that on 3/13/26 she notified the MD and administered 7 units; however she was unable to identify who the MD was that she notified and stated whoever the (resident's) attending is. LPN #3 reviewed the face sheet in Resident #3's chart, and identified she contacted MD #3. Following surveyor inquiry regarding her discussion with MD #3, LPN #3 identified she did not talk to MD #3 and it was the RN supervisor who spoke with him regarding Insulin orders. LPN #3 again identified that she recalled who the RN supervisor was on 3/13/26, and identified that she would have waited for instructions and that the RN supervisor would have assessed the resident. LPN #3 identified in both instances on 3/11 and 3/13/26, the resident representative should have been contacted regarding the blood glucose levels and identified she only would attempt to contact the resident representative if she had time, otherwise the RN supervisor would make the notifications. LPN #3 also identified that she was unsure why she did not document anything regarding Resident #3's assessment and status following the identification of elevated blood sugars. Review of the nurse staffing schedules identified RN #7 was the RN supervisor on duty with LPN #3 on 3/11 and 3/13/26. Review of the clinical record and interview with the DNS on 4/21/26 at 11:03 AM identified that she was not aware Resident #3 was having any issues related to blood pressures or blood glucose levels. The DNS identified that the licensed nurses were to notify the physician with any change of condition, especially when the change coincided with order parameters and medication. The DNS also identified that LPN #2 and LPN #3 should have notified the resident representative regarding the out of range blood pressures and blood sugars and that the RN supervisor should also have been notified as well. The DNS identified all notifications related to the resident's condition should have been documented in the clinical record. Interview with MD #3 on 4/21/26 at 12:22 PM identified he was not aware and had not been notified that Resident #3 had blood pressures outside the order parameters for Diltiazem and would expect to be notified per the physician's order. MD #3 identified if the blood pressures had been reported to him, he likely would have requested a repeat blood pressure be done, but that the directive to repeat the blood pressure should have come from him. MD #3 also identified he was not aware of any blood glucose levels above 300 on 3/11 and 3/13/26 for Resident #3. MD #3 identified that following a review of messages and call logs, the only notification he received regarding Resident #3 was on 3/9/26 related to elevated blood glucose levels and at that time he ordered laboratory work up for any possible underlying issues and in addition ordered an additional 3 units of regular Insulin as Resident #3 had a blood glucose over 400. MD #3 identified he should have been notified of the elevated blood glucose levels on 3/11 and 3/13/26 due to the recent previous elevated blood glucose levels as Resident #3 may have required additional insulin coverage at that time.Although attempted, an interview with RN #7 and MD #1 (Medical Director) was not obtained.Although requested, the facility failed to provide a policy on nursing assessments, physician's orders, vital sign monitoring and nursing documentation. The facility policy on change of condition directed that it was the policy of the facility to report a change in the residence condition to the attending physician and or medical director in a timely manner. The policy directed that the attending physician would be notified of a change of condition reviewing the residents vital signs and assessment of the resident. The policy also directed that documentation must reflect all observations of the resident, vital signs, notification to the resident's family, the physician, etcetera. The documentation should be precise, including exact times, persons contacted and detailed conversations.The policy on hyper and hypoglycemia directed that it was the policy of the facility that appropriate medical and nursing care would be provided to residents with diabetes who required insulin to minimize the risk and ensure prompt recognition of hyperglycemia. The policy also directed that all diabetic residents would receive insulin and diets according to the physicians' orders. The policy also directed that the facility staff would give insulin ss ordered by the physician for emergency administration for hyperglycemia and that the facility would notify the family regarding any change of condition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #3) reviewed for behaviors and mood, the facility failed to review and revise the care plan after the initiation of psychotropic medications. The findings include:Resident #3 was admitted to the facility in June 2023 with diagnoses that included diabetes, glaucoma, and depression. A physician's order dated 3/17/24 directed to administer Escitalopram (a medication used to treat depression) 20 mg by mouth daily.The quarterly MDS dated [DATE] identified Resident #3 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff for toileting, bathing, and dressing. The MDS also identified Resident #3 had not exhibited any behavioral symptoms including verbal behaviors like screaming or disruptive sounds and had not exhibited any behavioral symptoms related to rejection of care. The care plan dated 9/3/25 identified Resident #3 had depression. Interventions included to administer medications as ordered.A psychiatric note dated 9/11/25, by APRN #1 (psychiatric APRN), identified that she was asked by facility staff to see Resident #3 due to increased yelling out. APRN #1 identified that staff also reported Resident #3 was withdrawn, stayed in his/her room, yelled out, and did not join activities. APRN #1 identified Resident #3 was evaluated while his/her resident representative was present. Resident #3 reported his/her mood was good, he/she felt good, and that he/she had good family support. APRN #1 identified she discussed the staff reported behaviors with Resident #30's representative along with medication options and Resident #3's representative was in agreement to start Trazadone (a medication used to treat depression) 25 mg by mouth as needed every 8 hours for 14 days to decipher efficacy and frequency of scheduled dosing.A physician's order dated 9/11/25 directed to administer Trazadone 50 mg tablet-give 0.5 tablet (25 mg) two times daily for depression.Review of the clinical record failed to identify any documentation related to Resident #3 having behaviors that included yelling out or self-isolation prior to the 9/11/25 note. Further the clinical record failed to identify any documentation that non pharmacologic interventions were initiated or implemented prior to the initiation of Trazadone. The clinical record also failed to identify that target behavior monitoring was ordered or implemented following the start of Trazadone to monitor Resident #3's response to the medication.A psychiatric note dated 9/18/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen and evaluated by staff request for medication change follow-up, and staff endorsed no change in behaviors which included Resident #3 being withdrawn, frequently staying in his/her room, not joining activities, and frequently yelling out. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified Trazadone would be discontinued and Depakote 125 mg would be started. Review of the diagnoses at the time of this visit also identified a new diagnosis of adjustment disorder with mixed anxiety and depressed mood. A physician's order dated 9/18/25 directed to administer Depakote (also known as Valproic Acid, a medication used to treat epilepsy and acute bipolar mania and used off label as a treatment for anxiety) 125 mg by mouth twice daily for anxiety. Review of the care plan failed to identify that subsequent to the initiation Trazodone and Depakote, non-pharmacologic behavioral interventions and/or target behavior monitoring and/or bloodwork to monitor valproic acid levels was implemented. A psychiatric note dated 11/6/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen for request to increase visit cadence by facility staff. APRN #1 identified facility staff had reported Resident #3 had not had any yelling out, was participating in activities, and denied Resident #3 had any behavioral disturbances. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified she would continue to monitor. A psychiatric note dated 11/24/25 by MD #2 (psychiatric MD) identified Resident #3 was seen and evaluated at the request of the facility to assess resistance to care, anxiety, sadness, confusion, restlessness, yelling out, memory problems, and medication review (the clinical record failed to document these behaviors). MD #2 identified Resident #3 had anxiety symptoms and his treatment plan included discontinuing Depakote, adding Trazodone 25 mg by mouth every morning and 50 mg every evening at 8:00 PM for anxiety and insomnia, and to continue to observe the resident for increase in anxiety symptoms, observing for side effects from medication, and supportive therapy provided; (a physician's order was not written for this recommendation). Review of the diagnoses at the time of this visit also identified the previous diagnosis of adjustment disorder with mixed anxiety and depressed mood was removed and a new diagnosis of anxiety disorder was added. Review of the care plan failed to identify any behaviors or interventions to address reported behaviors (resistance to care, anxiety, sadness, confusion, restlessness, or yelling out) prior to or following the 11/24/25 psychiatric visit by MD #2. A psychiatric note dated 12/11/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen for routine follow-up. APRN #1 identified facility staff had reported Resident #3 had not had any yelling out and was participating in activities. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified she would continue to monitor. Review of the physician's orders for December 2025 through April 2026 identified the resident continued to receive Depakote 125 mg twice daily and a valproic acid level had not been obtained. Further, the care plan had not been revised to include the residents behaviors and/or interventions to address such. Interview with APRN #1 on 4/21/26 at 9:40 AM identified she was not aware if any non-pharmacological interventions had been attempted prior to starting Trazadone on 9/11/25 to treat Resident #3's staff reported behaviors. APRN #1 also identified that following the discontinuation of Trazadone and starting Depakote, she did not order any bloodwork to ensure that the medication was safe to start and identified she would have only checked a valproic acid level when Resident #3's behavioral symptoms had stabilized. Upon surveyor inquiry regarding standard of care with Depakote initiation, APRN #1 then identified a valproic acid level should have been checked 14 days following initiation of Depakote, but she would have to review her notes to determine if/when this was done. APRN #1 also identified she did not order target behavior monitoring for Resident #3 following the initiation of Trazadone or Depakote, as she did not have the ability to order behavior monitoring, however the behaviors the medications were prescribed for were identified in her visit notes. APRN #1 also identified that she did work with MD #2, and she did routinely review his notes, but was unable to identify if she reviewed his visit note from 11/24/25 prior to her visit with Resident #3 on 12/11/25, as MD #2 identified his plan to discontinue Depakote and restart Trazadone. APRN #1 then identified both she and MD #2 were contracted employees of the facility, and that any directions or orders regarding a resident's treatment plan were not actual orders, but suggestions, and all suggestions had to be reviewed and approved by MD #1 (the Medical Director), including medications and behavior monitoring. Interview with MD #2 on 4/21/26 at 11:37 AM identified that he had been providing treatment for Resident #3 along with APRN #1 for his/her psychiatric conditions. MD #2 identified that Resident #3 should have had target behavior monitoring in place with the initiation of Trazadone on 9/11/25, and with the initiation of Depakote on 9/18/25 to determine if the medications were effective in addressing Resident #3's behaviors. MD #2 identified that even with an order for target behavior monitoring, it could be a challenge to monitor based on staffing levels at the facility. MD #2 also identified that prior to the start of Depakote, the standard of care associated with the start of this medication would include checking LFTs (liver function) and a CBC (complete blood count) due to the risk of liver toxicity and thrombocytopenia with Depakote use. MD #2 also identified that following the initiation of Depakote, that a valproic acid level should have been checked 5 days following the start of the medication to ensure that the drug levels were therapeutic and not at a toxic level. MD #2 identified he also was unsure why his order that directed to discontinue Depakote and restart of Trazadone was not reflected in the clinical record and there may have been an issue with the nursing staff activating the order in the eMAR. MD #2 identified that Resident #3 should not be on Depakote due to the risks and side effects associated with this medication and also identified it did not work well for anxiety and insomnia, which were issues that Resident #3 had reported to him, and would address with issue with APRN #1. Although attempted, an interview with MD #1 was not obtained. The facility policy on behavioral assessment, monitoring, and intervention directed that behavioral symptoms would be identified using a facility approved behavioral screening tool and comprehensive assessment. The policy also directed that the facility would comply with regulatory requirements related to the use of medications to manage behavioral symptoms. General guidelines of the policy directed that behavior was a response of an individual to a wide variety of factors and could be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that could not be articulated. The policy also directed that as part of a comprehensive assessment, staff would evaluate based on the input from the resident family and caregivers, review of the medical record, and general observations:The resident's usual patterns of cognition, mood and behavior.The resident's usual method of communicating things like pain, hunger, thirst, and other discomfort.The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers.The resident's previous patterns of coping with stress, anxiety, and depression. The nursing staff would identify, document, and inform the physician about specific details regarding changes in a residence mental status, behavior, and cognition, including: Onset, duration, intensity and frequency of behavioral symptoms.Any recent precipitating or relevant factors or environmental triggers (i.e medication changes, infection, recent transfer from the hospital).The appearance and alertness of the resident and related observations. The policy also directed the any new onset or changes any residence behavior would be documented regardless of the degree of risk to the resident, or others and new onset or changes of behaviors. The policy also directed that the interdisciplinary team would thoroughly evaluate any new or changing behavioral symptoms in a resident in order to identify underlying causes and address any modifiable factors that might have contributed to the residents change of condition including physical or mental changes; emotional, psychiatric, and or psychological stressors; Functional, social, or environmental factors. The policy other directed that the interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary to protect the resident and others from harm. The residents care plan would also incorporate findings from the comprehensive assessment and be consistent with current standards of practice. The resident and resident representative would be involved in the development and implementation of the care plan. The policy also directed that interventions related to behaviors would be individualized and part of an overall care environment that supported the physical, functional, and psychological needs of the resident, and strive to understand, prevent, or relieve the residents distress or loss of abilities. Interventions and approaches would be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as potential and environmental reasons for the behaviors. The care plan would include, as a minimum: a description of the behavioral symptoms which included frequency, intensity, duration outcomes, location, environment, precipitating factors, or situations; targeted and individualized interventions for the behavioral and or psychosocial symptoms; the rationale for the interventions and approaches; specific and measurable goals for targeted behaviors; and how facility staff would monitor the effectiveness of interventions. The policy also directed that non pharmacologic approaches would be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. The policy also directed that when medications were prescribed for behavioral symptoms documentation would include:The rationale for use potential underlying causes of a behavior; other approaches and intervention tried prior to use; potential risk and benefit of the medications as discussed with the resident and/or family; the specific target behaviors and expected outcomes; dosage, duration, monitoring for efficacy and adverse consequences and plans related to a gradual dose reductionThe policy also directed that if a resident was being treated for an altered behavior or mood the interdisciplinary team would seek and document any improvements or worsening in the residence behavior, mood, and function, and interventions would be adjusted based on the impact on the behaviors and other symptoms, including any adverse consequences related to the treatment.The facility policy on psychoactive medications and gradual dose reductions directed that psychoactive medications would be used in accordance with standards set forth by federal law and the state operations manual (SOM). The policy further identified that the prescriber of a psychoactive medication would order psychoactive medications only to treat specific conditions, and that the prescriber was responsible to monitor and assess for efficacy, tolerability, and side effects, and adjust the dosing as necessary. The facility policy on psychotropic medication directed that residents would not be given psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication was beneficial to the resident as demonstrated by monitoring and documentation of the residents response to the medication. The policy defined A psychotropic medication as any drug that affected brain activity associated with mental processes and behavior then that psychotropic drugs included, but were not limited to, the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The policy directed that residents and/or representatives would be educated on the risk and benefits of psychotropic drug use as well as alternative treatments and non-pharmacologic interventions. The policy directed that residents who used psychotropic medications should also receive non pharmacologic interventions to facilitate the reduction or discontinuation of psychotropic medications.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for abuse, the facility failed to ensure the resident was treated in a dignified and respectful manner while using the bathroom. The findings include: Resident #23 was admitted to the facility in October 2025 with diagnoses that included adjustment disorder and anxiety. The admission MDS dated [DATE] identified Resident #23 was cognitively intact, and required one person assistance with bed mobility, transfers and ambulation with a walker. The care plan dated 12/24/25 identified Resident #23 had mixed incontinence related to an overactive bladder and reduced mobility and a self-care deficit. Interventions included to provide assistance with toileting and encourage participation in ADL performance to the fullest extent possible. A reportable event form dated 4/19/26 at 10:00 AM identified Resident #23 reported NA #1 was rude towards him/her sometime last week but was unable to recall the day or shift. NA #1 was immediately removed from the schedule pending investigation. An investigation statement dated 4/19/26 completed by Resident #23 alleged within the past few days, NA #1 told the resident that he/she took too long in the bathroom. Resident #23 acknowledged that he/she took a long time due to bladder incontinence and comorbidities. Resident #23 asked for patience and indicated he/she would finish as quickly as possible. Interview with NA #1 on 4/20/26 at 3:24 PM identified she was the assigned NA on 4/17/26 during the 7:00 AM shift to 3:00 PM shift. NA #1 indicated Resident #23 was in the bathroom while she was providing care to his/her roommate at the bedside. NA #1 needed access to the bathroom to discard basin water in the toilet and provide toileting assistance to Resident #23's roommate. Resident #23 remained in the bathroom for over 40 minutes while NA #1 left to care for other residents, checking back intermittently. Upon return, NA #1 reminded Resident #23 he/she needed to be mindful of other residents sharing the bathroom. NA #1 further identified she offered a bedside commode to Resident #23's roommate who declined; however, she did not offer an alternate bathroom while Resident #23 occupied the main bathroom. Interview with RN #6 on 4/21/26 at 9:32 AM identified on 4/19/26 Resident #23 reported that a few days earlier, NA #1 was rude and disrespectful towards him/her while Resident #23 was using the bathroom. The allegation was reported to the administrator and NA #1 was removed from the schedule. Interview with the DNS on 4/21/26 at 9:40 AM identified while the matter was still under investigation, she planned to provide education to staff on abuse and customer service in response to the resident reported concern. Review of the policy for Resident [NAME] of Rights directed that all residents had the right to be treated with consideration, respect and full recognition of dignity and individuality.