Every finding on record at Silver Springs Care Center

Based on observations, interviews, and facility policy, the facility failed to ensure facial hair was covered when prepping food and that a soiled fan facing the food preparation area was not in use when food was being prepared. The findings include: 1. Observation and interview with the Director of Dietary Services on 8/25/26 at 11:30 AM identified that Dietary Aide (DA) #1 was standing at the food preparation area whisking yellow liquid in a large rectangular pan without the benefit of wearing a beard cover. DA # had facial hair on his chin approximately 1/2 inch to 1 inch in length (goatee). The Director of Dietary Services indicated that he was unsure of the length of facial hair that required a beard cover. The Director of Dietary Services stated that DA # was a new hire and it was his second day of employment and was not aware if he had received education regarding beard covers when in the food preparation area. The Director of Dietary Services instructed DA #1 to cover his facial hair with a beard cover. 2. Observation and interview with the Director of Dietary Services on 8/25/26 at 11:45 AM identified a medium-size square, homestyle type of fan that had thick accumulation of black dust on the blades and in the front and back of the fan grill. The fan was on top of a counter and in use and was approximately 100 to 125 feet away from the food prepping area. The Director of Dietary Services stated that the fan was pretty dirty and that it should not be blowing in the direction of the food prepping area. The Director of Dietary Services stated that he was unsure of who was responsible for cleaning the fans in the kitchen but most likely it was the dietary department. The Director of Dietary services stated, this thing is ancient, I am going to throw it away right nowSubsequent to surveyor inquiry, the Director of Dietary Services initiated education to all dietary employees on the facility policy for beard covers. In addition, he stated that new fans would be ordered for the kitchen and staff would be educated that it was the responsibility of the kitchen staff to ensure fans are clean and would be part of a cleaning schedule.The Hair Restraint Policy dated 1/20/2017, directed, in part, compliance to local and federal food service code requires that anyone within the kitchen, who will have close contact with the preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include facial hair. The purpose of hair restraints is to prevent hair from contacting food and food equipment surfaces, and to deter foodservice employees from touching their hair.The facility may dictate the definition of beard to read as stubble to scruffy to 2-day growth.Although requested, the facility did not have a policy related to the use of fans or cleaning of fans in the kitchen.

Based on observations, interviews and facility documentation, the facility failed to maintain an effective pest control program, as evidenced by the presence of multiple gnat/fruit fly type flying insects observed in the kitchen and throughout multiple areas of the facility. The findings include: Observation and interview with the Director of Dietary Services on 8/25/26 at 11:00 AM identified gnats/fruit fly type flying insects were noted to be in food prepping areas, near the 3 bay sinks, and in the dry food storage area. The Director of Dietary stated that he was aware of the flying insect issues and had attempted to treat the drains himself but did not have the proper chemicals. He indicated that the pest control company serviced the kitchen every 2 weeks; however, he had not received a copy of their reports, nor did he think that the drains were professionally treated by the service to eradicate the flying insects. The Director of Dietary identified that professional treatment and scraping of the drains was needed to eliminate the insects, stating that he had informed the Administrator several times of the issue in the kitchen areas.An observation on 8/25/26 at 2:00 PM identified multiple gnat/fruit fly type flying insects in the kitchen area near the food prepping station and next to the dry food storage area.Observations in rooms [ROOM NUMBERS] on the first floor on 8/26/26 at 12:30 PM, identified multiple gnat/fruit fly type flying insects throughout the hallways and flying over the beds.Interview with the Administrator on 8/26/26 at 1:00 PM indicated she was aware of multiple gnat/fruit fly type flying insects in the facility and that the pest control company had serviced the facility every 2 weeks, but she was unaware if they had treated the kitchen or any other areas in the facility. The Administrator stated that she would need to review the pest control reports and that the Maintenance Department was responsible for the oversight of the pest control program.A review of the pest control company reports dated 5/26/26, 6/12/26, 6/25/26, 7/30/26, and 8/14/26 failed to indicate any servicing of the drains in the kitchen to eliminate the multiple gnat/fruit fly type flying insects. The 8/14/26 report indicated that fly spray was applied in strategic areas in basement to help control fly activity. Observation on 8/27/26 at 5:15 AM identified multiple gnat/fruit fly type flying insects noted to be flying around in the supervisors office on the first floor.Observation on 8/27/26 at 5:30 AM indicated multiple gnat/fruit fly type flying insects flying around over the bed in room [ROOM NUMBER]. Observation and interview with the Director of Nursing (DNS) in her office on 8/27/26 at 7:20 AM identified multiple gnat/fruit fly type flying insects. The DNS was noted to be swatting and shewing away flies around her stating that there were flying insects throughout the facility.Observation and interview on the first floor with Housekeeper #2 on 8/27/26 at 7:45 AM identified her carrying garbage bags from the soiled utility room with multiple gnat/fruit fly type flying insects noted flying around the garbage bags. Housekeeper #2 stated that the flies were from the garbage and the sink area located in the dirty utility roomObservation on the second floor in the hallway during breakfast service on 8/27/26 at 8:41 AM identified multiple gnat/fruit fly type flying insects in the area during serving from the steam table.Interview with Director of Housekeeping on 8/28/26 at 9:30 AM identified he was new to his role and was aware of the multiple gnat/fruit fly type flying insects noted. He stated that the Maintenance Department was responsible for pest control in the facility. The Director of Housekeeping indicated that the flying insects had been an ongoing concern, and he tried to assist with elimination by requesting residents discard food items kept in their rooms. He stated he had placed Isopropyl Alcohol (typically used for cleaning the skin) in a bottle and sprayed areas in the dirty utility rooms, but never in resident areas. He indicated that he never has instructed his staff to use this method, but he had done this a few times as it helped to kill the flying insects. He stated that he had never contacted the facility's vendor for instruction on the use of appropriate chemicals that could be used in the facility to eradicate the multiple gnat/fruit fly type flying insects noted. Interview with the Director of Maintenance on 8/28/26 at 10:00 AM identified that he was responsible for pest control in the facility and that he had treated the drains with bleach periodically but did not keep a log of his treatments. Furthermore, the Director of Maintenance was unable to state if the use of bleach was an effective treatment to eradicate the multiple gnat/fruit fly type flying insects noted. In addition, he indicated that the pest control company had never treated the drains in the facility, but he was aware that the multiple gnat/fruit fly type flying insects noted were an ongoing issue and that it was difficult to control due to many residents keeping food in their rooms. Interview with the Corporate Physical Plant Director on 8/28/26 at 10:10 AM indicated that bleach was not an effective treatment for drains to eradicate the multiple gnat/fruit fly type flying insects noted and that the facility would be contacting the pest control company to address the issue. Subsequent to surveyor inquiry, the Director of Maintenance indicated that the pest control company would be servicing the facility next week to treat drains and any necessary treatment needed for the multiple gnat/fruit fly type flying insects noted. The treatment plan would be added to the bi-monthly service, and the service reports would be generated directly to the Physical Plant Director and Food Service Director.Although requested, the facility did not have a policy on pest control.

Based on initial tour, observations, record reviews and interviews for the 3 out of 3 nourishment rooms, the facility failed to ensure no items were stored under the sinks, and for the facility environment, the facility failed to provide a safe, sanitary environment in various common areas noted throughout the building. The findings include: 1. A tour of all 3 nourishment rooms on 8/28/26 at 12:30 PM with the Director of Dietary Services identified that the cabinets under the sink had storage of multiple items and the bottom of the cabinets had dust and small amounts of debris. In the first-floor nourishment room there were several sleeves of unused large Styrofoam cups stored under the sink. In the second-floor nourishment room under the sink there were 3 milk containers, 4 empty plastic water bottles, a dirty toaster, and several sleeves of unused Styrofoam cups. In the third-floor nourishment room, under the sink contained several unused Styrofoam cups. Interview with the Director of Dietary Services on 8/28/26 at 12:35 PM stated that he was not responsible for overseeing what was stored under sinks in the nourishment rooms and he believed it was a housekeeping and/or maintenance responsibility. The Director of Dietary Services indicated that items should not be stored under the sink, and the area should be free of dust and debris. Interview with the Administrator on 8/28/26 at 1:00 PM identified that she was unsure who was responsible for cleaning and maintaining the cabinets under the sink in the nourishment rooms but would speak to housekeeping as items should not be stored under the sink. Interview with the Director of Housekeeping on 8/28/26 at 1:15 PM indicated that he was not aware that housekeeping was responsible for cleaning and maintaining under the sink in the nourishment rooms, but he would instruct the housekeeping staff to remove items and clean under the sink. Subsequent to surveyor inquiry, the items under the sink were removed, area was cleaned and secured so items could not be stored. The administrator indicated that she would assign housekeeping to clean under the sinks and maintenance would be responsible to ensure that under the sinks were secure so items could not be stored. Although requested, the facility did not have a policy related to cleaning and maintaining under the sinks in the nourishment rooms. 2. Resident #100 diagnosis included diabetes, hypertension, and anxiety. The quarterly Minimum Data Set, dated [DATE] identified Resident #100 was cognitively intact and was independent with toileting, bathing, dressing, and transfers. The Resident Care Plan (RCP) dated 8/10/26 identified Resident #100 had a history of physical mobility issues related to weakness. Intervention identified that the resident was independent with bed mobility, transfer, and ambulation without an assistive device. A Brief interview for mental status score was 15 indicating intact cognition. Review of the email dated 7/2026 with a quarterly environmental rounds attachment provided by Registered Nurse (RN) #1 to the Administrator identified shower rooms on the first floor were dirty, heater vents were dented and the grout need to be repaired. Observations on 8/26/25 at 9:45 AM identified: A. One East Shower Room: Rusted heater vents Chipped paint Holes in the walls B. One [NAME] Shower Room: A black substance covering the white pull down shade for the window Holes in the walls Chipped paint Rusted heater vents C. Two East Shower Room: Ceiling tile ripped and pulled away from the ceiling Soap dispensers were broken and plastic pieces remain on the wall next to the replaced soap dispenser. Rusted heater vents Chipped paint from grab bars D. Two [NAME] Shower Room: Holes in the walls Rusted heater vent Broken soap dispensers Broken cabinets E. room [ROOM NUMBER] The window on the right side of the room had large piece of sheet rock missing by the window air conditioner (AC) with a dead bug sitting in it along with cobwebs. Broken chipped tile in the bathroom Stained ceiling tile in the bathroom with a brown colored substance The window AC vents contained a brown like substance F. Basement Resident Lounge identified the following items being stored: Five Mechanical Wheelchairs Two hospital beds Five mattresses on the floor in a pile against the wall Numerous boxes of AC units Observation and interview with Recreation Aid #1 on 8/26/26 at 9:40AM of the Basement Resident Lounge identified 10 residents having coffee before going out to smoke. Although Recreation Aid #1 initially identified the items in the basement had been there for years after making eye contact with RN #3, Recreation Aid #1 then retracted her statement. Interview and observation on 8/26/26 9:56 AM in room [ROOM NUMBER] with Housekeeper #1 identified he was aware of the hole in the wall by the window AC unit, chipped tiles, and stained ceiling tile in the bathroom and these had been present for years. Housekeeper #1 also identified that he has reported these concerns to the Maintenance Department, but the areas were unchanged. Interview and observation made on 8/26/26 at 10:05 AM with Nurse Aid (NA) #2 identified the black substance on the white roll down blind, rust, chipped paint for East 1 and East 2 shower rooms have been like that for 2 months. Interview and observations made on 8/26/26 at 11:45 AM with Registered Nurse (RN) #1 and RN #3 identified the concerns (rusty heater vents, chipped paint, holes in the walls, broken soap dispensers and cabinets, and the black material on the white pull down shade) in the shower rooms on East 1, East 2, [NAME] 1, and [NAME] 2. RN#1 identified she was aware of the blind from the 1 East shower room as she performed quarterly rounds on 7/21/26, taken a photo of the blind and emailed the Administrator outlining the concern. RN #1 further identified the black substance as mildew noting it should have been cleaned or replaced immediately and identified the shower rooms need a good cleaning, painting and items to be repaired. Interview with the Director of Maintenance on 8/28/26 at 1:00 AM identified the AC units were delivered 2 weeks ago but he was unable to provide a delivery invoice upon request. The Maintenance Director indicated that the facility had a plan for remodeling the shower rooms but had not provided basic repairs because of the remodel project but provided no explanation as to when the remodel project was to take place. He further identified the wheelchairs, beds and mattresses were in stored because the items needed repair and moved out on a regular rotating basis although this area was used for residents. Interview on 8/28/26 at 11:00 AM with Housekeeper #1 identified the black substance on the shade from the 1 [NAME] shower room was black mold and he had cleaned the shade on 8/26/26 and the black substance was removed. Housekeeper #1 stated that he was responsible for cleaning the shade and it was an oversight on his part because the shade was rolled up. Interview on 8/28/26 at 11:52 AM with the Administrator identified the 2 showers rooms on the first floor and the 2 shower rooms on the second floor were not homelike and needed repairs. Interview and observation with Resident #100 on 8/31/26 at 9:25 AM in the basement Resident Lounge identified the wheelchairs, hospital beds, mattresses, and AC boxes had been there for at least 2 months, the facility used the area as a revolving door for storage of various items needing repair and was also used as an area to receive delivered items. Resident #100 indicated that over the past 4 years, the facility had used a storage container to house these items and was unaware why the items were being housed in the resident area. Review of the facility policy for Environmental Rounds directed, in part, the corrective action form will be completed by the supervisor/department head and will outline corrective actions to be taken and anticipated completion dates. Environmental survey worksheets will be retained for review to illustrate the improvement of quality of life within the facility and for review/comparison purposes within the facility over a period of time.

Based on observations, interviews, and facility policy, during a review of medication storage, the facility failed to ensure 3 of 3 medication refrigerators had temperatures logged appropriately according to the facilty policy, and for 2 of 3 medication carts and 1 of 2 medication rooms failed to ensure a clean environment in which to store medications. The findings include:An observation of the second floor medication room on [DATE] at 10:15 AM with LPN #8 identified the medication/insulin refrigerator temperature log had not been completed and was missing 1 out of 31 mornings and 6 out of 30 afternoon temperatures and the nursing supervisor was responsible to oversee temperature logging. The medication/insulin fridge contained: 1 box of Invega (anti-psychotic), 1 box of Bisacodyl suppositories (used for constipation), 1 Xalatan (eye drops), 9 insulin pens, 1 Risperdal (anti-psychotic), and 15 Trulicity (diabetic medication) pens. An observation of the medication cart on unit 2 East on [DATE] at 10:35 AM with LPN #9 identified loose pills on the bottom of the second drawer. Additionally, there was a thick white substance on the outside of the cart. LPN #9 observed the pills in the drawer and stated the nurses were responsible for cleaning the inside of the medication carts and housekeeping was responsible for cleaning the outside. Subsequent to surveyor inquiry the housekeeper cleaned outside of cart. An observation of the medication cart on unit 1 [NAME] on [DATE] at 10:50 AM with the Assistant Director of Nursing Services (ADNS) identified loose pills in the second and fourth drawers as well as debris in the third drawer and a used medication syringe. The ADNS identified the charge nurses were responsible for keeping the medication carts clean on the inside. Subsequent to surveyor inquiry she removed the debris and discarded the used medication syringe.An observation of the first floor Medication Room on [DATE] at 11:10 AM with the ADNS identified incomplete medication refrigerator temperatures for 2 out of 31 opportunities in the morning and 19 out of 30 opportunities in the afternoon. Per the facility policy, the ADNS stated that nursing supervisors were responsible for completing the temperature log and the night supervisor should have been monitoring the logs daily for completion. The medication refrigerator contained: 1 vial tuberculin (used to test for tuberculosis), 2 vials of Shingrix (Shingles vaccine), 1 Vivitrol (used to treat alcohol and/or opioid dependence), 3 bags of Daptomycin (antibiotic), 28 insulin pens, and 13 vials of insulin. The medication room was observed with expired insects in the windowsill, and the floor had debris such as a balled-up paper towel. The ADNS stated it was the responsibility of housekeeping to clean the medication rooms.An interview and review of findings on [DATE] at 11:40 AM with the Director of Nursing Services (DNS) indicated the charge nurses were responsible for recording refrigerator temperatures, and the nursing supervisors were responsible for the oversight to ensure completion. The DNS stated that nurses who spilled medications were responsible for cleaning up after themselves and that the overnight nurses should have been cleaning the carts daily. The DNS indicated housekeeping was responsible for cleaning the outside of the medication carts and the medication rooms.A Storage of Medications policy dated 8/2020 directed medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. Medication storage areas are kept clean, well lit and free of clutter and extreme temperatures and humidity. All medications are maintained within the temperature ranges notices in the United States Pharmacopeia (USP) and the Centers for Disease Control (CDC) and refrigerator temperatures should be between 36 degrees to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. The facility should check the refrigerator or freezer in which vaccines are stored at least two times a day, per CDC guidelines.

