Every finding on record at Suffield House Rehabilitation and Healthcare Cente

Based on observations, interviews, facility documentation and facility policy review for 1 of 2 sampled residents (Resident #121) reviewed for positioning, the facility failed to set a specialty mattress per physician's orders. The findings include:Resident #121 diagnoses included pilonidal cyst with abscess (to coccyx), myelodysplastic syndrome and abnormalities of gait and mobility.A physician's order dated 7/1/26 directed for an alternating pressure air mattress to the bed, set to resident's weight. Check placement and function every shift for pressure injury prevention.The Braden Scale Assessment predicting pressure sore risk dated 7/5/26 at 1:32 AM identified Resident # 121 was a 14 indicating moderate risk.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #121 had a Brief Interview of Mental Status of 15 indicating intact cognition, required substantial/maximal assistance for lower body dressing, changing position in bed (sit to lying and rolling), and transfers. Additionally, the MDS identified Resident #121 was at risk of developing pressure ulcers and had open lesions as well as moisture associated skin damage. Skin and ulcer/injury treatments included a pressure reducing device for the bed.The Braden Scale Assessment predicting pressure sore risk dated 7/12/26 at 3:48 PM and 7/20/26 at 1:14 PM identified Resident # 121 was a 17 indicating low risk.The Resident Care Plan dated 7/23/26 identified Resident #121 had alteration in skin integrity related to a coccyx pilonidal sinus wound with potential for further alteration in skin integrity related to weakness, decreased mobility and incontinence. Interventions included a specialized alternating pressure mattress as ordered and treatment per physician or advanced practice registered nurse orders.Observation on 7/22/26 at 11:47 AM and 7/23/26 at 9:30 AM identified Resident #131 in bed with the alternating pressure mattress set to 330.Interview and observation of Resident #121 on 7/27/26 at 9:02 AM identified him/her laying on their left side, arms shaking. Resident #121 stated that his/her back was hurting, the alternating pressure mattress was noted to be set at 330. Interview, clinical review and observation with Licensed Practical Nurse (LPN) #2 on 7/27/26 at 9:13 AM identified it was the facility's policy for alternating pressure mattresses to be set per resident's weight, with the nurses responsible for ensuring it was at the correct setting. Review of Resident #121's clinical record identified he/she weighed 193 pounds and had an order for an alternating pressure mattress to the bed, set to the resident's weight. Observation of Resident #121 with LPN #2 identified him/her in bed with the mattress set and locked to 330. Subsequent to surveyor inquiry LPN # 2 unlocked the bed setting, set it to the appropriate weight and then relocked the bed setting.Interview with the Infection Prevention nurse (RN) #2 on 7/27/26 at 9:54 AM identified it was the facility's policy to provide air mattresses to residents that had a high Braden scale score, as an intervention to help with wound healing or MASD or if the resident was declining functionally. Additionally, RN #2 identified that the alternating pressure mattresses should be set to the resident's weight, and nurses were responsible for checking the setting every shift, adding that an incorrectly set air mattress might possibly cause the resident pain or worsening of the wound. RN #2 identified Resident #121 had the mattress in place to prevent deterioration and promote healing of his/her chronic cyst and the mattress should have been set to his/her weight.Review of the undated Use of Support Surfaces Policy directed in part that support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure ulcers. Additionally, support surfaces will be utilized in accordance with physician orders, and for powered devices or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and/or inflation.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 2 of the 5 sampled residents (Resident #8 and Resident #64) reviewed for falls, for Resident #8 the facility failed to perform a thorough investigation following an unwitnessed fall, and for Resident #64 the facility failed to follow a post fall intervention. The findings include: 1. Resident #8's diagnoses included dementia, depression, anxiety, and left ankle fracture. The annual Minimum Data Set assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 8 indicating moderate cognitive impairment, required substantial to maximal assistance with bed mobility and was dependent on staff with chair/bed to chair transfers; only used a wheelchair and was dependent on staff to manually propel the resident in his/her wheelchair. The Resident Care Plan (RCP) in effect from 12/18/25 through 2/15/26 identified Resident #8 was at increased risk for falls. Interventions included that staff were not to leave the resident alone in the bathroom, to check in with the resident every 2 hours and as needed to ensure his/her needs were being met (thirst, hunger, toileting, etc.) and remove the mechanical lift pad from under Resident #8 when he/she was in the chair. Review of the Reportable Event form dated 2/15/26 at 3:35 PM identified Resident #8 was found on the floor, had an unwitnessed fall, and had been seated in his/her recliner chair prior to the fall. Upon staff entry, the recliner was noted in the upright position, and Resident #8 was on the floor in front of the recliner lying on his/her right side with complaints of pain and guarding (protecting) his/her hip and shoulder. A supervising Registered Nurse (RN) note dated 2/15/26 at 4:47 PM identified that she was called to Resident #8's room to perform an assessment following the residents fall, and that the resident was exhibiting increased confusion along with other signs/symptoms of delirium like an inability to pay attention and disorganized thinking. Further, it was unknown if Resident #8 had a loss of consciousness (LOC). He/she remained on the floor with staff until Emergency Medical Services (EMS) attendants arrived and transported Resident #8 to the local Emergency Department. The note failed to identify any attempts to obtain neurological signs (level of consciousness, movement, hand grasps, pupil size speech, and vital signs) A Licensed Practical Nurse note dated 2/15/26 at 5:01 PM identified that Resident #8 was found on the floor lying on his/her right side guarding their hip and shoulder, in front of the recliner chair, with the chair elevated. She was unable to obtain vital signs due to the resident's positioning on the floor, and the resident was only able to express pain by stating ouch, ouch. Resident #8 was noted to be uncommunicative, which was not his/her baseline behavior. The note failed to identify any attempts to obtain neurological signs other than the inability to obtain vital signs. Interview and clinical record review with the DON on 7/29/26 at 12:31 PM identified that 1 staff member was interviewed after Resident #8 had an unwitnessed fall and was found in his/her room on the floor. The DON indicated that the staff member who performed and documented the interview was the same staff member who initially found the resident and that no other interviews or investigative information was obtained. The DON stated that the facility should have at least interviewed all staff members assigned to or had access to the resident during the shift he/she fell. She indicated that Resident #8's fall had occurred prior to her employment with the facility, so she was unable to explain the lack of statements from other staff members. The DON indicated that the facility did not have a policy/procedure for unwitnessed falls and that the Interdisciplinary Team was responsible for the investigative and interview process, but she was unable to provide documentation that this occurred. Review of the staffing schedules dated 2/15/26 for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts identified there were at least 11 Nurse Aid (NAs) that worked on Resident #8's unit around the time he/she was found on the floor, not including the housekeeping staff, and/or Recreation Department staff who may have also had access to the resident during the time he/she fell. 2. Resident #64's diagnoses included repeated falls, severe dementia and glaucoma. The change of condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 had a Brief Interview of Mental Status of 99 indicating severe cognitive impairment and was fully dependent on staff for all Activities of Daily Living (ADL's) (bed mobility and transfers). The Resident Care Plan dated 6/19/26 identified Resident #64 was at risk for falls related to muscle weakness, decreased strength and balance, unsteady gait, altered cognition & judgement (dementia), decreased hearing & vision (glaucoma), and blindness. Interventions included a low bed with mats on the floor, assisting with mobility and anticipating residents' needs. Review of the undated Resident Care Card for Resident #64 (directs care by nurse aids) identified low bed with mats on the floor for safety. A physician's order initiated 5/28/24 and in place on 7/22/26 directed for bed to be in lowest position with mats in place every shift for safety. Observation on 7/22/26 at 9:32 AM identified Resident #64 in bed with eyes closed, bed was in low position with one floor mat folded up by the curtain on the left side of the room, and the other mat was folded up, leaning against the wall behind the bed on the right side of the room without the benefit of laying on the floor in case of a fall. Observation on 7/27/26 at 9:02 AM identified Resident #64 in in bed with eyes closed, bed was in low position with one mat folded up by the curtain on the left side of the room, and the other mat was folded up, leaning against the wall behind the privacy curtain on the right side of the room without the benefit of laying on the floor in case of a fall. Observation and Interview on 7/27/26 at 9:18 AM with Licensed Practical Nurse (LPN) #1 identified it was the facility's policy that floor mats were a safety measure for some residents and should be in place on the floor anytime the resident was in bed, with nurses and Nurse Aid's (NA) responsible for ensuring placement. LPN #1 observed Resident #64 in bed without the benefit of floor mats placement. The floor mats were located one folded up by the curtain to the left side of the room, and the other mat was folded up, leaning against the wall behind the privacy curtain on the right side of the room. LPN #1 identified that Resident #64 had an order for floor mats and the care card located on the inside of the closet identified the mats should have been on the floor on either side of the bed when the resident was in bed. Subsequent to surveyor inquiry LPN #1 applied the mats to the floor on both sides of the bed. Interview with the Director of Nurses (DNS) on 7/28/26 at 11:10 AM identified that although there was no official policy on floor mats, they were used as a safety measure for identified residents and if indicated they were expected to be on the floor anytime the resident was in bed. Review of the undated Falls Policy directed in part that each resident will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High risk protocols included indicating a fall risk on the care plan, and providing interventions as directed by the resident's assessment. Review of the Fall Prevention Program policy dated 2025 directs, in part, that when any resident experiences a fall, the facility will assess the resident; complete a post-fall assessment; complete an incident report; notify the physician and family; review the resident's care plan and update as indicated; document all assessments and actions; and obtain witness statements in the case of an injury. Although requested, the facility did not have a policy for unwitnessed falls.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 5 sampled residents (Resident #4) reviewed for falls, the facility failed to revise the Resident Care Plan to reflect wandering and hallucinating behaviors. The findings include:Resident #4 's diagnoses included dementia with mood disturbance, fracture of the upper end of the right tibia and traumatic subdural hemorrhage without loss of consciousness.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status score of 10 indicating moderate cognitive impairment and was supervision or touch assistance with bed mobility, transfers, and dressing, and was noted to have hallucinations, but no wandering behavior was identified.The Resident Care Plan dated 3/13/26 failed to identify wandering and hallucinating.The Care Kardex (nurse aide instructions for care) failed to identify monitoring for wandering behavior or hallucinationsA social work note dated 5/12/26 at 5:54 PM identified Resident #4 was observed with increased confusion and signs of hallucinations. Resident #4 was in the social worker's office seeing a red car in front of him/her reaching out to open the door that was not present. Resident #4 indicated he/she was trying to get the red car. The social worker redirected Resident #4 and notified the nursing staff.A nurse's note dated 5/12/26 at 11:08 PM identified Resident #4 had confusion and hallucinations, seeing an imaginary boy. Resident #4 asked And what is your name little boy? Resident #4 replied by saying [NAME]. Asked Resident #4 where [NAME] was and he/she replied he was right there. The Supervisor was notified. The APRN was notified and a new order to collect a urine sample was obtained but was unable to be collected.An Adult Gerontology Primary Care Nurse Practitioner (AGPCNP) #1 note dated 5/13/26 at 10:45 AM identified the nursing facility reported Resident #4 had hallucinations and ongoing confusion, Urinalysis and culture were ordered due to history of recurrent urinary tract infections. Cognition was limited due to dementia. Monitor for worsening confusion or hallucinations.An AGPCNP #1 note dated 5/14/26 at 1:00 PM identified increased confusion and hallucinations. Laboratory studies were normal, negative urine for infection. The family member was aware of Resident #4's increased confusion and hallucinations as well as laboratory work. This was likely worsening of dementia rather than an infectious process. Hallucinations were improving, cognition was limited due to dementia. Monitor for worsening confusion or hallucinations, notify the provider of any symptom progression.AGPCNP #1 note dated 5/21/26 at 1:00 PM identified ongoing continuation of confusion from baseline with intermittent weakness. Continued to wander, unaware of where his/her room was, requiring more redirection. Monitoring for worsening confusion, hallucinations or wandering, and notify the provider of any symptom progression.An AGPCNP #1 note dated 5/22/26 at 11:30 AM identified ongoing work up for confusion from baseline, urinary frequency and wandering. Laboratory studies were normal with no concern of infectious process, well hydrated, symptoms of confusion and wandering were progressing and appear to be related to progression of dementia rather than infection.A social work note dated 5/29/26 at 8:08 PM identified Resident #4 with intermittent confusion with hallucinations at times. Brief Interview for Mental Status score of 9 indicating moderate cognitive impairment and a decline since last quarter.An APRN #2 follow up note dated 6/4/26 at 12:09 PM identified Resident #4 with moderate dementia with mood disorder, depression and multiple medical comorbidities with fluctuating mood and behaviors more notable in the evening with intermittent confusion, easily redirected without aggressive behaviors. Intermittent confusion and mild agitation in the evening, sundowning pattern. Intermittent periods of visual hallucinations.Although AGPCNP #1 directed the facility staff to monitor for worsening confusion or hallucinations a review of the Resident Care Plan and Medication Administration Record from 3/13/26 to 7/22/26 failed to identify monitoring for hallucinations or wandering behaviors. Interview with the Director of Nursing (DON) and the Administrator on 7/28/26 at 2:01PM indicated a room change had been offered to the family for Resident #4's safety due to impulsivity and was declined. The DON and Administrator were unaware of wandering behaviors or hallucinations. The DON further indicated that those behaviors should have been on the Resident Care Plan and could not explain the lack of resident care planning with interventions. The DON and Administrator indicated that Resident #4 was social and visited other residents because he/she knew everyone.Subsequent to surveyor inquiry, the Resident Care Plan and the Medication Administration Record were revised to include wandering and behaviors. Although requested, a facility policy for revising care plans was not provided.A review of the Resident Assessment Instrument Manual dated October 2025 directed, in part, to develop individualized care plans and revise the care plans accordingly by tracking changes in the resident's status. Care plans should consider the impact of wandering on resident safety and disruption to others.

