Every finding on record at Complete Care at Groton Regency

Based on observations, review of facility documentation and interviews for two of three nursing units (C/D and E/F), the facility failed to ensure resident areas were kept in good repair. The findings include:Observations on all days of the survey, 1/21/26, 1/22/26, 1/27/26, 1/28/26 and 1/29/26 identified that many of the resident rooms on the C/D and E/F nursing units were noted with following:The frames of the drop ceilings contained an excessive amount of what appeared to be rust stains. The wallpaper and wallpaper borders at the top of the walls appeared discolored, ripped and/or hanging off the wall.Ceiling tiles that were bowed, bulged, or broken.Cove base molding that was not adhered to the wall and with dirt, debris or black growth observed behind the moldingThe thresholds to some resident rooms were missing.Chipped flooring tiles A tour of the nursing units with the Regional Maintenance Director on 1/28/26 and 1/29/26 identified that he wrote the specific rooms and areas where the environmental concerns were noted. Interview with the Regional Maintenance Director on 1/21/26 at 2:30 PM identified that the rooms throughout the facility were being redone and that there is a QAPI (Quality assurance project) outlining the plan. Review of the QAPI plan dated 10/21/25 identified a plan to address the environment on the A/B nursing unit and noted that resident rooms would be renovated. Further review of the plan failed to identify that the environment on the C/D and the E/F units would be addressed. Interview with the Administrator on 1/21/26 at 2:45 PM identified facility environmental rounds paperwork and QAPI plan dated 10/21/25 which addressed the topic Homelike Environment and renovation plans for Units A and B and projected repairs were for the 31 resident rooms on those 2 units. There was no information provided regarding repairs on the C, D, E or F unit. Interview with the ADNS on 1/22/2026 at 3:25 PM identified that she was responsible for environmental rounds with a focus on infection control and indicated she does not focus on the maintenance or repair of items unless it affects infection control. Interview with the Director of Housekeeping and the District Manager for Environmental Services (EVS) on 1/22/2026 at 3:31 PM identified EVS environmental rounds were focused on cleanliness of the areas but indicated if something was in grave disrepair it would be noted. Interview with the Maintenance Supervisor on 1/22/2026 at 3:36 PM identified that he reviews a reporting system that staff can put in maintenance requests and completes repairs to the facility based on the reporting system requests. When asked if there was a general maintenance audit or list with items that needed upkeep or if there was a system in place for general upkeep, the Maintenance Director identified that he had not completed a building audit and indicated the rooms are looked at when the maintenance staff are in the rooms to complete work. The Maintenance Director identified that when the rooms are empty and available they are looked at. He presented maintenance and housekeeping rounds dated 5/7/25, 6/11/25, 6/18/25, 6/25/25, 7/2/25, 7/9/25, 7/16/25, 7/23/25 and 7/3025 which identified items on the E/F unit for cleaning and an audit for repairs and room improvements that the Maintenance Director identified was primarily initiated by the E/F unit coordinator and indicated he did not have the same paperwork for the C/D unit. Interview with the E/F Unit Manager on 1/28/2026 at 7:56 AM identified that as he does daily rounds he notes if something needs to be repaired and puts that request for repair in the computer system so that maintenance is notified. Interview with the Administrator on 1/28/2026 at 11:07 AM identified that he received quotes for flooring throughout the building but did not have a timeline or a plan for implementation of the plan. The Administrator indicated he was aware that repairs needed to be completed but noted he did not have a written plan. The Administrator identified that the facility had completed repairs concentrated on the A/B unit because it was identified in a previous survey. Following surveyor inquiry, the Regional Maintenance Director submitted a prioritized plan for room repairs for resident rooms and identified the facility will complete corrections on A/B and move throughout the remaining units based on need and prioritization.

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews for one of six sampled residents (Residents #98) reviewed for resident-to-resident abuse, the facility failed to ensure the resident was free from abuse. The findings include:Resident #15's diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. The quarterly MDS assessment dated [DATE] identified Resident #15 was cognitively intact, had hallucinations, and delusions, exhibited verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. The assessment further identified Resident #15 required moderate assistance with toileting hygiene, lower body dressing, clean-up assistance with personal hygiene, was non-ambulatory and independently utilize a manual wheelchair. The care plan dated 2/19/25 identified Resident #15 exhibited or had the potential to demonstrate verbal behaviors related to cognitive loss/dementia, history of verbal outburst such as yelling out, and swearing with interventions that included provide consistent, trusted caregiver, provide structured daily routine when possible, evaluate need or provide psychiatric/behavioral health consultation and provide a calm quiet well-lit environment. Review of the physician's orders for the period of February 2025 through March 2025 identified an order to monitor Resident #15 for the targeted behaviors of hallucinations and delusions. Resident #130's was admitted to the facility in February of 2025 with diagnoses that included Alzheimer's disease, anxiety disorder, and cognitive communication deficit. The admission MDS assessment dated [DATE] identified Resident #130 had severely impaired cognition, had delusions, displayed physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, and rejection of care. The assessment further identified Resident #130 required maximal assistance with toileting hygiene, dressing, and was able to ambulate 10 to 50 feet with moderate assistance utilizing a walker. The care plan dated 2/20/25 identified Resident #130 was resistive to care related to difficulty adjusting to facility, cognitive loss/dementia, refusal of care, use of assistive devices, physical/verbal aggressive behaviors, yells, has delusions, hits, and has incessant pacing. Interventions included: if resident becomes combative or resistive postpone care/activity and allow resident time to regain composure, monitor and report laboratory test results to physician, monitor for anxiety, verbal/physical aggression and delusions. Review of the physician's orders from February 2025 through March 2025 identified an order to monitor Resident #130 for the targeted behaviors of delusions, physical aggressive to staff, resident, and verbal aggressive to staff, resident.The Reportable Event Report dated 3/21/25 at 12:30 PM identified Resident #15 was in the bathroom in his/her room, when Resident #130 entered the bathroom and was instructed to get out by Resident #15. The report further identified that Resident #130 proceeded to slap Resident #15 on the left cheek with an open hand. The reportable event report further identified Resident #15 had no injuries, distress or discomfort and noted the actions taken included a neurological assessment and vital signs, follow-up with psychiatric evaluation and social services, and to place a stop sign on across Resident #15's doorway. The Psychiatric evaluation and consultation dated 3/21/25 identified Resident #130 was on antibiotics for an infection and was a poor historian related to dementia and appears unaware that the incident occurred. The evaluation further identified Resident #130 was likely confused and wandered into Resident #15's bathroom and responded to the other resident telling him/her to leave the bathroom.The care plan dated 3/21/25 identified Resident #130 exhibits or has the potential to exhibit physical behaviors related to cognitive loss/dementia, negative interaction with another resident. The care plan further identified that the resident used to work in a prison and is triggered when he/she is told no. Interventions included evaluating the need for psychiatric/behavioral health consult, social service visit to provide support as needed or requested, diverting resident by giving alternative objects or activities, remove the resident from the environment if needed, observe for non-verbal signs of physical aggression and evaluate the nature and circumstances of physical behavior. The care plan did not address the possibility of Resident #130 wandering into other residents' rooms. The nurse's note dated 3/21/25 at 5:16 PM identified Resident #130 hit staff and threw a cup of juice into staff member's face after attempts to redirect. The nurse's note dated 3/29/25 at 12:16 AM identified Resident #130 was verbally aggressive toward staff, refused to use walker, refused to stop wandering into residents' room and refused to be redirected.The nursing note dated 3/31/25 at 9:00 PM identified Resident #130 was agitated, refused care, was aggravating other residents and was not easily redirected. Resident #98 was admitted to the facility in March 2025 and had diagnoses that included Alzheimer's disease, anxiety disorder and bilateral hearing loss. The admission MDS assessment dated [DATE] identified Resident #98 had moderate cognitive impairment, required setup or clean-up assistance with dressing, personal hygiene, was independent with bed mobility and ambulation. The care plan dated 4/8/25 identified Resident #98 had exhibit or had the potential to exhibit physical behaviors related to cognitive loss/dementia with a history of combative behavior in the community, lacked personal space boundaries and had the behavior of yelling with interventions that included social service visits to provide support as needed and or as requested, evaluate the need for psychiatric/behavioral health consult, remove resident from environment if needed and gently guide the resident from the environment while speaking in a calm reassuring voice. Review of Resident #98's physician's order dated 4/1/25 directed to monitor the target behavior of paranoia every shift. The Reportable Event Report dated 4/4/25 at 10:00 AM identified Resident #130 entered Resident #98's room and slapped the resident on the left side of the face and grabbed the resident's right upper arm. The report further identified that actions taken included a stop sign at the doorway, a neurological assessment, vital signs and an examination of the face and arm. The Unit Manager's (RN #5) note dated 4/4/25 at 2:14 PM identified he was called to Resident #98's room at around 10:15 AM when the resident reported that another resident entered the room and asked him/her something and then slapped him/her on the left side of the face. The nurse's note further noted the resident had pinkness to the left side of the face, resident denied pain and was alert and oriented to person and place. The note further noted that a stop sign was placed in the doorway to Resident #98's room. Interview with Resident #98 on 1/29/26 at 2:36 PM identified he/she was slapped in the face by a resident that is no longer at the facility. Resident #98 identified at the time of the incident he/she was upset but got over it quickly.The psychiatric evaluation and consultation dated 4/4/25 identified Resident #98 reported being hit in the face by another resident in the morning, and thinks the resident was confused and wanted him/her to go with him/her but once he/she declined, Resident #98 struck him/her. The Reportable Event Report dated 4/4/25 at 10:00 AM identified Resident #130 went into another resident's room (Resident #98) yelled at the resident, demanded them to do what he/she asks, slapped the resident and grabbed them on the right upper forearm. The report further identified Resident #130 was placed on one-to-one supervision following the incident. The Psychiatric evaluation and consultation dated 4/4/25 identified Resident #130 entered another resident's room and the other resident reported that Resident #130 hit her in the face with an open hand. The evaluation further identified Resident #130 had a previous resident to resident incident which occurred on 3/21/25 wherein Resident #130 went into another resident's bathroom and the other resident yelled at him/her and Resident #130 hit the other resident and Resident #130 was worked up for infection and there was no evidence of an active infection. In addition, the evaluation further identified based on recent episodes of physical aggression with no evidence of infection, Resident #130 should remain on one-to-one supervision and should be sent to a psychiatric facility for treatment. Review of the nurses' notes from 4/4/25 to 4/8/25 identified that the resident remained on one-to-one observation. The physician's progress note dated 4/8/25 identified the resident was transferred to an inpatient psychiatric hospital. Review of the Abuse, Neglect and Exploitation policy identified that this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility failed to implement effective interventions for Resident #130, who displayed wandering, verbal and physical aggression and was not easily redirected. These failures contributed to an incident of resident-to-resident abuse.

Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews for one of three residents (Resident #23) reviewed for pressure ulcer/injury, the facility failed to appropriately track and place a resident with an open wound on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was utilized when providing wound care. The findings include:Resident #23's diagnoses included vascular dementia, non-pressure chronic ulcer of skin of other sites with fat layer exposed, anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #23 had severely impaired cognition, was dependent on staff for bed mobility, personal hygiene, dressing, eating, transfers and was non-ambulatory. The assessment further identified Resident #23 had treatments for skin and ulcer/injury for pressure reducing device for chair and bed, application of non-surgical dressing other than to feet and applications of ointment/medications other than feet.The care plan dated 1/24/26 identified Resident #23 was at risk for skin breakdown related to fragile skin, incontinent of bowel and bladder, end stage failure with interventions that included low air mattress related to sacral wound and for pressure reduction, setting per manufacturer guidelines, treatment per provider order, weekly wound assessment to include measurements and description of wound status.The physician's order dated 12/4/25 directed to cleanse sacrum with wound cleanser, pat dry, apply xeroform followed by dry protective dressing as needed for soiled or dislodged monitor for placement and every day shift wound care.The wound evaluation and management summary dated 12/18/25 written by the Wound physician (MD #2) identified Resident #23 had an end stage skin failure to sacrum full thickness measuring 3 centimeter (cm) in length, 0.8 cm in width, and 0.2 cm in depth with moderate serosanguinous exudate.The wound evaluation and management summary dated 1/22/26 written by the Wound physician (MD #2) identified Resident #23 had an end stage skin failure to sacrum full thickness measuring 0.5 cm in length, 0.8 cm in width, and 0.2 cm in depth with moderate serosanguinous exudate.Observation on 1/27/26 at 2:00PM identified posted signage that identified the need for Enhanced Barrier Precautions (EBP) which noted the need for everyone to perform hand hygiene before entering and when leaving the room, providers, and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing, showering, device care or care of a urinary catheter.Interview with NA #1 on 1/27/26 at 2:00 PM identified the EBP signage posted outside Resident #23's room was for the roommate as the resident has a foley catheter. She identified that staff is aware of who is on EBP by the sign placed outside of the room and if they have questions, they can ask the nurse.Review of the facility's EBP list dated 1/13/26 with the Infection Preventionist (RN #1) in the presence of the Clinical Manager RN #3 on 1/28/26 at 10:49 AM failed to reflect that Resident #23 was placed on the EBP list.Interview with the Infection Preventionist (RN #1) in the presence of the Clinical Manager RN #3 on 1/28/26 at 10:49 AM identified any resident with an open wound even if it is small is placed on EBP. RN #1 identified that staff is aware that a resident is on EBP by the signage placed on the outside of the room, the nurse aide care card, the resident care plan, the physician's order, and a list is placed at the nurse's station. RN #1 identified that Resident #23 should be on EBP due to the open wound on the sacrum. She identified that it was her responsibility to place the resident on EBP and add them to the list as he/she did have an open wound to the sacrum.Observation of wound care treatment for Resident #23 on 1/29/26 at 9:28 AM identified LPN #2 cleaned the treatment cart, performed hand hygiene, brought the cart to the room, donned gloves, gathered supplies of wound cleanser, xeroform dressing, dry protective dressing, gauzes, scissors, and marker. LPN #2 requested NA #1 to assist with positioning the resident during the wound care treatment. LPN #2 brought supplies to the beside while NA #1 repositioned Resident #23 on the left side exposing the affected area which was open and red, and proceeded to complete the treatment as directed by the physician. LPN #2 and NA #1 donned gloves but failed to wear a gown when providing and assisting with the wound care treatment.Interview with LPN #2 on 1/29/26 at 9:40 AM identified she did not wear the required PPE while administering the wound care treatment because the resident was not on EBP. She identified that the EBP signage outside of the room was for the roommate who had a foley catheter and would require EBP. LPN #2 further noted that when a resident is on EBP there is a physician's order in the chart, a care plan, a note in the special instructions banner, and his/her name would be listed on the EBP/MDRO list at the nursing station. A review of all the locations described failed to reflect that Resident #23 was on EBP. Interview with the Unit Manager (LPN #1) on 1/29/26 at 9:49 AM identified the resident was not on EBP and should have been on EBP precautions after reviewing the wound notes and LPN #2 identifying it was an open wound.Interview with the Wound Nurse (RN #4) on 1/29/26 at 9:59 AM identified Resident #23 should be on EBP due to the open wound to sacrum. She identified it was her responsibility to ensure that the resident was on EBP, as this resident is seen by the wound provider weekly.Review of the Enhanced Barrier Precautions identifies an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (example chronic wounds such as pressure ulcers, diabetic ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and indwelling medical devices (example central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheter, PICC lines, midlines) even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 2 of 6 residents (Resident #4 and Resident #73) reviewed for involuntary seclusion, the facility failed to ensure the comprehensive care plan was reviewed and revised to reflect each resident's changing goals, preferences and needs of the resident including placement and continued placement on a secured unit. The findings included:Review of resident roster for the E/F secured nursing unit on 1/21/26 at 11:00 AM identified Resident #4 resided on the secured unit.Review of the clinical record on 1/22/26 identified a consent form for the secured unit (E/F) that identified Resident #4 had dementia and was a wandering risk and would only be allowed to leave the unit with supervision. The form identified that verbal consent was obtained from Resident #4's responsible party on 10/30/25 and was signed by facility staff.The physician's orders dated 1/26/26 directed Resident #4 directed to monitor the target behaviors of agitation, and insomnia. Interview with Resident #4's Responsible Party on 1/29/26 at 8:48 AM identified she did not have any concerns with Resident#4's placement on the secured unit due to wandering behaviors, confusion and safety decline.Interview with the Unit Manager (E/F) (RN# 10) on 1/29/26 at 10:35 AM identified Resident #4 was a resident on the secured unit and indicated that admission to the secured unit is interdisciplinary and that the social worker is responsible for updating the care plan to reflect the resident residing on a secured unit.Interview with Social Services Director on 1/29/26 at 1:15 PM identified Resident #4's care plan failed to identify interventions implemented related to the resident being on a secured unit. The facility policy for Comprehensive Care Plans identified the comprehensive care plan should describe, at a minimum, the following: the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, and resident specific interventions that reflect the residents' needs.The Secure Dementia Care Unit Policy identified that the interdisciplinary team conducts quarterly and periodical reviews on patients residing on the secured unit to assess for ongoing appropriateness of residing on the unit.The policy indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and indicated that alternative interventions will be documented and identified that qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Resident #73's diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Alzheimer's disease and vascular dementia with other behavioral disturbances. The quarterly MDS assessment dated [DATE] identified Resident #73 had moderately impaired cognition, did not exhibit behaviors, was dependent on staff for position changes, transfers and mobility and did not utilize any alarms or restraints. Review of facility unit roster for E/F secured unit on 1/21/26 at 11:00 AM identified Resident #73 resided on the secured unit. Memory unit program physician authorization dated 1/6/26 and signed by the Medical Director identified Resident #4 would benefit from a structured program including the provision of a secured residence/neighborhood based on Resident #4's diagnosis of Alzheimer's disease.Facility documentation for E/F secure unit with dementia features consent signed 1/6/26 identified Resident #73's conservator gave verbal permission for secured unit placement over the phone. Observation of Resident #73 on 1/21/26 at 2:16 PM identified Resident #73 resided in a resident room on the secured unit and indicated he/she could not leave the unit without permission. The physician's orders dated 1/26/26 directed to monitor for target behaviors of yelling/screaming, and sad affect/weeping. The care plan dated 1/28/26 identified Resident #73 had the potential to exhibit behaviors of irritability and restlessness secondary to a diagnosis of depression, swearing, yelling at staff and forgetting when care provided with interventions to explain all care including procedures, and the reason for performing the care before initiating, provide consistent, trusted caregiver and structured daily routine, when possible, remove resident from environment, if needed and gently guide the resident from the environment while speaking in a calm, reassuring voice, provide a calm, quiet, well-lit environment. The care plan did not identify Resident #4 resided on a secure unit.Interview with the Unit Manager (E/F) (RN# 10) on 1/29/26 at 10:35 AM identified Resident #73 was a resident on the secured unit and indicated that admission to the secured unit is interdisciplinary and that the social worker is responsible for updating the care plan to reflect the resident residing on a secured unit.Interview with Social Services Director on 1/29/26 at 1:15 PM identified the care plan failed to address Resident #73's residence on the secure unit and/or interventions to direct the resident specific care on the unit. The facility policy for Comprehensive Care Plans identified the comprehensive care plan should describe, at a minimum, the following: the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, and resident specific interventions that reflect the residents' needs.The Secure Dementia Care Unit Policy identified that the interdisciplinary team conducts quarterly and periodical reviews on patients residing on the secured unit to assess for ongoing appropriateness of residing on the unit.The policy indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and indicated that alternative interventions will be documented and identified that qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures, and interviews for 1 of 5 residents (Resident #4) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered or history assessed. The findings include:Resident #4's diagnoses included dementia, atrial fibrillation, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #4 had severely impaired cognition. The assessment further identified that Resident #4 was not up to date with the COVID-19 vaccination.Review of the COVID-19 Vaccine Administration and Consent Form with the Infection Preventionist (RN #1) in the presence of the Clinical Manager (RN #3) on 1/28/26 at 10:49 AM identified Resident #4 Power of Attorney (POA) gave the facility permission on 10/20/25 to administer the COVID-19 vaccine and boosters. Further review of Resident #4 physician's orders, preventative health care report and progress notes with RN #1 and RN #3 failed to reflect that Resident #4 had received the COVID-19 booster vaccine for 2025-2026 as requested or had refused the vaccine when attempted to administer. Interview with RN #1 on 1/29/26 at 10:34 AM identified she had seen the previous COVID-19 consent that was signed in August of 2025 for refusal but did not see the new consent that was signed in October of 2025. She further indicated that the resident should have received the vaccine as the facility had started administering the vaccine to residents at that time. RN #1 identified she had spoken to the POA, and he/she still wants the resident to offer the vaccine. Review of the COVID-19 Vaccination policy identifies the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our resident and staff the COVID-19 vaccine.

