Every finding on record at River Glen Health Care Center

. Based on observation, review of the clinical record, facility documentation and facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision to prevent a resident from leaving the facility without staff knowledge after they were notified the resident was planning to leave the facility, and failed to ensure a complete investigation was completed after a resident left the facility without staff knowledge. The facility failed to implement appropriate interventions after they became aware of the resident's intent to leave the facility, resulting in the resident exiting the building unescorted and without staff knowledge. The findings include: Resident #1's diagnoses included cerebral infarction, atrial fibrillation, chronic kidney disease, dysphagia, and aphasia. The Resident Care Plan dated 5/19/26 identified Resident #1 is at risk for difficulty understanding/communicating related to expressive/receptive aphasia. Interventions include minimizing excess noise. Using yes/no questions and responses when able. Gaining the resident's attention before initiating conversation. Mirroring the resident's facial expressions and body language to demonstrate understanding. Providing reassurance and patience with repetition of information as needed. Obtaining Speech-Language Pathology evaluation and treatment as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen (3/15), indicating of being severely cognitively impaired. Resident #1 had no wandering behaviors and ambulated independently. Review of the State of Connecticut Probate Court documentation dated 5/26/26 revealed Resident #1 was under a court-appointed conservatorship, with Person #1 being appointed for both the person and estate.A social services progress note dated 6/19/26 at 3:55 PM by SW #1 identified SW #1 received a call from Person #1. He/she stated that Resident #1 had called Person #1 to let him/her know that Resident #1 is calling an uber and he/she is heading home. Person #1 had sent Person #1 a picture of him/her packing his/her belongings. Person #1 added that Resident #1 does not understand that he/she needs to wait for staff through the state program. SW #1 alerted RN #1 and receptionist.A nursing progress note dated 6/20/26 at 12:13 AM by RN #2 identified at beginning of evening shift, DON (Director of Nursing) reported to RN #2 that Resident #1 had left building via uber earlier today. RN #2 called APRN #1 regarding the above and Social Services updated as well. DON updated RN #2 that Person #1 would be coming this evening at 7:00 PM to sign discharge paperwork. At 9:00 PM, Person #1 had not arrived to SNF (skilled nursing facility) to sign paperwork, RN #2 called Person #1, and indicated he/she will not be coming to sign paperwork, wants paperwork emailed to him/her, RN #2 updated DNS.Interview with the DON, Social Worker (SW) #1, and the Administrator on 7/13/26 at 10:40 AM identified Resident #1 was alert and oriented to place and family and had aphasia, which limited his/her ability to communicate effectively. The team stated Resident #1 had no prior history of elopement behaviors while residing at the facility. The DON, SW #1, and Administrator initially stated Person #1 had not notified them of Resident #1's intention to leave the facility. However, SW #1 clarified that on 6/19/26, at approximately 1:00 PM, Person #1 contacted her and reported Resident #1 had sent photographs showing he/she was packing his/her belongings and intended to leave the facility. SW #1 immediately notified RN #1 and confirmed Resident #1 remained in his/her room. SW #1 then left the area while RN #1 continued to assess the situation and attempted to apply a wander guard; however, Resident #1 refused the device. SW #1 further stated Person #1 contacted the facility again between approximately 2:30 PM and 3:00 PM and reported Resident #1 had arrived home. The DON acknowledged that, despite Resident #1 refusing the wander guard, additional interventions should have been implemented to ensure the resident's safety, including increased monitoring, frequent safety checks, or one-to-one supervision. The DON confirmed no additional supervision, or monitoring interventions were initiated after the facility became aware of Resident #1's intent to leave. The DON and Administrator stated the interdisciplinary team considered the incident an against medical advice (AMA) departure rather than an elopement because Resident #1 chose to leave before discharge services could be arranged.Interview with RN #1 on 7/13/26 at 11:45 AM identified she received a call from the receptionist reporting that Person #1 had contacted the facility and stated Resident #1 intended to leave the facility. RN #1 immediately went to Resident #1's room, confirmed the resident was present, and asked if he/she planned to leave. Resident #1 denied any intention to leave, and RN #1 stated she did not observe any indications the resident was preparing to leave, such as packed belongings. Due to the concern reported by Person #1, RN #1 attempted to apply a Wander guard device; however, Resident #1 refused. RN #1 stated she did not implement any additional interventions because Resident #1 denied planning to leave. RN #1 notified the DON and first-floor nursing staff of the reported concern but confirmed no increased supervision, frequent monitoring, or other safety interventions were initiated. RN #1 stated she updated the DON regarding the situation during a facility team meeting at approximately 2:30 PM and recalled the last time she observed Resident #1 was between approximately 2:00 PM and 2:30 PM. At approximately 3:30 PM, while with the DON, a staff member informed them that Person #1 had contacted the facility and reported Resident #1 had arrived home.Interview with the DON on 7/13/26 at 1:30 PM identified the facility did not report Resident #1's 6/19/26 unescorted departure to the State agency and did not conduct an investigation into the incident because the facility determined Resident #1's departure was an against medical advice (AMA) discharge rather than a reportable unescorted departure/elopement event.Review of facility documentation and staff interviews identified the facility did not conduct an investigation into the circumstances surrounding Resident #1's unescorted exit from the building. Despite the resident leaving the facility without staff knowledge and later being confirmed at home by Person #1, the facility was unable to provide documentation of an investigation to determine how the resident exited the building, identify contributing factors, or implement corrective actions to prevent a recurrence.Review of the Wandering and Elopements Policy dated 03/2019 identified the facility will identify residents who are at risk of unsafe wandering and stive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation(s), review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #118) reviewed for respiratory care, the facility failed to properly store medication and obtain a physician order with completion of a self administration assessment for a resident with chronic obstructive pulmonary disease (COPD). The findings include:Resident #118's diagnoses included COPD, chronic respiratory failure with hypoxia, emphysema, and pneumonia. A physician's order dated 7/16/25 directed Ventolin HFA (a bronchodilator used to treat asthma) aerosol solution 108mcg/act (Albuterol Sulfate HFA) 2 puffs inhaled orally every 4 hours as needed for shortness of breath.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was cognitively intact and required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS indicated Resident #118 was on continuous oxygen therapy.The Resident Care Plan (RCP) dated 7/29/25 identified Resident #118 had a risk for respiratory impairment related to COPD and an infection of the respiratory tract (pneumonia). Interventions included to administer medications and treatments per the physician's order and to monitor lung sounds and changes in respiratory rate and effort.The Medication Administration Record (MAR) for August 2025 identified Resident #118 had a physician's order for Ventolin HFA Aerosol Solution 108 mcg/act (Albuterol Sulfate HFA) 2 puffs inhaled orally every 4 hours as needed for shortness of breath. The MAR failed to indicate documentation of any dates or times of administration of Ventolin to Resident #118 from 8/1/25 through 8/14/25.A physician's progress note dated 8/4/25 at 11:24 AM identified Resident #118 had a chest x-ray ordered for acute worsening of a cough with congestion and was declining nebulizer treatments and preferred to use a metered dose inhaler.A respiratory treatment progress note dated 8/4/25 at 11:54 AM identified Resident #118 had an increased cough and congestion with coarse rhonchi and an expiratory wheeze throughout his/her lung fields. The progress note recommended to continue maintenance inhalers.A physician's progress note dated 8/7/25 at 11:16 AM identified Resident #118 had developed congestion and a cough with some wheezing. The progress note indicated Ventolin as a current medication.A physician's progress note dated 8/11/25 at 6:21 PM identified Resident #118's cough and shortness of breath had improved, and the resident didn't feel the nebulizer was helpful and preferred to use a metered dose inhaler.Observation and interview with Resident #118 on 8/14/25 at 9:50 AM identified he/she had an Albuterol Inhaler on the nightstand next to his/her bed and that it was given to him/her by the facility. Resident #118 indicated he/she kept the inhaler next to his/her and would self-administer the inhaler as needed 3-4 times per day. Resident #118 stated the nurses were aware he/she had the inhaler at the bedside, and he/she was not asked by and did not inform the nurses when he/she self-administered the inhaler or what its effectiveness was.An interview and observation with Nurse Aide (NA) #3 on 8/14/25 at 9:55 AM identified Resident #118 was in bed and an Albuterol inhaler was unsecured/not locked up on the nightstand next to the bed. NA #3 indicated the inhaler was always there and she had observed Resident #118 using the inhaler on a few occasions. NA #3 identified although medications should not be left at a resident's bedside, she failed to inform the nurse the inhaler was there and should have. An interview, observation, and review of the clinical record on 8/14/25 at 10:00 AM with Licensed Practical Nurse (LPN) #3 identified Resident #118 was in bed and an Albuterol inhaler was resting on the nightstand next to the bed. LPN #3 indicated although it was not brought to her attention by other staff, she had observed the Albuterol inhaler on the resident's nightstand and was aware the resident was using it. LPN #3 identified the inhaler was from the facility and contained a pharmacy label on its side which indicated the resident's name and the name of the medication. Review of the clinical record with LPN #3 failed to identify Resident #118 had a physician's order to self-administer or a self-administration assessment completed for the use of the Albuterol inhaler. LPN #3 further indicated the Albuterol inhaler should have been locked in the medication cart between uses and not left on Resident #118's nightstand. LPN #3 proceeded to remove the Albuterol inhaler from Resident #118's room and locked the inhaler in the medication cart.Interview and review of the clinical record on 8/14/25 at 10:10 AM with the RN Supervisor (RN # 2) identified the Albuterol inhaler should not have been at Resident #118's bedside and review of the clinical record failed to indicate a physician's order for self-administration, or a self-administration of medication assessment had been completed for the resident. RN #2 indicated it was the responsibility of the nurse who verified the physician's order to clarify with the physician and assess the resident for self-administration. RN #2 identified that even with the physician's order for self-administration and an assessment completed, the Albuterol inhaler should have remained locked in the medication cart between uses so that the resident's usage and the medications effectiveness was documented.Subsequent to surveyor inquiry, a self-administration of medication assessment was completed by RN #2 on 8/14/25 for Resident #118 to self-administer Ventolin (Albuterol). The assessment was incomplete and failed to indicate if the resident had been interviewed.Review of the facility policy, Self-Administration of Medications, undated, directed residents have the right to self-administer medications if it has been determined by an assessment that it is clinically appropriate and safe for the resident to do so. If deemed safe and appropriate for a resident to self-administer medications, it would be documented in the resident's medical record and care plan. The policy further directed that self-administered medications must be stored in a safe and secure location and any medications found at the bedside should be turned over to the nurse.

Based on review of the clinical record, facility policy and interviews for the 1 of 32 sampled residents (Resident #2) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent. The findings include:Resident #2's was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, acute respiratory failure with hypercapnia (retention of carbon dioxide) and chronic kidney disease. A State of Connecticut Department of Public Health transfer of Do Not Resuscitate (DNR) order form signed by the physician on [DATE] indicated Resident #2 had a valid DNR order which was written on [DATE] and was retained in the resident's medical record. A hospital discharge summary for Resident #2 dated [DATE] at 11:59 PM identified the discharge code status as do not resuscitate/do not intubate (DNR/DNI). An admission physician's order dated [DATE] indicated Resident #2 was a DNR. An Advanced Practice Registered Nurse (APRN) order written by APRN #2 dated [DATE] directed Resident #2 was a Full Code (meaning in the event of his/her heart stopping, cardiopulmonary resuscitation would be performed). An APRN #2 progress note dated [DATE] at 9:45 AM identified Resident #2 had a code status of Full Code/CPR (despite the physician signed State of Connecticut Department of Public Health transfer of DNR order form dated [DATE] and physician order indicating DNR). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact and required partial/moderate assistance with bed mobility, toileting, and transfers. A Resident Care Plan (RCP) dated [DATE] identified Resident #2 had an advance directive for a full code (perform CPR). Interventions included to honor and to re-evaluate advance directives as needed. (despite the physician signed State of Connecticut Department of Public Health transfer of DNR order form dated [DATE] and physician order indicating DNR). Review of Resident #2's clinical record on [DATE] at 11:06 AM identified Resident #2 had both a DNR and Full Code order in place. Interview and review of the clinical record with the Registered Nurse supervisor (RN #2) on [DATE] at 10:16 AM identified Resident #2 was a full code based on what was listed on the resident's face sheet. Review of the active physician's orders for Resident #2 with RN #2 indicated the resident had both DNR and Full Code orders in place. RN #2 identified the [DATE] admission DNR order was signed by the physician on [DATE] and a [DATE] Full Code order from APRN #2 was also signed on [DATE]. RN #2 indicated Resident #2's advanced directive orders were confusing, and the resident should not have had two different advanced directive orders in place at the same time. RN #2 indicated she was unsure what Resident #2's current code status was, and she was unable to indicate why a new order was written by APRN #2 on [DATE] for Resident #2 to be a Full Code. RN #2 indicated she would immediately address the residents advanced directives with the resident and the physician and make the necessary corrections. Subsequent to surveyor inquiry, Resident #2's DNR/DNI order (dated [DATE]) was discontinued on [DATE] and Resident #2 was made a Full Code. Attempts to interview APRN #2 were unsuccessful. Review of facility policy, Advanced Directives, dated [DATE], directed a resident has the right to formulate an advanced directive and advanced directives are honored in accordance with state law and facility policy. The policy further directed that if the resident has executed an advanced directive, copies of the documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's physician and direct care staff by placing the advance directive documents in a prominent accessible location in the medical record.

