Every finding on record at Avalon Health Care Center at Stoneridge

Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for unnecessary medications, the facility failed to notify the physician when the resident was observed over several days with delayed processing, drowsiness and a reported concern by the resident representative of Resident #8's alertness. Subsequently, the resident exhibited low blood pressure and an oxygen saturation of 90 %. The findings include: Resident #8 was admitted to the facility in October 2025 with diagnoses that included spinal stenosis, dementia, and osteoarthritis of the right and left knees. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition, had the presence of pain, almost constantly, received a scheduled pain medication regimen and received as needed pain medication or was offered and declined, and was receiving medication from the following high-risk drug classes: antidepressant, diuretic, opioid, and anticonvulsant. A physician's order dated 4/7/26 directed to administer Lyrica 100mg, 1 capsule by mouth two times daily, for neuropathy. A physician's order dated 4/17/26 directed to administer Fentanyl transdermal patch 72-hour 12mcg/hour, apply 12 mcg transdermal in the afternoon every 3 day(s) related to unilateral arthritis in the right knee and unilateral osteoarthritis in the left knee and FYI; remove Fentanyl patch if too sedated, every shift. A physician's order dated 4/21/26 directed to administer Oxycodone 5mg, 1 tablet by mouth every 6 hours, as needed for leg pain for 14 days moderate (4-6) to severe (7-10). The Consultant Pharmacist Report dated 4/21/26 identified Resident #8 has a prescription for an opioid Oxycodone, Fentanyl in combination with a medication that may increase adverse effects, Lyrica. Please consider avoiding or minimizing concomitant use, perhaps decreasing Lyrica. Rationale for the recommendation: this combination may increase the risk of toxicity and overdose. The FDA has issued a boxed warning stating that healthcare professionals should limit prescribing opioid pain medications with other CNS depressants only to those whose alternative treatment options are inadequate. Additionally, concomitant use of stimulants may mask the signs and symptoms of overdose. If prescribed together, the minimum dose and duration of each drug needed to maintain the desired clinical effect should be used. MD #1 signed the report on 4/28/26, accepted the recommendations and identified the following modifications: will wean as tolerated, in process of switching. The care plan dated 4/23/26 identified Resident #8 was on pain medication related to diagnosis of spinal stenosis and arthritis. Interventions included administering medications per the physician's order and monitoring, documenting, and reporting signs and symptoms of analgesic complications such as constipation, new or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, diarrhea, and falls. Notify the physician of abnormalities. The physical therapy (PTA) note dated 4/30/26 identified Resident #8 was received supine in bed and when awoken by this therapist, he/she reported being tired and did not open his/her eyes. When asked if he/she had any pain Resident #8 reported that he/she did not have pain and was left supine in bed with call bell available and advised that PT would return later if able. Resident #8 verbalized understanding. The PTA note dated 5/1/26 (untimed) identified Resident #8 was received supine and PTA noted increased delayed processing when asked questions if he/she was having pain. Resident #8's nurse aide was present and also reported the resident's answering questions were delayed as of recently and that she noticed increased difficulty with feeding, but the resident was receptive with getting supervision/help with feeding. Resident #8 did reply that he/she did not want heat or ice to decrease any pain and was unable to communicate his/her thoughts effectively to this writer. Resident #8 and PTA discussed that he/she will be going to pain clinic later this month for further evaluation. Findings reported to the nursing supervisor, Resident #8 was left in the nurse aide's care. The nurse's note (RN) dated 5/1/26 at 3:26 PM identified Resident #8 had edema +2 to left inner knee, compression stockings readjusted, will monitor. No pain or heat noted to the site, Resident #8 was in agreement with this plan of care. The nurse's note dated 5/2/26 at 2:59 PM identified Resident #8 was noted with drowsiness throughout the shift, arouses to verbal with tactile stimuli, upon conversing noted to look at nursing staff then gaze fell off and appeared to be looking off into space, answering verbally at times. During mealtime, Resident #8 appeared confused with utensil use when food placed in hand he/she would bring food to his/her mouth at times yet not every time, requiring assistance with food and fluids. Resident #8's representative (Person #1) was in to visit, questioning alertness and reported while visiting with family pet, no response from Resident #8, and stated an understanding this was normal through aging process and does not want Resident #8 to be in pain yet verbalized concerns medical versus aging process. Resident #8 was dependent for ADL's and hoyer transfers out of bed to wheelchair. Oral medications were administered as ordered with no difficulty swallowing with verbal prompts. Lung sounds diminished, no cough noted or reported. The clinical record failed to identify an RN assessment had been completed following the resident representatives concerns. Observation on 5/3/26 at 11:50 AM identified Resident #8 sleeping during an activity in the recreation room. Interview with Recreation Aide #1 on 5/3/26 at 1:17 PM identified that she had noticed that Resident #8 had increased sleepiness in the last 10 days or so, it appears that Resident #8 is sleeping but he/she is listening. Recreation Aide #1 indicated that Resident #8 would still sing along to songs but doesn't say all the words. Interview with LPN #1 on 5/3/26 at 1:27 PM identified that they have been monitoring Resident #8 for drowsiness since starting him/her on the Fentanyl patch, and that Resident #8 had been noted to have drowsiness since before the medication changes. LPN #1 indicated that she had recently discussed Resident #8's drowsiness with his/her representative (Person #1) after Person #1 had expressed that Resident #8 did not demonstrate usual behaviors when visiting with the family pet, and that Person #1 had felt that there was a change in Resident #8's baseline since his/her last visit which was around 4/24/26. LPN #8 indicated that she has noticed a progressive change in Resident #8 over the last few months, but she had not identified any acute changes with Resident #8 nor noticed any pattern or consistent drowsiness since starting the patch. LPN #1 identified that she had discussed Person #1's concerns with RN #1 and he evaluated Resident #8 and did not think that he/she was lethargic or not responding. LPN #1 further indicated that neither the nurse aides nor PT had brought any concerns regarding Resident #8 to her attention. Interview with NA #1 on 5/3/26 at 1:30 PM identified that he/she had noticed a fast change in Resident #8, one day Resident #8 was ok and then maybe 2 weeks ago (the second to last week in April) he/she had seen changes in Resident #8, including being more spacey, less responsive, difficulty holding a drinking glass, and looking blankly. NA #1 indicated that she had notified LPN #1 of her observations, the week prior. Observation of Resident #8 on 5/3/26 at 1:33 PM identified Resident #8 was awake and sitting up in bed, the nurse aide was taking his/her vital signs, blood pressure was 112/65 (normal range 90-120/60-80), pulse was 67 (normal range 60-100 bpm), and his/her oxygen saturation was 92% (normal range 95-100%) on room air. Interview with RN #1 on 5/3/26 at 1:40 PM identified that Resident #8 had days where he/she was more alert and less alert due to his/her progressive dementia, and that they were trying different things to manage Resident #8's pain; Resident #8 had been taking Oxycodone, and then Lyrica was added, and most recently a Fentanyl patch was added to the regimen. RN #1 indicated that he had been reviewing Resident #8's meal intake over time and identified that while his/her alertness [NAME] and flows, he/she has been alert enough to eat and there were no changes in his/her vital signs. RN #1 identified that he did see Resident #8 when LPN #1 notified him/her of Person #1's concerns and he confirmed LPN's evaluation that there was no acute change. The nurse's note dated 5/3/26 at 8:20 PM identified Resident #8 was alert, oriented to self with slow verbal responses, and appeared to be too sedated. The nursing supervisor was notified and agreed to remove the Fentanyl patch, as ordered. It was removed. The nurses' note dated 5/3/26 at 8:52 PM identified Resident #8 presented to nursing with increased drowsiness; he/she has an order to remove Fentanyl patch with notable increased sedation, vital signs: blood pressure was 86/48, pulse was 60, respiratory rate was 16 (normal rate 12-20 breaths per minute), oxygen saturation was 90% on room air. The patch was removed and the on-call physician was notified of the removal. Interview with the Director of Rehabilitation Services (PTA #1) on 5/5/26 at 8:30 AM identified that a referral came from nursing for Resident #8, and he/she was picked back up by PT to assist with pain management, as Resident #8 was very arthritic and pain management had been a challenge because Resident #8 was bone on bone. PTA #1 indicated that per her note on 5/1/26, Resident #8 was not in pain, but she had noticed a change in his/her processing; it was more delayed from how he/she had been presenting while seeing the resident throughout the facility during rounds. PTA #1 identified that she had notified RN #1 of her observation. Clinical record review and interview with the Medical APRN (APRN #1) on 5/5/26 at 10:20 AM identified that they had been working on Resident #8's pain regimen for months, as his/her CT scan showed lumbar degeneration; Resident #8's pain was neuropathic but also muscular and had impacted his/her daily activities. APRN #1 indicated that Resident #8 had gone for a consultation at the pain clinic on 5/1/26 and that their recommendation was to continue with the current regimen. Upon review of the nursing progress notes from 5/1/26 and 5/2/26, APRN #1 indicated that Resident #8 does wax and wane, but she would have expected the on-call provider to have been notified, in that scenario. Follow-up interview with RN #1 on 5/5/26 at 10:36 AM identified that he had not reported the observations made by Person #1 and PTA #1 because when he had followed up to see Resident #8, he/she looked ok, and he did not feel like there was a change in condition, but it was part of his/her decline with the progressive dementia and that there were good days and bad days. There was no indication of an acute change, and he did not notify the provider because he did not feel that there was a change in condition. Interview with the DNS on 5/5/26 at 10:58 AM identified that over the last several months, Resident #8 has had an increase in pain due to severe arthritis that had been impacting his/her ADLs; Resident #8 had a consultation at the pain clinic, on 5/1/26, and they did not find issues with his/her pain management regimen. The DNS further identified that her observations were one day Resident #8 would be sitting at the nursing station sleeping in his/her chair and the next day Resident #8 would be more active and less sleepy. The DNS indicated that she would expect a medical provider notification if the nurse or the family felt that there was a change in condition, but she would defer to the nurse that completed the assessment to say if there was a true change in condition as she was not the nurse that completed the assessment. The DNS identified that RN #1's note on 5/1/26 identified that an assessment was completed following PTA #1's observation of Resident #8's delay in processing, although the time between PTA #1's observation and RN #1's assessment was undetermined; while RN #1 was adjusting the compression stockings he would have been able to identify if Resident #8 was demonstrating a delay in processing; the next RN assessment following the 5/2/26 report of Person #1's concerns, was completed on 5/3/26, but review of Resident #8's vital signs on 5/1/26 and 5/2/26 identified his/her vital signs were stable. The DNS identified that if there was a true change in condition the physician should have been notified as soon as possible. Although attempted, an interview with Person #1 was not obtained The Change in a Resident's Condition or Status policy directs the facility to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been an: accident or incident, discovery of injuries of unknown source, adverse reaction to a medication, significant change, need to alter the residents medical treatment significantly, refusal of treatment or medications two or more consecutive times, need to transfer the resident to a hospital, discharge without proper medical authority, and specific instruction to notify the physician of changes of the residence condition.

