Every finding on record at Essex Meadows Health Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #5) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse by a staff member. The findings include: Resident #5 was admitted to the facility in March 2025 with diagnoses that included aphasia, difficulty in walking, hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, and dementia. The annual MDS dated [DATE] identified Resident #5 had severely impaired cognition, had normally used the following mobility devices in the last 7 days: walker and wheelchair, and required supervision or touching assistance with lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers. The cognition/communication care plan dated 3/31/26 identified Resident #5 had dementia and a history of a stroke with aphasia (impairment of a person's ability to speak, understand, read, and write), at times his/her words were clear and there was a delay in response. Resident #5 wore glasses. Interventions included allowing Resident #5 extra time to process information, to follow commands, or to answer questions, speaking in short phrases providing simple one or two step commands during care, approaching from the left due to left sided vision only, and establishing daily routines to promote a predictable environment. The Psychotropics/Mood/Behaviors care plan dated 3/31/26 identified Resident #5 had dementia and a history of right frontal meningioma and stroke. The resident is unpredictable, usually friendly but the dementia could lead to combativeness or resistance to care. Interventions included administering psychotropics as ordered and approaching Resident #5 from the left. The consultant psychiatric note date 4/1/26 identified the focus of Resident #5's treatment continued to be aggression and combativeness with care, which has become much less frequent on the current medication regimen, but occurred intermittently. The note further identified that Resident #5 did not, at this time, present an imminent, predictable risk to harm self or others. The Summary of Session identified that Resident #5 had been doing much better with regard to his/her behavior, no recent behavior issues were reported or documented by nursing staff, however agitation did occur from time to time. Recommendations included to continue current medications and plan of care. Investigation of Resident Skin Event Form dated 4/1/26 completed by NA #5 identified that around 7:30 AM she had identified a black raised area on Resident #5's left forearm. Description of the injury identified that during morning care, Resident #5 complained of pain to the left forearm and upon observation, a black raised area on the left forearm was seen. The area was not present during her previous shift (yesterday) when she last provided care for the resident. An SBAR dated 4/1/26 identified that Resident #5 had a change in skin color or condition with an onset date of 4/1/26. The nurse's note dated 4/1/26 at 1:50 PM identified that the nurse aide reported a bruise to Resident #5's left forearm during morning care. The area was bluish in color measuring 1.0 x 1.0 inch. The resident denied discomfort and range of motion was within normal limits. The nurse's note dated 4/1/26 at 2:15 PM identified the bluish discoloration to the left forearm area was raised. The Skin Check dated 4/1/26 at 5:13 PM identified Resident #5 had a new skin issue, acquired in-house: bruising to the left outer forearm. A Reportable Event Form dated 4/2/26 identified that Resident #5 alleged that a nurse aide (NA #2) caused a bruise to his/her left forearm. Investigation of Resident Skin Event Form dated 4/2/26 completed by NA #3 identified that she was getting ready to start her shift and was walking by Resident #5's room and NA #2 was standing in the doorway just staring at her. Resident #5 was hanging off the bed. This writer asked NA #2 what happened, and NA #2 said Resident #5 was out of control. This writer went to get the nurse, and the nurse, NA #2 and this writer were standing by the bed to help Resident #5 and the resident said, this guy did it, what are you going to do about it referring to NA #2. The Witness Statement form dated 4/2/26 completed by LPN #2 identified that in the morning, the nurse aid called this writer to help her transfer Resident #5 who was sitting at the edge of the bed, legs down, feet on the floor, holding his/her walker. The female nurse aide from this shift and the male nurse aide from the night shift were in Resident #5's room. This writer stood on the right side of Resident #5 and the female nurse aide (NA #3) on the left side. The male nurse aide (NA #2) was standing away from us. This writer instructed Resident #5 to stand, and Resident #5 pointed to his/her left forearm bruise and stated, You see what happened here? This guy did it. What are you going to do about it? Resident #5 stood up and sat in the wheelchair with assistance. The incident was reported to the DNS right away. A verbal statement obtained from NA #2 via telephone on 4/2/26 (untimed) identified that NA #2 was asked if he could have caused the bruise on Resident #5, and NA #2 stated, that Resident #5 is physical and he has to protect himself. When NA #2 was asked to explain that statement, he stated that he holds the resident's hands, so the resident doesn't hurt him. NA #2 stated that the resident hurts him sometimes, he/she grabs and squeezes his hands. NA #2 indicated for being elderly, the resident is strong. When NA #2 was asked again if he could have caused the bruise, he stated, it is a possibility. NA #2 indicated he grabbed the resident's forearms to get the resident to release his hands. This writer then explained to NA #2 that he was off the scheduled pending investigation, and NA #2 identified the he was the one who had been abused and indicated the resident has hurt him before and has busted his lip. A written statement obtained from NA #2 via email on 4/3/26 at 2:24 PM identified that Resident #5 displayed aggressive behavior during the shift and became physically agitated and was hostile when NA #2 tried to get him/her up for the day. Resident #5 grabbed NA #2's hands and forcefully squeezed. During the incident the resident applied significant pressure causing pain and discomfort, so NA #2 had to pry the residents hands by grabbing the resident by the wrist and asking him/her to release, but the resident did not release so NA #2 had to remove his hands from the residents hands, finger by finger as gently as possible. NA #2 then left the room and left the resident in the position he/she was in because the resident was being hostile and uncooperative with the simple directions NA #2 was giving him/her. The written statement signed by the DNS and the Administrator on 4/3/26 identified that it was not their belief that NA #2 intended to cause harm to Resident #5, on 4/2/26. Per NA #2's written statement, he was trying to remove Resident #5's hands finger by finger off his own arm as gently as possible, due to the pain NA #2 was experiencing. NA #2 has had no prior allegations of abuse. The Reportable Event Summary Report dated 4/6/26 at 12:53 PM identified that the facility completed a timely and thorough investigation into the reported allegation. Based on interviews, record review, and clinical assessment, it was determined that the nurse aide did not intend to cause harm to the resident. The resident grabbed the nurse aide's hand and when the nurse aide was attempting to free himself, he held on to the resident's forearm resulting in a bruise. The resident has a diagnosis of dementia with agitation and was care planned for combative behaviors. The resident was also being followed by psychiatry. The intervention for this incident was two for care at all times. There was no evidence identified to substantiate the allegation of abuse. Review of NA #2's personnel file identified he was hired on 8/27/24. A Separation Notice dated 4/6/26 identified employment was separated for policy violation-failure to follow care plan. The Psychotropics/Mood/Behaviors care plan dated 4/7/26 included staff to monitor Resident #5 for mood changes, status post a bruise, he/she had periods of grabbing staff and needed his/her grip released manually. Interview with NA #3 on 7/1/26 at 12:29 PM identified that on 4/2/26, she was just starting her shift and NA #2 was coming off from working the 11:00 PM - 7:00 AM shift. NA #2 would usually get Resident #5 up before the start of the day shift. NA #3 indicated she walked by Resident #5's room and NA #2 was standing in the doorway and appeared angry, with a look on his face that she had never seen. NA #2 told her that Resident #5 was out of control. NA #3 indicated that Resident #5 was laying with his/her back on the bed, feet on the floor, and holding his/her walker, so she called LPN #2 for help. NA #3 further indicated Resident #5 appeared upset, pointed to NA #2 and to the best of her recall said something like (he did it, he did it) pointing to his/her arm. NA #3 identified that she did not witness the event and she was not a nurse and could not speak clinically to what Resident #5's arm looked like, but it looked like something had just happened; it looked fresh. Review of the nurse staffing schedule dated 3/30/26 through 4/5/26 identified NA #5 had worked 3:00 PM - 11:00 PM on 3/31/26 and 7:00 AM - 3:30 PM on 4/1/26. Interview with NA #5 on 7/1/26 at 1:59 PM identified that she saw the bruise on Resident #5's left forearm on 4/1/26 and notified the nurse, who came in to assess it and then asked her to write a statement. NA #5 indicated that she thought the area looked like one bruise on the mid left forearm and it was not there the day before. Review of the nurse staffing schedule dated 3/30/26 through 4/5/26 identified RN #5 had worked 7:00 AM - 3:00 PM on 4/1/26 and 4/2/26. Interview with RN #5 on 7/1/26 at 2:09 PM identified that she worked from 7:00 AM - 3:00 PM on 4/2/26 and she initially was not made aware that an incident had occurred between NA #2 and Resident #5. She later learned while speaking with some of the other nurses that there was a concern with NA #2. RN #5 indicated that during the morning, she stumbled upon a single circular bruise, approximately 1 x 1 in size and purplish in color, it had the appearance that it had already been there. When RN #5 asked Resident #5 what happened he/she said, (the man did this). RN #5 further indicated that Resident #5 had dementia and was not always accurate in his/her statements. RN #5 identified that Resident #5 was known to have combative behaviors and was very strong. Review of the nurse staffing schedule dated 3/30/26 through 4/5/26 identified that LPN #2 had worked 7:00 AM - 3:00 PM on 4/1/26 and 4/2/26. Interview with LPN #2 on 7/01/26 at 2:26 PM identified that she could not accurately recall the timeline of what took place between the identification of Resident #5's left forearm bruise on 4/1/26 and the allegation that NA #2 had caused a bruise to the left forearm on 4/2/26. LPN #1 indicated that she was the on-coming nurse for the morning shift and the male aide had just worked 11:00 PM - 7:00 AM. LPN #2 indicated that she could not remember if it was the male or female nurse aide that called her for help on 4/2/26, but when she entered Resident #5's room, the resident was upset and was pointing to the male nurse aide and the discoloration on his/her forearm and stated (this guy did it) just as it was written in her statement. LPN #1 indicated that the area was small and was bluish greenish in color, and that she immediately notified the DNS, the family, and the physician. LPN #1 identified that she did not ask NA #2 what happened but asked him to write a statement. Review of the nurse staffing schedule dated 3/30/26 through 4/5/26 identified that NA #2 worked 11:00 PM - 7:00 AM on 3/30/26, 3/31/26, and 4/1/26. NA #2 was removed from the schedule on 4/2/26. Although attempted, an interview with NA #2 was not obtained. Interview with the DNS on 7/1/26 at 2:39 PM identified that a bruise was found on Resident #5's left forearm on 4/1/26. A change in condition assessment for the new skin area was completed, and an investigation was initiated. Resident #5 did not report what happened until 4/2/26. The DNS indicated the allegation was first mentioned when NA #2 was standing in the doorway and Resident #5 accused him of causing the bruise. The DNS further indicated that while there was no nursing documentation of a skin assessment following the allegation, she was aware of only one bruise. The DNS indicated that she was notified of the incident via telephone around 7:30 AM and when she arrived at the facility, NA #2 had already left, and she obtained his statement via the telephone. NA #2 said that Resident #5 had grabbed him, and he was trying to get the resident's arm off of him and get his hands free. The DNS indicated that following the facility's investigation, abuse was not substantiated because NA #2 was trying to free himself and did not have the intention to cause harm. The DNS indicated that Resident #5 was care planned for having 2 providers for care and that NA #2 was in Resident #5's room by himself and was terminated for not following the 2-for-care care plan (this is in conflict with review of the care plan that indicated the intervention for 2 for care was initiated on 7/2/26, subsequent to surveyor inquiry). The DNS identified that NA #2's statement did not identify other efforts attempted by NA #2 to get Resident #5 to let go of his arm, but she would expect that a staff member would first gently talk to and calm the resident, attempt to understand why the resident was grabbing the staff member, and call for help. Deescalation efforts should be gentle, reassuring, redirecting, and should not have the potential to cause bruising. During an interview with the DNS and Administrator on 7/2/26 at 8:57 AM the DNS identified that NA #2 had not reported prior incidents to her that Resident #5 had hurt him or busted his lip. The DNS further identified that on 4/1/26 the facility initiated an investigation due to bruising and on 4/2/26 around 7:30 AM, the allegation of abuse came forth, and when she asked NA #2 if he could have caused the bruising, he said he could have. The Administrator indicated that the investigation did not substantiate that NA #2 intentionally harmed the resident, but he was trying to free himself from a painful hold, and she would have expected to NA #2 to have provided care with another staff member, in the event that Resident #5 started to demonstrate aggressive behaviors. Review of the care plan on 7/2/26 at 11:04 AM with the DNS failed to identify a care plan was in place for 2 staff members for care, prior to the 4/2/26 abuse allegation. During an interview with the DNS and Administrator on 7/2/26 at 11:04 AM, the DNS indicated that the intervention for 2 staff members for care would have been documented on the handheld care card and that would be where NA #2 would have looked for care instructions. The Administrator identified that there was no physician's order for 2-for care in the clinical record and that the handheld care card that was in effect for 4/1/26 and 4/2/26 was not available. The Psychotropics/Mood/Behaviors care plan was revised on 7/2/26, subsequent to surveyor inquiry, with an intervention to include 2 staff with care as ordered. The Abuse Prevention Program directs that it is the policy of the community to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, neglect, misappropriation of property, exploitation, corporal punishment, and involuntary seclusion. We have established policies and procedures that will provide personnel with the knowledge to further ensure each resident is treated with individual respect and dignity. The policy directs that during orientation of new employees the community will cover, in part, at least the following topics, how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. On an annual basis, staff will receive a review of the above topics. The policy further directs that on a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the community's progressive discipline policy.