Based on observations, review of the clinical record, interviews and facility policy for the only resident reviewed for communication/sensory (Resident #8), for 1 of 3 sampled resident (Resident #32) reviewed for pressure ulcers, for the only sampled resident reviewed for positioning (Resident #90), the facility failed to ensure a comprehensive care plan was in place for hearing (Resident #8), for refusals of care (Resident #32) and for functional limitation in range of motion (Resident #90). The findings include: 1.Resident #8 diagnoses included failure to thrive, heart failure, and osteoarthritis. A facility contracted audiology consult form dated 9/17/24 identified that Resident #8 had a right and left hearing aid from another company. The aids were cleaned for wax and debris and were functioning. Resident #8 declined to receive new hearing aids at that time. No follow up audiology consults were in the clinical record. The Resident Care Plan (RCP) dated of 5/22/25 identified Resident #8 was hard of hearing with interventions that included to attempt to minimize noise, refer to audiology as needed and when talking to Resident #8 use simple sentences, maintain eye contact and use gestures. The RCP failed to include that Resident #8 utilized hearing aids until 8/14/2025 indicating an appointment was scheduled with Miracle Ear. A Nursing re-admission Evaluation dated 6/7/25 identified that Resident #8 had hearing aids for both ears and hearing was adequate with the use of hearing aids. The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was cognitively intact and required supervision/set up for activities of daily living and did not utilize hearing aids. An interview with Resident #8 on 8/11/25 at 12:35 PM noted that his/her right hearing aid was not working. When the interview started, Resident #8 turned his/her head to the right and pointed to his/her right ear. Resident #8 stated speak loudly so can I hear you. Resident #8 had the left hearing aid in his/her ear and indicated he/she made staff aware a few weeks ago that the right hearing aid was not working but was not sure who he/she told. Resident #8 indicated that he/she has had hearing aids for a very long time and got them from a hearing aid company prior to coming to the facility. Resident #8 stated he/she always wore the hearing aids but stopped wearing the right hearing aid a few weeks ago when it stopped working. Resident #8 indicated that he/she takes care of the hearing aids independently. Resident #8 stated that he/she puts them in his/her ears every morning and removes them and places them in the recharger case every night. The recharger case was stored in the top drawer of Resident #8's nightstand Observations of Resident #8 on 8/14/25 and 8/15/25 at 9:00 AM noted Resident #8 had his/her hearing aid in the left ear. Interview with Nurse Aide (NA) #2 on 8/14/25 at 9:20 AM identified that she was Resident #8's primary aide on 7:00 AM to 3:00 PM shift and was aware that Resident #8 was hard of hearing and wore hearing aids. Interview with RN #1 on 8/14/25 at 10:05 AM indicated that she completed the MDS and care plan for Resident #8 she was not aware Resident #8 wore hearing aids and that nurses update the care plan most of the time Subsequent to surveyor inquiry, the interim DNS indicated that the Care Plan Coordinator was responsible for ensuring the care plan was accurate when conference meetings were conducted. 2.Resident #32's was admitted to the facility on [DATE] with diagnosis that included heart failure, diabetes and chronic kidney disease. A nursing note dated 5/15/25 identified Resident #32 was admitted to the facility on [DATE] and consultation was requested for evaluation of the resident's right buttock. Also, identifying Resident #32 refused to have her right heel evaluated. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was cognitively intact, required maximal assistance for bathing and toileting. Also, identified Resident #32 required moderate assistance for transfers and set up assistance for eating. A nursing note dated 5/21/25 identified Resident #32 refused to be weighed and stated, I am not doing my weights every day. A nursing note dated 5/22/25 identified Resident #32 refused to have an evaluation of his/her right heel. A nursing note dated 5/28/25 identified Resident #32 refused a shower. The Resident Care Plan (RCP) dated 6/19/25 identified Resident #32 had actual skin breakdown to the right heel and a reopened stage 2 ulcer. Interventions included to administer treatment per physician orders, flex boot while the resident was in bed, and wound consultation as needed. A wound care specialist note dated 6/19/25 at 8:10 PM identified Resident #32 refused to allow the dressing to the right heel be removed for an assessment. Also, identifying education was provided to Resident #32 about the risk of the area worsening. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #32 as cognitively intact and required moderate assistance for dressing. Also, identified Resident #32 required maximal assistance with showering, toileting and transfers. Further, refusal of care was not identified. A nursing note dated 8/14/25 identified Resident #32 refused to wear flex boots at night. An interview on 8/13/25 at 1:59 PM with Registered Nurse (RN) #6 Identified Resident #32 often refused care. An interview on 8/14/25 at 11:26 AM with the Advanced Practice Registered Nurse (APRN) identified Resident #32 refused a wound care and assessments at times. Also, identifying Resident #32 refused to have his/her heel evaluated until 6/19/25 although several attempts were made to assess the wound to the right heel from Resident #32's admission of 5/10/25. An interview on 8/14/25 at 11:30 AM with Licensed Practical Nurse (LPN)#1 identified Resident #32 refused care often. An interview on 8/14/25 at 11:32 AM with LPN #5 identified Resident #32 refused his/her boots and wound care to the right heel numerous times. Also, identifying if the resident refused care, she would chart the resident's refusal of care and inform the supervisor on duty On 8/14/2025 at 11:39 AM an interview and review of the RCP with the DNS identified Resident #32 had a history of refusals of care and the resident did not have care plan for refusals. Also, identifying she did not know the policy for refusal of care 3.Resident #90 had diagnoses that included dementia, diabetes, and chronic pulmonary edema. The Resident Care Plan (RCP) dated 4/14/25 identified Resident #90 had a self-care deficit for activities of daily living (ADL) related to physical limitations. Interventions included to provide assistance of 1 staff member for ADL's, obtain occupational therapy evaluation and treatment per physician orders, and use assistive/adaptive equipment such as rolling walker and wheelchair. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 was moderately cognitively impaired, had no functional limitation in range of motion to upper or lower extremities, used a wheelchair, required setup or clean-up assistance with eating, and required substantial/maximal assistance with personal hygiene, bed mobility and chair/bed transfers. The MDS assessment further identified Resident #90 had received occupational therapy services that began on 4/9/25. A Status Update Form signed by Occupational Therapist (OT) #2 on 5/6/25 directed to place a left palm roll at night with evening care and remove in the morning with morning care. A physician order dated 5/6/25 directed to place a right hand palm guard on at bedtime and off in the morning every day and evening shift. The order failed to identify the correct hand for placement of the palm guard (per OT note dated 5/6/25, the left palm required a palm roll). The Resident Care Plan (RCP) dated 6/12/25 identified Resident #90 had a self-care deficit for activities of daily living (ADL) related to physical limitations. Interventions included Resident #90 required assist of 1 staff member for ADL's, obtain occupational therapy evaluation and treatment per physician orders, and use assistive/adaptive equipment such as rolling walker and wheelchair. The RCP failed to identify Resident #90 had limited range of motion in his/her left hand which required use of a palm guard splint for management. Additionally, the use of the palm guard also limited Resident #90's range of motion and use of the left hand while it was being worn. Review of the Medication Administration Record for June 2025 for the dates of 6/1/25-6/30/25 identified documentation that Resident #90 had a right palm guard placed on at bedtime on the 3:00 PM to 11:00 PM shift and removed in the morning on the 7:00 AM to 3:00 PM shift (a discrepancy regarding Resident #90's left hand requiring the palm). Observation on 8/11/25 at 1:24 PM in Resident #90's room identified Resident #90 wore a blue palm guard splint on his/her left hand (not right hand). Observation on 8/12/25 at 10:46 AM in Resident #90's room identified Resident #90 wore a blue palm guard splint on his/her left hand (not right hand). Interview with OT #2 on 8/13/25 at 2:30 PM identified Resident #90 had an order for a left palm guard because he/she had a contracture with hand tightness of the 3rd, 4th, and 5th fingers on his/her left hand. OT #2 identified Resident #90 had limited range of motion in his/her left hand and that it was a progressive contracture that was getting worse so the palm guard was being used to help decrease/slow down the progression of the left hand's contracture (not right hand). OT #2 identified Resident #90 had 2 different palm guards, one with finger separators that was worn at night and one without finger separators that was worn in the day time. OT #2 was not aware the physician order entered by the nursing staff on 5/6/25 directed for the palm guard to be worn on the right hand. OT #2 indicated Resident #90 always had it on the left hand when he/she was seen by OT #2. Observation on 8/14/25 at 9:10 AM on the second floor west wing hallway identified Resident #90 self-propelled his/her custom wheelchair down the hall and wore a blue palm guard splint on his/her left hand. Review of the Resident Care Card (that directs the Nurse Aide on what type of care Resident #90 required) dated 8/15/25 identified under the category of Special Needs that Resident #90 had a palm roll to the left hand on at bedtime and off in the morning. Interview and review of the clinical record with MDS Coordinator Registered Nurse (RN) #1 on 8/14/25 at 1:50 PM identified when completing the MDS assessments she collected the information she needed from the Nurse Aide (NA) documentation, nursing notes/documentation and rehabilitation/therapy notes/documentation. RN #1 identified she must have missed the order for Resident #90's palm guard. Interview with MDS Coordinator RN #7 on 8/15/25 at 11:40 AM identified Resident #90's limited range of motion in his/her left hand should be in the RCP and RN #1 must have missed it. Review of the Care Plans, Comprehensive Person-Centered policy directed, in part, the comprehensive person-centered care plan includes measurable objectives and timeframes. The policy directed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility policy for Requesting, refusing and/or discontinuing care or treatment identified residents have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms. Also, identifying if a resident requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident to determine why he or she was requesting, refusing or discontinuing care treatments. If the decision to refuse or discontinue treatment results in a significant change of condition, a reassessment would occur, and appropriate changes would be made to the Resident's care plan.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #15) reviewed for advance directives, the facility failed to update the resident care plan (RCP) for a resident with comfort measures only (CMO) and no intravenous hydration (IVs). The findings include:Resident #15 had diagnoses that included dementia, anemia, and hypertension.A Do Not Resuscitate Consent Form dated [DATE] identified do not resuscitate (DNR) was discussed with Resident #15's responsible party by the Advanced Practice Registered Nurse (APRN) #4 and Resident #15's responsible party signed the form in agreement with changing Resident #15 to DNR.An APRN #4's progress note dated [DATE] at 11:53 AM identified Resident #15's code status/advance directives was changed by probate court on [DATE] from full code to DNR. The note further identified an order was in place for DNR and registered nurse may pronounce (RNP)(the RN may officially declare a resident deceased ).An APRN advance directives order dated [DATE] directed DNR, RNP.The Resident Care Plan (RCP) dated [DATE] identified Resident #15 advance directives would be honored and reevaluated as needed. Interventions included to discuss advance directives with the Resident #15 and/or his/her responsible party and that Resident #15 was a full code (CPR would be performed). The RCP failed to identify Resident #15's advance directives order for DNR, RNP.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required substantial/maximal assistance with eating, bed mobility, and chair/bed transfers.An interview with MDS Coordinator Registered Nurse (RN) #1 on [DATE] at 1:50 PM identified she attended the RCP meetings for the long-term care residents. RN #1 identified she reviewed the advance directives if needed due to a resident's decline. RN #1 further identified she did not give a copy of the RCP to the resident/responsible party for review at the RCP meeting because the family knew the care plan and they didn't need to look at it. An interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 10:10 AM identified after a change in advance directives the order would be updated by the Nursing Supervisor. LPN #3 further identified it would be the RN/Supervisor who would then be responsible for updating the care plan. LPN #3 could not identify why Resident #15's RCP had not been updated after a change in his/her advance directives.An interview with the Nursing Supervisor Registered Nurse (RN) #6 on [DATE] at 10:20 AM identified that she did not think anyone was responsible for updating the care plan for a change in advance directives. RN #6 indicated in her experience when she entered advance directives orders for new admissions it would automatically populate in the RCP without her having to go in to the RCP separately. Interview with the MDS Coordinator (RN #7) on [DATE] at 11:40 AM identified that the resident's current RCP was reviewed in the RCP meetings and that the code status was reviewed. RN #7 indicated she tried to stay away from specifics in the RCP regarding advance directives because they could change, and she was unaware why the RCP for Resident #15 indicated he/she was a full code. RN #7 indicated Resident #15's RCP should not say Resident #15 was a full code but instead that the advance directives were according to physician's orders. Review of the Advance Directives policy directed, in part, the resident has the right to formulate an advance directive , including the right to accept or refuse medical treatment. The policy directed the plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. The policy directed changes or revocations of a advance directive must be submitted to the administrator, and the interdisciplinary team would be informed of changes so that appropriate changes can be made in the resident medical record and care plan.