Based on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 4 residents (Resident #4) reviewed for accidents, the facility failed to develop a comprehensive care plan to include interventions to address observed behaviors during eating such as eating fast and putting too much food in his/her mouth. Subsequently, the resident choked while eating and required the Heimlich, transfer to the hospital and laryngoscopy to remove a 3-inch piece of lamb from the airway. The findings include: Resident #4 was admitted to the facility in June 2025 with diagnoses that included mild intellectual disabilities and obesity. Review of the Nursing Clinical admission Evaluation, nutrition section, dated 6/10/25 failed to identify documentation of Resident #4's intake or signs and symptoms of a possible swallowing disorder; review of the MDS section did not indicate Resident #4 had a loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, complaints of difficulty or pain when swallowing, or a swallowing disorder. The Plan of Treatment for Rehabilitation dated 6/12/25 identified Resident #4 had treatment diagnoses that included dysphagia and mixed receptive-expressive language disorder. The reason for referral identified that Resident #4 was referred following recent changes in status due to a recent fall at his/her prior assisted living facility, resulting in a functional decline in expressive language, oral motor function, receptive language, safety awareness, and swallow function. Resident #4 was seen for a skilled Speech Therapy (ST) swallow and speech evaluation and was somewhat uncooperative and not sitting up while in bed, he/she tolerated the SLP feeding him/her while he/she held his/her own cup. Resident #4 consumed regular food with 1 slight outward cough, but did evidence an increased rate of eating, and reduced ability to swallow after each intake. It would be medically necessary for Resident #4 to be seen for skilled ST to improve his/her ability to communicate effectively with others and to use safe swallowing compensatory strategies consistently.Oral/Pharyngeal Function-ROM Oral/Pharyngeal Function was moderately/severely impaired (17-29% accuracy), deficits limiting functional performance included Resident #4's decreased swallow function related to extended oral transit time, decreased range of motion of the oral musculature was leading to increased pocketing and oral transit time, tongue base retraction deficits were leading to decreased oral transit and bolus formation, and oral motor weakness was negatively impacting swallow function.Standardized Test-[NAME]- [NAME] Assessment of Swallowing Ability Standardized Test notes identified Resident #4 was with reluctant cooperation, some breath control first swallow, mild impairment in range for tongue movement, minimal tongue weakness, and mild tongue in coordination. During oral preparation stage, Resident #4 was with minimal chew thrust gravity assisted, and some clearance for bolus clearance, oral transit time was delayed over one second, laryngeal elevation mildly restricted with slow initiation and incomplete clearance for pharyngeal phase and cough after swallow for pharyngeal response.Swallowing-Compensatory Strategy Use Swallowing: 10 % accuracy with no cueing, deficits limiting functional performance included Resident #4 demonstrated decreased ability to utilize compensatory strategies for oral intake, coughing after the swallow indicated possible airway penetration or aspiration, overall oral motor weakness affects safety with oral intake. Bolus formation and swallow safety were impacted because of decreased sensation in the oral cavity. The change in condition nurse's note dated 6/12/25 at 2:57 PM identified the resident was sent to the hospital due to abnormal blood pressure, heart rate, respiratory rate, weight change, shortness of breath and oxygen saturation 91.0 % (normal range 95-100%). The Discharge summary dated [DATE] identified Resident #4 presented to the emergency department on 6/12/25 with tiredness, shortness of breath, and hypotension; multiple prior mechanical falls were reported. Resident #4 was hypotensive; blood pressure 92/71, heart rate 100, respiratory rate 27, and was placed on 4 liters of oxygen via nasal cannula. CTA chest showed saddle pulmonary embolism. A mechanical thrombectomy was completed bilaterally on 6/13/25 with the removal of moderate amount of acute appearing thrombus. The Discharge Summary identified that Resident #4 was on a Cardiac Consistent Carbohydrate diet and additional therapy recommendations were made for physical therapy (PT) services in the discharge environment; the summary did not identify a recommendation for ST in the discharge environment. Resident #4 was readmitted to the facility on [DATE] with new diagnoses that included pulmonary embolism without acute cor pulmonale and acute embolism and thrombosis of unspecified deep veins of the right extremity. The admission nurse's note dated 6/24/25 at 5:14 PM identified Resident #4 was readmitted to the facility on a regular, no salt added carbohydrate control diet with thin liquids Review of the Nursing Clinical admission Evaluation, nutrition section, dated 6/24/25 identified the field for Resident #4's taking of nutrition and hydration orally, no signs and symptoms of a swallowing disorder, and moist mucous membranes were not met. Resident #4's intake required assistance with meals (feed/set up as needed), had no complaints of thirst, and no signs and symptoms of a possible swallowing disorder. The admission Interview Report (Speech Language Deficits/Dysphagia section) dated 6/24/25 through 6/26/25 identified Resident #4 did not have a swallowing problem and did not have a speech and language deficit. The report further identified that Resident #4 required a setup or clean up assist for eating: the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. The Dietary/Nutrition Evaluation dated 6/27/25 identified Resident #4 was on a Regular Level 7 diet, a regular/thin fluid consistency, and had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before him/her. The admission MDS dated [DATE] identified Resident #4 had intact cognition, required setup or clean-up assistance with eating, and had no signs and symptoms of possible swallowing disorder. The physician's order dated 7/22/25 directed for Resident #4 to have a regular level 7 texture (normal everyday foods) and thin liquids. The Dietary/Nutrition Evaluation dated 1/27/26 identified Resident #4 was on a Regular Level 7 diet, a regular/thin fluid consistency, and was independent in his/her ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before him/her. The quarterly MDS dated [DATE] Resident #4 had intact cognition, required setup or clean-up assistance with eating, and had no signs and symptoms of possible swallowing disorder. The care plan dated 2/11/26 identified Resident #4's current ADL functional status had interventions that included regular diet and thin liquids and independent eating. The nurse's note dated 3/2/26 at 10:33 PM identified that at about 6:20 PM, the nurse aide called the nurse to Resident #4's room now. All RN's immediately responded to the call. Resident #4 was observed to be sitting up in his/her recliner with food tray in front of him/her, was noted to be pale with difficulty breathing. When asked if Resident #4 was choking, the resident nodded. Resident #4 was encouraged to cough but could not. Several pats to the back were applied which enabled him/her to spit out a small piece of meat. Abdominal thrusts were performed while in recliner; staff had difficulty reaching around the resident. Resident #4 was lowered to the floor and staff took turns doing abdominal thrusts. While doing so, 911 was activated simultaneously at approximately 6:22 PM. The police came in first, took over giving abdominal thrusts until EMT's arrived, oxygen was also administered. Resident #4 was transported out via stretcher at about 6:40 PM. Resident #4 was mildly alert, but respirations were increased. The ED Provider notes dated 3/2/26 identified Resident #4 presented to the ED after choking on a piece of lamb. Staff and first responders attempted the Heimlich maneuver, the obstruction moved somewhat but the resident continued to have respiratory distress. On EMS evaluation Resident #4 had an oxygen saturation of 35 to 44% with finger cyanosis. The resident was minimally responsive, could nod but could not speak, heart rate was about 130 beats per minute, and he/she was in atrial fibrillation. Resident #4 denied pain, but could not speak due to the obstruction, and was hypoxic. Differential diagnosis included but was not limited to acute airway obstruction due to food impaction: airway obstruction was caused by a large piece of lamb lodged in the airway, confirmed by direct visualization and removal, with history of choking and failed maneuvers at the nursing facility. Acute airway obstruction was due to food impaction and hypoxic respiratory failure; a direct laryngoscopy was performed and removed the obstructing food bolus with forceps, rapid sequence intubation was performed for airway management, oxygen was administered, oxygen saturation was monitored, and adequate suctioning was completed to ensure clear residual obstruction. The interdisciplinary team risk review note dated 3/3/26 at 11:37 AM identified that at approximately 6:20 PM, another nurse aide entered the resident room and observed Resident #4 sitting upright in his/her chair, eyes closed with wheezing and increased respirations. The nurse aide called his/her name and Resident #4 opened his/her eyes but could not speak and made the universal choking sign. The nurse aide immediately called for the nurses. Within seconds the nurses entered the room. The nurses could not visualize anything obstructing the airway. Two nurses remained with the resident while the third nurse initiated the EMS response. The Heimlich was performed and a piece of the lamb that Resident #4 was eating came out. It was determined on further assessment that the resident continued with a partial airway obstruction. Multiple further attempts of the Heimlich were unsuccessful. Approximately 8 minutes after the resident was discovered, EMS arrived and attempted the Heimlich and were unsuccessful. Approximately 5 minutes after arrival to the facility, EMS transported Resident #4 to the ED for further evaluation. Resident #4 did not require CPR nor lost consciousness during event. At the hospital, a 3-inch piece of lamb was extracted from the airway. Due to the event Resident #4 went into rapid A-fib and RVR (atrial fibrillation with rapid ventricular rate) requiring cardioversion (medical procedure used to restore a rapid or irregular heartbeat), Spo2 (peripheral capillary oxygen saturation) dropped, and he/she required intubation and ventilation. Review of the facility's investigation Summary Report dated 3/7/26 identified Resident #4 was admitted to the facility on a regular diet with no concerns. The resident was positioned properly, sitting upright in a chair during the meal in his/her room, as the resident was independent with eating. The appropriate utensils were provided. Interview conducted with the kitchen staff and another resident had determined that the lamb was not tough and was prepared properly. Resident #4 was served a regular diet per the physician's order (lamb, ravioli, and spinach). It was determined that Resident #4 had only eaten the lamb provided. The nurse aide staff were frequently rounding during the meal and discovered that Resident #4 was having difficulties and immediately informed nursing. The nursing staff immediately responded and followed appropriate procedure by confirming the resident had an obstruction and starting the Heimlich maneuver and initiating EMS. At no point during the event did Resident #4 lose consciousness or require CPR. Resident #4 was transferred to the hospital and was successfully extubated and remained stable at the hospital. Resident #4 was readmitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia and food in larynx causing asphyxiation. The nurse's note dated 3/11/26 at 2:09 PM identified Resident #4 was on a minced and moist diet, nectar thick liquid, 1:1 supervision, and no straw. During an interview and clinical record review with the Director of Rehabilitation (PTA #1) and the Speech Language Pathologist (SLP #1) on 5/4/26 at 10:08 AM, SLP #1 indicated that she was asked by nursing staff to evaluate Resident #4 on 6/12/25 due to his/her lack of oral intake. Resident #4 had no medical history of dysphagia and ate a regular diet independently without supervision in the assisted living facility prior to hospitalization and admission to this facility. SLP #1 indicated that during her ST evaluation, Resident #4 was participating minimally and was difficult to assess. SLP #1 did observe one cough which was concerning but at the time of the assessment she could not identify if Resident #4 was refusing to eat due to difficulty in swallowing or if he/she was feeling emotional due to the transition to the facility resulting in a poor appetite. Resident #4 would have needed further ST treatment and assessments to determine if there was actually a swallowing problem. SLP #1 indicated that the 10% accuracy on the [NAME] - [NAME] Assessment was her best assessment at that time because Resident #4 was not really compliant with the assessment and was only eating minimally, and the slow coordination and mild weakness was identified because Resident #4 was weakly moving his/her tongue and not moving the food around his/her mouth that much. SLP #1 identified that she wanted to put Resident #4 on ST services in an effort to continue assessing him/her, and that her recommendation for services was to meet once weekly for 15 minutes, which if she had felt that Resident #4 had a the potential for a severe problem related to swallowing difficulties, she would have made the recommendation to see him/her more than once a week. PTA #1 identified that on the