Every finding on record at Aspire Senior Living Malden

Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and the end of each shift for one medication cart out of two sampled medication carts. The facility's census was 39. Review of the facility's policy titled, Narcotic Count, revised, March 2015, showed: - The purpose of this policy is to complete a physical inventory of narcotics at each shift change to identify discrepancies; - One Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of the narcotics supply for each individual resident at the change of each shift; - Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. - After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying the count is correct. 1. Review of the CMT Narcotic Count Records, dated 01/01/25 - 01/31/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 124 missed opportunities out of 248 opportunities. Review of the CMT Narcotic Count Records, dated 02/01/25 - 02/28/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 112 missed opportunities out of 224 opportunities. Review of the CMT Narcotic Count Records, dated 03/01/25 - 03/31/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 124 missed opportunities out of 248 opportunities. Review of the CMT narcotic count records, dated 04/01/25 - 04/30/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 120 missed opportunities out of 240 opportunities. 5. Review of the CMT narcotic count records, dated 05/01/25 - 05/13/25, showed: - No signature and/or initials by the charge nurse or oncoming CMT on the shift verification of controlled substance count sheet for 60 missed opportunities out of 104 opportunities. During an interview on 05/13/25 at 10:17 A.M., CMT K said that he/she did count with the charge nurse at the beginning and the end of his/her shift but there wasn't space on the form for the nurse to sign or initial. During an interview on 05/16/25 at 12:48 P.M., the Director of Nursing (DON) said she expects oncoming and offgoing staff to count and reconcile the narcotics in the medication cart every shift. During an interview on 05/16/25 at 1:03 P.M., the Administrator said staff were to be counting the narcotics on the medication cart every shift. Two staff, the oncoming and offgoing staff, were to count together to ensure no discrepancies had occurred on the prior shift.

Based on interview and record review, the facility failed to ensure staff utilized safe transfer techniques for three residents (Residents #29, #32, and #37) when staff failed to transfer the resident with the assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) out of four sampled residents. The facility census was 39. Review of the facility's policy titled, Gait Belt Use, undated, showed: - The purpose of a gait belt is to provide better control and balance while assisting a resident with ambulation or transfer; - Assist the resident to a sitting position; - Apply the belt to the resident's waist; tighten to fit snugly with the buckle at the side; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. Review of Resident #29's medical record showed: - An admitted [DATE]; - Diagnoses of hemiplegia (paralysis of one side of the body), cerebral infarction (stroke), muscle weakness, and a history of falls. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) , dated 02/04/25, showed: - Severe cognitive impairment; - Substantial/Maximal assistance with lying to sit, bed to chair transfers, and activities of daily living (ADLs). Review of the resident's Care Plan, dated 05/07/25, showed: - Dependent on staff for all ADLS; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:37 A.M., of the resident's transfer from the bed to the wheelchair showed: - Certified Nursing Assistant (CNA) F and CNA G did not put a gait belt around the resident's waist; - CNA F locked the wheelchair wheels and lifted the resident to the side of the bed; - CNA F and CNA G placed their hands under the resident's armpits; - CNA F and CNA G pulled up on the resident to assist him/her to a semi-standing position, pivoted the resident, and positioned him/her in the wheelchair. 2. Review of Resident #32's medical record showed: - An admitted [DATE]; - Diagnoses of hemiplegia, spastic quadriplegic cerebral palsy (a permanent and severe neuromuscular disorder that affects all four limbs and the trunk), vascular dementia (impaired blood supply to the brain), and chronic pain. Review of the resident's quarterly MDS, dated [DATE], showed: - Mild cognitive impairment; - Maximal assistance with lying to sit, bed to chair transfers, and ADLs; Review of the resident's Care Plan, dated 03/03/25, showed: - Dependent on staff for all ADLs; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:05 A.M., of the resident's transfer from the bed to the wheelchair showed: - CNA F and CNA J did not put a gait belt around the resident's waist; - CNA J assisted the resident to the side of the bed; - CNA J pulled up resident from around the waist, pivoted the resident, and CNA F pulled on the resident's pants waistband to position the resident in the wheelchair. Observation on 05/15/25 at 10:14 A.M., of the resident's transfer from the wheelchair to the toilet showed: - CNA F and CNA J did not put a gait belt around the resident's waist; - CNA J lifted the resident from around the waist to position the resident on the toilet; - CNA F lifted the resident from the side to reposition the resident on the toilet; - CNA J lifted the resident from around the waist from the toilet while CNA F placed a brief under the resident; - CNA J pivoted the resident from a standing position to the wheelchair. 3. Review of Resident #37's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (decline in cognitive functioning that affects memory, language, problem-solving) cerebrovascular disease (affects blood vessels and supply to the brain), neuropathy (nerve damage), and tremors (involuntary movements). Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial/Maximal assistance with lying to sit, bed to chair transfers, and ADLs. Review of the resident's Care Plan, dated 05/1/25, showed: - Dependent on staff for all ADLS; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:31 A.M., of the resident's transfer from the bed to the wheelchair showed: - CNA G and CNA J did not put a gait belt around the resident's waist; - CNA J assisted the resident to the side of the bed; - CNA J pulled up the resident from around the waist and pivoted the resident to the wheelchair During an interview on 05/15/25 at 3:25 P.M., Licensed Practical Nurse (LPN) D said staff should use a gait on the residents during transfers. Staff were reminded this morning. During an interview on 05/15/25 at 3:26 P.M., Registered Nurse (RN) I said Resident #29 was a two person gait belt transfer. Gait belts should always be used on everyone that required assistance. RN I said whether the resident was a one or two person transfer, a gait belt should be used. During an interview on 05/16/25 at 9:30 A.M., CNA G said Resident #29 was a two person gait belt transfer and a gait belt should always be used. Staff should always use a gait belt when transferring any of the residents for safety. During an interview on 05/16/25 at 12:20 P.M., the Director of Nursing (DON) said any resident that was not independent with transfers should have a gait belt applied to them for a safety transfer unless they were transferred with a mechanical lift. During an interview on 05/16/25 at 12:25 P.M., the Administrator said she would expect a gait belt to be used on residents that required assistance with transfers. 48532

