Every finding on record at Hanover Terrace Health and Rehabilitation

Based on interview and record review, it was determined that the facility failed to develop a water management program that identified where in the facility that Legionella, or other opportunistic waterborne pathogens, could grow and spread and did not include established ways to intervene when control limits were not met. This failure had the potential to affect the facility census of 52 residents.Findings include:Review on 12/3/25 of the facility's Legionella Water Management Plan dated 10/10/25 revealed .III. Areas Where Legionella Could Grow and Spread: Dead legs and areas where water is used very little (Empty Rooms) . V. Ways to Intervene When Control Limits Are Not Met . was coded N/A or Not Applicable. The plan did not identify where the dead legs were in the facility and did not identify additional areas such as ice machine, eye wash stations and resident equipment (CPAP (Continuous Positive Pressure Airway)). Interview on 12/4/25 at 8:33 a.m. with Staff D (Maintenance Director) confirmed that the plan did not identify where the dead legs were or ways to intervene if control limits were not met. Staff D revealed that the facility had two shower rooms that each had a capped dead leg. Staff D revealed that the facility used the CDC (Centers for Disease Control and Prevention) for standards and guidance. Review on 12/4/25 of the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings dated September 30, 2025 revealed, .3. Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in you building water systems . Each potentially hazardous condition should be addressed individually with a control point, measure, and limit . 5. Establish Ways to Intervene When Control Limits Are Not Met . You should plan for your monitoring results to vary over time and be prepared to apply corrective actions. Corrective actions are taken in response to systems performing outside of control limits . Review on 12/4/25 of the CDC's Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit revealed, . Any Device that Contains Nonsterile Water Can Grow Legionella. In the absence of control, Legionella can grow in almost any system or equipment containing nonsterile water, such as tap water, at temperatures favorable to Legionella growth. Devices that may grow Legionella in the absence of control include the following . eyewash stations . medical equipment (e.g., .CPAP) . Ice machines .

Based on interview and record review, it was determined that the facility failed to implement the facility's antibiotic stewardship program and antibiotic use protocols for 6 of 6 months of antibiotic use reviewed. Findings include:Review on 12/4/25 of the facility's policy titled Infection Prevention and Control Program dated May 30, 2023 revealed, . Infection Control Preventionist Duties include: Conducts surveillance for facility associated infections and/or communicable diseases . Surveillance. Ongoing surveillance is recognized as fundamental component of a strong effective infection control and prevention program. The Infection Preventionist will perform ongoing surveillance to identify opportunities to prevent and/or reduce the rate of infections within residents, employees, and visitors. The Mcgeer's criteria will be used to standardize the definition and criteria for infection. Standardized logs will be used for line listing infections throughout the month. These will be reviewed regularly by the facility Infection Control Preventionist for any trends that need to be addressed before the month ends . Surveillance activities will be ongoing and documented for the purposes of tracking, trending and identifying needs . Surveillance activities will be part of the Infection Control Sub-committee's report to the facility wide Quality Assurance Performance Improvement committee . Interview on 12/4/25 at 11:02 a.m. with Staff E (Director of Nursing) revealed the above policy was current through 10/31/25 when the facility had change of ownership. Staff E revealed the following policies took effect on 11/1/25. Review on 12/4/25 of the facility's policy, dated September 2023 and titled Antibiotic Stewardship - Antibiotic Orders revealed, . 3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis . 4. Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record . Review on 12/4/25 of the facility's policy, dated September 2023 and titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revealed, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship . 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee . 4. All resident antibiotic regimens will be documented on the facility -approved antibiotic surveillance tracking form . Review on 12/4/25 of the facility's Infection Control Line Listing Detail revealed that the antibiotic line listings included the resident's name; room; category; date of onset; symptoms; culture date; site and result; treatment; total number of treatment days; if was re-evaluated for potential early stop due to lab results/resident status; infection cleared; comments and final status count. The antibiotic line listings did not indicate if the antibiotics were appropriate for use or if McGeer Criteria were utilized. Further review revealed the following:For June 2025, there were twelve residents on antibiotics. For July 2025, there were eight residents on antibiotics. For August 2025, there were four residents on antibiotics. For September 2025, there were eight residents on antibiotics.There were no antibiotic line listings for October and November 2025 Review on 12/4/25 of a list of residents with physician's orders for antibiotics, provided by Staff E, revealed that there were three residents in October 2025 and four residents in November 2025 who received antibiotics. Interview on 12/03/2025 at 2:08 p.m. with Staff E confirmed that above line listings did not indicate if antibiotic use met criteria and that there was no surveillance done for October and November 2025. Interview on 12/4/25 at 11:53 a.m. with Staff F (Administrator) revealed there was no antibiotic stewardship data presented in QAPI or discussion about antibiotic use, such as tracking and trending of appropriateness of antibiotic treatments in the past four months.

