Every finding on record at Gill Odd Fellows Home of Vermont

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 3 sampled residents (Resident #1). Findings include:Per record review Resident #1 has diagnoses that include dementia and difficulty walking. S/he has care plan interventions that include extensive assist of 1-2 with rolling walker and as needed Hoyer lift. Per progress notes written on 7/9/2026 Resident #1 had vomited and was assisted to the toilet by Licensed Nursing Assistant (LNA) #1 and LNA #2 when Resident #1 became weak unable to stand. S/he sustained a skin tear measuring 3 cm X 2.7 cm x 0.1 cm. Review of the facility report submitted to the licensing agency on 7/9/2026 revealed that LNA #2 reported that during transfer, LNA #1 was forceful with Resident #1 which caused the resident to hit her/his head on the wall and face on the call light box and sustained a skin tear to the left elbow.Per review of LNA #2's witness statement provided to the facility, on 7/9/2026 just before 5:00 PM Resident #1 had vomited and was being brought to the tub room by LNA #1 for assistance. While standing with assistance from LNA #1 and LNA#2, the Resident's legs became weak, and s/he could not stay standing. Instead of assisting Resident #1 to sit back on the toilet to try again, LNA #1 pushed Resident #1 up against the wall trying to keep her/him up. LNA #2 witnessed the Resident's head bump into the wall and heard the Resident yelp. LNA #1 then forcibly sat the Resident back down onto the toilet and s/he yelped again. The Resident was then assisted to stand again; at this time, her/his face hit the call light box and s/he started to cry. LNA #1 sat the Resident down again and yelled something to the effect of I can't pick you up on your own. You are heavy, you need to help us, or you will end up on the floor. Understand? Resident #1 said yes. At this time LNA #3 came to assist and she and LNA #1 attempted to assist the Resident to stand. The Resident was being pushed up against the wall while LNA #1 attempted to pull up a brief, at this point Resident #1 was crying. LNA #2 noted that the Resident had sustained a skin tear. Per interview with the Director of Nursing on 7/15/2026 at 11:00 AM Resident #1 had sustained a skin tear and bruising on her/his right arm during transfer. During an interview with LNA #2 on 7/17/2026 at 10:10 AM she confirmed that LNA #1 had been forceful with Resident #1, the Resident had been injured, was crying, and scared as a result of the way LNA #1 had assisted her/him. Based on corrective actions completed on 7/14/2026, prior to the onsite, this citation is designated as past non-compliance with the compliance date of 7/14/2026. The following actions were completed by the facility:The facility reported the incident to the Licensing Agency, police, and the Office of Professional Regulation.LNA #1's employment was terminated.All residents were assessed for injury that may indicate possible abuse.Staff were educated on staff to resident abuse and recognizing potential concerns in coworker behaviors.The results of the audits are reported and evaluated during the quality assurance, performance improvement quarterly meetings.

Based on observation and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food service safety. Findings include:Per observation during the initial tour of the kitchen on 2/23/26 at 10:13 AM a 5-ounce box of cornbread muffin mix with an expiration date of 11/5/25, and a 5-ounce bag of tortilla strips with a date opened on 1/7/26 with no expiration date on the packaging, were identified in the dry storage area. In the freezer, there was a bag of 24 frozen fish sticks in a bag open to air, with no date on the package, as well as one bag containing 3 frozen pie crusts that was opened without an expiration/opened date. Per interview with [NAME] # 1 on 2/23/26 at 10:40 AM, they confirmed these items did not have dates, were open to air, and/or expired.Per observation on 2/23/26 at approximately 12:03 PM [NAME] # 2 was observed in the kitchen without a hair restraint while cooking, assembling, and plating food.Per interview on 2/23/26 at approximately 12:15 PM [NAME] # 2 stated staff in the kitchen do not need a hair restraint if their hair is of a certain length. He was unsure of what the specific, permitted length of hair a staff member was allowed to be working in the kitchen without a hair restraint.Per interview with the Dietary Manager 2/24/26 at 9:45 AM, she confirmed staff whose hair is short enough do not need to wear a hat or a hair net while preparing or assembling food, or while in the kitchen where these tasks are performed. She stated there is not a specific length that the facility adheres to in order to determine that someone's hair is short enough to not wear a hair restraint while working in the kitchen. She stated that as long as hair is short enough to not fall into the food, it is acceptable.Per review of a facility policy titled Food Safety the policy states under the Facility Employees Part 3, Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Based on observations and interviews the facility failed to provide a system that enables residents to file an anonymous grievance. Findings include:Per observation on 2/25/26 at approximately 9:20 AM a grievance procedure was posted outside the dining room in the lobby. The grievance posting did not contain information regarding how to file an anonymous grievance. The posting stated if a resident has a concern or complaint to speak with the grievance officer/ Social Service Director or the Director of Nursing and lists their phone numbers. There were no blank grievance forms or a drop box to submit grievance forms observed.Per interview on 2/25/26 at 10:06 AM the Social Worker confirmed that the residents file grievances with either the Social Worker or the Director of Nursing. The Social Worker stated he did not know how a resident would file a grievance anonymously as they would have to ask a staff member for the form and submit the form back to a staff member. The Social Worker stated that blank grievance forms are located in the social work office and residents do not have access to blank forms independently. He stated there is not a drop box for grievances and that residents physically submit the form(s) to the Social Worker, the Director of Nursing, or another staff member. Per review of the facility's admission agreement there is a section titled: Resident Rights & Grievance Procedure that states that grievances may be filed anonymously by placing them in the mailbox near the front door of lobby. There are no grievance forms available to residents without requesting them from a staff member.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices during medication administration by not practicing appropriate hand hygiene during preparation and administration of medications and the presence of a staff member's personal drink on 1 of 2 medication carts. This is a repeat deficiency for this facility, with violations cited during the previous three re-certification surveys dated 1/11/23, 1/24/24, and 3/19/25. Findings include:During a medication administration observation on 2/24/2026 at 9:20 AM, a Registered Nurse (RN) put on gloves and poured medications into individual 30 cc (1oz) cups. He accessed the nurse's station refrigerator twice to obtain pudding to use for crushed medication administration. The RN did not remove his gloves or perform hand hygiene before continuing to prepare medications for administration. The RN crushed the pills and mixed them with the pudding. Without taking his gloves off and performing hand hygiene the RN carried the cups with his gloved fingers inside the medication cups and administered the medications to Resident #41. Proper hand hygiene before, during and after glove use reduces the risk of contamination and spreading germs to residents (per CDC) Per facility Handwashing/Hand Hygiene Policy review it states to reduce/prevent transmission of organisms from nursing staff to resident.wash hands before and after resident contact (i.e., meds, treatments, cares). During a medication administration observation on 2/25/2026 at 9:30 AM, a large cup with a lid and straw was sitting on the medication cart. When asked, the nurse stated the drink was hers and that she thought it was ok because the cup had a lid on it. Per interview with the Director of Nursing (DON) on 2/25/2026 at 12:20 PM, she confirmed that not performing proper hand hygiene before or during medication preparation and placing fingers (gloved or ungloved) inside the medication cup before administering increases the risk of contamination. The DON stated that staff drinks are not allowed to be on the medication cart because it is an infection control issue, regardless of whether there is a lid on the cup or not. Work cited:Clinical Safety: Hand Hygiene for Healthcare Workers | Clean Hands | CDC

Based on observation, interview and record review, the facility failed to revise a plan of care to reflect an identified concern of a decline in mobility for 1 of 13 sampled residents (Resident #27). Findings include: Per a record review, Resident #27 has a diagnosis of progressive multiple sclerosis (MS). Per observation on 2/24/25 at 9:45 am, Resident #27 was noted to be dragging his/her right foot while attempting to self-propel his/her wheelchair, inhibiting his/her movement. There was no leg rests installed on his/her wheelchair. Per a record review, Resident #27's care plan intervention for wheelchair mobility (last revised on 1/12/25) did not address the use of wheelchair leg rests when in his/her wheelchair to improve his/her ability to self-propel. Per an interview with LNA #1 on 2/24/26 at 3:35 pm, she was aware that sometimes Resident #27 did have a problem self-propelling in his/her wheelchair because [his/her] feet get tangled up. She stated she had reported it to a nurse. Per an interview on 2/24/26 at 3:45 pm with an OTR (Occupational Therapist, responsible for evaluating and addressing the level of assistance needed with activities of daily living such as ambulation and mobility), she stated she was aware of Resident #27's feet dragging and inhibiting his/her self-propulsion. She stated she had provided leg rests for his/her wheelchair and educated staff to utilize the leg rests on his/her wheelchair. The OTR stated that if Resident #27 has leg rests in place for his/her feet, that he/she has the upper body strength to self-propel by using his/her hands to roll the wheels on his/her chair. She was unable to confirm whether this had been addressed in his/her care plan. Per observation on 2/25/26 at 9:11 am, Resident #27 was lying in bed. The wheelchair was noted to have leg rests attached. However, further review of the Resident's care plan revealed that it still had not been revised to include the use of leg rest on the wheelchair.