Based on observations, review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #15) reviewed for positioning and mobility, the facility failed to ensure that a discontinued physician order for a specialty mattress was not erroneously signed by staff as being currently in use indicating staff had observed on every shift that the mattress was set to the resident's weight, and that the mattress settings and function had been observed by staff for over a 2 month time period, and for 7 of 7 sampled residents (Resident #27, #91, #93, #110, #119, #130, and #139) reviewed for the Medication Assisted Treatment (MAT) Program for opioid use disorder (OUD), the facility failed to ensure nurses consistently documented on the medication administration record (MAR) that Methadone was administered. Additionally, for 1 of 4 sampled residents (Resident #137) reviewed for falls, the facility failed to complete and document a post fall assessment after the resident fell twice. The findings include: 1. Resident #15's diagnoses included vascular dementia, rectal prolapse, and abnormality of gait and mobility. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required substantial/maximal assistance with transfers and was dependent with bed mobility and toileting. The MDS indicated Resident #15 was at risk of developing pressure ulcers/injuries and had a pressure reducing device for the bed. The Resident Care Plan (RCP) dated 7/30/26 identified Resident #15 had limited physical mobility, was no longer getting out of bed due to a rectal prolapse and was at risk for pressure ulcer development related to immobility. Interventions included offering to reposition/assist every 2 hours and as needed, position off of the rectal prolapse as able, and provide a low air loss mattress set to the resident's weight. A physician's order written 6/23/25 and in effect on 8/25/26, 8/26/26, and 8/27/26 directed placement of a low air loss mattress with normal/alternating pressure set to weight, check settings and function every shift. Observations of Resident #15 in bed on 8/25/26 at 10:41 AM and 8/26/26 at 11:05 AM failed to identify an air mattress in place. Observation, interview, and review of the clinical record with Licensed Practical Nurse (LPN) #3 on 8/27/26 at 11:27 AM identified Resident #15 in bed without the benefit of an air mattress being utilized. Review of Resident #15's physician's orders in effect on 8/25/26, 8/26/26 and 8/27/26 directed the use of a low air loss mattress check function and settings every shift. Review of the Treatment Administration Record (TAR) identified that although LPN #3 had signed off the air mattress as being in use on 8/27/26, she was unable to explain Resident #15's lack of an air mattress, why she had signed off that an air mattress was in use, stating she would have to speak to the nursing supervisor. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 8/27/26 at 1:32 PM identified although Resident #15 had an active physician's order for a low air loss mattress on the bed, the physician's order should have been discontinued. The DNS stated the resident was put on a perimeter mattress after a fall months ago (she was unsure of the date and stated she would find out) and when the perimeter mattress was put on the resident's bed, the air mattress was removed. The DNS further indicated that the charge nurses should not have continued to sign the TAR indicating Resident #15 used an air mattress when it had not been in place for months. Review of the Treatment Administration Record indicated signatures for the entire months of July and August indicating low air loss mattress use for Resident #15. Interview and review of the clinical record with the nursing supervisor, Registered Nurse (RN) #2, on 8/28/26 at 11:40 AM identified it would have been the responsibility of the charge nurse to report to her that Resident #15 did not have an air mattress on the bed. RN #2 indicated the charge nurses should not have continued to sign the TAR for the air mattress if it was not on Resident #15's bed. RN #2 indicated she would need to provide further education to the charge nurses. Subsequent to surveyor inquiry, the physician's order for a low air loss mattress was discontinued. Although requested, a documentation policy was not provided. Although requested, an air mattress policy was not provided. 2. Resident #27's diagnoses included opioid dependence The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, was independent with all activities of daily living (ADLs) and received an opioid medication 7 days a week. The Resident Care Plan (RCP) dated 6/10/26 identified substance abuse related to history of addiction and was currently receiving Medication Assisted Treatment (MAT). Interventions included allowing time to express feelings, provide empathy, encouragement and reassurance, evaluate the need for psychiatric/behavioral health, and monitor conditions that may contribute to substance abuse. Physician's orders dated 7/12/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml), give 60 mg, once daily for opioid dependence. A review of the Medication Administration Record (MAR) from 8/1/26 through 8/26/26 identified that Methadone was not signed off as given at 6:00 AM on August 3, 9, 10, 13, 16, 23, and 24 (7 out of 26 opportunities). A review of the Methadone Chain of Custody Records 8/1/26 to 8/26/26 identified that Resident #113 signed he/she administered 60 mg of Methadone in Aug on 3, 9, 10, 13, 16, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #27 had taken his/her Methadone. 3. Resident #91's diagnoses included Substance Abuse Disorder (SAD). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and required maximum assistance with activities of daily living, set up assistance for eating and received opioid medication 7 days a week. Physician's orders dated 7/31/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 130 mg once daily for pain. The Resident Care Plan (RCP) dated 8/13/26 identified substance abuse related to history of addiction and was currently receiving Medication Assisted Treatment (MAT). Interventions included allowing time to express feelings, provide empathy, encouragement and reassurance, evaluate the need for psychiatric/behavioral health, and monitor conditions that may contribute to substance abuse. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/26/26 identified that Methadone had not been signed as being given at 6:00 AM on August 3, 9, 10, 12, 16, 23, and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 8/1/26 through 8/26/26 identified that Resident #91 signed he/she administered 130 mg of Methadone in Aug on 3, 9, 10, 12, 16, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #91 had taken his/her Methadone. 4. Resident #93 diagnoses included cocaine abuse. The admission Minimum Data Set (MDS) dated [DATE] identified that Resident #93 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and required maximum assistance with activities of daily living (ADLs), set up assistance for eating, and received opioid medications 7 days a week. Physician's orders dated 7/12/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 33 mg once daily for cocaine abuse. The Resident Care Plan (RCP) dated 7/14/26 identified substance abuse related to history of addiction, and currently as Medication Assisted Treatment (MAT). Interventions included allowing time to express feelings, provide empathy, encouragement and reassurance, evaluate the need for psychiatric/behavioral health, and monitor conditions that may contribute to substance abuse. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/26/26 identified that Methadone was not signed as given at 6:00 AM on August 2, 9, 10, 15, 17, 23, and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 8/1/26 through 8/26/26 identified that Resident #93 signed the that he/she administered 33 mg of Methadone in Aug on 2, 9, 10, 15, 17, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #93 had taken his/her Methadone. 5. Resident #110 diagnoses included opioid dependence and psychoactive substance abuse. The admission Minimum Data Set (MDS) dated [DATE] identified that Resident #110 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with all activities of daily living (ADLs) and received opioid medications 7 days a week. The Resident Care Plan (RCP) dated 7/2/26 identified substance abuse related to history of addiction, and currently receiving Medication Assisted Treatment (MAT). Interventions included allowing time to express feelings, provide empathy, encouragement and reassurance, evaluate the need for psychiatric/behavioral health, and monitor conditions that may contribute to substance abuse. Physician's orders dated 8/12/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 15 mg daily for pain. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/26/26 identified that Methadone was not signed as given at 6:00 AM on August 3, 9, 10, 13, 16, 23, and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 8/1/26 through 8/26/26 identified that Resident #110 signed he/she administered 15 mg of Methadone in Aug on 3, 9, 10, 13, 16, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #93 had taken his/her Methadone. 6. Resident #119 diagnoses included opioid dependence with withdrawal. Resident #119's admission Minimum Data Set (MDS) dated [DATE] identified that Resident #119 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with all activities of daily living (ADLs), and received opioid medication 7 days a week. Physician's orders dated 7/30/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 110 mg by mouth daily for pain. The Resident Care Plan (RCP) dated 8/12/26 identified substance abuse related to history of addiction, and currently receiving Medication Assisted Treatment (MAT). Interventions included if resident shows signs of overdose administer Narcan a ordered and call 911, offer resident counseling, and provide resident/responsible party with education on signs and symptoms of overdose and what they should do if experiencing these signs. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/26/26 identified that Methadone was not signed as given at 6:00 AM on August 2, 9, 10, 15, 17, 23, and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 7/30/26 through 8/26/26 identified that Resident #119 signed the that he/she administered 110 mg of Methadone in August on 2, 9, 10, 15, 17, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #119 had taken his/her Methadone. 7. Resident #130's diagnoses included opioid dependence. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #130 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with all activities of daily living (ADLs) and received opioid medications 7 days a week. The Resident Care Plan dated 6/4/26 identified complications related to use of psychotropic drugs and currently receiving Medication Assisted Treatment (MAT). Interventions included Abnormal Involuntary Movement Scale testing per protocol, complete behavior monitoring flowsheet, gradual dose reduction as ordered, monitor changes in mental status, monitor continued need for medication as related to mood and behavior, monitor for side effects, and psychiatric evaluation as ordered. Physician's orders dated 7/31/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 90 mg daily for substance abuse disorder. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/27/26 identified that Methadone was not signed as given at 6:00 AM on August 3, 9, 10, 13, 16, 23 and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 7/30/26 through 8/26/26 identified that Resident #130 signed that he/she administered 110 mg of Methadone in Aug on 3, 9, 10, 13, 16, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #130 had taken his/her Methadone. 8. Resident #139's diagnoses included Opioid Dependence Resident #139's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and was totally dependent on staff for activities of daily living (ADLS) except required set up for eating and received opioid medications 7 days a week. The Resident Care Plan (RCP) dated 6/30/26 identified Methadone use. Interventions included signs of common side effects may be headaches, mild dizziness, numbness or tingling, stomach pain, and sleep disturbances, if has cravings, flu-like symptoms such as runny nose, lack of appetite, diarrhea, cramping, watery eyes, dilated pupils, the dosing may not be correct, provide education on the signs and symptoms of overdose, provide me with education on high risk for overdose when leaving the nursing home because I haven't used illicit drugs for so long, provide me with Methadone as ordered, prepare Methadone and ensure I can take it without your assistance. Physician's orders dated 7/12/26 directed to administer Methadone oral concentrate 10 milligrams/milliliter (mg/ml) give 110 mg by mouth daily for substance abuse. A review of the Medication Administration Record (MAR) from 8/1/26 to 8/26/26 identified that Methadone was not signed as given at 6:00 AM on August 2, 9, 10, 15, 17, 23, and 24 (7 days out of 26 opportunities). A review of the Methadone Chain of Custody Records from 7/30/26 through 8/26/26 identified that Resident #139 signed that he/she administered 110 mg of Methadone on August 2, 9, 10, 15, 17, 23, and 24 and a licensed Registered Nurse (RN) co-signed (initialed) that Resident #119 had taken his/her Methadone. Interview and review of the clinical records with the Director of Nursing (DNS) on 8/27/26 at 1:20 PM identified that there were missing initials for the administration of Methadone on the Medication Administration Record (MAR) for Residents #27, #91, #93, #110, #119, #130 and #139. The DNS indicated that the MAR should be signed after Methadone was administered. The DNS was unable to explain why they were missing signatures for the 7 residents who were prescribed Methadone. The DNS indicated that the Methadone Chain of Custody Sheets were signed that the Methadone was administered. The DNS stated that MAR is a part of the residents' medical record. The Chain of Custody Records are facility documentation and are not part of a resident's medical record. The DNS indicated that the facility policy is to sign the MAR after a medication is given. Interview with the DNS on 8/31/26 at 1:00 PM indicated that she had researched the signing of the MAR and there was a glitch with the electronic medical record and for some reason the signed MAR was not appearing on the dates identified, however, the DNS was unable to provide any documentation from the electronic medical record that the MAR had been signed. The Methadone Protocol Policy dated 7/15/26, directed, in part, the RN supervisor and/or charge nurse is responsible for storage & counting of Methadone, as well as distributing to the resident for administration. Both the resident & nurse will sign the Chain of Custody form after each use and the nurse will sign the MAR. 9. Resident 137 had diagnoses that included fibromyalgia, adult failure to thrive, and restless leg syndrome. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #137 was cognitively intact, used a walker and wheelchair, had no functional limitation in range of motion to upper and lower extremities, required partial/moderate assistance with eating, was independent with bed mobility, and required substantial/maximal assistance with chair/bed transfers. The MDS assessment further indicated Resident #137 had a history of falls prior to admission, had not fallen since admission, and had received both occupational and physical therapy for at least 15 minutes in the last 7 days. The Resident Care Plan (RCP) dated 4/1/26 identified Resident #137 was at risk for falls due to his/her recent admission and history of falls. Interventions included to ensure Resident #137's call light was in reach and there was prompt response to all care requests and ensure Resident #137 had appropriate footwear when ambulating or mobilizing in the wheelchair. A nursing note written by Registered Nurse (RN) #10 on 4/2/26 at 11:14 PM identified Resident #137 had a fall with no apparent injury after an attempt to self-transfer from the toilet. Review of the clinical record failed to identify a post fall assessment had been completed after the fall on 4/2/26. A nursing note written by Licensed Practical Nurse (LPN) #12 on 4/8/26 at 7:12 AM identified Resident #137 had a fall without injury after attempting to remove his/her slippers caused him/her to lose their balance and the resident was lowered themselves to the floor. The note indicated the RN was at the bedside performing an assessment. Review of the clinical record failed to identify a post fall assessment for the fall on 4/8/26. Interview with the Director of Nursing (DNS) on 8/31/26 at 12:20 PM identified post fall assessments should be completed in the electronic medical record (EMR) following every fall. She indicated it was a new process for the facility and prior to that they didn't have a post fall assessment. She indicated the nursing staff may have still been getting accustomed to completing the post fall assessment in the computer for Resident #137's falls in April 2026. Review of the Fall Management Program policy directed, in part, in the event a fall occurs, a root cause analysis will be conducted to determine factors that contributed to the fall. The policy indicated on admission, re-admission and significant change in condition, residents would be evaluated for risk of falls. In the event of a fall the following measure will be implemented: physical assessment to determine injury if any, notification of nursing supervisor, and notification of physician and family/responsible party. Unwitnessed falls or suspected head injury require neurological checks. Additionally, the resident will be monitored for 72 hours and referred to rehabilitation therapy if needed. The policy procedure failed to identify completion of a post-fall assessment.

Based on observation, interviews, review of the clinical record and facility policy for 1 of 2 sampled residents (Resident #113) reviewed for activities of daily living, the facility failed to ensure a physician's order and medication self-administration assessment was completed for Resident #113 who was self-administering an inhaler and eye drops. The findings include:Resident #113 diagnoses included chronic respiratory failure, aphasia (difficulty speaking), and hemiplegia on left side after cerebral infraction (stroke).The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #113 was unable to participate in a Brief Interview of Mental Status (BIMS) and was totally dependent on staff for activities of daily living (ADLS) except was able to eat with set up assistance from staff.The Resident Care Plan (RCP) dated 7/9/26 identified communication with impaired cognitive function with difficulty in making decisions as an area of focus. Interventions included monitor resident's ability to express and comprehend language, memory, reasoning, and problem solving, nonverbal overall but able to answer yes/no to some questions, uses cues and gestures to help with communication, refer to oral evaluation per protocol as needed, administer medications and monitor/document side effects and effectiveness, discuss concerns about confusion, disease processes, keep the resident's routine consistent and try to provide consistent care givers in order to decrease confusion, and monitor for any changes in cognitive function.The RCP dated 7/9/26 also identified chronic respiratory failure as an area of focus with interventions that included advise resident to minimize contact with known offending allergens, assist resident in identifying asthma triggers, encourage fluid intake, keep head of bed elevated, administer medications as ordered and document side effects, and give nebulizer and oxygen therapy as needed.Physician orders dated 7/19/26 directed to administer Symbicort inhalation aerosol (inhaler) 160-4.5 micrograms/actuation (MCG/ACT) 1 inhalation orally every morning and bedtime for asthma and Refresh Tears 1 drop in both eyes three times a day for dry eyes. Observation on 8/26/26 at 9:00 AM noted Resident #113 had 2 Symbicort inhalers and 1 bottle of Refresh tears on his/her over the bed table that were not secured.Review of the clinical record on 8/26/26 revealed Resident #113 did not have a physician order, a medication self-administration assessment or a care plan to self-administer Symbicort inhaler or Refresh tears. Interview, observation and review of clinical record with Registered Nurse (RN) #2 at 10:10 AM identified that Resident #113 still had 2 Symbicort inhalers and 1 bottle of Refresh Tears on the over the bed table in his/her room. RN #2 indicated that the medications should not be left at the bedside for Resident #113 to self-administer. Review of the clinical record with RN #2 confirmed that Resident #113 did not have a physician order, self-administration assessment or care plan to self-administer medications. RN #2 stated that Resident #113 needed to have an order, assessment, care plan and a locked box for the medications to be self-administered and it was the facility policy. RN #2 stated that it was the responsibility of nursing to ensure all is completed prior to a resident self-administering medication.Interview with Resident #113's charge nurse/Licensed Practical Nurse (LPN) #2 on 8/26/26 at 10:20 AM stated that she did not leave the inhalers or Refresh Tears at Resident #113's bedside and that she believed they were always on Resident #113's bedside table. LPN #2 was unaware if Resident #113 had an order to self-administer the inhalers or Refresh Tears. LPN #2 indicated that if Resident #113 did not have an order to self-administer then the medications should not be left at the bedside.Interview and review of the clinical record with the Director of Nursing (DNS) on 8/26/26 at 11:30 AM identified that Resident #113 did not have a physician order to self-administer, a self-administer assessment or care plan for the inhalers or Refresh Tears. The DNS indicated it would be the responsibility of the nursing supervisor to obtain a physician order, complete the self-administration assessment and care plan as it is the facility policy in order to self- administer medications and that the medications would need to be in a locked box in Resident #113's room. The DNS stated that Resident #113 should not be self-administering the medications. Furthermore, the DNS indicated that nursing would complete a self-administration assessment for Resident #113, but she did not think he/she would qualify for self-administration as Resident #113 would not be able to communicate the indications for use or side effects of the medications.Subsequent to surveyor inquiry, RN #2 removed the Symbicort inhalers and Refresh Tears from Resident #113's bedside and stated that a self-administration for medications would be completed for Resident #113. A review of the Self-Administration of Medications/Oxygen/Nebulizer Policy dated 12/19/25 directed, in part, the IDT will determine if it is safe for a resident to self-administer medications. Residents will be assessed for self-administration on admission, quarterly and upon a significant change in condition using the Self-Administration form. Medications will be kept secure at the bedside.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 2 sampled residents (Resident #11) reviewed for edema, the facility failed to ensure the provider was aware of Resident #11's repeated refusals to wear ace wraps to both legs as ordered. The findings include:Resident #11's diagnoses included heart failure, lymphedema (swelling/buildup of fluid), and venous thrombosis and embolism (blood clots travelling in blood stream). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was cognitively intact, was dependent on staff for activities of daily living (ADLs) including lower body dressing and required set up for eating and oral care.Physician orders dated 7/12/16 directed Aquaphor external ointment to bilateral legs topically every morning and bedtime for xerosis (abnormally dry, rough cracked skin) and wrap lower legs in ace bandages/compression stockings for edema (swelling) 2 times a day.The Resident Care Plan (RCP) dated 7/21/26 identified potential impairment of skin related to immobility and edema managed with stockings/meds can increase risk for pressure ulcers with interventions that included apply compression stocking per MD orders, be aware of efficacy be alert for changes in skin integrity with application and removal of stockings wraps and as needed, be alert for skin changes with the application of topical medications, intake and output per protocol, blood work as ordered, follow facility protocol for treatment of injury, and offer antibiotic per MD order and be aware of efficacy. Observation on 8/25/26 at 11:30 AM, 8/26/26 at 10:00 AM and 8/27/26 at 9:00 AM noted Resident #11 was lying in bed without ace wraps/compression stockings. Both legs with edema and blue/red in color.The Treatment Administration Record (TAR) identified that nursing had been documenting that Resident #11 refused ace wraps/compression from 8/1/26 through 8/27/26 (27 days). Nursing notes dated 8/1/26 through 8/27/26 identified there was no nursing documentation that the physician/Advanced Practice Registered Nurse (APRN) was notified that Resident #11 had been refusing the ace wraps/compression stockingsConsultation reports identified that Resident #11 saw his/her Cardiologist on 8/17/26 and the Cardiologist was not made aware that Resident #11 was not wearing the ace wraps/compression stockings.Review of Resident #11's RCP on 8/28/26 failed to reflect Resident #11's refusals of care related to the ace wraps.Practitioner progress notes dated 8/1/26 through 8/27/26 failed to reflect documentation that Resident #11 refused to wear the ace wraps.Interview with Advanced Practice Registered Nurse (APRN) #2 on 8/28/26 at 10:00 AM identified that he was not aware that Resident #11 had been refusing to wear the ace wraps. APRN #2 stated that he was aware that Resident #11 had a history of refusing medications, but nursing had not told him that Resident #11 had been refusing the ace wraps in August 2026. APRN #2 indicated that had he been aware, he might have adjusted Resident #11's Lasix (diuretic for fluid overload) as Resident #11 had an extensive cardiac history and he would have re-educated Resident #11 on the benefits and risk of not wearing the ace wraps. Furthermore, APRN #2 stated that the Cardiologist should have been notified. Interview and review of the clinical record with the Director of Nursing (DNS) on 8/28/26 at 2:00 PM revealed that she was not aware Resident #11 was refusing to wear the ace wraps. The DNS indicated that the practitioner should have been notified by the supervisor that Resident #11 was refusing to wear his/her ace wraps. The DNS indicated that the nurses could communicate with the APRNs using the APRN communication book and a nurse could have written in the book to notify the practitioner that Resident #11 was refusing the ace wraps. In addition, the DNS indicated that the nurses were documenting refusals on the TAR for the month of August and stated that it was the responsibility of the charge nurse or the supervisor to ensure the practitioner was notified of refusals and that the care plan was updated. The Change in Condition Policy revised on 6/10/2014, directed, in part, it is the policy of the facility to notify the physician when there is a change in condition. The charge nurse will notify the RN supervisor. The RN will do a follow up assessment to ensure the assessment is documented and reported to the physician. The physician or alternate will be contacted to report findings and obtain any new orders as warranted by the physician.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 2 (Resident #11) sampled residents reviewed for edema, the facility failed to ensure Resident #11's care plan was comprehensive related to repeated refusals to wear ace wraps and for 1 of 3 sampled resident (Resident #87) reviewed for pressure ulcers, the facility failed to develop a comprehensive care plan regarding Enhanced Barrier Precautions (EBP). The findings include: 1. Resident #11's diagnoses included heart failure, lymphedema (swelling/buildup of fluid), and venous thrombosis and embolism (blood clots travelling in blood stream). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #11 was cognitively intact, was dependent on staff for activities of daily living (ADLs) including lower body dressing and required set up for eating and oral care. Physician orders dated 7/12/16 directed Aquaphor external ointment to bilateral legs topically every morning and bedtime for Xerosis (extreme dry, scaley, cracked skin) and wrap lower legs in ace bandages/compression stockings for edema (swelling) 2 times a day. The Resident Care Plan (RCP) dated 7/21/26 identified potential impairment of skin related to immobility and edema managed with stockings/meds can increase risk for pressure ulcers with interventions that included apply compression stocking per MD orders, be aware of efficacy be alert for changes in skin integrity with application and removal of stockings wraps and as needed, be alert for skin changes with the application of topical medications, intake and output per protocol, blood work as ordered, follow facility protocol for treatment of injury, and offer antibiotic per MD order and be aware of efficacy. Observation on 8/25/26 at 11:30 AM, 8/26/26 at 10:00 AM and 8/27/26 at 9:00 AM noted Resident #11 was lying in bed without ace wraps/compression stockings. Both legs were noted with edema and blue/red in color. The Treatment Administration Record (TAR) identified that nursing had been documenting that Resident #11 refused ace wraps/compression from August 1 through August 27 (27 days). Review of Resident #11's RCP on 8/28/26 failed to reflect Resident #11's refusals of care related to his/her ace wraps. Interview and review of Resident #11's care plan with the care plan coordinator, Licensed Practical Nurse (LPN) #2 on 8/31/26 at 11:30 AM revealed that Resident #11 did not have refusals of care and treatments in his/her care plan related to ace wraps. LPN #2 indicated that the care plan should have included Resident #11's refusals of medications and treatments and stated that it was the responsibility of nursing to ensure the care plan was comprehensive which would include Resident #11's refusals of medications and treatments. Interview with the Regional Corporate MDS Registered Nurse (RN) #6 indicated that the care plans should be comprehensive and include refusals of any type of care. The Care Plan Policy revised on 12/17/24, directed, in part, the Interdisciplinary Team (IDT) develops, in collaboration with the resident, a comprehensive plan of care based on the Resident Assessment Instrument, which is comprised of the Minimum Data Set (MDS), care area assessments, other applicable clinical information, resident's goals for admission, resident preferences and potential for discharge. The care plan contains resident's goals, resident's strengths, resident's preferences, identified problems, measurable realistic goals, and the interventions utilized to reach these goals. 2. Resident #87's diagnosis included sacral ulcer with necrosis of the muscle, diabetes, and coronary artery disease. A Social Service note dated 8/18/26 at 12:44 PM identified Resident #87 was admitted to the facility on [DATE] with a diagnosis of sacral ulcer with necrosis of the muscle. A physician order dated 8/17/26 directed to cleanse the sacrum pressure ulcer with Normal Saline, apply Colagenage-santyl (an ointment used to remove dead/damaged tissue from skin ulcers), then apply Hydrofera blue (an antibacterial foam wound dressing infused with methylene blue and gentian violet) and cover with a foam dressing every day. An Advanced Practice Registered Nurse (APRN) progress note dated 8/19/26 at 1:00 PM identified Resident #87 had a history of osteomyelitis and was currently being treated with antibiotics. The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #87 was cognitively intact, dependent on transfers and setup assistance with eating and oral hygiene. Also identifying Resident #87 required substantial maximal assistance for toileting, bathing, dressing, and personal hygiene and had a Stage 4 pressure ulcer. The Resident Care Plan (RCP) dated 8/17/26 identified Resident #87 had an activity of daily living self-care deficit related to deconditioning and decreased mobility. Interventions included assist of 1 for bathing, dressing, grooming, toileting, and therapy services as needed. The RCP failed to identify Resident #87 was on EBP related to having a Stage 4 pressure ulcer. An interview on 8/26/26 at 2:45 PM with Registered Nurse (RN) #1 identified Resident #87 had a pressure ulcer and required an RCP for EBP. Also, identifying she was responsible for ensuring the RCP included EBP and it was an oversight. She further identified a physician order was not in place for EBP because it wasn't required. Further identifying the policy for a resident on EBP was that an RCP should have included EBP. Review of the facility policy for Enhanced Barrier Precautions directed, in part, an RCP will be initiated for residents requiring enhanced barrier precautions. Subsequent to surveyor's inquiry the RCP was updated on 8/26/26 to include enhanced barrier precautions. Interventions included to ensure appropriate personal protective equipment (PPE) was readily available, provide a receptacle inside room or near the exit of room for discarding PPE after removal, prior to exiting the room.