Based on interview and record review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for an individual who required greater than 30 days of nursing services (Resident identifier is #6).Findings include:Review on 12/2/2025 of Resident #6's PASARR dated 9/30/2025 (date of resident admission) revealed in Section 6. Exemption/Exclusion that this PASARR was for a Hospital Discharge that will require less than 30 days of nursing services. For a long-term care stay longer than 30 days a new PASARR would be required to be submitted by 11/9/2025.Interview on 12/3/2025 at approximately 12:50 p.m. with Staff C (Social Worker) confirmed a second PASARR was not completed by 11/9/25.

Based on interview and record review, it was determined that the facility failed to ensure that residents were free from abuse and neglect for 3 of 6 allegations of abuse reviewed (Resident identifiers are #2, 3, and 4). Findings include: Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance report was filed by Staff G (Licensed Nursing Assistant (LNA)) for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (Licensed Practical Nurse (LPN)), Staff A (Director of Nursing (DON)) and Staff B (Administrator) and dated 12/28/22. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. The LNA came in and said they were alone and had to help someone else and would be back. Resident #3 stated that they laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke back up and rang again and that is when the day LNA came in and helped them. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22. 40522 Resident #2 Interview on 1/3/23 at approximately 11:00 a.m. with Anonymous #2 revealed that at the end of last week, Resident #2 was observed to have large dark purple area to left elbow with swelling, dark purple bruise to right upper arm with swelling, large purple area across the rib cage in alignment with the breast. Anonymous #2 stated that the DON was aware about these bruises. Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that it was alleged by staff that Staff F (LNA) was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. an LNA reported that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9 [length] x [by] 6 [width] cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:32 a.m. nurse's note revealed that the DPOAH [Durable Power of Attorney for Health] was updated regarding Resident #2's bruising. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in the chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of the chair that lines up perfectly with the bruise to [pronoun omitted] left side. and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [Physical Therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed resident [Resident #2] is presenting with a 10 / [out of] 10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing]. gave resident [Resident #2] Tylenol. -1/2/23 at 7:12 a.m. nurse's notes revealed that Large fluid filled pockets noted on bilateral upper arms near bruises areas. Resident [Resident #2] continues to display signs of pain when arms are touched or moved. PRN [as needed] Tylenol given with no effect. Noted in MD [Doctor of Medicine] communication book, oncoming nurse aware. -1/2/23 at 9:56 a.m. nurse's note revealed Writer spoke with On Call Provider [provider name omitted] regarding increase in pain. MD sent order to [pharmacy name omitted] for 2.5 mg [milligram] Oxycodone po [by mouth] q3h [every 3 hours] PRN, MD stated if 2.5 [mg] was not effective in 30 minutes to call back and [pronoun omitted] would increase dose to 5 mg po prn q3h. Orders entered. Writer spoke with POA [Power of Attorney] who agreed to have resident try the Oxycodone to keep [pronoun omitted] comfortable. Resident resting in bed, anytime writer or other staff attempt to reposition resident [pronoun omitted] [sic] expresses 10/10 pain in right arm. -1/2/23 at 11:22 a.m. nurse's note [late entry, created date of 1/5/23 at 11:24 a.m.] revealed that .It was noted by nurse that resident existing bruising had become larger and was causing more pain to the resident. Nurse gave prn Tylenol with good results. Resident is at end of life and is starting the mottling process. Bruising has spread die to poor circulation. MD and family notified. Will continue to monitor. Further review of the nurse's note revealed no other documentation regarding Resident #2's bruises. Interview on 1/5/23 at 2:30 p.m. with Staff A revealed that he/she was notified on 12/28/22 that Resident #2 had bruises on both arms and left lateral