Every finding on record at Summit at Plantsville Center for Health & Rehabili

Based on review of clinical records, interviews, facility documentation and facility policies for one (1) of three (3) sampled residents (Resident #1) reviewed for abuse, the facility failed to revise and implement resident-specific care plan and care card interventions following repeated resident-to-resident physical altercations to ensure cognitively impaired residents residing on a secured unit were supervised and maintained at a safe distance from one another. The facility failed to update Resident #1's care plan and care card with specific behavioral triggers, de-escalation approaches, and direction to keep Resident #1 and Resident #2 separated following physical altercations on 3/22/26 and 3/28/26, which resulted in another physical altercation on 4/10/26 when assigned staff were unaware of the residents' history and required interventions to prevent further resident-to-resident aggression.The findings include:1. Resident #1 was admitted to the facility April 2025 and had diagnoses of dementia, anxiety disorder, and violent behavior.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 5), required partial assistance with bathing and personal hygiene, and was able to ambulate fifty (50) feet with supervision/touch assistance. The Resident Care Plan (RCP) dated 3/25/26 identified Resident #1 had the potential to be physically aggressive related to progressive cognitive impairment. Interventions identified Resident #1 expressed fear that others may steal his/her personal belongings, particularly his/her remote control, his/her behavior tended to escalate when he/she noticed unfamiliar individuals in the environment, to reduce anxiety, staff was to proactively introduce new staff and residents and provide frequent reassurance regarding who was present, and to monitor, document, and report signs/symptoms of posing a danger to self and others.Review of the Resident Care Card (RCC) dated 3/21/26 identified the following resident care interventions: assist resident with hand hygiene and monitor/record for target behavior symptoms, agitation, and restlessness.2. Resident #2 was admitted to the facility March 2026 and had diagnoses which included dementia, cognitive communication deficit, and post-traumatic stress disorder, unspecified.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required maximal assistance with lower body dressing and personal hygiene, and had wandering behavior. The Resident Care Plan (RCP) dated 3/26/26 identified Resident #2 had a diagnosis of dementia with wandering occurring and roommate incompatibility with recent room transfer. Interventions directed to assist the resident in orienting to a new setting, routine and caregivers, to introduce to compatible peers, and to encourage the resident to verbally express his/her daily needs and feelings of loss/worry.A nurse's note dated 3/20/26 at 2:33 PM identified Resident #2 was admitted to room [ROOM NUMBER] at 12:00 PM.A nurse's note by LPN #2 on 3/21/26 at 6:00 PM identified Resident #2 got into an argument with Resident #1, they were separated several times, and the supervisor was called. Resident #1 and Resident #2 were redirected with an activity without further issue. A Reportable Event (RE) form dated 3/22/26 at 8:05 AM identified a witnessed, verbal altercation turned physical when Resident #1 struck Resident #2 on the left cheek, causing bruising/swelling and a small 0.5-centimeter laceration to the left cheek. Interventions included a one-to-one assignment for Resident #1 until hospital transfer for a psychiatric evaluation (which cleared Resident #1 of harm to self and others); Resident #2's neurological status was evaluated and room changed per family request.A written statement by NA #2 on 3/22/26 identified he/she was two doors down when he/she overheard Resident #1 yelling at Resident #2. NA #2 indicated he/she observed Resident #2 pushing his bedside table forward (not into Resident #1) and Resident #1 punching Resident #2 on the left side of his face. NA #2 immediately separated the residents and called for assistance from staff. Review of the RCP for Resident #1 identified the following interventions were added following the 3/22/26 incident: a one-to-one monitor for safety, a psychiatric/psychogeriatric consult as indicated, and fear that others may steal his/her personal belongings, particularly his/her remote control, his/her behavior tended to escalate when he/she noticed unfamiliar individuals in the environment, to reduce anxiety, staff was to proactively introduce new staff and residents and provide frequent reassurance regarding who was present.Review of the RCC for Resident #1 dated 3/22/26 through 3/27/26 identified the following resident care interventions: assist resident with hand hygiene and monitor/record for target behavior symptoms, agitation, and restlessness.An RE dated 3/28/26 at 6:25 PM identified LPN #1 heard yelling in the hallway and witnessed Resident #2 getting pushed by Resident #1, falling, and striking his/her head on the floor, which resulted in a small laceration to the crown of Resident #2's head. Interventions involved assigning a one-to-one monitor to Resident #1 and administering a cool compress to his/her tongue due to an injury sustained during the incident. Resident #2 was transferred to the hospital for further evaluation with no injury identified. A written statement by LPN #1 on 3/28/26 identified he/she heard yelling while at the nurse's station and observed Resident #1 and Resident #2 standing in close proximity, yelling at each other. While running down the hallway, calling out to the residents, LPN #1 witnessed Resident #1 strike Resident #2, Resident #2 strike Resident #1, and Resident #1 return to strike while pushing Resident #2. LPN #1 further indicated Resident #2 lost his/her balance, fell to the floor and struck his/her head with Resident #1 partially landing on Resident #2. Resident #1 was able to get up and ambulate away from the area, LPN #1 called for assistance, and applied direct pressure to Resident #2's head due to active bleeding. Review of the RCP for Resident #1 identified a one-to-one monitor was assigned on 3/28/26, however failed to identify additional interventions to deter/prevent further altercations between Resident #1 and other residents.A provider's note by APRN #1 on 3/29/26 at 8:42 AM identified the one-to-one monitor was discontinued for Resident #1.Review of clinical documentation identified the implementation of fifteen (15) minute checks for Resident #1 starting 3/29/26 through 4/7/26 and restarting on 4/9/26 through 4/10/26.Review of the RCC for Resident #1 dated 3/28/26 through 4/9/26 identified the following resident care interventions: assist resident with hand hygiene and monitor/record for target behavior symptoms, agitation, and restlessness (no changes were made to the RCC since 3/21/26). An RE dated 4/10/26 at 3:40 PM identified Resident #2 entered Resident #1's room, Resident #1 yelled at and punched Resident #2, and Resident #2 hit Resident #1 back. Interventions involved assigning a one-to-one monitor to Resident #1, psychiatric evaluation, Physician's Emergency Certificate for medical/behavioral evaluation, and hospital transfer. Resident #2 was administered Tylenol and ice to his/her cheek.Interview with NA #1, assigned to Resident #1 on 4/10/26 during the 3:00 PM to 11:00 PM shift, on 4/24/26 at 11:12 AM identified he/she had only worked with Resident #1 twice prior to the 4/10/26 incident and was unfamiliar with Resident #2. NA #1 identified he/she was in the hallway near Resident #1's room when he/she observed Resident #2 walk by. NA #1 indicated he/she asked Resident #2 where his/her walker was because he/she had an unsteady gait. Resident #2 responded he did not know and entered Resident #1's room. NA #1 identified he/she followed Resident #2 into Resident #1's room, informed Resident #2 it was not his/her room and tried to guide him/her out to locate the walker. However, Resident #1 yelled at Resident #2 to get the f**k out of his/her room, and as NA #1 attempted to guide Resident #2 out of the room, Resident #2 touched Resident #1's walker and was punched in the face by Resident #1. Resident #2 punched back, and the two residents continued to exchange punches until NA #3 entered the room and was able to redirect Resident #2 out of the room. NA #1 further identified he/she received report regarding the residents at the start of the shift, however, did not receive specific instructions regarding Resident #1 and Resident #2 needing to be kept at a safe distance from each other or how to manage them if in close proximity, and was unaware of previous altercations between them.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 9:15 AM identified he/she implemented and relied on staff huddles at the beginning and end of each shift to communicate issues, concerns or incidents between Resident #1 and Resident #2. The DNS further indicated that new staff (who had never worked on the secured unit before) would get direct report from the charge nurse with specific instructions on how to manage Resident #1 and Resident #2 when in close proximity of one other and strategies for how to maintain ample distance between them. The DNS identified the RCP and RCC for Resident #1 was not updated with specific interventions as he/she implemented what was thought to be appropriate at the time while investigating the cause of Resident #1's aggression and was utilizing huddles to manage and communicate issues/concerns amongst floor staff. The DNS further indicated Resident #1's medications were adjusted at that time and felt that would have been sufficient to satisfy/modify his/her behaviors.Review of the Abuse Policy and Procedure identified each resident has the right to be free from abuse, neglect, and misappropriation of resident property and exploitation and it was the policy of all National Health Care Associates facilities to encourage an environment that recognizes the special qualities of its residents and provide them with a safe environment.PAST NON-COMPLIANCE:The facility presented a corrective action plan dated 3/31/26 which included:Immediate Interventions: Separating residents, initiating 1:1 observation, updating care plans to include triggers, early warning signs, specific deescalation strategies, adding behavior specific interventions.Trends and Concerns: Care plans lack specific target behavior/deescalation strategies with root cause of failure to proactively identify and manage behavioral triggers.Implementation of the following corrective actions: Care Plan Optimization, Mandatory Staff Education, and Clinical Review/IDT reviewStaff education/training: Deescalating aggressive behavior, Dementia Communication, Programming and ObservationOn-going steps/follow up audits to ensure corrective actions remain in place and the facility is in substantial compliance: Resident Engagement; Process Review, Care plan drives care, Care Observations, Abuse reporting, HCW Interviews and Observations.Date of Substantial Compliance: 4/11/26

Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for care planning, the facility failed to update Resident #1's plan of care with specific care instructions following the 3/28/26 physical altercation to ensure a cognitively impaired resident (Resident #2) on a secured unit was kept safe from harm. The findings included: Resident #1 was admitted to the facility April 2025 and had diagnoses of dementia, anxiety disorder, and violent behavior.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 5), required partial assistance with bathing and personal hygiene, and was able to ambulate fifty (50) feet with supervision/touch assistance. The Resident Care Plan (RCP) dated 3/25/26 identified Resident #1 had the potential to be physically aggressive related to progressive cognitive impairment. Interventions identified Resident #1 expressed fear that others may steal his/her personal belongings, particularly his/her remote control, his/her behavior tended to escalate when he/she noticed unfamiliar individuals in the environment, to reduce anxiety, staff was to proactively introduce new staff and residents and provide frequent reassurance regarding who was present, and to monitor, document, and report signs/symptoms of posing a danger to self and others.Review of the Resident Care Card (RCC) for Resident #1 dated 3/22/26 through 3/27/26 identified the following resident care interventions: assist resident with hand hygiene and monitor/record for target behavior symptoms, agitation, and restlessness.A Reportable Event (RE) Form 3/28/26 at 6:25 PM identified LPN #1 heard yelling in the hallway and witnessed Resident #2 getting pushed by Resident #1, falling, and striking his/her head on the floor, which resulted in a small laceration to the crown of Resident #2's head. Interventions involved assigning a one-to-one monitor to Resident #1 and administering a cool compress to his/her tongue due to an injury sustained during the incident. Resident #2 was transferred to the hospital for further evaluation with no injury identified. Review of the RCP for Resident #1 identified a one-to-one monitor was assigned on 3/28/26, however failed to identify additional interventions to deter/prevent further altercations between Resident #1 and other residents.A provider's note by APRN #1 on 3/29/26 at 8:42 AM identified the one-to-one monitor was discontinued for Resident #1.Review of the RCC for Resident #1 dated 3/28/26 through 4/9/26 identified the following resident care interventions: assist resident with hand hygiene and monitor/record for target behavior symptoms, agitation, and restlessness (no changes were made to the RCC since 3/21/26). An RE dated 4/10/26 at 3:40 PM identified Resident #2 entered Resident #1's room, Resident #1 yelled at and punched Resident #2, and Resident #2 hit Resident #1 back. Interventions involved assigning a one-to-one monitor to Resident #1, psychiatric evaluation, Physician's Emergency Certificate for medical/behavioral evaluation, and hospital transfer. Resident #2 was administered Tylenol and ice to his/her cheek.Interview with NA #1, assigned to Resident #1 on 4/10/26 during the 3:00 PM to 11:00 PM shift, on 4/24/26 at 11:12 AM identified he/she had only worked with Resident #1 twice prior to the 4/10/26 incident and was unfamiliar with Resident #2. NA #1 further identified he/she received report regarding the residents at the start of the shift, however, did not receive specific instructions regarding Resident #1 and Resident #2 needing to be kept at a safe distance from each other or how to manage them if in close proximity, and was unaware of previous altercations between them.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 9:15 AM identified he/she implemented and relied on staff huddles at the beginning and end of each shift to communicate issues, concerns or incidents between Resident #1 and Resident #2. The DNS further indicated that new staff (who had never worked on the secured unit before) would get direct report from the charge nurse with specific instructions on how to manage Resident #1 and Resident #2 when in close proximity of one other and strategies for how to maintain ample distance between them. The DNS identified the RCP and RCC for Resident #1 was not updated with specific interventions as he/she implemented what was thought to be appropriate at the time while investigating the cause of Resident #1's aggression and was utilizing huddles to manage and communicate issues/concerns amongst floor staff.The Baseline/Comprehensive Person-Centered Care Plan policy directed the Comprehensive Person-Centered Care Plan would be kept current by all disciplines on an outgoing basis and disciplines would be responsible for updating the care plan when there was a new problem that required that discipline to intervene.

