Every finding on record at Villa Maria Nursing and Rehabilitation Community

Based on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #4) reviewed for notification of change, the facility failed to notify the resident representative (Person #1) of a significant change in status when Resident #4 attempted to exit the facility and a Wanderguard (an electronic monitoring device that alerts staff when at risk individuals approach or attempt to exit secured areas) was applied to the right wrist. The failure to notify Person #1 resulted in Resident #4's representative being unaware of the change in condition and unable to participate in care decisions. The findings include:Resident #4's diagnoses included vascular dementia with mood disturbances and chronic lymphocytic leukemia of B cell in relapse.The Clinical admission by RN #3 dated 5/14/26 at 9:08 PM identified Resident #4 was transported to the facility by Person #1, who left after arrival. Resident #4 was admitted on hospice services, was alert to person only, was confused, required cues, wandered without a goal, was pleasant, and had no impairments to the upper or lower extremities.The Elopement Evaluation by RN #3 dated 5/14/26 identified Resident #4 was at risk for elopement and a Wanderguard was applied to the right wrist. The Elopement Evaluation did not identify Person #1 was notified or that consent was obtained prior to applying the Wanderguard.A physician's order dated 5/14/26 directed staff to check placement of the Wanderguard to the right wrist every shift.A Nurse's note by RN #3 dated 5/14/26 at 9:20 PM identified Resident #4 attempted to exit through a side door, was redirected without difficulty, and a Wanderguard was applied to the right wrist without complaint. The note did not identify Person #1 was notified or that consent was obtained prior to applying the Wanderguard.The clinical record dated 5/14/26 did not identifiy that Person #1 was informed Resident #4 attempted to exit the facility or that a Wanderguard was applied.Nurse's notes dated 5/15/26 through 5/19/26 did not identify Person #1 was notified of wandering risk, exit seeking, or Wanderguard use.Interview with RN #3 on 6/8/26 at 12:12 PM identified Resident #4 pushed on the back door shortly after admission, activating a door alarm, and was easily redirected. RN #3 identified she applied the Wanderguard immediately rather than continuing to monitor Resident #4 or utilizing less restrictive interventions. She did not recall contacting Person #1 and identified her note did not document consent. She identified consent should have been obtained prior to applying the Wanderguard.Interview with the Director of Nursing Services (DNS) on 6/8/26 at 12:29 PM identified RN #3 should have attempted less restrictive interventions prior to applying the Wanderguard. The DNS identified Person #1 should have been contacted to obtain consent if Resident #4 continued exit seeking and documentation should have been completed. She identified she was unaware Person #1 had not been contacted.Interview with Person #1 on 6/8/26 at 2:53 PM identified he/she was not informed Resident #4 attempted to exit the facility or that a Wanderguard was applied. Person #1 identified he/she would not have authorized the Wanderguard and would have picked up Resident #4 if the resident was distressed or attempting to leave.The Wandering, Unsafe Resident policy dated 8/2014 identified the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment. The policy directed staff to assess residents at risk for unsafe wandering, identify potentially correctable risk factors, ensure the care plan identified elopement risk, and include interventions such as a detailed monitoring plan. The policy identified the importance of maintaining the least restrictive environment while ensuring safety.Although requested, the facility policies for Wanderguards and At Risk for Elopement were unavailable.

Based on clinical record review, facility documentation, facility policies, and interviews, for two (2) of five (5) sampled residents (Residents #1 and #2) reviewed for allegations of abuse, the facility failed to ensure Resident #2 was free from abuse when Resident #1 entered Resident #2's room and touched Resident #2 inappropriately. The findings include:1.Resident #2's diagnoses included affective mood disorders, Parkinson's disease, depression, and anxiety.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required partial assistance for bed mobility and transfers, did not ambulate, and did not exhibit behaviors.The Resident Care Plan (RCP) dated 5/7/26 identified Resident #2 had a mood problem related to depression and anxiety and utilized psychotropic medications. Interventions directed staff to encourage Resident #2 to express feelings, provide a calm and quiet atmosphere when restless or anxious, provide psychological services as needed, administer psychotropic medications as ordered, and observe and document effectiveness and side effects. The RCP identified a history of Resident #2 making physical accusations towards another resident.2.Resident #1's diagnoses included conversion disorder with seizures or convulsions and anxiety disorder.The 5 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (BIMS score of 15), required partial assistance with transfers, did not ambulate, and was independent with wheelchair mobility. No behaviors were identified.The Resident Care Plan (RCP) dated 5/8/26 identified Resident #1 had a mood problem related to mild depression and utilized psychotropic medications. Interventions directed staff to encourage Resident #1 to express feelings, provide psychological services as needed, administer psychotropic medications as ordered, and observe and document effectiveness and side effects.A Nurse's note by RN #1 dated 5/8/26 at 8:07 PM identified Resident #1 was accused of touching Resident #2 over clothing and blankets. Resident #1 denied the interaction. The provider was notified and an order was obtained to send Resident #1 to the Emergency Department (ED) for psychiatric clearance. Resident #1 was placed on one to one observation until Emergency Medical Services (EMS) arrived, and the police were notified of the alleged incident.The Reportable Event (RE) form by RN #1 dated 5/8/26 identified that at 7:00 PM Resident #2 alleged Resident #1 touched him/her in the private area over clothing and blankets and denied direct skin contact. Resident #2 was fully clothed with blankets on and no injuries were observed. The police and provider were notified. The provider ordered an additional 25 milligrams (mg) of trazodone to be administered one time with Resident #2's regularly scheduled bedtime medications. Resident #2 had no emotional distress at the time and was sitting at the nurse's station per Resident #2's request. Resident #1 was placed on one to one observation and an order was obtained to send Resident #1 to the ED for psychiatric evaluation.Resident #1's clinical record did not identify any history of sexual or aggressive behaviors prior to 5/8/26. Resident #1 did not return to the facility following ED transfer.A written statement by Resident #1 dated 5/8/26 identified Resident #1 denied touching Resident #2 but said Resident #2 asked him/her to.Interview with the Director of Nursing Services (DNS) on 6/5/26 at 12:57 PM identified she had been the day shift supervisor prior to the 7:00 PM allegation on 5/8/26. She identified Resident #1 self propelled in a wheelchair, and she had not observed Resident #1 entering or exiting other residents' rooms. She identified that if staff observed a resident wandering into rooms, they should have checked on the residents and notified the nursing supervisor immediately. Following the allegation, she identified it was determined the facility's admission policy and checklist had not been followed and Admissions had not completed a sexual offender screening for Resident #1 prior to admission. She identified a later review determined Resident #1 had a previous sexual assault charge and that correct screening would have prevented Resident #1's admission to the facility.Interview with Resident #2 on 6/5/26 at 1:16 PM identified that at approximately 6:15 PM on 5/8/26 Resident #1 entered the room in a wheelchair and touched Resident #2's feet. Resident #2 told Resident #1 not to touch him/her, and Resident #1 left. At approximately 7:00 PM Resident #1 returned, reached under the sheets, touched Resident #2's feet and legs, and placed hands on top of Resident #2's brief without touching skin of the private area. Resident #2 identified telling Resident #1 to stop and Resident #1 responded that most people like that and left. Resident #2 identified feeling violated, wanting to crawl up into a ball and cry, and was relieved when Resident #1 was removed from the facility. Resident #2 identified attempting to press charges.Interview with the Admissions Director on 6/5/26 at 1:28 PM identified the facility's process required completing a sexual offender screening prior to admission. She identified that a regional Admissions staff member filling in for her processed Resident #1's referral and failed to complete the screening. She identified that if the screening had been completed and the criminal history known, Resident #1 would not have been admitted to the facility.Interview with LPN #1 on 6/5/26 at 1:53 PM identified that on 5/8/26 Resident #1 was self propelling throughout the facility. At approximately 6:45 PM she observed Resident #1 watching pornography on a cellphone. Following the allegation, she notified RN #1. She identified no other behaviors by Resident #1 and had not seen Resident #1 entering or exiting other residents' rooms.Interview with LPN #2 on 6/5/26 at 2:17 PM identified she worked both day and evening shifts on 5/8/26 and saw Resident #1 self propelling throughout the building. She identified that she never saw Resident #1 entering or exiting rooms but that NA #2 reported seeing Resident #1 coming out of Resident #2's room earlier. She identified Resident #2 was visibly upset, shaking, and crying the following day.Interview with RN #1 on 6/5/26 at 2:56 PM identified Resident #1 had been self propelling and wandering prior to the 5/8/26 allegation, though she had not seen Resident #1 entering or exiting rooms. At approximately 7:00 PM she answered Resident #1's roommate's call bell and saw Resident #1 in the doorway. Resident #2 reported Resident #1 touched the private area over blankets and later reported Resident #1 reached under the sheets and touched the legs and private area over the brief. Resident #2 was visibly upset but denied injuries.Interview with NA #2 on 6/5/26 at 3:03 PM identified Resident #1 self propelled throughout the hall and she saw Resident #1 in Resident #2's doorway prior to the allegation. She denied seeing Resident #1 go into or come out of other residents' rooms.Interviews with NA #1, NA #3, and NA #4 on 6/5/26 identified they saw Resident #1 self propelling on 5/8/26 and had no interactions with Resident #1. NA #1 identified NA #2 reported seeing Resident #1 coming out of Resident #2's room.A follow up interview with the DNS on 6/8/26 at 12:29 PM identified the facility did not ensure residents were protected from abuse when Resident #1 was admitted without completing a sexual offender screening. She identified the police report had not been finalized, as Resident #2 continued efforts to press charges.Attempts to interview Resident #1 were unsuccessful.The Abuse Prohibition & Quality Assurance/Reporting Reasonable Suspicion of Crime Elder Justice Act policy dated 4/12/25 identified the facility maintained zero tolerance for abuse, would provide a safe environment free from harassment or abuse, required staff to know resident whereabouts, required sufficient staffing, and required assessment and planning to identify behaviors that could lead to conflict or harm. The policy directed immediate notification of the Administrator for alleged abuse, immediate police notification for allegations of sexual assault, and required ED evaluation. The policy defined sexual abuse as non consensual sexual contact of any type with a resident.The Admissions policy dated 7/15/17 identified a sexual offender screening would be completed for each potential resident prior to admission using the Connecticut sex offender registry; documentation of the search would be maintained.

Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #4) reviewed for elopement risk, the facility failed to ensure Resident #4 was free from restraint. After a single, easily redirected attempt to exit the facility, staff applied a Wanderguard without obtaining prior consent from the responsible party and without attempting less restrictive interventions, despite no further documented wandering or exit seeking behaviors. This resulted in unnecessary restriction of Resident #4's freedom of movement. The findings include:Resident #4's diagnoses included vascular dementia with mood disturbances and chronic lymphocytic leukemia of B cell in relapse.The Clinical admission by RN #3 dated 5/14/26 at 9:08 PM identified Resident #4 was transported to the facility by the responsible party (Person #1), who left after arrival. Resident #4 was admitted on hospice services, was alert to person only, was confused, required cues, wandered without a goal, was pleasant, and had no impairments to the upper or lower extremities.The Elopement Evaluation completed by RN #3 dated 5/14/26 identified Resident #4 was at risk for elopement and a Wanderguard was applied to the right wrist. The Elopement Evaluation did not identify that the responsible party was notified or that consent was obtained prior to applying the Wanderguard.A physician's order dated 5/14/26 directed staff to check placement of the Wanderguard to the right wrist every shift.A Nurse's note by RN #3 dated 5/14/26 at 9:20 PM identified Resident #4 was a new hospice admission, was walking independently, was alert and confused, oriented to self only, pleasant, cooperative, and wandered aimlessly but was easily redirected. The note identified Resident #4 attempted to exit through a side door, was redirected without difficulty, and a Wanderguard was applied to the right wrist without complaint. The note did not identify that consent from Person #1 was obtained prior to applying the Wanderguard.The clinical record dated 5/14/26 did not demonstrate that less restrictive interventions were attempted prior to applying the Wanderguard.The Resident Care Plan (RCP) dated 5/15/26 identified Resident #4 had impaired cognitive function/dementia and was receiving hospice care. Interventions included providing orientation, providing validation, explaining care before providing it, and providing comfort measures.The Brief Interview for Mental Status (BIMS) Evaluation dated 5/15/26 identified Resident #4 had severely impaired cognition, as indicated by a BIMS score of 4.Nurse's notes dated 5/15/26 through 5/19/26 did not identify further wandering, independent ambulation, or exit seeking behaviors.The May 2026 Documentation Survey Report dated 5/15/26 through 5/19/26 did not identify Resident #4 ambulated independently.The May 2026 Medication Administration Record (MAR) did not identify monitoring of wandering or exit seeking behaviors despite application of the Wanderguard.The RCP dated 5/16/26 identified Resident #4 was an elopement risk due to cognitive impairment and independently ambulating. Interventions included applying the Wanderguard to the right wrist and using verbal cues for direction to minimize exit seeking behaviors.Interview with RN #3 on 6/8/26 at 12:12 PM identified Resident #4 was admitted during the evening shift on 5/14/26 and ambulated independently. She identified Resident #4 pushed on the back door shortly after admission, activating a door alarm, and was easily redirected. RN #3 identified she applied the Wanderguard immediately rather than continuing to monitor Resident #4, utilizing less restrictive interventions, or allowing Resident #4 time to settle into the unit. She did not recall contacting Person #1 and identified her note did not document consent. She identified consent should have been obtained prior to applying the Wanderguard. She further identified she did not observe additional wandering or exit seeking and that she forgot to initiate an RCP addressing wandering and the Wanderguard use on 5/14/26. She identified the care RCP should have been initiated prior to the end of her shift.Interview with the Director of Nursing Services (DNS) on 6/8/26 at 12:29 PM identified RN #3 should have attempted less restrictive interventions prior to applying the Wanderguard, especially because Resident #4 was easily redirected. She identified Person #1 should have been contacted to obtain consent if the resident continued exit seeking and documentation should have been completed. She identified Resident #4 should have been monitored for wandering and exit seeking behaviors after the Wanderguard was applied and an RCP should have been initiated on 5/14/26. She was unaware the RCP was not initiated until 5/16/26.Interview with Person #1 on 6/8/26 at 2:53 PM identified Resident #4 was admitted for five (5) days of respite care. Person #1 identified he/she was not informed Resident #4 attempted to exit the facility or that a Wanderguard was applied. Person #1 identified he/she would not have authorized the Wanderguard and would have picked up Resident #4 if the resident was distressed or wanted to leave.The Wandering, Unsafe Resident policy dated 8/2014 identified the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment. The policy directed staff to assess residents at risk for unsafe wandering, identify potentially correctable risk factors, ensure the care plan identified elopement risk, and include interventions such as a detailed monitoring plan. The policy identified the importance of maintaining the least restrictive environment while ensuring safetyAlthough requested, the facility policies for Wanderguards and At Risk for Elopement were unavailable.