Based on review of clinical records, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for abuse, the facility failed to protect Resident #56 rights to be free from verbal abuse from Resident #5. 1.Resident #5's diagnosis included diabetes, chronic kidney disease, and peripheral vascular disease.The Resident Care Plan (RCP) dated 7/22/26 identified Resident #5 had an activity of daily living self-care performance deficit. Interventions included to be aware the resident can request a shower and then decline to accept, encourage to shower as needed, update the nurse for decline of needed care.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, independent for eating, toileting, dressing, and bathing. Also, identified Resident #5 required partial moderate assistance for transfers.2. Resident #56's diagnoses included diabetes, congestive heart failure and hypertension.The Quarterly MDS assessment dated [DATE] identified Resident #56 was cognitively intact, was independent for eating, toileting, dressing, and personal hygiene, Also, identified Resident #56 required partial moderate assistance for bathing and transfers.The RCP dated 8/6/26 identified Resident #56 had an activity of daily living self-care deficit. Interventions included to Resident #56 used a urinal to void independently, wheels the wheelchair independently and wears glasses.A SW note dated 8/7/26 at 3:01 PM identified there was a verbal disagreement between Resident #5 and Resident #56, Resident #56 was upset because Resident #5 called him/her a racial slur (used the N word). The Administrator was made aware of the resident-to-resident conflict and RN #9 was present during the conversation.A Social Worker's (SW) note dated 8/7/26 at 3:07 PM identified there was a verbal disagreement between Resident #5 and Resident #56 around 1:50 PM. Resident #5 admitted to a verbal exchange but would not give any specific details about what words were he/she said to Resident #56. When Resident #5 was asked to provide reassurance that he/she would not react or interact with peer (Resident #56) Resident #5 stated I cannot do that. Resident #56 was offered a room change which was refused. The Administrator was made aware of the situation and Registered Nurse (RN) #9 was present during the conversation.A nursing note dated 8/7/26 at 11:51 PM identified Resident #56 was on 1 to 1 (1:1) observation secondary to an altercation with a peer.A nursing note dated 8/10/26 at 11:44 PM identified Resident #5 (the resident who exchanged words with Resident #56) was transferred to another room.A SW note dated 8/10/26 at 12:29 PM identified approval from Resident #5's Conservator to move Resident #5 to another room.During initial tour on 8/25/26 at 12:29 PM Resident #5 identified a resident-to resident interaction with his/her previous roommate stating that he/she yelled at his/her roommate (Resident #56) but would not say what he/she said. Additionally, a few days later, Resident #5 stated he/she was moved to another room. Also, identifying the interaction did not become physical.Interview and review of the SW note from Resident #5's clinical record dated 8/7/26 with the Administrator on 8/28/26 at 12:27 PM identified the resident-to resident interaction was a very heated argument but did not feel an investigation was warranted because the incident was just verbal. Also, identifying she did not know the abuse policy off the top of her head and was unsure if the social worker reported the incident to the state agency. Further, identifying no accident and incident report or reportable event was on file for 8/7/26 for either Resident #5 or #56. (refer to F 609 and F 610).Interview on 8/31/26 at 11:08 AM with Resident #56 identified the resident -to -resident incident was not the first incident he/she has had with Resident #5, who previously kicked kicked his/her bed, called him/her racial slurs (using the N word) and turning up the tv or radio so loud that the other residents in the room couldn't listen to their own devices, all of which Resident #56 identified as being reported. Also, identifying on 8/7/26 Resident #5 was listening to his/her device very loud, Resident #56 requested the device be turned down, Resident #5 then called Resident #56 another racial slur. Further, identifying he/she requested Resident #5 have a room change because this was not the first incident with this resident, it took the facility about a week to move Resident #5 and in meantime the facility had a staff member sitting in the room until Resident #5 was moved.Interview on 8/31/26 at 11:19 AM with the Director of Nursing Services (DNS) identified the resident-to-resident incident was just a verbal disagreement and she was on vacation at that time. Also, identifying neither resident was placed on 1:1 when asked for the records of the 1:1, she identified it was a community observation staff member not 1:1. Further, identifying she knew the policy for verbal abuse, a racial slur can be verbal abuse and she was unaware of any history of any other incidents between Resident #5 and #56 in the past.Review of the Abuse policy dated 1/28/26 directed, in part, abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property was prohibited. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the residents. The definition of Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. It also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled with technology. Verbal Abuse: Any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents regardless of their age, ability to comprehend, or disability.

Based on review of clinical records, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #5 and Resident #56) reviewed for verbal abuse, the facility failed to report a resident-to-resident altercation involving verbal abuse from Resident #5. The findings include: 2a.Resident #5's diagnosis included diabetes, chronic kidney disease, and peripheral vascular disease.The Resident Care Plan (RCP) dated 7/22/26 identified Resident #5 had an activity of daily living self-care performance deficit. Interventions included to be aware the resident can request a shower and then decline to accept, encourage to shower as needed, update the nurse for decline of needed care.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, independent for eating, toileting, dressing, and bathing. Also, identified Resident #5 required partial moderate assistance for transfers.b. Resident #56's diagnoses included diabetes, congestive heart failure and hypertension.The Quarterly MDS assessment dated [DATE] identified Resident #56 was cognitively intact, was independent for eating, toileting, dressing, and personal hygiene, Also, identified Resident #56 required partial moderate assistance for bathing and transfers.The RCP dated 8/6/26 identified Resident #56 had an activity of daily living self-care deficit. Interventions included to Resident #56 used a urinal to void independently, wheels the wheelchair independently and wears glasses.A SW note dated 8/7/26 at 3:01 PM identified there was a verbal disagreement between Resident #5 and Resident #56, Resident #56 was upset because Resident #5 called him/her a racial slur (used the N word). The Administrator was made aware of the resident-to-resident conflict and RN #9 was present during the conversation.A Social Worker's (SW) note dated 8/7/26 at 3:07 PM identified there was a verbal disagreement between Resident #5 and Resident #56 around 1:50 PM. Resident #5 admitted to a verbal exchange but would not give any specific details about what words were he/she said to Resident #56. When Resident #5 was asked to provide reassurance that he/she would not react or interact with peer (Resident #56) Resident #5 stated I cannot do that. Resident #56 was offered a room change which was refused. The Administrator was made aware of the situation and Registered Nurse (RN) #9 was present during the conversation.A nursing note dated 8/7/26 at 11:51 PM identified Resident #56 was on 1:1 secondary to altercation with a peer.During initial tour on 8/25/26 at 12:29 PM Resident #5 identified a resident-to resident interaction with his/her previous roommate stating that he/she yelled at his/her roommate (Resident #56) but would not say what he/she said. Additionally, a few days later, Resident #5 stated he/she was moved to another room. Also, identifying the interaction did not become physical.Interview and review of the SW note from Resident #5's clinical record dated 8/7/26 with the Administrator on 8/28/26 at 12:27 PM identified the resident-to resident interaction was a very heated argument but did not feel an investigation was warranted because the incident was just verbal. Also, identifying she did not know the abuse policy off the top of her head and was unsure if the social worker reported the incident to the state agency. Further, identifying no accident and incident report or reportable event was on file for 8/7/26 for either Resident #5 or #56. (refer to F 600 and F 609).Interview on 8/31/26 at 11:19 AM with the Director of Nursing Services (DNS) identified the resident-to-resident incident was just a verbal disagreement and she was on vacation at that time. Also, identifying neither resident was placed on 1:1 when asked for the records of the 1:1, she identified it was a community observation staff member not 1:1. Further, identifying she knew the policy for verbal abuse, a racial slur can be verbal abuse and she was unaware of any history of any incidents between Resident #5 and #56 in the past.Interview and review of the abuse policy on 8/31/26 at 11:30 AM with SW #3 identified after reading the abuse policy the resident-to-resident incident on 8/7/26 was verbal abuse, should have been investigated.Interview on 8/31/26 at11:50 AM with RN #9 identified she was called to the unit on 8/7/26 because of a verbal altercation, and no investigation was done because Resident #5 and Resident #56 declined any issues.The facility's Abuse policy dated 1/28/26 directed, in part, abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property was prohibited. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the residents. An investigation of alleged abusive action, neglect, exploitation, mistreatment, misappropriation of resident property or an injury of unknown source, will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or the designee to initiate the investigation. The following measures will be taken to protect the resident during the period of investigation of alleged abuse: Remove the residents from the alleged abuser and remove alleged abuser from the area of the resident. An investigation of the alleged abuse will begin. This may include, but not limited to, statements from witnesses and staff, consultation with family, physicians, Department of Public Health, and other state agencies as required. Consultation with local law enforcement for suspected crimes. The investigation and findings will be documented and submitted to the facility's Medical Staff Meetings.

Based on interviews, review of the clinical record, review of facility documentation and facility policy for 1 of 3 sampled residents (Resident #4) reviewed for an injury of unknown origin and 2 of 2 sampled resident (Resident #5 and Resident #56) reviewed for a resident-to-resident altercation involving verbal abuse from Resident #5, the facility failed to conduct a thorough investigation. The findings include: 1. Resident #4's diagnoses included dementia with behaviors, schizophrenia, and anxiety. The Resident Care Plan (RCP) dated 8/26/25 identified increased dependence with activities of daily living (ADLs) as an area of focus with interventions that included assist with ADLs, offer incontinent care, if declines reapproach three times, if yelling or swearing notify nurse, encourage to assist with ADLs as much as possible, and encourage to use call bell. In addition, the RCP identified schizophrenia as an area of focus with verbally abusive behaviors towards others with interventions that included as needed alternative coping skills, encourage to express frustrations with staff, if he/she becomes delusional or hallucinating attempt to engage in the conversation of activity that would distract him/her, psych and social services to provide support and assistance/medication management and individualized sessions, and supervisor resident and others as needed to ensure freedom from accidents or injury. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 was severely cognitively impaired, was totally dependent on staff for personal hygiene and transfers, maximum assistance with dressing, moderate assistance for toileting, and did not ambulate and utilized a wheelchair. Physician orders dated 9/12/25 directed assist of 2 out of bed with Hoyer (a mechanical) lift, administer Lurasidone (antipsychotic) 100 milligrams (mg) daily for schizophrenia and Clonazepam (antianxiety) 0.5 mg 2 times a day for anxiety. An x-ray report of Resident #4's right foot dated 9/12/25 identified that Resident #4 had a possible mildly displaced fracture of the base of the first proximal phalanx (toe) with mild degenerative joint disease in the interphalangeal joints (between the toes) with osteopenia (low bone density). A Reportable Event form dated 9/13/25 noted an injury of unknown origin and identified that Resident #4 complained of right foot pain with noted bruising and swelling. An x-ray was obtained and Resident #4 had a fracture of his/her right great toe. Resident #4 was unable to recall any events due to cognitive status. Resident #4 had sustained a fall on 9/4/25 with no apparent injuries. A hospital discharge summary and Inter-Agency Patient Referral Form (W-10) o dated 9/13/25 identified that Resident #4 had a fractured right great toe and to follow up with his/her primary care physician. Nursing notes dated 9/15/25 indicated that after an in-depth investigation, the findings were that Resident #4 had often been observed with feet dragging on the floor instead of being properly placed on the footrest of wheelchair (w/c). Staff had witnessed other residents pushing the w/c and it was likely that Resident #4's foot bent backwards while being propelled in w/c by his/her peers. Interview with RN #7 on 8/28/26 at 3:00 PM indicated that she could not locate the investigation but was sure it was completed as she was aware of the investigation as the Regional Corporate Nurse and she had contacted the previous DNS to locate the investigation. Interview and review of nursing note dated 9/15/25 with the DNS on 8/31/26 at 9:30 AM indicated that the investigation could not be located. The DNS stated she could not provide any evidence of the investigation (interviews with staff, written statements, witnesses to behavior etc.) The DNS indicated that she could not provide statements that supported the conclusion of the nursing note dated 9/15/25. Interview with RN #7 on 8/31/26 at 9:45 AM indicated that the facility policy was to maintain originals or copies of all reportable event investigations and that it was not the norm that the investigation could not be located. RN #7 could provide any information related to the nursing note dated 9/15/25. 2a.Resident #5's diagnosis included diabetes, chronic kidney disease, and peripheral vascular disease. The Resident Care Plan (RCP) dated 7/22/26 identified Resident #5 had an activity of daily living self-care performance deficit. Interventions included to be aware the resident can request a shower and then decline to accept, encourage to shower as needed, update the nurse for decline of needed care. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, independent for eating, toileting, dressing, and bathing. Also, identified Resident #5 required partial moderate assistance for transfers. b. Resident #56's diagnoses included diabetes, congestive heart failure and hypertension. The Quarterly MDS assessment dated [DATE] identified Resident #56 was cognitively intact, was independent for eating, toileting, dressing, and personal hygiene, Also, identified Resident #56 required partial moderate assistance for bathing and transfers. The RCP dated 8/6/26 identified Resident #56 had an activity of daily living self-care deficit. Interventions included to Resident #56 used a urinal to void independently, wheels the wheelchair independently and wears glasses. A SW note dated 8/7/26 at 3:01 PM identified there was a verbal disagreement between Resident #5 and Resident #56, Resident #56 was upset because Resident #5 called him/her a racial slur (used the N word). The Administrator was made aware of the resident-to-resident conflict and RN #9 was present during the conversation. A Social Worker's (SW) note dated 8/7/26 at 3:07 PM identified there was a verbal disagreement between Resident #5 and Resident #56 around 1:50 PM. Resident #5 admitted to a verbal exchange but would not give any specific details about what words were he/she said to Resident #56. When Resident #5 was asked to provide reassurance that he/she would not react or interact with peer (Resident #56) Resident #5 stated I cannot do that. Resident #56 was offered a room change which was refused. The Administrator was made aware of the situation and Registered Nurse (RN) #9 was present during the conversation. A nursing note dated 8/7/26 at 11:51 PM identified Resident #56 was on 1:1 secondary to altercation with a peer. During initial tour on 8/25/26 at 12:29 PM Resident #5 identified a resident-to resident interaction with his/her previous roommate stating that he/she yelled at his/her roommate (Resident #56) but would not say what he/she said. Additionally, a few days later, Resident #5 stated he/she was moved to another room. Also, identifying the interaction did not become physical. Interview and review of the SW note from Resident #5's clinical record dated 8/7/26 with the Administrator on 8/28/26 at 12:27 PM identified the resident-to resident interaction was a very heated argument but did not feel an investigation was warranted because the incident was just verbal. Also, identifying she did not know the abuse policy off the top of her head and was unsure if the social worker reported the incident to the state agency. Further, identifying no accident and incident report or reportable event was on file for 8/7/26 for either Resident #5 or #56. (refer to F 600 and F 609). Interview on 8/31/26 at 11:19 AM with the Director of Nursing Services (DNS) identified the resident-to-resident incident was just a verbal disagreement and she was on vacation at that time. Also, identifying neither resident was placed on 1:1 when asked for the records of the 1:1, she identified it was a community observation staff member not 1:1. Further, identifying she knew the policy for verbal abuse, a racial slur can be verbal abuse and she was unaware of any history of any incidents between Resident #5 and #56 in the past. Interview and review of the abuse policy on 8/31/26 at 11:30 AM with SW #3 identified after reading the abuse policy the resident-to-resident incident on 8/7/26 was verbal abuse, should have been investigated. Interview on 8/31/26 at11:50 AM with RN #9 identified she was called to the unit on 8/7/26 because of a verbal altercation, and no investigation was done because Resident #5 and Resident #56 declined any issues. The Abuse CT Policy revised 11/19/25, directed, in part, all abuse allegations will be reported and investigated promptly. The investigations of abuse, neglect, misappropriation, exploitation will be reviewed at regularly scheduled QAPI meetings. An investigation will be initiated within 24 hours of its discovery. It is the responsibility of the administrator or designee to initiate the investigation. Statements from all witnesses and staff. All injuries of unknown sources will be investigated. Injuries of unknown sources will be reported to the state agency if the resident cannot explain the source of the injury, no witnesses to the injury, and if the injury is suspicious in nature.