Based on observations, review of facility documentation, review of facility policies and procedures, and interviews, the facility failed to ensure that environmental rounds were conducted/completed monthly, the facility failed to ensure the monthly Infection Control Surveillance data collection reports were inclusive of all infections identified within the facility and the facility failed to identify a possible communicable disease/outbreak amongst residents and for 3 sampled residents (Residents #150, #46, #116) reviewed for dining, the facility failed to ensure infection control practices were followed in the dining room. The findings include: 1. Review of the infection control environmental round documentation for the period of January 2024 to August 2025 failed to identify the monthly environmental rounds that were completed for the months of January, February and March of 2024. Review of the environmental rounds provided by the facility with the Infection Preventionist (IP) Nurse (LPN #2) on 9/10/25 at 12: 23 PM identified the monthly environmental rounds were not completed for January to March of 2024. Interview with LPN #2 on 9/10/25 at 12: 23 PM identified she was unable to locate the months of January, February and March in 2024 in the binder. She identified the environment rounds are conducted monthly with the housekeeping director, the Infection Preventionist, Administrator, food service/dining, and Maintenance Director to complete a cumulative report. LPN #2 identified it was the responsibility of the previous IP nurse to ensure they were conducted as she had only started in the role of an IP at the facility in April 2024. Review of the Environmental Rounds policy identifies rounds will be conducted monthly by the Infection Prevention Committee and appropriate department heads and the environmental rounds tool checklist will be completed for each area of the building as it is surveyed. The committee, at a minimum, consists of the Administrator, Infection Control Nurse, Housekeeping supervisor, environmental/maintenance supervisor and food service supervisor. Review of the infection control program for the period of November 2024 to August 2025 failed to identify on the monthly infection surveillance reports any resident who had an infection and were not treated with an antibiotic. Interview and review of the facility documentation with the Infection Preventionist (IP) Nurse (LPN #2) on 9/10/25 at 12: 23 PM in the presence of the ADNS identified facility had a COVID-19 outbreak which occurred in April 2025 and none of the residents who were affected was identified on the April infection control surveillance report. LPN #2 identified she only tracks the residents who are treated with antibiotics on her reports. LPN #2 indicated if residents had any symptoms of an infection the nurse would document in the resident's individual chart, but she does not track those residents. LPN #2 identified in the past when she was using paper documentation, she would track residents who were treated with antiviral but since they went electronic, she had stopped. LPN #2 identified she was responsible for tracking all infections within the facility and document the infections. Interview with the DNS on 9/10/25 at 1:51PM in the presence of the Corporate Clinical Nurse (RN #3) identified she was unaware that the IP nurse was not tracking residents with respiratory symptoms or any other symptoms of infections that were not treated with an antibiotic. The DNS identified the IP should be tracking all infections in the facility not only the ones that are been treated with antibiotics. Review of the Infection Surveillance policy identifies the infection surveillance process includes data collection which is conducted by a trained infection preventionist either concurrently or retrospectively, based on the situation. The policy further identifies the source of the data: resident electronic health records, laboratory reports, incident and infection logs device utilization data. In addition, the policy identified infection to monitor includes ventilator-associated pneumonia, respiratory tract infections, urinary tract infections, bloodstream infections gastrointestinal infections and skin and soft tissue infections. Review of the facility monthly infection report for the month of July 2025 identified a total of 16 cases of facility acquired respiratory tract infections. The facility had a total of 5 units with 3 of the 5 units being affected, with one unit having a total of 9 cases. Review of the Infection Control Data Collection tool McGeer (criteria tool used to identify infections) of each identified case on the July 2025 monthly infection surveillance tracking identified the following: Resident #1 McGeer data collection dated 7/18/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #1 had symptoms of new/increased cough, new or changed in lung examination abnormalities, a chest x-ray which demonstrated pneumonia or the presence of a new infiltrate and leukocytosis with the infection/symptom beginning on 7/16/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #1 further identifies in the section which asked if the infection was reported to the local public health agency with a response of no, not reportable. Resident #26 McGeer data collection dated 7/10/25 identified was suspected of having a potential infection of lower tract infection. Resident #26 had symptoms of new/increased cough, and functional decline with the infection/symptom beginning on 7/7/25. The McGeer data collection for Resident #26 further identifies in the section which asked if the infection was reported to the local public health agency with a response of no, not reportable. Resident #39 McGeer data collection dated 7/18/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #39 had symptoms of new/increased cough, pleuritic chest pain, a chest x-ray which demonstrated pneumonia or the presence of a new infiltrate, leukocytosis, and acute functional decline with the infection/symptom beginning on 7/17/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #39 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #59 McGeer data collection dated 7/18/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #59 had symptoms of new/increased cough, new or increased sputum production, new or changed in lung examination abnormalities, a chest x-ray which demonstrated pneumonia or the presence of a new infiltrate, acute change in mental status from baseline and acute functional decline with the infection/symptom beginning on 7/18/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #59 further identifies in the section which asked if the infection was reported to the local public health agency with a response of no, not reportable. Resident #67 McGeer data collection dated 7/2/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #67 had symptoms of new/increased cough, new or changed in lung examination abnormalities, a chest x-ray which demonstrated bilateral infiltrates with the infection/symptom beginning on 7/1/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #67 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #68 McGeer data collection dated 7/7/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #68 had symptoms of new/increased cough, new or increased sputum production, a chest x-ray which demonstrated atypical pneumonitis, and acute functional decline with the infection/symptom beginning on 7/2/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #68 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #82 McGeer data collection dated 7/29/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #82 had symptoms of new/increased cough, new or changed in lung examination abnormalities, a chest x-ray which demonstrated opacities in lung bases, and acute functional decline with the infection/symptom beginning on 7/28/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #82 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #85 McGeer data collection dated 7/21/25 identified he/she was suspected of having a potential infection of COVID-19. Resident #85 had symptoms acute functional decline with the infection/symptom beginning on 7/17/25 wherein resident went to the hospital on 7/17/25 and was diagnosed with COVID and returned to the facility in the evening. The McGeer data collection for Resident #85 further identifies in the section which asked if the infection was reported to the local public health agency with a response of yes. Resident #89 infection McGeer nurses note dated 7/15/25 identified he/she had a respiratory infection and had a dry cough. Resident #94 McGeer data collection dated 7/4/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #94 had symptoms of new/increased cough, new or increased sputum production, a chest x-ray which demonstrated bilateral infiltrates, and new or changed in lung examination abnormalities with the infection/symptom beginning on 7/3/25. The McGeer data collection for Resident #94 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #103 McGeer data collection dated 7/5/25 identified was suspected of having a potential infection of upper respiratory infection. Resident #103 had symptoms of stuffy nose or nasal congestion and dry cough with the infection/symptom beginning on 7/4/25 which met criteria. The McGeer data collection for Resident #103 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #109 McGeer data collection dated 7/18/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #109 had symptoms of new/increased cough, new or increased sputum production, new or changed in lung examination abnormalities, acute functional decline, leukocytosis, and a chest x-ray was done which demonstrated no acute disease process with the infection/symptom beginning on 7/15/25. The McGeer data collection for Resident #109 further identifies in the section which asked if the infection was reported to the local public health agency with a response of no, not reportable. Resident #120 McGeer data collection dated 7/10/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #120 had symptoms of new/increased cough, a chest x-ray which demonstrated faint right basal infiltrate, and acute functional decline with the infection/symptom beginning on 7/9/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #120 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Resident #151 McGeer data collection dated 7/6/25 identified he/she was suspected of having a potential infection of pneumonia. Resident #151 had symptoms of new/increased cough, new or increased sputum production, new or changed in lung examination abnormalities, pleuritic chest pain, a chest x-ray which demonstrated right middle lobe infiltrate, and acute functional decline with the infection/symptom beginning on 7/6/25 which met the criteria of pneumonia infection. The McGeer data collection for Resident #151 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Review of Resident #154's clinical records identified a nurse's note dated 7/6/25 at 2:21 PM by the ADNS identified Resident #154 had worsening cough this shift, audible inspiratory and expiratory wheeze throughout lung, positive for shortness of breath and productive cough with green sputum. The note further identified the resident had new order for a chest x-ray and labs to be completed as soon as possible, viral respiratory panel and monitor respiratory status. Resident #55 McGeer data collection dated 7/2/25 identified he/she was suspected of having a potential infection of the lower respiratory tract. Resident #155 had symptoms of new/increased cough, new/increase sputum production, new or changed in lung examination abnormalities, fever, and leukocytosis with the infection/symptom beginning on 7/1/25. The McGeer data collection for Resident #155 further identifies in the section which asked if the infection was reported to local public health agency with a response of no, not reportable. Review of the Trend and Track Healthcare Acquired Infection Rates/MDRO Variance Analysis report identified the rate of pneumonia infections in July/2025 was 2.05 and in June/2025 the rate was 1.64, showing an increase in the rate from the previous month. The report also identified an increase in lower respiratory tract/bronchitis infections July/2025 (1.59) than in June/2025 which had a rate of 1.17. A line list was requested for the increasing facility acquired respiratory tract infections in July/2025 but was not provided by the facility. The DNS identified she could not recall a line list was initiated at the time of the increase. An interview with the Infection Preventionist (IP) (LPN #2) on 9/9/25 at 11:54 AM identified the facility had an increase rate of respiratory infections especially pneumonia in July 2025. However, she would not have reported/thought the pneumonia infections as an outbreak. The IP identified the increasing respiratory cases in July was out of the normal occurrence for respiratory illnesses, with a few cases starting in June 2025 but majority of the cases were in July/2025. Interview with LPN #2 and the ADNS on 9/10/25 at 12:23 PM identified a line list would have been started if the residents met the criteria of an outbreak. They were then asked what the facility criteria for outbreak is, which they reviewed the outbreak policy and responded based on the policy and reviewing of the documentation the facility did have an outbreak. The ADNS and LPN #2 identified the increase in respiratory illness was discussed during morning report and they decided to keep the resident on the unit, implement surgical mask usage on the units by staff, extra cleaning by housekeeping staff and provided education on hand hygiene to staff. LPN #2 and the ADNS indicated they treated the increase respiratory infections as an outbreak, however, did not consider this incident as an outbreak. LPN #2 identified testing for Legionnaires disease was not considered or completed with the increasing facility acquired pneumonia cases. The ADNS further indicated she was told yesterday she was responsible for overseeing the IP infection control responsibilities and not only just the wound portion of the IP's role. The ADNS and IP identified they could not recall if their regional staff who would provide guidance in determining if the facility was experiencing an outbreak was contacted during the increasing facility acquired respiratory tract illness. Interview with the DNS on 9/10/25 at 1:51PM in the presence of the Corporate Clinical Nurse (RN #3) identified when the increase in respiratory cases was discussed during morning report, she stopped communal activities but had not initiated a line list to be completed. The DNS identified they had no line list completed, and the facility had not reached out to their corporate IP for guidance during the time of the increase as to identify the facility had an outbreak. Review of the At-Risk Meetings dated 7/2/25 and 7/18/25 failed to identify the increase in cases of respiratory infections/illnesses. Review of the weekly Medical Director Rounds conducted identified on 7/2/25 indicated antibiotic use was reviewed; on 7/16/25 indicated infection control report was reviewed and on 7/23/25, indicated antibiotics report was reviewed. The rounds failed to indicate any discussion regarding a respiratory outbreak, increase in respiratory illnesses and measures implemented to reduce or prevent further cases. Review of the Outbreak management policy identified an outbreak is defined as three (3) or more cases of clinically significant, facility acquired infections caused by the same organism occurring in the same general area within a period of seven (7) das OR twice the average number of these infections per month observed for three (3) consecutive months OR two or more with nosocomial cases of non-aspiration pneumonia within a 10-day period will be reviewed as a potential outbreak, consider testing for Legionnaires. The policy further identified when a commonality of symptoms is evident among residents or staff who have other factors in common such as person, place, time or event, suspect an outbreak. In addition, the policy identifies to notify state and local health officials as required by public health codes or ordinances, report excess illnesses and new or unusual infections to public health agencies as soon as possible. 2. Observation on 9/3/25 at 11:45 AM identified Resident #150, 46 and 116 in the dining room awaiting lunch service. At 11:50 AM lunch service arrived from the dietary staff with two carts wheeled to the dining room. LPN#7 and NA#3 along with three other staff started to serve the residents in the dining room. Trays were unloaded from both carts. LPN#7 helped to push Resident#46 closer to the food and then started to cut the chicken sandwich in half placing one bare hand on the chicken sandwich to steady it while cutting with the other hand. NA#3 at the same time asked Resident #150 if she would like the bread buttered. NA#3 then proceeded to butter the bread holding the bread with her bare hand and buttering with the knife. Following the assistance given to Resident #150 NA#3 went back to the second dining storage cart and closed the door then returned to a different table where Resident #116 was seated. NA#3 then proceeded to butter Resident #116's bread handling the bread in her bare hand. Interview on 9/3/25 at 12:28 PM with LPN#7 identified that it was not a clean practice to touch the food with her bare hands as well as helping residents and that it could be an infection control issue and that she should have washed her hands before touching the food and probably should have worn gloves. Interview on 9/3/25 at 12:35 PM with NA#3 identified that she should not be touching the residents' food with her bare hands. She further noted that she should wash her hands before providing assistance with food. She further noted that she does not wear gloves in the dining room. Review of the Food Safety policy identified food, and food service supplies are procured, handled, prepared, stored, distributed, served, and disposed of in accordance with professional standards for food service safety (e.g., FDA food Code and CDC Food Safety guidance) to minimize the risk of and/or prevent contamination and foodborne illness.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure expired medications were removed from the medication carts and not in use, failed to ensure multiple use vials were labelled upon opening to ensure they were discarded after 30 days. The findings include:Observation with LPN #5 on 9/8/25 at 11:53 AM identified the medication cart on the secured unit contained the following outdated medications: a bottle of aspirin 81mg with no expiration date a bottle of calcium 600 plus D5 mcg with an expiration date of 7/2025, there was a noted date of 8/31/25 that identified the bottle was opened on that date (post expiration date) 4 multi-use vials of Lidocaine 1% that were not marked with an opened date Interview on 9/8/25 at 12:12 PM with LPN #5 identified that the vials should be marked with the date opened. LPN#5 identified the facility had night shift staff delegated to check expiration dates but indicated that it was the responsibility of the nurse managing the medication cart to check expiration dates. Observation with LPN #7 on 9/8/25 at 12:37 PM identified the 1st floor medication cart contained an expired resident specific bubble pack of Meclizine 25mg tablets with an expiration date of 6/18/25. The bubble pack had 7 remaining tablets. Interview on 9/8/25 at 12:40 PM with LPN #7 identified that all nurses are responsible for removing expired medications from the medication cart. LPN#7 identified expired medications should be given to the supervisor and identified that she did not administer the medication and therefore did not check whether the medication was expired. Interview on 9/8/25 at 12:54 PM with the Nursing Supervisor (RN #2) identified that if something doesn't have an expiration date, it should not be put into circulation. RN#2 identified the multi-use vials should be labelled when opened and should be discarded 30 days from the opened date. RN#2 further noted there is a designated person to inspect the medication rooms on a weekly basis and remove the expired medications. Interview on 9/8/25 at 1:58 PM with the ADNS and DNS identified that all staff are required to check expiration dates and discard if needed. Additionally, the DNS indicated that if the medication is no longer prescribed, it should be removed from the medication cart. The facility policy for medication storage identified that prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself, and once expired should be removed from circulation.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for five of ten sampled residents (Resident #3, Resident #20, Resident #151, Resident #153, and Resident #154) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed, offered/ and administered as requested by the resident upon/on admission. The findings include: 1. Resident #3 was admitted to the facility in May of 2025 and had diagnoses that included cerebral infarction, anemia and respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #3 had severely impaired cognition. The assessment further identified Resident #3 had not received the pneumococcal vaccine as it was not offered. Review of the clinical records for Resident #3 immunization consents and records failed to identify a consent/declination was obtained or a record of a documented vaccine was found in the resident record. Review of Resident #3 immunization consents and records with the Infection Preventionist (LPN #2) on 9/9/25 at 12:46 PM failed to identify that the pneumococcal vaccine was offered to the resident, or the resident had received the vaccine prior to admission. Interview with the Infection Preventionist (IP) (LPN #2) on 9/9/25 at 12:46 PM identified vaccine consent is obtained on admission by the admitting nurse or by herself when she is in the facility. LPN #2 identified she was responsible for reviewing the vaccine consent and added there were issues with the admission packets not having the vaccine paperwork included in the paperwork. The IP nurse (LPN#2) identified she did not have a tracking system in place to check resident vaccination status. Interview on with LPN #2 and the ADNS on 9/10/25 at 12:23 PM identified they had problems with residents' vaccination status and had conducted a whole house audit as there was a break the facility's process. The ADNS further identified consents were not obtained on admission as they were not included as a part of the admission process and they had added another nurse recently to assist the IP nurse to give her extra time to complete other tasks. A request for the audits that were completed and when the process had begun, however, they failed to provide such documentation of the audits and timeline as to when the break in the process had begun. Review of the Pneumococcal Vaccination policy identifies all residents admitted to this facility will be evaluated to determine if they have received pneumococcal vaccination. The facility will educate the resident/representative on the benefits of pneumococcal immunization, and offer administration unless immunization is medical contraindicated, the resident has already been immunized or resident and or responsible party declination. The policy further identifies the purpose of the pneumococcal vaccination is to ensure that the residents receive optimal protection against the pneumococcal infection. 2. Resident #20 was admitted to the facility in July of 2025 and had diagnoses that included Alzheimer's disease, type 2 diabetes mellitus, and interstitial pulmonary disease. The admission MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition. Review of the Pneumococcal Vaccination Series (PCV/PPSV23) consent form identified Resident #20's responsible party gave the facility permission on 8/4/2025 to administer/complete the pneumococcal series as directed by the Center for Disease Control and Prevention (CDC) guidelines and my physician. Review of the clinical records for Resident #20 immunization consents and vaccination records failed to identify Resident #20 had received the pneumococcal vaccine as requested by the resident. Review of Resident #20's clinical records with the Infection Preventionist (LPN #2) on 9/9/25 at 11:54 AM indicated Resident #20 had received the Pneumovax 23 outside of the facility on 11/11/2019 but failed to identify that he/she had received any pneumococcal vaccines while at the facility to complete the pneumococcal series. In addition, the records did not contain any documentation that the resident had refused the vaccine while at the facility. Interview with the Infection Preventionist (IP) (LPN #2) on 9/9/25 at 11:54 AM identified the admitting nurse or if she is here at the facility would obtain vaccine consent. She indicated if the facility staff obtained the consent for the vaccine, they would place a copy in her mailbox or email her a copy. She identified she was responsible for reviewing the consent forms to identify the appropriate vaccine for resident and obtain the physician's order. LPN #2 was asked why Resident #20 did not received the vaccine when consented she responded that she don't have an answer. She was also asked if the vaccine was available at the pharmacy and responded that she had no information that the vaccine was not available. Interview with the DNS on 9/9/25 at 2:00 PM identified after vaccine consent is obtained for pneumococcal vaccine that she expects the vaccine it to be administered as soon as possible. Review of the Pneumococcal Vaccination policy identifies all residents admitted to this facility will be evaluated to determine if they have received pneumococcal vaccination. The facility will educate the resident/representative on the benefits of pneumococcal immunization, and offer administration unless immunization is medical contraindicated, the resident has already been immunized or resident and or responsible party declination. The policy further identifies the purpose of the pneumococcal vaccination is to ensure that the residents receive optimal protection against the pneumococcal infection. 3. Resident #151's diagnoses included type 2 diabetes mellitus, chronic obstructive pulmonary disease, and acute respiratory distress. The significant change MDS assessment dated [DATE] identified Resident #151 had severely impaired cognition. The assessment further identified Resident #151 had not received the pneumococcal vaccine as it was not offered.Review of the Pneumococcal Vaccination Series (PCV/PPSV23) consent form identified Resident #151's gave the facility permission on 6/2/2025 to administer/complete the pneumococcal series as directed by the Center for Disease Control and Prevention (CDC)guidelines and my physician. Review of the clinical records for Resident #151 immunization consents and vaccination records failed to identify Resident #151 had received the pneumococcal vaccine as requested by the resident. Review of Resident #151's clinical records with the Infection Preventionist (LPN #2) and the ADNS on 9/10/25 at 12:23 PM failed to identify that he/she had received any pneumococcal vaccines while at the facility to complete the pneumococcal series nor did the records contain any documentation that the resident had refused the vaccine or was unable to receive the vaccine or had received the vaccine historical. Interview with the DNS on 9/9/25 at 2:00 PM identified after vaccine consent is obtained for pneumococcal vaccine that she expects the vaccine it to be administered as soon as possible. Interview on with LPN #2 and the ADNS on 9/10/25 at 12:23 PM identified they had problems with residents' vaccination status and had conducted a whole house audit as there was a break the facility's process. The ADNS further identified consents were not obtained on admission as they were not included as a part of the admission process and they had added another nurse recently to assist the IP nurse to give her extra time to complete other tasks. A request for the audits that were completed and when the process had begun, however, they failed to provide such documentation of the audits and timeline as to when the break in the process had begun. The IP nurse indicated Resident #151 was unable to receive the vaccine as he/she was ill, however, failed to provide any documentation in the clinical records which indicated why the pneumococcal vaccine was not administered as requested by the resident. Review of the Pneumococcal Vaccination policy identifies all residents admitted to this facility will be evaluated to determine if they have received pneumococcal vaccination. The facility will educate the resident/representative on the benefits of pneumococcal immunization, and offer administration unless immunization is medical contraindicated, the resident has already been immunized or resident and or responsible party declination. The policy further identifies the purpose of the pneumococcal vaccination is to ensure that the residents receive optimal protection against the pneumococcal infection. 4. Resident#153 was admitted to the facility in March of 2025 and had diagnoses that included chronic obstructive pulmonary disease, pneumonia, and muscle weakness. The quarterly MDS dated [DATE] identified Resident #153 had severely impaired cognition, an active diagnosis of a cardiorespiratory condition, had not received the pneumococcal vaccine. Review of the medical record for Resident#153 immunization consents and records failed to identify a consent/declination was obtained or a record of a documented vaccine was found in the resident record. The documented cause of death as primary on the death certificate was listed Pneumonia. The review of the Resident#153 vaccination record with the Infection Preventionist (LPN#2) on 9/9/25 at 12:50PM failed to identify that the pneumococcal vaccine was offered to the resident, or the resident had received the vaccine prior to admission. The IP nurse (LPN#2) identified she did not have a tracking system in place to check/track resident vaccination status. Interview with the Infection Preventionist (IP) (LPN #2) on 9/9/25 at 12:46 PM identified vaccine consent is obtained on admission by the admitting nurse or by herself when she is in the facility. LPN #2 identified she was responsible for reviewing the vaccine consent and added there were issues with the admission packets not having the vaccine paperwork included in the paperwork. The IP nurse (LPN#2) identified she did not have a tracking system in place to check resident vaccination status. Interview on with LPN #2 and the ADNS on 9/10/25 at 12:23 PM identified they had problems with residents' vaccination status and had conducted a whole house audit as there was a break the facility's process. The ADNS further identified consents were not obtained on admission as they were not included as a part of the admission process and they had added another nurse recently to assist the IP nurse to give her extra time to complete other tasks. A request for the audits that were completed and when the process had begun, however, they failed to provide such documentation of the audits and timeline as to when the break in the process had begun. Interview with the DNS on 9/9/25 at 2:00 PM identified after vaccine consent is obtained for pneumococcal vaccine that she expects the vaccine it to be administered as soon as possible. Review of the Pneumococcal Vaccination policy identifies all residents admitted to this facility will be evaluated to determine if they have received pneumococcal vaccination. The facility will educate the resident/representative on the benefits of pneumococcal immunization, and offer administration unless immunization is medical contraindicated, the resident has already been immunized or resident and or responsible party declination. The policy further identifies the purpose of the pneumococcal vaccination is to ensure that the residents receive optimal protection against the pneumococcal infection. 5. Resident #154's diagnoses included hypertension, asthma, and diastolic congestive heart failure. The annual MDS assessment dated [DATE] identified Resident #154 was cognitively intact. The assessment further identified Resident #154 had not received the pneumococcal vaccine as it was not offered. Review of the Pneumococcal Vaccination Series (PCV/PPSV23) consent form identified Resident #154's gave the facility permission on 7/19/2025 to administer/complete the pneumococcal series as directed by the Center for Disease Control and Prevention (CDC)guidelines and my physician. Review of the clinical records for Resident #154 immunization consents and vaccination records failed to identify Resident #154 had received the pneumococcal vaccine as requested by the resident. Review of Resident #154's clinical records with the Infection Preventionist (LPN #2) on 9/9/25 at 11:54 AM indicated Resident #154 had received the Pneumovax 23 outside of the facility on 9/16/2019 but failed to identify that he/she had received any pneumococcal vaccines while at the facility to complete the pneumococcal series. In addition, the records did not contain any documentation that the resident had refused the vaccine while at the facility. Interview with the DNS on 9/9/25 at 2:00 PM identified after vaccine consent is obtained for pneumococcal vaccine that she expects the vaccine it to be administered as soon as possible. Interview on with LPN #2 and the ADNS on 9/10/25 at 12:23 PM identified they had problems with residents' vaccination status and had conducted a whole house audit as there was a break the facility's process. The ADNS further identified consents were not obtained on admission as they were not included as a part of the admission process and they had added another nurse recently to assist the IP nurse to give her extra time to complete other tasks. A request for the audits that were completed and when the process had begun, however, they failed to provide such documentation of the audits and timeline as to when the break in the process had begun.Review of the Pneumococcal Vaccination policy identifies all residents admitted to this facility will be evaluated to determine if they have received pneumococcal vaccination. The facility will educate the resident/representative on the benefits of pneumococcal immunization, and offer administration unless immunization is medical contraindicated, the resident has already been immunized or resident and or responsible party declination. The policy further identifies the purpose of the pneumococcal vaccination is to ensure that the residents receive optimal protection against the pneumococcal infection.