Based on observation, record review, and interview the facility failed to ensure medication error rates were less than 5% or greater. There were 31 medication administration opportunities, 29 were observed to be given and 2 were omitted, resulting in errors for 2 of 6 sampled residents (Resident #14 and Resident #16). The total error rate for all observations was calculated at 6.45%. Findings include:During a medication administration observation on 02/24/2026 at 9:50 AM, the Registered Nurse (RN) administered medications to Resident #16 and stated, That's all for [Resident #16].Per record review of the Medication Administration Record (MAR) it was noted that one prescribed medication (docusate sodium, stool softener) was documented as administered by the RN but was not observed to be given. During a medication administration observation on 2/25/2026 at 9:40 AM, the RN administered medications to Resident #14 and confirmed that all medications for Resident #14 were given. Per record review of the (MAR) it was noted that one prescribed medication (Miralax Powder [laxative solution]) was documented as administered but was not observed to be given. Per interview with the Director of Nursing (DON) on 2/25/2026 at 12:20 PM she produced a time stamp report which showed the docusate sodium was administered to Resident #16 at the same time as his/her other prescribed medications, and the Miralax was documented as administered to Resident #14 at the same time as his/her other prescribed medications. Per surveyor observation these medications were not given.

Based on observation and interviews the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication carts. Findings include: Per observation on 2/23/26 at 11:44 AM, a medication cart in the long hallway between room [ROOM NUMBER]-119 was unlocked. There was not a nurse or a staff member present within sight of the medication cart. Residents were observed self-propelling in this hallway towards the dining room. At 11:56 AM, an RN (Registered Nurse) was observed walking from the nurse's station around the corner towards the medication cart.Per interview with this RN on 2/23/26 at 11:57 AM he confirmed the medication cart contained over the counter medications, syringes, topical medications, injectables, prescribed resident specific medications and narcotics in a separate locked compartment. The RN confirmed the cart was left unlocked while unattended and that it should have been locked.Per interview on 2/24/26 at approximately 2:30 PM, the DON (Director of Nursing) confirmed that the medication cart should be locked when unattended by the nurse on duty.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) in accordance with State law through established procedures for 1 resident [Resident #1] of 3 sampled residents. Findings include:Per review of Physician Assessment Notes for Resident #1, dated 7/17/25 and 7/24/25, Resident #1 has a primary medical history of dementia, depression and insomnia, does not evidence any signs of cognitive impairment, h/her insight and judgement are good/intact, there are no indications today of audio hallucinations or visual hallucinations or delusions, no indication of risk to h/herself or others, and is a good historian.An interview was conducted with Resident #1 on 8/6/25 at 9:30 AM. The resident stated A couple of nights ago a [resident] came into my room and hit me 7 times with my walking stick [Resident picked up a grabber/reaching tool on an end table next to a television and held it up]. I was hit on the back [left] side of my head and my shoulder. I have no idea what has happened since. They may have talked to me about it afterwards, but I don't remember. What upsets me the most is they don't tell me what is going on, what the consequences are. I'm the [person] they beat on. I have a right to know. I want them to call the police. I want them to arrest [h/her]. The police did not talk to me. I have had no communication from the management. Do I feel safe here? The next time somebody walks into my room I will be ready to defend myself. Review of Progress Notes for Resident #1 dated 3 days prior on 8/3/25 record Resident is complaining that another resident came into [h/her] room. Nurse did not witness any physical aggression no bruises or skin issues noted, will continue to monitor both residents closely.Further review reveals no mention of the identity of the other resident, and no documentation of any monitoring of either resident. Review of Progress Notes dated the next day, 8/4/25 record Resident #1 being interviewed by the facility's Social Worker [SW]. Per the SW's note- Writer followed up on events from this weekend. Resident has requested a Velcro stop sign. This will help prevent unwanted guests and wandering, several residents who are mobile are nearby. An interview was conducted with the Social Worker [SW] on 8/6/25 at 10:58 AM. The SW stated that s/he had a conversation with Resident #1 on 8/4/25 where the resident reported another resident wandered into h/her room and struck [h/her] 7 or 8 times. Resident #1 wanted police called. The SW stated s/he was unaware of any physician or family notification, and unaware of any report of the incident to the required state agency[s] or law enforcement. The SW stated s/he did not report the allegation of abuse to the facility's Administrator or any state agency or law enforcement. An interview was conducted with the facility's Director of Nursing [DON] on 8/6/25 at 11:30 AM. The DON stated that after hearing of the initial observations of staff regarding Resident #1 and after conducting an interview with the alleged perpetrator the DON deemed the abuse unlikely to have happened. The DON confirmed that any allegation of abuse was required to be reported, including to the State Survey Agency, but was not.

Based on interview and record review, response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations are thoroughly investigated regarding 1 resident [Resident #1] of 3 sampled residents.Findings include:Per review of Physician Assessment Notes for Resident #1, dated 7/17/25 and 7/24/25, Resident #1 has a primary medical history of dementia, depression and insomnia, does not evidence any signs of cognitive impairment, h/her insight and judgement are good/intact, there are no indications today of audio hallucinations or visual hallucinations or delusions, no indication of risk to h/herself or others, and is a good historian.An interview was conducted with Resident #1 on 8/6/25 at 9:30 AM. The resident stated A couple of nights ago a [resident] came into my room and hit me 7 times with my walking stick [Resident picked up a grabber/reaching tool on an end table next to a television and held it up]. I was hit on the back [left] side of my head and my shoulder. I have no idea what has happened since. They may have talked to me about it afterwards, but I don't remember. What upsets me the most is they don't tell me what is going on, what the consequences are. I'm the [person] they beat on. I have a right to know. I want them to call the police. I want them to arrest [h/her]. The police did not talk to me. I have had no communication from the management. Do I feel safe here? The next time somebody walks into my room I will be ready to defend myself.Review of Progress Notes for Resident #1 dated 3 days prior on 8/3/25 record Resident is complaining that another resident came into [h/her] room. Nurse did not witness any physical aggression no bruises or skin issues noted, will continue to monitor both residents closely.Further review of Progress Notes reveals no mention of the identity of the other resident, and no documentation of any monitoring of either resident. Review of Progress Notes dated the next day, 8/4/25 record Resident #1 being interviewed by the facility's Social Worker [SW]. Per the SW's note, Writer followed up on events from this weekend. Resident has requested a Velcro stop sign. This will help prevent unwanted guests and wandering, several residents who are mobile are nearby.An interview was conducted with the Social Worker [SW] on 8/6/25 at 10:58 AM. The SW stated that s/he had a conversation with Resident #1 on 8/4/25 where the resident reported another resident wandered into h/her room and struck [h/her] 7 or 8 times. Resident #1 wanted police called. The SW stated s/he knew the identity of the resident who allegedly struck Resident #1, but that it was not documented anywhere. The SW confirmed there was no documentation in the second resident's record that any increased monitoring was conducted after the alleged incident, as was stated in the nurse's Progress Note of 8/3/25. The SW stated s/he was unaware of any formal investigation of the incident, and did not contribute any written material to an investigation. An interview was conducted with the facility's Director of Nursing [DON] on 8/6/25 at 11:30 AM. The DON stated that after hearing of the initial observations of staff regarding Resident #1 and after conducting an interview with the alleged perpetrator, the DON deemed the abuse unlikely to have happened. The DON confirmed that an investigation was required to determine if the allegation is substantiated or unsubstantiated. The DON confirmed there was no written record of the staff and resident interviews or evidence that the physical abuse allegations were thoroughly investigated.