Based on staff interviews, review of the clinical record and policy for 1 of 1 sampled resident (Resident #131) reviewed for death, the facility failed to ensure the Registered Nurse Pronouncement was comprehensive to include a full assessment. The findings include:Resident #131's diagnoses included congestive heart failure, cerebral infarction, and hypertension.A Resident Care Plan dated 4/17/25 identified Resident #131 had a self-care deficit related to impaired mobility and incontinence. Interventions included to aid in bathing resident as needed and provide assistance with eating, dressing, grooming and oral care as needed.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #131 was cognitively intact, required substantial maximal assistance for toileting, bathing, and transfers. Also, identifying Resident #131 required set up assistance for eating.A physician's order dated 6/22/25 directed Do Not Resuscitate (DNR), Register Nurse Pronouncement (RNP), and comfort measures only.Nursing notes dated 6/22/25 at 5:34 AM and written by RN #5 identified Resident #131 was observed to not be breathing and without a heartbeat. RN pronounced Resident #131 at 5:20 AM. The next of kin, funeral home, and the Advance Practice Registered Nurse (APRN) covering for the physician was notified of Resident #131's death (the assessment failed to include pupillary reaction and lack of blood pressure).In an interview and clinical record review with RN #2 and RN #8 on 8/14/25 at 3:27 PM identified a RNP assessment needed to include heartbeat, respirations, blood pressure, and to check if pupils are dilated or responsive. Also, identifying a heartbeat should be checked for 1 full minute. Further, identifying the RN pronouncement note written on 6/22/25 was incomplete, and was missing blood pressure and pupillary reactions.Interview and clinical record review on 8/15/25 at 1:18 PM with Registered Nurse #5 identified that a RNP assessment should include breathing, blood pressure, pulse and pupils' responsiveness. Also, RN #5 identified her note from 6/22/25 failed to include pupillary responsiveness and blood pressure. RN #5 further identified she had become busy with something else, the nurse's note was incomplete, and she was responsible for performing a complete assessment upon death.Department of Public Health Public Health Code: Pronouncement of Death by a Registered Nurse7-62-1. Definitions(a) Determination of Death means observation and assessment that a person has ceasedvital bodily functions irreversibly including, but not limited to, the following: pulse,respiration, heartbeat, and pupil reaction.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #87) reviewed for falls, the facility failed to provide supervision for a resident who required assistance of 1 with toileting and supervision with ambulation, resulting in a fall. The findings include: Resident #87 had diagnoses that included Alzheimer's disease, macular degeneration, and hypertension.A Fall Risk Evaluation assessment dated [DATE] at 10:10 AM and completed by Registered Nurse (RN) #1 identified Resident #87 was at a high risk for falls related to poor recall, judgement, and safety awareness. Additionally, the Fall Risk Evaluation identified Resident #87 had 1-2 falls in the past 3 months. The Resident Care Plan (RCP) dated 7/2/24 identified Resident #87 was at risk for falls related to medication side effects, history of falls, and deconditioning. Interventions included to transfer Resident #87 with contact guard assistance/ hand hold assistance and a rolling walker, toilet Resident #87 on first rounds, have commonly used articles within easy reach, re-education with Resident #87 on fall precautions and to request assistance with transfers and ambulation. The RCP further identified Resident #87 had an activities of daily living (ADL) self-care deficit related to physical limitations. Interventions included that Resident #87 required assistance of 1 staff member with ADLs, and Resident #87 required limited assistance with bed mobility, extensive assistance with transfers using contact guard/hand hold, and extensive assistance with toilet hygiene.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 was cognitively intact, had no falls since the previous assessment (7/12/24), used a walker for mobility, required setup or clean-up assistance with eating, partial/moderate assistance with toileting hygiene, substantial/maximal assistance with lower body dressing, and supervision or touching assistance with chair/bed (getting in out of a chair or the bed) and toilet transfers (getting on/off the toilet), and walking 10 to 50 feet.A Fall Risk Evaluation assessment dated [DATE] at 3:16 AM and completed by Licensed Practical Nurse (LPN) #4 identified Resident #87 had diminished safety awareness, had impaired mobility, was continent, required assistance with toileting, used an assistive device (walker) and had no falls in the past 3 months.Review of Resident #87's physician's orders failed to identify mobility/transfer orders.Review of the task section in the electronic medical record (EMR) identified Resident #87's toileting ability was last updated on 5/5/24 and Resident #87 required assistance of 1 staff member for toileting. The tasks identified Resident #87's ADL ability was last updated on 5/5/24 and Resident #87 required assistance of 1 staff member. The tasks identified Resident #87's transfer ability was last updated on 7/4/24 and Resident #87 required supervision with transfers using a rolling walker. The tasks identified Resident #87's ambulation ability was last updated 7/4/24 and Resident #87 required supervision with a rolling walker and indicated Resident #87 ambulated with distant supervision with frequent reminders to use his/her walker. The tasks further identified Resident #87's bed mobility ability was last updated on 7/4/24 and was left blank, but the previous bed mobility ability dated 2/8/24 identified Resident #87 required assistance of 1 person with bed mobility. A facility Reportable Event (RE) Form dated 10/18/24 at 2:45 AM identified Resident #87 was observed lying on his/her right side on his/her bathroom floor with his/her head inside the doorway and blood observed on the floor underneath his/her head. The RE identified skin tears were observed on Resident #87's bilateral knees and the right forehead. The RE further identified Resident #87 sustained a hematoma under the right eye, and Resident #87 was disoriented after being non-responsive to verbal or light tactile stimuli for over a minute. The RE indicated prior to the event Resident #87 walked independently with a rolling walker (a discrepancy with the task section in the EMR which Nurse Aides follow which identified Resident #87 required supervision with a rolling walker), independently transferred (a discrepancy with the task section in the EMR which Nurse Aides follow which identified Resident #87 required supervision with a rolling walker), independently toileted him/herself (a discrepancy with the task section of the EMR which identified Resident #87 required assistance of 1 for toileting), and required assistance of 1 staff member for bathing. The RE identified 911 was called and Resident #87 was sent to the hospital for evaluation. A nursing note written by Registered Nurse (RN) #5 on 10/18/24 at 5:35 AM identified a Nurse Aide (NA) had heard a sound coming from Resident #87's bathroom and upon investigation had found Resident #87 lying prone on the bathroom floor with the right side of his/her face down and his/her head in the bathroom doorway. The nursing note identified the NA alerted the charge nurse who then requested evaluation by RN #5. The note identified when RN #5 entered the bathroom, Resident #87 was breathing but was not responsive to verbal stimuli. The note identified within 1-2 minutes, Resident #87 started to respond but was disoriented, not aware of what had happened and blood was noted on the floor beneath Resident #87's face. Resident #87's blood pressure was elevated, a hematoma was noted under his/her right eye, and skin tears were noted on the left forehead, and both knees. The nursing note further identified 911 had been called, voicemails were left for Resident #87's representative and the Advanced Practice Registered Nurse (APRN), and Resident #87 left the faciity on a stretcher at 3:05 AM transported by ambulance. A facility obtained witness statement written by NA #4 and dated 10/18/24 identified Resident #87 had walked out to her in the hallway at 2:30 AM and had requested a pull-up brief. The statement identified NA #4 had asked Resident #87 if he/she needed anything else, and Resident #87 had responded to have a good night and went back to his/her room. The statement identified at 2:45 AM, NA #4 heard a noise and when she went to look inside Resident #87's room she saw Resident #87 on the floor.A facility obtained witness statement by NA #5 dated 10/18/24 identified Resident #87 had been asleep in bed from 11:00 PM through 2:25 AM. The statement identified Resident #87 had come out to the linen cart at 2:30 AM and had asked NA #4 for a pull-up brief, like he/she always does. The statement identified NA #4 had given Resident #87 a pull-up, NA #5 had gone to the other unit at 2:35 AM to cover a break and had heard about Resident #87's fall at 2:45 AM.A facility obtained witness statement by LPN #7 and dated 10/18/24 identified she had gone up to Resident #87's unit to assist staff because Resident #87 was on the floor, Resident #87 was disoriented and observed Resident #87 lying on his/her stomach with the toilet at his/her feet, the incontinent brief around his/her ankles and feces was noted in the toilet, in the brief and on the floor. The hospital Discharge summary dated [DATE] at 2:27 PM identified Resident #87 was sent to the hospital by the facility after a fall/syncopal event, and Resident #87 had a superficial forehead laceration/facial swelling, mild rhabdomylysis (destruction or degeneration of muscle tissue that can occur due to various factors such as traumatic injury, excessive exertion, or stroke), mild acute kidney injury (acute decline in kidney function), chronic kidney disease, and hypokalemia. A Resident Evaluation nursing note written by RN #5 and LPN #8 on 10/22/24 at 10:33 PM identified Resident #87 had been readmitted from the hospital via stretcher (4 days after being transferred to the hospital from the facility).A progress note written by APRN #3 on 10/23/24 identified Resident #87 was hospitalized [DATE] to 10/22/24 after a fall with a head laceration. The note identified the hospital trauma workup was negative for fractures, but Resident #87 had right frontal scalp soft tissue swelling and hematoma, and abrasions to bilateral knees. The note identified the hospital stay was complicated by mild rhabdomyolysis and mild acute kidney injury in addition to Resident #87's chronic kidney disease.Interview with Occupational Therapist (OT) #1 on 8/13/25 at 12:38 PM identified mobility directions for residents were located under task section in the EMR for nursing staff to follow. OT #1 identified in October 2024 at the time of Resident #87's fall his/her mobility directions were distant supervision for ambulation, supervision for transfers (bed/chair/toilet), and extensive assistance of 1 staff member for toileting hygiene and lower body dressing.Interview with the Rehabilitation Director, Physical Therapist (PT) #1 on 8/13/25 at 1:20 PM identified distant supervision did not require constant eyes on Resident #87 while ambulating, more that staff needed to be aware that Resident #87 did not leave the unit while ambulating. PT #1 identified that transfers with supervision required a staff member to be present while Resident #87 completed the transfer on his/her own without staff assistance. PT #1 identified ADL assistance of 1 staff member required hands on assistance from a staff member at some level (minimum or extensive) to complete the activities of bathing, dressing, and toileting. PT #1 further identified toileting assistance of 1 staff member also required hands on assistance from a staff member at some level.Interview with NA #4 on 8/14/25 at 3:41 PM identified that at the time of Resident #87's fall on 10/18/24, Resident #87 was independent for everything, getting dressed, transfers, and toileting (a discrepancy with the task section of the EMR that identified resident required supervision with transfers and ambulation). NA #4 identified Resident #87 would usually get up during the night and come out in the hallway to get a pull-up brief, then he/she would go back and use the bathroom and change his/her pull-up by him/herself. NA #4 identified on 10/18/24 after giving Resident #87 a pull-up brief, she had heard noise coming from Resident #87's room and when she went to check on Resident #87 she found him/her lying on the floor. Interview with NA #5 on 8/14/25 at 3:54 PM identified she had been on the other unit covering for a break at the time of Resident #87's fall, but at that time it was an almost daily occurrence for Resident #87 to come out in the middle of the night to ask for paper pants, and then he/she would go into the bathroom and then change him/herself. NA #5 indicated Resident #87 was independent for transfers and toileting and could do everything by him/herself at that time (although the task section of the EMR identified Resident #87 required supervision with transfers and ambulation). NA #5 identified Resident #87 would call if he/she needed help with something, otherwise he/she did it all by him/herself. NA #5 further identified in order to know what a resident's mobility level was you had to look at the resident's care card in the task section of the EMR, but Resident #87 was completely different now, and required staff assistance with everything. Interview with Interim Director of Nursing (DNS) on 8/15/25 at 12:29 PM identified that the nursing staff should have assisted and/or supervised Resident #87 on 10/18/24 when Resident #87 came out to the hallway to ask for a pull-up brief. The DNS identified letting Resident #87 return to his/her room after getting a pull-up brief was not an appropriate level of supervision for Resident #87 who had directions for supervision with transfers and assistance of 1 staff member for toileting. DNS identified a staff member should have gone back into the room with Resident #87 to supervise his/her return to bed or a chair, or to assist with him/her with toileting, since that was Resident #87's routine every night.Review of the Activities of Daily Living (ADL), Supporting policy directed, in part, that appropriate care and services will be provided for residents who are unable to independently carry out ADLs in accordance with the plan of care. The policy directed this included assistance with mobility (transfer and ambulation), elimination (toileting), and hygiene (bathing and dressing). The policy directed a resident's ability to perform ADLs will be measured and for independent the resident completed the activity with no help, limited assistance the resident received non-weight bearing assistance with the task, and for extensive assistance the resident received weight-bearing support to complete the task.Review of the Falls and Fall Risk, Managing policy directed, in part, the staff with input from the physician will implement a resident-centered fall prevention plant to reduce the specific risk factors of falls for each resident at risk for or with a history of falls. The policy directed if falling recurs despite initial interventions, staff will implement additional or different interventions.