Based on review of the clinical record, review of facility policy/procedures and interviews for the one sampled resident (Resident #20) reviewed for Advanced Directives, the facility failed to ensure the physician's orders accurately reflected the resident's code status of do not resuscitate. The findings included:Resident #20 was admitted to the facility [DATE]. Diagnoses included Alzheimer's disease, and Type 2 diabetes mellitus with hyperglycemia. The hospital Discharge summary dated [DATE] identified a code status of full code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive including cardiopulmonary resuscitation (CPR)). The physician's orders dated [DATE] did not direct a code status for Resident #20. The care plan dated [DATE] identified Resident #20 had an advanced directive of cardio pulmonary resuscitation with interventions to honor the advanced directives as directed by resident/responsible party for guidance. The APRN progress notes dated 7/23, 7/28, 7/30, 7/31, 8/1, 8/5, 8/13, 8/14, 8/19, 8/21, 8/22, 9/2 and [DATE] identified Resident #20's code status was full code. The admission MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition and utilized a walker for mobility. Review of the clinical record identified an advanced directive form dated/signed on [DATE] by the resident's responsible party, and the DNS that directed a code status of do not administer cardiopulmonary resuscitation (DNR), artificial respiration, artificial nutrition, IV hydration or hospitalization. The care plan meeting notes dated [DATE] identified Resident #20 as a full code. Interview on [DATE] at 10:53 AM with Person #1 (responsible party and emergency contact for Resident #20), who signed the advanced directive identified the directive choice was DNR/DNI (do not intubate). Interview on 9/ 9/2025 at 6:31 AM with LPN#4 identified after verification in the computer that Resident #20's code status was designated as full code (provide CPR if needed). Interview on [DATE] at 6:36 AM with the DNS identified that she was the witness signature on Resident #20's advance directive. The DNS indicated that the paperwork, once completed, is given to the nursing supervisors to enter into the care plan and place an order. The DNS identified that in the event of a need for CPR she would expect the staff to check the medical record, and the electronic health record (EHR). The DNS verified in the computer that Resident #20 was listed as a full code. Interview on [DATE] at 11:13 AM SW#1 identified that social work may reach out to the family if there is a delay, but that nursing takes care of the advance directives. The facility policy for Advanced care planning code status identified that orders not to attempt cardiopulmonary resuscitation of a resident will be in writing, after consent had been obtained. The policy identified that at admission the facility will check code status with the transferring agency and will be valid until the facility can verify and obtain its own record of the residents/family/surrogate/designated representative's wishes regarding CPR but in no event shall the order be valid for more than 48 hours. The policy indicated that a physician's order must be written to reflect the choice of choosing to resuscitate or not to resuscitate.

Based on review of clinical records, review of facility policy/procedures and interviews for 1 of 2 sampled residents (Residents #101) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the MDS accurately reflected the residents' status. The findings include: Resident # 101's diagnoses included bipolar disorder, anxiety, and insomnia.The PASRR level II screening dated 8/5/2015 identified Resident #101 had a positive level II PASRR.The annual MDS assessments dated 4/27/24 and 4/8/25 identified Resident #101 had intact cognition, no behaviors, was dependent on staff assistance for dressing, personal hygiene, and transfers. The assessment further identified Resident #101 had active psychiatric mood disorder of anxiety and bipolar disorder. The assessment further reflected that the resident did not have a positive level 2 PASRR. The assessment failed to reflect the resident's accurate status. The Resident Care Plan (RCP) dated 3/16/25 identified Resident #101 had a behavior problem related to extreme fear and bipolar disorder. Care plan interventions directed to administer medication as physician orders, anticipate and meet resident's need, assessed resident behavior episode and attempt to determine the underlying cause, and explained all procedures to the resident before starting a procedure.Interview with the Social Worker (SW#1) on 9/8/25 at 11:21 AM identified she was responsible for completing the PASSR section of the MDS assessment and when a resident is has a positive level II assessment, she enters the information on the MDS. After reviewing Resident #101's annual MDS assessments she noted that they should have been coded to reflect the positive level II assessment status. Although requested, a policy for accuracy of MDS coding was not provided.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of five sampled residents (Resident #110) reviewed for unnecessary medication, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of anticoagulant medication. The findings include: Resident #110's diagnoses included major depressive disorder, anxiety disorder, hypertensive heart disease, and spastic diplegic cerebral palsy. The quarterly MDS assessments dated 7/14/25 identified Resident #110 had intact cognition, required supervision or touching assistance with eating. The physician's orders for the month of July 2025 directed Xarelto (anticoagulant) 20 milligrams (mg) one tablet by mouth at bedtime for deep vein thrombosis (DVT). Interview and clinical record review with the MDS Coordinator Director (RN #4) on 9/8/25 at 11:05 AM identified Resident #110 is taking an anticoagulant medication, and his/her current care plan did not include a care plan that addressed the use of anticoagulant medication. RN #4 identified the resident had a care plan for anticoagulant therapy that was resolved on 7/22/25 when the care plan was reviewed and revised. She identified the focused area should not have been resolved as the resident is still on the medication. Further she noted the care plan should include educating the resident on and reporting of any bleeding and for staff to monitor sign/symptoms of bleeding. She identified it was the responsibility of the person who reviews the care plan to ensure the resident had the appropriate care plans. Interview with Care Plan Coordinator (LPN #6) in the presence of the ADNS on 9/8/25 at 12:00 PM identified she was responsible for updating and revising care plans. She further identified she had not resolved the anticoagulant care plan as the resident was still taking the medication. LPN #6 identified the facility was in the process of switching care plans to the new company's care plan, however, she would have added the new company's care prior to removing the old care plan. LPN #6 and the ADNS identified the resident care plan should have reflected the use of the anticoagulant medication with the inclusion to monitor for bleeding. Subsequent to surveyor's inquiry a care plan for potential for untoward effects due to anticoagulant therapy dated 9/8/25 was developed and implemented with interventions that included administer medication as ordered by the physician and monitor for signs/symptoms of abnormal bruising or bleeding, and report side effects of anticoagulant therapy to the nurse including coffee ground emesis, melena, hematuria, bleeding gums, petechial, easy bruising, shortness of breath and change in level of consciousness. The Baseline and Comprehensive Person Centered Care Plan policy identified the interdisciplinary team utilizes the comprehensive person-centered care plan to address resident's strength, needs, and/or problems as identified. The policy also identified that the care plan is periodically reviewed and revised based upon any changes in status.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Residents #110) reviewed for pressure ulcer/injury, the facility failed to ensure the alternating pressure relief mattress was in place as ordered and set to the ordered weight. The findings include: Resident #110's diagnoses included major depressive disorder, anxiety disorder, hypertensive heart disease, and spastic diplegic cerebral palsy. The quarterly MDS assessments dated 7/14/25 identified Resident #110 had intact cognition, no behaviors, was dependent on staff for transfers, personal hygiene and toileting hygiene, required substantial to maximal assistance with upper body dressing, was non ambulatory and utilized a wheelchair for mobility. The MDS further identified Resident #110 was at risk for developing pressure ulcers/injury, had no current skin impairments, and utilized a pressure reducing device in a chair, and bed. The care plan dated 7/22/25 identified Resident #110 had a potential for skin breakdown related to impaired mobility with interventions that included offload heels while in bed, and pressure redistribution mattress. The care plan entry dated 8/12/25 identified resident had a deep tissue injury (DTI) to the right heel with interventions that included air mattress set at alternating 200 per current weight and heel lift boots. The physician's order dated 8/13/25 directed to check function and setting of air mattress, set at 200 every shift. A review of Resident #110's clinical record identified Resident #110's weight was noted as 181 pounds on 8/2/25. The wound physician's note dated 8/28/25 identified Resident #110 had a deep tissue injury with persistent non-blanchable deep red, maroon or purple discoloration to the right medial heel that was noted to be not healed, the measurements were noted as 1.7 centimeters (cm) in length by 2.1 cm in width with no measurable depth and no drainage or odor noted. The note further identified orders for off-loading and facility pressure injury prevention protocol. Observation on 9/3/25 at 11:00 AM identified Resident #110 in bed positioned on his/her side facing the door. The resident was lying on a regular mattress and did not have an alternating air pressure mattress in place. Observation on 9/8/25 at 8:56 AM identified Resident #110 in bed positioned on his/her back with the alternating pressure mattress with the weight set at 325 pounds. A review of the air mattress audit completed on 9/3/25 identified Resident #110 had an air mattress set to 200 pounds. A review of the medication administration record/treatment administration record (MAR/TAR) for September 2025 identified LPN#3 signed off on 9/4/25, 9/5/25 and 9/8/25 at 7:21 AM for the checking of the mattress setting (day shift) and LPN#8 signed off on 9/3/25. Interview with the Charge Nurse (LPN #3) on 9/8/25 at 10:41 AM identified she signed off in the MAR/TAR that she had checked the air mattress setting at 7:21 AM on all the identified days; however, she identified that she had not checked the mattress at that time. LPN #3 identified that signing off the MAR/TAR means that the order was being followed but acknowledged that she had not physically checked the mattress to ensure the mattress was in place and the setting was correct. Interview with the Wound Nurse (LPN #2) on 9/8/25 at 11:28 AM identified Resident #110 was placed on an alternating pressure mattress that utilized a pump on 8/13/25 when the DTI to the right heel was identified. She identified that if the mattress was set to 325 pounds, it would be too hard and could potentially cause skin issues. Interview with the Director of Housekeeping and Housekeeper #1 on 9/8/25 at 12:55 PM identified the housekeeping department is responsible for changing the resident's mattresses. The Director of Housekeeping identified he was notified by the IP nurse on 8/12/25 to provide Resident #110 with an alternating pressure mattress which he did, and within the next 2 days he was told to change the mattress back to the resident regular mattress, which he also did. He identified during the week of 9/1/25, he could not identify the exact date when the IP nurse told him to change Resident #110 regular mattress back to the alternating air pressure mattress which was done on 9/5/25. He identified the IP/nurse would set the settings. Interview with LPN #2 on 9/8/25 at 2:00 PM identified she had completed the air mattress audit at 7:00 AM as soon as she came in and Resident #110 air mattress was set to 200. Interview with NA #1 and NA #2 on 9/8/25 at 2:21 PM identified Resident #110 mattress was changed on Friday (9/5/25) to the alternating mattress and prior to that, the resident had a regular mattress. Interview with LPN #8 on 9/8/25 identified Resident #110's mattress was changed on Friday (9/5/25) to the alternating air loss mattress. She indicated she worked on 9/3/25 and did sign off the MAR/TAR but could not recall if the mattress was there when she signed off the MAR/TAR. Interview with the ADNS (oversees wounds care in the facility) on 9/10/25 at 8:39 AM identified Resident #110 was on an alternative air mattress as preventative measure for pressure injuries. She identified if the resident was not utilizing the air mattress as ordered or if the setting was incorrect, it will put the resident at risk for skin breakdown and worsening of the DTI as at times Resident #110 spends most of the day in bed. Review of the Pressure Injury Prevention Program - Pressure Injury Prevention Support Surfaces protocol policy under the guidelines for use of support surfaces identified that use of support surfaces will be based on the interdisciplinary team recommendation, the surface will be placed on the bed by housekeeping/maintenance and/or vendor. The support surface will be secured properly to the bed frame, the correct setting will be set by the nurse based on resident's weight or comfort level, and monitoring of the support surface inflation will be done by the nurse every shift and documented on the TAR.

Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #95) reviewed for nutrition, the facility failed to ensure that the dietician completed a quarterly assessment for a resident with weight loss. The findings include:Resident #95's with diagnoses that included Alzheimer's disease, dysphagia, hypertension, and GERD (Gastro-Esophageal Reflux Disease).The Dietician's progress note dated 3/12/25 identified Resident #95 had 15 percent weight loss and a current weight of 148 pounds. The Resident Care Plan (RCP) dated 3/14/25 identified Resident #95 was at risk for malnutrition related to Alzheimer's disease, dysphagia, and mechanically altered diet. Care plan interventions directed resident to have sufficient time to eat, diet as prescribe, encourage and monitor resident intake throughout the day, provide feeding assistance as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #95 had severe cognitive impairment, required limited assistance with eating and had an unplanned weight loss and was on a mechanically altered diet.The physician's order dated 5/7/25 directed to give regular diet with minced and moist texture, thin liquid consistency, no rice and keep resident seated upright for all meals and 30 minutes after eating.The quarterly MDS assessment dated [DATE] identified Resident #95 had severe cognitive impairment, required limited assistance with eating, did not have weight loss within the past 3 months, and was on a mechanically altered diet.Review of Dietician progress notes and/or nutritional evaluation from 3/13/25 to 6/14/25 failed to identify that Resident #95 nutritional status was evaluated on a quarterly basis following the last assessment dated [DATE] where it was noted that the resident had experienced a weight loss. Interview with the Dietician on 9/8/25 at 11:00 AM identified that she is responsible for assessing the residents' nutritional status. She identified that she completes assessments on admission, quarterly, and/or when there is a significant change in the resident nutritional status. She further identified that she documents either in the nutritional evaluation form and/or a progress note. In addition, her nutritional evaluation includes medical diagnoses, review of the current diet and changes in texture, review of the resident preferences, review of the average meal intake and review of the current medications. Further, the Dietician could not produce her quarterly nutritional assessment and/or progress notes from 3/13/25 to 6/14/25 for Resident #95. The Culinary and Nutrition policy identified that the nutritional status of the residents will be assessed on admission, quarterly, annually, and/or when a significant change occurred or more frequently as deemed necessary by the interdisciplinary team.

Based on review of the clinical records, review of facility policy, facility documentation, and interview for one of six residents (Resident #3) reviewed for immunizations, the facility to ensure that the COVID-19 booster vaccine was offered on admission to the resident. The findings include:Resident #3 was admitted to the facility in May of 2025 and had diagnoses that included cerebral infarction, anemia and respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #3 had severely impaired cognition. The assessment further identified Resident #3 was not up to date with the COVID-19 vaccination. Review of Resident #3 clinical records on 9/9/25 failed to identify that he/she received the COVID-19 booster for the 2024-2025 vaccination historically or any documentation the resident had received/refused the vaccine at the facility. Interview with the Infection Preventionist (IP) (LPN #2) on 9/9/25 at 12:46 PM identified vaccine consent is obtained on admission by the admitting nurse or by herself when she is in the facility. LPN #2 identified she was responsible for reviewing the vaccine consent and has identified there was an issue with the admission packets not having the vaccine paperwork included in the paperwork. The IP nurse (LPN#2) identified she did not have a tracking system in place to check resident vaccination status. Review of Resident #3's immunization consents and records with the DNS on 9/10/25 at 3:00 PM failed to identify that COVID-19 booster vaccine was offered to the resident. In an interview with the DNS on 9/10/25 at 3:00 PM identified she was unable to locate a consent form for the COVID-19 booster vaccine for Resident #3, and if it was not there, then it was not offered, which should have been done on admission. Review of the Infection Prevention and Control Program in the Immunizations for Resident section of the policy identifies the facility will educate and offer the COVID-19 vaccine to all eligible residents as per recommendations of the ACIP/CDC. The policy further identified vaccines are offered by the facility or through an arrangement with a pharmacy partner, local health department or other appropriate health entity and any new vaccine information will be dispersed as they become available.

Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were a potential for falls, the facility failed to implement a care plan intervention directing staff to encourage the resident to sleep in his/her own bedroom after the resident was observed by multiple staff sleeping in a chair in the dining room just prior to the resident sustaining a fall with fractures. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, anxiety and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating poor memory recall, had behaviors of rejection of care and wandering, was independent with bed mobility, transfers and ambulation, and had one (1) fall with minor injuries in the past ninety (90) days. The Resident Care Plan dated 9/12/25 identified Resident #1 had a behavior of sleeping in the dining room at bedtime. Interventions directed staff to encourage the resident to sleep in his/her own bedroom. The nurse's note dated 10/25/25 at 3:20 AM identified the Nursing Supervisor was called to the dining room by the charge nurse at 1:45 AM where Resident #1 was observed sitting on the floor in front of a chair with his/her back resting against the chair. The note identified Resident #1 reported he/she was attempting to walk and slipped, and Resident #1 was noted to be wearing shoes and no slip or fall hazards were noted surrounding the area. The note indicated Resident #1 reported severe eight (8) out of ten (10) pain to the right thigh area, there was no shortening or rotation noted to the extremities, and Range of Motion (ROM) was limited due to the pain. The note indicated the on-call Advanced Practice Registered Nurse (APRN) was notified, an order was obtained to transfer Resident #1 to the Emergency Department (ED) and Resident #1 was transferred to the hospital at 2:45 AM (one hour after the fall). The hospital documentation dated 10/25/25 identified imaging of Resident #1's pelvis showed Resident #1 had sustained an acute minimally displaced fracture (when the bone fragments remain close together and without a significant movement out of alignment) of the sacral ala (a break in the triangular shaped bone at the bottom of the spine), acute minimally displaced fractures of the bilateral inferior (below/away from the head) and left superior (positioned above/towards the head end of the body) pubic rami (the bony branches that extend from the pubis to the ischium in the pelvis) and a minimally displaced age indeterminate (unknown when it occurred) fracture of the anterior wall (front facing) of the right acetabulum (the socket part of the ball-and-socket hip joint where the femoral head meets with the pelvis). Interviews with the 11PM-7AM nurse aide, Nurse Aide (NA) #2 and charge nurse, Licensed Practical Nurse (LPN) #1, on 11/6/25 identified that although they observed Resident #1 sleeping in the dining room with the lights off prior to the fall on 10/25/25, they did not turn the lights on, wake Resident #1 or encourage him/her to return to his/her room to sleep per the plan of care. Interview with APRN #1 on 11/6/25 at 2:01 PM identified it was not safe for Resident #1 to be sleeping in the dining room with the lights off, out of view from staff and the staff should have turned the lights on and encouraged Resident #1 to return to his/her room. Interview with the Assistant Director of Nursing (ADON) on 11/6/25 at 2:28 PM identified that all staff are expected to follow the plan of care, and both NA #2 and LPN #1 should have woken Resident #1 when they observed him/her sleeping in the dining room and encouraged Resident #1 to return to their room. Review of the Baseline/Comprehensive Person-Centered Care Plan policy dated 3/2023 directed, in part, that the Person-Centered Care Plan is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals and desired outcomes. The Comprehensive Person-Centered Care Plan will be implemented by qualified members of facility staff.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall with injury, the facilityfailed to medicate the resident for severe pain while waiting one (1) hour to be transferred to the hospital. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, anxiety and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating poor memory recall, had behaviors of rejection of care and wandering, was independent with bed mobility, transfers and ambulation, and had one (1) fall with minor injuries in the past ninety (90) days. The Resident Care Plan dated 9/12/25 identified Resident #1 had a behavior of sleeping in the dining room at bedtime. Interventions directed staff to encourage the resident to sleep in his/her own bedroom. The nurse's note dated 10/25/25 at 3:20 AM identified the Nursing Supervisor was called to the dining room by the charge nurse at 1:45 AM where Resident #1 was observed sitting on the floor in front of a chair with his/her back resting against the chair. The note indicated Resident #1 reported he/she was attempting to walk and slipped, and Resident #1 was noted to be wearing shoes and no slip or fall hazards were noted surrounding the area. The note identified Resident #1 reported severe pain, eight (8) out of ten (10), to the right thigh area, there was no shortening or rotation noted to the extremities, and Range of Motion (ROM) was limited due to the pain. The note indicated the on-call Advanced Practice Registered Nurse (APRN) was notified, an order was obtained to transfer Resident #1 to the Emergency Department (ED) and Resident #1 was transferred to the hospital at 2:45 AM (one hour after the fall). The pain assessment dated [DATE] identified Resident #1 was complaining of pain to the right front thigh when attempting to move the leg or get up. Review of the October 2025 Medication Administration Record (MAR) identified an order to administer acetaminophen 325 milligrams (mg), give two (2) tablets (650 mg) by mouth every six (6) hours as needed for pain. Upon further review, the MAR failed to reflect documentation the acetaminophen had been administered on 10/25/25 for Resident #1's complaint of severe pain post fall. The hospital documentation dated 10/25/25 identified imaging of Resident #1's pelvis showed Resident #1 had sustained an acute minimally displaced fracture (when the bone fragments remain close together and without a significant movement out of alignment) of the sacral ala (a break in the triangular shaped bone at the bottom of the spine), acute minimally displaced fractures of the bilateral inferior (below/away from the head) and left superior (positioned above/towards the head end of the body) pubic rami (the bony branches that extend from the pubis to the ischium in the pelvis) and a minimally displaced age indeterminate (unknown when it occurred) fracture of the anterior wall (front facing) of the right acetabulum (the socket part of the ball-and-socket hip joint where the femoral head meets with the pelvis). Interview with the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1, on 11/6/25 at 12:13 PM identified the charge nurse called her on 10/25/25 to report Resident #1's fall, and when she responded she observed Resident #1 laying on the dining room floor with his/her head and shoulders supported by the foot of the recliner. RN #1 stated Resident #1 was holding his/her right thigh and complaining of pain and when she attempted to turned Resident #1 onto his/her left side to inspect for skin injuries, Resident #1 started screaming in pain. RN #1 identified she did not medicate Resident #1 with pain medication, reporting that it would have been the responsibility of the charge nurse. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/6/25 at 12:44 PM identified that she was the first to respond to Resident #1 screaming in the dining room on 10/25/25, the lights were off, Resident #1 was lying on the floor on his/her back up against the reclining chair, grabbing his/her right leg. LPN #1 explained when the Nursing Supervisor, RN #1, arrived, RN #1 turned Resident #1 to the left side to assess for injuries and Resident #1 immediately began yelling out in pain. LPN #1 identified although Resident #1 was yelling out in pain and grabbing his/her right leg post fall and was not transferred to the hospital until one (1) hour later, she did not attempt to medicate Resident #1 with the as needed pain reliever medication. Interview with APRN #1 on 11/6/25 at 2:01 PM identified if Resident #1 was complaining of severe eight (8) out of ten (10) pain, she would have expected Resident #1 to be made comfortable and pain relievers administered prior to being transferred to the hospital, as Resident #1 had acetaminophen available for pain. Interview with the Assistant Director of Nursing (ADON) on 11/6/25 at 2:28 PM identified either RN #1 or LPN #1 should have addressed Resident #1's pain in the one (1) hour prior to Resident #1 being transferred to the hospital. Review of the Pain Management policy dated 12/2024 directed, in part, that the resident will be evaluated for pain upon development of new symptoms of acute or chronic pain that has not been previously evaluated and that pain relief medications will be administered when needed and the resident will be monitored for effect.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of five (5) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to ensure two (2) staff members were assisting the resident with a transfer in accordance with the care plan to prevent the resident from sustaining a laceration to the left shin. The findings include:Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of five (5) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to ensure two (2) staff members were assisting the resident with a transfer in accordance with the care plan to prevent the resident from sustaining a laceration to the left shin. The findings include:Resident #1's diagnoses included dementia with agitation, Alzheimer's Disease, anxiety and weakness.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating Resident #1 had short- and long-term memory problems, exhibited physical and verbal behaviors towards others, and was dependent on staff for transfers. The Resident Care Plan dated 5/2/25 identified Resident #1 had a deficit in functional mobility. Interventions directed for two (2) person partial or moderate assistance for transfers.The care plan identified Resident #1 was resistive to care related to dementia. Interventions directed to give clear explanation of all care activities prior to and as they occur during each contact and if the resident resists with activities of daily living, reassure the resident, leave and return five (5) to ten (10) minutes later and try again.The nurse's note dated 6/14/25 at 9:30 PM identified the charge nurse was called to Resident #1's room by the nurse aide at 8:00 PM and the nurse aide, Nurse Aide (NA) #1, stated Resident #1 was combative during the transfer from the wheelchair to the bed and hit his/her left lower leg on the wheelchair causing a laceration. The note identified Resident #1 complained of moderate pain to the area, the as needed Tylenol was administered, the Advanced Practice Registered Nurse (APRN) was notified, an order was given directing to send Resident #1 to the Emergency Department (ED), and Resident was transferred at 9:15 PM.The nurse's note dated 6/15/25 at 12:25 AM identified Resident #1 returned from the hospital at 11:30 PM on 6/14/25, there were sixteen (16) sutures to the left shin covered with a dry, clean, dressing, Resident #1 denied pain and an order directed to change the dressing daily and remove the sutures in eight (8) days.The facility's Summary Report dated 6/18/25 identified on 6/14/25 the nurse aide attempted to complete a transfer alone, despite Resident #1 being care planned for a two (2) person assist. During the attempted transfer, Resident #1 became more agitated and combative, attempted to kick the nurse aide and when doing so hit the wheelchair sustaining a laceration that required sixteen (16) sutures to be repaired. Review of the facility's fall investigation statement from the 3-11PM nurse aide, Nurse Aide (NA) #1, dated 6/14/25 identified during the transfer from the wheelchair to the bed without another staff member present to assist, Resident #1 became combative, and Resident #1 hit his/her left leg on the wheelchair sustaining a laceration.Interview and clinical record review with the Assistant Director of Nursing (ADON) on 7/9/25 at 12:24 PM identified Resident #1's care plan directed for two (2) staff members to transfer Resident #1. The ADON identified on 6/14/25 NA #1 transferred Resident #1 without another staff member which did not follow the care plan. Review of the facility policy titled Baseline/Comprehensive Person Centered Care Plan, last revised 3/2023, directed, in part, the interdisciplinary team will utilize the Comprehensive Person-Centered Care planning process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services and the MDS. The policy further directed, in part, the care plan is developed to include information necessary to properly care for the residents and will address the residents' preferences, goals, desired outcomes and plan for discharge and this will be implemented by qualified members of the facility staff.Although attempted, an interview with NA #1 was unable to be obtained.The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of July 17, 2025.Resident #1 was assessed by the nurse, sustained a laceration to the left leg, was transferred to the Emergency Department and required sixteen (16) sutures.A full review of all residents requiring two (2) person assistance for transfers was conducted. Care plans and kardexes were cross-checked for accuracy.The nurse aides received mandatory in-service education on the importance of following the care plan, how to review the care plan and kardex for each resident prior to providing care.Conduct five (5) random resident transfer audits weekly for four (4) weeks then monthly for three (3) months to ensure compliance.Monthly QAPI meeting will review the audit data and identify trends.

Based on observations, clinical record reviews, facility documentation and interviews for one (1) of five (5) resident units, the facility failed to ensure a medication cup containing pre-poured medications was secured in the medication cart when the medication cart was left unattended and not within the line of sight of the nurse. The findings include:During a tour of the facility with the Assistant Director of Nursing (ADON) on 7/9/25 observations of the medication cart on the Mountain Laurel unit at 9:50 AM identified the charge nurse, Licensed Practical Nurse (LPN) #3, walked away from her medication cart to assist a resident with putting his/her shoes on, leaving dispensed medications in a medication cup on top of the medication cart unattended in the hallway. The medication cart was noted not to be in LPN #3's line of sight. The observation was brought to the attention of the ADON at the time of occurrence and the ADON acknowledged that she saw the medication cup was left on top of the medication cart. Upon further observations several residents were noted to be sitting in the hallway in proximity to the medication cart. Review of the medication administration record identified the medications were that of Resident #5. The medication administration record identified the following medications were in the cup:Citalopram (antidepressant) 5 milligrams (mg), Empaglifozin (antidiabetic) 12.5mg, Folic acid 1mg, Loratadine (antihistamine) 10mg, Norvasc (blood pressure) 2.5mg, Risperidone (antipsychotic) 3mg, Apixaban (blood thinner) 5mg, Entresto (heart failure) 24-26mg, Metformin 875mg (antidiabetic), Senokot S 8.6-50mg, and Vitamin B12 500 micrograms (mcg). An interview with LPN #3 on 7/9/25 at 10:20 AM identified she was aware that she should not have left the medications on top of the medication cart unattended. LPN #3 indicated the ADON had asked her to assist a resident with his/her shoes when she walked away from the medication cart, and she stated it is her responsibility to ensure medications were secured. An interview with the ADON on 7/9/25 at 10:30 AM identified that medications should not be left unsecured/unattended on the medication cart and the charge nurse was responsible for ensuring medications are secured in the medication cart. The ADON stated it was not appropriate for the nurse to leave poured medications on top of medication cart as the facility policy is that medications are not to be left unattended if they are not secure. A review of the Medication Administration and Documentation policy directed, in part, the licensed nurse assures medications are not left unattended. Keep medications secured in a locked area or in visible control at all times.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a safe Hoyer lift (mechanical lift) transfer for a resident, due to environmental constraints that impeded stabilization of the Hoyer lift's legs, resulting in the resident being struck in the head by the Hoyer lift arm. The findings include: Resident #1's diagnoses included atrial fibrillation (irregular heart rate), neuropathy (nerve damage causing weakness, numbness and pain), right hand contracture, muscle wasting and atrophy (decreasing in size) and adjustment disorder (excessive reaction to stress that causes negative thoughts, emotions and behavioral changes). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/3/25 identified Resident #1 bumped his/her forehead on the Hoyer lift arm. Interventions included providing three (3) staff to assist with mechanical lift transfers as needed. A nurse's note dated 3/3/25 at 7:30 AM identified that RN #1 was paged to Resident 1's room for reports that Resident #1 bumped his/her forehead on the Hoyer lift arm. The note identified that Resident #1 was alert and oriented, reported discomfort to the area which later resolved, denied a headache or dizziness and neurological vital signs were within normal limits. The note identified that a bump with redness was noted, the Advanced Practice Registered Nurse (APRN) was notified and a new order was obtained to ice the area every two (2) hours as needed for 24 hours. The facility Accident & Investigation (A & I) report dated 3/3/25 at 7:30 AM identified that Resident #1 bumped his/her head on the arm of the Hoyer lift during a transfer in his/her room and sustained a bump to his/her mid forehead and bruising to both eyes The report identified that the APRN was notified and new orders were obtained to apply ice to the area as needed for 24-hours and to hold Eliquis (blood thinner medication) for three (3) days. The report identified that NA #2 and NA #3 witnessed the incident, performed a reenactment with RN #1 (day shift supervisor), and Hoyer lift transfer reeducation was provided at that time. An APRN note dated 3/3/25 at 9:30 AM identified that Resident #1 was evaluated for a head contusion after an incident that morning during a Hoyer lift transfer where he/she hit their forehead, between the eyes, into the Hoyer lift, and staff reports of a small hematoma. The note identified that upon evaluation, Resident #1 was aware of the bump, was icing his/her forehead, reported having a mild headache and was administered tramadol with good effect. Resident #1 was noted to have worsening ecchymosis (discoloration of the skin caused by blood leaking from broken blood vessels into the surrounding tissue) around the eyes but denied dizziness, nausea, vomiting or chest pain and remained alert and oriented to person, place and time. The note identified that Resident #1 had no signs and symptoms of neurological changes and that they would continue ice as ordered and hold Eliquis for the next 48-hours. The note indicated that if Resident #1 presented with significant mental status changes, he/she would be sent to the Emergency Department (ED) for a possible CAT scan (x-rays that are used to create detailed cross-sectional images of the body) or evaluation. A physician's order dated 3/3/25 directed to apply ice to forehead 20-minutes on and 20-minutes off every two (2) hours as needed for one (1) day. A physician's order dated 3/3/25 directed to hold Apixaban (Eliquis) 2.5 milligram (mg) oral tablet twice daily from 3/3/25 to 3/5/25. Review of nurse's notes from 3/3/25 through 3/4/25 identified no notable neurological changes or complaints. A nurse's note dated 3/5/25 at 11:14 AM identified Resident #1 was assessed after reporting a headache with ten (10) out of 10 pain (severe). The note identified Resident #1 denied dizziness or double vision and neurological checks were within normal limits. The APRN was notified, and a new order was obtained to transfer Resident #1 to the ED for evaluation. The hospital discharge summary dated 3/7/25 identified Resident #1 was admitted to the hospital from 3/5/25 through 3/7/25 with worsening tachycardia (faster than normal heart rate) which was likely due to headache and recent head injury and further identified that a head CT scan was completed, and a brain bleed was not seen on imaging. Interview with LPN #1 (day shift charge nurse on 3/3/25) on 3/26/25 at 10:38 AM identified that NA #2 and NA #3 reported when they pulled Resident #1 back with the Hoyer lift pad to position him/her over the shower chair, the Hoyer lift tilted sideways and struck Resident #1 on the forehead. LPN #1 identified Resident #1 initially said he/she was fine and he/she appeared to be at baseline, so NA #2 and NA #3 showered Resident #1 per his/her request. LPN #1 identified that, after the shower, visible bruising was noted to his/her forehead that spread to both eyes. LPN #1 identified that the APRN assessed Resident #1 shortly after and gave an order to apply ice to the area. Interview with RN #1 on 3/26/25 at 11:21 AM identified that Resident #1, NA #2 and NA #3 reported that when Resident #1 was turned in the Hoyer lift to be positioned to sit in the shower chair, the Hoyer lift started to tip sideways, and the arm of the lift struck Resident #1 on the forehead. RN #1 identified that Resident #1 initially complained of pain from the impact, had a bump and redness above the bridge of his/her nose, and she requested the APRN evaluate Resident #1 right away. Interview with NA #2 on 3/26/25 at 11:28 AM identified that on 3/3/25, NA #3 and herself placed the Hoyer pad under Resident #1, attached the pad to the hooks of the Hoyer pad, covered Resident #1 with a blanket and lifted Resident #1 into the air. She identified that due to space constraints, the large shower chair was positioned in the doorway because it did not fit next to the bed with the Hoyer lift. NA #2 identified that NA #3 pushed Resident #1 from his/her window bed in the Hoyer lift, past Resident #2 (roommate) to the shower chair positioned between Resident #2 and the doorway of the room. NA #2 identified that she was inside the room behind the back of the shower chair and NA #3 was controlling the Hoyer lift and then she (NA #2) pushed the shower chair in between the Hoyer lift legs, locked the shower chair, and NA #3 began to lower Resident #1. She reported that she pulled the Hoyer lift pad slightly from behind to position Resident #1 over the shower chair and as she did that, the Hoyer lift tipped to its side and struck Resident #1 on the forehead. NA #2 identified the incident happened fast, and although she was unable to fully see if the Hoyer lift legs were completely opened, due to where she was positioned behind Resident #1, she indicated she was able to push the shower chair forward between the Hoyer lift legs so she assumed the Hoyer lift legs were completely open for stabilization. NA #2 identified that she never worked with NA #3 prior to the 3/3/25 incident but reported that she had given Resident #1 numerous showers in the past and had never had an issue with the Hoyer lift tipping before. Additionally, she identified that they used the regular Hoyer lift (not bariatric) to transfer Resident #1. Interview with the DNS on 3/26/25 at 11:41 AM identified that although she was unable to determine how or why the Hoyer lift tipped and struck Resident #1 on the forehead, she reported that if the staff operated the lift correctly, it should not have tipped. Further, she identified that when NA #2 and NA #3 redemonstrated the transfer with Resident #1, they demonstrated it correctly with no issues. Observation on Resident #1's unit on 3/26/25 at 11:45 AM identified one Hoyer lift in the shower room. Review of the manufacturer's guidelines for the Hoyer lift provided by the Administrator identified a weight capacity of up to 500 pounds. Review of the clinical record identified Resident #1's weight was 228 pounds on 3/3/25. Observation and interview with Resident #1 on 3/26/25 at 11:49 AM identified dark discoloration under both eyes. Resident #1 identified that on 3/3/25, the NA's hooked him/her up to the Hoyer lift and pushed him/her to the shower chair, by the door, and when they went to lower him/her, the Hoyer lift tipped and struck him/her in the head. Resident #1 identified his/her head hurt but he/she still wanted to be showered. Resident #1 identified he/she has had intermittent headaches since the incident. Interview with NA #3 on 3/26/25 identified that he was employed by an agency and had never met Resident #1 prior to the 3/3/25 incident. He identified that NA #2 was present during Resident #1's Hoyer lift transfer and indicated he pushed Resident #1, in the Hoyer lift, to where the shower chair was positioned by the doorway, because there was not enough space on Resident #1's side of the room to fit both the Hoyer lift and shower chair. He identified that Resident #2's (roommate) bed side table was in the way and when he asked Resident #2 to move it, Resident #2 barked at him and told him not to touch his/her stuff. NA #3 identified that although the space was tight and the bedside table was too close to the area they were transferring Resident #1 in, he opened the Hoyer lift legs as much as he could. NA #3 identified he was facing the room door and the Hoyer lift leg, on his right side, was against the long wall opposite the bathroom door. NA #3 indicated the position of the Hoyer lift prevented the Hoyer lift legs from opening completely. He identified that as they started to lower Resident #1 onto the shower chair, the Hoyer lift started to tip and Resident #1's forehead swung into the arm of the Hoyer lift. NA #3 identified they were able to keep the Hoyer lift from completely falling over, as it fell against the long wall and he used the emergency release on the Hoyer lift to slowly lower Resident #1 into the shower chair. NA #3 identified the battery on the Hoyer lift was charged but he used the emergency release to enable more control and get the Hoyer lift back on both legs. He identified that the Hoyer lift tipped over due to not having enough space to open the Hoyer lift legs. Re-interview with NA #2 on 3/26/25 at 12:41 PM identified that it is difficult to transfer Resident #1 onto the shower chair due to performing the transfer partially on Resident #2's side of the room. She reported that she could not recall exactly what was in the way at the time of Resident #1's transfer, but identified that Resident #2 does not want his/her stuff touched. Re-interview with the DNS on 3/26/25 at 2:08 PM identified that she was unaware that staff were having difficulty maneuvering both the Hoyer lift and the large shower chair in Resident #1's room and that they were having to push Resident #1 in the Hoyer lift to the area between Resident #2 and the doorway to the room. She identified that the staff should not have transferred Resident #1 with the Hoyer lift if the environment was not clear of hazards and if there was not enough space to open the Hoyer lift legs completely. Review of the Mechanical Lift policy dated 01/2023 directed, in part, that the base legs of the lift will be locked in the maximum open position. The base legs must be always locked for stability and resident safety when lifting and transferring a resident.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) who were reviewed for an allegation of abuse, the facility failed to report an allegation of abuse to the Director of Nursing or Administrator and State Agency within two (2) hours after the incident occurred. The findings include: Resident #4's diagnoses included Alzheimer's disease, vascular dementia, hemiplegia and hemiparesis following cerebral infarction, post traumatic stress disorder, and anxiety disorder. The Resident Care Plan (RCP) dated 8/19/24 identified Resident #4 has the potential to be verbally abusive by making accusatory statements regarding care. Interventions include psychiatric/psychogeriatric consults as indicated. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide positive feedback for good behavior and emphasize positive aspects of compliance. The significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had some difficulty making decisions regarding tasks of daily life, required was extensive assistance of two (2) with bed mobility, toilet use, and transfers, and exhibited physical behaviors towards others. The Facility Reported Incident and Summary Form identified on 9/20/24 at 11:40 AM Resident #4 reported to the Recreation Assistant that he/she was afraid of was a afraid of a nurse aide, Nurse Aide (NA) #3, and alleged that NA #3 hit him/her. The report indicated NA #3 was immediately removed from the floor, the local town police were called, NA #3 was placed on administrator leave pending the investigation, psych and social services followed up with Resident #4. Review of a written statement by NA #3 on 9/20/24 identified today at breakfast time, NA #3 saw Resident #4 lying down in bed with his/her breakfast tray on the bedside table. NA #3 asked NA #4 (who was already in Resident #4's room assisting the roommate) to help assist with a boost. As NA #3 walked into the room, Resident #4 became aggressive and calling NA #3 curse words and belittling her intelligence, including to stating, you hurt me. NA #3 indicated she wasn't even at the bedside yet prior to the abuse allegation. NA #3 and NA #4 continued with care and provided the boost for Resident #4, as Resident #4 continued to attempt to punch and hit NA #3. NA #3 identified once Resident #4 was appropriately positioned and settled, she immediately reported the allegation of abuse to the charge nurse, Licensed Practical Nurse (LPN) #3 but was brushed off. Later in the shift, NA #3 asked Resident #4 if he/she would like to get washed up for the day, to which he/she replied, I'm ready when you are. NA #3 asked NA #5 to help assist with bathing, and during care, Resident #4 became agitated again and threw the washcloth over NA #3's head and punched and hit NA #3. NA #3 and #5 were able to redirect Resident #4 enough to place a new brief and Hoyer pad underneath him/her, during the Hoyer transfer, Resident #4 began to shout, help me x 4, which NA #3 expected LPN #3 to come by and see the commotion, since the allegations and behaviors were reported earlier, but LPN #3 did not come by. Once the transfer was complete, NA #3 once again reported the allegations and behaviors to LPN #3, but she did not get any response or reaction from LPN #3. NA #3 continued with the shift and documented all behaviors. Review of the written statement by NA #4 on 9/20/24 identified she was Resident #4's room assisting the roommate, when NA #3 requested assistance with a boost for Resident #4. Prior to starting care and during care, Resident #4 yelled at NA #3, and then stated, you hurt me, once finished with care, NA #4 reported the allegation to LPN #3. Interview with NA #3 on 10/10/24 at 10:35 AM identified on 9/20/24, Resident #4 was agitated at breakfast time, which NA #3 asked NA #4 for assistance during care. NA #3 explained before starting care, Resident #4 was alleging I was hurting him/her and once care was provided both she and NA #4 reported the allegation and behaviors to LPN #3 between 8:00-8:30 AM. NA #3 identified LPN #3 did not question and pursue anything further at that time, and NA #3 continued with the day. NA #3 indicated later in the shift, she and NA #5 assisted Resident #4 out of bed with a Hoyer lift transfer, and during this process, Resident #4 once again alleged NA #3 was hurting him/her and she again reported the incident to LPN #3 at approximately 9:30-10:00 AM, which there was no response too. NA #3 identified at approximately 12:30 PM, she was taken off the floor pending an investigation. Interview with NA #5 on 10/10/24 at 10:50 AM identified herself and NA #3 were assisting Resident #4 with a Hoyer lift transfer and during the transfer, Resident #4 was alleging that NA #3 was hurting him/her, and once finished she reported the abuse concerns to LPN #3. NA #5 believes LPN #3 reported the allegations to the Nursing Supervisor afterwards. Interview and review of the facility reported incident investigation with the Director of Nursing (DON) on 10/10/24 at 11:30 AM identified the allegation of abuse was reported timely upon notification by the Recreation Assistant. The DON identified the Assistant Director of Nursing (ADON) performed the investigation and she did not review the written statement by NA #3 and after reviewing the written statements, she verified the allegation of abuse should have reported immediately by either NA #3 or LPN #3 at the first occurrence/allegation to the Nursing Supervisor. The DON identified allegations of abuse are to be reported to the State Agency within two (2) hours. Although attempted, interview with LPN #3 and NA #4 was not able to be obtained. Review of the CMS (Centers for Medicare/Medicaid Services) Interpretive Guidelines for abuse identified alleged violations of abuse or if there is resulting serious bodily injury, the facility must report the allegation immediately, but no later than two (2) hours after the allegation is made. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of the Abuse, Neglect, and Exploitation Policy dated 02/2023 identified it is the policy of this facility to provide protections for the health, welfare 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. Under Reporting/Response, identified the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within the specified timeframes. 1a. Immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who required staff supervision during meals due to dysphagia (difficulty with swallowing) and non-compliant with following the plan of care, the facility failed to ensure the resident's safety when the nurse aide left the resident unsupervised in the room and failed to inform the nurse that the resident refused meal supervision. The findings include: Resident #2's diagnoses included dysphagia, aphasia, traumatic brain injury, and right sided hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some difficulty in new situations, required staff supervision with eating and was dependent with all other daily living skills and was on a mechanically altered diet. The Resident Care Plan dated 9/12/24 identified Resident #2 had dysphagia, was at risk for aspiration, and often refused to be supervised during meals. Interventions directed a regular, mechanical soft diet ground texture with thin liquids, aspiration precautions, continuous supervision with eating, small bowls for meals, cue resident to eat at a slow rate, provide a teaspoon only, inform resident of risks of non-compliance with supervision, provide education on dietary restrictions, and notify nursing staff if resident refuses supervision. Review of the August 2024 physician orders identified an order initiated on 11/29/23 that directed Resident #2 be on a regular mechanical soft ground texture, thin liquid diet with aspiration precautions, continual supervision with eating, and meals in small bowls, to provide a teaspoon utensil only, no soup spoon and may have regular consistency chips, hard cookies, or peanut butter crackers. The nurse's note dated 9/23/24 at 7:31 PM identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2 was in the hallway and heard a cough with a high pitch sound. The note indicated when LPN #2 entered Resident #2's room she noted the Resident #2's eyes were watery and Resident #2 was performing the universal choking sign. The note identified LPN #2 yelled for a nurse aide to call for assistance and began performing the Heimlich maneuver while encouraging the resident to cough. The nurse's note dated 9/23/24 at 7:44 PM identified the Assistant Director of Nursing (ADON) was called to the unit at 6:15 PM and when she entered Resident #2's room LPN #2 was performing the Heimlich maneuver, Resident #2 remained alert, and although no food visibly passed with the Heimlich, Resident #2's airway cleared. The Advanced Practice Registered Nurse (APRN) note dated 9/23/24 identified Resident #2 was seen due to active choking and upon arrival nursing staff was performing the Heimlich maneuver, Resident #2 was able to drink a glass of water and resumed normal breathing and did not appear to be in acute distress and swallowed the food. The note indicated Resident #2 had a history of noncompliance with getting out of bed to eat meals and supervision during meals. The note identified a chest x-ray was not taken due to the lungs sounds being normal, and staff to monitor vital signs, oxygen levels and lung sounds over the next twenty-four (24) to seventy-two (72) hours. The nurse aide care card identified Resident #2 required supervision when eating. The Speech Language Pathologist (SLP) note dated 9/24/24 identified the SLP recommended Resident #2's diet be downgraded to a pureed diet due to Resident #2 being at risk for aspiration and frequent refusals to allow staff to supervise during meals. A written statement dated 9/23/24 by the 3-11PM nurse aide, Nurse Aide (NA) #2, that was assigned to Resident #2 identified when she went in to Resident #2's room to assist Resident #2, Resident #2 pointed to the door for her to leave the room. NA #2 indicated she positioned Resident #2 in the bed in an upright position to eat dinner prior to leaving the room. NA #2 identified she did not inform the charge nurse that Resident #2 refused to be supervised while eating. An interview with the Assistant Director of Nursing (ADON) on 10/15/24 at 12:09 PM identified if a resident that required supervision for eating refused supervision, it was the responsibility of the nurse aide to inform the nurse so the nurse could speak with the resident, and the nurse would then follow proper protocol if the resident continued to refuse and notify the MD. The ADON identified NA #2 did not follow physician's order to notify the nurse that Resident #2 refused meal supervision on 9/23/24. An interview with LPN #2 on 10/15/24 at 1:20 PM identified she was working on 9/23/24 and heard the resident coughing while she was in the hallway passing medications. LPN #2 indicated she noted Resident #2 using the universal sign for choking, called for assistance and began the Heimlich maneuver. LPN #2 identified when the Nursing Supervisor arrived, and she took over doing the Heimlich and Resident #2 returned to baseline. LPN #2 identified she was not informed by NA #2 that Resident #2 refused to be supervised during the dinner meal and the nurse aides are responsible to inform the nurse if Resident #2 refused care and then the nurse would follow protocol and speak to Resident #2. Review of the facility policy Feeding the Resident identified the steps involved in feeding a dependent resident The policy did not address steps to take if a resident refused assistance.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for mistreatment, the facility failed to ensure resident was treated with respect. The findings include: Resident #1's diagnoses included Alzheimer's and left sided hemiparesis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had moderate cognitive impairment and was dependent for toileting, ADLs, transfers, and independent with manual wheelchair use. The Resident Care Plan (RCP) dated 6/24/2024 identified Resident #1 required assistance with ADLs. Interventions directed encourage independent mobility in wheelchair, assist if needed and give the resident sufficient time to accomplish each task. Review of nurse aide care card directed dependent with wheelchair use. Review of Facility Reportable Event Form dated 7/3/2024 at 2:30 PM identified the hairdresser reported a NA pushing Resident #1 quickly down the hallway, and Resident #1 wanted the NA to slow down. The NA pushed Resident #1's wheelchair into the resident's room and Resident #1's hand got stuck between wheelchair wheel and door frame. Redness was noted to the left hand, and a new order was obtained for an x-ray. Review of facility indicated summary (titled Final Report) dated 7/8/2024, identified when NA #1 was pushing Resident #1 quickly in his/her wheelchair, the NA turned into Resident #1's room and Resident #1's hand hit the doorframe causing the resident to call out. The summary identified the x-ray was negative. Facility investigation identified although Resident #1 had requested NA #1 to slow down, NA #1 continued to push the wheelchair quickly. Interview and facility documentation review on 7/22/2024 at 11:04 AM with NA #1 identified that on 7/3/2024 around 2:30 PM, Resident #1 was in his/her wheelchair in the middle of the hallway when the laundry staff was trying to get by. NA #1 stated Resident #1 was trying to wheel him/herself down the hallway and then just completely stopped. NA #1 indicated that she and another NA asked Resident #1 to move his/her chair, but he/she did not, and NA #1 then pushed the resident at a regular speed as she would push any other resident and Resident #1 did not ask her to slow down. NA #1 stated she assumed Resident #1's hand got caught between the wheelchair and doorframe when Resident #1 said ow and Resident #1 stated he/she was o-[NAME]. Interview, clinical record review, and facility documentation review with the DNS on 7/22/2024 at 1:18 PM identified NA #1 should have slowed down when Resident #1 requested and should have been careful going through the doorway to prevent hitting his/her hand. Review of facility Residents' [NAME] of Rights directed in part, you (resident) have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