Based on interview and record review, the facility failed to ensure as needed [PRN] orders for psychotropic drugs are limited to 14 days for 3 of 19 sampled residents [Resident #37, #21, and #22] unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and documents their rationale. Findings include: 1.) Review of Physician Orders for Resident #37, dated 3/18/24, reveal an order for Lorazepam [an anti-anxiety psychotropic medication] 0.5 milligrams- give one tablet by mouth every 8 hours as needed for 365 days. Per review of Resident #37's medical record, there was no documentation of a Physician rationale for ordering the PRN psychotropic medication for longer than the 14 day limit. 2.) Review of Physician Orders for Resident #21, dated 3/2/25, reveal an order for Ativan [brand name for Lorazepam] Oral Tablet 0.5 milligrams-Give 2 tablet by mouth every 2 hours until 8/19/2025 [order is > 5 months]. Per review of Resident #21's medical record, there was no documentation of a Physician rationale for ordering the PRN psychotropic medication for greater than 5 months time. An interview was conducted with the Director of Nursing [DON] on 3/19/25 at 1:57 PM. The DON confirmed both Resident #37 and Resident #21's PRN orders for Lorazepam/Ativan exceeded 14 days, and confirmed there was no documentation of a physician's rationale as to why the length of time for the psychotropic medication order needed to exceed the 14 day limit. 3.) Record review showed that on 8/30/24 at 1:00 PM Resident #22 was prescribed Clonazepam 0.5 MG as needed every 12 hours for post traumatic stress disorder for 365 days. Record review of Resident #22's medical records do not include a rational from a physician or other prescriber for extending the PRN Clonazepam order to 365 days. A facility policy titled Policy: unnecessary drugs which was approved on 3/5/24 stated that PRN (as needed) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, the following must be met: . The rational for extending the PRN order for more than 14 days is documented in the resident's medical record. In an interview with the DON at 2:23 PM on 3/19/25, the DON was unable to provide evidence of a provider's rationale for extending Resident #22's order for Clonazepam.

Based on observations, interviews, and record review, it was determined that the facility failed to maintain facility-wide systems for the prevention, identification, and control of infection and communicable diseases of residents, staff, and visitors through surveillance, staff training, and following established policies and procedures related to proper use of personal protective equipment (PPE) specifically Enhanced Barrier Precautions (EBP) for 4 of 4 of the applicable sample (Residents #7, #11, #10, and #38). Findings include: Per observation on 3/19/2025 at approximately 2:00 PM, a Licensed Nursing Assistant (LNA) was observed emptying an indwelling catheter bag containing urine without wearing a protective gown. When asked if gowns were available, she explained that the staff are not instructed to wear a gown when emptying urine from a catheter bag. Per observation on 3/19/2025 at approximately 9:00 AM, a facility tour revealed no signage or indication to the staff that Enhanced Barrier Precautions (EBP) were required for residents with indwelling medical devices (urinary catheters). Per record review, Resident # 7 has a diagnosis of specified disorders of the kidney and ureter and has an indwelling urinary catheter. Resident #11 has a diagnosis of Parkinson's disease and has a suprapubic (a urinary catheter inserted through the abdominal wall) urinary catheter. Resident # 10 has a diagnosis of benign prostatic hyperplasia (enlarged prostate) and has an indwelling urinary catheter. Resident #38 has a diagnosis of neuromuscular dysfunction of the bladder and requires a urinary catheter. A review of the care plans of Residents #7, #11, #10, and #38, there is no evidence found in the care plan to direct the staff to use Enhanced Barrier Precautions during high-contact resident care. The Centers for Disease Control and Prevention recommends the use of gown and gloves (EBPs) for high-contact resident care activities, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and /or indwelling medical devices regardless of MDRO (multidrug resistant organisms) colonization. Per interview with the Director of Nursing (DNS) on March 19, 2025, at approximately 2:20 PM, she confirmed that the facility Infection Control Policy did contain the CDC recommendations for EBPs and that the facility was not utilizing Enhanced Barrier Precautions.

Based on interview and record review, the facility failed to notify the physician of 1 resident [Resident #28] of 19 sampled residents regarding physician orders not followed related to medications not administered as ordered. Findings include: Per record review, Resident #28 was admitted to the facility with diagnoses that include Parkinson's Disease [Parkinson's disease (PD) occurs when brain cells that make dopamine, a chemical that coordinates movement, stop working or die. PD causes tremors, slowness, stiffness, and walking and balance problems]. Review of Physician Orders reveals the resident was ordered the medication Amantadine- give 1 capsule by mouth in the evening related to Parkinson's Disease. Review of Res.#28's Medication Administration Record for January 2025 records Resident #28 did not receive the Amantadine medication as ordered on 6 days, including 5 consecutive days. [1/23 - 1/27/25, 1/29/25]. Nursing Progress notes record on 1/23/25 the medication is Unable to give, incorrect dose with no further documentation. On 1/24/25 Nursing Progress notes read Spoke with [family member], about residents Amantadine which is 'delayed'. [S/he] is aware resident is out of medication. Notes on 1/25/25 record medication reported as 'delayed' by family member], so unavailable at this time. Notes on 1/26/25 record Not available (family supply's medication). On 1/27/25, Nursing Progress notes record see progress note, which refers to itself and contains no further documentation. Nursing Progress notes on 1/29/25 record Medication on order. Per review of drug information from the manufacturer of Amantadine: Rapid dose reduction or abrupt discontinuation of Amantadine may cause an increase in the symptoms of Parkinson's disease or cause delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression, or slurred speech. Avoid sudden discontinuation of Amantadine. (https://www.gocovrihcp.com/safety) A review was conducted of in-service education provided to nursing staff on 8/1/24 regarding Medication Not Available. The education provided included When we fail to follow an order and fail to give a medication that is ordered to a resident this can be considered a medication omission or medication error . there is a process to be followed when a medication is unavailable. The facility process includes If medication will not arrive in time for dose, contact Director of Nursing or Assistant Director of Nursing, they will notify the Physician. Document in a progress note the steps you just took. An interview was conducted with the Director of Nursing [DON] on 3/19/25 at 1:57 PM. The DON confirmed there was no documentation that Resident #28's physician was notified the resident's Parkinson's Disease medication was not given as ordered on 6 different occasions, including on 5 consecutive days.