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #5) reviewed for abuse, the facility failed to ensure the comprehensive care plan was revised to reflect a resident with known periods of combativeness and resistance to care required 2 staff members for care. The findings include: Resident #5 was admitted to the facility in March 2025 with diagnoses that included aphasia, difficulty in walking, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dementia, and the presence of an artificial eye. The annual MDS dated [DATE] identified Resident #5 had severely impaired cognition, had normally used the following mobility devices in the last 7 days: walker and wheelchair, and required supervision or touching assistance with lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers. The Psychotropics/Mood/Behaviors care plan dated 3/31/26 identified Resident #5 had dementia and a history of right frontal meningioma, CVA, and TIAs; he/she was unpredictable, usually friendly but the dementia could lead to combativeness or resistance to care, with interventions that included administering psychotropics as ordered and approaching Resident #5 from the left. The Reportable Event Form dated 4/2/26 identified that Resident #5 alleged that a nurse aide (NA #2) caused a bruise to his/her left forearm. The Reportable Event Summary Report dated 4/6/26 at 12:53 PM identified that the facility completed a timely and thorough investigation into the reported allegation. Based on interviews, record review, and clinical assessment, it was determined that the nurse aide did not intend to cause harm to the resident. The resident grabbed the nurse aide's hand and when the nurse aide was attempting to free himself, he held on to the resident's forearm resulting in a bruise. The resident had a diagnosis of dementia with agitation and was care planned for combative behaviors. The resident was also being followed by psychiatry. The intervention was that the resident will be two for care at all times. There was no evidence identified to substantiate the allegation of abuse. Review of NA #2's personnel file identified he was hired on 8/27/24 and a Separation Notice dated 4/6/26 identified separation of employment effective 4/6/26 for policy violation-failure to follow care plan. The Psychotropics/Mood/Behaviors care plan identified a new intervention initiated on 4/7/26 which included staff to monitor Resident #5 for mood changes, status post a bruise, the resident had periods of grabbing staff and needed his/her grip released manually. Although attempted, an interview with NA #2 was not obtained. Interview with the DNS on 7/1/26 at 2:39 PM identified that Resident #5 was care planned for having 2 providers for care and that NA #2 was in Resident #5's room by himself and was terminated for not following the 2-for-care care plan. Review of the care plan on 7/2/26 at 11:04 AM with the DNS failed to reflect the intervention for 2 staff members for care, prior to the 4/2/26 abuse allegation. During an interview with the DNS and Administrator on 7/2/26 at 11:04 AM, the DNS indicated that the intervention for 2 for care would have been documented on the handheld care card and that would be where NA #2 would have looked for care instructions. The Administrator identified that there was no physician's order for 2 for care in the clinical record and that the handheld care card that was in effect for 4/1/26 and 4/2/26 was not available. The Psychotropics/Mood/Behaviors care plan was revised on 7/2/26, subsequent to surveyor inquiry, with an intervention to include 2 staff with care as ordered. The Care Plan policy directs the facility to develop, implement, maintain and evaluate a resident care plan. The care plan is an individualized written plan which includes input from the resident, the resident's family, the resident's responsible party, and disciplines involved in the care of the resident. The plan focuses on assisting residents to achieve and maintain maximum levels of physical, social and independent and emotional focusing. The plan will be developed through a systemic process including assessment, the setting of goals, the development of strategies and methods to meet the goals and evaluation of the results. The resident care plan is available to all personnel who provide care to the residents, as well as the handheld care plan.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure employees received training on how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff, per the facility. The findings include: Review of NA #2's personnel file identified he was hired on 8/27/24 and a Separation Notice dated 4/6/26 identified separation of employment effective 4/6/26, employment was separated for policy violation-failure to follow care plan. Review of NA #2's facility online education transcript identified that he had completed the Abuse Prevention Program module on 6/20/25 and the Preventing, Recognizing, and Reporting Abuse module on 9/10/24 and 6/24/25. The facility was unable to provide documentation that the education provided to the facility staff, including NA #2, included a focus on managing aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff, per the facility policy. The Staff Development Nurse (LPN #1) was not available for a review of facility documentation and interview. During an interview with the DNS and Administrator on 7/2/26 at 8:57 AM the DNS indicated that the Staff Development Nurse was not on-site and that she and the Administrator would continue to look for documentation of staff education modules that spoke the facility's policy on managing aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. The Administrator indicated that some of the residents at the facility have behaviors, and that an outside provider was invited to the facility to present an in-service to the staff on how to manage these types of behaviors. The Administrator was unable to recall when the in-service was completed. Although requested the education and staff sign-in for the in-service were not provided. The Abuse Prevention Program directs that during orientation of new employees the community will cover how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. On an annual basis, staff will receive a review of the above topics. The policy further directs that on a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the community's progressive discipline policy.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were at risk for falls, the facility failed to ensure the provider was notified immediately when there was swelling of the heft hip and increased pain after the resident experienced a fall two (2) days prior. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, unsteadiness on feet, pain and repeated falls. The Fall Risk Evaluation dated 8/30/25 identified that Resident #1 was at risk for falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 did not make decisions regarding tasks of daily living and required supervision with bed mobility, transfers and ambulating. The Resident Care Plan dated 9/2/25 identified Resident #1 was a fall risk, had a history of frequent falls and fractures, arthritis to both knees and osteopenia (a loss of bone density) and was highly prone to fractures. Interventions directed two (2) quarter side-rails to be in the up position while in bed for mobility and a scoop mattress in place to the bed for improved boundary awareness. A physician's order dated 10/6/25 directed the assistance of one (1) staff for contact guard with gait-belt and rolling walker for transfers and ambulating. The nurse's Post Fall Evaluation dated 10/17/25 at 11:42 PM identified Resident #1 was observed self-ambulating stating he/she needed to use the bathroom after being toileted less than one (1) hour prior and when Resident #1 took a step backwards he/she lost his/her balance and fell, hitting his/her head on the bottom metal bedrail of the bed. The note reported Resident #1 was immediately assessed, Resident #1 had no loss of consciousness, neurological signs were within normal limits, vital signs were obtained, his/her blood pressure was slightly elevated, and Resident #1 was noted with a skin tear to the left wrist and a bump to the back of the head. The note did not identify that range of motion or rotation of the extremities were checked during the post-fall assessment but reported that the family and the provider were notified of the fall, Resident #1 was not transferred to the hospital, and no new orders were documented. Review of the nurse's notes from 10/17/25 at 11:42 AM through 10/19/25 at 4:10 AM identified Resident #1 had no ill effects from the 10/17/25 fall. The nurse's note dated 10/19/25 at 4:10 AM identified Resident #1 was complaining of pain that was noted to be eight (8) out of ten (10) on the pain scale, edema and swelling were noted to the left hip and acetaminophen (a pain reliever) was administered with good effect. The note failed to reflect documentation a provider was notified of the edema and swelling. The Post Fall Evaluation dated 10/19/25 at 6:13 AM identified a physician (MD #1) was notified of the pain and swelling to Resident #1's left hip and they requested an order for an x-ray but failed to identify MD #1's response. The note did not indicate that the physician gave an order. The nurse's note dated 10/19/25 at 2:53 PM identified Resident #1 continued with pain, six (6) out of ten (10), to the left hip and swelling. The note indicated MD #1 was notified and a new order was obtained for a left hip x-ray to be completed in-house. The radiology report dated 10/19/25 identified Resident #1 had sustained an acute mildly displaced fractures (new bone fractures where the bone fragments are only slightly out of alignment) of the left superior (positioned above/towards the head end of the body) ischial ramus (the bottom of the pelvis that forms the lower and back part of the hip bone) and the left inferior (below/towards the feet) pubic ramus were seen. The Situation Background Assessment Recommendation note dated 10/20/25 at 12:41 PM identified Resident #1 was on bedrest since the 10/17/25 fall due to pain with movement. The nurse's note dated 10/20/25 at 2:29 PM identified Resident #1 had increased pain since the 10/17/25 fall, the left arm and elbow had extensive bruising, the left foot was externally rotated, MD #1 and the family were notified and agreed to send Resident #1 to the shoreline clinic for further evaluation. The nurse's note dated 10/20/25 at 10:00 PM identified Resident #1 returned to the facility with no new orders. Interview with the 7PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/29/25 at 1:07 PM identified she worked on 10/18/25 into 10/19/25, and NA #4 notified her in the evening on 10/18/25 Resident #1 was complaining of increased pain, and she had difficulty turning Resident #1 and providing care. LPN #1 identified although she notified RN #3, who then assessed the left hip area, she did not document the findings until 10/19/25 at 4:10 AM and did not notify the provider until around 6:00 AM. LPN #1 identified she did not call the provider instead she sent a text message and did not hear back prior to leaving the facility at 7:00 AM. LPN #1 explained she notified RN #4 and requested he follow-up. LPN #1 identified RN #4 had not reported to her at 7:00 PM shift change on 10/18/25 that Resident #1 had complained of or showed signs and symptoms of pain or regarding any swelling to the left hip. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #3, on 10/29/25 at 1:21 PM identified she worked the 7AM-7PM shift on 10/18/25 and cared for Resident #1. NA #3 reported although she usually provides care and gets Resident #1 up out of bed for breakfast, on 10/18/25 Resident #1 was sleeping, so she let him/her sleep. NA #3 identified when she went to provide care and get Resident #1 up prior to lunch, what usually took her fifteen (15) to twenty (20) minutes to complete, it took over an hour. NA #3 explained Resident #1 was trying to sit up when she was turning Resident #1 side to side, especially when placed on the left side and stated Resident #1 was wincing and was not redirectable. NA #3 identified Resident #1 was difficult to stand with the transfer out of bed and would not assist so she had to pick-up Resident #1 and place him/her in the chair. NA #3 stated when she attempted to feed Resident #1, Resident #1 would not eat, which was very unlike him/her and Resident #1 wanted to go back to bed. NA #3 identified she then notified the charge nurse, Registered Nurse (RN) #4, that Resident #1 appeared to be in pain, had refused lunch and wanted to go back to bed, and she thought Resident #1's left leg was broken. Interview with RN #4 on 10/29/25 at 1:38 PM identified that he worked 7:00 AM to 7:00 PM on both 10/18/25 and 10/19/25 and NA #3 had notified him in the early afternoon on 10/18/25 Resident #1 appeared to be in pain with care, did not want to eat and did not want to get out of bed, stating although that was abnormal for Resident #1, he did not assess Resident #1 or notify the provider and he should have. RN #4 indicated LPN #1 reported to him around 7:00 AM at shift change on 10/19/25 Resident #1 had complained of pain overnight, there was left hip edema and swelling and she had texted the provider and requested an x-ray. RN #4 identified he did not follow-up with the provider regarding LPN #1's text until MD #1 responded after 2:00 PM directing to obtain a left hip x-ray in-house. Interview with MD #1 on 10/29/25 at 2:16 PM identified the facility first notified her of Resident #1's increased pain and swelling to the left hip at 5:53 AM on 10/19/25 but reported she was at the hospital and did not respond to them with the order for the left hip x-ray until 2:30 PM. Interview with the Director of Nursing (DON) on 10/29/25 at 2:44 PM identified NA #3 should have notified RN #4 once she first realized Resident #1 had a change in condition and not continue with providing care. The DON explained RN #4 should have assessed Resident #1 and notified the provider when he was notified Resident #1 had a change in condition in the afternoon on 10/18/25. The DON identified she does not want providers notified overnight for non-urgent findings but a resident who has a change in condition, the provider should be notified when the change is identified, and there was no need for LPN #1 to wait until 6:00 AM to notify the provider. The DON explained once a provider was notified of a change, she expects the staff to follow up in twenty (20) to thirty (30) minutes if they do not receive a response from the provider. Review of the Change of Condition/Notification policy dated January 2012 directed, in part, that communication with the physician is maintained among the health care professionals and the resident when changes in a resident's condition affect the current level of care to ensure the appropriate medical follow-up. The head nurse manager or team leader will assess the resident's condition as soon as it's practicable and notify the attending physician or advanced practice registered nurse, resident, and responsible party when the resident's physical, communicative or functional status changes unexpectedly, the resident is injured or if treatment is significantly altered. Monitoring will be put into place where deemed necessary. If nursing is unable to reach an attending physician, the long-term facility medical director or the physician on-call is to be notified.

Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a fall, the facility failed to assess the resident when there was swelling of the heft hip and increased pain after the resident experienced a fall two (2) days prior. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, unsteadiness on feet, pain and repeated falls. The Fall Risk Evaluation dated 8/30/25 identified that Resident #1 was at risk for falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 did not make decisions regarding tasks of daily living and required supervision with bed mobility, transfers and ambulating. The Resident Care Plan dated 9/2/25 identified Resident #1 was a fall risk, had a history of frequent falls and fractures, arthritis to both knees and osteopenia (a loss of bone density) and was highly prone to fractures. Interventions directed two (2) quarter side-rails to be in the up position while in bed for mobility and a scoop mattress in place to the bed for improved boundary awareness. A physician's order dated 10/6/25 directed the assistance of one (1) staff for contact guard with gait-belt and rolling walker for transfers and ambulating. The nurse's Post Fall Evaluation dated 10/17/25 at 11:42 PM identified Resident #1 was observed self-ambulating stating he/she needed to use the bathroom after being toileted less than one (1) hour prior and when Resident #1 took a step backwards he/she lost his/her balance and fell, hitting his/her head on the bottom metal bedrail of the bed. The note reported Resident #1 was immediately assessed, Resident #1 had no loss of consciousness, neurological signs were within normal limits, vital signs were obtained, his/her blood pressure was slightly elevated, and Resident #1 was noted with a skin tear to the left wrist and a bump to the back of the head. The note did not identify that range of motion or rotation of the extremities were checked during the post-fall assessment but reported that the family and the provider were notified of the fall, Resident #1 was not transferred to the hospital, and no new orders were documented. The nurse's note dated 10/19/25 at 4:10 AM identified Resident #1 was complaining of pain that was noted to be eight (8) out of ten (10) on the pain scale, edema and swelling were noted to the left hip and acetaminophen (a pain reliever) was administered with good effect. The note failed to reflect documentation an assessment of the left hip was conducted. The nurse's note dated 10/19/25 at 2:53 PM identified Resident #1 continued with pain, six (6) out of ten (10), to the left hip and swelling. The note indicated MD #1 was notified and a new order was obtained for a left hip x-ray to be completed in-house. The radiology report dated 10/19/25 identified Resident #1 had sustained an acute mildly displaced fractures (new bone fractures where the bone fragments are only slightly out of alignment) of the left superior (positioned above/towards the head end of the body) ischial ramus (the bottom of the pelvis that forms the lower and back part of the hip bone) and the left inferior (below/towards the feet) pubic ramus were seen. The nurse's note dated 10/20/25 at 2:29 PM identified Resident #1 had increased pain since the 10/17/25 fall, the left arm and elbow had extensive bruising, the left foot was externally rotated, MD #1 and the family were notified and agreed to send Resident #1 to the shoreline clinic for further evaluation. The nurse's note dated 10/20/25 at 10:00 PM identified Resident #1 returned to the facility with no new orders. Interview with the 7PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/29/25 at 1:07 PM identified she worked on 10/18/25 into 10/19/25, and NA #4 notified her in the evening on 10/18/25 Resident #1 was complaining of increased pain, and she had difficulty turning Resident #1 and providing care. LPN #1 identified although she notified RN #3, who then assessed the left hip area, she did not document the findings until 10/19/25 at 4:10 AM and did not notify the provider until around 6:00 AM. LPN #1 identified she did not call the provider instead she sent a text message and did not hear back prior to leaving the facility at 7:00 AM. LPN #1 explained she notified RN #4 and requested he follow-up. LPN #1 identified RN #4 had not reported to her at 7:00 PM shift change on 10/18/25 that Resident #1 had complained of or showed signs and symptoms of pain or regarding any swelling to the left hip. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #3, on 10/29/25 at 1:21 PM identified she worked the 7AM-7PM shift on 10/18/25 and cared for Resident #1. NA #3 reported although she usually provides care and gets Resident #1 up out of bed for breakfast, on 10/18/25 Resident #1 was sleeping, so she let him/her sleep. NA #3 identified when she went to provide care and get Resident #1 up prior to lunch, what usually took her fifteen (15) to twenty (20) minutes to complete, it took over an hour. NA #3 explained Resident #1 was trying to sit up when she was turning Resident #1 side to side, especially when placed on the left side and stated Resident #1 was wincing and was not redirectable. NA #3 identified Resident #1 was difficult to stand with the transfer out of bed and would not assist so she had to pick-up Resident #1 and place him/her in the chair. NA #3 stated when she attempted to feed Resident #1, Resident #1 would not eat, which was very unlike him/her and Resident #1 wanted to go back to bed. NA #3 identified she then notified the charge nurse, Registered Nurse (RN) #4, that Resident #1 appeared to be in pain, had refused lunch and wanted to go back to bed, and she thought Resident #1's left leg was broken. Interview with RN #4 on 10/29/25 at 1:38 PM identified that he worked 7:00 AM to 7:00 PM on both 10/18/25 and 10/19/25 and NA #3 had notified him in the early afternoon on 10/18/25 Resident #1 appeared to be in pain with care, did not want to eat and did not want to get out of bed, stating although that was abnormal Resident #1, he did not assess Resident #1 or notify the provider and he should have. Interview with the Director of Nursing (DON) on 10/29/25 at 2:44 PM identified NA #3 should have notified RN #4 once she first realized Resident #1 had a change in condition and not continue with providing care. The DON explained RN #4 should have assessed Resident #1 and notified the provider when he was notified Resident #1 had a change in condition in the afternoon on 10/18/25. Review of the Change of Condition/Notification policy dated January 2012 directed, in part, that the head nurse manager or team leader will assess the resident's condition as soon as it's practicable and notify the attending physician or advanced practice registered nurse, resident, and responsible party when the resident's physical, communicative or functional status changes unexpectedly, the resident is injured or if treatment is significantly altered. Monitoring will be put into place where deemed necessary.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #8) reviewed for urinary tract infections (UTI ' s) and 2 of 3 residents (Resident #8 and Resident #36) reviewed for weight changes, the facility failed to notify a provider of a medication omission for treatment of a UTI and failed to notify a provider of a significant weight gain for a resident with congestive heart failure (CHF) and failed to notify a provider of significant weight changes per facility policy. The findings include: 1. Resident #8 was admitted to the facility in December of 2024 and had diagnoses that included cellulitis of left lower limb, CHF, and UTI. The Clinical Admission assessment dated [DATE] at 3:51 PM identified Resident #8 was alert, disoriented, and confused with incoherent unclear speech that can sometimes be understood. Resident #8 required assistance with meals, used a walker and manual wheelchair, had a limb prosthesis due to amputation with lower extremity range of motion impairment on one side, had an unsteady gait with poor balance and was bedfast all or most of the time. The Resident Care Plan (RCP) dated 12/13/2024 identified Resident #8 was at risk for infection related to chronic illness, and a history of bacteremia and cellulitis. Interventions included encouragement and assistance with good hand hygiene, and social distancing as indicated. A Provider order dated 1/6/2025 directed to administer ciprofloxacin 500 mg (antibiotic) by mouth 2 times a day for 7 days related to a UTI. A nursing progress note by RN #7 on 1/6/2025 at 8:29 PM identified that ciprofloxacin 500mg was not available for administration in the Omnicell (automated medication dispensing system used to ensure the availability of certain medications) or medication cart. The progress note failed to identify that the provider had been notified. Interview with MD #1 on 1/10/2025 at 12:08 PM identified that she was not notified of the missed dose of ciprofloxacin 500 mg scheduled to be administered on 1/6/2025 at 8:00 PM. Review of Policy on Physician's Orders identified if a medication is not available the provider will be notified. 2. Resident #8 was admitted to the facility in December of 2024 and had diagnoses that included cellulitis of left lower limb, CHF, and UTI. The Clinical Admission assessment dated [DATE] at 3:51 PM identified Resident #8 was alert, disoriented, and confused with incoherent unclear speech that can sometimes be understood. Resident #8 required assistance with meals, used a walker and manual wheelchair, had a limb prosthesis due to amputation with lower extremity range of motion impairment on one side, had an unsteady gait with poor balance and was bedfast all or most of the time. The Resident Care Plan (RCP) dated 12/13/2024 identified Resident #8 was at risk for fluid overload, dehydration and electrolyte abnormalities related to CHF and use of a diuretic. Interventions included assessment for dependent edema, administration of diuretics per provider order, and to obtain daily weights and report a weight gain greater than 2 pounds (lbs.) in a day to the provider. A Provider order dated 12/13/2024 directed to obtain a daily weights. A provider order dated 12/17/2024 directed to administer bumetanide (diuretic) 1 milligram (mg) by mouth 1 time a day related to CHF and to administer bumetanide 1 mg by mouth 1 time a day as needed (PRN) if Resident #8's weight increased 2 lbs. in one day or 5 lbs. in one week and to notify the provider. A Nursing progress note by RN #2 on 1/6/2025 at 3:06 PM identified she notified MD #1 of a 3 lb. weight gain in 1 day for Resident #8. A Nursing progress note by RN #2 on 1/6/2025 at 3:08 PM identified she received instructions from MD #1 to utilize the PRN bumetanide order for Resident #8. Review of the Weights and Vitals Summary report identified the following weight entries: 130.8 lbs. on 12/14/2024 132.6 lbs. on 12/17/2024: weight gain of 2.6 lbs. since the last weight entry 12/14/2024 136.0 lbs. on 12/18/2024: weight gain of 3.4 lbs. in 1 day 137.0 lbs. on 12/20/2024: weight gain of 6.2 lbs. in 6 days (from 12/14/2024) 137.8 lbs. on 12/22/2024 140.4 lbs. on 12/23/2024: weight gain of 2.6 lbs. in 1 day 139.6 lbs. on 12/24/2024 140.4 lbs. on 12/26/2024 143.4 lbs. on 12/29/2024: weight gain of 3 lbs. since the last weight entry 12/26/24 Review of the clinical record failed to identify documentation of provider notification of weight gains on 12/18/2024, 12/20/2024, and 12/22/2024. of 2 lbs. in 1 day or 5 lbs. in 1 week Interview with RN #3 on 1/8/2025 at 12:50 PM identified Resident #8 had a weight increase of 2.6 lbs. on 12/23/2024 and it was her understanding that the facility policy directed to report a weight gain of 3 lbs. in 1 day or 5 lbs. in 1 week to the provider. RN #3 identified she was unaware Resident #8 had a PRN order which instructed to update the provider of a weight increase of 2 lbs. in 1 day or 5 lbs. in 1 week. RN #3 indicated there was no instruction in the daily weight order regarding reporting parameters and if she knew about the instructions in the PRN order she would have notified the provider of the 2.6 lb. weight gain in 1 day. Subsequent to surveyor inquiry, a Provider order dated 1/8/2025 directed daily weights and included instructions that directed to administer an extra dose of bumetanide 1 mg if Resident #8's weight increased 2 lbs. in 1 day or 5 lbs. in 1 week, and to notify the provider. Interview with RN #2 on 1/9/2025 at 3:00 PM identified that she follows parameters ordered by the provider for reporting of weight gains for residents with CHF, and these parameters are usually included within the order for daily weights. RN #2 identified that on 1/6/2025 she updated MD #1 of a 3 lb. weight gain in one day because she knew MD #1 used these parameters, and that at the time of her call she was not aware there was an active PRN order for bumetanide 1 mg for an increased weight of 2 lbs. in one day or 5 lbs. in one week. RN #2 further identified that she did not notify MD #1 on 12/20/2024 of a 6.2 lb. weight gain in 6 days because 3 different scales were used to obtain the weights and subsequently she questioned the accuracy of the weights. RN #2 identified she should have notified MD #1 of the weight changes even if she were uncertain of the accuracy and that moving forward she would do so. Interview with RN #4 on 1/10/2025 at 11:00 AM identified that she usually included parameters for reporting weight gain within the daily weight orders for residents with CHF. RN #4 identified that there were parameters for reporting weight gain in Resident #8's bumetanide 1 mg PRN order but she could not identify why the parameters were not included in the daily weight order or how nurses would know to look at the PRN order for further instructions. RN #4 identified the daily weight order had been revised to include instructions with weight gain parameters for reporting to the provider. Review of the Congestive Heart Failure policy identified weights will be obtained daily and a weight that has increased 3 lbs. in one day or 5 lbs. in one week will be reported to the provider. 3. Resident #36 was admitted to the facility in October of 2024 with diagnoses that included hypertension, hypo-osmolarity and hyponatremia (low sodium level in blood), chronic kidney disease, and diabetes. Review of the hospital Discharge Summary document dated 10/17/24 identified that Resident #36 was discharged on [DATE] and a weight of 199.0 pounds (Lbs) was obtained on 10/17/24. A Dietary/Nutrition Profile note dated 10/20/24 at 9:44 AM by the Dietician identified that Resident #36 was at risk for altered nutrition due to abnormal labs, diabetes with Hemoglobin A1C (average blood sugars in blood during the past 2 to 3 months) of 7.0 (normal range: below 5.7%) and hyponatremia (low blood sodium level) which improved upon being discharged from the hospital. The note identified a reweight request which was not reflected in the clinical record. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and required maximum assistance for toileting, bed mobility and transfers and moderate assistance for personal hygiene. The MDS further identified that Resident #36 used a walker and wheelchair for mobility. A Resident Care Plan dated 10/21/24 identified Resident #36 was at risk for nutritional deficit. Interventions included administering a carbohydrate consistent diet, dietary counseling as needed, monitoring blood sugar as ordered, monitoring for digestive complaints as needed, monitoring labs as needed, monitoring weights per physician order, seeing resident for meal preferences, and skin checks as ordered. Review of the Weights and Vitals Summary identified the following weights: 10/18/24: 181.2 pounds (Lbs.), 10/30/24: 181.2 Lbs., 11/14/24: 181.2 Lbs., 12/2/24: 226.2 Lbs., 12/3/24, 227.9 Lbs., and 12/16/24, 226.4 Lbs. Resident #36's weights for 10/30/24 (181.2 Lbs.) and 11/14/24 (181.2Lbs.) were struck out on 12/9/24 by RN #6 as incorrect documentation. Review on Nursing Progress notes dated 10/18/24 through 12/20/24 failed to identify nursing documentation that physician was notified of significant weight loss of 17.2 Lbs. (8.94%) in one day between 10/17/24 (199 Lbs.) and 10/18/24 (181.2 Lbs.) and significant weight increase of 27.2 Lbs. (13.67%) in less than 2 months between 10/17/24 (199.0Lbs) and 12/2/24 (226.2 Lbs.). Interview and clinical record review with RN #6 on 1/9/25 at 1:35 PM, identified that she documented weights on 10/30/24 and 11/14/24 in the Electronic Medical Record (EMR). RN #6 indicated that on 12/9/24 she struck out the 10/30/24 and 11/14/24 weights because she thought the weights were incorrect based on a significant weight gain reflected on 12/3/24. RN #6 was unable to explain why Resident #36 was not weighed weekly for 4 weeks post admission to the facility or why Resident #36 was not reweighed on 10/18/24 due to the discrepancy between hospital discharge weight and the facility admission weight. Interview and clinical record review with the DNS on 1/9/25 at 3:20 PM, identified Resident #36 should have been weighed on admission and then weekly for 4 weeks according to the facility weight policy. The DNS identified that NA ' s are responsible for obtaining weights under the direction of the unit manager. The DNS identified licensed nurses are responsible for ensuring weights are documented in the EMR and for updating the provider, family and dietician of weight changes. The DNS was unable to explain why a reweight was not obtained subsequent to the facility admission weight reflecting a significant weight loss of 17.8 Lbs (8.94%) between 10/17/24 (199 Lbs.) and 10/18/24 (181.2 Lbs.) or why a reweight was not obtained on 10/20/24 as directed by the dietician. The DNS was unable to explain why Resident #36 ' s weights were obtained and documented on 10/30/24 as 181.2 Lbs. and on 11/14/24 as 181.2 Lbs. then struck out 1 month later (on 12/9/24) by RN #6 with a documented reason of: inaccurate documentation. The DNS was unbale to provide documentation that interventions were initiated for Resident #36 due to a significant weight increase of 27.2 Lbs. (13.67%) between 10/17/24 (199.0Lbs) and 12/2/24 (226.2 Lbs.). Subsequent to surveyor inquiry, the EMR was updated to reflect the following late entry weights: 10/28/24: 215.2 Lbs. and 11/25/24: 189.3 Lbs. Interview with MD #1 on 1/10/25 at 10:35AM, identified that physician weight notifications are documented in a physician's notification book which is usually with the unit manager and could not identify if she had been notified of the weight changes without referencing the notification book. Interview and clinical record review with the Unit Nurse Manager (RN#4) on 1/10/25 at 11:30 AM, identified that all weights should have been documented in EMR after Resident #36 was weighed and further indicated that if weights were not documented, it means they were not done. RN #4 was unable to identify if the physician was notified when Resident #36 experienced significant weight increase and loss. Review of facility policy titled, Policy and Procedure for Weights/Re-weights, identified in part, that, each Health Center resident will be weighed upon admission and then once weekly for four weeks, then monthly on bath day unless specified by the physician. When a significant weight loss or gain occurs (5 Lbs.), the following measure will be implemented. a). Resident will be reweighed to ensure accuracy. If weight loss is confirmed, Dietician will be notified. b) Consultant dietician will reassess during the next visit. c) Physician and family will be notified by nursing staff as appropriate. d). Documentation in nurses notes that weight loss has taken place, and the physician, Dietician and family have been notified. Weights are recorded in the EMR. Supervisor/designee will review weights weekly and report concerns. 51183

Based on clinical record review, facility documentation, facility policy, and interviews for the only sampled resident (Resident #36), reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency (SA) within 2 hours of the alleged violation. The findings include: Resident #36 was admitted to the facility in October of 2024 with diagnoses that included hypertension, chronic kidney disease and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and required maximum assistance for toileting, bed mobility and transfers, moderate assistance for personal hygiene and was dependent for bathing. The MDS further identified Resident #36 was always incontinent of urine and bowel. The Resident Care Plan dated 12/6/24 identified Resident #36 had a functional ability decline. Interventions included set up assistance for eating, assist of 2 for bathing, toileting hygiene and dressing, notifying the nurse of refusals and physical, occupational and speech therapies to evaluate and treat per physician's order. A Reportable Event form dated 12/24/24 at 12:30 PM by the DNS identified that during the medication pass Resident #36 reported to RN #2 that Nurses Aid (NA) #1 touched him/her inappropriately while performing personal care. The form identified that Resident #36 described NA #1 as a Hispanic NA with short straight hair and that Resident #36 requested NA #1 no longer provide care for him/her. The form identified that Resident #36 reported that he/she spoke in Spanish to NA #1 and when he/she stopped speaking in Spanish to NA #1, NA #1 got mad. Additionally, Resident #36 reported that NA #1 also offered to stay with him/her if he/she rented a room. The form further identified that the physician, family, administrator and law enforcement agency were notified of the incident, and an investigation was initiated on 12/24/24 and concluded on 1/2/24 with no findings. The form identified that the allegation was reported by the DNS to the overseeing SA on 12/31/24 at 11:30 AM. Interview with Resident #36 on 1/8/25 at 9:30 AM, identified that he/she reported the incident to the facility and spoke to the DNS about the incident 2 weeks prior and did not want to further discuss the incident. Interview with NA #2 on 1/10/24 at 9:30 AM identified that she was not assigned to provide care for Resident #36 on 12/24/24 but was later assigned to provide care for Resident #36 by the Unit Manager (RN #4), after an allegation of abuse by Resident #36 was made towards NA #1. NA #2 identified that she assisted Resident #36 with personal care and did not have any issues providing care for Resident #36 during her shift. Interview with RN #2 on 1/10/24 at 9:45 AM identified that Resident #36 reported NA #1 touched him/her inappropriately while providing personal care. RN #2 identified that Resident #36 requested that NA #1 no longer provide care for him/her. RN #2 identified that she immediately reported the abuse allegation to RN #4. Interview with NA #1 on 1/10/24 at 10:30 AM identified that she was assigned to provide care for Resident #36 on 12/24/24 during the 7:00 AM to 3:00 PM shift. NA #1 identified that she was not feeling well during her shift and left the facility around 10:20 AM. NA #1 identified that she did not provide personal care to Resident #36 during the shift, but only provided apple juice when she passed out drinks to residents. NA #1 further identified that it was not until after she left the facility that RN #4 contacted her via phone to enquire about an allegation of abuse by Resident #36. NA #1 identified that she reported back to work on 12/27/24 from sick leave and had not provided care for Resident #36 since. In addition, NA #1 identified that she has long hair and does not speak Spanish. Interview with RN #4 on 1/10/24 at 11:20 AM identified she was informed by RN #2 that Resident #36 reported an allegation of abuse. RN #4 identified that she spoke with Resident #36 who was upset and then contacted NA #1 by phone to enquire about the allegation since NA #1 already left the facility. RN #4 updated the physician, DNS and Human Resources Manager and an investigation was initiated. Interview with the DNS on 1/10/25 at 11:30 AM identified that she did not report Resident #36's allegation of abuse, within 2 hours of the allegation, to the SA. The DNS identified that the Administrator and the DNS were responsible for reporting incidents to the SA. The DNS identified that Resident #36 had a history of making allegations and recanting his/her allegations. The DNS indicated that she did not immediately report the abuse allegation because she was not sure if Resident #36 would recant the allegation as he/she had previously done. The DNS reported the allegation of abuse to the overseeing SA on 12/31/2024 at 11:30 AM. Review of facility policy titled, Abuse Prevention Program, identified, in part, all allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and residents' representative immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.

Based on review of the clinical record, facility policy and interviews for 1 sampled resident (Resident #8) reviewed for edema and 1 of 3 residents (Resident #36) reviewed for skin conditions, the facility failed to utilize an as needed (PRN) medication according to provider order for a resident with congestive heart failure (CHF) and the facility failed to complete preventative weekly skin assessments according to facility policy. The findings include: 1. Resident #8 was admitted to the facility in December of 2024 and had diagnoses that included cellulitis of left lower limb, CHF, and dementia. The Clinical Admission assessment dated [DATE] at 3:51 PM identified Resident #8 was alert, disoriented, and confused with incoherent unclear speech that could sometimes be understood. Resident #8 required assistance with meals, used a walker and a manual wheelchair, had a limb prosthesis due to an amputation with lower extremity range of motion impairment on one side, had an unsteady gait with poor balance and was bedfast all or most of the time. The Resident Care Plan (RCP) dated 12/13/2024 identified Resident #8 was at risk for fluid overload, dehydration and electrolyte abnormalities related to CHF and use of a diuretic. Interventions included assessment for dependent edema, administration of diuretics per provider order, and to obtain daily weights and report a weight gain greater than 2 pounds (lbs.) in a day to the provider. A Provider order dated 12/13/2024 directed to obtain a daily weight. A Provider order dated 12/17/2024 directed to administer bumetanide 1mg by mouth one time of day related to CHF and to administer bumetanide 1 mg by mouth one time a day PRN if Resident #8's weight increased 2 lbs. in one day or 5 lbs. in one week and to notify the provider. A Nursing progress note by RN #4 on 12/17/2024 at 5:43 PM identified Resident #8 was seen by MD #1 and Resident #8's scheduled bumetanide (diuretic) order was decreased to 1 milligram (mg) daily, and a PRN dose of bumetanide was ordered for administration if Resident #8's weight increased 2lbs. in 1 day or 5 lbs. in 1 week. A Nursing progress note by RN #2 on 1/6/2025 at 3:06 PM identified she notified MD #1 of a 3 lb. weight gain in 1 day for Resident #8. A Nursing progress note by RN #2 on 1/6/2025 at 3:08 PM identified she received instructions from MD #1 to utilize the PRN bumetanide order for Resident #8. Review of the Weights and Vitals Summary report identified weights of 130.8 lbs. on 12/14/2024, 132.6 lbs. on 12/17/2024, 136.0 lbs. on 12/18/2024 (a weight gain of 3.4 lbs. in 1 day), 137.0 lbs. on 12/20/2024 (a weight gain of 6.2 lbs. in 6 days from 12/14/2024), 137.8 lbs. on 12/22/2024, 140.4 lbs. on 12/23/2024 (a weight gain of 2.6 lbs. in 1 day), 141.7 lbs. on 1/5/2025, and 144.4 lbs. on 1/6/2025 (a weight gain of 3.3 lbs. in 1 day). Interview with RN #3 on 1/8/2025 at 12:50 PM identified she was unaware Resident #8 had a PRN diuretic order. RN #3 identified there was no instruction in the daily weight order to direct her to Resident #8's diuretic order for an extra dose of bumetanide 1mg as needed for weight increased 2 lbs. in one day or 5 lbs. in one week and to notify the provider. Subsequent to surveyor inquiry, there was a new Provider order dated 1/8/2025 for daily weights which contained instructions that directed to administer an extra dose of bumetanide 1 mg if Resident #8's weight increased 2 lbs. in one day or 5 lbs. in one week, and to notify the provider. Interview with RN #2 on 1/9/2025 at 3:00 PM identified she did not notify MD #1 of a 6.2 lb. weight gain in 6 days on 12/20/2024 nor did she administer the PRN bumetanide because she did not know the accuracy of the weight entries and she was unaware Resident #8 had a PRN diuretic order for bumetanide 1 mg for an increased weight of 2 lbs. in one day or 5 lbs. in one week. RN #2 further identified she was unaware of Resident #8's PRN bumetanide order until 1/6/2025 after reporting a 3 lb. weight gain in 1 day for Resident #8 to MD #1. Review of the Progress Notes report dated 1/10/2025 identified there was no documentation of an extra dose of bumetanide 1mg administered PRN on 12/18/2024, 12/20/2024, or 12/23/2024. Interview with RN #4 on 1/10/2025 at 11:00 AM identified Resident #8 had both a scheduled dose of bumetanide 1mg and a PRN order for bumetanide 1 mg. RN #4 stated the PRN bumetanide order was ordered for administration for weight increased 2 lbs. in one day or 5 lbs. in one week. RN #4 could not identify why weight gain parameters or instructions to administer a PRN dose of bumetanide were not included in the daily weight order or how nurses would know to look in the PRN orders without these instructions. RN #4 identified that the daily weight order for