Based on review of clinical records, review of facility documentation, and interviews for one of two sampled residents (Residents #15) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure the comprehensive assessments were accurately coded to reflect the resident's positive Level II PASRR status and for three of three sample residents (Resident #12, Resident #14, and Resident #44) reviewed for resident assessment, the facility failed to ensure the Brief Interview for Mental Status (BIMS) (a screening tool to assess resident's cognitive function) was completed. The findings include: Resident #15's diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. The PASRR level II screening dated 2/7/2023 identified Resident #15 had a positive level II PASRR. The annual MDS assessment dated [DATE] identified under the Preadmission Screening and Resident Review (PASRR) section a response of no to the question that asks if the resident was currently considered by the level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. The correct response should have been yes because the resident has a positive Level II assessment and a yes would have led to more questions that pertain to why the resident has a Level II PASRR assessment. Interview on 1/27/26 at 11:30 AM with the Director of Social Services (SW #1) identified that the social workers are responsible for completing section A1500 on the admission, annual, and significant change in status MDS assessments. SW #1 identified he started working at the facility in August of 2025 and during that initial orientation phase, a per diem MDS Coordinator was completing the PASRR section of the MDS assessments. He further identified Resident #15 had a positive level 2 PASRR assessment and the MDS should have been coded accurately to reflect the positive level 2 PASRR assessment. Interview on 1/28/26 at 2:00 PM with the MDS Coordinator (RN #2) identified she was responsible for coding the PASRR section of the MDS assessment dated [DATE]. She identified that she obtained information from the electronic record system to complete the assessment and at the time of the review she saw a document entitled level of care in the miscellaneous section of Resident #15's record but did not open the document. RN #2 identified that the assessment was coded incorrectly, and she had submitted a correction as it is the policy that MDS assessments should be coded accurately. Review of the Conducting an Accurate Resident Assessment identifies the purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The policy further identified each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment, whether the MDS assessments are manually completed, or computer-generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. Resident #12's diagnoses included vascular dementia, anxiety, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #12's cognitive assessment in (section C) was not assessed, meaning the BIMS was not completed nor was the cognition assessed by the staff, which is supposed to be done when the resident is unable to complete the brief interview for mental status. Interview with the Director of Social Work (SW #1) on 1/22/26 at 1:25 PM identified that the social worker is responsible for conducting the BIMS and completing the section C of the MDS (this is the part pertaining to the assessment of cognition). He identified that section C is completed during the seven-day look back period of the MDS assessment. He further identified that not assessed means the BIMS nor alternate staff assessment of the cognition were completed. He could not provide a reason why the interviews or the staff assessments were not completed for Resident #12, Resident #14, and Resident #44. Interview with the MDS Coordinator (RN#2) on 1/28/26 at 2:10 PM identified that the social worker is responsible for conducting the BIMS in section C of the MDS to assess the resident's cognition. She identified that she coded not assessed in section C because there was no BIMS completed during the seven day look back period. She identified that she works per diem as the MDS Coordinator. She noted that she did explore why the cognitive function of the resident was not assessed. The Resident Assessment of Cognitive Patterns policy identified that the facility completes section C of the MDS to determine the resident's attention, orientation, and ability to register and recall new information. Each resident's cognitive functioning will be assessed and documented in section C of the MDS assessment. Resident #14's diagnoses included bipolar disorder, post-traumatic stress disorder (PTSD), type 2 diabetes mellitus. The annual MDS assessment dated [DATE] identified Resident #14's cognitive assessment in section C was marked off as not assessed meaning the BIMS was not completed nor was the cognition assessed by the staff, which is supposed to be done when the resident is unable to complete the brief interview for mental status. Interview with the Director of Social Work (SW #1) on 1/22/26 at 1:25 PM identified that the social worker is responsible for conducting the BIMS and completing the section C of the MDS (this is the part pertaining to the assessment of cognition). He identified that section C is completed during the seven-day look back period of the MDS assessment. He further identified that not assessed means the BIMS nor alternate staff assessment of the cognition were completed. He could not provide a reason why the interviews or the staff assessments were not completed for Resident #12, Resident #14, and Resident #44. Interview with the MDS Coordinator (RN#2) on 1/28/26 at 2:10 PM identified that the social worker is responsible for conducting the BIMS in section C of the MDS to assess the resident's cognition. She identified that she coded not assessed in section C because there was no BIMS completed during the seven day look back period. She identified that she works per diem as the MDS Coordinator. She noted that she did explore why the cognitive function of the resident was not assessed. The Resident Assessment of Cognitive Patterns policy identified that the facility completes section C of the MDS to determine the resident's attention, orientation, and ability to register and recall new information. Each resident's cognitive functioning will be assessed and documented in section C of the MDS assessment. Resident #44's diagnoses included heart failure, atrial fibrillation, and spinal stenosis. The quarterly MDS assessment dated [DATE] identified Resident #44 cognitive assessment in section C was marked off as not assessed meaning the BIMS was not completed nor was the cognition assessed by the staff, which is supposed to be done when the resident is unable to complete the brief interview for mental status. Interview with the Director of Social Work (SW #1) on 1/22/26 at 1:25 PM identified that the social worker is responsible for conducting the BIMS and completing the section C of the MDS (this is the part pertaining to the assessment of cognition). He identified that section C is completed during the seven-day look back period of the MDS assessment. He further identified that not assessed means the BIMS nor alternate staff assessment of the cognition were completed. He could not provide a reason why the interviews or the staff assessments were not completed for Resident #12, Resident #14, and Resident #44. Interview with the MDS Coordinator (RN#2) on 1/28/26 at 2:10 PM identified that the social worker is responsible for conducting the BIMS in section C of the MDS to assess the resident's cognition. She identified that she coded not assessed in section C because there was no BIMS completed during the seven day look back period. She identified that she works per diem as the MDS Coordinator. She noted that she did explore why the cognitive function of the resident was not assessed. The Resident Assessment of Cognitive Patterns policy identified that the facility completes section C of the MDS to determine the resident's attention, orientation, and ability to register and recall new information. Each resident's cognitive functioning will be assessed and documented in section C of the MDS assessment.

Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the resident was not left unattended with administered medications. The findings included:Resident #1 was admitted to the facility in October of 2025 with diagnoses which included congestive heart disease, anxiety, and Type 2 diabetes mellitus.Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation, was verbally appropriate, and required extensive assistance with personal hygiene, bed mobility, and transfers.The Resident Care Plan (RCP) dated 10/25/25 identified Resident #1 required assistance/was dependent for activities of daily living which included bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to a recent hospitalization which resulted in fatigue, activity intolerance, and confusion. Interventions directed to monitor medications, especially new/changed/discontinued, for side effects and responses contributing to cognitive loss/dementia, drug interactions, adverse drug reactions, drug toxicity, or errors. A physician's order dated 10/25/25 directed to administer fifteen (15) grams of sodium polystyrene sulfonate powder by mouth daily for hyperkalemia (elevated serum potassium levels) mixed in sixty (60) milliliters of fluid of choice.A nurse's note dated 10/29/25 at 3:05 PM identified Resident #1 was found lying prone (on his/her stomach) on the floor, with copious wet marks on the right side of his/her shirt and right pant leg, and when asked what happened, Resident #1 responded the nurse gave me liquid that tasted horrible and I started to vomit. Then, you found me.Interview with LPN #1 on 11/13/25 at 12:22 PM identified on the morning of 10/29/25, Resident #1 was seated in his/her wheelchair during the medication pass. LPN #1 indicated he/she administered half of Resident #1's medications before Resident #1 requested additional applesauce. LPN #1 identified when he/she went to the med cart to retrieve more applesauce he/she took the remaining pills to the med cart, however, left the half-filled cup of sodium polystyrene sulfonate mixture on the bedside table positioned in front of the Resident #1. LPN #1 further identified upon reaching the medication cart (stationed at the doorway of Resident #1's room), he/she heard a loud noise behind him/her and turned to find Resident #1 lying on the floor. Interview with LPN #1 on 11/14/25 at 9:50 AM identified the remaining sodium polystyrene sulfonate mixture should not have been left on Resident #1's bedside table. LPN #1 further indicated he/she was unsure if Resident #1 consumed the remaining sodium polystyrene sulfonate mixture prior to the fall.Interview with the Director of Nurses on 11/14/25 at 2:20 PM identified facility practice was to watch residents take their medication(s) in entirety prior to leaving the resident or their room. Review of the Medication Administration policy dated 1/18/24 directed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice in a manner to prevent contamination or infection. The policy further directed staff to observe resident consumption of medication.

Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for resident rights, the facility failed to ensure the resident was treated with respect during medication administration. The findings included:Resident #1 was admitted to the facility in October of 2025 with diagnoses which included congestive heart disease, anxiety, and Type 2 diabetes mellitus.Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation, was verbally appropriate, and required extensive assistance with personal hygiene, bed mobility, and transfers.The Resident Care Plan (RCP) dated 10/25/25 identified Resident #1 required assistance/was dependent for activities of daily living which included bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to a recent hospitalization which resulted in fatigue, activity intolerance, and confusion. Interventions included to monitor medications, especially new/changed/discontinued medications, for side effects and responses contributing to cognitive loss/dementia.The Department of Public Health Reportable Event Summary Report dated 10/24/25 identified Resident #1 alleged a staff member went into his/her room at 6:00 AM on 10/24/25 to administer medications, Resident #1 informed the staff member that he/she could not take medications without applesauce and Resident #1 heard the staff member state Jesus Christ before leaving the room.A Nursing note dated 10/25/25 at 12:06 PM identified Resident #1 alleged RN #1 used inappropriate language and demeanor during an interaction.A Disciplinary Action Form dated 10/26/25 identified RN #1 was cited for unprofessional conduct and failed to maintain professional demeanor during an interaction with a resident. RN #1 was educated on professionalism and customer service.Interview on 11/14/25 at 9:15 AM with RN #1 (11:00 PM to 7:00 AM nurse supervisor) identified he/she was assigned to provide care for Resident #1 on 10/24/25. RN #1 identified that during the morning medication pass, Resident #1 informed him/her that he/she took medication(s) with applesauce. Upon returning from the kitchen with applesauce, RN #1 indicated Resident #1 was fumbling with the remote control to his/her bed and that prior to taking the remote from Resident #1, had uttered Jesus Christ under his/her breath. RN #1 identified Resident #1 did not react to what he/she said at that time and further indicated that he/she was uncertain as to why it was even said. RN #1 further indicated he/she apologized to Resident #1 approximately thirty (30) minutes following the incident.Interview with the Director of Nursing Services (DNS) on 11/14/25 at 2:20 PM identified that uttering Jesus Christ was poor bedside manner and indicated the language was offensive. The DNS further identified that it was the facility's standard of practice for staff to maintain professionalism and respect at all times.Review of the Resident Rights policy dated 7/1/24 directed residents had a right to be treated with respect and dignity.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to transport the resident to an orthopedic appointment per physician's order and failed to complete a fall risk assessment after a fall in accordance with facility policy. The findings include: Resident #1's diagnoses included repeated falls, right humerus fracture (a bone in the upper arm running from the shoulder to the elbow), bone density disorder, anxiety disorder and dementia with behavioral disturbances. The Resident Care Plan (RCP) dated 5/31/24 identified that Resident #1 is at risk for falls due to cognitive loss, lack of safety awareness and advanced Alzheimer's disease and had a history of falls and seizure like activity with interventions included to follow-up with the orthopedist for the right humerus fracture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required moderate assistance with bed mobility and supervision assistance with transfers and ambulation. Review of the Department of Public Health Facility Licensing & Investigation Complaint Submission dated 7/11/24 identified that Resident #1 had a traumatic fall at the facility and sustained a fractured shoulder. Person #1 reported that he/she called the facility to ensure Resident #1 was on their way to his/her orthopedic surgeon appointment and was told that nothing had been arranged so he/she would be missing the appointment, despite Person #1 reporting that he/she had called the facility a few days prior to remind the staff of the appointment. Review of the facility Reportable Event (RE) dated 5/30/24 identified that at 7:55 AM, Resident #1 sustained an unwitnessed fall, reporting that staff heard a loud noise and observed the resident face down in the hallway. Staff rolled the resident onto his/her back and upon assessment he/she became unresponsive and involuntary jerking movements were observed. The resident was transferred to the Emergency Department (ED) for evaluation, returning to the facility with sutures to the chin but no imaging had been obtained. Shortly after the resident returned to the facility, staff observed the resident with facial grimacing, guarding his/her right arm and swelling was noted to the right shoulder. STAT x-rays were obtained in the facility and resulted with an acute displaced comminuted fracture (broken into more than two pieces caused by a significant amount of force) of the right humeral head (the junction of insertion into the shoulder). The resident was sent back to the ED and consulted with Orthopedics, where no surgical intervention had been scheduled at that time, but the resident was to follow-up with Orthopedics. A. Review of Report of Consultation notes for Resident #1 dated 6/19/24 and written by MD #2 (orthopedic doctor) identified that the resident was to follow-up with him/her again in three (3) weeks. A physician's order dated 6/19/24 directed to follow-up with orthopedics, MD #2 in 3-weeks on 7/11/24 at 3:45 PM. A nurse's note dated 7/11/24 at 4:00 PM, written by RN #2, identified that Resident #1 was unable to attend his/her follow-up orthopedic appointment due to transportation issues and the appointment was rescheduled for 7/26/24 at 10:30 AM. Interview with RN #2 on 11/07/24 at 12:44 PM identified that she could not recall the details of what the transportation issue was on 7/11/24 that caused Resident #1 to miss his/her appointment but identified that she rescheduled the appointment the same day. Interview with Person #2 (orthopedic office scheduler) on 11/07/24 at 1:10 PM identified that Resident #1 had an appointment with MD #2 on 7/11/24 at 3:45 PM that was rescheduled by the facility on 7/11/24 at 3:26 PM. Review of Report of Consultation notes for Resident #1 dated 7/26/24 identified that Resident #1 was seen by MD #2 on 7/26/24. Interview with the DNS on 11/07/24 at 3:51 PM identified that they were unable to confirm that transportation had been set up for Resident #1 for the 7/11/24 orthopedic appointment and she was unsure why, identifying that RN #2 was aware of the appointment and it should have been notated in the appointment book. She reported that although there was a physician's order for the orthopedic appointment on 7/11/24, and the resident did not attend. Although attempted, an interview with Person #1 was not obtained. Although requested, facility policies for following physician's orders and coordinating community appointments were not provided. B. Review of Resident #1's clinical record failed to identify that a fall risk assessment was completed after the 5/30/24 fall until 6/22/24 (23 days after the fall). Review of the Fall Risk assessment dated [DATE] at 7:20 PM identified that Resident #1 was a moderate fall risk. Interview with the DNS on 11/08/24 at 1:12 PM identified that a Fall Risk Assessment was not completed after the 5/30/24 fall because that is not the facility policy, reporting that the quarterly Fall Risk Assessments were completed on 3/22/24 and 6/22/24, but that there were not any completed between that time period. Review of the Fall Prevention Program policy dated 1/20/24 directed, in part, that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall risk assessment is to be completed every 90 days and as indicated when the resident's condition changes. When any resident experiences a fall, the facility will complete a post-fall assessment.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to follow the plan of care to adequately supervise a resident who required assistance with ambulation resulting in falls. The findings include: Resident #1's diagnoses included repeated falls, right humerus fracture (a bone in the upper arm running from the shoulder to the elbow), right femur fracture (bone in the upper leg, spanning from the hip to the knee), bone density disorder, anxiety disorder and dementia with behavioral disturbances. The Resident Care Plan (RCP) dated 5/31/24 identified that Resident #1 is at risk for falls due to cognitive loss, lack of safety awareness and advanced Alzheimer's disease and had a history of falls and seizure like activity with interventions included to follow-up with the orthopedist for the right humerus fracture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required moderate assistance with bed mobility and supervision assistance with transfers and ambulation. Further, it identified that since the last quarterly MDS on (4/22/24), Resident #1 sustained two (2) falls with no injuries, one (1) fall with injury and one (1) fall with major injury. Review of the facility Reportable Event (RE) dated 5/30/24 identified that at 7:55 AM, Resident #1 sustained an unwitnessed fall, reporting that staff heard a loud noise and observed the resident face down in the hallway. Staff rolled the resident onto his/her back and upon assessment he/she became unresponsive and involuntary jerking movements were observed. The resident was transferred to the Emergency Department (ED) for evaluation and was subsequently diagnosed with an acute displaced comminuted fracture (broken into more than two pieces caused by a significant amount of force) of the right humeral head (the junction of insertion into the shoulder). The RE identified was previously independent with ambulation and after the 5/30/24 fall, the resident was made an assist of one (1) for ambulation. a) A nursing note dated 7/24/24 at 8:15 AM identified that the resident was observed on the floor on his/her stomach bracing him/herself with their left arm. Upon assessment, the resident was able to move both lower extremities and the left arm without any difficulty or signs of pain. A Situation, Background, Assessment, Recommendation (SBAR) note dated 7/24/24 at 11:32 AM identified that LPN #1 walked into Resident #1's room and he/she was observed on his/her belly on the floor. The supervisor was notified, and an assessment was completed, identifying no new skin issues and no complaints of pain. The SBAR noted that Resident #1 was able to stand with an assist of one (1) and was then ambulating freely with no signs of distress. The resident was subsequently placed on a one-to one supervision with the nurse for the morning. Review of a facility Reportable Event (RE) form dated 7/24/24 identified that at 8:15 AM, Resident #1 had an unwitnessed fall in his/her room after receiving care and breakfast, reporting that no injuries were sustained. The RE identified that the resident was an assist of one (1) for mobility, eating, transferring, ambulation and toileting both prior to and after the event. The intervention for the fall included one-to-one supervision for the morning and for the resident to be out of the room after morning care. Interview and clinical record review with RN #2 on 11/07/24 at 12:44 PM identified that she assessed Resident #1 after the 7/24/24 fall and he/she appeared to be at baseline without any injuries or signs of pain. She reported that she didn't normally work on the unit that Resident #1 resided on, but identified that whenever she interacted with Resident #1, he/she was walking the halls independently. She identified that Resident #1 was a fall risk and had a history of falls and that it was all staff's responsibility to keep an eye on him/her to ensure his/her safety but reported she was not aware that Resident #1 was an assist of one (1) for ambulation. b) A nursing note dated 7/25/24 at 3:00 PM, written by RN #1, identified that he was called to Resident #1's room in the late morning and observed the resident lying on his/her back on the floor near the foot of his/her bed. He identified that the resident's range of motion was normal to all extremities and that he/she displayed no signs or symptoms of pain. He reported that Resident #1's pants were noted to be too long and loose around the waist, identifying that staff assisted resident up to a standing position and adjusted the pants and the nurse (LPN #1) called the family to request new better fitting clothing be brought in for the resident. Review of the facility Reportable Event (RE) form dated 7/25/24 identified that at 11:15 AM, Resident #1 had an unwitnessed fall in his/her bedroom due to ill-fitting pants (too long), with no injuries noted. The RE identified that the resident was an assist of one (1) for mobility, eating, transferring, ambulation and toileting both prior to and after the event. The intervention for the fall included that the nurse would call the family and request jogger style pants and the NA's would put the resident in the new pants when received to promote safety. Interview with RN #1 on 11/07/24 at 11:25 AM identified that he assessed Resident #1 after the fall he/she sustained on 7/25/24 and reported there were no signs of injury or pain, and that the resident was ambulating after the fall at baseline. He identified that Resident #1 paces and wanders around the unit at baseline and reported that although he/she is an assist of one (1) for ambulation, supervision at all times is not possible stating that the staff did the best they could to keep him/her in view. Interview and review of statements with LPN #1 on 11/07/24 at 11:50 AM identified that she was assigned to Resident #1 on a regular basis, the resident was frequently anxious, and his/her baseline was to pace and walk around the unit continuously, reporting she was aware that Resident #1 was an assist of one (1) for ambulation but reported that the staff couldn't walk around with him/her all day, as they wouldn't be able to care for any other residents. She reported that after the 7/24/24 fall, the intervention was for her to provide one-to-one supervision of Resident #1 for the morning, reporting that she tried to keep the resident close to her medication cart so that she could keep an eye on him/her but reported that it was impossible to keep eyes on him/her at all times and identified that the other NA's would also try and help but they also had residents to care for. She identified that for the 7/25/24 fall, she had set the resident up in the dining room with his/her horse books and then went on break, telling the NA's on the unit (unable to recall who). When she returned ten (10) minutes later to the resident on his/her bedroom floor. Although attempted, an interview with NA #1 (who was assigned to the resident on 7/25/24) was not obtained. Review of the facility Reportable Event (RE) form dated 7/27/24 identified that Resident #1 was noted with a decrease in mobility while ambulating and had pain to the right lower extremity. The RE identified that x-rays were obtained within the facility and resulted with an age indeterminate (unknown age) fracture of the right femoral neck (insertion of the upper thigh bone into the hip) and the resident was subsequently sent to the Emergency Department (ED) for evaluation. A nurse's note dated 7/27/24 at 2:30 PM identified that Resident #1 was noted to be limping on the left leg but could not verbalize pain scale or describe where the pain was located. The nursing supervisor was notified and x-rays to the left leg were ordered. A nurse's note dated 7/27/24 at 9:48 PM, written by RN #3, identified that x-rays resulted for a fracture to the right femoral neck. Resident #1 was sent to the hospital for evaluation at 9:30 PM. Review of the RE Summary Report dated 8/3/24 identified that prior to breakfast on 7/27/24, Resident #1 was resistive to standing on the side of the bed with staff, so they transferred him/her to the wheelchair and brought him/her to the dining room and then transferred the resident to a table chair. After breakfast the resident was observed having difficulty ambulating and limping, appearing as if he/she was avoiding bearing weight to the left lower extremity but did not appear to be in or express pain. The resident was transferred to the bed and the APRN was notified. X-rays were obtained in the facility on 7/27/24 and resulted around 7:30 PM which showed an age-indeterminate fracture of the right femoral neck, as well as osteopenia. The resident was sent to the ED and underwent surgical intervention to the right hip. Interview with APRN #1 on 11/07/24 at 2:11 PM identified that although the fracture that Resident #1 sustained to the right femoral neck was indeterminate in age and could have happened at any time, the resident had risk factors including being post-menopausal, and having osteopenia that was shown in the x-ray. She reported that although they are unable to give a definitive cause of the fracture, it could have been from the falls on either 7/24/24 or 7/25/24. Interview with the DNS on 11/07/24 at 3:51 PM identified that the plan of care directed that the resident was an assist of one (1) for ambulation due to prior falls, but that it wasn't always plausible because the resident would ambulate continuously throughout the unit. She reported the facility attempted to do what they could to prevent the falls of Resident #1 short of one-to-one observation, including placing the resident in common areas, placing the resident by the nurse's medication cart, providing him/her with books, animated cats and baby dolls to keep him/her from getting up unassisted and ambulating. She reported that recreation and therapy were involved but that due to his/her cognitive status, he/she couldn't follow direction and participation and involvement was difficult. Further, she identified that Resident #1 had not been on any increased supervision and that bed and chair alarms are not utilized within the facility. Although attempted, an interview with RN #3 was not obtained. Review of the Fall Prevention Program policy dated 1/20/24 directed, in part, that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. They will provide interventions that address unique risk factors measured by the risk assessment tool including medications, psychological, cognitive status or recent changes in functional status. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on clinical record reviews, facility documentation, facility policies and interviews for two of four sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical altercation, the Nurse Aide that witnessed the physical altercation and tried to intervene failed to report the altercation to licensed staff. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, anxiety, abnormalities of gait, and history of stroke. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with dressing, transfers, and ambulation, and utilized a walker for mobility. The Resident Care Plan dated 2/16/24 identified Resident #1 exhibited verbal behaviors due to dementia, had anxiety, and was on an anticoagulant. Interventions directed to monitor medications, evaluate for trigger of verbal outbursts, provide psych services as needed, explain care one step at a time, redirect resident in a gentle, calming voice, allow time for expression of feelings, if resident becomes combative or resistive, postpone care or activity and allow time for the resident to regain composure, and gently guide the resident from the environment while speaking in a calm reassuring voice if needed. The nurse's note dated 5/2/24 at 11:26 PM identified a skin check was completed and no skin injury or wounds were noted. The nurse's note dated 5/3/24 written at 6:05 PM identified Resident #1 had bruising on the right forearm and wrist area and Resident #1 was seen by the Advanced Practice Registered Nurse (APRN). The Advanced Practice Registered Nurse (APRN) progress note dated 5/3/24 identified she was asked to see Resident #1 for right hand bruising and pain. The note indicated Resident #1 was seen by the endocrinologist two (2) days earlier, blood work was drawn, and that the bruising could be related to needle puncture. The note identified the APRN directed to hold the blood thinner, Plavix, for three (3) days and administer pain medication as needed. Interview with one of Resident #1's family member, Person #1, on 5/30/24 at 1:40 PM identified on 5/3/24 he/she was visiting Resident #1 and noticed a brace on Resident #1's hand and bruising under the brace. Person #1 stated he/she approached the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, to inquire about the bruise and RN #1 explained she was not aware of the bruise. Person #1 identified he/she and RN #1 asked Resident #1 what happened, and Resident #1 pointed to a 3-11PM nurse aide, Nurse Aide (NA) #1. Interview with RN #1 on 5/29/24 at 12:00 PM identified on 5/3/24 between 5:00 and 6:00 PM Person #1 approached her regarding a bruise on Resident #1's right hand and arm. RN #1 stated when she asked Resident #1 how the bruise happened, Resident #1 went into the hallway and pointed to NA #1. RN #1 stated Person #1 asked if an investigation had been started and she directed Person #1 to the Director of Nursing (DON) or Administrator. RN #1 identified she did not report the bruise to the DON because she thought the DON was already aware of it. Interview with the DON on 5/29/24 at 4:45 PM identified she was made aware by staff on 5/3/24 Resident #1 had a bruise on his/her right hand and arm and initially the bruise was thought to have been caused by blood work that had been obtained on 4/30/24, however during the investigation it was discovered this was not the cause of the bruise. The DON indicated NA #1 approached her and informed her on 5/2/24 she heard yelling in Resident #1's room. The door was closed and when she went into the room, she found Resident #1's roommate in Resident #1's bed and Resident #1 was trying to pull the roommate out of the bed and when she attempted to intervene, and Resident #1 began yelling at her and attempting to hit NA #1, so NA #1 blocked her own face. The DON stated NA #1 did not report the altercation because she was scared. The DON identified NA #1 should have reported the altercation immediately. Attempts to interview NA #1were unsuccessful. Review of the facility policy for Abuse, Neglect, and Exploitation, date implemented 7/2023, directed, in part, reports of all violations will be given to the Administrator immediately, but not later than 2 hours after the allegation is made.