Based on interview and record review, the facility failed to ensure that 1 [Resident #43] of 4 sampled residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Findings include: Per review of the facility's Trauma-Informed Care policy [approval date 3/5/24]: The facility must ensure that residents receive culturally competent care in accordance with professional standards of practice and accounting for resident experiences and preferences to eliminate triggers that may harm the resident. Policy procedures include: Assessments, screening and early identification begins with the resident's admission to the facility and periodically with behavioral and/or condition changes, and The resident's comprehensive care plan will reflect goals and approaches to address mental health, including management of triggers . Per review of Resident #43's medical record, the resident was admitted to the facility on [DATE]. Resident #43 began receiving psychiatric therapy on 7/29/24, with the physician diagnosing the resident with PTSD (post-traumatic stress disorder). Per review of Psychiatric Therapy notes from September 2024 up through the time of the recertification survey in March 2025, physician notes recorded the diagnosis of PTSD on each monthly session. Further record review revealed no assessment to identify triggers and no Care Plan for the PTSD diagnosis along with no interventions developed related the preventing possible triggers. An interview was conducted with the Director of Nursing [DON] on 3/18/25 at 2:02 PM. The DON confirmed that despite the physician diagnosis of PTSD, Resident #43 did not undergo an assessment or screening to identify behavioral triggers, and was not care-planned for the PTSD diagnosis to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Based on interview and record review, the facility failed to provide services that meet professional standards of quality regarding proper actions following a fall which resulted in harm for one resident [Res.#1]. Findings include: Per review of the Lippincott Manual of Nursing, The standards of care for professional nursing include assessment, diagnosis, implementation and evaluation. Departure from Standards of Care include: Failure to adhere to facility policy or procedural guidelines, failure to monitor or observe a patient's clinical status adequately, failure to make prompt, accurate entries in a patient's medical record. [Lippincott Manual of Nursing Practice-11th Edition 2018] An interview was conducted with the Director of Nursing [DON] on 11/12/24 at 2:22 PM. The DON stated on 10/26/24 at approximately 4:00 AM, s/he received a voicemail from a Licensed Practical Nurse [LPN] at the facility. The DON provided a printed transcript of the voicemail. Per review of the transcript, the LPN reported a Licensed Nurse's Aide [LNA] was pushing Res.#1 in a wheelchair down a hallway. The LPN stated Res.#1 had a fall .kind of fell out of the wheelchair and [s/he] didn't land hard. The DON confirmed the information in the voicemail s/he received on 10/26/24 met the facility's definition of a fall. Per interview with the DON on 11/12/24 and confirmed by record review, the DON reported that a 'Risk Management' form regarding Res.#1's fall on 10/26/24 the resident appeared to be in distress. The DON stated during subsequent interviews with staff who were present after the incident it was revealed that Res.#1 suffered instant bruising after the fall. Per review of the facility's 'Managing of a Fall Policy and Procedure'- Actions/ Responsibilities: Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake . conduct a comprehensive assessment. Step two: notification and communication. Notify the physician and emergency contact. Step three: monitoring and reassessment. Step four: documentation: Incident note or progress notes documenting a fall. Thorough documentation helps ensure that appropriate nursing care and medical attention are given. Whether it is written on the patient's chart or entered in the electronic medical record, documentation for a fall should include: All observations Patient statements Assessments Notifications Interventions Evaluation. [Policy # 06-01 Reviewed/Revised :2/8/24] Additionally, the facility's Fall Protocol lists For any fall whether witnessed or unwitnessed, a thorough head to toe evaluation must be completed to assess for injury. The protocol lists for a WITNESSED FALL- Initial set of vitals [heart rate, respiration rate, blood pressure] and neuros [neurological signs- confusion, pupil reaction, level of consciousness] every shift for 3 days Review of the Risk Management form completed by the LPN who left the fall phone message reports Immediate Action Taken: Full assessment completed. There were no bruises or skin tears. Review of Res.#1's medical record reveals no documentation of any evaluations, vital signs, neurological checks, or assessments conducted on the resident as a result of the fall on 10/26/24, or that a fall had even occurred. Additionally, per interview on 11/12/24, the DON stated during subsequent interviews with staff who were present after the incident it was revealed that Res.#1 suffered instant bruising after the fall. The DON confirmed there was nothing in Res.#1's medical record that demonstrated any of the actions in the Fall Policy and Procedure were conducted after the fall on 10/26/24, including monitoring, assessment, notification, and documentation The DON further stated that 2 days later, on 10/28/24, a review of Res.#1's medical record by the DON revealed that no appropriate actions, including assessments, had been implemented regarding Res.#1's fall on 10/26/24. The DON stated that an 'Incident Order' was then initiated on 10/28/24 that identified the incident on 10/26/24 as a fall in the medical record and triggered staff to initiate the Fall Policy and Procedure, including a comprehensive assessment of the resident. Per review of Res.#1's medical record and confirmed by the DON, on 10/28/24 there again were no actions conducted including comprehensive assessments regarding the resident's fall and the facility's Fall Policy and Procedure. The DON further stated that documentation was then added to Res.#1's medical record on 10/28/24 by the Assistant Director of Nursing [ADON]. The DON stated that the entry was dated effective 10/26/24, and copied from the LPN's Risk Management note. The ADON documented that Res.#1 fell out of a wheelchair, Full assessment completed .there were not bruises or skin tears. The DON confirmed that at the time of the record addition by the ADON, there was still no documentation of a full assessment having been conducted on Res.#1, and there had been instant bruising after the fall. Per record review of progress notes for Res.#1 dated 10/29/24, 3 days after the fall, reveals the resident has not been taking anything significant by mouth on [day] shift for days. However, when [s/he] appears in pain and has nonverbal signs of pain [s/he] is able to take a scant amount of liquid Morphine [opioid pain-relieving medication] in [h/her] cheeks. Resident has been unable to arouse enough to eat or drink safely. [S/he] has not verbalized or made eye contact in days. Further progress notes later on 10/29/24 record Resident slept entire shift. [S/he] would not take anything by mouth. Morphine given at beginning of shift. Resident very shaky . Per review of a statement provided by the DON, and confirmed during interview on 11/12/24, the DON reported that 4 days after the fall, on 10/30/24, a Nurse performing skin check documented old bruising on right shoulder and right upper forehead [of Res.#1] and reported to me [DON]. It is clear these bruises are days old (dark and yellow) and consistent with the fall on 10/26 . MD was notified .X-ray of right shoulder ordered. Per review of LNA task documentation for Res.#1, under Skin Observation, Discoloration is noted by LNAs on 2 different shifts on 10/29/24, the day before the nurse reported bruising to the DON. Per interview with a staff LNA on 11/12/24 at 10:34 AM, if an LNA discovers any skin issues such as discoloration on a resident, the LNA reports those issues to the resident's nurse. Per record review, there is no documentation of any skin discoloration or bruising on Res.#1 by Nursing prior to 10/30/24, or by LNAs prior to 10/29/24, despite staff later reporting instant bruising after the fall. Additionally, the DON confirmed that per record review, on 10/31/24, the day after the bruising was reported by nursing, LNA task documentation again recorded no issues including discoloration observed. Per review of Progress Notes for Res.#1 dated 10/31/24, Mobile Xray in facility to perform shoulder injury due to bruising from 10/26 fall. Result indicates Right clavicle fracture [break in the collar bone]. Per interview with the facility's DON on 11/12/24 and per record review, on 10/26/24, Res.#1 suffered a fall which resulted in instant bruising, distress, and a fractured right clavicle. After the fall, the facility failed to ensure appropriate assessment, notification, and documentation occurred until 4 days later when old bruising prompted diagnostic testing, which identified the fracture. Additionally, documentation in the resident's record that was present or added after the fall did not accurately reflect the actions taken or resident's status.

Based on interview and record review, the facility failed to ensure nursing staff possessed and implemented the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one resident [Res.#1]. Findings include: An interview was conducted with the Director of Nursing [DON] on 11/12/24 at 2:22 PM. The DON stated on 10/26/24 at approximately 4:00 AM, s/he received a voicemail from a Licensed Practical Nurse [LPN#1] at the facility. The DON provided a printed transcript of the voicemail. Per review of the transcript, the LPN reported a Licensed Nurse's Aide [LNA #1] was pushing Res.#1 in a wheelchair down a hallway. The LPN stated Res.#1 had a fall .kind of fell out of the wheelchair and [s/he] didn't land hard. The DON reported to the State Agency that s/he did not know or was not told that Res.#1 suffered a fall, despite confirming during interview that the statements in the voicemail received on 10/26/24 met the facility's definition of a fall. Per interview with the ADON on 11/12/24, the ADON confirmed that s/he conducted Fall Procedure education for facility staff on 10/17/24, 9 days before the fall. The ADON confirmed that the education provided included A progress note needs to be documented [including] explaining how you found them, vitals ['vital signs'-respirations, heart rate, blood pressure], and assessment. Per record review and confirmed by the DON, the Licensed Practical Nurse [LPN #1] who left the voicemail had attended the Fall education 9 days prior to the fall. Per record review and confirmed by the DON, LNA #1, who was pushing the wheelchair when Res.#1 fell , had not received any Fall education since 2023. The ADON stated that after s/he reviewed Res.#1's record and contrary to the education provided 9 days before, s/he discovered LPN #1 provided no documentation in the medical record of the fall or that an assessment had been. The ADON confirmed that the Fall education s/he provided on 10/17/24 included STICK TO THE FACTS ONLY, do not assume what happened. The ADON confirmed that on 10/28/24, two days after the fall, s/he added a note to Res.#1's medical record noting a Full assessment completed .there were not bruises or skin tears despite staff statements regarding instant bruising and no documentation in the medical record of any assessment having been conducted immediately after the fall or during the following 2 days. The ADON reported the Fall Education provided to staff included See Policy for assessment and monitoring tips. Per review of the facility's 'Managing of a Fall Policy and Procedure'- Actions/ Responsibilities: Incident note or progress noted documenting a fall . Documentation for a fall should include; all observations, assessments, evaluations . [Policy # 06-01 Reviewed/Revised :2/8/24] Per interview on 11/12/24, the DON stated during subsequent interviews with staff who were present after the incident it was revealed that staff observed Res.#1 suffered instant bruising after the fall. The DON confirmed that there was no documentation of any observations of bruising for Res.#1 until 3 days after the fall, on 10/29/24. The DON further confirmed that despite instant bruising after the fall and then LNA documentation on 10/29/24, the bruising was not reported to nursing until the evening of 10/30/24. In h/her statement to the State Agency, the DON reported that there have been no reports of bruising as all staff assumed that it had already been reported and that s/he has been told that everyone assumed the bruising was from the fall. The DON confirmed that Fall education referring to Policy and Procedure provided to staff on 10/17/24, included Documentation for a fall should include; all observations, assessments, evaluations . and this was not done. Additionally, during the interview conducted with the DON and ADON on 11/12/24, the DON and ADON stated they were not aware that it was possible that LNAs could and were documenting skin observations on residents' charts. After reviewing the LNA documentation on Res.#1, the DON confirmed the bruising on the resident should have been recorded on 10/26/24 but was not done until 10/29/24. The DON further confirmed that even after the bruising was finally documented, the documentation was inconsistent and the day after reporting the bruising to nursing, LNAs documented no bruising on all 3 shifts. Summary: The DON received a voicemail on 10/26/24 from LPN#1 stating that Res.#1 had a fall .kind of fell out of the wheelchair and [s/he] didn't land hard. The DON reported to the State Agency that s/he did not know or was not told that Res.#1 suffered a fall, despite confirming during interview that the statements in the voicemail received on 10/26/24 met the facility's definition of a fall. LPN #1, despite receiving Fall Education 9 days prior to the fall, failed to follow facility procedures including assessment of the resident and documenting the incident and follow up. LNA staff who received the Fall Education on 10/17/24 failed to document and report bruising and assumed other staff had done so. The ADON, who conducted the Fall Education on 10/17/24, failed to follow procedures noted in the education and recorded that a Full Assessment had been completed despite no documentation in the medical record. Both the DON and ADON determined on 10/28/24 that no complete assessment had been documented on Res.#1 since the fall on 10/26/24 and failed to follow up until nursing reported on 10/30/24 old bruising on right shoulder and right upper forehead [of Res.#1]. Per review of Progress Notes for Res.#1 dated 10/31/24, [5 days after the fall], Mobile Xray in facility to perform shoulder injury due to bruising from 10/26 fall. Result indicates Right clavicle fracture [break in the collar bone].