Resident #8 had been revised to include weight parameters with instructions for utilization of Resident #8's PRN bumetanide. Review of the Congestive Heart Failure policy identified weights will be obtained daily and a weight that has increased 3 lbs. in one day or 5 lbs. in one week will be reported to the provider. The policy failed to include direction for utilization of medications per provider orders for management of weight gain. 2. Resident #36 was admitted to the facility in October of 2024 with diagnoses that included hypertension, chronic kidney disease, diabetes and dermatophytosis (a common fungal infection of skin, hair or nails). The admission Minimum Data Set (MDS) assessment dated [DATE] identified the Resident #36 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and required maximum assistance for toileting, bed mobility and transfers, moderate assistance for personal hygiene and was dependent for bathing. The MDS further identified that Resident #36 was always incontinent of urine and bowel, was at risk of developing pressure ulcers/injuries and had moisture associated skin damage (MASD) at the time of admission. A Resident Care Plan dated 10/21/24 identified Resident #36 was at risk for alteration in skin integrity. Interventions included applying medicated cream to fungal rash as needed, assessing heels for redness, offloading heels with blue bolster while in bed, cleansing and drying skin folds thoroughly related to chronic rash due to moisture, encouraging/assisting with periodic repositioning to avert pressure injuries, using pressure reducing mattress, completing skin audit on admission and weekly, monitoring skin during care and reporting any changes or concerns and monitoring feet closely for changes in skin integrity. Review of Physician's orders dated 11/1/24 identified an order for weekly skin assessments. Further review of physician's orders identified an order to complete a skin check every shift over bony prominences for redness, blanching and integrity and to document and notify the physician of changes. Review of the Treatment Administration Record dated 11/1/24 identified a physician order to complete skin check over bony prominences for redness, blanching and integrity and to document and notify the physician of changes. Further review identified that nurses were documenting the order as administered on all three shifts. Review of progress notes dated 10/17/24 through 1/9/24 failed to identify documentation of weekly skin assessments/condition or refusals. Review of the clinical record from 10/17/24 through 1/9/25 identified skin assessments dated 10/18/24, 10/25/24, 11/1/24, 11/8/24, 11/20/24, 12/5/24 and 12/16/24. The record failed to identify skin assessments from 12/16/24 through 1/9/25. Interview and record review with RN #5 on 1/9/25 at 1:30 PM identified that skin checks/assessments are completed weekly by a licensed nurse on shower days. RN #5 was not able to identify documentation of weekly skin assessments after 12/16/24 in the electronic medical record (EMR) or paper chart. RN #5 identified that skin assessments should have been completed on 12/23/24, 12/30/24 and 1/6/25 and results documented in Resident #36's clinical record. RN #5 was unable to explain why weekly skin assessments were not completed for 3 consecutive weeks. Interview with the DNS on 1/9/25 at 3:00 PM, identified that skin assessments should be completed weekly by a licensed nurse on shower days and documented in the EMR. The DNS was unable to explain why Resident #36's weekly skin assessments were not completed for 3 consecutive weeks but indicated that the facility recently transitioned to a new charting system and staff were still learning the new system. The DNS indicated that after 1 assessment was missed, the missed assessment would stop subsequent assessments from automatically triggering when due. Subsequent to surveyor inquiry, a skin assessment was completed and documented in the clinical record on 1/9/25. No alteration in skin integrity was identified. Review of facility policy titled, Protocols for Prevention of Pressure Ulcers, Identified, in part, routine skin inspection is done daily when care is being provided by the nurse aid. Any changes in skin integrity are reported to the nurse for assessment such as reddened or open areas, edema and spongy or blistered areas. Skin assessment and documentation is done on admission by the nurse and then weekly (usually on bath day) by the nurse aide with the nurse assessing any changes. 51183

Based on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #8) reviewed for urinary tract infections (UTI), the facility failed to timely start treatment for a resident with a confirmed infection. The findings include: Resident #8 was admitted to the facility in December of 2024 and had diagnoses that included cellulitis of left lower limb, dementia, and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10) and was dependent for eating, toileting hygiene, and transfers. The Resident Care Plan (RCP) dated 1/2/2025 identified Resident #8 was at risk for infection related to chronic illness, and a history of bacteremia and cellulitis. Interventions included encouragement and assistance with good hand hygiene, and social distancing as indicated. The RCP further identified Resident #8 had a self-care deficit and required assistance with activities of daily living. Interventions included staff assistance with toileting. A provider order dated 12/31/2024 directed to obtain a clean catch urine specimen for laboratory testing for urinalysis (UA) with culture and sensitivity (C&S) related to Resident #8 ' s complaint of dysuria. A Nursing progress note by RN #4 dated 12/31/2024 at 5:11 PM identified Resident #8 had complaints of dysuria which was reported to MD #1, and a new order to obtain a (UA)/(C&S) was obtained. A Nursing progress note by RN #7 dated 12/31/2024 at 10:39 PM identified that a clean catch urine specimen had been obtained for UA/C&S and the laboratory was called for pickup. A provider order dated 1/3/2025 directed to administer cephalexin 500mg by mouth 2 times a day for 7 days related to cellulitis of the left lower limb. A Nursing progress note by RN #7 dated 1/3/2025 at 11:17 PM identified an order had been obtained from MD #1 for cephalexin 500 milligrams (mg) by mouth 2 times a day for 7 days related to cellulitis of the left lower limb and Resident #8's family had been updated. A Laboratory report dated 1/6/2025 at 11:37 AM identified Resident #8 had a positive UA which triggered a culture be performed and the C&S results identified Resident #8 had growth of 2 different bacteria and further provided a list of antibiotic medications which would be effective treatments. The list contained the antibiotic ciprofloxacin which both bacteria were sensitive to. A provider order dated 1/6/2025 directed to administer ciprofloxacin 500 mg by mouth 2 times a day for 7 days for UTI. A Nursing progress note by RN #4 dated 1/6/2025 at 2:26 PM identified MD #1 reviewed the C&S results, Resident #8 was positive for a UTI, a new order for ciprofloxacin 500 mg by mouth 2 times a day for 7 days was obtained, and Resident #8's family member was notified. A Nursing progress note by RN #7 on 1/6/2025 at 8:29 PM identified that ciprofloxacin 500mg was not available for administration in the Omnicell (automated medication dispensing system used to ensure the availability of certain medications) or medication cart. The progress note failed to identify that the provider had been notified. A Nursing progress note by RN #7 on 1/6/2025 at 11:05 PM identified Resident #8 was to start on ciprofloxacin, but the facility was waiting for the ciprofloxacin delivery from the pharmacy and ciprofloxacin was unavailable in the Omnicell. The progress note failed to identify that the provider had been notified. Review of the Administration Record report dated 1/10/2025 for the Medication Administration Record from 1/1/2025 through 1/31/2025 identified documentation that Resident #8 ' s first dose of ciprofloxacin 500 mg was administered on 1/7/2025 at 8:00 AM (this administration was more than 17 hours after documentation of order receipt of ciprofloxacin from MD #1). Interview with the DNS on 1/10/2025 at 11:30 AM identified antibiotics stocked in the facility Omnicell are automatically ordered by the computer when items are removed by the nurses and the pharmacy is efficient at filling those orders. The current facility stock for ciprofloxacin was verified and revealed 2 ciprofloxacin 250 mg capsules with an expiration date of 8/2025 and 4 ciprofloxacin 250mg capsules with an expiration date of 12/2025. The Omnicell did not contain ciprofloxacin in a dosage form of 500mg. The DNS stated she was confident the ciprofloxacin 250mg capsules were available for administration on 1/6/2025, that RN #7 would only have needed to remove 2 capsules, and could not identify why RN #7 had documented the medication was unavailable in the Omnicell. The DNS identified that after completion of the shift on 1/6/2025 RN #7 had resigned without notice. Interview with MD #1 on 1/10/2025 at 12:08 PM identified that she had not been notified that Resident #8 had not started antibiotic treatment for his/her UTI until 8:00 AM on 1/7/2024 because the medication was unavailable for administration. Interview with RN #7 on 1/10/2025 at 2:50 PM identified she did not administer ciprofloxacin 500 mg to Resident #8 on 1/6/2025 at 8:00 PM because it was not in the Omnicell. RN #7 identified she did not know ciprofloxacin 250mg was available in the Omnicell. Review of the Policy on Physician's Orders identified if a medication is not available the provider will be notified.

Based on clinical record review, review of facility policy, and interviews for 1 of 3 residents (Resident #36) reviewed for weight changes, the facility failed to obtain weights per facility policy. The findings include: Resident #36 was admitted to the facility in October of 2024 with diagnoses that included hypertension, hypo-osmolarity and hyponatremia (fluid and electrolyte imbalance), chronic kidney disease, and diabetes. Review of the hospital Discharge Summary document dated 10/17/24 identified that Resident #36 was discharged on [DATE] and a weight of 199.0 pounds (Lbs) was obtained on 10/17/24. A Dietary/Nutrition Profile note dated 10/20/24 at 9:44 AM by the Dietician identified that Resident #36 was at risk for altered nutrition due to abnormal labs, diabetes with Hemoglobin A1C (average blood sugars in blood during the past 2 to 3 months) of 7.0 (normal range: below 5.7%) and hyponatremia (low blood sodium level) which improved upon being discharged from the hospital. The note identified a reweight request which was not reflected in the clinical record. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and required maximum assistance for toileting, bed mobility and transfers and moderate assistance for personal hygiene. A Resident Care Plan dated 10/21/24 identified Resident #36 was at risk for nutritional deficit. Interventions included administering a carbohydrate consistent diet, dietary counseling as needed, monitoring blood sugar as ordered, monitoring for digestive complaints as needed, monitoring labs as needed, monitoring weights per physician order, seeing resident for meal preferences, and skin checks as ordered. Review of the Weights and Vitals Summary identified the following weights: 10/18/24: 181.2 pounds (Lbs.), 10/30/24: 181.2 Lbs., 11/14/24: 181.2 Lbs., 12/2/24: 226.2 Lbs., 12/3/24, 227.9 Lbs., and 12/16/24, 226.4 Lbs. Resident #36's weights for 10/30/24 (181.2 Lbs.) and 11/14/24 (181.2Lbs.) were struck out on 12/9/24 by RN #6 as incorrect documentation. Interview and clinical record review with RN #6 on 1/9/25 at 1:35 PM, identified that she documented weights on 10/30/24 and 11/14/24 in the Electronic Medical Record (EMR). RN #6 indicated that on 12/9/24 she struck out the 10/30/24 and 11/14/24 weights because she thought the weights were incorrect based on a significant weight gain reflected on 12/3/24. RN #6 was unable to explain why Resident #36 was not weighed weekly for 4 weeks post admission to the facility or why Resident #36 was not reweighed on 10/18/24 due to the discrepancy between hospital discharge weight and the facility admission weight. Interview and clinical record review with the DNS on 1/9/25 at 3:20 PM, identified Resident #36 should have been weighed on admission and then weekly for 4 weeks according to the facility weight policy. The DNS identified that NA ' s are responsible for obtaining weights under the direction of the unit manager. The DNS identified licensed nurses are responsible for ensuring weights are documented in the EMR and for updating the provider, family and dietician of weight changes. The DNS was unable to explain why a reweight was not obtained subsequent to the facility admission weight reflecting a significant weight loss of 17.8 Lbs (8.94%) between 10/17/24 (199 Lbs.) and 10/18/24 (181.2 Lbs.) or why a reweight was not obtained on 10/20/24 as directed by the dietician. The DNS was unable to explain why Resident #36 ' s weights were obtained and documented on 10/30/24 as 181.2 Lbs. and on 11/14/24 as 181.2 Lbs. then struck out 1 month later (on 12/9/24) by RN #6 with a documented reason of: inaccurate documentation. The DNS was unbale to provide documentation that interventions were initiated for Resident #36 due to a significant weight increase of 27.2 Lbs. (13.67%) between 10/17/24 (199.0Lbs) and 12/2/24 (226.2 Lbs.). Subsequent to surveyor inquiry, the EMR was updated to reflect the following late entry weights: 10/28/24: 215.2 Lbs. and 11/25/24: 189.3 Lbs. Interview with the Unit Nurse Manager (RN #4) on 1/10/25 at 11:30 AM, identified that all weights should have been documented in the EMR after Resident #36 was weighed and further indicated that if weights were not documented, it means they were not done. Review of facility policy titled, Policy and Procedure for Weights/Re-weights, identified in part, that, each Health Center resident will be weighed upon admission and then once weekly for four weeks, then monthly on bath days unless specified by the physician. When a significant weight loss or gain occurs (5 Lbs.), the following measure will be implemented. a). Resident will be reweighed to ensure accuracy. If weight loss is confirmed, Dietician will be notified. b) Consultant dietician will reassess during the next visit. c) Physician and family will be notified by nursing staff as appropriate. d). Documentation in nurses notes that weight loss has taken place, and the physician, Dietician and family have been notified. Weights are recorded in the EMR. Supervisor/designee will review weights weekly and report concerns.