Based on clinical record reviews, facility documentation, facility policies and interviews for two of four sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical altercation, the facility failed to maintain the safety of Resident #1 who sustained bruises around the right forearm, wrist, and hand when facility staff intervened during the altercation. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, anxiety, abnormalities of gait, and history of stroke. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with dressing, transfers, and ambulation, and utilized a walker for mobility. The Resident Care Plan dated 2/16/24 identified Resident #1 exhibited verbal behaviors due to dementia, had anxiety, and was on an anticoagulant. Interventions directed to monitor medications, evaluate for trigger of verbal outbursts, provide psych services as needed, explain care one step at a time, redirect resident in a gentle, calming voice, allow time for expression of feelings, if resident becomes combative or resistive, postpone care or activity and allow time for the resident to regain composure, and gently guide the resident from the environment while speaking in a calm reassuring voice if needed. The nurse's note dated 5/2/24 at 11:26 PM identified a skin check was completed and no skin injury or wounds were noted. The nurse's note dated 5/3/24 written at 6:05 PM identified Resident #1 had bruising on the right forearm and wrist area and Resident #1 was seen by the Advanced Practice Registered Nurse (APRN). The Advanced Practice Registered Nurse (APRN) progress note dated 5/3/24 identified she was asked to see Resident #1 for right hand bruising and pain. The note indicated Resident #1 was seen by the endocrinologist two (2) days earlier, blood work was drawn, and that the bruising could be related to needle puncture. The note identified the APRN directed to hold the blood thinner, Plavix, for three (3) days and administer pain medication as needed. The nurse's note dated 5/5/24 at 7:26 AM identified Resident #1 was very frustrated and angry regarding the roommate. The Facility Reported Incident form dated 5/6/24 identified a family member who reported to the facility that Resident #1 had reported to them a staff member grabbed Resident #1's wrist. The investigative summary report identified a light bruise to the right upper wrist and forearm were noted on 5/3/24, Resident #1 was seen by the APRN, and the bruising could not be ruled out from the venipuncture at the endocrinologist's visit on 4/30/24. The report indicated on 5/6/24 family reported during the visit, Resident #1 stated that someone came into his/her room, pulled his/her hair, and threw him/her on the bed and Resident #1 provided a description and name. The report identified after numerous interviews a nurse aide, Nurse Aide (NA) #1, explained on 5/2/24 she went into Resident #1's room and observed Resident #1 pulling on the roommate's (Resident #2) clothing to get Resident #2 off Resident #1's bed, and when she tried to intervene Resident #1 would not let go of the clothing. NA #1 attempted to quickly guide Resident #1's hand from the roommate at which time Resident #1 became more agitated and attempted to strike and scratch NA #1. NA #1 put her arm up to try to block Resident #1 from making contact with her face, tried to get the roommate into their own bed in which the roommate declined help and NA #1 then left the room. NA #1 explained she re-entered the room to find Resident #1 attempting to get the roommate out of their own bed and as NA #1 attempted to intervene again Resident #1 became angry, put both fists up in the air and attempted to swing at NA #1 and when NA #1 was trying to exit the room, Resident #1 grabbed NA #1's clothing. Interview with one of Resident #1's family member, Person #1, on 5/30/24 at 1:40 PM identified on 5/3/24 he/she was visiting Resident #1 and noticed a brace on Resident #1's hand and bruising under the brace. Person #1 stated he/she approached the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, to inquire about the bruise and RN #1 explained she was not aware of the bruise. Person #1 identified he/she and RN #1 asked Resident #1 what happened, and Resident #1 pointed to a 3-11PM nurse aide, NA #1. Interview with RN #1 on 5/29/24 at 12:00 PM identified on 5/3/24 between 5:00 and 6:00 PM Person #1 approached her regarding a bruise on Resident #1's right hand and arm. RN #1 stated when she asked Resident #1 how the bruise happened, Resident #1 went into the hallway and pointed to NA #1. Interview with the Director of Nursing (DON) on 5/29/24 at 4:45 PM identified she was made aware by staff on 5/3/24 Resident #1 had a bruise on his/her right hand and arm, the APRN assessed the bruise, and she looked in the EPIC (computer system which links health care facilities) system, she discovered on 4/30/24 Resident #1 had bloodwork done while at the endocrinologist's visit, and the APRN identified the bruising could be related to the needle puncture. The DON identified on 5/6/24 another of Resident #1's family member, Person #2, alerted her the bloodwork at the endocrinologist was obtained via a fingerstick and not a venipuncture. The DON stated she immediately began a seventy-two (72) hour look back to try to determine the cause of the bruising. The DON indicated Person #1 and Person #2 contacted her on 5/6/24 at approximately 8:30 PM and identified Resident #1 had told Person #1 someone had grabbed him/her and threw him/her against the closet. The DON identified NA #1 at first denied being assigned to the resident and then NA #1 informed her on 5/2/24 she heard yelling in Resident #1's room, the door was closed and when she went into the room, she found the Resident #1's roommate in Resident #1's bed and Resident #1 was trying to pull the roommate out of the bed. The DON stated NA #1 stated she attempted to intervene, and Resident #1 began yelling at her and attempting to hit her, so she blocked her own face. Review of the written statement from NA #1 identified on 5/2/24 around 8:00 PM she heard yelling from Resident #1's room and when entering the room saw Resident #1 attempting to pull the roommate out of the bed. NA #1 indicted she attempted to get Resident #1's hands off the roommate and Resident #1 attempted to scratch her and at that point she blocked her face. Review of the behavior tracking sheets and nurse's notes failed to identify any behaviors for Resident #1 were documented or reported on 5/2/24. Attempts to interview NA #1 were unsuccessful. Review of the facility policy for Abuse, Neglect, and Exploitation, date implemented 72023, directed, in part, that abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy further directed identifying, correcting, and intervening in situations in which abuse is more likely to occur and to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse including an examination of the alleged victim for any sign of injury.

Based on observations, review of facility policy and interviews, the facility failed to ensure expired food was dated and removed from the refrigerator. The findings include: Observation during the initial tour of the dietary department with the Food Service Director (FSD #2) on [DATE] at 9:54 AM identified 2 large plastic zip bags full of sliced ham with the date ,d+[DATE] handwritten on both bags. Two peaches in a plastic produce bag with two slices out of them that was undated. Interview with FSD #2 on [DATE] at 10:10 AM identified the two bags of sliced ham would be good for three days past the labeled date then should be discarded. The FSD #2 further identified that he did not know why the peaches were in an undated bag in the fridge. Interview with the Food Service Director (FSD #1) on [DATE] at 11:50 AM identified FSD #2 had told her about the expired foods, and she identified the ham would be good for seven days past the labeled date of [DATE]. She noted that the ham should have been discarded by [DATE]. She also could not explain why the peaches had been in an undated plastic bag in the fridge. FSD #1 further identified that she and/or the Dietary Manager in Training were responsible for going through the refrigerator daily and discarding outdated foods and noted that missing the ham and peaches were an oversight. Review of the Food Storage and Retention Guide directed ready to eat prepared foods that are edible without additional preparation to achieve food safety to be stored in the refrigerator up to 7 days with Day 1 as the day of preparation

Based on review of facility documentation, and interviews, the facility failed to ensure staff was available to transport residents to the [NAME] dining room on the weekends. The findings include: The Resident Council Interview on 3/25/24 at 1:00 PM with Resident #6, Resident #10, Resident #64, Resident #72, and Resident #102 identified that the [NAME] dining room had been closed on the weekend for several weeks. The facility Quality Assurance (QA) and Performance Improvement (PI) documentation dated 2/20/24 identified the issue of re-opening the [NAME] dining on the weekends and point of service. The goal was to re-open the [NAME] dining room by 5/1/24. The facility plan of action was to reach safe staffing levels by holding NA classes and training new NAs for dining procedures and transport. Review of staffing schedules on 3/16/24 (Saturday) identified there was 6 licensed nurses and 10 NA for the 7-3 shift and on 3/24/24 (Sunday) there was 6 licensed nurses and 9 NAs for the 7-3 shift. Interview with Dietary Aide (DA) #1 and Dietary Aide #2 on 3/26/24 at 12:00 PM identified that the [NAME] dining room was closed on weekends. The residents' meals are delivered to the residents' rooms on the weekends. DA #1 and DA #2 identified that the [NAME] dining room had been closed on the weekends for several weeks. They further identified that the nursing staff did not have enough staff to transport the residents to the [NAME] dining room on the weekend. Interview with the Food Service Director (FSD) on 3/26/24 at 1:00 PM identified that the [NAME] dining room was closed on weekends. She further identified that dietary utilized tray service and delivered meals to the residents' rooms on weekends. She also identified that the nursing staff did not have enough staff on the weekends to transport the residents to the [NAME] dining room. Further, The FSD identified that she and the nursing department had collaborated and decided to close the [NAME] dining room on the weekends. Interview with NA #1 on 3/26/24 at 1:35 PM identified she worked on 3/24/24 (Sunday) on the 7AM -3PM shift on the E and F unit (dementia unit). She identified that the E and F unit had the residents listed at the nurses' station who were supposed to be transported to the [NAME] dining room for meals. She further identified that she had not transported any residents to the [NAME] dining room on 3/24/24 because it was closed. Interview with LPN #1 (charge nurse) on 3/26/24 at 2:15 PM identified the [NAME] dining room was closed on the weekends. She identified that the FSD notified the nursing department that the [NAME] dining room would be closed on the weekends due to the staffing shortage. Interview with the DNS on 3/27/24 at 10:00 AM identified that the [NAME] dining room was available to the residents every day; however, she identified that the [NAME] dining room had a low participation rate from the residents on the weekends. She further identified the facility had started a QAPI to increase the resident participation utilizing the [NAME] dining room on the weekends. Review of the facility QAPI materials with the DNS on 3/27/24 at 11:00 AM identified the facility problem was re-opening of the [NAME] dining room on the weekends and their action plan was safe staffing levels by holding NA class and to train NAs on the dining procedure and transport. She denied that the facility had a staffing shortage on the weekends after reviewing the QAPI for the re-opening of the [NAME] dining room. She further identified that the facility had not opened the [NAME] dining room on the weekends because the facility had until 5/1/24 to meet their goal. Interview with RN #2 (unit Manager) on 3/27/24 at 1:00 PM identified that E and F (dementia unit) had residents who were encouraged to go to the [NAME] dining room for meals. He further noted that the nursing staff, recreation department and the administration personnel assist to transport residents to the [NAME] dining room during the week days but he identified that he could not speak for the weekends because he does not work on the weekends. Interview with the Scheduler on 3/27/24 at 1:50 PM identified that she was responsible for scheduling the staff for the facility. She identified that the facility staffing level would depend on the resident census and noted for a resident census of 122, she was instructed to staff the facility for 6 licensed nurses for 7-3 shift and 3-11 shift and 4 licensed nurses for the 11-7 shift. The facility would have 13 to 14 NAs for the 7-3 shift, 11 NAs for 3-11 shift, and 7 NAs for 11-7 shift. She further identified that the facility was short staffed on 3/16/24 and 3/24/24 due to staff call outs and noted facility administration was aware of the short staffing. Interview with the Administrator on 3/27/24 at 2:20 PM identified that other staff members are available to transport residents to the [NAME] dining room during the week days; however, staffing on the weekends is limited to the nursing staff making the transport more difficult and that is why it was a QAPI was developed to address the issue of the dining room being closed on the weekend related to having enough staff to transport the residents on the weekends.

Based on observation, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the Main ([NAME]) dining room was open and utilized for resident dining consistently on the weekends. The findings include: Observation of the resident dining on 3/21/24 at 12:30 PM identified approximately 30 residents eating in the [NAME] dining room. The Resident Council Interview on 3/25/24 at 1:00 PM with Resident #6, Resident #10, Resident #64, Resident #72, and Resident #102 identified that the [NAME] dining room had been closed on the weekend for several weeks. Interview with Dietary Aide (DA) #1 and Dietary Aide #2 on 3/26/24 at 12:00 PM identified that the [NAME] dining room was closed on weekends. The residents' meals are delivered to the residents' rooms on the weekends. DA #1 and DA #2 identified that the [NAME] dining room had been closed on the weekends for several weeks. They further identified that the nursing staff did not have enough staff to transport the residents to the [NAME] dining room on the weekend. Interview with the Food Service Director (FSD) on 3/26/24 at 1:00 PM identified that the [NAME] dining room was closed on weekends. She further identified that dietary utilized tray service and delivered meals to the residents' rooms on weekends. She also identified that the nursing staff did not have enough staff on the weekends to transport the residents to the [NAME] dining room. Further, The FSD identified that she and the nursing department had collaborated and decided to close the [NAME] dining room on the weekends. Interview with NA #1 on 3/26/24 at 1:35 PM identified she worked on 3/24/24 (Sunday) on the 7AM -3PM shift on the E and F unit (dementia unit). She identified that the E and F unit had the residents listed at the nurses' station who were supposed to be transported to the [NAME] dining room for meals. She further identified that she had not transported any residents to the [NAME] dining room on 3/24/24 because it was closed. Interview with LPN #1 (charge nurse) on 3/26/24 at 2:15 PM identified the [NAME] dining room was closed on the weekends. She identified that the FSD notified the nursing department that the [NAME] dining room would be closed on the weekends due to the staffing shortage. Interview with the DNS on 3/27/24 at 10:00 AM identified that the [NAME] dining room was available to the residents every day; however, she identified that the [NAME] dining room had a low participation rate from the residents on the weekends. She further identified the facility had started a QAPI to increase the resident participation utilizing the [NAME] dining room on the weekends. The facility Quality Assurance (QA) and Performance Improvement (PI) documentation dated 2/20/24 identified the issue of re-opening the [NAME] dining room on the weekends. The goal was to re-open the dining room by 5/1/24. The facility plan of action was to reach safe staffing levels by holding nurses' aides (NA) classes and training new NAs for dining procedures and transport. Review of the facility QAPI materials with the DNS on 3/27/24 at 11:00 AM identified the facility problem was re-opening of the [NAME] dining room on the weekends and their action plan was safe staffing levels by holding NA class and to train NAs on the dining procedure and transport. She denied that the facility had a staffing shortage on the weekends after reviewing the QAPI for the re-opening of the [NAME] dining room. She further identified that the facility had not opened the [NAME] dining room on the weekends because the facility had until 5/1/24 to meet their goal. The Promoting and Maintaining Resident Dignity During Mealtime policy identified that the facility would treat each resident with respect and/or dignity and care for each resident in an environment that maintains or enhances the residents' quality of life.

Based on clinical record review, review of facility policy, and interviews for one of two sampled residents (Resident #119) reviewed for advanced directives, the facility failed to ensure the clinical record contained accurate documentation pertaining to advanced directives. The findings include: Resident #119's diagnoses included cerebrovascular disease, type 2 diabetes mellitus, and aphasia. The admission MDS assessment dated [DATE] identified Resident #119 had intact cognition, required moderate assistance with bed mobility, toileting hygiene, lower body dressing, was non-ambulatory, and utilized a wheelchair for mobility. The care plan dated 12/26/23 identified the resident's cardiopulmonary status as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) with interventions that included activate resident's advance directive as indicated. The physician's order dated 12/21/23 directed Resident #119 had full code status. Review of Resident #119's clinical record failed to identify a completed Resident/Patient Health Care Instructions form identifying the resident's election of full code status. The record did contain Resident #379's Resident/Patient Health Care Instructions form which indicated a do not resuscitate (DNR) code status. Interview and clinical record review with the Unit Manager (RN #3) on 3/21/24 at 11:45 AM identified that Resident #379 was discharged from the facility and his/her records should not have been in Resident #119's clinical records. RN#3 also indicated that a copy of the resident's advanced directive consents are kept in the chart with a physician's order in the computer. She further noted Resident #119 had a completed Resident/Patient Health Care Instructions form that indicated Full Code which was found in Resident #379's chart. RN #3 further identified that the forms are filed by the unit coordinator. Interview with the Unit Coordinator on 3/21/24 at 2:20 PM identified that she is responsible for filing and scanning records into the computer and noted that the nurses also file documents at times. The Unit Coordinator further indicated that when she removes records from the resident's chart, and scans them into the computer, she does not check the names because she is taking the information directly from the resident's chart and assumes the records in the chart belong to that resident. Interview with the DNS on 3/26/24 at 10:15 AM identified that it is the responsibility of the nurse, unit manager, and the unit coordinator to file documents. The DNS identified that after the consent is obtained it is flagged in the chart for the provider to sign, then it is scanned into the electronic health record. The DNS further identified that the resident's name should be double checked especially if the names are similar prior to filling a document into the resident's records and a copy of the resident's advanced directives consent form should be kept in the resident's physical chart. The Maintenance of Clinical Record policy identified that the facility must maintain medical records on each resident that are completely and accurately documented.

Based on clinical record review and interviews for one sample resident (Resident #12) reviewed for hospice care, the facility failed to complete a Significant Change in Status MDS assessment when the resident was admitted to hospice. The findings include: Resident #12's diagnoses included dementia, adult failure to thrive, bipolar disorder and malignant neoplasm of the colon. The quarterly MDS assessment dated [DATE] identified Resident #12 had severe cognitive impairment, required extensive assistance with toileting, hygiene, dressing, transfers, and was non-ambulatory. The physician's order dated 6/27/23 directed to refer Resident #12 for hospice services and treatment as appropriate for late-stage dementia. Review of the electronic health record (resident census) identified Resident #12 was admitted to hospice on 6/28/23. The Resident Care Plan (RCP) dated 6/28/23 identified Resident #12 was admitted to hospice care with interventions that identified: recognize and respect resident decision of no tube feeding and/or intravenous fluid, provide companionship and activities of daily living (ADL) support, do not resuscitate (DNR) advance directive, and bereavement services provided by hospice. Review of Resident #12's MDS record from 6/28/23 to 7/11/23 failed to identify that a significant change MDS assessment was completed when the resident was admitted to hospice. Interview with RN #1 (MDS Coordinator) and LPN #1 on 3/25/24 at 10:00 AM identified they were responsible for the scheduling and completion of the MDS assessments. They both identified that a resident who was admitted to the hospice program should have a significant change MDS assessment completed within 14 days of being admitted to hospice. They identified that they started working at the facility in July of 2023 and identified that the facility did not have an MDS Coordinator at that time. They further identified that Resident #12 should have had a significant change MDS assessment completed by 7/12/23. Interview with the DNS on 3/25/24 at 10:15 AM identified that the facility did not have an MDS Coordinator at the time Resident #12 was admitted to hospice. The Resident Assessment Instrument (RAI) 3.0 manual identified that a (SCSA) must be completed after a resident's enrollment in a hospice program. The Assessment Reference Date (ARD) must be set within 14 days from the effective date of the hospice election.