Based on review of the clinical record, facility documentation, facility policy, and interviews, for two (2) of five (5) sampled residents (Residents #1 and #2) reviewed for allegations of abuse, the facility failed to conduct a thorough investigation of an allegation of sexual abuse. Specifically, the facility did not interview residents who had the potential to be affected, despite the alleged perpetrator self propelling throughout the building in a wheelchair. The findings include:1.Resident #2's diagnoses included affective mood disorders, Parkinson's disease, depression, and anxiety.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required partial assistance for bed mobility and transfers, and did not ambulate. No behaviors were identified.The Resident Care Plan (RCP) dated 5/7/26 identified Resident #2 had a mood problem related to depression and anxiety and utilized psychotropic medications. Interventions included encouraging Resident #2 to express his/her feelings and providing psychological services as needed.2.Resident #1's diagnoses included conversion disorder with seizures or convulsions and anxiety disorder.The 5 day MDS assessment dated [DATE] identified Resident #1 had intact cognition (BIMS score of 15), required partial assistance with transfers, did not ambulate, and was independent with wheelchair mobility. No behaviors were identified.The RCP dated 5/8/26 identified Resident #1 had a mood problem related to mild depression and utilized psychotropic medications. Interventions included encouraging the resident to express feelings and providing psychological services as needed.The Reportable Event (RE) form dated 5/8/26 at 7:00 PM identified Resident #2 alleged Resident #1 touched him/her in the private area over clothing and blankets and denied direct skin contact. No injuries were observed. The police and provider were notified. An order was obtained to administer Resident #2 an additional 25 milligrams (mg) of trazodone one time at bedtime. Resident #1 was placed on one to one monitoring, and an order was obtained to send Resident #1 to the ED for psychiatric evaluation.A Nurse's note by RN #1 dated 5/8/26 at 8:07 PM identified Resident #1 was accused of touching Resident #2 over clothing and blankets. Resident #1 denied the interaction. The provider was updated and an order was obtained to send Resident #1 to the Emergency Department (ED) for psychiatric clearance. Resident #1 was placed on one to one monitoring until Emergency Medical Services (EMS) arrived, and the police were notified.Interviews with NA #1, LPN #1, RN #1, NA #2, NA #3, and NA #4 on 6/5/26 identified they saw Resident #1 self propelling throughout the building on 5/8/26. NA #2 reported seeing Resident #1 in Resident #2's doorway on 5/8/26.Interview with the Director of Nursing (DON) on 6/5/26 at 12:57 PM identified Resident #1 self propelled in a wheelchair throughout the building. She identified staff should have checked on residents and notified the nursing supervisor if they observed Resident #1 entering or exiting rooms.Despite the allegation and Resident #1's mobility throughout the building, the facility's investigation did not include interviews with other residents on the Annex unit who could have been affected.On 6/8/26, twelve (12) residents were identified as residing on the Annex unit on 5/8/26. Six (6) residents were male with BIMS scores ranging from 5-15. Six (6) residents were female with BIMS scores ranging from 2-15, three (3) of whom were severely cognitively impaired. Facility documents did not identify any interviews with these residents as part of the abuse investigation.Re interview with the DON on 6/8/26 at 12:29 PM identified other residents on the Annex unit were not assessed or interviewed following the allegation. The DON was unable to explain why this was not completed.Although attempted, an interview with Resident #1 was not obtained.The Abuse Prohibition & Quality Assurance/Reporting Reasonable Suspicion of Crime - Elder Justice Act policy dated 4/12/25 directed the facility to maintain a zero tolerance for abuse, protect residents from abuse by anyone including other residents, and conduct a thorough investigation of all allegations to determine if conduct violated standards of care. The policy directed staff to assess and monitor behaviors that could lead to conflict or abuse, including wandering into other residents' rooms.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) sampled residents (Resident #4) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure the clinical record was complete and accurate to include functional/mobility status, care provided and meal percentages consumed. The findings include:Resident #4's diagnoses included vascular dementia with mood disturbances and chronic lymphocytic leukemia of b-cell in relapse (a slow growing blood cancer that has returned/progressed after a period of improvement following initial treatment). The Clinical admission dated 5/14/26 at 9:08 PM identified Resident #4 was transported to the facility by a family member (Person #1) who left when Resident #4 entered the facility. Resident #4 was admitted to the facility on hospice and was alert to person only, was confused, required cues, was pleasant, had no impairments to the upper of lower extremities and had a steady gait. The Resident Care Plan (RCP) dated 5/15/26 identified Resident #4 has an ADL self-care performance deficit as evidenced by weakness, fatigue, activity intolerance and disease process. Interventions included providing an assist of one (1) staff participation to reposition and turn in bed, assist of 1 staff participation with transfers, assist of 1 with no device for ambulation, assist of 1 for personal hygiene, dressing and bathing and set-up assistance for eating. A nurse's note by RN #3 dated 5/14/26 at 9:20 PM identified Resident #4 was a new hospice admission transported by family and was walking independently. Resident #4 was alert and confused, oriented to self only, pleasant and cooperative and wanders aimlessly but is easily redirected. Resident #4 was conversational, though non-sensical and talked throughout the shift. Resident #4 attempted to exit the facility through a side door and was redirected without issue. A Wanderguard was placed to the right wrist without complaint. Seems to prefer group settings rather than being alone in room. Resident #4 will be in the facility for five (5) days only to provide caregiver relief. Resident #4 has his/her own healthy foods, prepared by spouse, in the refrigerator for the week for all meals and snacks with instructions. Review of the May 2026 Documentation Survey Report identified that required documentation for eating, dressing, personal hygiene, bathing, bed mobility, transfers, sit to stand, ambulation, and snacks offered was not completed on the following shifts:2:00 PM-10:00 PM and 10:00 PM-6:00 AM on 5/15/266:00 AM-2:00 PM and 2:00 PM-10:00 PM on 5/16/266:00 AM-2:00 PM on 5/17/266:00 AM-2:00 PM on 5/18/26As a result, documentation was completed for only 9 of 15 required shifts (60 percent). The facility also failed to ensure complete documentation of meals consumed. Review showed no meal documentation on the following shifts:2:00 PM-10:00 PM on 5/15/262:00 PM-10:00 PM on 5/16/266:00 AM-2:00 PM on 5/19/26Meal documentation was completed for only 11 of 15 required shifts (73 percent). Review of the clinical record from 5/15/26 through 5/19/26 failed to identify Resident #4 had any documented refusals related to eating, dressing, personal hygiene, bathing, bed mobility, transfers, sit to stand, ambulation, snacks or meals on the dates missing documentation. Interviews with the Director of Social Services, NA #5, NA #6, RN #3 and RN #4 on 6/8/26 identified Resident #4 was clean, out of bed and up for most meals, ate a majority of the meals and snacks provided and received assistance with ADLs. RN #3 identified Resident #4 was ambulating in the hall the morning Resident #4 discharged home on 5/19/26. Interview with the Director of Nursing (DON) on 6/8/26 at 12:29 PM identified NAs should have completely and accurately filled out their charting each day before leaving at the end of their shift. She was unaware of the lack of NA documentation for Resident #4 and identified that the interdisciplinary team monitors the completeness of NA documentation on residents regularly. She stated that Resident #4 must have been missed during this review process. Interview with Person #1 on 6/8/26 at 2:53 PM identified on 5/19/26 when Resident #4 returned home following a five (5) day respite at the facility, Resident #4 was no longer able to perform many ADL tasks that he/she could before entering the facility, such as feeding him/herself, transfers and ambulation and Resident #4 rapidly declined and subsequently passed away a few weeks later. Review of the Charting and Documentation policy dated 7/2017 directed, in part, all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Review of the Certified Nursing Assistant job description directed, in part, the primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisors. Duties and responsibilities include: Recording all entries on flow sheets, notes, charts, etc in an informative and descriptive manner, Assisting residents according to their needs ranging from minimal assistance to total dependent care on ADLs, assisting residents to walk with or without self-help devices as instructed, assisting residents with bathing functions as directed, assisting residents with dressing/undressing as necessary, assisting residents with personal grooming, assisting with lifting, turning, moving, positioning and transporting residents into and out of beds, chairs, wheelchairs, lifts, etc. Perform all assigned tasks in accordance with established facility policies and procedures and as instructed by your supervisors.

Based on observation, facility policies, and interviews for food and nutrition services, the facility failed to ensure food and drink items were labeled, expired food items were disposed of, and the Dining Room steam cart was clean and sanitary. Findings include:Tour of the facility on 5/11/26 at 10:45 identified the following:The Nourishment Room freezer contained expired ice pops, an unidentified frozen item in a cup, pancakes, and a water bottle and the Nourishment Room refrigerator contained expired yogurt cups and marshmallows, an unlabeled opened supplement drink, and multiple unlabeled supplements. The Nourishment Room supplement refrigerator contained expired supplemental ice creams and shakes. The Dining Room contained bread, individually packaged rolls, waffles, and potato chips which were opened and unlabeled and crescent rolls which had expired.Observation with the Director of Food service identified one compartment of the base of the steam table which was dirty and the Director of Food service identified it may have been caused by a spill of gravy.An interview with Dietary Aide (DA) #1 on 5/11/26 at 10:45 AM identified it was her responsibility to ensure that the food items in the Nourishment Room and the supplement refrigerator were monitored daily and that all food items were labeled and expired food items were removed. She was not aware of the reason unlabeled and expired food items were found in these locations.An interview with the Director of Food Service on 5/11/26 at 11:20 AM identified dietary aides were responsible for checking all unit refrigerators daily to ensure all food items were labeled and to dispose of anything that was unlabeled or expired. The cooks were responsible for doing the same for the refrigerators in the kitchen. The Director of Food Service was responsible for ensuring the cleanliness of all equipment used for the preparation, service, and storage of food. The Director of Food Service further identified staff did not follow the facility procedure for food storage and cleanliness. Although the Director of Food Service provided staff expectation guidelines that were given to new employees upon hire, the direction failed to identify who was responsible for labeling all food items and for checking for exposed items and the frequency of doing both. The Second Shift Cooks Duties form identified all stock that gets delivered must be dated and put in the proper place with the dates and stock rotated and the dietary aides must assist with this as well.

Based on clinical record review, facility policies, and interviews for pharmacy services, the facility failed to ensure accurate reconciliation of all controlled substances when staff did not document an accurate inventory of controlled substances at the change of shift. The findings include:Review of the facility Count Sheet Narcotics and Sedatives form for three (3) units for March 2026 identified there were a combined total of 279 shifts that controlled medications should have been counted. Of those 279 shifts, the clinical staff failed to document the control substance count 54 times. Review of the facility Count Sheet Narcotics and Sedative form for three (3) units for April 2026 identified there were a combined total of 270 shifts that controlled medications should have been counted. Of those 270 shifts, the clinical staff failed to document the control substance count 67 times. Interview with the Director of Nursing (DON) on 5/11/26 at 3:00 PM identified it was the licensed nurse's responsibility to complete the Count Sheet Narcotics and Sedative form at the change of every shift, and she was not aware of the reason this was not getting done consistently. The DON further identified the facility failed to follow its policy.The Controlled Substance facility policy identified, in part, controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The policy further identified that at the end of each shift the nurse coming on duty and the nurse going off duty count the medications together.