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #38) reviewed for unnecessary and psychotropic medications, the facility failed to enter a 14 day stop date for an as needed antipsychotic medication. The findings include: Resident #38 was admitted to the facility in November of 2024 and had diagnoses that included personal history of malignant neoplasm, severe sepsis with septic shock, and generalized anxiety disorder. A Provider order dated 11/29/2024 directed to administer prochlorperazine maleate (antiemetic-vomit prevention) 5 milligrams (mg) by mouth every 6 hours as needed for nausea/vomiting. The Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), had no issues found during a drug regimen review, required setup or clean-up assistance with oral hygiene, partial/moderate assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 12/4/2024 identified Resident #38 received psychotropics related to nausea and the prescribed medication was classified as an antipsychotic. Interventions included to administer psychotropic medications as ordered and monitor for efficacy and side effects. The RCP further identified Resident #38 required medication management related to chemotherapy. Interventions included administration of medications per provider orders and pharmacy review of medications. A Pharmacy Consultation Report dated 12/29/2024 from the Consultant Pharmacist failed to identify a recommendation for a 14 day stop date for the antipsychotic medication prochlorperazine maleate. Review of the Administration Record Report dated 1/10/2025 identified Resident #38 was administered prochlorperazine maleate 5 mg by mouth on 12/16/2024 at 12:08 PM, 12/19/2024 at 1:24 PM, 12/19/2024 at 9:31 PM, 12/23/2024 at 8:36 AM, 1/1/2025 at 4:07 PM, 1/7/2025 at 12:15 PM, and 1/9/2025 at 7:50 AM. This was a total of 7 administrations of prochlorperazine maleate 5 mg as needed beyond 14 days from the provider order date of 11/29/2024. Interview with the Consultant Pharmacist on 1/10/2025 at 10:22 AM identified prochlorperazine maleate is classified as an antipsychotic and when ordered on an as needed basis, requires a 14 day stop date. The Consultant Pharmacist stated she missed this medication order during her medication review for Resident #38, and that she would make a recommendation to the facility to add a stop date to the order for prochlorperazine maleate or change the order to a different antiemetic medication. Review of the Psychoactive Drug Management policy directed, in part, monthly pharmacy consultant reviews would be conducted to ensure appropriate diagnosis, indication, dose, monitoring for effectiveness, monitoring for side effects and adverse consequences, and potential for gradual dose reductions.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of eight (8) sampled residents (Resident #1) who were at risk for elopement, the facility failed to ensure Resident #1, who had exit seeking behaviors and required a wander guard bracelet, was not able to exit the facility unsupervised. The findings include: Resident #1's diagnoses included Alzheimer's, anxiety, restlessness and agitation. A physician's order dated 9/11/24 directed to check the functionality of the wander guard device one (1) time a day and placement of the wander guard on the right ankle every shift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short- and long-term memory deficits, poor decision-making skills regarding tasks of daily life, difficulty focusing attention, and utilized a wheelchair for mobility. The Resident Care Plan dated 10/30/24 identified Resident #1 was an elopement risk related to being forgetful. Interventions directed a wander guard in place, elopement assessments quarterly, and monitor for exit seeking behaviors. A nurse's note dated 11/15/24 at 11:02 PM identified Resident #1 was found by the security guard outside at approximately 10:20 PM in the parking lot. Resident #1 was seated in the wheelchair, fully dressed including a heavy jacket, shoes, and socks, in the parking lot close to the entrance door and security escorted Resident #1 back into the facility. The note identified Resident #1 was wearing the wander guard on the ankle, the alarm did not sound when Resident #1 came through the doors, and the wanderguard was replaced with a new one. The note indicated Resident #1 was assessed and had no ill effects from the incident. Review of the November 2024 Treatment Administration Record identified the function of the wanderguard was last checked on 11/14/24 during the 11PM-7AM shift and placement was checked on the 3-11PM shift on 11/15/24. Interview with the Director of Nursing (DON) on 11/27/24 at 10:00 AM identified the 3-11PM charge nurse called to inform her Resident #1 was found outside after 10:00 PM, sitting in his/her wheelchair, fully dressed and the wander guard was in place. The DON identified staff reported that they did not hear the wanderguard system alarm and Resident #1's wander guard was replaced to ensure proper functioning. The DON stated the wander guard system including residents wander guards are checked daily for appropriate functioning and are replaced if found to not function properly. In an interview with the Director of Plant and Operations on 11/26/24 at 10:43 AM he identified the facility had called him on 11/15/24 after 10:00 PM informing him that Resident #1 was found in the parking lot. The Director of Plant and Operations stated he went to the facility about 11:00 PM to ensure all the doors and exits were retested and working appropriately. The Director of Plant and Operations identified the wander guard doors are tested daily at 3:30 PM by security or maintenance. Interview with the 3-11PM charge nurse, Registered Nurse (RN) #4, on 11/26/24 at 3:15 PM identified she had seen Resident #1 shortly after 9:00 PM and Resident #1 was in his/her room. RN #4 identified she did not hear the wander guard alarm sound, and around 10:00 PM she heard voices coming from the front entrance, where she observed the evening security officer wheeling Resident #1 back into the facility. RN #4 stated she assessed the resident, checked the wander guard and although the wander guard was noted to be working, she changed the wander guard. Review of The Wandering Resident/Monitoring (Wander guard) use dated 11/20/24 policy states any resident determined to be a wanderer with input from the physician, family, or responsible party and the health center team to ensure the residents' safety while maintaining the maximum level of independence.

Based on observation, facility policy and interviews for one of two units reviewed for environment, the facility failed to maintain water temperatures within acceptable perimeters. The findings include: 1. Resident #25 ' s diagnoses included dementia with behavioral disturbance, delirium, and depression. Measurement of water temperatures in the Resident #25 ' s room on 11/10/22 at 10:30 AM identified a temperature of 125.3. 2. Resident #437 ' s Diagnosis included lymphoma and anxiety. Measurement of water temperature in Resident #437 ' s Room on 11/10/22 at 10:30 AM identified a temperature of 125.2 Interview and observation with the Plant Operation staff on 11/10/22 at 10:45 identified that he had calibrated his thermometer this morning prior to taking water temperatures. The water temperature in Resident #25 ' s room was noted to be 118.8 and the water temperature in Resident #437 ' s room was 118. Interview and observation of calibration with Maintenance staff ' s thermometer on 11/10/22 at 3:00 PM identified that when immersed in ice, the maintenance thermometer was incorrectly calibrated and read 33.3 degrees Fahrenheit (F) 1.3 degrees above the correct calibration level. Observation of calibration with the surveyor thermometer when immersed in ice correctly identified a temperature of 32 degrees F. Simultaneous rechecks of water temperatures with the Maintenance Director on 11/14/22 at 3:00 PM using both the Maintenance and surveyor ' s calibrated thermometers identified a Maintenance Director thermometer temperature of 122.3 degrees F in room [ROOM NUMBER] and 120.2 in room [ROOM NUMBER] degrees F, while the surveyor thermometer water temperatures identified a temperature of 125.9 in room [ROOM NUMBER] and a temperature of 123.3 in room [ROOM NUMBER]. Interview with the Maintenance Director identified that the facility policy follows the Public Health Code water temperature regulation which indicates water temperatures should be maintained between 105 degrees F and 120 degrees F. Subsequent to survey inquiry, the Maintenance Director indicated that he would turn the water temperature down and continuously monitor water temperatures until maintained at the acceptable temperature.

Based on clinical record reviews, facility documentation, facility policy, and interviews for 2 of 3 residents reviewed for abuse for (Resident #17), the facility failed to ensure reporting of verbal abuse timely and for (Resident # 29), the facility failed to report an injury of unknown origin to an overseeing state agency. The findings included: 1. Resident #17 was admitted with diagnoses that included morbid obesity, dementia with behavioral disturbances and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive two persons physical assistance with bed mobility, total dependence two persons for transfers and extensive one person assistance with personal hygiene. A care plan reviewed on 7/27/22 identified Resident #17 utilized medications for anxiety and depression. Interventions included to provide listening support and reassurance when anxious. Additionally, the care plan reviewed on 7/27/22 identified Resident #17 has impaired cognition due to dementia. Interventions that include to allow Resident #17 to express feelings and to use nonjudgmental listening techniques. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was severely cognitively impaired, required extensive assistance of 2 staff members for bed mobility and extensive assistance of 1 staff member for personal hygiene. The October 2022 physician's orders direct to monitor the resident for depression due to verbalization and sad affect, anxiety displayed calling out. A Reportable Event form dated 10/24/22 at 3:30 PM identified Nurse Aide (NA #1) reported that NA #2 (an agency NA) made inappropriate comments to a resident on 10/23/22. The facility investigation Summary Report dated 10/28/22 at 12:00 AM identified a part time NA (NA # 1) reported that an agency NA (NA # 2) made an inappropriate comment to Resident # 17 on 10/23/22 about the resident's size. When NA #2 was questioned about inappropriate size comment NA # 2 denied the statement. NA # 2 stated that he did state to NA #2 that Resident # 17 was a plus size but Resident # 17 never heard him. NA #2 further indicated on the day in question his conversation with the resident was normal, he introduced himself to Resident # 17 each time he entered the room secondary to resident's memory problems. The summary investigation dated 10/28/22 identified the agency NA (NA#2) was educated on the facility abuse policy by the nurse educator on 9/21/22 prior to working. Resident # 17 has not indicated any knowledge of the above interaction when asked about the incident by social services and days following the exchange. Resident # 17 has been in good spirits and offers no complaints about her/his care. Interview with the DNS on 11/10/22 at 2:20 PM identified on 10/24/22 at 3:30 PM, NA#1 was visibly upset when she (NA #1) reported NA #2 had made comments regarding Resident #17's weight being 12 triple X, NA #2's response to the Resident # 17 after asking about the definition of obese to Resident #17. Resident # 17's comment about trying to avoid being obese and NA #2's comment to the resident that he/she had news for Resident #17 that s/he was obese. The DNS indicated because of the email she reported the incident to the state agency as resident abuse on 10/24/22 at 3:30 PM. The facility failed to report an allegation of verbal abuse immediately or within two hours of the allegations. The facility policy for the Abuse Prevention Program directs any allegation of abuse is to be reported immediately or within two hours of the allegation. Additionally, the abuse policy notes in part that employees are required to report an incident, allegation, or suspicion of potential abuse, neglect, they observe, hear about, or suspect immediately to the administrator or the person in charge of the community, acting on behalf of the administrator, or immediate supervisor who must then immediately report to the administrator 2. Resident #29 was admitted with diagnoses that included dementia, hyperlipidemia, and arthritis. The annual MDS assessment dated [DATE] identified Resident #29 had severe cognitive impairment and required extensive two persons assist with bed mobility, transfers, and personal care. The care plan dated 9/23/22 identified Resident #29 had self-care deficits and required assist with bathing, dressing grooming and hygiene. Interventions included to provide oral care, bathing, dressing, grooming and toileting hygiene as needed. The Reportable Event dated 11/6/22 noted at 7:00PM a NA noted a bruise during care. The physician and family were notified, and arm sleeves were applied. The report did not include documentation of notification to the overseeing state agency. The clinical nursing progress note dated 11/7/22 at 12:31AM noted a NA reported a bruise on Resident # 29's right forearm with no documented origin. The physician and family were notified, and Resident #29 was noted to have been complaint with medications and care. An interview on 11/9/22 at 1:34 PM with the DNS identified she was not required to report the injury as it was considered minor, therefore she only needed to investigate the cause. The Reportable Event summary addendum dated 11/9/22 identified the nurse aides suggest Resident # 29's bruise came from the vertical grab bar an assistive device utilized for transfers to the bathroom was performed. The facility policy for the Abuse Prevention Program directs any allegation of abuse or injury of unknown origin is to be reported immediately or within two hours of the allegation or injury is noted. An injury is considered unknown when it cannot be explained by the resident and considered suspicious meaning located in an area vulnerable to trauma. 41223

Based on clinical record review and interviews for one resident (Resident # 24) reviewed for communication-vision, the facility failed to revise the resident's care plan to ensure current interventions were available to staff. The findings include: Resident # 24's diagnoses included need for assistance with personal care and falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 cognitive status was intact and required extensive assistance of one person for bed mobility, transfer, walking in room and corridor, toilet use and bathing and required limited assistance of one person for personal hygiene and with set up independent with eating. The MDS assessment further indicated Resident#24's vision was severely impaired. The Resident Care Plan (RCP) dated effective 10/20/2022 identified a vision concern as Resident #24 is unable to readily see within her/his environment due to poor eyesight. Interventions included in part to provide consistency in surroundings, to assist with speaker telephone, use of sight recovery glasses for transitioning between light and dark spaces can be used, directed staff to explain the positioning of the resident's belongings and the location of the call bell during routine care. The Resident care plan further indicated a self-care deficit with interventions including in part to set up for meals and oral hygiene and assist as needed. The Resident care plan further identified a risk for falls related in part to impaired vision. Interventions included to provide a clutter free pathway and to provide good lighting in the room. Interview with RN # 1 on 11/09/22 12:55 PM identified staff provides one to one communication regarding location of food items and explains all procedures to Resident #24 due to her/his vision loss. RN #1 identified Resident #24 can tell what time of day or night it is based to the routine that is kept and indicated the resident does not have a clock to tell time as s/he is just prompted by staff and relies on staff as s/he recognizes voices. RN #1 indicated Resident # 24 can still see a little bit. RN #1 indicated she/he was unable to locate evidence of providing specific assistance in the resident's care plan regarding vision impairment. She indicated the MDS nurse could assist with the care plan. On 11/09/22 at 1:10 PM interview with RN#2 indicated the comprehensive MDS assessment dated [DATE] indicated a severe vision impairment and care planning for the severe vision impairment would proceed. RN#2 indicated she was unsure if Resident #24 used anything special in her/his room to assist her/him with her/his vision and indicated the resident care plan did not really address how the resident is assisted by staff to meet the Resident # 24's specific needs. She also indicated it would be difficult to determine if there was a change in condition or if interventions in care plan were working or not working if no baseline was identified in the care plan. RN #2 further indicated she obtains information to develop the care plan through talking with staff and indicated she did not talk to the resident or have the resident complete a sample reading. RN #2 further indicate the resident had not voiced any concerns. The cognitive communication impaired vision care plan effective 11/1 2022 was updated and revised noted from 10/9/2022. Subsequent to inquiry, the care plan was revised to include in part Resident #24 can use the remote control by feeling number placement, has magnifying glasses for watching TV as needed and wears an adaptive wristwatch that has a button to hear the time of the day and indicated the resident was able to access this independently. Interview on 11/10/22 at 9:35 AM with the Recreation Director indicated to assist Resident #24's vision impairment visual items are placed on the big screen, we bring the resident as close as possible and if it is an educational activity, we try to blow it up as big as possible for her/him to see and if the light is bright, we assist to move her /him to a better location. An Interview on 11/10/22 9:40 AM with Recreation Aide #1 in the presence of the Recreation Director, indicated she provides a description of what she has at hand for clarification. Recreation Aide #1 further indicated Resident #24 had used special glasses that reduce bright light and had requested a special Bingo card which was provided the Recreation Director. However, Recreation Aide#1 were unable to find these interventions in the plan of care for Resident #24. Recreational Aide #1 further indicated the care plan only directed to have the resident next to the director during activities. The Recreation Director indicated this intervention should be part of the care plan and she/he would add the interventions to the care plan. The Activities care plan effective 11/1/2022 subsequent to inquiry indicated interventions dated 11/10/22 were added in part to adapt room to resident's preferences to promote engagement and sight, continue to aid resident in description and informing resident what images look like during programming and staff will continue to encourage use of Resident #24's adaptive sight equipment. On 11/10/2022 at 9:05 AM an interview with Resident #24 indicated the use of a watch with speaking device when the button on the side of it is pressed and noted family member will assists with maintaining the device. Resident #24 further indicated not using the watch when waiting for assistance from staff after using the call bell.

Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident # 1) reviewed for falls, the facility failed to implement the plan of care for fall prevention. The findings include: Resident #1 was admitted with diagnoses that included unspecified dementia with behavioral disturbance, history of alcohol abuse, repeated falls. The quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required one-person physical assist with bed mobility, transfers, toileting and personal care. The care plan dated 8/22/22 identified Resident #1 was at risk for falls due to poor safety awareness, lack of insight into deficits and decreased core strength and safety balance. Interventions included: maintaining the wheelchair in a locked position at bedside when in bed, to call for help by using the call bell and to ensure the motion sensor was placed in the bathroom. The physician's orders dated 9/6/22 directed to provide the assist of one for transfer ambulation and activities of daily living (ADL). The Reportable Event dated 9/27/22 identified at 2:10 PM Resident #1 was found on the floor next to the bed with his/her brief half off and the wheelchair behind him/her. The care plan was updated to include placing the motion sensor in the bathroom. The facility investigation of the Resident # 1's fall dated 9/27/22 identified care was last provided for Resident #1 at 1:30 PM after her/his meal and then assisted the resident to bed prior to the fall. Resident #1 had a motion sensor in place. An interview on 11/14/22 at 10:05 AM with NA #4 identified she was the assigned aide for Resident #1 on 9/27/22. NA #4 indicated she had toileted Resident #1 after lunch and placed him/her to bed. NA #4 indicated a motion sensor was placed near the bed but not the bathroom as she had never been informed a motion sensor was required in the bathroom. An interview on 11/14/22 at 10:23AM with the DNS identified she would expect staff to be following the plan of care for Resident #1. The facility Care Plan Policy directed a resident care plan to be updated at least quarterly or with a significant change of condition. The facility policy on Accident and Incidents directed the care plan be updated with a new intervention to prevent reoccurrence following an accident. 46046

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents reviewed for abuse (Resident #17), the facility failed to prevent verbal abuse. The findings include: Resident #17 was admitted with diagnoses that included morbid obesity, dementia with behavioral disturbances and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive two persons physical assistance with bed mobility, total dependence two persons for transfers and extensive one person assistance with personal hygiene. A care plan reviewed on 7/27/22 identified Resident #17 utilized medications for anxiety and depression. Interventions included to provide listening support and reassurance when anxious. Additionally, the care plan reviewed on 7/27/22 identified Resident #17 has impaired cognition due to dementia. Interventions that include to allow Resident #17 to express feelings and to use nonjudgmental listening techniques. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was severely cognitively impaired, required extensive assistance of 2 staff members for bed mobility and extensive assistance of 1 staff member for personal hygiene. The October 2022 physician's orders direct to monitor the resident for depression due to verbalization and sad affect, anxiety displayed calling out. A Reportable Event form dated 10/24/22 at 3:30 PM identified Nurse Aide (NA #1) reported that NA #2 (an agency NA) made inappropriate comments to a resident on 10/23/22. The social services note dated 10/24/22 at 5:04 PM identified Resident #17 was in good spirits and when asked about the weekend, Resident #17 reported that she had a wonderful weekend. A nursing progress note dated 10/24/22 at 5:12 PM identified that a voicemail was left for Resident #17's responsible party to update him/her on an inappropriate comment made to Resident #17 by an NA. An email was sent to the Director of Nursing Services (DNS) included in the facility investigation dated 10/24/22 at 11:03 PM from NA #1 identified she had witnessed NA #2 telling Resident #17 that s/he was a fat bitch, asked Resident #17 her/his shirt size then made fun of the size of the shirt. NA #2 then asked Resident #17 if s/he knew what obesity was and when Resident #17 replied yes and that s/he had tried very hard to stay away from it, NA #2 responded that it was too late, as Resident #17 was already obese. The email continued by noting NA #2 then asked Resident #17 how that made him/her feel and Resident #17 responded that made her/him sad and s/he wanted to cry. NA #2 then responded to Resident #17 telling her good, cry. NA #2 wanted Resident #17 to cry. A facility Educational Advisory form dated 10/24/22 identified NA #1 had reported that an agency NA # 2 made inappropriate comments to one of the residents and the concerns should have been brought to the nurse at the time the incident happened per facility policy. However, NA #1 waited a day before reporting the concerns therefore placing other residents at risk. A care plan dated 10/25/22 identified Resident #17 was subject to verbal abuse due to her/his weight. Interventions included to monitor Resident #17 for negative mood due to exposure to verbal abuse, provide a psychologic consult and 1 to 1 as needed. The facility investigation Summary Report dated 10/28/22 at 12:00 AM identified a part time NA (NA # 1) reported that an agency NA (NA # 2) made an inappropriate comment to Resident # 17 on 10/23/22 about the resident's size. When NA #2 was questioned about inappropriate size comment NA # 2 denied the statement. NA # 2 stated that he did state to NA #2 that Resident # 17 was a plus size but Resident # 17 never heard him. NA #2 further indicated on the day in question his conversation with the resident was normal, he introduced himself to Resident # 17 each time he entered the room secondary to resident's memory problems. The summary investigation dated 10/28/22 identified the agency NA (NA#2) was educated on the facility abuse policy by the nurse educator on 9/21/22 prior to working. Resident # 17 has not indicated any knowledge of the above interaction when asked about the incident by social services and days following the exchange. Resident # 17 has been in good spirits and offers no complaints about her/his care. Interview with the DNS on 11/10/22 at 2:20 PM identified on 10/24/22 at 3:30 PM, NA#1 was visibly upset when she (NA #1) reported NA #2 had made comments regarding Resident #17's weight being 12 triple X, NA #2's response to the Resident # 17 after asking about the definition of obese to Resident #17. Resident # 17's comment about trying to avoid being obese and NA #2's comment to the resident that he/she had news for Resident #17 that s/he was obese. The DNS indicated because of the email she reported the incident to the state agency as resident abuse on 10/24/22 at 3:30 PM. Interview with NA #1 on 11/14/22 at 9:00 AM identified she was starting at new job at another facility. She stated that on 10/23/22 during her shift, she and NA #2 entered Resident #17's room to provide care. The first thing NA #2 stated to Resident #17 was that s/he was a fat bitch asking what size shirt the resident wore. Resident #17 responded size 12 and NA#2 replied that must be a 12 triple X. NA #1 continued by stating that NA#2 then asked Resident #17 if s/he knew what obese was. Resident #17 replied yes and that s/he had been trying to avoid being obese her/his whole life. NA #2 then responded that he had news for Resident #17, that obese is what Resident #17 was. NA #1 stated she tried to change the subject and began to talk over NA#2. NA #1 stated NA #2 continued by asking Resident #17 about her/his spouse. NA #1 stated that Resident #17 loved to talk about her/his spouse, and she thought NA #2 was finally going to stop talking so rudely about Resident #17's weight. NA #1 continued by stating that during the conversation between Resident #17 and NA #2 she heard NA #2 state to Resident #17 that he wondered what her/his spouse saw in Resident #17. NA #2 then asked Resident #17 if he had upset her/him, and Resident #17 responded yes and that s/he wanted to cry to which NA #2 responded good because he wanted Resident #17 to cry. NA #1 stated that at that point, she just wanted to get NA #2 out of the room, and they proceeded to leave Resident #17's room. NA #1 also indicated NA# 2 commented to her in the hallway was that she should not worry about what happened between him and Resident #17, as Resident #17 would forget about the comment in about 15 minutes. NA #1 continued by stating that she did not inform the nurse at that time of the comment / incident and decided she would just work side by side with NA #2 for the rest of the shift to make sure he was not making bad comments to other residents. NA #1 continued to state that after she thought about it, she reported it directly to the DNS and administrator when she came to work the next day on 10/24/22. Interview with the DNS on 11/14/22 at 11:30 AM identified that NA#2 was an agency NA and did not work at the facility again after the 10/23/22 reported incident with Resident #17. Attempt to contact NA#2 was made but was unsuccessful. The facility failed to ensure the resident was free from verbal abuse by NA # 2 The facility policy, Abuse prevention program, in part identified that it is the policy of the facility to provide each resident an environment that is free from verbal, sexual, physical, and metal abuse.

Based on observations, review of facility documentation, review of facility policy, and interviews, for the only sampled resident, (Resident #1) reviewed for mistreatment, the facility failed to ensure staff provided treatment in a dignified manner. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required limited assistance with bed mobility, transfers, and dressing, and required supervision with walking and personal hygiene. The Resident Care Plan (RCP) dated 3/30/2020 identified Resident #1 required oversight, verbal cues, and at times physical assistance with Activities of Daily Living (ADL's). Interventions directed to provide verbal cues and monitor for increased need for physical assistance each day. The June, 2020 physician's orders [REDACTED]. The nurse's note dated 5/24/2020 at 6:37 AM identified that Resident #1 was up at approximately 4:10 AM attempting to go into the shower room to take a shower independently. Nurse Aide (NA) #1 tried to explain that it was night time when Resident #1 became verbally aggressive and was insisting it was afternoon. NA #1 went to the nursing station for assistance and Registered Nurse (RN) #2 went toward Resident #1. RN #2 was noted to be clapping his/her hands loudly and said something indiscernible. NA #2 was going toward the area of Resident #1 when RN #1 heard Resident #1 yell out and state she hit me that woman abused me and I'm going to call my (resident representative) and the authorities. RN #2 was bent over talking with Resident #1 with the shower room door handle in his/her hand and was talking to Resident #1 at eye level. Resident #1 was sitting on the seat of his/her rollator and was visibly upset. RN #1 explained it was night, showing the time to the resident and that it was dark outside and Resident #1 agreed to accept a snack and drink and go back to his/her room. After Resident #1 was calm, RN #1 called and informed the Director of Nurses (DNS) of the allegation at approximately 5:15 AM. The DNS nurse's note dated 5/24/2020 at 7:50 AM identified that Resident #1 was asking to speak with his/her representative and that he/she had been upset because a woman yelled at him/her that he/she couldn't wash his/her hair. Resident #1 stated that the woman was so rude and could have talked nicely and not loud to him her. The physician and resident representative were made aware. Review of the Reportable Event dated 5/24/2020 identified that Resident #1 was attempting to get into the shower room and NA #1 was unsuccessful at redirecting him/her and requested assistance. RN #2 observed Resident #1 hitting the ajar shower room door with his/her rollator attempting to enter. RN #2 was noted to hold the shower room door handle while holding Resident #1's back for support to prevent a fall while attempting to redirect the resident. Resident #1 continued to argue with RN #2 that he/she needed to take a shower and RN #2 clapped her hands to get the resident's attention, this lasted several minutes, and was observed by other staff. Resident #1 sat on his/her rollator, RN #2 guided the rollator over the threshold and being startled by the movement, Resident #1 yelled. RN #1 came over and RN #2 went back to his/her unit. RN #1 brought Resident #1 to his/her room and was told by Resident #1 that RN #2 had hit and abused him/her and that he/she was going to call his/her resident representative. Resident #1 was rubbing his/her left upper chest, which was noted to be slightly red. RN #2 was suspended pending the investigation. Interview and review of facility reportable event and RN #2 statement documentation with RN #2 on 6/30/2020 at 9:16 AM identified that, in part, his/her statement identified that after several minutes of holding the door against Resident #1 periodically pushing against it, Resident #1 sat on the roller walker. When Resident #1 was removed from the doorway Resident #1 screamed at the top of his/her lungs and RN #1 and NA #1 came to assist. RN #2 identified that he/she had been at the nursing station with RN #1, that NA #1 came in requesting assistance with Resident #1 and that by his/her face it was obvious he/she needed immediate help with Resident #1. RN #2 identified that he/she went to Resident #1 who was pushing on the shower door with his/her walker. RN #2 identified that he/she grabbed the door handle and explained it was not time for a shower and that they would wake people up. RN #2 identified Resident #1 stated that he/she would call his/her resident representative and that was how Resident #1 got what he/she wanted. RN #2 identified that he/she had to sometimes be firm with the resident and state we need to go back to the room now. RN #2 identified that Resident #1 got tired and sat on his/her walker. Resident #1's walker wheels were over the door threshold so RN #2 pulled Resident #1 out of the doorway, the door closed, and while doing so he/she knocked over a stool that made a loud noise and that Resident #1 screamed. RN #2 identified that RN #1 and NA #1 came over and said something and that was when he/she left. RN #2 initially denied clapping his/her hands but then identified he/she may have but did not recall doing so. RN #2 denied hearing Resident #1 making the allegation of being hit by him/her and identified that he/she only found out about the allegation when he/she heard RN #1 talking on the telephone. RN #2 identified that the Director of Nurses (DNS) had come in early that morning to speak with him/her, but that he/she did not receive any formal training or disciplinary action. RN #2 identified that during the time between the allegation and the arrival of the DNS that he/she had gone back to his/her own unit, passed medications, and did computer work. Interview and review of facility reportable event and NA #1 statement documentation with NA #1 on 6/30/2020 at 10:00 AM identified that, in part, his/her statement identified that he/she had requested assistance because Resident #1 was becoming verbally aggressive, insisting on taking a shower. NA #1 identified that while RN #2 was with Resident #1, Resident #1 stated she hit me, was rubbing the left side of his/her chest and stated he/she was going to call his/her resident representative and not going to take this abuse. NA #1 identified that Resident #1 was noted to be very distressed over the situation. NA #1 