side of chest. Staff A stated that staff had mention to him/her that since agency staff worked they have noticed increase bruising to residents. Staff A also stated that as there were no staff names and it was hearsay they did not investigate this allegation. Further interview with Staff A revealed that he/she was not aware of any allegations of rough handling by Staff F prior to this week. Staff A also stated that the cause of the right arm bruising was inappropriate repositioning and that Staff F did not utilize a draw sheet for repositioning and education was provided. Staff A was unable to provide documentation of education to staff for proper repositioning. Interview on 1/6/23 at approximately 10:10 a.m. with Staff R (LPN) revealed that he/she heard of rough handling by Staff F. Staff R stated that he/she brought this to management and was told by the DON that they are young. Staff R also stated that he/she had mentioned rough handling by Staff F to Staff C about 1 month ago and that Staff C was going to handle it. Staff R was not aware of any outcome of that reporting. Interview on 1/6/23 at 10:10 a.m. with Staff U (Advanced Practical Registered Nurse (APRN)) revealed that Staff U evaluated Resident #2 on 1/3/23 and Staff U stated that he/she did not have a discussion with the DON nor Nurse Unit Manager about the cause of Resident #2's bruises. Interview on 1/6/23 at 11:00 a.m. with Staff M (LNA) revealed that he/she had observed Staff F being rough during a transfer. Staff M stated that Staff F was hoyering Resident #2 with another staff out of bed and that the hoyer pad was not placed correctly. Staff M also stated that Staff F pulled the hoyer pad out under Resident #2 where Resident #2 hit the railing. Staff M also stated that this incident happened approximately 2 & 1/2 months ago and that he/she reported this to the nurse. Interview on 1/9/22 at approximately 10:00 a.m. with Resident #2's DPOA revealed that he/she was notified that Resident #2 had bruising in the arms the fourth week of December 2022 and also last week when Resident #2 had increase pain and bruising. Resident #2's DPOA stated that he/she was not aware of the extent of Resident #2's bruises and that he/she was told the Resident #2 has some bruises. Resident #2's DPOA also stated that if he/she was aware of the extent of Resident #2's bruises, he/she would have wanted to know what had happened. Interview with the Medical Examiner on 1/20/23 at aproximatley 1:30 p.m. revealed that an autopsy was performed and Resident #2 had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death. Resident #4 Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed there had been a report of alleged abuse by Staff F and that Staff F was suspended pending investigation. Review on 1/6/23 of email threads revealed that an anonymous email was sent to Human Resources (HR) on 1/4/23 5:56 p.m Further review of the anonymous email dated 1/4/23 revealed .I am concerned with [Staff F name omitted]. [pronoun omitted] is extremely unprofessional and abusive to the residents. I heard about the incident with [Resident #1's name omitted], and I was told about an incident with [Resident #4's name omitted] .This incident was witnessed by 3 other employees .The nurses [Staff Q [LPN] name omitted] and [Staff R [LPN] name omitted] were both in the room with [Staff F name omitted] .slap [Resident #4's name omitted] right across the stomach .[Staff F name omitted] calls the patient [sic] out their names [pronoun omitted] swears at them, [pronoun omitted] is extremely disrespectful . Review of the email threads revealed that the email dated 1/4/23 was forwarded to the Staff A on 1/5/23 at 8:09 a.m. and forwarded again on 1/5/23 at 10:30 a.m. to Staff C. Interview on 1/6/23 at 11:26 a.m. with Staff Q revealed that on 1/2/23, he/she was in Resident #4's room along with Staff F, Staff G, and Staff R to change Resident #4's catheter. Staff Q stated that he/she observed Staff F, with open hand, hit Resident #4's abdomen and Resident #4 responded by hitting Staff F. Staff Q stated that he/she felt uncomfortable about the situation. Staff Q also stated that he/she did not report this incident Interview on 1/6/23 at approximately 11:34 a.m. with Staff R revealed that on 1/2/23, he/she was assisting Staff Q with Resident #4's catheter change. Staff R stated that he/she was in Resident #4's room when he/she heard a loud smack and when he/she turned towards the noise Resident #4 was hitting Staff F. Staff R stated that he/she did not report this incident.