afternoon following the ST evaluation, Resident #4 was transferred to the hospital and was at the hospital for almost 2 weeks. PTA #1 further identified that in review of the hospital Discharge summary dated [DATE], Resident #4 was seen by physical and occupation therapy at the hospital but was not seen by speech therapy and returned to the facility on a regular texture diet. PTA #1 indicated that SLP would not typically see a patient, during hospital admission, if there were no eating and/or swallowing concerns identified during the hospital admission or history of swallowing difficulties. PTA #1 identified that she screened Resident #4 and completed the speech language deficits/dysphagia section of the admission Interview Report dated 6/24/25 through 6/26/25, and no swallowing problem or speech and language deficit was identified. SLP #1 identified that she did not reevaluate Resident #4 when he/she returned from the hospital on 6/24/25 because he/she returned on a regular diet, did not receive ST services or require meal supervision while he/she was in the hospital from [DATE] through 6/24/25; no difficulty with eating or swallowing medications or food was reported to her by nursing staff upon his/her return to the facility. SLP #1 further identified that given that information it was appropriate for PTA #1 to complete Resident #4's admission report for speech language deficits/dysphagia and additionally the Registered Dietitian (RD) would also complete the Swallowing/Nutritional Status report, which would identify loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals, or complaints of difficulty or pain when swallowing. SLP #1 identified that after her initial evaluation of Resident #4 on 6/12/25, she did not work with him/her again until after the choking incident in March of 2026. Resident #4 was discharged from ST services when he/she was transferred to the hospital on 6/12/25 and returned on 6/24/25, on a regular diet and did not require ST services while admitted . SLP #1 identified the facility uses International Dysphagia Diet Standardization Initiative (IDDSI) for diet orders and changes and that Resident #4 was on a regular level 7 texture and thin liquids diet and that indicates a regular diet, lamb would have been an appropriate meat for his/her diet order, however the 3 inch size piece of meat that was extracted from Resident #4's airway was not a standard sized food bolus; SLP #1 demonstrated that an appropriate sized food bolus was from the distal portion of her thumb to the interphalangeal joint (the top joint). PTA #1 identified that following Resident #4's choking incident on 3/16/26, the facility updated its procedure, if there is any indication that a resident/patient would need to be seen for ST services and was discharged to the hospital, the resident will be rescreened upon their return. Also to note, SLP will screen (new and readmitting) all residents to assess need for diet upgrades/downgrades as needed within the skilled nursing facility. SLP #1 identified that Resident #4's choking incident had occurred on 3/2/26 and he/she returned from the hospital on 3/11/26 on a puree and nectar thick diet, and when she evaluated him/her, Resident #4 was trying to take bigger bites and was reminded to take smaller bites and alternate bites and sips; Resident #4 now eats with supervision in the dining room and had training to take smaller bites and alternate bites with sips of liquid. During an interview with PTA #1 and OT #1 on 5/4/26 at 11:11 AM, OT #1 identified that prior to Resident #4's choking incident on 3/2/26, he/she required assistance with set-up and clean up, assistance was required with opening items and setting up utensils, but Resident #4 was independent with cutting. OT #1 indicated that the resident's ability to cut his/her own meat was evaluated, and he/she demonstrated the ability to cut food into safe sized pieces. OT #1 further indicated that nursing staff had not brought forth any concerns with Resident #4 cutting safe sized pieces. Interview with NA #1 on 5/4/26 at 12:40 PM identified that Resident #4 was a fast eater prior to the choking incident and would need reminding to take smaller bites. NA #1 indicated that Resident #4 would sometimes put 4-5 pieces of meat in his/her mouth at a time, and that nurses were aware. NA #1 identified that he/she would say, in general to the nursing supervisor RN #4, that Resident #4 needed to be reminded to take smaller bites or Resident #4 was taking large bites again. NA #1 indicated that he/she was not sure if there had been any follow-up. Interview with NA #3 on 5/4/26 at 1:44 PM identified that Resident #4 did not require supervision or assistance with cutting food prior to the choking incident, and that he/she had no observations of Resident #4 putting too much food in his/her mouth at once, but that Resident #4 would sometimes eat fast, but that was probably when he/she was first admitted and that Resident #4 had been working with ST. Interview with NA #4 on 5/4/26 at 1:53 PM identified that Resident #4 was a very fast eater, and it was his/her norm, so NA #4 never thought to discuss it with anyone. Resident #4 would usually be done with his/her meal in about 2-5 minutes of being served. NA #4 indicated that he/she had not observed Resident #4 taking too large of a bite or putting too much food in his/her mouth at once. Interview with RN #4 on 5/4/26 at 2:15 PM identified that he/she did not recall reports being brought to her attention that Resident #4 had been observed eating quickly or putting large amounts of food in his/her mouth at one time and indicated had concerns been reported to her she would have notified the SLP. During an interview with PTA #1 and SLP #1 on 5/4/26 at 2:25 PM, SLP #1 indicated that she did not recall any concerns of Resident #4 eating too fast or putting too much food in his/her mouth being brought forward to her and indicated if there had been she would have evaluated him/her and implemented interventions, if appropriate. PTA #1 indicated that if any concerns had been brought forth to her by the nursing staff, she would have documented the concern and notified SLP. Interview with the Dietitian (RD #1) on 5/5/26 at 8:58 AM identified that when she completes her admission and quarterly nutrition evaluations, she also completes a meal observation. RD #1 identified that during meal observations of Resident #4 she did not observe any swallowing difficulty, concerns with pacing, impulsive behaviors, or a need for cueing. Interview with the medical APRN (APRN #1) on 5/5/26 at 10:10 AM identified that she was not aware of any concerns from the interdisciplinary team that Resident #4 was eating too fast or putting too much food in his/her mouth, and that if she was aware of those concerns, she would have expected a notification and a referral for a SLP evaluation. APRN #1 further indicated that she could not speak to why Resident #4 choked on 3/2/26, but in general putting too much food in your mouth at a time would be a risk factor for choking. Interview with the MDS Coordinator (RN #2) on 5/5/26 at 10:20 AM identified that he was not made aware of concerns that Resident #4 had demonstrated fast eating habits or was putting too much food in his/her mouth at a time, even prior to the choking event. RN #2 indicated that if those behaviors were present the RN supervisor could initiate a care plan or once an evaluation was completed by the SLP and new orders were placed, he would have created a comprehensive care plan with interventions that were based off the providers orders. Interview with the DNS on 5/5/26 at 11:19 AM identified that she was unaware that nursing staff had observed Resident #4 eating fast or putting a lot of food in his/her mouth at one time, prior to 3/2/26, and that information was not disclosed to her during her investigation interviews, either, following Resident #4's choking incident. The DNS indicated that she would expect the nurse aide to report those observations to the nurse, and if the nurse aide felt like nothing was being done, she would have expected the nurse aide to bring their concerns directly to her; she would have ensured a referral to SLP assessment was completed, and a care plan would be created if the interdisciplinary team identified that there was an issue. Review of care plan identified that although staff were aware and had observed that the resident ate at a fast pace and at times put too much food in his/her mouth, the care plan failed to reflect interventions to address such. The Interdisciplinary Notification of Diet (Including Changes and Reports) policy directs nursing services shall notify the physician and dietitian when a nutritional problem including weight loss, pressure ulcer, eating problem, etc. has been identified and shall collaborate with the dietitian and physician to initiate an appropriate process of clinical review for causes of the nutritional problem. The Care Plans, Comprehensive Person-Centered policy directs that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Although attempted, an interview with Resident #4 was refused.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was not verbally abused by a staff member. The findings include: Resident #1's diagnoses included cognitive impairment and anxiety. The admission Resident Care Plan (RCP) dated 2/6/25 identified Resident #1 had a mood disorder and received an antidepressant medication. Interventions directed to monitor targeted behaviors, provide routine and as needed psychiatric visits, and medications as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some short and long term memory recall deficits, exhibited verbal outbursts towards others, required staff assistance with activities of daily living, and utilized a wheelchair for mobility. A physician's order dated 2/13/25 directed to administer a medication to help people with insomnia fall asleep slightly faster, Melatonin 5 milligrams (mg) at bedtime for sleep and an antidepressant for treating major depressive disorders, Trazadone 25 mg every four (4) hours as needed for insomnia. The nurse's note dated 2/14/25 written at 7:47 AM identified at the beginning of the 11PM-7AM shift on 2/13/25 Resident #1 was observed to be sitting in a recliner chair in front of the nurse's station, Resident #1 was noted to be upset and verbalized that he/she did not want to be in the hallway and he/she wanted to go back to bed. The note identified Resident #1 was assisted by two (2) staff members back to bed and was awake most of the night. The nurse's note dated 2/14/25 at 11:39 AM identified the psychiatric services were contacted to see Resident #1 due to an alleged verbal abuse committed by a staff member against Resident #1. The note identified Resident #1 was calm and cooperative with intermittent calling out when no one was in the room with him/her. The psychiatric note dated 2/14/25 identified Resident #1 was seen in follow-up for an allegation of verbal abuse by a staff member. Resident #1 admitted to the incident, stated he/she was upset over the incident, and was unable to sleep last night. The note indicated medications were changed the current Trazadone 25 mg every 24 hours as needed was discontinued, Trazadone 37.5 mg every hour of sleep and Trazadone 12.5 mg every 24 hours as needed if still unable to sleep were ordered, and to continue the Melatonin 5 mg at hour of sleep. The Facility Reported Incident form dated 2/14/25 identified a 3-11PM nurse aide reported to the 7AM-3PM Nursing Supervisor that on 2/13/25 she witnessed another 3-11PM nurse aide, Nurse Aide (NA) #1, state to Resident #1 Well if you'd shut up, you wouldn't have to be out here. The report identified Resident #1 reported, she put me at the station for 211 minutes, she told me not to say a word, and she is mean. The report indicated NA #1 was suspended pending an investigation and all parties were notified. Review of the nurse's notes from 2/14/25 through 2/15/25 identified Resident #1 had no ill effects from the alleged verbal abuse. In a written statement dated 2/14/25 a 3-11PM nurse aide, NA #5 identified she heard NA #1 say to staff, I know he/she doesn't want to be out here, and then NA #1 said very loud to Resident #1, Well if you'd shut up, you wouldn't be out here. Interview with the Director of Nursing (DON) on 3/4/25 at 11:15 AM identified she was notified on 2/14/25 at approximately 11:00 AM of the allegation of verbal abuse that occurred on the 3-11PM shift on 2/13/25. The DON identified an investigation was conducted and the facility concluded NA #1 verbally abused Resident #1 and NA #1 was terminated from employment for not following the facility's core values. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 3/4/25 at 11:36 AM identified on 2/14/25 Resident #1's family member approached her and reported Resident #1 told the family member that the night before, 2/13/25, Resident #1 was put at the nurse's station and told not to speak. Interview with NA #1 on 3/4/25 at 12:45 PM identified on 2/13/25 at approximately 10:00 PM she brought Resident #1 out to the nurse's station because he/she was screaming. NA #1 denied ever telling Resident #1 to shut up. Interview with NA #4 on 3/4/25 at 12:55 PM identified on 2/13/25 Resident #1 was brought out to the nurse's station because he/she was yelling and disrupting other residents that were trying to sleep. NA #4 explained when the staff were leaving at the end of their shift, she heard NA #1 say to Resident #1, Well if you shut up, you would be able to go back to bed. Review of NA #1's personnel file identified she last completed Elder Abuse Training on 12/27/24. Review of the facility policy for Abuse and Neglect identified, in part, that abuse includes verbal abuse and is a willful act. Review of the facility Resident's [NAME] of Rights, identified residents have the right to be free from verbal abuse and staff will be trained on preventing, recognizing, and reporting abuse prior to providing any direct care services to residents