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure injuries, the facility failed to ensure implementation of physician-ordered interventions, ongoing skin monitoring, and timely identification and reporting of changes in skin condition for a resident at very high risk for pressure injury development, resulting in the development of a facility-acquired, medical device-related Stage IV pressure injury to the right ankle. The findings include: Resident #1 was admitted to the facility with diagnoses that included fracture of the right femur and dementia. Resident #1 had a Power of Attorney for care. The Nursing admission assessment dated [DATE] identified Resident #1 had a pressure injury to the sacrum and right Achilles bruising.A Brief Interview for Mental Status (BIMS) interview dated 1/2/26 identified Resident #1 scored four (4) indicative of severe cognitive impairment.Physician's orders dated 1/3/26 directed an assist of two at bed level for activities of daily living (ADLs) and assist of two using a mechanical lift for transfers.The Skin assessment dated [DATE] identified Resident #1 had right Achilles bruising that was present on admission.The Resident Care Plan (RCP) dated 1/8/26 identified Resident #1 had a closed fracture of the right distal femur. Interventions included non-weight bearing to the right lower extremity (RLE), right leg brace on at all times and to remove the right leg brace every shift for skin checks and circulation, motion and sensation checks.The Braden Scale dated 1/19/26 identified Resident #1 was a very high risk for developing pressure injuries.The Skin assessment dated [DATE] identified Resident #1's right Achilles bruising, that was present on admission, was resolved.The Skin Assessments dated 2/9/26 and 2/16/26 identified Resident #1's skin was warm, dry, skin color was within normal limits, turgor was normal and no skin issues were identified. The Skin assessment dated [DATE] by LPN #1 identified Resident #1's skin was warm, dry and the skin color was within normal limits. A new issue was documented which identified moisture associated skin damage to the coccyx.Physician's orders dated 1/2/26 through 2/28/26 directed to remove the right leg brace; check skin and ensure placement of ABD (Army Battle Dressing) padding (a thick, highly absorbent medical dressing designed to manage large, heavily draining wounds or surgical incisions) was at the ankle and thigh every shift for wound management. The Accident and Incident (A&I) Form dated 2/28/26 identified on 2/28/26 at 9:20 AM a wound was found under Resident #1's brace by NA #1 during care.The nursing note dated 2/28/26 at 10:00 PM identified Resident #1 had a wound to the right lateral ankle, where the right leg brace was. The wound bed measured 5 centimeters (cm) by 2.7 cm by 0.2 cm, the peri-wound was non-blanchable, edematous, red, and the wound bed was open. The APRN was notified and ordered a wet to dry dressing until the physician could evaluate Resident #1 on 3/1/26. She ordered to keep the right leg brace off, non-weight bearing to the RLE, vital signs and a skin assessment every shift. The DNS and Administrator were aware of the wound. A Physician note dated 3/1/26 at 2:30 PM identified a broad area of denuded skin with exposure of underlying tendon from approximately mid lower leg to the ankle. Resident #1 was on Doxycycline 100 mg twice daily which was continued for another seven days.A Physician's order dated 3/1/26 directed a wound treatment to the right lateral ankle: cleanse skin with normal saline, apply Adaptic (non-adhering dressing) followed by silver alginate (absorbent wound dressing) and ABD pad, wrap with Kerlix and secure with tape.The APRN note dated 3/3/26 identified Resident #1 had an extensive lower extremity wound with suspected systemic infection. Resident #1's white blood cell count was 17.56 (normal range 4.5 - 11.0) and Doxycycline 100 mg was extended by the Physician on 3/1/26 for wound treatment. Resident #1's family chose a comfort care approach.The Wound Physician note dated 3/4/26 identified Resident #1 was assessed for a Stage IV pressure injury (full-thickness skin and tissue loss with directly exposed fascia, muscle, tendon, ligament, cartilage, or bone) of the right ankle. The note identified the duration was greater than three days, measured 5.8 cm by 2.3 cm by 0.5 cm, had moderate serous exudate, 20% granulation tissue and 80% tendon visible.Interview with LPN #1 on 4/6/26 at 10:38 AM identified she performed a skin assessment on 2/24/26 and identified there was bruising underneath the right leg brace from right mid-calf to ankle and she did not notify the provider. LPN #1 identified she performed a skin check on 2/26/26 during the 7:00 AM to 3:00 PM shift and observed the bruising remained and the skin was soft. She identified she did not notify the Supervisor and/or provider of the bruising and soft skin because the area was not open. LPN #2's statement dated 2/28/26 identified she was assigned to provide care for Resident #1 on 2/27/26 during the 7:00 AM to 3:00 PM shift. The statement identified that when performing the skin check, she opened the right leg brace, assessed the skin and did not observe abnormalities. She applied skin prep to the heels and toes.Although multiple attempts were made, an interview with LPN #2 was not obtained.LPN #3's statement dated 2/28/26 identified she was assigned to provide care for Resident #1 on 2/25/26 and 2/26/26 during the 3:00 PM to 11:00 PM shift and the RLE skin was clean, dry and intact with baseline discoloration. Although multiple attempts were made, an interview with LPN #3 was not obtained.LPN #4's statement dated 2/28/26 identified was assigned to provide care for Resident #1 on 2/27/26 during the 7:00 AM to 3:00 PM shift. The statement identified the right leg brace was removed, skin was assessed, there was no open areas or a wound and she applied skin prep to the heels and toes.Although multiple attempts were made, an interview with LPN #4 was not obtained.Interview with LPN #5 on 3/30/26 at 11:55 AM identified he was assigned to provide care for Resident #1 on 2/27/26 during the 3:00 PM to 11:00 PM shift. He identified that he performed a skin check by removing the right leg brace to visualize the skin, there was no barrier between Resident #1's skin and the right leg brace and the skin was bruised. He identified he did not report the bruising to the Supervisor because he thought the bruising was an existing skin impairment.Interview with NA #1 on 4/1/26 at 1:00 PM identified she was assigned to provide care for Resident #1 on 2/28/26 from 7:00 AM to 3:00 PM, which was her first day providing care to the resident. She reported she performed morning care and noted an odor of unknown source. During care, she checked the resident's heels and identified moisture on her gloves. She removed the right leg brace and observed no barrier between the brace and the resident's skin. Upon removal of the brace, she observed a large open wound to the right ankle with a white wound bed and exposed tendon.Interview with MD #1 (Contracted Wound Physician) on 3/30/26 at 2:45 PM identified Resident #1's right ankle pressure injury was defined as a medical device associated pressure injury and due to Resident #1's age and weight, skin breakdown could occur quickly. He identified that if he was notified of soft skin, redness or bruising, before a break in the skin occurred, he would have suggested padding between the right leg brace and skin as a barrier. MD #1 did not know there was an existing order for padding from the Orthopedic physician since discharge from the hospital. He identified that the facility should have followed the orders from the Orthopedic physician.Interview with the DNS on 3/30/26 at 3:30 PM identified the process for performing skin checks with a medical brace, was for the brace to be removed, skin observed, and any changes, such as discoloration or skin breakdown, should be reported to the physician.Review of the Change in Condition policy directed, in part, that the nurse will notify the resident's Attending Physician when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff.Review of the Splinting policy directed that when applying/assisting with splinting, follow the measures stated in the care plan.The facility presented a corrective action plan dated 2/28/26 which included:Staff education dated 2/28/26 to include skin assessments and resident change in condition.Facility-wide audit of residents requiring skin checks every shift due to brace use completed 3/2/26.Weekly Audits initiated on 3/4/26 to ensure braces are removed per MD order, skin is inspected and skin changes are reported, assessed and documented.Compliance date 3/5/26The corrective action plan for past noncompliance was accepted by the state agency during an on-site visit on 3/30/26.

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure injuries, the facility failed to ensure timely notification of the physician and registered nurse regarding a significant change in skin condition for a resident at very high risk for pressure injury development, including failure to report observed bruising and soft tissue changes under a medical device (right leg brace). This failure resulted in a delay in medical evaluation and intervention, and the subsequent development of a facility-acquired, medical device-related Stage IV pressure injury to the right ankle. The findings include:Resident #1 was admitted to the facility with diagnoses that included fracture of the right femur and dementia. Resident #1 had a Power of Attorney for care. The Nursing admission assessment dated [DATE] identified Resident #1 had a pressure injury to the sacrum and right Achilles bruising.A Brief Interview for Mental Status (BIMS) interview dated 1/2/26 identified Resident #1 scored four (4) indicative of severe cognitive impairment.Physician's orders dated 1/3/26 directed an assist of two at bed level for activities of daily living (ADLs) and assist of two using a mechanical lift for transfers.The Skin assessment dated [DATE] identified Resident #1 had right Achilles bruising that was present on admission.The Resident Care Plan (RCP) dated 1/8/26 identified Resident #1 had a closed fracture of the right distal femur. Interventions included non-weight bearing to the right lower extremity (RLE), right leg brace on at all times and to remove the right leg brace every shift for skin checks and circulation, motion and sensation checks.The Braden Scale dated 1/19/26 identified Resident #1 was a very high risk for developing pressure injuries.The Skin assessment dated [DATE] identified Resident #1's right Achilles bruising, that was present on admission, was resolved.Physician's orders dated 1/2/26 through 2/28/26 directed to remove the right leg brace; check skin and ensure placement of ABD (Army Battle Dressing) padding (a thick, highly absorbent medical dressing designed to manage large, heavily draining wounds or surgical incisions) was at the ankle and thigh every shift for wound management. The Accident and Incident (A&I) Form dated 2/28/26 identified on 2/28/26 at 9:20 AM a wound was found under Resident #1's brace by NA #1 during care.The nursing note dated 2/28/26 at 10:00 PM identified Resident #1 had a wound to the right lateral ankle, where the right leg brace was. The wound bed measured 5 centimeters (cm) by 2.7 cm by 0.2 cm, the peri-wound was non-blanchable, edematous, red, and the wound bed was open. The APRN was notified and ordered a wet to dry dressing until the physician could evaluate Resident #1 on 3/1/26. She ordered to keep the right leg brace off, non-weight bearing to the RLE, vital signs and a skin assessment every shift. The DNS and Administrator were aware of the wound. A Physician note dated 3/1/26 at 2:30 PM identified a broad area of denuded skin with exposure of underlying tendon from approximately mid lower leg to the ankle. Resident #1 was on Doxycycline 100 mg twice daily which was continued for another seven days.A Physician's order dated 3/1/26 directed a wound treatment to the right lateral ankle: cleanse skin with normal saline, apply Adaptic (non-adhering dressing) followed by silver alginate (absorbent wound dressing) and ABD pad, wrap with Kerlix and secure with tape.The APRN note dated 3/3/26 identified Resident #1 had an extensive lower extremity wound with suspected systemic infection. Resident #1's white blood cell count was 17.56 (normal range 4.5 - 11.0) and Doxycycline 100 mg was extended by the Physician on 3/1/26 for wound treatment. Resident #1's family chose a comfort care approach.The Wound Physician note dated 3/4/26 identified Resident #1 was assessed for a Stage IV pressure injury (full-thickness skin and tissue loss with directly exposed fascia, muscle, tendon, ligament, cartilage, or bone) of the right ankle. The note identified the duration was greater than three days, measured 5.8 cm by 2.3 cm by 0.5 cm, had moderate serous exudate, 20% granulation tissue and 80% tendon visible.Interview with LPN #1 on 4/6/26 at 10:38 AM identified she performed a skin assessment on 2/24/26 and identified there was bruising underneath the right leg brace from right mid-calf to ankle and she did not notify the provider. LPN #1 identified she performed a skin check on 2/26/26 during the 7:00 AM to 3:00 PM shift and observed the bruising remained and the skin was soft. She identified she did not notify the Supervisor and/or provider of the bruising and soft skin because the area was not open. Interview with LPN #5 on 3/30/26 at 11:55 AM identified he was assigned to provide care for Resident #1 on 2/27/26 during the 3:00 PM to 11:00 PM shift. He identified that he performed a skin check by removing the right leg brace to visualize the skin, there was no barrier between Resident #1's skin and the right leg brace and the skin was bruised. He identified he did not report the bruising to the Supervisor because he thought the bruising was an existing skin impairment.Interview with NA #1 on 4/1/26 at 1:00 PM identified she was assigned to provide care for Resident #1 on 2/28/26 from 7:00 AM to 3:00 PM, which was her first day providing care to the resident. She reported she performed morning care and noted an odor of unknown source. During care, she checked the resident's heels and identified moisture on her gloves. She removed the right leg brace and observed no barrier between the brace and the resident's skin. Upon removal of the brace, she observed a large open wound to the right ankle with a white wound bed and exposed tendon.Interview with MD #1 (Contracted Wound Physician) on 3/30/26 at 2:45 PM identified Resident #1's right ankle pressure injury was defined as a medical device associated pressure injury and due to Resident #1's age and weight, skin breakdown could occur quickly. He identified that if he was notified of soft skin, redness or bruising, before a break in the skin occurred, he would have suggested padding between the right leg brace and skin as a barrier. MD #1 did not know there was an existing order for padding from the Orthopedic physician since discharge from the hospital. He identified that the facility should have followed the orders from the Orthopedic physician.Interview with the DNS on 3/30/26 at 3:30 PM identified the process for performing skin checks with a medical brace, was for the brace to be removed, skin observed, and any changes, such as discoloration or skin breakdown, should be reported to the physician.Review of the Change in Condition policy directed, in part, that the nurse will notify the resident's Attending Physician when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff.The facility presented a corrective action plan dated 2/28/26 which included:Staff education dated 2/28/26 to include skin assessments and resident change in condition.Facility-wide audit of residents requiring skin checks every shift due to brace use completed 3/2/26.Weekly Audits initiated on 3/4/26 to ensure braces are removed per MD order, skin is inspected and skin changes are reported, assessed and documented.Compliance date 3/5/26The corrective action plan for past noncompliance was accepted by the state agency during an on-site visit on 3/30/26.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 sampled residents (Resident #25, Resident #31, Resident #39) reviewed for care plans, the facility failed to review and revise the Resident Care Plan (RCP) and for Resident #31 failed to conduct Resident Care Plan Conferences per the requirement. The findings include: 1. Resident #25's diagnoses included malignant neoplasm of the head, face, and neck, chronic heart failure, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with personal hygiene and chair/bed-to-chair transfers and required maximal assistance in rolling left and right. The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #25 had a problem with anxiety and agitation. Interventions included an assist of 2 at all times due to accusatory behavior, allow time to communicate effectively, and re-offer behavioral health services as needed. Interview and review of clinical record review on 6/9/2025 at 11:37 AM with Social Worker (SW) #1 identified that a resident's care plan would be completed within 5 days of a Resident Care Conference (RCC). SW #1 was unable to determine when Resident #25's RCCs had occurred, as the MDS Coordinator, Licensed Practical Nurse (LPN) #1, was responsible for those records. Interview and review of clinical record on 6/9/2025 at 12:51 PM with SW #1 and LPN #1 identified that Resident #25 had RCCs on 4/4/2024, 9/12/2024, 10/10/2024, and 3/6/2025. SW #1 and LPN #1 identified the facility failed to update the care plan within 5-7 days, pre the requirement, of the 4/4/2024, 10/10/2024, and 3/6/2025 RCCs. Although LPN #1 stated she was responsible for updating the care plans, she was unable to identify why the care plans were not updated in a timely manner after the 3 RCCs held on 4/4/2024, 10/10/2024, and 3/6/2025. 2. Resident #31's diagnoses included dementia, type 2 diabetes, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had a Brief Interview of Mental Status (BIMS) score of 1 indicating severe cognitive impairment, required moderate assistance with personal hygiene, upper and lower body dressing, and chair/bed-to-chair transfers. The Resident Care Plan (RCP) dated 6/4/2025 identified Resident #31 required staff assistance with his/her involvement in activities related to behavioral symptoms that may affect his/her participation. Interventions included to explain/ encourage the importance of social interaction, leisure activity time and participation, encourage to participate with activities of choice, and inform the resident that he/she may leave activities at any time, and was not required to stay for the entire activity. Interview and review of clinical record on 6/9/2025 at 11:37 AM with Social Worker (SW) #1 identified that a RCP would be completed within 5 days of a Resident Care Conference (RCC). SW #1 was unable to determine when Resident #31's RCCs had occurred, as the MDS Coordinator, LPN #1, was responsible for those records. Interview and review of clinical record on 6/9/2025 at 12:59 PM with SW #1 and LPN #1 identified that RCCs should be held on a quarterly basis, once every 3 months. a. Resident #31 had RCCs on 4/4/2024, 6/27/2024, 10/31/2024, 4/24/2025 and 5/1/2025. SW #1 and LPN #1 identified the facility failed to update the care plan within 5-7 days of the 4/4/2024, 6/27/2024, 4/24/2025, and 5/1/2025 RCCs. Although LPN #1 stated she was responsible for updating the care plans, she was unable to identify why the care plan was not updated in a timely manner after the 4 RCCs held on 5/1/2025, 4/24/2025, 6/27/2024, and 4/4/2024. b. Resident #31 had a RCC on 10/31/2024 with the next RCC occurring on 4/24/2025 (a gap of 5 months and 24 days). SW #1 was unable to explain why the facility did not hold an RCC quarterly as required (every 3 months) from the date of the 10/31/2024 RCC, but did note there was a change in staffing during that time. 3. Resident #39's diagnoses included hemiplegia and hemiparesis, diabetes, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, required maximal assistance with lower body dressing and chair/bed-to-chair transfers. The Resident Care Plan (RCP) dated 10/24/2024 identified Resident #39 had an alteration in psychosocial well-being. Interventions included facilitation of Resident #39's opportunities to self-direct his/her care plan, allowing him/her to verbalize feelings, and encouraging him/her to verbalize pleasures and requirements to achieve peace and happiness. Interview and review of clinical record on 6/9/2025 at 11:37 AM with Social Worker (SW) #1 identified that a resident's care plan will be completed within 5 days of a Resident's Care Conference (RCC). She was unable to determine when Resident #39's RCCs had occurred, as the MDS Coordinator, Licensed Practical Nurse LPN #1, was responsible for those records. Interview and review of clinical record review on 6/9/25 at 12:51 PM with SW #1 and LPN #1 identified that Resident #39 had RCCs on 10/10/2024, 12/12/2024, 2/20/2025, and 4/24/2025. Further, SW #1 and LPN #1 identified the facility failed to update the care plan within 5-7 days of the 10/10/2024, 2/20/2025, and 4/24/2025 RCCs. Although LPN #1 stated she was responsible for updating the care plans, she was unable to identify why the care plan was not updated in a timely manner after the 3 RCCs held on 10/10/2024, 2/20/2025, and 4/24/2025. Review of the facility's Comprehensive Person-Centered Care Plan Policy identified, in part, that care plans will be developed no later than 7 days after the comprehensive MDS is completed, and that the care plan will be updated at least quarterly.

