Every finding on record at Fresh River Healthcare

Based on clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #4) reviewed for discharge, the facility failed to ensure the resident had home nursing services established upon discharge from the facility. The findings included:Resident #4 was admitted to the facility [DATE] with diagnoses of infection following a procedure, disruption or dehiscence of closure of other specified surgical wound, Alzheimer's, and anxiety disorder.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and indicated Resident #4 was cognitively intact. The MDS further identified Resident #4 required partial assistance with bathing, dressing, chair/bed and toileting transfers, and when walking ten (10) feet. Review of Resident #4's Care Plan dated [DATE] identified an activity of daily living self-care performance deficit and mobility deficit related to post surgical intervention and impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: dementia (other than Alzheimer's disease). Interventions directed to encourage the resident to use the call bell for assistance and to monitor medications, especially new/changed/discontinued for side effects and the resident's response contributing to cognitive loss/dementia.Review of Recapitulation of Stay documentation dated [DATE] identified Resident #4 was discharged from the skilled nursing facility on [DATE], was now independent with activities of daily living, and that the resident had home health care to deliver his/her medications and provide wound care.Review of SW#2 note dated [DATE] at 11:51 AM identified Resident #4 was discharged home, that the visiting nurse agency and home care would visit the resident today for his/her re-open, and that Resident #4 was very knowledgeable regarding his/her discharge services, medications, and two upcoming appointments. Interview with Person #1 (clinical team leader at the home health care agency) on [DATE] at 11:40 AM identified Resident #4 received care from the agency prior to his/her admission to the skilled nursing facility (SNF), which entailed behavioral health services twice daily for medication administration and home health aide services five (5) times per week for showering, activities of daily living assistance, and physical therapy. Person #1 identified Resident #4's certification for services expired on [DATE] (following admission to the SNF) without plans for renewal as the resident's medical needs had risen to a level above what the agency could provide. Person #1 further identified the home care agency was informed either on [DATE] or [DATE] by Resident #4 that he/she had been discharged from the SNF and needed services. Person #1 indicated that prior to re-opening his/her case with the home care agency, Resident #4 needed to be evaluated by a physician for wound care as this was now the primary component (medical versus behavioral) of the nursing services needed. Interview with SW #1 on [DATE] at 3:23 PM identified the facility would make referrals to home care agencies, send the paperwork over via fax, and then receive confirmation via phone call if the resident was accepted for the services requested. However, SW #1 was unable to provide a fax confirmation indicating Resident #4's discharge packet was sent to the home care agency regarding his/her medical needs (which included medication management, wound care, physical therapy, and patient care assistance) and/or that he/she was accepted back for services. SW #1 further identified her contact at the home care agency was Person #2.Interview with Person #2 (Intake Manager for Behavioral Services at the home care agency) on [DATE] at 9:20 AM identified he/she did not receive any discharge paperwork (fax) requesting services for Resident #4 and was not aware a request for services was made prior to or upon his/her discharge from the SNF. Person #2 further indicated he/she communicated with the SNF, within a week following Resident #4's admission to the SNF, that the resident would not be accepted back for services as the agency was unable to provide the increased level of care Resident #4 required. However, Person #2 did indicate the case could be reviewed closer to the date of discharge if Resident #4's service needs had changed. Following notification that Resident #4's was discharged from the SNF without medical services/support in place, the agency made an allowance to accept the resident back and took appropriate steps to recertify the resident for services.Review of the Discharge Planning policy directed the facility social work staff to assist, as needed or requested, with referrals to community-based agencies for coordination of as needed post-discharge services.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for two of five sampled residents (Residents #55 and #71) reviewed for unnecessary medication, the facility failed to ensure physician's orders for a Valproate level and for Sinemet were followed as ordered. The findings include: 1. Resident #55's diagnoses included schizoaffective disorder bipolar type, depression, and major depressive disorder and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #55 was severely cognitively impaired, dependent with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident did not ambulate, utilized a wheelchair for mobility, and received antipsychotic, antidepressant, diuretic, hypoglycemic and anticonvulsant medication. The care plan dated 1/25/25 identified Resident #55 was at risk for adverse effects related to psychotropic medication with interventions that included changes/adjustments per recommendation of the clinician, complete behavior monitoring flow sheet, monitor changes in mental status and functional level and report to physician, and monitor for continued need of medication as related to behavior and mood. The physician's order dated 3/2/25 directed a fasting Valproate level. The pharmacy medication regimen review dated 2/20/25 identified Resident #55 was receiving Atorvastatin (Lipitor) for dyslipidemia and a recent lipid serum was unable to be located in the chart. The physician and/or APRN reviewed and agreed to the recommendation which was noted on 3/7/25. Review of the pharmacy medication regimen review dated 3/18/25 identified Resident #55 had a Valproate level ordered on 3/3/25 and no results were found in the resident record. In the follow up comments section there was no indication that it was reviewed by the physician/APRN. The physician's order dated 4/29/25 directed the following laboratory tests be conducted: CBC with diff, CMP, TSH, A1C, Lipids, and Valproate level ordered. Review of the pharmacy medication regimen review dated 5/19/25 identified Resident #55 was receiving Depakote, and they did not locate a recent serum level in the record. The pharmacy consultant recommended serum levels be completed two weeks after the start of the medication and then every 6 months thereafter. The recommendation was noted as reviewed and lab ordered that was signed by the physician on 5/21/25. A review of the clinical record failed to identify that the recommended labs were completed. The laboratory record sheet identified Resident #55 refused to have the Depakote level drawn on 4/30/25. The physician's order dated 5/22/25 identified an order for a fasting Depakote level. The laboratory record sheet failed to indicate pending or recent attempts to draw as ordered by the physician. Interview on 6/9/25 at 12:30 PM with the DNS identified that the laboratory technician comes on Mondays and Fridays each week to draw blood for ordered laboratory tests. The DNS further noted that if there is not a lab completed it is usually due to a refusal and it should be documented by the lab technician in the lab book then the nurse should be notified and the nurse should document and notify the physician/APRN. Interview on 6/10/25 at 11:25 AM with the Laboratory Director identified that the last laboratory results on file for Resident #55 was in January of 2025 and it was not a valproate level. The Residents Right to Refuse Treatment and Formulate Advance Directives directed it is the policy of the company to recognize and respect a residents right to refuse and discontinue treatment. Physician notification policy directed the physician will be kept informed of changes in an appropriate timely manner. The nurse will document in the nurses notes regarding assessments, findings, changes, physician notification, and resident and or responsible party notification. 2. Resident #71's diagnoses included Parkinson's disease with dyskinesia with fluctuations, mood disorder, and anxiety disorder The quarterly MDS assessment dated [DATE] identified Resident #71 had moderately impaired cognition, was feeling down, depressed or hopeless for several days, sometimes socially isolated, did not exhibit hallucinations, delusions, physical or verbal behaviors, rejection of care or wandering and was independent with sit to stand, sit to lying, chair/bed to chair transfer, and lying to sitting on the side of the bed. Physician's orders dated 5/20/25 directed Resident #71 be administered: 1. Carbidopa-Levodopa tablet 25-250 mg Give 1 tablet by mouth six times a day for Parkinson's Disease related to PARKINSON'S DISEASE WITH DYSKINESIA, WITH FLUCTUATIONS per Neurologist, give Levodopa EXACTLY on time!!! 8A, 11A, 2p, 5p, 8p,11p 2. Carbidopa-Levodopa 25-100mg Give 1 tablet orally 3 times a day related to Parkinson's disease. The care plan dated 4/12/25 identified Resident #71 had Parkinson's disease that will cause cognitive and physical decline as it progresses with interventions to give medications as ordered by the physician that will help to maintain dopamine levels and to administer medications at the scheduled times as it is important to keep a therapeutic level in the system to help prevent exacerbation of symptoms, monitor/document side effects and effectiveness and monitor/document/report to MD as needed signs and symptoms of Parkinsons complications to include poor balance, constipation, poor coordination, insomnia, dysphagia, tremors, gait disturbance, incontinence, muscle cramps or rigidity, decline in range of motion, skin breakdown, mood changes and decline in cognitive function. The neurology consultation report dated 11/12/24 identified Resident #71 was discontinuing a medication and indicated it should be replaced with Sinemet 25-250 immediate release administering 1 tablet every 3 hours at 8am-11am-2pm-5pm-8pm-11pm. The report also directed to continue Sinemet 25-100 immediate release 1 tablet at 8am-2pm-8pm. Corresponding prescriptions from this visit identified directions for medication administration as directed in the consultation note. Review of the MAR from November 12, 2024, through May 6, 2025 identified that the administration of the Carbidopa-Levodopa (Sinemet) 25-100mg tablet orally three times a day identified Resident#71 received the medication at 11 am, 2 pm and 5 pm daily. Neurology visit summary dated 1/15/25 identified Resident #71 was directed to receive carbidopa-levodopa (Sinemet) 25-100mg 1 tablet by mouth 3 times a day at 8am, 2pm and at 8pm and carbidopa-levodopa (Sinemet) 25-250 mg 1 tablet every 3 hours (8am, 11am, 2pm, 5pm, 8pm and 11 pm) continue with Sinemet 25-100mg 1-tab TID. Prescription written on 4/7/25 and signed as received by the facility directed carbidopa-levodopa (Sinemet) 25-250 mg per tablet every 3 hours (8am, 11am, 2pm, 5pm, 8pm and 11pm). Continue with Sinemet 25-200mg 1-tab TID. This prescription identified a start date of 11/19/24. Consultation report dated 4/28/25 identified Resident #71's Levodopa should be given on time and requested to please administer Levodopa exactly on time (in capital letters and underlined) at 8am-11am-2pm-5pm-8pm-11pm. Additionally, the consultation note indicated the carbidopa-levodopa 25-100mg per tablet be administered 3 times a day at 8am, 2pm and at 8 pm and the carbidopa-levodopa 25-250 mg per tablet be administered every 3 hours 8am, 11am, 2pm, 5pm, 8pm and 11pm. Review of the medication audit report dated May 2025 identified for the carbidopa levodopa 25-250 mg administered 6x daily at specified times of 8am, 11am, 2pm, 5pm, 8pm and 11pm identified there were one hundred eighty-six (186) administrations over the month. Forty (40) of the 186 administrations were administered late or outside of the 1-hour window of the designated administration time for regularly scheduled medications. Ninety-seven (97) of the 186 administrations were administered over twenty-five (25) minutes before or after the scheduled administration times. Forty-six (46) times throughout the month doses were administered with 2 hours or less between the doses. Thirty (30) times throughout the month doses were administered with 4 hours or more between administrations. Ten (10) days out of the 31 days identified administration times of two or more doses within 15 minutes according to the administration times in the audit. Review of the medication administration audit for May 2025 for carbidopa levodopa 25-100 mg TID identified 93 doses for the month of May. Thirteen (13) of the 93 doses were administered late, or more than an hour after the scheduled administration time. Additionally, this order was transcribed incorrectly from the consultant prescribing recommendations and 62 of the 93 administrations were not administered at the prescribed times due to a transcription error. Interview on 6/9/25 at 11:53 AM with RN#5 (the neurology office nurse), identified the directions for administration of the Carbidopa/Levodopa was to administer the medication every 3 hours, on time, and indicated the dosing could be difficult to keep up with but should be administered at the designated times. RN#5 identified the timing of the three times a day dosing was usually considered 8am, 2pm, 8pm, and that the timing was also specified by the doctor. RN#5 indicated the 11a, 2p, 5p administration would be too close together in addition to every three hours administration. Interview on 6/9/25 at 1:58 PM with RN#6 (nursing supervisor), identified that a medication ordered for three times a day is normally 9a, 1p, and 5pm. RN#6 indicated the expectation for administration for a medication scheduled every 3 hours throughout the day would be administration within 10-15 minutes of the scheduled time, not the normal hour on each side of the scheduled time. RN#6 identified the Carbidopa/Levodopa medication scheduled every 3 hours was time sensitive and should be administered as directed. Interview on 6/9/25 at 2:05 PM with Resident #71 identified getting medications late or grouped together with presenting side effects of depressed mood, anxiety, panicky and disoriented. Resident #71 indicated that on certain days the carbidopa/levodopa was administered in multiple doses at a time so the nurse doesn't have to keep coming back to the room every 3 hours. Resident #71 identified having nightmares and not being able to move or not feeling functional until around lunch time. Interview on 6/9/25 at 2:19 PM with the DNS identified standard three-time a-day orders are 9a, 1p, and 5pm. Review of the medication administration record for January 2025 through [DATE], noted the medication was ordered for 8am, 2pm, and 8pm and noted there was a problem but did not know how to pull a report to see the administration times. Interview on 6/9/25 at 3:21 PM with RN#2, Regional Clinical Director identified a TID (3x per day) administration according to this facility would be 9a, 1p, 8p unless specified by the prescribing doctor. Subsequent to surveyor inquiry RN#2 indicated the facility would provide immediate in servicing for the entire staff regarding the precise administration for the Sinemet and following doctor's orders for administration times. RN#2 identified the process for order transcription would be for the nursing supervisor to review them with the APRN or MD and the orders would be written based on the response to that review. RN#2 identified that if the consult required specific times of 8a, 2p, 8p according to the consult note, then there was a transcription error from the consult and needs to be fixed. Interview on 6/10/25 at 8:47 AM with RN#5 identified the Neurologist does not have time in her schedule for an interview but reiterated that the Carbidopa/Levodopa be administered exactly as she had prescribed it and communicated with the facility regarding administration. RN#5 indicated the communication is sent via visit notes and directions for administration are detailed in that communication. RN#5 identified that if a patient had too little medication, they would have movement issues, like not being able to move or headaches, nausea, dizziness, but that each patient presents differently. RN#5 indicated that the TID medication used to be administered 11a, 2p, and 5p when administered with a different medication but that those times were altered in November 2024 and were very specific in the doctor's communication with the facility. Interview on 6/10/25 at 10:39 AM with APRN#1 identified she cares for Resident #71 at the facility and took over care in December 2024. APRN#1 indicated when referrals come back with residents from outside appointments, the RN supervisor goes over it with the APRN or doctor and that the supervisor was responsible for putting the new orders into the computer. APRN#1 identified that if a specialty provider specifically ask for a certain medication administration time then the orders should reflect the certain specified times. APRN#1 indicated she relied on the supervisor specifically following the recommendations and identified that with the 6x daily every 3-hour administration, the order should reflect the specifications from the consultant and the administration should reflect the time of the scheduled administration. Interview on 6/10/25 at 3:00 PM with LPN#2 identified medication administration allows an hour on either side of the scheduled time for administration. LPN#2 indicated she was not aware that the carbidopa-levodopa that is scheduled 6 times daily had to be administered at the designated time although she acknowledged the order directions were specific. LPN#2 indicated the acuity of the unit makes it difficult to administer medications on time or document in the computer at the time of administration. LPN#2 identified if one of the doses was late, she would delay the administration of the next medication and denied notifying the supervisor, doctor or APRN when the medications were administered late. Interview on 6/10/25 at 3:18 PM with LPN#3 identified that he sometimes documents at the time of administration and then sometimes he does not and will mark them off at the end of the shift. LPN#3 indicated he was just informed yesterday that the Sinemet had to be administered on time and not have the hour window. Interview on 6/11/25 at 9:56 AM with Pharmacist #1 identified medication administration in the facilities is not always perfect but identified the medication should be administered according to the doctor's orders and indicated the doctor would be more appropriate to discuss side effects or effects of wrong administration times. Pharmacist #1 indicated the total dosing was within dosing parameters for a 24-hour period. Interview on 6/11/25 at 11:24 AM with RN#7 (PDC/ICN and wound nurse) and RN#8 (regional coordinator of education and infection control), identified the facility did not provide education regarding specific medication administration unless an issue had been identified. RN#7 indicated there was not another resident with the administration times similar to Resident #71. RN#7 identified that if the medication wasn't given as ordered or late, the provider should be notified and that the expectation for documentation was to chart correctly and at the point of care or in real time. Interview on 6/11/25 at 12:25 PM with the Medical Director identified the misinput of the carbidopa-levodopa TID medication was an error. The Medical Director indicated that the administration of the carbidopa-levodopa 25-250mg 6x daily has the same dopamine dosing throughout the day regardless of the administration times and that he will educate staff on how to administer the medications on time. Medication times provided by the facility indicated the TID, or three times a day, administration was scheduled at 9am, 1pm, and 5pm. Facility policy for physician orders - transcription identified all orders from the signed interagency referral or from the discharge orders to the facilities physician order sheet should be transcribed including medications. The attending physician should be called to confirm orders and should be documented as confirmed with the date, time, physician who confirmed orders and the nurses signature. The policy for Medication Administration and Documentation identified medication administration and documentation occur in a timely and accurate manner. The policy identified medications are to be administered within a two-hour time frame (i.e. one hour before and one hour after) and directs that the licensed nurse reviews physician/physician assistant orders and compares against medication administration record and assures the 5 rights: Compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label. Additionally, the policy directs to document administration of medication on the medication administration record immediately following administration and documents any medications not administered and documents reason.