Based on observations, clinical record review, interviews, and facility policy for 1 of 4 residents (Resident #2) reviewed for respiratory care, the facility failed to obtain a physician's order for a resident utilizing a continuous positive airway pressure (CPAP) machine nightly. The findings include: Resident #2's diagnoses included obstructive sleep apnea (OSA), acute respiratory failure with hypercapnia (retention of carbon dioxide) and asthma. A respiratory care evaluation form dated 7/17/25 identified Resident #2 had his/her own CPAP machine with a nasal mask at the bedside which the resident indicated he/she had worn on the prior night and to continue to observe and educate the resident with CPAP use. An Advanced Practice Registered Nurse (APRN) progress note dated 7/21/25 at 9:45 AM and written by APRN #2 identified Resident #2 had a history of obstructive sleep apnea, should be encouraged to use the CPAP machine during his/her skilled nursing facility (SNF) stay and the resident should be educated on the importance of adherence with use of the CPAP machine to prevent respiratory complications. A physician's progress note dated 7/21/25 at 6:27 PM identified Resident #2 had a history of OSA and was using his/her own CPAP machine while at the facility. The progress note indicated the resident was encouraged to continue use of the CPAP machine while at the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact and required partial/moderate assistance with bed mobility, toileting, and transfers. The MDS indicated a pulmonary diagnoses and OSA but failed to indicate use of a CPAP machine. A Resident Care Plan (RCP) dated 8/7/25 identified Resident #2 utilized CPAP therapy with interventions that included educating the resident on the importance of CPAP therapy and to encourage the residents use of the CPAP machine. Observations on 8/11/24 at 12:21 PM and 8/12/25 at 11:00 AM identified Resident #2 had a CPAP machine on his/her bedside table which he/she indicated was his/her own machine from home and that he/she wore and utilized the CPAP machine every night while at the facility. Interview and observation with LPN #3 on 8/14/25 at 10:20 AM identified Resident #2 had a CPAP machine at his/her bedside and that it had always been there. LPN #3 indicated she was unsure when the resident's family member brought the CPAP machine in or if there was a physician's order for the resident to use it. Although LPN #3 identified there should have been a physician's order for Resident #2 to use the CPAP machine, she deferred reviewing the resident's physician's orders due to needing to tend to her assignment. Observation, interview, and review of the clinical record with the Nursing Supervisor (RN #2) on 8/14/25 at 10:24 AM identified although she saw a note and diagnosis of OSA in Resident #2's hospital discharge record, the resident did not have a physician's order to use a CPAP machine. An observation with RN #2 indicated a CPAP machine was resting on Resident #2's bedside table and the resident stated he/she used it every night and that LPN #4 helped him/her put it on at night. RN #2 identified the CPAP machine should not have been there and the resident should not have used the CPAP machine without a physician's order in place. RN #2 was unsure why a physician's order was not obtained by a nurse for Resident #2's CPAP machine and that she would need to investigate it further. Interview with Person #1 on 8/14/25 at 3:49 PM identified although she was asked to bring in Resident #2's CPAP machine from home the day after the resident was admitted , she was unable to indicate which nurse had asked her to do so. Person #1 indicated Resident #2 did use the CPAP machine while at home and he/she would need help to put it on. Person #1 further identified that Resident #2 was a reliable source and if the resident indicated he/she was using the CPAP machine while at the facility then that was the truth. Observation, interview, and review of the clinical record with LPN #4 on 8/14/25 at 3:58 PM indicated that although there was not a physician's order for Resident #2 to wear a CPAP machine, he did help the resident put the CPAP machine on before bed. LPN #4 indicated he was aware the resident's family member brought the CPAP machine into the facility from home and had observed the resident with the CPAP machine on at night. LPN #4 identified it would have been the admitting nurse or the respiratory therapist that should have obtained an order for the CPAP machine and he was unsure why an order was not obtained. LPN #4 further indicated he wasn't really paying attention to the fact that the resident didn't have an order for the CPAP machine and that he didn't let anyone know that an order was needed but he should have. Subsequent to surveyor inquiry, an order was obtained on 8/14/25 which directed CPAP at hour of sleep (HS) no ramp time, 4-12 mm HG (millimeters of mercury). Assist resident to situate the mask for comfort and effective seal at bedtime for CPAP. Attempts to interview APRN #2 were unsuccessful. Review of facility policy, CPAP/BiPAP Support, dated March 2015, directed CPAP provided a spontaneously breathing resident with continuous positive airway pressure and improved arterial oxygenation in residents with OSA. The policy further directed prior to use of the CPAP machine the physician's order should be reviewed to determine the flow and pressure settings for the machine and the physician should be notified if the resident refused the procedure or if the resident experienced any adverse consequences.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #15) reviewed for pressure ulcer/injury, the facility failed to ensure Resident #15 was placed on Enhanced Barrier Precautions (EBP) for a Stage 3 pressure ulcer. The findings include:Resident #15 had diagnoses that included dementia, anemia, and hypertension.The Resident Care Plan (RCP) dated 6/28/25 identified Resident #15 was at risk for alteration in skin integrity related to impaired mobility, incontinence, shearing, friction, and cognition. Interventions included to observed skin condition with care daily and report abnormalities, and provide preventative skin care routinely and as needed. The RCP further identified Resident #15 had actual skin breakdown related to a stage 2 pressure injury on the right buttock. Interventions included administer treatment per physician orders, encourage and assist to turn and position as needed, and obtain wound consult as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, was at risk of developing pressure injuries, had 1 unhealed Stage 2 pressure injury, and required substantial/maximal assistance with eating, bed mobility, and chair/bed transfers.An Advanced Practice Registered Nurse (APRN) wound progress note identified Resident #15's right buttock wound advanced to a Stage 3 pressure ulcer.Observation of Resident #15's room on 8/14/25 at 9:16 AM failed to identify measures were initiated for Enhanced Barrier Precautions related to Resident #15 having a Stage 2 pressure ulcer as evident by a lack of posted signage, lack of personal protective equipment in proximity to Resident #15's room, and lack of a laundry bin inside of Resident #15's room.Observation on 8/14/25 at 9:16 AM identified Licensed Practical Nurse (LPN) #1 and Advanced Practice Registered Nurse (APRN) #1 entered Resident #15's room to change Resident #15's right buttock wound dressing, but failed to don appropriate personal PPE of (gowns). LPN #1 and APRN #1 were observed to perform hand hygiene and demonstrated appropriate use and changing of gloves throughout the dressing change, but they did not wear a gown at any time during the dressing change. LPN #1 identified staff were alerted to wear PPE by signage posted at the doorway and a bin with necessary PPE outside the doorway of the room. LPN #1 identified any resident on EBP or any other type of precautions would have a sign posted at the doorway that shows what PPE needs to be worn inside that resident's room.Subsequent to surveyor inquiry, an observation on 8/14/25 at 1:00 PM identified an EBP sign posted at the doorway of Resident #15's room. No bin with PPE was observed outside the room.Review of the Enhanced Barrier Precautions policy directed, in part, EBP apply when a resident has a wound or indwelling medical device and does not have secretions that are unable to be contained. The policy directed EBP's used targeted gown and glove use for high contact resident care activities which included wound care. The policy directed signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. The policy further directed PPE and alcohol-based hand rub are readily available for staff.

Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual policy for the only resident reviewed for communication/sensory (Resident #8), for 1 of 3 reviewed for pressure ulcers (Resident #15), for the only sampled resident reviewed for position/mobility (Resident #90) and for 1 of 3 reviewed for accidents (Resident #117), the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded correctly for the use of hearing aids (Resident #8), limited range of motion (Resident #15), position/mobility (Resident #90) and falls (Resident #117). The findings include: 1.Resident #8 diagnoses included failure to thrive, heart failure, and osteoarthritis. The Resident Care Plan (RCP) dated 5/22/25 identified Resident #8 was hard of hearing with interventions that included to attempt to minimize noise, refer to audiology as needed and when talking to Resident #8, use simple sentences, maintain eye contact and use gestures. The RCP lacked documentation that Resident #8 utilized hearing aids until 8/14/25 indicating an appointment was scheduled with a hearing aide company. A 6/7/25 Nursing readmission Evaluation identified that Resident #8 had hearing aids for both ears and hearing was adequate with the use of hearing aids. The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was cognitively intact, required supervisor/set up for activities of daily living and did not utilize hearing aids (despite the 6/7/25 Nursing readmission Evaluation identifying Resident #8 utilized hearing aids in both ears). An interview with Resident #8 on 8/11/25 at 12:35 PM identified that his/her right hearing aid was not working. When the interview started, Resident #8 turned his/her head to the right and pointed to his/her right ear. Resident #8 stated speak loudly so I can hear you. Resident #8 had the left hearing aid in his/her ear. Resident #8 indicated she made staff aware a few weeks ago that the right hearing aid was not working but was not sure who he/she told. Resident #8 indicated that he/she had hearing aids for a very long time and got them from a hearing aid company prior to coming to the facility. Resident #8 stated he/she always wears the hearing aids until recently when the right hearing aid stopped working a few weeks ago. Resident #8 indicated that he/she takes care of the hearing aids independently and that he/she puts them in his/her ears every morning and removes them and places them in the recharger case every night (the recharger case was stored in the top drawer of Resident #8's nightstand). Resident #8 demonstrated his/her routine with hearing aids while describing the process. A facility contracted audiology consult form dated 9/17/24 identified that Resident #8 had a right and left hearing aid from a hearing aid company. The aids were cleaned for wax and debris and were functioning at that time. Resident #8 declined to receive new hearing aids at that time and no follow up audiology consults were in the clinical record. Observations of Resident #8 on 8/14/25 and 8/15/25 at 9:00 AM noted Resident #8 had his/her hearing aid in the left ear only. Interview with Nurse Aide (NA) #2 on 8/14/25 at 9:20 AM identified that she was Resident #8's primary aide on 7-3 shift. She indicated that she was aware that Resident #8 was hard of hearing and wears hearing aids. Interview with RN #1 on 8/14/25 at 10:05 AM indicated that she completed the MDS for Resident #8 and that Resident #8 did not have hearing aids. When informed that Resident #8 had hearing aids, RN #1 stated then Resident #8 must not wear them. RN #1 indicated that she coded section B on the MDS as Resident #8 not having hearing aids because Resident #8 must not have had them in. RN #1 was informed that Resident #8 indicated that he/she always wore the hearing aids up until a few weeks ago when Resident #8 stopped wearing the right hearing aid as it was not functioning. RN #1 stated she was not aware. 2. Resident #15 had diagnoses that included dementia, anemia, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, had no signs/symptoms of a possible swallowing disorder, had no functional limitation in range of motion to his/her upper extremities, had impairment in functional range of motion to both lower extremities, and required substantial/maximal assistance with eating, bed mobility, and chair/bed transfers. The Resident Care Plan (RCP) dated 6/28/25 identified Resident #15 had a self care deficit related to impaired mobility, cognition, and failure to thrive. Interventions included to assist at meals, assist to bathe as needed, and to assist with activities of daily living. The RCP failed to identify Resident #15 had contractures or stiff extremities that caused difficulty with positioning due to limited range of motion. A nutritional follow-up note written by the Dietician on 6/30/25 at 2:53 PM identified Resident #15 exhibited delayed swallowing with an occasional cough, had been seen by speech therapy and his/her liquid portion of diet was changed to mildly thick liquids. The note identified Resident #15 was dependent for eating. A nursing note written by Licensed Practical Nurse (LPN) #1 on 7/3/25 at 11:49 AM identified Resident #15 was seen by the wound Advanced Practice Registered Nurse (APRN) that morning, had been very hard to turn in bed and Resident #15 was noted to be very contracted. A Physical Therapy Evaluation and Plan of Treatment note written by Physical Therapist (PT) #2 and dated 7/11/25 at 3:13 PM identified Resident #15 had been seen for a PT evaluation due to positioning difficulties. The note identified Resident #15 had severe rigidity with loss of functional mobility of his/her bilateral lower extremities, bilateral upper extremities, and trunk (torso). The note identified Resident #15 had extensor tone (tension in the muscle groups responsible for extending the arms and legs) that was severe when lying on his/her back in bed and when sitting in the wheelchair. The note identified Resident #15's mobility function score (ranges from 0-12 with 12 being the highest function) was 0 and identified Resident #15 was dependent for bed mobility and bed/chair transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, had no signs/symptoms of a possible swallowing disorder, had no functional limitation in range of motion to his/her upper or lower extremities, and required substantial/maximal assistance with eating, bed mobility, and chair/bed transfers. The MDS assessment failed to identify Resident #15 had functional limitation in range of motion to both upper and both lower extremities, and was dependent for all functional mobility areas (eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, bed mobility, sit to lying, lying to sitting, and transfers). Interview and clinical record review with the MDS Coordinator (RN #7) on 8/15/25 at 11:40 AM identified the quarterly MDS assessment dated [DATE] showed he/she had a functional limitation in range of motion to both side of the lower extremities, but the quarterly MDS assessment dated [DATE] showed Resident #15 had no functional limitation in range of motion to his/her upper or lower extremities. RN #7 identified the documentation of no functional limitation in range of motion in the 7/11/25 quarterly MDS assessment was incorrect. Interview and clinical record review with MDS Coordinator (RN #1) on 8/15/25 at 12:00 PM identified she was aware Resident #15 was dependent for eating, bed mobility, chair/bed transfers, but had coded Resident #15's section GG of the quarterly MDS' dated 6/19/25 and 7/11/25 as substantial/maximal assistance for eating, bed mobility, and chair/bed transfers. RN #1 identified that she was unable to code the MDS assessments as dependent for Resident #15's functional mobility areas even though there was physician documentation, rehabilitative therapy documentation, and nursing documentation that said he/she was dependent for functional mobility. RN #1 identified that all documentation must match 100% for her to code the MDS Section GG as dependent for Resident #15, and that if even 1 nurse aide (NA) documented that Resident #15 required only substantial/maximal assistance then she would have to code that functional area as substantial/maximal assistance. RN #1 further identified that the NA documentation for Resident #15's functional mobility areas consistently showed documentation of at least 1 NA inaccurately coding Resident #15's functional mobility as substantial/maximal assistance even though the NA care card directed Resident #15 was dependent. RN #1 identified that she had sent emails to the staff education and administration about the inaccurate NA documentation resulting in her having to code the GG section of MDS as substantial/maximal instead of dependent. Although requested a copy of an email sent to staff development and/or administration by RN #1 to notify them of the inaccurate documentation of NAs for the functional mobility of residents with orders that directed that they were dependent for care was not provided. 