Based on observations, interviews, facility documentation, and review of facility policies for 1 of 2 sampled residents (Resident #64) reviewed for skin conditions, the facility failed to thoroughly investigate an injury of unknown origin. The findings include:Resident #64's diagnoses included primary osteoarthritis of both hands, severe dementia, and glaucoma. The change of condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 had a Brief Interview of Mental Status of 99 indicating severe cognitive impairment and was fully dependent on staff for all Activities of Daily Living (ADL's) (eating, dressing, personal hygiene, bed mobility and transfers). Additionally, the MDS identified Resident #64 did not exhibit rejections of care.The Resident Care Plan (RCP) dated 6/19/26 identified Resident # 64, had an actual self-care deficit related to cognitive impairment, decreased independence with activities of daily living, and decreased strength/endurance. Interventions included providing assistance of 2 staff members at bed level with ADLs, and monitor for pain, stiffness, decreased range of motion, and contracture status during all care and report any changes. Review of the undated Nurse Aid (NA) Care Card (directs resident care needs) for Resident #64 identified resident care should include nail care and assistance of 2 staff members at bed level for ADL's. Review of the Nail Care Task identified nail care for Resident #64 was documented as performed on 7/3/26 at 3:55 PM.Review of the facility Reportable Even for dated 7/4/26 at 10:00 AM identified Licensed Practical Nurse (LPN) #5 was called to Resident #64's room by a housekeeper and shown 2 abrasions to his/her right cheek/below the right eye. Resident #64's mental status before and after the event was identified as nonverbal with no behaviors noted, and the physical status before and after the event was identified as total dependence on staff for all ADL's, transfers, etc. The action taken was identified as nails to be kept short, and filed, injury appeared self-inflicted. (The investigative interviews included LPN #5 and NA #3).The Skin Investigation Interview form document by LPN #5 dated 7/4/26 identified she last saw Resident #64 during medication administration and that the resident was being provided with care by NA #3 prior to the incident. Additionally, LPN #5 identified the possible cause of the skin concern was fingernails needing to be cut, and dry skin or rubbing his/her face.The Skin Investigation form Interview document by NA #3 dated 7/4/26 identified the last time she had seen Resident #64 was 5 minutes before the issue was identified. Additionally, NA #3 indicated that Resident #64 had dry skin and his/her fingernails were not smooth but could not identify a possible cause of the skin concern. The form failed to identify if 2 staff were present during care per the RCP and the NA Care Card.Review of LPN #5's nurse note dated 7/4/26 at 11:57 AM identified she was called to Resident #64's room by the housekeeper who noticed that the resident's face was bleeding. LPN #5 went in and assessed the patient and noted 2 abrasions side-by-side to Resident #64's right cheek/below the right eye. Resident #64 did not have the abrasions when she administered medications that morning. NA #3 was asked if she knew how the abrasions were obtained, she stated she was unsure, then LPN #5 immediately notified the supervisor, cleaned the area with wound cleanser, obtained vitals and filed the resident's nails to keep them short.Review of LPN #5's Change in Condition Report dated 7/4/26 at 12:11 PM identified Resident #64 sustained a skin wound/ulcer accompanied by significant pain or bleeding described as abrasions noted to the right cheek and under the right eye. The abrasion closer to Resident #64's nose measured 2.5 cm (just over an inch), and the abrasion closer to his/her ear measured 1.5 cm.A physician's order dated 7/5/26 directed to apply A & D ointment to the abrasions every shift.Observations of Resident #64 on 7/22/26 at 9:32 AM and 7/27/26 at 9:02 AM identified the resident in bed, eyes closed with arms crossed over his/her chest, with hands curled into fists. Observations of Resident #64 in his/her wheelchair on 7/22/26 at 12:11 PM in their room and on 7/24/26 at 11:13 AM in the common area, noted him/her to have their eyes closed and hands under a light blanket with the outline of his/her arms crossed over his/her chest, hands curled into fists.Interview and observation with LPN #1 on 7/27/26 at 10:58 AM identified Resident #64 in the common area sitting in a wheelchair with his/her eyes closed, arms crossed over his/her chest, hands curled into fists. LPN #1 identified that she was a regularly scheduled nurse on the unit and this was Resident #64's usual position; sitting in the wheelchair with arms crossed across the chest, hands closed into fists because Resident #64 never moved his/her arms.Observation of Resident #64 on 7/28/26 at 12:59 PM identified him/her in their room, sitting in a wheelchair, eyes closed and hands under a light blanket with the outline of his/her arms crossed over his/her chest, hands curled into fists.Observation of Resident #64 on 7/29/26 at 10:39 AM identified him/her in bed, eyes closed with arms crossed over his/her chest, hands curled into fists.Interview with NA #3 on 7/29/26 at 9:20 AM identified she alone provided morning care to Resident #64 on 7/4/26, stating that she stepped out of the resident's room for a couple of minutes, and when she returned, the nurse and housekeeper were present because the nurse had been notified of an abrasion on Resident #64's cheek. Additionally, NA #3 stated that the abrasion was not present when she began providing care and further explained that the scratch might have been caused by a rough towel, noting that Resident #64 typically kept his/her hands in front of his/her chest and that she has only ever observed him/her bring his/her finger up as far as the nose.Interview and facility documentation review with the Director of Nurses (DNS) on 7/29/26 at 10:38 AM identified it was the facility's policy that injuries of unknown origin would go through the supervisor and the charge nurse to determine the root cause, and if unable to be determined, then an investigation would be initiated which included a Reportable Event form, interviews, investigating potential environmental factors and documentation review. The DNS stated that Resident #64's Reportable Event form dated 7/4/26 was discussed thoroughly at morning report, and it was decided the cause of the injury was known (although the resident was nonverbal and the event was unwitnessed) because after reviewing all documentation and interviews, she would have come to the same conclusion as the charge nurse (injury self-inflicted). Additionally, the DNS identified that Resident #64 can sometimes move his/her arms at times even though he/she is immobile and has contractures. Although the DNS indicated she did not need to interview any other staff besides LPN #5 and NA #3, she was unable to state if anyone else, staff, visitor, or another resident, had come into the room between the time NA #3 exited and the abrasion being found, or that Resident #64 was not injured during care (The RCP and NA Care Card required 2 staff for ADL care). The DNS added that given the scope and severity of the injury she did not believe it rose to the level of harm, especially given the fact that Resident #64's nails had sharp edges, the abrasion was not deep without need of a treatment, and she was elderly with very, very frail skin.Interview with Occupational Therapist (OT) #1 on 7/29/26 at 11:04 AM identified that she was familiar with Resident #64 and had worked with him/her earlier in the year. OT #1 stated that Resident #64 required staff assistance to reposition his/her arms and to open his/her hands, as he/she was unable to do so voluntarily and independently due to degenerative joint disease. OT #1 further added that in order for Resident #64 to bring up and open his/her hands to the area of the abrasion (agreeing with NA #3's statement), staff would need to position him/her that way.Interview with the Administrator on 7/29/26 at 12:40 PM identified it was the facility's policy to investigate injuries of unknown origin by completing a Reportable Event, interviewing all pertinent individuals, and if appropriate, notifying the State Agency. The Administrator indicated that after reviewing the interviews, the DNS had not needed any further information and came to the conclusion that the abrasion was self-inflicted due to jagged nails. Further, the Administrator stated that she would not have expected an interview from the housekeeper, who found the abrasion because the nursing statements were sufficient to identify the cause of the injury.Attempts to contact LPN #5 were unsuccessful.Review of the Abuse, Neglect and Exploitation Policy directed in part that it was the facility policy to provide protection for the health, wealth and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged violation is a situation or occurrence that is observed or reported by staff, resident relative, visitor, or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source. Additionally, identification of abuse, neglect and exploitation included in part possible indicators of abuse to include physical marks and physical injury of a resident of an unknown source. An immediate investigation is warranted when suspicion of abuse neglect or exploitation or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations focusing the investigation on determining if abuse occurred. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies to occur immediately but no later than 2 hours after the allegation was made but no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Review of the Unexplained Injuries Policy directed in part that all unexplained injuries including bruises, abrasions, and injuries of unknown origin will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #4 and Resident #8) reviewed for falls, the facility failed to follow their policy for neurological checks after an unwitnessed fall. The findings include: 1. Resident #4's diagnoses included dementia with mood disturbance, fracture of the upper end of the right tibia and traumatic subdural hemorrhage without loss of consciousness. The significant change Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment and was dependent on staff for bed mobility, transfer, dressing and eating, with functional limitation in range of motion on 1 side of the lower extremity, utilizing a wheelchair for mobility and without wandering or behavior changes. The Resident Care Plan in effect from 6/9/26 through 7/18/26 identified at risk for falls related to altered cognition and judgement, history of falls, poor balance, unsteady gait, syncope, dizziness, decreased hearing and vision, and self-transfers. Risk for injury/fracture secondary to vitamin d deficiency, fall on 6/9/26. Interventions included assist with mobility, bed in low position, bilateral bolsters in bed due to high fall risk in bed, call bell within reach, transfer with assist, Physical Therapy/Occupational Therapy screen as ordered, notify physician/Advanced Practice Registered Nurse of changes or complications, and medication review by pharmacy as needed. A review of the Reportable Event form dated 7/18/26 at 11:30 AM identified Resident #4 was lying on the right side on the floor in front of the bathroom door, head towards the door. Resident #4 had no injuries noted. Resident #4's mental status was alert, forgetful, baseline confusion, before and after the event and physical status was transfer with assistance of 1 with wheeled walker, toileting assistance of 1 with stand pivot, before and after the event. An unwitnessed fall assessment dated [DATE] at 11:30 AM identified Resident #4 had no injuries, vital signs were stable, neurological checks were within normal limits, alert with forgetfulness and baseline Range of Motion (ROM) to all extremities Nurse's note dated 7/18/26 at 11:45 AM, 7/18/26 at 7:10 PM, and 7/21/26 at 3:45 PM failed to identify neurological status post unwitnessed fall. Review of the Electronic Medical Record and the paper chart failed to identify documentation of neurological checks. 2. Resident #8's diagnoses included dementia, depression, anxiety, and left ankle fracture. The annual Minimum Data Set assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 8 indicating moderate cognitive impairment, required substantial to maximal assistance with bed mobility and was dependent on staff with chair/bed to chair transfers; only used a wheelchair and was dependent on staff to manually propel the resident in his/her wheelchair. The Resident Care Plan (RCP) in effect from 12/18/25 through 2/15/26 identified Resident #8 was at increased risk for falls. Interventions included that staff were not to leave the resident alone in the bathroom, to check in with the resident every 2 hours and as needed to ensure his/her needs were being met (thirst, hunger, toileting, etc.) and remove the mechanical lift pad from under Resident #8 when he/she was in the chair. Review of the Reportable Event dated 2/15/26 at 3:35 PM identified Resident #8 was found on the floor, had an unwitnessed fall, and had been seated in his/her recliner chair prior to the fall. Upon staff entry, the recliner was noted in the upright position, and Resident #8 was on the floor in front of the recliner on his/her right side with complaints of pain, guarding (protecting) his/her hip and shoulder. A supervising Registered Nurse (RN) note dated 2/15/26 at 4:47 PM identified that she was called to Resident #8's room to perform an assessment following the residents fall, and that the resident was exhibiting increased confusion along with other signs/symptoms of delirium like an inability to pay attention and disorganized thinking. Further, it was unknown if Resident #8 had a loss of consciousness (LOC) and that he/she remained on the floor with staff until Emergency Medical Services (EMS) attendants arrived to transport the resident to the local Emergency Department. The note failed to identify any attempts to obtain neurological signs (level of consciousness, movement, hand grasps, pupil size speech, and vital signs) A Licensed Practical Nurse note dated 2/15/26 at 5:01 PM identified that Resident #8 was found on the floor lying on his/her right side guarding their hip and shoulder, in front of the recliner chair, with the chair elevated. She was unable to obtain vital signs due to the resident's positioning on the floor, and the resident was only able to express pain by stating ouch, ouch. Resident #8 was noted to be uncommunicative, which was not his/her baseline behavior. The note failed to identify any attempts to obtain any part of the neurological signs (level of consciousness, movement, hand grasps, pupil size speech) with the exception of vital signs. Review of the Electronic Medical Record and the paper chart failed to identify documentation of neurological checks. Interview with RN #1 on 7/28/26 at 12:08 PM identified that neurological checks would be initiated immediately after an unwitnessed fall or a fall with a head strike and neurological checks were documented on the neurological check sheet which was a separate paper not attached to the incident report. Interview and clinical record review with Director of Nursing (DON) on 7/28/26 at 12:31 PM identified that the neurological checks were documented on paper and kept in the paper chart not in the electronic medical record. The DON indicated that the paper sheets were being misfiled so she was streamlining the process. She indicated that she did not know where Resident #4 or Resident #8's paper neurological check forms were filed following the unwitnessed falls, was unaware if the neurological checks had been completed indicating that with a known head strike and an unwitnessed fall, a neurological check form would be completed and continue for 72 hours. Although requested, a facility policy for neurological checks and unwitnessed falls was not provided. Review of the head injury policy dated 2025 directed, in part, assess a resident following known, suspected or verbalized head injury. The assessment shall include at a minimum, vital signs, physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred or slowed speech or slow to answer questions, evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding. Perform neuro checks as indicated or as specified by the physician, continuing monitoring for 72 hours following the incident or until the resident was asymptomatic for a period of time specified by the physician.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 5 sampled residents (Resident #10) reviewed for unnecessary medications for antipsychotic use, the facility failed to attempt a Gradual Dose Reduction (GDR), document a past unsuccessful attempt of a GDR, failed to document target behaviors when the antipsychotic was used for agitation, and failed to document any non-pharmacological approaches used in an attempt to facilitate the reduction of psychotropic medication. The findings include:Resident #10's diagnoses included dementia with behavioral disturbance, depression, and anxiety disorder.The quarterly Minimum Data Assessment (MDS) dated [DATE] identified Resident #10 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and had no evidence of psychosis or rejections of care. Additionally, the MDS identified Resident #10 was receiving an antipsychotic medication and a Gradual Dosage Reduction (GDR) had not been attempted because it was documented by a physician that a GDR was clinically contraindicated. The Resident Care Plan (RCP) dated 4/20/26 identified Resident #10 was receiving psychotropic medication. Interventions included monitoring, documenting, and reporting signs and symptoms of anxiety and depression and to monitor, document, and report side effects of the antipsychotic medication. The RCP failed to identify target symptoms specific to Resident #10 to support the use of an antipsychotic medication and failed to document non-pharmacological approaches to use with a psychotropic medication.A physician order dated 4/28/26 directed the administration of quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg) 1 tablet at bedtime for dementia with behavioral disturbance. The 4/28/26 order had been revised from a 12/20/22 order directing the use of quetiapine for agitation. The physician order failed to identify targeted behaviors.A physician order dated 5/14/26 directed to perform behavioral monitoring for psychotropic medication and to document absence of episodes, or presence of crying, poor sleep, decreased appetite, anxiety, restlessness, anger, irritability, depressed mood, isolation, weight loss, low energy levels, refusal of care, hallucinations, delusions, disorganized thinking, impulsiveness, hitting, kicking, scratching, pulling out medical equipment, pacing, screaming till exhausted, yelling, cursing/arguing, smearing body fluids, or paranoia. Review of prior physician orders dated 5/14/25 through 5/13/26 failed to identify that any target behaviors were monitored routinely prior to initiation on 5/14/26. A review of documentation for behavioral monitoring from 5/14/26 to 7/29/26 failed to identify the presence of any target behaviors occurring.A Psychiatric Evaluation on 4/23/26, signed by Advance Practice Registered Nurse (APRN) #2, identified Resident #10 had no behavioral symptoms or evidence of psychosis, hallucinations or agitation, and that he/she was calm, pleasant, and cooperative throughout the evaluation. Additionally, the note stated staff had not reported any behavioral outbursts, agitation, or sundowning.A Psychiatric Evaluation on 5/12/26, signed by APRN #2, identified Resident #10 was seen at the request of nursing staff due to a brief episode of crying earlier in the day and appearing to be depressed. It was further reported that the episode was related to a shower that Resident #10 was not ready to have at that time. When APRN #2 evaluated Resident #10 he/she was unable to recall the crying episode and denied feeling depressed, anxious, or worried and was observed participating in an activity on the unit and noted to be smiling, pleasant, and cooperative. Additionally, it was noted the crying episode was brief, situational, and isolated.A Psychiatric Evaluation on 6/16/26, signed by APRN #2, identified Resident #10 was stable with no mood or behavioral disturbances reported by staff and was pleasantly confused at baseline with no evidence of psychosis. A Psychiatric Evaluation on 7/15/26, signed by APRN #2, identified Resident #10 was psychiatrically stable with no reported agitation, behavioral disturbances, psychosis, or mood decompensation and that staff reported no hallucination, delusions. Additional review of APRN #2's Psychiatric Evaluations dated 5/12/26, 6/16/26, and 7/15,26 identified that Medication reduction is contraindicated due to the continued use of medication is in accordance with relevant current standards of practice based on patient's diagnosis (dementia with behavioral disturbance) and any attempt at reduction would likely impair the patients function or cause psychiatric instability by exacerbating an underlying psychiatric disorder. Documentation failed to identify the presence or occurrence of specific target symptoms being treated or the evidence that previous GDRs had been attempted and/or exacerbated an underlying psychiatric disorder or that non-pharmacological approaches had been attempted to facilitate the reduction of psychotropic medication. Observations on 7/23/26 at 9:54 AM and again on 7/25/25 at 2:30 PM identified Resident #10 was calm, conversant with no behavioral symptoms noted.Interview with APRN #2 on 7/29/26 at 10:30 AM identified she had followed Resident #10 for less than a year and that she had spoken to nursing staff, and they stated Resident #10 had behavioral disturbance (undocumented) on the night shift (11:00 PM to 7:00 AM) and that she wanted to be careful with medication changes due to a past history but would consider a GDR in the future. APRN #2 failed to identify a previous GDR had been attempted. On 7/29/26 at 11:15 AM and subsequent to surveyor inquiry, APRN #2 stated she spoken with a Resident #10's family who refused a GDR due to Resident #10's being sensitive to medication changes. Interview and record review with Director of Nursing (DON) on 7/29/26 at 1:25 PM identified although she was aware of the requirement for documentation of target behaviors for residents receiving antipsychotic medications, she was unable to provide documentation of Resident #10 being monitored for the presence/occurrence of target behaviors from 5/14/25 through 5/13/26, or that once monitoring began on 5/14/26 that Resident #10 had exhibited any targeted behaviors. Additionally, the DON indicated that although she was aware of the requirement to conduct yearly GDRs for residents on antipsychotics unless the resident had a previous failed GDR with return of symptoms or there was evidence of a clinical contraindication, she was unable to identify a GDR had ever been attempted on Resident #10 since their admission.Review of the undated Gradual Dose Reduction of Psychotropic Drugs policy directed, in part, Residents who used psychotropic drugs would receive gradual dose reductions and behavioral interventions unless clinical contraindicated, in an effort to be managed at a lower dose or to discontinue the drugs. Additionally, continued use would be in accordance with relevant current standards of practice, and the physician would document the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder.Review of the Use of Psychotropic Medication policy dated 12/24 directed, in part, residents would not be given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and directed to offer gradual dosage reduction unless clinically contraindicated, in an effort to discontinue the drugs. The policy also directed that residents would receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Further, in cases of enduring conditions (i.e., non-acute, chronic, or prolonged), continued use of the medication would be consistent with procedures for gradual dosage and the resident's symptoms and therapeutic goals would be clearly and specifically identified and documented.