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations involving abuse were reported to the Administrator, State Survey Agency (SSA) and other officials for 5 out of 6 allegations of abuse reviewed (Resident identifiers are #1, #2, #3, #4, and #6). Findings include: Resident #1 Review on 1/5/23 at approximately 11:30 a.m. of facility investigation for Resident #1 alleged abuse dated 1/2/23, with a time stamp of 22:20 [10:20 p.m.], revealed the following: Resident #1 reported that they did not want the young [pronoun omitted] who took care of [pronoun omitted] today to take care of [pronoun omitted] again. Resident #1 reported that the Licensed Nursing Assistant (LNA) slapped [pronoun omitted] buttocks, smacked them with plastic bags, and laughed about it. Resident #1 described the LNA by approximate age and hair color. Resident #1 also stated that they had stated I wish to die if I am going to be beat, and the LNA responded by stating I wish you would die too. Further review of the facility investigation revealed that the Director of Nursing (DON) and the Nurse Unit Manager were notified at the time of filling out the report. Two staff statements were attached to the investigation. The statements were from Staff F (LNA) and Staff G (LNA). Interview on 1/5/23 at approximately 2:30 p.m. with Staff A (DON) revealed they were notified of 1/2/23 incident involving Resident #1 around 10:30 a.m. on 1/3/23. Staff A stated that Resident #1 denied allegations so no further investigation or reporting was necessary. Staff A confirmed that no education was provided after the conclusion of this incident as nothing was identified as a concern. Staff A confirmed that no report to the SSA was sent regarding this incident. Interview on 1/6/23 at approximately 8:42 a.m. with Staff D (Licensed Practical Nurse (LPN)) revealed that on 1/2/23 they had called and spoke to Staff A regarding incident with Resident #1 when they completed the investigation form. Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance was filed by Staff G for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D, Staff A and Staff B (Administrator) and dated 12/28/22 Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they had met with Resident #3 on the morning of 12/28/22 and resolved the situation by having the day LNA take care of [pronoun omitted]. Staff C stated that they did not initiate an investigation and did not identify the LNA in question but handed the grievance report off to the DON and was unaware of what occurred after that. Interview on 1/5/23 at approximately 2:00 p.m. with Staff B revealed they had no knowledge of any investigation for Resident #3's grievance as it was marked resolved on 12/28/22. Staff B confirmed that to their knowledge no report was made to the SSA regarding this incident. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22. Staff A confirmed no report was made to the state survey agency regarding this incident. Surveyor: Wee Sit, [NAME] C. Resident #2 Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that it was alleged by staff that Staff F was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. nurse's notes revealed that an LNA reported that that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9x6 [length x width] cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in their chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of their chair that lines up perfectly with the bruise to [pronoun omitted] left side. and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [physical therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed resident [Resident #2] is presenting with a 10/10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing], gave resident [Resident #2] tylenol. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that he/she was notified about Resident #2's bruises, as mentioned above, the morning of 12/28/22. Further interview with Staff A also revealed that at that time, there were staff accusing agency staff and that there were no staff names mentioned and what was told to him/her was after agency staff started working more bruises were observed on residents and that they were hearsay. Staff A stated that there were no reports submitted to the SSA related to the bruising as it was related to the wheelchair positioning and the improper repositioning by staff. Staff A also stated that the accusation from staff related to the agency nursing staff was hearsay and there were no staff names mentioned and so this was not reported to the SSA. Staff A also stated that the staff should have reported to him/her that night that they initially observed the bruises on Resident #2. Resident #4 Review on 1/6/23 of an email thread revealed that an anonymous email was sent to Human Resources (HR) on 1/4/23 at 5:56 p.m Further review of the anonymous email dated 1/4/23 revealed .I am concerned with [Staff F [LNA] name omitted]. [pronoun omitted] is extremely unprofessional and abusing to the residents. I heard about the incident with [Resident #1's name omitted], and I was told about an incident with [Resident #4's name omitted] .This incident was witnessed by 3 other employees .The nurses [Staff Q [LPN] name omitted] and [Staff R [LPN] name omitted] were both in the room with [Staff F name omitted] .slap [Resident #4's name omitted] right across the stomach .