Based on record review and interview the facility failed to ensure that nursing staff were assessed for skills competency upon hire and annually, based on the care needs of the residents who reside in the facility. Findings include: Per review of employee training and competency records, nursing staff did not have evidence of annual skills competency evaluations. An employee record for a Registered Nurse (RN) who was hired on 11/20/23 had a Competency Checklist dated 12/7/23. This checklist lists various skills and offers instructions as follows: 1. Observe each skill below 2. Provide a Pass or fall rating 3. Place an N/A for any skill that doesn't applying current resident population. Any skill failed will need follow up. This checklist was signed by the RN who assists with staff education on 12/7/2023. However, there were no actual competencies present in the file. A Licensed Practical Nurse (LPN) hired on 2/4/2021 had competencies completed in 2023 for hand washing and IV's. However, there was no Competency Checklist completed, and there were no other competency reviews for 2023 in the file. A Licensened Nursing Assistant hired on 6/3/2020 had a Competency Checklist signed by the RN who assists with staff education on 1/5/23. There was no evidence of completed competencies in the file. A LNA hired on 3/17/2020 had a Competency Checklist completed on 1/5/2023 with no evidence of actual completed competencies. Another LNA had a Competency Checklist completed on 9/26/23 with no actual competencies completed. Per interview on 1/24/24 at 1:01 PM with a staff Registered Nurse (RN) the facility has not assessed him/her for competency including the use of a CPAP machine (a machine that uses mild air pressure to keep breathing airways open while you sleep. The air pressure delivered is determined by the pressure setting on the device), blood glucose monitoring, or blood draws. During an interview on 1/24/24 at 1:17 PM the Registered Nurse who assists with the education of staff confirmed that staff are not assessed for proper medication administration on hire or annually. The RN stated if they are experienced we just let them do it, we do not watch them. On 1/24/24 at 2:30 PM the RN also confirmed that s/he does not routinely do competencies with staff. The Checklist is reviewed and instruction is provided when needed. During an interview on 1/24/24 at 2:12 PM the Director of Nursing confirmed that the nurses had not been assessed for competency in the care and use of a CPAP machine or routine blood draws. During an interview on 1/24/24 at 4:30 PM the Director of Nursing confirmed that the facility has not implimented a fully intact competency evaluation process that includes the skills required to care for the residents who reside there. 46442

Based on observation, interview, and record review the facility failed to ensure that professional standards of practice were followed for 3 of 26 residents in the sample. (Resident #36) related to assessment and monitoring after a choking episode, and (Resident # 188 and Resident #7 ) related to safe administration and monitoring of diabetic medications and blood glucose monitoring. Findings include: 1. Per record review Resident #36 experienced a choking episode which required oropharangeal suctioning. A SBAR (Situation, Background, Assessment, Request form) Note written by the Registered Nurse (RN) on duty on 9/21/2023 states LNA (Licensed Nurse Assistant) brought resident to me, from Lunch room, to Nurse station. Resident was breathing rapidly and pointing to [his/her] mouth, unable to speak or cough. This RN obtained code cart and used suction and yankeur to clean mouth back of throat and illicit cough which produced chocolate milk. Resident immediately felt better. The progress note states that both the Director of Nursing and the Physician were notified however, there were no recommendations documented. There was no evidence of further assessment or monitoring to ensure the resident did not develop complications related to aspiration (food or fluid entering the airway and lungs by accident. This can lead to pneumonia and scarring of the lungs) and suctioning. During an interview on 1/24/24 the Director of Nursing confirmed that Resident #36 should have been further assessed and monitored, but was not. 46442 2. During an interview with Resident #188 on 1/22/23 at 5:12 P.M. a round object covered in bandage tape was observed on Resident #188's upper arm. Per Resident #188 the object on his/her arm was a continuous blood sugar monitor (A continuous glucose monitor (CGM) estimates what your glucose is every few minutes and keeps track of it over time. A tiny sensor is inserted under the skin on your abdomen or arms with an adhesive patch that helps it stay in place). She/he uses his/her cell phone to obtain blood sugar values and then he/she tells the nurses, stating this is how the nurses monitor his/her blood glucose level. The resident also stated that the nurses do not do blood glucose finger sticks. The resident revealed that the glucose monitor has tape over it because it has been in his/her arm for a while. She/he is unable to recall how long exactly, but at least since before he/she was originally admitted to the hospital, and he/she does not want it to fall out. Per record review a physician order states Lispro (a short-acting insulin)16 units three times a day with meals and Lantus (a long-acting insulin) 50 units subcutaneously at bedtime. There is no physicians order for glucose monitoring. There is also no order for the CGM device that the resident has in his/her right upper arm. A care plan focus problem states: Resident has Type 2 diabetes Goal: Resident will not experience complications from diabetes through the review date interventions include monitoring blood sugar as ordered, and notifying MD of blood glucose levels outside of ordered parameters. There are no interventions in place related to the CGM device. According to American Diabetes Association the following professional standard related to the CGM device; 1. When prescribing a device, ensure that people with diabetes/caregivers receive initial and ongoing education and training . https://diabetesjournals.org/ 2. For safety you may sometimes need to compare your CGM glucose readings with a finger-stick test and a standard blood glucose meter Disposable CGM sensors should be replaced every 7 to 14 days . https://www.niddk.nih.gov/ 3. Calibrate the device with a fingerstick blood glucose reading https://my.clevelandclinic.org/ Per interview on 1/24/24 at 1:01 PM with a Registered Nurse (RN) Resident #188 tells her/him what their glucose is before the RN gives Resident #188's insulin before meals. The RN confirmed that there is no order for glucose monitoring and no order for the CGM device. This RN also confirmed he/she has had no training or competency on the care or management of the CGM Device, she/he is unaware of any schedule to change the device. During an interview on 1/24/24 at 1:17 P.M. a second RN confirmed there was no order for glucose monitoring for Resident #188 and this RN has had no training or competency on the CGM device. Per interview on 1/24/24 at 2:12 PM the Director of Nursing (DON) stated I didn't know she/he had that thing (in reference to the CGM device). We do not have a policy for them, we should be checking finger stick blood sugars with a glucometer. (a glucometer is a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip). 3. Per record review, Resident # 7 has a diagnosis of Diabetes Type 2. A review of Physician orders reveals an order for Novolog (short-acting insulin) 10 units three times a day with meals and an order for Levemir (long-acting insulin) twice a day. There is no order to check Resident #7's blood sugar. During an interview on 1/23/24 at 8:45 AM Resident #7 stated They do not check my blood sugar and I take insulin The resident stated that this worries him/her. Resident #7 further stated that he/she has requested to have his/her blood sugars monitored and staff told him/her they would check his/her blood sugar in the in morning, but this is not happening. According to the American Diabetes Association Blood glucose (blood sugar) monitoring is the primary tool you have to find out if your blood glucose levels are within your target range. This tells you your blood glucose level at any one time. It's important for blood glucose levels to stay in a healthy range. If glucose levels get too low, we can lose the ability to think and function normally. If they get too high and stay high, it can cause damage or complications to the body over the course of many years. https://diabetes.org/ During a phone interview on 1/23/24 at 3:05 PM with Resident # 7's physician confirmed that Resident #7 should have glucose monitoring in place. Per interview on 1/24/24 at 11:00 AM the DON confirmed that Resident #7's blood glucose had not been being monitored. The DON stated that s/he had spoke with the doctor yesterday and obtained orders for Blood sugar monitoring.