Based on interviews, observation, review of the clinical record, facility documentation and facility policy for 1 of the 2 sampled residents (Resident #52) reviewed for dignity, the facility failed to treat the resident with dignity following a request for assistance. The findings include:Resident #52's diagnoses included left lower leg fracture, right-sided muscle weakness with partial to complete nerve disruption and generalized muscle weakness.The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #52 had a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment, dependent on staff with toileting hygiene, for lower body dressing and chair/bed to chair transfers and required partial/moderate assistance to roll left to right and substantial/maximal assistance from lying to sitting on the side of the bed. The Resident Care Plan (RCP) in effect from 5/8/26 through 7/29/26 identified Resident #52 had a self-care deficit. Interventions included having assistance of 1 staff member for the resident's activities of daily living, with bed mobility and positioning, and required staff not to leave the resident alone on the commode; to allow sufficient time to accomplish his/her tasks; to offer positive reinforcement and to talk with Resident #52 during all aspects of care and always address the resident by name. Additionally, Resident #52 had bowel and urinary incontinence. Interventions included staff to monitor/report any changes in the resident's skin integrity. A physician's order in effect from 6/5/26 through 7/29/26 directed staff to place Resident #52's knee brace on his/her left knee only for transferring him/her to/from bed to chair. Interview with Resident #52 on 7/22/26 at 12:10 PM identified that approximately 6 weeks ago a Nurse Aid (NA) placed him/her on the bedpan. Another NA answered the call light and yelled at him/her, stating not to use the call light anymore because she already knew the resident was in his/her room. Resident #52 further identified that the comments made by the NA made him/her so upset he/she cried. The resident indicated that he/she told a housekeeper of the incident earlier today and that he/she had not notified any other staff prior to today.Interview with Housekeeper #1 on 7/22/26 at 2:40 PM identified that she was the housekeeper who had Resident #52 on her assignment today, and she had not spoken to Resident #52 today, or in the recent past regarding any occurrences that upset him/her. On 7/23/26 at 2:21 PM the surveyor made the Director of Nursing (DON) aware that Resident #52 reported he/she was yelled at for using his/her call light. The DON identified that she would speak with Resident #52 to find out what happened.Interview on 7/27/26 at 2:00 PM with the DON identified that she had spoken with Resident #52, on 7/23/26, and that she believed the resident was confused.Interview and observation with Resident #52 and the DON on 7/28/26 at 11:49 AM identified he/she was told not to use the call bell about 2-3 weeks ago before breakfast, and that NA #5 was the NA who yelled you can't keep ringing the bell.or something like that. Resident #52 indicated he/she rang the call bell approximately 3 to 4 times because NA #4, who originally had placed him/her on the bedpan, had left him/her for about an hour and that he/she didn't want to have to wait another hour for NA #4 to return. Resident #52 indicated that NA #5 came to the room after the 4th time of him/her pressing the call light, she never asked the resident what he/she needed, yelled at him/her for repeatedly pressing the call light, and then turned the call light off by pressing a button by the door of the resident's room. Resident #52 also stated that NA #4 eventually came back to the room to get him/her off the bedpan, cleaned him/her up and apologized for his/her being left on the bedpan for such a long time. Resident #52 identified that since that occurrence, he/she has been hesitant to use the call light feeling that he/she would be bothering the NAs when needing assistance. The DON was able to demonstrate the ability to cancel the call light from the doorway entrance. Interview with NA #4 on 7/29/26 at 9:23 AM identified that she did not recall an incident with Resident #52 in the last 2-3 weeks, when the resident was left on the bedpan for an extended period of time. NA #4 stated that her and the resident have a routine, where he/she is put on the bedpan right after breakfast, and when called she removes the bedpan. NA #4 further identified that I wouldn't know if someone turned off the call light, because I wait for (Resident #52) to use the call light before I go back in the room. Interview with DON on 7/29/26 at 10:15 AM identified if a resident sat on their bedpan for an hour, it would not be indicative of a dignified existence, and the entire Nursing Department, which included the nurses, NAs and nursing supervisors were responsible for monitoring residents call lights and to ensure they were not being left on a bedpan for an extended period. The DON was unable to state why Resident #52 was left on a bedpan for an extended period of time, stating that she didn't know for a fact that the incident had actually happened, and that on 7/28/26 she had spoken with NA #4, who could not recall the incident and had indicated that she and the resident had a normal routine of placing him/her on the bedpan and then waiting for a call to notify her he/she was ready to be taken off. NA #5 indicated that Resident #52 called for NA #4 every morning, that she (NA #5) would answer the call light, ask the resident if anything was needed and the resident would state that he/she only wanted NA #4 to assist. The DON identified she didn't say Resident #52 was fabricating this incident, but that the resident might become anxious and fixated on certain things and the investigation was ongoing so was unable to make any conclusions at the time. Interview with NA #5 on 7/29/26 at 2:00 PM identified that she wasn't assigned to Resident #52 and had not answered the resident's call bell when the resident requested to be taken off the bedpan. NA #5 further identified that Resident #52 rang his/her call light every morning to notify his/her NA he/she required help, but NA #5 would tell the resident that his/her NA (NA #4) wasn't available, because she was busy feeding other residents. NA #5 indicated that she would shut the resident's call light off after answering it, attempt to find NA #4 to notify her Resident #52 was requesting assistance if the NA could be found. Review of the Call Lights: Accessibility and Timely Response policy dated 2025 directs, in part that the process for responding to call lights were to: turn off the signal light in the resident's room; identify yourself and call the resident by name; listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel; and then inform the appropriate personnel of the resident's need.Review of the Resident Rights policy dated 2025 directs, in part that the residents have the right to receive the services and/or items included in the plan of care and that the residents have the right to be treated with respect and dignity

Based on observations, interviews, facility documentation and review of facility policies for 1 of 2 sampled residents (Resident #64) reviewed for skin conditions, the facility failed to report an injury of unknown origin to the State Agency. The findings include:Resident #64's diagnoses included primary osteoarthritis of both hands, severe dementia, and glaucoma.The change of condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 had a Brief Interview of Mental Status of 99 indicating severe cognitive impairment and was fully dependent on staff for all Activities of Daily Living (ADL's) (eating, dressing, personal hygiene, bed mobility and transfers). Additionally, the MDS identified Resident #64 did not exhibit rejections of care.The Resident Care Plan (RCP) dated 6/19/26 identified Resident # 64 had an actual self-care deficit related to cognitive impairment, decreased independence with activities of daily living, and decreased strength/endurance. Interventions included providing assistance of 2 staff members at bed level with ADLs, and monitor for pain, stiffness, decreased range of motion, and contracture status during all care and report any changes.Review of the undated Nurse Aid (NA) Care Card (directs resident care needs) for Resident #64 identified resident care should include nail care and assistance of 2 staff members at bed level for ADLs.Review of the Nail Care Task identified nail care for Resident #64 was documented as performed on 7/3/26 at 3:55 PM.Review of the facility Reportable Even dated 7/4/26 at 10:00 AM identified Licensed Practical Nurse (LPN) #5 was called to Resident #64's room by a housekeeper and shown 2 abrasions to his/her right cheek/below the right eye. Resident #64's mental status before and after the event was identified as nonverbal with no behaviors noted, and the physical status before and after the event was identified as total dependence on staff for all ADL's, transfers, etc. The action taken was identified as nails to be kept short, and filed, injury appeared self-inflicted. (The investigative interviews included LPN #5 and NA #3).The Skin Investigation Interview form document by LPN #5 dated 7/4/26 identified she last saw Resident #64 during medication administration and that the resident was being provided with care by NA #3 prior to the incident. Additionally, LPN #5 identified the possible cause of the skin concern was fingernails needing to be cut, and dry skin or rubbing his/her face.The Skin Investigation form Interview document by NA #3 dated 7/4/26 identified the last time she had seen Resident #64 was 5 minutes before the issue was identified. Additionally, NA #3 indicated that Resident #64 had dry skin and his/her fingernails were not smooth but could not identify a possible cause of the skin concern. The form failed to identify if 2 staff were present during care per the RCP and the NA Care Card.Review of LPN #5's nurse note dated 7/4/26 at 11:57 AM identified she was called to Resident #64's room by the housekeeper who noticed that the resident's face was bleeding. LPN #5 went in and assessed the patient and noted 2 abrasions side-by-side to Resident #64's right cheek/below the right eye. Resident #64 did not have the abrasions when she administered medications that morning. NA #3 was asked if she knew how the abrasions were obtained, she stated she was unsure, then LPN #5 immediately notified the supervisor, cleaned the area with wound cleanser, obtained vitals and filed the resident's nails to keep them short.Review of LPN #5's Change in Condition Report dated 7/4/26 at 12:11 PM identified Resident #64 sustained a skin wound/ulcer accompanied by significant pain or bleeding described as abrasions noted to the right cheek and under the right eye. The abrasion closer to Resident #64's nose measured 2.5 cm (just over an inch), and the abrasion closer to his/her ear measured 1.5 cm.A physician's order dated 7/5/26 directed to apply A & D ointment to the abrasions every shift.Observations of Resident #64 on 7/22/26 at 9:32 AM and 7/27/26 at 9:02 AM identified the resident in bed, eyes closed with arms crossed over his/her chest, with hands curled into fists. Observations of Resident #64 in his/her wheelchair on 7/22/26 at 12:11 PM in their room and on 7/24/26 at 11:13 AM in the common area, noted him/her to have their eyes closed and hands under a light blanket with the outline of his/her arms crossed over his/her chest, hands curled into fists.Interview and observation with LPN #1 on 7/27/26 at 10:58 AM identified Resident #64 in the common area sitting in a wheelchair with his/her eyes closed, arms crossed over his/her chest, hands curled into fists. LPN #1 identified that she was a regularly scheduled nurse on the unit and this was Resident #64's usual position; sitting in the wheelchair with arms crossed across the chest, hands closed into fists because Resident #64 never moved his/her arms.Observation of Resident #64 on 7/28/26 at 12:59 PM identified him/her in their room, sitting in a wheelchair, eyes closed and hands under a light blanket with the outline of his/her arms crossed over his/her chest, hands curled into fists.Observation of Resident #64 on 7/29/26 at 10:39 AM identified him/her in bed, eyes closed with arms crossed over his/her chest, hands curled into fists.Interview with NA #3 on 7/29/26 at 9:20 AM identified she provided morning care to Resident #64 on 7/4/26, stating that she stepped out of the resident's room for a couple of minutes, and when she returned, the nurse and housekeeper were present because the nurse had been notified of an abrasion on Resident #64's cheek. Additionally, NA #3 stated that the abrasion was not present when she began providing care and further explained that the scratch might have been caused by a rough towel, noting that Resident #64 typically keeps his/her hands in front of his/her chest and that she has only ever observed him/her bring his/her finger up as far as the nose.Interview and facility documentation review with the Director of Nurses (DNS) on 7/29/26 at 10:38 AM identified it was the facility's policy that injuries of unknown origin would go through the supervisor and the charge nurse to determine the root cause, and if unable to be determined, the process included the initiation of a Reportable Event with reporting to the State Agency. She indicated the incident was discussed thoroughly in morning report at which time it was decided the cause of the injury was known (although the resident was nonverbal and the event was unwitnessed) and that she would have come to the same conclusion as the nurse, a self-inflicted abrasion due to Resident #64's nails (nail care was performed the day before) and the resident could sometimes move his/her arms despite immobility and contractures. Given the scope and severity of the injury (bleeding from 2 abrasions) she did not believe it rose to the level of harm, especially given the fact that Resident #64's nails had sharp edges, the abrasion was not deep without need of a treatment, and the resident was elderly with very, very frail skin so the incident did not rise to the level of reporting to the State AgencyInterview with Occupational Therapist (OT) #1 on 7/29/26 at 11:04 AM identified that she was familiar with Resident #64 and had worked with him/her earlier in the year. OT #1 stated that Resident #64 required staff assistance to reposition his/her arms and to open his/her hands, as he/she was unable to do so voluntarily and independently due to degenerative joint disease. OT #1 further added that in order for Resident #64 to bring up and open his/her hands to the area of the abrasion (agreeing with NA #3's statement), staff would need to position him/her that way.Interview with the Administrator on 7/29/26 at 12:40 PM identified it was the facility's policy to investigate injuries of unknown origin by completing an Accident and Incident Report, interviewing within a 3-day look back, and if appropriate notifying the state agency. Review of Resident #64's incident on 7/4/26 identified she did not consider that an injury of unknown origin because the incident was thoroughly investigated and reviewed by the DNS with the conclusion that the resident holds his/her hands up to his/her face and the abrasion was self-inflicted due to jagged nails, even though nail care was performed the day before.Attempts to reach LPN #5 were unsuccessful.Review of the undated Abuse, Neglect and Exploitation Policy directed in part that it was the facility policy to provide protection for the health, wealth and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged violation is a situation or occurrence that is observed or reported by staff, resident relative, visitor, or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Additionally, identification of abuse, neglect and exploitation included in part possible indicators of abuse to include physical marks and physical injury of a resident of an unknown source. An immediate investigation is warranted when suspicion of abuse neglect or exploitation or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations focusing the investigation on determining if abuse occurred. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies to occur immediately but no later than 2 hours after the allegation was made but no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the undated Unexplained Injuries Policy directed in part that all unexplained injuries including bruises, abrasions, and injuries of unknown origin will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on a review of the clinical record, facility policy, and interviews for the only sampled resident, (Resident #13) reviewed for insulin administration, the facility failed to document notification to the provider for blood glucose levels outside of the prescribed parameters, and for 1 of 3 residents (Resident #109) reviewed for abuse, the facility failed to document an unusual occurrence in the medical record. The findings include: 1. Resident #13's diagnoses included type 2 diabetes, long-term use of insulin, and kidney failure. The quarterly Minimum Data Set assessments dated 5/22/26 identified Resident #13 had a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment, required daily insulin injections, and required set-up assistance to perform oral hygiene. The Resident Care Plan in effect on 5/22/26 directed diabetes monitoring. Interventions included to follow the hypoglycemic (low blood sugar) protocol as needed. A physician's order in effect on 5/22/26 directed facility staff to obtain blood glucose levels before meals and at bedtime and notify the provider if glucose levels are less than 70 or greater than 400. Additionally, a standing order to administer Humalog (quick-acting insulin) 2 units before meals, hold Humalog 2 units if glucose levels were less than 70mg/dL, administer insta-glucose and notify the provider, if glucose levels were greater than 351 mg/dL, administer 10 units of Humalog and notify the provider for further orders. Review of the clinical record, weights and vital sign sheet, and nursing and physician/Advance Practice Registered Nurse (APRN) notes identified the following: On 5/25/26 at 9:41 AM Resident #13 had a documented glucose of 383 mg/dL and at 11:56 AM, had a documented glucose of 391 mg/dL. Although the facility administered Humalog 10 units, documentation failed to indicate notification to the physician or APRN. On 5/27/26 at 8:18 AM Resident #13 had a documented glucose level of 66 mg/dL. The facility failed to administer insta-glucose per the physician order (the order had not been signed off as given) and failed to document notification to the physician or APRN. On 6/1/26 at 4:18 PM, Resident #13 had a glucose of 387 mg/dL. Although the facility administered Humalog 10 units, documentation failed to indicate notification to the physician or APRN. On 6/18/26 at 10:07 AM Resident #13 had a glucose of 61 mg/dL; A re-check at 10:25 AM, glucose of 61 mg/dL. The facility failed to administer insta-glucose per the physician order (the order had not been signed off as given) and failed to document notification to the physician or APRN. Review of the clinical record identified Resident #13 was discharged to the hospital and readmitted on [DATE]. Review of the readmission physician's order dated 6/27/26 directed staff to check finger stick glucose levels before meals and at bedtime, and to notify the provider if glucose levels are less than 70 or greater than 400. A standing order to administer Humalog 2 units before meals, with additional Humalog according to a sliding scale, hold Humalog 2 units if glucose levels were less than 70mg/dL, administer insta-glucose and notify the provider. Additionally, if glucose levels greater than 351 mg/dL, administer 10 units of Humalog and notify the provider for further orders. A physician's order dated 7/8/26 discontinued the standing order to administer Humalog 2 units before meals and sliding scale Humalog. A new sliding scale order for Humalog dated 7/8/26 directed staff to administer 10 units of quick-acting insulin for blood glucose levels between 401 mg/dL and 450 mg/dL and notify the provider to obtain further orders if Resident #13's blood glucose level was greater than 401 mg/dL. Review of clinical record, weights and vital sign sheet and nursing and physician/Advance Practice Registered Nurse (APRN) notes identified the following: On 7/8/26 at 8:33 AM, a glucose level of 65 mg/dL was documented. The facility failed to document notification to the physician or APRN. On 7/9/26 at 7:40 AM, Resident #13 had a glucose level of 50 mg/dL. The facility failed to document notification to the physician or APRN. On 7/23/26 at 5:11 PM, identified Resident #13 had a glucose level of 421mg/dL. The facility failed to document notification to the physician or APRN. Interviews with the DNS on 7/27/26 at 11:10 AM and 7/29/26 at 11:00 AM identified a progress note would pop-up to document the provider was updated and if there were any orders given and nursing should document when the provider is notified about a resident's change in status. Review of the Blood Glucose Monitoring policy directed, in part, staff to report critical test results to the physician timely. Review of the Notification of Changes policy directed, in part, staff to notify the resident's physician when there are circumstances that require a need to alter treatment. 