Based on clinical record review, review of facility documentation, review of facility policy and staff interviews for one of five sampled residents (Resident #39) reviewed for unnecessary medications and receiving Depakote, the facility failed to ensure a documented response to a pharmacist's recommendation for a valproic acid level (Depakote level) was completed and failed to provide documentation that the physician ordered a Depakote level as recommended. The findings include: Resident #39's diagnosis included psychotic disorder with delusions, anxiety and depression. The quarterly MDS assessment dated [DATE] identified Resident #39 was cognitively intact, had verbal behaviors of agitation towards others and experienced physical symptoms of calling out, disorientation and was dependent for all activities of daily living. The care plan dated 4/14/25 identified Resident #39 was at risk for behaviors of agitation, shouting and cursing, related to cognitive loss and anxiety with interventions that included administering medications as ordered, monitoring and documenting for any side effects and effectiveness. The monthly physician's orders for April/2024 (origination date of 10/28/24) directed to administer Depakote 125mg every 12 hours related to psychotic disorder with delusions due to known physiological condition. The Consultant Pharmacist's drug regimen review for the month of April/2025 identified a recommendation dated 4/23/25 for a serum Depakote level and indicated that it should be done two weeks after the start of the medication and every six months thereafter for the duration of the time that a resident is receiving Depakote. Further review of the recommendation failed to identify that it had been reviewed and responded to by an APRN or Physician. Review of physician's orders failed to identify an order for a Depakote level and/or instructions that the resident should have a Depakote level drawn every six months (this is recommended for patients in a stable therapeutic range to ensure continued effectiveness and to minimize the risk of serious die effects). Interview on 6/5/25 at 1:44 PM with the Regional DNS identified that she could not identify why the Pharmacist's recommendation dated 4/23/25 was not responded to by the APRN or MD, which should be indicated on the recommendation form. She also could not locate orders for labs that corresponded with the recommendation. Further, although there was no order written for a Depakote level the laboratory record sheet (facility documentation and not a part of the clinical record) indicated that Resident #39 refused to have laboratory tests including a Depakote (Valproic Acid) level drawn on 5/23/25. Following surveyor inquiry, a physician's order dated 6/5/25 was written that directed to have a CBC, CMP, A1C, Lipid profile, and Depakote level drawn on Friday 6/6/25. Further review of the clinical record failed to identify the resident's refusals to have laboratory work drawn. A nurse's note dated 6/5/25 written by the DNS indicated Resident #39 had been scheduled for a lab draw on 5/23 and refused to allow the tech to draw blood. APRN and Conservator of Person (COP) notified. A nurse's note dated 6/6/25 written by the DNS indicated Resident #39 refused to have laboratory blood work drawn that morning Interview on 6/9/25 at 12:20 PM with the Regional Clinical Director (RN #2), indicated there were no physician orders prior to after 4/23/25 and prior to 6/5/25 for a Depakote level to be obtained. Interview on 6/9/25 at 2:38 PM with APRN #1 indicated the monthly pharmacy review dated 4/23/25 did not make it to them to be signed. The APRN was out on leave beginning 3/3/25 and returned to work on 4/14/25 and was present at the facility when that recommendation was made. The APRN further identified that she reviews the monthly recommendations and signs the monthly pharmacy sheet and indicates whether she is in agreement or not with the recommendation made. Additionally, she noted that a Depakote level helps to identify toxicity, and or a therapeutic level. Interview on 6/10/25 at 11:21 AM with the Lab Director indicated that when residents refuse a lab draw, the lab technician notes it in the laboratory record sheet and then updates the nurse in charge. The laboratory staff do not directly document refusals in the electronic medical record. Interview on 6/11/25 at 9:56 AM with the Regional Clinical Director of the consulting pharmacy indicated that when there were recommendations that are not responded to, the pharmacist would follow up the following month, to ensure the recommendation was reviewed and to verify the results. The Monthly Drug Regimen Review policy directed that the prescriber or designee shall act upon the drug regimen review findings/recommendations in a timely manner of 7-14 days or less and shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendations and provide a brief clinical rationale if no change is to be made.

Based on review of clinical records, review of facility documentation, and interviews for two of three sampled residents (Residents #47 & #105) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure the comprehensive assessments were accurately coded to reflect the residents had positive Level II PASRR assessments. The findings include: 1. Resident #47's diagnoses included Huntington's disease, schizophrenia, anxiety disorder, and depression. Review of Resident #47's electronic medical record with the Social Worker (SW #1) and the Director of Social Services (SW #2) on 6/5/25 at 12:05 PM failed to identify a positive Level II assessment; however, SW #2 maintains a paper copy of the positive Level II assessments of residents and was able to locate Resident #47's PASRR assessment. SW #2 identified Resident #47's PASRR Level II was completed on 1/22/20 prior to Resident #47's admission to the facility and was also identified on the facility positive level II tracking list. The annual MDS assessments dated 2/12/24 and 12/17/24 identified under the Preadmission Screening and Resident Review (PASRR) section a response of no to the question that asks if the resident was currently considered by the level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. The response should have been yes because the resident has a positive Level II assessment and a yes would have led to more questions that pertain to why the resident has a Level II PASRR assessment. Interview with SW #1 and SW #2 on 6/5/25 at 12:08 PM identified that social services are responsible for obtaining and requesting PASRR screening. They both added that social services only started completing the PASRR section of the MDS on April 1, 2024, but prior it was the responsibility of the MDS Coordinator's. SW #2 identified Resident #47 had a positive level 2 assessment completed prior to his/her admission to the facility with no recent changes and should have been coded as such on the MDS assessment dated [DATE] and 12/17/24. Interview with the MDS Coordinator (RN #3) on 6/5/25 at 12:31 PM identified the annual MDS assessments dated 2/12/24 and 12/17/24 was coded incorrectly because Resident #105 had a positive Level II PASRR. She further identified that the assessment should have reflected yes instead of no. She further identified that the PASRR information in section A (question 1500, 1510 and 1550) of the MDS assessment was completed by a MDS staff who worked per diem. RN #3 identified her role when signing off the MDS assessment is to check to ensure the assessment was complete and not to check for accuracy. She further noted that the individual completing the MDS is responsible for ensuring the information entered is accurate. Interview with the MDS nurse (LPN #1) in the presence of the Cooperate Nurse (RN #4) on 6/9/25 at 10:30 AM identified that she obtains information from the physical chart, the electronic medical record, and checks with the social worker to complete section A of the MDS assessment as it relates to PASRR. LPN #1 identified she could not recall if she had checked Resident #105's PASRR status. LPN #1 noted that she should have selected yes instead of no in section A of the assessment. RN #4 asserted that corrections would be made to both assessments. Review of the Resident Assessment Instruction (RAI) Process policy identified that each person completing a section of the MDS must sign for accuracy and completion in section Z0400. 2. Resident #105's diagnoses included schizophrenia, depression, and major depressive disorder. Review of Resident #105's electronic medical record identified Resident #105's PASRR Level II was completed on 6/8/23 and was also identified on the facility's positive level II tracking list. The annual MDS assessments dated 12/19/24 and 1/4/24 identified under the Preadmission Screening and Resident Review (PASRR) section a response of no to the question that asks if the resident was currently considered by the level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. The response should have been yes because the resident has a positive Level II assessment and a yes would have led to more questions that pertain to why the resident has a Level II PASRR assessment. Interview with SW #1 and SW #2 on 6/5/25 at 12:08 PM identified that they are responsible for obtaining and requesting PASRR screenings. They both added that social services only started completing the PASRR section of the MDS on April 1, 2024, but prior it was the responsibility of the MDS Coordinator. SW #2 identified Resident #105 had a positive level 2 assessment completed with no recent changes and should have been coded as such on the annual MDS assessments dated 12/19/24 and 1/4/25. Interview with the MDS Coordinator (RN #3) on 6/5/25 at 12:31 PM identified the annual MDS assessments dated 12/19/24 and 1/4/24 was coded incorrectly because Resident #105 had a positive Level II PASRR. She further identified that the assessment should have reflected yes instead of no. She further identified that the PASRR information in section A (question 1500, 1510 and 1550) of the MDS assessment was completed by a MDS staff who worked per diem. RN #3 identified her role when signing off the MDS assessment is to check to ensure the assessment was complete and not to check for accuracy. She further noted that the individual completing the MDS is responsible for ensuring the information entered is accurate. Interview with the MDS nurse (LPN #1) in the presence of the Cooperate Nurse (RN #4) on 6/9/25 at 10:30 AM identified that she obtains information from the physical chart, the electronic medical record, and checks with the social worker to complete section A of the MDS assessment as it relates to PASRR. LPN #1 identified she could not recall if she had checked Resident #105's PASRR status. LPN #1 noted that she should have selected yes instead of no in section A of the assessment. RN #4 asserted that corrections would be made to both assessments. Review of the Resident Assessment Instruction (RAI) Process policy identified that each person completing a section of the MDS must sign for accuracy and completion in section Z0400.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for change in condition, the facility failed to ensure a resident was transferred to a higher level of care in a timely manner. The findings include: Resident #1 was admitted to the facility with diagnoses that included displaced fracture of the base of the neck of the left femur and atrial fibrillation. Resident #1's responsible party was Person #1. Resident #1 was a full code. A physician's order dated 12/9/25 directed apixaban (Eliquis) five (5) mg every twelve (12) hours for atrial fibrillation. A Physician's history and physical dated 12/10/24 identified Resident #1 was admitted to the hospital after a fall sustaining a left femoral neck fracture and was started on Eliquis for atrial fibrillation. The admission MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition, was frequently incontinent of bowel and bladder and required one staff assistance for bed mobility and two staff assistance for transfers. The care plan dated 12/17/24 identified Resident #1 had Activities of Daily Living (ADL) care performance and mobility deficit with interventions that included to assist with ADL's as needed. Review of the resident's pulse rate from admission on [DATE] through 1/16/25 identified pulse rates ranging from 74 to 82 Beats Per Minute (BPM) with a regular rhythm (normal rate). Review of Resident #1's vitals dated 1/7/25 identified at 9:16 PM Resident #1's pulse was 156 BPM irregular, new onset (normal pulse 60 - 100 BPM). A nurse's note written by LPN #1 dated 1/7/25 at 9:24 PM identified Resident #1 was observed being restless, lethargic with increased confusion, attempted to climb out of the bed and had unstable vital signs. The supervisor (RN #2) was made aware of resident's altered mental status. Resident #1's family member insisted Resident #1 be sent out to the emergency department for an evaluation. Resident #1 left the building with the EMT's at exactly 9:15 PM. The hospital transfer form dated 1/7/25, completed by RN #2, identified Resident #1's vital signs were blood pressure of 159/97, heart rate 156 BPM and respiratory rate of 22 breaths/minute. Resident #1 was transferred out of the facility at 9:17 PM. Review of the pre-hospital report (ambulance documentation) dated 1/7/25 identified dispatch received the call at 8:57 PM for a resident with altered mental status. Person #1, in Resident #1's room, identified Resident #1 also had a high pulse rate. Upon assessment, Resident #1 had an irregular pulse rate and rhythm. Interview with LPN #1 on 3/5/25 at 11:56 AM identified on 1/7/25 around 8:00 and 8:15 PM she was in Resident #1's room and asked Resident #1 a question and Resident #1 did not make sense and had word salad (confused or unintelligible mixture of random words). She identified that was not Resident #1's baseline and took Resident #1's vital signs. She identified she told the supervisor of Resident #1's altered mental status and heart rate of 156 BPM. The nursing supervisor assessed Resident #1. She identified Resident #1's family member (Person #1) insisted Resident #1 go to the hospital right away and told him/her there is a protocol that needs to be followed. She identified that she followed up with the supervisor two to three times regarding sending Resident #1 to the hospital. She identified it was not in her power to send Resident #1 to the hospital immediately but is the supervisors' decision. She identified it was a total of about forty-five minutes until 911 was called. Interview with RN #2 on 3/5/25 at 3:00 PM identified on 1/7/25 (unable to identify the time) LPN #1 requested that she assess Resident #1. She identified she immediately went to assess Resident #1 and Resident #1 was restless, did not answer her, and had a high pulse. She identified she re-checked Resident #1's pulse and it was 122 BPM (however, this was not documented in the clinical record). She identified Resident #1 needed to be sent to the hospital so she then started the papers for a hospital transfer. She identified the paperwork usually takes about thirty minutes. She identified when she realized how long the paperwork was taking, about halfway through the paperwork, she stopped to call the physician (Medical Director). She identified the Medical Director answered right away and told her to send Resident #1 to the emergency department. She identified she then called 911 and finished her paperwork. However, she further identified Resident #1 had a history of atrial fibrillation which could result in a stroke and would send a resident to the hospital immediately if tachycardiac (high pulse). Interview with the Medical Director on 3/5/25 at 2:12 PM identified he could not remember if he was notified of Resident #1's change in condition on 1/7/25. He identified if the symptoms that Resident #1 had were reported to him he would have had staff call 911 right away. He further identified for stroke like symptoms, 911 should be called immediately. He further identified he is a phone call away and expects to be notified. He identified staff, using their judgement, can call 911 first and then notify him after. Interview with the DNS on 3/5/25 at 2:38 PM identified when there is a change in a resident she expects the supervisor the assess the resident right away and then notify the physician. She further identified when a resident is transferred to the hospital, the process is for the supervisor to complete the transfer paperwork. However, the paperwork should not delay the resident from going to the hospital. She identified staff should call 911 then do the paperwork. She identified depending on the emergency personal that respond, the EMT's either wait for the paperwork to be completed until they leave, or they have the staff fax it to the hospital. Review of the physician notification change in condition policy directed that if a resident is evaluated by a charge nurse to have a change in condition, the charge nurse will notify the RN supervisor on duty. The RN supervisor will do a follow up assessment to ensure that the assessment is documented and reported to the physician. All assessment findings and any relevant information should be complied prior to calling the physician to ensure accuracy of information. The nurse will document in the nurses notes regarding assessments, findings, changes, physician notified and resident and/or responsibility party notification.