Based on interview and record review, the facility failed to document likes and dislikes on the meal card and failed to follow the preferences for one resident (Resident #35) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident's Food Likes and Dislikes, last reviewed January 2025, showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager (DM) will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes; - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. Review of Resident #35's medical record showed: - An admitted [DATE]; - Diagnosis of heart failure (a heart condition when the heart does not pump like it should). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/20/25, showed: - Cognition intact; - Independent with eating. Review of the resident's undated meal card showed: - Dislikes included beans, broccoli, powdered eggs, and oatmeal. Observation on 05/13/25 at 12:26 P.M., of the noon meal plate served to the resident showed: - A pork chop, steamed broccoli, a baked potato, a lemon bar, and tea to drink. During an interview on 05/13/24 at 10:36 A.M., the resident said staff served him/her broccoli again. He/She didn't like broccoli and had told the kitchen staff that. The kitchen staff serve broccoli on his/her plate every time it was on the menu. During an interview 05/14/25 at 10:05 A.M., the DM said he/she had not been in this role for very long. If a resident had on their dietary card a dislike, the resident should not be served that item and an alternate should be offered. During an interview on 05/15/25 at 11:33 A.M., the Director of Nursing (DON) said the dietary department was responsible for the resident's meal card documentation and the assessment should be done right away upon admission. The dietary department needed to be talking to the residents about their likes and dislikes. During an interview on 05/16/25 at 12:20 P.M., the Administrator said the dietary department should be speaking with the residents upon admission, documenting their likes and dislikes on the dietary card, and serving the residents their preferences. The dietary cards should be updated as the resident's choices change.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 39. Review of the facility's policy titled, Storage of Food and Refrigeration, dated 01/30/24, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - All containers must be labeled with the contents and date the food item was placed in storage. Review of the facility's policy titled, Dish Washing, dated 01/30/25, showed: - Ensure dishes are properly sanitized after each use; - Facilities must have appropriate and adequate testing equipment, such as test strips and thermometers, to ensure adequate washing and sufficient concentration of sanitization solution is present to effectively clean and sanitize dishware and kitchen equipment. Review of the facility's policy titled, Cleaning, revised 01/30/25, showed: - Ensure a clean and sanitary environment; - All equipment, food contact surfaces, and utensils shall be cleaned; - The floor of the kitchen must be cleaned daily and after each spill or contamination. Review of the facility's policy titled, Employee Hygiene and Hair Restraints, undated, showed: - Ensure proper hygiene and work habits in the workplace; - Employees must keep hair from contacting exposed food, clean equipment, utensils, and linens; - Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. 1. Observation on 05/13/25 at 10:24 A.M., of the Traulsen stand up refrigerator near the Dietary Manager's (DM) office showed: - An opened bag of chocolate chip cookies undated, not labeled, and unsealed; - An opened bag of french fries undated, not labeled, and unsealed; - An opened bag of tortellini undated, not labeled, and unsealed. 2. Observation on 05/13/25 at 10:26 A.M., of the white Whirlpool refrigerator located near the deep freeze in the dry goods area showed: - Two clear lid covered aluminum containers with cooked chicken wings and vegetables undated and not labeled. 3. Observations on 05/13/25 at 10:29 A.M., 05/14/25 at 8:47 A.M., and 05/15/25 at 10:47 A.M., of the canned goods area showed: - A large dented 105 ounce (oz.) can of sliced pears on the top right-side shelf. 4. Observation on 05/13/25 at 10:32 A.M., of the dish machine showed: - A buildup of a white substance on the top, sides, and front panels; - A plastic storage box contained a dirty scour pad and a dirty scrub brush with scattered debris sat on top; - Two boxes of spoons, one box of knives, one box of forks, a squeegee, a green scrubbing brush, and a 38 oz. bottle of dishwashing liquid sat on top. 5. Observation on 05/13/25 at 10:34 A.M., of the Victory three-door standup refrigerator next to the kitchen sink showed: - Four plastic wrapped deli sandwiches undated and not labeled; - An opened zip lock bag of block cheese and individual cheese slices undated and unsealed; - An opened plastic container of mini blueberry muffins undated and unsealed; - A note located on the front-side of the third door, Make sure everything has a label, item name, date opened and use-by date. 6. Observation on 05/13/25 at 10:36 A.M., of the kitchen floors showed: - Dirt, debris, and a plastic cup under the three door Victory standup refrigerator; - Two biscuits, aluminum foil pieces, dirt, and debris under the Vulcan stove; - Dirt and debris under the Vulcan double fryer; - Dirt and debris under the five pan well electric steam table. 7. Observation on 05/13/25 at 10:41 A.M., of the ice machine showed, - A dirty apron, a dirty glove, and a door stopper sat on top. 8. Observation on 05/13/25 at 10:45 A.M., of the kitchen showed: - A ceiling light fixture with two non-working bulbs located over the can opener table in front of the Vulcan stove. 9. Observations of Kitchen Employee A showed: - On 05/13/25 at 10:48 A.M., Kitchen Employee A with facial hair on sides and front of his/her face and did not wear a beard guard ; - On 05/13/25 at 10:52 A.M., Kitchen Employee A did not wear a beard guard, opened the ice machine, and scooped out ice cubes into glassware; - On 05/13/25 at 12:14 P.M., Kitchen Employee A did not wear a beard guard and served resident food trays during the noon meal service; - Kitchen Employee A did not wear a beard guard while performing food preparation and/or delivering food services to staff and residents. 10. Observation on 05/14/25 at 8:32 A.M., of the five pan well electric steam table showed: - A buildup of a dark hardened substance and grease on the bottom of each steam compartment under the electric coils. Review of the May 2025 Kitchen Daily, Weekly, and Monthly Cleaning Schedule Sheets showed: - No dates of cleaning completed by kitchen staff. Review of the May 2025 Kitchen Dish Machine Sanitation Testing Log showed: - No documentation of testing. During an interview on 05/13/25 at 10:18 A.M., the DM said he/she was not doing sanitation strip checks for the dish machine. He/She wasn't in-serviced on testing the dish machine with the testing strips. During an interview on 05/15/25 at 10:39 A.M., Kitchen Employee B said the kitchen floors and equipment should be cleaned daily. Any opened food placed back into the refrigerator should be sealed, labeled, and dated. Dented canned goods should not be used and taken off the shelf. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food or drinks. During an interview on 05/15/25 at 10:43 A.M., the DM said he/she was aware the kitchen cleaning schedule sheets were not being completed and dated by staff. During an interview on 05/16/25 at 7:29 A.M., Kitchen Employee C said the kitchen floors and equipment should be cleaned daily. Any opened food placed back into the refrigerator should be sealed, labeled, and dated. Dented canned goods should not be used and taken off the shelf. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food or drinks. During an interview on 05/16/25 at 7:56 A.M., the DM said the kitchen floors and equipment should be cleaned daily. All foods opened should be sealed, dated, and labeled before placing back into the refrigerator. Dented canned goods should be removed from the inventory and not be used for resident consumption. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food and drinks. During an interview on 05/16/25 at 11:04 A.M., the Administrator said the kitchen floors and equipment should be cleaned daily. All foods opened should be sealed, dated, and labeled before placing back into the refrigerator. Dented canned goods should be removed from the inventory and not be used for resident consumption. Kitchen employees with facial hair should wear a beard guard to prevent hair from falling onto food and drinks during meal preparation and meal delivery.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) during tracheostomy (trach - a surgical opening in the neck through the wind pipe to allow air into the lungs) care (sterile suctioning and dressing change) for one resident (Resident #7) out of one sampled resident. The facility failed to implement enhanced barrier precautions EBP and proper infection control practices when staff administered medications through a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for one resident (Resident #27) out of one sampled resident. The facility also failed to maintain proper glove use during peri care for one resident (Resident #37) out of six sampled residents and one resident (Resident #32) outside the sample. The facility census was 39. The facility did not provide a policy addressing tracheostomy care. The facility did not provide a policy addressing infection control practices while connecting and disconnecting intravenous (IV) tubing during medication administration. Review of the facility's policy titled, Wound Care and Management of Indwelling Medical Devices, last reviewed April 2024, showed: - EBP will be used in conjunction with standard precautions and the use of personal protective equipment (PPE) to putting on of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing; - Indwelling medical devices, including, but not limited to central venous catheters (PICC), urinary catheters, peg tubes, and tracheostomy tubes, will be managed according to established protocols and best practices; - Ensure proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious material; - Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment will occur; - Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions; - Use protective eyewear and a mask, or a face shield, to protect the mucous membranes of the eyes, nose, and mouth during procedures and activities that could generate splashes or sprays of blood, body fluids, secretions, and excretions. Select mask, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Review of the facility's policy titled, Hand Hygiene, last reviewed January 2024, showed: - Hands should be washed for at least 20 seconds using soap and water under the following conditions: when coming on duty; whenever hands are visibly dirty; before having contact with a resident; after having direct contact with a resident (e.g., taking a pulse or BP, lifting, etc.); before performing invasive procedures; after contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; after handling items potentially contaminated with blood, body fluids, excretions, or secretions; before putting on gloves; after removing gloves; or whenever in doubt; - Hand sanitizers containing at least 60% alcohol may be used when soap and water is not readily available. Hand sanitizer should not be used when hands are visibly dirty or contaminated with blood; - Hands washed prior to providing resident care; - Hands washed between each resident; - Change gloves between dirty and clean; - Do not wear gloves in the hallway. Review of the facility's policy titled, Glove Use, undated, showed: - Gloves should be removed when changing or walking away from specific tasks and hands should be then washed per the guidelines. 1. Review of Resident #7's May 2025 Physician Order Sheet (POS) showed: - Diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting the right side, tracheostomy, and gastrostomy (G-tube - a tube inserted in the stomach to provide nutrition and medications); - An order for trach care, dated 02/25/25; - An order for cefdinir (an antibiotic medication) 300 milligram (mg) per G-tube two times daily for respiratory infection for seven days, dated 05/12/25. Observation on 05/15/25 at 8:50 A.M., of the resident's trach care showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - Licensed Practical Nurse (LPN) D performed hand hygiene and did not put on a gown or a face shield prior to entering the residents room; - LPN D performed the trach care; - LPN D failed to put on the appropriate PPE before performing the trach care. During an interview on 05/16/25 at 9:35 A.M., Certified Nurse Aide (CNA) G said staff should wear gloves, a gown, and a face shield when providing care for a resident with a trach. Staff should wear PPE when a resident was on EBP, isolation, or airborne precautions. During an interview on 05/16/25 at 11:47 A.M., LPN D said he/she forgot to put an isolation gown on before entering the Resident #7's room and should have put a face shield on before providing care. 2. Review of Resident #27's May 2025 POS showed: - An order for ertapenem sodium (an antibiotic medication) solution 1 gram (gm) intravenously (IV-administered into the vein) every 24 hours for infection, dated 05/15/2025; - An order for sodium chloride solution (salt water) 0.9 %, 10 milliliters (ml) IV flush every 24 hours for six days before administering IV medication and use 10 ml IV flush one time a day for five days after IV medication administration, dated 05/14/25. Observation on 05/15/25 at 9:45 A.M., of the resident's IV medication administration showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - LPN D performed hand hygiene, put on gloves, and did not put on an isolation gown; - LPN D disconnected the IV medication tubing and the PICC line connector lay against the resident's upper arm; - LPN D did not disinfect the PICC line connector prior to connecting the 10 ml sodium chloride solution flush syringe; - LPN D flushed the PICC line with 10 ml of sodium chloride solution; - LPN D clamped the PICC line; - LPN D did not apply a disinfectant lock cap to the connector and the PICC line connector lay on the resident's upper arm; - Resident #27 asked LPN D if he/she was going to put a cap on the end of the PICC line; - LPN D said no because there wasn't a cap on it when he/she started the antibiotic medication administration. - LPN D removed gloves and performed hand hygiene. Observation on 05/16/25 at 9:40 A.M., of the resident's IV medication administration showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - LPN D performed hand hygiene, put on gloves, and did not put on an isolation gown; - LPN D lay gloves and supplies on the resident's bed without a barrier; - LPN D used an alcohol swab to clean the PICC line connector prior to attaching the 10 ml sodium chloride solution flush syringe; - LPN D disconnected the 10 ml sodium chloride solution flush syringe and the PICC line connector rested on the resident's arm; - LPN D did not disinfect the PICC line connector prior to attaching the IV medication tubing; - LPN D removed gloves and performed hand hygiene. 3. Observation on 05/15/25 at 10:15 A.M., of Resident #37's peri care showed: - CNA G and CNA J entered the resident's room, did not perform hand hygiene, and put on gloves; - CNA G and CNA J removed the resident's soiled brief; - CNA G and CNA J did not remove gloves and did not perform hand hygiene; - CNA J cleaned the resident's front peri area; - CNA G rolled resident to the right side while CNA J cleaned the residents' back peri area; - CNA G and CNA J did not change gloves and did not perform hand hygiene; - CNA G and CNA J put a clean brief and pants on the resident; - CNA J moved the resident to the edge of the bed; - CNA J lifted the resident from around the waist to pivot the resident into a wheelchair; - CNA G did not remove gloves, did not perform hand hygiene, exited the resident's room, and pushed the resident in a wheelchair to the dining room; - CNA J exited the resident's room, did not remove gloves, did not perform hand hygiene, entered Resident #32's room, did not change gloves, and did not perform hand hygiene. 4. Observation on 05/15/25 at 10:25 A.M., of Resident #32's peri care showed: - CNA J entered the resident's room and did not change gloves and did not perform hand hygiene after providing care to Resident #37; - CNA F and CNA J performed peri care, did not change gloves, did not perform hand hygiene, and transferred the resident to a wheelchair; - CNA J removed gloves, did not perform hand hygiene, and exited the resident's room; - CNA F removed gloves, did not perform hand hygiene, exited the resident's room, and pushed the resident to the dining room in a wheelchair. During an interview on 05/15/25 at 10:45 A.M., CNA J said hand hygiene should be done before entering or leaving a resident's room. Gloves should be changed whenever they were dirty. During an interview on 05/15/25 at 10:45 A.M., CNA F said hand hygiene was done before going into a resident room or before leaving the room. When doing peri care, gloves and hand hygiene needed to be done when going from dirty to clean care. During an interview on 05/16/25 at 11:45 A.M., LPN D said he/she wasn't sure if PPE needed to be worn while administering IV medications through a PICC line. Sometimes information didn't get communicated to staff like it should. EBP should be in place for any resident with wounds, G-tube, trach, colostomy, and catheters. Gowns and gloves should be worn when providing care to residents with anything requiring EBP. When accessing a PICC line, nurses didn't have to do anything to the PICC line connector before or after connecting a flush or tubing. The only thing would be to put a disinfectant cap on the end. Staff should always remove gloves and wash hands before leaving a resident room, especially after peri care. During an interview on 05/16/25 at 11:50 A.M., the Administrator said nurses should be wearing PPE when providing care to residents with EBP. Nurses should scrub the hub of the PICC line with an alcohol swab before and after connecting anything to the PICC, such as a flush or IV tubing. Nurses should also be utilizing the disinfectant cap when the PICC was not being used to prevent any kind of infection. She expects staff to always wash their hands before and after resident care. Staff were to remove their gloves before leaving a resident room. During an interview on 05/16/25 at 12:15 P.M., the Director of Nursing (DON) said EBP was in place for residents with wounds, tracheostomies, ostomies, catheters or PICC lines. Staff should be putting on at a minimum of gloves and gowns when providing care to these residents. When nurses were administering IV medications, they should disinfect the PICC line connector with an alcohol swab before and after flushing or connecting medication lines. A disinfectant cap should be applied to the PICC line connector after use. Staff should always remove their gloves and perform hand hygiene before exiting a resident room. 48532