2. Resident #109 's diagnoses included amyotrophic lateral sclerosis, anxiety disorder and diabetes with ketoacidosis with coma. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #109 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairments and required total assistance from staff for dressing, eating, bed mobility, transfer and toileting with functional limitations on both sides of upper and lower extremities. The Resident Care Plan dated 6/4/26 identified potential for alteration in mood related to ALS, and anxiety. Interventions included attempting nonpharmacological interventions first, medication as ordered, monitor for signs and symptoms of anxiety, monitor for signs and symptoms of depression, notify physician of changes, provide psychiatric evaluation and follow up as needed, social services to provide 1:1 visits as needed to address needs/concerns. A physician's order dated 6/30/26 directed to administer Alprazolam 0.5 milligrams orally twice a day related to anxiety. Interview with Resident #109 on 7/22/26 at 11:16 AM during initial screening identified that another resident, Resident #4, came into his/her room while he/she was sleeping and grabbed their ankle and shook him/her. This occurred around 6/15/26 but he/she was unsure of the exact date and indicated that the information was reported to the Director of Nursing. Resident #109 identified that Resident #4 continued to enter his/her room. The last occurrence was on Sunday 7/19/26 and he/she did not feel safe because he/she could not defend themselves as he/she was dependent on staff for care. Interview with The Director of Nursing (DON) on 7/22/26 at 2:50 PM indicated that she did hear about this issue and when she interviewed Resident #109, he/she said they may have dreamt it, was not sure, but that Resident #4 may have scratched Resident #109. The DON indicated that she was unaware that this was continued to happen adding that she did not think this occurrence actually happened. Resident #109 has a history of confabulating things when fighting with their online girlfriend/boyfriend. Subsequent to surveyor inquiry, a late entry nurse's note was written on 7/22/26, dated 6/16/26 at 3:02 PM. A re-interview with Resident #109 on 7/27/26 at 1:06 PM indicated that he/she told the nurses about the occurrence and asked to speak with the social worker when inquiring if the occurrence had been reported. Resident #109 further indicated that Resident #4 had not entered the room since the previous Sunday but had been screaming during the night and woke Resident #109 up. Resident #109 further indicated that he/she was fearful and concerned that Resident #4 may take a pillow and place it on my head or Resident #4 may pull me out of bed. Resident #109 indicated that he/she discussed this with the social worker. Resident #109 additionally indicated that the DON did speak with him/her. A review of nurse notes and social service notes from 6/1/26 to 7/26/26 failed to identify any unusual occurrence between Resident #109 and Resident #4 and failed to identify any confabulating behaviors or hallucinations. A nurse's note dated 7/27/26 at 5:37 PM indicated subsequent to surveyor inquiry, Resident #109 indicated he/she was fearful of Resident #4 coming into his/her room and putting a pillow over my face, Resident #109 would not be able to do anything to stop it if Resident #4 did that. The DON assured Resident #109 that interventions were in place to ensure Resident #4 did not enter his/her room uninvited this evening/night. A room change to a private room on a different hallway was offered and Resident #109 was hesitant to agree and wanted to discuss it with a family member and let the staff know the decision in the morning. Interview with Director of Nursing (DON)and Administrator on 7/28/26 at 2:01PM identified the medical record failed to reflect documentation of the unusual occurrence between Resident #109 and Resident #4. The Administrator indicated that she was notified that Resident #4 tickled Resident #109's feet. The DON indicated that she should have documented the occurrence in the medical record when she spoke with Resident #109 and this was her oversight. She further indicated she did write a late entry note subsequent to surveyor inquiry. Although requested, a facility policy for documentation was not provided. State Operations Manual Appendix PP 483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized

Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of two (2) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure a resident, who had a known history of forward leaning posture, impaired sitting balance, fatigue in the afternoon, and required staff assistance for transfers, was protected from falling forward from the wheelchair during a staff assisted transfer. This failure resulted in the resident falling forward from the wheelchair, striking the head, and sustaining cervical spine fractures. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10), used a walker and/or wheelchair within the last seven (7) days, and was dependent on staff for chair to bed and bed to chair transfers.The Resident Care Plan (RCP) dated 4/30/26 identified Resident #1 had a self care deficit related to cognitive impairment, decreased independence with activities of daily living (ADL), decreased strength and endurance, decreased range of motion, and fluctuating ADL performance. The RCP identified Resident #1 was at risk for falls related to muscle weakness and decreased balance. Interventions included assist of two (2) staff for transfers using a four wheeled walker, use of anti tippers on the wheelchair, and staff assistance with mobility.The Fall Risk Evaluation dated 4/14/26 identified Resident #1 scored fifteen (15), indicating a high fall risk.1.The Accident and Incident (A&I) form by LPN #1 dated 4/17/26 at 8:15 PM identified Resident #1 was found on the back with no injuries. A Nurse Aide (NA) identified Resident #1 lost strength during a transfer and was eased to the floor. The form identified Resident #1 required assistance for wheelchair mobility prior to the fall and had no change in mobility after the fall.A Situation, Background, Assessment Recommendation (SBAR ) note by RN #1 dated 4/17/26 at 11:04 PM identified Resident #1 had a fall and a referral to rehabilitation was ordered for transfer concerns in the evening hours.A Physical Therapy note dated 4/20/26 identified Resident #1 received gait training focused on correcting center of mass over base of support, symmetrical stance, and weight shifting. Resident #1 demonstrated retropulsion and required maximum cues for leaning forward and maintaining center of gravity.A Nurse's note by RN #1 dated 5/5/26 at 11:35 PM identified Resident #1's wheelchair posture included a forward leaning trunk and head at mid chest level. When asked to lift the head, Resident #1 was unable to do so. Transfers required moderate to maximum assistance in the evenings.2.The A&I form by RN #1 dated 5/13/26 at 3:00 PM identified Resident #1 was observed on the floor with no injuries. The form identified Resident #1 required maximum assistance for transfers prior to the fall and had no change after the event.An SBAR note by RN #1 dated 5/13/26 at 11:36 PM identified Resident #1 was witnessed on the floor on the right side and had impaired sitting posture earlier in the afternoon. Resident #1 bent at the waist and was unable to maintain upright shoulder positioning.A Physical Therapy note dated 5/14/26 at 2:22 PM identified a nursing referral was received to evaluate the wheelchair, possible need for tilt in space positioning, and concerns regarding poor sitting posture in the evenings. Therapy recommended using the recliner chair in the early afternoon for rest breaks and positional change.A Physical Therapy treatment note dated 5/14/26 identified Resident #1 had a fall from the wheelchair on 5/13/26. Nursing reported Resident #1's posture tended to flex forward later in the day, likely related to fatigue due to spending extended periods in the wheelchair. Therapy again recommended transferring Resident #1 to the recliner after lunch for rest breaks and positional change.3.The A&I form by RN #2 dated 5/19/26 at 5:35 PM identified Resident #1 was being pushed in the wheelchair to the dining room by NA #1 when Resident #1 fell forward from the wheelchair and struck the head on the floor. Resident #1 was sent to the hospital.A Nurse's note by RN #2 dated 5/19/26 at 6:32 PM identified Resident #1 fell forward from the wheelchair, resulting in an abrasion with bleeding to the left forehead.The Hospital Discharge summary dated [DATE] identified computed tomography (CT) imaging revealed a posteriorly angulated type II dens fracture, minimally displaced fractures of the bilateral posterior arch of C1, and a possible minimally displaced left C4 lamina fracture.The Resident Care Plan (RCP) updated on 5/23/26 identified Resident #1 had a self care deficit related to cognitive impairment, decreased independence with activities of daily living (ADL), decreased strength and endurance, decreased range of motion, and fluctuating ADL performance. The updated intervention was to recommend utilizing the recliner after lunch for a change in position.Interview with RN #1 on 6/5/26 at 12:50 PM identified Resident #1 leaned forward in the wheelchair most afternoons, possibly due to fatigue or disease process. She identified she submitted a referral dated 5/13/26, to rehabilitation for decreased transfer ability in the afternoons and it was suggested to use a mechanical lift for transfers. Resident #1 previously self propelled the wheelchair but lost that ability and had decreased lower extremity strength in the evenings. She identified leg rests should be used when assisting Resident #1 in the wheelchair due to fatigue and forward leaning.Interview with NA #1 on 6/5/26 at 12:58 PM identified she worked the 3:00 PM to 11:00 PM shift on 5/19/26 and Resident #1 had been in the wheelchair since the start of the shift. Resident #1 was leaning forward when she pushed the wheelchair to the dining room, and she did not use leg rests. She identified she normally did not use leg rests for Resident #1.Interview with the Rehabilitation Director on 6/5/26 at 1:18 PM identified forward leaning posture and fatigue were recent concerns. Therapy recommended transferring Resident #1 to the recliner for rest breaks. Resident #1's baseline posture included forward leaning with the head down.Interview with the Director of Nursing Services (DNS) on 6/5/26 at 1:50 PM identified Resident #1 was on the Physical Therapy caseload and that therapy would identify a need for leg rests. She identified leg rests were not included in the RCP. She identified Resident #1's body position naturally leaned forward. She identified Resident #1 would go to bed after lunch and then Resident #1's family member would visit every day around 2:30 PM and Resident #1 would be placed back into his/her wheelchair.The Safe Resident Handling and Transfers policy identified residents require safe handling to prevent or minimize risk of injury to the resident and employees. It identified lifting and transferring should be performed according to the resident's individual plan of care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #2 and #3) reviewed for abuse, the facility failed to ensure the State Agency was notified timely when the facility had knowledge of an allegation of mistreatment and an injury of unknown origin. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #2 and #3) reviewed for abuse, the facility failed to ensure the State Agency was notified timely when the facility had knowledge of an allegation of mistreatment and an injury of unknown origin. The findings include: Resident #2's diagnoses included heart failure and atrioventricular heart block. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required substantial/maximal assistance with bathing and lower body dressing, partial/moderate assistance with bed mobility, toilet hygiene, transfers, ambulation and wheelchair use. The Resident Care Plan (RCP) dated 11/4/2025 identified Resident #2 had self-care deficit, interventions directed ADLs, bed mobility with assist of one (1), and transfers with assist of one (1) with four-wheeled walker. A physician order dated 10/29/2025 directed Plavix oral tablet 75 mg (milligrams) (Clopidogrel Bisulfate - antiplatelet medication used to prevent blood clots) give one (1) tablet by mouth one time a day for heart failure, atrial fibrillation and coronary artery disease, and Aspirin EC (enteric coated) tablet delayed release one (1) tablet one time a day for heart failure and atrial fibrillation. Nursing note (late entry by the ADNS) dated 11/10/2025 at 3:15 PM identified Resident #2 was noted to have a discolored area on the back of the left upper arm that measured 22.5 centimeters (cm) (8.8 inches) by 10 cm (3.9 inches). Resident #2 was unaware of the discolored area, denied pain, appropriate parties were notified and an order was placed to monitor (the area). APRN note dated 11/10/2025 at 8:30 AM identified Resident #2 was seen for significant discoloration on the back of the left bicep (upper arm) that is trending to the elbow, combination of petechiae, purpura (purple or reddish spots on the skin caused by blood leaking from small vessels, appearing as bruises that don't fade when pressed and can range from tiny dots (petechiae) to larger patches) and ecchymosis (bruising), no pain at site, warm and dry elsewhere, turgor normal, likely due to dual antiplatelet therapy with aspirin and Plavix, follow up with cardiologist next week. Review of skin assessment dated [DATE] indicated Resident #2 had a discolored area 22.5 centimeters (cm) (8.8 inches) by 10 cm (3.9 inches) to left elbow. Review of anonymous photos provided to surveyor identified the back of Resident #2's left arm was noted to be dark purple covering the entire back of the arm from just below the deltoid (top of the arm muscle) to below the elbow, and encompassed the entire width of the arm. Review of facility requested list of accident/incidents (A & I) provided on 12/22/2025, dated from 11/4/2025 to 12/15/2025 failed to include any incident reporting for Resident #2.Review of CT's Department of Health's FLIS Events Report Tracking System identified the facility failed to identify the State Agency was notified of the allegation on 11/10/2025 of rough care and new bruising measuring 22.5 cm x 10 cm to the left elbow.Interview, record review on 12/22/2025 at 1:03 PM with PTA #1 identified when she was working with Resident #2 on 11/10/2025, she noted the resident had a big dark bruise on his/her arm and she reported it to the ADNS and supervisor. PTA #1 stated Resident #2 had told her the night girl was a little rough, did not know her name, but implied it was an aide. PTA #1 stated she notified the ADNS/ nursing supervisor and her supervisor that Resident #2 had stated someone was kinda rough. On 12/22/2025 at 11:59 AM interview and record review with the ADNS identified Resident #2 was working with Physical Therapy Aide (PTA #1) on 11/10/2025 when the ADNS and LPN #2 saw the back of the Resident #2's arm as PTA #1 walked Resident #2 past them. The ADNS stated she spoke with PTA #1 who indicated during the therapy session PTA #1 observed the whole back of Resident #2's arm was dark purple. Resident #2 denied pain, and Resident #2 stated to the ADNS that someone had been rough with him/her and they grabbed his/her arm hard when weighing him/her. The ADNS stated weights are obtained by the overnight staff. The ADNS stated although the allegation of rough treatment was made by Resident #2 on 11/10/2025, she completed an incident report on 11/12/2025 (two days after the allegation) and gave it to the DNS who completed the investigation. Further, the ADNS stated she should have completed the incident report when Resident #2 made the allegation of rough care on 11/10/2025 and stated the State Agency should have been notified. Interview failed to identify why the incident report was completed two (2) days after the allegation. The ADNS stated she did not notify the State Agency because she did not have access to the on-line reporting system; she stated she had last attempted to obtain access to the system about one (1) year ago.Interview and record review with LPN #2 on 12/22/2025 at 1:27 PM identified therapy was working with Resident #2 she and the ADNS were sitting at the nursing station when Resident #2 walked by, and they observed Resident #2 had a large bruise to the back of his/her left arm. Resident #2 stated that the overnight aide was weighing him/her in the standing position and put his/her hand on the resident's arm. LPN #2 stated Resident #2 had told her that he/she didn't think the aide did it on purpose but it happened while being weighed.Interview with Resident #2 on 12/22/2025 at 11:54 AM identified some staff are rough with care but was unable to identify any individual staff member. Resident #2 stated he/she did have bruising issues on the left arm/elbow recently, and could not identify how the bruise on his/her arm occurred. Interview, clinical record review and facility documentation review with the DNS on 12/23/2025 at 12:56 PM identified Resident #2 was alert and oriented, and after she was notified about the bruise, she interviewed Resident #2 at unspecified time on 11/10/2025, and again on 11/11/2025. The DNS stated that the interview did not identify an injury at the time and Resident #2 reported he/she felt safe. Resident #2 reported the night staff get him/her up to a wheelchair for weighing on the scale chair and it is very hard and the aide has a strong voice. The DNS stated Resident #2 was asked if he/she had any concerns out of normal and if anyone did anything on purpose. Resident #2 denied any concerns, and gave no indication harm was intentional. The DNS stated the bruise was large, but Resident #2 was receiving anticoagulants. Review of the incident report list with the DNS failed to identify the 11/10/2025 allegation was included on the list. The DNS stated that she had an incident report for the allegation, but it was in her separate (soft) file and she did not include any of her records with the requested incidents because they were her files and not included in the facility incident reports. Although Resident #2 had verbalized to two (2) facility staff that a Nurse Aide (NA) was rough with care and had a 22.5 by 10 cm bruise, the DNS stated she did not notify the State Agency of the allegation because when she and the Administrator interviewed Resident #2 he/she did not say it was intentional. The DNS stated allegations of mistreatment are required to be reported to the State Agency within two (2) hours and she could have reported the allegation to the State Agency and then done her investigation instead of investigating first to determine if it was abuse. The DNS stated she should have reported the allegation first and then submitted the results of her investigation that it was not abuse.Review of additional information provided after surveyor exit dated 11/10/2025 (without a time indicated), identified the DNS interviewed Resident #2 after the allegation and after the bruise was identified and Resident #2 had indicated the hard weight scale may have been part of it. Resident #2 indicated the NA on the 11 PM to 7 AM shift tends to be quick and stated no one was mean or mistreated him/her. The documentation identified Resident #2 was receiving Plavix and Aspirin and had a history of purpura. Resident #2 was interviewed again on 11/11/2025. 