Based on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to ensure staff followed the resident plan of care for a resident that was continent. The findings include: Resident #1's diagnoses included Parkinson's disease, schizoaffective disorder, dementia with agitation and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and was independent with toileting, and ADL's (activities of daily living). The Resident Care Plan (RCP) dated 2/8/2023 identified Resident #1 was continent of bowel and bladder and was at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, bed mobility, and toileting related to cognitive status. Interventions directed resident was continent of bowel and bladder and independent with toileting and to provide cueing to maximize current level of function. A reportable event form and investigation dated 3/3/2023 at 10:45 AM identified Resident #1 alleged that a male nurse aide put his hands down his/her pants. The only male nurse aide on the unit was immediately removed from the schedule, a statement was obtained, and the NA was sent home pending investigation. Police and APRN were notified. An RN assessment was attempted for body audit, Resident #1 was agitated and declined the body audit. Medical staff recommended transfer to ER for further evaluation, the family was updated and agreed with plan of care, and upon return from the hospital Resident #1 would have no male NAs. Review of the Police Case/Incident Report dated 3/3/2023 at 11:01 AM identified Police Officer (PO) #1 and #2 were dispatched to the facility for staff report of a resident that was yelling at staff because a male staff member put his hands down resident's pants and felt him/her. The Report indicated Resident #1 was visibly upset and yelling at staff and indicated he/she was just assaulted; Resident #1 identified he/she was sleeping when he/she work to feel someone with their hand down his/her pants. Resdent #1 indicated it was a black male, new staff person. The Report further indicated that Resident #1 requested to speak with the police and PO #1 explained he was the police officer. Resident #1 became verbally agitated when asked to describe the staff member, moved close to PO #1, pointing his/her finger in the officer's face, and yelled at the officer. Resident #1 then reached below PO #1's belt and grabbed onto PO #1's groin. PO #1 stepped back, placed his hand to remove Resident #1's hand and directed Resident #1 not to touch him. Resident #1 then hit PO #1 on the left shoulder with an open palm while continuing to yell at the officer. PO #1 directed Resident #1 to sit in a chair, and explained he was trying to help. Resident #1 was agitated and continued to yell at the office and indicated he/she was just assaulted, indicated the officer was doing a terrible job and he/she wanted to go to the police station. Resident #1 was offered to speak with another officer, and Resident #1 indicated no, I want somebody that can do something about it. Not sit there and be Mister woohoohoo. Resident #1 began to yell profanities, and a staff member to ask Resident #1 to calm down. Resident #1 then stood up and walked towards the staff member and swore at the staff. PO #1 positioned himself between the staff member and Resident #1, and Resident #1 continued to yell to the staff member. PO #1 directed Resident #1 to sit in the chair. And Resident #1 repeatedly yelled No. Staff requested emergency transportation to the hospital based on Resident #1's violent outbursts and aggression toward the staff and police, and PO #2 followed EMS during Resident #1's transfer to the hospital. PO #1 interview with the ADNS identified NA #1 was assigned to provide care for Resident #1. The ADNS indicated NA #1 was new to provide care for Resident #1 and was unaware that Resident #1 was independent to use the bathroom on his/her own, and NA #1 checked Resident #1 for incontinence without waking Resident #1. PO #1 met with NA #1 who explained it was his first day working with Resident #1. NA #1 stated he went into Resident #1's room, found he/she was asleep and stated that he called to Resident #1's name, but Resident #1 did not wake up. NA #1 explained that he checked to see if Resident #1 was wearing a brief by slightly lifting and rolling over the waist of Resident #1's pants around the hip area. When NA #1 did this, Resident #1 woke up and began screaming at him. NA #1 could not calm Resident #1 and left his/her room to inform other staff members about what had happened. NA #1 explained that he did not check Resident #1's medical chart prior to entering the room and if he had checked the chart, he would have seen that Resident #1 was independent and did not use briefs. NA #1 stated he did not touch Resident #1 anywhere below his/her waistline or genital area. The Report further identified they determined there was no crime. Facility written statement by NA #1 dated 3/3/2023 identified NA #1 knocked on Resident #1's door and there was no answer. NA #1 entered Resident #1's room, noticed Resident #1 was sleeping and attempted to awaken Resident #1 by stating his/her name a few times. Resident #1 did not respond, and NA #1 opened Resident #1's pants to see if he/she needed incontinent care. Resident #1 woke up and started yelling I'm independent, I don't need help. NA #1 immediately stopped and apologized and left the room. Although attempted, an interview was unable to be obtained with NA #1 during survey. Review of the hospital discharge summary dated 3/3/2023 identified Resident #1 was seen for a complaint of possible sexual assault. Resident #1 had underlying dementia and reported different stories to multiple staff. Interview with DON on 3/3/2023 at 12:55 PM identified Resident #1 was independent with toileting. NA #1 was a staff member new to the unit, and NA #1 should have reviewed Resident #1's clinical record/plan of care prior to entering the room to identify if Resident #1 was incontinent or was independent with toileting. The DON indicated NA #1 was re-educated on how to approach/re-approach residents and following the plan of care. Additionally, no male care givers will be utilized for Resident #1. DON identified NA #1 should have woken Resident #1 up prior to initiating any contact and requested to check if the resident needed incontinent care if resident approved. NA #1 should have followed Resident #1's plan of care prior to providing any care. Although requested, a care plan policy was not provided for surveyor review. Review of the Quality of Life Dignity Policy identified each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident's private space and property shall be respected at all times. Staff will knock and request permission before entering residents' room. Staff will not handle or move a resident's personal belongings (including radios and televisions) without the resident's permission.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) reviewed for medication administration, the facility failed to administer an intravenous antibiotic according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 12/13/21 directed to administer the antibiotic [MEDICATION(S)] intravenously via catheter every twenty-four (24) hours, stop on 1/12/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Central Vascular Access Device physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The five-day Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life. The Resident Care Plan dated 1/11/22 identified a suspected/actual infection of [CONDITION(S)] and bacteremia. Interventions directed to administer [MEDICATION(S)] intravenously. A Central Vascular Access Device physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 1/7/22 at 11:11 AM identified the Registered Nurse (RN) #1 had spoken with ID regarding the intravenous administration of [MEDICATION(S)] and the [MEDICATION(S)] was to be extended until 1/31/22. Review of the January 2022 Medication Administration Record (MAR) failed to reflect documentation that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing Services (DNS) on 1/31/22 at 1:56 PM identified she had been aware there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS indicated that she would need to gather more information as to why the medication was discontinued after the 1/12/22 dose was administered. Interview and review of the clinical record with an Advance Practice Registered Nurse (APRN) #1 on 1/31/22 at 2:34 PM identified that a family member came in on 1/17/22 and inquired as to why the intravenous [MEDICATION(S)] was discontinued on 1/12/22. APRN #1 indicated she went to investigate and found that the [MEDICATION(S)] was discontinued on 1/12/22 but had thought it was to continue until 1/31/22. APRN #1 discovered Resident #1 had missed four (4) doses of [MEDICATION(S)], and the bloodwork levels of the C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) were elevated above previous levels. APRN #1 identified she spoke with RN #1 and found that although RN #1 had completed the written order on paper, she may have walked away from the computer without saving the information in the electronic record. APRN #1 indicated she directed to restart the [MEDICATION(S)] as ordered by the ID until 1/31/22. Interview with Registered Nurse (RN) #1 on 1/31/22 at 2:49 PM identified she was the RN Supervisor on 1/7/22 and had taken the order to extend the date of the [MEDICATION(S)] intravenous antibiotic. RN #1 indicated that she may not have pressed the correct button to save the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, clinical record review, review of facility policy, and interviews for one of three sampled residents (Resident #2) reviewed for medication administration, the facility failed to properly secure the resident's medications. The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily life and required extensive assistance with turning and repositioning while in the bed, and limited assistance with personal hygiene. The Resident Care Plan dated 1/7/22 identified Resident #2 was at risk for decreased ability to perform activities of daily living, had a Percutaneous Inserted Central Catheter (PICC) line for intravenous antibiotics, and a pressure ulcer on the sacrum. Interventions directed to monitor medications, flush the intravenous line per policy, and provide wound treatments as ordered. Observations of Resident #2's room on 1/31/22 at 1:43 PM identified Resident #2 had medications stored on the bedside stand, Dakin's solution, six (6) pre-filled syringes of normal saline, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and nu-skin. Interview with Resident #2 on 1/31/22 at 1:43 PM identified the Dakin's solution and syringes filled with ten (10) milliliters of normal saline were used by the nurses. Resident #2 identified the remaining medications, the [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and nu-skin had been brought in from home. Resident #2 indicated the medications had been stored on the bedside stand since admission and the nurses had assisted him/her with the application of the [MEDICATION(S)]. Resident #2 indicated staff had not questioned the medications being stored at the bedside or asked where the medications had come from. Interview and review of the clinical record with Licensed Practical Nurse (LPN) #1 on 1/31/22 at 12:00 PM identified that Resident #2 did not have permission to keep medications at the bedside. LPN #1 identified she was not sure if Resident #2 had been assessed for self-administration of medications and was not aware where she would look in the clinical record to find the documentation. LPN #1 indicated since 1/12/22 the Dakin's solution has been at the bedside and that she was just in there and saw what looked to be a bottle of Ambusol (similar to the Nu-Skin bottle) in a small dark container. LPN #1 identified the nursing staff leave the syringes to flush the PICC line in the room with the resident. LPN #1 identified she had not inquired about the medications or removed the medications from the room. Interview with the Staff Development Coordinator and Director of Nursing Services (DNS) on 1/31/22 at 12:24 PM identified that medications are not to be stored, unlocked, at resident's bedside, an assessment for self-administration of medication is only completed if the resident desired to self-administer medications, Resident #2 did not want to self-administer and, therefore, had no self-administration assessment conducted. The Staff Development Coordinator and DNS indicated that if the nurse had seen improperly stored medications, she should have removed the medication from the bedside stand and stored in an appropriate location. The Staff Development Coordinator identified when treatments and flushes are completed, only those required items should be brought into the room and not left there for future use.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 2 of 2 sampled residents (Residents #55 & #302) reviewed for accidents, the facility failed to ensure that the resident was transferred from the wheelchair to the bed without injury and failed to ensure the resident was safely transferred via mechanical lift. The findings include: A. Resident #55 had diagnoses that included dementia with behavioral disturbances, [CONDITION(S)] disorder, major depressive disorder and chronic diastolic heart failure. The quarterly MDS dated [DATE] identified Resident #55 had severe cognitive impairment, required extensive assistance of two people for transfers, did not ambulate, utilized a wheelchair for mobility and was not steady and only able to stabilize with staff assistance when transferring between surfaces. The care plan dated 6/9/2020 identified Resident #55 was at risk for decreased ability to perform ADL(s) (activities of daily living) in transfers and locomotion related to weakness with interventions that included; monitor for pain, attempt non-pharmacologic interventions to alleviate pain and document effectiveness, administer pain medication as ordered, monitor for shortness of breath, fatigue, change of condition, adjust ADL tasks accordingly, encourage resident to pace him/herself during ADL activity and bed rail(s) used as an enabler. The care plan further noted that a gait belt was to be utilized with all transfers. Review of the reportable event report dated 7/5/2020 with a noted time of 8:30 PM identified that during a transfer from wheelchair to bed, Resident #55's right leg brace became stuck on the side rail bar causing a laceration to the outer aspect of the resident's lower right leg which resulted in a wound. The lower leg was wrapped in gauze and the resident was sent to the hospital for evaluation. Further review of the report identified that the nurse aides involved in the transfer were educated to check when resident states that his/her foot is stuck. Resident to be transferred onto the center of bed and not near the side rails. The hospital emergency department discharge documentation dated 7/5/20 identified Resident #55 was sent to the emergency department because of a laceration to the right anterolateral leg sustained while being helped from wheelchair to bed by staff. The documentation further noted that the resident identified that he/she was in pain, the measurements of the laceration were identified as: Length - 8.5cm (centimeters), Depth - 10mm (millimeters). In addition, the documentation identified that laceration was treated with the application of eleven sutures followed by steri-strips for reinforcement. RN #4's written statement dated 7/5/20 identified Resident #55 was transferred from his/her wheelchair to bed by NA #2 and NA #3 with NA #3 on the right side of the resident and NA #2 on the left side. The statement noted that they stood Resident #55 up and immediately turned him/her so he/she could sit on the bed and Resident #55 stated My foot is stuck. RN #4's written statement noted that Resident #55 says his/her foot is stuck with every transfer because the right foot does not move. The documentation further noted that NA #2 and NA #3 sat the resident down on the bed and when the resident's legs were raised and placed on the bed and identified that the leg brace had gotten stuck on the side rail bar and the resident had a laceration to the lower extremity that the brace had been applied to. RN #4 further documented that the nurse aides should have checked when Resident #55 said his/her foot was stuck. Interview with NA #2 on 11/10/21 at 10:05 AM identified that she and NA #3 assisted Resident #55 from the wheelchair to the bed using a stand-pivot-transfer. NA #2 identified that Resident #55 had a right leg brace on, which got stuck on the bedrail. NA #2 further noted that she believes something was sticking out from the bed and must have caught on the resident's leg causing the laceration to the right leg. NA #2 identified that she did not recall if Resident #55 stated anything during the transfer and identified that once she saw the injury; she left the room to notify the charge nurse. Interview with NA #3 on 11/10/21 at 10:25 AM identified that during the transfer Resident #55's right leg brace got caught on the railing. NA #3 identified that Resident #55 stated Ouch, my leg, it ' s stuck. NA #3 identified that neither her nor NA #2 stopped the transfer, and instead continued through with the transfer and noted Resident #55 hit his/her leg on the railing. Interview with the DNS on 11/10/21 at 11:30 AM identified that the nurse aides should have stopped the transfer upon the resident stating his/her leg was stuck. It was identified the resident got his/her leg brace stuck on the bed rail. The facility identified a certain area on the railing as the potential cause of injury. Interview with COTA #1 on 11/10/21 at 12:00 PM identified Resident #55 was an assist of 1 with a gait belt prior to 07/05/20. Interview with Maintenance Director on 11/10/21 at 1:00 PM identified that he performed a full inspection of the bed after the event and a new bed was provided to the resident. B. Resident #302's diagnoses included Alzheimer's disease, transient cerebral ischemic attack and [CONDITION(S)]. The quarterly MDS assessment dated [DATE] identified Resident #302 had severely impaired cognition, required extensive assistance with dressing, personal hygiene, eating, toileting, bed mobility and transfers with the assistance of two people. The care plan dated 6/20/20 identified Resident #302 was at risk for decreased ability to perform activities of daily living with interventions that included; transfer with mechanical lift with assist of two using a full body large green sling. The nursing assistant care card dated 6/20/20 noted Resident #302 required extensive assist of two for transfers via mechanical lift from the bed to the wheelchair utilizing the large full body green sling. A physician's order dated 8/12/20 identified that Resident #302 required a mechanical lift to Geri chair with the assistance of two staff. A reportable event report dated 8/24/20 with a noted time of 11:30 AM identified that during a mechanical lift transfer from the bed to the wheelchair one of the straps form the mechanical lift pad/sling broke and Resident #302 fell from the mechanical lift to the floor. Resident #302 hit his/her head, sustained an abrasion to the left ear and to the right shoulder. The resident complained of pain to the affected shoulder, a pressure dressing was applied to the left ear to control the bleeding, and emergency services were called and the resident was sent to the hospital to be evaluated. Further review of the reportable event report identified a written statement dated 8/24/20 authored by NA #4 identified that at 11:00 AM, she went into Resident #302's room to provide care and get him/her ready for lunch. The statement further identified that she dressed the resident, attached the mechanical lift pad to the bars of the mechanical lift and asked for assistance. In addition, the statement identified that when no one came to assist, NA #4 proceeded to transfer the resident without the assistance of a second person. The hospital discharge summary dated 8/25/20 identified Resident #302 was admitted for a traumatic hemorrhage of the cerebrum, was brought to emergency room and found to have an acute intra-ventricular blood layering with the occipital horn bilaterally of the lateral ventricle. A repeat CT scan of the head on 8/25/20 identified the bleeding had stabilized and the resident was discharged back to the facility. Interview with the DNS on 11/19/21 at 11:00 AM identified that Resident #302 was transferred by one nursing assistant (NA #4) when the transfer should have been performed with two nursing assistants. In addition, the designated pad (sling) was not used and the application of the pad/sling that was used was incorrect. Further interview with the DNS on 11/19/21 at 12:15 PM identified that the facility policy regarding mechanical lift transfers dictates that the transfer be conducted with at least two people and sometimes a third person is needed. The DNS identified that NA #4 had failed to follow the policy for the amount of staff required for a mechanical lift transfer and had failed to utilize the appropriate pad/sling for the resident. The DNS identified that NA #4 had been oriented to the policy and procedure related mechanical lift transfers with the utilization of two or more staff members. In addition, the DNS identified that when interviewed NA #4 indicated that she had not inspected the pad/sling prior to using it. The DNS noted Resident #302 required a full sling/pad and NA #4 used the wrong type of mechanical lift /sling. The DNS also acknowledged that the sling/pad was applied incorrectly by NA #4, she placed the section of the sling that should have been at the resident's back and upper body on the lower part of the body and the section of the sling/pad that should have been at the resident's lower body was placed at the top portion of the body. The DNS further noted that housekeeping checks the pads for wear and tear when laundered and the nursing assistants were responsible for checking the pads/sling prior to using on a day to day basis. In a second interview with the DNS on 11/19/21 at 2:00 PM, she identified that Resident #302 had no truck control and was placed in the Trendelenburg position due to the incorrect placement of the sling/pad. She noted that Resident #302's head was down towards the floor and the legs where above the head. The DNS further indicated that due to the positioning and weight distribution she felt that was the reason why the strap did not hold resulting in the resident's fall to the floor. Review of the facility's Safe Resident Handling Program Skills Checklist identified that once the policy/procedure for mechanical lift transfers was reviewed and a return demonstration of the skill (transfer) was completed, the form should be signed by the orientee and the trainer. The DNS indicated that NA #4's form was not completed for mechanical lift transfers (there were no signatures indicating that a mechanical lift transfer was modeled for NA #4 or that a return demonstration of a mechanical lift transfer was performed by NA #4). All attempts to interview NA #4 were unsuccessful. Review of the facility's Safe Resident Handling Program dated 9/26/19 identified mechanical lift devices for residents who require a mechanical lift will be used in accordance with manufacturer recommendations. Appropriate staff will receive training on safe resident handling and demonstrate competency on the use of lifts and transfer devices. All lift equipment and slings will be inspected for safety before each use.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #4) who was reviewed for a fall, the facility failed to ensure a safe environment to prevent an accident with injury. The findings include: Resident #4's diagnoses included dementia with behavioral disturbance, anxiety, [CONDITION(S)] with delusions, [CONDITION(S)] disorder and difficulty in walking. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 rarely or never made decisions regarding tasks of daily life, had difficulty focusing attention, disorganized thinking, required supervision with ambulating in the room and corridor, and had two (2) falls in the past ninety days. The Resident Care Plan dated 7/2/21 identified a risk for falls related to dementia. Interventions directed to ensure shoes or non-skid socks when ambulating, encourage and assist toileting every two hours, and wear closed toes shoes only, no backless shoes. The Facility Reported Incidents form dated 7/19/21 at 5:00 PM identified a dietary aide hit Resident #4 with the food cart when he pulled into the unit and was not aware Resident #4 was close. Resident #4 was observed laying on his/her left side with a four (4) centimeter (cm) skin tear noted to the left elbow. Resident #4 complained of discomfort but was able to move extremities with no observed displacement. The physician was notified, and x-rays of the left hip and arm were ordered. The Situation, Background, Assessment and Recommendation (SBAR) nurse's note dated 7/19/21 at 6:22 PM identified a change in Resident #4's condition and that Resident #4 had a fall with pain. An x-ray was recommended by the medical staff. A nurse's note dated 7/19/21 at 11:01 PM identified Resident #4 complained of pain when his/her left hip was touched, the x-ray report showed a left femoral neck fracture with displacement and the physician was notified. Review of the facility x-ray report dated 7/19/21 identified a left femoral neck fracture with modest angulation and displacement with mild [CONDITION(S)] change and osteopenia. A physician's order dated 7/19/21 directed to send Resident #4 to the Emergency Department for evaluation. The Hospital Discharge Summary dated 7/26/21 identified Resident #4 underwent a surgical left hip open reduction, internal fixation and had an acute minimally displaced fifth rib fracture. Interview and review of facility Slips, Trips and Falls policy with the Food Service Director (FSD) identified that he had heard about Resident #4's fall on 7/20/21. The FSD identified that he changed the food truck delivery policy to pull, not push the food truck due to staff's inability to see over the truck as it was too tall and he had begun re-education immediately with the dietary staff. The FSD indicated that although the Dietary Aide, DA #1, was following the facility policy to push and not pull the food truck, DA #1 should have observed the area for residents and obstacles prior to turning. Interview and review of the fall statement with DA #1 on 7/27/21 at 11:41 AM identified that when he came through the door to the unit, he pushed the cart over to the drop off point, did not check the blind spot, and pushed Resident #4 over with the cart. DA #1 indicated there was a disruption in the kitchen just prior to him leaving with the food cart and he was upset. DA #1 identified that he had pushed the red button to enter the unit, using his foot to keep the door open he pulled the cart in and swung it around. DA #1 identified that he knocked Resident #4 over with the cart and only realized he had done so when the cart met resistance as he pushed it forward. DA #1 identified that the food cart was heavy, and Resident #4 was small. DA #1 identified that he had thought he had checked for safety prior to moving the cart. DA #1 identified that since being re-educated, he had learned to use the mirror to check the area to avoid hitting residents and objects and to take a few extra seconds to look around to ensure that his pathway was clear as to avoid future incidents of hitting residents with the food cart. Review of the facility Slips, Trips and Falls policy under general safety guidance that staff should avoid carrying items that would obstruct one's view of the walking pathway.