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to ensure a witnessed allegation of verbal abuse was reported to the Administrator and/or designee within two (2) hours after the event occurred. The findings include: Resident #1's diagnoses included cognitive impairment and anxiety. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some short and long term memory recall deficits, exhibited verbal outbursts towards others, required staff assistance with activities of daily living, and utilized a wheelchair for mobility. The nurse's note dated 2/14/25 written at 7:47 AM identified at the beginning of the 11PM-7AM shift on 2/13/25 Resident #1 was observed to be sitting in a recliner chair in front of the nurse's station, Resident #1 was noted to be upset and verbalized that he/she did not want to be in the hallway and he/she wanted to go back to bed. The note identified Resident #1 was assisted by two (2) staff members back to bed and was awake most of the night. The nurse's note dated 2/14/25 at 11:39 AM identified the psychiatric services were contacted to see Resident #1 due to an alleged verbal abuse committed by a staff member against Resident #1. The note identified resident #1 was calm and cooperative with intermittent calling out when no one was in the room with him/her. The Facility Reported Incident form dated 2/14/25 identified a 3-11PM nurse aide reported to the 7AM-3PM Nursing Supervisor that on 2/13/25 she witnessed another 3-11PM nurse aide, Nurse Aide (NA) #1, state to Resident #1 Well if you'd shut up, you wouldn't have to be out here. The report identified Resident #1 reported, she put her at the station for 211 minutes, she told me not to say a word, and she is mean. The report indicated NA#1 was suspended pending an investigation and all parties were notified. Interview with the Director of Nursing (DON) on 3/4/25 at 11:15 AM identified she was notified on 2/14/25 at approximately 11:00 AM of the allegation of verbal abuse that occurred on the 3-11PM shift on 2/13/25. The DON identified the 3-11PM nurse aides failed to notify the 3-11PM Nursing Supervising on 2/13/25 of the alleged abuse prior to leaving the facility. The DON explained that during the facility's investigation, there were other instances where NA #1 was heard talking inappropriately to residents and these instances were not reported to administration. The DON identified at the conclusion of the investigation, the facility concluded NA #1 verbally abused Resident #1 and NA #1 was terminated from employment for not following the facility's core values. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 3/4/25 at 11:36 AM identified on 2/14/25 Resident #1's family member approached her and reported Resident #1 told the family member that the night before 2/13/25, Resident #1 was put at the nurse's station and told not to speak. RN #2 indicated when NA #5 overheard the conversation she had with Resident #1's family member, NA #5 told her that she had witnessed the event the night before, 2/13/25. RN #2 identified she contacted the Director of Nursing and set up a psychiatric evaluation which was conducted that day. Interview with NA #4, on 3/4/25 at 12:55 PM identified on 2/13/25 she heard NA #1 say to Resident #1, Well if you would shut up, you would be able to go back to bed. NA #4 stated she did not report this to anyone. Review of the facility policy for Abuse and Neglect identified, in part, that suspected or identified abuse would be reported in a timely manner consistent with applicable laws and regulations.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #3) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during resident transport resulting in a fall with injury. The findings include: Resident #3's diagnoses included Parkinson's disease, fibromyalgia, hypertension, and anemia. The care plan dated 4/19/24 identified Resident #3 was at risk for falls related to decreased mobility and history of falls. Care plan interventions directed to encourage resident to wear appropriate footwear when ambulating or mobilizing in wheelchair, be sure the call light is within reach, physical and/or occupational therapy as ordered, and monitor and document to ensure appropriate use of safety and assistive devices. The admission MDS assessment dated [DATE] identified Resident #3 had intact cognition and required extensive assistance with bed mobility, dressing, toileting, hygiene, and transfers. It further identified the resident utilized a wheelchair and was dependent on staff for mobility. The fall risk assessment dated [DATE] identified Resident #3 at risk for falls. The nurse's notes dated 6/22/24 at 6:40 PM identified Resident #3 was being transported in the wheelchair from the dining room by the NA #1 back to his/her room when he/she put his/her right foot on the floor and Resident #3 fell forward from the wheelchair in the hallway. Resident #3 remained alert and oriented but forgetful, vital signs were noted as; blood pressure: 180/80, heart rate: 88 respirations:18. Resident #3 had 2 skin tears above his/her eye brow. The first skin tear was documented as 2.5 centimeters (cm) in length by 0.5 cm in width and the second skin tear was documented as 0.5 cm in length by 0.4 cm in width. Resident #3 complaint of a severe throbbing headache. The physician was notified the accident ordered the resident be sent to the hospital for evaluation. The Responsible party was also notified and agreed with the plan of care. The facility's accident and incident report dated 6/22/24 at 6:40 PM identified that during the transport and Resident #3's subsequent fall from the wheelchair, the wheelchair did not have the leg rests in place. The hospital admission history and physical dated 6/22/24 at 11:50 PM identified Resident #3 was admitted from the skilled nursing facility after sustaining a fall from a wheelchair. Resident #3 identified that he/she was being transported in the wheelchair by the facility staff and he/she put his/her right foot down while the wheelchair was in motion and was thrown from the wheelchair. Resident #3 hit his/her head, but did not lose consciousness and sustained a 2 cm laceration to the left eye brow which was approximated with derma bond (medical glue) for wound closure. The documentation further noted that a Computed Tomography (CT)-scan of the head was performed (an imaging procedure to create a detailed picture of the organ) and identified an acute subdural hematoma along the left cerebral convexity that measured 3 millimeter (mm) in thickness. There was no evidence of mass effect or midline shift. A CT-scan of the head, face, and neck were also done, and all diagnostic imaging tests did not indicate any bone fractures. The hospital treatment plan included admitting Resident #3 to the trauma unit, obtaining a neurosurgical consult, a repeat of the CT-scan of the head in 6 hours and Keppra (anti-seizure medication) 500mg by mouth twice a day for 7 days. The hospital neurosurgery consultation notes dated 6/23/24 at 11:42 AM identified Resident #3 was admitted for observation and repeat CT-scan of the head was done to verify the subdural hematoma. The repeat CT-scan of the head did not identify a concern for subdural hematoma, Keppra was discontinued, and no neurosurgical intervention follow-up was recommended. The hospital discharge summary dated 6/23/24 at 12:44 PM identified Resident #3 remained stable, and the repeat CT-scan of the head did not identify a concern with the subdural hematoma and no neurosurgical intervention follow-up was recommended. The nurse's note dated 6/23/24 at 3:30 PM identified Resident #3 was readmitted to the facility. Interview with RN #1 (3-11 shift nursing supervisor) on 9/24/24 at 10:15 AM identified NA#1 was transporting Resident #3 from the dining room to his/her room when the accident occurred. She identified that Resident #3 did not have the leg rests on the wheelchair. She also identified that Resident #3 fell forward when he/she put his/her right foot on the floor, fell forward to the floor out of the wheelchair and hit his/her head on the floor. She identified that Resident #3 was able to self-propel for short distances and that it is the facility's policy to transport with leg rests in place to prevent injuries to residents. RN #1 further noted that Resident #3 refused to have the leg rests on the wheelchair at the time of the accident. Interview with PTA #1 (rehab director) on 9/26/24 at 10:30 AM identified that leg rests should always be used when transporting a resident in a wheelchair. She identified that a risk of injury could occur if a resident does not use leg rests while being transported in the wheelchair. She further identified Resident #3's accident could have been avoided if the leg rests were used during the wheelchair transport. She further identified the staff should re-approach a resident, re-direct resident attention and/or staff assistance from the other staff when a resident refuses to use leg rests during wheelchair transport. She identified that Resident #3 was able to self-propel in his/her wheelchair for short distances. She further identified that she was not aware that Resident #3 had refused his/her leg rests when being transported in the wheelchair. Interview with NA #2 (7-3 shift nursing aide) on 9/26/24 at 1:00 PM identified that Resident #3 has never refused to use the wheelchair leg rests when she has transported the resident. She identified that the facility policy is to use the leg rests when a resident is being transported in the wheelchair. She identified that she never asks the residents' permission to place leg rests, but she explains to the resident that she is going to put his/her leg rests on the wheelchair for his/her safety. She further identified that she would let the nurse know if a resident refused to use the leg rests prior to transporting the resident. Interview with NA #1 (3-11 shift nursing aide) on 9/26/24 at 1:40 PM identified that she was transporting Resident #3 from the dining room to go back to his/her room without the leg rest on the wheelchair and Resident #3 put his/her right foot down on the floor when Resident #3 fell forward from his/her wheelchair near the recreation room. She identified that she transported Resident #3 in the wheelchair without leg rests because Resident #3 refused to use the leg rests. She identified that she did not attempt to put the leg rests on the wheelchair, but she asked Resident #3 whether he/she would like to use the leg rests. She further identified she was aware that the leg rests must be used while transporting residents in wheelchairs. Additionally, she identified that she did not let the nurse know that Resident #3 had refused to put the leg rests on the wheelchair, and she did not attempt to re-approach or re-direct Resident #3 when he/she refused the leg rests. Interview with Resident #3 on 9/27/24 at 10:15 AM identified that she could not recall the details of his/her fall from the wheelchair but identified that he/she had not refused to have his/her leg rests applied to the wheelchair. The Wheelchairs policy identified that in order to provide safe and comfortable transportation and to provide mobility for residents who are unable to walk the leg rests must be used during transport to prevent injury and when a resident refuses to use the leg rests, the staff should re-approach the resident.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #8) reviewed for positioning and range of motion, the facility failed to develop a comprehensive care plan to address the specific type of assistive device being utilized, how often the device should be worn, and the general care or monitoring of the device as it relates to the resident. The findings include: Resident #8 was admitted to the facility in August of 2024 with diagnoses that included rheumatoid arthritis of the left elbow, right pubis fracture, muscle weakness, and multiple rib fractures. The admission MDS assessment dated [DATE] identified Resident #8 was cognitively intact, had impaired range of motion to bilateral upper and lower extremities. It further identified the resident was dependent on staff for personal hygiene, lower body dressing, toileting hygiene, transfers, mobility, was non-ambulatory and utilized a wheelchair. Observation on 9/23/24 at 10:34 AM identified Resident #8 seated in a chair with an overbed table positioned in close proximity in front of him/her with a black colored splint that encompassed most off the upper and lower portion of the left arm. The resident identified that the splint was worn during the day and removed at bedtime. A review of the physician's orders for August/2024 failed to address the use of a splint to the left arm. A review of the care plan dated 8/23/24 failed to identify Resident #8 utilized a splint addressed the application of the splint and removal of the splint, and/or when to check the integrity of the resident's skin as it relates to the use of the splint. Resident #8's nurse aide care card failed to identify the use of the splint. Observation on 9/24/24 at 11:02 AM identified Resident #8 seated in a chair with the overbed table positioned in close proximity in front of the resident, with the black colored splint in place to the left arm. Observation on 9/26/24 at 9:54 AM identified Resident #8 was lying in bed with the black colored splint in place to the left arm. Observation with the Charge Nurse (RN #4) on 9/26/24 at 11:29 AM identified Resident #8 lying in bed with the splint in place to the left arm. Interview with the day-shift Nursing Supervisor (RN #3) on 9/26/24 at 11:37 AM identified that the physician's orders did not contain an order directing the use of the splint to the left arm and the care plan also did not reflect the use of the splint. RN #3 further identified that a physician's order, the care plan, and the nurse's aide care card should reflect when the splint is to be applied, and removed, and to check the resident's skin integrity. Interview with NA #2 on 9/26/24 at 11:40 AM identified she applied the splint to the left arm as Resident #8 requested. NA #2 identified that when a resident utilizes a splint, it is usually written in the NA care card. Interview with the MDS Coordinator (RN #5) on 9/26/24 at 12:10 PM identified that he was responsible for completing the comprehensive care plans within 14 days after the resident is admitted to the facility. He also identified that Resident #8 should have had a physician's order for the use of the splint as the physician's order directs the care of the resident which is added to the care plan. RN #5 indicated that the physician's order would direct how and when to apply the splint, and the checking of skin integrity. Further, RN #5 was unable to identify why the care plan lacked the inclusion of the splint as it should have included the splint, as it was a part of Resident #8's care routine. Interview with the Occupational Therapy Assistant (OTA #1) on 9/26/24 at 12:00 PM identified that when a resident is admitted to the facility with a splint, the nursing staff is supposed to notify the therapy department for the device to be evaluated. OT #1 further identified that a physician's order would be required for the use of the splint to direct the appropriate care for the resident. Interview with the DNS on 9/26/24 at 12:28 PM identified that Resident #8 should have had a care plan and a physician's order directing the use of the splint to the left arm. The DNS identified that it was the responsibility of therapy to ensure that a physician's order was in place after they evaluated the resident and trained the staff on how to apply and remove the splint. She further identified that the splint was visible to staff, hence if the resident brought the assistive device in the facility after admission, it was the responsibility of the nurses to ensure that therapy was aware, and orders were in place. The DNS identified that the care plan should have been completed to indicate the use of the splint, when to apply and remove the splint, and for the checking of the skin on applying and removing of the splint. Interview with the Occupational Therapist (OT #2) and the Director of Rehabilitation on 9/27/24 at 11:40 AM identified that OT #2 completed Resident #8's admission evaluation and identified that Resident #8 utilized a splint to the left arm for positioning and comfort, following a surgery to the left elbow years ago. OT #2 further identified that she applied the splint to the left arm in the morning when caring for the resident. OT #2 identified that she had told the Director of Rehabilitation that Resident #8 utilized a splint but had not provided training to the staff. The Director of Rehabilitation identified that OT #2 mentioned that Resident #8 utilized a splint but assumed that she had followed the procedures that included an evaluation, and training of the staff. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further identified that assessments are ongoing, and care plans are revised as information about the resident and resident's conditions change. Review of the Assistive Device and Equipment policy identified that recommendation for the use of devices and equipment are based on comprehensive assessment and documented on the resident care plan.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #8) reviewed for positioning and range of motion, the facility failed to ensure a physician's order was in place directing the use of an assistive device. The findings include: Resident #8 was admitted to the facility in August of 2024 with diagnoses that included rheumatoid arthritis of the left elbow, right pubis fracture, muscle weakness, and multiple rib fractures. The admission MDS assessment dated [DATE] identified Resident #8 was cognitively intact, had impaired range of motion to bilateral upper and lower extremities. It further identified the resident was dependent on staff for personal hygiene, lower body dressing, toileting hygiene, transfers, mobility, was non-ambulatory and utilized a wheelchair. Observation on 9/23/24 at 10:34 AM identified Resident #8 seated in a chair with an overbed table positioned in close proximity in front of him/her with a black colored splint that encompassed most off the upper and lower portion of the left arm. The resident identified that the splint was worn during the day and removed at bedtime. A review of the physician's orders for August/2024 failed to address the use of a splint to the left arm. A review of the care plan dated 8/23/24 failed to identify Resident #8 utilized a splint addressed the application of the splint and removal of the splint, and/or when to check the integrity of the resident's skin as it relates to the use of the splint. Resident #8's nurse aide care card failed to identify the use of the splint. Observation on 9/24/24 at 11:02 AM identified Resident #8 seated in a chair with the overbed table positioned in close proximity in front of the resident, with the black colored splint in place to the left arm. Observation on 9/26/24 at 9:54 AM identified Resident #8 was lying in bed with the black colored splint in place to the left arm. Observation with the Charge Nurse (RN #4) on 9/26/24 at 11:29 AM identified Resident #8 lying in bed with the splint in place to the left arm. Interview with NA #3 on 9/26/24 at 11:20 AM identified that the nurses' aides apply splints and other assistive devices after therapy provides them with training, she further noted that after training, it is placed on the care cards. In addition, she noted that sometimes therapy applies the splint and removes the splint. Interview and review of Resident #8's physician's orders and administration records with RN #4 on 9/26/24 at 11:29 AM failed to reflect a physician's order directing the use of a splint to the left arm. RN #4 identified that whenever a resident utilized a splint a physician's order should be in place that directed how and when the splint should be worn, and when to complete skin checks. RN #4 identified that she had not applied the splint that morning, and assumed the resident had a physician's order. She further identified that it would have been the responsibility of the admitting nurse to obtain an order. Interview and review of Resident #8's clinical record with the day-shift Nursing Supervisor (RN #3) on 9/26/24 at 11:37 AM failed to reflect physician's orders directing the use of the splint to the left arm. RN #3 identified that a physician's order, should have been completed to indicate when the resident to wear the splint, to check skin integrity and when to remove for care, as it was a part of the resident's care. Interview with the NA #2 on 9/26/24 at 11:40 AM identified that she was the nurse aide who took care of Resident #8 and had applied the splint to his/her left arm on all the days she worked since the beginning of the week, which was Monday, Wednesday and Thursday, as the resident had requested the splint to be applied. NA #2 identified that if a resident utilized a splint or splint it would be written in the electronic nurse's aide care card. However, upon reviewing the nurse aide care card of resident #8's with NA #2, she failed to identify on the care card that Resident #8 utilized a splint to the left arm. Interview with the Occupational Therapist Assistance (OT #1) on 9/26/24 at 12:00 PM identified that when a resident utilizes a splint/splint at home and it is brought into the facility, the nursing staff should notify the therapy department for it to be evaluated. OT #1 was asked if a physician's order would be needed if the splint was not a part of the occupational therapy care goals, which she identified that a physician's order would be required as the order would direct how and when to apply and remove the device and when to check the resident's skin integrity. OT #1 identified that an order was necessary so that staff would be able to provide the resident with the appropriate care when utilizing the assistive device to meet the goal/purpose of the device usage. Interview with the DNS on 9/26/24 at 12:28 PM identified that Resident #8 should have had a physician's order directing the use of the splint to the left arm. The DNS identified that it was the responsibility of therapy to ensure that a physician's order was in place after they had evaluated the resident and trained the staff on how to apply and remove the splint. She further identified that the splint was visible to staff, and it was the responsibility of the nurses to ensure that therapy was aware, and orders were in place. Interview with the Charge Nurse (LPN #1) on 9/27/24 at 10:33 AM identified that she had observed Resident #8 wearing the splint to the left arm since admission to the facility and had assumed that all the necessary paperwork was completed (physician's order, nurse's aide care card, and care plan) and in place. Interview with the DNS on 9/27/24 at 11:10 AM identified that although the policy does not mention the requirement of a physician's order for assistive devices, it is the practice of the facility to have a physician's order in place along with a therapy evaluation, and education provided to staff. Interview with the Occupational Therapist (OT #2) and the Director of Rehabilitation on 9/27/24 at 11:40 AM identified that OT #2 completed Resident #8's admission evaluation and identified that Resident #8 utilized a splint to the left arm for positioning and comfort, following a surgery to the left elbow years ago. OT #2 further identified that she applied the splint to the left arm in the morning when caring for the resident. OT #2 identified that she had told the Director of Rehabilitation that Resident #8 utilized a splint but had not provided training to the staff. The Director of Rehabilitation identified that OT #2 mentioned that Resident #8 utilized a splint but assumed that she had followed the procedures that included an evaluation, and training of the staff followed by a written order in the resident's chart as this was the facility's practice. Review of the Assistive Devices and Equipment policy identified that the facility would maintain and supervise the use of assistive devices and equipment for residents.