2. Resident #3's diagnoses included Alzheimer's, atrial fibrillation and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment, had limited mobility of both upper extremities, and was dependent for ADLs (activities of daily living). The Resident Care Plan (RCP) dated 9/29/2025 identified a self-care deficit, contractures, and risk for alteration in skin integrity. Interventions directed one (1) staff assist for bathing, dressing and two (2) staff for Hoyer lift transfers, apply splints as ordered, and monitor for bruising. Nursing note dated 12/3/2025 at 12:08 PM and 5:02 PM identified the RN (supervisor) was called at approximately 12 PM to assess Resident #3. The NA reported bilateral bruising under Resident #3's arms/armpits. Resident #3 was unable to describe the cause of the bruising. The APRN was notified, and staff were notified to use two (2) staff for care when transferring or repositioning Resident #3. Further, the note identified clothing was reviewed with the family and anything too tight or too small was sent home to make dressing easier. Record review failed to identify Resident #3 received any routine anticoagulant (blood thinner) or Aspirin. Review of facility incident report identified on 12/3/2025 at 11:45 AM Resident #3 was found to have bruising to bilateral upper extremities, right arm 9 x 4 cm and left arm 3.5 x 3 cm, discomfort when dressing resident, bruising under arms/armpit bilateral upper extremities. No staff witnesses, the APRN was notified, and the care plan was updated for two (2) for care, and loose clothing. Additional review of the incident report identified the section labeled investigation initiated was checked with the answer No. Upon further review, two (2) statements were attached to report by the two (2) Nurse Aides (NAs) who reportedly found the bruising on Resident #3. Although requested, no further investigative reporting, summary or findings information was provided for surveyor review. Review of CT's Department of Health's FLIS Events Report Tracking System identified the facility failed to notify the State Agency of the bruising of unknown origin identified by staff on 12/3/2025. Review of anonymous photos provided to surveyor identified the right armpit area and the area of the upper inner arm/bicep area and the side of the chest had a yellowish-blue and dark purple discoloration/bruise and the arm just above the bend of the elbow had three (3) dark purple circular areas approximately the same size as the fingers in the photo, surrounded by yellowish purple bruising and a small red open slit in the upper underarm area. Review of the left armpit photo identified the armpit area was dark brown/purple surrounded by greenish/yellow bruising. Interview and record review with the ADNS on 12/22/2025 at 11:59 AM identified Resident #3 had contractures and needed his/her care to be provided gently. The ADNS stated Resident #3 had a bruise in the shape of a handprint under his/her right underarm with four (4) fingerprint marks on his/her arm and bruising under his/her left underarm/armpit area. The ADNS stated the bruising appeared as if someone may have grabbed Resident #3 from behind and lifted or maybe boosted the resident incorrectly, or it may have occurred when staff dressed Resident #3 due to his/her contractures. The ADNS stated the incident should have been reported to the State Agency and she did not notify the State Agency because she did not have access to the on-line reporting system; she stated she had last attempted to obtain access to the system about one (1) year ago. Interview, review of clinical record and facility documentation with the DNS on 12/23/2025 at 12:56 PM identified Resident #3 required total assistance with personal care and on 12/3/2025 was noted to have bruising to the bilateral upper extremities in the underarm/armpit area. The DNS stated she completed an investigation and she did not notify the State Agency of the injury of unknown origin; the DNS stated she completed her investigation first and stated she thought the bruising was caused by tight clothing. The DNS stated she put the investigation off to the side because she had completed the investigation, and she did not reach out/call the State Agency to clarify if it was a reportable event (if it should be filed). The DNS stated she felt if it was investigated and found a reasonable reason for why it happened, so it did not need to be reported. Review of the undated facility Incidents and Accidents Policy directed in part, incidents of abuse will be managed and reported according to the facility abuse prevention policy. Alleged abuse require an incident report. Review of CT's Department of Health's Public Health Code 19-13-D8t Reportable Event(s) directed in part, a Class B event was a complaint of patient abuse or an event that involves an abusive act to a patient. Class B events require immediate notice by telephone to the Department.Review of facility the undated Abuse, Neglect and Exploitation Policy directed in part, physical abuse included but was not limited to hitting, slapping, and punching. Possible indicators of abuse include resident reports of abuse, physical marks such as bruising or patterned appearances such as a hand print on a resident's body. The Policy further directed all alleged violation to be reported to the State Agency immediately, but not later than 2 hours after the allegation is made.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for falls, the facility failed to provide adequate supervision for a resident at high risk for falls, who sustained seven (7) falls since admission to the facility leading up to a fall with injury. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare following an amputation and dementia. Resident #1's family member was his/her health care proxy.Review of the hospital Discharge summary dated [DATE] identified Resident #1 had impaired cognitive status, was disorientated to place, time and situation, had decreased awareness for safety, decreased awareness of deficits and was difficult to re-orient.The Nursing admission assessment dated [DATE] at 1:02 PM identified Resident #1 was orientated to person and confused, had episodes of bladder incontinence, was non-ambulatory and required staff assistance with elimination. Resident #1 could not bear weight and/or must have been assisted into chair or wheelchair. A Fall risk assessment dated [DATE] at 1:02 PM identified Resident #1 had a score of eight (8) indicating he/she was at low risk for falls. Physician's orders dated 10/7/25 directed Trazodone (antidepressant medication sometimes used to assist with sleep) 50 mg half tablet every 12 hours as needed for sleep or agitation. Physician's orders dated 10/7/25 directed non-weight bearing due to LLE amputee. 1. An Accident and Incident form (A&I) dated 10/8/25 at 1:30 PM identified Resident #1 had an unwitnessed fall and was found on his/her buttocks in front of his/her recliner. Resident #1 had an abrasion to his/her upper back; the APRN was notified and ordered a dressing. The RCP dated 10/8/25 identified Resident #1 was at risk for falls. Interventions included bed in lowest position, call bell within reach, transfer with assistance, lock wheelchair brakes prior to transfer and keep room free of clutter. 2. The A&I dated 10/9/25 at 12:15 AM identified Resident #1 had an unwitnessed fall from his/her bed to the floor with no injuries. The APRN and health care proxy were notified. The RCP was updated on 10/9/25 with interventions for bolsters to the side of the bed to promote boundary awareness and padding to the floor along the bed edge. A Psychiatric note dated 10/9/25 recommended to discontinue Trazadone due to reported inefficacy and initiate Seroquel (antipsychotic medication used to manage behavioral symptoms) 12.5 mg at bedtime. A Physician's order dated 10/9/25 - 11/3/25 directed Seroquel 12.5 mg every 12 hours for agitation/restlessness. A Nursing note dated 10/9/25 at 2:44 PM identified Resident #1 had complaints of back pain, the APRN was updated and directed a spine X-ray. The spine X-rays identified there were no compression deformities or fractures demonstrated radiographically. A note by APRN #1 dated 10/10/25 identified Resident #1 had recent falls and continued to be impulsive and unaware of limitations secondary to cognitive deficits. The note directed to continue scheduled Seroquel for behaviors, anxiety and agitation. 3. The A&I dated 10/11/25 at 10:20 AM identified Resident #1 had an unwitnessed fall without injuries when attempting to go to the bathroom. The health care proxy and APRN were notified with no new orders. A Nursing note dated 10/11/25 at 10:34 AM identified Resident #1 was found on floor and stated he/she was going home. The note indicated Resident #1's health care proxy was updated and requested a private duty Nurse Aid (NA) but was unwilling to pay. The RCP was updated on 10/11/25 with an intervention to check the incontinence brief and offer the urinal every two hours. A note by APRN #1 dated 10/12/25 identified Resident #1 had multiple recent falls and continued to require 1:1 supervision as he/she was impulsive with transfers. The note indicated a 1:1 private NA was discussed due to continued behaviors and fall risk. 4. The A&I dated 10/13/25 at 2:00 PM identified Resident #1 had an unwitnessed fall without injury and was found on the floor in his/her room with his/her head near the recliner. The APRN was updated. 5. The A&I dated 10/14/25 at 7:30 AM identified Resident #1 was witnessed sliding out of a standard wheelchair in the hallway. Resident #1 was assisted to the floor and had no injuries. The APRN and health care proxy were updated. An Occupational Therapy (OT) note dated 10/14/25 at 9:32 AM identified Resident #1 was evaluated for positioning in a tilt-in-space wheelchair (wheelchair that tilts the entire seating system for positioning and support) and would trial a Velcro removable lap tray to decrease falls. The RCP was updated on 10/14/25 with an intervention to apply a Dycem (wheelchair cushion) to chair/wheelchair. A Nursing note dated 10/15/25 at 1:20 PM identified a self-releasing lap buddy was applied to Resident #1's wheelchair by OT and Resident #1 was able to remove the lap buddy independently without cueing or assistance. A note by APRN #1 dated 10/15/25 identified Resident #1 continued to demonstrate impulsive behaviors and was unaware of limitations secondary to cognitive deficits. Resident #1 continued to require supervision as he/she was impulsive with transfers. 6. The A&I dated 10/16/25 at 10:00 PM identified Resident #1 had an unwitnessed fall and was found by his/her recliner, next to the bed, with no injuries. The APRN and health care proxy were updated. The RCP was updated on 10/16/25 with the intervention to have the psychiatric provider see Resident #1. A Nursing note dated 10/17/25 at 4:11 PM identified Resident #1's health care proxy was interested in hiring a private NA for Resident #1 and was provided with information. A note by the Social Worker dated 10/17/25 at 4:19 PM identified the team discussed Resident #1's behaviors and plan of care with Resident #1's health care proxy and Resident #1 would have a private NA from 10 pm to 5 am seven days per week beginning 10/18/25. A note by APRN #1 dated 10/17/25 identified Resident #1 had a fall overnight, continued to require frequent redirection, continued to demonstrate impulsive behaviors and was unaware of limitations secondary to cognitive deficits. Resident #1's son was agreeable to hire 1:1 assistance to help with the overnight hours from 10:00 PM to 5:00 AM with services beginning 10/18/25. A note by LPN #5 dated 10/18/25 at 7:26 AM identified Resident #1 was placed on 1:1 supervision due to behaviors and attempts to get out of bed during the night. A note by LPN #4 dated 10/18/25 at 9:45 PM identified Resident #1 made multiple attempts to self-transfer in and out of the wheelchair and in and out of bed and was re-directable for a short period. A note by LPN #1 dated 10/19/25 at 4:30 AM identified Melatonin 3 mg was administered due to insomnia. Resident #1 was up all shift, restless, confused, verbally abusive at times and attempting to climb out of the wheelchair. Close monitoring was in place from all staff members to maintain safety and wellbeing. A note by LPN #1 dated 10/19/25 at 6:23 AM identified Resident #1 continued with behavioral episodes and was still climbing out of bed. 7. The A&I dated 10/19/25 at 2:50 PM identified Resident #1 had an unwitnessed fall. Resident #1 complained of right sided rib discomfort and was transferred to the ED per the APRN and health care proxy. A note by RN #1 dated 10/19/25 at 4:06 PM identified Resident #1 had combative behaviors at the start of the shift. The previous supervisor from the 11:00 PM to 7:00 AM shift reported Resident #1 was combative with staff through the night and the private NA left the facility thirty minutes after arriving. Resident #1's health care proxy was updated by phone and agreed with transferring Resident #1 to the ED for a medication evaluation. Per the ADNS, instructions were given to change Resident #1's room to a private room. Around 3:00 PM, Resident #1 had an unwitnessed fall and left by ambulance at 3:33 PM. A note by LPN #3 dated 10/19/25 at 4:16 PM identified she was walking down the hallway and heard Resident #1 yelling for help. Resident #1 was found lying on the floor on his/her back in another resident's bathroom. Resident #1's right wheelchair foot pedal was observed positioned against the right side of his/her ribcage. Resident #1 was transferred to the ED. The RCP was updated on 10/19/25 with the intervention for a chair alarm to seating device when out of bed. A Physician's order dated 10/19/25 directed a chair alarm. The ED Discharge summary dated [DATE] identified Resident #1 had no acute intracranial findings and no acute fracture or traumatic malalignment of the cervical spine. A Physician's order dated 10/21/25 directed a STAT (now) X-ray of the spine for back pain. A Nursing note dated 10/21/25 at 10:14 AM identified Resident #1 complained of lower back pain and scheduled medications had no effect. The APRN was notified and ordered a one-time dose of pain medication and STAT X-rays of the spine. The X-ray showed a stable L1 fracture, not noted on the 10/19/25 X-ray. The APRN and health care proxy were notified and transferred Resident #1 to the ED. Review of Resident #1's A&I's identified Resident #1 had no further documented falls between 10/19/25 to 10/21/25 (when his/her spine fracture was identified) but did have five (5) more documented falls without injury after 10/21/25. Interview with LPN #5 on 11/17/25 at 12:00 PM identified she was the nurse assigned to provide care for Resident #1 during the 11:00 PM to 7:00 AM shift on 10/17/25. She identified Resident #1 was on 1:1 supervision during the night due to Resident #1's behaviors and attempting to get out of bed during the shift. She identified the 1:1 NA left at 6:00 AM and was not replaced. She could not identify if the 1:1 NA was a facility NA or private NA. She identified she reported to the oncoming nurse that the 1:1 NA left at 6:00 AM and Resident #1 needed to be watched due to his/her behaviors. Interview with LPN #4 on 11/18/25 at 1:00 PM identified she was the nurse assigned to provide care for Resident #1 during the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift on 10/18/25. She identified Resident #1 needed frequent monitoring due to frequent attempts to get out of his/her chair. She identified she would sit with Resident #1, listen to him/her, validate his/her feelings and distract him/her. She identified Resident #1 was pleasant when she calmly re-directed him/her. She identified Resident #1 did not have orders for 15-minute safety checks or 1:1 supervision. She identified the facility did not have the ability to schedule a 1:1 NA due to a lack of staffing. She identified Resident #1 did not have a private NA but soon would. Although multiple attempts were made, an interview with LPN #1 who worked 11:00 PM to 7:00 AM on 10/18/25 into 10/19/25 was not obtained. Interview with LPN #2 on 11/14/25 at 1:56 PM identified she was the nurse assigned to provide care for Resident #1 during the 7:00 AM to 3:00 PM shift on 10/19/25. She identified Resident #1 attempted to get out of bed during the shift, which was normal behavior for him/her. She identified Resident #1 was agitated and confused and was kept by the nursing station during the day. She identified Resident #1 was only re-directable for a short time. She identified Resident #1 was not receiving 1:1 supervision or 15-minute safety checks. Interview with RN #1 on 11/14/25 at 2:01 PM identified she was the RN supervisor for the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift on 10/18/25, and the 7:00 AM to 3:00 PM shift on 10/19/25. She identified Resident #1 had worsening dementia, was unpredictable, and had worsening behaviors during the afternoon/night. She identified that during morning report, she was notified Resident #1's private NA walked out of the facility at midnight due to Resident #1's aggression. She identified that at the start of her shift, around 10:00 AM, she asked Resident #1's POA to come into the facility to help calm Resident #1 down or, alternatively, Resident #1 would need to be transferred to the hospital for an evaluation. Resident #1's POA refused and requested Resident #1 be transferred to the hospital so she began the hospital transfer paperwork. She identified when she went into Resident #1's room, Resident #1's POA was present in the room and upset. She identified RN #2 assisted Resident #1 while she (RN #1) and Resident #1's POA left the room. She identified