Based on clinical record reviews, observation, facility documentation, review of facility policy and interviews for 1 of 2 sampled residents ( Resident # 5) reviewed for skin condition non-pressure, the facility failed to consistently conduct weekly wound assessment per facility policy and for 1 of 3 residents (Residents #45) reviewed for dining, the facility failed to ensure a physician's order for supervision and staff assistance during meals and for 3 of 10 residents ( Residents # 69, # 106 and # 120) reviewed for smoking, the facility failed to conduct smoking evaluation and safety per policy and for 1 of 7 sampled residents ( Resident # 57), the facility failed to administer the resident's medications as directed by the physician. The findings included: 1. Resident #5's diagnoses included Peripheral Vascular Disease (PVD), chronic venous hypertension with ulcer of left lower extremity, and non-pressure chronic ulcer of other part of left foot with unspecified severity. A physician's order dated 3/7/23 directed to rinse wounds with normal saline, apply triad paste to intact skin around wounds, apply gauze dampened with anasept gel, cover with optilock, followed by ABD pads, wrap with kerlix, and wrap with ace wraps every 24 hours as needed for if soiled. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 as cognitively intact and was independent in ambulating ten and fifty feet with two turns and changing positions. The MDS assessment dated [DATE] identified the resident's cognition and memory were intact and noted venous and arterial ulcers. The Resident Care Plan dated 10/29/23 identified a chronic venous ulcer to the left lower leg and left third toe. Interventions directed to treatments as ordered and weekly evaluation by wound advanced practice registered nurse as ordered. A review of Resident# 5 Wound Assessment Sheets dated 9/2023 through 12/8/23 failed to reflect that staff consistently conducted weekly wound assessment per facility policy. In an interview and clinical record review with Director of Nurses (DNS) on 1/8/24 at 1:30PM identified the clinical record failed to reflect non-pressure wound evaluations were not performed for Resident #5 from 9/29/23 through 10/27/23, from 11/3/23 through 11/7/23, and 11/20/23 through 12/8/23. The DNS further indicated wound evaluations were not completed weekly per facility policy secondary to the facility did not have an infection control nurse until 10/30/23. The DNS also indicated and nurse that came in to support the facility with wound evaluations did not capture the missing wound assessment above for Resident # 5. Review of the Non-Pressure Wound Assessment policy dated 1/3/24 directed venous wounds, arterial wounds or diabetic ulcers would be assessed on a weekly basis. 2. Resident #45's diagnoses included: dementia, diabetes mellitus, depression, and dysphagia (difficulty with swallowing). A Speech Language Pathologist (SLP) Evaluation note dated 10/31/23 indicated a recommendation to continue with the mechanical soft diet, thin liquids, patient/resident was found to have mucosal infection, unable to wear dentures, due possibly to oral infection, appeared to be at baseline swallow function. Additionally, the SLP recommended self-feeding and swallowing with set-up with verbal and/or tactile cues, and no further consults indicated. An Occupational Therapy (OT) Evaluation note dated 10/31/23 indicated functional skills assessment of supervised self-feeding, impressions indicated that due to documented physical impairments and associated functional deficits, risk factors for this resident included increased agitation, increased dependency on caregivers. An OT Evaluation note dated 11/9/23 functional assessment indicated self-feeding with supervision and OT evaluation visit only, no further consults indicated. A Nurse Aide Care Card dated 12/6/23 indicated continual supervision with intake by mouth, cue to eat at slow rate, small bites, and sips. A physician's order dated 12/7/23 directed supervision with all meals. The quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, mechanically altered diet and required supervision and set up help for meals. A Nutrition Evaluation dated 12/15/23 indicated small portions for meals, aspiration precautions, continual supervision with po (by mouth) intake. Resident Care Plan dated 12/26/23 indicated resident at nutritional risk related to dementia and dysphagia and at risk for aspiration related to diet. Interventions included Mechanical Soft (Dental) Ground texture, Thin (Regular) Liquids consistency, small portions for meals, aspiration precautions, continual supervision with by mouth, cue for slow rate, small bites/sips. Upright positioning 90 degrees during po (by mouth) intake and 30 minutes post, oral care 2-3 times a day. Observation on 1/2/24 at 12:38 PM noted Resident #45 was behind a curtain (not within eyesight), eating lunch in bed nearest to window, alone, roommate was not present, and his/her meal ticket dated 1/2/24 indicated diet of mechanical soft, ground food, with an Alert of Aspiration Precaution and Supervision. Additionally, Resident #45's call bell system was not within his/her reach and was located near the wall on the floor. On 1/2/24 at 12:43 PM observation, review of facility documentation and interview with LPN #1 identified Resident # 45's curtain was closed, not visible from the hallway and the resident was eating his/her lunch alone, and the resident's meal ticket indicated aspiration precautions and supervision. On 1/2/24 at 12:44 PM interview with SLP indicated that she was not sure where the order for aspiration precautions and supervision originated, and she would speak with her rehabilitation manager. On 1/2/24 at 2:53 PM interview with Rehabilitation Director indicated the SLP was not specifically looking at function when she last evaluated Resident #45 on 10/31/23 and OT evaluation on 12/7/23 left the resident's status as supervision for cueing and dignity to encourage the resident to utilize utensils rather than her/his hands. On 1/3/24 at 11:26 AM interview with SLP indicated the resident was now on a mechanical soft diet and if he/she was sitting upright, the resident no longer needed supervision with meals from a safety standpoint. She further indicated that she felt that residents' current meal needs set-up, required cueing to sit up, and reminded to go slow and take time to eat. Interview on 1/9/24 at 11:56 AM with DNS indicated she was not sure if the facility had a policy on supervision with meals and that she would investigate, however, DNS did not provide a policy on supervision with meals. Review of facility policy, annual review date of 1/2/24 titled Aspiration Precautions indicated that Aspiration Precautions will be utilized to reduce the risk of aspiration of food or liquid into the resident's lungs. The procedure indicates the resident must be assessed by Speech Language Pathologist (SLP) for the Aspiration Precautions to be discontinued, develop a care plan with the feeding strategies per speech therapy recommendation, and include on care plan as warranted. Subsequent to inquiry, an APRN's order dated 1/3/24 directed to discontinue supervision all meals order. 3. Resident # 69's diagnoses included COPD, major depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and a current tobacco user. The Resident Care Plan dated 11/3/2023 failed to identify Resident #69 as a smoker. The Smoking Evaluation and Safely Screen dated 7/17/23 identified Resident #69 as a current smoker. However, review of Resident # 69's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. 4. Resident # 106's diagnoses included dementia and generalized muscle weakness. Review of Resident #106's Smoking Evaluation and Safety Screen dated 7/25/23 identified he/she was a current smoker. The Resident Care Plan dated 9/30/23 identified Resident #106 had a smoking history and is choosing to smoke at this time. However, review of Resident # 106's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. 5. Resident #120's diagnoses included Alzheimer's disease, dementia, and nicotine dependence. The annual Minimum Data Set assessment dated [DATE] identified Resident #120 as a current tobacco user. The Resident Care Plan dated 7/17/23 identified Resident #120 had a smoking history, smoking safety screen completed, resident wishes to smoke and can safely smoke cigarette with supervision. However, review of Resident # 120's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. Interview with the DNS on 1/3/23 at 12:26PM identified Safety Screens are to be completed quarterly for all smokers and the charge nurses were responsible for completing the screens. The DNS also was unable to provide evidence as to why the assessments for Residents # 69, 106 and 120 were not completed. After inquiry, Smoking Evaluations and Safety Screens were completed for Residents # 69, 106, and 120 on 1/4/24. Review of the Smoking Policy revised on 1/2/24 directed residents who smoke will be evaluated for their ability to smoke upon admission, quarterly, and as directed by any significant change in condition to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. 6. Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled pain medication regimen. a. A review of the Controlled Substance Disposition Record and Medication Administration Record (MAR) identified Resident #57 was administered one 4mg dose of Dilaudid on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38PM. However, MAR for January 2024 failed to identify both doses were administered on 1/6/24. Interview with the Director of Nursing Services on 1/10/24 at 2:08 PM identified nurses are responsible for administering Resident #57's medication, following physician's orders, and documenting the medication administration in both the MAR and Controlled Substance Disposition Record (for narcotics). A telephone interview and review of the Controlled Substance Disposition Record and MAR with Licensed Practical Nurse (LPN #2) at 2:24PM on 1/10/24 identified Resident #57 was administered one 4mg dose on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38 PM. However, the Controlled Substance Disposition Record and MAR failed to identify both doses were administered. LPN #2 identified s/he gave both doses of the Dilaudid 4mg dose to Resident #57 at the times written on the Controlled Substance Disposition Record and watched him/her take both doses orally but forgot to sign them off on the MAR. LPN#2 indicated s/he was responsible for signing off medications following administration. LPN # 2 also indicated the policy was to follow the physician's order and sign that medications were administered in both the MAR and Controlled Substance Disposition Record. b. Review of the MAR for December 2023 identified Resident # 57 received four doses of 4mg dose of Dilaudid on 12/3/23. Review of clinical records and interview with the Director of Nursing (DNS) on 1/24/24 at 10:37AM identified Resident #57 was administered four doses of Dilaudid 4mg on 12/3/23. The DNS indicated the facility policy directs staff to follow physician's orders and the resident was scheduled to receive Dilaudid 4mg by mouth every 4 hours as needed and not to exceed three doses in twenty-four hours. The DNS further indicated she would investigate why the error occurred. . 47491