Based on clinical record review, facility documentation review, facility policy review, and interviews for three (3) of five (5) residents (Resident#6, #7 and #8) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of a resident-to-resident physical interaction. The findings include: 1. Resident #7 was admitted with diagnoses that included dementia. A resident care plan (RCP) dated 9/3/2024 identified Resident #7 had a potential to be physically aggressive with staff pushing others away due to poor impulse control and wandered aimlessly, pacing daily with entering other residents' rooms due to confusion. Interventions directed to engage in clam conversation and to distract from wandering by offering pleasant diversions. A quarterly MDS assessment dated [DATE] identified Resident #7 had a BIMS of 2 which indicated severe cognitive impairment and was independent for ambulation. 2. Resident #8 was admitted with diagnoses that included dementia, bipolar disorder, schizoaffective disorder and depression. An annual MDS dated [DATE] identified Resident #8 had a BIMS of 5 which indicated severe cognitive impairment and was independent for ambulation. A resident care plan (RCP) dated 12/9/2024 identified Resident #8 had impaired thought processes and anxiety. Interventions directed to allow resident time to answer questions. a) A facility reportable event form dated 12/12/2024 at 10:45 PM identified Resident #8 reported that Resident #7 had entered his/her room, had messed with Resident #8's stuff and Resident #8 punched Resident #7 one time. The residents were separated and assessments performed. Resident #7 was noted with multiple scratches and two (2) knots on his/her face. An ice pack was applied to Resident #7's face and both residents were placed on every 15-minute checks. Additional review of the reportable event form identified the State Agency was notified of the incident on 12/13/2024 at 8:00 AM, nine (9) hours and 15 minutes after the incident occurred. A facility summary dated 12/16/2024 identified Resident #7 was hit by Resident #8, and Resident #7 confirmed Resident #8 hit him/her. Resident #8 reported he/she hit Resident #7 for coming into his/her room and touching his/her pictures. Facility investigation indicated at approximately 10:40 PM NAs had observed Resident #7 on his/her bed and provided incontinent care. the summary indicated although staff did not witness the incident, Resident #7 was noted to have 2 small scratches on the forehead and two pink areas on his/her cheek, and Resident #8 was moved to another unit. Interview with RN #2/Supervisor on 12/19/2024 at 1:12 PM identified LPN #3 had notified her on 12/12/2024 about 10:45 PM that Resident #8 had come out of his/her room and told staff that he/she had just hit someone who was in his/her room. Resident #7 was walking in the hallway at the time, and Resident #8 identified it was Resident #7 who he/she had just punched. Resident #7 had scratches and a bump on his/her cheek and reported Resident #8 had hit him/her. Both residents were placed on every 15-minute checks and she notified the physician and the responsible parties. RN #2 stated she did not notify the DON of the incident and passed the information in report to the on-coming RN Supervisor at 7 AM. RN #2 further stated she did not realize that when a resident hits another resident that it was considered abuse and did not implement the facility's abuse policy. Interview and review of the 12/12/204 resident to resident investigation documents with the DON on 12/19/2024 at 1:30 PM identified the alleged punch by Resident #8 to Resident #7 should have been considered an allegation of abuse. The DON stated RN #2 should have immediately notified her and the Administrator of the incident, and the State Agency should have been notified. The DON identified she learned of the incident during morning report the day after the incident occurred and she notified the State Agency. 3. Resident #6's diagnoses included major depressive disorder, anxiety disorder, history of suicidal behavior and disruptive mood dysregulation disorder (ongoing irritability, anger and frequent, intense temper outbursts). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required setup assistance for showering/bathing self and was independent with toileting, dressing, bed mobility, transfers and ambulation. The Resident Care Plan (RCP) dated 7/23/24 identified that Resident #6's concerns will be listened to and explored with interventions that included not challenging Resident #6's beliefs as this may anger him/her. If the resident makes statements about his/her peers or staff that may not be true, attempt to limit his/her exposure to them and listen to what he/she is saying and determine if there's any truth to what was said. If the resident makes statements about staff that may not be true, provide him/her with two (2) care givers. Offer the resident one to one visits by the social worker so that he/she can discuss concerns/issues regarding others. Review of a facility grievance dated 9/26/24 and filled out by Social Worker #1 (Director of Social Services) identified, in part, that Resident #6's concerns included the response of two (2) staff members when he/she asked for the bathroom to be cleaned. The Investigation Details and Summary of Findings sections identified that showers were scrubbed and cleaned, and the shower was to be regrouted after the third-floor shower was repaired but failed to mention details on the concern about responses from the staff. The Actions Taken section identified that the resident was provided with wipes in the bathroom, the staff was instructed to randomly check on the bathrooms and the showers were scheduled to be cleaned with soft scrub. The form identified that a resolution to the grievance was reached on 9/27/24, but that Resident #6's acceptance fluctuates between accepting the resolution/outcome and not accepting the resolution/outcome. The form was signed by the Administrator on 9/27/24. Review of the interview statement collected by the facility from Resident #6 on 9/26/24 identified that LPN #1 verbally reprimanded him/her when Resident #6 reported to her that there was stool on the toilet from another resident. The resident also reported that RN #1 stated to him/her that, She doesn't have to worry about feces on her toilet at home because she owns her home and doesn't live in a nursing home. Resident #1 reported to Social Worker #1 that he/she had reported these concerns to the Administrator in the past and had not been updated on the resolution. Interview with Resident #6 on 12/18/24 at 10:18 AM identified that he/she had been having issues with LPN #1, stating she is very moody and if you question her about anything, she becomes snappy and asks why Resident #6 is questioning her. She identified that LPN #1 talks to him/her in a condescending manner and has yelled at him/her in front of other residents when he/she asks LPN #1 questions, stating she has also told Resident #6 not to bother her when he/she is eating dinner at the nursing station. Resident#6 reported that although he/she did not have specific dates he/she did file a grievance with Social Worker #1 on 9/26/24 and that a typed-out statement was attached, providing more detail. The resident reported that LPN #1 has been verbally abusive to him/her more than once and the facility has not responded to the written grievance, and he/she wants it addressed. Interview with Social Worker #1 on 12/18/24 at 10:48 AM identified that Resident #6 had come to her with concerns regarding LPN #1 and another nurse (RN #1) about the way they talked to and reprimanded him/her, along with other bathroom and housekeeping concerns. She identified that she filled out a grievance form and attached the interview she completed with Resident #6, notified and presented both documents immediately to the Administrator and the DNS. Social Worker #1 reported that normally the Administrator responds to the grievance and communicates the outcome to the resident/representative after the investigation is completed. She identified that although it was an allegation of mistreatment, she was unsure what transpired after she initially spoke with the Administrator and DNS, stating she was not asked to follow-up with the resident. Interview with the Administrator on 12/18/24 at 12:55 PM identified that she could not recall specifics of the 9/26/24 grievance regarding Resident #6 but identified that although it's required for all allegations of abuse that the State Agency be notified within two (2) hours, the resident could not provide dates or specifics, so the accusations towards the staff had been determined unsubstantiated and not reported. Interview with the DNS on 12/18/24 at 3:35 PM identified that she had received Resident #6's statement attached to the 9/26/24 grievance. She identified that although there was no investigation dated 9/26/24 for Resident #6, the allegations towards LPN #1 and RN #1 should have been reported then investigated, stating that she should have initiated audits with other residents but was unsure why it hadn't been done. Although attempted, interviews with LPN #1 or RN #1 were not obtained. Review of the Abuse CT policy dated 3/20/24 directed, in part, that allegations of abuse will be reported promptly and thoroughly investigated. Allegations of abuse or neglect are to be reported to the Department of Public Health immediately but not later than two (2) hours after the allegation is made if the allegations involve abuse. An investigation of the witnessed or alleged abusive action or neglect will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #6) reviewed for allegations of mistreatment, the facility failed to investigate an allegation of verbal abuse. The findings include: Resident #6's diagnoses included major depressive disorder, anxiety disorder, history of suicidal behavior and disruptive mood dysregulation disorder (ongoing irritability, anger and frequent, intense temper outbursts). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required setup assistance for showering/bathing self and was independent with toileting, dressing, bed mobility, transfers and ambulation. The Resident Care Plan (RCP) dated 7/23/24 identified that Resident #6's concerns will be listened to and explored. Interventions included not challenging Resident #6's beliefs as this may anger him/her. If the resident makes statements about his/her peers or staff that may not be true, attempt to limit his/her exposure to them and listen to what he/she is saying and determine if there's any truth to what was said. If the resident makes statements about staff that may not be true, provide him/her with two (2) care givers. Offer the resident one to one visits by the social worker so that he/she can discuss concerns/issues regarding others. Review of a facility grievance dated 9/26/24 and filled out by Social Worker #1 (Director of Social Services) identified, in part, that Resident #6's concerns included the response of two (2) staff members when he/she asked for the bathroom to be cleaned. The Investigation Details and Summary of Findings sections identified that showers were scrubbed and cleaned, and the shower was to be regrouted after the third-floor shower was repaired but failed to mention details on the responses from the staff. The Actions Taken section identified that the resident was provided with wipes in the bathroom, the staff was instructed to randomly check on the bathrooms and the showers were scheduled to be cleaned with soft scrub. The form identified that a resolution to the grievance was reached on 9/27/24, but that Resident #6's acceptance fluctuates between accepting the resolution/outcome and not accepting the resolution/outcome. The form was signed by the Administrator on 9/27/24. Review of the interview statement collected by the facility from Resident #6 on 9/26/24 identified that LPN #1 verbally reprimanded him/her when Resident #6 reported to her that there was stool on the toilet from another resident. The resident also reported that RN #1 stated to him/her that, She doesn't have to worry about feces on her toilet at home because she owns her home and doesn't live in a nursing home. Resident #1 reported to Social Worker #1 that he/she had reported these concerns to the Administrator in the past and had not been updated on the resolution. Interview with Resident #6 on 12/18/24 at 10:18 AM identified that he/she had been having issues with LPN #1, stating she is very moody and if you question her about anything, she becomes snappy and asks why Resident #6 is questioning her. She identified that LPN #1 talks to him/her in a condescending manner and has yelled at him/her in front of other residents when he/she asks LPN #1 questions, stating she has also told Resident #6 not to bother her when he/she is eating dinner at the nursing station. Resident #6 reported that although he/she did not have specific dates he/she did file a grievance with Social Worker #1 on 9/26/24 and that a typed-out statement was attached, providing more detail. The resident reported that LPN #1 has been verbally abusive to him/her more than once and the facility has not responded to the written grievance, and he/she wants it addressed. Interview with Social Worker #1 on 12/18/24 at 10:48 AM identified that Resident #6 had come to her with concerns regarding LPN #1 and another nurse (RN #1) about the way they talked to and reprimanded him/her, along with other bathroom and housekeeping concerns. She identified that she filled out a grievance form and attached the interview she completed with Resident #6 and submitted them to both the Administrator and the DNS. Social Worker #1 reported that normally the Administrator responds to the grievance and communicates the outcome to the resident/representative after the investigation is completed. She identified that she was unsure what transpired after she turned in the grievance form, stating she was not asked to follow-up with the resident. Interview with the Administrator on 12/18/24 at 12:55 PM identified that she could not recall specifics of the 9/26/24 grievance regarding Resident #6 but identified that the resident could not provide dates or specifics, so the accusations towards the staff had been determined unsubstantiated. She identified that although an investigation should have been initiated and statements should have been obtained if staff was mentioned by name, she was unsure if that had happened, but that it should have been documented on the grievance form and the resident should have been notified of the outcome. She reported that the resident interview should have been attached to the grievance and she was unsure why it wasn't available in the grievance book. Interview with the DNS on 12/18/24 at 3:35 PM identified that she had received Resident #6's statement attached to the 9/26/24 grievance. She identified that although there was no investigation dated 9/26/24 for Resident #6, the allegations towards LPN #1 and RN #1 should have been investigated, stating that she should have completed audits with other residents but was unsure why it hadn't been done. Although attempted, interviews with LPN #1 or RN #1 were not obtained. Review of the Abuse CT policy dated 3/20/24 directed, in part, that allegations of abuse, neglect and mistreatment will be thoroughly investigated. An investigation of the witnessed or alleged abusive action, neglect or mistreatment will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation. Review of the Resident Grievances policy dated 12/2016 directed, in part, that facility residents have the right to have prompt efforts made by the facility to attempt to resolve grievances.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for skin injuries, failed to ensure that interventions for skin protection were followed in accordance with the plan of care. The findings include: Resident #2 's diagnoses included Huntington's disease (an inherited condition where nerve cells in the brain break down over time resulting in progressive movement, cognitive and psychiatric symptoms) and chorea (neurological disorder that causes involuntary, irregular and unpredictable muscle movements). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Staff Assessment for Mental Status completed indicating moderate cognition impairment of both long- and short-term memory problems and required total staff assistance with hygiene, dressing and transfers and maximal assistance with bed mobility. Additionally, it identified that Resident #2 had no skin injuries but was at risk for developing pressure ulcers/injuries. The Resident Care Plan (RCP) dated 11/19/24 identified that Resident #2's skin is fragile, and he/she may get bruises and/or skin tears easily with interventions included to apply moisturizing lotion as indicated, encourage wearing long sleeves, inspecting skin during care and ensuring padded siderails with pillows. Review of the nurse's notes from 11/1-12/18/24 identified various entries for old bruises, bruises noted to legs, and bruises noted to both feet. Observations of Resident #2 with the DNS on 12/18/24 at 9:51 AM, identified the resident sitting in a specialized chair in the hallway wearing a short-sleeved shirt with scattered scabs and scratches to both lower extremities, left greater than right, baseball sized bruising to the right inner ankle and redness noted to the skin around the right eye. There was a pillow on the floor to the left of the resident, a positioning wedge was in place between the upper thighs and a pelvic belt was in place around the resident's waist. Observation on 12/18/24 at 2:44 PM identified Resident #2's bed in the lowest position, a floor mat on the right side of the bed next to the window and a pillow under the sheet on the right side of the bed. There was no padding to either siderail noted. Interview and observation with NA #7 on 12/18/24 at 2:47 PM identified that Resident #2 did not have siderail padding and hadn't for as long as she could remember, stating the resident did need the padding but that they propped pillows up on both sides of the resident's hips instead since the siderail padding was unavailable. Interview with LPN #2 on 12/18/24 at 2:50 PM identified that she was aware that Resident #2 required side-rail padding but reported that she was unsure why it wasn't available. Interview with the DNS on 12/18/24 at 2:15 PM identified that the resident was care planned for padded side rails and she was unsure why the padded side rails were utilized and she was unsure why the padded side rails were not available. Review of the Care Plan policy dated 11/16/23 directed, in part, that the interdisciplinary team (IDT) develops, in collaboration with the resident, a comprehensive care plan based on the Resident Assessment Instrument, which is compromised of the Minimum Data Set (MDS), Care Area Assessments (CAA's), other applicable clinical information, resident's goals for admission, resident's preferences and resident's preference and potential for discharge. Within seven (7) days of completing the MDS and CAA's, the IDT develops, reviews, and revises the plan of care to insure it is person centered and individualized to meet the needs of the resident. The care plan contains resident's goals, resident's strengths, resident's preferences, identified problems, measurable realistic goals, and the interventions to be utilized to reach the goals.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for skin alterations, the facility failed to document alterations in skin integrity in the clinical record upon identification and failed to monitor and measure the alterations in skin integrity upon identification and weekly until resolved. The findings include: Resident #2 's diagnoses included Huntington's disease (an inherited condition where nerve cells in the brain break down over time resulting in progressive movement, cognitive and psychiatric symptoms) and chorea (neurological disorder that causes involuntary, irregular and unpredictable muscle movements). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Staff Assessment for Mental Status completed indicating moderate cognition impairment of both long- and short-term memory problems and required total staff assistance with hygiene, dressing and transfers and maximal assistance with bed mobility. Additionally, it identified that Resident #2 had no wounds. The Resident Care Plan (RCP) dated 11/19/24 identified that Resident #2's skin is fragile, and he/she may get bruises and/or skin tears easily with interventions included to apply moisturizing lotion as indicated, encourage wearing long sleeves, inspecting skin during care and ensuring padded siderails with pillows. Review of the nurses notes and skin checks from 11/1/24 through 11/22/24 identified old bruises, bruises noted to legs, bruises noted to both feet. Observations of Resident #2 on 12/18/24 at 9:51 AM, identified the resident sitting in a recliner like chair in the hallway wearing a short-sleeved shirt with scattered scabs and scratches to both lower extremities, left greater than right, baseball sized bruising to the right inner ankle and redness noted to the skin around the right eye. There was a pillow on the floor to the left of the resident, a positioning wedge was in place between the upper thighs and a pelvic belt was in place around the resident's waist. Interview with the DNS on 12/18/24 at 2:15 PM identified that although skin abnormalities were noted in Resident #2's clinical record and identified as not new on 11/8/24, 11/15/24, 11/19/24 and 11/22/24, no A & I's were initiated, and the areas were not monitored and measured. She was also unable to identify when the resident sustained the scattered scabs and scratches to both lower extremities, left greater than right, and the baseball sized bruised area to the right inner ankle that was observed on 12/18/24 by the surveyor, as they don't correlate with the documentation in the clinical record, and she was unsure why. The DNS reported that for all new alterations in skin integrity, she expects nursing to document the location, appearance and size (measurement) in the clinical record. Although requested, a facility policy for altered skin integrity was not provided.