Based on interviews, review of the clinical record, review of facility documentations and facility policy for 1 of 1 sampled resident (Resident #1) reviewed for a respiratory infection, the facility failed to ensure revision of the Resident Care Plan (RCP) after Resident #1's pneumonia resolved, for 1 of 3 sampled residents (Resident #4) reviewed for abuse, the facility failed to review and revise the Resident Care Plan (RCP) when Resident #4 sustained a fractured toe of unknown origin and for 1 of 3 residents (Resident #140) reviewed for pressure ulcers, the facility failed to update the Resident Care Plan (RCP) while Resident #140 was on Enhanced Barrier Precautions (EBP). The findings include: 1. Resident #1's diagnoses included hemiplegia following cerebral infarction, diabetes, and chronic kidney disease. The Quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was cognitively intact, required supervision with personal hygiene, substantial assistance with showering for activities of daily living (ADLs), and supervision assistance with mobility. A physician order dated 3/12/26 directed Cefpodoxime Proxetil 200mg give one tablet by mouth every 12 hours for pneumonia for 7 days and Doxycycline Hyclate 100mg give one capsule by mouth every 12 hours for pneumonia for 7 days. The Resident Care Plan dated 3/17/26 identified Resident #1 had a respiratory care plan in place for a respiratory infection of pneumonia which Resident #1 received treatment for with antibiotic medication(s) from 3/12/26 to 3/19/26. The Resident Care Conference (RCC) held on 6/29/26 identified that the care plan was reviewed and updated at the RCC meeting with the interdisciplinary team in attendance. Interview with Licensed Practical Nurse (LPN) #1 on 8/27/26 at 1:30 PM identified that Resident #1's pneumonia infection was resolved in March 2026 with last day of antibiotic treatment on 3/19/26 but remained included in the RCP. LPN #1 indicated when the Quarterly MDS assessment dated [DATE] was completed, Resident #1's care plan should be reviewed by the MDS Coordinator to ensure the care plan reflected Resident's #1's current status. LPN #1 identified resident care plans were reviewed, revised and updated with the interdisciplinary team (IDT) at the resident care conferences. LPN #1 could not provide an explanation why the care plan for pneumonia was still active in Resident #1's plan of care because the pneumonia was resolved and did not reflect Resident #1's current status. Interview and record review on 8/31/26 at 9:04 AM with the Regional MDS Director, Registered Nurse (RN) #6 identified that Resident #1's still had an active pneumonia care plan in place from the 6/29/26 RCC and confirmed the pneumonia was resolved in March 2026. RN #6 identified that the MDS Coordinator should have reviewed the resident's care plan when the quarterly MDS assessment dated [DATE] was completed. RN #6 could not provide an explanation why the pneumonia care plan was still active in Resident #1's plan of care as it did not reflect Resident #1's current status. RN #6 indicated that the care plan may not have been reviewed by the MDS Coordinator when the Quarterly MDS assessment dated [DATE] was completed and/or at the resident care conference that was held with the interdisciplinary team (IDT) on 6/29/26. RN #6 identified the MDS Coordinator was responsible for reviewing, revising and updating the nursing care plans at the care conferences. RN #6 could not provide an explanation why the pneumonia care plan was not reviewed and discontinued at the resident care conference held on 6/29/26. RN #6 stated she would resolve the pneumonia care plan. 2. Resident #4's diagnoses included dementia with behaviors, schizophrenia, and anxiety. The Resident Care Plan (RCP) dated 8/26/25 identified increased dependence with activities of daily living (ADLs) as an area of focus with interventions that included assist with ADLs, offer incontinent care, if declines reapproach three times, if yelling or swearing notify nurse, encourage to assist with ADLs as much as possible, and encourage to use call bell. In addition, the RCP identified schizophrenia as an area of focus with verbally abusive behaviors towards others with interventions that included as needed alternative coping skills, encourage me to express my frustrations with staff, if I become delusional or hallucinating attempt to engage me in the conversation of activity that would distract me, psych and social services to provide support and assistance/medication management and individualized sessions, and supervisor resident and others as needed to ensure freedom from accidents or injury. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 was severely cognitively impaired, was totally dependent on staff for personal hygiene and transfers, maximum assistance with dressing, moderate assistance for toileting, and did not ambulate and utilized a wheelchair. Physician orders dated 9/12/25 directed assist of 2 out of bed with Hoyer (mechanical) lift, administer Lurasidone (antipsychotic) 100 milligrams (mg) daily for schizophrenia and Clonazepam (antianxiety) 0.5 mg 2 times a day for anxiety. An x-ray report of Resident #4's right foot dated 9/12/25 identified that Resident #4 had a possible mildly displaced fracture of the base of the first proximal phalanx (toe) with mild degenerative joint disease in the interphalangeal joints (between the toes) with osteopenia (low bone density). A Reportable Event form dated 9/13/25 identified Resident #4 complained of right foot pain with noted bruising and swelling. An x-ray was obtained and Resident #4 had a fracture of his/her right great toe. Resident #4 was unable to recall any events due to cognitive status. Resident #4 had sustained a fall on 9/4/25 with no apparent injuries. A hospital discharge summary and Inter-Agency Patient Referral Form (W-10) on 8/27/26 dated 9/13/25 identified that Resident #4 had a fractured right great toe and to follow up with primary care physician. An interview and review of Resident #4's care plan with Care Plan Coordinator, Licensed Practical Nurse (LPN) #2 and the Regional MDS Registered Nurse (RN) #6 failed to identify that Resident #4's injury of unknown origin and fractured toe was included in the care plan. The care plan only identified a cam boot to right foot without any indication of the injury of unknown origin or interventions related to prevention. RN #6 researched Resident #4's care plan that might have been on the facility's prior electronic medical record system but could not locate a care plan related to the fractured right great toe. LPN #4 and RN #6 stated the care plan was not revised to include Resident #4's fracture toe of unknown origin and that it was nursing's responsibility to revise the care plan. 3. Resident #140 had diagnosis that included moderate protein calorie malnutrition (a form of undernutrition where the body does not receive enough protein and calories to maintain normal tissue and organ function), hemiplegia (paralysis or severe weakness affecting one side of the body) and hemiparesis (muscle weakness affecting one side of the body) following cerebral infarction (blocked blood vessels to the brain) affecting right dominant side, and vascular dementia (caused by reduced or blocked blood flow to the brain). A Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #140 had severely impaired cognition and was dependent on staff for eating, oral hygiene, personal hygiene, toileting, dressing upper and lower body, showering/bathing, putting on and taking off footwear, rolling left to right ion bed, and bed to chair transfers. The MDS also indicated Resident #140 had no pressure injuries at that time. A Resident Care Plan (RCP) dated 7/27/26 identified a new pressure ulcer to Resident #140's right hip and sacrum. Interventions included to administer treatments as ordered, avoid positioning the resident on their right hip, a low air loss mattress, monitor dressing every shift to ensure it is intact and adhering, offload boots while in and out of bed, and weekly treatment and wound documentation. An observation on 8/25/26 at 12:00 PM identified an EBP sign outside of Resident #140's room and a Personal Protective Equipment (PPE) cart outside of their room. A clinical record review on 8/25/26 at 2:01 PM failed to reflect EBP for Resident #140 on the RCP. An interview on 8/26/26 at 2:45 PM with Registered Nurse (RN) #1 identified Resident #140 had a pressure ulcer and required an RCP for EBP. Also, identifying she was responsible for ensuring the RCP included EBP and it was on oversight. Further identifying the policy for a resident on enhanced barrier precautions was an RCP should have included enhanced barrier precautions. Subsequent to surveyor inquiry Resident #140's RCP was updated to include EBP. A facility policy, Enhanced Barrier Precautions, dated 5/12/26 indicated Policy: Staff will utilize the use of gowns and gloves for high-contact resident care activities as indicated, when Contact Precautions do not otherwise apply, min residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents without wounds or indwelling medical devices that have colonization of a CDC-targeted MDRO. Procedure: 6. A care plan will be initiated for residents requiring EBP and discontinued when no longer in use. The facility's Care Plan Policy with the revision date of 4/17/24 identified that it is the policy of the facility to develop comprehensive person-centered plan of care for its residents that is consistent with the residents' rights in order for them to attain and/or maintain their highest practicable level of physical, mental, and psychosocial well-being. Resident Care Conference is held within seven days of completion of the admission MDS, at least quarterly, annually, and when a significant change in status assessment is needed. The information presented during the conference should indicate the resident's current status, goals, preferences, strengths, problems, intervention implementation and any variances to the projected outcome. Information is utilized from the MDS assessment, clinical record, and input from the residents and any other assessments that are performed to develop and update the care plan. The MDS Coordinator or designated IDT member adds a goal or intervention for a problem by dating and writing the new goal or intervention and discontinues any care plans that have been resolved or no longer reflect the resident's current status.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 sampled resident (Resident #144) reviewed a medication concern, the facility failed to administer and document medication administration according to professional standards and for 1 of 3 sampled residents (Resident #154) reviewed for hospitalization, the facility failed to ensure readmission orders were reconciled and transcribed to reflect hospital discharge orders. The findings include:1. Resident #144 had diagnoses that included chronic obstructive pulmonary disease, hypertension, and adjustment disorder with mixed anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #144 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for transfers. A physician order dated 7/25/26 directed to administer Metoprolol Succinate 24 hour extended release (ER) oral tablet 25 milligrams (mg) 1/2 tablet (12.5 mg) by mouth 2 times a day for hypertension, and the administration times were 9:00 AM and 5:00 PM. The Resident Care Plan (RCP) dated 8/13/26 identified Resident #144 had hypotension related to hospitalization for septic shock and persistent hypotension. Interventions included to give medications as ordered, monitor and document signs or symptoms of dizziness, blurred vision, lack of concentration, and clammy, pale skin, and offer medication to manage heart disease per medical doctor. Interview with Resident #144 on 8/25/26 at 11:45 AM identified he/she had concerns related to his/her blood pressure medication (Metoprolol Succinate ER). Resident #144 indicated the facility nurses were not knowledgeable about the medications he/she received, and they did not administer them to him/her appropriately per the physician orders. Resident #144 indicated that often the morning dose of the medication was administered as late as 1:00 PM by the day shift (4 hours late) and the next dose is given to him/her at 4:00 PM (3 hours later). Resident #144 indicated that when he/she was home the doctor had said the medication needed to be taken 12 hours apart and he/she would take it at 6:00 AM and 6:00 PM. Resident #144 indicated that when the medication was administered too close together it would cause him/her to have a headache and/or blurry vision. Resident #144 further indicated that when he/she tried to tell the nurses that the medications were being administered too close together they would respond that they (knew how to do their job), or they would say (I'll take a look at it). Review of a Medication Administration Audit Report for 8/1/26 - 8/31/26 identified the 9:00 AM Metoprolol had been administered late on the following days. 8/3/26 at 12:03 PM (3 hours late). 8/6/26 at 10:40 AM (1 hour and 40 minutes late). 8/8/26 at 11:28 AM (2 hours and 28 minutes late). 8/10/26 at 11:27 AM (2 hours and 27 minutes late). 8/12/26 at 11:31 AM (2 hours and 31 minutes late). 8/13/26 at 11:21 AM (2 hours and 21 minutes late). 8/14/26 at 1:21 PM (4 hours and 21 minutes late). 8/15/26 at 12:00 PM (3 hours late). 8/16/26 at 1:15 PM (4 hours and 15 minutes late. 8/17/26 at 1:39 PM (4 hours and 39 minutes late). 8/19/26 at 12:54 PM (3 hours and 54 minutes late). 8/20/26 at 11:27 AM (2 hours and 27 minutes late). 8/31/26 at 10:23 AM (1 hour and 23 minutes late). Review of the clinical record between 7/1/26 and 8/31/26 failed to reflect information related to the late administration of the Metoprolol, including, if any, difficulty with documentation of medication administration. Interview and clinical record review with Licensed Practical Nurse (LPN) #10 on 8/28/26 at 12:19 PM identified the acceptable timeline for administration of medications was from 1 hour before their scheduled time to 1 hour after their scheduled time, and that she was able to complete her morning medication pass on time within that time range. She indicated most medications were ordered for 9:00 AM and a few were ordered for 8:00 AM so she was able to get them all done between 7:00 AM and 10:00 AM. When asked about the late administration of the Metoprolol, LPN #10 identified the laptop computer on her medication cart did not always work correctly and so she had to wait to document medication administration in the computer until she came back to the nurses station and used the desk top computer. She indicated that it was related to a Wi-Fi connection issue, and she had spoken with the Maintenance Director and the Director of Nursing (DNS) about trouble documenting the medications as she gave them. She indicated after speaking to them it got a little better, but she was still having trouble, and that it had been several months since she reported having a problem. She indicated that she didn't administer the medications late and only documented them late, so she didn't think she needed to notify anyone. She indicated she had not told the MD or APRN about the late documentation of the medications nor did she notify the nurses on the next shift. Interview and clinical record review with the DNS on 8/28/26 at 3:00 PM identified she was aware that there were times when the nurses had difficulty with their computers connecting to the internet and allowing for timely administration of the medication. She indicated that theoretically the nurses should be documenting the administration of their medications timely as they were being administered, but that when they were having difficulty with their computers connecting, the nurses needed to take alternative actions. She indicated that the facility did not provide printed paper medication administration records for the nurses to use. She indicated the problem was sporadic and did not occur every day, and she was not aware that Resident #144's medication was documented late on 12 days for the 7:00 AM to 3:00 PM shift and indicated boosters had been put in for the internet to increase the connection speed. She further indicated the nurses should have notified her and/or the Maintenance Director if they were still having difficulty documenting their medications timely. Interview with Maintenance Director on 8/31/26 at 12:15 PM identified the facility did not have a connectivity issue with the laptop computers on the nurses' medication carts. He indicated that he has not done anything to fix the problem because there wasn't a problem. He indicated that there were times when the computer timed out before the nurses' could document their medications but all they had to do was restart the computer and it would fix the problem. He indicated there were 3 hot spots on each floor and 5 on the fifth floor and the hot spots were all working. He indicated occasionally a hot spot required rebooting. He indicated that LPN #10 had only told him one time last year of an issue she was having with connecting and he had helped her to restart the computer, and it fixed the problem, and he indicated at this time all computers were functioning as they should. Interview with the DNS on 8/31/26 at 12:20 PM identified LPN #10 had not come to her at any time to report difficulty with documenting her medication administration as she was giving them and indicated that LPN #10 should have told her she was having a problem with documenting timely. Interview with LPN #8 on 8/31/26 at 2:45 PM identified she worked full time and worked on all floors, and she did not have any difficulty with documenting her medication administration while she was administering her medications today, but that there have been times when she had a problem. She indicated it was the internet and she had to sometimes wait a while for the computer to process. She indicated the longest she had ever waited to document her medication administration was 10-15 minutes, and that she had reported to the nursing supervisor and Maintenance Director when she had difficulty. She further indicated that the hot spot acted up occasionally, but not very often. Interview with LPN #9 on 8/31/26 at 2:48 PM identified she was relatively new to the facility, and about a month ago she had difficulty getting her computer to work due to a connection issue, and she had walked back and forth between her medication cart and the computer at the nurses' station to document her medications as she gave them so they would be documented timely. She indicated she had told maintenance when it happened. She indicated that was the only time she had a problem documenting on the laptop on her medication cart. 2. Resident #154's diagnoses included moderate dementia with agitation and adjustment disorder with mixed anxiety and depressed mood. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #154 was severely cognitively impaired and required supervision/touching assistance with toileting/hygiene and was independent with bed mobility and transfers. The MDS indicated Resident #154 had diagnoses of moderate non-Alzheimer's dementia with agitation. The Resident Care Plan (RCP) dated 6/11/26 identified Resident #154 had dementia with agitation, verbal aggression and self-inflicted injury or harm. Interventions included administering medications as ordered, close observation and sending the resident to the emergency department (ED) for self-inflicted harm. A hospital Discharge summary dated [DATE] at 10:44 AM identified Resident #154 had been sent by the facility for an evaluation of suicidal/homicidal ideation and escalating aggressive behavior. The resident's hospital presentation was most consistent with major neurocognitive disorder with behavioral disturbance which included agitation, aggression, impaired judgement and possible paranoid ideation. Resident #154 was started on Haldol (an antipsychotic medication) 0.5 milligrams (mg) 3 times daily which was progressively increased to 1.5 mg 3 times daily. The hospital course noted the resident made significant progress while in the hospital and became calm and pleasant to interact with, had no aggressive behaviors and his/her mood was described as good. A hospital Inter-Agency referral report (W-10) dated 8/17/26 at 11:39 AM identified the resident had a primary diagnosis of major neurocognitive disorder and was disoriented to time, place and situation. Medications to be administered after hospital discharge included Haloperidol (Haldol) 0.5mg tablet give 3 tablets (1.5mg dose) by mouth 3 times a day and Trazadone 50mg tablet by mouth nightly as needed for sleep. The W-10 indicated that Resident #154 was last administered Haldol 1.5mg on 8/17/26 at 8:16 AM. A facility nursing admission assessment dated [DATE] at 12:14 AM (for admission date of 8/17/26) identified Resident #154 was re-admitted to the facility via ambulance with an antipsychotic medication present on admission. Resident #154 was noted to have impaired memory with persistent anger, agitation and refused the full admission assessment. Physician orders dated 8/19/26 directed Haloperidol 0.5mg tablet give 3 tablets by mouth three times a day and Trazadone 50 mg tablet give 1 tablet by mouth every 24 hours as needed for sleep. A nursing note written by the Director of Nursing Services (DNS) on 8/19/26 at 6:26 PM identified upon review of Resident #154's re-admission paperwork medications (Haldol and Trazadone) had been omitted. The DNS notified the Advanced Practice Registered Nurse (APRN #1) and reconciled the medications. Physician orders that were note entered in the EHR on admission for Haloperidol 0.5mg by mouth three times daily and Trazadone 50 mg by mouth at hour of sleep as needed were entered into the electronic health record (HER). The residents responsible party was notified, and Resident #154 was at his baseline with not acute distress noted. Review of the facility Investigation Worksheet/Summary Medication Error form dated 8/19/26 and signed by the DNS identified Resident #154 had both Haloperidol 0.5mg (3 tabs) by mouth TID (3 times daily) and Trazadone 50 mg by mouth as needed at night omitted. The error was identified by a medication reconciliation and indicated RN #2 was the person who made the error. The report noted actions taken to prevent recurrence were that medication reconciliation would be done with a 2nd nurse. Interview and review of the clinical record with the DNS on 8/27/26 identified the nursing supervisor (RN #2) working on 8/17/26 from 7:00 AM to 2:00 PM when Resident #154 was re-admitted to the facility had failed to correctly reconcile and transcribe the resident's medication orders. The DNS was unsure why RN #2 had made the errors and stated RN #2 should have reviewed the discharge records from the hospital and transcribed the medication orders correctly. The DNS stated although she worked the shift after RN #2 on 8/17/26 from 3:00 PM to 11:00 PM and would have done a second check on Resident #154's re-admission medication orders, she was too busy and had several other admissions that evening. Further indicated the medication errors were discovered by Person #2 on 8/19/26 and then brought to her attention Interview with the nursing supervisor (RN #2) on 8/28/26 at 11:35 AM identified she was the nursing supervisor working on 8/17/26 from 7:00 AM to 2:00 PM, when Resident #154 was re-admitted to the facility. RN #2 indicated although she had started the resident's re-admission and transcribed and reconciled the resident's discharge medications with APRN #1, it was near the end of her shift and she was rushing. RN #2 stated she was responsible for the transcription error due to her failure to ensure the resident's medication orders were accurate. Further identified that when the DNS notified her about the transcription errors on 8/19/26 she was upset that another nursing supervisor did not re-reconcile Resident #154's medication orders for accuracy sooner. Interview and review of clinical record with APRN #1 on 8/28/26 at 12:47 PM identified she was aware of Resident #154's readmission to the facility on 8/17/26 and the transcription error with the Haldol and Trazadone orders. APRN #1 indicated it was the responsibility of the nursing supervisor to correctly reconcile and transcribe the medication orders from the hospital discharge paperwork, and she was unsure why that was not done. Additionally, she was unsure why another nursing supervisor had not done a second review of the Resident #154's re-admission medication orders to ensure accuracy. Interview with Person #2 on 9/3/26 at 11:37 AM identified she had remote access through her agency to the facility's EHR (for residents on her case load) and on 9/19/26 when she reviewed Resident #154's readmission (on 9/17/26) she discovered the transcription errors. Person #2 indicated on 8/19/26 she notified the facility and reported the errors to the State Agency. Person #2 stated she met with the DNS who confirmed that upon return from the inpatient psychiatric admission, Resident #154's Haldol and Trazodone orders were not transcribed. Person #2 indicated she was upset the psychotropic medications which were started and seemed effective during the resident's hospitalization were not continued upon Resident #154's readmission to the facility. Review of facility policy, admission Nursing Process, dated 2/18/26, directed a comprehensive nursing assessment will be completed upon the resident's admission and prior to beginning the assessment the Discharge Summary and W-10 should be reviewed. The licensed nurse is responsible for completing the admission documentation and the admission documentation should be co-signed by an RN.