3. Resident #90 had diagnoses that included dementia, diabetes, and chronic pulmonary edema. A physician order dated 5/6/25 directed to place a right hand palm guard on at bedtime and off in the morning every day and evening shift. (The physician order failed to identify the correct hand for placement of the palm guard). The Resident Care Plan (RCP) dated 6/12/25 identified Resident #90 had a self-care deficit for activities of daily living (ADL) related to physical limitations. Interventions included Resident #90 required assist of 1 staff member for ADL's, obtain occupational therapy evaluation and treatment per physician orders, and use assistive/adaptive equipment such as rolling walker and wheelchair. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 was moderately cognitively impaired, had no functional limitation in range of motion to upper or lower extremities, used a wheelchair, required setup or clean-up assistance with eating, and required substantial/maximal assistance with personal hygiene, bed mobility and chair/bed transfers. The MDS assessment failed to identify Resident #90 had a limitation in range of motion to one side of his/her upper extremities. Review of the Medication Administration Record (MAR) dated 6/1/25 through 6/30/25 identified documentation that Resident #90 had a right palm guard placed on at bedtime on the 3:00 PM to 11:00 PM shift and removed in the morning on the 7:00 AM to 3:00 PM shift. Observation on 8/11/25 at 1:24 PM and 8/12/25 at 10:46 AM identified Resident #90 located in his/her room wearing a blue palm guard splint on his/her left hand. Interview with OT #2 on 8/13/25 at 2:30 PM identified Resident #90 had a physician order for a palm guard because he/she had a contracture with hand tightness of the 3rd, 4th, and 5th fingers on his/her left hand. OT #2 identified Resident #90 had limited range of motion in his/her left hand and that it was a progressive contracture that was getting worse so the palm guards were being used to help decrease/slow down the progression of the left hand's contracture. OT #2 identified Resident #90 had 2 different palm guards. One with finger separators that was worn at night and one without finger separators that was worn in the day time. Interview and review of the clinical record with MDS Coordinator Registered Nurse (RN) #1 on 8/14/25 at 1:50 PM identified when completing the MDS assessments she collected the information she needed from Nurse Aide (NA) documentation, nursing notes/documentation and rehabilitation/therapy notes/documentation. RN #1 identified she must have missed the physician order for Resident #90's palm guard. 4. Resident #117's diagnosis included pneumonia, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #117 was moderately cognitively impaired and required set-up assist with eating. Also, Identified Resident#117 required partial moderate assistance for toileting, personal hygiene, and transfers. Further, identified Resident #117 required substantial moderate assistance for bathing and had falls prior to admission within the last 2 to 6 months. The Resident Care Plan (RCC) dated 7/10/25 identified Resident #117 was a risk for falls due mobility, ambulation, weakness, cognition, and recent falls at home, intervention to maintain bed in a low position, staff to reinforce the need to call for assistance, and have commonly used articles within easy reach. A facility Accident and Incident report dated 7/25/25 at 1:15 PM identified Resident #117 had an unwitnessed fall and sustained a large, raised area to left posterior side his/her head(hematoma). Also, identified Resident #117 was trying to get up and reach his/her wheelchair and fell to the floor hitting his/her head on the tray table. Nursing notes dated 7/25/25 at 2:42 PM identified Resident #117 had an unwitnessed fall and had pain to the left side of his/her posterior head. The Resident Care Plan (RCC) dated 7/25/25 identified Resident #117 was at risk for falls due to mobility, ambulation, weakness, cognition, recent fall at home, Chronic Foley Catheter, interventions to keep the resident's wheelchair locked at the bedside, provide assistance to transfer and ambulate as needed. The Reentry Minimum Data Set (MDS) dated for7/28/25 identified Resident #117 as cognitively intact, and requiring moderate assistance for toileting, and maximal assistance for bathing, and transfers. Further, identifying Resident #117 had a fall without an injury (which did not identify the fall of 7/25/25 where Resident #117 sustained a hematoma to the head). An interview on 8/14/25 at 1:51 PM with Registered Nurse (RN) #7 identified the MDS dated [DATE] coded the fall incorrectly and should have been coded for fall with a minor injury. Further, identifying it was an oversight, and falls were reviewed during the daily morning report meeting. The Resident Assessment Instrument (RAI) manual identified that when a resident has a fall with a minor injury, the MDS should be coded to reflect the fall with a minor injury. Also, identifying a minor injury as skin tears, abrasions, lacerations, superficial bruises, hematomas, sprains and any other injury that causes the residents to complain of pain. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual which contained instructions the facility must follow when submitting MDS assessments directed, in part a resident's functional status can be impacted by the environment or situations encountered at the facility. Observing the resident's interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident's functional status. If the resident's functional status varies, record the resident's usual ability to perform each activity. Do not record the resident's best performance and do not record the resident's worst performance, but rather record the resident's usual performance. The manual directed when coding the resident's usual performance, use the six-point scale (Code 06-independent, Code 05-setup or clean-up assistance, Code 04-supervision or touching assistance, Code 03-partial/moderate assistance, Code 02-substantial/maximal assistance, and Code 01-dependent). The manual directed to use Code 02-substantial/maximal assistance if the helper does more than half the effort to complete the activity. The manual further directed to use Code 01-dependent if the helper does all of the effort and the resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity.

Based on review of facility documentation, facility policy and interviews related to facility bi-monthly narcotic audits, the facility failed to ensure that bimonthly narcotic audits were completed to monitor for possible drug diversion in the facility. The findings include: An interview with the interim DNS on 8/12/25 at 12:30 PM identified that she was unable to locate any facility documentation of bi-monthly narcotic audits conducted by the facility since the previous re-certification survey dated 12/22/23. The DNS indicated that she had only been employed by the facility since March 2025 as the ADNS and had been the interim DNS since July 2025. She stated that she had not completed any bi-monthly narcotic audits and that audits would have been conducted by the previous DNS at the facility. The interim DNS was able to provide a facility binder that contained all the current yellow narcotic reconciliation sheets for the residents in the facility receiving narcotics but there were no complete narcotic audit forms. The DNS presented 3 yellow narcotic reconciliation sheets with a date of July 2025 in the middle of the sheet indicating that these 3 narcotic sheets must have had some type of partial audit. However, the DNS could not state what type of audit would have been conducted and was unable to provide any further documentation related to narcotic audits by the facility. On 8/12/25 at 1:00 PM the Administrator stated she was not aware of the location of any bi-monthly narcotic audits that may have been conducted by the facility. She indicated that she and the DNS would contact the previous two DNS' to locate the bimonthly narcotic forms. Per the administrator and the DNS on 8/14/25 several attempts were made to contact the previous two DNS' without success.A review of the Controlled Substance Policy dated November 2022 directed, in part, the facility complies with all laws, regulations, and other requirements related to the handling, storage, disposal and documentation of controlled medications.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The Director of Nursing services documents irreconcilable discrepancies is a report to the administrator.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from verbal mistreatment. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate reported that LPN #1 was verbally abusive when caring for Resident #1. Facility written statement from NA #1 on 6/16/2025 identified when she was providing care for Resident #1's roommate, Resident #1 started yelling and LPN #1 responded to the room. LPN #1 stated he was sick and tired of Resident #1. NA #1 stated she then heard LPN #1 tell Resident #1 go ahead fall on the floor and break your hip so I can send you out. Please go ahead and fall on the floor and bust your hip. RN #1/RN supervisor came to the unit around 6:30 AM and NA #1 reported what had happened during the night. Cross reference F603. Social Services note dated 6/16/2025 at 10:40 AM identified Resident #1's roommate reported inappropriate actions between staff and Resident #1 during the night of 6/16/2025, due to Resident #1 was restless and trying to get out of bed. The note indicated Resident #1 had no recollection of the incident. Resident #1 was confused and had no distress. Record review identified Resident #2 was Resident #1's roommate and was alert and oriented, with a BIMS of 15 (no impairment). Facility incident summary dated 6/23/2025 identified the facility did not substantiate the allegation of verbal abuse, and indicated the comments were misheard or misinterpreted. Interview with LPN #1 on 7/7/2025 at 12:51 PM identified he was caring for Resident #1 during the early morning of 6/16/2025 and stated Resident #1 was trying to get out of bed throughout the shift. LPN #1 denied verbally abusing Resident #1 in any way, or witnessing anyone verbally abusing Resident #1. LPN #1 stated he did not tell Resident #1 to fall and break their hip when he went into the room. Interview with the Director of Social Services and Social Worker #1 on 7/7/2025 at 1:39 PM identified Resident #2 was alert and oriented stated Resident #1 was agitated and trying to get out of bed during the morning of 6/16/2025. Resident #2 stated he/she reported LPN #1 threaten Resident #1 by stating he hoped he/she falls so he can send Resident #1 back to the hospital. Interview and record review with the DNS on 7/7/2025 at 2:35 PM identified Resident #2 called the facility about 6:30 AM and spoke with RN #1, and then RN #1 then went to the residents room. Although the facility summary indicated the allegation of verbal abuse was not substantiated, however the DNS stated the allegation was substantiated. Although attempted, interviews with RN #1 and NA #1 were not obtained during the survey. Facility Abuse Prevention Program policy dated 4/5/2018 directed in part, residents have the right to be free from abuse, including verbal abuse.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from involuntary seclusion. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate reported that LPN #1 was verbally abusive when caring for Resident #1. Facility written statement from NA #1 dated 6/16/2025 identified when she was providing care for Resident #1's roommate, Resident #1 started yelling and LPN #1 responded to the room. The statement indicated she heard LPN #1 state he was sick and tired of Resident #1 and to go ahead fall on the floor and break your hip so I can send you out. Further, NA #1 observed LPN #1 placed items around Resident #1's bed. LPN #1 pushed Resident #1's bed and pushed items in the room included two (2) wheelchairs, one nightstand against the sides of Resident #1's bed below the side rails (the sides of the bed were blocked by raised side rails, wheelchairs and a nightstand). LPN #1 then pushed Resident #2's bed against the wheelchair that was against Resident #1's side of the bed. The statement indicated that RN #1/RN supervisor came to the unit around 6:30 AM and NA #1 reported what had happened during the night and RN #1 helped NA #1 remove all the items surrounding Resident #1's bed. Facility incident summary dated 6/23/2025 identified on 6/16/2025 at approximately 9 AM, Resident #2 (alert and oriented with BIMS score 15) reported to the social worker that LPN #1 had yelled at Resident #1. The investigation indicated that Resident #1 was restless, attempting to climb out of bed, and yelling out during the 11 PM to 7 AM shift and NA #1 positioned herself outside the room. The investigation identified that LPN #1 had pushed items against Resident #1's bed (wheelchairs and a nightstand), and both quarter side rails were raised on the upper portion of the bed. The summary indicated that the allegation of abuse was not substantiated. Cross reference F600. Social Services note dated 6/16/2025 at 10:40 AM identified Resident #1's roommate reported inappropriate actions between staff and Resident #1 during the night of 6/16/2025, due to Resident #1 was restless and trying to get out of bed. The note indicated Resident #1 had no recollection of the incident. Resident #1 was confused and had no distress. Statement from RN #1 on 6/18/2025 identified she received a call about 6:40 AM from Resident #2 (Resident #1's roommate). Resident #2 requested to see RN #1, and RN #1 went to the room. The statement indicated when RN #1 entered the room she observed a bedside stand was wedged with a wheelchair between the bed and bedside stand and in-between the two (2) beds was another wheelchair on the opposite side. RN #1 then rearranged the wheelchairs and furniture. Interview with LPN #1 on 7/7/2025 at 12:51 PM identified he was caring for Resident #1 during the early morning of 6/16/2025 and stated Resident #1 was trying to get out of bed throughout the shift. LPN #1 stated about 4:30 AM he took Resident #1's nightstand and placed it on the right side of the bed against the bed. He then took the resident's wheelchair and placed it on the right side of the bed below the nightstand running along the resident's bed below the quarter side rail. Then, LPN #1 stated he placed the roommate's wheelchair on the left side of the bed below the quarter side rail running and indicated the position of the wheelchairs and nightstand prevented the resident from being able to exit his/her bed. LPN #1 stated he placed the items against the bed to prevent the resident from falling, and stated he was not supposed to place items against the bed to prevent the resident from getting up because it could be considered involuntary seclusion or a restraint. LPN #1 further indicated he did not attempt any other interventions for Resident #1's attempts to get out of bed (i.e. getting the resident out of bed or calling the physician), and thought he was handling the situation. Interview and record review with the DNS on 7/7/2025 at 2:35 PM identified LPN #1 had barricaded Resident #1 in his/her bed which prevented the resident from getting out of bed. The DNS indicated the incident was witnessed by NA #1 around 4 AM to 4:30 AM. When RN #1 was notified, she responded to the room around 6:30 AM and started removing the wheelchairs and furniture from the bed. The DNS stated the facility substantiated the allegation of involuntary seclusion. Facility Abuse Prevention Program policy dated 4/5/2018 directed in part, that residents have the right to be free from abuse, including involuntary seclusion. Facility Involuntary Seclusion policy dated September 2022 directed examples of involuntary seclusion include any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. Review of facility documentation identified an QAPI meeting was held on 6/16/2025, education was initiated on 6/18/2025 for all staff regarding abuse and involuntary seclusion. Audits were initiated on 6/24/2025. Based on review, past non-compliance was identified.