Based on observation, interview, and record review the facility failed to provide reasonable accommodations of needs and preferences related to a mattress for 1 of 26 residents sampled. (Resident #7). Findings include: Per telephone interview on 1/23/24 at 8:38 AM with Resident #7's family member he/she has been advocating for Resident #7 to receive an air mattress because of the resident's back pain, but the facility refuses to provide one. The family member stated the reason provided is that the resident does not qualify for an air mattress as he/she can move in bed independently and that Resident #7 does not have any open skin. The family member states that she has told them that s/he is willing to pay for the air mattress and the facility just needs to work with her/him to get it. During an interview on 1/23/24 at 9:09 AM Resident #7 was observed sitting in a recliner chair in his/her room. Resident #7 stated that s/he sleeps in the chair all the time because his/her bed is not comfortable. Resident #7 also said that when s/he requested a new mattress the facility did provide one however, the new mattress still hurts his/her back. S/he is unable to turn in bed because of the mattress. During the interview this surveyor applied pressure to the mattress and it sunk down to the point that the bed frame could be felt. On 1/23/24 review of Resident # 7 record reveals that on 4/15/23 resident #7 was sent to the emergency room for evaluation of severe back pain and right hip pain after he/she had fallen a week prior. The resulting diagnosis possible compression fracture of the Thoracic vertebra 11 ( a fracture of the mid-back area). Per interview on 1/23/24 at 1:45 P.M. with a Licensed Nurse Assistant Resident #7 does sleep in his/her recliner, and occasionally will try to get into the bed but it doesn't last long because it is too uncomfortable. During a phone interview on 1/23/24 at 3:05 P.M. Resident #7's physician said that they recall that the Director of Nursing (DON) had stipulations in regards to providing an air mattress for Resident #7. The Physician does agree that an overlay air mattress may help to relieve the pain and he/she will discuss this with the DON. The Physician confirmed that the overlay air mattress is appropriate for Resident #7.

Based on observation, interview, and record review the facility failed to accept a resident back after being transferred to an acute care facility for evaluation for 1 of 26 residents sampled. (Resident #33). Findings include: Per the record review Resident #33 was admitted to the facility on [DATE] for Long Term Care with diagnoses of Parkinson's and Dementia with Psychotic disturbance. Progress notes written between 9/19/23- 9/21/23 reveal that Resident #33 began exhibiting aggressive behaviors, was placed on 1:1 supervision for safety, and was then transferred to the hospital on 9/21/23. A review of the hospital Discharge summary dated 9/29/23 reveals that Resident #33 was seen in the emergency department (ED) and the initial workups was unremarkable. The facility refused to allow Resident #33 to return and s/he stayed in the ED for a week. A Social Services progress note written on 9/19/23 states that the Director of Social Services (DSS) spoke to Resident #33's spouse and explained that the facility could not always provide 1:1 supervision and that if the behaviors continued s/he may be discharged home. On 9/21/23 Resident #33 was transferred to the hospital with aggressive behaviors. A progress note written on 9/21/23 by the Director of Nursing (DON) states the resident had been on 1:1 supervision most of the night. The resident was kicking LNAs and trying to trip people as they walked by . Resident threw [his/her] walker across the hallway which luckily did not make contact with another resident . Another progress note written on 9/21/23 by the DON reveals that although the resident was not exhibiting and behaviors for a few hours at the hospital emergency department the DON refused to allow Resident #33 to return to the facility. Per an interview with the Director of Nursing (DON) on 1/24/24 at 9:33 AM her/his understanding of Resident #33 before admission to the facility was that behaviors were not a problem for him/her. However, a hospital discharge summary found in the resident's record dated 9/13/23 (original date admitted to the facility) reveals under the hospital summary .overnight and this morning patient required an as-needed dose of (PRN) Seroquel (Seroquel is an anti-psychotic medication used to treat certain mental health mood disorders) for impulsive behavior and requires frequent re-direction would suggest scheduled evening dose of Seroquel with additional PRN (as needed) dose indicating that Resident #33 did have behaviors prior to admission. Therefore, the facility staff should have known there was a potential for behaviors. The DON confirmed that Resident #33 was on 1:1 monitoring when he/she flipped the table over and that no other residents were harmed during this event. The DON said that transferring Resident #33 was the only way his/her behavior could be managed by the facility. The DON confirmed that Resident #33 was not allowed to return to the facility based off his/her behaviors at the time of transfer, not per his/her current condition. A review of the Facility Assessment Tool (a facility assessment is a required document used to evaluate the facility's capabilities to provide services to the residents in the facility) Part 2 reveals that the facility has the ability to care for residents with Mental Health issues and Behaviors including Managing the medical conditions and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD and other psychiatric diagnoses.

Based on observation, interview, and record review the facility failed to comprehensively assess a resident's physical needs related to requiring a Continuous Positive Airway Pressure Machine (CPAP) for 1 of 26 residents sampled. (Resident #188). Findings include: During an interview with Resident #188 on 1/22/23 5:12 P.M. a Continuous Positive Airway Pressure Machine (CPAP) was noted on the resident's bedside table. (This is a machine that uses mild air pressure to keep breathing airways open while you sleep. The air pressure delivered is determined by the pressure setting on the device.). Resident #188 stated that he/she wears his/her CPAP at night, and the nursing staff does not assist him/her with the CPAP. He/she stated s/he puts it on, turns it on, and removes it him/herself. Per record review Resident #188 has a diagnosis of sleep apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts.) requiring the use of the CPAP. A physician's order is in place for CPAP at night and for naps every evening and night shift document refusals to wear or frequent removal. The Admission comprehensive assessment/ Minimum Data Set (MDS) with Assessment Reference Date (ARD) (This is a 7-day look back period where the facility gathers the information to be entered into the MDS) of 1/16/24 Section O Special treatments, procedures, and programs the use of a CPAP is coded NO. Indicating the resident does not use a CPAP. Per an interview with the Director of Nursing (DON) on 1/24/24 at 2:12 p.m. completing the resident MDS is part of his/her job, he/she confirmed that the CPAP is not coded on the Admission MDS, therefore the MDS does not accurately reflect Resident #188's status.