Based on clinical review, facility documentation, interviews, and facility policy for 1 of 3 sampled residents (Resident #9) reviewed for hospitalizations, the facility failed to administer medication as prescribed on 7 out of 24 occasions. Findings include:Resident #9 had diagnosis of congestive heart failure (CHF), hypertension, and the presence of a cardiac pacemaker.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 had intact cognition and was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, personal hygiene, putting on and taking off footwear, rolling left to right in bed, sitting to lying, lying to sitting on edge of bed, sit to stand, and chair to bed transfers. A Resident Care Plan (RCP) dated 8/5/26 indicated Resident #9 had hypertension, cardiac pacemaker, coronary artery disease (narrowed or blocked arteries), hyperlipidemia (high cholesterol), and atrial fibrillation (an irregular heartbeat) related to cardiovascular disease and returned from the hospital on 3/13/26 with worsening heart failure. Interventions included monitoring and documenting edema, offer medication to manage heart disease, and obtain weights per MD orders.A physician order dated 8/5/26 directed to obtain 6:00 AM daily weights before breakfast and after first urination, give as needed Bumex (Bumetadine) (a diuretic, a medicine that helps treat fluid retention (edema) and swelling that was caused by congestive heart failure) if weight greater than 205 pounds (lbs). A physician order dated 8/5/26 directed to administer Bumex 0.5 milligrams (mg) one tablet by mouth one time a day, as needed, for congestive heart failure for daily weights greater than 205 lbs.A review of the Medication Administration Record (MAR) indicated 23 out of 24 days Resident #9 had a weight greater than 205 lb. The MAR indicated on 10 of the 23 days where the weight was greater than 205 lbs. Bumex 0.5 mg one tab by mouth one time per day, as needed, was not administered, despite a physician order being in place.A review of clinical documentation identified that on 3 of the 10 days (8/9/26, 8/20/26, and 8/24/26) the nurse indicated in their note that the Bumex 0.5 mg one tab by mouth one time per day was given, even though the medication had not been signed out in the MAR.An interview and record review on 8/28/26 11:00 AM with the Nurse Supervisor, Registered Nurse (RN) #1 identified the facility failed to administer Bumex 0.5mg as prescribed to Resident #9 when their weight was greater than 205 lbs. RN #1 indicated the medication should have been administered, and she did not know why it hadn't been administered.An interview and record review on 8/28/26 at 11:15 AM with the Director of Nursing Services (DNS) indicated the facility failed to administer Bumex 0.5mg as prescribed to Resident #9 when their weight was greater than 205 lbs. The DNS indicated the medication should have been administered, and she did not know why it hadn't been administered.An interview on 8/28/26 at 12:36 PM with the Advanced Practice Registered Nurse (APRN) #1 indicated she was not aware Resident #9 had not received 7 doses of their Bumex when their daily weight indicated it should have been given. She indicated Resident #9 was at risk for a CHF exacerbation related to not receiving their medication as prescribed. She reviewed the medication order and indicated it may have been missed because it had been transcribed as an as needed medication rather than as a scheduled daily medication. She stated she would contact the facility and change the medication to scheduled daily medication rather than as needed and she would add hold parameters to the order that if the weight was less than 205lb.On 8/28/26, subsequent to surveyor inquiry, Resident #9's Bumex was order was changed to a scheduled daily medication with medication hold parameters for weights less than 205lbs. A facility policy titled Medication Administration and Documentation-General indicates Policy; Medication Administration and Documentation occurs in a timely and accurate manner. 4. The medication administration record (MAR) is the form onto which all medication orders are transcribed, from which medications are poured and administered and on which medication doses are charted. The MAR is a permanent part of the resident's medical record. Action: Licensed Nurse, 17. Documents administration of medication on the mediation administration record immediately following administration. Documents any medications not administered (i.e. refused, etc.) and documents reason. 18. Documents specific reason for each dose of PRN medication on the MAR plus follow sup and documents effectiveness for each dose. 21. Documents all held or refused medications on MAR. Uses prudent professional judgement by informing physician in a timely manner when medications are held, refused, or otherwise unavailable for administration.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #102) reviewed for pain the facility failed to obtain a medication to adequately manage migraine pain. The findings include:Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #102) reviewed for pain the facility failed to adequately manage a resident's pain related to migraines and left shoulder pain. The findings include: Resident #110 had diagnoses that included metabolic encephalopathy, low back pain, and alcohol dependence with withdrawal. The clinical record failed to identify a medical diagnosis for history of migraine headaches and surgical history of left shoulder surgery with current limited range of motion to the left upper extremity.Review of an Inter-Agency Patient Referral Report (W-10) from the hospital dated 8/14/26 identified Resident #102 was hospitalized for hypotension from hypovolemia with additional diagnoses of lactic acidosis, alcohol dependence, alcohol abuse with withdrawal, alcohol withdrawal delirium, metabolic encephalopathy, acute kidney injury, history of migraine headaches, low back pain, and acute deep vein thrombosis of the left upper extremity brachial vein. The W-10 indicated that Resident #102 was medicated with Fioricet (narcotic) 50-325-40 milligram (mg) tablet, 2 tablets on 8/12/26, 8/13/26, and 8/14/26, and Resident #102 was medicated with hydromorphone (narcotic) 2 mg tablet, 1 tablet, 3 times on 8/13/26, and Resident #102 was medicated with tramadol 50 mg tablet, 1 tablet, on 8/14/26. The hospital failed to send an updated W-10 printed on 8/15/26 upon Resident #102's discharge from the hospital to the facility on 8/15/26, and the W-10 failed to indicate an order for Fioricet for Resident #102 which was administered at the hospital. Review of an Inpatient Discharge summary dated [DATE] identified Resident #102 presented to the hospital on 8/5/26 for alcohol detoxification. The summary indicated Resident #102 had a history of migraine headaches and was on Fioricet. Additionally, the summary indicated Resident #102 had peripheral neuropathy related to chronic bilateral low back pain and was on gabapentin. The Nursing admission assessment dated [DATE] and completed by Registered Nurse (RN) #5 and identified Resident #102 cognitively intact (alert and oriented to person, place, time, and situation). The assessment failed to identify Resident #102 functional mobility level and level of assistance needed with activities of daily living (ADLs). The assessment further indicated Resident #102 was not experiencing pain although it indicated Resident #102's pain level on 8/15/26 at 5:56 PM was 5 out of 10.The Baseline Care Plan dated 8/15/26 at 7:23 PM was signed by RN #5 on 8/16/26 and identified Resident #102 was admitted to the facility because he/she fell. The BCP indicated Resident #102 had no pain and a pain focus was not applicable although the Nursing admission Assessment indicated Resident #102's pain level on 8/15/26 at 5:56 PM was 5 out of 10. A physician order dated 8/15/26 directed to administer acetaminophen 325 milligram (mg) tablet, 2 tablets by mouth every 6 hours as needed (PRN) for general discomfort/temperature above 101, with additional instructions not to exceed 3,000 grams in 24 hours.A physician order dated 8/15/26 directed to administer gabapentin 600 mg tablet by mouth 3 times a day for neuropathy.A physician order dated 8/15/26 directed to administer tramadol 50 mg tablet by mouth every 12 hours PRN mild to severe pain. This order ended on 8/31/26.A physician order dated 8/15/26 directed to apply a lidocaine pain relief 4% patch topically to the lower back daily for low back pain, with additional instructions to apply patch and leave on for 12 hours then remove. This order was discontinued on 8/26/26.A history and physical (H&P) progress note written by Medical Doctor (MD) #1 on 8/16/26 at 1:49 PM identified Resident #102 was admitted on [DATE] and had weakness and unsteady gait. The note indicated Resident #102 was discharged from the hospital but the discharge summary was not available for his review at the time of his admission (H&P) note. The note listed the current medication orders, but failed to identify if Resident #102 had pain, and if so, where was his/her pain, and was it appropriately managed.An Advanced Practice Registered Nurse (APRN) note written by APRN #1 on 8/17/26 identified she had seen Resident #102 for complaints of headaches and indicated Resident #102 had a history of dependence with withdrawal and had last had a drink on 8/3/26 which could have contributed to his/her having headaches. The note indicated a new order for naproxen 250 mg tablet every 12 hours PRN for 3 days was implemented.An APRN order dated 8/17/26 directed to administer naproxen 250 mg tablet, 1 tablet by mouth every 12 hours PRN for headache for 3 days. This order ended on 8/20/26.Review of the Medication Administration Record (MAR) for August 2026 identified the Naproxen 250 mg was administered 1 time on 8/19/26 for a pain level of 6 out of 10.A physician order dated 8/26/26 directed to apply a lidocaine pain relief 4% patch topically to the left shoulder daily for left shoulder pain, with additional instructions to apply patch and leave on for 12 hours and remove per schedule.Interview with Occupational Therapist (OT) #1 on 8/28/26 identified Resident #102 had chronic shoulder pain with decreased range of motion to his/her left shoulder related to a history of surgery to that shoulder. She indicated that in therapy she was using diathermy (electromagnetic waves) for myofascial release and deep tissue healing due to knots on Resident #102's left shoulder blade causing radiating pain. She indicated the diathermy brought circulation to the area and was intended to increase Resident #102's range of motion and decrease his/her pain. She indicated that Resident #102 didn't always complain of pain with therapy, but when he/she did, she would notify the nurse.Interview with Resident #102 on 8/26/26 at 11:29 AM identified he/she was getting naproxen and gabapentin for pain and no narcotics. He/she indicated chronic left shoulder pain since falling about 5 years ago and demonstrated his/her range of motion was decreased (only able to lift the left arm up to just under shoulder height). He/she indicated the medication the facility was giving him/her didn't help his/her pain and that at that moment his/her pain was 8 out of 10. He/she indicated at night the pain was 5 out of 10 and he/she would wake up confused and then couldn't get back to sleep for a couple hours. He/she indicated that hospital had given Fioricet and hydromorphone for pain which helped, but that the facility was not giving him/her either one of those medications. He/she further indicated she had seen APRN #1 on 8/25/26 and APRN #1 had told him/her that the medical record did not indicate a migraine diagnosis and his/her headaches were related to alcohol withdrawal. Review of the clinical record failed to identify a progress note written by APRN #1 for a visit with Resident #102 on 8/25/26.Interview with Resident #102 on 8/28/26 at 12:15 PM identified he/she had spoken with APRN #1 early that morning before breakfast and was told again that his/her headaches were related to alcohol withdrawal and she didn't offer him/her any other medication options. He/she indicated knowledge of the Tramadol order and indicated it was not effective at managing his/her migraine headaches which was why he/she had requested the previous night to have the APRN come see him/her again. Resident #102 indicated that he/she had experienced migraines for the last 5 years and at home used the Fioricet or alcohol to manage the headaches. He/she indicated in rehabilitation therapy they were doing a treatment which released his/her shoulder and it felt so much better when they did that, but he/she further indicated that his/her pain was not being managed due to continued headaches without adequate relief.Interview with Advanced Practice Registered Nurse (APRN) #1 on 8/28/26 at 1:27 PM identified she had not seen Resident #102 for a formal visit on 8/25/26, and indicated that Resident #102 had come down to the desk while she was meeting with a different resident. She indicated that Resident #102 had expressed to her wanting something for his/her headaches and she had told Resident #102 the headaches were likely related to his/her alcohol withdrawal, and she had not gone down to Resident #102's room afterward to follow-up. She indicated she had seen Resident #102 this morning for a visit related to the headaches and that he/she had asked for Fioricet. She indicated that she had not done Resident #102's admission note and so needed to check the hospital paperwork to see what had been ordered at the hospital. She was not aware that Resident #102 had a history of migraines or that the hospital had given Resident #102 Fioricet during his/her admission. She indicated that she had told Resident #102 that she would look at the hospital paperwork and then proceed accordingly, and indicated that she had not yet looked at the hospital paperwork nor had he/she ordered Fioricet (it had been more than 5 hours since her visit with Resident #102).Subsequent to surveyor inquiry physician order dated 8/29/26 directed to administer Fioricet 50-300-40 mg capsule every 8 hours PRN for headache for 3 days. This order differed from the Fioricet dosage administered by the hospital during Resident #102's admission which was Fioricet 50-325-40 mg 2 tablets.Review of the MAR for August 2026 identified an order for Fioricet 50-300-40 mg, but failed to identify any doses were administered since the order was entered on 8/29/26.Interview with Resident #102 in his/her room on 8/31/26 at 8:35 AM identified he/she was unaware of the new order for Fioricet for 3 days that was entered on 8/29/26. He/she stated that the nurse was asked that morning before breakfast if there were any changes to his/her medication orders and he/she was told, no. She expressed frustration at not being told about the new order and indicated that his/her current pain level was 8 out of 10.Interview with Licensed Practical Nurse (LPN) #5 on 8/31/26 at 9:46 AM identified Resident #102 had reported pain of 7 out of 10 to his/her left shoulder during her shift on Saturday 7AM-3 PM on 8/29/26. She indicated that Resident #102 had physician orders for pain medications of tramadol and acetaminophen to use as needed for pain. She was unaware of any new orders for pain medication and indicated she was not aware of an order for Fioricet for Resident #102.Interview with APRN #1 and Resident #102 on 8/31/26 at 10:40 AM identified Resident #102 stated the nurse looked in her medication cart a couple hours ago and there was no Fioricet available for her to give to him/her. APRN #1 indicated that he/she didn't work Saturday (8/29/26), but had called in an order that morning for Fioricet to the nursing supervisor (RN #5). She was unable to identify why the medication was not available and placed a call to the pharmacy with the surveyor and Resident #102 present. APRN #1 indicated the pharmacy said the dosage of Fioricet ordered on 8/29/26 was not available and had to be ordered and was due to arrive at the pharmacy today (8/31/26) at which point it would be sent to the facility. She further indicated the pharmacy had told her they called the facility to notify them at approximately 2:54 PM on 8/29/26 and the nursing supervisor had informed them the APRN would be notified. APRN #1 indicated that she would look at the notes to see if the on-call APRN was notified on 8/29/26 and informed Resident #102 she would rewrite the order since it was only for 3 days and hadn't arrived to the facility yet.Interview and facility documentation review on 8/31/26 at 11:15 AM identified a progress note written by APRN #4 on 8/29/26 at 4:35 PM which indicated the nursing supervisor had called to say the pharmacy did not have the dosage of Fioricet that was ordered but did have an alternative dosage (Fioricet 50-325-40 mg), and that she had instructed the nursing supervisor to change the order to the one available from the pharmacy. APRN #1 indicated that the nursing supervisor should have put in the new order, and that the on-call APRN's do not input orders themselves into the electronic medical records.Interview with the pharmacy quality assurance pharmacist (Pharm #1) on 8/31/26 at 11:45 AM identified the Fioricet order placed by the facility on 8/29/26 was not available in the ordered dosage and would have to be ordered from their supplier, she indicated that a different dosage was available at the pharmacy and they had called and told the facility if they could get a new order for the available dosage they would be able to send the medication that day, but it not they would have to wait until the medication could be ordered from their supplier. She further indicated that although the pharmacy had informed the facility of the alternative dosage available so that there wouldn't have been a delay in filling the prescription, a new order was not received and so the pharmacy had ordered the medication from their supplier, and she indicated it was expected to arrive that afternoon and would then be sent to the facility. Interview with the Director of Nursing (DNS) on 8/31/26 at 12:20 PM identified APRN #1 gave an incorrect order for Fioricet, and so APRN #3 gave a new Fioricet order to RN #5. She indicated that when the pharmacy had called to notify RN #5 that the current Fioricet dosage wasn't available at the pharmacy, she should have gotten approval from the APRN #4 for the dosage that the pharmacy did have available and then she should have put the new order into the electronic medical record.Interview with RN #5 on 9/1/26 at 10:14 AM identified APRN #1 had called her with an order for Fioricet 2 mg. She indicated that wasn't a actual dosage for that medication and so APRN #3 had given her a different order for the Fioricet. She indicated she had received a call from the pharmacy saying they didn't have the dosage of Fioricet that was ordered, but that they had a different dosage available and could send that if they received a new order. She indicated she had call the on-call APRN, APRN #4, who told her that the she would look at the order and change it to the dosage the pharmacy had available. RN #5 indicated APRN #4 had not told her to put in the order, and indicated that she had finished her shift about an hour later and was unaware the new order was never entered and so the Fioricet never arrived that weekend.Review of the Pain Management policy directed, in part, all residents will have an initial pain evaluation on admission and that pain management will include the resident and the facility staff collaboration and pain management interventions will be reassessed as needed and changes made as needed and as appropriate.

Based on observation, review of the clinical record, facility policy and interviews for 2 residents (Resident #26 and 136) reviewed for infection control practices, the facility failed to ensure a resident with a chronic wound (Resident #26) and a resident with a feeding tube (Resident #136) was on enhanced barrier precautions (EBP) and for the facility failed to ensure infection control practices related to storage of medical personal use items. The findings include:1. Resident #26 had diagnoses that included anxiety, 3rd degree burns on the buttock, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 had moderately impaired cognition and was dependent for toileting and required partial/moderate assistance for toileting and dressing. Additionally, the MDS assessment indicated Resident #26 required supervision or touching assistance for all transfers and walking. The Resident Care Plan (RCP) dated 11/26/25 identified Resident #26 had been placed on Enhanced Barrier Precautions (EBP). An intervention included to maintain a homelike environment and protect privacy, an orange sticker be placed next to my name tag. 2. Resident #136 had diagnoses that included feeding tube, schizoaffective disorder, and multiple sclerosis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #136 was cognitively impaired and was dependent for all activities of daily living. The Resident Care Plan (RCP) dated 8/2/26 identified the resident had been placed on Enhanced Barrier Precautions (EBP). An intervention included to maintain a homelike environment and protect privacy, an orange sticker be placed next to name tag. Observation on 8/25/26 at 10:30 AM failed to identify an EBP sign on the name plate of Resident #26 and Resident #136's room. Observation on 8/26/26 at 11:15 AM failed to identify an EBP sign on the name plate of Resident #26 and Resident #136's room. Observation on 8/27/26 at 10:00 AM failed to identify an EBP sign on the name plate of Resident #26 and Resident #136's room. Interview with Licensed Practical Nurse (LPN) #8 on 8/26/26 at 11:25 AM identified that residents with an orange sticker on their name plate were on enhanced barrier precautions. She further indicated that only residents with Multi Drug Resistant Organism (MDRO) infections required EBP, but not all wound care required these precautions. (This is in conflict with the facility policy for EBP and current infection control standards). Interview with Director of Nursing Services (DNS) on 8/31/26 at 12:15 PM indicated that enhanced barrier precautions should only be used when caring for residents with MDROs. She further clarified that she did not believe chronic wounds or tube feedings required EBP's unless the site was infected. (This is in conflict with the facility policy for EBP and current infection control standards). Interview with the Infection Preventionist Registered Nurse (RN) #1 on 8/31/26 at 1:30 PM indicated that an orange sticker should be located on the name plate of all residents on EBP. She further indicated EBP should be used on all residents with wounds including Resident #26 and all residents with feeding tubes including Resident #136. She believed that the orange sticker may have fallen off the resident's name plate for Resident #136 and confirmed that she needed to add a sticker to Resident #26's name plate because he/she was now back on EBP's. Subsequent to surveyor inquiry, on 8/31/26 orange stickers were added to the name plates of Resident #26 and Resident #136. Review of the Enhanced Barrier Precautions policy dated 5/12/26 indicated EBP is implemented to prevent transmission of multidrug-resistant organisms (MDRO) and involves gown and glove use during high-contact resident care activities. The policy indicated all staff receive training on what are high-contact resident care activities and organisms that require EBP. In addition, the policy listed high contact resident care activities which included the use of feeding tubes and caring for chronic wounds, and in part #1 stated to maintain a homelike environment that an orange sticker would be placed on resident's name card. The policy further indicated in #6 that a care plan would be initiated and discontinued when no longer applicable. 3. Observations on 8/25/2026 at 3:28 PM on the first and second floor identified the following: room [ROOM NUMBER], 2 large wash basins stored on the floor, a urinary hat was located inside the wash basins, the items were unlabeled. room [ROOM NUMBER], 2 large wash basins stored on floor in the bathroom unlabeled. room [ROOM NUMBER], 1 urinal hanging on handicap rail in the bathroom unlabeled. room [ROOM NUMBER], 4 large wash basins in bathroom unlabeled, one stored inside other. Observations made on 8/26/26 at 11:45 AM with the Infection Control, Registered Nurse (RN)#1 identified the following: room [ROOM NUMBER], 2 large wash basins on floor in bathroom, not labeled. room [ROOM NUMBER], 1 urinal hanging on railing in the bathroom, not labeled. room [ROOM NUMBER], 1 urinal hanging on the rail in the bathroom, not labeled. room [ROOM NUMBER], 4 large wash basins on the counter in the bathroom inside each other, not labeled. Interview on 8/26/26 at 11:45 AM with RN#1 identified that per the facility policy all personal care items should be labeled, covered and stored in the resident's nightstand and that she was responsible for oversight. RN #1 indicated she had previously provided numerous staff trainings on infection control practices regarding the storage and use of resident person care items. Although requested, a facility policy for storage of personal care items was not provided.

Based on review of facility documentation, facility policy and interviews for 1 of 5 licensed staff employee files reviewed, the facility failed to ensure that the required employee Communication training/in-services were completed. The findings include:Licensed Practice Nurse (LPN)#10 's date of hire was 7/20/2012 and upon review of the facility documentation provided for LPN #10 the facility failed to identify that in-service training had been completed for Communication in 2026 (per the course completion documentation provided representing the date of 8/31/2026). Although requested, the facility could not provide documentation that the required training had been completed by LPN #10.The corrective Action Record dated 7/20/26 by Human Resource #1 identified LPN#10 did not complete mandatory training as of 7/6/26 before the applicable deadlines.Interview on 8/31/2026 at 4:00 PM with the Corporate Human Resource identified LPN#10 did not complete all her mandatory trainings for 2026 and LPN#10 had been placed on corrective action on 7/20/26. Also, identifying if LPN#10 does not complete her mandatory trainings she will be removed from the schedule.Interview on 8/31/2026 at 4:21 PM with Human Resource #1 identified LPN#10 did not complete her mandatory training for 2026 and he had filed a corrective action form on 7/20/26. Also, identifying that next quarter he would review the mandatory training to see if LPN#10 training was completed, if not she would need to come into the office, complete the mandatory training on site in the office and be taken off the schedule until the training was completed.Review of facility Employee code of conduct policy, dated 3/1/2019 directed, in part, staff will actively participate in all required training and in-services.

Based on review of facility documentation, facility policy and interviews for 1 of 5 licensed staff employee files reviewed, the facility failed to ensure that the required employee abuse training/in-services were completed. The findings includeLicensed Practice Nurse (LPN)#10 's date of hire was 7/20/2012 and upon review of the facility documentation provided for LPN #10 the facility failed to identify that in-service training had been completed for Abuse Prevention in 2026 (per the course completion documentation provided representing the date of 8/31/2026). Although requested, the facility could not provide documentation that the required training had been completed by LPN #10.The corrective Action Record dated 7/20/26 by Human Resource #1 identified LPN#10 did not complete mandatory training as of 7/6/26 before the applicable deadlines.Interview on 8/31/2026 at 4:00 PM with the Corporate Human Resources identified LPN#10 did not complete all her mandatory trainings for 2026 and LPN#10 had been placed on corrective action on 7/20/26. Also, identifying if LPN#10 does not complete her mandatory trainings she will be removed from the schedule.Interview on 8/31/2026 at 4:21 PM with Human Resource #1 identified LPN#10 did not complete her mandatory training for 2026 and he had filed a corrective action form on 7/20/26. Also, identifying that next quarter he would review the mandatory training to see if LPN#10 training was completed, if not she would need to come into the office, complete the mandatory training on site in the office and be taken off the schedule until the training was completed.Review of facility Employee code of conduct policy, dated 3/1/2019 directed, in part, staff will actively participate in all required training and in-services.Review of facility policy, Abuse dated 1/28/26 directed, in part, Resident abuse education was required on hire for all employees as part of the employee orientation process and annually thereafter.

Based on review of facility documentation, facility policy and interviews for 1 of 5 licensed staff employee files reviewed, the facility failed to ensure that the required employee Behavioral Health training/in-services were completed. The findings include:Licensed Practice Nurse (LPN) #10 's date of hire was 7/20/2012 and upon review of the facility documentation provided for LPN #10 the facility failed to identify that in-service training had been completed for Behavioral Health in 2026 (per the course completion documentation provided representing the date of 8/31/2026). Although requested, the facility could not provide documentation that the required training had been completed by LPN #10.The corrective Action Record dated 7/20/26 by Human Resource #1 identified LPN#10 did not complete mandatory training as of 7/6/26 before the applicable deadlines.Interview on 8/31/2026 at 4:00 PM with the Corporate Human Resources identified LPN#10 did not complete all her mandatory trainings for 2026 and LPN#10 had been placed on corrective action on 7/20/26. Also, identifying if LPN#10 does not complete her mandatory trainings she will be removed from the schedule.Interview on 8/31/2026 at 4:21 PM with Human Resource #1 identified LPN#10 did not complete her mandatory training for 2026 and he had filed a corrective action form on 7/20/26. Also, identifying that next quarter he would review the mandatory training to see if LPN#10 training was completed, if not she would need to come into the office, complete the mandatory training on site in the office and be taken off the schedule until the training was completed.Review of facility Employee code of conduct policy, dated 3/1/2019 directed, in part, staff will actively participate in all required training and in-services.