Based on record review, facility documentation, and staff interviews for 1 of 3 residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate reported that LPN #1 was verbally abusive when caring for Resident #1. Facility written statement from NA #1 dated 6/16/2025 identified when she was providing care for Resident #1's roommate, Resident #1 started yelling and LPN #1 responded to the room. The statement indicated she heard LPN #1 state he was sick and tired of Resident #1 and to go ahead fall on the floor and break your hip so I can send you out. Further, NA #1 observed LPN #1 placed items around Resident #1's bed. LPN #1 pushed Resident #1's bed and pushed items in the room included two (2) wheelchairs, one nightstand against the sides of Resident #1's bed below the side rails (the sides of the bed were blocked by raised side rails, wheelchairs and a nightstand). LPN #1 then pushed Resident #2's bed against the wheelchair that was against Resident #1's side of the bed. The statement indicated that RN #1/RN supervisor came to the unit around 6:30 AM and NA #1 reported what had happened during the night and RN #1 helped NA #1 remove all the items surrounding Resident #1's bed. Facility incident summary dated 6/23/2025 identified on 6/16/2025 at approximately 9 AM, Resident #2 (alert and oriented with BIMS score 15) reported to the social worker that LPN #1 had yelled at Resident #1. The investigation indicated that Resident #1 was restless, attempting to climb out of bed, and yelling out during the 11 PM to 7 AM shift and NA #1 positioned herself outside the room. The investigation identified that LPN #1 had pushed items against Resident #1's bed (wheelchairs and a nightstand), and both quarter side rails were raised on the upper portion of the bed. The summary indicated that the allegation of abuse was not substantiated. Statement from RN #1 on 6/18/2025 identified she received a call about 6:40 AM from Resident #2 (Resident #1's roommate). Resident #2 requested to see RN #1, and RN #1 went to the room. The statement indicated when RN #1 entered the room she observed a bedside stand was wedged with a wheelchair between the bed and bedside stand and in-between the two (2) beds was another wheelchair on the opposite side. RN #1 then rearranged the wheelchairs and furniture. Review of the CT Department of Public Health, Facility Licensing and Investigation Section events report tracking system identified the incident occurred on 6/16/2025 at 2 AM. An additional review identified the incident was reported at 9:24 AM. Interview and record review with the DNS on 7/7/2025 at 2:35 PM identified although NA #1 witnessed the incident at approximately 4:30 AM, NA #1 did not notify the RN supervisor at that time. Further, RN #1 became aware of the allegation at 6:30 AM. The DNS stated she and the Administrator were not notified of the allegation until approximately 9 AM, and she then notified the Stated Agency. The DNS stated NA #1 should have reported the allegation when it occurred, and RN #1 should have reported the allegation when she became aware at 6:30 AM. Interview failed to identify why NA #1 and RN #1 did not report the abuse timely. Review of Abuse Investigation and Reporting policy dated July 2017 directed in part, that staff are to notify Administration immediately of an allegation of abuse.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include documentation of an allegation of abuse timely. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate reported that LPN #1 was verbally abusive when caring for Resident #1. Facility written statement from NA #1 dated 6/16/2025 identified when she was providing care for Resident #1's roommate, Resident #1 started yelling and LPN #1 responded to the room. The statement indicated she heard LPN #1 state he was sick and tired of Resident #1 and to go ahead fall on the floor and break your hip so I can send you out. Further, NA #1 observed LPN #1 placed items around Resident #1's bed. LPN #1 pushed Resident #1's bed and pushed items in the room included two (2) wheelchairs, one nightstand against the sides of Resident #1's bed below the side rails (the sides of the bed were blocked by raised side rails, wheelchairs and a nightstand). LPN #1 then pushed Resident #2's bed against the wheelchair that was against Resident #1's side of the bed. The statement indicated that RN #1/RN supervisor came to the unit around 6:30 AM and NA #1 reported what had happened during the night and RN #1 helped NA #1 remove all the items surrounding Resident #1's bed. Social Services note dated 6/16/2025 at 10:40 AM identified Resident #1's roommate reported inappropriate actions between staff and Resident #1 during the night of 6/16/2025, due to Resident #1 was restless and trying to get out of bed. The note indicated Resident #1 had no recollection of the incident. Resident #1 was confused and had no distress. Facility incident summary dated 6/23/2025 identified on 6/16/2025 at approximately 9 AM, Resident #2 (alert and oriented with BIMS score 15) reported to the social worker that LPN #1 had yelled at Resident #1. The investigation indicated that Resident #1 was restless, attempting to climb out of bed, and yelling out during the 11 PM to 7 AM shift and NA #1 positioned herself outside the room. The investigation identified that LPN #1 had pushed items against Resident #1's bed (wheelchairs and a nightstand), and both quarter side rails were raised on the upper portion of the bed. The summary indicated that the allegation of abuse was not substantiated. Statement from RN #1 on 6/18/2025 identified she received a call about 6:40 AM from Resident #2 (Resident #1's roommate). Resident #2 requested to see RN #1, and RN #1 went to the room. The statement indicated when RN #1 entered the room she observed a bedside stand was wedged with a wheelchair between the bed and bedside stand and in-between the two (2) beds was another wheelchair on the opposite side. RN #1 then rearranged the wheelchairs and furniture. Record review identified although NA #1 alleged to have witnessed the incident between LPN #1 and Resident #1, and RN #1 observed the furniture against the bed that prevented Resident #1's egress from the bed, the clinical record failed to identify the incident prior to the social service note dated 6/16/2025 at 10:40 AM. Review failed to identify the allegation, and failed to identify the physician and responsible party were notified. Although attempted, an interview with RN #1 was not obtained during the survey. Interview and record review with the DNS on 7/7/2025 at 2:35 PM identified RN #1 was aware of the incident on 6/16/2025 at 6:30 AM. The DNS was unable to provide documentation that RN #1 wrote a nursing note, to include that the physician and responsible party were notified. Further, the DNS indicated RN #1 should have written a nursing note and she did not know why it was not done. Facility Charting and Documentation policy dated July 2017 directed in part, information was to be documented in the resident's medical record, events, incidents or accidents involving the resident and notification of the family.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was treated in a respectful and dignified manner. The findings include: Resident #1 had diagnoses that included moisture associated skin damage (MASD), anxiety, dysthymic disorder, muscle weakness, difficulty walking, lymphedema, and type 2 diabetes mellitus. The Resident Evaluation dated 3/7/2025 at 7:35 P.M. by Licensed Practical Nurse (LPN) #4 indicated Resident #1 was admitted to the facility with a superficial 3 centimeter slit to the coccyx, sacral-coccyx, and buttocks with excoriation. A physician's order dated 3/7/2025 directed to apply triad cream to buttocks and coccyx every shift for excoriation. The 5-day [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicative of intact cognition, was always incontinent of bowel and bladder, required substantial assistance with toileting hygiene, moderate assistance with personal hygiene, bed mobility, and transfers. The Resident Care Plan dated 3/14/2025 identified Resident #1 had actual skin breakdown, MASD to the gluteal folds, and bogginess to the bilateral heels with interventions that directed to administer treatment per physician orders, encourage and assist as needed to turn and reposition; use assistive devices as needed, wound consult as needed, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain and notify the physician as needed. A Situation Background Appearance Review and Notify (SBAR) assessment dated [DATE] at 12:00 P.M. completed by Registered Nurse (RN) #1 identified that Resident #1 had a change in condition that started on 3/14/2025. The assessment identified Resident #1 complained of possible abuse, that a nurse aide treated h/her badly and may have caused a painful abrasion on h/her right buttock. The assessment identified Resident #1 had blanchable redness with MASD present to the gluteal folds and buttocks, a pinpoint abrasion to h/her right buttock, and pain when h/her right buttock was touched. The assessment indicated the DNS, APRN #1, and Family Member #1 were notified. A Reportable Event (RE) form dated 3/14/2025 at 1:32 P.M. identified, on 3/14/2025 at 12:00 P.M., Resident #1 reported that on 3/13/2025 at 12:00 P.M., during morning care, NA #1 was rough and forcefully pulled the blanket h/she was lying on out from under h/her. Resident #1 reported when h/she requested NA #1 be gentler during care, NA #1 stated suck it up. NA #1 was suspended pending the outcome of the investigation. MD #1 was notified and the police were called. The facility summary dated 3/21/2025 identified that the allegation of abuse was unsubstantiated. The corrective action plan was to provide re-education to NA #1 on customer service and delivery of care to a resident who may have a sensitive area on h/her body due to a medical condition. An interview with the nursing supervisor (RN #1) on 3/31/2025 at 10:56 A.M. identified, on 3/14/2025 at approximately 12:00 P.M., LPN #3 notified her, Resident #1 reported that NA #1 was rough and mistreated h/her while providing care on the previous day. RN #1 identified she interviewed Resident #1 who reported that on 3/13/2025 when NA #1 was moving h/her to h/her side, NA #1 ripped a draw sheet out from under h/her causing an abrasion on h/her backside, and when Resident #1 yelled out, NA #1 told h/her to stop being a baby. RN #1 indicated that upon assessment, she identified Resident #1 continued to have MASD to h/her buttocks and gluteal folds that were present upon admission, Resident #1 had a pinpoint abrasion on h/her right buttock with one spot of serosanguineous drainage on the inside of the brief, and no bruising or any other skin impairments were noted. RN #1 indicated Resident #1 denied any pain or discomfort. RN #1 indicated she notified the DNS who took over the investigation. An interview with NA #1 on 3/31/2025 at 11:12 A.M. identified on 3/13/2025 while Resident #1 was standing up, h/she was incontinent of bowel, and when she started providing incontinent care, Resident #1 stated that h/her backside was hurting. NA #1 indicated she could not see the area that Resident #1 said hurt so she transferred Resident #1 into bed. NA #1 indicated once Resident #1 was in bed, she placed her hand on Resident #1's hip to turn h/her and observed that Resident #1 had a red rash which was causing discomfort. NA #1 identified when Resident #1 initially complained of discomfort to h/her backside she told Resident #1 we need to work through it so I can clean you. NA #1 indicated Resident #1 had no further complaints of discomfort or pain. NA #1 indicated she did not think she was rough while providing incontinent care to Resident #1, but identified she understood why Resident #1 felt like care was rough due to the rash. An interview with Resident #1 on 3/31/2025 at 1:25 P.M. identified that a few weeks prior, when NA #1 went into h/her room, NA #1 was in a bad mood, and when NA #1 started to change h/her, NA #1 grabbed h/her right leg to turn h/her and then pulled the bedspread causing a mark on h/her backside. Resident #1 identified h/she felt that NA #1 was disrespectful, so the next day h/she reported what happened. Resident #1 could not recall exactly what was said to h/her by NA #1 since the encounter was weeks prior. An interview with the DNS on 3/31/2025 at 2:00 P.M. identified, on 3/14/2025 at approximately 12:00 P.M., she was notified by RN #1, that Resident #1 reported h/she was treated roughly during care by NA #1. The DNS identified she interviewed Resident #1 and Resident #1 reported on 3/13/2025, while providing incontinent care, NA #1 was rough, ripped a draw sheet quickly from under h/her, used Resident #1's arm and leg to turn h/her, and when Resident #1 screamed, NA #1 said suck it up. The DNS indicated she assessed Resident #1 and did not observe any new skin impairments, bruises, or fingerprints. The DNS indicated Resident #1 denied any pain or discomfort and felt safe at the facility. The DNS indicated the allegation of staff to resident abuse was unsubstantiated. The DNS identified NA #1 did not treat Resident #1 in a respectful and dignified manor, therefore, was subsequently terminated. The DNS further identified that all staff are to treat residents with respect and dignity. Review of facility resident rights policy, dated February 2021, indicated employees shall treat all residents with kindness, respect, and dignity.