Based on observation, interviews, and a temperature test, the facility failed to ensure that food was palatable and served at a safe and appetizing temperature. The findings included: Interview with Resident #4 on 6/05/2025 at 10:25 AM identified the food was cold and sometimes the meat was raw. Interview with Resident #59 on 6/4/2025 at 10:30 AM identified there was often cold toast, coffee, and eggs. Interview with Resident #47 on 6/4/2025 at 12:24 PM identified he is hungry even after eating and doesn't get enough food served at meals. Interview with Resident #8 on 6/6/2025 at 12:55 PM identified that the facility serves food that is cold. On 6/10/2025 at 11:26 AM a temperature check of the tray line was performed with the Dietary Director using the kitchen's calibrated thermometer as the first meal cart was being plated. The temperature of the potatoes was 168.1 degrees Fahrenheit (*F), chicken nuggets were 166.0 *F, cauliflower was 169.3 *F, and the coleslaw was 57.1 *F. Interview and observation with the Dietary Director on 6/10/2025 at 11:26 AM identified the temperature of the coleslaw should be served at no greater than 45 *F for safety and palatability. Subsequent to surveyor inquiry the container of coleslaw was placed back into the kitchen fridge by the Dietary Director who stated he would serve residents coleslaw in souffle cups when it was colder. Observation identified that plates with coleslaw already on them did not have the coleslaw removed from the plate. On 06/10/2025 a test/temperature tray conducted with the Dietary Director identified the lunch tray consisting of chicken nuggets and French fries, with no coleslaw, left the kitchen at 12:00 PM. The test tray arrived on the second floor at 12:02 PM and was delivered to residents starting at 12:02 PM. The last tray was delivered at 12:07 PM. The temperature of the test tray was conducted with the Dietary Manager at that time and identified the following: The chicken nuggets were 116.0 *F per the surveyor calibrated thermometer and the Dietary Manager's thermometer. The French fries internal temperature was 96.2 *F per the surveyor calibrated thermometer and 96.3 *F per the Dietary Manager's thermometer. Interview and observation with the Dietary Director on 6/10/2025 at 12:09 PM identified a palatable temperature for both the chicken nuggets and French fries should be 140 *F or above. He indicated the reason for the heat loss to the plate was due to the lid not holding the food's temperature properly. Interview on 6/10/2025 at 12:14 PM with the Administrator identified he was aware of resident complaints of cold food, and that the facility was looking into purchasing steam tables to provide a point of service option for residents. An observation on 6/10/2025 at 12:18 PM identified that coleslaw was being delivered to the residents, 16 minutes after the trays were delivered to the dining room. Review of the facility's food preparation on serving policy identified, in part, that proper hot and cold temperatures are to be maintained during food service.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to notify the physician for a change in condition and for 1 of 5 sampled residents (Resident #213) reviewed for medication administration, the facility failed to notify the physician when the medication was not available for administration. The findings include: 1. Resident #212 was admitted to the facility in November 2024 with diagnoses that included end stage renal disease, diabetes, hypertension, and cerebral infarction (death of brain tissue) without residual deficits. The annual Minimum Data Set assessment dated [DATE] identified Resident #212 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene, was dependent on bed to chair transfers, and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of May of 2025 identified Resident #212 was on hemolytic treatment due to end stage renal failure. Interventions included administer/hold/monitor effectiveness of medications per the physician order, check/complete hemolytic treatment communication log on return for any reports, communicate and collaborate with the hemolytic center regarding medications and treatments. A physician's order in effect for the month of May 2025 directed to send Resident #212 to hemolytic treatments 3 times per week on Tuesdays, Thursdays, and Saturdays, and to administer Nitroglycerin (for chest pain) sublingual (under the tongue) 0.4 MG every 5 minutes as needed for chest pain up to 3 doses, if not relieved call the physician. Review of Resident #212's nurse's note written by LPN #3 dated 5/16/2025 at 11:12 PM identified Resident #212 complained of chest pain and Nitroglycerin 0.4 mg was administered. A reassessment was performed at 12:00 AM and the resident's Blood Pressure (BP) was 131/61 (normal BP 120/80). Resident #212 denied any further chest pain, his/her color was pale, and the head of bead was elevated. A nurse's note dated 5/17/2025 at 12:47 AM written by LPN #3 identified Resident #212's BP had decreased and was 80/40. The resident's BP was taken again 7 hours later at 7:48 AM and noted to still be low at 85/40. No further BP rechecks were documented and there was no documentation the provider was notified of Resident #212's abnormally low BP. A nurse's note dated 5/17/2025 at 7:41 AM written by LPN #3 identified that Resident #212 presented with increased lethargy, mild shortness of breath, diminished lung sounds. The note failed to document the provider was contacted for notification of a change in condition. Interview and record review with LPN #5 on 6/6/2025 at 3:40 PM identified that she was the nurse taking care of Resident #212 on 5/17/2025 on the 7:00 AM to 3:00 PM shift. LPN #5 indicated that Resident #212 did not look good when she assumed his/her care at 7:00 AM and was unable to recall if she had rechecked the resident's vital signs as no vital signs were apparent in the clinical record. LPN #5 identified that although Resident #212 had received nitroglycerin, had a low BP on the night shift, and did not appear well, she had not informed the facility physician or notified the hemolytic center of the change in condition prior to sending him/her for treatment. When Resident #212 returned from treatment in the evening, he/she was still unstable and was subsequently sent to the emergency room (ER). Interview with LPN #3 on 6/10/2025 at 9:12 AM identified that she notified RN #3 (RN Supervisor) about Resident #212's change in condition on 5/17/2025 but that RN #3 did not notify the physician of the resident's change in condition on her shift. LPN #3 indicated that she did not recheck Resident #212's vital signs again until 7:48 AM (7 hours) after Resident #212's initial presentation of his/her low BP that occurred at 12:47 AM and did not explain why she waited 7 hours to recheck the residents BP. Additionally, LPN #3 stated that she failed to notify the provider of Resident #212 change when he/she presented with increased lethargy, mild shortness of breath, and diminished lung sounds and did not explain why she did not call the provider. Review of the clinical record failed to identify RN #3 had assessed or documented Resident #212's change in condition or that the physician had been notified. A nursing note dated 5/17/2025 at 4:47 PM identified that when Resident #212 returned from the hemolytic center at 4:00 PM his/her vital signs were unstable. Resident# 212's oxygen saturation was around 80% (normal 95% to 100%). The facility was unable to stabilize Resident #212, and he/she was sent out to the ER for further evaluation. Review of hospital documentation identified that Resident #212 was admitted to the hospital on [DATE] with hypoxic respiratory failure. During hospitalization Resident #212 exhibited stroke like symptoms, was treated and was discharged back to the facility. Interview with APRN#1 on 6/10/2025 at 10:00AM identified that the physician should have been notified for hypotension (low BP) and for the changes in condition. Interview with the DNS on 6/10/2025 at 11:10 AM identified that the physician should have been notified for Resident #212's change in condition and was unable to explain why none of the facility staff had done so. Attempts to contact RN #3 were unsuccessful. Review of the facility's policy, Resident Change in Condition, identified in part, that a resident's change in condition will be reported immediately to the unit manager or shift nursing supervisor. The licensed nurse will assess the resident for signs and symptoms of physical or mental change of condition. If a change in condition is non emergent the licensed nurse will complete a progress note and all attempts of physician notification will be documented in the progress notes. 2. Resident #213 was admitted with diagnoses that included anxiety, arthritis and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #213 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set up assistance for eating, and was independent for bed mobility and transfers. The Resident Care Plan dated 5/27/2025 identified Resident #213 used psychotropic medications related to antianxiety to manage restlessness. Interventions included administering medications as ordered and to observe/document for side effects and effectiveness. A physician's orders dated 6/4/25 at 1:00 PM directed to administer Prozac 20 milligrams (mg), 1 capsule in the morning for depression. Interview and review of the Medication Administration Record (MAR) for Resident #213 on 6/6/2025 at 8:30 AM, with LPN #4 identified Prozac was not available in the medication cart and she would contact the pharmacy to inquire about the medication. LPN #4 reported to RN #2 that Prozac had not been delivered by the pharmacy and requested him follow up. Subsequently RN #2 updated LPN #4 that he had reached out to APRN #1 regarding the medication, was instructed to place Prozac on hold for 6/6/2025, and was to restarted the Resident #213's medication the following day, 6/7/2025, so that the facility would not be out of compliance. Although a review of the nurse's notes and MAR identified that Prozac had been ordered on 6/4/2025 at 1:00 PM and was scheduled to be started on 6/5/2025 at 9:00 AM, the MAR failed to identify Resident #213 received his/her scheduled Prozac on 6/5/2025 or 6/6/2025. A notation, indicating the number 9, directed to refer to the nurse's note for an explanation. Review of LPN #4's nursing notes failed to identify why the medication was not administered as directed on 6/5 or 6/6/2025. A nursing note dated 6/6/2025 identified that the start date for Prozac had been moved to 6/7/2025 and the pharmacy had been contacted regarding the order. Re-interview with LPN #4 on 6/6/2025 at 10:00 AM identified that Prozac was not available to be administered on 6/5/2025 and 6/6/2025 despite having been ordered on 6/4/2025. LPN #4 identified that she had failed to report the unavailability of Resident #213's Prozac to the nursing supervisor, had not contacted the pharmacy, and had not notified the physician on 6/5/2025 when she realized that the medication was not available. Further, LPN #4 identified that it was her responsibility to ensure medications were administered as directed and she should have notified the physician on 6/5/2025 to inform then that Resident #213 would not receive his/her medication per the physician's order. Interview with RN #2 on 6/6/2025 at 10:10 AM identified he was never notified that Resident #213's Prozac not available to be administered on 6/5/2025 but should have been. RN #2 further indicated that had he been notified, he would have contacted the pharmacy to inquire about the missing medication and would have notified the physician for further directions. RN #2 was unable to explain why LPN #4 had not followed the facility policy to notify the physician when a medication was not available or administered. Interview with the APRN #2 on 6/6/2025 at 11:30 AM indicated that she was not aware that Prozac was not available to be administered to Resident #213 until today when RN #2 notified her. APRN#2 indicated that she should have been notified when Resident #213's Prozac was unavailable and had not been administered. Interview with the DNS on 6/10/2025 at 10:30 AM identified that the RN supervisor should have been notified the Prozac was not available, a phone call to the pharmacy should have been placed to determine why the medication had not been delivered, and that the unavailability and lack of administration of Resident #213's Prozac should have been reported to the physician. The DNs was unable to explain why LPN #4 failed to follow up when Resident #213's medication was not available. Review of facility policy titled, Ordering and Receiving Non-Controlled Medications, identified in part, medications and related products will be received from pharmacy on a timely basis . Licensed nurse promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on interviews, review of clinical records, facility documentation, and facility policy for 1 of 3 residents, (Resident #25) reviewed for dignity, the facility failed to investigate an allegation of sexual abuse and failed to remove the staff member from the schedule following the allegation. The findings include: Resident #25's diagnoses included malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with personal hygiene and chair/bed-to-chair transfers and required maximal assistance in rolling left and right. The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #25 had a problem with anxiety and agitation. Interventions included an assist of 2 at all times due to accusatory behavior, allow time to communicate effectively, and re-offer behavioral health services as needed. Interview on 6/4/2025 at 11:05 AM with Resident #25 identified that a few months ago, Nurse Aide (NA) #3 came into his room shaking her bootie and flashed the resident her breasts. Resident #25 stated that he/she notified NA #2 about the incident shortly after it had occurred, which resulted in NA #3 being taken off of his/her care assignment. Interview with NA #2 on 6/6/2025 at 11:52 AM identified that Resident #25 told him in February or March of 2025 that NA #3 had flashed her breasts at him/her. NA #2 stated he reported the incident to RN #5. NA #2 stated he had also reported the incident to the Administrator and was told by the Administrator that the incident was just a hallucination. NA #2 further indicated that NA #3 continued to report for work after he reported the incident, that she would still go into the resident's room, sit on the bed, and would talk to the resident like a sex operator. NA #2 stated he was concerned that Resident #25 had NA #3's personal cell phone number. Interview with the Administrator on 6/6/2025 at 12:25 PM identified that the incident was not investigated because he was unaware of the incident that had occurred between Resident #25 and NA #3. Subsequent to surveyor inquiry, the Administrator reported the allegation of sexual abuse to the State Agency (SA) on 6/6/2025 at 1:00 PM and an investigation into the allegations commenced. A written statement by NA #3 dated 6/6/2025 at 2:19 PM identified that 2 co-workers had informed her in February of 2025 that Resident #25 had made an