Based on review of the clinical record, facility documentation, facility policy and interviews for 6 of 8 residents (Resident #59, Resident #67, Resident #89 and Resident #93, Resident #129, and Resident #155) reviewed for choices, the facility failed to allow the residents the right to see the room, meet the roommates, or ask questions about the room prior to the room change, failed to provide a written notice of a change in room prior to or following the room change, and failed to ensure residents were aware of their right to return to their previous room due to being moved emergently. The findings include:1. Resident #59 had diagnoses that included chronic obstructive pulmonary disease, diabetes, and vascular dementia with anxiety. Review of the clinical record census information (movement within or out of the facility) identified on 8/11/26, Resident #59 was transferred to a 4-bed room on the second floor after residing in his/her room for over 1.5 years. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was cognitively intact, and independent with eating, chair/bed transfers, and walking. The Resident Care Plan (RCP) dated 6/30/26 identified Resident #59 wished to remain a long-term resident of the facility and was not interested in referral to community-based living. Interventions included to occasionally ask Resident #59 how he/she feels about their stay in the facility. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #59 prior to the room change and/or after completion of the room change. Review of facility documentation emails provided by the facility identified an email addressed to Resident #59's conservator written by Social Worker (SW) #2 on 8/11/26 at 11:06 AM, requesting permission for a room change for Resident #59 due to the emergency evacuation of another nursing home in town. A social services note written by SW #1 on 8/11/26 at 11:54 AM identified an email and voicemail was left for Resident #59's responsible party requesting that Resident #59 have a room change from his/her room on the first floor to a room on the second floor to accommodate other residents due to an emergency evacuation at another facility. The note further indicated SW #1 had spoken to Resident #59, and he/she was in agreement with the room change and would voluntarily change rooms once consent was received from his/her responsible party. Review of a facility provided email addressed to Resident #59's conservator written by SW #2 on 8/11/26 at 12:03 PM identified she had addressed a second email to Resident #59's responsible party related to the urgent room change for Resident #59. Review of a facility provided email written to SW #2 on 8/11/26 at 12:17 PM by Resident #59's responsible party identified consent was provided for Resident #59's room change. A Notification of Change in Room or Roommate evaluation dated 8/11/26 at 12:17 PM identified Resident #59 would be moved to a new room on 8/11/26 for the reason of providing accommodation for other residents of the same gender. (Although a review of the clinical records indicated that both male and female gender residents had received room changes.) Further review of the clinical record failed to identify written documentation of a written notice including the reason for the room change prior to or following Resident #59's change in room. A revision to the RCP dated 8/11/26 identified Resident #59 had a voluntary room change on 8/11/26. Interventions included to encourage Resident #59 to express any concerns or issues with staff, provide psychiatry services as needed, and social services to provide support as needed. Interview with Resident #59 on 8/25/26 at 12:40 PM identified he/she had a room change on 8/11/26 due to an emergent need for my room for an evacuated resident from another building, and he/she indicated that when staff came into the room and started to pack up his/her belongings he/she knew something was going on. The resident indicated that when staff began packing his/her belongings, this was the first he/she knew of the move despite SW #1's note dated 8/11/26 at 11:54 AM indicating that prior consent had been obtained by Resident #59. He/she indicated that there was approximately a 10 minute notice prior to staff telling him/her that a room change was necessary as they began packing his/her belongings until he/she was brought to the new room, which was the first time he/she had seen the room, became known as a 4-bed room, and met the other residents. Resident #59 indicated that he/she had asked the staff if he/she would be returning back to his/her long-standing room, but they did not provide a response to the question. 2. Resident #67 had diagnoses that included dementia, paranoid schizophrenia, and chronic kidney disease. Review of the clinical record census identified on 8/11/26 Resident #67 had been I his/her room for 25 days and was then transferred to a 4-bed room on the same floor (second floor) on the same unit. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was moderately cognitively impaired, required setup or clean-up assistance with eating, and was independent with transfers, and walking. The Resident Care Plan (RCP) dated 8/5/26 identified Resident #67 wished to remain a long-term care resident of the facility and was not interested in a referral to community-based living. Interventions included occasionally asking Resident #67 how he/she feels about their stay in the facility. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #67 prior to the room change and/or after completion of the room change. A social services note written by Social Worker (SW) #2 on 8/3/26 at 10:45 AM identified Resident #67 and his/her conservator were provided a copy of the 14-day room change letter. Review of the 14-day room change letter dated 7/27/26 sent by SW #2 on 8/3/26 via email to Resident #67's responsible party identified the facility planned to move Resident #67's to another room on the same floor on 8/11/26, 15 days from this notice (but 8 days after the letter was originally sent). The letter apologized if the room was not what Resident #67 had wished for but indicated that according to Connecticut statutes for Resident Rights, the facility was allowed to change the room because Resident #67 did not require short term rehabilitation which was the focus of the specialized unit where the room was presently located. (Both rooms were located on the same unit on the second floor). The letter further indicated because Resident #67 had declined the move, a consultative process involving Resident #67, the doctor, nurse, and responsible party had not determined the move was medically contraindicated. The letter referred to Social Services Department for support and the Ombudsman if a consult was desired and was signed by the Administrator. A social services note written by SW #1 on 8/11/26 at 11:29 AM identified Resident #67 had a voluntary room change (the resident declined the move according to the14-day room change letter dated 7/27/26 sent by SW #2 on 8/3/26) from his/her room on the second floor to a different room on the second floor to accommodate other residents due to an emergency evacuation at another facility. The note further indicated that Resident #67's conservator previously consented to a room change. (The resident census indicated that the room change occurred on 8/12/26.) A Notification of Change in Room or Roommate evaluation dated 8/11/26 at 11:32 AM identified Resident #67 would be moved to a new room on 8/11/26 for the reason of providing accommodation for other residents of the same gender. A social services note written by SW #1 on 8/12/26 at 1:40 PM identified Resident #67's responsible party called by SW #1 regarding a potential move to the dementia unit and the responsible party indicated he/she thought they had previously given approval for the move to the dementia unit but had not. The further note indicated Resident #67's responsible party was notified that Resident #67 had been moved to a 4-bed room on the second floor as previously discussed. The note further indicated that Resident #67's responsible party agreed to the room change to the 4-bed room on the second floor and indicated that she also approved a room change to the dementia unit if needed in the future. A revision to the RCP dated 8/11/26 identified Resident #67 had a voluntary room change on 8/11/26. Interventions included to encourage Resident #67 to express any concerns or issues with staff, provide psychiatry services as needed, and social services to provide support as needed. The RCP showed a discrepancy for a voluntary room change as the 14-day letter had indicated an involuntary room change. Interview with Resident #67 in his/her room on 8/31/26 at 9:26 AM identified he/she wanted to go home, and he/she could not recall the situation regarding his/her room change. 3. Resident #89 had diagnoses that included diabetes, atrial fibrillation, bipolar disorder, and hypertension. Review of the clinical record identified Resident #89 was admitted into a 2-person semi-private room on the first floor and on 8/12/26, Resident #89 had a room change and was transferred into a 4-person room. (20 days after admission.) The admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #89 was cognitively intact, required supervision assistance for showers, independent to set up assistance for hygiene and dressing, and independent with transfers and ambulation. The Resident Care Plan (RCP) dated 7/26/26 identified Resident #89 was admitted for short term/long term care. Resident #89 wishes were to be discharged to the community. Interventions included making arrangements with required community resources to support independence post-discharge, establish a pre-discharge plan with the resident/family/caregivers, evaluate progress and revise plan as needed, and identify, discuss, and address limitations, risks, benefits, and needs for maximum independence. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #89 prior to the room change and/or after completion of the room change. A social services note written by Social Worker (SW) #3 on 8/12/26 at 12:35 PM identified SW #3 reached out to Resident #89 conservator of person (COP) to inform the COP that Resident #89 would be moving from a 2-person room to a 4-person room due to an emergency evacuation from another facility. SW #3 left a voice mail with contact information. Review of the Notification of Change in Room or Roommate Form dated 8/12/26 at 9:16 AM identified Resident #89's room change was due to provide accommodations for other residents of the same gender. Review of the social worker Interim Occurrence Response Form dated 8/12/26 and signed by SW #3 on 8/17/26 identified Resident #89 had a voluntary room change to accommodate other residents due to an emergency evacuation at another facility. Resident #89 was conserved and a call was placed to COP in regard to the room change. A voice mail was left with contact information. Support provided. Interview with Resident #89 on 8/26/26 at 8:54 AM identified the facility did not provide Resident #89 with a notice for the room change. Resident #89 stated that he/she was told the room change was for an emergency and he/she needed to move his room. Resident #89 stated he/she was given no choice for the room change. 4. Resident #93 had diagnoses that included rhabdomyolysis, chronic obstructive pulmonary disease, adjustment disorder with anxiety and depressed mood, and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 cognitively intact, required partial/moderate assistance with toileting and personal hygiene, substantial assistance with bathing, and partial/moderate assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 6/30/26 identified Resident #93 was admitted for short term care. Resident #93 wishes were to return to the community. RCP dated 8/11/26 identified Resident #93 had a voluntary room change from room [ROOM NUMBER]B to room [ROOM NUMBER]C. Interventions included to encourage the resident to express any concerns or issues with staff, psych to provide med management and individual sessions as needed and social services to provide support and assistance as needed. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #93 prior to the room change and/or after completion of the room change. A social services note written on 8/11/26 at 11:44 AM by SW #1 identified Resident #93 had a voluntary room change to accommodate other residents due to an emergency evacuation at another facility. Resident #93 was self-responsible and in agreement with the change. Review of the Notification of Change in Room or Roommate Form dated 8/11/26 at 11:42 AM identified Resident #93's room change was due to providing accommodations for other residents of the same gender. Review of the social worker Notification of Change in Room or Roommate Form dated 8/11/26 at 11:42 AM and signed by SW#3 on 8/13/26 identified Resident #93 had a voluntary room change to accommodate other residents due to an emergency evacuation at another facility. Interview with Resident #93 on 8/25/26 at 2:38 PM identified Resident #93 was not provided with any notice and was not given a reason and/or a choice from the facility for the room change. Resident #93 stated she/he was told she had to move. 5. Resident #129 had diagnoses that included unspecified cord compression, adjustment disorder with depressed mood, and hypertension. Review of the clinical record census identified on 8/11/26 Resident #129 was in his/her room over 5 months and transferred to a 4-bed room on the second floor. The Resident Care Plan (RCP) dated 6/11/26 identified Resident #129 was having adjustment issues related to his/her admission. Interventions included encourage Resident #129 to participate in activities of choice, introduce Resident #129 to residents with a similar background and interests, and provide Resident #129 with situations that give him/her control over their environment and delivery of care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #129 was cognitively intact, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for bed/chair transfers. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #129 prior to the room change and/or after completion of the room change. A Notification of Change in Room or Roommate evaluation dated 8/11/26 at 11:50 AM identified Resident #129 would be moved to a new room on 8/11/26 for the reason of providing accommodation for other residents of the same gender. A social services note written by Social Worker (SW) #1 on 8/11/26 at 11:52 AM identified Resident #129 had a voluntary room change from his/her room on the first floor to a room on the second floor to accommodate other residents due to an emergency evacuation at another facility. The note indicated Resident #129 was self-responsible and in agreement with the room change. The note failed to identify if Resident #129 was offered to return to his/her previous room following the discharge of the evacuated resident(s) to their original facility. A revision to the RCP dated 8/11/26 identified Resident #129 had a voluntary room change on 8/11/26. Interventions included to encourage Resident #129 to express any concerns or issues with staff, provide psychiatry services as needed, and social services to provide support as needed. Interview with Resident #129 in his/her room on 8/31/26 at 9:40 AM identified that on 8/11/26 the facility had informed him/her that they needed to move residents out of another facility and so needed to move him/her to a different room. He/she indicated, I don't think I had a choice about the move and was unaware he/she had the right to refuse the room change. 6. Resident #155 had diagnoses that included kidney stones, chronic obstructive pulmonary disease, and bipolar schizoaffective disorder. Review of the clinical record census identified on 8/11/26 Resident #155 was transferred to a 4-bed room on the first floor. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #155 was cognitively intact, used a walker and wheelchair, was independent with eating, and required partial/moderate assistance with transfers, and walking 10 feet. The Resident Care Plan (RCP) dated 8/3/26 identified Resident #155 wished to return back to his/her home that is shared with family in the community. Interventions included evaluate Resident #155's motivation to return to the community to live, make arrangements with community resources required for support after discharge, and encourage Resident #155 to discuss concerns and feelings related to his/her impending discharge. Review of the clinical record failed to identify a written notice of the room change with the reason for the change was given to Resident #155 prior to the room change and/or after completion of the room change. A Notification of Change in Room or Roommate evaluation dated 8/11/26 at 11:35 AM identified Resident #155 would be moved to a new room on 8/11/26 for the reason of providing accommodation for other residents of the same gender. A revision to the RCP dated 8/11/26 identified Resident #155 had a voluntary room change on 8/11/26. Interventions included to encourage Resident #155 to express any concerns or issues with staff, provide psychiatry services as needed, and social services to provide support as needed. Review of the clinical record identified Resident #155 was discharged to home on 8/13/26 (2 days after his/her room change). Review of the facility bed board dated 8/12/26 identified for the 6 room changes were conducted between 8/11/26 and 8/12/26, 2 out of 6 were males, and 4 out of 6 were females. The room changes that occurred were all same gender filled 2-bed rooms moved to a 4-bed rooms emptying out 3 full 2-bed rooms. Interview with the Administrator on 8/26/26 at 9:30 AM identified their corporate office informed them they would receive 7 residents from a local nursing home that had been evacuated, but the residents never came to the facility. Interview with Person #1, a family member, on 8/26/26 at 4:08 PM identified he/she had spoken with the Administrator following the implementation of Connecticut Public Act No. 24-141 (prohibits nursing homes with nursing supervision from putting newly admitted residents in rooms containing more than 2 beds) and had been informed that the facility was not supposed to back fill 4-bed rooms who had 3 resident occupancy with an additional resident to make 4 residents in a room. Person #1 indicated on 8/11/26 his/her family member called and reported that a fourth resident had been added to the residents 4-bed room that already was occupied by 3 residents. Person #1 indicated that he/she had met with the Regional Director of Operations who had informed him/her that the Department of Public Health had given the facility a waiver to put residents into the 4-bed rooms due to an emergency evacuation. Interview with SW #1 on 8/27/26 at 3:10 PM identifiedSW#1 indicated that she was informed the emergency admissions were the evacuation residents from another skilled nursing facility. SW #1 stated the facility never ended up admitting any of those emergency admissions. SW#1 identified when the facility did not receive the emergency admissions, Resident #89 and Resident #93 were not offered to return to the semi-private rooms where they were moved from. SW #1 could provide an explanation why the residents were not offered the chance to return to their rooms stating the facility could not admit into 3 or 4 person rooms. SW #1 indicated she did not provide Resident #89 or Resident #93 or their responsible party with a written notice for their room changes. SW#1 stated giving a resident notice for a room change would all depend on the situation and she did not have a specific written notice form that was to be given to the residents or their responsible party. SW #1 stated she wrote progress notes and completed a Notification of Change of Room or Roommate Form and an Interim Occurrence Response Form located in the resident's electronic chart and the forms were not provided to the resident or their responsible party as written notification for the room changes. Interview with SW #2 on 8/27/26 at 3:10 PM identified on 8/11/26 during morning report she and other staff were informed that they needed to make room changes to create open beds to accommodate 6 residents being evacuated from a local nursing home. She indicated they were informed they needed to make those room changes that day as quickly as possible and were told, All hands on deck., so the staff immediately looked at which rooms had open (unassigned/vacant) beds and it was mostly the 4-bed rooms. She indicated because of the new public act preventing admission into the 4-bed rooms they needed to make internal transfers into those rooms to empty some of the semi-private 2-bed rooms for the evacuated residents and so she and the other social workers began to decide which residents could be moved quickest and spoke to those residents and/or sent emails to their responsible party to request consent for the room change. SW #2 stated that she was unable to move transferred residents into the 4-bed room as they were considered new residents to the facility. She identified that each resident moved was a voluntary move, that they were told the move needed to happen that day as soon as possible and was for an emergency to due to an evacuation of another facility. She indicated at the time of the move none of the residents moved on were offered a return to their rooms after the evacuated residents returned to their original facility. Additionally, she stated that no residents from the evacuated nursing home ended up coming to their facility and there was no process for providing written notification of the room change when it was done quickly as occurred on 8/11/26 and that none of the residents were provided with written notice. She confirmed that Resident #59's room change was quick and that he/she was fully moved within 10-20 minutes of being informed the room change was needed. Re-interview with the Administrator on 8/27/26 at 3:30 PM identified that on 8/11/26 she had received a call from the corporate office saying a local nursing home had contacted them about needing room for some of their residents related to an emergency evacuation and so the facility notified residents, called conservators to obtain consent to make moves, and showed residents their new rooms. She indicated about 5 or 6 residents had been moved to make room for the incoming residents. She stated about a week later no one had come and then they received a call to confirm that no one was coming even though they had made the rooms available for the evacuated residents. She identified that they had met with each resident following their room changes on 8/11/26 and since none of the residents reported any complaints or requested to return back to their previous rooms they were left in the 4-bed rooms. Additionally, she indicated that the facility had not provided the residents and/or their responsible parties with written notice of the room changes because they were voluntary room changes that were needed for an emergency and so written notice wasn't required. The Administrator was unable to identify if it was common practice for the facility to move their own residents out of their room(s), which were their homes to make room for outside residents to be admitted to the facility even when there was not an internal facility emergency which threatened their safety. She indicated that the Ombudsman and 1 family member had reported complaints regarding the room changes into the 4-bed rooms. She further indicated that she was not sure if the roommates in the 4-bed rooms had been followed up with after the room changes to ensure they didn't have any concerns related to the room changes and/or their new roommate(s). Although the Administrator reviewed the facility policy, she indicated that since the move was an emergency she did not need to provide any written notices. Interview with the Administrator on 8/31/26 at 12:05 PM identified the facility moved internal residents for emergency admissions from another skilled nursing facility. The Administrator stated that all residents whose rooms were moved were given a choice before they were moved and she disagreed with Resident #89 and Resident #93 stating they were given no choice. The Administrator indicated that when the facility did not receive the emergency admissions, the internal residents were not offered the chance to return to their previous rooms because the room changes were a permanent move, not a temporary move. The Administrator stated she did not know if Resident #89 and Resident #93 were told it was a permanent move and to follow up with social services. The Administrator identified that the new emergency admissions could not be admitted into 4 person rooms. Interview with the Director of Nursing (DNS) on 8/31/26 at 12:20 PM identified in response to Connecticut Public Act No. 24-141 after 7/1/26 they were no longer able to admit new residents into their 4-bed rooms, so the facility was in the process of performing room changes to move in-house residents into the long-term 4-bed rooms. She indicated on 8/11/26 room changes were needed to accommodate the residents coming into the facility from another facility and so they moved their in-house residents into their open long-term beds. She indicated she was not involved with the conversations with the residents and/or their responsible parties on 8/11/26, but they should have been informed that although a room change was requested, they had the option to refuse the room change. Interview with the Person #3 on 8/31/26 at 1:51 PM identified he/she was informed that multiple residents had room changes on 8/11/26 that resulted in them being placed into 4-bed rooms. After speaking with several moved residents, he/she was told that their rooms were changed on the same day they were notified that they needed to change their rooms due to an emergency. He/she indicated that Resident #89 had told him/her initially after the room change that they wanted to go back to their original room but now stated that it doesn't matter because they would be going home soon. Additionally, he/she indicated that Resident #93 wanted to go back to their previous room, but it hadn't been offered as an option. Person #3 indicated he/she had spoken to the Administrator about why the residents were moved out of their rooms and into the 4-bed rooms, and the Administrator had indicated a local nursing home needed to send some evacuated residents and so the facility had to make moves to accommodate those residents. Person #3 indicated the Administrator did not provide a reason why the residents were not returned to their original rooms when none of the evacuated residents admitted to the facility. Interview with SW#1 on 8/31/26 at 2:00 PM identified Resident #89 and Resident #93 were given about a 2 hour verbal notice before the room changes occurred. SW #1 indicated the facility was trying to move the least amount of residents as possible and did not provide an explanation why Resident #89 and Resident #93 stated that they were not given a choice on their room changes. SW #1 indicated she wrote on the Change of Room or Roommate evaluation the change was to provide accommodations for other residents of the same gender because it was the only option that seemed appropriate. SW #1 stated the Administrator informed her the room changes were for emergency admission purposes but was never made aware the room changes were permanent room. SW #1 stated the Administrator and Corporate Office were holding the 2-bed rooms open in case the emergency admits from evacuated building ended up being admitted and was unaware if the facility received any of those displaced residents. SW #1 stated the open beds from the semi-private room changes were held for about a 6 to 7 day period before the facility started to admit new, nonemergent residents into the semi-private beds. During the 6-7 day bed hold period, SW#1 stated she was not aware if Resident #89 and Resident #93 were offered to return back to the semi-private rooms. Review of the Resident Rights and Responsibilities policy directed, in part, the facility will protect the rights of each resident, and the Social Services Department will promote, protect, and provide education on the rights of facility residents. Review of the Nursing Facility Resident's [NAME] of Rights identified, in part, residents of a nursing facility have rights under federal and state law which include: the right to treat their living quarters as their home; the right to notice before their roommate is changed; and 15 days written notice must be provided for an involuntary room change, unless the room change is for nonemergency repairs or eligibility for Medicaid assistance in which case a 30 day notice is required. No advance notice is required in an emergency in which there is risk of danger or harm to residents requiring an immediate move Review of the Resident Room Changes-Connecticut policy, dated 7/14/26, directed, in part, a resident may be transferred from one room to another within the facility only to promote the resident's well-being or for reasons defined by Connecticut statutes. The policy directed for a voluntary room change; residents have the right to request room changes which will be accommodated if an appropriate room is available. For an involuntary room change, residents may be transferred to another room without their consent for the following reasons: the move is necessary for physical plant repairs that could otherwise not be accomplished, and the resident may return to the room when repairs are completed if they choose to; the move is necessary due to irreconcilable differences between roommates which is or can be harmful to the well-being of a resident; the move is necessary when there are 2 vacancies available in separate rooms for residents of the same sex with no expected admission(s) of that sex and so those residents are moved together to create an open room to admit a resident of the opposite sex; the move is necessary to allow access to specialized medical equipment no longer being used by the resident and needed by another resident; and the move is necessary due to the resident no longer needing the specialized services/programming provided in that area of the facility. The policy directed the facility will ensure room changes affect the least disruption to the resident, and the resident will be monitored after the room change, and the resident/responsible party will be notified in writing before or as soon as possible following an urgent room change. The policy directed a resident may be involuntarily moved immediately from one room to another for the following reasons: to protect the resident from physical