Resident #1 had a room change to a different hallway and shortly thereafter a nurse called her and informed her Resident #1 fell. She identified Resident #1 was not receiving 15-minute safety checks or 1:1 supervision and that 1:1 supervision would be unrealistic due to staffing challenges. Interview with LPN #3 on 11/14/25 at 1:40 PM identified she was at the nursing station at the start of the 3:00 PM to 11:00 PM shift on 10/19/25, when another nurse stated, where's Resident #1?. She identified she walked down the hallway and heard yelling coming from another Resident's room. Resident #1 was found on the floor in the bathroom. Interview with the DNS on 11/14/25 at 3:00 PM identified Resident #1 had no documented close observations during his/her time in the facility (e.g. 15-minute safety checks or 1:1 supervision). She identified staff were aware of keeping an eye on Resident #1 because he/she was quick and staff tried to keep him/her at the nursing station during the day for observation. She identified the facility did not have the ability to meet Resident #1's needs and was looking into other facilities equipped with a secure dementia unit. Review of the fall prevention program directed for each resident to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on clinical record review, review of facility policy and interview for 1 of l resident (Resident # 223) at risk for dehydration, the facility failed to consistently monitor the resident's intake and output per policy. The findings include: Resident #223's diagnosis includes End Stage Renal Disease. The Dietary Nutrition assessment dated [DATE] indicated Resident #223's daily (24 hour) fluid needs of 1440 Cubic Centimeter (CC). A physician's order dated 1/27/24 at 9:03 PM directed to monitor Intake and output every shift for 3 days or until the goal has been met and laboratory blood work orders are reviewed by the physician or Advanced Practice Registered Nurse (APRN). The admission MDS assessment dated [DATE] indicated Resident #223 was cognitively intact and received transfusions and specialized services while not a resident A review of Resident # 223's Comprehensive Intake and Output Record dated 1/28/23 through 2/20/23 identified 9 missing entries from 1/28/23 through 2/13/23, 5 missing entries from 2/15/23 through 2/20/23 and no documentation from 2/3/23 through 2/7/23. The care plan dated 2/10/23 indicated Resident #223 was at risk for dehydration. Intervention included: dietician to provide estimated fluid needs, monitor, document, and report any signs or symptoms of dehydration including decreased or no urinary output, obtain laboratory blood work as ordered and notify physician/APRN with any changes, encourage fluids if not contraindicated. The care plan 2/10/23 further indicated Resident #223 requires specialized treatment and noted at risk for shortness of breath, blood pressure elevation and edema due to specialized treatments. Interventions included, in part, arranging specialized treatment visits on Monday, Wednesday, and Friday, and to monitor intake and output as ordered. Interview and record review with the Director of Nursing Services (DNS) on 1/8/25 at 1:32 PM indicated there really is no fluid goal for any resident to meet. Fluid goals are nursing judgment along with the physician or APRN who determines if monitoring of intake and output is needed or no longer needed. After reviewing the Comprehensive Intake and Output Record for Resident #232 dated 1/28/23 through 2/20/23 identified 9 missing entries from 1/28/23 through 2/13/23, 5 missing entries from 2/15/23 through 2/20/23 and no documentation from 2/3/23 through 2/7/2023 noted for the resident's intake and output. On the above dates there was no way to identify if Resident # 223 met his/her fluid goal based on the dietician assessment/31/23. The DNS further indicated there was no other location for documentation of Resident # 232's intake and outputs and she/he was unsure if in 2023 the electronic system utilized by the facility had documentation and indicated she/he could not access the above records. The DNS also could not explain why Resident # 223's intake and output from 1/28/23 through 2/20/23 was incomplete and had missing intake and output entries. The amount taken in and out over the 14-hour period had no total during Resident #223's stay. The DNS indicated it is the 3-11 PM nurses' responsibility to total the 24-hour intake and output for residents. The facility policy, in effect during Resident #223's stay labeled Intake and Output indicated in part nursing personnel would keep an accurate record of a resident's fluid balance per the physician's orders. The policy also indicated the 11-7 AM nurse implements a new weekly Intake and Output worksheet every Sunday night and the 3-11 PM nurse would total the 24-hour amounts taken in and out on the worksheet at the end of the shift. The 7-3 PM nurse would update the residents' physician and family if the residents' 24-hour totals were not consistently meeting the daily required amount over a 3-day period.

Based on observations, clinical reviews, review of facility documentation, policy reviews and interviews for 2 of 5 residents reviewed for Accidents for ( Resident # 59), the facility failed to apply footrest to the resident's wheelchair according to the plan of care to prevent an accident and for (Resident # 78), the facility failed to ensure a resident requiring assistance with transfers was free from accidents resulting in an injury. The findings included: 1. Resident #59 's diagnoses included displaced avulsion fracture, difficulty walking and spinal stenosis lumbar region without neurogenic claudication. The quarterly Minimum Data Set (MD) assessment dated [DATE] identified Resident #59 as cognitively intact and noted the resident required maximal assistance with bed mobility. The assessment identified dependent from chair to bed and toilet with transfers. Additionally, the assessment noted the utilization of a manual wheelchair. The Resident Care Plan (RCP) dated 6/19/24 for potential/ actual alteration in mobility. An intervention (updated 10/28/24) directed to place footrests on wheelchairs when transporting Resident #59. A nursing progress note dated 10/28/24 at 10:38AM identified Resident #59 as alert and pleasant. The note further indicated Resident #59 complained of pain to his/her right ankle and foot. Resident #59 stated when he/she was in his/ her wheelchair yesterday (10/27/24) a staff member (Recreational Assistance #1) offered to push him/her in the wheelchair. Resident #59 reported during the transport by Recreational Assistance #1 on 10/27/24 she/he twisted her/his ankle because her/his foot was not lifted. The Nurse Practitioner was updated regarding Resident # 59's complaint of pain to the right ankle and directed staff to obtain an X-ray of the resident's right ankle and foot. A nursing progress note dated 10/28/24 at 1:53 PM identified Resident #59 complained of increased right ankle pain from yesterday (10/27/24). Resident # 59 reported during the transport on 10/27/24 in the wheelchair by Recreational Assistant #1 her/his foot touched the ground, and her/his ankle got twisted. Resident # 59 reported she/he did not have the footrests on her/his wheelchair as she/he likes to move around in room without them. The APRN was notified today of the incident. An x ray of the right ankle identified negative results. An intervention was put in place which directed staff to ensure footrests are applied to wheelchairs when transporting residents. The Accidents and Incident Report dated 10/28/24 indicated Resident# 59 complained of pain and reported yesterday (10/27/24) when she/he requested assistance with transportation Recreational Assistant #1 transported her/him in the wheelchair at which time her/his foot touched the ground, and his/her ankle twisted. Resident #59 complain of increased pain. For Disposition the report noted right foot and ankle assessed and noted with redness, bruising and swelling. A nursing progress note dated 10/29/2024 at 10:59 AM identified Resident #59 was transferred to the Emergency Department (ER) per Advanced Practiced Registered Nurse (APRN) order for further imaging of right foot. The X-ray performed yesterday in the facility was inconclusive, showing possible mildly displaced fractures of right foot. Resident #59 refused to go to hospital yesterday due to family visiting and facility Halloween party. Resident #59 and family were agreeable to the transfer to hospital today. Resident 59 was transferred via Emergency Medical Services (EMS) at this time. The resident's family was notified of transfer and will meet Resident #59 at the hospital. A nursing progress note dated 10/29/24 at 9:31 PM identified Resident #59 returned from the emergency room with a diagnosis of a Fractured Talus, (Talus Avulsion Fracture). A boot was given to Resident #59 to wear when weight bearing. Further instructions directed the following: boot does not need to be worn when in bed or when seated, patients need to follow-up with New England Orthopedics. A physician's order dated 10/29/24 directed to elevate right leg on pillows while in bed, to elevate right leg lower extremity while seated in wheelchair and to wear walking boot when weight bearing standing/ walking. Additionally,the physician order directed no boot on while seated in bed. The RCP dated 12/6/24 noted a diagnosis on 10/29/24 for right talus avulsion fracture (small break in the ankle bone). Interventions included: checking Circulation, Motion and Sensory (CMS) of affected area every shift, elevating right leg on pillows while in bed, elevating right lower extremity while seated in wheelchair every shift. Follow-up medical appointments as needed, ice pack to right ankle as ordered, physical therapy, occupational screen/evaluation as needed. 0n 1/3/25 11:15 AM observation of Resident # 59 identified the resident sitting in the room with his/her right foot elevated with a foot device on. Resident #59 reported she/he has a broken his/her ankle due to twisting of foot in the wheelchair. Interview with Recreation Assistant #1 on 1/07/25 at 12:42 PM identified the day in question (10/27/24) there was a game planned for recreation. She also indicated she/he assists residents who are not able to ambulate on their own to and from activities. Recreation Assistance #1 reported, Resident #59 appeared to be struggling making it back to his/her room, therefore she offered to assist Resident # 59. She directed Resident #59 to pick up his/her feet during the transport secondary to the resident not having foot/ pedals on the wheelchair. Recreation Assistant #1 also indicated prior to the in-service after the incident residents who used their foot to scoot, never had a foot pedal on their wheelchair. However, since the in-service; all residents in a wheelchair have a foot pedal. She also indicated now residents have to put their foot on the pedal prior and during transport. Interview with Director of Nursing Service (DNS) on 1/8/25 at 8:31 AM identified Resident #59 historically self-propels. Resident #59 on the day of the incident was returning to his/her room from a recreation activity when Resident # 59 signaled Recreational Assistant #1 to help get her/him back to the room. The DNS further indicated the first choice is to put foot pedals on, however, if residents are alert and oriented and request transport and can put their foot up, staff would help. The DNS indicated the facility policy directs residents to be transported in a wheelchair with foot pedals on. DNS also indicated staff were made aware of this policy prior to the incident involving Resident #59. Interview with the Medical Director (MD) 1 on 1/8/25 at 10:38 AM identified any support of the ankle would have prevented the injuries. He believes the foot pedal would have provided the support needed to prevent the injury. The Medical Director also indicated the facility should be aware of the need for foot pedals and in servicing is required with staff is not aware. An interview with the Rehabilitation Director Occupational Therapist (OT #1) on 1/8/25 at 10:58 AM indicated proper use of a wheelchair would require residents to have leg rest while being transported. She also indicated that every resident should have a footrest. The Rehabilitation Director further indicated that without the proper leg rest the risk of injury is imminent. After inquiry, the Facility Wheelchair Transport/ Leg rest Policy was reviewed and revised on 10/30/24. The wheelchair Transport/ Leg rest policy in part notes, leg rests will be utilized on wheelchairs when transporting any resident that cannot hold their legs up independently. 2. Resident #78 had diagnoses that included dementia, anxiety and depressive disorders. The Minimum Data Set, MDS assessment dated [DATE] identified Resident #78 as severely cognitively impaired and required substantial maximum assist sitting to standing and transfers. The Resident Care Plan, RCP dated 10/14/24 identified Resident #78 had an actual self-care deficit related to cognition, decreased range of motion, was at risk for falls with a previous fall history and a potential alteration in mood due to anxiety. Interventions directed resident to have the assistance of two for all hands-on care, pivot transfer with assist of two using a pivot disk (assistive device to aide in transfers) and ensure needs were being met. The physician's orders dated 11/2/24 directed assist of two for all hands-on care every shift. The nurse's note dated 11/18/2024 at 10:42 PM identified at 8:40 PM, Resident #78 was found laying on floor between beds following a witnessed fall by Nurse Aide,(NA #5). NA #5 stated Resident #78 pushed off the wheelchair to transfer to bed at which time the wheelchair rolled backwards, and Resident #78 slid to the floor. Resident #78 did not hit h/her head but sustained an abrasion to the left side of the back with no other injuries noted on assessment. All appropriate parties were notified and an anti-rollback device was placed on the wheelchair. A facility Reportable Event dated 11/18/24 identified NA #5 was transferring Resident #78 back to bed when Resident #78 pushed off the wheelchair and slid to the floor sustaining an abrasion to the left side of h/her back requiring a dressing and Tylenol for complaint of discomfort. Actions taken included the anti-rollbacks being placed on the back of the wheelchair. An interview with Registered Nurse, RN #1 on 1/08/25 at 11:17 AM identified she was the assigned nursing supervisor during the 3:00 PM to 11:00 PM shift on 11/18/24. RN #1 identified she was notified Resident #78 was on the floor in h/her room between the two beds. On arrival, RN #1 observed Resident #78 laying face up towards the bottom of the bed with the wheelchair at the end of the bed. RN #1 identified NA #5 was in the room with Resident #78 who reported Resident #78 fell after the wheelchair rolled out from under h/her while she was attempting to transfer h/her to bed. NA #5 assisted in lowering Resident #78 to the floor. RN #1 identified there was no other staff involved in the incident and that although she was in part responsible for determining the root cause, she did not determine whether the wheelchair was locked at the time of the occurrence and was unaware Resident #78 required the assistance of two with transfers into bed with an assistive device. An interview with NA #5 on 1/08/25 at 11:55 AM identified she was the assigned nurse aide for Resident #78 during the 3:00 PM to 11:00 PM shift on 11/18/24 and well known to her. NA #5 identified using one hand to lift the back of Resident #78's pant and the other hand under h/her armpit, NA #5 attempted to transfer Resident #78 from the wheelchair at the side of the bed to the bed. During the transfer, Resident #78 became nervous and began dropping to the floor. NA #5 assisted lowering Resident #78 causing the wheelchair to be pushed back in the locked position and resident #78 sliding against the edge of the wheelchair while being lowered to the floor. NA #5 identified she/he was working alone with Resident #78 at the time of the incident and was unaware Resident # 78 required the assistance of two staff during transfers into bed using an assistive device. An interview and clinical record review with the Director of Nursing Services (DNS) on 1/9/25 at 9:07 AM identified determining the primary cause of an accident was a collaborative effort between herself and nursing staff. The DNS identified after reviewing the details of the incident, she determined NA #5, was working alone with Resident #78 at the time of the fall. The root cause was determined as accidental as Resident #78, who could become anxious at times, was exhibiting such behavior at the time of the fall. The DNS identified that although NA #5 could have paused during care when Resident #78 was exhibiting anxious behavior, nothing was incorrect in the way Resident #78 was transferred. The DNS further identified she was unaware Resident #78 required the assist of two with transfers into bed with an assistive device. A review of the facility policy for Fall Prevention identified a fall as being defined as an event where an individual unintentionally comes to rest on the ground, floor, or other level as a result of an external force. A near miss is also considered a fall, where the resident would have fallen if someone else had not caught the resident from doing so. When any resident experiences a fall, the facility will assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of an injury. 49100