identified that Resident #1 had been angry due to the inability to find his/her shampoo and conditioner prior to going to the shower room. When Resident #1 did find the items, he/she headed off to the shower and was standing in front of the shower room door when NA #1 left to get assistance. NA #1 identified that RN #2 went down to the shower, not far from the nursing station, and that when RN #2 clapped his/her hands it scared Resident #1 because it was so loud and it was quiet at night. NA #1 identified that he/she and RN #1 had heard the clap and then a bang which, NA #1 assumed was a metal stool that was located in the area that had fallen over. NA #1 went running down to Resident #1 and RN #1 followed behind after hearing the bang and the yell. NA #1 identified that RN #2 had stated Hey yo, (Resident name) and questioned out loud who does that to an elderly (person) at 4:00 AM? NA #1 identified that when he/she arrived on the scene, Resident #1 was seated and struggling with RN #2 over the door handle. NA #1 identified that when RN #1 arrived he/she asked RN #2 to leave, bent down, and asked what happened. Resident #1 identified repeatedly that RN #2 had hit him/her and was rubbing his/her left chest and stated that he/she shouldn't have had this abuse. Resident #1 then pulled his/her top over and said you see, you see and showed us a red mark. Interview and review of facility reportable event with the DNS on 6/30/2020 at 11:05 AM identified that after the allegation had been reported to him/her, he/she had told RN #1 that RN #2 was not to go down there and that he/she needed statements. The DNS could not recall if he/she had directed RN #1 to tell RN #2 not to go back to his/her unit. The DNS identified that he/she had arrived at the facility at approximately 6:00 AM and that when he/she arrived RN #2 had been cleaning his/her medication cart on the unit and that the DNS went to see Resident #1 and he/she had been sleeping. The DNS identified that the facility abuse policy directs that staff who have an allegation of abuse should not work with patients. Interview and review of facility reportable event and RN #1 statement documentation with RN #1 on 6/30/2020 at 11:20 AM identified that, in part, his/her statement identified Resident #1 stated she hit me, that woman abused me and I'm going to call my (resident representative) and the authorities. RN #1 identified that he/she had heard RN #2 loudly clapping and say something that he/she could not make out. RN #1 identified that Resident #1 yelled and he/she stated to NA #1, I can't let him/her fall. When he/she arrived to Resident #1, RN #2 was bent over the rollator Resident #1 was seated upon his/her walker and Resident #1 stated honey, honey she hit me. Resident #1 identified that he/she wanted to call the authorities and his/her resident representative and that Resident #1 was really upset. RN #1 identified that RN #2 was present when Resident #1 made the allegation. RN #1 identified that after settling Resident #1 back in his/her room he/she telephoned the DNS to report the allegation. RN #1 identified that he/she was told to obtain statements from all staff, that RN #2 was to stay away from Resident #1, but he/she was never instructed to have RN #2 leave the unit or the facility. Re-interview with the DNS on 6/30/2020 at 12:45 PM identified that he/she was unable to substantiate the allegation because the red area on Resident #1's chest looked more like a rubbed area and nothing was seen on the skin audit, the time was short, and that there was nothing there. Additionally, the resident representative, when interviewed, identified that this was what Resident #1 did when he/she was mad and didn't get what he/she wanted. While unable to substantiate abuse the facility failed to ensure a staff member spoke to a resident in a dignified manner. Review of facility Resident Rights policy identified, in part, that a resident has the right to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on observations, review of facility documentation, review of facility policy, and interviews, for the only sampled resident, (Resident #1) reviewed for mistreatment, the facility failed to follow the abuse prevention policy during the COVID-19 pandemic. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required limited assistance with bed mobility, transfers and dressing, and required supervision with walking and personal hygiene. The Resident Care Plan (RCP) dated 3/30/2020 identified Resident #1 required oversight, verbal cues and at times physical assistance with Activities of Daily Living (ADL's). Interventions directed to provide verbal cues and monitor for increased need for physical assistance each day. The June, 2020 physician's orders [REDACTED]. The nurse's note dated 5/24/2020 at 6:37 AM identified that Resident #1 was up at approximately 4:10 AM attempting to go into the shower room to take a shower independently. NA #1 tried to explain that it was night time when Resident #1 became verbally aggressive and was insisting it was afternoon. NA #1 went to the nursing station for assistance and Registered Nurse (RN) #2 went toward Resident #1. RN #2 was noted to be clapping his/her hands loudly and said something indiscernible. NA #1 was going toward the area of Resident #1 when RN #1 heard Resident #1 yell out and state she hit me that woman abused me and I'm going to call my (resident representative) and the authorities. RN #2 was bent over Resident #1 with the shower room door handle in his/her hand and was talking to Resident #1 at eye level. Resident #1 was sitting on the seat of his/her rollator and was visibly upset. RN #1 explained it was night, showing the time to the resident and that it was dark outside and Resident #1 agreed to accept a snack and drink and go back to his/her room. After Resident #1 was calm, RN #1 called and informed the DNS of the allegation at approximately 5:15 AM. The DNS nurse's note dated 5/24/2020 at 7:50 AM identified that Resident #1 was asking to speak with his/her representative and that he/she had been upset because a woman yelled at him/her that he/she couldn't wash his/her hair. Resident #1 stated that the woman was so rude and could have talked nicely and not loud to him/her. The MD and resident representative were made aware. Review of the Reportable Event dated 5/24/2020 identified that Resident #1 was attempting to get into the shower room and NA #1 was unsuccessful at redirecting him/her and requested assistance. RN #2 observed Resident #1 hitting the ajar shower room door with his/her rollator attempting to enter. RN #2 was noted to hold the shower room door handle while holding Resident #1's back for support to prevent a fall while attempting to redirect the resident. Resident #1 continued to argue with RN #2 that he/she needed to take a shower and RN #2 clapped her hands to get the resident's attention, this lasted several minutes, and was observed by other staff. Resident #1 sat on his/her rollator, RN #2 guided the rollator over the threshold and being started by the movement, Resident #1 yelled. RN#1 came over and RN #2 went back to her his/unit. RN #1 brought Resident #1 to his/her room and was told by Resident #1 that RN #2 had hit and abused him/her and that he/she was going to call his/her resident representative. Resident #1 was rubbing his/her left upper chest, which was noted to be slightly red. RN #2 was suspended pending the investigation. Review of the Director of Nurses (DNS) statement dated 5/24/2020 identified that Resident #1 was banging on the shower room door with his/her walker and insisting it was time to shower. RN #2 was holding the shower room door handle and supporting the resident's back. When another nurse intervened and showed the resident the time, Resident #1 agreed to return to bed. RN #2 identified that she could have let the resident go into the shower room to avoid upsetting Resident #1. Interview and review of facility reportable event and RN #2 statement documentation with RN #2 on 6/30/2020 at 9:16 AM identified that, in part, her statement identified that after several minutes of holding the door against Resident #1 periodically pushing against it, Resident #1 sat on the roller walker. When Resident #1 was removed from the doorway Resident #1 screamed at the top of his/her lungs and RN #1 and NA #1 came to assist. RN #1 identified that he/she had been at the nursing station with RN #1, that NA #1 came in requesting assistance with Resident #1, and that by the look on his/her face it was obvious he/she needed immediate help with Resident #1. RN #2 identified that he/she went to Resident #1 who was pushing on the shower door with his/her walker. RN #2 identified that he/she grabbed the door handle and explained it was not time for a shower and that they would wake people up. RN #2 identified Resident #1 stated that he/she would call his/her resident representative and that was how Resident #1 got what he/she wanted. RN #2 identified that he/she had to sometimes be firm with the resident and stated we need to go back to the room now. RN #2 identified that Resident #1 got tired and sat on his/her walker. Resident #1's walker wheels were over the door threshold when he/she sat, so she pulled Resident #1 out of the doorway, the door closed, and while doing so RN #2 knocked over a stool that made a loud noise and that Resident #1 screamed. RN #2 identified that RN #1 and NA #1 came over and said something and that was when she left. RN #2 initially denied clapping her hands but then identified she may have but did not recall doing so. RN #2 denied hearing Resident #1 making the allegation of being hit by her and identified that she only found out about the allegation when she heard RN #1 talking on the telephone. RN #2 identified that the DNS had come in early that morning to speak with him, but that he/she did not receive any formal training or disciplinary action. RN #2 identified that the DNS inferred he/she could have done what NA #2 had done in the past and let Resident #1 go in the shower room to look around. RN #2 identified that during the time between the allegation and the arrival of the DNS that he/she had gone back to her own unit, passed medications, and did computer work and was never told to stay off her unit. Interview and review of facility reportable event with the DNS on 6/30/2020 at 11:05 AM identified that that after the allegation had been reported to him/her, he/she had told RN #1 that RN #2 was not to go down there and that he/she needed statements. The DNS could not recall if he/she had directed RN #1 to tell RN #2 not to go back to her unit. The DNS identified that he/she had arrived at the facility at approximately 6:00 AM and that when he/she arrived RN #2 had been cleaning his/her medication cart on the unit and that he/she went to see Resident #1 and he/she had been sleeping. The DNS identified that the facility abuse policy directs that staff who have an allegation of abuse should not work with patients. Interview and review of facility reportable event and RN #1 statement documentation with RN #1 on 6/30/2020 at 11:20 AM identified that, in part, his/her statement identified Resident #1 stated she hit me, that woman abused me and I'm going to call my (resident representative) and the authorities. RN #1 identified that he/she had heard RN #2 loudly clapping and say something that he/she could not make out. RN #1 identified that Resident #1 yelled and he/she stated to NA #1, I can't let him/her fall. When he/she arrived to Resident #1, RN #2 was bent over the rollator, Resident #1 was seated upon his/her walker and Resident #1 stated honey, honey she hit me. Resident #1 identified that he/she wanted to call the authorities and his/her resident representative and that Resident #1 was really upset. RN #1 identified that RN #2 was present when Resident #1 made the allegation. RN #1 identified that after settling Resident #1 back in his/her room he/she telephoned the DNS to report the allegation. RN #1 identified that she was told to obtain statements from all staff, that RN #2 was to stay away from Resident #1 but he/she was never instructed to have RN #2 leave the unit or the facility. Re-interview with the DNS on 6/30/2020 at 12:45 PM identified that he/she was unable to substantiate the allegation because the red area on Resident #1's chest looked more like a rubbed area and nothing was seen on the skin audit, the time was short and that there was nothing there. Additionally, the resident representative, when interviewed, identified that this was what Resident #1 did when he/she was mad and didn't get what he/she wanted. The DNS identified that after a review of the medication kardex, RN #2 had given one medication to a resident that was due at 6:00 AM. The DNS identified that when he/she went to RN #2's unit he/she asked where RN #2 was and was told that he/she had just gone into a room. The DNS identified that she opened the door to the room, stood there, observed RN #2 explain the resident's medication to the resident, administer the medication and then told RN #2 that he/she was not supposed to be with residents. Additionally, the DNS identified that he/she knew that nothing happened (to the resident receiving the medication) because he/she was there. Review of facility Abuse Policy identified, in part, that an employee of the community who has been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee.

Based on observations, review of facility policy, and interviews, the facility failed to ensure appropriate screening prior to facility entry and failed to ensure appropriate staff use of a facial mask and social distancing in the facility to prevent the transmission of COVID-19. The findings include: a. During entrance screening to the facility on [DATE] at 8:10 AM, it was identified that visitors to the health center had their temperature taken but were not asked any COVID-19 related questions such as symptomatology and travel destinations. Observation on 5/27/2020 at 8:45 AM with registered Nurse (RN) #1 identified Facility Contractor #1 being escorted through the health center entrance doors by Security Guard #1 from the Assisted Living Service Agency (ALSA) side of the complex. Interview with Contractor #1 identified that although he/she had a temperature taken and signed in at the ALSA entrance prior to being brought to the health center by Security Guard #1 he/she had not been asked any questions by facility staff. Contractor #1 identified that he/she thought this was unusual as all the other Skilled Nursing Facilities (SNF's) he/she entered required questions to be answered. Interview with RN #1 on 5/27/2020 at 8:50 AM identified that everyone who enters the health center should be asked screening questions. Interview and review of facility policy with ALSA Manager #1 and RN #1 on 5/27/2020 at 9:02 AM identified that he/she was the individual screening visitors and staff at the ALSA entrance, and that he/she had not been asking any screening questions of visitors, but did require a temperature to be taken. ALSA Manager #1 identified that there were two entrance signature documents at the entrance desk; one for visitors requiring only a temperature and one for staff requiring a temperature and screening questions. Subsequent to surveyor inquiry, RN #1 directed ALSA Manager #1 to ask all entrants the appropriate screening questions. Additionally, the visitor signature document was updated to include the appropriate screening questions. b. Observation and interview with RN #2 at the nurse's station on 5/27/2020 at 9 AM identified RN #2 speaking with RN #3. RN #2 was not wearing a face mask and was not maintaining 6 feet of social distancing. Although RN #2 identified that the facility policy required all staff to wear a face mask at all times and to maintain social distancing in the facility, he/she had been drinking coffee and her lips were wet. RN #2 identified that it had just been for a minute.