Based on clinical record review, facility documentation review, and facility policy review and interviews for two of three Residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: 1. Resident #1 was admitted with diagnoses that included stroke with left hemiplegia (paralysis) and left hemiparesis (weakness), obesity, chronic kidney disease and anxiety. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, required total staff assistance for transfers and ADLs, and weight was 167 pounds. A Resident Care Plan (RCP) dated 1/6/2023 identified Resident #1 required assist with care. Interventions directed to assist with ADLs and transfer via Hoyer lift. A social services progress note dated 3/27/2023 at 4:54 PM identified that Resident #1 reported an allegation of verbal mistreatment by a NA. A facility reportable event form dated 3/27/2023 identified Resident #1 alleged on 3/26/203 at 9 AM, NA #1 stood next to Resident #1's bed and while NA #1 was almost nose to nose with Resident #1, NA #1 told Resident #1 to shut up. Facility investigation included a statement from NA #3 that indicated when Resident #1 requested to be repositioned in the wheelchair, NA #1 responded by telling Resident #1 he/she was too heavy and NA #1 was not breaking her back. Interview with NA #3 on 4/12/2023 at 11:26 AM identified that she was assigned to Resident #1 on 3/26/23 and at around 9:30 AM she had asked NA #1 to assist with Resident #1's transfer from the bed to her/his chair. NA #3 left Resident #1's room to get the Hoyer lift and upon her return to Resident #1's room she heard NA #1 tell Resident #1 to shut up. After NA #1 and NA #3 transferred Resident #1 into the wheelchair, Resident #1 requested the staff reposition him/her in the chair. NA #3 indicated that she heard NA #1 respond to Resident #1 that Resident #1 was too heavy to be repositioned, and that it would hurt NA #1's back to do so. NA #1 proceeded to leave the room and Resident #1 began to cry. NA #1 then asked LPN #1 to assist to reposition Resident #1 in the chair. NA #3 continued that she did not inform LPN #1 of the incident, and later when LPN #1 asked her if anyone told Resident #1 to shut up she did not notify LPN #1 of the incident because she was not a regular staff on the day shift and she felt uncomfortable identifying a regular day staff NA. Interview with LPN #1 on 4/12/2023 at 12:00 PM identified on 3/26/2023 when she assisted NA #3 to reposition Resident #1, Resident #1 began to cry and told LPN #1 that one of NAs had told her/him to shut up and asked what gives the NA the right to tell Resident #1 to be quiet and shut up. LPN #1 indicated she consoled Resident #1, and then asked the NAs on the unit if anyone had witnessed a NA telling Resident #1 to shut up. NA #1 and NA #3 both indicated they did not know anything or witnessed anything. LPN #1 further indicated she did not report the allegation to anyone as it she though it did not seem like an issue, and she did not witness anything. Interview with the Director of Nurses (DNS) on 4/12/2023 at 1:00 PM identified NA #1 was alleged to have told Resident #1 to shut up, refused to reposition Resident #1 and had told Resident #1 that he/she was too heavy and NA #1 would hurt her back. The DNS indicated NA #1 should not have made the comments. Review of facility documentation identified NA #1's employment with the facility was terminated. 2. Resident #2 was admitted with diagnoses that included dementia with behavioral disturbance, restlessness and agitation, anxiety disorder, and abnormalities of gait and mobility. A quarterly MDS assessment dated [DATE] identified Resident #2 was severely cognitively impaired and ambulated independently. A RCP dated 2/23/2023 identified Resident #2 was confused, was a fall risk, and required assistance with ADLs. Interventions directed to assist to gather to clothing, toiletries, and equipment, encourage self-performance, and to provide assistance and or cuing to maximize current level of function, and assist as needed for transfers/ambulation. A facility reportable event form dated 4/3/2023 identified that on 3/31/2023 at approximately 4:25 PM Dietary Aide #1 witnessed NA#2 push and slap Resident #2's hand when Resident #2 was attempting to take washcloths. Interview with the Dietary Aide (DA #1) on 4/12/2023 identified she was delivering items to the unit on 3/31/2023 (Friday) at approximately 4:30 PM, heard loud voices and she observed NA #2 and Resident #2 standing next to each other by the clean laundry cart. Resident #2 was reaching onto the cart, trying to take a washcloth. DA #1 indicated she observed NA #2 use both hands to push Resident #2 towards another Resident and then NA #2 slapped Resident #2's hand while saying don't touch my d--n washcloths. DA #1 indicated she observed Resident #2 had a surprised reaction and moved away from NA #2 and the linen cart. DA #1 further identified she returned to the kitchen and reported her observations to the Dietary Supervisor, who instructed DA #1 to write a note to the Dietary Director and leave the note in the Dietary Director's office. Interview with the DNS on 4/12/2023 at 1:00 PM identified NA #2 completed her shift on 3/31/2023 (worked until 11 PM) because the allegation was not reported on 3/31/2023. When the Dietary Director found the note on 4/3/2023 (Monday morning), the Dietary Director reported the allegation. The DNS indicated NA #2 was off over the weekend and was suspended on 4/3/2023. The DNS indicated the incident should have been reported immediately on 3/31/2023 when it was observed, and NA #2 would have been removed from the schedule at that time. Review of facility documentation identified NA #2's employment with the facility was terminated. Review of the facility Abuse, Neglect and Exploitation Policy, dated 2/2023 directed in part, verbal abuse was the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend or disability. It defines mental abuse as including but not limited to, humiliation, harassment, threats of punishment or deprivation. Physical abuse included but was not limited to hitting, slapping, punching, biting, or kicking and that it is the policy of the facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing policies and procedures that prohibit and prevent abuse. Review of the facility, Residents [NAME] of Rights Policy, dated 7/2021, directed in part that residents have the right to be free from verbal, physical or mental abuse and the right to be treated with consideration, respect and full recognition of their dignity. The policy further directed residents have the right to receive care and services with reasonable accommodation of individual needs.

Based on clinical record review, observations, review of facility documentation and policies, and interviews for one sampled resident (Resident #2) who had a compulsive disorder and swallowed non-food items, the facility failed to provide appropriate supervision to prevent a resident from removing and swallowing batteries from a remote control. The findings include: Resident #2's diagnoses included pica, an eating disorder in which a person eats things not usually considered food, mild intellectual disabilities, schizoaffective disorder, diabetes mellitus and major depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall deficits, required extensive one (1) person assistance with transfers in and out of the bed and chair, and was self-sufficient with self-propelling once in the wheelchair. The resident care plan dated 8/18/22 identified Resident #2 presented with signs and symptoms of pica behavior and delusions and had a recent episode on 8/18/22. Interventions directed to ensure television remotes are out of the resident's reach when out of bed, closely supervise the resident when out of bed, keep television remote controls in the nurse's medication cart, inquire if the resident has ingested any inedible objects or items every shift, notify the physician or Advanced Practice Registered Nurse immediately if the resident has swallowed any items or objects, no small objects within reach of the resident, resident's clothing will not have buttons, snaps or zippers that could have small parts that could be removed and swallowed. A physician's order, initiated on 3/14/22 and remains current, directed staff to assist resident with television channels, no television remote control every shift. The Facility Reported Incident form dated 10/17/22 at 2:30 PM identified the Digital Video Disc (DVD) player remote located inside the nurses' station was noted without any batteries and Resident #2 was noted by a staff member up in the wheelchair in the vicinity of the nurses' station. The report indicated Resident #2 denied swallowing any batteries, the Nursing Supervisor was immediately updated and assessed Resident #2 noting no acute distress. The report identified Resident #2 was placed on one to one (1:1) supervision and an order was obtained from the Advanced Practice Registered Nurse (APRN), APRN #1, for an abdominal x-ray. The report identified the x-ray results showed two (2) batteries in the left upper quadrant, possibly within the stomach and a third battery in the right lower quadrant, likely within the cecum. An order was obtained by APRN #1 to transfer Resident #2 to the hospital for an evaluation and treatment as indicated. The hospital report dated 10/18/22 identified two (2) batteries were extracted via an Upper Endoscopy, the remaining battery was stable in the right lower quadrant intestines, no bowel obstruction was noted, the plan was for a bowel prep and follow-up with the gastroenterologist, and Resident #2 returned to the facility on [DATE]. The APRN progress note dated 10/19/22 at 8:55 PM identified Resident #2 was being seen for pneumonia and Pica. Resident #2 was sent to the Emergency Department (ED) due to a positive x-ray showing three (3) batteries in the resident's abdomen. Resident #2 was kept in the ED for observation, had an upper endoscopy to retrieve two (2) batteries, and one (1) battery remains in the ascending large intestines. The note indicated Resident #2 continued to be at risk of harming self-due to ingestion of small objects (screws, batteries, coins) and to continue plan of care for resident preventing access to small things, observations for 1:1 monitoring while out of bed 10-12 hours a day for one (1) week, check zinc and iron levels if not checked in the past, recommend adding Seroquel 75 milligrams (mg) every morning, discontinue all Trazadone orders, recommend to check a Clomipramine and valproic acid level if none recently, KUB (Kidney, Ureters, Bladder x-ray) in the morning and give laxatives as ordered. Review of the physician orders identified the following interventions to evacuate the battery were implemented after Resident #2 returned from the hospital on 10/18/22 through 11/3/22: KUB (Kidney, ureters, bladder) x-rays to be obtained daily, Dulcolax tablets were administered on five (5) different times, Dulcolax suppository administered on five (5) different dates, MiraLAX powder administered twice, Soap Suds Enemas administered on five (5) different dates, Lactulose Solution administered on five (5) different days, the diet was changed to clear liquids, honey thick consistency, intravenous fluids for hydration were started on 11/2/22 for three (3) days, and finger sticks for blood sugar levels before meals three (3) times a day and call the physician if the finger stick is less than 60 or greater than 240. The APRN progress note dated 11/2/22 at 11:33 AM identified the battery remained unmoved in Resident #2's right ascending large colon for the past twelve (12) days. Resident #2 with no nausea, vomiting, fever, and no abdominal pain. Resident #2 is on a clear liquid diet for ileus for the past two (2) days and positive large bowel movement daily. The note indicated the consulting gastroenterologist had ordered a prep, however unable to administer to Resident #2 due to thickened liquid dysphagia status. Resident #2 continued to have stools in the colon per KUB. Continue follow-up with gastroenterologist for possible emergency colonoscopy to remove battery. The nursing progress note dated 11/3/22 at 8:30 AM identified the KUB results of a worsening ileus with the right lower quadrant foreign body was reported to APRN #1. APRN #1 ordered Dulcolax 5 milligram (mg) tablet, give three (3) tables by mouth, one (1) time and Soap Suds Enema, rectally, one time, give additional two (2) Liters of D5 1/2 Normal Saline at 75mL/hour, repeat KUB after the Soap Suds Enema, call placed to the gastroenterologist to update, awaiting call back. The note indicated Resident #2 was alert, verbal at base line mental status, abdomen was soft, non-tender with positive bowel sounds in all four quadrants, there were no complaints of abdominal pain or discomfort. The nursing progress note dated 11/3/22 at 12:30 PM identified the gastroenterologist returned the call and directed Resident #2 be transferred to the hospital for an evaluation and treatment. The hospital discharge summary dated 11/9/22 identified Resident #2 was admitted on [DATE] and had a colonoscopy performed on 11/8/22 for foreign body retrieval. The note indicated a poor prep, and colonoscopy procedure was very long and tortuous, thus a technically difficult procedure (estimated one (1) hour and thirty (30) minutes), the battery was retrieved near the ileocecal valve with a Roth net. Observations of the nursing station, located outside of Resident #2's room, on 11/3/22 identified residents with or without a wheelchair would be able to propel inside the nursing station and retrieve any accessible items within. Interview with Director of Nursing (DON) on 11/3/22 at 9:30 AM identified per Resident #2's care plan, the expectation of close supervision would be that staff always know and are aware of Resident #2's whereabouts and the nursing staff should be aware of resident's surroundings as well. Interview with Recreational Therapist #1 on 11/3/22 at 9:45 AM identified on 10/17/22, he found the DVD remote at the nurse's station, next to the computer monitor. Recreational Therapist #1 identified the remote control was not working and he noted there were no batteries inside. Recreational Therapist #1 noted Resident #2 was out of bed and there was no nursing staff within the area during this time. Recreation Therapist #1 identified he was aware of Resident #2's past medical history and interventions related to plan of care. Recreational Therapist #1 identified he returned the remote control back to its original place and notified the Nursing Supervisor of his suspicions. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/3/22 at 10:50 AM identified she was normally assigned to Resident #2's unit and on 10/17/22, Resident #2 was on her assignment during the day shift. LPN #1 identified Resident #2 was out of bed during the shift but did not display any behaviors. LPN #1 identified in the days and weeks leading up to 10/17/22, she had seen the DVD remote control behind the nurse's station, either next to the pencil holder, computers or on top of the counter where the TV and DVD player are located. LPN #1 noted it was common to see the remote not in a secured area, such as a drawer or locked box. LPN #1 noted that when she sees the remote at any time, she will normally place it inside one (1) of the drawers at the nurse's station.