Based on interview and record review, the facility failed to provide and document that residents received or declined the influenza (a viral infection of the respiratory system) immunizations and failed to provide and document pertinent education to residents or resident representatives regarding benefits, side effects, or warnings of the influenza immunization for two residents (Residents #37 and #40) out of five sampled residents. The facility's census was 39. Review of the facility's policy titled, Immunizations of Residents, last reviewed January 2024, showed: - The purpose of this policy is to ensure all residents are afforded the opportunity to receive vaccinations for preventable diseases; - Administering essential immunizations/vaccinations is key to the health and well-being of long-term care residents. Establishing an immunization program facilitates achievement to this objective; - Vaccinating persons at high risk for complications and their contacts each year before seasonal increases in influenza virus circulation is the most effective means of reducing the effects of influenza. When vaccine and epidemic strains are well-matched, achieving increased vaccination rates among persons living in closed settings (e.g., nursing homes) and among staff can reduce the risk for outbreaks by inducing herd immunity. 1. Review of Resident #37's medical record showed: - admitted [DATE]; - No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this influenza season; - No documentation of the consent or refusal for the influenza vaccination for this influenza season; - No documentation the influenza vaccination was administered or declined for this influenza season. 2. Review of Resident #40's medical record showed: - admitted [DATE]; - An order for an annual influenza vaccination, dated 04/30/25; - No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this influenza season; - No documentation of the consent or refusal for the influenza vaccination for this influenza season; - No documentation the influenza vaccination was administered or declined for this influenza season. During an interview on 05/16/25 at 10:23 A.M., the Director of Nursing (DON) said the admitting nurse was responsible for administering and following up on immunizations. During an interview on 05/16/25 at 10:45 A.M., the Administrator said the admitting nurse obtained consent during the admission. The admitting nurse was responsible for administering any immunizations, but the Infection Preventionist and DON should be conducting audits of the new admissions.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for one resident (Resident #27) out of two sampled residents. The facility's census was 39. Review of the facility's policy titled, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, last reviewed January 2024, showed: - This facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. If the resident uses a different bed or when bed rails are added, the assessment and subsequent documentation must be repeated. Review of the facility's policy titled, Bed Rails, last reviewed January 2025, showed; - This facility will attempt to use appropriate alternatives prior to installing a side or bed rail; - If a bed or side rail is used, this facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: a.) assess the resident for risk of entrapment from bed rails prior to installation, b.) review the risks and benefits of bed rails with the resident or resident representative and obtained consent prior to installation, c.) ensure the bed's dimensions are appropriate for the resident's size and weight, d.) follow the manufacturers' recommendations and specifications for installing and maintaining bed rails, e.) the facility will assess the resident's need for bed rails and all factors involved, including alternatives. Alternatives to bed rails will always be attempted before consideration of bed rail application. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs; - Before bed rails are installed, the facility should: a.) check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible since most bed rails and mattresses are purchased separately from the bed frame; - When installing and using bed rails, the facility should: a.) ensure the bed's dimensions are appropriate for the resident, b.) confirm the bed rails to be installed are appropriate for the size and weight of the resident using the bed, c.) install bed rails using the manufacturers' instructions to ensure proper fit, d.) inspect and regularly check the mattress and bed rails for areas of possible entrapment, e.) regardless of mattress width, length, and/or depth, the bed frame, bed rail, and mattress should leave no gap wide enough to entrap a resident's head or body, f.) check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. Ongoing precautions may include following manufacturer equipment alerts and recalls and increasing resident supervision; - The facility must also conduct routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 1. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of type 2 diabetes mellitus (DM - high blood sugar), chronic obstructive pulmonary disorder (COPD - a lung disease that causes breathing difficulties), congestive heart failure (where the heart can't pump effectively), peripheral vascular disease (narrowing of the blood vessels outside the heart and brain), and bilateral (both sides) above the knee amputation; - No documentation of the maintenance inspection for the side rails. Observations on 05/13/25 at 10:25 A.M., and 2:45 P.M., 05/14/25 at 8:17 A.M., 05/15/25 at 9:48 A.M., and 05/16/25 at 11:11 A.M., and 1:15 P.M., of the resident's bed showed: - The resident's bed with bilateral quarter side rails in the upright position, loosened, and moved with minimal effort. During an interview on 05/13/25 at 10:25 A.M., the resident said the side rails didn't fit his/her bed. Both side rails moved whenever he/she used them for transfers and bed mobility and that was a concern. Staff were aware that the side rails were loose, but no one has done anything about it. During an interview on 05/16/25 at 9:20 A.M., the Maintenance Supervisor (MS) said he/she had not done any inspections/assessments for side rails and/or grab bars. He/She had only been in this position for two weeks. During an interview on 05/16/25 9:30 A.M., the Administrator said the facility had been without a MS since September 2024. The current MS started at the beginning of May. She and the Director of Nursing (DON) had been conducting visual inspections of the bed rails daily. Monthly inspections of the side rails to assess for proper fit had been completed monthly, but she didn't have any documentation to provide. During an interview on 05/16/25 9:33 A.M., the DON said that visual daily inspections of the resident side rails had been completed. She was not sure about about monthly inspections. A side rail consent, physicians order, and bed dimensions should be obtained prior to side rails being placed on a resident's bed. Weekly visual checks, an initial assessment, and then quarterly assessments should be done and side rails should be added to the resident's care plan.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for four residents (Residents #18, #27, #29 and #33) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident Assessment Instrument (RAI/MDS) Process, last reviewed, January 2025, showed: - One of the functions in the RAI/MDS process is to gather data to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; - Ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment by staff qualified to assess relevant core areas and are knowledgeable about the resident's status, needs, strengths and areas of decline. 1. Review of Resident 18's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia (paralysis of one side of the body) right dominant side, cerebral infarction (stroke) and cerebral vascular disease (a condition that affects blood flow to the brain). Review of the resident's May 2025 Physician's Order Sheet (POS) showed: - An order for aspirin (an antiplatelet medication that prevents platelets (small cell fragments in the blood that form clots) from sticking together and forming a blood clot) 81 milligram (mg) chewable tablet by mouth one time a day related to cerebral infarction, dated 12/18/24; - No order for an anticoagulant (a medication used to slow the formation, prevent, or treat blood clots and also known as a blood thinner) medication. Review of the resident's annual MDS, dated [DATE], showed: - Received an anticoagulant; - Did not receive an antiplatelet. Review of the resident's Care Plan, dated 10/16/24, showed: - History of cardiovascular accident (heart attack) and transient ischemic attacks (TIA - mini-strokes); - Resident at risk related to antiplatelet therapy due to a history of stroke episodes. During an interview on 05/15/25 at 10:00 A.M., the resident said he/she did not take a blood thinner. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of type 2 diabetes mellitus (DM - high blood sugar), chronic obstructive pulmonary disorder (COPD - a lung disease that causes breathing difficulties), congestive heart failure (where the heart can't pump effectively), peripheral vascular disease (narrowing of the blood vessels outside the heart and brain), and bilateral (both sides) above the knee amputation. Review of the resident's May 2025 POS showed: - An order for Xarelto (an anticoagulant medication) 15 mg tablet by mouth one time a day, dated 02/15/25. Review of the resident's annual MDS, dated [DATE], showed: - Resident did not receive an anticoagulant medication. Review of the resident's Care Plan, dated 03/05/25, showed: - Resident on anticoagulant therapy (Xarelto) and was at risk for bleeding and bruising. 3. Review of Resident #29's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia and stroke. Review of the resident's May 2025 POS showed: - An order for Eliquis (an anticoagulant medication) 5 mg by mouth two times a day related to cerebral infarction, dated 11/18/24; - No order for an antidepressant. Review of the resident's annual MDS, dated [DATE], showed: - Received an antidepressant; - Did not receive an anticoagulant. Review of the resident's care plan dated, 05/07/25, showed: - Received anticoagulant medication daily; - The use of an antidepressant medication not addressed. 4. Review of Resident #33's medical record, showed: - admitted on [DATE]; - Diagnoses of dementia (a disease that affects thinking, memory, and behavior), psychosis (mental health condition that causes a loss of contact of reality), depression (mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety (a feeling of uneasiness or worry about something that is going to happen or could happen). Review of the resident's May 2025 POS showed: - An order for Eliquis 5 mg by mouth two times daily, dated 12/02/24; - No order for insulin; - No order for an an antiplatelet medication. Review of the resident's annual MDS, dated [DATE], showed: - The resident received insulin injections daily; - The resident received an antiplatelet medication; - The resident did not receive an anticoagulant medication. Review of the resident's Care Plan, dated 03/04/25, showed: - Insulin, anticoagulant, and antiplatelet medications not addressed. During an interview on 5/16/25 at 10:20 A.M. the MDS Coordinator said he/she was fairly new to this position and got the information from the POS and spoke with staff before completing the residents' MDS. He/She said aspirin was an anti-platelet medication and not an anticoagulant medication, and should not be documented as such. During an interview on 05/16/25 at 12:25 P.M., the Director of Nursing (DON) said aspirin was not an anticoagulant and should not be documented as one on the MDS. She did not believe Eliquis was an anticoagulant either. She said the MDS should be completed and should reflect the medications the residents were receiving. During an interview on 05/16/25 at 12:09 P.M., the Administrator said if the residents were taking the medications, then the MDS should be completed correctly for what the residents were taking. 45872 48532