Based on clinical record review, staff interviews, and facility documentation review for two of three residents (Resident #2, Resident #3) review for abuse, the facility failed to ensure the residents were free from abuse. Residents #2 and #3 had a physical altercation, resulting in both residents with injuries to their faces, and were transferred to the hospital for treatment. The finding includes: 1. a. Resident #2 had a diagnosis of malignant neoplasm of the brain, bipolar disorder, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 indictive of an intact cognition and was independent with mobility and had no behaviors. The Resident Care Plan (RCP) dated 10/15/2024 identified Resident #2 had the potential for verbal aggression and accusatory behaviors and ambulated independently. Interventions directed to monitor for accusatory behavior and offer tasks to minimize disruptive behavior. Record review identified no physician orders for behavior monitoring. b. Resident #3 had a diagnosis of dementia, bipolar disorder, and unspecified mood disorder. The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of 12 indicating moderately impaired cognition, was dependent for mobility, independent with wheelchair mobility, and no had behaviors in the prior seven (7) days. The RCP dated 9/12/2024 identified Resident #3 had dementia. Interventions directed to keep call light within reach and to anticipate and meet the resident's needs. Record review identified no prior aggressive behaviors. Review of the facility incident report dated 10/29/2024 at 9:30 AM identified Residents #2 and #3 had a verbal disagreement followed by a physical altercation. Resident #3 alleged he/she was hit by Resident #2. Resident #2 admitted he/she had hit Resident #3 and stated Resident #3 also hit him/her. Resident #3 was noted to have laceration to the left eyebrow, redness to the left eye and nose swelling. Resident #2 was noted to have redness to her/his right cheek, a 0.5-centimeter (cm) scratch to the right cheek, and a 0.5 cm scratch to the left cheek. Both residents were transferred to the hospital for further evaluation. The report further indicated Resident #3 was identified to have an acute nasal fracture. Facility incident summary dated 11/3/2024 identified Resident #3 entered Resident #2's room and requested Resident #2 pay back $7 that had been borrowed. Resident #2 stated he/she did not have the cash, but would get it, and Resident #3 then hit Resident #2 twice in the face. Resident #2 then hit Resident #3. Hospital emergency department summary CT scan results dated 10/29/2024 identified Resident #3 had an acute, minimally displaced bilateral nasal bone and anterior maxillary spine (upper jaw) fractures. Interview with NA #1 on 10/31/2024 at 2:27 PM identified on 10/29/2024 Resident #2 reported that Resident #3 had entered his/her room asking for $7 to be repaid, and that Resident #3 hit him/her, and Resident #2 responded to defend him/herself. Interview with RN #1 on 10/31/24 at 2:38 PM identified she responded to the unit around 9:30 PM for the altercation between Residents #2 and #3. Resident #2 reported that Resident #3 came into his/her room demanding $7 that was owed to him/her. Resident #2 had a cut on the right cheek, redness on the right cheek, left eye, nose, and on the neck. Resident #3 had blood on his/her face and shirt and a bandage was placed on Resident #3's forehead and both residents were transferred to the hospital for evaluation. Interview and record review with the DNS on 10/31/24 at 3:31 PM identified Residents #2 and 3 were friends prior to the incident, and the incident was over $7 that was owed to Resident #3. Resident #2 had told Resident #3 he/she would have the money the next day and Resident #3 called Resident #2 a liar, stood up and punched Resident #2 twice in the face. Resident #2 indicated he/she then pushed Resident #3 back into his/her chair and punched him/her in the head three (3) times to defend him/herself. The DNS stated although Resident #3 refused to talk about the incident, the allegation of abuse was substantiated. After the incident, Resident #3 wanted to see Resident #2 to say he/she wanted to apologize for the incident. Review of facility Abuse policy dated 3/20/2024 identified residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident.

Based on clinical record review, observation, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #28) reviewed for abuse, the facility failed to ensure a resident was free from physical injury by another resident (Resident #133). The findings include: Resident #28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 was responsible for self. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was without cognitive impairment and required physical assist of one with ambulation on and off the unit with wheelchair support. The care plan dated 3/31/22 identified Resident #28 had a concern with Activities of Daily Living (ADL) and fracture of pelvis and sacrum. Interventions included: Occupational Therapy (OT) Physical Therapy /(PT) as ordered, weight bearing as tolerated and toe touch weight bearing to right lower extremity and noted independence in the bedroom with the use of a rolling walker. The nursing progress note dated 4/24/22 at 9:40 PM identified at 3:50 PM the charge nurse was called to the basement for a resident-to-resident altercation. Observation identified Resident # 28 in the hallway bleeding from the mouth, bridge of the nose and arms. Resident # 28 was upset and reported s/he was attacked on the elevator by Resident # 133 as s/he was attempting to get off the elevator for a smoke break. Resident # 28 stated his/her wheelchair got stuck in the elevator and Resident # 133 became upset and started punching her/him in the face and head. Lacerations were noted on Resident # 28's bridge of the nose, chest, and bilateral arms. Following the smoke break, Resident #28 was transferred to an acute care hospital for further evaluation. Resident #133 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment dated [DATE] identified Resident #133 had a severe mental illness, severe cognitive impairment and was independent with ambulation on and off the unit. The care plan dated 3/8/22 identified Resident #133 had a concern related to behavior and a history of taking other residents belongings resulting in verbal and physical altercations. The care plan also noted a history of pushing/bumping through residents to get to the front of the line to smoke. Interventions included: monitoring the resident's status and directed staff to report changes, to provide verbal cues to not to push and to maintain distances from others through staff supervision. The Reportable Event dated 4/24/22 at 4:16 PM identified Resident #28 was involved in a resident-to-resident altercation where Resident #28 reported s/he was assaulted by another resident (Resident #133). Resident #28 reported s/he was attempting to exit the elevator to go to the designated smoking area for smoking time at which time s/he became stuck at threshold. The aggressor, (Resident #133) became impatient. Resident # 28 reported s/he was hit in the face, scratched on both arms, sustained a laceration to the bridge of the nose, chest, and arms. The facility Advanced Practice Registered Nurse (APRN), family and police were notified, and an investigation was initiated. Resident #28 was transferred to the Emergency Department (ED) for further evaluation and was noted to have superficial injuries to the nose and chest. Resident # 28 returned to the facility on [DATE]. Resident #133 was also transferred to the ED for evaluation following the incident. The APRN progress note dated 4/26/22 noted Resident #28 had an altercation with another resident and had a scratch mark on the left cheek with no other injury. Resident # 28 was transferred to an outside hospital where a Computed Tomography (CT) scan of the chest, abdomen and pelvis were performed and identified unremarkable for acute process then transferred back to the extended care facility. Resident # 28 and Resident # 133 care plans were revised on 4/24/22 to include psychiatric and social work support. Resident #28 and Resident #133 were to have opposite smoke times. Resident #28 was offered a room change. Resident #133 was placed on 1:1 supervision until seen by psychiatry. The Alternate Community Living Center report dated 5/11/22 identified Resident #133 was being referred to alternate community placement secondary to a recent altercation where s/he was the aggressor and punched a peer (Resident #28) in the face, chest and scratched arms and that jewelry on his/ her hands were considered a weapon, therefore requiring removal. The report also noted Resident # 133 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 6/15/22 at 10:29 AM with Resident #28 identified the incident occurred when both s/he and Resident # 133 were getting off the elevator in the basement region to smoke. There were no other residents or staff around at the time of the incident. Resident #28 reported while s/he was exiting the elevator s/he had trouble crossing the threshold with her/his wheelchair. Resident #133 started yelling at Resident #28 and hitting her/him. Resident #28 screamed for help and other residents came to pull Resident #28 off Resident #133. Staff arrived and brought Resident #28 upstairs. Resident #28 reported s/he was sent to the emergency department (ED) for evaluation. The shift Nursing Supervisor staff told her/him Resident # 133 was also sent out to the ED for an evaluation and would not be returning but s/he observed Resident #133 did return to the unit the following day. Resident # 133 was placed on one-to-one supervision which lasted a couple of days causing her/him to feel fearful. Resident # 28 indicated staff told her/ him s/he (Resident # 28) and Resident #133 would have separate smoke times and offered her/him (Resident #28) a room change. Resident # 28 declined the room change and felt penalized even though s/he was the victim. Resident #28 spoke to the DNS and Social Worker (SW #1) about his/her concerns and was told this was (Resident #133's) home and that Resident #133 did not have the capacity to understand what s/he did. Resident #28 indicated the event had been traumatizing for him/her. An interview on 6/15/22 at 1:45 PM with SW#1 and corporate [NAME] President of Operations identified SW #1 met with Resident #133 following the incident who was sent to the hospital for further evaluation and placed on a 1:1 supervision. Resident #133 was evaluated by psychiatry, cleared, and placed on every 15 minute checks, separate smoke times and a referral was sent to an outside community agency for possible placement. Resident #133 was evaluated and deemed at appropriate level of care. SW #1 indicated Resident #133 would at times push his/her way to the front of the line to smoke, but not in a malicious manner and indicated the resident had no history of violence towards others. An interview on 6/24/22 at 2:04 PM with the Medical Director identified the behavior was not usual for Resident #133 and indicated his expectation would the facility ensure that a resident was free from any mistreatment. A subsequent interview and clinical record review on 7/12/22 8:47 AM with SW #1 identified Resident #133 baseline behaviors included mumbling, talking about unrealistic events, delusional, would lay on the floor in the basement and stayed in bed. When provoked, Resident #133 would talk loudly and, if observing others wearing jewelry, would make false accusations and state items were his/hers. Resident #133 was also known to squeeze her/his way through residents but not in a malicious manner. SW #1 stated that although she indicated Resident #133 had no previous aggressive behaviors, she documented Resident #133 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 7/12/22 at 9:41 AM with NA # 2 identified she was working the second shift on the unit where both residents previously resided on the day of the incident. NA # 2 stated she heard screaming and went downstairs to investigate. When NA # 2 arrived to the area, she observed both Resident #28 and Resident #133 outside the elevator in the basement with the nursing supervisor and other residents. NA # 2 observed bleeding to Resident #28's face. However, it was Resident #133 who reported to NA # 2 that Resident #28 had spit and thrown water at him/her which was the reason s/he hit Resident # 28. Resident #28 denied the allegations. NA #2 removed the other residents from the area while the residents were separated, and she/he believed the nursing supervisor brought Resident #28 upstairs. NA #2 indicated although she had not witnessed aggressive behavior by Resident #133, she had heard there was a history of aggressive behavior towards peers. Attempts to interview Nursing Supervisor were unsuccessful during the survey. The facility policy for Abuse in effect for 4/2022 directs a resident has the right to be free from abuse.