Based on clinical record review, observations, review of facility policy and interviews for two sampled residents (Residents #28 and #47) reviewed for dining, the facility failed to ensure a dignified experience. The findings include: 1. Resident #28's diagnoses included other abnormalities of gait and mobility, bicipital tendinitis right shoulder, and abnormal posture. The quarterly MDS assessment dated [DATE] identified Resident #28 had intact cognition and required set up assistance with eating and oral hygiene. Resident #28's care plan dated 11/28/23 identified an ADL (activities of daily living) self-care deficit related to muscle weakness with interventions that included: assist with daily hygiene, grooming, dressing, oral care and eating as needed. Observations on 12/18/2023 at 8:05 AM 12/18/2023 at 12:42 PM identified Resident # 28 was served breakfast and lunch in a Styrofoam container with plastic utensils and a plastic cup. Interview with Resident #28 on 12/18/2023 at 8:00 AM identified residents are served several meals a week utilizing plastic utensils and Styrofoam containers, and that it was very unappetizing and made him/her not want to eat. The Administration had been made aware of the issue and it had been brought up in Resident Council and identified that it was due to a shortage of kitchen staff. Interview with the Director of Dietary on 12/19/2023 at 10:00 AM identified the kitchen has been understaffed and the kitchen utilizes Styrofoam and plastic utensils when they are short staffed. Interview with NA #2 on 12/21/23 at 12:40 PM identified that Styrofoam and plastic utensils were utilized at least once per week due to short staff in the kitchen, NA #2 further noted that sometimes it's regular plates with just plastic utensils, and sometimes it is both plastic utensils and Styrofoam containers. In addition, NA#2 identified she was concerned with the choking risk that utilizing plastic utensils could pose. Interview with NA#1 on 12/21/23 at 12:45 PM identified that plastic utensils and Styrofoam containers were used at least once a week and that it was very hard to cut up food for residents who require assistance using plastic. Review of the Disposable Dishes and Utensils policy identified the facility used single service items only in extenuating circumstances, such as dish-machine failure, individual resident needs, or other documented reason. 2. Resident #47's diagnoses included Parkinson's disease without dyskinesia, muscle weakness, and essential tremor. The quarterly MDS assessment dated [DATE] identified Resident #47 had intact cognition, required set up assistance with eating, and oral hygiene. Resident #47's care plan dated 8/8/23 identified the potential for alteration in nutrition status related to history of planned weight gain with interventions that included: utilize adaptive equipment built up utensils, encourage and assist as needed to consume foods and/or supplements and fluids offered at and between meals. Observations on 12/18/2023 at 7:42 AM of the breakfast meal and 12/18/2023 at 12:35 PM of the lunch meal identified Resident #47 was served both meals in a Styrofoam container. Interview with the Director of Dietary on 12/19/2023 at 10:00 AM identified the kitchen has been understaffed and Styrofoam and plastic utensils are utilized when they are short staffed in the kitchen. Interview with NA #2 on 12/21/23 at 12:40 PM identified that Styrofoam and plastic utensils were utilized at least once per week due to short staff in the kitchen, NA #2 further noted that sometimes it's regular plates with just plastic utensils, and sometimes it is both plastic utensils and Styrofoam containers. In addition, NA#2 identified she was concerned with the choking risk that utilizing plastic utensils could pose. Interview with NA#1 on 12/21/23 at 12:45 PM identified that plastic utensils and Styrofoam containers were used at least once a week and that it was very hard to cut up food for residents who require assistance using plastic. Review of the Disposable Dishes and Utensils policy identified the facility used single service items only in extenuating circumstances, such as dish-machine failure, individual resident needs, or other documented reason.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of four sampled residents (Resident #72 and Resident #86) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to request a PASRR level 2 assessment for a resident with a new psychiatric diagnosis and failed to obtain and complete a PASRR level II screen in timely manner when the resident's approved stay had expired. The findings include: 1. Resident #72's diagnoses included delusional disorder. The quarterly MDS assessment dated [DATE] identified Resident #72 had moderately impaired cognition, required set-up assistance with eating and supervision or touching assistance with oral hygiene, and substantial/maximal assistance with toileting hygiene. Resident #72's care plan dated [DATE] identified the problem of increased agitation, and yelling out, with interventions that included: observe for mental status/behavioral changes when new medication is started or with changes in dosage, and psychiatric referral as needed. A physician's order dated [DATE] identified a new diagnosis of delusional disorder. Interview with SW #1 on [DATE] at 11:10 AM identified that a level 2 PASSR screening assessment had not been completed following the addition of the diagnosis of delusional disorder and wasn't sure if delusional disorder was a qualifying diagnosis for a Level 2 to be completed. SW #1 was also not made aware of the delusional disorder diagnosis for Resident #72 and identified that the information would be transferred to her usually in morning report or directly by the nurse or physician once the new diagnosis was made. Interview with Social Worker #2 on [DATE] at 11:20 AM identified that the diagnosis of delusional disorder is a qualifying diagnosis that would require a level 2 PASSR evaluation. She further noted that a referral was not made for a level 2 assessment to be completed because she was unaware of the diagnosis. Review of the admission policy identified that the social worker is responsible for making referrals to the appropriate state-designated authority for a level 2 PASSR. 2. Resident #86's diagnoses included recurrent major depressive disorder, anxiety, dysphagia, and atrial fibrillation. Review of the PASRR screen level II dated [DATE] identified Resident #86 was approved to be in the facility for care through [DATE]. The quarterly MDS assessment dated [DATE] identified Resident #86 had intact cognition and required extensive assistance for bed mobility, transfers, toileting, and hygiene. Interview with SW #1 (Director of Social Work) on [DATE] at 10:30 AM identified the social work department was responsible for submitting PASRR screening requests to the authoritative entity responsible for conducting the PASRR assessments. She further identified that SW #2 attempted to submit another screening on [DATE] but received a message that it was too early to submit for a new assessment. She further identified that it was an oversight when their department failed to submit a request for PASRR level screening after it expired on [DATE]. Subsequent to surveyor inquiry, SW #1 submitted a request for a PASRR Level II screening, which was 94 days past the expiration date of the prior PASRR Level II assessment. Review of the Admission Criteria policy identified that all new admissions and re-admissions will be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process. 47402

Based on observation, review of clinical record, facility policy review, and interviews for one of three sampled residents (Resident #91) reviewed for medication administration, the facility failed to ensure medication error rate of less than five percent. The findings include: Resident #91's diagnoses included cervical spinal cord injury, quadriplegia, spinal stenosis, and neuromuscular dysfunction of bladder. The physician's orders dated 11/5/23 directed to administer Aripiprazole (anti-psychotic medication) 5 milligrams (mg) by mouth every day and to administer Duloxetine (anti-depressant medication) 60 mg capsules 2 capsules (a total of 120 mg) by mouth daily. The admission MDS assessment dated [DATE] identified Resident #91 had intact cognition and required extensive assistance with bed mobility, transfers, toileting, and hygiene. Observation of medication administration for Resident #91 on 12/18/23 at 8:35 AM, with LPN #1 identified that he placed 4 capsules of Duloxetine 60 mg (total of 240mg), 2 tablets of Aripiprazole 5 mg (total of 10mg) and 3 capsules of Gabapentin (anticonvulsant and nerve pain medication) 400mg (1200 mg) into a plastic medication cup. Review of the 2 small, labeled envelopes with cellophane areas that exposed the medications contained within dated 12/18/23; 9:00 AM identified each bag contained 2 capsules of Duloxetine 60 mg, 2 capsules of Gabapentin 400 mg and 1 tablet of Aripiprazole 5 mg. After pouring the medications, LPN #1 proceeded to enter Resident #91's room and was preemptively stopped by the surveyor prior to him administering the incorrect dose of medication to the resident. Interview and review of the Medication Administration Record (MAR) with LPN #1 at 9:00 AM identified that the physician's orders directed to administer Aripiprazole 5 mg by mouth every day and Duloxetine 60 mg 2 capsules by mouth every day. LPN #1 identified that although he had read the directions on the MAR and verified the dosages, he did not realize that the 2 envelopes had the same medications. He further identified that the facility had implemented a new way of dispensing medications that just started on 12/13/23. The combined medication administration observations identified that there were 2 medication errors out of 25 opportunities for errors resulting in a medication error rate of 8 percent. The Adverse Consequences and Medication Errors policy identified that a medication error is defined as the preparation or administration of drugs that is not in accordance with the physician's orders, manufacturer specifications or accepted professional standards and principles of the professional providing services.