Based on review of clinical records facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Residents #1), reviewed for abuse, the facility failed to ensure that the resident was treated with dignity and respect. Resident #1 had diagnoses of schizoaffective disorder, dementia, traumatic brain injury, spastic hemiplegia affecting the right dominant side, and contractures of the right ankle and knee. Review of the Quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as severely cognitively impaired and was dependent with Activities of Daily Living. Review of the Resident Care Plan dated 6/21/24 identified Resident #1 has a diagnosis of schizoaffective disorder and a traumatic brain injury causing behaviors such as placing self on the floor with interventions that included to provide increased observation as needed and re-direction as needed. Review of Resident #1's care card identified Resident #1 was an extensive two person assist with the use of a of sling lift (mechanical/Hoyer lift). Review of the Patient Care Report from the Ambulance Service of [NAME] (Run Sheet #58024 dated 7/18/24 at 10:58 AM) identified emergency medical services were dispatched to the facility to transport Resident #1 to a doctor's appointment. Upon arrival to Resident #1's floor, the nurse went to Resident #1's room and the EMT's followed and observed the nurse and a NA lifting Resident #1 from the floor to the bed by grasping Resident #1's wrists and ankles. The EMT's further indicated the nurse had also slapped Resident #1 on the hip with his/her unused glove and told the resident to stop screaming. The patient care report further indicated that after EMT's returned with the nurse to the nurse's station and another staff member had reported to the nurse that Resident #1 was again on the floor. The nurse had refused to assist the resident up from the floor, stating he/she had already done so three times that morning. The EMT's then assisted Resident #1, who was alert and visibly agitated, from the floor onto the stretcher and transported Resident #1 to his/her doctor's appointment. Interview with EMT #1 on 8/13/24 at 11:58 AM identified that her and EMT #2 were bringing Resident #1 to a doctors appointment on 7/18/24 and upon arrival to the facility it was reported that Resident #1 was on the floor of his/her room. EMT #1 indentified that she was by told by staff that Resident #1 was frequently on the floor due to behaviors. Upon entrance to Resident #1's room with the nurse, EMT #1 saw Resident #1 lying supine on the floor mat next to his/her bed, the nurse had a pair of unused gloves in his/her hand and slapped the patient on the right hip the gloves, stating you're always on the floor. The staff proceeded to pick up Resident #1 by the wrists and ankles, and placed Resident #1 back into bed. EMT #1 indicated he/she returned to the nurse's station to retrieve the transport paperwork when a NA came to the desk and stated that Resident #1 was on the floor again. EMT #1 indentified that a nurse's aide who previously helped transfer the resident from the floor to his/her bed stated, Resident #1 could remain on the floor, as I am not going to blow out my back picking h/her up again. EMT #1 indicated EMT #2 had gone to check on Resident #1 following the second incident to ensure Resident #1 was not injured and observed the resident on his/her floor mat. The EMT's transferred Resident #1 onto the stretcher from the floor and transported him/her to his/her doctor appointment. EMT #1 was unable to provide the names of the nurse and nurse's aide that were involved in the incident. Interview with EMT #2 on 8/13/24 at 2:41 PM identified that upon arrival at the facility it was reported that the resident was on the floor, The staff went to Resident #1's room and observed Resident #1 on the floor, the nurse took a pair of unused gloves and slapped Resident #1's right hip with the unused gloves 3-4 times and stated you are always on the floor. The nurse and NA then took the resident by the wrists and ankles and placed the resident back into bed. When she went to get the transport paperwork from the nurse, A NA stated that the resident was on the floor again and the nurse stated that She would not be picking the resident up again. At that time she went to assess Resident #1 to ensure that the resident was not injured and placed the resident on the stretcher and transported the resident to the appointment. Review of staffing for 7/18/24 on the 7:00 AM to 3:00 PM shift identified that NA #1, NA#2 and LPN #2 were assigned to Resident #1's unit. Interview with NA #1 on 8/13/24 at 2:31 PM failed to identified that h/she had no involvement in the initial transfer of Resident #1 from the floor to his/her bed that morning. NA #1 indicated he/she wasn't in the area when Resident #1 fell to the floor a second time and was assisting another patient with care. NA #1 further indicated when Resident #1 required a transfer from the floor to his/her bed, the staff would use a Hoyer lift to place him/her back into bed. Interview with NA #2 on 8/13/24 at 2:33 PM identified he/she was at the desk the entire time the EMT's were in the unit and that no-one reported Resident #1 was on the floor at any time that morning. NA #2 further indicated when Resident #1 required a transfer from the floor to his/her bed, the staff would use a Hoyer lift to place him/her back into bed with an assist of two. Interview with LPN #2 on 8/13/24 at 2:51 PM identified that she was assigned to Resident #1's unit and another unit on 7/18/24 and was administering medication outside on the other unit when the resident was picked up by the EMT's to be transported to the doctors appointment, she was not aware that the resident was on the floor prior to going to the doctor's appointment. Interview with RN #1 on 8/13/24 at 3:01 PM identified he/she was called to the nursing unit on 7/18/24 to assist with Resident #1's transport paperwork and while on Resident #1's wing never received report from anyone that Resident #1 was on the floor or that any staff member went to the resident's room to assist the resident or had requested staff assistance. Interview with the DNS on 8/13/24 at 12:55 PM identified that she was unaware of the alleged incident that occurred on 7/18/24, and she would be starting an investigation. Resident #1 had behaviors in which the resident was found frequently on the floor. The resident was a mechanical lift for transfers and staff should not be transferring the resident without the use of the mechanical lift, and further transferring Resident #1 back to bed holding the resident by his/her wrists and/or ankles, as this is not an appropriate transfer technique. The DNS further indicated at 3:27 PM on 8/13/24 that slapping a resident on the hip with gloves was inappropriate and unacceptable. Review of the Resident Rights policy identified that all residents have the right to be treated with dignity and respect.

Based on review of clinical records facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Residents #1), reviewed for abuse, the facility failed to ensure that the resident transferred in an appropriate manner and in accordance with the plan of care. The findings include: Resident #1 had diagnoses of schizoaffective disorder, dementia, traumatic brain injury, spastic hemiplegia affecting the right dominant side, and contractures of the right ankle and knee. Review of the Quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as severely cognitively impaired and was dependent with Activities of Daily Living. Review of the Resident Care Plan dated 6/21/24 identified Resident #1 has a diagnosis of schizoaffective disorder and a traumatic brain injury causing behaviors such as placing self on the floor with interventions that included to provide increased observation as needed and re-direction as needed. Review of Resident #1's care card identified Resident #1 was an extensive two person assist with the use of a of sling lift (mechanical/Hoyer lift). Review of the Patient Care Report from an ambulance company (Run Sheet #58024 dated 7/18/24 at 10:58 AM) identified emergency medical services were dispatched to the facility to transport Resident #1 to a doctor's appointment. Upon arrival to Resident #1's floor, the nurse went to Resident #1's room and the EMT's followed and observed the nurse and a nurse's aide lifting Resident #1 from the floor to the bed by grasping Resident #1's wrists and ankles. The patient care report further indicated that after EMT's returned with the nurse to the nurse's station and another staff member had reported to the nurse that Resident #1 was again on the floor. The EMT's then assisted Resident #1, who was alert and visibly agitated, from the floor onto the stretcher and transported Resident #1 to his/her doctor's appointment. Interview with EMT #1 on 8/13/24 at 11:58 AM identified that her and EMT #2 were bringing Resident #1 to a doctors appointment on 7/18/24 and upon arrival to the facility it was reported that Resident #1 was on the floor of his/her room. EMT #1 identified that she was by told by staff that Resident #1 was frequently on the floor due to behaviors. Upon entrance to Resident #1's room with the nurse, EMT #1 saw Resident #1 lying supine on the floor mat next to his/her bed, the nurse had a pair of unused gloves in his/her hand and slapped the patient on the right hip the gloves, stating you're always on the floor. The staff proceeded to pick up Resident #1 by the wrists and ankles, and placed Resident #1 back into bed. EMT #1 was unable to provide the names of the nurse and nurse's aide that were involved in the incident. Interview with EMT #2 on 8/13/24 at 2:41 PM identified that upon arrival at the facility it was reported that the resident was on the floor, The staff went to Resident #1's room and observed Resident #1 on the floor, the nurse took a pair of unused gloves and slapped Resident #1's right hip with the unused gloves 3-4 times and stated you are always on the floor. The nurse and NA then took the resident by the wrists and ankles and placed the resident back into bed. Review of staffing for 7/18/24 on the 7:00 AM to 3:00 PM shift identified that NA #1, NA#2 and LPN #2 were assigned to Resident #1's unit. Interview with NA #1 on 8/13/24 at 2:31 PM failed to identified that h/she had no involvement in the initial transfer of Resident #1 from the floor to his/her bed that morning. NA #1 further indicated when Resident #1 required a transfer from the floor to his/her bed, the staff would use a Hoyer lift to place him/her back into bed. Interview with NA #2 on 8/13/24 at 2:33 PM identified he/she was at the desk the entire time the EMT's were in the unit and that no-one reported Resident #1 was on the floor at any time that morning. NA #2 further indicated when Resident #1 required a transfer from the floor to his/her bed, the staff would use a Hoyer lift to place him/her back into bed with an assist of two. Interview with LPN #2 on 8/13/24 at 2:51 PM identified that she was assigned to Resident #1's unit and another unit on 7/18/24 and was administering medication outside on the other unit when the resident was picked up by the EMT's to be transported to the doctors appointment, she was not aware that the resident was on the floor prior to going to the doctor's appointment. Interview with RN #1 on 8/13/24 at 3:01 PM identified he/she was called to the nursing unit on 7/18/24 to assist with Resident #1's transport paperwork and while on Resident #1's wing never received report from anyone that Resident #1 was on the floor or that any staff member went to the resident's room to assist the resident or had requested staff assistance. Interview with the DNS on 8/13/24 at 12:55 PM identified that she was unaware of the alleged incident that occurred on 7/18/24, and she would be starting an investigation. Resident #1 had behaviors in which the resident was found on the floor frequently. The resident was a mechanical lift for transfers and staff should not be transferring the resident without the use of the mechanical lift, and further transferring Resident #1 back to bed holding the resident by his/her wrists and/or ankles, as this is not an appropriate transfer technique.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Residents #1), reviewed for advance directives, the facility failed to ensure that the code status accurate throughout the clinical record. The findings included: Resident #1 had diagnoses of traumatic brain dysfunction, dementia, and spastic hemiplegia affecting the right dominant side. Review of the Quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as severely cognitively impaired and was dependent Activities of Daily Living. A physician's order dated 10/27/23 directed to discontinue full code status (provide cardio-pulmonary resuscitation) and a new physician's order was written for a DNR/I (do not resuscitate/do not intubate) and RNP (registered nurse to pronounce) code status. Review of Resident #1's face sheet (which included Resident #1's demographic information) with a date and time stamp of 2/2/23 at 10:22 AM and located in Resident #1's paper chart identified full code status. Review of an incident report dated 7/23/24 at 9:22 AM identified Resident #1 was transported to his/her doctor's appointment on 7/18/24 and paperwork given to the emergency medical team (EMT's) transporting the resident did not clearly indicate the resident's code status. Interview with EMT #1 on 8/13/24 at 2:41 PM indicated the face sheet provided for transport of Resident #1 on 7/18/24 listed the resident as a full code, however the medication administration report (MAR) and the physician's orders directed that the resident was a DNR/I and RNP, EMT #1 identified that they could not transport the resident without knowing for sure what the residents code status was. Interview with LPN #1 on 8/13/24 at 3:30 PM identified the code status of the face sheet located in Resident #1's paper chart (with date and time stamp of 2/2/23 at 10:22 AM and what the facility would have provided for transport) identified full code status. However, LPN #1 identified that Resident #1's code status in both electronic medical record and on the MAR directed DNR/I and RNP. Interview the DNS on 8/13/24 at 2:41 PM identified that if there is code status change it should be updated throughout the clinical record. Review of the Advanced Directive policy identified it was the practice of the facility to provide information and discuss all health care decisions with the resident and/or certain authorized decision-makers, that the facility would listen and make note of the resident's preferences. concerning medical care, including withdrawal of life support systems, and would consult a

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents,(Resident #1), reviewed for hydration, the facility failed to document the resident's intakes and outputs while receiving Intravenous (IV) hydration therapy. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia, bipolar and schizoaffective disorder. Resident #1 had a conservator of the person. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, ambulated independently in his/her room, required supervision for bed mobility, transfers and walking in the unit and was frequently incontinent of urine and occasionally incontinent of bladder. The care plan dated 12/13/22 identified Resident #1 was at risk for alteration in nutritional status related to multiple diagnoses which include dementia, major cognitive disorder and bipolar disorder with interventions that included diet and labs as ordered, monitor for aspiration, assistance with meals if needed/accepted and alternate meal choice when applicable. Review of Resident #1's labs dated 12/31/23 identified Resident #1's white blood cells were 14.1 (reference range 3.7 - 10.3 indicative of infection) and blood urea nitrogen test was 21 (reference range 7 - 18 indicative of dehydration). A physician's order dated 1/1/24 directed to administer IV hydration for two (2) liters via peripheral line of D51/2 NS at fifty (50) cc/hour and to start Keflex 500 mg three (3) times a day (an antibiotic) for seven (7) days. Review of the clinical infusion documentation dated 1/1/23 at 3:30 PM identified Resident #1 received a peripheral IV for D51/2 at 50 cc/hour for two (2) liters. An APRN note dated 1/2/23 identified Resident #1 was sick on the weekend with poor PO (oral intake) and more confusion. Resident #1's white blood cells were 14.1. She identified to give fluid 50 cc/hour for two (2) liters and Keflex 500 mg three times a day for possible infection. Review of Resident #1's intake and output (I & O's) identified: a. On 1/1/23 at 9:03 PM Resident #1's intake was zero (0). The flowsheet failed to identify all output for 1/1/23 and intakes for the 11:00 PM - 7:00 AM shift. b. On 1/2/23 at 8:25 PM Resident #1's intake was zero (0). The flowsheet failed to identify all output for 1/2/23 and intakes for the 7:00 AM - 3:00 PM shift and 11:00 PM - 7:00 AM shift. c. On 1/3/23 at 8:25 PM Resident #1's intake was sixty (60). The flowsheet failed to identify all output for 1/3/23 and intakes for the 7:00 AM - 3:00 PM shift. An APRN note dated 1/3/23 identified 2 liters of IV fluids had been completed. Review of the medication administration report dated January 2023 identified the order for D51/2 at 50 cc/hr for two liters was documented with the licensed nurse initials and identified a second bag was started at 2:00 PM on 1/2/23. A physician's order dated 1/5/23 directed Resident #1 to the emergency department for evaluation. Interview with the Corporate Nurse on 1/24/24 at 3:00 PM identified that intakes and outputs (I & O)'s should be completed for a resident who is on IV hydration. She further identified the I & O flowsheet would only capture the intake the resident takes in by mouth and the fluid from the IV therapy would be documented on the treatment administration record (TAR), however, the TAR only had signatures that the IV hydration was administered. Review of the hydration policy directed any resident identified as high risk for dehydration will be monitored for at least seventy-two hours. It further directed a licensed nurse will review the daily monitoring sheet and intake and output (I & O) record after seventy-two hours and determine if continued monitoring is indicated.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) resident, (Resident #1), reviewed for falls, the facility failed to document administration of medications and document neurological checks per facility policy. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, bipolar and schizoaffective disorder. Resident #1 had a conservator of the person. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, ambulated independently in his/her room, required supervision for bed mobility, transfers and walking in the unit and was frequently incontinent of urine and occasionally incontinent of bladder. The care plan dated 12/13/22 identified Resident #1 was at risk for falls because he/she took psychotropic medication and was independent ambulatory on the unit. Interventions included to keep the call bell within reach, keep Resident #1's room free of clutter, therapy to evaluate and treat as ordered and if Resident #1 was too tired and resisted resting to spend some time sitting with Resident #1 until he/she could rest on his/her own. a) An APRN note dated 1/2/23 identified Resident #1 was sick on the weekend with poor PO (oral intake) and more confusion. Resident #1's white blood cells were 14.1. She identified to give fluid 50 cc/hour for two (2) liters and Keflex 500 mg three times a day for possible infection. An APRN note dated 1/4/23 identified Resident #1's white blood cells were 14.0 and was on Keflex for four days and would discontinue it and start doxycycline 100 mg twice a day for seven days. A physician's order dated 1/4/23 directed to discontinue Keflex and start Doxycycline 100 mg PO twice a day for one week and Acidophilus one tablet twice a day for ten days. Review of the medication administration report (MAR) dated January 2023 identified the following: Doxycycline 100 mg by mouth twice a day for one week at 9:00 AM on 1/6/23 and 1/7/23 was blank and Acidophilus one tablet by mouth twice a day for ten days at 9:00 AM on 1/6/23 was blank. Review of the nursing notes on 1/6/23 failed to identify if Resident #1's Doxycycline and Acidophilus was administered, and if not, the interventions taken. The medical record failed to identify and nursing notes for 1/7/23. Interview with the Administrator on 1/24/24 at 1:00 PM identified RN #2 was responsible for Resident #1's medications during the 7:00 AM - 3:00 PM shift on 1/6/23 and was unable to identify the nurse responsible for Resident #1's medications during the 7:00 AM - 3:00 PM shift on 1/7/23. Interview with RN #2 on 1/24/24 at 2:49 PM identified she could not recall not administering Resident #1's medications. She identified she is very good at documenting and maybe forgot to sign the medication administration report after administration. Review of the medication administration and documentation policy directed that the medication administration form (MAR) is the form onto which all medication orders are transcribed, poured and administrated and on which medication doses are charted. The MAR is a permanent part of the resident's medical record. It further directed after medication administration to document administration of the medication of the medication administration record immediately following administration. It further directed to document any medications not administered and document reason. b. RN #1's nursing note dated 12/26/23 at 2:59 PM identified at 2:10 PM she was called into Resident #1's room to assess the resident and a reported fall. Resident #1 was sitting on the floor in the room, facing towards the door with his/her back up against the bed. Resident #1 did not answer any questions asked about the fall. The APRN was notified about the fall and vital signs. Resident #1's pupils were equal and reactive to light and no injury was noted during the assessment. The accident and incident form dated 12/26/23 identified Resident #1 had an unwitnessed fall and was observed sitting on the floor. It identified to monitor Resident #1 for seventy-two hours for any acute changes in status and report the physician. A nursing note dated 12/26/23 at 11:48 PM identified neuro checks were ongoing, a nursing note dated 12/28/23 at 9:12 AM identified neuros were at baseline, a nursing note dated 12/28/23 at 11:15 PM identified neuro checks were ongoing, otherwise no documentation for the rest of the dates and shifts were identified Review of Resident #1's medical record failed to identify a neurological check sheet was completed for Resident #1 following the unwitnessed fall on 12/26/23 that contained documentation of Resident #1's neurological signs for seventy-two hours following the event. Interview with RN #1 on 1/24/24 at 11:45 AM identified she could not recall the event on 12/26/23. She further identified what she documented in notes is what occurred. Interview with RN #2 on 1/24/24 at 2:49 PM identified neurological checks are always completed if a resident fall is unwitnessed, even if a resident is found sitting on the floor because you don't know how they fell. Review of the neurological check sheet template identified the sheet tracks the resident's blood pressure, pulse, respirations, hand grasp, level of consciousness and comments that are tracked every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the next five hours, every two hours for the next eight hours, every four hours for the next sixteen hours and then every eight hours for the next thirty two hours. Review of the fall management program directed for a fall that is unwitnessed to monitor neurological signs per physician orders. Review of the neurological checks policy directed for residents with a suspected head injury will have neurological signs monitored and recorded for seventy-two hours per policy unless otherwise ordered by a physician. It further identified neurological checks include blood pressure, pulse, respiration, hand grasp, level of consciousness and pupils.