Based on observation, interview, and record review, the facility failed to monitor and keep three resident's (Residents #1, #29, and #40) equipment in good, working order. The facility also failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 39. Review of the facility's policy titled, Safe Environment, dated 01/30/25, showed: - The resident has a right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely; - Housekeeping and maintenance services necessary to maintain a sanitary, including but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored, orderly, and comfortable interior; - Environment refers to any environment in the facility that is frequented by residents, including but not limited to the residents' rooms, bathroom, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. 1. Observations on 05/13/25 at 12:41 P.M., 12:44 P.M., and 12:47 P.M., of the facility's linen carts showed: - The protective covering tattered and torn with rips on the 100 Hall; - The protective covering with a large rip toward the front top-side area, tattered and torn on the 200 Hall; - The protective covering tattered and torn with rips on the 300 Hall. 2. Observations on 05/13/25 at 10:00 A.M., 05/14/25 at 8:06 A.M., and 2:20 P.M., 05/15/25 at 7:30 A.M., and 05/16/25 at 6:50 A.M., and 10:30 A.M., of the 100 Hall showed: - A strong urine odor; - Large visible areas of a dark, brown-like stain on the carpet in front of Rooms 102, 103, 104, and 105. 3. Observations on 05/13/25 at 11:15 A.M., 05/15/25 at 10:20 A.M., and 05/16/25 at 12:18 P.M., of room [ROOM NUMBER] showed: - A four inch (in.) by six in. area of exposed and broken dry wall behind the resident door. 4. Observations on 05/13/25 at 12:12 P.M., and 05/14/25 at 12:02 P.M., of Resident #40's wheelchair showed: - A two in. by three in. opened ripped area with exposed foam on the right-side armrest; - The resident lay his/her right arm on the right-side armrest. 5. Observations on 05/13/25 at 12:34 P.M., 05/14/25 at 12:05 P.M., and 05/15/25 at 11:52 A.M., of Resident #29's wheelchair showed: - A one in. by three in. opened ripped area with exposed foam on the right-side armrest; - The resident lay his/her right arm on the right-side armrest. 6. Observations on 05/13/25 at 12:37 P.M., 05/14/25 at 12:07 P.M., and 05/15/25 at 11:54 A.M., of Resident #1's wheelchair showed: - A seven in. opened area of exposed foam on the left-side armrest; - The resident lay his/her left arm on the left-side armrest. 7. Observation on 05/15/25 at 9:07 A.M., of the 100 Hall showed: - A three in. by five in. cracked piece of corner molding near the floor adjacent to the spa. 8. Observations on 05/15/25 at 2:31 P.M., and 05/16/25 at 12:09 P.M., of the dining room floor showed; - A large visible oblong water-like stained area on the carpet connected to the vinyl flooring near the nurses' station; - A visible three foot (ft.) straight line dark stained area on the carpet near the employee time clock; - A large visible area of a dark, brown-like stain on the carpet in front of the wall vent near the nurses' station leading past the piano toward the 300 Hall. 9. Observations on 05/15/25 at 2:34 P.M., and 05/16/25 at 12:13 P.M., of the 300 Hall showed: - Large visible areas of a dark, brown-like stain on the carpet in front of Rooms 301, 302, 303, 305, and 306; - A five in. by two in. exposed sheetrock area on the ceiling located over the television in room [ROOM NUMBER]. 10. Observation on 05/16/25 at 7:00 A.M., of the 100 Hall showed: - A missing piece of molding on the right side of the door frame in room [ROOM NUMBER]; - A missing piece of molding on both sides of the door frame in room [ROOM NUMBER]; - A missing piece of molding on the left side of the door frame in room [ROOM NUMBER]; - A missing piece of molding on the left side of the door frame in room [ROOM NUMBER]. Review of the Maintenance Repair Log, dated 12/24/25 - 05/08/25, showed: - No documentation of areas of concerns addressed. During an interview on 05/14/25 at 7:11 A.M., Licensed Practical Nurse (LPN) D said the carpets had always been this dirty. Family members and visitors had asked about the odors and the carpet being so dirty. Housekeeping cleaned, however the odors were still there. During an interview on 05/15/25 at 2:57 P.M., the Maintenance Supervisor (MS) said the facility had a special type of floor machine specifically used for the upkeep of the facility's carpet, but it was no longer used. He/She used a residential type carpet shampoo machine recently to clean some areas of the the carpet in the dining room. By the time he/she shampooed a three ft. x three ft. section of the carpeted floor, the water had to be dumped. The water turned black within five minutes of using the facility's carpet shampoo machine. The facility needed a machine that could clean larger areas of the carpet throughout the facility. During an interview on 05/16/25 at 9:27 A.M., Certified Nurse Aide (CNA) G said there was a clipboard at the nurses' station and anyone could add areas that needed to be fixed to the clipboard. The maintenance staff checked it daily. During an interview on 05/16/25 at 9:29 A.M., LPN D said there was a clipboard laying on the nurses' desk ledge and staff could add to it for things to be fixed and the maintenance staff reviewed it. During an interview on 05/16/25 at 9:46 A.M., the MS said he/she had only been in this role for about two weeks, however, staff did put items that needed repaired on the clipboard at the nurses' station. He/She checked it daily and sometimes in the evening before leaving the facility. During an interview on 05/16/25 at 12:15 P.M., the Administrator said the facility had went awhile without any maintenance staff, other than the administration staff assisting. There was not any maintenance staff from September 2024 until about two weeks ago. The repair log clipboard was kept at the nurses' station and staff could write down repairs and also tell the maintenance staff of any concerns related to the facility environment. 48532