Based on clinical record review, review of facility policy and interviews for one of two residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided safely to prevent a fall. The findings included: Resident #1 was admitted to the facility with diagnoses that included dementia with behavioral disturbance, Alzheimer's disease, receptive-[CONDITION(S)], muscle weakness and lack of coordination. A nursing Fall Risk assessment dated [DATE] identified that Resident #1 was at high risk for falls due to history of falling, impaired gait and forgets limitations. The fall risk assessment directed to implement high risk fall prevention interventions. An admission Minimum Data Set (MDS) dated [DATE] identified that Resident #1 was severely cognitively impaired requiring extensive assistance of 2 staff for bed mobility and transfer, noted the resident did not ambulate in room or on unit. Additionally, the admission assessment noted Resident #1 needed extensive assistance with 1 staff member for movement on the unit. A care plan dated 3/24/22 identified that Resident #1 requires the use of antipsychotic medication for targeted behaviors of biting, hitting, kicking, and banging and due to her/his diagnosis of dementia directed staff to keep environmental stimuli to a minimum. The care plan for at risk for falls due [CONDITION(S)] medication use, impaired cognition and decreased mobility dated 3/16/22 and updated 3/26/22 noted the resident sustained a fall on 3/26/22. Interventions included floor mats, slipper socks when in bed and bed in low position. A nursing fall risk assessment dated [DATE] identified that Resident #1 was at high risk for falls due to history of falling, secondary diagnosis and forgets limitations. The fall risk assessment directed to implement high risk fall prevention interventions. A physician's order dated 4/1/22 noted Resident #1 is alert and oriented times 1 (knows who s/he is but not the time of day or where s/he is at) requiring multi-modal cuing (verbal, visual and touch) to complete her/his activities of daily living. An Occupational Therapy evaluation note dated 4/28/22 identified that Resident #1 had decreased trunk control affecting ability to perform lower extremity dressing with static (still) balance deficits as evidenced by decreased ability to maintain upright sitting requiring cues (reminders either verbal or touch) due to decreased attention span. A Speech Therapy evaluation note dated 4/28/22 identified that Resident #1 has difficulty with short term memory recall that impacts safety and increases fall risk as well as deficits in judgement. Decision making ability is impacted due to decreased safety awareness. A nursing progress not dated 5/22/22 at 7:53 PM identified that Resident #1 had a witnessed fall in the morning at 9:30 AM. Resident #1 was seated on the bench, leaned too far to the right, and slid off the bench to the floor, landing on her/his right arm. No injury noted. A facility Post Fall Investigation form dated 5/22/22 at 10:30 AM completed by RN #2 identified that Resident #1's cognitive and behavioral factors at the time of the fall included confusion /memory impairment, poor safety awareness and balance problems identifying herself and OT #2 as the only witnesses to the fall. Interview with RN #2 on 6/22/22 at 9:00 AM identified that she was the nurse on shift on 5/22/22 but did not witness the fall. She arrived on the scene Resident #1 was already on the floor. She stated that she had assessed Resident #1 and there were no visible injuries. She continued by stating that Resident #1 gets very agitated at times especially when s/he is in her/his wheelchair as s/he likes to have her/his feet flat on the ground. RN #2 further indicated the NAs transferred the resident to the bench to try to calm Resident #1. She could not recall ever seeing Resident #1 on the bench prior to that day. She continued by stating she did not believe it was a safe place for Resident #1 to be placed on the bench as it only had support on either side pointing to the bench (2-person width, with back support with an approximately 48-inch-wide seating area with arm rests on either side) in front of the nurse's station. RN # 2 could not recall if anyone was at the desk when she arrived or in the area other than OT #2 who had seen Resident #1 fall. Interview with Occupational Therapist (OT #1) on 6/22/22 at 10 :00 AM identified that she would not have recommended that Resident #1 be transferred to the bench from the wheelchair. She was aware Resident #1 became agitated by being in her/his wheelchair at times. OT #1 continued by stating that the primary concern with the bench was not Resident #1's trunk balance but that Resident #1 had poor safety awareness. While Resident #1 was on the bench, s/he would require contact and/or verbal cuing (reminders) by a staff member to stay safe due to the resident's impulsive behavior. Resident #1 should have been supervised to maintain her/his safety. Interview with NA #1 on 6/22/22 at 11:00 AM identified that on 5/22/22, Resident #1 was in the dining room for breakfast in her/his wheelchair and was becoming increasingly anxious in the chair. Resident #1 continued to fidget in her/his wheelchair and began banging on the table becoming increasingly upset and agitated. NA #1 further indicated that she knew Resident #1 did not like her/his new wheelchair and at times just removing the footrests would calm Resident #1 down, but it did not affect Resident #1's behavior at that time. NA #1 thought it was the footrests that upset Resident #1 as in her experience with Resident #1, Resident #1 would sometimes calm down if her/his feet were on the ground. NA #1 stated that Resident #1 was continuing to become more fidgety and when Resident #1 started to bang on the table, she wheeled Resident #1 into the common area in front of the nurse's station, got another NA to help and proceeded to transfer Resident #1 to the bench, thinking that would make Resident #1 more comfortable and would help her/him calm down. NA #1 continued by stating that she and NA #2 left the Resident #1 on the bench as s/he seemed calmer, and both returned to work with the other residents and did not let anyone know Resident #1 had been agitated and that she had transferred her/him out of the wheelchair. NA #1 stated that she should not have left Resident #1 alone on the bench without making sure someone was keeping an eye on Resident #1. NA #1 continued by stating that the bench was in the common area, and she thought that Resident #1 would always be within eyesight of someone. NA #1 also indicated that she did not see any staff member in the immediate area and since the incident, she was educated that she should have stayed with Resident #1 to monitor her/him after she transferred Resident #1 out of her/his wheelchair. NA #1 continued by stating that she had not transferred Resident #1 previously to the bench but had worked with the Resident #1 a lot over the past few months. NA #1 continued that stating that she had been focusing on getting Resident #1 to a place where the resident's feet could touch the floor. Interview with the Unit Manager (RN #1) on 6/22/22 at 12:30 PM identified that the incident with Resident #1 had occurred on the weekend and she was not on shift that day. She continued by stating she would expect if a NA transferred an agitated resident from a wheelchair to another seat in order to address the resident's agitated behavior, she would expect the NA to stay with the resident and to also report the incident to the nurse. RN #1 continued by saying she was aware that Resident #1 could become agitated when she was in her/his wheelchair, and she would expect the staff to observe the resident to provide if needed cueing to the resident for safety if on the bench. Interview with Certified Occupational Therapy Aide (COTA) # 2 on 6/22/22 at 1:00 PM identified that she was down the hallway and assisting another resident when she saw Resident #1 from afar roll to the right and slip off the bench. She was unable to respond quick enough to provide any verbal or touch redirection or to prevent the fall. She identified that she did not observe any staff in the area as she approached Resident #1. She continued by stating that due to Resident #1's poor safety awareness she would have anticipated that a staff member be within visual distance of the Resident #1 to provide appropriate cuing to maintain safety. Interview with the Director of Nurses on 6/23/22 at 10 :00 AM identified it was reported to her that Resident #1 was transferred safely to the bench in the past without incident although, she never observed this herself and that her investigation concluded that the staff had followed the plan of care. The DNS further indicated after the fall, the care plan was updated on 5/23/22 to direct that Resident #1 should not be left alone when sitting in a standard chair or on the bench. The facility policy Falls and Fall Risk, Managing directs in part based on previous evaluations and data, staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling. Although requested the facility could not provide a policy for identification of high risk fall interventions.