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #2) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident received routine and necessary dental services, including timely evaluation and treatment, from an outside dentist or the facility dentist per the facility dental policy. The findings include:Review of a dental note (outside dentist MD #4) dated 4/17/23 identified first initial visit Resident #2 was seen for a dental evaluation accompanied by his/her representative and caretaker. Documentation indicated Resident #2 reported a need for cleaning and tooth sensitivity. Examination findings included generalized cervical caries, gingival recession, abfractions, bone loss, and chronic generalized moderate to severe periodontitis. A prophylaxis was completed, including ultrasonic scaling, polishing, and flossing. Resident #2 was referred to a hospital based special needs dental unit for additional evaluation and treatment. Resident #2 appeared not capable of maintaining oral hygiene.Resident #2 was admitted to the facility in March 2024 with diagnoses that included down syndrome and anxiety disorder.Review of the clinical record dated 3/22/24 through 9/18/25 (17 months) failed to identify documentation that the resident was seen by an outside dentist or the facility dentist.The care plan dated 8/5/25 identified Resident #2 has an Activities of Daily Living (ADL) self-care performance deficit related to reduced functional mobility and intellectual disability. Intervention included staff assistance with mouth-care. The nurse's note dated 9/4/25 at 10:55 AM identified that an RN assessment was completed due to Resident #2's poor intake related to mouth pain. Resident #2 was evaluated by the dietitian within the previous weeks for poor intake and a supplement was ordered. Resident #2 was also evaluated by speech therapist, resulting in a modified and downgraded diet due to mouth pain. Review of the oral evaluation form dated 9/4/25 at 11:31 AM identified Resident #2 complained of mouth and teeth pain. Assessment findings included missing and fractured teeth and generalized teeth breakdown. Soft tissues pink in color and edematous, lips smooth and moist, tongue pink in color and smooth. Resident #2 indicated that he/she has been experiencing mouth and teeth pain. Resident #2 was unable to quantify pain using a numeric scale, and no non-verbal signs of pain were observed at the time of assessment. The physician was notified and new orders were obtained for oral assessment time seventy-two hours.The physician's order dated 9/4/25 directed for dental consultation with the facility dental consultant due to teeth pain and perform evaluation of oral cavity and mouth pain twice daily, for seventy-two hours and documentation of evaluation and mouth pain in nursing progress note every day and evening shift. Additionally, administer Acetaminophen 325 mg give 2 tablets before meals for oral and teeth pain for five days, please give medication 30 minutes before meals.The care plan dated 9/5/25 identified Resident #2 was at increased risk for oral/dental health problems related to impaired dentition, history of dental abscess, teeth grinding, and unable the inability to perform oral hygiene independently. Interventions included staff to assist with oral care twice a day, document refusals, assist with brushing, encourage rinsing after eating to remove food debris, and ensure teeth were brushed after meals to address heavy plaque and food debris.The physician's order dated 9/5/25 directed for an oral surgery consultation for diagnoses of mouth pain. The order further directed to administer Amoxicillin-Clavulanate (antibiotic) 875mg-125mg, one tablet by mouth two times a day for ten (10) days for oral infection. Additionally, the order directed to administer Chlorhexidine Gluconate oral solution 10ml every morning and at bedtime for gingivitis, with instructions to swish around mouth for 30 seconds then spit out, do not swallow. And do not take anything by mouth for 30 minutes after taking this medication.The nurse's note dated 9/5/25 at 4:49 PM identified the nurse contacted the resident representative regarding whether Resident #2 had previously seen by a community dentist. The nurse contacted the dental office and was informed that Resident #2 was last evaluated in 2023 and had been referred to a hospital for further treatment. The nurse had scheduled an appointment with an oral surgeon for 10/2/25 at 12:45 PM. Resident #2 was scheduled to be evaluated by the facility dentist on 9/12/25. The physician and resident representative were notified. The dental consultation dated 9/19/25 by the facility dentist (MD #5) identified first initial visit, Resident #2 reported no pain or discomfort during the examination. The examination documented generalized plaque accumulation contributing to high a caries risk. Copious plaque and debris were noted, which limited the ability to fully assess the extent of dental decay and tooth mobility. Recommendation for a six-month examination, cleaning, and fluoride varnish application. X-rays and a hygienist evaluation to further assess and develop a treatment plan. The consultation further documented that tooth numbering/identification was unclear, noting that tooth #6 was not clinically observed in expected alignment between Teeth #5 and #7, with uncertainty as to whether the area represented an erupting tooth or a retained root tip distal to tooth #4. X-ray evaluation was recommended to clarify dental anatomy and update the tooth chart accordingly.The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition and required supervision or touching assistance with oral hygiene.Review of the evaluation form dated 9/29/25 at 3:01 PM identified Resident #2 had no complaints of oral and dental pain. Resident #2 was resistive to assessment. Assessment findings included missing and fractured teeth and generalized teeth breakdown. However, the resident remained asymptomatic and clinically stable. Continue oral care twice a day. Document all refusals of care.The physician's order dated 9/29/25 directed to perform oral care every morning and at bedtime and document refusal. The nurse's note dated 10/2/25 at 2:28 PM identified Resident #2 was transported to an oral surgery appointment for 12 :45 PM with a nurse aide. Upon arrival the provider's office declined to see the resident due to the absence of a required resident representative. As a result, the appointment was not completed and was rescheduled for 12/19/25 at 10:45 AM. The resident's representative and nursing supervisor were notified.The hygienist consultation dated 10/17/25 (Hygienist #1) identified first initial visit Resident #2's oral condition included poor dentition, heavy food debris buildup, and moderate hard calculus. Resident #2 exhibited severe gingival inflammation with swelling, bleeding gums, poor periodontal condition, and having moderate risk for dental caries. Resident #2 was noted to be unable to perform independent oral hygiene and did not report any dental complaints. Oral prophylaxis was attempted and polishing was performed with a toothbrush. Oral hygiene instruction was provided. However, the resident was resistant to care during the examination, would not consistently open the mouth, and was minimally cooperative. Scaling was completed only to the extent possible due to the resident's refusal and limited cooperation. The resident was evaluated at bedside.The hygienist consultation dated 2/11/26 (Hygienist #2) identified Resident #2 was refusing dental assessment. With encouragement, the resident agreed to limited attempts. During the procedure, the resident intermittently opened mouth but closed rapidly, preventing proper instrument and x-ray placement. Resident #2 bit down on equipment once and did not reopen mouth despite verbal cues and redirection. However, cooperation remained minimal, and a few x-rays were captured and uploaded. Based on observed behaviors, staff indicated that the resident is unlikely to tolerate further dental treatment at this time.The dental consultation dated 3/5/26 by the facility dentist (MD #5) identified Resident #2 demonstrated poor tolerance and lack of cooperation during treatment limited the ability to complete oral care services. MD #5 contacted the resident's representative regarding the resident's oral care needs. The resident representative reported that the resident was scheduled for an evaluation with an outside dentist on 4/21/26. Recommendation to reach out for follow ups.The hygienist consultation dated 4/9/26 (Hygienist #1) identified Resident #2 was assessed and found to have poor dentition, with heavy food debris buildup, and moderate hard calculus. Resident #2 exhibited moderate gingival inflammation with swelling, bleeding gums, and fair periodontal condition. The resident was identified as being at high risk for dental caries.The resident care card dated 4/19/26 identified staff to assist with brushing and encourage to rinse after eating to remove food, and brush teeth after meals to control heavy plaque and food debris. The resident is unable to do own oral care.Interview with the Administrator on 4/21/26 at 11:00 AM identified the resident's prior representative was addressing the resident's dental issues with an outside dentist. The Administrator indicated she was not aware that the nurse aides failed to document oral hygiene care in the resident's clinical record.Interview with the DNS on 4/21/26 at 11:30 AM identified she was not aware that the nurse aides were not documenting oral hygiene care in the resident's clinical record. The DNS indicated she would provide in-service education to nurse aides regarding documentation in the clinical record.The nurse's note dated 4/21/26 at 12:52 PM identified that Resident #2 returned from a scheduled dental appointment without being seen and was rescheduled for 6/5/26 at 2:15 PM. The dental office reported attempting to contact the facility on 4/20/26 to cancel the appointment; however, no response was received from the facility. The resident's representative met the resident at the dental office and was informed of the situation.Interview with MD #4 (outside dentist) on 4/24/26 at 1:58 PM identified her initial visit with Resident #2 occurred on 4/17/23. MD #4 indicated that Resident #2 was accompanied by the previous representative and a caretaker at that time. MD #4 indicated that Resident #2 was there for dental cleaning and complained of tooth sensitivity. MD #4 indicated based on her assessment, she referred Resident #2 to a hospital based special needs dental unit for further evaluation and treatment. MD #4 indicated that Resident #2 did not return to the clinic following that visit.Interview with MD #5 (facility dentist) on 4/27/26 at 1:35 PM identified her initial evaluation of Resident #2 was on 9/19/25. MD #5 indicated during the examination, the resident's teeth were coated with food debris, with additional food noted in the buccal (cheek) area, making the examination very difficult. MD #5 indicated the resident exhibited biting and grind teeth behaviors, which limited the ability to safely perform oral examination with dental instruments. MD #5 indicated she communicated with the nursing staff and recommended referral to an outside dentist due to the resident's special needs, as well as a hygienist consultation. MD #5 indicated she remains available to evaluate the resident for any urgent dental needs.Interview with Person #1 on 4/27/26 at 2:57 PM identified Resident #2's initial appointment with an outside dentist was scheduled for 10/2/25 at 12:45 PM; however, the resident did not attend the appointment. A subsequent appointment was scheduled for 12/19/25 at 10:45 AM, the resident was not seen on that date. Person #1 indicated Resident #2 had a scheduled appointment on 4/21/26 at 12:45 PM and that it was rescheduled by the dental clinic for 6/5/26 at 2:15 PM. Person #1 indicated that Resident #2 has not been seen by the outside dentist to date. Interview with Hygienist #1 on 4/28/26 at 9:28 AM identified that Resident #2 was initially seen on 10/17/25. During the examination, the resident was observed to have poor oral hygiene with heavy food debris buildup. Hygienist #1 indicated the resident was uncooperative and did not open his/her mouth, which limited the ability to safely complete a comprehensive oral examination using dental instruments. Hygienist #1 indicated the resident was referred to an outside dentist by MD #5.Although attempted an interview with MD #3, was not obtained.The facility dental policy identified that all residents will be seen yearly by a dentist. However, more frequently if residents have pain/discomfort or other type of issue. Dentist recommendations and treatment will be followed.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #6) reviewed for limited range of motion and who had contractures of both elbows and hands, the facility failed to apply splinting devices according to therapy recommendations. The findings include: Resident #6 was admitted to the facility in May 2019 with diagnoses that included osteoarthritis and dementia. The quarterly MDS dated [DATE] identified Resident #6 required two person assist with bed mobility, transfers, dressing and had functional limitations in the upper extremities. The care plan dated 11/18/25 identified Resident #6 was dependent with ADL's due to impaired mobility and bilateral hand contractures. Interventions included the application of towel rolls as tolerated, apply in the morning, off in the evening, provide skin checks during morning/evening care and check nail length. Physician's orders dated April 2025 (original 2/4/25) directed Evaluation and treatment with bilateral hand splints to improve ROM every shift. Occupational Therapy (OT) Discharge summary dated [DATE] identified Resident #23 had bilateral hand contractures, a hand splinting trial had been completed, and nursing would implement a schedule for bilateral palm rolls, to be placed 'on' after morning care and removed 'off' after evening care. Physician's orders dated 4/7/25 directed OT 5 times weekly for initial orthotic evaluation, subsequent orthotic treatment, therapeutic exercise and neuromuscular education. OT Discharge summary dated [DATE] identified Resident #23 had contractures to the right and left elbow, a wear schedule was discussed with nurse aide and will be implemented. Resident #23 was discharged to the care of nursing on the unit for bilateral elbow extensions every other day, alternating with palm grip splints to maintain residents current ROM. An Inservice sheet was signed by a nurse aide staff. Observation on 4/19/26 at 7:10 AM identified Resident #6 lying in bed, arms folded, both hands contracted. Observation on 4/19/26 at 10:55 AM identified Resident #6 was up in his/her wheelchair, dressed without the benefit of hand/elbow splints. Interview with LPN #4, the assigned nurse on 4/19/26 at 10:55 AM identified there were no resident concerns/refusals reported by the assigned aide that morning. Interview with the Director of Rehabilitation on 4/19/26 at 1:37 PM identified therapy services will evaluate and trial residents requiring splints then turn over to nursing with education provided to the nurse aides. Additionally, a visual will be posted inside of the closet for the specific residents detailing the splint and wear schedule. Nurse aides were able to apply the splint, and nursing monitors to ensure its placement. Interview with NA #2 on 4/19/26 at 2:23 PM identified she was the assigned nurse aide during the 7:00 AM to 3:00 PM shift and there were no resident concerns or refusals. Observation on 4/20/26 at 2:01 PM identified Resident #6 was up, dressed and in his/her wheelchair without the benefit of bilateral hand/elbow splints. Interview with LPN #6 on 4/20/26 at 2:01 PM identified there were no resident concerns/refusal related to care. Interview, observation and review of the nurse aide care card with NA #2 (LPN #6 present) on 4/20/26 at 2:49 PM identified Resident #6 had no concerns/refusal of care that shift. NA #2 acknowledged hand splint instructions were posted on the inside of the closet door but indicated the nurse aide care card did not include splinting instructions for Resident #6. NA #2 asked LPN #6 and LPN #4 (on the previous day) about splints and was told Resident #6 did not require them. Subsequent interview and clinical record review with LPN #4 on 4/20/26 at 2:54 PM identified that although use of splints was signed off every shift by nursing, she interpreted the order for evaluation and treatment to mean ongoing evaluation only and could not recall the last time she observed Resident #6 wearing splints. Interview and clinical record review with LPN #6 on 4/20/26 at 3:00 PM identified that although the MAR was signed off each shift for evaluation and treatment of hand splints, she thought the splints had since been discontinued and could not recall the last time she observed Resident #6 wearing splints. Interview with the Director of Rehabilitation on 4/20/26 at 3:04 PM confirmed Resident #6 should be wearing splints according to the splinting instructions. The Director of Rehabilitation indicated she discussed Resident #6's splinting schedule with LPN #4 the preceding day and the unit was being provided with updated splinting instructions. The Director of Rehabilitation further identified not maintaining regular use of the splints placed Resident #6 at risk for further contracture. Interview with the Director of Nursing on 4/20/26 at 3:18 PM identified she would expect Resident #6's splints to be applied in accordance with rehabilitation therapy recommendations and the splinting instructions. An observation of Resident #6's skin with RN #9 on 4/21/26 at 11:38 AM a small circular white non blanchable area in the palm of his/her right hand with no open areas. Resident #6's nails were approximately 3/4 inch in length. Interview with MD #6 on 4/21/26 at 11:38 AM identified he provided wound services for Resident #6. MD #6 indicated that while splinting is an effective method to prevent further contracture, eventually a resident can develop skin integrity issues with the use of splinting due ongoing pressure against the skin. For Resident #6, given his/her comorbidities, age and history of contractures, the non-blanchable area to the palm was unavoidable. A re-evaluation of Resident #6's contractures identified no changes with a plan to refer to physiatry. Review of the facility policy for Splinting directed splints are used to provide proper body support, prevent unwanted motion, contracture management or reduction, pain management, and to facilitate motor activity. Therapists coordinate with the interdisciplinary team to determine splinting needs and to monitor appropriate use and fit on a regular basis. The procedure includes:The therapist evaluates the patient to determine the appropriate type of splint.The splint is fabricated or purchased.Once the wear schedule is established, the physician's certification order should specify the type of splint, where it is to be applied and the wear schedule.The treating therapist is to provide instruction to the nursing staff regarding the wear schedule, application and removal of the splint, precautions and when to contact the therapist. Written instructions should be left available to nursing staff, placed in the medical record, nursing unit, or other designated area. Although requested, current physician orders for splinting were not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #2) reviewed for Activities of Daily Living (ADL) and who was dependent on staff for oral care, the facility failed to provide oral care/hygiene per the plan of care and physician's orders, and for 1 resident (Resident #3) reviewed for behaviors and mood, the facility failed to obtain a valproic acid level after the initiation of Depakote, according to professional standard, and for 1 of 4 residents (Resident #46) reviewed for catheter/urinary tract infection (UTI), the facility failed to ensure urine culture results were reviewed in a timely manner resulting in a treatment delay for a resident with a symptomatic UTI. The findings include: 1. Review of a dental note (outside dentist MD #4) dated 4/17/23 identified first initial visit Resident #2 was seen for a dental evaluation accompanied by his/her representative and caretaker. Documentation indicated Resident #2 reported a need for cleaning and tooth sensitivity. Examination findings included generalized cervical caries, gingival recession, abfractions, bone loss, and chronic generalized moderate to severe periodontitis. A prophylaxis was completed, including ultrasonic scaling, polishing, and flossing. Resident #2 was referred to a hospital based special needs dental unit for additional evaluation and treatment. Resident #2 appeared not capable of maintaining oral hygiene. Resident #2 was admitted to the facility in March 2024 with diagnoses that included intellectual disability and anxiety disorder. Review of the clinical record dated 3/22/24 through 9/18/25 (17 months) failed to identify that the resident was seen by the community dentist or the facility dentist. Review of the nurse aide flowsheets dated 8/1/25 through 9/30/25 identified the following. August 2025 there were (12 out of 31 occasions) where staff failed to document that the resident had been provided oral hygiene on the 7:00 AM – 3:00 PM shift and (27 out of 31 occasions) on the 3:00 PM – 11:00 PM shift. September 2025 there were (5 out of 30 occasions) where staff failed to document that the resident had been provided oral hygiene on the 7:00 AM – 3:00 PM and (16 out of 30 occasions) on the 3:00 PM – 11:00 PM shift where staff failed to document that the resident had been provided oral hygiene. The care plan dated 8/5/25 identified Resident #2 has a self-care performance deficit related to reduced functional mobility and intellectual disability. Intervention included staff assistance with mouth care. The nurse's note dated 9/4/25 at 10:55 AM identified that an RN assessment was completed due to Resident #2's poor intake related to mouth pain. Resident #2 was evaluated by the dietitian within the previous weeks for poor intake and a supplement was ordered. Resident #2 was also evaluated by speech therapist, resulting in a modified and downgraded diet due to mouth pain. The physician and resident representative were notified of resident conditions Review of the oral evaluation form dated 9/4/25 at 11:31 AM identified Resident #2 complained of mouth and teeth pain. Assessment findings included missing and fractured teeth and generalized teeth breakdown. Soft tissues pink in color and edematous, lips smooth and moist, tongue pink in color and smooth. Resident #2 indicated that he/she has been experiencing mouth and teeth pain. Resident #2 was unable to quantify pain using a numeric scale, and no non-verbal signs of pain were observed at the time of assessment. The physician was notified and new orders were obtained for oral assessment time seventy-two hours. The physician's order dated 9/4/25 directed for dental consultation with the facility dental consultant for teeth pain, perform evaluation of oral cavity and mouth pain twice daily, for seventy-two hours and documentation of evaluation and mouth pain in nursing progress note every day and evening shift. Additionally, administer Acetaminophen 325 mg give 2 tablets before meals for oral and teeth pain for five days, please give medication 30 minutes before meals. The care plan dated 9/5/25 identified Resident #2 was at increased risk for oral/dental health problems related to impaired dentition, history of dental abscess, teeth grinding, and unable the inability to perform oral hygiene independently. Interventions included staff to assist with oral care twice a day, document refusals, assist with brushing, encourage rinsing after eating to remove food debris, and ensure teeth were brushed after meals to address heavy plaque and food debris. The physician's order dated 9/5/25 directed for an oral surgery consultation for diagnoses of mouth pain. The order further directed to administer Amoxicillin-Clavulanate (antibiotic) 875mg-125mg, one tablet by mouth two times a day for ten (10) days for oral infection. Additionally, the order directed to administer Chlorhexidine Gluconate oral solution 10ml every morning and at bedtime for gingivitis, with instructions to swish around mouth for 30 seconds then spit out, do not swallow. And do not take anything by mouth for 30 minutes after taking this medication. The nurse's note dated 9/5/25 at 4:49 PM identified the nurse contacted the resident representative regarding whether Resident #2 had previously seen a community dentist. The nurse contacted the dental office and was informed that Resident #2 was last evaluated in 2023 and had been referred to a hospital for further treatment. The nurse had scheduled an appointment with an oral surgeon for 10/2/25 at 12:45 PM. Resident #2 was scheduled to be evaluated by the facility dentist on 9/12/25. The physician and resident representative were notified. The dental consultation dated 9/19/25 by the facility dentist (MD #5) identified first initial visit, Resident #2 reported no pain or discomfort during the examination. The examination documented generalized plaque accumulation contributing to high a caries risk. Copious plaque and debris were noted, which limited the ability to fully assess the extent of dental decay and tooth mobility. Recommendation for a six-month examination, cleaning, and fluoride varnish application. X-rays and a hygienist evaluation to further assess and develop a treatment plan. The consultation further documented that tooth numbering/identification was unclear, noting that tooth #6 was not clinically observed in expected alignment between Teeth #5 and #7, with uncertainty as to whether the area represented an erupting tooth or a retained root tip distal to tooth #4. X-ray evaluation was recommended to clarify dental anatomy and update the tooth chart accordingly. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition and required supervision or touching assistance with oral hygiene. Review of the evaluation form dated 9/29/25 at 3:01 PM identified Resident #2 had no complaints of oral and dental pain. Resident #2 was resistive to assessment. Assessment findings included missing and fractured teeth and generalized teeth breakdown. However, the resident remained asymptomatic and clinically stable. Continue oral care twice a day. Document all refusals of care. The physician's order dated 9/29/25 directed to perform oral care every morning and at bedtime and document refusal. Review of the nurse aide flowsheet dated 10/1/25 through 10/31/25 identified in October 2025 there were (10 out of 31 occasions) where staff failed to document that the resident had been provided oral hygiene on the 7:00 AM – 3:00 PM shift and (30 out of 31 occasions) on the 3:00 PM – 11:00 PM shift were staff failed to document that the resident had been provided oral hygiene. The nurse's note dated 10/2/25 at 2:28 PM identified Resident #2 was transported to an oral surgery appointment for 12 :45 PM with a nurse aide. Upon arrival the provider's office declined to see the resident due to the absence of a required resident representative. As a result, the appointment was not completed and was rescheduled for 12/19/25 at 10:45 AM. The resident's representative and nursing supervisor were notified. The hygienist consultation dated 10/17/25 (Hygienist #1) identified first initial visit Resident #2's oral condition included poor dentition, heavy food debris buildup, and moderate hard calculus. Resident #2 exhibited severe gingival inflammation with swelling, bleeding gums, poor periodontal condition, and having moderate risk for dental caries. Resident #2 was noted to be unable to perform independent oral hygiene and did not report any dental complaints. Oral prophylaxis was attempted and polishing was performed with a toothbrush. Oral hygiene instruction was provided. However, the resident was resistant to care during the examination, would not consistently open the mouth, and was minimally cooperative. Scaling was completed only to the extent possible due to the resident's refusal and limited cooperation. The resident was evaluated at bedside. Review of the nurse aide flowsheet dated 11/1/25 through 11/30/25 identified in November 2025 there were (7 out of 30 occasions) where staff failed to document that the resident had been provided oral hygiene on the 7:00 AM – 3:00 PM shift and (18 out of 30 occasions) on the 3:00 PM – 11:00 PM shift were staff failed to document that the resident had been provided oral hygiene. Review of the nurse aide flowsheet dated 12/1/25 through 12/31/25 identified in December 2025 there were (1 out of 31 occasions) where staff failed to document that the resident had been provided oral hygiene on the 7:00 AM – 3:00 PM shift and (18 out of 31 occasions) on the 3:00 PM – 11:00 PM shift were staff failed to document that the resident had been provided oral hygiene. The hygienist consultation dated 2/11/26 (Hygienist #2) identified Resident #2 was refusing dental assessment. With encouragement, the resident agreed to limited attempts. During the procedure, the resident intermittently opened mouth but closed rapidly, preventing proper instrument and x-ray placement. Resident #2 bit down on equipment once and did not reopen mouth despite verbal cues and redirection. However, cooperation remained minimal, and a few x-rays were captured and uploaded. Based on observed behaviors, staff indicated that the resident is unlikely to tolerate further dental treatment at this time. The dental consultation dated 3/5/26 by the facility dentist (MD #5) identified Resident #2 demonstrated poor tolerance and lack of cooperation during treatment limited the ability to complete oral care services. MD #5 contacted the resident's representative regarding the resident's oral care needs. The resident representative reported that the resident was scheduled for an evaluation with an outside dentist on 4/21/26. Recommendation to reach out for follow ups. The hygienist consultation dated 4/9/26 (Hygienist #1) identified Resident #2 was assessed and found to have poor dentition, with heavy food debris buildup, and moderate hard calculus. Resident #2 exhibited moderate gingival inflammation with swelling, bleeding gums, and fair periodontal condition. The resident was identified as being at high risk for dental caries. The resident care card dated 4/19/26 identified staff to assist with brushing and encourage to rinse after eating to remove food, and brush teeth after meals to control heavy plaque and food debris. The resident is unable to do own oral care. Interview with the Administrator on 4/21/26 at 11:00 AM identified the resident's prior representative was addressing the resident's dental issues with an outside dentist. The Administrator indicated that the facility was not aware that the last time Resident #2 was evaluated by a dentist prior to admission in 2024 was on 4/17/23. The Administrator indicated she was not aware that the prior representative was not bringing the documentation from the dental office to the facility. The Administrator indicated Resident #2 has a different representative at this time who is aware of the dental issues and the need for an outside dentist. The Administrator indicated she was not aware that the nurse aides failed to document oral hygiene care in the resident's clinical record. Interview with RN #1 on 4/21/26 at 11:15 AM identified she was not aware that the facility lacked documentation from an outside dental provider for the period of 3/22/24 through 9/18/26. RN #1 indicated she was not aware that the nurse aides failed to document oral hygiene care in the resident's clinical record. in the resident's clinical record regarding oral hygiene. Interview with the DNS on 4/21/26 at 11:30 AM identified she was not aware that the facility lacked documentation from an outside dental provider for the period of 3/22/24 through 9/18/26 and she was not aware that the nurse aides failed to document oral hygiene care in the resident's clinical record. The DNS indicated she would provide in-service education to nurse aides regarding documentation in the clinical record. The nurse's note dated 4/21/26 at 12:52 PM identified that Resident #2 returned from a scheduled dental appointment without being seen and was rescheduled for 6/5/26 at 2:15 PM. The dental office reported attempting to contact the facility on 4/20/26 to cancel the appointment; however, no response was received from the facility. The resident's representative met the resident at the dental office and was informed of the situation. Interview with MD #4 (outside dentist) on 4/24/26 at 1:58 PM identified her initial visit with Resident #2 occurred on 4/17/23. MD #4 indicated that Resident #2 was accompanied by the representative and a caretaker at that time. MD #4 indicated that Resident #2 was there for dental cleaning and complained of tooth sensitivity. MD #4 indicated based on her assessment, she referred Resident #2 to a hospital based special needs dental unit for further evaluation and treatment. MD #4 indicated that Resident #2 did not return to her clinic following that visit. Interview with Person #3 on 4/27/26 at 10:28 AM identified Resident #2 was scheduled for a dental appointment on 4/21/26 at 10:30 AM. Person #3 indicated she met the resident at the dental office, accompanied by a nurse aide. The appointment was cancelled by the dental office due to a dentist's emergency and rescheduling the appointment for 6/5/26 at 2:15 PM. Interview with MD #5 (facility dentist) on 4/27/26 at 1:35 PM identified her initial evaluation of Resident #2 was on 9/19/25. MD #5 indicated during the examination, the resident's teeth were coated with food debris, with additional food noted in the buccal (cheek) area, making the examination very difficult. MD #5 indicated the resident exhibited biting and grind teeth behaviors, which limited the ability to safely perform oral examination with dental instruments. MD #5 indicated she communicated with the nursing staff and recommended referral to an outside dentist due to the resident's special needs, as well as a hygienist consultation. MD #5 indicated she remains available to evaluate the resident for any urgent dental needs. Interview with Person #1 on 4/27/26 at 2:57 PM identified Resident #2's initial appointment with the dentist was scheduled for 10/2/25 at 12:45 PM; however, the resident did not attend the appointment. A subsequent appointment was scheduled for 12/19/25 at 10:45 AM, the resident was not seen on that date. Person #1 indicated Resident #2 had a scheduled appointment on 4/21/26 at 12:45 PM and that it was rescheduled by the dental clinic for 6/5/26 at 2:15 PM. Person #1 indicated that Resident #2 has not been seen by the dentist to date. Interview with Hygienist #1 on 4/28/26 at 9:28 AM identified that Resident #2 was initially seen on 10/17/25. During the examination, the resident was observed to have poor oral hygiene with heavy food debris buildup. Hygienist #1 indicated the resident was uncooperative and did not open his/her mouth, which limited the ability to safely complete a comprehensive oral examination using dental instruments. Hygienist #1 indicated the resident was referred to an outside dentist by MD #5. Interview with NA #1 on 4/28/26 at 12:13 PM identified that she did not have Resident #2 that often. NA #1 indicated that she would give Resident #2 the toothbrush with toothpaste to brush his/her own teeth. NA #1 indicated Resident #2 brushed his/her teeth. Interview with NA #5 on 4/28/26 at 12:26 PM identified that when she is assigned to Resident #2, she assists the resident with oral hygiene. NA #5 indicated that the resident is unable to perform oral hygiene and refuses oral hygiene at times. NA #5 indicated that when Resident #5 does not allow her to brush his/her teeth, she would you the swab and mouth wash to clean his/her mouth. Interview with NA #14 on 4/28/26 at 12:54 PM identified that she rarely has Resident #2 and that the resident refuses oral hygiene when she is assigned to the resident. Interview with NA #3 on 4/28/26 at 3:06 PM identified that she is assigned to Resident #2 at times. NA #3 indicated that Resident #2 sometimes is resistive to care and refuses oral hygiene. NA #3 indicated that Resident #2 is unable to perform oral care independently. NA #3 indicated that when Resident #2 refuses oral hygiene, she reported it to the nurse. Although attempted an interview with MD #3, was not obtained. The facility oral assessment policy identified that all residents oral/dental status will be assessed by nurse within twenty-four (24 hours) hours of admission. The assessment will include: The condition of the oral cavity, teeth and tooth supporting structures. The presence or absence of natural teeth or dentures. That ability to function with or without natural teeth or dentures. Pain in mouth. The facility dental policy identified that all residents will be seen yearly by a dentist. However, more frequently if residents have pain/discomfort or other type of issue. Dentist recommendations and treatment will be followed. 2. Resident #3 was admitted to the facility in June 2023 with diagnoses that included diabetes, glaucoma, and depression. A physician's order dated 3/17/24 directed to administer Escitalopram (a medication used to treat depression) 20 mg by mouth daily. The quarterly MDS dated [DATE] identified Resident #3 had intact cognition, had not exhibited any behavioral symptoms including verbal behaviors like screaming or disruptive sounds and had not exhibited any behavioral symptoms related to rejection of care. The care plan dated 9/3/25 identified Resident #3 had depression. Interventions included to administer medications as ordered. A psychiatric note dated 9/11/25, by APRN #1 (psychiatric APRN), identified that she was asked by facility staff to see Resident #3 due to increased yelling out. APRN #1 identified that staff also reported Resident #3 was withdrawn, stayed in his/her room, yelled out, and did not join activities. APRN #1 identified Resident #3 was evaluated while his/her resident representative was present. Resident #3 reported his/her mood was good, he/she felt good, and that he/she had good family support. APRN #1 identified she discussed the staff reported behaviors with Resident #30's representative along with medication options and Resident #3's representative was in agreement to start Trazadone (a medication used to treat depression) 25 mg by mouth as needed every 8 hours for 14 days to decipher efficacy and frequency of scheduled dosing. A physician's order dated 9/11/25 directed to administer Trazadone 50 mg tablet-give 0.5 tablet (25 mg) two times daily for depression. A psychiatric note dated 9/18/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen and evaluated by staff request for medication change follow-up, and staff endorsed no change in behaviors which included Resident #3 being withdrawn, frequently staying in his/her room, not joining activities, and frequently yelling out. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified Trazadone would be discontinued and Depakote 125 mg would be started. Review of the diagnoses at the time of this visit also identified a new diagnosis of adjustment disorder with mixed anxiety and depressed mood. A physician's order dated 9/18/25 directed to administer Depakote (also known as Valproic Acid, a medication used to treat epilepsy and acute bipolar mania and used off label as a treatment for anxiety) 125 mg by mouth twice daily for anxiety. Review of the clinical record failed to identify that subsequent to the initiation Depakote, bloodwork to monitor valproic acid levels was ordered and/or obtained. Review of the physician's orders for December 2025 through April 2026 identified the resident continued to receive Depakote 125 mg twice daily and a valproic acid level had not been obtained. Interview with APRN #1 on 4/21/26 at 9:40 AM identified that following the discontinuation of Trazadone and implementation of Depakote, she did not order any bloodwork to ensure that the medication was safe to start and identified she would have only checked a valproic acid level when Resident #3's behavioral symptoms had stabilized. Upon surveyor inquiry regarding standard of care with Depakote initiation, APRN #1 then identified a valproic acid level should have been checked 14 days following initiation of Depakote, but she would have to review her notes to determine if/when this was done. Interview with MD #2 on 4/21/26 at 11:37 AM identified that he had been providing treatment for Resident #3 along with APRN #1 for his/her psychiatric conditions. MD #2 that prior to the start of Depakote, the standard of care associated with the start of this medication would include checking LFTs (liver function) and a CBC (complete blood count) due to the risk of liver toxicity and thrombocytopenia with Depakote use. MD #2 also identified that following the initiation of Depakote, a valproic acid level should have been checked 5 days following the start of the medication to ensure that the drug levels were therapeutic and not at a toxic level. MD #2 identified that Resident #3 should not be on Depakote due to the risks and side effects associated with this medication and also identified it did not work well for anxiety and insomnia, which were issues that Resident #3 had reported to him, and would address with issue with APRN #1. Although attempted, an interview with MD #1 was not obtained. The facility policy on psychoactive medications and gradual dose reductions directed that psychoactive medications would be used in accordance with standards set forth by federal law and the state operations manual (SOM). The policy further identified that the prescriber of a psychoactive medication would order psychoactive medications only to treat specific conditions, and that the prescriber was responsible to monitor and assess for efficacy, tolerability, and side effects, and adjust the dosing as necessary. The facility policy on psychotropic medication directed that residents would not be given psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication was beneficial to the resident as demonstrated by monitoring and documentation of the residents response to the medication. The policy defined A psychotropic medication as any drug that affected brain activity associated with mental processes and behavior then that psychotropic drugs included, but were not limited to, the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The policy directed that residents and/or representatives would be educated on the risk and benefits of psychotropic drug use as well as alternative treatments and non-pharmacologic interventions. The policy directed that residents who used psychotropic medications should also receive non pharmacologic interventions to facilitate the reduction or discontinuation of psychotropic medications. 3. Resident #46 was admitted to the facility in March 2024 with diagnoses that included dementia and chronic kidney disease. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition, was always incontinent of bowel and bladder, and required substantial/maximal assistance with toileting and personal hygiene. The care plan dated 3/3/26 identified Resident #46 had mixed bladder incontinence related to dementia, weakness, and a deficit in ADLs, with interventions that included monitoring and documenting for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The nurse's note dated 4/7/26 at 1:51 PM identified that Resident #46 was noted to be very confused and talkative. Fluids were encouraged, offered, and accepted. The Psychiatric APRN note dated 4/7/25 identified Resident #46 was seen and evaluated per facility request; staff endorse a sudden increase in restlessness and difficulty redirecting and calming. Resident #1 was seen in the halls, affect was anxious and was difficult to calm and redirect, will order labs to rule out medical cause and will continue to monitor. The nurse's note dated 4/7/26 at 9:57 PM identified that the psychiatric APRN (APRN #1) was in to see Resident #46 and an order was written for a urinalysis (UA), culture and sensitivity (C&S), complete blood count with differential (CBC with diff), and comprehensive metabolic panel (CMP), and the order was approved by the Medical Director (MD #1). The nurse's note dated 4/10/26 at 2:14 PM identified that Resident #46 was alert and confused, oral fluid taken well, appetite was good, some anxious behavior noted after lunch where the resident was actively searching for a door/elevator to go home and at the time mentioning my mother the baby, no aggressive/combative behavior noted, he/she was redirected multiple times with fair effect. Urine culture and sensitivity results were pending. The laboratory diagnostic report dated 4/10/26, initialed but not date or time stamped, identified Resident #46's complete urinalysis identified the following out of range measurements: appearance was turbid (cloudy reference range-clear), occult blood was 2+ (reference range-negative), protein was 1+ (reference range-negative), Leukocyte Esterase was 2+ (reference range-negative), WBC was packed (reference range-less than or equal to 5/HPF), RBC was 20-40 (reference range-less than or equal to 2/HPF), and bacteria was many (reference range-none seen). The laboratory diagnostic report dated 4/11/26 identified Resident #46's final urine culture results identified 10,000-49,000 CTU/ml of E.coli, additional non-predominating organisms were isolated. These organisms were commonly found on external and internal genitals and considered colonizers. The Psychiatric APRN note dated 4/15/26 identified Resident #46 was seen and evaluated per facility request, lab follow-up. Staff endorse ongoing increase in restlessness and difficulty redirecting and calming. Resident #46 was seen and evaluated in the halls; affect was anxious and he/she was difficult to calm and redirect. The note further identified that labs were reviewed, UA C&S were positive, and Augmentin 500-125 mg (antibiotic), twice daily by mouth was ordered. The nurse's note dated 4/15/26 at 3:14 PM identified Resident #46 had increased confusion, urine specimen returned for a positive UTI. APRN #1 ordered to start Augmentin 500-125 mg, twice daily for 5 days. The resident representative was updated and agreed with the plan of care. A physician's order dated 4/15/26 (8 days after the initial report of symptoms and 4 days after the final urine culture results were reported) directed to administer Augmentin 500-125 mg, 1 tablet by mouth, twice daily for 5 days. Review of Resident #46's clinical record failed to identify documentation that the facility's infection surveillance system tool (McGeer Criteria) was completed prior to the initiation of antibiotics. The April 2026 Medication Administration Record identified Resident #46 received Augmentin 500-125 mg, 1 tablet on 4/16/26 at 5:00 PM (9 days after the initial report of symptoms and 5 days after the final urine culture results were reported), 4/17/26 through 4/20/26 at 9:00 AM and 5:00 PM, and on 4/21/26 at 9:00 AM. Interview with the 7:00 AM - 3:00 PM Nursing Supervisor (RN #9) on 4/20/26 at 2:25 PM identified that lab results would be sent from the laboratory and received in the business office, once the labs were received they would be brought to the charge nurse or nursing supervisor for review, if it was a Tuesday or Thursday the nurses would give it to MD #1 and on Monday and Wednesday the results would be given to the medical APRN. RN #9 indicated that the labs would then be reviewed by the provider and orders written, if appropriate. RN #9 further indicated that Resident #46's UA and C&S were reported on 4/10/26 and initialed by MD #1. RN #9 identified that MD #1 does not date or time stamp when the labs were reviewed, and she did not work on 4/10/26 or 4/11/26. Interview with the Psychiatric APRN (APRN #1) on 4/21/26 at 9:59 AM identified that she saw Resident #46 on 4/7/26 for altered mental status, increased frequency of urination, and periumbilical pain, and she ordered labs. APRN #1 identified that after she writes orders, they would be reviewed and approved by the Medical Director (MD #1). APRN #1 indicated that she comes to the facility once a week and that while she could not speak to the facility's policy for reporting abnormal laboratory results, the facility staff does not call her to notify her of abnormal lab results; she would review the labs once she returned to the building. APRN #1 identified that in her experience typically the medical provider would be provided with the lab results, and she would follow-up to ensure everything was in place, but she would order treatment if she was the provider that reviewed the labs first; it was a situation of who gets to it first. APRN #1 further identified that when she returned to the facility on 4/15/26, she decided to order antibiotics for Resident #46 because he/she was still symptomatic and had a high bacterial count in his/her urine. Interview with the Medical Director (MD #1) on 4/21/26 at 11:11 AM identified that when laboratory testing was ordered by another provider, he would not be part of the process to look for the results. MD #1 indicated that eventually he would look at the results and sign off on them, but it would not be done in real time. MD #1 indicated that it was a collaborative understanding with the other providers, and it would have been APRN #1's responsibility to review Resident #46's labs and order a treatment, if necessary. MD #1 further indicated that he could not speak to the timeliness of the laboratory review or the timeliness for ordering a treatme