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 30 opportunities with four errors made, resulting in an error rate of 13.33% for three residents (Residents #8, #10 and #30) out of six sampled residents. The facility's census was 39. Review of the facility's policy titled, Insulin Administration, last revised May 2012, showed: - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the Humalog/lispro (a rapid insulin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the Fiasp/Novolog/insulin aspart (fast-acting insulin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed: - Prime the pen by turning the dose selector to two units; - Keep the needle upwards and press the push-button until the dose selector reads zero; - Turn the dose selector to select the number of prescribed units; - Push the needle into the skin, then press the dose button until dose selector indicates zero; - Keep the push-button fully pushed in after injection; - Leave the needle under the skin for six seconds and then remove it. 1. Review of Resident #8's Physician Order Sheet (POS), dated May 2025, showed: - An order for insulin aspart Pen per sliding scale for blood sugar of 0-200 = 0 units, 201-300 = 5 units, 301-400 = 7 units, 401 - 500 = 9 units, if over 500 call physician, subcutaneously (injection under the skin) before meals and at bedtime, dated 04/02/25; Observation on 05/14/25 at 11:20 A.M., of Resident #8's medication administration showed: - Licensed Practical Nurse (LPN) E administered 5 units of Novolog subcutaneously for a blood sugar of 217; - LPN E failed to prime the Novolog FlexPen per the manufacturer's instructions prior to the insulin administration. 2. Review of Resident #10's POS, dated May 2025, showed: - An order for Novolog FlexPen per sliding scale for blood sugar of 0-200 = 0 units, 201-300 = 4 units, 301-400 = 8 units, 401-500 = 12 units subcutaneously before meals, dated 02/05/25. Observation on 05/14/25 at 11:47 A.M., of Resident #10's medication administration showed: - LPN E administered 4 units of Novolog subcutaneously for a blood sugar of 257; - LPN E failed to prime the Novolog Flex Pen per the manufacturer's instructions prior to the insulin administration. 3. Review of Resident #30's POS, dated May 2025, showed: - An order for insulin lispro Pen per sliding scale for blood sugar of 0-150 = 0 units, 151-200 = 5 units, 201-250 = 7 units, 251-300 = 9 units, 301-350 = 11 units, 351-400 = 13 units, 401+ = 15 units, if greater than 400 give 15 units and if greater than 500 call the physician subcutaneously before meals and at bedtime, dated 04/01/25; - An order for insulin lispro 3 units subcutaneously before meals, dated 04/20/25. Observation of at 05/14/25 at 11:30 A.M., of Resident #30's medication administration showed: - LPN E administered 11 units of Humalog subcutaneously for a blood sugar of 322; - LPN E failed to prime the Humalog Kwik Pen per the manufacturer's instructions prior to the insulin administration; - LPN E administered the 3 units of Humalog subcutaneously as ordered; - LPN E failed to prime the Humalog Kwik Pen per the manufacturer's instructions prior to the insulin administration. During an interview on 05/14/25 at 11:45 A.M., LPN E said he/she was unaware of the need to waste 2 units of insulin to prime the pen needle before administering insulin to residents. During an interview on 05/16/25 at 11:33 A.M., LPN D said he/she dialed up 2 units of insulin to waste in order to prime the needle before giving the insulin to the resident. During an interview on 05/16/25 at 12:07 P.M., the Administrator said she expects staff to waste 2 units of insulin in order to prime the pen needle before administering insulin to the resident. During an interview on 05/16/25 at 12:29 P.M., the Director of Nursing (DON) said she expects nursing staff to prime the pen needle of the insulin pen by wasting 2 units of insulin before administration of insulin.

Based on observation, record review and interview the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 38. Review of the facility's policy titled, Safe Environment, undated, showed: - A safe, clean, comfortable and homelike environment environment, allowing the resident to use his or her personal belongings to the extent possible; - This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Observations made on 06/18/24 at 12:22 P.M. and 06/20/24 at 8:52 A.M., of the 100 hall and unit, showed: - Several areas of exposed sheetrock and peeled paint on the right side wall by bed 1 in resident room [ROOM NUMBER]; - Several areas of exposed sheetrock, peeled paint and scuff marks on the left side wall by the air conditioner/heating unit near bed 2 in resident room [ROOM NUMBER]; - A 3-1/2 foot (ft.) x 5 inches (in.) of missing flooring at the entrance of resident room [ROOM NUMBER]; - A missing hand rail between resident room [ROOM NUMBER] and resident room [ROOM NUMBER]; - An 18 in. x 12 in. area of the ceiling with exposed sheetrock over bed 2 in resident room [ROOM NUMBER]; - Several areas of exposed sheetrock and peeled paint between the two windows in the unit dining room; - Several areas of exposed sheetrock, peeled paint and scuff marks on the wall with the large butterfly canvas picture in the unit dining room; - Three light fixtures with no protective covering in the unit hallway. Review of the maintenance log, dated 05/02/24 to 06/01/24, showed no documentation of the areas of concern addressed. During an interview on 06/20/24 at 9:27 A.M., Housekeeper C said any environmental concerns are reported to maintenance or written down on the maintenance log located at the nurse's station. During an interview on 06/20/24 at 9:44 A.M., Housekeeper D said he/she writes any environmental concern on a piece of paper and is given to maintenance to repair or fix. He/She has not seen anything recently to report to maintenance as an environmental concern. During an interview on 06/20/24 at 10:32 A.M., the Maintenance Supervisor (MS) said staff should be writing down any environmental concerns on the maintenance repair log. MS said it is hard to remember what needs to be fixed when he/she is told in passing. MS said daily rounds are done and in the process of fixing the things he/she has been made aware of on the maintenance log. MS has been in the maintenance supervisory position since April. During an interview on 06/20/24 at 10:37 A.M., the Administrator said she would expect staff to write down any environmental concern that needed to be addressed in a timely manner on the maintenance repair log located at the nurse's station.

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments, a federally mandated assessment tool to be completed by the facility staff, for one resident (Resident #8) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Resident Assessment, undated, showed: - This facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity; - The comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, uses the resident assessment instrument (RAI - a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life) specified by the Centers for Medicare and Medicare (CMS, the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace); - Within 14 days after this facility completes a resident's assessment, this facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System including an annual assessment. 1. Review of Resident #8's medical record showed: - The brief interview for mental status (BIMS) (a test used to get a quick snapshot of how well the resident is functioning cognitively), score of 15, indicated the resident to be cognitively intact; - No documentation of a urinary tract infection (UTI, an infection that occurs when bacteria enters and grows in the urinary tract). Review of the resident's annual MDS assessment, dated 04/07/24, showed section I2300 marked for urinary tract infection in the last 30 days. Review of the facility's CMS 802 Matrix (a tool used to identify pertinent care categories), dated 06/17/24, showed resident marked for a UTI. During an interview on 06/19/24 at 10:02 A.M., the resident said he/she has not had a UTI since last year in 2023 and it was treated with medication. During an interview on 06/19/24 at 10:50 A.M., the MDS Coordinator (MDSC) said he/she has only been in the position for three weeks and works at another facility. He/She is currently reviewing resident soft charts and has found discrepancies. If a resident does not have a urinary tract infection and is not being treated with an antibiotic, it should not be marked on the resident assessment. During an interview on 06/19/24 at 10:58 A.M., the Director of Nursing (DON) said the resident had a UTI and a physician order for Cefdnir (an antibiotic for bacterial infections) which was completed back in July 2023. The resident assessment should not have been marked for a UTI in the last 30 days on the annual MDS or indicated on the CMS 802 Matrix. This will be addressed with the MDSC.