Based on review of facility documentation, review of facility policy and interviews, the facility failed to have NA staff complete the annual competency course for dementia care. The findings include: Review of NA #9's personnel file identified she has been employed at the facility since 3/30/22 on the 11pm to 7 am shift at 37.5 hours weekly. The file further identified a letter dated 7/6/23 that noted that NA #9 had not completed her yearly in-service trainings and that she would be removed from the schedule if the trainings were not completed. A review of the staffing schedule dated 12/10/23 and 12/15/23 identified NA #9 worked one eight-hour shift. Interview on 12/21/23 at 10:53 AM with the ADNS identified that when staff do not complete the annual training requirements, we try to give them time to complete the training at the facility or to complete it at home to make it easier for them. We provide reminders and time to complete the training, for example, if the training is due in October, we would give them until the end of December to complete it. When the training is not completed, we make the staff member aware that they will be removed from the schedule until the required training is completed. Interview on 12/22/23 at 12:34 PM with the Facility Educator (FE) identified that the nurse aides get at least 12 hours of in-service training annually. She noted that NA #9 had not attended the annual competency fair for 2023. The FE further identified that NA #9 had not completed the required dementia training. She noted that she and the DNS are responsible for ensuring that the nurses' aides complete the required training. Review of the facility's matrix identified thirty-one residents as having a diagnosis of Alzheimer's or Dementia The facility failed to ensure that required yearly training was completed and failed to suspend NA #9 when it was identified that she had not completed all of the required yearly training.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents reviewed for accidents (Resident #7 and Resident #39), the facility failed to transport the resident in a safe manner and/or failed to provide care in a timely manner resulting in a fall. The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified that R #7 had severely impaired cognition, required use of a wheelchair, required one staff physical assist for locomotion in the wheelchair, and had no falls since the last assessment. The Resident Care Plan (RCP) dated 5/16/18 identified R #7 required assistance for mobility, and a risk for falls due to history of falls, impaired mobility and dementia. Interventions directed to allow to attempt movements by self before offering assistance, reinforce wheelchair safety as needed such as locking brakes, reinforce the need to call for assistance and have commonly used articles within reach. Review of facility documentation dated 7/22/18 at 12 noon identified R #7 was being pushed in his/her wheelchair toward the dining room by LPN #1 when R #7 put his/her feet down on the floor, propelled forward from the wheelchair, fell and hit his/her forehead on the floor. R #7 suffered a 1.5 cm laceration on the right forehead, pressure was applied, 911 was called and the resident was transferred to the hospital. Review of the nurse's note dated 7/22/18 at 7:34 PM identified R #7 returned from the hospital with three sutures to the right forehead and was to have neuro checks started. Interview, clinical record review, and facility documentation review with LPN #1 on 4/16/18 at 1:00pm identified she could not remember if R #7 had leg/foot rests. Review of the clinical record, facility documentation and interview on 4/16/19 at 12:15 PM with RN #1 identified there were no foot rests on R #7's wheelchair when LPN #1 pushed R #7 in the wheelchair, and R #7 fell out of the wheelchair when he/she put his/her feet on the floor. RN #1 stated when LPN #1 was pushing R #7 in the wheelchair, LPN #1 should have had foot rests on the wheelchair. Interview with the DON on 4/16/19 at 1:19 PM identified if a resident is self-mobile in a wheelchair, and staff are going to push the resident in the wheelchair any distance, like to an activity, leg rests should be applied to the wheelchair. Interview with LPN #1 on 4/17/19 at 11:30 AM identified R #7 was confused, hard of hearing, and unable to follow directions. LPN #1 stated if directions were given to R #7 to lift his/her feet off the ground when the wheelchair was being pushed, R #7 would not be able to follow directions. Interview with RN #1 identified there was no facility policy for leg/foot rest use, however the expectation was that leg/foot rests should have been applied when staff were pushing the resident in the wheelchair. Review of facility fall policy indicates the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident care plan dated 3/19/18 identified a problem with being at risk for falls due to history of falls, impaired cognition, recurrent TIA, impaired balance and mobility, and poor safety awareness. Interventions included to provide assistance to transfer-reinforce use of rolling walker, and remind resident to call for assistance with transfers. A significant change Minimum Data Set assessment dated [DATE] identified Resident #39 was moderately cognitively impaired, requiring extensive assistance of two staff for bed mobility and transfers, non-ambulatory, not steady and only able to stabilize with staff assistance moving on and off the toilet, and a recent fall with a fracture. A Fall risk evaluation dated 4/13/18 identified score of 13 indicating high risk for falls. A facility Reportable Event form dated 4/21/18 at 12:00 PM indicated Resident #39 fell while attempting to toilet self. Facility investigation identified that Resident #39 told the Recreation Therapist that he/she needed to go to the bathroom after an activity, Resident #39 was escorted downstairs for lunch in his/her wheelchair, was left in the hallway and attempted to toilet him/herself and fell . Resident #39 complained of left hip pain, was sent to the emergency room and diagnosed with [REDACTED]. Therapist statement obtained by the facility at the time of the event indicated Resident #39 informed the therapist he/she needed to go to the bathroom, was brought downstairs for lunch, the therapist went back upstairs to get more residents, when the therapist got back downstairs he/she did not see Resident #39 and asked NA#5 if Resident #39 could go to the bathroom on his/her own. Recreation Therapist #1 was no longer employed at the facility and attempts to reach Recreation Therapist #1 were not successful. Interview with NA#5 on 4/18/19 at 10:40 AM indicated NA#5 was informed by a volunteer that Resident #39 was in the bathroom by him/herself, went to the bathroom and found Resident #39 on the floor. NA#5 further indicated he/she was not informed by Recreation that Resident #39 needed to go to the bathroom before being left unattended in the hallway. Facility fall policy indicates the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on clinical record review and staff interview, for one of three residents (Resident #84) in the survey sample reviewed for accidents, the facility failed to provide care and services as ordered by the physician and/or indicated in the resident care plan to prevent a fall. The findings include: Resident #84 [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #84 had no cognitive deficits, had severely impaired vision, required extensive assist with transfers, walking in the room and corridor, was not steady and only able to stabilize with staff assist for walking and turning around, and utilized a walker for a mobility device. A resident care plan dated 8/23/17 identified a problem with mobility. Interventions included provide limited assist with one person and the rolling walker and transfer with assist of 2 people. A problem with a risk for falls due to a history of falls, visual deficit, and forgetfulness was identified. Interventions included encourage the resident to transfer and change positions slowly, provide assistance to transfers and ambulate, and transfers and ambulation with the assist of a rolling walker. A physician's orders [REDACTED].#84 to transfer and ambulate with assist of 1 and a rolling walker. A physical therapy evaluation dated 10/11/17 indicated Resident #84 had a shuffling gait and used a rolling walker for transfers and mobility. A nurse's note dated 10/31/17 dated 8:51 AM indicated while ambulating with the nurse aide from the bathroom to the bed, Resident #84 tripped. The nurse aide attempted to lower the resident. The nurse aide lost his/her balance and they both fell . The resident hit his/her back of the head on the door and complained of left hip pain. The resident was unable to move his/her leg. The Advanced Practice Registered Nurse (APRN) was notified and Resident #84 was sent to the hospital emergency room . A hospital discharge summary dated 11/6/17 indicated Resident #84 sustained a left femur fracture on 10/31/17. On (MONTH) 2, (YEAR) Resident #84 underwent an open reduction and internal fixation of the left femur. A reportable event form dated 10/31/17 indicated while the nurse aide was walking with Resident #84 out of the bathroom to the room the resident tripped on the threshold of the bathroom. Resident #84 had a shuffling gait, lost his/her balance and fell on his/her left side. The threshold was inspected and no defects were noted. An observation and interview on 2/28/18 11:55 AM with Nurse Aide (NA) #1 indicated that at the time of the incident Resident #84 was at the bathroom sink brushing his/her teeth. Resident #84 did not have the rolling walker with the resident. The rolling walker was placed in the resident's room. Nurse Aide # 1 indicated he/she did not have a gait belt on the resident. Nurse Aide #1 indicated he/she took the resident's arm and turned him/her away from the sink and walked him/her out of the bathroom. Nurse Aide #1 indicated as he/she was walking out of the bathroom Resident #84 tripped on the threshold between the bathroom and room. Nurse Aide #1 indicated Resident #84 shuffled his/her feet while walking. He/she tried to prevent Resident #84 from falling by grabbing his/her waist, but he/she and the resident fell to the ground. At that time of the interview it was observed that the rolling walker fit in the bathroom and was able to go through the bathroom door. Nurse aide #1 indicated he/she did not bring the walker in the bathroom because he/she always left it in the room and walked the resident out of the bathroom without it and never had a problem before. He/she further indicated he/she should have used the gait belt on the resident while walking with the resident, but he/she did not that day. He/she was unable to explain why. An interview on 02/28/18 at 12:01 PM with the Director of Nursing Services (DNS) indicated he/she expected NA #1 to have used a gait belt on Resident #84 for all transfers and ambulation. He/she further indicated the rolling walker should have been used in the bathroom when walking the resident in and out of the bathroom. A facility policy on gait/transfer belt use indicated a gait belt will be used for all assisted transfers, pre-gait and gait activities unless contraindicated by the resident's condition.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 sampled resident (Resident #364) reviewed for medication administration, the facility failed to ensure that the resident was free from a significant medication error. The findings include: Resident #364 was admitted on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge instruction dated 5/25/17 directed [MEDICATION NAME] Tarte 37.5 mg oral tablet 0.333 tablet (12.5 mg ) by mouth every 12 hours. The admission physician's orders [REDACTED]. The care plan dated 5/25/17 identified Resident #364 had [MEDICAL CONDITION] related to history of [MEDICAL CONDITION] infarction and hypertension. Interventions directed to administer medication per physician's orders [REDACTED]. Review of Medication Administration Record [REDACTED]. The nurse's note dated 5/30/17 at 4:44 AM identified that Resident #364 had change in condition related to complaint of feeling dizzy, nauseous, and diaphoretic. Further the nurse's note identified Resident #364's heart rate of 42 beats per minute (normal from 60 to 100 beats per minute) and blood pressure was 120/50 (normal 120/80). Additionally nurse's note identified that the physician was notified and Resident #364 was sent to hospital for evaluation. Reportable event dated 5/30/17 identified a transcription error. Further the reportable event identified that hospital discharge instruction directed [MEDICATION NAME] Tarte 37.5 mg, 0.33 tablet every 12 hours, discharge summary directed [MEDICATION NAME] Tarte 37.5 mg, 0.333 tablet, and last dose at the hospital was [MEDICATION NAME] Tarte 12.5 mg, 0.5 tablet. Additionally, the reportable event identified [MEDICATION NAME] Tarte 37.5 mg by mouth every 12 hours was written as the order at the facility, and Resident #364 complained of dizziness and nausea, was diaphoretic, and had heart rate of 42 beats per minute and blood pressure of 120/50. Review of hospital documentation dated 6/1/17 identified Resident #364 presented at the hospital with symptomatic [MEDICAL CONDITION], suspected due to increased dose of beta blocker (medication used to control heart rhythm) at the facility. Further the hospital documentation identified that Resident #364 was previously discharged on [DATE] with [MEDICATION NAME] Tarte 12.5 mg twice daily, however had been receiving 37.5 mg twice daily since 5/26/17 due to an error. Additionally, the hospital documentation identified that Resident #364 was monitored on the telemetry unit, continued to have low heart rate of 30 to 40 beats per minute up to the 50 beats per minute, and the [MEDICATION NAME] Tarte was stopped. An interview and clinical record review with RN #1 on 2/27/18 at 12:18 PM noted that RN #1 was training RN #2 for the supervisor position on 5/25/17 and RN #2 transcribed Resident #364's [MEDICATION NAME] Tarte order. Further RN #1 identified that both RN #1 and RN #2 validated the accuracy of transcribed admission orders [REDACTED]. A phone interview with RN #2 on 2/27/18 at 1:27 PM identified that RN #2 transcribed the hospital admission orders [REDACTED]. A phone interview with RN #5 on 2/27/18 at 2:16 PM identified that Resident #364 complained on 5/30/17 that he/she did not feel well. Further RN #5 identified that Resident #364 was sweaty, clammy, his/her heart rate was fluctuating, and the heart rate of 42 beats per minute was the best that night and Resident #364 was sent to hospital for evaluation. Interview and clinical record review with DNS on 2/28/18 at 11:05 AM, identified that although 2 nurses validated the transcription of all admission orders [REDACTED]. Further the DNS identified that Resident #364 was discharged on [DATE] with [MEDICATION NAME] Tarte 12.5 mg twice daily, however he/she had been receiving [MEDICATION NAME] Tarte 37.5 mg twice daily from 5/26/17 through 5/30/17 (8 doses) when he/she was transferred to hospital for evaluation due to a low heart rate. Review of facility physician's orders [REDACTED].

Based on a review of clinical records, facility documentation, job descriptions, interviews, and facility policies, for one of three residents who had dietary restrictions and/or had a feeding tube (Resident #1), the facility failed to ensure that the resident did not have any oral intake in accordance with the physician's orders [REDACTED]. The finding includes: Resident #1 was admitted to the facility on [DATE] at 9:11 PM following a 32 day hospitalization and placement of a gastric feeding tube on 3/23/16. Admission [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that the resident was alert, oriented, had reliable safety awareness and lungs were clear. Physician orders [REDACTED]. The Medication Administration Record [REDACTED]. Nursing narratives and/or the facility investigation dated 3/26/16 noted that R #1 ate 90% of another resident's breakfast tray delivered to him/her by NA #1, developed coughing with respiratory distress and vomited (clear fluid and undigested egg). The nursing narratives and/or nursing transfer documentation identified that the resident became [MEDICAL CONDITION] (pulse of 140 beats per minute), had increased respiratory rate (respirations 28/minute), an oxygen saturation level of 85% (normal 90-100%) with gurgled respirations, and required suctioning. Interview with NA #1 on 4/11/16 at 12:05 PM stated that on the morning of 3/26/16 at approximately 8:15 AM she delivered a breakfast tray to R #1 that was meant for a resident in the next room and misread the room number. Although NA #1 verified that the tray slip contained a printed resident name, she read only the room number. NA #1 further identified that R #1 was in bed at the time, she emptied two (2) small plastic cups that contained water from the resident's overbed table, boosted the resident up in bed with another NA, raised the resident's head of the bed, left the breakfast tray on the resident's table, and left the room. Subsequently, the resident was transferred to Hospital #3 per physician's orders [REDACTED]. The chest x-ray shows a right lower lobe infiltrate and the patient was admitted with respiratory distress secondary to an acute aspiration pneumonia. The facility policy for tray identification directed nursing staff check each food tray for the correct diet before serving the residents. The facility job description for CNA identified to use wrist band or photo card file to identify residents before administering treatments, serving meals, etc., and as necessary. Immediately following this event on 3/26/16, education for tray pass to include resident identification was provided for nursing staff on all three shifts.