Based on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for nine sampled residents ( #19, #21, #26, #29, #41, #49, #74, #77, and #110) who resided on a secured unit, the facility failed to ensure Resident Rights were maintained by not permitting residents to leave the secured unit for the first seventy-two hours following admission and after the initial seventy-two hours the residents are not permitted to leave the unit without being escorted by a staff member for up to two weeks, and when residents' were permitted to leave independently, they were required to wear a lanyard that identified that they resided on the secured unit. The facility also failed to ensure the facility guidelines were in congruence with the facility practice. The findings include: Resident #77's diagnoses included Parkinson's Disease, tremor, other psychoactive substance use, unspecified with psychoactive substance induced psychotic disorder, anxiety, and psychotic disorder with hallucinations due to known physiological condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 made reasonable and consistent decisions regarding tasks of daily life and was independent with transfers and ambulation. The Resident Care Plan (RCP) dated 5/24/2023 identified behavioral health program participation on the secured unit by resident consent or the consent of the responsible party. Interventions directed to participate in unit level system, orient to Participation Agreement Manual, encourage participation in behavioral programs and recreational groups, encourage use of off floor pass usage as earned/allowed, evaluate safety status per guidelines, encourage acceptance of placement in facility, Resident #1 will follow the rules of the unit, will not be destructive of property, will not go into other resident's rooms and/or space, will not involve self with altercations with others, the resident will reside on a secured unit, will work toward a less structured setting, offer off unit programs/time as is directed by safety level/status, offer off unit relocations as condition, preferences and availability indicated, provide increased attention when needed, provide mental health professionals services as indicated/ordered, provide validation of feelings and concerns, provide reality orientation if indication, redirect when needed and reduce stimuli when possible. The social services note dated 6/6/23 at 2:27 PM identified Resident #1 continued to be reviewed for being classified as Safety Level 3 which would allow Resident #1 off unit privileges as well as being able to go outside to the courtyard. The note identified the facility was currently having magnetic locks installed on the outside fence for increased security which was notable for Resident #1 as he/she had a previous history of elopement. The social service note dated 6/13/23 at 3:42 PM, late entry for 6/12/23, identified six (6) months after admission the treatment team reviewed Resident #1's request for Safety Level 3. The note identified magnetic locks had been installed on the back outside patio gate which the team was waiting for before granting Safety Level 3. The social services note dated 7/3/23 at 1:18 PM identified Resident #1's court appointed Conservator (COP) was contacted to discuss concerns expressed by Resident #1 to Person #1. The note identified Resident #1 had been granted permission to leave the behavioral unit up to eight (8) hours daily. The COP requested to transfer Resident #1 to a non-secured unit when a bed was available because Resident #1 felt like he/she was in jail, and he/she was not allowed access to his/her cologne and mouthwash. The note identified the items were removed as Resident #1 was not allowed to have a glass container (for the cologne) and mouthwash was not allowed due to alcohol content. Review of facility Safety Status System Guidelines, revised in 2019, directed in part, Safety Status 1, wear a red wristband, resident is primarily unit-based on supervised every 15-minute (or more frequent) checks, require staff supervision while off the unit, and may have visitors on the unit. Safety Status 2, wear a yellow wristband, may be on supervision checks while on the unit, can leave the unit under conditions specified by the treatment team, may only leave the facility under conditions specified by the treatment team. And Safety Status 3, wear a purple wristband, not on supervision checks unless otherwise specified, has the opportunity to participate in community trips, may go on Leave of Absence (LOA) and is able to go off the unit independently. Review of the facility Behavioral Health Guidelines Manual, last revised date of [DATE], directed in part, new admissions will typically be places on Safety Status 1 for two (2) weeks, unless otherwise specified, during which time they will be assessed by the treatment team to determine the appropriate safety status using clinical information including, but not limited to care plans, incidents and accidents, conflicts with staff and other residents, emotional/behavioral stability and mental status change. The Guidelines further directed the resident to complete an orientation to the program and facility prior to independent status within the facility (Safety Status 2-4). Review of the facility Behavioral Health Guidance dated 2019, failed to identify the color-coded wrist bracelets were removed from the guidelines when the facility stopped using the color-coded bands, and failed to identify the COVID-19 guidance was current. The Guidelines define the safety status levels as follows: Level 1 -Safety observation and assessment status (in some programs, residents on this status are provided with a red wristband), resident is primarily unit-based; supervised on 15-minute (or more frequent) checks for 72 hours unless otherwise indicated, resident attends program groups and activities on the unit, resident will require increased staff supervision while off the unit, residents may have visitors on the unit and other safety limits as determined by the interdisciplinary treatment team. Level 2 -Stabilization (in some programs residents on this status are provided with a yellow wristband), the resident may be on supervision checks while on the unit, resident can leave the unit, under conditions specified by the treatment team and residents may only leave the facility under conditions specified by the treatment team. Level 3 -Independent status within the facility (in some programs residents on this status are provided with a purple wristband), residents will not be on supervision checks unless otherwise specified, residents have the opportunity to participate in community trips, residents may go on time/locations specified independent leave of absence (LOA) from the facility, with an order from the attending physician and the resident is able to go off unit independently, and may go to unrestricted or non-secured common access areas within the facility and on facility grounds. Interview with Person #1 on 7/24/23 at 8:59 AM identified a meeting was held with the Administrator and Social Woker (SW) Designee #1 at which time Person #1 was informed of a stepdown program where Resident #1 would be allowed to leave the unit from 1:00 PM-4:00 PM and would remain on the secured unit for remainder of the day. Person #1 identified a concern that the limitation and keeping residents on a secured unit for long periods of time violated resident rights. Interview with SW #2 and SW Designee #1 on 7/24/23 at 12:16 PM identified safety levels are determined on admission. Residents are observed for any negative thoughts or behaviors, reassessed formally at least weekly, and indicate the safety levels are an ongoing process. SW #2 and SW Designee #1 identified Resident #1 initially exhibited an elopement risk, was not accepting of his/her chronic disease at the time, Resident #1 was assessed for Safety Level 1, and the facility was currently waiting for an available bed to transfer Resident #1 off the secured unit. SW #2 and SW Designee #1 identified the guidelines for the safety levels, specifically Level 3, state the resident can only be off the unit between the hours of 1:00 PM-4:00 PM, and indicated that was only a recommended parameter and if a resident requested a different time limit, staff would not be opposed to that time limit as it is just a guideline. Interview with the Director of Nursing (DON) on 7/24/23 at 2:23 PM identified Resident #1 was granted a Level 3 several weeks ago, which would allow Resident #1 to go off the unit unsupervised. The DON identified safety status levels are determined by the behavioral health social workers and it is assessed more often than monthly. Interview with SW Designee #1 on 7/26/2023 at 9:49 AM identified the color-coded wristbands identified in the facility Safety Status System are not used by the facility. SW Designee #1 identified all new behavioral health residents are initially placed on a Safety Level 1 (they are unable to leave the secured unit unsupervised for up to two (2) weeks, based on the information they receive from the referring facility. SW Designee #1 identified the criteria for a resident to be placed on a Level 1 is reviewed on an individual case basis, and would include a psychiatric diagnosis, anger issues, verbally and/or physically acting gout, suicidal ideations, delusions, hallucinations and elopement issues, as provided by the referring facility prior to admission, and residents or their responsible parties sign consent for the Level 1 designation prior to admission to the facility. A resident admitted as a Safety Level 1 is confined to the secure unit for at least seventy-two (72) hours, for the facility to get to know the resident and the resident to get to know the facility, residents would be allowed to leave the unit if accompanied by a staff member or family, and if a resident smokes they would be accompanied by staff when off the unit to smoke. Interview and facility policy review with the Administrator on 7/26/23 at 10:31 AM identified the facility currently had one resident who was on a modified Safety Level 1 which means that resident can go out to smoke and attend activities with supervision by staff or visitor as long as the resident is not exhibiting any suicidal ideations or self-harm behaviors. The Administrator identified the behavioral health guidelines were made as a standard across the board in the facility, and the facility does not use color coded wristbands to identify what level a resident was on. The Administrator indicated when a resident signs the behavioral health secure unit agreement it was a structured environment to keep the resident safe (the resident can leave the unit with staff or visitors) and they were not relinquishing their resident rights. The Administrator identified that although it was the responsibility of the behavioral health team at the corporate level to update the guidelines, he was unable to explain why the guidelines had not been updated to remove the color-coded wristbands. Interview with RN #1 (Corporate Clinical RN) on 7/26/23 at 12:48 PM identified it was the responsibility of the corporate behavioral health team to update the behavioral health guidelines. RN #1 identified that this writer had been given an older version and although RN #1 indicated the latest version was updated in 2021 the copy provided indicated a last revision date of 2019. RN #1 identified residents were not signing away their resident rights when they sign the behavioral health secured unit agreement, and they were only agreeing to be on the secure unit (with limited independent mobility to leave the unit) and they still have access across the facility just may need supervision to have access safety. Review of the Nursing Facility Residents [NAME] of Rights, last revised 12/6/21, directed in part, the resident has the right to participate in community activities both inside and outside the facility. The [NAME] of Rights further identified the resident has the right to be free from involuntary seclusion. All residents on the Behavioral Health Unit have the potential to be affected by this. Residents reviewed at time of survey: Resident (#19, #21, #26, #29, #41, #49, #74, and #110) 47826

Based on review of the clinical record, facility documentation review, facility policy review, and interviews for two of three sampled residents (Resident #29 and #49) reviewed for Resident Rights, the facility failed to allow the resident the right to participate in the development and implementation of his or her person-centered plan of care. The findings include: 1. Resident #29's diagnosis included schizophrenia bipolar type, history of alcohol abuse, legally blind, hypertension, and chronic diastolic pulmonary disease. A Resident Care Plan (RCP) dated 7/17/23 for Resident #29 included the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. The care plan further addressed the resident's participation in a Behavioral Health Program with interventions that included assistance with problem solving, participation in behavioral programs and recreational groups, evaluating safety status and assistance with activities of daily living if needed. A Quarterly MDS dated [DATE] identified Resident #29 had no observed psychosis, was moderately cognitively impaired, required limited assistance with bed mobility and transfers, required extensive assistance with dressing, hygiene and toilet use, and supervision for eating. Review of the Care Plan Signature Sheets dated 11/17/22 and 2/9/23 identified that the MDS Coordinator and Social Services staff were in attendance. The documents did not indicate that Resident #29 or Resident #29's Conservator were invited and/or attended the care plan conference. Review of Care Conference Meeting Note dated 5/4/23 identified that the MDS Coordinator, Behavioral Health Director, and Resident #29's Conservator were in attendance. The note failed to identify whether or not the resident was invited to attend the meeting. Review of Care Conference Meeting Note dated 8/10/23 identified that the MDS Coordinator and Behavioral Health Supervisor were in attendance. The note failed to identify whether or not the resident or the conservator were invited to attend the meeting. Interview with Resident #29 on 8/15/23 at 11:30 identified he/she does not ever recall being invited to his/her care plan meetings. He/she further stated he/she would like to go to them. Interview with the MDS Coordinator on 8/17/23 at 11:20 identified that the process for inviting residents to their care plan meeting is for the front desk or the recreation staff to give the resident a written invitation 2-3 weeks prior to the meeting. The recreation staff explains the contents of the invitation to the residents that don't understand it. The MDS Coordinator identified that it is up to the resident's conservator to decide if they want a resident to attend a meeting or not. In addition, the MDS Coordinator was unable to identify documentation that identified whether or not Resident #29's conservator had decided that the resident should not be included in the care conference meetings. The MDS Coordinator identified that she reviews the outcome of the meeting with the residents and documents this in the care conference section of the meeting attendance form, however she does not do this with every resident. There was no documentation in the record to indicate she reviewed the meeting with Resident #29. The Care Plan Policy indicated that the resident has the right to participate in the development and implementation of the person-centered care plan and that the care planning process will facilitate the inclusion of the resident/representative. The policy further states that residents and or their responsible party are invited to attend to ensure both the team and resident/responsible party understand the care plan and goals. If the IDT (interdisciplinary team) determines that participation is not practicable for the resident or representative, the rationale for this is to be documented in the medical record. 2. Resident #49's diagnosis included schizoaffective disorder, anxiety disorder, depression, dementia related to human immunodeficiency virus, psychosis not otherwise specified, hypertension, and encephalopathy, An annual MDS assessment dated [DATE] and a quarterly MDS dated [DATE] indicated Resident #49 was cognitively intact, independent with bed mobility, transfers, and toilet use, required limited assistance with dressing, and hygiene. The Resident Care Plan (RCP) dated 7/29/23 addressed schizophrenia with interventions that included keeping the resident informed about her/his meds, keeping the resident/representative involved/informed of the care plan, offer support and kindness, when delusional or hallucinating attempt to engage in conversation or activity to distract. The RCP further noted that Resident #49's participation in the Behavioral Health Program with interventions that include participation in the unit level system, referrals to community-based agencies if needed/requested, assistance with problem solving, evaluate safety status per guidelines assistance with activities of daily living if needed. The care plan further addressed the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. The Care plan meeting signature sheet dated 11/23/22 indicated that the MDS Coordinator, Social Services staff, and Resident #49's Conservator were present, and documentation indicated that the resident was not invited due to diagnosis. The care plan meeting signature sheet dated 2/16/23 indicated the MDS Coordinator and Social Services staff were present at the meeting and the Conservator participated by phone. It further noted that Resident #49 was invited to attend. The Care Conference note dated 8/8/23 indicated the MDS Coordinator and the Behavior Health Unit Manager participated in the Care Conference. The Conservator was sent an update by email. There was no documentation of the resident being invited to the meeting and/or attending the meeting. Interview with the MDS Coordinator on 8/17/23 at 11:20 AM identified the process for inviting residents to the care plan meeting is for the front desk or recreation to give the resident a written invitation 2-3 weeks prior to the meeting. Recreation will explain the contents of the invitation to the residents that don't understand it. The MDS Coordinator stated that it is up to the conservator if they don't want a resident to attend a meeting. The MDS Coordinator was not able to identify where this decision gets documented. She further stated that the reason for not being invited as patient's diagnosis that was documented on the invitation sheet is not an acceptable reason for not being invited to the meetings. In addition, The MDS Coordinator noted that she reviews the outcome of the meeting with the residents and documents this in the care conference section of the meeting attendance form, however she does not do this with every resident. There was no documentation in the record to indicate she reviewed the meetings with Resident #49. Review of the clinical record failed to identify documentation that indicated the conservator made the choice for the resident to not attend the meetings. The Care Plan Policy indicated that the resident has the right to participate in the development and implementation of the person-centered care plan and that the care planning process will facilitate the inclusion of the resident/representative. The policy further states that residents and or their responsible party are invited to attend to ensure both the team and resident/responsible party understand the care plan and goals. If the IDT (interdisciplinary team) determines that participation is not practicable for the resident or representative, the rationale for this is to be documented in the medical record.