Based on observation, interview and record review, the facility failed to develop a care plan with specific interventions to meet individual needs of two residents (Residents #1 and #35) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Comprehensive Care Plans, not dated, showed: - The purpose of this policy is each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. - Measurable objectives and timeframes to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the Resident Assessment Instrument (RAI) process; - The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) and paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly, out of touch with reality, disorganized speech or behavior). Review of the resident's care plan, revised 06/07/24, showed - The resident smoked; - No individualized interventions for smoking. Observations showed: - On 06/17/24 at 10:20 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/18/24 at 3:30 P.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision. 2. Review of Resident # 35's medical record showed: - admitted [DATE]; - Diagnosis of cerebral palsy ( a group of neurological disorders that affect the brain and nervous system, causing lifelong impairments in movement and coordination) and anxiety (a feeling of worry, nervousness or unease about an imminent event or something with an uncertain outcome). Review of the resident's care plan, revised 06/10/24 , showed - The resident smoked; - No individualized interventions for smoking. Observations showed: - On 06/17/24 at 10:40 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/18/24 at 10:36 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/19/24 at 10:25 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision. During an interview on 06/18/24 at 1:01 P.M., the resident said he/she wears the apron when he/she smokes. During an interview on 06/20/24 at 11:37 A.M., the Director of Nursing (DON) said any resident that smokes and has an apron/protector should be included on the care plan. The DON said the resident has worn the protector since he/she has been in this facility. During an interview on 06/20/24 at 12:20 P.M., the Clinical Liaison said if a resident smokes then it should be on the care plan with interventions in place. 45872 48532

Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to using bed rails and appropriately plan care for one resident (Resident #34) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Restraints-Physical-Side Rails, not dated, showed: - Assess resident's need for restraint use; - Obtain physician's order for restraint; - Develop or review resident care plan for type of restraint, reason for use, alternate methods to be used and method application; - Determine the type of side rails to be used; - Determine the medical symptoms to be treated with the side rails; - Involve the resident and the resident's representative in planning for side rail use. Many residents request to have side rails up when in bed to improve bed mobility and provide a feeling of safety; 1. Review of Resident #34's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe), falls, severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function); - No documentation of any attempts made with alternative methods prior to bed rail use; - No documentation of an informed consent signed explaining the risks and benefits for the bed rail use; - No documentation of a bed rail assessment completed. Review of the resident's quarterly Minimal Data Set (MDS-a federally mandated assessment completed by the facility), dated 03/24/24, showed: - Requires substantial assistance with bed mobility; - No bed rail use. Review of the resident's care plan, dated 06/03/24, showed the use of bed rails not addressed. Observation of the resident on 06/17/24 at 10:22 A.M. and 06/18/24 at 12:17 P.M., showed quarter bed rails on right and left side of bed with left side of bed up against the wall closest to the door. During an interview on 06/17/24 at 10:22 A.M., the resident said he/she uses the bed rails to get in and out of bed. During an interview on 06/19/24 at 4:12 P.M., LPN J said the resident uses the bed rails for bed mobility and to get in and out of bed. He/she said the resident's bed was from hospice and it came with the bed rails. The charge nurse should have completed an assessment for the use of the side rails. During an interview on 06/20/24 at 11:30 A.M., the Director of Nursing (DON) said side rail assessments should be completed upon admission and quarterly. She said the charge nurse is responsible for completing the assessment. During an interview on 06/20/24 at 12:00 P.M., the Administrator said the charge nurse starts the bed rail assessment, should notify DON and update MDS (Minimal Data Set) Coordinator. She said bed rail assessments should be completed upon admission, when the need arises and quarterly.

Based on interview and record review, the facility failed to provide food of the resident's preferences, and failed to document likes and dislikes on the meal cards for three residents (Residents #18, #34, and #38) out of 12 sampled residents and one resident (Resident #37) outside the sample. The facility census was 38. Review of the facility's policy, titled, Resident's Food Likes and Dislikes, not dated showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes. - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. Review of Resident #18's medical record showed: - Diagnoses of anemia (a condition when blood produces a lower-than-normal amount of healthy red blood cells), hypertension (HTN) (high blood pressure), diabetes (a disease that occurs when the body has too much blood sugar), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and depression (a common and serious mental health condition that can affect how people think, feel, and act). During an interview on 06/18/24 at 12:30 P.M., the resident said he/she did not like spaghetti and had asked for chicken strips and fries for lunch. He/She said, I just tell them what I want. Review of the resident's meal card showed no dislikes documented. 2. Review of Resident #34's medical record showed: - Diagnoses of anemia and chronic obstructive pulmonary disease (COPD) (a chronic lung disease that makes it difficult to breathe). Review of the resident's quarterly MDS, dated [DATE] showed: - A BIMS score of 15 out of 15, indicated the resident to be cognitively intact; - Independent for eating, hygiene, dressing and transfers. During an interview on 06/17/24 at 10:22 A.M., the resident said he/she does not like white gravy and the kitchen staff continue to put it on his/her plate. The resident said he/she has asked the staff several times for it not to be served to him/her. He/she said that card means nothing, just this morning they served it on the plate again. Review of the resident's meal card showed white gravy documented under the dislikes. 3. Review of Resident #38's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a heart condition when the heart does not pump like it should). Review of the resident's admission MDS, dated [DATE] showed: - A BIMS score to be 14 out of 15, indicated the resident to be cognitively intact; - Independent for eating. Observation on 06/17/24 at 12:26 P.M. noon meal plate served to the resident showed sliced ham, steamed broccoli, stuffing, roll, pears with cool whip and tea to drink. During an interview on 05/17/24 at 12:45 P.M., the resident said he/she takes medications and cannot have green vegetables. The resident said, they served me broccoli again today and I have told the kitchen staff before about it. He/she said his/her dislikes are coffee and fruit punch. Review of the resident's meal card showed no dislikes or the resident cannot have green vegetables documented. 4. Review of Resident #37's medical record showed: - Diagnoses of diabetes and cardiorespiratory conditions (serious disorders that affect the heart and lungs). Review of the resident's quarterly MDS, dated [DATE] showed: - A BIMS score to be 13 out of 15, indicated the resident to be cognitively intact; - Independent with all Activities of Daily Living (ADL's). During an interview on 05/19/24 at 12:35 P.M., the resident said he/she does not like eggs of any kind. He/She said staff has been told numerous times no eggs for him/her. Review of the resident's meal card showed no dislikes documented. During an interview 06/20/24 11:05 A.M., the dietary manager (DM) said she is responsible for assessing residents upon admission for their likes and dislikes. She said she would document the resident's likes and dislikes on their individualized dietary cards. The DM said if she is notified of a change, then the dietary card is updated at that time, and the residents are assessed periodically for changes. During an interview on 06/20/24 at 11:33 A.M., the Director of Nursing (DON) said the dietary department is responsible for the resident's meal card documentation and the assessment should be done right away upon admission. He/She said the dietary department needs to be talking to the resident's about their likes and dislikes. During an interview on 06/20/24 at 12:20 P.M., the Administrator said the dietary department should be speaking with the resident's upon admission and documenting their likes and dislikes on the dietary card and serving the resident's their preferences. She also said the card should be updated as the resident's choices change.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two Certified Nurse Assistants (CNA) A and CNA B out of two sampled CNA's. The facility's census was 38. Review of the facility's policy titled, Nurse Aide Regular In-Service Training,, dated 01/30/24 showed: - The facility's in-service training must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. 1. Review of the in-service record for CNA A showed: - A hire date of 01/24/23; - A total of eight hours and 25 minutes of annual in-service training for January 2023 through January 2024; - Less than twelve hours of in-service education for January 2023 through January 2024. 2. Review of the in-service record for CNA B showed: - A hire date of 05/13/23; - A total of 7 hours and 45 minutes of annual in-service training for May 2023 through May 2024; - Less than twelve hours of in-service education for May 2023 through May 2024. During an interview on 6/19/24 at 8:00 A.M., the Clinical Liaison said the facility does the in-services face to face and cannot get the employees to attend the in-services at times. She said the CNA's should have at least 12 hours of annual in-service training.