Based on clinical record review, facility documentation, facility policies and staff interviews for the one sampled resident (Resident #1) who experienced a choking episode, the facility failed to provide prompt lifesaving abdominal thrusts or the [MEDICATION NAME] maneuver in accordance with facility policy and standards of practice when the resident who was sitting in a customized wheelchair was found to be choking. The findings include: Resident #1's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#1 receive a liberalized regular texture diet. The orders further directed a Full Code. An admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was cognitively intact, frequently incontinent of bladder, always incontinent of bowel, required the assistance of two staff for transfers and needed set up help for eating. A resident care plan (RCP) dated [DATE] identified that Resident #1 had an established advance directive of a full code. The care plan included an intervention for the resident's advance directive to be activated in accordance with the physician's orders [REDACTED]. A nurse's note dated [DATE] at 1:13 PM identified Nurse Aide (NA) #1 had responded to Resident #1's room after the call bell sounded and found the resident signaling that he/she was choking. The nurse's note indicated that Nurse Aide (NA) #1 called for the charge nurse who found Resident #1 unresponsive and called a code. The note identified that although Resident #1 was breathing, the resident's respirations were labored and the skin color was gray. The note further indicated that the resident was subsequently lowered to the floor from a wheelchair using a Hoyer lift pad, and a non-rebreather mask was applied with oxygen administered at the rate of fifteen (15) liters a minute. Further review of the nurse's note indicated that some meat (i.e. pork) which had been lodged deep in Resident #1's throat was removed by LPN #2 who performed a deep throat sweep with his/her fingers. The note identified that although Resident #1 continued to breathe on his/her own, the resident remained unresponsive. Review of the EMS Run Sheet dated [DATE] identified that when emergency medical personnel arrived at 12:46 PM, Resident #1 was cyanotic with agonal respirations and stridor. The run sheet indicated that upon visualization, a foreign body was not observed in Resident #1's throat although the airway was suctioned for blood secretions. The EMS Run Sheet further identified that while Resident #1 was being transported to an ambulance, the resident became bradycardic, and a foreign body was removed during airway placement. The resident subsequently became pulseless, and CPR was initiated with compressions and ventilation continued en route to the hospital. Resident #1 was subsequently admitted to an acute care hospital and remained on a ventilator at the time of the survey. During an interview on [DATE] at 1:25 PM Nurse Aide #1 indicated that Resident #1 was able to eat meals independently after set up assistance was provided. NA #1 identified that on the day of the incident s/he had given Resident #1 the lunch meal which included pork and a baked potato. NA #1 stated s/he cut the potato and meat into small pieces since the resident was unable to use the left hand. NA #1 stated that after leaving the room, s/he responded to Resident #1's call bell, and the resident indicated s/he was choking. NA #1 identified that Resident #1's skin color looked normal at the time. NA #1 stated that s/he called for assistance from NA #2 who was across the hall and ran to ask LPN #1 for additional assistance. Upon returning to the room, NA #1 noted that Resident #1's skin color was blue. Interview with LPN #1 on [DATE] at 2:00 PM indicated s/he was on the opposite side of the unit when NA #1 called out that Resident #1 was choking. LPN #1 stated that s/he ran to Resident #1's room and found RN #1 with the resident. LPN #1 identified that when s/he entered Resident #1's room, the resident was unresponsive with labored respirations and gray skin color. LPN #1 indicated s/he brought oxygen and a non-rebreather mask to the resident's room, called a code and 911. Interview with RN #1 on [DATE] at 2:25 PM identified that s/he was the Nursing Supervisor on the 7:00 AM to 3:00 PM shift on [DATE]. RN #1 stated that when NA #1 reported Resident #1 was choking. RN #1 ran to the resident's room. RN #1 identified that Resident #1 was seated in a customized wheelchair, was unresponsive and his/her color was blue. RN #1 indicated s/he did not perform the [MEDICATION NAME] maneuver since Resident #1 was seated in a customized wheelchair. RN #1 stated although s/he attempted to push into the resident's abdomen, there was not any effect because of the resident's weight (203 pounds, 63 inches). RN #1 further stated that although food was not observed, s/he attempted a sweep of the resident's mouth and was able to feel food in the throat. RN #1 indicated that although oxygen was given to the resident, there were not any changes in the resident's symptoms. RN #1 identified that Resident #1 was then lowered from the chair to the floor, and LPN #2 performed a sweep of Resident #1's mouth and retrieved particles of food. RN #1 indicated the resident was blue with stridor and was taking only a few breaths per minute. RN #1 further stated that no one performed abdominal thrusts or the [MEDICATION NAME] maneuver after Resident #1 was lowered to the floor, and CPR was not initiated since the resident was breathing. Interview with LPN #2 on [DATE] at 2:30 PM indicated that when Resident #1 was lowered from the wheelchair to the floor, the resident was experiencing labored respirations and the pupils were fixed. LPN #2 indicated s/he tried to visualize Resident #1's mouth but could not see anything in the mouth. LPN #2 stated s/he put her fingers into Resident #1's throat and removed food that was lodged in the throat. Interview with NA #2 on [DATE] at 3:15 PM indicated that when s/he was called to Resident #1's room by NA #1, the resident was not able to speak, was making sounds, and the resident's eyes were rolling back in the head. NA #2 stated s/he rubbed the resident's back while NA #1 went to obtain additional assistance. Interview with the Director of Nursing (DNS) and Assistant Director of Nursing (ADNS) on [DATE] at 11:15 AM indicated they shared the responsibilities of staff development. They stated that mock drills have been conducted with staff to provide education on the response to a resident who experiences a choking incident and/or resuscitation. The DNS stated that staff had not been re-educated on the [MEDICATION NAME] maneuver since 2019, and the last mock drill was held in [DATE] although licensed nursing staff were expected to maintain current CPR certification. The DNS stated when Resident #1 was found to be choking while seated in a specialized wheelchair, staff should have moved Resident #1 to the floor and performed abdominal thrusts, followed by visualizing the mouth for foreign bodies and continuing abdominal thrusts until the food was dislodged or until emergency medical personnel arrived. The DNS identified that sweeping of the mouth should not have taken place until the foreign body was visualized. The DNS further stated that the focus should be on opening the resident's airway, and CPR would have been started only if Resident #1 became pulseless. Review of the facility's policy on Obstructed Airway Intervention identified that if a patient is conscious and sitting or standing, wrap around his/her waist, clasp hands together in a double fist and place the fist just below the patient's ribs, make quick hard movements inwards and upwards until the object is forced out or until the patient becomes unconscious. The policy further directed that if the patient becomes unconscious, carefully support the person to the ground, immediately activate Emergency Medical Services and begin cardiopulmonary resuscitation. Each time the airway is opened, look for an object in the patient's mouth, and if found, remove it.