Based on clinical record review, observations, review of facility documentation, review of facility policy and interviews for five of five sampled residents (Resident #13, #29, #41. #49 & #74) reviewed for care planning, the facility failed to ensure that the care plan conferences involved the complete interdisciplinary team and failed to ensure that residents were included in the care plan development. The findings include: 1. Resident #13's diagnoses included Type 2 diabetes, schizoaffective disorder, and vascular dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 had intact cognition, required supervision for transfers, dressing, toileting, and personal hygiene. The Resident Care Plan dated 8/18/23 identified Resident #13 would be able to participate in his/her daily life choices and care through the next review. Interventions included: invite and assist to activities the resident likes, and it may take longer for the resident to respond to your conversation so give more time. Interview with RN #4 on 8/17/23 at 11:20AM and 1:55PM identified the front desk sends invitations to the responsible party for care plan meetings, residents are invited to meetings on an individual basis depending on if the resident is requesting to come, or conservator wants them to come. When a resident is invited, they are given a letter. No one specifically goes to get the resident prior to the meeting to bring them down to it. The social worker and MDS coordinator are always involved in the meetings. Dietician is only involved if there are weight loss issues or dietary issues, rehab is only involved if someone is on rehab or looking to discharge, recreation doesn't usually attend. RN #4 further identified that if residents come to the care conference, they really don't always go the direction they are supposed to go. Interview with the DNS on 8/18/23 at 10:23 AM indicated the expectation was for the meeting to be interdisciplinary, to include social services, recreation, nursing, and a NA if possible. The expectation would be for more than just the MDS Coordinator and Social Worker to attend the meeting from the facility. If the representative would like the resident to attend, they can bring them down to the meeting. Review of the care plan signature sheet dated 4/11/23 indicated the MDS Coordinator and Resident #13's Representative participated via phone. The care plan signature sheet dated 5/15/23 indicated MDS Coordinator, Resident #13's Representative (via phone) and nurse attended care conference. The care plan conference sheet dated 1/25/23 did not indicate Resident #13 or his/her Representative were invited and/or attended. The documentation indicated that the MDS Coordinator, Social Service and nurse attended. The care plan signature sheet dated 6/9/22 did not indicate resident was invited to the meeting and MDS Coordinator and Social Worker attended with representative via phone. Review of the Care Plan policy dated 1/19 identified residents have the right to participate in the development and implementation of the person-centered care plan, and the interdisciplinary team in collaboration with the resident develops a comprehensive care plan. The interdisciplinary team consists of representatives from nursing (charge nurse and a certified nursing assistants with responsibility for the resident), social services, behavioral health, dietary, rehabilitation, activities, the resident or the resident representative and any other staff or professionals in discipline requested by the resident. 2. Resident #29's diagnosis included schizophrenia bipolar type, history of alcohol abuse, legally blind, hypertension, and chronic diastolic pulmonary disease. A Resident Care Plan (RCP) dated 7/17/23 for Resident #29 included the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. The care plan further addressed the resident's participation in a behavioral health program with interventions that included assistance with problem solving, participation in behavioral programs and recreational groups, evaluating safety status and assistance with activities of daily living if needed. A quarterly MDS assessment dated [DATE] identified Resident #29 was moderately cognitively impaired, required limited assistance with bed mobility, transfers, required extensive assistance with dressing, hygiene, and toileting. Review of the Care Plan Signature Sheets dated 11/17/22 and 2/9/23 identified that the MDS Coordinator and Social Services staff were in attendance. The documents did not indicate that Resident #29 or Resident #29's Conservator were invited and/or attended the care plan conference. Review of Care Conference Meeting Note dated 5/4/23 identified that the MDS Coordinator, Behavioral Health Director, and Resident #29's Conservator were in attendance. The note failed to identify whether or not the resident was invited to attend the meeting. Review of Care Conference Meeting Note dated 8/10/23 identified that the MDS Coordinator and Behavioral Health Supervisor were in attendance. The note failed to identify whether or not the resident or the conservator were invited to attend the meeting. Interview with Resident #29 on 8/15/23 at 11:30 identified he/she does not ever recall being invited to his/her care plan meetings. He/she further stated he/she would like to go to them. Interview with the MDS Coordinator on 8/17/23 at 11:20 identified that the people that are expected to attend the Resident Care Plan Meetings are the MDS Coordinator, Social Work or the Behavior Person on the Behavior Unit, the resident and or the family/conservator. She further stated that a member from therapy would go if the resident was receiving therapy or needed therapy and that was the same for speech and dietary. She stated the nurse would go if there was an issue, but the NA was usually too busy to attend but that she (MDS Coordinator) would talk to the NA to see if there were any concerns. Review of the Care Plan Policy indicated that the Interdisciplinary team (IDT) consists of a nurse and a NA who is responsible for the resident, social service, behavioral health, dietary, rehabilitation staff, recreational staff, the resident or representative, any other staff or professionals in disciplines as required by the resident. The policy further identified that residents and or their responsible party are invited to attend to ensure both the team and resident responsible party understand the care plan and goals. The facility failed to ensure that the care plan meetings were inclusive of the IDT as a whole and failed to ensure the resident was included in the care plan process. 3. Resident #41's diagnosis included hyperlipidemia, spinal stenosis, congestive Heart failure, dementia, and anxiety. A Resident Care Plan (RCP) dated 7/17/23 for resident #41 indicated that the resident chooses to be independent with interventions that included provide resident with calendar of activities. The RCP further indicated Resident #41 participated in a Behavioral Health Program with interventions that include referrals to community-based agencies as needed/requested, assist with problem solving, encourage participation in Behavioral Programs and Recreational Groups, evaluate safety status per guidelines, assistance with activities of daily living, psychiatric evals as needed. The RCP indicates the resident has Dementia with interventions that include ensuring the Resident/Representative was involved/informed of this care plan. The care plan addressed the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. A quarterly MDS assessment dated [DATE] identified Resident #41 had moderate cognitive impairment, required supervision for bed mobility, transfers, and ambulation, and required extensive assistance for toilet use, hygiene, and dressing. The care plan meeting signature sheet dated 11/29/22 indicated that the MDS Coordinator and RN were present at the meeting and that Resident #41's Conservator was invited. The sheet did not identify whether or not Resident #41 was invited and/or participated in the care plan process. The Care Conference Notes dated 6/22/23 indicated that Resident #41's participated but there were no staff signatures on the form to indicate the staff that participated in the care plan conference. The Care Conference Notes dated 8/3/23 indicated the MDS Coordinator, the Behavior Health Unit Manager and Conservator participated in the Care Conference. There was no information indicating whether or not the resident participated in the care plan conference. Interview with the MDS Coordinator on 8/17/23 at 11:20 identified that the people that are expected to attend the Resident Care Plan Meetings are the MDS Coordinator, Social Work or the Behavior Person on the Behavior Unit, the resident and or the family/conservator. She further stated that a member from therapy would go if the resident was receiving therapy or needed therapy and that was the same for speech and dietary. She stated the nurse would go if there was an issue, but the NA was usually too busy to attend but that she (MDS Coordinator) would talk to the NA to see if there were any concerns. Review of the Care Plan Policy indicated that the Interdisciplinary team (IDT) consists of a nurse and a NA who is responsible for the resident, social service, behavioral health, dietary, rehabilitation staff, recreational staff, the resident or representative, any other staff or professionals in disciplines as required by the resident. The policy further identified that residents and or their responsible party are invited to attend to ensure both the team and resident responsible party understand the care plan and goals. The facility failed to ensure that the care plan meetings were inclusive of the IDT as a whole and failed to ensure the resident was included in the care plan process. 4. Resident #49's diagnosis included schizoaffective disorder, anxiety disorder, depression, dementia related to human immunodeficiency virus, psychosis not otherwise specified, hypertension, and encephalopathy. An annual MDS assessment dated [DATE] and a quarterly MDS dated [DATE] indicated Resident #49 was cognitively intact, independent with bed mobility, transfers, and toilet use, required limited assistance with dressing, and hygiene. The Resident Care Plan (RCP) dated 7/29/23 addressed schizophrenia with interventions that included keeping the resident informed about her/his meds, keeping the resident/representative involved/informed of the care plan, offer support and kindness, when delusional or hallucinating attempt to engage in conversation or activity to distract. The RCP further noted that Resident #49's participation in the Behavioral Health Program with interventions that include participation in the unit level system, referrals to community-based agencies if needed/requested, assistance with problem solving, evaluate safety status per guidelines assistance with activities of daily living if needed. The care plan further addressed the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. The Care plan meeting signature sheet dated 11/23/22 indicated that the MDS Coordinator, Social Services staff, and Resident #49's Conservator were present, and documentation indicated that the resident was not invited due to diagnosis. The care plan meeting signature sheet dated 2/16/23 indicated the MDS Coordinator and Social Services staff were present at the meeting and the Conservator participated by phone. It further noted that Resident #49 was invited to attend. The Care Conference note dated 8/8/23 indicated the MDS Coordinator and the Behavior Health Unit Manager participated in the Care Conference. The Conservator was sent an update by email. There was no documentation of the resident being invited to the meeting and/or attending the meeting. Interview with the MDS Coordinator on 8/17/23 at 11:20 identified that the people that are expected to attend the Resident Care Plan Meetings are the MDS Coordinator, Social Work or the Behavior Person on the Behavior Unit, the resident and or the family/conservator. She further stated that a member from therapy would go if the resident was receiving therapy or needed therapy and that was the same for speech and dietary. She stated the nurse would go if there was an issue, but the NA was usually too busy to attend but that she (MDS Coordinator) would talk to the NA to see if there were any concerns. Review of the Care Plan Policy indicated that the Interdisciplinary team (IDT) consists of a nurse and a NA who is responsible for the resident, social service, behavioral health, dietary, rehabilitation staff, recreational staff, the resident or representative, any other staff or professionals in disciplines as required by the resident. The policy further identified that residents and or their responsible party are invited to attend to ensure both the team and resident responsible party understand the care plan and goals. The facility failed to ensure that the care plan meetings were inclusive of the IDT as a whole and failed to ensure the resident was included in the care plan process. 5. Resident #74's diagnosis included cerebral vascular accident, opioid abuse, Hepatitis C, and hypertension. A Quarterly MDS dated [DATE] identified Resident #74 was severely cognitively impaired, exhibits some physical aggression towards others and intrusion of privacy, requires extensive assistance with bed mobility and transfers and dressing, toileting, personal hygiene, and minimal assistance with eating. A Resident Care Plan (RCP) dated 5/29/23 for Resident #74 included the resident's history of wandering with interventions that included offer to assist if resident appears to be searching for something, offer preferred activities, offer snacks and/or drinks, offer to call my family/friends to help redirect me. RCP further addressed the use of Psychotropic Medication, depression and dementia with interventions that included monitoring for side effects of meds and effectiveness of meds, AIMS test every 6 months, talking with therapist as needed, reassurance from staff. The care plan addressed the resident's desire to remain a resident on the current unit indefinitely with interventions that included revisiting this choice with the resident periodically and to continue to assist with adjustment of staying at the facility and the routines of the facility. The care plan meetings held on 3/16/23 and 5/25/23 noted the participants were the MDS Coordinator, Behavior Health Supervisor, and Resident #74's sibling. The notes failed to identify whether any other staff participated in the care plan conference. Interview with the MDS Coordinator on 8/17/23 at 11:20 identified that the people that are expected to attend the Resident Care Plan Meetings are the MDS Coordinator, Social Work or the Behavior Person on the Behavior Unit, the resident and or the family/conservator. She further stated that a member from therapy would go if the resident was receiving therapy or needed therapy and that was the same for speech and dietary. She stated the nurse would go if there was an issue, but the NA was usually too busy to attend but that she (MDS Coordinator) would talk to the NA to see if there were any concerns. Review of the Care Plan Policy indicated that the Interdisciplinary team (IDT) consists of a nurse and a NA who is responsible for the resident, social service, behavioral health, dietary, rehabilitation staff, recreational staff, the resident or representative, any other staff or professionals in disciplines as required by the resident. The policy further identified that residents and or their responsible party are invited to attend to ensure both the team and resident responsible party understand the care plan and goals. The facility failed to ensure that the care plan meetings and process of developing the person-centered care plan were inclusive of the IDT as a whole. 47826

Based on review of facility policy and documentation, the facility failed to follow the policy and procedural measures developed by the facility to prevent the growth of Legionella and other water borne pathogens in the building water system. The findings include: The Facility Water Management Plan Policy identified that the facility would maintain a daily operation log that included water flushing. The facility was unable to produce logs that identified that the water used for the ice machines was flushed per the policy. In addition, the facility failed to produce meeting minutes per the Facility Water Management Plan Policy.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three sampled residents (Resident #2) who were reviewed for an allegation of resident-to-resident abuse, the facility failed to prevent an inappropriate sexual encounter between Resident #2 and Resident #3. The findings include: Resident #2's diagnoses included other frontotemporal dementia, schizophrenia, unspecified intellectual disabilities, anxiety, and Pick's Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had poor decision making skills regarding tasks of daily life and required one (1) person supervision with getting in and out of the bed and chair and walking in the room and corridor. The Resident Care Plan (RCP) dated 1/9/23 identified Resident #2 with frontal temporal dementia which may cause memory problems, affect thinking, problem solving and language skills. Interventions directed to ask simple questions using key words, invite or assist to activities the resident may like, do not attempt to correct statements resident believes to be true, try to change the subject of the conversation or just provide with a simple response, ask yes or no questions, give more time to respond to conversations, and address by name and wait for a response. Resident #3's diagnosis included Chronic Obstructive Pulmonary Disease, mild cognitive impairment, alcohol abuse uncomplicated, and depression. The annual MDS dated [DATE] identified Resident #3 had poor decision-making skills regarding tasks of daily life and was independent with getting in and out of the bed and chair and ambulation. The RCP dated 1/5/23 identified Resident #3 was at risk of engaging in non-consensual sexual advances toward others. Interventions directed to provide mental health services as needed, medications as ordered, facility abuse policy protocols to be implemented as needed, close observations levels applied as indicated, per policy, check every fifteen (15) minutes. The Accident and Investigation (A&I) dated 1/19/23 at 10:50 AM identified Resident #3 was noted with his/her hands on Resident #2's genitals in Resident #3's room. The A&I identified both residents were separated immediately, Resident #2 was moved to a different unit and placed on every fifteen (15) minute checks for seventy-two (72) hours and Resident #3 was placed on constant observation with a psych consult was pending. The nurse's note dated 1/19/23 at 1:49 PM identified at approximately 10:50 AM Resident #2 was noted in Resident #3's room. The note indicated a staff member witnessed Resident #3 with his/her hands on Resident #2's genitals. The note identified Resident #2 was smiling during this interaction with no signs of distress. The note identified Resident #2 was redirected out of Resident #3's room and a room change was done to move Resident #2 to the memory care secured unit. The note identified the physician and Conservator of Person (COP) were notified and also identified Resident #2 did have recall of the event and did not verbalize any distress but smiled when asked and was at baseline emotional status. The nurse's note dated 1/19/23 at 2:24 PM identified Resident #3 was observed in his/her room with Resident #2, with Resident #3's hands on Resident #2's genitals. The note identified both residents were immediately separated, the supervisor was notified as well as the APRN and power of attorney (POA) and Resident #3 was placed on one to one (1:1) observation. The psych provider note dated 1/19/23 identified Resident #2 was seen for an evaluation status post participating in a sexually inappropriate behavior with Resident #3. The note identified Resident #2 has diagnosis of dementia and was not able to comprehend questions or what happened with no noted injury or reports of pain or discomfort. The note identified Resident #2 was placed on every fifteen (15) minute checks. The psych provider note dated 1/19/23 identified Resident #3 was seen for an evaluation after being observed by a staff member touching Resident #2's private parts while both were naked. The note identified Resident #3 was oriented to self and environment and reported that Resident #2 will wander into Resident #3's room and walk around. The note indicated Resident #3 stated he/she did not remember doing any sexual act. The note identified Resident #3 had vascular dementia, but not remembering what had just occurred remained unclear. The note identified Resident #3 was calm with no irritability or agitation and was already taking the highest dose of an antidepressant and a hormone to decrease libido. The social service's note dated 1/20/23 at 10:43 AM identified Resident #2 was seen for follow up of 1/19/23 incident. The note identified a report was completed, the police, Advanced Practice Registered Nurse, Director of Nursing and supportive care services were notified as well as the COP. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 7/24/23 at 11:44 AM identified on 1/19/23 she observed Resident #2 standing in front of Resident #3 with Resident #3 masturbating Resident #2. LPN #1 identified when she inquired as to what was going on both residents stopped, she immediately separated both residents and called the supervisor. LPN #1 identified Resident #2 was moved to a different unit and Resident #3 was placed on 1:1 observation and remained on 1:1 observation until the most recent hospitalization . Interview with the Director of Nursing (DON) on 7/24/23 at 2:39 PM identified Resident #2 went into Resident #3's room, their clothes were down, and Resident #3 was touching Resident #2's genital area. The DON identified at the time of the incident Resident #3 had been on every fifteen (15) minute checks. The DON identified the residents were immediately separated, Resident #2 was moved to the secure memory unit and placed on every fifteen (15) minute checks for seventy-two (72) hours and Resident #3 was placed on 1:1 observation. The DON identified an investigation was initiated and the results were the finding that Resident #3 did touch Resident #2, Resident #2 did say he/she went into Resident #3's room and reported he/she did not say no. The DON identified Resident #2 and Resident #3 had previously been roommates and there was a similar incident on 8/21/22 at which time Resident #2 was moved to a different room on the same unit, which was across the hall from Resident #3 and Resident #3 was initially placed on 1:1 observation at the time of the incident and then moved to every fifteen (15) minute checks up until this most recent incident of 1/19/23. Review of the facility policy titled Nursing Facility Residents' [NAME] of Rights, last revised 12/6/21, directed, in part, the resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment and involuntary seclusion. Review of the facility policy titled Abuse, last revised dated 1/23/18, directed, in part, to ensure each resident has the right to be free from abuse. The policy defined sexual abuse as including, but not limited to non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion, or sexual assault.