allegation against her that she had flashed her breasts in front of him/her during care. NA #3 stated that the allegations were reported by NA #2 to RN #5, who then reported the incident to the nurse supervisor RN #6. NA #3 further indicated that during a conversation with RN #6, she was directed not to return to Resident #25's room or provide care to him/her. Interview with NA #4 on 6/6/2025 at 4:01 PM identified that Resident #25 had informed her at 2:30 PM that NA #3 had flashed her breasts, but he/she didn't want to tell anyone about it now for fear of getting NA #2 in trouble. She further identified Resident #25 reported to her that while receiving care from NA #3 and NA #8, his/her genitalia were blown on by NA #8. NA #4 stated she had told the Administrator about the allegation of sexual abuse following which he had her write a statement. Interview with the Director of Nursing Service (DNS) on 6/9/25 at 8:50 AM identified that she was not notified by NA #2, RN #5, or RN #6 of the allegation of suspected abuse by NA #3 toward Resident #25. She was unable to explain why she was not notified of the allegation which would have allowed her to investigate at that time. Interview with RN #6 on 6/9/2025 at 10:56 AM identified he had not been informed that NA #3 had flashed her breasts at Resident #25 but had taken NA #3 off the resident's care assignment due to a question of the resident using the call light too frequently when NA #3 was assigned to the resident. Further RN #6 stated he failed to report his concerns to the Director of Nursing Services or the SA because the problem was already resolved and the resident had a previous care plan for accusatory behavior. Interview with NA #3 on 6/9/2025 at 3:28 PM identified that Resident #25 did have her personal cell phone number. She indicated she did not give her number to the resident, but another staff member did. NA #3 stated she had never flashed her breasts at Resident #25 and had been removed from his/her care assignment because of the allegation that she flashed him/her but had never been taken off the schedule following the allegation, only taken off Resident #25's assignment. Review of the facility's Abuse Reporting Policy identified, in part, the Administrator will be informed immediately of an allegation or suspicion of abuse, a thorough investigation of the alleged abuse will be investigated by the Administrator or Director of Nursing, and the resident involved in a case of suspected abuse will be protected from potential additional harm during the investigation. Upon notification of the allegation of abuse, the supervisor will take steps to protect the resident in question as well as other residents that may be affected. If someone is identified in the allegation, the person will be escorted to a non-resident area to be interviewed and document the events that allegedly occurred, and the identified alleged staff member will be suspended pending the outcome of the investigation.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews for 1 of 5 residents, (Resident #13) reviewed for accidents, the facility failed to ensure that a resident with obvious deformities of the wrist and hip was not moved according to standards of practice and for the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to complete a Registered Nurse (RN) assessment for change in condition according to standards of practice. The findings include: 1. Resident #13 was admitted to the facility in November of 2024 with diagnoses that included dementia, depression, heart failure and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment and required moderate assistance for personal hygiene and was independent for bed mobility and transfers. The Resident Care Plan (RCP) dated 2/27/2025, identified Resident #13 was at risk for falls. Interventions included use of appropriate footwear, remind the resident to request assistance prior to ambulation, keep the call light within reach, provide adequate lighting, and keep resident area free of clutter. A Reportable Event form dated 2/16/2025 at 3:20 AM written by Registered Nurse (RN) #3, identified that Resident #13 was in the dining room trying to throw something away and had tripped. Resident #13 was found on the floor with a head injury, left wrist deformity, and hip pain. RN #3 reported the fall as unwitnessed. An RN assessment was completed, neurological and vital signs were initiated, the physician was notified, and Resident #13 was transferred to the Emergency Department (ED) for further evaluation. Review of a nursing note dated 2/16/2025 at 3:49 AM written by RN #3 identified Resident #13 was sitting in dining room watching television throughout night. At approximately 3:20 AM, a loud thud was heard, and Resident #13 was found on the floor, against a wall, in the dining room. Resident #13 reported that he/she tripped while trying to throw something in the trash. Resident #13 was assessed while on the floor and had a visible deformity of left wrist, abrasion/black-and-blue to left temple, and complained of excruciating left hip pain. Resident #13's vital signs were all stable and there was no loss of consciousness reported. Resident #13 was assisted/lifted physically by 3 staff members from the floor to a chair. RN #3 applied ice and a splint to the left wrist, ice to the head injury, and off-loaded Resident #13's left hip to relieve pressure from the injury site. RN #3 further identified that based on the RN assessment and visible injuries, as well as fact that the resident had sustained a head injury while on a blood thinner, she made decision to send Resident #13 out to the Emergency Department (ED). The physician, resident's conservator, and family member were notified. Interview with RN #3 on 6/9/2025 at 7:40 AM identified that Resident #13 was a retired night shift worker, stayed awake most of the night, independently walked with a walker and had sustained multiple falls in the past without major injuries. RN #3 indicated that Resident #13 fell face down and by the time staff arrived she was sitting on the floor, leaning towards the wall. RN #3 indicated that she assessed Resident #13 while on the floor and noted a visible deformity on the left arm and the right leg was shorter (shortened, indicative of a hip fracture) more than the left leg. Resident #13 was then physically lifted from the floor to a chair by 3 staff members and the physician was notified of the fall once Resident #13 was in the chair. RN #3 further identified that she splinted Resident #13's left arm using a pillowcase across the chest, placed ice on his/her head and arm, and offloaded pressure against the right hip. During an interview with Physician #1 on 6/9/2025 at 1:50 PM he was unable to recall if he had been notified of Resident #13's fall on 2/16/2025. Physician #1 indicated that he no longer was a physician with the facility, so he was unable to retrieve his previous telephone logs from February 2025. Physician #1 identified that he did not recall the RN #3 discussing the extent of Resident #13's injuries with him. Although Physician #1 was unable to recall if he had been notified, he indicated that based on the extent of Resident #13's injuries, he would have expected RN #3 to follow the facility's standard practice not to move the resident until Emergency Medical Technician's (EMT) arrived. Interview with LPN #6 on 6/9/2025 at 3:00 PM identified that she responded with other staff to the fall. LPN #6 identified that Resident#13 was in pain and had an abrasion to his/her head but could not recall what she did to help Resident #13. Interview with NA #7 on 6/9/2025 at 4:30 PM identified that she assisted to transfer Resident #13 from the floor to the chair. Interview with NA #6 on 6/9/2025 at 4:40 PM identified that she assisted to transfer Resident #13 from the floor to the chair. NA #6 stated that 1 staff member was on each side of Resident #13 and that they, in a hook like fashion, took the resident under the arms, while a third staff member had the residents legs. They transferred Resident 13 from the floor to the chair. Review of the hospital records, radiological investigations (CT scan of the left hip) dated 2/16/2025 at 4:04 AM, identified an acute mildly displaced comminuted left femoral neck trans-trochanteric fracture with surrounding soft tissue swelling and x-ray of the left wrist identified a non-displaced distal radial fracture. Additionally, Resident #13 was being admitted to the hospital with a diagnosis of closed left hip fracture and closed fracture of the left radial bone due to a fall. Review of APRN #1's progress note dated 2/20/2025 at 10:30 AM, identified that Resident #13 had been readmitted back to the facility following a fall resulting in a femoral neck fracture and a non-displaced left distal radial fracture. Resident #13 was seen in consultation by orthopedics and underwent surgery on 2/27/2025, receiving a left femur intramedullary nail and closed reduction with splinting of her left distal radius fracture. Interview with the DNS on 6/10/2025 at 10:30 AM identified that based on injuries sustained by Resident #13, and described by RN #3, he/she should not have been physically lifted from the floor to the chair by staff. The DNS could not explain why Resident #13 was moved from the floor but indicated that he/she should not have been moved until EMS arrived. Review of facility policy titled, Falls Response and Management, identified, in part, that residents who have fallen are assessed to determine if there is injury while maintaining the safety of the resident. If a resident falls, avoid moving the resident until status is fully evaluated to prevent further injury if an injury has occurred as a result of a fall. Determine the extent of the resident's injuries, note any deviations from the resident's baseline condition and notify the physician. If an injury is suspected, don't move the resident until a doctor examines them. 2. Resident #212 was admitted to the facility in November of 2024 with diagnoses that included end stage renal disease, diabetes, hypertension and personal history of transient ischemic attack (brief stroke like attack), and cerebral infarction (death of brain tissue) without residual deficits. The annual Minimum Data Set assessment dated [DATE] identified Resident #212 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene, was dependent on bed to chair transfers and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of May of 2025 identified Resident #212 was on hemolytic treatment due to end stage renal failure. Interventions included administer/hold medications per the physician order, administer/monitor effectiveness of medications as ordered, check complete hemolytic treatment communication log record on return from hemolytic appointments for any reports, communicate with hemolytic center regarding medications, coordinate resident's care in collaboration with the hemolytic center, coordinate meals, activities, medications and treatments with the hemolytic center. A physician's order in effect for the month of May 2025 directed to send Resident #212 to hemolytic treatments 3 times per week on Tuesdays, Thursdays, and Saturdays and to administer Nitroglycerin (for chest pain) sublingual (under the tongue) 0.4 MG every 5 minutes as needed for chest pain up to 3 doses, if not relieved call the physician. Review of Resident #212's nurse's note by LPN #3 dated 5/16/2025 at 11:12 PM identified Resident #212 complained of chest pain and Nitroglycerin 0.4 mg was administered. A reassessment was performed at 12:00 AM and the resident's Blood Pressure (BP) was 131/61 (normal BP 120/80), and pulse oximetry 95% on oxygen at 2.5 liters per minute (lpm). Resident #212 denied any further chest pain, his/her color was pale, and the head of bead was elevated. The note failed to indicate the Resident #212 was seen by an RN. A nurse's note dated 5/17/2025 at 12:47 AM by LPN #3 identified Resident #212's BP was 80/40. The resident's BP was next taken, 7 hours later, at 7:48 AM, and noted to be 85/40. No further BP rechecks were documented prior to sending the resident for hemolytic treatment on the next shift. The note failed to document Resident #212 was seen by an RN or that the provider was notified of Resident #212's abnormally low BP. A nurse's note dated 5/17/2025 at 7:41 AM by LPN #3 identified that Resident #212 presented with increased lethargy, mild shortness of breath, diminished lung sounds, and was on oxygen at 2.5 lpm via nasal cannula. The note failed to document Resident #212 was seen by an RN or that the provider was notified of Resident #212's abnormally low BP. Interview and record review with LPN #5 on 6/6/2025 at 3:40 PM identified that she was the nurse taking care of Resident #212 on 5/17/2025 on the 7:00 AM to 3:00 PM shift. LPN #5 indicated that Resident #212 did not look good when she assumed his/her care at 7:00 AM and was unable to recall if she had rechecked the resident's vital signs as no vital signs were apparent in the clinical record. LPN #5 identified that although Resident #212 had received nitroglycerin, had a low BP on the night shift, and did not appear well once she assumed care, she had not informed the hemolytic center of the resident's change in condition prior to sending him/her for hemolytic treatment. Additionally, the note failed to document Resident #212 was seen by an RN or that the provider was notified of Resident #212's abnormally low BP. When Resident #212 returned from treatment in the evening, he/she was still unstable and was subsequently sent to the emergency room (ER). Interview with LPN #3 on 6/10/2025 at 9:12 AM identified that she notified RN #3 about Resident #212's change in condition on 5/17/2025 but that RN #3 did not notify the physician of the resident's change in condition on her shift. LPN #3 indicated that she did not recheck Resident #212's vital signs again until 7:48 AM (7 hours later) after Resident #212's initial presentation of his/her low BP that occurred at 12:47 AM. Additionally, LPN #3 stated that she had not notified the provider of the change in condition including increased lethargy, mild shortness of breath, and diminished lung sounds. Review of clinical record failed to identify RN #3 or any RN had assessed or documented Resident #212's change in condition or notified the physician. Interview with APRN #1 on 6/10/2025 at 10:00 AM identified that the physician should have been notified for hypotension (low BP) and for the change in condition. Interview with the DNS on 6/10/2025 at 11:10 AM identified that the physician should have been notified for Resident #212's change in condition and was unable to explain why none of the facility staff had done so. Attempts to contact RN #3 were unsuccessful. Review of facility's policy, Resident Change in Condition, identified in part, that a resident's change in condition will be reported immediately to the unit manager or shift nursing supervisor. The licensed nurse will assess the resident for signs and symptoms of physical or mental change of condition. If a change in condition is non emergent the licensed nurse will complete a progress note and all attempts of physician notification will be documented in the progress notes.

Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to ensure appropriate communication with the hemolytic treatment center. The findings include: Resident #212's diagnosis included end stage renal disease, diabetes, hypertension, and cerebral infarction (death of brain tissue) without residual deficits. The annual Minimum Data Set assessment dated [DATE] identified Resident #212 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene, was dependent on bed to chair transfers, and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of May of 2025 identified Resident #212 was on hemolytic treatment due to end stage renal failure. Interventions included administer/hold, monitor effectiveness of medications as ordered, check complete hemolytic treatment communication log record on return from hemolytic appointments for any reports, communicate with hemolytic center regarding medications, treatments, and coordination of care. A physician's order in effect for the month of May 2025, directed to send Resident #212 to hemolytic treatments 3 times per week on Tuesdays, Thursdays and Saturdays at 11:30AM. Review of the hemolytic treatment center's communication book and clinical record documentation of visits that occurred from 11/1/2024 through 6/5/2025 failed to identify documentation from the hemolytic treatment center. Additionally, a review of the nurse's notes from 11/1/2024 through 6/5/2025 failed to indicate facility staff had contacted the hemolytic treatment center to give information in regard to Resident #212's care, such as a list of diagnosis, current medications, contact information, dietary needs, the amount of assistance required for activities of daily living, fluid needs, or any changes in condition. Further review of nurse's notes identified a change in condition that occurred on 5/16/2025 at 11:12 PM and into 5/17/22025 when Resident #212 complained of chest pain and Nitroglycerin sublingual tablet 0.4 mg was administered. Subsequently the resident Blood Pressure (BP) was noted to drop to 80/40 on 5/17/2025 at 12:47AM and remained low 85/40 when the next BP was taken on 5/17/2025 at 7:48 AM. A nursing note dated 5/17/2025 at 7:41 AM by LPN #3 identified that Resident #212 presented with increased lethargy, presented with mild shortness of breath, and diminished lung sounds. Interview and record review with LPN #5 on 6/6/2025 at 3:40 PM identified that she was the nurse taking care of Resident #212 on 5/17/2025 on the 7:00 AM to 3:00 PM shift. LPN #5 indicated that Resident #212 did not look good when she assumed his/her care at 7:00 AM and was unable to recall if she had rechecked the resident's vital signs as no vital signs were apparent in the clinical record. LPN #5 identified that although Resident #212 had received nitroglycerin, had a low BP on the night shift, and did not appear well once she assumed care, she had not informed the hemolytic center of the resident's change in condition prior to sending him/her for hemolytic treatment. Additionally, when Resident #212 returned from treatment in the evening, he/she was still unstable and was subsequently sent to the emergency room (ER). Interview and record review with RN #2 on 6/9/2025 at 10:30AM failed to identify facility documentation that had accompanied Resident #212 to the hemolytic treatment center since Resident #212's admission in November of 2024. RN #2 indicated that even though the facility had not completed any hemolytic documentation the issue had been identified, and documentation had been started on 6/7/2025. RN #2 indicated that night shift was responsible for completing the paperwork and could not identify why there was no documentation completed since Resident#212 was admitted to the facility. Interview with RN #5 (hemolytic treatment center nurse) on 6/10/2025 at 11:00AM identified that communication with the facility is done in the communication book/binder which contains both facilities and hemolytic center's communication paperwork. RN #5 indicated that there was no communication from the facility to the hemolytic center regarding Resident #212's change in condition on 5/17/2025. RN #5 indicated that Resident #212 presented with increased lethargy, increased shortness of breath and decreased blood pressure than his/her baseline upon arrival. RN#5 identified that hemolytic treatment physician was notified and hemolytic treatment was administered but at minimum level and resident was monitored closely every 15 minutes. A nursing note dated 5/17/2025 at 4:47 PM identified that Resident #212 returned from the homolytic center at 4:00 PM and was subsequently sent to the ED. Interview with the DNS on 6/10/2025 identified that she had identified that staff were not completing facility hemolytic documentation as required and she had recently re-educated staff. The DNS indicated that documentation/communication with the hemolytic center had been started on 6/7/2025. The DNS was unable to explain why staff had failed to complete the required documentation since Resident #212 was admitted to the facility in November of 2024. Review of Facility's Hemolytic Communication Tool identified that the facility nurse should complete the following: Medication given in the six (6) hours prior to sending resident out for dialysis treatment .signs of infection . any changes in condition or information. Review of facility's End Stage Renal Disease (ESRD), identified in part, that agreements between the facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including .how information will be exchanged between facilities.

Based on observation, review of clinical records, facility policy, and interviews for 1 of 3 residents (Resident #9) reviewed for infection control practices, the facility failed to ensure proper hand hygiene during wound care. The findings include: Resident #9's diagnoses included cellulitis of lower left limb, non-pressure chronic ulcer of left lower leg, and congenital deformities of feet. The Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment and was dependent for chair/bed to chair transfer and required partial/moderate assistance for turning/repositioning in bed. The Resident Care Plan dated 5/14/2025 identified Resident #9 had DTIs (deep tissue injuries) to bilateral heels. Interventions included providing wound care treatment as ordered, soft boots to be worn at all times while in bed, and off load heels in bed at all times with pillows or bunny boots. A physician's order dated 5/20/2025 directed nursing staff to clean the left heel with wound cleanser, pat dry and apply xeroform, followed by the application of a bordered gauze every day shift and as needed. A physician's order dated 5/22/25 directed nursing staff to clean the right heel with wound cleanser, pat dry and apply xeroform, followed by the application of a bordered gauze every day shift. An observation of wound care and interview with LPN #4 on 6/5/2025 at 2:12 PM identified LPN #4 had removed the old dressing from the Resident #9's right heel, removed her gloves, and reapplied gloves without performing hand hygiene. LPN#4 cleansed the right heel and applied the xeroform. LPN #4 then removed her gloves and applied a new pair of gloves, again without the benefit of hand hygiene. LPN #4 was interrupted by the surveyor and identified that hand hygiene should have been performed before and after each glove change. Continued observation of LPN #4, who was now performing the left heel dressing, identified she did not perform hand hygiene or change gloves between removal of soiled dressing and cleansing of left heel wound. LPN #4 then she removed gloves, performed hand hygiene, donned new gloves and applied bordered gauze dressing to left heel. LPN#4 removed her gloves at the completion of dressing change and performed hand hygiene. Interview with DNS on 6/6/2025 8:31 AM identified that hand hygiene should be done before care, with each glove change, and when care is complete. Interview with Infection Preventionist/ Staff Development, Registered Nurse (RN) #1 on 6/9/2025 at 9:48 AM, identified that hand hygiene and glove changes would be expected upon entry into a resident room, after initial wound cleansing, when applying a clean dressing and after dressing completion. Review of the Pressure Ulcers Definitions, Management & Treatment Policy instructed, in part, that nursing staff were to remove their gloves and wash or sanitize their hands immediately after removal of a soiled dressing. The policy also instructs staff to sanitize or wash hands and put on clean gloves prior to cleansing the wound and applying the ordered dressing. Per this policy, gloves should be removed after wound treatment is complete followed by hand hygiene.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #28, Resident #48, Resident #58) reviewed for immunizations, the facility failed to identify Covid 19 vaccination status, offer the Covid 19 vaccination (or provide information where to obtain), and failed to educate the resident on the risks and benefits of Covid 19 vaccinations. The findings include: 1. Resident #28's diagnoses included cellulitis, lymphedema, and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status (BIMS) of 15 identifying cognitively intact and required set-up assistance with personal hygiene, substantial maximum assistance with dressing, and bed mobility. The Covid 19 immunization status was noted to not be up to date. The Resident Care Plan dated 5/6/2025 failed to reflect the Covid 19 vaccination status or that education provided for vaccination. Review of the electronic health record for immunizations failed to identify the Covid 19 vaccination was offered, or that vaccine education was provided. Review of the physician's order dated May 2025 did not direct any orders related to the Covid 19 vaccination. 2. Resident #42's diagnosis included end stage renal disease, diabetes and protein calorie malnutrition. The admission baseline Resident Care Plan dated 4/15/2025 failed to reflect the Covid 19 vaccination status or that education provided for vaccination. The Minimum Data Set, dated [DATE] identified the Brief Interview for Mental Status (BIMS) score of 13 which indicated cognitively intact, required partial moderate to substantial maximum assistance with dressing, substantial maximum assistance with bed mobility, and total assistance with transfers. The Covid 19 vaccination status was not up to date. Review of the electronic health record for immunizations failed to identify the Covid 19 vaccination was offered, or that vaccine education was provided. A physician's order dated 6/8/2025 did not direct any orders related to the Covid 19 vaccination. 3. Resident #58's diagnosis included Alzheimer's disease, rheumatic tricuspid insufficiency, and chronic kidney disease. The admission baseline Resident Care Plan dated 5/20/2025 failed to reflect the Covid 19 vaccination status or that education provided for vaccination. The Minimum Data Set assessment dated [DATE] identified the Brief Interview for Mental Status (BIMS) score of 0 indicating severely cognitively impaired and required, partial moderate assistance with bed mobility and transfer, and substantial maximum to total assistance with dressing. The Covid Vaccination status was not up to date. Review of the electronic health record for immunizations failed to identify the Covid 19 vaccination was offered, or that vaccine education was provided. A physician's order dated 6/9/2025 did not direct any orders related to the Covid 19 vaccination. Interview review of the clinical record review, and review of the vaccination report on 6/9/2025 at 12:50 PM with Registered Nurse (RN) #1, the Infection Preventionist (IP), failed to identify that Resident #28, Resident #42 and Resident #58 had their Covid 19 vaccination status obtained or that education regarding receiving the Covid 19 vaccination had been provided. Additionally, none of the residents appeared on the vaccination log. RN #1 indicated that staff were no longer required to offer the Covid 19 vaccination to residents or track a residents Covid 19 vaccination history. Review of the Covid 19 vaccination requirements for residents and staff policy dated 4/14/2025 directed, in part, to ensure education of resident or resident representatives with regard to the benefits and potential side effects associated with the COVID-19 vaccine. The vaccine is offered unless it is medically contraindicated, or the resident has already been immunized. Additionally, the facility will maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education and whether the residents received the vaccine.

Based on interviews, review of clinical records, facility documentation, and facility policy for 1 of 3 residents, (Resident #25) reviewed for dignity, and for 2 of 5 sampled residents (Resident #32 and #39) reviewed for abuse, the facility failed to report allegations of abuse to the State Agency. The findings include: 1. Resident #25's diagnoses included malignant neoplasm of the head, face, and neck, chronic heart failure, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with personal hygiene and chair/bed-to-chair transfers and required maximal assistance in rolling left and right. The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #25 had a problem with anxiety and agitation. Interventions included an assist of 2 at all times due to accusatory behavior, allow time to communicate effectively, and re-offer behavioral health services as needed. Interview on 6/4/2025 at 11:05 AM with Resident #25 identified that a few months ago, Nurse Aide (NA) #3 came into his/her room shaking her bootie and flashed the resident her breasts. Resident #25 stated that he/she notified NA #2 about the incident shortly after it had occurred, which resulted in NA #3 being taken off of his/her care assignment. Interview with NA #2 on 6/6/2025 at 11:52 AM identified that Resident #25 told him in February or March of 2025 that NA #3 had flashed her breasts at him/her. NA #2 stated he reported the incident to RN #5. NA #2 stated he had also reported the incident to the Administrator and was told by the Administrator that the incident was just a hallucination. NA #2 further indicated that NA #3 continued to report for work after he reported the incident, that she would still go into the resident's room, and that she would talk to the resident like a sex operator. NA #2 stated he was concerned that Resident #25 had NA #3's personal cell phone number. Interview with the Administrator on 6/6/2025 at 12:25 PM identified that a report had not been sent to the State Agency (SA) because he was unaware of the incident that had occurred between Resident #25 and NA #3. Subsequent to surveyor inquiry, the Administrator reported the allegation of sexual abuse to the SA on 6/6/2025 at 1:00 PM. A written statement by NA #3 dated 6/6/2025 at 2:19 PM identified that 2 co-workers had informed her in February of 2025 that Resident #25 had made an allegation against her that she had flashed her breasts in front of him/her during care. NA #3 stated that the allegations were reported by NA #2 to RN #5, who then reported the incident to the nurse supervisor RN #6. NA #3 further indicated that during a conversation with RN #6, she was directed not to return to Resident #25's room or provide care to him/her. Interview with NA #4 on 6/6/2025 at 4:01 PM identified that Resident #25 had informed her at 2:30 PM that NA #3 had flashed her breasts, but he/she didn't want to tell anyone about it now for fear of getting NA #2 in trouble. She further identified Resident #25 reported to her that while receiving care from NA #3 and NA #8, his/her genitalia were blown on by NA #8. NA #4 stated she had told the Administrator about the allegation of sexual abuse following which he had her write a statement. Interview with RN #6 on 6/9/2025 at 10:56 AM identified he had not been informed that NA #3 had flashed her breasts at Resident #25 but had taken NA #3 off the resident's care assignment due to a question of the resident using the call light too frequently when NA #3 was assigned to him/her. Further, RN #6 stated he failed to report his concerns to the Director of Nursing Services or the SA because the problem was already resolved and the resident had a care plan in place for accusatory behavior. Interview with NA #3 on 6/9/2025 at 3:28 PM identified that Resident #25 did have her personal cell phone number. She indicated she did not give her number to the resident, but another staff member did. NA #3 stated she had never flashed her breasts at Resident #25 and had been removed from his/her care assignment because of the allegation that she flashed him/her but had never been taken off the schedule following the allegation, only taken off Resident #25's assignment. Review of the facility's Abuse Policy identified that suspicion of any form of abuse should be reported to the Department of Public Health (State Agency) immediately but no later than 2 hours after the allegation after forming the suspicion. 