Based clinical record review, review of policy and interviews for 1 of 1 resident ( Resident #110) who required a when needed medication for palpitation, the facility failed to ensure the when needed medication was administered in accordance with physician's orders. The findings include: Resident #110 had diagnoses that included atrial fibrillation and hypertension. The Minimum Data Set, MDS assessment dated [DATE] identified Resident #110 was cognitively intact and independent with Activities of Daily Living (ADL). The Resident Care Plan (RCP) dated 9/17/24 identified Resident #110 had an alteration in cardiac status related to atrial fibrillation, hypertension and mitral valve regurgitation. Interventions directed to monitor for signs and symptoms of cardiopulmonary distress including chest pain and administer medications as ordered. The physician's orders dated 12/1/24 directed Diltiazem HCL Extended Release 240 mg by mouth one time a day for atrial fibrillation and Diltiazem HCl 30 Milligram (MG) by mouth every 24 hours PRN (as needed) for palpitations (heart flutter). The nurse's note dated 12/16/24 identified Resident #110 complained of palpitations at 10:50 PM and was requesting when needled ( PRN) Diltiazem HCl 30 mg. The Medication Administration Record dated 12/1/24 through 12/31/24 identified Diltiazem HCl 30 mg was administered one time on 12/16/24 at 10:55 PM. The afterhours emergency after hours medication cart identified Diltiazem HCL 30 mg was included in the emergency stock. An interview with Resident #110 on 1/08/25 at 1:50 PM identified she/he had prescription medication to take when experiencing palpitations that was fast acting. Resident #110 repeatedly asked about the PRN medication as she/he wanted to ensure the medication was on hand in the event it was needed with no response. Resident #110 identified she/he had experienced symptoms at some point recently. However, the fast-acting medication prescribed to her/him was not available. The nurse ended up giving her/him prescribed morning dose of the same medication which was in in a different dose and not fast acting. Resident #110 reported feeling relieved from symptoms after taking the medication but indicated the medication took a little longer than usual. An interview with Licensed Practical Nurse, LPN #2 on 1/09/25 at 10:14 AM identified she was the assigned nurse during the 3-11:00 PM shift on 12/16/24. LPN #2 identified Resident #110 reported having symptoms of palpitations. LPN #2 identified she notified Nurse Practitioner, NP #1 and gave Resident #110 her/his morning dose of Diltiazem HCL extended release 240 mg instead of Diltiazem HCL 30 mg prescribed PRN as she did not realize the different dosage and mechanism of action. LPN #2 further identified she did ask someone, uncertain who, if Diltiazem HCL 30 mg was in the emergency medication cart and was told it was not. LPN #2 was unable to explain why she would have asked about the availability in emergency stock if she was unaware of the dose discrepancy. An interview with the Director of Nursing Services ( DNS) on 1/09/25 at 10:59 AM identified the Diltiazem HCL 30 mg was ordered on admission. However, the pharmacy was told not to send as it was available in house and required only as needed. The DNS indicated she would expect all medications be administered according to physician's orders and nursing staff to refer to the after hours emergency list posted at all nursing stations to check availability of a prescribed medication not readily available in the medication cart. An interview with NP #1 on 1/9/25 at 11:32 AM identified she was notified Resident #78 was experiencing palpitations. She gave the order to give the PRN Diltiazem HCL 30 mg. NP #1 was not aware Resident #110 had received Diltiazem HCL extended release 240 mg instead. Although no harm came to Resident #110, NP #1 would have preferred the dosages been discussed with her and if discussed she/he may have considered an alternate plan. A review of the facility policy for Medication Administration directed that medications are administered by licensed nurses, or other staff legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice. 46046 48792

Based on clinical record review, observations, review of facility policy and interviews for 1 of 3 residents (Resident # 26) reviewed for choices, the facility failed to ensure the resident was ambulated according to restorative care plan. The findings include: Resident #26's diagnoses included Juvenile Rheumatoid Arthritis, Systemic Disorders of Connective Tissue, and adjustment disorder with anxiety. The Resident Care Plan dated 5/29/24 identified Resident #26 with a self-care deficit. Interventions included an ambulation program which required Resident # 26 to ambulate with a platform walker in the hallway 1-2 times per day with supervision. A review of the Nurse's Aide Information Sheet dated 7/24/24 indicated Resident #26 was on a Restorative Ambulation Program which included supervised ambulation with a rolling platform walker. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #26 was cognitively intact and required supervision for personal hygiene, maximum assistance with showering, and upper body dressing. A review of the Nurse Aide flow sheets dated December 2024 indicated Resident #26 was not provided supervised ambulation on the evening shift or the night shift but was provided supervised ambulation on the day shift for 10 days (12/1, 12/10, 12/17, 12/17, 12/18, 12/22, 12/28/ 2024) out of 31 days for the month. Review of a Special Instruction sheet dated 1/8/25 identified Resident # 26 was on an Ambulation Program. In an interview with Physical Therapist (PT #1) on 1/8/25 at 9:20 AM identified Resident # 26 was no longer on therapy services; however, the resident was on a restorative ambulation program which indicated Resident # 26 should be ambulated every shift with NA supervision. PT #1 further identified Resident # 26 was able to ambulate 150 feet with 2 turns using a platform walker and should ambulate every shift as tolerated. PT#1 taught his/her primary nurse aide how to use the platform walker. In an interview and review of the Resident Care Plan with RN#1(nursing supervisor) on 1/8/24 at 10:00 AM identified Resident # 26 should be ambulated with NA supervision every shift. RN # 1 further indicated there are times when the facility is short on nurse aides and indicated Resident # 26 is very complex so there is not enough time to ambulate the resident. In an interview with NA#1 on 1/8/25 at 11:00 AM identified she cannot always ambulate the r resident secondary to staffing issues. In an Interview with NA#2 on 1/8/25 at 11:45 AM identified she works 1 day per week and that is Resident #26's shower day. NA #2 indicated she does not ambulate Resident # 26 as she does not have the time. The resident's shower takes 45 minutes and then she has other tasks on the floor that leave her no time to ambulate the resident per care plan. Review of the current Comprehensive Care Plans Policy, undated, directed in part, qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, observations, review of facility policy and interviews for 1 of 3 residents (Resident #26) reviewed for choices, the facility failed to honor the resident's request to be out of bed before breakfast. The findings include: Resident #26's diagnoses included Juvenile Rheumatoid Arthritis, Systemic Disorders of Connective Tissue, and adjustment disorder with anxiety. The Resident Care Plan dated 5/29/24 identified Resident #26 with a self-care deficit. Staff were directed to ensure the resident was out of bed before breakfast daily. Review of a Nurse's Aide Information Sheet dated 7/24/24 directed that Resident #26 be out of bed before breakfast daily. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #26 was cognitively intact and required supervision for personal hygiene, maximum assistance with showering, and upper body dressing. A physician's order dated 12/26/24 directed that Resident# 26 be out of bed before breakfast every morning per resident's request. 0n 1/3/25 1:38 PM during screening of Resident identified she /he would like to be out of bed by breakfast or 10:30 AM at the latest to attend exercise classes. Resident # 26 also indicated she/he would be out bed by 10:30 AM especially if the aides are not able ambulating her/him enough. Resident # 26 also indicated this does not happen consistently. Observation of Resident # 26 on 1/3/25 at 11:00 AM identified the resident still in bed. Further observation on 1/6/25 and 1/7/25 identified the resident was not out of bed before breakfast. In an interview with Registered Nurse (RN#1) on 1/8/25 nursing supervisor at 10:00 AM identified Resident # 26 is not consistently out of bed before breakfast due to her/his complex care needs and being short staffed. In an interview with the Director of Recreation on 1/8/25 at 10:20 AM identified Resident # 26 loves to attend all activities. If she/he is up and ready Resident # 26 will attend the exercise program. The Director of Recreation also indicated Resident # 26 is not consistently at the exercise program. The Director of Recreation indicated she believes Resident # 26 does not attend the exercise program regularly because she/he is not out of bed in time. In an interview with Nurse Aide (NA#1) on 1/8/25 at 11:00 AM identified she doesn't usually get Resident # 26 out of bed until 10:00 AM or 11:00 AM due to staffing. Nurse Aide #1 also indicated that Resident # 26 wanted to be out of bed before breakfast. In an Interview with NA#2 on 1/8/25 at 11:45 AM identified she was not aware of any specific time Resident # 26 wanted to be out of bed. Review of the current Resident Rights policy, undated, directs in part, the resident has the right to participate in the development and implementation of his or her person-centered plan of care.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to ensure a resident was free from staff abuse. The findings include: Resident #1 had diagnoses that included fracture of the left leg, dementia and major depressive disorder. The nursing admission assessment dated [DATE] identified Resident #1 was only oriented to person (not place or time), had limited range of motion due to left hip surgical repair and required a mechanical lift and wheelchair. The accident and incident form (A & I) dated 8/10/23 at 8:00 AM identified Resident #1 became combative and agitated with staff on 8/9/23 - 8/10/23 during the 11:00 PM - 7:00 AM shift and was attempting to strike at staff. NA #1 and LPN #2 were in the resident's room when the charge nurse, LPN #1, heard yelling and went to the room to help. She identified she heard NA #1 repeatedly telling the resident you have the wrong aid and was observed tapping Resident #1 on the forehead with her finger. The nursing supervisor was alerted and asked NA #1 to leave the building immediately. The Social Worker note dated 8/10/23 at 12:06 PM identified she was informed by the DNS about an incident that occurred on 8/9/23 with staff. Resident #1 was visited by the Social Worker and Resident #1 was alert to self with forgetfulness due to dementia. Resident #1 appeared calm, relaxed, pleasantly confused, not in any distress and stated he/she had a good night with no issues. Interview with LPN #1 on 10/10/24 at 1:02 PM identified on 9/9/23 around 11:45 PM she heard Resident #1 yelling and went to see what was wrong. She identified NA #1 and LPN #2 were in Resident #1's room giving care, she observed NA #1 jab her fingers at Resident #1's forehead while stating you have the wrong aid. LPN #1 identified she positioned herself between Resident #1 and NA #1 in an attempt to separate NA #1 from Resident #1. Simultaneously, NA #1 attempted to take the Resident #1's blood pressure and grabbed Resident #1 by the upper arm and shook his/her arm. She identified NA #1 aggressively stated you're going to remember my face. Resident #1 then became more combative, and LPN #1 and LPN #2 told NA #1 multiple times to leave Resident #1's room. Once NA #1 left Resident #1's room, she left the room and immediately told the nursing supervisor. NA #1 was then told to leave the facility by the nursing supervisor. Interview with LPN #2 on 10/10/24 at 12:48 PM identified on 9/9/24 around 11:45 PM she heard Resident #1 screaming. She went to the room and witnessed Resident #1 was trying to hit NA #1, NA #1 squeezed Resident #1's left arm with malicious intent and stated you have the wrong aid. She identified Resident #1 became more agitated and LPN #1 stepped in between Resident #1 and NA #1. She identified LPN #1 and herself told NA #1 to leave Resident #1's room. Although multiple attempts were made, an interview with NA #1 was not obtained. Interview with DNS on 10/10/24 at 12:31 PM identified there is no policy on combative behaviors but staff are educated to step back from the resident, ensure the resident is safe, exit and then reapproach. She identified NA #1 actions were inappropriate and NA #1 should have made sure Resident #1 was safe, left Resident #1 alone, reapproached at a later time or asked another staff member to complete care. Review of the resident rights policy identified residents have the right to be free from abuse and neglect. Review of the abuse, neglect and exploitation policy identified abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse.

Based on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to address a resident's complaints of pain . The findings included: Resident #1's had diagnoses included lumbar spondylolisthesis, spinal stenosis, lumbar region with neurogenic claudication, and chronic pain syndrome. Review of the hospital Discharge summary dated [DATE] identified Resident #1 was admitted on [DATE] for lumbar spinal stenosis, underwent lumbar spine surgery. Review of the Resident Care Plan dated 5/17/24 identified an actual self-care deficit related to cognitive impairment, decreased strength/endurance, pain, and recent surgery. Interventions directed to an assist of one with activities of daily living observing back precautions, to avoid repetitive bending, lifting and twisting and monitor for pain, stiffness, decreased range of motion or worsening, contracture status during all care, and report changes. Review of the Nursing Pain assessment dated [DATE] identified pain within the last 5 days, occurring frequently, with occasional loss of sleep and occasionally limiting day to day activities. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with activities of daily living. A physician's order dated 5/17/24 directed Norco (hydrocodone-acetaminophen) 5-325mg (a narcotic pain medication), two tablets by mouth every 6 hours as needed for pain, with a maximum dose of 8 tablets in 24 hours. Review of the Medication Administration Report on 5/18/24 identified two (2) 5-325mg Norco tablet (were administered at 1:36 PM. Review of nurse's note dated 5/18/24 at 1:44 PM identified Resident #1 was alert and pleasant, adjusting well to his/her room, with complaints of back pain. Norco 5-325mg was administered at 1:00 PM and successfully reduced Resident #1's pain. Review of nurse's note dated 5/18/24 at 4:50 PM identified Resident #1 was upset as he/she requested a dose of Norco and was refused, with the nurse indicating the next dose was not yet due (due approximately 7:00-7:30 PM). Review of nurse's noted dated 5/18/24 at 5:03 PM identified Resident #1 was walking in his/her room, talking, picking up his/her things, packing while stating if he/she didn't get his/her dose of Norco now that she would be leaving. The nurse's note further indicated Resident #1 was punching, and combative. The nurse explained the medication schedule to the resident, and that pain medication was not yet due. The resident was unwilling to cooperate or understand the schedule, and the facility was going to send the resident to the emergency room for medication re-evaluation. Interview with RN #1 (the nursing supervisor) on 6/6/24 at 11:13 AM identified Resident #1 was upset between 3:30 PM and 4:00 PM as he/she had requested his/her pain medication from LPN #1 and was told it wasn't time. RN #1 indicated after being informed of the situation by LPN #1, he/she had approached the resident, whose behaviors had escalated, to explain why the pain medication couldn't be administered and to assess the resident. Further interview with RN #1 at 11:46 AM identified he/she should have contacted the physician regarding Resident #1's request for pain medication but in the midst of Resident #1's outburst, the resident didn't allow RN #1 to assess his/her pain. RN #1 indicated the standard of practice was to assess the patient, contact the physician to inform of the resident's pain and request his/her recommendation. Interview with the Director of Nursing Services on 6/6/24 at 12:13 PM identified the standard of practice was to explain the pain medication schedule to the resident, to offer a change in position or ice pack/hot pack to help relieve the pain, and if the interventions were ineffective and/or there was no other alternative, to contact the physician to see what could be done. Interview with MD #1 on 6/6/24 at 12:29 PM identified the next option for pain relief, if non-pharmacologic interventions failed, was to administer the next dose of the pain medication (Norco). MD #1 further identified he/she would have expected a call to determine if anything else could be done or if the narcotic needed to be administered. Review of the Pain Management policy directed that based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.

Based on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to ensure that the physician was notified when a resident requested pain medication and the next dose of pain medication was not yet due. The findings include: Resident #1's had diagnoses included lumbar spondylolisthesis, spinal stenosis, lumbar region with neurogenic claudication, and chronic pain syndrome. Review of the hospital Discharge summary dated [DATE] identified Resident #1 was admitted on [DATE] for lumbar spinal stenosis,and underwent lumbar spine surgery. Review of the Resident Care Plan dated 5/17/24 identified an actual self-care deficit related to cognitive impairment, decreased strength/endurance, pain, and recent surgery with interventions that directed to an assist of one with activities of daily living observing back precautions, to avoid repetitive bending, lifting and twisting and monitor for pain, stiffness, decreased range of motion or worsening, contracture status during all care, and report changes. A physician's order dated 5/17/24 directed Norco (hydrocodone-acetaminophen) 5-325mg ( a narcotic pain medication), two tablets by mouth every 6 hours as needed for pain, with a maximum dose of 8 tablets in 24 hours. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with activities of daily living. Review of the Medication Administration Record for 5/18/24 identified two (2) 5-325mg Norco tablets were administered at 1:36 PM. Review of nurse's note dated 5/18/24 at 1:44 PM identified Resident #1 was alert and pleasant, and had complaints of back pain. Norco 5-325mg was administered at 1:00 PM and successfully reduced Resident #1's pain. Review of nurse's note dated 5/18/24 at 4:50 PM identified Resident #1 was upset as he/she requested a dose of Norco and was refused, with the nurse indicating the next dose was not yet due (due at approximately 7:00-7:30 PM). Review of nurse's noted dated 5/18/24 at 5:03 PM identified Resident #1 was walking in his/her room, talking, picking up his/her things, packing while stating if he/she didn't get his/her dose of Norco now that she would be leaving. The nurse's note further indicated Resident #1 was punching, drug seeking, and combative. The nurse explained the medication schedule to the resident, the resident was unwilling to cooperate or understand the schedule, and the facility was going to send the resident to the emergency room for medication re-evaluation. Interview with RN #1 (the nursing supervisor) on 6/6/24 at 11:13 AM identified Resident #1 was upset between 3:30 PM and 4:00 PM as he/she had requested his/her pain medication from LPN #1 and was told it wasn't due for administration. RN #1 further indicated the situation escalated, Resident #1 had gathered her clothes and pushed RN #1 out of the way with the intention of leaving the building. RN #1 indicated he/she then called the police and Director of Nursing Services as LPN #2 stayed with Resident #1. RN #1 identified he/she should have contacted the physician regarding Resident #1's request for pain medication but in the midst of Resident #1's outburst, the resident didn't allow RN #1 to assess his/her pain. RN #1 indicated she should have assessed the patient, contacted the physician to inform of the resident's pain and request his/her recommendation. Interview with the Director of Nursing Services on 6/6/24 at 12:13 PM identified the standard of practice was to explain the pain medication schedule to the resident, to offer a change in position or ice pack/hot pack to help relieve the pain, and if the interventions were ineffective and/or there was no other alternative, to contact the physician to see what else could be done. Interview with MD #1 on 6/6/24 at 12:29 PM identified the next option for pain relief, if non-pharmacologic interventions failed, was to administer the next dose of the pain medication (Norco). MD #1 further identified he/she would have expected a call to determine if anything else could be done or if the narcotic needed to be administered. Review of the Pain Management policy directed that based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.