Based on clinical record review, review of facility policy and interviews for one sampled resident (Resident #49) reviewed for psychiatric medication use, the facility failed to ensure that an Abnormal Involuntary Movement Scale (AIMS) (used to measure involuntary movements known as tardive dyskinesia) was appropriately completed. The findings include: Resident #49's diagnosis included schizoaffective disorder, anxiety disorder, depression, dementia related to human immunodeficiency virus, psychosis not otherwise specified, hypertension, and encephalopathy, Review of the monthly physician's orders for August/2023 directed to administer Abilify (antipsychotic) 15mg daily and Seroquel (antipsychotic) 200mg at bedtime and Seroquel 300 mg take 1/2 tab (150 mg) daily. A quarterly MDS assessment dated [DATE] identified Resident #49 was cognitively intact, independent with bed mobility, transfers, and toilet use. The assessment further identified Resident #49 received antipsychotic medication daily for the past seven days. Resident #49's Resident Care Plan (RCP) dated 7/29/23 identified the diagnosis of schizophrenia with interventions that included: keep resident informed about her/his meds, monitor for abnormal muscle movements especially of lips, face, tongue, extremities, and trunk, AIMS every 6 months, when delusional or hallucinating attempt to engage in conversation or activity to distract. An AIMS test dated 3/29/23 identified Resident #49 scored 1 for muscles of facial expression and a 1 for upper arm movement (Scores are based on a five-point scale of severity from 0-4). The AIMS test used by the facility identified lips and perioral area (puckering, pouting, smacking) are scored 0 if none present, a 1 if minimal, 2 if mild, 3 if moderate and 4 if severe. Intermittent observations throughout all days of the survey identified Resident #49 exhibited constant lip and perioral area movement at a level 2. Interview with unit Program Director on 8/17/23 at 8:00 AM identified Resident #49 has had mouth movements for quite a long time that pre-date the March AIMS screen. Interview with LPN#1 on 8/18/23 at 10:55 AM identified that the observed abnormal lip and perioral area movements have been ongoing since before the AIMS scoring was done in March. She does not recall for how long, but she has seen these movements for some time. Call placed to APRN#2 on 8/18/23 at 1:30 PM that conducted AIMS screening on 3/29/23 with no return call by end of survey. Interview with LCSW#1 on 8/18/23 at 2:30 PM from the agency that took over psychiatric services. He saw Resident #49 on 7/13/23 walking in the hallway. He identified that he had difficulty understanding the resident and does not recall Resident #49's facial movements. This surveyor described observation and based on description he indicated that AIMS scoring would differ, however he does not do the AIMS testing. He further identified that he would alert the APRN that will do the AIMS testing and request it be done as soon as possible. The policy on Abnormal Involuntary Scale (Aims) identified that it is administered to residents who take Neuroleptics on a regularly scheduled basis or more than ten times per month to determine the presence of observed medication side effects. It is conducted every six months. The facility failed to ensure that Resident #49's extrapyramidal symptoms were assessed at the appropriate severity level.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 2) reviewed for abuse, the facility failed to ensure a resident was free from sexual mistreatment. The findings include: Resident #1 was admitted on [DATE] with diagnoses that included cerebral infarction (CVA), osteoporosis and anxiety. An Interdisciplinary Rehabilitation Screen dated 2/4/22 noted Resident #1 was independent with bed mobility, transfers, Independent with ambulation using a rolling walker. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, was independent with locomotion on the unit using a wheelchair and required extensive one person assist for toileting. The care plan dated 4/12/22 identified Resident #1 had dementia secondary to CVA which may limit judgement and insight. Interventions included involving responsible party in decision making, reality orientation as appropriate and close observation as indicated according to policy. The physician ' s orders dated 4/22/22 directed independence with ambulation with a walker, independent with bed mobility and transfers and use of a wheelchair as needed. Resident #2 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia with behavioral disturbance and osteopenia. An Interdisciplinary Rehabilitation screen dated 2/21/22 identified Resident #2 was independent with bed mobility, transfers, and ambulation. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment, required one person assists with bed mobility and transfers, assist with toileting and, independent with ambulation on the unit without supportive devices. The care plan dated 3/24/22 identified impaired cognitive skills related to dementia which limit judgement and insight. Interventions included: observation of peer relation patterns and document significant events, to modify room to promote familiarity and to provide close observation as indicated per policy. The facility Reportable Event dated identified 5/21/22 identified a NA (NA #1) observed (Resident #1) on top of (Resident #2) while in bed at approximately 4:15AM. NA #1 immediately separated the two residents. An assessment was completed by Registered Nurse (RN #1) who observed for injuries, and none were identified. (Resident #1) was noted with no distress and without pain or discomfort. The Advanced Registered Practice Nurse (APRN), family and police were notified, and an investigation was initiated. Resident #1 was placed on constant observation. The Intra Agency Report dated 5/21/22 from the facility to the acute care hospital noted (Resident #2) was involved in a resident to resident 1:1 contact questionable sexual in nature and that a physical examination was being requested. The After Visit Summary dated 5/21/22 at 3:10 PM noted (Resident #1) presented from a skilled nursing facility dementia unit with a concern for sexual /physical assault. Per emergency medical services (EMS) (Resident #2) was found at a (SNF) with another patient (Resident #1) on top of him/her with his/her pants halfway off. Patient (Resident #2) was sent for evaluation, denied pain or trauma, baseline confused and needs multiple redirections but is calm and cooperative. Also noted no signs of trauma but that a sexual assault could not be ruled out. Denied complaints. A Lengthy discussion was had with the conservator over the phone regarding potential approaches to patients' condition and addressing all parties to ensure patient safety. Discussed comprehensive Sexual Assault Nurse Examine (SANE) vs. a more conservative approach. Conservator express desire for more conservative approach. Facility has taken steps to mitigate future episodes by moving the other affected party to a different floor. A plan was in place for a noninvasive physical exam for injuries and a urinalysis would be obtained. Additionally noted also checking for sexually transmitted diseases (STD ' s) adding there were no signs of penetration. An interview on 5/24/22 at 11:25AM with the Administrator identified the incident allegedly occurred on the 11-7 AM shift 5/20/21 to 5/21/22. The Administrator stated she was alerted early Saturday morning just before 7:45AM by the Director of Nursing Services (DNS) who reported the night shift (NA #1) observed Resident #1 on top of Resident #2 in Resident #1's bed who both were naked from the waist down. (NA #1) immediately removed Resident #1 off Resident #2, brought Resident #1 to his/her room, and reported the incident. 1: 1 enhanced supervision was initiated for (Resident #1). Both residents had cognitive impairment and were located on a secure memory unit. Resident #2 and the roommate were moved to the end of the hall as it was speculated Resident #1 was able to gain access to Resident #2 through a shared bathroom. The DNS initiated an investigation and obtained statements. Resident #2 was sent to the emergency room (ER) for a rape test kit to be sure there was no penetration. According to the Administrator, NA #1 reported Resident #1 and Resident #2 did make actual skin to skin contact from the waist down. An interview on 5/24/22 at 12:29 PM with RN #1 identified she was working the 11-7 AM shift on 5/20/22 to 5/21/22 as the Nursing Supervisor and was completing paperwork on another unit when NA #1 came to her between 4:20AM and 5:00AM reporting she observed Resident #1 on top of Resident #2. NA #1 reported she separated the two and brought Resident #2 back to his/her room and back to bed. RN #1 then went to Resident #1 and Resident #2 's room where she found them both in their own beds, Resident #2 with eyes closed described as sleeping and Resident #1 awake lying in bed. An assessment was completed for Resident #2 who did not have signs of injury, did not appear to be in any distress and, there was no indication of bodily fluids on either resident or surface areas. Both residents had no recollection of the incident and presented with their baseline disposition. RN #1 indicated she contacted the DNS and both residents were placed on enhanced monitoring. RN #1 notified the facility APRN and responsible party. RN #1 initiated a Reportable Event and obtained statements. RN #1 indicated Resident #1 had not previously exhibited inappropriate sexual behaviors towards others. An interview on 5/24/22 at 2:08 PM with the DNS identified she spoke with the night shift supervisor at 6:30AM who reported the allegation stating NA #1 reported finding Resident #1 lying on top of Resident #2 while doing rounds. Both were not wearing briefs or clothing from the waist down. NA #1 immediately separated the two residents and there were no indications of injury and no indication that there was an erection of penetration. According to the DNS, the conservator for Resident #2 agreed to an evaluation at the emergency department (ED) but did not want Resident #2 to undergo any invasive examinations. An interview on 5/25/22 at 11:30AM with the Medical Director of the facility identified he was notified of the allegation the following day by the facility nurse practitioner who discussed the treatment plan with the conservator. The Medical Director also reviewed the emergency (ER) notes and discussed the risks versus benefits. Given Resident #2's functional and cognitive deficits, an extensive examination would have been invasive and distressing. The plan was discussed with the conservator who agreed. The Medical Director indicated it was his expectation that residents be free from abuse including sexual abuse and the facility provide safe environments for all residents including following policies for reporting. Both residents had significant cognitive impairment. The Medical Director indicated he understood Resident # 1 was in the room and on top of Resident #2. Consenting or not, cognitively impaired persons could not make the decision. An interview on 5/25/22 at 3:31PM with NA #1 identified she was the assigned NA for Resident #1 and Resident #2 that evening. NA#1 last observed Resident #1 and Resident #2 previously at 3:00AM during hourly rounds and both were asleep. NA #1 stated when completing rounds at 4:15AM, she observed Resident #1 on top of Resident #2 in Resident #2 's bed and that both were naked from the waist down. Resident #1 was described as squirming around while on top of Resident #2. NA #1 immediately removed Resident #1 from Resident #2 and returned Resident #1 back to his/her room before returning to Resident #2 to make sure s/he was ok. Resident #2 appeared somewhat agitated but was otherwise calm, quiet and did not appear in distress or pain. NA #1 indicated she was unable to determine if Resident #1 had achieved sexual arousal but did observe that skin to skin contact had taken place. NA #1 also stated she felt Resident #1's actions seemed intentional as s/he was able to gain access through a shared bathroom into Resident #1's room without going into the hallway indicating s/he would have been seen by NA #1 who monitors the halls during the shift. NA #1 immediately notified the Nursing supervisor after separating the two residents and returning Resident #1 to his/her bed. The facility policy for Abuse directs that all residents have the right to be free from abuse, which includes but not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion, or sexual assault.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident # 10) reviewed for accidents, the facility failed to implement enhanced supervision for a resident exhibiting behaviors of restlessness resulting in an injury that required sutures to close the wound. The findings include: Resident #10 was admitted on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)] and essential hypertension. The quarterly (MDS) assessment dated [DATE] identified Resident #10 with impaired cognition was independent with bed mobility, transfer to wheelchair from bed and toilet and self-mobile with wheelchair, assist of one with ambulation, and indicated the resident did not exhibit wandering behavior. The RCP dated 3/30/20 identified Resident #10 had a history of depression for which antidepressants were prescribed and had a history of recent falls due to environmental hazards. Interventions included: monitoring for over sedation or side effects, to wear sneakers for ambulation and encourage the resident to ask for help. Physician's orders dated 4/8/20 directed that Resident #10 ambulate with assist of one and independent with transfers from bed or toilet. Resident #10 had a DNR order in place. Physicians progress note dated 5/19/20 noted Resident #10 had tested positive for COVID 19, was afebrile and on room air without [CONDITION(S)]. A plan was in place to initiate end of life medications that included [MEDICATION(S)] (pain medication) MS and [MEDICATION(S)] (antianxiety) for severe [CONDITION(S)] and [CONDITION(S)] to promote comfort. Physicians orders dated 5/23/20 included orders that directed comfort measures only with request for a Hospice Evaluation and, [MEDICATION(S)] 0.5 Milligrams (MG) subcutaneously every 4 hours as necessary for restlessness and anxiety. The Medication Administration Record (MAR) dated 5/26/20 at 10:15 P.M. noted Resident #10 received [MEDICATION(S)] 0.5 MG for restlessness. A nursing progress noted dated 5/26/20 at 11:35 P.M. noted Resident #10 was observed lying face down in a pool of blood in his/her room on the floor. Resident #10 was awake and verbal, words were not making sense. Resident #10 was noted to have a large laceration on his/her forehead and was transferred to an emergency room for further evaluation of the head trauma. The APRN and responsible party were notified. A Reportable Event dated 5/26/20 identified Resident #10 with increasing confusion and restlessness was in his/her room with the door closed when she/he fell and sustained a laceration to his/her forehead. The resident was sent to the emergency room for evaluation and returned to the facility with 5 staples in his/her forehead. Reportedly, just prior to the fall, Resident #10 had been medicated with [MEDICATION(S)] and had been out of his/her room multiple times looking for things that did not exist. the care plan was amended to include keep door to room open and make frequent checks. The APRN started comfort measures. The nursing progress note dated 5/27/20 at 4:53A.M. identified Resident #10 returned to the facility with 5 staples placed to close the forehead wound. Resident #10 was resting with his/her eyes closed and was able to be aroused by sound. An interview on 4/26/21 at 11:52 A.M. with RN #1 identified she was the nursing supervisor of the shift. RN #1 did not make any direct observations of Resident #10 prior to the incident. She did indicate she was notified of the fall, completed an assessment prior to the resident's departure and indicated she made all the appropriate notifications herself. RN #1 indicated she was informed Resident #10 had received [MEDICATION(S)] and that she/he had been placed in bed prior to the incident and indicated the nurses were checking on Resident #10 periodically. RN #1 also indicated because there was medication in place for agitation for Resident #10 the nursing staff were not necessarily required to notify her of Resident # 10's agitation. An interview on 4/26/21 at 1:14 P.M. and 4/26/21 at 2:15 P.M. with the DNS identified Resident #10 was placed on comfort measures and anxiety medications were ordered. According to the DNS there were no specific policies related to required monitoring following the administration of [MEDICATION(S)]. The DNS further indicated while residents' doors were kept closed due to COVID19, staff checked on residents hourly and were checking on Resident #10 more frequently to offer reassurance secondary to his/her fears related to dying. An interview on 4/26/21 at 1:42 P.M. and 4/28/21 at10:44 A.M. with NA #1 identified Resident #10 was in bed, agitated, trying to get out of bed. Verbal redirection was ineffective. The nurse Licensed Practical Nurse (LPN #1) was notified who in turn directed staff to get Resident #10 out of bed. The resident was taken out of bed and placed in the hallway for closer observation. Resident #10 then attempted to get out of the wheelchair and LPN #1 redirected NA #1 to put Resident #10 back to bed, which she did, and left the door open. NA #1 indicated she was not aware when Resident #10 was medicated. NA #1 continued to check on Resident #10 every 15 minutes and noted Resident #10 continued to make attempts to get out of bed. NA #1 continued with attempts at verbal redirection and notified LPN #1 of the Resident #10's status. An interview on 4/28/21 at 11:33 A.M with LPN #1 identified she was the assigned nurse on the unit that evening at the time of the incident. According to LPN #1, Resident #10 was agitated while in bed, attempting to get out of bed. Staff transferred Resident #10 out of bed and into a wheelchair where she/he was placed in the hallway and observed for safety. LPN #1 recalled having administered [MEDICATION(S)] at 10:15 P.M. to Resident #10 but was unsure when the medication was administered during the incident. LPN #1 believed Resident #10 was calm so staff put him/her back to bed although she could not recall if it was at her direction. The door to Resident #10's room was left open and LPN #1 did observe Resident #10 to be calm initially, but then began with attempts to get out of bed once again. LPN #1 indicated she notified the nursing supervisor (RN #1) of the events and Resident #10 ' s status and indicated she could not recall if there was any further direction. LPN #1 did not know who was responsible for deciding if additional enhanced supervision would be warranted for a resident who continued to exhibit a safety risk but felt the facility staff did everything, they could ensure Resident #10 was safe. A review of the clinical record on 4/28/21 failed to reflect interventions were put in place to address Resident # 10's continued attempts on getting out of bed frequently and when the resident's verbal redirection and repositioning were all ineffective. A subsequent interview on 4/28/21 11:59 A.M. with the DNS identified measures for enhanced supervision should have been in place when Resident #10 continued to exhibit behaviors placing him/her at risk for safety and indicated she was not sure why the interventions were not put in place. An interview on 4/28 21 at 3:47 P.M .with the former Medical Director identified he would expect the facility to implement a greater level of supervision for a resident who was exhibiting behaviors that pose a safety risk where interventions of frequent checks ( 15 minute checks), verbal redirection and repositioning were all ineffective. The policy dated 4/30/14 given at the time of the visit titled Close Observation directs applying close observation levels for the purpose of ensuring resident safety. Residents are placed on close observation when the physician, nursing supervisor or Interdisciplinary team deem it necessary to ensure their safety or the safety of others. Risk factors include decompensated mental status (impulsivity, impaired judgement, paranoia, agitation, delusion command hallucinations).