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #23) reviewed for grievances, the facility failed to promptly acknowledge and initiate the grievance process according to policy when the resident reported disrespectful treatment by a staff member. The findings include: Resident #23 was admitted to the facility in October 2025 with diagnoses that included adjustment disorder and anxiety. The admission MDS dated [DATE] identified Resident #23 was cognitively intact, and required one person assistance with bed mobility, transfers and ambulation with a walker. The care plan dated 12/24/25 identified Resident #23 was prone to inappropriate behavior characterized by accusatory confabulation/making up stories, maladaptive interactions and being intrusive. Interventions included assisting with appropriate methods of coping and encouragement to express feelings. Interview with Resident #23 on 4/19/26 at 10:07 AM identified he/she reported being treated disrespectfully by Recreation Assistant #1. Resident #23 indicated he/she had reported this to facility staff. Resident #23 indicated during an activity, Recreation Assistant #1 told Resident #23, in front of other residents, that he/she talked too much. The Administrator was notified immediately. Interview with the Administrator on 4/19/26 at 10:58 AM identified the event did not happen. The Administrator indicated Resident #23 had a diagnosis, is conserved, and the facility deals with this all the time. Subsequent interview with the Administrator on 4/19/26 at 12:44 PM identified she had not yet spoken with Resident #23 regarding the reported concern. The Administrator described Resident #23 as intrusive, delusional and someone who makes things up. The Administrator would not identify the steps and/or policy regarding a resident reported care concern, only that the issue would be addressed. Interview with Recreation Assistant #1 on 4/20/26 at 11:51 AM identified Resident #23 had not previously reported any concerns to her regarding their exchanges. Recreation Assistant #1 indicated Resident #23 will often arrive 30-40 minutes late for scheduled activities, talking and saying hello to other residents. The engaging with other residents is at times disruptive to the flow of the activity and residents could not fully participate once interrupted. Recreation Assistant #1 did have a conversation at one time, in private, with Resident #23 that if she elected to come to activities when scheduled she could fully participate with the other residents. Recreation Assistant #1 further identified while the Administrator made her aware of the report that she was rude to Resident #23, there had been no further discussion on how to manage future interactions with Resident #23 following the reported concern. Interview with SW #1, the Director of Social Services, on 4/21/26 12:59 PM identified the Administrator was overseeing Resident #23's reported concern and had all the information about the grievance. SW #1 indicated grievances were handled by the Administration and nursing staff and her role was to provide support after. Interview with the Administrator on 4/21/26 at 3:58 PM, 2 days after Resident #23 reported Recreation Assistant #1 was rude to him/her, identified she had not yet spoken to Resident #23 regarding the concern or initiated a grievance regarding the concern. The Administrator indicated she instructed Recreation Therapist #1 to provide a statement after speaking with the surveyor.The Administrator indicated the plan to address Resident #23's concern included informing Resident #23 that he/she needed to be on time for activities in order to participate. The Administrator would not discuss a plan that addressed Resident #23's specific concern regarding rude and disrespectful behavior and future interactions with Recreation Therapist #1 going forward. Review of the Grievance policy directs staff to acknowledge and work to resolve as quickly as possible, any resident concerns as soon as the staff is made aware of them. Residents and representatives are asked to present any difficulties, questions or complaints by contacting the Director of Social Services during regular business hours and the nursing supervisor outside of regular business hours. Grievances not immediately resolved will be followed through to resolution by the Director of Social Services. The Director of Social Services will meet with the resident/ responsible party to interpret center policies, answer questions, present possibilities for conflict resolution to assist to a satisfactory resolution of conflicts. The Director of Social Services will maintain a log of grievances. The procedure includes meeting with the resident/responsible party as soon as possible after becoming aware of the grievance, accurately document the concerns in the medical record, report in writing to the department head who will have 5 days to report back in writing the results of the investigation and resolution, complete a grievance report, meet with the resident / responsible party to review the grievance and ensure it meets with complete satisfaction by all parties/proceed with further the formal Grievance Committee if needed and document resolution in the medical record.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #3) reviewed for behaviors and mood, the facility failed to ensure non-pharmacologic behavioral interventions were initiated or attempted prior to the initiation of psychotropic medications and failed to ensure that target behavior monitoring was initiated or implemented following the initiation of psychotropic medications. The findings include:Resident #3 was admitted to the facility in June 2023 with diagnoses that included diabetes, glaucoma, and depression. A physician's order dated 3/17/24 directed to administer Escitalopram (a medication used to treat depression) 20 mg by mouth daily.The quarterly MDS dated [DATE] identified Resident #3 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff for toileting, bathing, and dressing. The MDS also identified Resident #3 had not exhibited any behavioral symptoms including verbal behaviors like screaming or disruptive sounds and had not exhibited any behavioral symptoms related to rejection of care. The care plan dated 9/3/25 identified Resident #3 had depression. Interventions included to administer medications as ordered.A psychiatric note dated 9/11/25, by APRN #1 (psychiatric APRN), identified that she was asked by facility staff to see Resident #3 due to increased yelling out. APRN #1 identified that staff also reported Resident #3 was withdrawn, stayed in his/her room, yelled out, and did not join activities. APRN #1 identified Resident #3 was evaluated while his/her resident representative was present. Resident #3 reported his/her mood was good, he/she felt good, and that he/she had good family support. APRN #1 identified she discussed the staff reported behaviors with Resident #30's representative along with medication options and Resident #3's representative was in agreement to start Trazadone (a medication used to treat depression) 25 mg by mouth as needed every 8 hours for 14 days to decipher efficacy and frequency of scheduled dosing.A physician's order dated 9/11/25 directed to administer Trazadone 50 mg tablet-give 0.5 tablet (25 mg) two times daily for depression.Review of the clinical record failed to identify any documentation related to Resident #3 having behaviors that included yelling out or self-isolation prior to the 9/11/25 note. Further the clinical record failed to identify any documentation that non pharmacologic interventions were initiated or implemented prior to the initiation of Trazadone. The clinical record also failed to identify that target behavior monitoring was ordered or implemented following the start of Trazadone to monitor Resident #3's response to the medication.A psychiatric note dated 9/18/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen and evaluated by staff request for medication change follow-up, and staff endorsed no change in behaviors which included Resident #3 being withdrawn, frequently staying in his/her room, not joining activities, and frequently yelling out. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified Trazadone would be discontinued and Depakote 125 mg would be started. Review of the diagnoses at the time of this visit also identified a new diagnosis of adjustment disorder with mixed anxiety and depressed mood. A physician's order dated 9/18/25 directed to administer Depakote (also known as Valproic Acid, a medication used to treat epilepsy and acute bipolar mania and used off label as a treatment for anxiety) 125 mg by mouth twice daily for anxiety. Review of the clinical record failed to identify that target behavior monitoring was ordered or implemented following the start of Depakote to monitor Resident #3's response to the medication.Review of the clinical record failed to identify any recent bloodwork orders or results for Resident #3 prior to the initiation of Depakote and failed to identify any bloodwork orders or results of valproic acid levels. A psychiatric note dated 11/6/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen for request to increase visit cadence by facility staff. APRN #1 identified facility staff had reported Resident #3 had not had any yelling out, was participating in activities, and denied Resident #3 had any behavioral disturbances. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified she would continue to monitor. A psychiatric note dated 11/24/25 by MD #2 (psychiatric MD) identified Resident #3 was seen and evaluated at the request of the facility to assess resistance to care, anxiety, sadness, confusion, restlessness, yelling out, memory problems, and medication review. MD #2 identified Resident #3 had anxiety symptoms and his treatment plan included discontinue Depakote, add trazadone 25 mg by mouth every morning and 50 mg every evening at 8:00 PM for anxiety and insomnia, and to continue to observe the resident for increase in anxiety symptoms, observe for side effects from medication, and supportive therapy provided. Review of the diagnoses at the time of this visit also identified the previous diagnosis of Adjustment Disorder with mixed anxiety and depressed mood was removed and a new diagnosis of Anxiety Disorder was added. Review of the clinical record failed to identify new orders to discontinue Depakote and restart Trazadone as per MD #2's note dated 11/24/25. Review of the clinical record failed to identify documentation of Resident #3 demonstrating behaviors related to resistance to care, anxiety, sadness, confusion, restlessness, or yelling out prior to or following the 11/24/25 psychiatric MD visit. A psychiatric note dated 12/11/25 by APRN #1 (psychiatric APRN) identified Resident #3 was seen for routine follow-up. APRN #1 identified facility staff had reported Resident #3 had not had any yelling out and was participating in activities. APRN #1 identified Resident #3 denied any issues with depression, anxiety, or insomnia, and reported feeling good, with good mood and had good family support. APRN #1 identified she would continue to monitor. Review of the physician's orders for December 2025 through April 2026 identified the resident received Depakote 125 mg twice daily per the physician order. Further, there were no orders to obtain a valproic acid level.Interview with APRN #1 on 4/21/26 at 9:40 AM identified she was not aware if any non-pharmacological interventions had been attempted prior to starting Trazadone on 9/11/25 to treat Resident #3's staff reported behaviors. APRN #1 also identified that following the discontinuation of Trazadone and starting Depakote, she did not order any bloodwork to ensure that the medication was safe to start and identified she would have only checked a valproic acid level when Resident #3's behavioral symptoms had stabilized. Upon surveyor inquiry regarding standard of care with Depakote initiation, APRN #1 then identified a valproic acid level should have been checked 14 days following initiation of Depakote, but she would have to review her notes to determine if/when this was done. APRN #1 also identified she did not order target behavior monitoring for Resident #3 following the initiation of Trazadone or Depakote, as she did not have the ability to order behavior monitoring, however the behaviors the medications were prescribed for were identified in her visit notes. APRN #1 also identified that she did work with MD #2, and she did routinely review his notes, but was unable to identify if she reviewed his visit note from 11/24/25 prior to her visit with Resident #3 on 12/11/25, as MD #2 identified his plan to discontinue Depakote and restart Trazadone. APRN #1 then identified both she and MD #2 were contracted employees of the facility, and that any directions or orders regarding a resident's treatment plan were not actual orders, but suggestions, and all suggestions had to be reviewed and approved by MD #1 (the Medical Director), including medications and behavior monitoring. Interview with MD #2 on 4/21/26 at 11:37 AM identified that he had been providing treatment for Resident #3 along with APRN #1 for his/her psychiatric conditions. MD #2 identified that Resident #3 should have had target behavior monitoring in place with the initiation of Trazadone on 9/11/25, and with the initiation of Depakote on 9/18/25 to determine if the medications were effective in addressing Resident #3's behaviors. MD #2 identified that even with an order for target behavior monitoring, it could be a challenge to monitor based on staffing levels at the facility. MD #2 also identified that prior to the start of Depakote, the standard of care associated with the start of this medication would include checking LFTs (liver function) and a CBC (complete blood count) due to the risk of liver toxicity and thrombocytopenia with Depakote use. MD #2 also identified that following the initiation of Depakote, that a valproic acid level should have been checked 5 days following the start of the medication to ensure that the drug levels were therapeutic and not at a toxic level. MD #2 identified he also was unsure why his order that directed to discontine Depakote and restart of Trazadone was not reflected in the clinical record and there may have been an issue with the nursing staff activating the order in the eMAR. MD #2 identified that Resident #3 should not be on Depakote due to the risks and side effects associated with this medication and also identified it did not work well for anxiety and insomnia, which were issues that Resident #3 had reported to him, and would address with issue with APRN #1. Although attempted, an interview with MD #1 was not obtained. The facility policy on behavioral assessment, monitoring, and intervention directed that behavioral symptoms would be identified using a facility approved behavioral screening tool and comprehensive assessment. The policy also directed that the facility would comply with regulatory requirements related to the use of medications to manage behavioral symptoms. General guidelines of the policy directed that behavior was a response of an individual to a wide variety of factors and could be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that could not be articulated. The policy also directed that as part of a comprehensive assessment, staff would evaluate based on the input from the resident family and caregivers, review of the medical record, and general observations:The resident's usual patterns of cognition, mood and behaviorThe resident's usual method of communicating things like pain, hunger, thirst, and other discomfortThe resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggersThe resident's previous patterns of coping with stress, anxiety, and depression. The nursing staff would identify, document, and inform the physician about specific details regarding changes in a residence mental status, behavior, and cognition, including: Onset, duration, intensity and frequency of behavioral symptoms.Any recent precipitating or relevant factors or environmental triggers (i.e medication changes, infection, recent transfer from the hospital).The appearance and alertness of the resident and related observations. The policy also directed the any new onset or changes any residence behavior would be documented regardless of the degree of risk to the resident, or others and new onset or changes of behaviors. The policy also directed that the interdisciplinary team would thoroughly evaluate any new or changing behavioral symptoms in a resident in order to identify underlying causes and address any modifiable factors that might have contributed to the residents change of condition including physical or mental changes; emotional, psychiatric, and or psychological stressors; Functional, social, or environmental factors. The policy other directed that the interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary to protect the resident and others from harm. The residents care plan would also incorporate findings from the comprehensive assessment and be consistent with current standards of practice. The resident and resident representative would be involved in the development and implementation of the care plan. The policy also directed that interventions related to behaviors would be individualized and part of an overall care environment that supported the physical, functional, and psychological needs of the resident, and strive to understand, prevent, or relieve the residents distress or loss of abilities. Interventions and approaches would be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as potential and environmental reasons for the behaviors. The care plan would include, as a minimum: a description of the behavioral symptoms which included frequency, intensity, duration outcomes, location, environment, precipitating factors, or situations; targeted and individualized interventions for the behavioral and or psychosocial symptoms; the rationale for the interventions and approaches; specific and measurable goals for targeted behaviors; and how facility staff would monitor the effectiveness of interventions. The policy also directed that non pharmacologic approaches would be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. The policy also directed that when medications were prescribed for behavioral symptoms documentation would include:The rationale for use potential underlying causes of a behavior; other approaches and intervention tried prior to use; potential risk and benefit of the medications as discussed with the resident and/or family; the specific target behaviors and expected outcomes; dosage, duration, monitoring for efficacy and adverse consequences and plans related to a gradual dose reduction The policy also directed that if a resident was being treated for an altered behavior or mood the interdisciplinary team would seek and document any improvements or worsening in the residence behavior, mood, and function, and interventions would be adjusted based on the impact on the behaviors and other symptoms, including any adverse consequences related to the treatment. The facility policy on psychoactive medications and gradual dose reductions directed that psychoactive medications would be used in accordance with standards set forth by federal law and the state operations manual (SOM). The policy further identified that the prescriber of a psychoactive medication would order psychoactive medications only to treat specific conditions, and that the prescriber was responsible to monitor and assess for efficacy, tolerability, and side effects, and adjust the dosing as necessary. The facility policy on psychotropic medication directed that residents would not be given psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication was beneficial to the resident as demonstrated by monitoring and documentation of the residents response to the medication. The policy defined A psychotropic medication as any drug that affected brain activity associated with mental processes and behavior then that psychotropic drugs included, but were not limited to, the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The policy directed that residents and/or representatives would be educated on the risk and benefits of psychotropic drug use as well as alternative treatments and non-pharmacologic interventions. The policy directed that residents who used psychotropic medications should also receive non pharmacologic interventions to facilitate the reduction or discontinuation of psychotropic medications.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for abuse, the facility failed to report allegation(s) of resident-to-resident abuse to the overseeing state agency and local law enforcement according to established timeframes. The findings include: 1a. Resident #23 was admitted to the facility in October 2025 with diagnoses that included adjustment disorder and anxiety. The admission MDS dated [DATE] identified Resident #23 was cognitively intact, and required one person assistance with bed mobility, transfers and ambulation with a walker. The care plan dated 12/24/25 identified Resident #23 was prone to inappropriate behavior characterized by accusatory confabulation/making up stories, maladaptive interactions and being intrusive. Interventions included to assist with appropriate methods of coping and encouragement to express feelings. Communication / Grievance Sheet dated 3/10/26 identified Resident #23 did not want residents who wander to come into his/her room and had to ask a resident not to come into his/her room. The form did not include information specific to the events or any resident that prompted the request. Social work follow-up intervention (no date) identified there were no reports of a resident entering his/her room. Resident #23 was assured that residents who attempt to wander into his/her room will be monitored, Resident #23 was to report timely for concerns and psychiatry to visit with Resident #23. The care plan was revised on 3/23/26 to include a stop strip to be placed in front of Resident #23's door for accusatory behavior against other residents. b. Resident #52 was admitted to the facility in October 2021 with diagnoses that included depression and hemiplegia / hemiparesis (weakness / paralysis) following a cerebral infarction (stroke) affecting the left non-dominant side. The quarterly MDS dated [DATE] identified Resident #52 was moderately cognitively impaired, did not exhibit wandering behaviors and required supervision with locomotion using a manual wheelchair. The care plan dated 10/16/25 identified Resident #52 had potential for adjustment issues and a diagnosis of depression with mild cognitive impairment. Interventions included to allow control over environment as much as possible and observe for signs of depression including attention seeking. Interview with Resident #23 on 4/19/26 at 10:07 AM identified while eating breakfast on 12/25/25, Resident #52 entered his/her room, said (hi hun, I want to be friends) and blew a kiss. Resident #23 became frightened, placed the tray table between him/herself and Resident #52, then attempted to call for help. Resident #52 said (oh, come on) and blew a second kiss that Resident #23 interpreted as a solicitation. Resident #23 told Resident #52 to get out of his/her room twice which eventually he/she did. Resident #23 further identified he/she did not report the incident that day as to not spoil the holiday. Beginning 12/26/25, Resident #23 began reporting the incident to staff and continued in the days that followed including to the day shift charge nurse, LPN #4. Days later, SW #1, the Director of Social Services came to see Resident #23, did not ask about the event but offered to transport the resident to the Administrator who requested to see him/her. Resident #23 met with the Administrator in her office and reported the event. The Administrator responded by informing Resident #23 that surveillance cameras were reviewed and the event did not occur, rather it was his/her perception that the event occurred. Review of the clinical record and facility documentation identified no documented reportable event form detailing the reported incident or that the event had been reported to the