Based on clinical record reviews, facility documentation, facility policy and interviews for two of six resident's reviewed for accidents, (Resident #499 and Resident # 500), the facility failed to ensure that a resident was seated in the correct wheelchair and that staff was educated on how to maneuver a wheelchair on an even surface and failed to ensure that intervention were in place to supervise a resident who exhibited restless behaviors to prevent falls with major injuries. The findings included: 1. Resident # 499's diagnoses included a late effect [CONDITION(S)] ([CONDITION(S)]), acute on [CONDITION(S)] and bilateral carotid stenosis. A Re-Admission assessment dated [DATE] identified the resident was readmitted with a diagnosis of a right middle cerebral artery infarct due to an embolism with left sided weakness, was alert and responsive, required total care with Activities of Daily Living ( ADL) and indicated the resident was a high risk for falls. The care plan dated [DATE] identified a risk for falls related to a right sided [CONDITION(S)] with left sided weakness and noted the utilization of an Adaptive Wheelchair (AWC) due to impaired mobility. Interventions included to ensure proper positioning, and to assist the resident out of bed via Hoyer Lift with two staff assist to the AWC. The Occupational Therapy (OT) Evaluation dated [DATE] identified Resident #499 was referred for OT services following a hospital stay for an acute [CONDITION(S)]. The OT evaluation also noted Resident # 499 presents with a recent onset of left [CONDITION(S)], and left sided upper extremity flaccidity and noted the resident had poor sitting balance. A physician's order dated [DATE] directed to transfer the resident out of bed to an Adaptive Wheelchair (AWC), with a pelvic positioning belt and left arm pad. The Occupational Therapy Progress note dated [DATE] identified an assessment was conducted of Resident # 499's body alignment in the wheelchair, an assessment of the resident's current seating system for appropriate modifications and instruction in body alignment. The resident was assessed in an AWC with lateral support to improve upright positioning and adjusted head rest for comfort with good effect. A Reportable Event (RE) and investigation dated [DATE] identified Resident # 499 was transported to a medical appointment in a wheelchair by Nurse Aide (NA# 3) an escort. The Reportable Event and investigation further indicated as NA #3 and Resident #499 were exiting the medical office building, NA # 3 did not notice that the pavement was uneven, NA#3 turned the wheelchair to the left and Resident # 499's wheelchair tipped sideways causing the resident to fall onto his/her right side, striking his/her head. The resident was then transferred to the emergency room for an evaluation where a Computed Tomography (CT) scan of the head revealed a subarachnoid hemorrhage. Review of the facility fall scene investigation dated [DATE] identified the Root Cause of the fall was that the resident was status post [CONDITION(S)], poor trunk control, and uneven pavement. Following the incident an additional care plan intervention was added to ensure that the resident use his/her own wheelchair for appointments at all times. The emergency room (ER) record dated [DATE] identified Resident #499 was diagnosed with a subarachnoid hemorrhage after a mechanical fall. The hospital physician had a conversation with the Advanced Practice Registered Nurse (APRN) #1 at the skilled nursing facility regarding the resident's condition and indicated that APRN #1 understood that the subarachnoid hemorrhage could be a life threatening bleed. ER record dated [DATE] also indicated that a decision was made to transfer the resident back to the facility to receive a Hospice Evaluation. The progress note written by APRN #2 on [DATE] identified Resident #499 had suffered a fall hitting his/her head while out of the facility at a cardiology appointment. Resident # 499 was taken to the Emergency Department (ED) where he/she was diagnosed with a subarachnoid hemorrhage and his/her condition was deemed to be terminal by the Emergency Department (ED) physician. The Conservator of Estate / Person was contacted and the decision was made to provide comfort care and to obtain a Hospice Evaluation as ordered. Review of the clinical record identified that Resident # 499 expired on [DATE]. Review of the Death Certificate dated [DATE] signed by the Medical Director identified the cause of death as failure to thrive and subarachnoid hemorrhage. Interview with OT #1 on [DATE] at 1:39 P.M. identified Resident # 499 required the use of a tilt in space AWC because he/she would slide forward and lean to the left at times because of his/her poor trunk control due to the right sided [CONDITION(S)]. On [DATE] Resident #499 was provided with a tilt in space AWC that was adapted to his/her positioning needs which included a left sided lateral support, to prevent him/her from leaning to the left, a pelvic positioning belt, to prevent him/her from sliding forward, and a tilt in space feature to assist with positioning. OT #1 identified on [DATE] she went to the nursing unit around 10:00 A.M. and noticed Resident # 6 was seated in Resident #499's AWC. OT #1 further indicated she directed NA# 4 to take Resident #6 out of Resident #499's chair so Resident # 499 could be in his/her appropriate chair when it came time for therapy. OT #1 further identified NA#4 seemed a little resistive to the direction, and appeared that she/he (NA# 4) did not want to put the residents' in their appropriate chairs. OT #1 indicated he/she assumed that NA#4 would switch the chairs. When it came time for Resident #499's therapy, OT#1 was informed that the resident was going out for an appointment and was in another resident's chair. OT #1 identified that she went out to the wheelchair van that had arrived to pick up Resident #499 for the appointment, and noted that Resident #499 was in Resident # 501's AWC. OT #1 further stated that she identified that the resident was in the wrong AWC, although she assessed that Resident #501's chair had lateral supports, a pelvic positioning belt and a tilt in space feature and basically had all the same features as Resident #499's AWC. OT #1 informed NA#3 that the resident was not in the correct chair, and to watch for a left lateral lean, and to use the tilt in space feature, because she wanted NA#4 to keep an eye on the positioning, since the resident was not accustomed to this wheelchair as he/she was his/her own chair. Furthermore although OT #1 identified that although Resident #499 should have been in the AWC that was adapted to meet his/her positioning needs, Resident #501's AWC met all of Resident #499's positioning needs, and the resident then left for the doctor's appointment. Interview with NA#4 on [DATE] at 2:00 P.M. identified she had placed Resident #6 in Resident #499's wheelchair that morning because Resident #6's pad was still wet from being washed the night before. NA # 4 stated that OT#1 did ask her to take Resident #6 out of Resident #499's wheelchair, but thought OT #1 would come up and provide Resident #6 with another wheelchair. NA # 4 further indicated that when it was time to get Resident #499 out of bed she went into the shower room with NA#3 and found a wheelchair, which she stated that she remembered the chair to be standard wheelchair with a seat belt, and placed Resident #499 in the chair, then asked the supervisor, Registered Nurse (RN) # 2 if it was ok to send the resident in that chair, and indicated they were told it was OK. Attempts to contact RN #2 were unsuccessful. Interview with NA#3 on [DATE] at 12:30 P.M. identified that she came to the facility 15 minutes early on [DATE] to take Resident #499 to the medical appointment, she identified the resident was already in an adaptive, tilt in space wheelchair when she arrived at the facility. OT #1 came onto the van before the van left and told her that Resident # 499 was in the wrong wheelchair. OT #1 tried to adjust the resident in the wheelchair, and shifted the wheelchair a little. NA#3 also indicated that OT #1 did not tell her to watch for the resident's left sided lean or to use the tilt in space feature if the resident was leaning. NA#3 stated that throughout the appointment the residents positioning was poor, and he/she was leaning to the left side therefore she reclined the tilt in space wheelchair as far as it could go back. After the appointment, the wheelchair van called her and told her that they were in the back of the building waiting to pick the resident up. NA#3 identified she went to the back of the building, and although at that time the resident was still leaning towards the left in the chair, and the AWC was fully reclined, she proceeded to exit the building, (a person held the door so she could exit). NA# 3 identified she exited the building with the resident's feet first, and as soon as she exited the building, she hit a threshold and uneven pavement (that she was unable to see because the wheelchair was fully reclined), and attempted to turn left and the wheelchair tipped to the right, and Resident # 499 fell to the ground. She then summoned for help and the resident was sent to the ED. NA#3 stated that after the incident she was educated on ensuring that the resident was in the correct chair prior to a doctor's appointment and safe wheelchair maneuvering. Observation on [DATE] at 4:00 P.M. of the medical office back entrance, identified that the doors to exit were manual, and to exit from the building to the sidewalk there was a threshold, and once you exit the building there was a slight downward pitch to the pavement. Approximately 30 feet to the right of the exit door was a handicapped accessible ramp. Further interview with NA#3 on [DATE] at 12:00 P.M. identified she was not educated regarding the proper position of an AWC if the wheelchair encountered an uneven surface or a surface that is considered a decline that the wheelchair should be turned around, and taken through the doorway backwards. NA#3 further identified that she should have repositioned the resident (who was leaning to the left) prior to moving the wheelchair following the medical appointment to ensure proper positioning. NA #3 was not able to explain how Resident #499 who was in an ACW, leaning to the left tipped over landing on his/her right side. Further interview with OT#1 on [DATE] at 11:30 A.M. identified that a tilt in space wheelchair can be moved when it is reclined, but should not be maneuvered fully reclined because it would make for an awkward transport. OT #1 further stated that if the resident was leaning to the left, he/she should have been repositioned before NA #3 attempted to maneuver the wheelchair, and additionally indicated NA # 3 should have turned the wheelchair backwards to allow for better control of the wheelchair while exiting the building. Interview with the Director of Nurses on [DATE] at 10:30 A.M. identified it is the responsibility of the nurse aides to ensure that Resident #499 was in the correct chair prior to the transport to the physician's office, although the AWC that the resident was transported in met all of Resident #499's positioning needs. The DON further indicated that if the resident was leaning, NA#3 should have repositioned the resident prior to maneuvering the wheelchair. The DON stated that the cause of the fall was NA#3's inability to turn the wheelchair with the uneven pavement, which caused the wheelchair to become off balance. The DNS also indicated that NA#3 may not have seen the uneven surface because of the leg rests on the wheelchair. Interview with the Medical Director on [DATE] at 1:45 P.M. identified that it would be her expectation that if a wheelchair was adapted to meet a resident's positioning needs that the resident be placed in that wheelchair only. The Medical Director further identified that the cause of the Resident #499's death was a failure to thrive which was caused by the subarachnoid hemorrhage sustained in the fall. Review of NA#3's employee file identified that a Job Performance Corrective Action form dated [DATE] identified that NA#3 did not use proper body mechanics when maneuvering the wheelchair over the curb, this action resulted in the wheelchair tipping over and the patient landing face first onto the pavement causing serious injuries, employees are expected to use proper body mechanics and take safety precautions when caring for patients. Subsequent to the incident on [DATE] all staff were educated on ensuring that a resident is in the proper adaptive and or customized wheelchair prior to being transported to a medical appointment, and safe wheelchair maneuvering that included when a hill or incline is encountered to turn the wheelchair around and back down carefully, and to be observant of any curbs, cracks or crevices in the pavement. Audits were also conducted of residents who were in AWC, prior to doctor's appointments. The facility stated that they did not have a policy on AWC. 2. Resident #500 was admitted to the facility on [DATE] with diagnoses that included dementia, a left sided [CONDITION(S)], and [CONDITION(S)] syndrome. An admission assessment dated [DATE] identified that the resident had severely impaired vision, was alert and confused, required assistance with ADL, including transfer, and mobility. Review of a Fall Risk Scale dated [DATE] identified that the resident was at high fall risk. The behavior section of the fall risk assessment identified that the resident had agitation, restiveness to care, poor judgement, poor cognition, and combativeness. A fall care plan dated [DATE] identified that the resident was at risk for falls related to [CONDITION(S)] with interventions that included to apply gripper socks and education on call bell use. The physician's orders dated [DATE] directed to administer [MEDICATION(S)] 25 (Anti-psychotic) Milligrams (MG) twice a day as needed for agitation, and to transfer and ambulate the resident with assist of one person. The Reportable Event (RE) form dated [DATE] identified that the resident had an unwitnessed fall and was noted on the floor next to the bed with his/her gripper socks on, positive range of motion to the bilateral upper and lower extremities, and no injuries identified. Review of the investigation identified that prior to the fall Resident #500 was confused and yelling out. The investigation further identified in NA#7's statement regarding the fall identified behaviors during the shift that could have contributed the fall which included the resident trying to get up multiple times. The [DATE] Medication Administration Record (MAR) identified that Licensed Practical Nurse (LPN) #4 had signed off that she had medicated the resident with as needed [MEDICATION(S)] on [DATE] (the documentation lacked what time the medication was administered). A RE form dated [DATE] identified that the resident had an injury of unknown origin, with the injury identified as a right displaced closed [CONDITION(S)]. Review of a summary report dated [DATE] identified that after an investigation it was determined that the right [CONDITION(S)] is likely due to the fall on [DATE]. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 9:01 A.M. identified that she was Resident # 500 charge nurse on [DATE] when the fall occurred. LPN # 4 further identified that during the morning medication pass the resident was agitated and repeatedly standing up from his/her wheelchair. She further indicated that although she/he recalled medicating the resident with [MEDICATION(S)], she could not recall if it was during the morning medication pass, and could not remember if the medication was effective. LPN # 4 also indicated that although she was aware of the resident's behavior, she could not recall if she had notified the supervisor. LPN#4 further stated that after the fall the staff placed the resident at the nurse's station, where the resident continued to stand from the wheelchair. Interview with NA #7 on [DATE] at 12:00 P.M. identified that Resident #500 was very impulsive, and was attempting to stand all morning prior to the fall, and was non-compliant with requests for him/her to sit down once found standing. NA#7 stated that during the lunch time meal the resident continued to attempt to stand from the wheelchair. After lunch NA#7 brought Resident # 500 to his/her room, and although the resident continue to yell out and attempt to stand, he/she (NA# 7) left the resident unattended in his/her room. He further stated that he could not recall if he had informed the charge nurse of the resident's behavior once Resident # 500 was in the room. NA # 7 also indicated after leaving the resident in the room unattended he/she then left the floor for a few minutes, and when he returned he was informed Resident # 500 was found on the floor. Attempts to contact RN#2 who was supervising on the day of the fall were unsuccessful. Interview with the Director of Nurses (DON) on [DATE] at 2:15 P.M. identified that it would be her expectation that if staff observe a resident continually standing up from the wheelchair and was unable to be redirected that the staff move the resident to a more visible area. The DON further identified that the fall on [DATE] was most likely the cause of the right [CONDITION(S)] identified on [DATE]. The facility failed to implement additional interventions when Resident #500 exhibited attempts to stand without assistance. Review of the fall policy identified that the facility will maintain a safe environment in order to minimize falls and injuries related to falls, and a fall management plan will be initiated for residents who are at high risk for falls.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for 3 of 6 residents reviewed for skin conditions (Resident #73, 103, and 181) and/or for 2 of 5 residents reviewed for specialized services (Resident #47 and 109), the facility failed to assess and monitor skin conditions weekly and/or obtain treatments and/or failed to monitor intake and output on residents on a fluid restriction. The findings include: 1. Resident #47's [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] identified Resident #47 had intact cognition, required limited assistance with care, received a therapeutic diet, and was receiving [MEDICAL TREATMENT]. A care plan dated 7/31/17 identified Resident #47 was at risk for dehydration due being on a fluid restriction. Additionally, the care plan identified Resident #47 was non-compliant with the fluid restrictions. The care plan further identified to follow diet and fluid restrictions as ordered and to observe intake and output. Physician's orders dated 8/2/17 directed Resident #47 be on a fluid restriction of 1000ml/24hrs (500ml dietary and 500ml nursing). Review of the resident care card identified Resident #47 was on a fluid restriction of 1000ml/24hr, 500ml/24hrs from nursing, and 500ml/24hr from dietary. Review of the clinical record and facility documentation on 9/26/17 failed to reflect that Resident #47's intake and output was monitored per the physician's order. Interview on 9/26/17 at 2:00 PM with LPN #5 identified that although Resident #47 was on a 1000ml/24hr fluid restriction, the nursing staff were no longer required to monitor and/or document daily on intake and output, and were told that they are to just observe for compliance. Interview with the Corporate Nurse #1 & #3 on 9/26/17 at 2:45 PM identified that residents on fluid restrictions should be on daily intake and output in order to monitor and evaluate for compliance with fluid restriction orders. 2. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission care plan dated 7/28/17 identified an open area to the coccyx with interventions that included treatment as ordered, monitor for signs and symptoms of infection, provide a low air loss mattress and pressure reducing cushion, incontinent care as needed, and reposition every 2 hours and as needed. The resident admission profile dated 7/28/17 identified Resident #73 was incontinent of bowel and bladder and had several alterations in skin integrity, including an excoriation to the coccyx. Review of the physician's orders dated 7/28/17 directed staff to apply Med cap/tab Citric Acid skin paste to buttock wound twice daily. An admission MDS dated [DATE] identified Resident #73 had severely impaired cognitive skills, required extensive assistance of two for bed mobility, transfers, and toilet use, was frequently incontinent of bowel and bladder, and was without the presence of any non-pressure wound or skin problems. Review of the clinical record and facility documentation with Corporate Nurse #2 on 9/29/17 at 11:00 AM failed to reflect that the treatment to the buttock wound was administered according to physician's orders on 7/28, 7/29, 7/30 and 7/31/17. Review of facility documentation and clinical record failed to identify than an assessment was completed on the buttock area until 8/15/17 when Resident #73 was seen and examined by MD #1. Interview with the Infection Control Nurse, (RN #1) on 9/29/17 at 11:30 AM identified that he/she did not complete any documentation on Resident #73's buttocks, including measurements and/or descriptions of the area between 7/28/17 and 8/15/17 when she/he completed rounds with MD #1. Further interview with RN #1 identified that he/she had MD #1 see Resident #73 during his/her weekly wound rounds because he/she heard during morning report on 8/15/17 that Resident #73's excoriation on buttocks had worsened. Further interview with RN #1 identified that he/she should have been assessing, documenting, and tracking the area on Resident #73's buttocks weekly on the non-pressure wound report. 3. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #103 was without cognitive impairment and required extensive assistance with bed mobility, transfer and toilet use, and required applications of ointments and/or medications other than to feet. Wound assessment report dated 7/11/17 identified a skin tear to the right lateral shin that measured 8cm by 4cm with no drainage, no infection, no pain, edges not well approximated, and missing torn skin flap. The area was identified on 7/5/17. A physician's order dated 7/12/17 directed to apply skin prep (protective barrier wipe) daily for 14 days to right shin wound. Interview and clinical record review with RN #1 on 9/29/17 at 2:30 PM failed to reflect documentation that an assessment of the skin tear to right lateral shin was conducted on 7/5/17 when the wound was identified. Further review of clinical record identified that a treatment order for the skin tear to right lateral shin was obtained on 7/12/17, however failed to reflect documentation that treatment order was obtained when skin tear was identified on 7/5/17 until 7/12/17 (7 days later). 4. Resident #109 had [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that Resident #109 had intact cognition, required supervision with ADL's, was non-ambulatory, was on a therapeutic diet, and was receiving [MEDICAL TREATMENT]. A Care Plan dated 8/28/17 identified that Resident #109 was receiving [MEDICAL TREATMENT], had a history of [REDACTED]. Further review of the care plan identified that Resident #109 had a history non-compliance with [MEDICAL TREATMENT] and fluid restriction and staff was instructed to monitor his/her Intake & Ooutput. A physician's order dated 9/21/17 identified Resident #109 was on a fluid restriction of 1200ML/24hrs. Review of the clinical record and facility documentation on 9/29/17 failed to reflect that intake and output was being monitored per physician's orders for resident's 1200ml/24hr fluid restriction. Interview with Corporate Nurse #1 & #3 on 9/29/17 at 2:45PM identified that residents on fluid restrictions should be on daily intake and output in order to monitor and evaluate for compliance with fluid restriction orders. Review of the facility policy and procedure for [MEDICAL TREATMENT] residents included fluid restrictions as ordered by physician and to maintain fluid intake and output. 5. Resident #181 was admitted on [DATE] with [DIAGNOSES REDACTED]. Discharge summary dated 7/25/17 identified Resident #181 had excoriation to left calf measuring 2.7 cm by 2 cm. Resident admission profile dated 7/25/17 identified Resident #181 had a pressure injury to left calf with serous drainage and odor, however was unable to stage or size the wound due to cast. A physician's order dated 7/26/17 directed skin prep (protective barrier wipe) daily and as needed for 14 days to left calf excoriation. The care plan dated 7/26/17 identified excoriation to left calf. Interventions directed treatment as ordered, record, and/or report any concerns or changes to physician. A physician's order dated 8/10/17 directed skin prep (protective barrier wipe) twice daily for 14 days to left calf. A podiatry note dated 8/25/17 identified that there were no open skin wounds. A physician's order dated 9/26/17 directed to clean bilateral lower extremities with normal saline, pat dry, apply clean dry dressing to wounds until evaluated by Infection Control Nurse. A physician's order dated 9/27/17 directed to clean bilateral lower extremities with normal saline, apply [MEDICATION NAME] extra wound dressing cutting to fit wound bed, apply dressing to cover wound of left and right posterior calf daily and as needed for 14 days. Interview with RN #1 on 09/26/2017 at 10:42 AM identified that he/she did not assess the wound to left calf because Resident #181 was followed by podiatry. Interview and clinical record review with corporate RN #1 on 9/29/17 at 2:30 PM, failed to reflect documentation that an assessment of excoriation to left calf was conducted weekly. Review of the facility's policy and procedure for wound documentation identified that the nurse will initiate a weekly wound flow sheet (pressure or non-pressure) for each wound. Weekly wound assessments will be performed and documented until healed which will include the following: type of wound, staging or classification, correct anatomical position, measurements in centimeters including depth, wound base tissue, drainage, odor, tunneling/undermining, wound edges, periwound, pain scale and treatment.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #43) who had a fall with injury, the facility failed to follow the plan of care and ensure the appropriate number of staff assisted with bed mobility. The findings include: Resident #43's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #43 had moderate cognitive impairment, required cues and supervision, extensive one person assistance for bed mobility, had history of falls, was non-ambulatory, had functional limitations in range of motion to both of the lower extremities and received an anticoagulant medication daily. The resident care plan dated 6/29/15 identified the resident had limited mobility related to obesity, and a history of falls. Interventions directed two (2) half side rails to assist with bed mobility and ensure that two (2) people assist with bed mobility. A physician's orders [REDACTED]. The nurse's note dated 8/15/15 at 8:30 PM identified the Registered Nurse (RN) Supervisor was called to Resident #43's room by staff. Resident #43 was noted lying on the floor at the bedside. The note indicated Resident #43 was conscious but lethargic and was unable to state the cause of the fall out of bed. The nurse's note identified that the Nurse Aide (NA) stated she was providing care when the resident rolled off the side of the bed and fell to the floor. Resident #43 was noted to have a skin tear to the right breast and left groin. When the resident was assessed by the Emergency Medical Service severe bruising was noted across Resident #43's upper chest. The resident was transferred to the hospital for treatment. The hospital discharge summary dated 8/20/15 identified Resident #43 had a fall and sustained a chest hematoma that measured 10 centimeters (cm) by 10 cm, injury to the left internal mammary artery and left clavicular fracture. The Reportable Event Form dated 8/15/15 at 8:30 PM identified Resident #43 fell out of bed while being providing care. The investigation identified that NA #1 had provided care and assisted the resident with bed mobility without a second person present. The documentation indicated that although NA #1 had looked at the resident's care card and saw the resident was an assist of one person for grooming she failed to look to see the number of staff that was required for bed mobility. The nurse's note dated 8/31/15 at 2:45 PM identified increased bleeding was noted to the site of the hematoma. Subsequent to physician notification Resident #43 was transferred to the hospital. Interview with Licensed Practical Nurse (LPN) #1 on 9/1/15 at 11:20 AM identified that NA #1 came to her and stated Resident #43 was on the floor. LPN #1 stated she entered the room saw the resident lying on the floor and called for the supervisor. LPN #1 identified that she spoke to NA #1 after the resident was sent to the hospital and NA #1 told her that she was assisting the resident alone with his/her bed mobility. Interview with the Director of Nursing (DON) on 9/1/15 at 2:00 PM identified that NA #1 did not follow the resident's plan of care with bed mobility and the resident rolled out of bed. The DON stated that NA #1 was suspended for five days. The DON stated that after the 8/15/15 fall Resident #43's bed was changed to include four (4) side rails. Several attempts were made to interview NA #1 and Registered Nurse (RN) Supervisor, neither returned the call.

Based on clinical record review and interviews for one of one sampled resident reviewed for an allegation of physical abuse, (R#1), the facility failed to protect the resident from physical abuse. The findings include: Resident #1's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as alert and requiring supervision for all ADL's. A RCP dated 7/29/13 identified the resident becomes angry when asked not to remove garbage/soiled linen. Interventions included to educate the resident on infection control and reinforce, approach in a calm non-disciplinary manner and allow resident to perform tasks not involved in soiled items. A nurse's note dated 9/07/13 at 3:10 PM identified that the resident claimed that a worker hit him while trying to retrieve cans in the trash. The resident was noted to have a small bruise to the left neck measuring 1.0 cm by 1.0 cm and left shoulder 0.5 cm by 1.0 cm by 3.5 cm, a small scrape on the back of the left arm and left hip bruise. Offers to be transferred to the ED to be evaluated were declined by the resident and police were notified. A RE dated 9/7/13 at 2:13 PM identified that R#1 reported to the supervisor that a staff member attempted to hit him several times while in the basement. The staff member was removed from duty pending investigation, the allegation was substantiated and the staff member terminated. A body audit was completed and a bruise to the left side of neck and shoulder were noted, with a skin scrape to the back of the left arm and left hip bruise. Review of R#1's statement dated 9/7/13 identified he/she was downstairs in the laundry area, picked up the garbage cover and tried to pick up 2 cans, when Person #4 approached him/her and said "no." Person # 1 indicated they both went back and forth, placing the cover on and then taking the cover off the garbage can. R#1 indicated person #4 started pushing him/her and R#1 spit in Person #1's face and called Person #1 a "nigger". R#1 indicated he/she then flipped the housekeeping bin onto it's side and Person #4 took the "wet sign" and hit him/her with it three times. Review of Person #1's statement dated 9/7/13 identified that when he was coming down the stairs to the basement lounge and headed to the patio, he heard a loud noise, turned around to see a large box on the floor near R#1. Person #1 indicated she suddenly saw Person #4 coming out of the side and into view. R#1 then took out a towel/bib and threw it at Person #4's face. Person #4 then picked up a plastic bin and threw it at R#1 hitting him/her several times. Review of Person #4's statement dated 9/7/13 identified that when he was finished emptying the trash in the basement, he noticed R#1 looking for bottles in the trash. Person #4 informed the resident that he could not stay and so R#1 started calling him "nigger" and spat in his face. R#1 then threw over the housekeeping bin, cursing and calling him "nigger". Person # 4 indicated that he pushed R#1 because he/she was in Person #4's face. Interview with the Administrator on 9/07/13 at 10:30 AM identified that after the investigation was concluded, the allegation of physical abuse was substantiated and Person #4 was terminated. Review of the facility's abuse policy identifies physical abuse as hitting, slapping, pinching, kicking, etc. Attempts to interview Person #1 and Person #4 on 10/07/13 were unsuccessful.

Based on clinical record reviews, observations and staff interviews for 2 (R#2, R#3) of 3 residents reviewed for provision of a safe environment, the facility failed to provide a safe environment resulting in elopement from the facility. The findings include: A. R#2 was admitted with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#2 had moderately impaired cognition with long and short term memory deficits. Wandering risk assessments were completed quarterly and indicated R#2 was at risk for wandering. The MDS identified R#2 had not exhibited wandering behaviors. A resident care plan (RCP) dated 10/1/12 indicated R#2 had the potential to wander. Interventions included to record and report any concerns or changes to the physician. A facility investigation dated 12/22/12 indicated R#2 left the facility unattended on 12/22/12. According to the investigation R#2 had been let into the shower room by a staff member to use the toilet. While in the shower room R#2 opened the window, kicked out the screen, and exited through the first floor shower room window sometime after 12:15 PM. R#2 was located in a park behind the facility and returned to the facility at approximately 12:45 PM. An assessment indicated R#2 had not sustained any injuries related to the incident. A physicians order dated 12/22/12 indicated R#2 was to be observed every fifteen minutes until evaluated by psychiatry. A RCP dated 12/22/12 identified R#2 was sent to the Emergency Department (ED) for evaluation after leaving the facility without authorization and upon return to the facility was placed on observation every 15 minutes. B. R#3 was admitted with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#3 had severely impaired cognition with long and short term memory deficits. Wandering risk assessments were completed quarterly and indicated R#3 was at risk for wandering. The MDS identified R#3 had not exhibited wandering behaviors. A resident care plan (RCP) dated 2/22/13 indicated R#3 had the potential to leave the facility without authorization. Interventions included to record and report any concerns or changes to the physician. A RCP dated 4/9/13 indicated R#3 had the potential to wander from the facility and interventions included observation of R#3 every fifteen minutes. A physicians order dated 4/9/13 indicated R#3 was to be observed every fifteen minutes for exit seeking behaviors. Facility investigation dated 4/10/13 indicated R#3 was on observations every fifteen minutes and had last been seen on 4/10/13 at 4:00 PM. At 4:15 PM R#3 could not be located. During the search for R#3 it was noted that a window in the first floor lounge was open. R#3 was located approximately two blocks from the facility at 4:30 PM. According to the facility investigation R#3 stated he/she had fallen and had sustained scrapes on his/her back leg, knee and right hand. R#3 was sent to the ED for evaluation. A subsequent RCP dated 4/10/13 identified R#3 had been placed on constant observation related to a fall incurred while R#3 had eloped from the facility. Upon return to the facility on [DATE] R#3 was placed on one to one observation, per physician order. . During an interview with the Administrator on 4/30/13 at 9:00 AM, the Administrator indicated at the time of the incident windows were secured with screws to prevent the windows from opening greater than six inches and access to the shower room is available by key only. The Administrator indicated the facility was not able to determine how or why the screws were removed from the windows. During an interview and review of maintenance logs with the Director of Maintenance on 5/1/13 at 2:15 PM, the Director of maintenance indicated weekly and sometimes daily rounds are made by maintenance to ensure the windows are secure. Facility maintenance log indicated the East Lounge windows were checked by maintenance on 4/8/13 (elopement 4/10/13) and the first floor East Shower Room windows were checked on 12/21/12 (elopement was 12/22/12) and no issues were identified.

Based on clinical record review, observations and staff interview, for one of five sampled residents (Resident #107) who was reviewed for range of motion, the facility failed to implement measures to prevent contractures. The findings include: Resident #107's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified the resident had short and long term memory problems, severly impaired cognition, required total assistance with all care, was non ambulatory and had no functional limitation in range of motion. The care plan dated 8/23/11 did not identify and/or address contractures. Observation of the resident on 9/22/11 at 2:15 PM with the Director of Therapy identified the resident's bilateral hands appeared contracted and were not able to be fully extended. Additionally, bilateral elbows were tight and appeared contracted. The left leg appeared contracted at the hip and knee. The Director of Therapy stated she had not received a referral from nursing to screen the resident for contractures and that she was unaware the resident had a delcine in range of motion. The Director of Therapy stated there is a communication book available on the unit for nursing communication to therapy, however, observation of the book identified there was no documentation related to Resident #107. Additionally, the Director of Therapy was unaware the resident had a decline in range of motion and would have Occupational Therapy (OT) assess the resident. Interview with OT#2 on 9/22/11 at 2:45 PM identified she assessed the resident and would be picking him/her up for contracture management. Review of the facility policy on resident screening directed that a comprehensive screening program is a mandatory program that must be implemented in each facility. Additionally, an interdiciplinary screen will be completed upon admission and annually by the RPT/PTA and OTR/COTA, as permitted by the state practice act and will contain sufficient documented information concerning the residents status in order to track changes. Documentation was lacking that this had occured.