Based on observation, clinical record review, facility documentation and staff interviews for three of three residents who required transmission-based infection control precautions (Residents #1, #2 and #3), the facility failed to ensure that clean linen was properly stored and further failed to ensure that isolation gowns were discarded or laundered following each use. The findings include: 1. During a tour of the facility on 5/24/20 at 8:37 AM observation identified a clean linen cart stored in the hallway without the benefit of a cover. Interview with Nurse Aide (NA) #1 on 5/24/20 at 8:40 AM indicated the cover that was attached to the top of the linen cart should have been closed in order to keep the linens clean during storage. Interview with the Director of Nursing Services (DNS) on 5/24/20 at 9:40 AM identified the facility would immediately ensure that linens were covered during storage, 2. Review of the facility's Long Term Care Respiratory Surveillance Line List on 5/24/20 identified twenty-two of the facility's twenty-five current residents had been tested for coronavirus disease 2019 (COVID-19) through a Point Prevalence Survey (PPS) on 5/19/20. The PPS screening results dated 5/21/20 and 5/22/20 identified that the twenty-two residents had tested negative for COVID-19. Further review of the line list indicated that three residents (Residents #1, #2 and #3) had not been included in the testing. Interview and clinical record review with the Director of Nursing Services (DNS) on 5/24/20 at 9:10 AM identified that although the three residents had tested negative for COVID-19 prior to admission to the facility, all newly admitted residents were placed on droplet transmission-based isolation precautions for a fourteen-day observation period on a separate nursing unit and were isolated from the other facility residents. Resident #1 had been admitted to the facility on [DATE], Resident #2 was admitted on [DATE] and Resident #3 was admitted on [DATE]. Observations during a tour of the nursing unit designated for residents who had been placed on transmission-based isolation precautions and interview with Licensed Practical Nurse (LPN) #1 on 5/24/20 at 9:43 AM identified three storage units that were stocked with personal protective equipment (PPE) that included yellow disposable isolation gowns as well as cloth gowns. Further observations and interview with LPN #1 identified that hooks were attached to the inside of the door of each resident's room. The hooks, which were labeled C for the CNA and N for the licensed nurse, were used to hang the isolation gowns after each use. LPN #1 stated that the gowns were reused throughout a shift by the assigned nurse aide and nurse. Subsequent interview with the Director of Nursing Services on 5/24/20 at 9:50 AM and review of current guidance issued by the Centers for Disease Control and Prevention and the State of Connecticut identified that the practice of reusing isolation gowns placed the healthcare professional at increased risk of self-contamination with each reuse. The guidance recommended that the gown be removed and discarded after each use if designed as a disposable gown or laundered after each use if the gown was washable.