overseeing state agency and local law enforcement. Interview with the DNS on 4/19/26 at 12:53 PM identified she was not aware of any resident-to-resident allegation between Resident #23 and Resident #52 on 12/25/25 therefore, did not report or investigate the allegation. Interview with the Administrator on 4/19/26 at 1:01 PM identified she was not aware of an allegation that Resident #52 entered Resident #23's room and blew kisses at him/her on 12/25/25. The Administrator further identified a grievance was submitted on 3/10/26, (74 days after the allegation) by Resident #23 to address residents wandering into his/her room but was unable to specify which residents or circumstances that led up to the request. In response, a STOP strip was provided to restrict entry into Resident #23's room for any resident that wandered. Interview with SW #1 on 4/19/26 at 1:17 PM identified she learned on 12/29/25 that Resident #52 entered Resident #23's room on 12/25/25 but was not aware Resident #23 reported that Resident #52 had blown kisses at him/her. SW#1 indicated a STOP strip had already been placed on Resident #23's door at that time and Resident #52 was instructed to stay out of Resident #23's room. SW #1 further identified she did not visit with or document the concern related to Resident #23 following the event as the issue had already been taken care of. Interview with LPN #4 on 4/19/26 at 1:37 PM identified she was the assigned charge nurse on 12/27/25 and 12/28/25 during the 7:00 AM to 3:00 PM shift. LPN #4 identified during her shift on one of those days, Resident #23 reported Resident #52 entered his/her room on 12/25/25 and blew kisses towards him/her. Resident #23 reported that he/she did not like it at all and told Resident #52 to leave, which he/she eventually did. LPN #4 reported the event to the nursing supervisor, RN #6. Interview with APRN #1 on 4/27/26 at 1:39 PM identified she provided psychiatric services for Resident #23 on a weekly basis. APRN #1 indicated Resident #23 made frequent accusations against staff and residents while also stating he/she felt safe and liked the facility, staff and residents. Resident #23 did not have a confirmed diagnosis of schizophrenia but exhibited symptoms of paranoia and delusions. APRN #1 could not recall the specifics of the allegation but indicated the her opinion was that the impact of allegations made did not cause harm. c. Resident #3 was admitted to the facility in February 2026 with diagnoses that included dementia and anxiety. The admission MDS dated [DATE] identified Resident #19 was severely cognitively impaired and independent with ambulation. The care plan dated 2/25/26 identified Resident #19 had impaired cognition, was at risk for wandering and had an anxiety disorder. Interventions included monitoring and reporting changes in cognitive function, distract from wandering, and allowing to verbalize feelings. Interview with Resident #23 on 4/19/26 at 10:07 AM identified sometime within the last month, Resident #23 was in the activities room talking with another resident in the group while recreation staff were out of the room transporting residents following an activity. Resident #23 indicated he/she was talking about Resident #19 using the staff bathroom but using a fictitious name. Resident #19 who was sitting nearby, approached Resident #23 and confronted him/her, pointing his/her finger in Resident #23's face saying no one talks about him/her and gets away with it. Resident #23 denied talking about Resident #19 and proceeded to exit the activities room and return to the nursing unit to report the incident. Once at the nurse's station, Resident #23 realized Resident #19 was right behind him/her and proceeded to push on his/her back very hard and stated that he/she did not want anyone to talk about him/her. Resident #23 indicated she reported to LPN #4 who was at the nurse's station that Resident #19 put his/her hands on him/her (Resident #23) and indicated LPN #4 claimed not to have observed the interaction. Resident #23 later spoke with the Director of Recreation and the Administrator about the incident and a STOP strip was provided to prevent Resident #19 from entering Resident #23's room. Review of the clinical record and facility documentation identified no documented reportable event form detailing the incident or documentation that the event was reported to the overseeing state agency and local law enforcement. Interview with the DNS on 4/19/26 at 12:53 PM identified she was not aware of any resident-to-resident allegation between Resident #23 and Resident #19 within the last month; therefore, did not report or investigate the allegation. Interview with the Administrator on 4/19/2026 at 1:01 PM identified she was not aware of any resident-to-resident allegation between Resident #23 and Resident #19 within the last month. The Administrator further identified a grievance was submitted on 3/10/26, by Resident #23 to address residents wandering into his/her room but was unable to specify which residents or circumstances that led up to the request. In response, a STOP strip was provided to restrict entry into Resident #23's room for any resident that wandered and was not related to any specific resident. Interview and clinical record review with SW #1, Director of Social Services, on 4/19/26 at 1:17 PM identified LPN #4 notified her of an interaction between Resident #23 and Resident #19 where he/she walked closely passed Resident #23, but there was no physical touch reported. SW #1 indicated for the allegation, social services will meet with the resident for three days to offer emotional support. SW #1 indicated she did visit Resident 23 after incident on 4/15/26 but did not ask about any specifics related to the allegation just how Resident #23 was doing in general who had no complaints. Interview with LPN #4 on 4/19/26 at 1:37 PM identified in recent weeks, Resident #23 reported Resident #19 pushed him/her in the back while exiting the activity room. Resident #19 then reapproached Resident #23 upon return to the unit where she observed Resident #19 approach Resident #23 from behind and tap him/her on the shoulder in a confused state asking a question which could not be recalled. LPN #4 indicated she reported the event to the Administrator. Within an hour, the Administrator, Recreation Director and LPN #4 met with Resident #23 who began changing his/her story to suggest Resident #19 only walked by closely. Interview with the Director of Recreation on 4/19/26 at 3:00 PM identified sometime within the last month, she was called to Resident #23's room where together with the Administrator and LPN #4 she was informed by Resident #23 that Resident #19 came up closely from behind following an activity and asked Resident #23 something which could not be recalled. The Director of Recreation further identified she asked Resident #23 why it was not reported to her at the time and was told there were no staff in the room during transport and that he /she wanted to get out of the activity room. Interview with Resident #44, (cognitively intact) on 4/20/26 at 1:01 PM identified he/she was present during an activity with the past month when he/she observed an unpleasant interaction between Resident #23 and Resident #19. Resident #44 indicated Resident #23 was talking to him/her about another resident using the staff bathroom but used a fictitious name. Resident #19, who was sitting across the room, somehow knew Resident #23 was talking about him/her, approached Resident #23 and confronted him her in an aggressive and combative manner accusing Resident #23 of talking about him/her. Resident #23 denied talking about Resident #19, got up and left the activity area. Resident #44 indicated there were no staff present when the event occurred. Resident #44 further identified while he/she did not observe Resident #19 make physical contact with Resident #23, he/she was shocked and taken aback by Resident 19's behavior and that no staff member had come to speak with him/her about following the event. The facility failed to ensure allegations of resident-to-resident mistreatment were reported to the overseeing state agency in a timely manner resulting in unmanaged safety risks and unreliable recall of events at a later time. Review of the facility policy for abuse directed all staff immediately report any allegations or incidents of abuse, neglect, mistreatment, injuries of unknown source, misappropriation, exploitation and abandonment. To their immediate supervisor. Any supervisor receiving such a report will contact the administrator immediately after the allegation is made or incident occurs. Immediately, but not less than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. It is the responsibility of all employees to immediately report all allegations of abuse in accordance with state and federal laws for reporting requirements and facility policy. Attempts to interview RN #6 were unsuccessful.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for abuse, the facility failed to ensure a thorough investigation was completed following a resident-to-resident allegation of sexual abuse by another resident, (Resident #52) and alleged inappropriate verbal/physical abuse by a another resident (Resident #19). The facility did not complete a reportable event form, document the reported event in the clinical record, and allowed the residents to remain on the same unit following the allegation. Inconsistent staff accounts and lack of documentation impeded an appropriate investigation and updates to the care plan to prevent further instances. The psychiatric provider identified the potential for negative psychiatric impact to the resident when allegations of mistreatment are not addressed. The findings include: 1a. Resident #23 was admitted to the facility in October 2025 with diagnoses that included adjustment disorder and anxiety. The admission MDS dated [DATE] identified Resident #23 was cognitively intact, and required one person assistance with bed mobility, transfers and ambulation with a walker. The care plan dated 12/24/25 identified Resident #23 was prone to inappropriate behavior characterized by accusatory confabulation/making up stories, maladaptive interactions and being intrusive. Interventions included assisting with appropriate methods of coping and encouragement to express feelings. A psychiatric consult dated 1/8/26 identified Resident #23 exhibiting increased behavioral disturbances and an alleged reported incident. Per staff, Resident #23 has been presenting with increased accusatory statements, with increased accusations against staff and other residents and showing a decrease in intrusiveness and restlessness. The conservator reports being contacted nightly with reports that staff are out to get him/her. Resident #23 was guarded and agitated during evaluation, continued with accusations, feelings of persecution and paranoia. The plan for treatment included starting Abilify (an antipsychotic medication) 2mg every evening and monitor. Communication / Grievance Sheet dated 3/10/26 identified Resident #23 did not want residents who wander to come into his/her room and had to ask a resident not to come into his/her room. The form did not include information specific to the events or any resident that prompted the request. Social work follow-up intervention (no date) identified there were no reports of a resident entering his/her room. Resident #23 was assured that residents who attempt to wander into his/her room will be monitored, Resident #23 was to report timely for concerns and psychiatry to visit with Resident #23. The care plan was revised on 3/23/26 to include a stop strip to be placed in front of Resident #23's door for accusatory behavior against other residents. b. Resident #52 was admitted to the facility in October 2021 with diagnoses that included depression and hemiplegia / hemiparesis (weakness / paralysis) following a cerebral infarction (stroke) affecting the left non-dominant side. The quarterly MDS dated [DATE] identified Resident #52 was moderately cognitively impaired, did not exhibit wandering behaviors and required supervision with locomotion using a manual wheelchair. The care plan dated 10/16/25 identified Resident #52 had potential for adjustment issues and a diagnosis of depression with mild cognitive impairment. Interventions included to allow control over environment as much as possible and observe for signs of depression including attention seeking. Interview with Resident #23 on 4/19/26 at 10:07 AM identified while eating breakfast on 12/25/25, Resident #52 entered his/her room, said (hi hun, I want to be friends) and blew a kiss. Resident #23 became frightened, placed the tray table between him/herself and Resident #52, then attempted to call for help. Resident #52 said (oh, come on) and blew a second kiss that Resident #23 interpreted as a solicitation. Resident #23 told Resident #52 to get out of his/her room twice which eventually he/she did. Resident #23 further identified he/she did not report the incident that day as to not spoil the holiday. Beginning 12/26/25, Resident #23 began reporting the incident to staff and continued in the days that followed including to the day shift charge nurse, LPN #4. Days later, SW #1, the Director of Social Services came to see Resident #23, did not ask about the event but offered to transport the resident to the Administrator who requested to see him/her. Resident #23 met with the Administrator in her office and reported the event. The Administrator responded by informing Resident #23 that surveillance cameras were reviewed and the event did not occur, rather it was his/her perception that the event occurred. Review of the clinical record and facility documentation identified no documented reportable event form detailing the incident, separation of residents (the residents remained on the same unit), no documented nursing assessment, social services notes, outcomes following the event and interventions care planned to mitigate future resident interactions. Interview with the DNS on 4/19/26 at 12:53 PM identified she was not aware of any resident-to-resident allegation between Resident #23 and Resident #52 on 12/25/25 therefore, did not report or investigate the allegation. Interview with the Administrator on 4/19/2026 at 1:01 PM identified she was not aware of an allegation that Resident #52 entered Resident #23's room and blew kisses at him/her on 12/25/25. The Administrator further identified a grievance was submitted on 3/10/26, (74 days after the allegation) by Resident #23 to address residents wandering into his/her room but was unable to specify which residents or circumstances that led up to the request. In response, a STOP strip was provided to restrict entry into Resident #23's room for any resident that wandered. Interview with SW #1 on 4/19/26 at 1:17 PM identified she learned on 12/29/25 that Resident #52 entered Resident #23's room on 12/25/25 but was not aware Resident #23 reported that Resident #52 had blown kisses at him/her. SW#1 indicated a STOP strip had already been placed on Resident #23's door at that time and Resident #52 was instructed to stay out of Resident #23's room. SW #1 further identified she did not visit with or document the concern related to Resident #23 following the event as the issue had already been taken care of. Interview with LPN #4 on 4/19/26 at 1:37 PM identified she was the assigned charge nurse on 12/27/25 and 12/28/25 during the 7:00 AM to 3:00 PM shift. LPN #4 identified during her shift on one of those days, Resident #23 reported Resident #52 entered his/her room on 12/25/25 and blew kisses towards him/her. Resident #23 reported that he/she did not like it at all and told Resident #52 to leave, which he/she eventually did. LPN #4 reported the event to the nursing supervisor, RN #6. Interview with MD #2 on 4/21/26 at 11:31 AM identified he provided psychological services for Resident #23 on a routine basis. MD #2 indicated that a person could experience symptoms of depression, anxiety, and hopelessness when they feel reported concerns are not being addressed. MD #2 further identified, subsequent to surveyor inquiry, he was notified of the resident allegations. Resident #23 who was pleasant and reported residents entering his/her room had since been resolved. Resident #23 had depression, anxiety and accusatory behavior and refused medications as part of therapy. MD #2 indicated that regardless of the behavior, a perception that reported concerns are not being addressed can exacerbate symptoms. Interview with APRN #1 on 4/27/26 at 1:39 PM identified she provided psychiatric services for Resident #23 on a weekly basis. APRN #1 indicated Resident #23 made frequent accusations against staff and residents while also stating he/she felt safe and liked the facility, staff and residents. Resident #23 did not have a confirmed diagnosis of schizophrenia but exhibited symptoms of paranoia and delusions. APRN #1 could not recall the specifics of the allegation, but indicated in her opinion, the impact of allegations made did not cause harm. c. Resident #3 was admitted to the facility in February 2026 with diagnoses that included dementia and anxiety. The admission MDS dated [DATE] identified Resident #19 was severely cognitively impaired and independent with ambulation. The care plan dated 2/25/26 identified Resident #19 had impaired cognition, was at risk for wandering and had an anxiety disorder. Interventions included monitoring and reporting changes in cognitive function, distract from wandering, and allow to verbalize feelings. Interview with Resident #23 on 4/19/26 at 10:07 AM identified sometime within the last month, Resident #23 was in the activities room talking with another resident in the group while recreation staff were out of the room transporting residents following an activity. Resident #23 indicated he/she was talking about Resident #19 using the staff bathroom but using a fictitious name. Resident #19 who was sitting nearby, approached Resident #23 and confronted him/her, pointing his/her finger in Resident #23's face saying no one talks about him/her and gets away with it. Resident #23 denied talking about Resident #19 and proceeded to exit the activities room and return to the nursing unit to report the incident. Once at the nurse's station, Resident #23 realized Resident #19 was right behind him/her and proceeded to push on his/her back very hard and stated that he/she did not want anyone to talk about him/her. Resident #23 indicated she reported to LPN #4 who was at the nurse's station that Resident #19 put his/her hands on him/her (Resident #23) and indicated LPN #4 claimed not to have observed the interaction. Resident #23 later spoke with the Director of Recreation and the Administrator about the incident and a STOP strip was provided to prevent Resident #19 from entering Resident #23's room. Review of the clinical record and facility documentation identified no documented reportable event form detailing the incident or outcome, no documented assessment in the clinical record, separation of residents (the residents remained on the same unit and independently ambulatory), no documented social services notes or documented interventions for Resident #19 following the event. Interview with the DNS on 4/19/26 at 12:53 PM identified she was not aware of any resident-to-resident altercation between Resident #23 and Resident #19 within the last month; therefore, did not report or investigate the allegation. Interview with the Administrator on 4/19/2026 at 1:01 PM identified she was not aware of any resident-to-resident altercation between Resident #23 and Resident #19 within the last month. The Administrator further identified a grievance was submitted on 3/10/26, by Resident #23 to address residents wandering into his/her room but was unable to specify which residents or circumstances that led up to the request. In response, a STOP strip was provided to restrict entry into Resident #23's room for any resident that wandered and was not related to any specific resident. Interview and clinical record review with SW #1, Director of Social Services, on 4/19/26 at 1:17 PM identified LPN #4 notified her of an interaction between Resident #23 and Resident #19 where he/she walked closely passed Resident #23, but there was no physical touch reported. SW #1 indicated for the allegation, social services will meet with the resident for three days to offer emotional support. SW #1 indicated she did visit Resident 23 after incident on 4/15/26 but did not ask about any specifics related to the allegation just how Resident #23 was doing in general who had no complaints. Interview with LPN #4 on 4/19/26 at 1:37 PM identified in recent weeks, Resident #23 reported Resident #19 pushed him/her in the back while exiting the activity room. Resident #19 then reapproached Resident #23 upon return to the unit where she observed Resident #19 approach Resident #23 from behind and tap him/her on the shoulder in a confused state asking a question which could not be recalled. LPN #4 indicated she reported the event to the Administrator. Within an hour, the Administrator, Recreation Director and LPN #4 met with Resident #23 who began changing his/her story to suggest Resident #19 only walked by closely. Interview with the Director of Recreation on 4/19/26 at 3:00 PM identified sometime within the last month, she was called to Resident #23's room where together with the Administrator and LPN #4 she was informed by Resident #23 that Resident #19 came up closely from behind following an activity and asked Resident #23 something which could not be recalled. The Director of Recreation further identified she asked Resident #23 why it was not reported to her at the time and was told there were no staff in the room during transport and that he /she wanted to get out of the activity room. Interview with Resident #44, (cognitively intact) on 4/20/26 at 1:01 PM identified he/she was present during an activity with the past month when he/she observed an unpleasant interaction between Resident #23 and Resident #19. Resident #44 indicated Resident #23 was talking to him/her about another resident using the staff bathroom but used a fictitious name. Resident #19, who was sitting across the room, somehow knew Resident #23 was talking about him/her, approached Resident #23 and confronted him her in an aggressive and combative manner accusing Resident #23 of talking about him/her. Resident #23 denied talking about Resident #19, got up and left the activity area. Resident #44 indicated there were no staff present when the event occurred. Resident #44 further identified while he/she did not observe Resident #19 make physical contact with Resident #23, he/she was shocked and taken aback by Resident 19's behavior and that no staff member had come to speak with him/her about following the event. The facility failed to ensure allegations of resident-to-resident abuse were reported and investigated in a timely manner including documented staff and resident statements, documented efforts to separate during the course of the investigation and include a summary of outcomes with interventions to mitigate future resident to resident altercations in a timely manner resulting in unmanaged safety risks and unreliable recall of events at a later time. Review of the policy for Resident Rights directs all residents have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Review of the facility policy for abuse directed an investigation will be initiated immediately when an allegation of abuse is made. The investigation will be conducted in a comprehensive manner, specific to the incident and documented. The facility shall, whenever possible, complete the investigation within 5 working days. If the allegation is verified, the facility with take appropriate corrective action. The policy further directed protections to residents by removing an employee during the course of an investigation but did not include a directive for resident protections following a resident-to-resident altercation. Attempts to interview the nursing supervisor, RN #6 were unsuccessful.