Based on observation, review of records, and confirmed by staff interview the facility failed to ensure that the residents' environment remains as free from accident hazards as possible. Hot water temperatures have been documented registering above 120 degrees Fahrenheit (F), in resident rooms dated back to 11/20/17. A deficiency regarding hot water temperatures was also cited during the 7/11/17 annual recertification survey. The findings include the following: Per facility tour on 1/3/18 at 8:57 AM by the surveyor, hot water was identified as running freely in resident rooms. When residents were asked why the water was running the response was to prevent the pipes from freezing. Temperatures were tested throughout the 3 units and the findings included the following: room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 132 degrees F; room [ROOM NUMBER] temperature registered at 124 degrees F; room [ROOM NUMBER] temperature registered at 140 degrees F; room [ROOM NUMBER] temperature registered at 126 degrees F; room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 128 degrees F. The above information was brought to the attention of the Maintenance Director and the Licensed Nursing Home Administrator (LNHA). Temperatures were re-measured using a pocket thermometer and an infrared thermometer, in the presence of both the Maintenance Director and the LNHA. Confirmation was made on 1/3/18 at 9:45 AM that the temperatures were elevated to the degree that residents/staff/visitors could sustain a 3rd degree burn in as quickly as 5 seconds with temperatures at 140 degrees F. Per inspection of water temperature logs, conducted by the Maintenance Department, dating back to 11/20/17, there have been forty-three (43) instances when water temperatures registered above 120 degrees F, and reached as high as 144.9 degrees F. On 1/1/18, facility logs identify that the water temperature in a resident room was 144.9 degrees F. There is no evidence any action was taken after observing that temperature, and no water temperatures were taken until 2 days later, on 1/3/18. Fourteen (14) rooms in the facility are occupied by residents whom the nursing staff confirm (on 1/3/18 at approximately 12:30 PM) are independent and can use the sink without assistance. There are two (2) residents identified as residents who wanderer and ambulate throughout the facility with cognitive impairment. Per interview with the Maintenance Director on 1/3/18 at 10:15 AM, confirmation is made that at various times there has been adjustments to the mixing valves. However, there has been no follow through to ensure that hot water temperatures decreased by the adjustment made, nor were temperatures checked consistently. Water temperatures were only checked on 11/20, 11/30, 12/1, 12/4, 12/7, 12/11, 12/15, 12/20, 12/28, 12/29/17, 1/1 and 1/3/18 all of which registered temperatures above 120 degrees F. All temperature logs identify the reviews were conducted between the hours of 7 AM through 11:35 AM. The Maintenance Director confirms at this time that s/he did not report to administration the elevated water temperatures. Per interview with the LNHA on 1/3/18 at approximately 1:40 PM, confirmation is made that s/he was aware that water temperatures had registered above 120 degrees F. in resident rooms and that mixing valves were being adjusted. The LNHA confirms that s/he did not ensure that the temperatures decreased after valve adjustments nor that the temperatures were being checked inconsistently. S/He confirms that there is no policy/process directing staff to log temperatures at specific times, only what had been identified on the plan of correction dated 7/11/17. The plan documents that room water temperatures will be taken daily, randomly throughout the building and randomly at different times during the day. The temperatures will be monitored to be below 120 degrees. Per interview with the LNHA on 1/3/18 at approximately 3 PM, s/he was questioned as to the content of the education provided to the staff at the time of the citation in July 2017. The LNHA responded staff were told to put their hands under the running water from the faucet and if it was hot they were to let someone know. Confirmation was also made by the Director of Nurses (DNS), who was in charge while the LNHA was away (12/23/17 through 1/2/18), that s/he was not notified by the Maintenance Director of the elevated water temperatures on 1/1/18. Per interview with the DNS confirmation is made that Quality Assurance meetings takes place quarterly. Meeting on 7/18/17, agenda did include discussion pertaining to the citations cited during the annual recertification survey. The next meeting occurred on 10/17/17 and there is no documented agenda, related to hot water temperatures.

Based on observation, review of records, and confirmed by staff interview the facilities Administrator failed to utilize resources effectively and efficiently to ensure that the residents' environment remains as free from accident hazards as possible. Hot water temperatures have been documented registering above 120 degrees Fahrenheit (F), in resident rooms dated back to 11/20/17. This was cited during the 7/11/17 annual recertification survey. The findings include the following: Per facility tour on 1/3/18 at 8:57 AM by the surveyor, hot water was identified as running freely in resident rooms. When residents were asked why the water was running the response was to prevent the pipes from freezing. Temperatures were tested throughout the 3 units and the findings included the following: room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 132 degrees F; room [ROOM NUMBER] temperature registered at 124 degrees F; room [ROOM NUMBER] temperature registered at 140 degrees F; room [ROOM NUMBER] temperature registered at 126 degrees F; room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 128 degrees F. The above information was brought to the attention of the Maintenance Director and the Licensed Nursing Home Administrator (LNHA). Temperatures were re-measured using a pocket thermometer and an infrared thermometer, in the presence of both the Maintenance Director and the LNHA. Confirmation was made on 1/3/18 at 9:45 AM that the temperatures were elevated to the degree that residents/staff/visitors could sustain a 3rd degree burn as quickly as 5 seconds with temperatures at 140 degrees F. Per inspection of water temperature logs conducted by the Maintenance Department, dating back to 11/20/17, there have been forty-three (43) instances when water temperatures registered as high as 144.9 degrees F. On 1/1/18, facility logs identify that the water temperature in a resident room was 144.9 degrees F. There is no evidence any action was taken after observing that temperature, and no water temperatures were taken until 2 days later, on 1/3/18. Fourteen (14) rooms in the facility are occupied by residents whom the nursing staff confirm (on 1/3/18 at approximately 12:30 PM) are independent and can use the sink without assistance. There are two (2) residents identified as residents who wanderer and ambulate throughout the facility with cognitive impairment. Per interview with the Maintenance Director on 1/3/18 at 10:15 AM, confirmation is made that at various times there has been adjustments to the mixing valves. However, there has been no follow through to ensure that hot water temperatures decreased by the adjustment made, nor were temperatures checked consistently. Water temperatures were randomly checked on 11/20, 11/30, 12/1, 12/4, 12/7, 12/11, 12/15, 12/20, 12/28, 12/29/17, 1/1 and 1/3/18 all of which registered temperatures above 120 degrees F. All temperature logs identify the reviews were conducted between the hours of 7 AM through 11:35 AM. The Maintenance Director confirms at this time that s/he did not report to administration the elevated water temperatures. Per interview with the LNHA on 1/3/18 at approximately 1:40 PM, confirmation is made that s/he was aware that water temperatures had registered above 120 degrees F. in resident rooms and that mixing valves were being adjusted. The LNHA confirms that s/he did not ensure that the temperatures decreased after valve adjustments nor that the temperatures were being checked inconsistently. S/He confirms that there is no policy/process directing staff to log temperatures at specific times, only what had been identified on the plan of correction dated 7/11/17. The plan documents that room water temperatures will be taken daily, randomly throughout the building and randomly at different times during the day. The temperatures will be monitored to be below 120 degrees. Per interview with the LNHA on 1/3/18 at approximately 3 PM, s/he was questioned as to the content of the education provided to the staff at the time of the citation in July 2017. The LNHA responded staff were told to put their hands under the running water from the faucet and if it was hot they were to let someone know. Confirmation was also made by the Director of Nurses (DNS), who was in charge while the LNHA was away (12/23/17 through 1/2/18), that s/he was not notified by the Maintenance Director of the elevated water temperatures on 1/1/18. Per interview with the DNS confirmation is made that Quality Assurance meetings takes place quarterly. Meeting on 7/18/17, agenda did include discussion pertaining to the citations cited during the annual recertification survey. The next meeting occurred on 10/17/17 and there is no documented agenda, related to hot water temperatures.

Based on observations, review of records, and staff interview, the facility Quality Assurance Committee failed to put in place a plan to ensure that hot water temperatures did not exceed 120 degrees F. These elevated hot water temperatures affect the safety of residents, staff and visitors. During the last recertification survey in July 2017, the facility was cited for accident hazards related to elevated hot water temperatures. The findings during this investigation are as follows: Per inspection of water temperature logs conducted by the Maintenance Department, dating back to 11/20/17, there have been forty-three (43) instances when water temperatures registered as high as 144.9 degrees F. According to Centers for Medicare/Medicaid Services (CMS) State Operations Manual Interpretive Guidance, at a temperature of 140 degrees F, it takes only 5 seconds of exposure to cause a 3rd degree burn. On 1/1/18, facility logs identify that the water temperature in a resident room was 144.9 degrees F. There is no evidence any action was taken after observing that temperature, and no water temperatures were taken until 2 days later, on 1/3/18. Fourteen (14) of the forty-three (43) rooms are occupied by residents whom the nursing staff confirm (on 1/3/18 at approximately 12:30 PM), are independent and can use the sink with no assistance. One (1) resident identified that s/he mixes cold water when the water feels too hot. There are two (2) residents identified as residents who wanderer and ambulate throughout the facility, with cognitive impairment. Water temperatures were randomly checked by the maintenance department on 11/20, 11/30, 12/1, 12/4, 12/7, 12/11, 12/15, 12/20, 12/28, 12/29/17, 1/1 and 1/3/18 all of which registered temperatures above 120 degrees F. All temperature logs identify review between the hours of 7 AM through 11:35 AM, no off-hour reviews. Per interview with the DNS confirmation is made that Quality Assurance meetings takes place quarterly. The meeting on 7/18/17, had an agenda that included a discussion pertaining to the citations cited during the annual recertification survey. The next meeting occurred on 10/17/17 and there was no documented agenda, related to hot water temperatures. The next quarterly meeting is scheduled of the 3rd week of January 2018.