Based on observation, review of facility Mechanical Check logs and staff interviews, the facility failed to ensure that hot water was maintained in a safe range. The findings include: During a tour of the facility on 5/24/20 at 8:30 AM observation identified the temperature of hot water in room [ROOM NUMBER] was 127.7 degrees Fahrenheit. room [ROOM NUMBER] was subsequently identified with a hot water temperature of 122.4 degrees Fahrenheit at 8:33 AM on 5/24/20. Following the observations, Medical Records Assistant #1 was immediately notified of the temperatures that exceeded a safe range. Interview with Physical Plant Staff Person #1 on 5/24/20 at 8:43 AM indicated that he had adjusted the hot water mixing valve to ensure hot water temperatures were within a range of 110 degrees to 120 degrees Fahrenheit. Following the facilty's adjustment of the mixing valve, the surveyor identified the temperature of the hot water in room [ROOM NUMBER] to be 116.4 degrees Fahrenheit. Review of Mechanical Check Logs identified water temperatures were monitored daily on each shift, and temperatures on the wing where room [ROOM NUMBER] was located had been documented at 119.6 degrees Fahrenheit on 5/24/20 at 7:26 AM.

Based on a review of the clinical record, staff interviews and a review of the facility policy, for four of five residents (Resident #6, #8, #10, and #15), reviewed for immunizations, the facility failed to ensure an immunization program for the prevention of pneumococcal pneumonia in accordance with the standards of practice. The findings include: 1. Resident #6 who was born in 1929, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician's orders dated 6/20/19 failed to identify an order for [REDACTED].>Review of facility immunization informed consent form dated 6/20/19 identified Resident #6 declined Pneumococcal (PPSV 23) vaccine at the facility due to having already received this vaccine. A date as to when PPSV 23 was administered was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. The admission Minimum Data Set ((MDS) dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. 2. Resident #8 who was born in 1937, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility immunization informed consent form dated 3/29/19 identified Resident #8 had been administered PPSV 23 prior to admission, however a date was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. The quarterly MDS dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. Physician orders dated 4/16/19 failed to direct the administration of Pneumococcal vaccinations. 3. Resident #10 who was born in 1920, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the clinical record failed to identify if Pneumococcal vaccines had been administered and/or if they were consented for. The annual MDS dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. 4. Resident #15 who was born in 1933 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderate cognitive impairment and the Pneumococcal vaccine was up to date. Physician orders dated 8/16/19 failed to identify an order for [REDACTED].>Review of immunization informed consent form dated 8/18/19 identified Resident #15 had been administered PPSV 23 prior to admission, however a date was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. Interview with the infection control registered nurse (ICRN) on 10/9/19 at 11:25 AM identified Prevnar (PSV) 13 was not administered by the facility as the Medical Director indicated it was difficult to obtain accurate vaccination records and/or information from the residents on past vaccination schedules. Although requested, a tracking log for immunizations was not provided by the facility, as they do not utilize one. Further interview with the ICRN indicated all immunizations are in the computer however, the date of administration was not documented as the residents did not usually know when the immunization was administered. Other means of obtaining vaccination information was not conducted by the facility. A statement received from the Medical Director on 10/9/19 identified Prevnar 13 was not offered at the facility as the short term population typically discharges from the facilty prior to one year. Additionally, the Medical Director identified long term residents are not offered Prevnar 13 vaccine due to a unknown history of vaccine administration. The facility policy entitled Pneumococcal Vaccination of Residents directed in part that a Resident or responsible party would be asked on admission if they have previously had Pneumococcal vaccinations, and their age at the time of vaccination. If there was no prior evidence of the vaccinations, the vaccine would be offered to the resident at that time. The facility failed to address the administration of both Pneumococcal vaccinations in accordance with the guidelines from the Centers of Disease Control.

Based on observation and review of facility documentation and interview with the Administrator and the Director of Environmental Services the facility failed to ensure that a water management plan was in place to Reduce Legionella Risk in the Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) as required by 42 CFR §483.80 for skilled nursing facilities and nursing facilities: The finding include: On 03/20/18 at 1:30 PM, the surveyor was not provided with documentation by the Administrator and the Director of Environmental Services to indicate facility had a comprehensive water management plan in place as required. The facility's plan did not identify dead ends in the water system that were identified during the survey and the plan did not include control measures such as physical controls, temperature management, disinfection level control, visual inspections and environmental testing for Legionella and other opportunistic waterborne pathogens; e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria and fungi that could grow and spread in the facility's water system.

Based on review of the clinical record, review of the facility documentation and interview for one of three resident's reviewed for Abuse (R#22), the facility neglected to provide appropriate care and services in a timely manner. The findings included: Resident # 22's [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance of two persons for bed mobility and transfers, total dependence on two persons for toilet use and personal hygiene, and was always incontinent of bowel and bladder. The RCP dated 7/31/14 continued through present identified that the resident was at risk for impaired skin integrity related to a history of pressure ulcers, [MEDICAL CONDITION] UTI, weakness, and impaired mobility. Interventions included toilet every 2 to 3 hours, incontinent care with the assistance of two persons after each incontinent episode, and the application of house barrier cream. Nurse's notes dated 5/19/17 at 3:52 PM identified that an allegation of neglect was reported at 12:30 PM and identified that the resident had not been provided incontinent care in a timely manner. The facility's investigation of the incident dated 5/19/17 identified that a 1 to 1 sitter for the resident's roommate reported to NA#1 (the day shift NA) that the resident had not been provided with any incontinent care and/or repositioning during the 11:00 PM to 7:00 AM shift. At 6:15 AM, NA#1 found the resident incontinent of urine and proceeded to provide incontinent care. A statement written by NA#2, the 11:00 PM to 7:00 AM NA assigned to the resident, identified that at 4:30 AM she/he had changed the resident and left the resident in the same position while the 1 to 1 sitter was not present in the room. Interview, review of the clinical record and facility documentation on 8/2/17 at 10:15 AM with the DNS identified that the 3:00 PM to 11:00 PM shift NA provided the resident with incontinent care and repositioning at approximately 10:30 PM the evening before (5/18/17) and NA#2 was not able to provide care to the resident because she/he stated she/he was busy with other residents. Based on the investigation, no care including repositioning and/or incontinent care had been provided to the resident from 10:30 PM on 5/18/17 until at least 4:30 AM on 5/19/17, totaling 6 hours. Additionally, the resident remained positioned on the same side from 10:30 PM until 6:15 AM, totaling 7 hours and 45 minutes. The DNS identified that NA #2 should have informed the charge nurse if she/he was unable to provide timely care to the resident. NA #2 was terminated for not following the resident's plan of care. The Facility's Abuse Prevention Program identifies neglect as a failure to provide the goods and services necessary to avoid physical harm, pain, mental anguish, mental illness, or emotional distress.

Based on observation, review of facility documentation and interviews for kitchen sanitation, the facility failed to ensure proper kitchen cleaning was maintained and/or comply with food storage standards. The findings include: On 11/23/14 at 10 AM, kitchen inspection in the presence of the Food Service Director (FSD) identified the following: 1. Six individual serving cups of ice cream, two frozen juice cups, discarded pieces of card board, spillage of an orange colored substance and discarded pieces of clear plastic were identified on the floor, under the shelves in the walk-in freezer. 2. On the floor in the walk-in refrigerator, an accumulation of a clear watery substance was identified below the shelving where the fresh fish was being stored. On the third shelf up were (4) ten pound boxes of frozen shrimp thawing without the benefit of a drip-proof container. The drippings from the thawing shrimp saturated the lid of the container stored below on the second shelf that was identified a fresh sword fish. 3. On the floor in the dry storage area were various pieces of discarded paper, an onion and two potatoes with evidence of sprouting were identified under the shelves. 4. The shelf below the food preparation table had a moderate amount of food splatters accumulated on the shelf as well as the bins that were stored on the shelf. 5. Two of Two ovens were identified with an accumulation of a charred black substance on the bottom surface of the oven as well as an accumulation of baked on splatters evident within the oven and and on the oven doors. Interview with the FSD on 11/23/15 at 11 AM indicated the frozen shrimp was placed in the refrigerator for thawing on 11/22/15. Review of the facility policy and standard food handling practice to prevent potential cross-contamination for thawing food in a refrigerated space with the FSD indicated in part, the use of a drip-proof container.

Based on observations, review of facility documentation and interview the facility failed to maintain the dietary department in a clean and sanitary manner. The findings include: During tour of the dietary department on 2/11/15 at 10:30 AM chemical titration level testing for two of two kitchen sanitation buckets containing cleaning cloths was completed. The sanitizer concentration was tested by the FSD and found indication of no chemical/sanitizer present. The FSD indicated that the facility policy directed sanitizer buckets to be filled and tested prior to use. If the titration level was not reached the bucket would be refilled and retested until proper titration levels were met. Subsequent to surveyor inquiry retesting was completed and results remained the same. The facility indicated additional manufacture's information would be provided to explain why the two sanitizer buckets that were filled on 2/11/15 at 9:30 AM tested at the recommended 200-400 ppm (parts per million) but did not maintain titration level due to the ionization changes when the cleaning cloth was added to the bucket.

Based on clinical record review, observations, review of facility documentation and interviews for one of one sampled resident reviewed for ADL's (R#103), the facility failed to provide the necessary care and services to maintain personal hygiene. The findings include: Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day scheduled MDS assessment dated [DATE] identified the resident as severely cognitively impaired, requiring extensive assistance with ADL's and totally dependent for full body bath/shower. The Resident Care Plan (RCP) dated 1/07/15 identified the resident with a potential to improve functional mobility due to weakness. Interventions included to provide skilled OT treatment five times a week. Observations on 2/09/15 at 2:00 PM, on 2/10/15 at 12:45 PM and 2/11/15 at 9:50 AM identified the resident's hair as oily in appearance. Interview with the DNS on 2/11/15 at 10 AM and clinical record review identified the resident receives two showers a week on Tuesday & Friday and a body audit was completed on the scheduled shower day of Tuesday 2/10/14. Review of the nursing notes dated 2/09/15 through 2/11/15 failed to reflect that the resident refused ADL care. Interview with NA #1 and observation on 2/11/15 at 10:05 AM in the presence of the DNS identified the resident's hair as oily in appearance. NA #1 indicated R#103 was provided grooming, however hair care products were not applied. Interview with NA#2 on 2/11/15 at 10:50 AM indicated that although he/she was assigned to provide R#103's with ADL care on 2/10/15 he/she did not provide bathing or grooming assistance. NA#2 indicated that the resident was assisted with bathing and grooming as part of the OT treatment. Interview with OT #1 on 2/11/15 at 10:55 AM indicated he/she assisted R#103 with morning ADL's on 2/10/15 without regard to the posted shower schedule and so the resident's bathing and grooming was completed without the benefit of full body bath/shower as per schedule.

Based on clinical record reviews, review of facility documentation and interviews for one of four sampled residents (Resident #16) who were reviewed for falls, the facility failed to ensure that appropriate footwear was utilized in accordance with the care plan. The findings include: Resident #16's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #16 had moderate cognitive impairments, some memory deficits, required extensive one person assistance with transfers and toilet use, limited one person assistance with ambulating, balance during transitions and walking was not steady and the resident was only able to stabilize with assistance, utilized a walker for mobility and had a history of [REDACTED]. The resident care plan dated 5/12/14 through 10/9/124 identified that the resident was at risk for falls related to poor safety awareness. Interventions, in part, directed to assist with activities, encourage and/or remind to use assistive devices daily i.e. transfer bars in the bathroom, laser alarm while in bed and to ensure the resident wears appropriate footwear i.e. non-skid shoes, slippers and/or socks. The nurse's note dated 10/9/14 at 10:48 PM identified that while being toileted at 9:15 PM Resident #16 stood up and fell to the floor onto the left side, striking his/her head on the floor. An assessment indicated a hematoma to the left side of the forehead with a moderate amount of bleeding, the resident complained of left hip and arm pain and subsequent to physician notification Resident #16 was transferred to the hospital for an evaluation. The Reportable Event From dated 10/9/14 identified that Resident #16 fell in the bathroom. The investigation identified that at 9:15 PM the laser alarm was sounding and Nurse Aide (NA) #3 and #4 assisted the resident to the bathroom. NA #3 stayed with Resident #16 while NA #4 left the room to get a pair of slipper socks. NA #3 turned away from Resident #16 to have a conversation with the roommate and that was when Resident #16 stood up and quickly fell to the floor. In a written statement dated 10/9/14 NA #3 indicated that Resident #16 did not have anything on his/her feet for slipper socks so after the nurse aides seated the resident on the toilet NA #4 went to get the socks. The nurse's note dated 10/10/14 at 5:30 AM identified that Resident #16 returned to the facility with [DIAGNOSES REDACTED]. Interview and review of the clinical record with the Director of Nurses on 2/11/15 at 1:30 PM identified that the care plan intervention of appropriate footwear had not been followed.