Based on interview and record review, the facility failed to send monthly transfer logs to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (a program that advocates for residents, provides information and help resolve problems) in a timely manner. The facility's census was 38. Review of the facility's policy titled, Transfer and Discharge, Voluntary - Notification of State LTC Ombudsman, undated, showed: - Provide State LTC Ombudsman with notification of voluntary resident transfers and discharge from this facility as required by guidance in F623; also to provide added protection to residents from being appropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Office of State LTC Ombudsman is aware of the facility practices and activities related to transfers and discharges; - Written notice to the State LTC Ombudsman when a resident is voluntarily discharged from the facility or has a transfer/emergency admission to the hospital can be sent as a list of residents monthly. Review of the monthly transfer logs, dated December 2023 through May 2024, showed: - December 2023 transfer log not submitted with a sent confirmation; - January 2024 and February 2024 transfer logs not submitted with a sent confirmation. During an interview 06/12/24 at 9:41 A.M., the Regional LTC Ombudsman said he/she did not receive the facility's monthly transfer logs for the year 2023 or the beginning months of year 2024. During an interview on 06/18/24 at 3:08 P.M., the Social Service Director (SSD) said he/she only had faxed confirmations for March, April and May 2024. Monthly transfer logs should be sent to the ombudsman on a monthly basis, in a timely manner with a confirmation it has been sent. During an interview on 06/20/24 at 12:05 A.M., the Administrator said she would expect the designee responsible for sending the facility's transfers logs to the LTC Ombudsman to submit reports on a monthly basis, in a timely manner with proof of sent confirmation.

Based on observation, interview and record review, the facility failed to ensure residents were informed of resident rights and responsibilities information verbally and in writing. The facility census was 38. Review of the facility's policy titled, Protecting, Promoting and Ensuring Resident Rights - Facility Responsibility, undated, showed: - Each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside this facility. This facility promotes and protects the exercise of all resident's rights; - Residents will be informed of the resident rights in writing upon admission. This may be accomplished by giving them a copy of the Resident Rights or the Resident Handbook; - The list of resident rights will be available for residents to review at any time. This facility also posts resident rights at the following location(s); - The policy did not address the location(s) of the list of resident rights and/or posting. Observation made on all days of the survey, 06/17/24 through 6/20/24, of the 100 Hall, 200 Hall, 300 Hall, dining room and front lobby, showed no large print texts of the facility's resident rights and responsibilities. During a resident council meeting on 06/19/24 at 3:25 P.M., four residents present said they were not aware of any resident rights reading material and/or posters in the facility. They do not remember anyone going over resident rights with them while at the facility or upon admission. During an interview on 06/19/24 at 3:27 P.M., the resident council president said there used to be a resident rights poster on the wall in the dining room, but it has been gone for a while. The Activity Director (AD) goes over resident rights topics, but not at every resident council meeting. During an interview on 06/20/24 at 9:08 A.M., the AD said he/she has not noticed a resident rights poster in the facility since her employment in February 2023. AD said a resident rights poster will be requested and placed in the facility for residents to view at anytime. During an interview on 06/20/24 at 10:48 A.M., the Administrator said she would expect a resident rights poster be available for residents to view at his/her leisure. There are paper copies on a table next to her office in the front lobby.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents. The facility census was 38. Review of the facility's policy titled, Pest Control Program, dated 04/01/24, showed: - It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; - Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated; - Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. Observations on 06/17/24 at 10:45 A.M., of resident room [ROOM NUMBER], showed: - Three flies laid on a bedpad on top of bed 1; - Several flies laid on a comforter on top of bed 2. Observations on 06/18/24 at 12:22 P.M., of resident room [ROOM NUMBER], showed: - Two flies laid on a bedside table beside bed 1; - Two flies laid on a bedpad on top of bed 1; - Several flies laid on a comforter on top of bed 2. Observations on 6/19/24 at 11:48 A.M., showed Certified Nursing Assistant (CNA) E walked with a fly swatter in his/her hand and swatted at flies on the 100 unit hall. Observations on 06/20/24 at 8:58 A.M. showed: - Resident #16 sat in his/her recliner asleep while a fly laid on his/her forehead; - Two flies laid on the right armrest of his/her recliner. Observations on 06/20/24 at 9:04 A.M. showed two flies buzzed in the 100 unit hallway. Observations on 06/20/24 at 9:40 A.M. showed two flies laid on the outer covering of the clean linen cart. Observations on 06/20/24 at 10:22 A.M., showed Housekeeper C walked with a fly swatter in his/her hand and swatted at flies on the 100 hall. Review of the maintenance log, dated 05/02/24 to 06/01/24, showed no documentation regarding pest control issues. Review of the pest control inspection reports, dated April 2024 and May 2024, showed no issues with pest control in residential areas of the facility. During an interview on 06/20/24 at 9:33 A.M., Resident #8 said there are flies in his/her room, but they are not as bad this week. During an interview on 06/20/24 at 9:40 A.M., CNA F said flies have been an issue on the 100 hall and unit. There are two fly swatters available that he/she used to kill the flies. Maintenance has been told about the fly concern. During an interview on 06/20/24 at 9:44 A.M., Housekeeper D said any environmental concerns are reported to maintenance or written down on the maintenance log located at the nurse's station. He/she has seen flies in the facility, but has not reported it because the staff kill them. During an interview on 06/20/24 at 10:32 A.M., the Maintenance Supervisor (MS) said staff should be writing down any environmental concerns like pest control issues. MS said he/she has been in the position since April and the facility just got a new pest control vendor in the last couple of months. During an interview on 06/20/24 at 10:37 A.M., the Administrator said she would expect staff to write down any environmental concerns such as pest control issues and let maintenance know in a timely manner to address the concern.

Based on observation and interview, the facility failed to post daily menus and a list of available substitutions for residents to reference. The facility census was 38. Review of the facility's policy titled, Menu Posting and Display, undated, showed: - All menus for the current week are clearly posted and dated to adequately document meals that are to be served and to guide staff assisting with the meal service; - The dated menu for the current week is posted in areas easily accessible to residents and families. Observations on 06/17/24 at 9:58 A.M., 06/18/24 at 8:45 A.M. and 06/19/24 at 10:05 A.M., of the main dining room and the unit dining room, showed: - No daily menus posted; - No list of available substitutions. During an interview on 06/18/24 at 12:15 P.M., Activity Director (AD) said he/she has never seen daily lunch menus posted. AD said he/she had been employed since February 2024. During a resident council meeting on 06/19/24 at 3:18 P.M., four residents present said daily menus were not posted in the dining room. He/She said posted menus would be nice to reference in case something changed on the menu. It would also be nice to have a list of substitutions to reference in case he/she wants to change his/her meal choice. During an interview at 06/19/24 at 3:27 P.M., the resident council president said there was a cabinet in the dining room with three sections that used to have daily menus posted for breakfast, lunch and supper. It has been a while since daily menus have been posted in the dining room. During an interview on 06/20/24 at 10:02 A.M., the Dietary Manager (DM) said there should be daily menus placed in the designated area located in the dining rooms for referencing. There should also be a list of available substitutions posted for resident choices. During an interview on 06/20/24 at 11:02 A.M., the Administrator said she would expect food menus be posted daily in the dining rooms for residents to view and available substitutions should be posted as well. 45872 48532