Based on clinical record reviews, review of facility documentation and policies and interviews for one of three sampled residents (Resident #2) who required staff assistance when ambulating, the facility failed to ensure the appropriate number of staff were present to safely transfer the resident in accordance with the physician's order to prevent a fall with injury. The findings include: Resident #2's diagnoses included [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)] affecting the left non-dominant side, anxiety disorder, and a history of falls due to weakness. A physician's order dated 10/12/20, after a fall, directed to transfer Resident #2 with the assistance of two (2), one (1) staff on standby assist, utilize the hemi-walker, apply the left knee ankle foot orthosis (KAFO) and the left upper extremity brace. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no short or long term memory problems, was alert and oriented, exhibited no behaviors, required extensive one (1) person assistance with getting in and out of the bed and chair, walking in the room, toilet use, the resident's balance during transitions and walking was not steady and the resident was only able to stabilize with staff assistance, had functional limitation in range of motion on one (1) side of the upper and lower extremities, and had one (1) fall with no injury sin the past ninety (90). The Resident Care Plan dated 12/14/20 identified Resident #2 was at risk for falls due to decreased endurance and decreased muscular coordination and psychoactive medications. Interventions directed the assistance of two (2) staff with transfers with the second staff on standby assistance. The nurse's note dated 12/16/20 at 6:28 AM identified at 6:20 AM Resident #2 was observed in a sitting position on the floor with the left leg brace on. The note indicated Resident #2 was lowered to the floor by a staff member as Resident #2 lost their balance during the transfer from the bed to the wheelchair. The note identified although there was no redness, bruising or open areas noted, Resident #2 complained of left shoulder pain, the on call Advanced Practice Registered Nurse (APRN) was updated and a new order directed for an x-ray of the left shoulder. The nurse's note dated 12/16/20 at 7:32 AM identified at 6:20 AM the charge nurse was called to Resident #2's room by a nurse aide and upon entering the room Resident #2 was noted to be sitting on the floor facing the bed. The note indicated the nurse aide who cared for Resident #2 stated while transferring Resident #2, Resident #2's leg buckled and as she assisted Resident #2 to the floor, Resident #2 bumped the left shoulder against the wall. The note identified Resident #2 complained of having some discomfort to left shoulder, the scheduled Tylenol was administered and Resident #2 was to be transferred with the assistance of two (2) staff until a physical therapy evaluation was conducted. The x-ray results dated 12/16/20 identified Resident #2 had sustained an acute minimally displaced fracture of the greater tuberosity of the left humerus, the results were reported to the APRN and a new order was given for [MEDICATION(S)] 5-235 milligrams (mg) by mouth times one (1) dose now for pain and to transfer Resident #2 to the hospital for an evaluation. The nurse's note dated 12/16/20 at 2:27 PM identified Resident #2 returned to the facility with a left arm sling. The physical therapy evaluation and treatment note dated 12/17/21 identified Resident #2 was being evaluated by physical therapy post a fall and fracture of the left humerus yesterday during a transfer. The physical therapy evaluation indicated Resident #2's previous level of function was to transfer Resident #2 with the assistance of one (1) with stand by assistance of a second staff member. Although the Resident #2's care card reflected to transfer the resident with assistance of two (2) staff, one staff as stand by, left KAFO, left arm sling and hemi-walker, the care card failed to reflect the date when the care card was updated last. Interview with Resident #2 on 3/29/21 at 9:30 AM identified that he/she sat on the edge of the bed and the nurse aide helped him/her to get up from bed. Resident #2 indicated that he/she held on to the half walker, however he/she lost their balance and fell on his/her left shoulder on the floor. Resident #2 identified that she went to the hospital and returned to the facility the same day with his/her left arm in a sling. Interview with 11-7AM nurse aide, Nurse Aide (NA) #1, on 3/30/21 at 8:10 AM identified that she transferred Resident #2 from the bed to the wheelchair the morning of 12/16/21. NA #1 indicated that she asked Resident #2 if he/she was ready to stand up, Resident #2 replied that he/she was ready to stand up, and she gave Resident #2 the hemi-walker. NA #1 identified she had the wheelchair positioned next to the bed, however once Resident #2 stood up, the resident walked away from the wheelchair instead just sitting down. NA #1 identified that as Resident #2 was walking, the resident started to lose their balance, so she grabbed Resident #2 by the gait belt and lowered Resident #2 to the floor. NA #1 indicated that she had Resident #2 sitting on his/her buttock on the floor, however she could not control Resident #2's shoulder due to left sided paralysis and Resident #2's shoulder hit the wall. NA #1 indicated that it was her first time caring for Resident #2 and as far as she knew Resident #2 only required the assistance of one (1) staff member with transfers. NA #1 identified she did not know Resident #2 required the assistance of two (2) staff, one (1) staff on standby. NA #1 indicated that she followed Resident #2's care card and if she had known Resident #2 required the assistance of two (2) staff with transfers, she would not have transferred Resident #2 by herself. Interview and review of the clinical record with the Director of Physical Therapy on 3/30/21 at 10:40 AM identified Resident #2 required assistance of one (1) staff member with standby assistance of second staff member prior to the fall on 12/16/20. The Director of Physical Therapy indicated NA #1 should have had a second staff member with her once Resident #2's feet hit the ground due to Resident #2's impulsivity. The Director of Physical Therapy indicated if Resident #2 exhibited an anxious behavior so the resident may not have waited for everything to be in place and that was why Resident #2 required a second staff member just to make sure things were done safely. The Director of Physical Therapy identified the second person could stand by just in case Resident #2 needed guidance and safety. Review of the clinical record with the Director of Physical Therapy identified a physician's order 10/12/20 directed to transfer with assistance of two (2) staff members with one (1) staff member standing by. Interview and clinical record review with the Director of Nursing (DON) on 3/30/21 at 12:30 PM identified there should have been two (2) staff members in the Resident #2's room while Resident #2 was being transferred from the bed to the wheelchair. Falls Management Policy directed the interdisciplinary team will develop, initiate and implement an appropriate individualized care plan based on the fall risk evaluation score. Residents who were identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with the information made available at the time of admission to implement a safety related care plan.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #348) reviewed for accidents, the facility failed to ensure the resident's legs were fully supported during a hoyer lift transfer which resulted in a laceration that required sutures to close. The findings include: Resident #348 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/7/18 identified Resident #348 had impaired physical mobility. Interventions included a physical therapy screen and to treat as directed. physician's orders [REDACTED].#348 via a hoyer lift. physician's orders [REDACTED].#348 assistance with ADL's, and to transfer the resident with a mechanical lift out of bed to an adapted wheelchair per the schedule. The admission MDS dated [DATE] identified Resident #348 had severely impaired cognition, was incontinent of bowel, frequently incontinent of bladder and required total assistance of 2 staff with transfers between surfaces. Facility documentation dated 10/13/18 at 10:33 AM identified that Resident #348 had no abrasions or excoriations. A reportable event form dated 10/14/18 identified that at 11:30 AM a laceration was noticed on Resident #348's left lower extremity after a hoyer transfer into the wheelchair. Resident #348 required treatment in the emergency department for the laceration to the leg. The investigation identified that Resident #348 had periods of restlessness or agitation. Additionally, staff were provided education on proper transfers utilizing a hoyer lift and to ensure that residents are wearing long pants prior to being transferred. An investigative statement by NA #2 dated 10/14/18 identified that she and NA #3 were transferring Resident #348 with the hoyer lift. NA #2 indicated they took off the leg rests because the room was small, and identified that when she pulled Resident #348 back, Resident #348's leg got caught on the spot where the leg rest fits. After the resident was unhooked from the hoyer, NA #2 noticed the resident was bleeding, and she and reported it immediately to the nurse. An investigative statement by NA #3 dated 10/14/18 identified that she and NA #2 could not maneuver the wheelchair in the position they needed because the room was so tight. NA #2 and NA #3 took off the legs of the wheelchair and transferred the resident with the hoyer into the wheelchair. After unhooking Resident #348, NA #2 and NA #3 noticed the area of blood. NA #3 documented that Resident #348 got cut from the metal pieces where the leg rest attach. An investigative statement by LPN #6 dated 10/14/18 identified that she was called into Resident #348's room by NA #2 and NA #3 for blood observed on the floor. Resident #348's left lower extremity was lacerated and blood was noted on a round metal fixture of the modified wheelchair where Resident #348 was seated. A nurse's note dated 10/14/18 at 1:24 PM identified that Resident #348 sustained a 6.3cm partial thickness laceration to the left lateral aspect of the calf during a transfer into wheelchair via hoyer lift. The note identified that bleeding to the laceration was controlled and the area was cleansed. Additionally, Resident #348 complained of pain when the calf was manipulated. The APRN was notified of the incident and directed that Resident #348 be transported to the emergency room for treatment. The hospital discharge documentation dated 10/14/18 identified that Resident #348 was treated in the emergency department for a laceration and received a tetanus-[MEDICATION NAME] immunization. Recommendations included to keep the wound clean and dry, apply antibiotic ointment daily for 3 days, return to the hospital for any fever, chills, redness or drainage. Additionally, Resident #348 would require follow up with a physician for suture removal in 7 to 10 days. Nurse's note dated 10/14/18 at 4:41 PM identified that Resident #348 returned to the facility from the emergency room following treatment for [REDACTED]. Resident #348 required 5 sutures and a tetanus [MEDICATION NAME] injection in the hospital. An investigation statement (reenactment done on 10/15/18) with NA #2 identified that during the transfer, the residents legs were not fully supported during the end of the lowering. Education was provided on the need to fully support the legs during the process of the transfer. A clinical competency on transferring a resident using a mechanical lift included the direction that staff monitors the resident's legs and head during the lift to avoid injury. An employee warning notice labeled dated 10/18/18 identified that NA #2 was directly involved with an improper and unsafe mechanical lift transfer with another employee present. An employee warning notice dated 10/26/18 identified that NA #3 was directly involved with an improper an unsafe mechanical lift transfer with another employee present. Interview with NA #3 on 5/14/19 at 2:42 PM identified that she was operating the controls of the mechanical lift when transferring Resident #348 from the bed to a wheelchair. NA #3 identified that NA #2 was standing to the back of Resident #348's wheelchair guiding Resident #348 in the sling of the lift into the wheelchair. NA #3 identified her memory of the event was somewhat cloudy and although she noted that Resident #348's feet were being supported as the resident was lifted off the bed by the mechanical lift, NA #3 could not identify who, if anyone, guided Resident #348's legs to the ground as he/she was being lowered into the wheelchair. Furthermore, NA #3 identified that when they lowered Resident #348 into the wheelchair from the mechanical lift, the pad moved Resident #348's capri pants up exposing Resident #348's leg to the metal on the wheelchair where the legs for the wheelchair attach which cut Resident #348's leg. Interview with RN #1 on 5/15/19 at 11:35 AM identified that she and the ADNS participated in observation of the reenactment of the hoyer lift incident of 10/14/18 with NA #2 and NA #3. Although RN #1 could not recall specifics of NA #2 and NA #3's reenactments of the mechanical lift events precipitated by Resident # 348's leg laceration following a mechanical lift on 10/14/18, RN #1 was able to recall that education was provided to NA #2 and NA #3 to reinforce the importance of supporting a resident's legs during a mechanical transfer to ensure no injuries would occur. Interview and review of clinical record with the Director of Rehabilitation, (PT #1), on 5/19/19 at 9:49 AM identified that the rehabilitation department is responsible for repairs to wheelchairs that are identified as having mechanical issues or problems. PT #1 identified that there was no documentation of any mechanical issues or problems with Resident #348's wheelchair related to the incident of 10/14/18. Interview with RN #3 on 5/16/19 at 10:09 AM identified that although she could not recall specifics of the reenactment of 10/14/19 with NA #2 and NA #3, she stands by her documentation which identified that the reenactment demonstrated NA #3 required reinforcement related to the importance of supporting a resident's legs when lowering them from a hoyer lift to a wheelchair. Although attempted, interviews with NA #2 and LPN #6 were not obtained. Review of facility policy for total lift identified that staff is to ensure the resident is guided while lowered in the lift to ensure no entrapment occurs. The facility failed to ensure Resident #348's legs were fully supported during a hoyer lift transfer which resulted in the resident sustaining a 6.3cm partial thickness laceration to the left lateral aspect of the calf. Subsequently, Resident #348 was transported to the hospital, required 5 sutures to close the laceration, a tetanus-[MEDICATION NAME] (Td) injection, and the application of antibiotic ointment for 3 days.

Based on clinical record review and staff interview for two of four residents reviewed for accidents (Resident's #40 and #8), the facility failed to ensure the resident was transferred according to the plan of care to prevent an accident resulting in an injury and/or the facility failed to follow the resident's plan of care and provide adequate supervision to prevent an accident. The findings include: 1. Resident # 40's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified intact cognition, required extensive assist of two staff for bed mobility and transfers, and did not ambulate. The care plan dated 7/25/17 identified Resident #40 requires assistance with positioning in bed and with transfers out of bed. Interventions included to transfer the resident with the assistance of two staff via a lift. Additionally, the care plan identified Resident #40 had a history of [REDACTED]. Interventions included if angry or sad at one point of the day, attempt care at a later time of the day when mood may improve The physician's order dated 7/27/17 directed to transfer Resident #40 via a sit/stand lift (Sarita). A reportable event form dated 9/26/17 identified Resident #40 bumped his/her leg on the Sarita lift. The left lower leg had a 6.0cm by 7.0cm fluid filled area. A review NA #1's statement dated 9/26/17 identified while hooking up Resident #40 to the sarita lift, the resident was irritated and yelling at NA #1. NA #1 indicated he/she leaned on the sarita lift and the resident said that NA #1 bumped his/her leg. A nurse's note dated 9/26/17 at 6:46 AM identified Resident #40's left lower extremity has a 6.0cm by 7.0cm fluid filled area. Resident #40 complained of pain, 8 out of a maximum of 10 on the pain scale. Scheduled [MEDICATION NAME] was administered. A pain assessment dated [DATE] at 7:12 AM identified Resident #40 had complaints of moderate left lower leg pain which was described as sharp shooting to ache. A nurse's note dated 9/26/17 at 4:22 PM identified the presence of a hematoma to the left shin which was tender to touch and moderate complaints of pain to the area. Reported injury was sustained from transfer device. The physician's order dated 9/26/17 identified Resident #40 had a hematoma to the left shin, the sarita lift hit the residents left shin. The order directed to apply ice to the hematoma for 20 minutes every shift for 48 hours, administer [MEDICATION NAME] 800 mg by mouth for 1 dose and [MEDICATION NAME] (narcotic pain medication) 1 tablet by mouth every 6 hours as needed for pain. Additionally, obtain an x-ray to the left shin. An On the Job Training form dated 9/27/17 identified NA #1 was trained on all sit-to-stand lift transfers which directed that a second staff member is present for the entire duration, including assisting the resident's feet/legs into the foot pedals and strapping legs in. A wound assessment dated [DATE] identified the residents hematoma to the left lower leg was large and swollen, with weeping serosanguinous fluid from a small opening in the mid portion. Review of the Physician's orders dated 9/29/18 directed to place xeroform gauze over the weeping area of the hematoma every day, and do not cover with a dressing. A wound assessment dated [DATE] identified the top of the hematoma on the left lower extremity was exposed. The wound bed was blue/purple and the surrounding skin was deep brown. Physician's order dated 10/6/17 directed to irrigate the open wound on the left leg/shin with saline and apply calcium alginate with silver and cover daily. A physician consult dated 10/6/17 identified a large open wound on the left leg which was necrotic and subcutaneous tissue was visible. The physician recommended wet to dry dressings. A wound consult dated 10/31/17 identified Resident #40's left lower extremity wound measured 18.3cm by 13.1cm by 0.2cm. The wound was beefy red, mild drainage. Resident #40 complained of severe pain to the leg. Recommendations included to continue current wound care. A plastic surgery consult dated 11/15/17 indicated the wound was clean, and the plan was for Resident #40 to receive a skin graft of the left leg . Review of a hospital note dated 12/13/17 identified Resident # 40 underwent a skin graft to an open wound of the left lower extremity. The resident was to keep leg elevated with wound vac (vacuum) intact, do not remove the dressing until fresh skin graft was noted under the vac. Review of the medication administration records identified Resident #40 requested and received [MEDICATION NAME] 1 tablet three times per day, every day, from 9/27/17 through 12/13/17 for pain. A Physician's order dated 12/14/17 directed a wound vac at 125 mm/Hg continuously. A wound assessment dated [DATE] identified the left shin wound measured 0.5 cm x 0.5 cm of 100% healthy tissue with a small amount of drainage. An assessment dated [DATE] indicated the left shin wound measured 0.5 cm x 0.3 cm of healthy dry tissue. A wound APRN consultant note dated 3/1/18 indicated the left lower leg wound was healed. A review of an investigation statement dated 9/26/17 and interview on 3/28/18 at 9:37 AM with NA # 1 identified on 9/26/17 Resident # 40 was sitting on the edge of the bed. NA #1 indicated he/she was going to transfer the resident from the bed to a wheelchair using a Sarita lift. The resident was agitated, which included yelling and shaking. NA #1 identified this was not unusual behavior for the resident and proceeded with the transfer. He/she attempted to place the resident's legs in the cones on the lift and during the process bumped the residents left lower leg with the plastic cone. NA # 1 identified although he/she was waiting for another nurse aide to assist him/her with the transfer, he/she attempted to get the resident's legs in the lift by him/herself. NA # 1 indicated after the incident he/she was informed he/she should have had two people to assist the resident into the lift. A review of the facility policy on Sara (Sarita) lift and interview on 3/28/18 at 1:00 PM with the DNS identified it is the responsibility of the staff to ensure two staff members were present when Resident # 40 was being placed in the transfer lift on 9/26/17, especially with the resident was exhibiting agitated behaviors. The policy indicated to identify self and staff assistant prior to performing the procedure. The facility failed to ensure two staff members assisted the resident into the mechanical lift per policy and/or followed the resident care plan which indicated if the resident was angry or sad at one point of the day, attempt care at a later time of the day when mood may improve. 2. Resident #8's [DIAGNOSES REDACTED].The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognition and required supervision of one person for walking and all locomotion on the unit and supervision with one person assist for eating. The care plan dated 12/28/17 identified a high fall risk with interventions which directed staff to explain in simple statements, redirect to use call bell, assistive devices when ambulating, offer staff assistance if the resident is observed not using his/her rolling walker, offer the rolling walker and if refuses than assist resident. Physician orders dated 2/23/18 directed nursing staff to provide a mechanical soft diet and supervision with cues for slow rate/small bites and sips. Further review of the care plan dated 2/21/18 identified that the resident should have a mechanical soft diet and supervision with one person for all meals and cue for slow rate (1 bite/sip at a time) and small bites/sips. Review of the accident/incident report dated 3/25/18 at 8:40AM identified Resident #8 had an unwitnessed fall while entering the dining room that morning. NA#1 had served Resident #8 breakfast in his/her bedroom and went to feed residents in the main dining room. While feeding a resident, NA#1 heard Resident #8 fall. Further review of the accident/incident report identified the resident did not have his/her walker with him/her prior to the fall. NA#1 informed the nurse of the fall and the resident was assessed and had no injuries. Review of the Nurses' Aides care card identified Resident #8 eats his/her meals in the dining room. Interview with NA#1 on 3/27/18 at 11:30AM identified he/she was assigned to Resident #8 on 3/25/18. He/she further identified Resident #8 does not like to eat in the dining room for breakfast and he/she brought Resident #8's breakfast to his/her room that morning. NA#1 identified Resident #8 required supervision during meals and that there is someone monitoring the hallways when residents eat in their rooms, however he/she failed to inform another staff member Resident #8 was left in his/her room for breakfast. Observation on 3/27/18 from 11:50AM to 12:30PM observed the resident's lunch not eaten at the table where the resident has assigned seating. Resident #8 was observed wandering outside of the dining room up and down the hallway. Resident #8 was observed initially with his/her rolling walker from 11:50AM to 12:00PM than left the walker at the nurses' desk. Resident #8 was observed walking up and down the corridor on the unit without the benefit of staff present and/or redirecting the resident to the lunch room and/or the use of the rolling walker. Interview with the DNS on 3/27/18 at 1:00PM identified the staff failed to provide Resident #8 supervision with meals and when ambulating on 3/25/18 and 3/27/18 as directed in the plan of care.