Based on observation, record review and confirmed by staff interview the facility failed to provide a safe environment for residents, staff and the public. Hot water temperatures have been documented registering above 120 degrees Fahrenheit (F), in resident rooms dated back to 11/20/17. This was cited during the 7/11/17 annual recertification survey. The findings include the following: Per facility tour on 1/3/18 at 8:57 AM by the surveyor, hot water was identified as running freely. When residents were asked why the water was running the response was to prevent the pipes from freezing. Temperatures were tested throughout the 3 units and the findings included the following: room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 132 degrees F; room [ROOM NUMBER] temperature registered at 124 degrees F; room [ROOM NUMBER] temperature registered at 140 degrees F; room [ROOM NUMBER] temperature registered at 126 degrees F; room [ROOM NUMBER] temperature registered at 138 degrees F; room [ROOM NUMBER] temperature registered at 128 degrees F. The above information was brought to the attention of the Maintenance Director and the Licensed Nursing Home Administrator (LNHA). Temperatures were re-measured using a pocket thermometer and an infrared thermometer in the presence of both the Maintenance Director and the LNHA. Confirmation was made on 1/3/18 at 9:45 AM that the temperatures were elevated to the degree that residents/staff/visitors could sustain a 3rd degree burn as quickly as 5 seconds with temperatures at 140 degrees F. Per inspection of water temperature logs conducted by the Maintenance Department, dating back to 11/20/17, there have been forty-three (43) instances when water temperatures registered as low as 120.2 degrees F and/or as high as 144.9 degrees F. On 1/1/18, facility logs identify that the water temperature in a resident room was 144.9 degrees F. There is no evidence any action was taken after observing that temperature, and no water temperatures were taken until 2 days later, on 1/3/18. Fourteen (14) resident rooms are occupied by residents whom the nursing staff confirm (on 1/3/18 at approximately 12:30 PM) are independent and can use the sink independently and there are two (2) residents identified as residents who wander and ambulate throughout the facility, with cognitive impairment. Per interview with the Maintenance Director on 1/3/18 at 10:15 AM, confirmation is made that at various times there has been adjustments to the mixing valves as documented. However, there has been no follow through to ensure that hot water temperatures decreased by the adjustment made, nor were temperatures checked consistently. Water temperatures were randomly checked on 11/20, 11/30, 12/1, 12/4, 12/7, 12/11, 12/15, 12/20, 12/28, 12/29/17, 1/1 and 1/3/18 all of which registered temperatures above 120 degrees F. All temperature logs identify review between the hours of 7 AM through 11:35 AM. The Maintenance Director confirms at this time that s/he did not report to administration the elevated water temperatures. Per interview with the LNHA on 1/3/18 at approximately 1:40 PM, confirmation is made that s/he was aware that water temperatures had registered above 120 degrees F. in resident rooms and that mixing valves were being adjusted. The LNHA confirms that s/he did not ensure that the temperatures decreased after valve adjustments nor that the temperatures were being checked consistently. S/He confirms that there is no policy/process directing staff to log temperatures at specific times, only what had been identified on the plan of correction dated 7/11/17. The plan documents that room water temperatures will be taken daily, randomly throughout the building and randomly at different times during the day. The temperatures will be monitored to be below 120 degrees. Confirmation was also made by the Director of Nurses (DNS), who was responsible professional while the LNHA was away (12/23/17 through 1/2/18), that s/he was not notified by the Maintenance Director of the elevated water temperatures on 1/1/18.

Based on record review and confirmed by staff interview the facility failed to ensure that 1 sampled resident, who was admitted with pressure ulcers, received the necessary care to promote healing and avoid further breakdown (Resident #1) . The findings include the following: Resident #1 was admitted for a 6 week respite stay with multiple pressure ulcers. [DIAGNOSES REDACTED]. Per review of the medical record, on the Admission evaluation dated 11/14/17, the Licensed Practical Nurse (LPN) documents wounds as follows: -Right Elbow pressure (no measurements); -Right Heel pressure 6 centimeters (cm) by 4 cm stage III; -Right Toes pressure (no measurements); -Left Toes pressure (no measurements); -Sacrum pressure 5.5 cm by 4.0 cm depth 1 cm stage II; -Multiple areas bilateral feet. Bilateral malleolous dime sized reddened areas-blanchable. Right outer foot necrotic area-unable to stage. Left foot intact large blister medial heel-unable to stage. DNS confirms during an interview on 1/3/18, that Resident #1's sacral pressure ulcer worsened during the 20 day stay at the nursing home. On 12/1/17, Resident #1's left lateral heel blister developed a foul odor and on 12/3/17 was draining serosanguinous fluid from an opening, where it had been intact. Confirmation was also made that wounds were not measured weekly as per policy. The sacral wound was measured on admission and then again 19 days later, right heel was measured on admission then 12 days later and the left lateral heel was identified on admission and measured 15 days later. Actual nursing notes include: A 12/1/17 LPN progress note identifies the wound at the left lateral foot area has a very foul odor. A 12/3/17 RN progress note identifies the sacrum wound 5.5 cm x 0.85 cm wide with a 0.8 deep area at one point, with a foul odor. RN describes the wound bed as having several small brown areas mixed with red areas and copious amount of serosanguinous drainage. There is also a 4 cm x 4 cm red excoriated area below the above area. A MD progress note dated 11/24/17, documents that the patient refuses position change. Nurses notes throughout the 20 day stay, evidence only 2 occasions the resident requested to not be disturbed and one occasion refused a bath. There is no further evidence documented in the medical record, identifying that Resident #1 refused care. Interviews with Licensed Nurse Aides (LNAs), do not confirm that the resident refused care. The facility skin care policy identifies, if pressure in nature, wounds will be assessed, measured and documented on a weekly basis by the wound team.

Based on interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable well-being for 1 applicable resident regarding emergency medical care and neurological assessments after a fall (Resident #1). Findings include: Per interview on 02/15/11 at 12:45 PM, a family member expressed concern regarding Resident #1's well-being after a fall on 02/08/11, stating that the resident was not sent to the emergency room (ER) for nearly 10 hours after a severe fall. Per record review of the incident/accident report, the fall occurred at approximately 3:50 AM on 2/08/11, and stated that the "resident was found on rounds prone on floor with head under bed." Per a verbal order dated 02/08/11 at 2:00 PM 'transport to ER for evaluation of right wrist'. Per the ER note's dated 02/08/11 at 2:47 PM, the resident sustained [REDACTED].laceration repair: length 8.0 cm (approximately 3 inches) complex requiring alignment (with sutures) of multiple flaps and revision of wound margins". Per review of the nurses's notes dated 02/08/11, a late entry note at 1:38 PM states "cleaned all areas, wrapped non-adherent pad to right hand with kerlix, padded [MEDICATION NAME] applied to left hand, bleeding controlled...complains of pain, refuses Tylenol...MD, family, DNS and Administrator aware". Per review of the resident's medical record, the Neurological Record dated 02/08/11 had only 2 assessments obtained during the first several hours ( 3:50 AM & 4:20 PM) and 1 obtained prior to sending to the ER at 12:15 PM. Per the facility's Neurological Record, used for falls, staff were to monitor the resident's neurological status every 30 minutes for the first 2 hours, then every hour for 4 hours, every 4 hours for the first 24 hours and every 8 hours for 72 hours. Per interview on 02/15/11 at 2:30 PM, the staff nurse was not able to verbalize why the resident was not sent to the ER after sustaining severe injuries, where the policy and procedure manuals for falls/ER referrals are located to help direct staff for optimal resident care in emergent situations, nor why there was a lack of monitoring of the neurological/vital signs for this resident after this fall. Per interview at 2:45 PM, the Director of Nursing (DNS) confirmed that the resident's highest well-being was not maintained, as the necessary care and services were delayed.