2. Interview with the Administrator on 6/5/2025 at 3:11 PM identified that following Resident #4's report of a missing cell phone he went to interview Resident #4. Resident #4 indicated that both Resident #32's and Resident #39's cell phones had been missing. A. Resident #32's diagnosis included Chronic Obstructive Pulmonary Disease, anxiety, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Resident #32 required a wheelchair for mobility, and assistance with personal hygiene, bed mobility and all transfers. The Resident Care Plan in effect in May 2025 identified Resident #32 was on psychotropic medications related to a major depressive disorder and anxiety. Interventions directed staff to encourage participation in activities, observe for medication side effects, and administer medication as ordered. Review of the Facility Reported Incident (FRI) event dated 6/5/2025 at 3:30 PM identified Resident #32's cell phone had been missing for more than 3 weeks. The facility initiated an investigation and searched Resident #32's room and the Laundry Department but did not locate the phone. The facility notified the police, the MD and Resident #32's family. Education was provided to Resident #32 to utilize the lock box in the resident's room to store all personal items. According to the facility's investigation report, the facility failed to identify the allegation of a missing cell phone was previously reported by Resident #32 to a staff member. Interview with Therapeutic Recreation Director (TRD) #1 on 6/10/2025 at 10:58 AM identified approximately 2 months prior, Resident #32 reported to her that he/she was missing a cell phone. TRD #1 reported that Resident #32 informed her of the missing cell phone while she was passing beverages from room to room. She stated she searched through Resident #32's belongings but could not locate the cell phone. In addition, she stated that she did not report the incident to the Administrator, nor did she complete a grievance. She did, however, reach out to the Director of Environmental Services (EVS) #1 and told him the cell phone was missing and to notify her if he found a phone in the laundry. TRD #1 acknowledged she should have reported the incident and completed a grievance, but stated, I really don't have a good answer for you as to why I did not report the missing cell phone. Observation and interview with Resident #32 on 6/10/2025 at 11:24 AM identified Resident #32's cell phone had been missing for approximately two weeks. Resident #32 believed it may have fallen off the tray table but stated he/she had told the facility Administrator the cell phone was missing. Interview with the Director of EVS #1 on 6/10/2025 at 12:18 PM identified he had been informed that Resident #32 was missing a cell phone and was asked to check the room and the laundry area. He searched both locations but did not find the cell phone. EVS #1 indicated he did not file a report because he assumed TRD #1 had already done so. He stated he would have expected the person who discovered Resident #32's phone was missing would report the issue to the Social Services Department and the Administrator. Interview with the Director of Nursing (DNS) on 6/10/2025 at 11:47 AM identified the DNS would have expected staff to report Resident #32's missing cell phone to either herself or the Administrator. She stated a grievance and incident report should have been completed and could not explain why this was not done. B. Resident #39's diagnosis included hemiplegia following a cerebral infarction, attention and concentration deficit, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment. Resident #39 used a walker and wheelchair for mobility, and required extensive assistance with personal hygiene, bed mobility, and moderate assistance with all transfers. The Resident Care Plan dated 4/24/2025 identified Resident #39 was at risk for alterations in psychosocial well-being related to little or no interest in activities. Interventions directed staff to encourage Resident #39 to participate in activities of interest. Review of the Facility Reported Incident (FRI) event dated 6/5/2025 at 3:30 PM identified Resident #39's cell phone went missing approximately 3 weeks ago. The facility initiated an investigation and searched Resident #39's room and the laundry Department but did not find the phone. The police, the MD, and the family were notified of the incident. Education was provided to Resident #39 to utilize the lock box located in his/her room for storage of all personal items. According to the facility's investigation report, the facility failed to identify the allegation of the missing cell phone was previously reported to a staff member. Observation and interview with resident #39 on 6/10/2025 at 11:18 AM identified that Resident #39's cell phone had been missing for approximately 4 weeks. Resident #39 stated he/she normally kept the phone in the drawer and had informed NA #8 that the phone was missing. Resident #39 indicated that NA #8 thoroughly searched for the phone, but the phone was never found. Attempts to interview NA # 8 were unsuccessful. Interview with NA #4 on 6/10/2025 at 12:08 PM identified she was aware that Resident #39's cell phone was missing. She stated she did not report the issue as she had assumed it had already been addressed since several other nursing assistants were aware and had searched for the cell phone. NA #4 acknowledged that she should have reported the missing cell phone when she learned of the incident to the DNS or the Administrator. Interview with the DNS on 6/10/2025 at 12:35 PM identified per the facility policy, missing resident property should be reported immediately to either the DNS or the Administrator. The DNS could not explain why staff had failed to report Resident #39's missing cell phone. Interview with the facility Administrator on 6/10/2024 at 12:48 PM identified subsequent to surveyor inquiry, a Reportable Event form was completed and reported to the State Agency on 6/5/2025 at 3:30 PM and an investigation was initiated, along with police notification. During the facility's initial investigations of multiple reports of missing personal property (cell phones), he stated he had learned that some staff members may have been aware of the missing cell phones but had not reported the incident or filed a grievance. The Administrator stated he was unsure why staff failed to report the allegations and noted that the facility had recently been provided with an updated abuse policy and education was administered in April. The facility determined the allegations of the missing cell phones were unsubstantiated. Review of the Abuse Prohibition Policy directed, in part, all staff who have knowledge of apparent abuse or neglect of a resident or misappropriation of a resident's property shall be obligated to report such incidents to his or her immediate supervisor. Any allegation or suspicion of abuse must be reported to the DNS and Administrator. Reporting crimes must be reported to the State Regulatory Agency immediately, but not later than 2 hours.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was status post fracture of the right lower leg and required a knee brace and an assistive device for standing, the facility failed to apply the hinged knee brace to the right leg prior to standing the resident which caused the resident's leg to buckle resulting in a fall and the resident sustained an acute fracture of the proximal tibia. The findings include: Resident #1's diagnoses included dementia, fracture lower end of right femur, osteoarthritis of the right knee, and generalized weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) indicating short and long-term memory recall deficits and was dependent on staff for dressing, showers, and transfers. The Resident Care Plan dated 10/31/24 identified Resident #1 had a self-care deficit and was at risk for falls due to weakness and deconditioning related to traumatic brain injury and history of a distal femur fracture. Interventions directed assistance of two (2) with transfers, weight bearing as tolerated (WBAT), and the application of a hinged knee brace to the right knee which may be removed for showers and skin checks. A physician's order dated 11/26/24 for Resident #1 directed a right knee hinged brace in place at all times, may be unlocked for mobility and may be removed for showers and skin checks. A physician's order dated 12/3/24 directed to transfer assistance of two (2) with the [NAME] Hall [NAME] (SHT) assistive device (this device is a safe and practical standing and turning aid), and WBAT with the right knee brace. The nurse's note dated 12/8/24 at 9:55 PM identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, was called into the shower room at 4:00 PM by a 3-11PM nurse aide, Nurse Aide (NA) #1. The note indicated when NA #1 and another nurse aide, NA #2 attempted to transfer Resident #1 from the shower bench back to the wheelchair, once Resident #1 was in the standing position, Resident #1's knees buckled two (2) times so NA #1 and NA #2 lowered Resident #1 to the floor, Resident #1 did not have the hinged knee brace on. The note identified the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1 and a Physical Therapist (PT) #1 were called to the room, the resident was transferred back to bed with the mechanical lift, the physician was notified, and x-rays were ordered. Resident #1 was subsequently transferred to the Emergency Department for further evaluation and treatment. The hospital record dated 12/9/24 identified Resident #1 sustained an acute fracture of the proximal tibia. The record identified Resident #1 was discharged back to the facility with a long posterior splint and non-weight bearing status until follow up with orthopedics. The nurse's note dated 12/9/24 at 11:02 PM identified Resident #1 returned from the hospital at 10:45 PM with a diagnosis of an acute fracture of the proximal tibia and old fractures of the distal tibia and proximal tibia. A right lower leg splint was in place, secured with an ace wrap, and a physician's order directed non weight bearing (NWB) status until an orthopedic follow-up. The physician's progress note dated 12/10/24 at 3:45 PM identified Resident #1 was diagnosed with an unspecified fracture of the upper end of the right tibia and the physician's order directed Resident #1 remain non weight bearing, to wear the splint and ace wrap and a follow up with orthopedics. Review of the facility's summary report dated 12/12/24 indicated Resident #1 was being transferred from the shower chair to the wheelchair when Resident #1's knees buckled, and he/she was lowered to the floor by two (2) nurse aides. According to staff interviews, NA #1 and NA #2 identified that after the shower, they assisted Resident #1 to hold onto the grab bar as they assisted him/her to rise, and the resident's knees buckled. The nurse aides indicated they were unable to pull the wheelchair closer to allow Resident #1 to sit so they lowered Resident #1 to the floor. The report identified Resident #1's hinged knee brace was not on at the time of the event. Interview with Physical Therapist, (PT) #1, on 1/2/25 at 11:40 AM identified the purpose of the right hinged knee brace was to prevent the knee from buckling and to promote healing of a femur fracture sustained in August 2024. PT #1 explained she assessed Resident #1 immediately after the fall and identified NA #1 and NA #2 did not use the SHT device for the stand pivot transfer and they attempted to stand Resident #1 without the knee brace on. Interview with NA #1 on 1/2/25 at 12:10 PM identified on 12/8/24 she assisted NA #2 with Resident #1's transfer into the shower. NA #1 identified she and NA #2 transferred Resident #1 from the wheelchair to the shower chair with the knee brace on and the resident had no difficulty with the transfer. NA #1 indicted they removed the knee brace and NA #2 proceeded to shower Resident #1. After the shower was completed, she and NA #2 assisted Resident #1 to stand to dry his/her bottom, Resident #1's leg buckled, and they attempted to sit Resident #1 back down when Resident #1's leg buckled again. NA #1 identified they slowly lowered Resident #1 to a seated position on the floor. NA #1 identified she and NA #2 had not applied the knee brace prior to standing Resident #1. NA #1 identified she did not review Resident #1's nurse aide Kardex and was not aware of the orders for the knee brace on when weight bearing and to utilize the SHT device. Interview with the Director of Nursing (DON) on 1/2/25 at 2:50 PM identified the nurse aides were responsible to review the nurse aide Kardex for all transfer requirements for a resident or take directions from a nurse. The DON indicated the knee brace should have been applied prior to Resident #1 being assisted to a standing position and at the point a transfer was to occur, the SHT device should have been used. The DON identified the facility's investigation determined the cause of the fall was when the Resident #1's knees buckled due to not wearing the knee brace, the nurse aides failed to follow the plan of care. The facility policy, Care Plans, Comprehensive Person-Centered identified the Interdisciplinary Team (IDT) in conjunction with the resident and his/her legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further states, in part, that the care plan will aid in preventing or reducing decline in the resident's functional status and/or functional levels and enhance the optimal function of the resident by focusing on a rehabilitative program. The facility policy Activities of Daily Living (ADL) identified, in part, that appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Attempts to interview LPN #1 and NA #2 were unsuccessful.

Based on record review and interviews for one sampled resident who received an anticoagulant (blood thinner, increases risk for bleeding) medication (Resident ID #1) the facility failed to obtain an order to discontinue the anticoagulant medication prior to a dental procedure where twenty-three (23) teeth extracted. Subsequently Resident #1 continued to receive the anticoagulant medication, experienced bleeding requiring sutures, had a change in condition, was sent to the hospital where he/she suffered cardiac arrest and expired. This resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included paroxysmal atrial tachycardia (atrial arrythmia), hypertension, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and was receiving an anticoagulant. The Resident Care Plan dated [DATE] identified Resident #1 was on anticoagulant therapy due to arial fibrillation with a goal to minimize the risk of complications and oxygen therapy due to heart failure. Interventions directed to provide a safe environment, assist with transfers as needed to protect extremities from trauma top lessen the possibility of bleeding, observe, document and report to the physician signs of anticoagulation complication that included lethargy, shortness of breath, sudden changes to mental status or vital signs. A physician's order dated [DATE] directed to administer Eliquis (blood thinner) 5 milligrams (mg) twice daily at 9:00 AM and 8:00 PM and dental consult as needed. The nurse's note dated [DATE] identified Resident #1 went for an appointment to the dentist for complaints of toothaches. The medical clearance form for dental treatment dated [DATE] from the dentist's office noted handwritten instructions to hold the anticoagulant forty-eight (48) hours prior to the extraction and one (1) day after the extractions and the date for the extractions had not been scheduled at this time. Interview on [DATE] the Director of Nursing was unable to provide any other documentation for the [DATE] dental appointment except for a prescription that directed to administer Amoxicillin 500 mg, take four (4) caps one (1) hour before the dental appointment scheduled for [DATE]. The Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified she was called to evaluate Resident #1 due to right lower tooth pain and to follow up with dentist to try to get an appointment sooner. The appointment consultation progress note written by Secretary #1 dated [DATE] at 1:27 PM identified she spoke with the dental office, Resident #1 was on a wait list, and Resident #1 would need to be off the blood thinner for forty-eight (48) hours prior to the extractions. Review of the Supervisor's twenty-four (24) hour report dated [DATE] identified although the information to hold the Eliquis was placed on the report, a review of the clinical record failed to identify an order to hold Eliquis was obtained. A physician's order dated [DATE] directed Eliquis (a blood thinner) 5 mg twice daily at 9:00 AM and 8:00 PM. Review of [DATE] Medication Administration Record revealed Resident #1 received Eliquis 5 mg on [DATE] at 9:00 AM and 8:00 PM, on [DATE] at 8:00 PM, and on [DATE] at 9:00 AM, ([DATE] the day of the dental extraction procedure). Further record review failed to reveal evidence the Amoxicillin 500 mg was administered one (1) hour before the [DATE] dental appointment. The nurse's note dated [DATE] at 4:00 PM identified Resident #1 returned to the facility after the having teeth extractions, was noted to be bleeding, the dentist was updated, staff informed the dentist Resident #1 received the Eliquis, a new order was given for tea bags and gauze and biting down for thirty (30) minutes, update the dentist in thirty (30) minutes. The note indicated the bleeding continued through the gauze after thirty (30), the dentist was contacted and requested Resident #1 be brought back to the office for sutures. The note identified Resident #1 returned to the dentist's office accompanied by staff. The APRN was notified and new orders to hold the Eliquis until [DATE], vital signs every four (4) hours times forty-eight hours, monitor for bleeding and obtain a Complete Blood Count on [DATE]. The nurse's note dated [DATE] at 9:22 PM identified at 8:40 PM Resident #1's blood pressure was ,d+[DATE], heart rate was 73, respiratory rate 18. At 9:15 PM the blood pressure was ,d+[DATE], heart rate was 88, respiratory rate 22 and labored, and the oxygen saturation was 95 percent (%) on three (3) liters of oxygen. The nurse's note dated [DATE] at 10:15 PM identified Resident #1 was sent to the hospital for labored breathing, confusion, and continued bleeding. Review of hospital documentation dated [DATE] identified Resident #1 went unresponsive at 11:40 PM to verbal and painful stimuli, was showing difficulty breathing, gasping for air, unable to obtain blood pressure and oxygen saturation, cardiopulmonary resuscitation was started on [DATE] at 1:03 AM and time of death was called at 1:27 AM. Review of a documented interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #2, on [DATE] at 9:50 AM identified on [DATE] Secretary #1 informed her that Resident #1's dentist was on the phone wanting to confirm Resident #1's blood thinner (Eliquis) was held secondary to a dental procedure the next day that required Resident #1's remaining teeth to be extracted. LPN #2 indicated she did not look back to see if the Eliquis was held the previous day. Interview with Secretary #1 on [DATE] at 10:30 AM and review of her facility statement