Based on record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident with a diagnosis of dementia and a known fall risk was properly supervised and failed to ensure the resident was not left alone in the bathroom, to prevent a fall with injury. The findings include:Resident #1 had a diagnosis of dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition, had no behaviors, and was dependent on staff assistance for toileting and transfers. The Resident Care Plan (RCP) dated 11/12/2025 identified a risk for falls and self-care deficit. Interventions directed to provide assistance of one (1) staff with transfers and toileting. Facility reportable event dated 12/1/2025 at 2 PM identified Resident #1 was noted lying on the bathroom floor, and complained of right hip pain. Resident #1 was unable to explain what happened. The report identified Resident #1's baseline mental status was confused, a fall risk, and required total care with ADLs and transfers. Resident #1 was transferred to the hospital for evaluation. Additional information indicated NA #1had assisted Resident #1 to the bathroom and the fall was not witnessed by staff. NA #1 left Resident #1 sitting on the toilet for privacy and was waiting outside the door when she heard a noise and observed Resident #1 on the floor. Nursing note dated 12/1/2025 at 7:24 PM identified Resident #1 was noted to be the floor of the bathroom, with open purpura (red/purple skin discoloration) to the left shin. Resident #1 denied having bumped his/her head however, given Resident #1's state of dementia with confusion, writer unable to verify the credibility of Resident #1's account. Vital signs were within normal parameters and noted Resident #1 was receiving Coumadin (Blood thinner). The MD/APRN was notified, and Resident #1 was transferred to the hospital for evaluation. Orthopedic progress note dated 12/2/2025 at 7:16 AM identified Resident #1 had an unwitnessed fall after using the toilet. X-ray results identified a displaced right femoral neck fracture (broken and shifted out of place top of the thigh bone). Reportable event summary dated 12/8/2025 identified Resident #1 was confused (BIMS 6) and required assistance with ADLs. On 12/1/2025 at approximately 6:45 PM Resident #1 was assisted to the bathroom by a NA, who left the resident sitting on the toilet for privacy per the resident's request. The NA was waiting outside the bathroom door when she heard a noise and entered the bathroom and observed Resident #1 sitting on the floor next to the toilet seat. The NA activated the call light and the RN supervisor responded. Resident #1 was observed sitting on the floor next to the toilet and was unable to explain what happened. Resident #1 stated I stood up and I think I'm walking with my daughter. Resident #1 complained of right hip pain and had a skin tear on the left shin. A neurological assessment was conducted, and Resident #1 was able to move upper extremities but not his/her lower extremities. The physician was notified, and Resident #1 was transferred to the hospital. A hospital update was obtained on 12/2/2025 and identified Resident #1 was admitted with a diagnosis of a right displaced femoral neck fracture. Interview with Physical Therapist #1 on 12/9/2025 at 10:58 AM identified prior to the fall, Resident #1 required assistance of one (1) staff for transfers. Physical Therapist #1 stated Resident #1 would need assistance when standing up from the toilet. Interview with NA #1 on 12/9/2025 at 11:31 AM identified she was taking care of Resident #1 at the time of the fall on 12/1/2025. NA #1 assisted Resident #1 to the bathroom and placed him/her on the toilet. NA #1 stated she then gave Resident #1 the call bell and directed him/her to ring when finished, and she stood outside the bathroom door with the door ajar. Another NA was in a room across the hall and called NA #1 for help. NA #1 left Resident #1's room to assist another NA, leaving Resident #1 alone in the bathroom. NA #1 stated when she was across the hall in the other room, she heard Resident #1 scream and she went back into the room and found the resident sitting upright on the bathroom floor by the door. NA #1 stated she should not have left Resident #1 alone in the bathroom; she stated she should have waited until Resident #1 was out of the bathroom before leaving the room. NA #1 failed to provide supervision for a resident with a diagnosis of dementia and a known fall risk, while in the bathroom to prevent a fall. Interview and record review with the Administrator and Director of Nursing (DNS) on 12/9/2025 at 12:28 PM identified on 12/1/2025 Resident #1 required assistance of one (1) staff for transfers and toileting. Resident #1 was transferred to the toilet by NA #1 and NA #1 stood outside the bathroom door per residents request for privacy. The DNS further stated staff should stay in the room while residents with dementia are using the bathroom. Interview identified Resident #1 had a diagnosis of dementia with a BIMS score of 6 (indicating severely impaired cognition), and NA #1 should not have left Resident #1 alone in the bathroom. Although requested, a facility policy regarding supervising residents or toileting residents with dementia was not provided for surveyor review.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for respiratory care, the facility failed to obtain a physician's order for oxygen administration in a timely manner. The findings include: Resident #1 had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, atrial fibrillation, shortness of breath, and dependence on supplemental oxygen. The nursing admission evaluation dated 4/29/2025 at 8:42 P.M. by Registered Nurse (RN) #1 identified that Resident #1 was alert, answered questions readily, and had quick comprehension. RN #1 identified Resident #1 was continent of bowel and bladder, used the toilet, required one person assistance for transfer, ambulation, personal hygiene, and limited assistance with dressing. The care plan dated 4/30/2025 identified Resident #1 has impaired gas exchange due to chronic obstructive pulmonary disease and respiratory failure with interventions that directed to evaluate pulse oximetry, evaluate capillary refill, educate resident/representative regarding energy conservation techniques, evaluate respiratory rate and effort, evaluate skin color, monitor for changes in respiratory rate or shallow breathing, and administer oxygen as prescribed or per standing order. Review of a undated care card identified Resident #1 required oxygen at 6 liters as needed. A nurse's note dated 4/30/2025 at 1:53 A.M. by RN #1 identified Resident #1 as dependent on oxygen. RN #1 identified that Resident #1 required oxygen at 6 to 7 liters while at rest and 8 to 10 liters with ambulation. The admission history and physical note dated 5/1/2025 by MD #1 identified Resident #1 had severe emphysema and required 5 to 6 liters of oxygen via nasal cannula at rest and up to 7 liters with exertion. A nurse's note dated 5/1/2025 at 2:49 P.M. by Licensed Practical Nurse (LPN) #1 identified that Resident #1 was on oxygen therapy and was receiving 6 liters of oxygen via nasal cannula. A nurse's note dated 5/2/2025 at 2:01 P.M. by LPN #1 identified Resident #1 was on oxygen at 6 liters via nasal cannula. A nurse's note dated 5/4/2025 at 1:13 P.M. by the Director of Nurses identified Resident #1 is on continuous oxygen at 6 liters via nasal cannula. A nurse's note dated 5/5/2025 at 2:28 P.M. by LPN #1 identified that Resident #1 continues with oxygen at 6 liters via nasal cannula. A physician's order dated 5/6/2025 (8 days after Resident #1 was administered continous oxygen) at 10:48 A.M. directed to administer oxygen at 5 to 6 liters as needed for shortness of breath. Interview and clinical record review with the DNS on 5/27/2025 at 12:55 P.M identified upon admission Resident #1 did not have an order for oxygen and that there should be a physician's order for oxygen when oxygen is administered. The DNS indicated on 5/6/2025 while reviewing Resident #1's clinical record she noted Resident #1 did not have an order for oxygen, so she obtained the verbal order from MD #1. The DNS identified that RN #1 should have obtained a verbal order when Resident #1 was admitted to the facility. Review of the facility oxygen administration policy dated 5/7/2009 identified only licensed staff are to administer oxygen by adjusting the liter flow as prescribed by the physician.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #39) reviewed for pressure ulcers, the facility failed to ensure appropriate infection control techniques were implemented during a dressing change for a resident on enhanced barrier precautions. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, bladder cancer, and dementia. The care plan dated 5/20/24 identified Resident #39 required a suprapubic catheter due to neurogenic bladder from bladder cancer. Interventions included to monitor for signs/symptoms of urinary tract infections. Further review of the care plan failed identify interventions related to potential alteration in skin integrity or enhanced barrier precautions. The quarterly MDS dated [DATE] identified Resident #39 had severely impaired cognition, was frequently incontinent of bowel and always incontinent of bladder and required maximal assistance from staff with transfers, bathing, and toileting. The MDS failed to identify Resident #39 required a suprapubic catheter for bladder. A physician's order dated 8/4/24 directed Resident #39 required enhanced barrier precautions be maintained at all times related to use of a suprapubic catheter. Review of a facility transmission-based precautions list dated 8/1/24 identified Resident #39 was on enhanced barrier precautions due to a suprapubic tube in place. Review of the clinical record identified Resident #39 developed a newly identified pressure injury to the sacrum on 8/13/24. A wound care physician note dated 8/14/24 identified Resident #39 was seen for an initial exam of an unstageable sacral pressure ulcer which measured 2.8cm x 2.5cm x 0.2cm. Treatment plan identified the wound would be dressed daily and as needed with Santyl, Calcium Alginate, and a dry clean dressing. The physician's orders dated 8/24/24 directed new wound orders to the sacral pressure ulcer included cleans daily with saline, then apply santyl ointment followed by Bactroban (an antibiotic ointment) and a dry clean dressing. Observation of RN #2 on 8/26/24 at 11:13 AM completing Resident #39's pressure ulcer dressing change identified the following. A sign posted on Resident #39's room door identified STOP. Enhanced barrier precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for high contact resident activities including wound care (any skin opening requiring a dressing). RN #2 was observed placing a treatment cart directly outside of Resident #39's door and using Resident #39's bedside table to set up an area for the dressing change. RN #2 was observed using gloves to set up the table but was not wearing a gown. After setting up the table in Resident #39's room, RN #2 removed his gloves, stepped outside the doorway, moved the treatment cart to access a hand sanitizing dispenser located directly outside of Resident #39's room, and then donned a new pair of gloves. RN #2 did not don a gown during this observation. At 11:16 AM, RN #2 was observed removing Resident #39's previous dressing. A small amount of feces was observed on a brief pad and on the resident's skin at the rectum, directly below the dressing. Immediately following observation of the dressing removal, this surveyor inquired if Resident #39 had any transmission-based precautions in place. RN #2 identified that Resident #39 was on enhanced barrier precautions. The surveyor inquired what type of PPE was required, and RN #2 identified I should have put on a gown and mask. RN #2 stopped the dressing change, removed his gloves, left the room, and used the hand sanitizer outside of the room. At 11:19 AM, RN #2 reentered the room after donning a gown. RN #2 donned a face mask and gloves. RN #2 continued with the removal of the old dressing and cleansed the wound with saline and a 4 x 4 gauze pad, which RN #2 had opened after removing the old dressing. RN #2 removed his gloves and went to the hand sanitizer dispenser directly outside of Resident #39's room. With the gown on RN #2 opened the treatment cart and obtained Santyl ointment and reentered Resident #39's room and donned a new pair of gloves. While observing RN #2 during this observation, the DNS was also observed at the nurse's station on the unit. At 11:22 AM, RN #3 applied santyl ointment to Resident #39's wound with his right gloved hand using his index finger. RN #2 removed the right glove and donned a new glove to the right hand without performing hand hygiene. RN #2 used the right gloved hand to apply Bactroban ointment with gloved right index finger. RN #2 wiped the remaining ointment onto an unsoiled portion of Resident #39's brief pad and opened a clean dressing pad package, without touching the dressing inside and removed the right hand glove and disposed of it in the trash. At 11:24 AM, RN #2 used his ungloved right hand and placed the opened dressing package on Resident #39's bed, partially applied a new right glove to his fingers but not the thumb, removed the adhesive with his left gloved hand, and applied the clean dressing with his left gloved and partially gloved right hand, and removed the right glove. No hand hygiene was observed. RN #2 then identified he would need to find a marker to label Resident #39's dressing time/date. RN #2 identified he had a pen in his pocket that he could use. RN #2 used his right ungloved hand to reach into his left upper chest pocket while pulling the gown away to attempt to access his pocket. RN #2 pulled a blue pen out, attempted to label the dressing with the pen but was unsuccessful, and placed the pen back into the same left upper chest pocket. RN #2 removed the left glove, gathered the dressing supplies and packages from the bedside table, and removed his gown and mask with his ungloved hands. RN #2 then disposed of these items, exited the room to use the hand sanitizer dispenser outside Resident #39's door, obtained a marker from the treatment cart and labeled Resident #39's new dressing. Interview with RN #2 immediately following the observations identified that he was aware that Resident #39 was on enhanced barrier precautions but was focused on the dressing supplies and did not remember to don a gown. RN #2 identified that he was an agency nurse, and it was only his second day working in the facility. RN #2 further identified that he did not think to use Resident #39's sink for hand hygiene or bring in a separate hand sanitizer dispenser to allow him to remain in the room for the duration of the dressing change. RN #2 also identified he did not think reaching into his pocket under his gown for a pen was an issue, since he did not have a glove on his hand, but identified he should have performed hand hygiene prior reaching into his pocket. Although requested, the facility failed to provide any policies related to dressing changes, donning and doffing personal protective equipment (PPE), and hand hygiene. The facility policy on Enhanced Barrier Precautions (EBP) in skilled nursing directed that EBP expanded the use of PPE to include use of gown and gloves during high contact resident care activities that provided opportunities for transfer of multidrug resistant organisms (MDROs) to staff hands and clothing. The policy further directed EBP was indicated for residents who had wounds and/or any indwelling medical devices even if the resident was not known to be colonized with a MDRO, and these devices included urinary catheters. The policy also directed high contact resident care activities that included wound care to any skin opening requiring a dressing.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for falls, the facility failed to develop and implement a comprehensive care plan for a resident who had a history of repeated falls on admission and was identified as a moderate fall risk. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, Alzheimer's disease, and repeated falls. The admission fall risk assessment dated [DATE] identified Resident #42 had a history of 1 - 2 falls within the last 3 months, was taking diuretics, hypoglycemic agents, antihypertensives, and psychotropics more than 3 times weekly, had an inadequate vision pattern, and a gait analysis included: inability to independently come to a standing position, loss of balance while standing, requiring a hands-on assist to move from place to place, utilizing an assistive device, and had a decrease in muscle coordination. The fall risk assessment further identified that Resident #42 was at a moderate risk for falls. The admission MDS dated [DATE] identified Resident #42 had intact cognition, required supervision or touching assistance to ambulate 10 feet, required a walker as an assistive device and had sustained a fall in the last month and the last 2 - 6 months, prior to admission The care plan dated 10/22/23 and 4/10/24 failed to identify a focus, goals, or interventions related to Resident #42's history of falls and moderate risk for falls. The nurse's note dated 6/14/24 at 2:23 AM identified that Resident #42 was observed lying on the floor on his/her left side complaining of severe (10/10) left hip pain extending to the left leg. According to the resident he/she lost balance while walking with a cane to the bathroom and landed on his/her left hip. The resident was sent to the emergency department at 1:45 AM. The RN Assessment of Incident document dated 6/14/24 identified the care plan intervention(s) implemented was for PT/OT evaluation. The reportable event form dated 6/16/24 identified that Resident #42 was admitted to the hospital due to a left hip fracture. The nurse's note dated 6/20/24 at 9:26 PM identified Resident #42 was readmitted from the hospital back to the facility via stretcher around 3:48 PM. A fall risk assessment dated [DATE] identified Resident #42 was taking diuretics, hypoglycemic agents, antihypertensives, nonsteroidal anti-inflammatory medications, narcotics, psychotropics, and sedatives/hypnotics more than 3 times weekly, had an inadequate vision pattern, had total incontinence in the last 14 days, was confined to a chair and disoriented, and a gait analysis included: inability to independently come to a standing position and decrease in muscle coordination. The fall risk assessment further identified that Resident #42 was at a high risk for falls. The significant change MDS dated [DATE] identified Resident #42 had moderately impaired cognition, had a one-sided lower extremity impairment, and a chair/bed-to-chair transfer was not attempted due to medical condition or safety concerns. The care plan dated 7/17/24 identified Resident #42 had an actual fall with major injury. Interventions included a PT consult for screen, status post fall. Interview and review of the clinical record with the DNS on 8/27/24 at 9:38 AM failed to provide documentation that a comprehensive care plan was developed addressing Resident #42's history and risk for falls, prior to his/her fall with injury on 6/14/24. The DNS identified that she would have expected a care plan to be in place identifying Resident #42's risk for falls and appropriate interventions. The DNS indicated that the nursing supervisor can initiate a care plan, but typically it is the responsibility of the MDS coordinator, in collaboration with the interdisciplinary team, to develop the comprehensive care plan. Interview and review of the clinical record with the MDS coordinator (LPN #3) on 8/27/24 at 10:52 AM failed to provide documentation that a comprehensive care plan was developed addressing Resident #42's history and risk for falls, after admission to the facility. LPN #3 identified that she created a care plan after Resident #42 sustained an actual fall with injury when he/she returned to the facility on [DATE], but she was not aware that Resident #42 was a moderate risk for falls when he/she was admitted to the facility, or she would have created a fall care plan. LPN #3 further indicated that the RN supervisor usually starts the interim care plan, and then she would update the on-going comprehensive care plan. The Comprehensive Care Plan policy directs the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS assessment. All care assessment areas triggered by the MDS will be considered in developing the plan of care, and other factors identified by the interdisciplinary team, or in accordance with the resident's preferences will also be addressed in the plan of care. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for falls, the facility failed to ensure quarterly fall risk assessments were completed, per the facility policy. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, Alzheimer's disease, and repeated falls. The admission fall risk assessment dated [DATE] identified Resident #42 had a history of 1 - 2 falls within the last 3 months, was taking diuretics, hypoglycemic agents, antihypertensives, and psychotropics more than 3 times weekly, had an inadequate vision pattern, and a gait analysis included: inability to independently come to a standing position, loss of balance while standing, requiring a hands-on assist to move from place to place, utilizing an assistive device, and had a decrease in muscle coordination. The fall risk assessment further identified that Resident #42 was at a moderate risk for falls. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, was independent walking 150 feet, and had not sustained any falls since admission to the facility. The nurse's note dated 6/14/24 at 2:23 AM identified that Resident #42 was observed lying on the floor on his/her left side complaining of severe (10/10) left hip pain extending to the left leg. The resident was sent to the emergency department at 1:45 AM. The fall risk assessment dated [DATE] identified Resident #42 was taking hypoglycemic agents, antihypertensives, and nonsteroidal anti-inflammatory medications more than 3 times weekly, and a gait analysis included utilizing an assistive device. The fall risk assessment further identified that Resident #42 was at a low risk for falls. The nurse's note dated 6/20/24 at 9:26 PM identified Resident #42 was readmitted from the hospital back to the facility via stretcher around 3:48 PM. A fall risk assessment dated [DATE] identified Resident #42 was taking diuretics, hypoglycemic agents, antihypertensives, nonsteroidal anti-inflammatory medications, narcotics, psychotropics, and sedatives/hypnotics more than 3 times weekly, had an inadequate vision pattern, had total incontinence in the last 14 days, was confined to a chair and disoriented, and a gait analysis included: inability to independently come to a standing position and decrease in muscle coordination. The fall risk assessment further identified that Resident #42 was at a high risk for falls. Interview and review of the clinical record with the DNS on 8/27/24 at 9:38 AM failed to provide documentation that quarterly fall risk assessments were completed for Resident #42 following the admission fall risk assessment dated [DATE] and prior to the post-fall risk assessment dated [DATE] (9 months). The DNS identified that she would expect the fall risk assessments to be completed by the nurse on admission, quarterly, and after a fall occurs, per the facility policy. The Fall Risk policy directs the facility to have an objective tool to assess fall risk potential of each resident. The nurse will assess the resident upon admission, significant change of condition, and quarterly for their fall/risk potential, using the fall risk assessment form.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure annual performance evaluations were completed for nurse aide staff for 2023. The findings included: During a review of performance evaluations for facility nurse aide staff on 8/26/24 for 2023 and 2024, the facility failed to provide any documentation of performance evaluations completed for NA #1 and NA #2 for 2023. Subsequent to this review, an additional request was made to the DNS provide additional annual performance evaluations for NA #1 and NA #2 for 2023. Interview with the DNS on 8/27/23 at 11:00 AM identified she was unable to locate any annual performance evaluations for nurse aide staff that had been completed in 2023. The DNS identified she was new to the facility and had completed annual evaluations for 2024 but was unable to locate any evaluations for nursing staff for 2023. The DNS further identified that she identified that the evaluations had not been completed and implemented an annual performance evaluation policy in 6/2024 to ensure that the annual evaluations were completed going forward. The facility annual performance evaluation policy, dated 6/27/24, directed that the purpose of the policy was to ensure a consistent approach was followed for conducting annual performance reviews and that job related skills, knowledge, and employee competencies would be evaluated. The facility assessment policy directed that the purpose of the assessment was to determine what resources were needed to competently care of residents of the facility. The policy further directed that facility resources needed to provide competent care included staff training, education, and competencies.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #32 and 31) reviewed for falls, the facility failed to ensure staff followed the plan of care and/or provided appropriate assistance during a transfer. The findings include: 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A reportable event form dated 1/19/19 at 4:20 AM identified Resident #32 was attempting to ambulate in his/her room and was found on the floor when the alarm sounded. The fall investigation identified that Resident #32 was wearing socks. A new intervention to avoid future falls included the resident to wear non-skid socks at bedtime. An undated nurse aide care card identified Resident #32 was a high fall risk and was to wear non-skid socks when in bed, staff to discourage removal, and reapply as needed. The quarterly MDS dated [DATE] identified Resident #32 had severely impaired cognition, exhibited physical behavioral symptoms not directed toward other 1 to 3 days per week, required extensive assistance with bed mobility, transfers and toileting and limited assistance with ambulation. A fall risk assessment dated [DATE] identified Resident #32 had a moderate risk for falls. The care plan dated 3/4/19 identified Resident #32 was at risk for falls, injury and/or fracture due to gait/balance problems, psychoactive drug use, poor safety awareness and impaired vision. Interventions included to anticipate needs, ensure appropriate footwear when ambulating and follow fall protocol. A physician's orders [REDACTED].#32 twice daily to meals and to the bathroom using a roller walker and limited assistance. A reportable event form dated 4/29/19 identified Resident #32 had an unwitnessed fall and was found on the floor at 12:30 AM when the alarm sounded. Resident #32 had sneakers in his/her hands, was wearing regular socks, and did not have non-skid socks on. A nurse's note dated 4/29/19 at 10:57 PM identified Resident #32's resident representative indicated Resident #32 was having chest pain and was rubbing his/her chest area as well as the left arm, and facial grimacing was noted. Resident #32 was sent to the emergency department at 7:20 PM. A CT scan dated 4/29/19 identified acute fractures of the anterior left sixth and seventh ribs, and several fractures of the sternum. A nurse's note dated 4/30/19 at 6:02 AM identified that at approximately 11:40 PM yesterday, Resident #32 returned to the facility with a [DIAGNOSES REDACTED]. Resident #32 complains of pain when asked, difficulty expressing location or intensity. Standing Tylenol given as ordered. Interview and review of facility documentation with the DNS on 10/3/19 at10:25 AM identified Resident #32 gets out of bed in the middle of the night, removes everything, and at one point, had a helmet that he/she would remove. The DNS identified that the intervention after the fall on 1/19/19 was to add non-skid socks at bedtime. The DNS identified that the intervention after the fall on 4/29/19 was to add non-skid socks at all times, add a winged mattress and bilateral fall mats. The DNS could not explain or show documentation why Resident #32 was not wearing the non-skid socks at the time of the fall on 4/29/19 and indicated the intervention was not followed as Resident #32 had on regular socks at the time of the fall. Additionally, the DNS was unable to identify when the intervention (non-skid socks at bedtime) was placed on the nurse aide care card as the care card was undated, but the new intervention added on 4/29/19 was to place non-skid socks on Resident #32 at all times. The DNS identified that the nurse aides were responsible to place the non-skid socks on Resident #32 at night, and the licensed staff were responsible to ensure the intervention was implemented. Review of the fall policy identified nurse aides are to follow the interventions as outlined on the care plan and personalized resident assignment sheet. Although Resident #32 was at moderate risk for falls, had fallen on 1/19/19 while attempting to ambulate with socks on, and had a new intervention to wear non-skid socks at bedtime, Resident #32 was found on the floor on 4/29/19 at 12:30 AM wearing regular socks. Subsequently, Resident #32 was transferred to the emergency department after he/she complained of chest and left arm pain, and exhibited facial grimacing. At the hospital, a CT scan identified acute rib and sternal fractures. 2. Resident #31 had [DIAGNOSES REDACTED]. The care plan dated 3/4/19 identified Resident #31 was at risk for falls, leans to the right side in the customized wheelchair and often refuses to wear the seatbelt for position purposes despite encouragement from the staff. Interventions included to transfer Resident #31 out of bed via a sarita lift with the assistance of 2 to a customized wheelchair with velcro belt per 24 hour positioning plan. A fall risk assessment dated [DATE] identified Resident #31 was at moderate risk to fall. The quarterly MDS dated [DATE] identified Resident #31 had severely impaired cognition and required extensive assistance of 2 plus persons for transfers. A reportable event form dated 9/12/19 at 7:45 PM identified Resident #31 was lying on the floor in front the of the sarita lift. The report indicated Resident #31 was on the sarita lift for transfer and went down on his/her knees, and NA #4 lowered the resident to the floor. Resident #31 complained of pain to the left knee and right shoulder, and an x-ray was ordered. Actions taken directed transfers via sarita lift with the assistance of 2 staff. In a written statement dated 9/12/19, NA #4 documented that Resident #31 required 1 person for transfers. Additionally, NA #4 documented Resident #31 was lowered to the ground because he/she knelt down on the sarita lift. A nurse's note dated 9/12/19 at 11:44 PM identified at approximately at 7:45 PM Resident #31 was alert and responsive observed lying on the floor next to the bed and in front of the sarita lift. NA #4 indicated Resident #31 was on the sarita lift for transfer then went down on his/her knees. NA #4 then lowered Resident #31 down to the floor. Resident #31 complained of pain to the left knee and right shoulder. Subsequent to physician notification, an x ray of left knee and right shoulder-2 views was ordered. A radiology report dated 9/12/19 identified no fracture or dislocation. The reason for decision form dated 9/13/19 identified NA #4 demonstrated how she went behind Resident #31 and slowly lowered the resident to the floor. NA #4 indicated Resident #31's left leg was positioned backwards when she lowered the resident to the floor. Facility documentation dated 9/13/19 identified NA #4 received a written warning because she did not follow Resident #31's plan of care which directed 2 staff during sarita lift transfers. Additionally, re-in servicing was preformed regarding the importance of adhering to each resident's plan of care. The request for rehabilitation screen dated 9/13/19 identified, according to the primary nurse aide, Resident #31 was having behavioral disturbances when the incident happened which is not new. Resident #31 may continue to use sarita lift for transfers with the assistance of 2 in order to prevent further incidents. A nurse's note dated 9/13/19 identified RN #1 was called to the unit regarding Resident #31's left knee which was swollen and red in color. RN #1 conducted an assessment which identified the left leg was internally rotated and the resident was unable to significantly lift it up or wiggle toes (only slightly). NA #4 indicated Resident #31 usually is able to move left leg and toes. Resident #31 complained of discomfort to the left knee and received Tylenol 650 mg. Resident #31 appeared sleepy today but easily aroused. Subsequent to physician and responsible party notification, Resident #31 was sent to the emergency room for evaluation. The hospital radiology report dated 9/13/19 identified no detected acute fracture or dislocation of the hip and left knee. Interview with the DNS on 10/3/19 at 11:40 AM identified she was not aware that Resident #31 had a care plan which identified Resident #31 was to be transferred via sarita lift with the assistance of 2 staff. Interview with NA #4 on 10/3/19 at 11:50 AM identified she worked a double shift on 9/12/19 and was assigned to Resident #31 during the evening shift. NA #4 indicated she has always transferred Resident #31 alone with the sarita lift. NA #4 indicated Resident #31 was in the wheelchair and it was time to put the resident to bed. NA #4 indicated she explained the procedure to Resident #31 as she went along. NA #4 identified she placed the straps underneath both arms and proceeded with lifting the sarita at that time. Interview and demonstration on 10/3/19 at 12:05 PM with NA #4 identified Resident #31 was sitting in the wheelchair at the foot and in between both beds. NA #4 indicated she placed the straps underneath both arms and both feet were on the footrest. NA #4 indicated after lifting the sarita lift in the up position during the turn with the sarita lift to the left towards the bed. Resident #31 started going down on her knees. NA #4 indicated she left the front of the sarita lift and went behind the resident at that time and indicated Resident #31 was kneeling on both knees on the footrest. NA #4 indicated she removed the straps and lowered the resident to the floor and called for the nurse. NA #4 indicated she straighten out the right leg, but does not remember the position of the left leg at that time. Review of facility sarita lift policy identified it is the policy of the facility for trained nurses and nursing assistants to use the sarita lift as needed for transporting appropriate residents who can weight bear partially. Tell resident what you are doing. Raise the resident up until they are supported in a sitting position - their feet being supported on the footrest. Addendum: The sarita lift requires the assistance of one person unless otherwise indicated by the nurse. This will be reflected in the nurse assignment and on the care plan. Review of the facility fall prevention and management program policy identified the purpose of the falls prevention and management program is to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and management strategies that foster resident independence and quality of life while ensuring safety for the resident and other residents and staff. A fall is any unintentional change in position where the resident ends up on the floor, ground or other lower level.

Based on review of the clinical record, facility documentation and staff interview for the only sampled resident, (Resident #78), reviewed for a medication error, the facility failed to ensure the resident was free from a significant medication error. The findings include: Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A laboratory report dated 12/5/16 identified Resident #78 had a [MEDICATION NAME] [MEDICATION]) level of 69 ug/ml (therapeutic range 50-100). The significant change MDS dated [DATE] identified Resident #78 had severely impaired cognition, exhibited no behaviors, required extensive assistance with care, and did not have an active [DIAGNOSES REDACTED]. The care plan dated 1/25/17 identified a history of [MEDICAL CONDITION], with the most recent [MEDICAL CONDITION] on 7/1/16. Interventions included to administer medications as ordered, and monitor Resident #78's blood work for therapeutic doses of medication per the physician. The physician's orders [REDACTED]. Review of the March 2017 MAR failed to reflect Resident #78 received [MEDICATION NAME] 250mg every morning or [MEDICATION NAME] 500mg every evening from 3/1/17 to 3/27/17 (a total of 27 days). Nurse's note dated 3/27/17 at 5:15 PM identified Person #1 reported to staff that while he/she was feeding Resident #78, Resident #78 started to have a [MEDICAL CONDITION]. Person #1 reported that in a split second, Resident #78 became rigid, sucked in liquid that was in his/her mouth, and became congested. Upon assessment, Resident #78 had audible congestion, pale color and was unresponsive. Resident #78 was suctioned by the DNS for a moderate amount of white liquid with small food particles. Eventually Resident #78 became responsive and spoke a couple of words to Person #1. The physician was notified of the [MEDICAL CONDITION] and that Resident #78 had not received [MEDICATION NAME] since 3/1/17. The physician directed to restart the [MEDICATION NAME] and to obtain a chest x-ray in the morning to rule out aspiration pneumonia. The nurse's note dated 3/28/17 at 12:20 AM identified Resident #78 had abnormal vital signs, blood pressure 155/114, pulse 124, and a temperature of 100.3. Subsequent to physician notification, Resident #78 was transported to the hospital for an evaluation. The reportable event form dated 3/30/17 identified Resident #78's [MEDICATION NAME] had accidentally been discontinued and was not administered from 3/1/17 to 3/27/17 (27 days). Additionally, the reportable event form identified Resident #78 possibly had [MEDICAL CONDITION] activity. The hospital discharge summary dated 4/4/17 identified Resident #78 was admitted on [DATE] with a [MEDICAL CONDITION] due to not receiving the prescribed [MEDICAL CONDITION] medication. Resident #78's [MEDICATION NAME] level on admission to the hospital was 6.9 ug/ml (therapeutic range 50-100 ug/ml), well below the therapeutic range. Resident #78 was started on [MEDICATION NAME] 2mg every 2 hours via IV. The documentation identified Resident #78 had not been receiving sufficient medication to prevent [MEDICAL CONDITION]. Interview and review of the clinical record with the DNS on 7/12/17 at 10:00 AM identified that although the facility does not have a written policy for monthly medication reconciliation, it is the responsibility of the 11:00 PM to 7:00 AM charge nurse to complete the monthly medication reconciliation while reviewing current physician orders. Additionally, while LPN #1 was completing the monthly medication reconciliation for Resident #78 on 3/1/17, the computer system broke down and was not accessible. During that time, the physicians order for [MEDICATION NAME] was inadvertently removed from the physician orders, and not placed on the March 2017 MAR. The DNS indicated Resident #78 did not receive the ordered [MEDICATION NAME] in accordance with physician orders [REDACTED].#78 being transferred and admitted to the acute care hospital on [DATE] with a [DIAGNOSES REDACTED].