Based on observation, staff interview and review of facility policy for 3 of 7 nurses interviewed and/or observed cleaning glucometers, the facility failed to maintain an infection prevention/control program to prevent the development and transmission of communicable diseases and infections by failing to ensure that staff followed manufacturer guidelines on required cleaning and disinfection of a multi-use glucometer to prevent the possible transmission of blood-borne pathogens between residents, which resulted in a finding of immediate jeopardy and for and for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #106), the facility failed to maintain infection control practices during a treatment to an open area. The findings include: 1. On 9/20/18 at 4:40PM, LPN #1 (who was working on A/B Wing) was observed cleaning a True Metrix Pro glucometer using a Professional Disposable International (PDI) instant hand sanitizing wipe from a blue topped container. Further interview with LPN #1 at that time identified that he/she had just completed blood sugar monitoring with Resident #64 using the glucometer and he/she usually utilizes the wipes from the blue topped container to clean the glucometer. Additionally, LPN #1 further identified that he/she had already completed 3 other resident's blood glucose monitoring prior to surveyor inquiry, and had cleaned the glucometer in the same manner (using the instant hand sanitizing wipes). Observation on 9/20/18 at 5:00PM identified LPN #2 obtained Resident #56's blood sugar using a True Metrix Pro glucometer. Further observation identified LPN #2 cleansed the glucometer using a PDI instant hand sanitizing wipe from the blue topped container. Interview with LPN #2 at that time, identified he/she utilizes the blue topped container wipes to clean the glucometer and only utilizes the purple topped container wipes (PDI Super Sani Cloth Wipes) for wiping the top of the medication cart. Further interview with LPN #2 identified that he/she was inserviced on cleaning the glucometer approximately 2-3 weeks ago by the Infection Control Nurse (ICN). Additionally, LPN #2 identified that he/she was instructed to utilize a PDI wipe to clean the glucometer, but could not recall what type of PDI wipe to use (blue topped container wipes or purple topped container wipes). On 9/20/18 at 5:30PM, interview with LPN #3 (who was working on B Wing) identified he/she completed glucometer testing on 3 residents from 3:00 to 5:30 PM and utilized the PDI instant hand sanitizing wipe from the blue topped container to clean the glucometer in between resident usage. Further interview with LPN #3 identified that he/she was notified verbally to wipe the glucometer with a PDI wipe from the blue topped container, but could not recall when he/she was verbally notified and/or could not recall signing an inservice sheet. Interview with the DNS on 9/20/18 at 6:05PM identified a verbal inservice was done with licensed staff on the procedure for cleaning glucometers in between resident usage and the policy was located in the front of the Medication Administration Record [REDACTED] The policy for cleaning the glucometer which was located in the front of the MAR, identified to rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter using only PDI Super Sani Cloth Wipes or any disinfectant product with EPA reg. no. 9480-4. Manufacturer guidelines for a True Metrix Pro glucometer identified that all parts of the glucose monitor are considered potentially infectious and capable of transmitting blood-borne pathogens. Guidelines for cleaning/disinfecting the glucometer further identify to rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter using only PDI Super Sani Cloth Wipes or any disinfectant product with EPA reg. no. 9480-4. Further guidelines for cleaning identified to use a fresh wip and make sure that all outside surfaces of the meter remain wet for 2 minutes. Review of the PDI Super Sani Cloth Wipes (purple topped) container identified an EPA reg. no. 9480-4 and noted the usage as a bactericidal, tuberculocidal and virucidal. The container further identified it's usage was for cleaning and decontaminating [MEDICAL CONDITION] virus, the [MEDICAL CONDITION] virus, and surfaces with blood/body fluids. Review of the PDI instant hand sanitizing wipes (blue topped) container listed it's active ingredient as 70% alcohol by volume and it's purpose was for antiseptic use (used to kill bacteria on the skin of humans and animals) and did not include a disinfectant product with EPA reg. no. 9480-4. The facility was cleaning the glucometer with hand sanitizing wipes that were not part of the manufacturer guidelines and should have been utilizing PDI Super Sani Cloth Wipes (purple topped container) to clean the glucometer in between usage. Subsequent to surveyor inquiry, the facility submitted a written action plan that included inservicing staff on the proper cleaning guidelines for glucometers by directing staff to utilize the purple topped container to clean the glucometer. The facility also implemented a quality assurance program under the supervision of the DNS to monitor the implementation of the facility's policies to ensure achievement and sustained compliance with glucometer cleaning. The written action plan also included twice a week monitoring by the DNS for four weeks and randomly thereafter. According to the action plan, the surveillance will ensure that glucometers would be cleaned in accordance with the facility policy. 2. Resident #106's [DIAGNOSES REDACTED]. A significant change Minimum (MDS) data set [DATE] identified Resident #106 was moderately impaired for decision-making skills, requiring extensive assistance for most activities of daily living, and without a pressure ulcer. The Resident Care Plan dated 9/15/18 identified a problem with having a Stage 2 coccyx wound. Interventions included weekly skin checks and treatment per MD and/or APRN orders. A review of the clinical record identified Resident #106 as having a Stage 2 pressure ulcer to the coccyx area as of 9/15/18 measuring 1.5 centimeter (cm) by 0.5 cm in size. physician's orders [REDACTED]. a. Observation of a wound treatment for [REDACTED].#6 on 9/21/18 at 1:42 PM in the presence of the ADNS, identified LPN #6 was observed opening Resident #25's incontinent brief and placing the stack of clean 4 inch by 4 inch gauze pads (that were to be utilized to clean the wound with skin cleanser) on the back portion of Resident #25's incontinent brief without the benefit of providing a clean set up for the wound treatment. LPN#6 was attempting to cleanse Resident #106's coccyx wound without the benefit of providing a clean surface. Subsequent to surveyor inquiry, LPN #6 suspended the treatment and the ADNS assisted LPN #6 in providing an impervious drape as a clean set up to place Resident #25's treatment supplies on. b. Further observation of wound care for Resident #106 being completed by LPN #6 and in observance with the ADNS on 9/21/18 at 1:42 PM identified LPN #6 attempting to continue the wound treatment, without the benefit of setting up a clean field, and/or opening the cotton swabs and/or dispensing Santyl Ointment prior to applying it to Resident #106's wound. Further observation of wound care with LPN #6 identified after washing his/her hands and donning a new set of gloves, LPN #6 was noted to continue with the treatment by opening and dispensing supplies at the time of use, while wearing gloves. An interview at the time with the ADNS indicated that all treatment supplies such as the dressing, creams, ointments, measuring device and cotton swabs, are to be pre-opened and/or dispensed and/or set up prior to the start of care and/or treatment.

Based on clinical record review, observation and interview for 1 of 3 sampled residents reviewed for falls (Resident #98), the facility failed to ensure supervision was provided in the bathroom to prevent a fall. The findings include: Resident #98's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A resident care plan dated 5/6/18 identified a problem with falls related to muscle weakness, decreased strength and balance, history of falls, decreased safety awareness, and decreased hearing and vision. The care plan also indicated Resident #98 self transferred at times and wanted to do everything for him/herself. The care plan further identified Resident #98 was not always compliant with using the call bell. Care plan interventions initiated 5/6/18 included toileting/assist every 2 hours to prevent self transferring secondary to Resident #98 not always using the call bell for transfers. A quarterly Minimum (MDS) data set [DATE] identified Resident #98 was moderately cognitively impaired, required extensive one person assistance for bed mobility and transfers, was not steady with moving from seated to standing position, was not steady moving on and off the toilet, and as having a recent fall. A Reportable Event form dated 7/10/18 at 2:30 PM indicated Resident #98 was on the toilet and told the NA to give him/her a few minutes by him/herself on the toilet. Upon NA re-entering the bathroom to assist Resident #98, Resident #98 was noted to be on the floor, on his/her right side, in front of the toilet and attempting to self transfer. The call bell was not used by Resident #98. Resident #98 was transferred to the hospital and diagnosed with [REDACTED]. Interview with Occupational Therapist #1 (OT) on 9/25/18 at 11:00 AM identified Resident #98 had a physicial therapy screen on 5/6/18 after a prior attempted self tranfer and fall. OT #1 identified the results indicated Resident #98 remained an assistance of one staff for transfers. OT #1 further indicated Resident #98 should not have been left alone on the toilet because he/she required assistance of one staff, which included assistance with all care and transfers, including care in the bathroom. Interview with NA #5 on 9/25/18 at 2:15 PM indicated NA #5 could not recall who initially took Resident #98 to the bathroom, NA #5 asked the resident if he/she was finished, but Resident #98 identified he/she was not ready to leave the bathroom/toilet. Therefore, NA #5 went to help another resident and then heard Resident #98 yell. NA #5 indicated Resident #98 was usually able to be left alone as long as someone stayed in the room. NA #5 further indicated Resident #98 often stated he/she was not ready, wanted to remain on the toilet for a long time, and may have tried to reach for something and fell . NA #5 could not recall if Resident #98's care card listed specific instructions regarding toileting. The facility's plan of correction identified a fall risk assessment would be completed on all residents to determine their fall risk which was used to develop the individualized plan of care. The plan of correction further identified a revision to the fall policy completed on 8/17/18 which included that occupational/physical therapy would conduct a screen on all new admisions to determine sitting balance, specifically as it relates to the ability to independently remain on the toilet or commode. The plan also indicated that current residents with a history of falls, confusion, forgetfulness or dementia, residents with non-compliant behaviors and any resident unable to maintain proper stability/balance in a sitting position will be deemed unsafe and unable to be left unattended in the bathroom or on the commode. Effective 8/17/18, a quality-assurance program was implemented under the supervision of the DNS to monitor the implementation with the fall prevention protocol. The surveillance would ensure that the transfer of residents and toileting procedures was implemented in the residents' fall preventions care plan was being followed. The Quality Assessment and Assurance would ensure the corrective action was evaluated for it's effectiveness. Staff inservicing was completed from 8/17/18 to 8/23/18.

Based on clinical record review, review of facility documentation and interviews for two of three sampled residents reviewed for accidents (R#46, R#116) the facility failed to implement the plan of care resulting in a fall with injury. The findings include: 1. Resident #46 [DIAGNOSES REDACTED]. An MDS dated [DATE] and 6/24/11 identified the resident as severely cognitively impaired, totally dependent on staff for transfers and required a minimum of two staff to assist with all transfers. A care plan dated 1/4/11 and revised on 9/22/11 identified that the resident had self-care deficit related to dementia with left-sided weakness. Interventions included the resident to be out of bed to a modified tilt in space wheel chair with two persons assistance and in a tilted position. A review of the occupational assessment dated [DATE] recommended that the resident should be placed in a tilt position while in chair secondary to poor trunk support, control, lateral lean and increased risk for fall/skin breakdown. A review of the nursing notes dated 11/30/11 at 8:00 AM indicated that the resident was assisted by two nursing assistants from his/her bed to a modified customized wheel chair (CWC) and while care was being provided in the modified CWC, the resident fell to the floor and sustained a frontal subarachnoid hemorrhage. Interview with NA#3 on 8/22/12 at 1:30 PM indicated that as she was leaving to return to her assignment, the resident was observed in an upright position, (not in a tilted position) leaned forward and fell out of the wheelchair. NA#3 indicated that while in the room he/she proceeded to make R#46's roommate's bed. NA#3 indicated that she recalls seeing the resident leaning forward and fall out of the CWC. NA#3 indicated that he/she did not see NA#4 within close proximity of the resident and could not recall where NA#4 was at the time of the fall. Attempts to interview NA#4 were unsuccessful. Interview with the DNS on 8/22/12 at 11:00 AM indicated that the nursing staff should have followed the resident's care plan as directed. The DNS indicated that after Resident #46 fell , nursing staff were re-educated on safe transfers with the tilt in space wheel chair. 2. Resident #116 [DIAGNOSES REDACTED]. An MDS dated 5/22/12 identified the resident as moderately cognitively impaired. Additional review of the MDS indicated that the resident required extensive assistance with transfers and required 2 staff support. A RCP dated 5/01/12 identified the resident at risk for falls. Interventions included to monitor for orthostatic hypotension, and discourage resident from abrupt position changes. Nursing notes dated 5/21/12 through 5/24/12 identified the resident as confused and with hallucinations. Nursing notes dated 5/24/12 identified R#116 requested assistance to the bathroom and NA #1 assisted the resident to the toilet via a wheelchair without the benefit of a second nursing staff. The resident subsequently fell off the toilet and sustained a fracture to her right cheek bone. Interview with NA#1 on 8/22/12 at 11:00 AM indicated that she was not familiar with the resident and assisted the resident to the bathroom without the benefit of another staff member because the resident expressed urgency. NA #1 could not recall why she did not call for assistance and indicated she had no information regarding the resident's transfer status/abilities. Review of the facility's transfer policy indicated that the nursing staff assisting resident's with transfers are to be informed of the resident's physical and mental abilities when transferring a resident. Interview with the DNS on 8/23/12 at 9:00 AM indicated that the resident required supervision when on the toilet because the resident exhibited impulsive behaviors (i.e. attempting to self transfer). The DNS indicated that the nurse aide should have called for assistance and/or obtained information related to the resident's mental and physical abilities with regards to transfers.

Based on clinical record review, facility documentation and interviews for one sampled resident (R#1) the facility failed to ensure that the resident was appropriately and safely positioned while rendering care and/or that the side rails were properly maintained to prevent an accident. The findings include: Resident #1's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident with short term memory impairment, moderate impaired cognition, periods of lethargy, required total assistance with activities of daily living, had fallen it the past 31-180 days and utilized side rails for bed mobility. Review of facility documentation dated 9/30/10 identified that R#1 fell out of bed while being provided care and sustained two lacerations to the face. The resident was transferred to the hospital where three sutures were required to close two wounds. Review of the hospital discharge summary dated 9/30/10 identified R#1 with multiple lacerations to the face. Review of facility documentation/investigation dated 10/02/10 indicated that upon inspection the side rail was noted to lack a holding pin in the latching mechanism. The documentation also noted that there was a " visible hole in the metal latching mechanism thus the rail could not lock in place. " Interview with RN#1 on 10/26/10 at 10:45 AM identified the resident should have been positioned facing the caregiver with the side rail in the up position during care. Interview with NA#1 on 10/26/10 at 1:31 PM identified she was providing incontinent care when the half side rail on the opposite side of the resident released and fell down. At that time R#1 fell to the floor and hit his/her face on the floor lamp that was close by. NA#1 also indicated that he/she positioned the resident towards her and then repositioned the resident away from her when the side rail released to the floor and the resident fell to the floor. Review of the facility's follow up report dated 10/2/10 identified the nurse aides inservice education/training indicates that when providing care to residents; to turn the resident and position the resident facing the care giver versus away from the care giver when rendering care. As a result of the investigation the NA#1 was terminated.