Based on clinical record review, review of facility policies, review of staff job descriptions and interviews for two of three residents who had a change in status (Residents #1 and #2), the facility failed to ensure that STAT( immediate) bloodwork results and/or changes in mentation were communicated. The finding includes: 1. Resident #1 had a history of [REDACTED]. The quarterly assessment dated [DATE] identified that the resident had severe cognitive impairment, unclear speech, ambulated with a walker with supervision and ate independently. Review of the plan of care dated 11/29/17 included interventions to administer medications as ordered and notify MD as needed. The PT (physical therapy) assessment dated [DATE] indicated that the resident had existing deficit (shuffling of feet, limping, loss of balance, falling, using walker/cane) with ambulation. Review of nursing narratives dated 2/10/18 noted that the resident's speech was more garbled, APRN #1 was notified and bloodwork was ordered. A subsequent call by LPN #1 to APRN #1 at 3:13 PM indicated that the resident's speech did not improve, the prior bloodwork was ordered as STAT and the labs were drawn as ordered on the evening shift. Review of the STAT bloodwork (complete blood count to include white blood cell count) noted that the bloodwork was reported at 6:37 PM to the facility and did not indicate the presence of infection. Review of nursing narratives lacked documentation that APRN had been notified of the negative results and/or had called to inquire about the results for possible interventions for further assessment as to the cause for the resident's change in condition and lack of improvement. Review of nursing narratives/assessments dated 2/11/18 at 3:20 AM indicated that the resident's blood pressure had increased from 138/72 to 166/100 (at rest), the supervisor was notified at 7:15 AM, a repeat blood pressure was taken and was 140/90. Although the Supervisor was aware of the Resident's elevated BPs at 7:15 AM, documentation did not reflect that a practitioner was notified. Review of nursing narratives dated 2/11/18 indicated that when Person #1 visited the resident, Person #1 requested an ED (emergency department) evaluation for possible [MEDICAL CONDITION]. APRN #1 was then notified of the resident's STAT bloodwork and Resident #1 was sent the ED at 3:30 PM per Person #1's request. Review of Hospital #1's record dated 2/11/18 identified that Resident #1 was diagnosed with [REDACTED]. Interviews with NA #1 and LPN #1 on 3/1/18 at 11:14 AM and 3:25 PM respectively, noted that prior to 2/10/18 the resident stuttered, was able to be understood and could not be understood beginning the morning of 2/10/18 at approximately 7:15 AM. Interview with NA #1 further indicated that prior to 2/10/18, the resident was independent with feeding and required assistance on 2/10/18 and 2/11/18. Interview with APRN #1 on 3/1/18 at 11:38 AM identified that it was reported to him/her that Resident #1 had increased garbled speech, was at baseline otherwise, and bloodwork was ordered to rule out an infectious cause for the change. Further interview with APRN on 3/1/18 at 11:38 AM noted that the Resident was sent out for further evaluation when he/she was informed that the Resident's labs were normal and that the family requested the transfer to the ED (2/11/18 at 3:30 PM). APRN #1 indicated that because the labs were normal the change in the Resident did not seem like an infectious process. Interview with RN #4 on 3/2/18 identified that he/she was informed by RN #3 that the Resident's STAT bloodwork was normal on 2/10/18 at approximately 5:00 PM -6:00 PM, neither he/she nor RN #3 informed APRN #1 about the bloodwork results because they were normal and the order did not direct immediate notification. Interview with the Director of Nursing on 3/1/18 at 4:15 PM noted it was the responsibility of the Supervisor to notify practitioners of lab results and would have expected the STAT lab results to be reported as soon as the results came in. Interview with MD #1 on 3/1/18 at 3:50 PM indicated that ordering bloodwork and neurological checks would be what most physicians might do and could not disagree that once the testing was known to be negative for infection the next step would be to have the Resident evaluated at the hospital. The facility LPN job description identified that the LPN is responsible and accountable to carry out assigned duties and report directly to the RN. The facility supervisor description identified a responsibility to document and report unusual or significant findings: contact the physician when necessary. The facility APRN contract identified a standard of conduct to perform duties in accordance with the prevailing standards of practice. 2. Resident #2's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident was cognitively intact and continent of bowel and bladder. The plan of care dated 12/19/17 identified that Resident #2 was at risk for infection. Review of nursing narratives dated 2/11/18 at 12:10 PM indicated that the resident had more confusion, insisted that he/she had a job in the kitchen, put his/her pants on inside out and was placed on a three day monitoring for UTI (urinary tract infection). Further review of the the clinical record lacked documentation to indicate that the resident had been assessed by the RN and/or Practitioner and/or that either had been notified of the change. Interview with the Director of Nursing on 3/1/18 at 12:37 PM noted that he/she would expect the LPN to notify the RN with resident changes so that the RN could assess the resident. The facility LPN job description identified that the LPN is responsible and accountable to carry out assigned duties and report directly to the RN. The facility supervisor description identified a responsibility to document and report unusual or significant findings: contact the physician when necessary.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident # 132), the facility failed to ensure the resident was free from any significant medication error. The finding include: Resident # 132's [DIAGNOSES REDACTED]. The Resident Care Plan (RCP) dated 3/20/17 identified the resident was at risk for alteration in cardiac output. Interventions directed to assess and document any dizziness, to monitor for chest pain and to administer medication as ordered. The admission MDS assessment dated [DATE] identified Resident # 132 had a Brief Interview for Mental Status (BIMS) score of 14 out of fifteen, indicative of no cognitive impairment and the required extensive assistance of two person for transfer. The Medication Administration Record [REDACTED].M. The nurse's note dated 3/28/17 at 4:37 P.M. identified the resident's physician was made aware Resident # 132 received kayxelate as ordered and indicated the physician requested that staff repeat the resident's Basic Metabolic Panel (BMP) in the A.M. to evaluate Resident # 132's BUN and creatinine levels in response to intravenous fluid and potassium level. Additionally, the nurse's note dated 3/29/17 at 1:43 A.M. identified Resident # 132 was given the wrong medication and indicated the resident was alert and oriented at the start of the shift but later reported to staff he/she saw a person outside of the window talking to him/her. A review of facility Accident/Incident report dated 3/28/17 identified an in correct medication was administered to Resident # 132 at 1:00 P.M. Additionally, the report noted the resident was noted with increased confusion. The physician was notified and staff was directed to transport the resident to the emergency room (ER) for an evaluation. The facility investigation dated 31/17 identified Resident # 132 was inadvertently given Vitamin K 30 MG instead of [MEDICATION NAME] 30 grams. The supervisor was notified and the resident was assessed and noted with confusion. The acute care facility discharge summary dated 3/30/17 noted for final Diagnoses: [REDACTED]. The discharge summary also noted Resident # 132 in the emergency room (ER) received D50 , insulin, [MEDICATION NAME] 30 mg by mouth time one and one liter of bolus Normal Saline. Resident # 132 was admitted to the hospital and started on IV Normal Saline at 100 ML/hour, the resident's [MEDICATION NAME] (anti-hypertensive) and [MEDICATION NAME] (diuretic) was discontinued because of the [MEDICAL CONDITION]. Additionally, the report also noted the resident received [MEDICATION NAME] in the Emergency Department (ED) and her/his potassium level progressively dropped from 6.9 ( 3.5- 5.0 MEq/L) to 5.7 in a few hours of admission. The resident's at the time of discharge from the hospital potassium decreased to 4.9, BUN creatinine went from 65 (Normal Range 7- 20 mg/dl) and 1.4 (Normal Range 0.6- 1.2 mg/dl) on admission decreased to 46 and 1 on discharge. In an interview with RN#4 on 4/26/17 at 12:05.P.M. identified she/he took the verbal order from the physician and transcribed the resident's orders on the day in question. RN # 4 on 4/26/17 indicated on 3/28/17 ( the day in question) the resident physician's orders [REDACTED]. In an interview with LPN#2 on 4/26/17 at 12:10 P.M. identified she/he received a call from the supervisor that Resident #132 had an order for [REDACTED].#2 further indicated RN # 4 indicated she/he would bring the medication down to her/him on the unit. LPN#2 indicated she/he received three (3) vials of medication with the letter K written on the medication which was given to her/him by RN # 4 and indicated she/he thought the three vials with K written on them were genetic for Kayxelate. LPN#2 indicated she/he administered 30 MG of the IM medication (which she/he thought was the generic for kayxelate) into Resident #132's right arm per instruction of RN # 4 ( the supervisor) . LPN#2 indicated although, she/he had questions regarding the medication she/he did not speak to the Director of Nursing and/or verify if the medication was correct with the prescribing APRN prior to administering. In an interview with APRN#1 on 4/26/17 at 3:53 P.M. she/he indicated an order was given for Kayxelate 30 MG orally and if the charge nurse had questions she/he should have contact him/her for clarification. In an interview and clinical record review with the Director of Nursing Services (DNS) on 3/26/17 at 3:53 P.M. identified on 3/28/17 Resident #132 had pre-operative laboratory blood work which revealed potassium level of 6.2 (Normal Range 3.5-5.3) and the Nurse Practitioner had given an order to administer Kayxelate 30 MG by mouth but the order was transcribed as Vitamin K 30 MG IM. The DNS further indicated the Vitamin K was administered on 3/28/17 at approximately 1:30 P.M. but the error was not identified until approximately 10:30 P.M. (nine hours later). DNS also indicated the charge nurse should have spoken to the Director of Nursing and/or APRN prior to administering medication when she/he had concerns/questions regarding the medication. Review of facility policy and procedure for medication administration directs to verify medications prior to administration.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #224) reviewed for change in condition, the facility failed to transfer the resident to the emergency department in accordance with the plan of care. The findings include: Resident #224's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #224 had no cognitive impairments and required assistance with activities of daily living. The Resident Care Plan dated 6/17/15 identified the resident requested to be a full code and all clinical appropriate interventions to be initiated. Interventions directed to initiate 911, notify the physician, to monitor oxygen saturation and vital signs and to follow the physician's orders [REDACTED]. The nurse's note dated 7/19/15 at 3:09 AM identified at 2:20 AM the 11-7AM Nursing Supervisor was called to Resident #224's room due to a decrease in response from the resident. The resident was pale, skin cool, poor response to verbal and tactile stimuli, the resident was grunting and moaning and the blood pressure was 114/94, pulse rate 70, respirations rate 12, temperature 97.6, oxygen saturation level 92% on room air and the blood sugar results read Hi. The note at 2:40 AM identified the on-call Advanced Practice Registered Nurse (APRN) was contacted regarding a change in condition [MEDICAL CONDITION], awaiting response. The follow up note at 2:50 AM identified the attending physician was called since there was no response from the APRN, awaiting response. The note identified at 3:00 AM Resident #224's oxygen saturation level was 79%, oxygen therapy at fifteen (15) liters via a non- rebreather was initiated, the oxygen saturation level increased to 95% and the blood sugar was rechecked and the glucometer reading was Hi. The note at 3:10 AM identified the physician was called, awaiting response. The nurse's note dated 7/19/15 at 8:51 AM identified Resident #224 was transferred first to the local hospital, then transferred to another hospital and was admitted to the Intensive Care Unit [MEDICAL CONDITIONS] and pneumonia. Review of the hospital discharge summary dated 7/22/15 identified the initial bloodwork results were noted to be white blood cell count 13.2 (normal range 4.0-11.0) and the glucose level was 359 (normal two (2) hours after eating is less than 140). The summary identified the discharge [DIAGNOSES REDACTED]. In an interview on 6/14/16 at 3:10 PM, the 11:00-7:00AM the Nursing Supervisor, Registered Nurse (RN) #2, identified she overheard a nurse aide reporting to the charge nurse that Resident #224 was not doing well. Upon assessment of the resident, RN #2 identified Resident #224 was non-responsive to sternal rub stimulation with only a response of fluttering his/her eyes. RN #2 stated the resident's vital signs were acceptable but the blood sugar result on the glucometer read Hi therefore she decided to notify the on call APRN for the purpose of obtaining an order for [REDACTED].#2 identified that Resident #224 had a Full Code status but believed the blood glucose should be priority. RN #2 identified while waiting for a response from the on call APRN, Resident #224's oxygen levels dropped and she then decided to call the physician since there was no response from the on call APRN. In an interview on 6/15/16 at 11:15 AM, the attending physician, Medical Doctor (MD) #1, identified if there was no response from the on call medical staff when a resident has acute mental status changes and is a full code, he expects the resident to be sent to the hospital immediately.

Based on record review and staff interview for 1 of 6 sampled residents reviewed for falls (R#186), the facility failed to provide supervision to prevent a fall with injury and for 2 out of 3 nursing units the facility failed to secure hazardous chemicals and/or other hazards resident care items. The findings include: 1. Resident 186's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as moderately cognitively impaired and requiring extensive assistance of two for bed mobility. The MDS further identified the resident required extensive assistance of one staff member for transfers, toileting and personal hygiene. The MDS further identified the resident required limited assistance of one staff member for ambulation in the room and/or corridor. A fall risk assessment dated [DATE] identified the resident was at risk for falls related to being over the age of 60, having weakness, impaired vision and judgement and being on medication that can cause hypotension. A care plan dated 12/17/13 identified a risk for falls related to having a history of falls on 9/20/13, 9/27/13, 10/18/13, 10/23/13, 12/12/13, 12/16/13 and 1/31/14 with interventions that included to leave personal items within reach, assess resident's gait, to make sure he/she has slipper socks on in bed and shoes on when ambulating on the unit. Physical therapy recommendations dated 9/16/13 included to transfer the resident with a rolling walker with assist of one and to ambulate on the unit with the rolling walker and supervision of staff. Interview with the Rehabilitation Program Manager on 5/21/14 at 10:43 AM identified that "supervision" means that the resident should be within eye view of staff when ambulating. Facility Accident/Incident report dated 1/31/14 at 8:15 PM identified the resident walked into the hallway without the walker, the nurse stated to the resident that he/she must have the walker and as the nurse turned to get the resident's walker, the resident fell on to his/her right side. Nurse's note dated 1/31/14 at 8:42 PM identified the resident's right leg was shortened and externally rotated and complained of pain to the right lateral upper thigh when questioned. The resident was transferred to the ED and admitted with a [DIAGNOSES REDACTED]. Interview LPN#1 on 5/21/14 at 11:45 AM identified that he/she witnessed the resident in the hallway outside the bedroom door ambulating without his/her walker. LPN #1 further identified that he/she told the resident that he/she needed the walker, and walked past the resident to obtain the walker which was located near the resident's night stand. LPN#1 further identified the resident fell before he/she could bring the walker back to the resident. Interview with the Rehabilitation Program Manager on 5/21/14 at 10:43 AM identified that because R#186 needed the walker to ambulate for steadiness. LPN#1 was to have braced the resident and called for assistance to retrieve the walker. 2. Observations on the first floor clean utility room on 5/19/14 at 9:45 AM identified that the door to the utility room was unlocked and once opened, unlocked cabinets were noted with razors, peritoneal cleansers, shaving cream, mouthwash, and protective ointment were observed. Observations of the second floor clean utility room on 5/19/14 at 9:55 AM identified that the door to the clean utility room was unlocked and once opened, there was shelving noted, the shelving held razors, peritoneal wash and mouthwash. Interview with the ADNS on 5/19/14 at 10:00 AM identified that the items should be secured and locked and was unable to identify why this was not done. Interview with the Administrator on 5/20/14 at 9:30 AM identified that the clean utility rooms had switches on the doors for the locking mechanism, but that they had been disabled. The Administrator further identified that he was unsure why the locking mechanism was disabled, but the clean utility rooms on the first and second floor were now secure with the locking mechanism in place. Review of the storage of sharps policy, identifies that certain sharp items such as razors, are stored and secured in designated areas at all times when not in use.

Based on clinical record review and interview for 2 of 3 sampled residents (Residents #78 and Resident #225) who were reviewed for accidents, the facility failed to ensure that the resident received the necessary supervision to prevent an accident. The findings include: a.) Resident #78 ' s [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified intact cognition, required extensive assistance of two staff members with transfer and toilet use, impaired range of motion on one side in upper and lower extremities, and no falls. The care plan dated [DATE] identified a fall risk with interventions which included transferring the resident with assistance of two people. The Occupational Therapy (OT) Discharge Summary on [DATE] identified Resident #78 stated that her/his hand is frequently slipping on the grab bar in the bathroom noting that the resident requires assistance of two staff members for transfers. The monthly physician's order [REDACTED]. The Reportable Event Investigation dated [DATE] identified Nurse Aide (NA #1) was transferring Resident #78 independently in the bathroom at 1:10PM when the resident ' s legs gave out and they became " stuck " between the toilet and wheelchair. Further review noted that staff was unable to lift the resident onto the toilet and subsequently lowered the resident to the floor. Interview with NA #1 on [DATE] at 1:30 PM identified that although he/ she was aware that Resident #78 required assistance of two people, he/she independently attempted to transfer the resident from the wheelchair to the toilet, told the resident to hold on to the bar but the residents legs " folded". NA#1 held the resident with her knee and lowered the resident to the floor. Interview with the DNS on [DATE] at 2:00 PM identified that the NA#1 assigned to the resident had not followed the plan of care when he/she transferred the resident independently. Resident #78 did not sustain any injuries following the incident on [DATE]. b.) Resident #225's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified intact cognition, required the extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. The assessment further identified that the resident had impaired range of motion of the lower extremities, utilized a wheelchair for mobility and was continent of bowel and bladder. The care plan dated [DATE] identified a fall risk with interventions which included assistance of two for stand pivot transfers. The nurse aide care card dated [DATE] identified Resident #225 should be transferred utilizing the stand pivot method with the assistance of two staff members and toileted with the assistance of two staff members. A review of the accident and incident report dated [DATE] identified Resident #225 fell in the bathroom and bumped her/his head on the floor at 11:00 AM. The facility investigation identified that during the time of the fall, the resident was transferred with the assistance of one staff member and not two as specified in the care card. A review nurses' notes and clinical documentation identified that following the fall the resident was assessed and neurological checks were conducted every 30 minutes between 11:00AM and 1:00PM and were within normal limits. According to a nurse's note dated [DATE] at 1:10PM Resident #225 was assessed and found to be diaphoretic, slurring his/her words and became unresponsive. The radial pulse could not be palpated however, the carotid pulse was bounding and the pupils were fixed and pinpoint. The physician was notified and directed to transfer the resident to the emergency department. Interview with the DNS on [DATE] at 2:00 PM identified Resident# 225 was admitted to the hospital with [REDACTED]. Interview with nurse aide (NA) #2 on [DATE] at 3:29 PM identified he/she assisted Resident#225 to the bathroom and attempted to transfer the resident without assistance of another staff member from the wheelchair to the toilet because the resident was in a rush to use the toilet. NA#2 identified the resident began to lean forward during the transfer and he/ she held on to the gait belt and guided the resident to the floor however, the resident fell forward and bumped his/ her head on the floor during the process. NA#2 also noted that at the time of the fall the resident was alert and oriented and was asking the staff to get him/her her up off of the floor. He/she further identified that she was aware that the care cards are located on the back of the resident door but that he/she had not reviewed the care card prior to assisting Resident #225 to the bathroom. A review of the hospital discharge summary dated [DATE] identified Resident #225 expired on [DATE] as a result of a subdural hematoma following a fall. .

Based on clinical record reviews, review of facility policies, review of facility documentation, observations and interviews for one of three residents who utilized a hand splint (Resident #1), the facility failed to prevent the development of pressures ulcers. The finding includes: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. The cast was removed and a Volar splint (immobilizer) was applied by the orthopedic surgeon 12/3/12 with orders to keep splint in place and remove for showers. Resident #1 was hospitalized for [REDACTED]. Although the plan of care dated 12/31/12 directed left wrist splint as ordered, physician orders [REDACTED]. Physician orders [REDACTED]. Occupational therapy (OT) notes dated 1/1/13 through 1/14/13 and interview with OT #1 on 1/25/13 at 11:30 AM noted that s/he removed the resident's splint on 1/8/13, the resident's skin was intact and OT was discontinued on 1/14/13 due to the resident's decline. The weekly body audits dated 1/4/13 and 1/14/13 documented by LPN #2 indicated that the resident's skin was intact. The record failed to reflect if LPN #2 removed the resident's Volar splint for inspection of the resident's skin. Nursing wound documentation dated 1/18/13 identified that the RN was called to assess R#1's left hand. R #1's thumb was [MEDICAL CONDITION], red and painful to touch. When the hand was turned over, a stage IV pressure ulcer was noted between the left thumb and index finger that measured 1cm long by 0.2cm wide by 0.5cm deep. The resident's splint was subsequently discontinued with wound treatments and antibiotics administered per physician's orders [REDACTED]. Review of LPN #2's written statement dated 1/21/13 and interview with the Director of Nursing (DON) on 1/25/12 at 12:07 PM noted that although LPN #2 documented that s/he performed the resident's body audits, LPN #2 did not remove the resident's left hand splint to assess the resident's skin. The facility splint policy directed that nursing staff will observe residents' skin for [MEDICAL CONDITION], redness, irritation, or pressure areas as part of daily care and that nursing staff included the nurse aides. The weekly body audit policy directed that a licensed nurse perform a weekly body audit, looking for any alteration in skin integrity.

Based on review of the clinical record, facility documentation and interviews for one of three sampled residents reviewed for fractures (Resident #1), the facility failed to implement measures to prevent an injury. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated that Resident #1 was a fall risk. The quarterly Minimum Data Set ((MDS) dated [DATE] identified severe cognitive impairment, extensive assistance for transfers with a two person assist and a history of falls. The nursing care plan dated 3/1/11 identified osteoporosis as a problem with interventions that included not lifting the resident under the arms, no over head tops, keep resident positioned per plan in the custom wheel chair, evaluate the effectiveness of medications, and observe the left extremity for swelling or pain. Review of the facility documentation on 5/5/11 identified at approximately 2:00 PM after a transfer from the toilet to the customized wheelchair Resident #1 was noted to have swelling and bruising to the left shoulder and arm. Resident #1's physician was notified and imaging was completed at the facility at 10:00 PM. Review of the nurse's notes indicated the resident was medicated for pain on 5/5/11 and 5/6/11 however the left arm remained swollen and bruised. On 5/6/11 at 10:20 AM the physician was notified of the imaging results which identified the examination was limited due to the portable technique and the resident's osteoporosis. The report further indicated that a questionable fracture may be present with a recommendation for a repeat examination. Resident #1 was sent to an acute care hospital on [DATE] at 11:25 AM for an evaluation of the left arm. The hospital imaging revealed a comminuted impacted surgical neck fracture with mild lateral positioning of the shaft relative to the humeral head. Resident #1 was sent back to the facility in a large arm sling with a swath to immobilize the extremity. Subsequent to the injury activity orders dated 5/10/11 directed the transfer of Resident #1 via a Hoyer lift to the customized wheelchair. Interview with Nurse Aide (NA) #1 on 1/18/12 at 1:30 PM identified that she and another nurse's aide lifted Resident #1 on 5/5/11 under the arms during a transfer instead of using the gait belt. NA # 1 indicated that after the transfer the resident complained of pain and she notified the nurse. Interview on 2/16/12 at 1:00 PM with RN #1 identified that she assessed Resident #1 on 5/5/11 at approximately 4:00 PM and noted that the resident's left upper arm just below the shoulder was swollen, however was not bruised or discolored. Further interview with RN #1 indicated on 5/5/11 at 10:00 PM Resident #1's upper arm continued to be swollen and began to appear red and purple in color. Interview with the Assistant Director of Nursing on 2/16/12 at 1:15 PM identified it was not safe to transfer Resident #1 under the arms and a gait belt should have been utilized for the transfer. Interview on 1/19/12 at 11:30 AM with MD #1 indicated that the fracture could have occurred from a transfer assisted by lifting Resident #1 under his/her arms due to significant osteoporosis, osteopenia with left hemiparesis and contractures.The facility policy for the use of gait belts directed that all employees use transfer/gait belts when transferring or ambulating residents, unless contraindicated.