Based on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #5) from abusing two residents outside the sample (Residents #13 and #16) affecting one sampled resident (Residents #9) and two additional residents (Residents #15 and #17) with the potential to affect all residents from a facility census of 43. 1. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/5/14, showed: - Signs and symptoms of [MEDICAL CONDITION] (temporary state of mental confusion and clouded consciousness) including inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION]; - Evidence of an acute change in mental status; - [MEDICAL CONDITION] indicated by delusions (a false belief); - Physical and verbal behaviors directed toward others as well as behaviors not directed toward others; - Significant disruption of care and living environment and putting others at risk for physical injury; - Behavior has worsened compared to previous assessment; - A [DIAGNOSES REDACTED]. - Receives antipsychotic (a medication that aide in controlling symptoms or behaviors of mental illness), antianxiety, and antidepressant medications. Review of a history and physical dated 4/16/14 showed: - [DIAGNOSES REDACTED]. - Referred by the facility for screaming at residents, hitting, and agitation. Review of psychiatry consultant notes showed: - On 4/27/13 visit, the resident still actively psychotic, becomes easily agitated when not understood, responds to his/her active hallucinations, difficult to redirect at times; - On 7/25/13 visit, staff report that resident starts becoming more psychotic usually towards the third week of the month one week before his/her [MEDICATION NAME] (taken in the body or administered in a manner other than the digestive tract) antipsychotic medication is given; - On 2/20/14 visit, the resident followed for delusions related to his/her dementia, becomes quite loud, assaultive, and agitated, and had recent psychiatric hospitalization [DATE] to 1/28/14. Resident delusional and hallucinating at the time of the visit; - On 3/27/14 visit, the resident followed for delusions related to his/her dementia, becomes quite loud, assaultive (suggestive of violent attack), and agitated, and had recent psychiatric hospitalization [DATE] to 3/26/14 subsequent to a severe altercation with another resident. Resident has exacerbation of [MEDICAL CONDITION] and upon return to the facility, started acting out again, slamming doors and becoming threatening to others. Resident is quite suspicious of others. Review of nursing notes for the resident showed: - On 4/26/13, the resident's family member up to nursing station upset due to resident being sent to psychiatric facility for behaviors stating "those places never help anyone". Referred to Director of Nursing (DON) per telephone who later called to have them cancel transport to psychiatric facility. - On 4/28/13, the resident up all shift pacing up and down halls; - From 5/3/13 through 5/23/13 delusional thinking, conversation with self, nonsensical speech, resident yelling, repeated sexual behaviors toward staff, and letting self out for smoke breaks., - On 9/12/13, the resident continues to have occasional outbursts with the reason not always known by staff; - On 11/21/13, the resident refused medications, yelled at nurse, and slapped the pills out of her hand, and continued to yell at the nurse; - On 12/5/13 and 12/25/13 yelling out at staff and inappropriate speech and cursing; - On 1/5/14 and 1/6/14, the resident repeatedly banging on kitchen window, yelling and refusing medications, and asking for coffee; - On 1/21/14, the resident hit another resident in the face, yelling, cursing, refused medications and was transported for psychiatric evaluation. - On 1/28/14, the resident returned to the facility with medications changes of [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 250 milligram (mg) three times daily decreased to two times daily, and added [MEDICATION NAME] (a parkinson medication) 0.5 mg one tab by mouth twice daily. - On 1/29/14, the resident refused medications and yelling at staff; - From 2/14/14 through 2/27/14, the resident refused medications, yelling disruptive all shifts, sexual inappropriate behavior to staff; - On 3/7/14, Resident #5 struck Resident #16 with a coffee mug in the face causing swelling, redness and a cut under Resident #16's left eye. The family refused initially to send the resident out to the psychiatric facility. The DON later spoke with the resident's wife and she agreed to have the residents transferred to the psychiatric facility. - On 3/8/14 Resident #5 transferred for psychiatric evaluation. - On 3/26/14, Resident #5 returned to the facility with medications changes of [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 10 mg one tablet at bedtime increased to [MEDICATION NAME] 15 mg one tablet twice daily, [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 5 mg one tablet by mouth twice daily decreased to [MEDICATION NAME] 2 mg twice daily. - From 3/27/14 through 3/29/14, Resident #5 verbally harassing Resident #16, refusing to come in from smoking, slamming shoes on tables and yelling at staff. - On 4/4/14, Resident #5 kicked over the carpet cleaner, chased staff member, and cursing. - On 4/15/14, Resident #5 shoved the wheelchair of Resident #16. No injuries documented. Resident #5 sent out to psychiatric facility; - On 4/25/14, Resident returned to the facility with no changes to medication regimen. - On 5/1/14 through 5/6/14 the resident emptied his/her catheter bag in the smoking area, refused medications, yelling, cursing and struck Resident #13. Hematoma to the left forearm with compression dressing applied by a staff member. Resident #5 transferred to psychiatric facility. Review of Resident #5's activity notes, dated 4/16/14, showed the resident continues to be more confused, hollers out at staff and other residents, pushed over vacuum, hit another resident, and had recent stay in hospital. Review of Resident #5's social service notes showed: - On 1/6/14, the resident sat in the dining room yelling out; - On 2/3/14, the resident is having outbursts of angry yelling and cursing in the dining room. When the Social Service Designee (SSD) talked to him/her about yelling and cursing, the resident looked at the SSD with anger in his/her face; - On 4/4/14 while the SSD helped a CNA with breakfast meal service, the SSD told the resident his/her breakfast was on the table, the resident began yelling and cursing him/her in front of the other residents. The resident proceeded to go over and push over the floor shampooer that the Maintenance was using, again yelling and cursing; - On 4/10/14, the resident was drinking mouth wash; - On 4/16/14, the resident has been having anger issues with outbursts cursing, and he/she shoved a wheelchair with a resident in it. Resident was sent to a psychiatric facility. Review of the resident's care plan, dated 2/4/14, showed: - Since return from psychiatric hospital, the resident continues to holler out, curse, get upset when smoke break is a little late, and goes to kitchen every few minutes demanding another cup of coffee; - On 2/11/14, the resident hollering, cursing loudly in the dining room, broke the door to the dietary department; - On 2/21/14, the resident started talking about a new imaginary friend "Clarence" and had a soda for him at a party today. Review of the resident's care plan, dated 2/4/14, showed the following behavioral approaches/interventions: - Maintain a calm environment and approach to the resident; - Encourage resident to work on his/her sketch pad he/she has been drawing on and praise for his/her drawings; - If resident has delusions/hallucinations, do not try to reason or confront him/her, but offer reassurance; - Assure resident that staff is bringing his/her cigarettes for smoke break; - Avoid power struggles with resident; - Refocus conversation when resident becomes verbally abusive, talk to him/her about his/her drawings; - Administer medications [MEDICATION NAME], and monitor and record effectiveness and report any adverse side effects, continue psych therapy. During a resident group interview on 5/5/14 at 2:30 P.M., Resident #15 said he/she was not usually afraid of anyone, but he/she was afraid of him/her (Resident #5). Observations on 5/6/14 at 10:50 A.M., a resident yelled loudly in the dining room, and Resident #5 stood with both left and right fists alternately and repeatedly hit the seated Resident #13 in the head and face as well as the left arm as Resident #13 tried to block the punches. Resident #13's glasses were bent and the lenses loose. Resident #13's spouse helplessly watched as staff members arrived and got Resident #5 to go to his/her room and staff began assessing Resident #13 for injuries. The resident did not need to be sent to the hospital for his/her injuries. During an interview on 5/6/14 at 11:00 A.M., the facility's Quality Assurance Nurse Consultant said the nurses were calling now to find a place for the resident because he/she cannot stay here due to his/her behaviors. During an interview on 5/6/14 at 1:20 P.M., the Administrator said the ambulance transported the resident (Resident #5) without incident and the resident was laughing and thought it funny that they were taking him/her out. During an interview on 5/8/14 at 9:00 A.M., the facility's corporate Director of Operations said she had looked at the medical record and could see the issues concerning the resident's behaviors. During an interview on 5/8/14 at 9:20 A.M., Housekeeping Staff M, N, and O all said sometimes the resident sat quietly and sometimes he/she would yell. Housekeeping Staff M said on his/her bad days, he/she was slamming doors, cursing, and yelling. During an interview on 5/8/14 at 9:25 A.M., Resident #15 said the resident (Resident #5) yelled regularly and sometimes at meals, and one day he/she balled up his/her fist and wanted to hit me, but the bookkeeper at the time took care of it. Resident #15 said one time he/she saw him/her (Resident #5) kick in the cabinet by the kitchen and broke it. During an interview on 5/8/14 at 9:35 A.M., Resident #9 said one night after supper Resident #5 followed him/her to his/her room, grabbed me by the arm and tried to kiss me. He/she said I told him/her never to do that again. He/she said the resident would yell real loud daily and would be loud at night getting ice. During an interview on 5/8/14 at 9:45 A.M., the Activities Director said some days Resident #5's yelling would disturb the general population and some residents would yell back at him/her. She said the resident went after Residents #13 and #16, empties pee in the floor, and has broken kitchen doors. During an interview on 5/8/14 at 9:55 A.M., the Dietary Manager said the Resident #5 yells to smoke and yells sometimes for coffee. During an interview on 5/8/14 at 10:47 A.M., Licensed Practical Nurse (LPN) D, the DON, and the MDS Coordinator all agreed the resident's yelling was only occasional and that he/she mostly just sat and talked to him/herself, but would yell sometimes when he/she wanted to smoke. During an interview on 5/8/14 at 10:52 A.M., Resident #17 said Resident #5 yelled and cursed daily and has been taken out of the facility two or three times for his/her behavior. During an interview on 5/8/14 at 10:55 A.M., the SSD said Resident #5 yells sometimes, but mostly for smoke breaks. During an interview on 5/16/14 at 2:30 P.M., Resident #5's Psychiatric Consultant said he does not make the decisions on the placement of patients, but treats psychiatric patients where they reside. He said there must be considerations made for length of stay at the facility, the fact that the paranoid [MEDICAL CONDITION] will act out upon the delusion or internal stimuli rather than necessarily being provoked, and the patient may be on numerous medications and still be the same. During an interview on 5/16/14 at 2:45 P.M., the Nurse Practitioner (NP) Q said she was only aware of the incident that happened on 5/6/14. NP Q said if the resident is having behaviors such as 5/6/14 then he/she is inappropriately placed. Review of the facility's policy on abuse prohibition shows: - It is the purpose of this facility to prohibit mistreatment, neglect, and abuse of residents; - Physical abuse is defined as hitting, slapping, pinching, kicking, etc. Review of the facility's abuse and neglect response and reporting guidelines showed a resident unusual occurrence requiring an investigative report form to be completed included resident to resident altercations in which the resident is injured to the extent that physician intervention and/or transfer to a hospital is required.