Based on clinical record review, interviews and review of facility documentation for one of three sampled residents (Resident #59) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident # 59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly minimum data set assessment dated [DATE] identified the resident had severe cognitive dysfunction, required extensive assist with transfers, did not walk, and required extensive assist with personal hygiene and dressing. A resident care plan dated 8/5/13 identified a problem with alteration in behavior resulting in resistive and aggressive behavior. Interventions included when the resident becomes aggressive or refuses care re-approach later and be sure the resident is safe. A nurse's note dated 9/11/13 identified an allegation was made by nurse aide # 2 (NA #2) that nurse aide # 1 (NA #1) tapped Resident # 59's left side of his/her face near the mouth while providing evening care at approximately 6:30 PM. The note identified that the Director of Nurses (DON), the physician, and police were notified. The note further identified that no redness or bruising were noted on the resident's face at that time and that the resident did not appear to be in any discomfort and that no behavioral changes were noted at the time. Review of the reportable event and investigation dated 9/11/13 identified that NA # 1 alleged that NA # 2 tapped Resident # 59's left side of his/her face during evening care. The assessment conducted at that time identified no markings, redness and/or bruising on the resident ' s face. A statement dated 9/11/13 signed by NA # 2 and witnessed by RN # 2 identified that while providing care to Resident # 59 he/she witnessed NA # 1 tap the resident on his/her face. A statement dated 9/11/13 signed by NA # 1 and witnessed by RN # 2 identified that Resident # 59 was grabbing his/her hand while attempting to provide pericare, at which time NA # 1 swatted Resident #59's hand. The investigation identified that based on the results of a facility investigation the allegation was substantiated and NA # 1 was terminated on 9/13/13. Attempts to interview NA # 1 were unsuccessful. Interview on 3/11/14 at 1:15 PM with RN # 1 identified that he/she was the RN supervisor the evening of 9/11/13. He/she recalled the event when NA # 2 alleged NA # 1 tapped R # 59 ' s face. He/she identified that NA #2 was very distraught and crying when he/she reported the incident to RN # 1. RN #1 identified that when NA # 1 was interviewed he/she changed his/her story two times. RN# 1 identified that although NA # 1 denied hitting the resident he/she did admit to touching the resident ' s face. RN # 1 identified that he/she would have expected the nurse aides to notify him/her if the resident was combative and/or resistive during care. RN# 1 identified that he/she was not made aware of Residents# 59's resistive behavior until after the incident. Interview on 3/12/14 at 11:04 AM with RN # 2 identified that he/she conducted the investigation related to the allegation of mistreatment to Resident #59 on 9/11/13. RN# 2 identified that he/she did not observe the mistreatment, but had no reason not to believe NA # 2 who witnessed and reported the mistreatment. RN # 2 identified that NA # 1 was terminated because the mistreatment was witnessed and the facility had a zero tolerance policy for mistreatment of [REDACTED]. Interview on 3/12/14 at 12:40 PM with NA # 2 identified that on 9/11/13 he/she was assisting NA # 1 with providing pericare to R # 59. NA # 2 identified that the resident was resistive to the care by attempting to push their hands away. He/she identified that toward the end of the care he/she witnessed NA # 1 tap R # 59's cheek with an open hand and told the resident to stop. NA# 2 identified that he/she told NA # 1 that he/she could not do that to a resident. NA # 1 identified that he/she was sorry and would not do it again. Review of facility policy on abuse prevention and reporting indicated abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting hurt, pain or mental anguish to a resident. The definition presumes that instances of abuse to any resident, even one in a coma causes physical harm or pain or mental anguish. Should the investigation determine that abuse was committed, the staff member will be terminated.

Based on clinical record review, observations and interview for one of six residents reviewed for wounds (Resident #79) the facility failed to ensure care and services were provided to prevent the development of an ulcer. The findings include: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A visual skin assessment dated [DATE] identified the resident had intact skin. The visual skin evaluation dated 12/19/13 identified the resident had a blister on the left lateral heel that measured 4.0 cm by 5.0 cm with a bloody appearance. physician's orders [REDACTED]. An investigation dated 12/20/13 identified that the resident's new slippers caused the blister on the left heel. New interventions directed slipper socks to be worn until the area was healed and the resident's family would provide appropriate footwear when needed. The MDS dated [DATE] identified the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility, was at risk to develop pressure ulcers and had an unstageable pressure ulcer. Although the 12/2013 treatment administration record documented that skin prep had been applied to the heels twice daily on the 11-7am and 3-11pm shifts, there was no documentation that diabetic foot care had been done on the 7- 3pm shift. Interview with RN#3 on 3/12/14 at 2:15 pm identified that the blister on the left lateral heel was attributed to the resident's shoes being too tight. Review of the facility Diabetes Clinical protocol directed to ensure the use of non-constricting, well-fitting shoes, slippers and hose. Additionally, assessment of the feet should include hygiene, temperature, color, circulation, any abrasions/sores/injuries/corns/calluses and the condition of the toes and toenails.

Based on clinical record reviews, interviews, and review of facility documentation, for one of four sampled residents (Resident #54) reviewed for accidents, the facility failed to ensure a safe transfer. The findings include: Resident #54 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had intact cognition and required limited assistance of one staff for transfers. An accident/incident report dated 3/6/14 at 6:10AM identified that while being assisted from the bed to the wheelchair, the resident hit his/her right leg on the foot rest and acquired a 1.0 cm by 0.1cm skin tear. Interview with NA#3 on 3/13/14 at 1:25 PM identified that he/she forgot to remove the leg rests prior to the transfer on 3/6/14 and the resident bumped his/her leg on the foot rest. Interview with the DNS on 3/13/14 at 1:30 PM identified the expectation was for NA#3 to remove the leg rests prior to the transfer. Review of the facility transfer policy directs that staff either remove or seeing the foot rests to the side.

Based on review of the clinical records, observations, and interviews for two residents observed during medication administration (R#66 and R#77), and/ or for 1 of 2 sampled residents reviewed with pressure ulcers, (R#72), the facility failed to inquire and /or assess the resident's pain. The findings include: 1. Resident# 72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The plan of care dated 1/21/13 identified pain management as an issue. Interventions included to medicate the resident for pain 30 minutes before therapy, wound treatment,or bathing. Interview on 1/30/2013 10:13:54 AM identified that R#72 had a dressing change for a stage 3 pressure ulcer wound and complained of pain before, during and after the procedure. The interview further noted that the resident attended an interview later and experienced discomfort due to the dressing change prior to the interview. Review of the Treatment Record and the Pain Management Flowsheet dated 1/29/13 reflected the resident had no pain although the resident had voiced complaints of pain. On 1/31/13 at 9:35 AM, R#72 refused to have the dressing change observed. The resident indicated that the dressing change was painful and he/she screamed and would be embarrassed. Interview with LPN #2 on 1/31/13 at 10:38 AM identified that he/she assesses the resident for pain at the beginning of the shift and if pain is identified later in the shift, he/she does not document the pain. LPN#2 indicated that in the prior couple of days the resident had complained of pain during the dressing change. LPN #2 further stated that on 1/31/13 she had medicated the resident prior to the dressing change because the state had requested to observe the dressing change. The record lacked documentation that the physician was notified or that interventions to alleviate pain had been developed and/or implemented. 2. Resident # 66's [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] identified severe cognitive impairment and total dependence on staff for ADLs physician's orders [REDACTED]. Observation during the medication pass on 1/30/13 at 9:30 AM identified that after LPN# 3 poured the resident's medication she documented a "0" on the MAR indicated [REDACTED]. She proceeded to give the resident the morning medication with out asking the resident if she/he had any pain. 3. Resident #77's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Observation during the medication pass on 1/30/13 at 9:35 AM identified that after LPN #3 poured the resident's medication he/she documented a "0" on the MAR indicated [REDACTED]. She proceeded to give the resident her morning medication with out asking the resident if she/he had any pain. Interview and review of the MAR indicated they never have pain". Interview and review of the facility's policy with LPN #4, the Unit Manager on 1/31/2013 at 2:30 PM identified that pain assessments should be conducted every shift with the use of a scale to determine the pain level. Additionally, LPN #3 should have inquired about pain prior to documenting on the MAR.

Based on clinical record review and staff interview for 1 of 3 sampled residents (R#62), who required supervision with meals, the facility failed to ensure appropriate supervision was provided to a resident during a meal to prevent a burn and/or failed to ensure that food was served to a cognitively impaired resident at a temperature that would not cause 2nd degree burns. The findings include; Resident #62's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified severe cognitive impairment, and limited assistance required with eating. The resident care plan dated 9/23/12 identified alteration in nutrition related to Dementia and poor food/fluid intake. Interventions included to allow adequate time to eat, provides cues, assist as needed. Review of the Occupational therapy notes dated 8/22/12 identified R# 62 was treated for [REDACTED]. Review of the Occupational Discharge summary dated 8/29/12 identified a plate guard was provided to the resident to assist with eating. Nurse's notes dated 9/25/12 at 2:18 PM identified R# 62 sustained a scald burn to the left thigh. The lateral burn was noted to be 8 cm x 4 cm, and the anterior/medial burn was noted to be 27 cm x 5 cm. Both areas were noted with intact blistering indicating 2nd degree burns. Review of Nurse's notes dated 9/25/12 at 3:43 PM identified during lunch, R#62's soup spilled on the resident's left thigh. R #62 received burns to the upper and inner left thigh. Upon assessment R # 62 left thigh was bright red in color with blisters. Facility documentation dated 9/25/12 at 1 PM noted R # 62 spilt hot soup on the left thigh resulting in second degree burns. Additionally, the documentation identified all staff were provided education to increase supervision of residents during meals when soup is served. The resident required localized burn treatments daily. Interview with OT # 1 on 1/31/13 at 12 PM stated that R # 62 was seen in August 2012 related to chronic bilateral shoulder pain. OT #1 stated that R # 62 had limited ROM in both arms and shoulders. Additionally, OT #1 stated that many times the resident would require a lot of assistance with eating and that was why he/she was at a supervised table. Interview with NA #1 on 1/30/13 at 2:10 PM identified R # 62 sat at a supervised table for meals and that although she was sitting next to the resident when the resident spilled the soup, she did not see the incident happen. NA# 1 stated that although R#62 was able to feed him/her self, the resident would miss his/her mouth with the food and have trouble getting the food on the spoon or fork. NA # 1 further stated that when the resident spilled the soup, she patted the resident's pants dry with napkins and continued on with the lunch meal. Approximately 45 minutes later, the resident was returned to his/her room for care and when the pants were removed, blisters were noted on the resident's leg. Review of the food temperature logs indicated that the soup was served at 180 degrees.