Based on observations, clinical record reviews, review of facility policy/procedure and interviews for 4 of 6 sampled residents reviewed for pressure ulcers (R# 2, 40, 42, 44), the facility failed to conduct complete wound assessments on admission and/or weekly, and/or failed to revise the plan of care to prevent repeated pressure sores to the same area, and /or failed to implement interventions to prevent the development of and/or ensure healing of pressure ulcers. The findings included: 1. Resident #2 ' s [DIAGNOSES REDACTED]. The care plan (RCP) dated 09/06/15 identified the potential for skin breakdown. Interventions included applying a barrier cream after incontinent care and as needed and to turn and re-position every two hours. Wound documentation identified that R#2 developed a stage II pressure ulcer on 11/01/15, located on his/her coccyx and that it healed on 11/10/15. The coccyx area then developed a stage II pressure area again on 12/31/15 that healed on 01/09/16 and another stage II that developed on 01/22/16 and was healed on 02/12/16. A quarterly assessment dated [DATE] the resident was cognitively impaired, totally dependent on staff for bed mobility, at risk for development of pressure ulcers and had a history of [REDACTED]. Nurse's notes dated 5/30/16 at 11:00 PM identified a new area of excoriation located on the resident's coccyx. An interim care plan dated 05/30/2016 identified a coccyx excoriation. Interventions included application of [MEDICATION NAME] (barrier) cream after incontinent care and as needed and to turn and reposition every two (2) hours. Nurse's notes dated 06/02/16 at 4:10 PM identified that R#2 developed an open area located on his/her coccyx. A wound assessment dated [DATE] identified a new stage two (2) pressure ulcer located on R#2's coccyx that measured 1.0 CM x 1.4 CM. A wound assessment dated [DATE] identified that the coccyx area measured 1.0 cm x 0.5 cm x 0.2 cm. Intermittent observation of R#2 on 06/15/2016 from 6:12 AM to 9:15 AM (three (3) hours) noted the resident in bed with the head of bed at greater than a 45 degree. The resident was positioned on his/her back without the benefit of repositioning and/or off-loading off of his/her back/buttocks and/or heels for that time period. Although a pillow was placed under the resident's left shoulder at approximately 9:15 AM, the resident's buttocks, coccyx and heels remained directly in contact with the mattress. During an interview and review of R#2's clinical record with RN#1 on 06/15/2016 at 9:51 AM, s/he indicated that although an interim plan of care was written, s/he was unable to provide documentation that R#2's care plan was revised with new approaches to prevent repeated pressure ulcers to the coccyx area from reoccurring. Interview with LPN #4 on 06/15/2016 at 1:29 PM indicated that R#2 required frequent repositioning and that the air mattress provided adequate pressure relief. Facility policy procedure for the prevention of pressure ulcer development identified in part, to assess bed /chair mobility and how the resident will be positioned at least every two (2) hours and if heels are of concern, support surfaces would include bed pillows placed lengthwise under legs to keep heels off bed and for prevention of friction and shear, limit head of bed elevation, bed-gatch at knee to reduce sliding in bed or to place wedge at foot of bed. 2. Resident # 40 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission nursing evaluation dated 2/14/16 indicated R # 40 had multiple bruises but no skin breakdown. Bed mobility and transfer ability were unknown at that time. Physician orders [REDACTED]. A PT evaluation dated 2/15/16 indicated R #40 required maximum assist for bed mobility and transfers. On 2/17/16, a wound assessment documented a new onset, 2.8 cm x 4.8 cm blister on the left heel. A resident care plan dated 2/17/16 identified a left heel blister. Interventions included monitor for skin integrity, skin prep to heels and heel boots at all times. Physician orders [REDACTED]. A review of the clinical record and interview on 6/15/16 at 8:02 AM with RN #1 failed to provide documentation that a care plan had been developed and/or implemented on admission (2/14/16) to prevent skin breakdown. He/she indicated that interventions were put in place including offloading the resident ' s heels when the blister was identified on 2/17/16. Although the resident had surgery to repair a left femoral neck (leg) fracture and a fractured humerus, RN #1 indicated that preventative interventions were not put in place because the resident was considered to be low risk for developing a pressure ulcer. The facility policy on pressure ulcer prevention directed to ensure heels are free from the surface of the bed. Heel-protection devices should elevate the heel completely (off-load). 3. Resident #42's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated that the resident was severely cognitively impaired, totally dependent on two staff for all bed mobility and transfers, dependent for eating, incontinent of bowel and bladder, at risk for developing pressure sores and had no pressure sores present. The care plan initiated on 11/16/15 identified a risk for development of pressure sores. Interventions included monitoring heels every shift for infection and pain. Nurse's notes dated 11/22/15 indicated that bilateral heels redness persists. Off loaded on pillows. No other nursing notes before or after indicated the presence of redness or offloading of heels. On 11/26/15 at 11:25 PM, nurse's notes documented a right heel pressure ulcer (unstageable) was found that had intact eschar and a blister. No further assessment and/or description of the area was documented until 11/27/15 when wound records indicated that the resident had developed a right heel deep tissue injury with a dark purple center that was fluid filled and had eschar. The physician and family were notified at that time. Treatment records for November 2015 indicated that offloading of the heels was not initiated until after the unstageable pressure ulcer was found on 11/27/15. The quarterly MDS dated [DATE] identified that the resident remained as previous but now had one unstageable pressure ulcer. On 2/18/16, the care plan was updated to include off loading heels on pillows when in bed. Wound Care Center notes dated 5/23/16 noted that the pressure sore of the heel had continued to decline with evidence of osteo[DIAGNOSES REDACTED] (bone infection) and visible bone and tendon in the wound. The nurse aide care card (assignment) as of 6/15/16 directed application of multi podus boots to both feet and offload heels. Observations on 06/15/2016 at 6:45:27 AM noted the resident in bed on his/her back with knees bent, both heels resting on the mattress and no offloading boots in place. At 7:45 AM, the resident remained in the same position. Observations at 8:10 AM with RN#1 noted that the right heel had been offloaded on a pillow and the left heel was sitting on the bed. No boots were on and RN#1 found the boots in the tub room sitting in the resident's wheelchair. The boots were not multi-podus boots but were heel lift boots. RN#1 noted that s/he thought that those boots were multi-podus boots. NA# 7 was providing care to the roommate and responded when asked, that s/he had elevated the resident's right foot on the pillow when s/he came into the room (to give roommate care). NA#7 did not see the resident's boots since coming on duty at 7AM. Interview and review of the clinical record with RN#1 on 06/15/2016 at 8:10 AM and 9:07 AM failed to provide documentation that R#42 who was at risk for pressure sore development at the time of admission, had interventions initiated to prevent heel breakdown, and/or that the resident with an unstageable heel wound, received appropriate care to aide in healing the wound by off loading pressure. 4. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified both heels were reddened and had scabs ; no further description of the areas was documented including the color, size, stage, any exudate, odor, the condition of the wound area, as well as surrounding area. Physician orders [REDACTED]. The admission MDS assessment dated [DATE] identified the resident was without cognitive impairment, required extensive assistance of two for bed mobility and transfers, was frequently incontinent of bowel and bladder, and was at risk for developing pressure ulcers with no pressure ulcer present at that time. Physician orders [REDACTED]. The RCP dated 3/2/16 identified a potential for pressure ulcer development. Interventions included skin prep to both heels secondary to scabs; follow facility policies/protocols for the prevention/treatment of [REDACTED]. Interview and review of the clinical record with RN #1 on 6/14/16 at 12:00 PM identified when a resident is admitted to the facility, a complete body assessment is completed by the charge nurse and documented on the weekly skin assessment form. If a resident is identified with a pressure ulcer/skin condition, a weekly assessment of the area is completed and documented on the weekly wound assessment form. RN#1 was unable to provide any comprehensive wound assessments or weekly assessments of the resident ' s heels from 2/20/16 through 3/16/16. Facility policy and procedure for care of pressure ulcers and prevention identified it is the policy to prevent the development of pressure ulcers in residents whenever possible by relief of pressure, appropriate skin and incontinence care and adequate nutrition. A complete skin condition audit will be done upon admission. A skin audit will be done weekly thereafter. Additionally wound assessment documentation will be completed on admission, at least weekly and as changes in the wound are apparent. Documentation will include a description of the area, including color, size, depth, location, extent of drainage, condition of the wound area, as well as the surrounding area.

Based on clinical record review and interview, for one of two sampled residents with [DIAGNOSES REDACTED]. The findings include: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident was moderately cognitively impaired, totally dependent on staff for mobility and eating, and was on a mechanically altered diet. The care plan dated 3/9/12 identified the risk for altered nutrition due to dysphagia. Interventions included puree diet with honey thick liquids, to assist with meals and provide 2 cal HN 120 cc four times a day. The dietitian's initial assessment dated [DATE] identified the need for 1365-1650 cc of fluid per day. The dietitian noted that the resident was "meeting fluid needs". Review of intake and output (I&O) records noted the following intakes from 2/28/12 through 3/4/12: 900 cc, 780cc, 900 cc, 720 cc, 740 cc, and 640 cc respectively. On 2/28, 3/2, and 3/4/12, the I&O's were incomplete and/or not totalled. On 3/9/12 the physician was notified of poor fluid/food intake and orders were written for [MEDICATION NAME] (appetite stimulant) daily. Intake and output records from 3/9/12 through 3/13/12 noted the following intakes; 560 cc, 900 cc, 1000 cc, 470 cc. On 3/13/12 the resident was transferred to the hospital for lethargy and altered mental status. The hospital discharge summary dated 3/15/12 indicated that upon admission, the resident had dry oral mucosa, and a BUN of 62 (normal 7-25). The resident's prior BUN on 3/1/12 was 23. The discharge [DIAGNOSES REDACTED]. Interview and review of the clinical record with the DNS on 4/26/12 at 11:15 AM failed to provide documentation that the resident was assessed for signs and symptoms of dehydration and/or that interventions were initiated to prevent dehydration when the resident repeatedly failed to meet the estimated fluid goals.

Based on clinical record review and staff interview, for one of two residents in the survey sample reviewed with pressure ulcers (Resident #71), the facility failed to ensure measures were in place after a splint was applied to prevent skin breakdown. The findings include: A Minimum Data Set assessment dated [DATE] identified the resident with a severe cognitive deficit, was independent with bed mobility, required limited assist with transfer and walking, required total care with locomotion, and had no pressure ulcers. A Braden scale pressure ulcer risk dated 3/9/11 identified the resident with a risk score of 18 (12 or less = high risk). A weekly skin assessment dated [DATE] noted no problem areas. Bilateral dry skin on feet. A resident care plan dated 3/9/11 noted a problem with potential for skin breakdown. Interventions included barrier cream for incontinent episodes as needed. Review of a nurse's note dated 5/22/11 at 8:00 PM noted Resident #71 complained of pain in the right foot when NA # 3 attempted to transfer the resident out of the wheelchair. No bruising, open areas, or obvious deformity was observed. The resident had slight [MEDICAL CONDITION] to the right outer ankle. An x-ray was ordered and completed on 5/23/11. An x-ray report of the right ankle dated 5/23/11 noted a comminuted spiral [MEDICAL CONDITION] right tibia with mild displacement and a nondisplaced proximal fibular fracture. The resident was sent to the emergency roiagnom on [DATE] for evaluation. An emergency department report dated 5/23/11 noted a short leg splint -posterior, outer lower leg, toe to knee was applied. A nurse's note dated 5/24/11 at 9:30 AM noted Resident #71 was out to an appointment with the orthopedist. At 12:00 PM Resident #71 returned with the directions that the splint was to remain in place to right lower leg. An orthopedic consult progress note dated 5/24/11 directed to continue splint, nonweight bearing right lower extremity, and follow-up in 6 weeks for repeat x-rays. A treatment record dated 6/3/11 indicated to monitor right lower leg status [REDACTED]. A nurse's note dated 6/22/11 at 3:45 PM noted Resident #71 with increased pain and guarded body language. The physician was notified and recommended consult with orthopedist. A nurse's note dated 6/24/11 at 1:20 PM noted Resident #71 out to orthopedist for follow-up appointment. An orthopedic follow-up dated 6/24/11 noted a wound on the right anterior medial foot. Patient requires vascular, plastics, or wound care consult. Continue non weight bearing in CAM walker boot. A nurse ' s note dated 6/24/11 noted a right anterior medial wound measuring 15 centimeters (cm) x 9.5 cm with a black-yellow wound bed; a right inner ankle wound measuring 7 cm x 8.5 cm with a darkened wound bed; a right outer aspect of foot wound measuring 5cm x 3.5 cm of black eschar; a right heal wound measuring 6.5cm x 6.5 cm with black eschar; and a right bunion area wound measuring 3.2 cm x 3.2 cm with a darkened reddened wound bed. A vascular consult dated 6/27/11 indicated in part, extensive soft tissue loss secondary to right lower leg fracture and cast. Non-salvageable foot secondary to severe extensive soft tissue loss. Review of physician progress notes [REDACTED]. Comfort measures. Hospice consult. An interview and review of the clinical record on 4/26/12 at 11:30 AM with the assistant of director noted a resident care plan dated 5/23/11 that addressed the fractured tibia/fibula. Interventions included monitor CMS to right leg toes, monitor splint, and maintain non-weight bearing to the right leg. At that time she was unable to provide documentation that the resident care plan was reviewed and revised to include interventions to monitor for and/or prevent skin breakdown after the resident's change in condition and the splint was in place.

Based on clinical record review and staff interview, for two of seven residents in the survey sample reviewed for accidents (Residents #25 and 67) the facility failed to ensure a chair alarm was turned on per the resident care plan to prevent a resident fall. The findings include: 1. Resident # 25 [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] identified the resident with a severe cognitive deficit, required extensive assist with transfer and did not walk. A resident care plan dated 8/24/11 identified a problem with potential for falls/fractures. Interventions included keep environment simple and uncluttered and routine care providers as possible. A nurse's note dated 9/3/11 at 12:50 PM noted the resident was found on the floor in a sitting position. A lump was noted on the back of the residents head. The resident was sent to the emergency roiagnom on [DATE] at 1:25 PM for evaluation. A radiology report dated 9/3/11 noted fractures and sclerosis of the right superior and inferior public ramus and a fracture of the left inferior pubic ramus.Review of a reportable event and investigation dated 9/3/11 indicated Resident # 25 was found on the floor with legs extended and back towards bathroom door. Resident was at risk for falls. Interventions included alarms (bed and chair). At the time of the fall the alarm did not sound. Nurse aide forgot to put alarm on. An interview on 4/25/12 at 1:05 PM with the Director of Nursing indicated Nurse Aide (NA) # 1 had turned off the chair alarm to toilet the resident and forgot to turn the chair alarm back on prior to the resident being found on the floor. An interview on 4/26/12 at 9:15 AM with NA #1 indicated she did not recall the event. The facility failed to ensure that measures were in place to prevent a fall. 2. Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated that Resident #67 was a high fall risk. The quarterly Minimum Data Set ((MDS) dated [DATE] identified moderate cognitive impairment, supervision with bed mobility and transfers and limited assistance with ambulation. A physical therapy evaluation was conducted on 2/13/12 after Resident #67 returned from the hospital on [DATE] status [REDACTED]. The nursing care plan dated 2/16/12 identified Resident #67 had a hip fracture with interventions that included an air mattress to bed, a call bell within reach and a clip alarm when in bed. Review of the facility documentation dated 2/18/12 identified that at 9:15 PM Resident #67 was found lying on the floor in his/her room near the end of the bed complaining of right leg pain and was unable to extend his/her right leg. The physician was notified and Resident #67 was transferred to the hospital at 9:50 PM. Imaging revealed a left hip fracture and Resident #67 underwent surgery for [REDACTED]. Interview with NA #4 on 4/26/12 at 10:00 AM identified she did not see an alarm clip in the residents room and therefore did not place the alarm on the resident when she put him/her to bed. The treatment record dated 2/18/12 identified the clip monitor was on while in bed and was checked for placement and function on each shift. Interview with RN #2 on 4/26/12 at 4:19 PM identified she checked the function of the clip monitor early in the shift when Patient #67 was not in bed. RN #2 indicated the clip monitor was in the room and functioning on 2/18/12. Interview with the Director of Nursing on 4/24/12 at 12:45 PM identified it was the responsibility of the nursing assistant to ensure the clip alarm was on when Resident #67 was placed in bed. The facility failed to ensure measures were in place to prevent a fall.