Based on a review of clinical records, review of facility documentation, observations, interviews, and policy review, for one of three residents reviewed for falls, (Resident #1), the facility failed to provide the necessary supervision for Resident #1 when s/he exhibited restless behaviors and had multiple attempts to get out of bed independently, failed to report to the nursing supervisor that the resident was exhibiting such behaviors, and failed to ensure there was a 3 foot bed clearance around the bed in accordance with Connecticut Public Health Code. As a result, Resident #1 fell out of bed and became wedged between the wall and the radiator resulting in 2nd [MEDICAL CONDITION] both lower legs when his/her legs were resting on the radiator. In addition, although the facility implemented an action plan following this incident (1/27/20), observations during the survey noted one bed without the adequate bed clearance and two radiators that posed a safety risk. As a result, a finding of Immediate Jeopardy was identified. During the onsite visit on 2/13/20, Immediate Jeopardy was abated when the facility implemented an immediate action plan to mitigate further risk to all residents. The findings include: a. Resident #1 had [DIAGNOSES REDACTED]. Review of a care plan dated 11/5/19 identified that the resident was at risk for falls related to [MEDICAL CONDITION] and lack of safety awareness, with interventions that included a low bed, and a motion alarm. A quarterly minimum data set assessment dated [DATE] identified that the resident had significant cognitive impairment, required extensive assistance with activities of daily living, including extensive assistance with transfers, had an inability to move from a seated to standing position without staff assistance, was at risk for falls, and had 2 falls with no injury since the last assessment. A change in condition nurse's note dated 1/25/2020 at 9:21 PM identified that the resident had a fever of 101.3 degrees Fahrenheit (F), and was noted with a burn to the left inner knee and right inner knee to above the inner ankle. The physician was notified and the resident was transferred to the hospital for evaluation. Review of the reportable event report dated 1/25/2020 at 7:00 PM identified that Resident #1 had a temperature of 101.3 F at 6:00 PM, Tylenol was administered and a cool washcloth was applied. The resident was restless and rolled out of bed making contact with the heating unit. The right inner knee and left inner knee to above the left inner ankle were observed to be red with no blister. A skin abrasion was noted to left inner knee and above left ankle with no drainage. Resident #1 was sent to the emergency room for evaluation of the elevated temperature and burn and was subsequently admitted with pneumonia. Review of the facility investigation noted a statement from Nurse Aide (NA) #1, dated 1/25/20 at 7:00 PM that identified Resident #1 was acting very strangely for hours once s/he was in bed and kept trying to get out of bed. NA #1 tried to explain to the resident not to fall off the bed but s/he was really sick and still managed to fall off the bed. Upon entry to the room, NA #1 observed the resident behind the bed and his/her legs were on the radiator (the room has baseboard heat which was affixed to the wall). Review of the Hospital record dated 1/25/2020 identified that Resident #1 presented to the Emergency Department for bilateral lower leg 2nd degree [MEDICAL CONDITION] blistering. The left leg burn was described as serous filled bullas and open ulcers areas extending from the knee area to the lower leg with a small amount of slough and necrotic tissue, and measured 31.5 centimeters (cm) in length by 7 cm in width and 0.5 cm in depth. An incision and drainage on the bulla was performed with approximately 40 milliliters expressed. The right medial upper leg had a small ulcer with slough and necrotic tissue with exposed dermis that measured 2.5 cm in length, 4 cm in width, and 0.1 cm in depth. The areas were dressed with silver hydrogel and a foam cover for autolytic debridement and moist wound healing. The resident was noted to have mild distress from pain at the burn sites and received [MEDICATION NAME] and [MEDICATION NAME] during the ED visit. Review of NA #1's written statement dated 1/26/20 with NA #1 on 2/13/2020 at 1:35 PM identified that at the beginning of the shift on 1/25/20 at approximately 3:00 PM, the charge nurse asked him to check on the resident as she was unable to understand what s/he was saying. NA #1 stated Resident #1 wasn't acting like him/herself, was continually ringing the call bell, and that he needed to go in the room several times within an hour to attend to the resident. NA #1 identified that the resident's face was beet red and he felt something was wrong, therefore, obtained the resident's vital signs and the resident was noted with a temperature of 101.9 degrees F. The nurse was notified and came to the resident's room. At dinnertime, the resident was shaking uncontrollably and was unable to feed him/herself. NA #1 attempted to feed the resident but s/he was unable to swallow then vomited. The nurse was notified and the resident was assisted to bed. NA#1 stated when he left the room, Resident #1 was screaming really loud, was reaching and pulling the privacy curtain, and pulling the right ¼ side rail (the side closest to the wall/radiator). NA #1 then repositioned the resident from the right side of the bed to the center of the bed, and pulled the privacy curtain back to the head of the bed but needed to pull the curtain back from the left side of the bed because there was not room for him to stand on the right side of the bed because the bed was very close to the wall. NA #1 stated a few minutes later, he heard the resident screaming and again found the resident pulling the privacy curtain and grabbing the right sided bed rail, pulling him/herself to the right side of the bed. NA#1 stated he repositioned the resident to the center of the bed and notified the nurse that Resident #1 was trying to get out of bed and she had come into speak with the resident. NA #1 further identified that he came back to check on the resident about 10 minutes later, and the resident had pulled him/herself off of the low bed to the right side and was wedged between the bed and the wall with his/her knees on the radiator. NA #1 stated he called for the nurse, and they pulled the resident's legs off the radiator and assisted him/her back into bed. NA #1 further stated that the resident's bed had been close to the wall/radiator for at least a month since he had taken over this assignment. Review of Licensed Practical Nurse (LPN) #1's written statement (undated) and interview with LPN #1 on 2/13/2020 at 12:05 PM identified that on 1/25/20, Resident #1 was asking for assistance throughout the shift and had asked the NA to determine what the resident needed as she was unable to understand the resident. LPN #1 was notified by NA #1 that the resident had a fever of 101.3 degrees F, she had administered a Tylenol suppository and placed cool washcloths on the resident's head. She then notified the nursing supervisor of the fever, who then placed a call to the physician. While awaiting the return call from the physician NA #1 reported to her that the resident was trying to get out of the low bed by pulling the privacy curtain and the side rails, and that NA #1 had to move the resident back into the center of the bed twice. A short time later NA#1 called her to the room because the resident was noted to be in between the bed and the wall with his/her upper body still on the low bed and the resident's legs resting on the radiator. LPN#1 and NA#1 placed the resident's legs back into the bed and noted redness to the right and left legs, she notified the supervisor who did an assessment, and the resident was sent to the hospital for evaluation. LPN#1 stated that she was aware that the bed should be 3 feet from the wall, however, did not notice that the bed was close to the wall/radiator. LPN#1 stated that she did not tell the nursing supervisor about the resident's continued attempts to get out of bed and his/her restless behaviors. LPN #1 failed to address the resident's restless behaviors to ensure safety. Interview with Registered Nurse (RN) #1 on 2/13/2020 at 1:45 PM identified that on 1/25/20, she assessed the resident after LPN#1 reported that s/he had a fever, the resident was free from distress and all vitals were normal except for the temperature. She then placed a call to the physician to report the resident's fever. RN #1 identified that she was called to the unit less than an hour later because it was reported that the resident had rolled out of bed, and was found with his/her legs resting on the radiator. When RN #1 arrived to the resident's room, Resident #1 was in bed and she noted redness to the right inner knee and left inner knee that reached the inner ankle. RN #1 called the physician and described that the resident's knees were found on the radiator with redness noted to the lower extremities and the resident was sent to the hospital for evaluation. RN #1 stated that LPN#1 did not report that the resident had multiple attempts to get out of bed otherwise she would have done an assessment and put an intervention into place to address the behavior. RN #1 further identified that although she was aware of the 3 foot bed clearance, she did not notice that the bed was close to the wall when she was assessing the resident prior to the resident's fall out of bed. Interview with the Director of Nurses (DON) on 2/13/2020 at 2:00 PM stated she had been called by RN #1 on 1/25/2020 (a Saturday) at about 7:30 PM regarding Resident #1's fall out of bed and was found with his/her legs resting on the radiator. At that time she was not aware that the bed was too close to the wall allowing the resident to come in contact with the radiator. On Monday 1/27/2020 she asked LPN #1 to demonstrate what happened, and at that time, observed that the bed was approximately 12 inches or less away from the wall/radiator. The DNS identified that the bedside stand should have been on the right side to allow enough room between the bed and the wall/radiator. On 1/27/2020 the facility did an audit of all radiators to ensure they were in proper working order, and to ensure there was a 3 foot clearance around each bed with a subsequent audit done on 2/4/2020. The staff was also educated on 1/31/2020 to check bed placement and ensure adequate space between the bed and the radiators. The DNS further identified although they do not have a policy on bed clearance, they follow the Connecticut Public Health Code which directs a 3 foot clearance between the bed and the wall. The DNS further identified that LPN #1 should have reported to the supervisor that the resident was restless on 1/25/20 so she could have done an assessment and possibly put an intervention into place to prevent the resident from falling out of bed. Interview with the Director of Maintenance (DOM) on 2/13/2020 at 11:30 AM identified that although he was aware a 3 foot bed clearance was required, he was unable to identify why Resident #1's bed was less than 12 inches from the wall/radiator. Interview with the Administrator on 2/13/20 at 4:30 PM stated that she would expect Maintenance staff to monitor the 3 foot bed clearance and document this information. The facility identified that there was no bed clearance policy or a system in place to document that this was monitored. The policy entitled, Falls Management, revised on 11/1/19, identified that residents who are at risk for falls will receive appropriate interventions to reduce the risk and minimize injury. The facility failed to provide the necessary supervision for Resident #1 when s/he exhibited restless behaviors and had multiple attempts to get out of bed independently, failed to report to the nursing supervisor that the resident was exhibiting such behaviors, and failed to ensure there was a 3 foot bed clearance around the bed. As a result, Resident #1 fell out of bed and became wedged between the wall and the radiator resulting in 2nd [MEDICAL CONDITION] both lower legs when his/her legs were resting on the radiator. b. Constant observation on 2/13/20 at 9:05 AM to 10:10 AM of room [ROOM NUMBER] identified a radiator cover that was hanging down, exposing the heating element. Interview and observation of the radiator at 9:30 AM with NA #3 who cared for the resident that morning in the bed by the window identified that the radiator cover was falling off with the heating element exposed. NA #3 identified that she did not notice the radiator cover was falling off when she was in the room, and headed back to the other unit she was working on. At 9:36 AM the Housekeeper entered the room and mopped the floor (the floor was identified as wet under where the radiator cover was hanging off). The housekeeper then went to room [ROOM NUMBER], had a discussion with maintenance worker #2 but did not mention the radiator cover falling off of the radiator. At 9:53 AM NA #2 entered the room to provide care for the resident that was in the bed by the door, and was in the room until 10:02 AM. Interview with NA#2 and Housekeeper #1 on 2/13/2020 at 10:10 AM identified that they did not notice that the radiator cover was partially off. Further interview with NA#3 at 10:10 AM identified that she had not reported to anyone that the radiator cover was hanging down when it was pointed out to her at 9:30 AM by the surveyor, and subsequent to surveyor inquiry at that time, she reported the radiator to maintenance worker #1 at 10:11 AM, and the radiator was repaired. Interview and observation of the radiator in room [ROOM NUMBER] with the DNS on 2/13/2020 at 10:11 AM identified that the radiator was visible from the hallway, and the radiator cover was falling off with the heating element exposed. She further identified that all staff had been educated and were instructed to immediately report any issues with the radiators, and that NA #3 should have reported the issue with the radiator as soon as it was pointed out to her. The facility failed to ensure that staff reported that the radiator cover was not intact to ensure the resident's safety. c. During a tour with the DNS on 2/13/20 at 10:20 AM, the radiator cover in the second floor dining room was observed to be flexed outward and had a sharp, jagged edge. The DNS stated that it possibly could have happened recently because there are residents sitting at a table next to the radiator and they could have hit the radiator with their wheelchair. The Maintenance Director was notified and the cover was repaired. The facility failed to ensure that the radiator was free from safety hazards. d. Observation of room [ROOM NUMBER] at 10:30 AM with the DNS identified that there was approximately 18 inches between the wall and the bed. The DNS identified that lack of bed clearance had been identified on their audits on 1/27/2020 and a bed side table was placed between the bed and the wall. The DNS identified that subsequent to putting that piece of furniture in, it was never re-evaluated to ensure it met the 3 foot clearance. The facility failed to have adequate space in between the bed and the wall. On 2/13/20, the Facility submitted an Allegation Letter for the Removal of Immediate Jeopardy which identified that the facility conducted a facility wide audit of resident's rooms to ensure that radiator covers were in place and that beds had a 3 foot clearance at sides and foot of bed in accordance with Connecticut Public Health Code. Staff were educated to monitor as they enter resident rooms and report issues immediately to Maintenance staff. If a safety risk is identified then staff should stay in room until maintenance arrives to repair. Staff were educated that any changes in residents' behavior, while in bed, must be reported to the nurse, an intervention needs to be put in place, the MD needs to be updated and the careplan needs to be revised to reflect the new intervention. Daily audits were initiated with results documented. Based on the submission of this action plan, Immediate Jeopardy for F689 was abated as of 2/13/20.

Based on clinical record review, facility documentation and interviews for two of three residents ( Resident #73 and Resident #132), reviewed for accidents, the facility failed to ensure adequate supervison was provided to prevent a fall resulting in an injury and/or the environment was free of accident hazards. The findings include: 1. Resident # 73's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified intact cognition and required extensive assistance of one person for transfers. The October 2016 care plan identified a risk for falls. Interventions directed to provide assistance for transfers. An accident and injury report investigation dated 11/27/16 at 11:02 AM identified Resident # 73 was transferring back to bed with the assistance of NA # 7 when Resident # 73 lost his/her balance and fell landing on his/her left side. The accident and injury investigation further identified when Resident #73 fell , he/she struck the left side of his/her head, resulting in a three inch long and half inch wide laceration on the left side of his/her forehead. Subsequent to fall, Resident # 73 was sent to the emergency room for evaluation and returned to the facility on [DATE] at 8:19PM with six sutures and bruising under the eyes, side of the head, arms and trunk. The investigation identified the root cause of the fall to be a failure of NA# 7 to use a gait belt when transferring Resident # 73. Interview with the DNS on 4/27/17 at 1:30 PM identified a gait belt should be use whenever transferring a resident who requires assistance. NA # 7 was not available for interview.Review of the facility policy identified that a gait belt is used with residents who can safely ambulate with assistance and/or perform greater than or equal to 50% of lift/transfer with stand pivot assistance with one staff member. 2. Resident #132 [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] identified severely impaired cognition and required one to staff members to provide extensive physical assistance with activities of daily living. The care plan dated 2/9/17 identified Resident#132 required extensive physical assistance of one to two staff for all activities of daily living (ADL) due to cognitive loss/dementia. Interventions included to provide assistance of two staff members for repositioning in bed. The physician orders dated 3/1/17 directed the staff to reposition the resident four times every shift. Additional review of the physician's order's dated 3/3/17 directed the staff to clean the area to the left buttock and apply Silvedene daily. a. A review of the nurse's notes dated 3/3/17 at 6:55AM identified Resident#132 fell out of bed during incontinent care which was being provided by NA#1. The nurse's note indicated Resident#132 sustained a 17 centimeter (cm) x 9 cm red area to the left buttock and an abrasion on the right knee. Further review of the nursing notes dated 3/3/17 at 7:10 AM identified Resident#132 had a bruise above the right side of the forehead and right cheek, abrasion to the right knee and approximately 4 blisters on the left buttock. Review of the skin integrity report dated 3/3/17 identified a burn on the left buttock was 100% epithelial tissue and measured 18 cm x 10 cm. Pain was identified as being present and treated effectively with pain medication as needed. Interview with Nurse Aide #1 on 4/24/17 at 12:10PM indicated that s/he was responsible for providing care to Resident#132 on 3/3/17 during the 11:00PM-7:00AM shift. NA#1 indicated that the unit was very busy and that s/he attempted to provide incontinent care to Resident#132 without the benefit of another staff member as directed by the nursing care plan. NA#1 indicated while s/he attempted to reposition Resident#132, the bed moved unexpectedly and Resident#132 fell on the floor landing with his/her buttocks pressed against the wall radiator. NA#1 identified after she assisted Resident#132 to the floor she called for help from the door way of the resident's room, however when the nurse did not respond. NA#1 received assistance from NA#2 and transferred the resident back to bed via a Hoyer lift prior to a nursing assessment. Interview with the Director of Nurses on 4/24/17 at 12:15PM identified NA#1 did not follow the plan of care by providing incontinent care without the assistance of another staff member. The DNS further identified it is the facility policy for the licensed staff to complete an assessment prior to transferring a resident following a fall. The DNS identified it is the responsibility of the nurse aide to notify the Nursing Supervisor if the charge nurse is not available to assess a resident following a fall. An attempt to interview LPN#1 and NA#2 on 4/25/17 at 11:28 AM were not successful. b. A review of the facility investigation of the accident identified the locks on Resident#132's bed were not functioning at the time of the fall. The investigation indicated that even though the brakes on the bed were applied, the bed moved when the resident was repositioned. A review of the investigation and interview with the Director of Maintenance (DOM) on 4/24/17 at 1:50PM identified that with the exception of electrical checks, there were no documentation of a maintenance check on the Resident #132's bed with in the last year. The DOM identifed the beds were not routinely inspected for wear and tear. A review of the operation and maintenance manual for the NOA medical industries (the manufacturer of the bed) identified maintenance and cleaning procedures (including checking the casters to ensure the brakes lock) should be performed at least once a year. Review of the investigation identified following the incident fifty four beds were identified as having damaged wheels (and moved when the breaks were locked) and/ or needed repair. Interview with the DOM on 4/24/17 at 2:10PM identified although he has begun replacing the casters to beds that needed repair there were several that have not been fixed. S/he could not quantitate how many were fixed and or needed to be fixed. Interview with the Director of Nurses on 4/25/17 at 1PM indicated that even though the 54 beds were identified as needing repair and were being used by the residents, the staff was not in-serviced and/or educated on the damaged wheels and/or the need for repair. 3. Observation on 4/23/17 at 9:55 AM identified the Environmental Services office located on the C unit was unattended and unlocked. Inside the office were 2 one quart bottles of Trukleen, a spray bottle containing yellow liquid labeled window cleaner, 2 one quart bottles of Air RX 75, one bottle of Air RX carpet and room deodorizer crystals, 1 bottle of Clausen carpet and upholstery crystals, one bottle of Elmer's carpenter wood glue, and one bottle of hydrogen peroxide. Interview with the Director of Housekeeping on 4/23/17 at 10:00 AM identified the Environmental Services office should be locked when unattended. The Director of Housekeeping further identified it was his responsibility to lock the door when he left the office and he had forgot to lock the door when he left the office five minutes earlier. Observation on 4/24/17 at 11:00 AM identified a bottle of Megabuff left unattended in a wheelchair in the hallway outside room 110 on the C unit. Interview with the Director of Housekeeping identified that the bottle of Megabuff should not have been left unattended and immediately removed the bottle of Megabuff. Interview on 4/26/17 at 2:15 PM with the Director of Housekeeping identified that Housekeeper # 2 was buffing the floors on the C unit and forgot to put the Megabuff away when he left for lunch.Review of facility policy identified that storage areas are locked to prevent unauthorized access and that all drugs and biologicals, including treatment items are stored in a locked cabinet/cart or locked medication room, inaccessible to patients and visitors. 4. Observation on 4/25/17 at 10:00AM identified in room 202 the electric baseboard radiator cover was fully detached from the radiator and resting on the floor below the radiator exposing the radiator coils. Further observation identified in room 205 the radiator cover was detached from the radiator and the cover was partially resting on the floor, exposing the radiator coils. Both radiators were cool to touch at the time of observation. Interview with the Director of Maintenance on 4/25/17 at 10:15AM identified the exposed radiator coils are a potential accident hazard. He further identified his department does not do regular environmental checks of the resident's rooms and they rely on the nursing and housekeeping staff to report if there is anything in a resident's room that is broken or in disrepair. .