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (R #1) reviewed for abuse, the facility failed to provide adequate supervision in accordance with the physician order [REDACTED].#1 who had a history of [REDACTED].#3 in a sexual manner. The findings include: R #1's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R #1 was confused, unable to recall words or state the correct day, month or year, had behavior symptoms (physical, sexual, verbal), and required limited assistance of one for mobility on the unit and utilized a wheelchair. Further review identified that R#1 had a court appointed Conservator of Person. Review of the physician's orders [REDACTED]. The Resident Care Plan (RCP) dated 2/26/19 identified R #1 may not inappropriately touch other residents or use sexual language toward others withi interventions directed to provide 1:1 observation, psychiatric services as needed, and provide with privacy as needed for self-gratification. a. Review of the facility incident report dated 3/29/19 at 10:15 AM identified that R #1 was observed by staff touching R #2's private areas over his/her clothes. Statement written by NA #1 stated R #1 held onto R #2's hand and used his/her other hand to feel R #2's groin. The residents were separated and R #1 was placed on 1:1 monitoring. Review of the 24 hour report sheet dated 3/29/19 for the 7-3 shift identified that R #1 was started on 1:1 monitoring and every 15 minute checks at 10:15 AM. Further review identfied that the 24 hour shift report sheets identified no 1:1 monitoring was provided during the 7-3 shifts on 3/26, 3/27, 3/28, and 3/29/19 and prior to 10:15 AM on 3/29/19 absent an assessment and/or physician's orders [REDACTED]. Interview and review of the clinical record and facility documentation with LPN #1 on 4/29/19 at 12:25 PM identified he was aware R #1 had a history of [REDACTED].#1 was self-mobile in his/her wheelchair on the unit, and R #2 was non-verbal, confused, and able to ambulate independently. LPN #1 stated on 3/29/19 he observed R #1 in his/her wheelchair with his/her in front of R #2 who was standing. R #1 was observed with his/her hand on top of R #2's clothes over R #2's private parts. R #2 attempted to push R #1's hands away but R #1 held R #2's hand to stop him/her from pushing R #1's hand away, and then R #1 continued to touch R #2's private area. LPN #1 immediately separated R #1 and #2, and placed R #1 on 1:1 monitoring. LPN #1 indicated that a few days prior to the incident, he was directed that R #1 no longer needed 1:1 monitoring on the 7-3 shift, and R #1 was not being monitored with 1:1 prior to the incident occurrence. Interview and review of the clinical record and facility documentation with the DON on 5/1/19 at 11:07 AM identified that R #1 had a physician's orders [REDACTED]. The DON further stated that R #1 should have been on 1:1 monitoring when the incident occurred, and a physician's orders [REDACTED]. Interview and review of the clinical record with APRN #1 on 5/1/19 at 2:19 PM identified that R #1 should have been on 1:1 monitoring at the time of the incident on 3/29/19. Interview and review of the clinical record with Physician #1 on 5/2/19 at 3:57 PM identified he did not give an order to discontinue the 1:1 monitoring for R #1. Interview with the DON on 5/1/19 identified there was no facility policy regarding following physician orders, however the expectation was that physician orders [REDACTED]. b. R #3's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified R #3 was moderately confused, and ambulated independently. Review of the clinical record identified R #3 had a court appointed Conservator of Person. Review of facility documentation dated 4/9/19 at 11:30 PM identified that R #1 was observed by NA #2 having inappropriate sexual contact with R #3. Interview, review of clinical record and facility documentation with NA #2 on 4/29/19 at 2:09 PM identified on 4/9/19, she entered R #1's room and observed R #1 sitting on the side of the bed facing R #3 who was standing in front of R #1, and stated they were engaged in inappropriate sexual contact. NA #2 directed R #3 out of the room, and notified the charge nurse after R #3 left the room. Interview, review of the clinical record and facility documentation with the DON on 5/1/19 at 11:07 AM identified that R #1 had a history of [REDACTED]. The DON further stated R #1 was on 1:1 monitoring on 7-3 and 3-11 shifts, and every fifteen (15) minute checks during the 11-7 shift for behavior monitoring. Subsequent to the incident, R #1 was placed on 1:1 monitoring around the clock. Review of facility Abuse Policy directed in part, that residents have the right to be free from abuse, and abuse includes non-consensual sexual contact. Review of facility Close Observation Policy directed in part, that for 1:1 observation, the staff assigned will remain within reach of the resident in order to ensure resident safety.

Based on clinical record reviews, review of facility documentation and interviews for one sampled resident (Resident #2) who had behavioral symptoms and resided on a secured unit, the facility ensure the resident was not able to obtain a cleansing solution to prevent an accident. The findings include: Resident #2's [DIAGNOSES REDACTED]. The Resident Care Plan dated 11/16/17 identified Resident #2 was a participant in the facility's behavioral health program which included residence on a secure unit and the resident had a history of [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had poor decision making skills regarding tasks of daily living, experienced hallucinations and delusions, exhibited no behavioral symptoms, required antipsychotic and antianxiety medications, and was independent with ambulating, personal hygiene, eating and toilet use. A physician's orders [REDACTED]. The nurse's note dated 2/14/18 identified that at 6:05 AM Resident #2 was found unresponsive on the floor in her/his room, the resident was lying on her/his back and vomit was noted in her/his hair. The note indicated Resident #2's oxygen saturation level was 88% on room air, congested lung sounds were noted, the blood pressure was 94/50, the pulse was 114, the respiratory rate was 22 breaths per minute and a blood sugar was 124. The note identified a re-breather oxygen mask was donned, oxygen therapy at fifteen (15) liters was administered and Resident #2's oxygen saturation level returned to 96%. The note indicated emergency services was notified and Resident #2 was transferred to the hospital emergency department at 6:30 AM. The Reportable Event Form dated 2/14/18 identified Resident #2 was observed lying on the floor next to the bed unresponsive, with vomit in his/her hair and slightly short of breath. The investigation dated 2/15/18 identified that an empty bottle of hand sanitizer was noted under Resident #2's bed. The hospital discharge summary dated 2/20/18 identified that on admission to the hospital Resident #2's blood alcohol level was elevated, communication with the nursing facility identified that although not verified, the resident had a prior suicide attempt by ingesting bleach and no history of [MEDICAL CONDITION] and/or withdrawal hospitalization s. At the hospital Resident #2 confirmed that he/she had ingested hand sanitizer prior to the hospital admission. The Discharge Summary identified a chest x-ray identified bilateral infiltrates consistent with aspiration pneumonitis. The summary identified the resident was intubated on 2/14/18 and extubated on 2/16/18, received a five (5) day course of antibiotics, [MEDICATION NAME], and [MEDICATION NAME], the supplements [MEDICATION NAME] and folic acid were initiated and the psychiatry consultation indicated the resident could return to the secure unit in the nursing facility. The discharge summary identified Resident #2 was transferred back to the skilled nursing facility on 2/20/18 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Behavioral Health Follow up dated 2/21/18 identified that Resident #2 denied suicidal ideation and was not a danger to self and/or others. Interview and review of the clinical record with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 7/10/18 at 10:30 AM identified that she could not recall if a bottle of hand sanitizer was present on the medication cart during the 3-11PM shift on 2/13/18 prior to the 2/14/18 incident. LPN #1 stated the resident usually paced in the hall and would enter other resident rooms during her shift, and she never witnessed the resident near the medication cart where the hand sanitizer was kept. LPN #1 identified Resident #2 was known to hoard clothing. Interview with two (2) 3-11PM nurse aides, Nurse Aide (NA) #2 and NA #3, on 7/10/18 at 10:45 AM and 11:30 AM, who were on duty the evening before the 2/14/18 incident, identified they had not witnessed Resident #2 attempting to take the bottle of hand sanitizer from the medication cart. Interview with NA #1 on 6/19/18 at 1:30 PM identified after Resident #2 was transferred to the hospital, she found an empty bottle of hand sanitizer under the resident's bed. NA #1 stated she immediately reported the finding to the charge nurse, Registered Nurse (RN) #1, who called the emergency department. Interview with the 11PM-7AM shift nurse, RN #1, on 6/19/18 at 9:15 AM and on 6/22/18 at 1:15 PM identified she observed Resident #2 sleeping at the beginning of the shift and did not observe the resident again until she found the resident on the floor in the morning. RN #1 stated that the only place on the unit where there was access to hand sanitizer was on the top of the medication cart. RN #1 indicated she did not recall seeing a bottle of hand sanitizer on the medication cart when she arrived at 11:00 PM and explained that she does not use the hand sanitizer during medication passes. RN #1 stated NA #1 had reported to her that the resident got up to use the bathroom around 3:00 AM. Subsequent to the 2/14/18 incident the Resident #2's care plan was revised to include every fifteen (15) minute location checks. Interview with the Director of Nursing (DON) on 6/22/18 at 10:45 AM and 6/22/18 at 11:30 AM identified the secured behavioral unit did not have hand sanitizer dispensers on the unit and staff are expected to carry hand sanitizer in their pockets to ensure the residents' safety. The DON identified that the investigation was unable to determine if the bottle of sanitizer was from the facility or brought in by a visitor, therefore she the concluded Resident #2 must have taken the hand sanitizer from the medication cart on the unit. The DON stated all hand sanitizers were removed from the medication cart on the behavioral unit, the staff were provided with in-services and audits were conducted to ensure staff were in compliance with the new policy.

Based on clinical record reviews, a review of facility policies and procedures and interviews with facility personnel for 9 of 16 sampled residents (R#1, R#4, R#8, R#9, R#14, R#14, R#15, R#16 and R#19), the facility failed to ensure that a personal property list identifying resident belongings and/or that residents who were identified with behaviors were monitored every fifteen minutes per physician order [REDACTED]. 1. Resident #1 [DIAGNOSES REDACTED]. A review of facility pre-admission intake information dated 3/21/12identified that the resident had a former history of arson. Resident #1 was admitted to the facility on [DATE] after a hospitalization commencing on 3/14/12. Prior to the hospital admission, R#1 had resided in a Residential Care Home (RCH) for a [AGE] year duration where the resident had a history of [REDACTED]. Review of the admission assessment dated [DATE] identified that the resident was alert and orientated to person, place and time but was forgetful, and a non-smoker. A review of the clinical record on admission did not identify that a personal property list was obtained. Review of the physician orders [REDACTED]. Review of the nurse's notes dated 4/17/12 identified that the resident had expressed feeling very hostile, delusional and stated "If I have a weapon, I'll use it" and had thoughts about hurting staff related to being awaken at midnight by staff. Further review identified that the resident was sent to the Emergency Department (ED) for an evaluation and then was sent back to the skilled nursing facility on 4/18/12 after being deemed not a danger to him/herself or others. On 4/18/12 upon return from the hospital the resident was seen by the psychiatric Advanced Practice Registered Nurse (APRN) #1 with a recommendation to follow the hopsital's plan to increase the resident's antipsychotic medication, Respirdal from 1 milligram (mg) to 2 mg BID (twice daily). Interview with APRN #1 on 5/15/12 at 2:00 pm identified that upon return from the hospital on [DATE], the expectation was that the physician's orders [REDACTED]. A review of the psychiatric evaluation completed by APRN # 1 on 4/25/12 identified that the resident was not threatening harm but was expressing the desire to die and wanted to go to the Emergency Department (ED) because he was bored. Review of a psychiatrist's physician ' s emergency certificate dated 4/26/12 identified that the resident was suicidal and was a danger to himself and/or others. Resident #1 was transferred to the Emergency Department (ED) for placement in a psychiatric hospital for an involuntary commitment. Resident #1 was returned to the facility by the ED on 4/27/12 after being deemed not to be a danger to him/herself and/or others. Again, an interview with APRN #1 on 5/15/12 at 2:00 pm identified that upon return from the hospital on [DATE] the expectation was that the resident would remain on every every fifteen minute checks secondary to the resident's behavior of delirum, in accordance with thephysiican's order dated 4/17/12. Review of the nursing care plan dated 5/1/12 identified that the resident was on every fifteen checks, indefinitely. On 5/3/12, Resident #1 was transferred to the secured dementia unit for aggressive behaviors, which included threatening of staff, refusing medications and expressing the desire to leave, as well as delirium. Interview with Maintenance Worker #1 on 5/10/12 at 10:00 identified that on 5/7/12, the resident ' s belongings were delivered by the RCH at 2:30 PM and were left in the resident's room, where they were made available to the resident. Further review failed to identify that the resident ' s belongings were checked for contraband and/or that a personal property list was completed by staff before placing them in the resident ' s room. The interview further identified that according Maintenance Worker #1 the resident had multiple bags of personnel belongings and a cart was needed to bring them up to the unit and that the charge nurse instructed him/her to bring the resident ' s belongings to the resident ' s room. Interview with RN #1 on 5/10/12 at 11:00 am identified that she had seen the resident ' s belongings being delivered by the maintenance worker on 5/7/12 and did not have them checked prior to placing them in the resident ' s room. Interview with LPN #1 on 5/8/12 at 3:30 pm identified that when she came on shift at 3:00 pm on 5/7/12, the resident ' s belongings were already in his/her room and assumed that they were already checked for contraband and/or that a personal property list had been completed by staff. According to the social worker noted dated 5/8/12 on the 3:00 pm -11:00 pm shift and as a result of interview with R#1, he/she had taken a lighter from his belongings and lit his/her clothing under the bed and walked out of the room and sat at the nurse ' s station until the fire alarm went off. Resident #1 was later found to have four lighters, multiple books of matches and rolling papers in his possession. Review of Resident #1 ' s fifteen minute check sheets dated 4/17/12, 4/18/12, 4/29/12 4/30/12 and 5/2/12 identified that the resident was not monitored every fifteen minutes per the physician order. Further review from 5/3/12-5/8/12 identified that when the resident was admitted to the secure unit on 5/3/12, the resident was never monitored every fifteen minutes per physician's order [REDACTED]. Review of facility policy identified that residents identified on every fifteen minute checks, monitoring should be entered on a every fifteen minute interactive check sheet. Interview with APRN #1 on 5/15/12 at 2:00 pm identified that the he/she had written an order to place the resident on every fifteen minute checks on 4/17/12 secondary to the resident exhibiting behaviors of delirium and making statements that he wanted to harm staff and had no reason to expect that the every 15 minute checks would not have been completed. 2. Resident #4 who was admitted on [DATE] had [DIAGNOSES REDACTED]. Review of the clinical record failed to identify that the resident ' s inventory of valuables/belongings were checked upon admission for contraband and/or that a personal property list had been completed. 3. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing care plan 4/27/12 identified that the resident had behavioral disturbances, repetitive and forgetful at times. Review of the clinical record failed to identify that the resident ' s inventory of valuables/belongings were checked upon admission. Interview with the charge nurse on 5/8/12 identified that when resident came into the facility, the resident only had the clothing he/she was wearing and the resident should have been checked for contraband. 4. Resident #9 was admitted to the secured psychiatric unit on 12/15/10 with [DIAGNOSES REDACTED]. Review of the nursing care plan dated 3/29/12 identified that the resident had long/short term memory loss, mental illness and dementia. Review of the clinical record failed to identify that the resident ' s inventory of valuables/belongings were checked upon readmission for contraband and/or that a personal property list had been completed. Observation of the resident ' s room with the charge nurse on 5/8/12 identified that the resident had clothing and other valuables in his room. 5. Resident #14 was admitted to the secure dementia unit on 2/26/11 with [DIAGNOSES REDACTED]. Review of the nursing care plan dated 2/22/12 identified that the resident had a history of [REDACTED]. Further review identified that on 5/3/12, the resident was found in a male peer's room and was placed on every fifteen minute checks. Review of the every fifteen minute check sheets dated 5/8/12 on the 3:00 pm -11:00 pm shift failed to identify that the resident was monitored every fifteen minutes. 6. R# 15 was admitted to the facility on [DATE] at 4:30 pm with [DIAGNOSES REDACTED]. Review of the nursing care plan dated 6/10/11 identified that the resident had limited judgment, insight, and needed to be monitored for any unauthorized leave. Review of the every fifteen minute sheets dated 5/8/12 failed to identify that the resident was started on every fifteen minute checks upon admission. Further review identified that the every fifteen minute checks were started on 5/9/12 at 11:00 pm (6 ? hours later). 7. Resident #16 was admitted to the secured dementia unit on 9/1/10 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the nursing care plan dated 3/19/12 identified that the resident had inappropriate boundaries and needed to be on every fifteen minute checks for intrusiveness. Review of the every fifteen minute check sheets dated 3/28/12, 3/30/12-4/2/12, 4/15/12, 4/24/12-5/2/12 and 5/10/12 identified on multiple shifts, the resident was not monitored per physician order. 8. Resident #17 was admitted to the secured dementia unit with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the nursing care plan dated 3/14/12 identified that the resident wanders in other resident ' s rooms and is exit seeking with interventions to monitor the resident every fifteen minutes. Review of the every fifteen minute check sheets dated 2/2/12-5/9/12 failed to identify that the resident was monitored consistently per physician order. In addition, further review identified that the resident was not monitored from 4/14/12-4/26/12. 9. Resident #19 was admitted to the secured dementia unit on 2/6/12 and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the nursing care plan dated 2/6/12 identified that the resident was on every fifteen minute checks and had a wander guard. Review of the nurse's notes dated 4/26/12 identified that the resident stated that she was leaving the facility on multiple occasions. Review of the every fifteen minute check sheets dated 2/10/12-5/8/12 identified on multiple shifts the resident was not monitored every fifteen minutes. Review of facility policy identified that a list of items considered to be potentially dangerous, or items that may pose significant health risks, are therefore considered " contraband " and to be handled on facility premises by or under the supervision and/or discretion of staff will be reviewed with all new admissions. Further review identified that in the event contraband items are suspected to be present, the staff will immediately notify the nursing supervisor and a determination will be made as to whether a " room-search " will be conducted. Review of facility behavior health program guide identified that containers, bags, purses, etc. that are brought in by visitors may be searched by staff if it is suspected that those items contain contraband items should be posted in the lobby area or on your unit. Review of the inventory of valuables policy identified that resident ' s personal belongings of value are properly labeled and documented on appropriate forms. Review of facility practice with multiple staff members on 5/10/12 indicated the facility practice is for all new admissions and if any belongings are brought in by family members, the staff checks the belongings for contraband prior to giving them to the resident. Immediate Jeopardy was identified as a result of the facility's failure to ensure that residents' environment remained free of accidental hazards and/or failed to provide supervision to protect residents from harm through the failure to implement every fifteen minute checks as directed by physicians.