dated [DATE] identified she coordinated outside appointments for the residents. Secretary #1 stated she is notified by the nursing staff, and will contact the appropriate service to schedule, once scheduled she will enter the information as a progress note in the resident's electronic record and will also manually record the scheduled appointment in a facility appointment calendar on the unit. Secretary #1 identified on [DATE], as documented in her note, the dental office called and told her the anticoagulant needed to be held for forty-eight (48) hours prior to the [DATE] dental appointment. Secretary #1 indicated she could not recall if she told any nursing staff but in general, she would have told the Nursing Supervisor and her notation in the resident's clinical record would trigger to automatically be placed on the facility's morning report. Secretary #1 stated on [DATE] the dentist's office called to confirm Resident #1's [DATE] dental appointment and Resident #1's Eliquis had been held. Secretary #1 stated she placed the dentist's office on hold and walked over to Resident #1's unit and asked the charge nurse, LPN #2, whether Resident #1's Eliquis was being held for twenty-four (24) to forty-eight (48) hours prior to the scheduled procedure on [DATE]. Secretary #1 observed LPN #2 looked at the computer and LPN #2 told her she would hold the [DATE] 9:00 AM Eliquis dose and the [DATE] 8:00 PM dose was not given so Resident #1 was all set. Secretary #1 stated informed the dental office Resident #1 was all set per nursing for the hold on the Eliquis. An interview was conducted with the Staff Development Coordinator, Registered Nurse (RN) #1, on [DATE] at 11:22 AM. RN #1 stated she was the Nursing Supervisor on [DATE] and transcribed the dentist's order to administer Amoxicillin 500 mg by mouth four (4) caps one time only for pre dental prophylaxis on [DATE] and she did not see any other orders. RN #1 indicated it would be the responsibility of the 7AM-3PM Nursing Supervisor on [DATE] to review the twenty-four (24) hour report to determine if any resident required follow up or any additional orders. An interview was conducted with LPN #1 on [DATE] at 12:22 PM. LPN #1 stated she was assigned to Resident #1 on [DATE] on the ,d+[DATE]PM shift. LPN #1 identified she ran late that evening, arriving 30 minutes late, got a quick report from LPN #2, and the report did not include information about Resident #1 going out for a dental appointment on [DATE] and to hold the 8:00 PM Eliquis dose. LPN #1 stated she administered the 8:00 PM Eliquis dose on [DATE] as ordered. Interview with the Director of Nursing (DON) on [DATE] at 1:00 PM identified she would have expected the 7AM-3PM Nursing Supervisor (RN #2) who was on duty on [DATE] to review the twenty-four (24) hour report as preparation for morning report and the report would have identified a need for an order to hold Resident #1's anticoagulant for forty-eight (48) hours prior to the [DATE] procedure. The DON indicated Secretary #1 should have informed the Nursing Supervisor as well. The DON stated she did not know why RN #2 did not pick up the notation on the [DATE] twenty-four (24) hour report that was entered by Secretary #1 on [DATE]. The DON stated Resident #1's anticoagulant was not discontinued forty-eight (48) hours prior to the tooth extractions on [DATE] due to the miscommunication that occurred. An interview was conducted on [DATE] at 4:45 PM with Dentist #1. Dentist #1 stated he performed the suturing post extraction on [DATE] and it was not his practice and the dental practice's standard to conduct dental extractions if a resident was on Eliquis due to the possibility of bleeding. Dentist #1 stated he and Dentist #2, who had performed Resident #1's extractions, were unaware the Eliquis had not been stopped and if they were informed they would not have performed the procedure. Attempts to contact LPN #2, RN #5 were unsuccessful, and RN #2 was unavailable for interview during survey.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 6 sampled residents (Resident #2) reviewed for nutrition, the facility failed provide care and services to address a significant ongoing weight loss. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutrition Risk assessment dated [DATE] identified Resident #2 has had no significant weight change, had a current food intake of 50 - 75%, required no therapeutic nutritional supplements, and had no swallowing difficulties. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weights and Vitals Summary dated 2/14/21 identified Resident #2 weighed 137 lbs. A Dietary Note dated 2/25/21 identified Resident #2 was eating a regular diet well and maintaining weight. Additionally, meals, snacks and fluids were encouraged, and the note indicated the resident would benefit from Ensure supplement if meal intake was less than 50%. The care plan dated 2/26/21 failed to reflect measures to address the resident's nutritional needs. Review of the Weights and Vitals Summary dated 3/1/21 identified Resident #2 weighed 126 lbs., (11 lb. loss or 8% in 16 days) Review of the Weights and Vitals Summary dated 4/19/21 identified Resident #2 weighed 128.6 lbs., (5.8 lbs. loss). Review of the Weights and Vitals Summary dated 5/3/21 identified Resident #2 weighed 121.2 lbs. The significant change MDS dated [DATE] identified Resident #2 had severely impaired cognition, required supervision for eating, had no weight loss/gain, and had no issues with swallowing. A Nurse's Note dated on 5/28/21 identified Resident #2 needed some assistance with his/her meal trays. The care plan dated 7/13/21 failed to reflect measures to address the resident's nutritional needs. Review of the Weights and Vitals Summary dated 7/26/21 identified Resident #2 weighed 120.9 lbs. Observation on 8/2/21 at 11:58 AM identified Resident #2 ate 100% of lunch independently after his/her tray was set up. Review of the Weights and Vitals Summary dated 8/2/21 identified Resident #2 weighed 119.5 lbs. (17.5 lbs. weight loss since admission). Interview and review of the clinical record with the charge nurse, (RN #3) on 8/9/21 at 11:35 AM identified she was not aware that Resident #2 lost 11 lbs. in 16 days as per the weight of 3/1/21 or that the resident continued to lose weight (17.5 lbs. since admission) Additionally, RN #3 could not provide documentation that the physician or dietitian had been made aware of the ongoing weight loss. RN #3 further identified that the charge nurse is responsible to notify the supervisor, dietitian, and physician when a weight change is identified. Although RN #3 could not identify what a significant weight loss was, she indicated the charge nurse should notify the physician with a weight loss of 10%. RN #3 further identified a quarterly assessment should have been completed when Resident #2 weight loss was identified. Interview with MD #1 on 8/9/21 at 1:22 PM identified he was not notified of Resident #2 ' s significant ongoing weight loss. MD #1 clarified those weight changes are considered significant and he would have expected to be notified by the nursing staff the day the weight was obtained. MD #1 furthered identified if he was aware of the significant weight loss, he would have ordered a supplement for Resident #2. Interview with another charge nurse (LPN #2) on 8/9/21 at 1:55 PM identified she was not aware of Resident #2 ' s ongoing weight loss, and she did not know why it was overlooked. LPN #2 further explained the charge nurse should compare new weights to the previous weights in the electronic record and if there is a change of + or - 3 lbs., an assessment would be completed, and the physician would be notified. Interview and review of the clinical record with the DNS on 8/9/21 at 2:15 PM identified Resident #2 has had several significant weight losses since 2/14/21. The DNS indicated she would have expected the charge nurse to alert the supervisor who would then contact the dietitian and physician. The clinical record failed to reflect any physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the DNS further identified the policy is to notify the physician for weight loss of 5% weekly and/or 10% monthly. Further, the computer calculates the weight change percentages and triggers them on the weight and vitals summary. The DNS identified the charge nurse is responsible to review the TAR for completion of weights, and the supervisor is responsible to review the TAR for significant weight changes. Interview and review of the clinical record with the Dietitian on 8/10/21 at 8:32 AM identified when Resident #2 had the significant ongoing weight loss, she was not notified. Additionally, the Dietitian identified a significant weight change is a 5 % weekly and/or 10 % monthly, increase or decrease, and had she been aware of the weight loss, she would have recommended a between meal snack plan or supplement. The Dietitian further identified she reviews weights monthly and the charge nurse reviews weights weekly. If there is a change, the charge nurse is responsible to notify her of significant changes. Although there is a mechanism in place via the computer and weigh change triggers, the Dietitian indicated they were not set up for her and she does not get the triggers on the electronic record. The Dietitian indicated Nutrition Assessments are completed yearly or with full MDS trigger and nutrition progress notes completed quarterly. The Dietitian further identified she had not done a nutritional assessment nor progress note for Resident #2 ' s nutritional status since 2/16/21. The dietitian indicated she missed the quarterly nutritional progress note in May 2021 because Resident #2 was not put on the list to have the quarterly MDS done, so the Dietitian did not get an alert to do the quarterly nutritional progress note. The dietitian further indicated that Resident #2 did not have a care plan for nutritional needs since admission. The Dietician identified she comes in at least once a week and has a 32 hour a week contract. Subsequent to surveyor inquiry, the dietitian note completed on 8/10/21 at 9:02 AM identified upon chart review, Resident #2 had an approximately 18 lbs. weight loss since admission. Resident #2 is on a regular diet and intake has been well. Recommendations included to add Ensure supplement twice a day between meals. Interview and review of clinical record with LPN #1 on 8/10/21 at 11:30 PM identified she is the 7:00 AM - 3:00 PM charge nurse and indicated weights are obtained during the 11:00 PM - 7:00 AM shift. If there is an issue with the weight taken, the charge nurse would alert the 7:00 AM - 3:00 PM staff for a re-weigh. LPN #1 further identified a significant weight loss is a +- 3 lb. change from previously taken weight. LPN #1 identified she was not aware of any weight changes for Resident #2 and that the resident can be a picky eater. Review of the Weight Loss Treatment Protocol policy directed the MDS Coordinator will determine if any residents have experienced a weight loss. Once it is determined that a resident requires nursing intervention to prevent or treat a weight loss, the MD will be notified. The MDS Coordinator will hold a care conference to reflect the change of condition, and treatment modalities will be discussed with the MD. Review of the Weight, Significant Changes policy identified that significant weight change is defined as 5% change in 30 days or 10% change in 180 days and indicated a change in condition requires a new MDS assessment. Notifications of weight change will be made to physician, dietitian, and responsible party. Review of the Supplements, Nutritional Policy identified that a significant weight loss was a weight loss of 5% in one month, or 10% in six months.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents reviewed for accidents (Resident # 16), the facility failed to safely transfer the resident via mechanical lift to prevent an injury. The findings include: Resident # 16's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident # 16 had a severe cognitive impairment, required total assistance from the staff with transfers, bed mobility, ADL and noted no falls. The Resident Care Plan (RCP) dated 6/30/16 identified the resident had an ADL self-care performance deficit related to CVA, dementia, and musculoskeletal impairment, limited mobility and the resident was a high fall risk. Interventions directed to transfer the resident with the assistance of two aides via Hoyer lift (mechanical lift) to a customized wheelchair. A physician's orders [REDACTED]. The Accident/Incident report dated 9/27/16 identified Resident # 16 while being transferred back to bed from the chair via mechanical lift with two nurse aides, the resident fell forward and landed on the floor. Additionally, noted Resident #16 sustained 1.5 CM laceration to forehead and was sent to emergency department for an evaluation. The nurse's note dated 9/27/16 at 10:37 PM identified during a transfer with a mechanical lift the resident fell forward landing on floor (while two NA's were operating lift), one nurse aide was noted in the forward position and other nurse aide was noted backward. The nurse's note also identified Resident #16 was noted to have a 1.5 CM laceration to forehead with scant amount of blood and indicated no ecchymotic areas were noted at the time of the incident. The Emergency Department (ED) note dated 9/27/16 identified the resident presented with a head injury after being dropped from a Hoyer lift. The ED note also noted the resident's head wound was irrigated and received six sutures. The nurse's note dated 9/28/16 at 2:01 A.M. identified Resident #16 returned from the ED at 12:50 A.M. with six sutures to forehead with an intact clean dressing and had no discomfort. The Resident Care Plan (RCP) dated 9/29/16 identified resident had an actual fall from Hoyer lift with falling forward landing on floor, two NA's were operating lift. Interventions directed to monitor, document, report to the physician signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, and inability to maintain posture or any agitation for 72 hours and when needed. Additionally, the care plan directed the nurse to supervise all Hoyer transfers in and out of bed for 72 hours, PT/OT to assess and educate the nurse aide staff on how to transfer into the chair over a leg pommel, to elevate the resident over the pommel before moving and to have a licensed staff present for 72 hours. Subsequent to the incident on 9/27/16 all nurse aides were re-educated on 9/27/16 and 9/29/16 on Hoyer lift transfers for residents who have CWC with a scissor board and on the facility Hoyer lift transfers. A phone interview with NA#1 on 2/15/17 at 2:15 P.M. identified he/she was transferring Resident #16 from the wheelchair to the bed with assistance of NA#2. NA#1 indicated he/she was operating the mechanical lift while NA#2 was behind Resident #16's wheelchair. NA#1 further indicated when he/she raised Resident #16 above the wheelchair using mechanical lift, he/she did not elevate Resident #16 high enough to clear the scissor board which was not leveled with the wheelchair cushion and permanently attached to the wheelchair. NA#1 identified that while Resident #16 was suspended in the sling attached to the lift above the wheelchair, NA#2 moved the wheelchair out from underneath the resident causing the Hoyer lift sling to become entangled with the scissor board resulting in Resident #16 propelling forward out of the sling and landing on to the floor sustaining a laceration to forehead.

Based on clinical record review and staff interview, for 1 of 3 sampled residents, (Resident #30), identified at risk for dehydration, the facility failed to ensure the resident's fluid needs were being met. The findings include: Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident care plan identified potential for dehydration with interventions including monitor Intake & Output, monitor for signs and symptoms of dehydration, and encourage good fluid intake. physician's orders [REDACTED]. A foley catheter was inserted on 4/24/12. Facility documentation identified that on 4/22/12 Resident #30's BUN was 22 and creatinine was 0.8 and on 4/25/12 was 27 and 1 respectively. Physician's Progress notes dated 5/3/12 identified multiple skin tears, large blisters, likely phemigus, and an increase in [MEDICATION NAME]. Review of the flow sheets identified that Resident #30's intake ranged from 0%-100% with inconsistent amounts. Supplement documentation was incomplete. When documented the consumption was noted to be between 0%-100% with inconsistent amounts. Intake and Output monitoring from 4/24/12 to 5/11/12 identified ranges of 370cc to 1140cc for intake and 125cc to 695cc for output. Review of Nursing notes from 5/3/12 thru 5/12/12 identified the resdient had a decline, dark cloudy urine with sediment, and poor oral intake. Further review of the clinical record failed to identify that the physician was made aware of the change until 5/12/12 when he ordered lab work to be completed and the resident was transferred to the hospital. Hospital documentation identified that the resident was admitted for treatment for [REDACTED]. The resident was placed on comfort measures only. The BUN was noted to be 56 and creatinine 1.3. Interview with the Director of Nursing on 8/15/12 at 10:30 am identified that if the resident's 24 hour total intake was noted to be less than 1000cc for two consecutive days the day shift nurse was to notify the physician. Further interview identified that she would expect the nurse to conduct an assessment for dehydration if the resident was not meeting their fluid needs. She further identified that at the time the nurses were not routinely assessing residents who were at risk for dehydration, however since Resident #30 was admitted to the hospital and treated for [REDACTED]. Review of the clinical record failed to reflect that the facility was accurately monitoring the resident's intake and output, had assessed the resdient for signs and symtoms of dehydration and/or that the physician was notified of the resdient's decline in a timely manner.