Based on clinical record reviews, review of facility documentation and interviews for one of two sampled residents (Resident #4) who was reviewed for allegation of abuse, the facility failed to ensure the resident was free from verbal abuse. The findings include: Resident #4's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had severe cognitive impairment, disorganized thinking, indicators of depression, and required extensive two person assistance with activities of daily living. The resident care plan dated 8/2/16 identified the resident exhibits distressed mood as evidenced by sadness, persistent anger, agitation and anxiety. Interventions directed to approach the resident in a calm and non-threatening manner, allow time to vent feelings, monitor for symptoms of depression, anxiety, and provide reassurance. The Reportable Event Form dated 9/12/16 at 8:30 AM identified a 7-3PM nurse aide, Nurse Aide (NA) #3, was witnessed by two (2) staff members on two (2) different occasions swearing and pointing her finger at Resident #4. The report identified NA #4 and NA #5 witnessed NA #3 point a finger at Resident #4 and said shut the f_ _ _ _ up. NA #5 also heard NA #3 address Resident #4 to be a little b_ _ _ h. The Social Service note dated 9/12/16 at 3:07 PM identified the social worker was informed of an alleged episode of verbal altercation between the resident and a nurse aide on 9/8/16. The note indicated Resident #4 did not appear to recall the incident and had no problems with staff to report. Interview with NA #4 on 10/7/16 at 10:35 AM identified she, NA #3, NA #5 and Resident #4 were in the hallway joking when NA #3 pointed a finger in the resident ' s face and said shut the f_ _ _ up. NA #4 stated that NA #3 was aggressive towards the resident and Resident #4 became upset and agitated. Interview with NA #5 on 10/7/16 at 10:45 AM identified that she, NA #3 and NA #4 and Resident #4 were standing in the hallway joking around when NA #3 pointed her finger at the resident and stated you are a f_ _ _ing b_ _ _ h. NA #5 stated the resident seemed upset and scared at the time. NA #5 identified later she and NA #3 went to put Resident #4 into bed and NA #3 in a very loud voice pointed her finger at the resident and stated Don't ever f_ _ _ing talk to me again. Interview with the Director of Nursing (DON) on 10/7/16 at 11:05 AM identified NA #4 and NA #5 reported to her that NA #3 swore at Resident #4. The DON stated NA #3 denied the incidences. The DON identified that when she went to suspend the nurse aide, NA #3 walked out and the facility has not been able to contact her since. The DON stated verbal abuse was substantiated and NA #3 was terminated.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had a food allergy, the facility failed to ensure the resident was served the appropriate diet to prevent an allergic reaction. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED].#1 had an allergy to peanuts and a no added salt diet. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairments and required supervision after set up assistance with eating. Review of the admission care plan failed to reflect documentation that Resident #1 had a food allergy and/or the physician's orders [REDACTED]. The physician was notified and directed to administer Epi-Pen times one and to transfer the resident to the hospital for an evaluation. The Reportable Event Form dated 9/26/16 identified Resident #1 was given the dessert at the dinner meal that included, Tandy cake which had a peanut butter layer underneath the top layer of frosting. The resident complained of an itchy throat and began to have a dry cough. The physician was notified, an order was obtained for an Epi-Pen and to transfer the resident to the hospital. In a written statement a 3-11PM nurse aide identified Resident #1 received a tray that was extra in the dietary cart. The hospital history and physical dated 9/26/16 identified Resident #1 was transferred to the hospital after eating cake with a question of a peanut ingredient and peanuts cause [MEDICATION NAME]. The summary identified at the facility, the resident developed a cough with white sputum, mild shortness of breath, had posterior oropharynx, uvula [MEDICAL CONDITION], itching and complained that his/her throat was closing. The resident was diagnosed with [REDACTED]. Interview with Resident #1 on 10/5/16 at 10:00 AM identified that he/she ate the cake that was given to him/her on the meal tray and after a couple of bites realized the cake had peanut butter in it. Resident #1 stated he/she called for help and felt his/her throat start to close. Interview with the 3-11PM nurse aide, Nurse Aide (NA) #1, on 10/5/16 at 2:05 PM identified she and NA #2 were passing dinner trays and at the end realized Resident #1 had not received a meal tray. NA #1 stated she told NA #2 she was going to go to the kitchen to get the resident a meal tray and was told by NA #2 not to go, to just give the resident the extra tray that was for Resident #2. NA #1 stated NA #2 ripped up the meal ticket that was on Resident #2's extra tray and handed her the tray to deliver to Resident #1. NA #1 stated she was aware Resident #1 had a peanut allergy but was not aware that there was peanut butter in the cake. NA #1 stated that they were busy and working short staffed so when NA #2 told her to use Resident #2's extra tray she figured she knew what she was saying and did not go to the kitchen and/or let the charge nurse know Resident #1 did not receive a tray. Interview with NA #2 on 10/5/16 at 3:00 PM identified that after passing trays she and NA #1 realized Resident #1 did not receive a tray. NA #2 indicated that normally two trays were placed in the dietary cart for Resident #2, so she took the extra tray, ripped the meal ticket up and gave the tray to NA #1 to give to Resident #1. NA #2 stated that she was aware of the resident's allergy, but did not know the cake had peanut butter and should have called the kitchen for Resident #1's tray. NA #2 stated after the resident had the allergic reaction she went to the charge nurse and told her how Resident #1 was served Resident #2's extra tray which had the cake with peanut butter. NA #2 stated she was told to write that in her statement but no one asked her to explain what she wrote in her statement about giving Resident #1 the extra tray. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/5/16 at 3:15 PM identified after Resident #1 went to the hospital was when she found out from NA #2 that the resident was given Resident #2's extra tray that was in the meal cart. LPN #1 stated she directed NA #2 to write the information in a statement but could not remember if she told anyone about what NA #2 said. Interview with 3-11PM Nursing Supervisor, Registered Nurse (RN) #1 on 10/5/16 at 2:25 PM stated that she was called to Resident #1's room and her assessment identified the resident had an itchy throat and felt like his/her throat was going to close up. RN #1 identified she notified the physician and obtained an order to administer an Epi-Pen times one and to send the resident to the hospital. RN #1 stated NA #1 reported to her that NA #2 handed her an extra tray that was on the food cart to give to the resident instead of going to the kitchen. RN #1 stated she had the nurse aides write statements of what happened. Upon review of the statements, RN #1 identified that NA #2 gave Resident #1 an extra tray that was for Resident #2 but she did not speak to the nurse aide about what she meant because NA #2 had left for the night so she placed the statements under the Director of Nursing's door. Interview with the Director of Nursing (DON) on 10/5/16 at 3:50 PM identified she was unaware Resident #1 received Resident #2's extra meal tray. The DON stated that she thought the dietary department had placed the wrong dessert on the resident's tray. The DON identified she did not follow through on how the resident received the cake with the peanut butter after the dietary statements were obtained. The DON stated that she delegated to RN #1 to speak to the two nurse aides because she was busy.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents reviewed for accidents (Resident #124) the facility failed to properly store resident's wheelchair leg rests to prevent an injury. The findings include: Resident #124 ' s [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #124 had no cognitive impairment, required extensive assistance with transfer, locomotion off the unit and required supervision with locomotion on unit. A Reportable Event dated 2/01/16 at 12:35 PM identified that NA#2 placed a pair of wheelchair leg rests on top of Resident #124 ' s closet (dresser) with the intention of putting them on resident's wheelchair later, however NA#2 forgot about the leg rests. When R#124 later opened his/her closet door, both leg rests fell and struck R#124 on top of his/her head and on the left dorsal hand causing two small skin tears. Additionally the RE identified that R#124 sustained closed head injury on top of his/her head, skin tears to left hand and complained of dizziness. Resident #124 was transferred to hospital for evaluation. A nurse ' s note dated 2/01/16 at 1:30 PM identified R#124 reports that NA#2 placed leg rests on top of the dresser and when R#124 tried to open the dresser the leg rests fell hitting R#124's forehead, left hand and right elbow. Nurse ' s note identified that R#124 experienced pain to top of forehead, right elbow and complained of dizziness. Additionally, the nurse ' s note identified that Resident #124 sustained skin tears to left hand: one measuring 1.0 cm by 0.5 cm and two smaller skin tears measuring 0.25 cm by 0.25 cm and 0.25 cm by 0.5 cm, a bruise to left hand, and small bump to top of forehead. Nurse ' s noted dated 2/01/16 at 3:40 PM identified that R#124 was seen by APRN, complained of dizziness and was subsequently transferred to the ED for evaluation. Hospital discharge summary dated 2/01/16 identified the resident was diagnosed with [REDACTED]. Head CT scan identified a small left frontal paramedian scalp hematoma but no skull fracture. Review of the facility investigation identified that NA#2 failed ensure that the wheelchair leg rests were stored appropriately and was educated on 2/01/16 following safety rules. Interview with NA #2 on 3/23/16 at 11:45 AM identified that NA #2 took the leg rests and placed them on top of R#124 ' s closet (dresser) and indicated R#124 normally does not use the leg rests. NA#2 indicated he/she forgot that he/she had placed the leg rests on top of R#124's closet. Additionally NA#2 indicated that R#124 later went to go into closet and the leg rests got caught on the door causing the leg rests to fall on R#124's head and hitting R#124's right arm causing a skin tear on right hand. Review of the facility's Material Handling and Storage policy indicates to ensure materials are stored appropriately storage of materials must not create a hazard.

Based on clinical record reviews, review of facility documentation and interviews for three of five sampled residents (Resident #3, #2, #1) who were reviewed for an accident, the facility failed to provide the appropriate supervision to prevent an accident with injury. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] identified Resident #3 was a high risk for falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #3 had severe cognitive impairment, difficulty focusing attention and was easily distracted, disorganized thinking, rejected care at times, required extensive two person assistance with transfers in and/or out of the bed and/or the chair, and functional limitations to both lower extremities and one upper extremity and was non-ambulatory. The Resident Care Plan (RCP) dated 6/4/15 identified the resident was at risk for functional mobility and falls. Interventions directed to transfer out of bed via a mechanical lift and the assistance of two. A physician's orders [REDACTED]. The nurse's note dated 7/20/15 at 1:08 PM identified Resident #3 fell out of the shower chair landing face down on the floor and sustained a large laceration to the head and an abrasion to the right knee. The Reportable Event Form dated 7/20/15 at 10:45 AM identified Resident #3 fell out of the shower chair landing face down and sustained a laceration from the forehead to scalp approximately four inches long. The investigation identified that a Nurse Aide (NA) had left Resident #3 alone in the shower room to look for help to transfer the resident and upon return to the shower room found Resident #3 face down on the floor. The resident was transferred to the hospital and received six sutures and six staples to the scalp and forehead area. Interview with NA #1 on 8/25/15 at 10:20 AM identified that she gave Resident #3 a shower and needed help transferring the resident into the chair. NA #1 indicated that she called for help out the shower room door but no one responded. NA #1 stated she left the shower room and went around the corner to get a staff person to assist with the transfer and upon return to the shower room Resident #3 was face down on the floor. NA #1 identified that she knew she should not leave a resident alone in the shower room and did not think to use the call bell system. Interview with the Director of Nursing (DON) on 8/25/15 at 10:45 AM identified that she was called to the shower room and found Resident #3 lying on the floor face down and blood was noted around the resident's head. The DON stated she assessed the resident, applied pressure to the head and called 911. The DON identified that any resident identified as a fall risk was not to be left alone in the shower room. The DON identified that NA #1 stated she forgot to use the call bell. Subsequent to the incident all shower chairs have safety belts on them and staff was re-educated to use the belt during a shower on high fall risk residents. 2. Resident #2's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified Resident #2 had moderate cognitive impairment, difficulty focusing attention, was easily distracted and had difficulty following instructions and was independent with eating after set up. The RCP dated 6/12/15 identified required assistance and/or was dependent for activities of daily living care. Interventions directed to encourage resident participation and when in bed place all necessary personal items within reach. The nurse's note dated 6/18/15 at 1:03 PM identified a change in condition in skin integrity, the location was a pink area with a small raised are in the center on the left thigh, the resident experienced pain and the physician was notified. The nurse's note dated 6/18/15 at 7:03 PM identified the status of the skin condition deteriorated status [REDACTED]. The physician was notified and directed the application of Silvadene and a dry protective dressing and change daily. The skin integrity report dated 6/18/15 identified a 1.5 cm by 1.5 cm blister to the left thigh. The Reportable Event Form dated 6/18/15 at 10:45 AM identified Resident #2 had dozed off and knocked over a cup of tea onto his/her lap. Interview with Nurse Aide (NA) #2 on 8/25/15 at 12:15 PM identified Resident #2 had asked for tea, so she heated the water up in the microwave and gave the cup to the resident telling Resident #2 the tea would be hot. NA #2 stated that although there were signs posted above the microwave with instructions that directed the microwave power, time and special instructions for food and beverages, she did not read the chart at that time nor did she check the temperature of the water before giving the cup to the resident. NA #2 identified that there was no thermometer available until after the 6/18/15 incident with Resident #2. Interview with Licensed Practical Nurse (LPN) #1 on 8/25/15 at 12:10 PM identified that she asked NA #2 how long she heated the water in the microwave but did not ask if she checked the temperature of the water prior to serving Resident #2. LPN #1 stated that there was a chart to follow by the microwave that explained how long to heat food and beverages and at what temperature they should be at to serve them. LPN #1 indicated that after the incident when she looked, there was no thermometer. Interview with the Assistant Director of Nursing (ADO) on 8/25/15 at 11:50 AM identified that she spoke to NA #2 after the incident and NA #2 explained what she did and that she followed the directions on the microwave for heating up the water and not the chart posted and she did not test the water temperature. The ADON stated that she checked for a thermometer after the incident and was unable to find one. The ADON identified that all staff were inserviced after the 6/18/15 incident to ensure they are monitoring the temperature of all microwave foods prior to serving. 3. Resident #1's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #1 had severe cognitive impairment, required limited one person assistance with transfers in and/or out of the bed and/or chair, one person supervision with ambulating in the room, extensive one person assistance with toilet use, balance during transitions and walking was not steady and the resident was only able to stabilize with staff assistance, a walker and/or wheelchair was utilized for mobility, was occasionally incontinent of urine and had a history of [REDACTED]. Interventions directed to place call light within reach, provide verbal cues for safety and sequencing as needed and maintain a clutter free environment in the resident's room and consistent furniture arrangement. The physical therapy discharge note dated 3/25/15 identified Resident #1's gait and posture remain compensated, the resident remains physically independent in gait and transfers with rolling walker on level surfaces, the resident still demonstrates decreased memory and carryover of cues and instructions. The nurse's note dated 4/5/15 at 7:35 PM identified that at 4:00 PM a nurse aide passing by Resident #1's room heard a loud thump to the floor and upon entering found the resident on the floor with a large pool of blood around the left temporal area. Resident #1 was assessed and transferred to the hospital. The nurse's note dated 4/5/15 at 8:05 PM identified that Resident #1 returned to the facility at 8:00 PM, the left temporal area was noted to have a large bandaid intact and the laceration required twelve (12) sutures. The Reportable Event Form dated 4/5/15 at 4:00 PM identified the resident was found on the floor with a large pool of blood by the left temporal area. The investigation identified that urine was noted on the floor where fall had occurred. Interview with LPN #2 on 8/27/15 at 1:05 PM identified that when she went into Resident #1's room she noticed there was urine on the floor but did not know if the resident had been incontinent. LPN #2 stated that after Resident #1 left for the hospital a staff member reported to her Resident #1's roommate's Foley bag was leaking urine on the floor again. LPN #2 indicated that the Foley bag was not clamped off and urine was leaking on the floor, so she figured that was how the resident fell . Interview with Registered Nurse (RN) #1 on 8/27/15 at 1:20 PM identified that he recalled urine being on the floor at the time of the fall and then was informed later the roommate's Foley bag had leaked. Interview with the ADON on 8/27/15 at 10:00 AM identified the information was reported to her the next day that the urine was on the floor at the time of the fall was because the roommate's Foley catheter was not clamped off. The ADON stated that she did not speak to any of the staff regarding who had emptied the Foley catheter. Interview with the DON on 8/27/15 at 9:30 AM identified they determined the cause of Resident #1's fall was from slipping in the urine that had leaked from the roommate's Foley catheter which had not been clamped. Several telephone calls attempts to interview Nurse Aide #3 were unsuccessful.

Based on clinical record review, review of facility documentation, and interview, for one of three residents for incontinent care (Resident #15), the facility failed to care for a resident in a manner to prevent an injury. The findings include: Resident #15's [DIAGNOSES REDACTED]. Review of the patient care plan dated 8/30/11 identified interventions to provide assist of two when using the Hoyer lift and to utilize a split leg type of Hoyer sling/pad and assist with perineal care as needed. Review of facility documentation dated 11/20/11 identified that during incontinent care provided to Resident #1, a loud popping noise was heard which was reported to the nursing staff immediately. Review of nursing progress notes dated 11/21/11 identified that on 11/20/11 at 1:50PM a loud popping noise was heard by the nurse aides in the process of providing incontinent care to Resident #15. Resident #15 was assessed immediately and was noted to have a lump approximately two inches above the knee to the outside of the thigh. The physician was notified and the resident was sent out to acute care facility at which time a fracture of the left femur was identified. Interview with NA#4 on 3/19/12 at 11:30 AM identified that he/she was holding one leg of the resident and NA#3 was holding the other and administering incontinent care. NA#3 proceeded to separate the legs and that is when the loud popping noise was heard. Interview with the Director of Nursing on 3/19/12 at 1:25PM identified that the fracture occurred inadvertently with incontinent care and was not intentional. Interview with the Radiologist (MD#2) on 3/20/ 12 at 10:45AM identified that Resident #15's femur fractured was displaced side by side as well as medially and that it is not a typical fracture for an elderly resident. He/she further stated that when osteopenia is addressed in a radiologic report it means that a loss of calcium has been addressed but in order to [DIAGNOSES REDACTED]. MD#2 stated that he/she can't address culpability but stated that the osteopenic condition was not enough to cause a spontaneous fracture and a fall or manipulation would have had to occurred. Attempts to interview NA#3 and NA#5 were unsuccessful. The facility failed to ensure that the resident received services to prevent an accident.