[Staff F name omitted] calls the patient out their names [pronoun omitted] sweats at them, [pronoun omitted] is extremely disrespectful . Review of the email threads revealed than the email dated 1/4/23 was forwarded to the Staff A on 1/5/23 at 8:09 a.m. and forwarded again on 1/5/23 at 10:30 a.m. to Staff C. Review on 1/6/23 of initial report dated 1/5/23 for Resident #4 revealed that the initial report was sent to the State Survey Agency (SSA) on 1/5/23 at approximately 2:45 p.m. via fax, which is more than 2 hours from the reported alleged violation as mentioned on above email dated 1/4/23. Interview on 1/6/23 at 11:26 a.m. with Staff Q (LPN) revealed that last Monday (1/2/23) Resident #4 needed their foley catheter change which Staff R (LPN), Staff F, and Staff G, assisted Staff Q. Staff Q stated that he/she observed Staff F hit Resident #4's stomach with an open hand. Staff Q also stated that he/she felt uncomfortable after witnessing what Staff F did and thought that what Staff F did was inappropriate. Staff F also stated that he/she did not report this to the DON or the Administrator. Resident #6 Review on 1/5/23 of Resident #6's nurse's notes revealed that on 12/26/22 Resident #6 was found to have a purple burises above their right eye measuring about 6 cm [centimeter] [length] by 2 cm [width], and periwound was yellow. Further review of the nurse's note dated 12/2622 revealed that Risk Management was noted. Review on 1/5/23 of the facility's incident report on Resident #6's bruise to right eye dated 12/26/22 at 9:22 a.m. revealed that the bruise to right eye had an unknown cause. Review on 1/5/23 of Resident #6's nurse's note revealed that on 12/27/22 at 1:55 p.m. Resident #6 had a bruise on right eye that he/she may have bumped their head on the cross bar of the hoyer lift. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A confirmed that the bruise to the right eye with the unknown cause when initially found should have been reported to him/her on 12/26/22. Staff A stated that he/she was not aware of Resident #6's bruise to right eye when initially found on 12/26/22 and that this bruise to right eye with an unknown cause was not reported to the SSA. 40522

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse or neglect were thoroughly investigated for 3 out of 6 abuse allegation reviewed (Resident identifiers are #2, #3, and #6). Findings include: Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance was filed by Staff G (Licensed Nursing Assistant (LNA)) for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (License Practical Nurse (LPN)), Staff A (Director of Nursing (DON)) and Staff B (Administrator) and dated 12/28/22. Review on 1/5/23 at approximately 11:30 a.m. of facility nursing schedule for Dementia Unit for the night shift on 12/27/22 into 12/28/22 revealed one LNA on for the entire shift and one nurse. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. The LNA came in and said they were alone and had to help someone else and would be back. Resident #3 stated that he/she laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke back up and rang again and that is when the day LNA came in and helped him/her. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they had met with Resident #3 on the morning of 12/28/22 and resolved the situation by have the day LNA take care of him/her. Staff C confirmed that they did not initiate an investigation and did not identify the LNA in question but handed the grievance report off to the DON and was unaware of what occurred after that. Interview on 1/5/23 at approximately 2:00 p.m. with Staff B revealed they had no knowledge of any investigation for Resident #3's grievance report as it was marked resolved on 12/28/22. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22. 40522 Resident #2 Interview on 1/3/23 at approximately 11:00 a.m. with Anonymous #2 revealed that at the end of last week, Resident #2 was observed to have large dark purple area to left elbow with swelling, dark purple bruise to right upper arm with swelling, large purple area across the rib cage in alignment with the breast. Anonymous #2 stated that the DON was aware about these bruises. Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that they were aware of occations that it was alleged by staff that Staff F (LNA) was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Interview on 1/5/23 at approximately 11:00 a.m. with Staff K (LNA) and Staff L (LNA) revealed that they were aware of Resident #2's bruising on the right arm, left elbow, and left lateral side of chest underneath the breast. Staff K and Staff L stated that they were not aware of any incidents that would cause the bruises and that they were told it was related to the wheelchair positioning. Staff K and Staff L also stated that Resident #2 was dependent with staff and that Resident #2 would not be able to self-reposition themselves in the wheelchair. Staff K and Staff L also stated that Resident #2 only had a positioning wedge in between their legs. Interview on 1/5/23 at approximately 1:19 p.m. with Staff N (Therapy Manager) revealed that there was a physical therapy referral for Resident #2 on 12/29/22 for wheelchair positioning. Staff N stated that the evaluation was not completed as Resident #2 was in bed and not able to get out of bed due to decline in condition and pain. Staff N also stated that there were no discussion with the nursing team regarding the possible correlation of the bruising, as mentioned above, with the wheelchair positioning. Interview on 1/5/23 at approximately 1:20 p.m. with Staff O (LPN) and Staff P (LPN) revealed that they were aware that last week (fourth week of December 2022) Resident #2 had bruising to right elbow, right upper arm, left lateral side of chest under the breast. Staff O and Staff P stated that Staff A and Staff C were aware. Staff O and Staff P also stated that the Staff A and Staff C had asked staff if anybody witnessed any incidents that would cause the bruising and that both Staff O and Staff P was unaware of any incidents which would have caused the bruising. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. nurse's notes revealed that an LNA reported that that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9x6 (length x width) cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:32 a.m. nurse's note revealed that the Durable Power of Attorney for Health (DPOAH) was updated regarding Resident #2's bruising. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in their chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of their chair that lines up perfectly with the bruise to [pronoun omitted] left side and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [physical therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed Resident [Resident #2] is presenting with a 10/10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing], gave resident [Resident #2] Tylenol. -1/2/23 at 7:12 a.m. nurse's notes revealed that Large fluid filled pockets noted on bilateral upper arms near bruises areas. Resident [Resident #2] continues to display signs of pain when arms are touched or moved. prn [as needed] Tylenol given with no effect. Noted in MD [Doctor of Medicine] communication book, oncoming nurse aware. -1/2/23 at 9:56 a.m. nurse's note revealed Writer spoke with On Call Provider [provider name omitted] regarding increase in pain. MD [Doctor of Medicine] sent order to [pharmacy name omitted] for 2.5 mg [milligram] Oxycodone po [by mouth] q3h [every 3 hours] prn, MD stated if 2.5 [mg] was not effective in 30 minutes to call back and [pronoun omitted] would increase dose to 5 mg po prn q3h. Orders entered. Writer spoke with POA [Power of Attorney] who agreed to have resident try the Oxycodone to keep [pronoun omitted] comfortable. Resident resting in bed, anytime writer or other staff attempt to reposition resident [pronoun omitted] [sic] expresses 10/10 pain in right arm. -1/2/23 at 11:22 a.m. nurse's note [late entry, created date of 1/5/23 at 11:24 a.m.] revealed that .It was noted by nurse that resident existing bruising had become larger and was causing more pain to the resident. Nurse gave prn Tylenol with good results. Resident is at end of life and is starting the mottling process. Bruising has spread die to poor circulation. MD and family notified. Will continue to monitor. Further review of the nurse's note revealed no other documentation regarding Resident #2's bruises. Review on 1/5/23 of Resident #2's incident report dated 12/27/22 10:00 p.m. revealed that the LNA reported bruising noted to the left elbow and right upper arm, which Resident #2 was unable to provide description. Further review of the incident report revealed predisposing physiological factors were impaired memory, confusion, and incontinent. Review on 1/5/23 of Resident #2's incident report dated 1/1/23 at 9:57 p.m. revealed that Resident #2 had increase pain and bruising. Resident #2 was unable to provide description, DON was notified and prn [as needed] Tylenol was given. Pain assessment revealed that resident had occasional labored breathing, short period of hyperventilation, occasional moaning or groaning, facial grimacing, rigid fist clenched, knees pulled up, and distracted or reassured by voice or touch. Review on 1/5/23 of Resident #2's paper chart revealed a therapy form with dated 5/26/21 that stated Patient has been evaluated by therapy and is being provided with the following posture/position in wheelchair .Implement the following: .ensure foot [NAME] in place to separate feet .when positioning patient, ensure butt positioned all the way back on wheelchair .check by placing hand underneath, behind back rest to see where coccyx located .Other Recommendations: .Ensure Velcro on bottom of cushion to reduce sliding .Alert maintenance to put Velcro for foot [NAME] and/or cushion when needed . Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that he/she was notified about Resident #2's bruises, as mentioned above, the morning of 12/28/22. Staff A stated that he/she started an investigation on 12/28/22, observed the bruises and saw that the bruising aligned with Resident #2's wheelchair positioning as there was a statement from a staff that the weekend prior to 12/28/22, approximately 12/24/22 to 12/25/22, staff noted Resident #2 slump over the left side while in the wheelchair. Staff A also stated that the bruising to right arm was a result of not using a draw sheet for repositioning in bed by Staff F and Staff G and that education was provided. Staff A was unable to provide documentation of staff re-education on safe repositioning practices. Further interview with Staff A also revealed that at that time, 12/28/22, there was staff accusing agency staff and that there were no staff names mentioned and what was told to him/her was after agency staff started working more bruises were observed on residents and that they were hearsay. Staff A stated that there were no reports submitted to the State Survey Agency (SSA) and that there was no formal investigation on the accusations made by staff related to agency staff. Staff A also stated that the investigation related to the bruises was not reported to the SSA as the bruises were found to be related to wheelchair positioning. Interview on 1/6/23 at 10:10 a.m. with Staff U (Advanced Practical Registered Nurse (APRN)) revealed that Staff U evaluated Resident #2 on 1/3/23 and at that time Resident #2 was actively dying and that he/she did not evaluate Resident #2's bruising. Staff U stated that the focus was comfort for Resident #2. Staff U stated that he/she did not have a discussion with the DON nor Nurse Unit Manager about the cause of Resident #2's bruises. Interview on 1/6/23 at 11:00 a.m. with Staff M (LNA) revealed that he/she had observed Staff F being rough during a transfer. Staff M stated that Staff F was hoyering Resident #2 with another staff out of bed and that the hoyer pad was not placed correctly. Staff M also stated that Staff F pulled the hoyer pad out under Resident #2 where Resident #2 hit the railing. Staff M also stated that this incident happened approximately 2 & 1/2 months ago and that he/she reported this to the nurse. Interview on 1/6/23 at 11:45 a.m. with Staff R (LPN) revealed that he/she called Resident #2's on call provider about Resident #2 having increase pain to right arm and increase bruising. Staff R stated that he/she asked the provider if x-rays were needed and that the provider told Staff R that it was not needed at that time. Staff R also stated that he/she had notified Resident #2's Durable Power of Attorney (DPOA) about Resident #2's pain and that bruises were larger, but did not go into detail of extent of the bruises. Staff R also stated that Resident #2's DPOA wanted to know what had happened to Resident #2's bruises and also wanted Resident #2 to be comfortable. Interview on 1/6/23 at approximately 1:00 p.m. with Staff S (LPN) that he/she got report from the prior shift nurses that Resident #2 had bruises to right arm and left elbow, let rib cage which was reported immediately to the DON. Staff S stated that the DON responded that he/she was aware of the bruising. Staff S also stated that a few nights ago the areas on arms had increased fluid pocketing, Resident #2 also had grimacing, whimpering and guarding with touch and movement of the arms. Review on 1/6/23 of Resident #2's provider note dated 1/2/23 that Staff T (Doctor of Medicine) had a telephone encounter. Resident #2's provider note dated 1/2/23 revealed .Developed bruises on both arms and chest under L [left] breast since last week, no clear cause. Now they are bigger and [pronoun omitted] has fluid filled pockets just distal to elbows. R [right] arm seems very weak-but this is where most pain is. Severe pain, respiratory rate 40's .GOC [goal of care] are comfort-focused. Will need to be evaluated in person for rashes and blisters . Interview on 1/6/23 at 1:28 p.m. with Staff T revealed that he/she received a call from the facility about Resident #2's bruising and that plan of care for Resident #2 was comfort focused and so interventions provided to the nurse was adjustment of pain regimen. Staff T stated that the bruising needs to be evaluated in person to determine cause and at that time Resident #2 was actively dying so the focus was comfort for Resident #2. Staff T also stated that there were no discussions about the cause of bruising. Interview on 1/9/22 at approximately 10:00 a.m. with Resident #2's DPOA revealed that he/she was notified that Resident #2 had bruising in the arms fourth week of December 2022 and also last week when Resident #2 had increase pain and bruising. Resident #2's DPOA stated that he/she was not aware of the extent of Resident #2's bruises and that he/she was told the Resident #2 has some bruises. Resident #2's DPOA also stated that if he/she was aware of the extent of Resident #2's bruises, he/she would have wanted to know what had happened. Interview with the Medical Examiner on 1/20/23 at aproximatley 1:30 p.m. revealed that an autopsy was performed and Resident #2 had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death. Resident #6 Review on 1/5/23 of Resident #6's nurse's notes revealed that on 12/26/22 Resident #6 was found to have a purple buries above their right eye measuring about 6 cm [centimeter] [length] by 2 cm [width], and periwound was yellow. Further review of the nurse's note dated 12/2622 revealed that Risk Management was noted. Review on 1/5/23 of the facility's incident report on Resident #6's bruise to right eye dated 12/26/22 at 9:22 a.m. revealed that the bruise to right eye had an unknown cause. Interview on 1/5/23 at approximately 2:00 p.m. with Staff J (LPN) revealed that Resident #6's had a bruise on the right eye. Staff J stated that he/she wrote a note and an incident report. Staff J did not know the cause of the bruise initially and was told it was from being hit during a hoyer lift transfer. Staff J also stated the incident reports, once opened gets sent to the DON, and there were no follow up education regarding safe hoyer lift transfers. Review on 1/5/23 of Resident #6's nurse's note revealed that on 12/27/22 at 1:55 p.m. revealed that Resident #6 has a bruise on right eye that he/she may have bumped their head on the cross bar of the hoyer lift. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A confirmed the above findings on Resident #6. Staff A was unable to provide any corrective actions in regards to re-educating staff on safe hoyer lift transfers. Observation on 1/6/23 at approximately 1:00 p.m. with Staff I (LNA) revealed that Resident #6 had a faded yellowish discoloration above the right eye near the eye brow. Staff I stated that he/she usually takes care of Resident #6 during the day and that Resident #6 was a hoyer lift for transfers. Staff I also stated that he/she has not had any follow up re-education on safe hoyer lift transfers.

Based on interview, record review, and policy review, it was determined that the facility failed to develop and implement the facility's abuse policy for 4 out of 6 residents reviewed for alleged abuse and neglect (Resident identifiers are #1, #2, #3, and #6). Findings include: Review on 1/5/23 of the facility policy titled, Abuse Prohibition, with revised date of 12/1/18, revealed .Identification: 2. Instruct staff, resident/patient, family, visitor, etc. [etcetera] to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/ or misappropriation of property. 2. Identify events, such as suspicious bruising of residents/patients, occurrences, patterns, and trends, that may indicate abuse, neglect, and/or mistreatment and investigate .Protection 1. Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property .Immediate suspension of suspected employee(s), pending outcome of the investigation .Investigation 1. The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process. 2. The Administrator and Director of Nursing are responsible for investigation and reporting. 3. Initiate the Reportable Event Report Investigation. 4. Collect factual data 5. Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interview able [sic] and have information regarding the allegation. 6. Document results of the investigation. 7. Conclusion must include whether the allegation was substantiated or not and what information supported the decision .Employee Suspension from Duty . Further review of the facility abuse policy revealed no indicated reporting timeframes and reporting alleged violations to the State Survey Agency (SSA) and other officials. The facility's abuse policy did not indicate response to investigation and corrective actions. Resident #2 Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. an Licensed Nursing Assistant (LNA) reported that that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9 [length] x [by] 6 [width] cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:32 a.m. The DPOAH [Durable Power of Attorney for Health] was updated regarding Resident #2's bruising. -12/28/22 at 10:43 a.m. Upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in the chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of the chair that lines up perfectly with the bruise to [pronoun omitted] left side and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [Physical Therapy] referral for positioning in wheelchair . Interview on 1/5/23 at approximately 2:30 p.m. with Staff A (Director of Nursing (DON)) revealed that he/she was notified about Resident #2's bruises, as mentioned above, the morning of 12/28/22. Staff A stated that he/she started an investigation on 12/28/22, observed the bruises and saw that the bruising aligned with Resident #2's wheelchair positioning as there was a statement from a staff that the weekend prior to 12/28/22, approximately 12/24/22 to 12/25/22, staff noted Resident #2 slumped over the left side while in the wheelchair. Staff A also stated that the bruising to right arm was a result of not using a draw sheet for repositioning in bed by Staff F (LNA) and Staff G (LNA) and that education was provided. Staff A was unable to provide documentation of re-education. Further interview with Staff A also revealed that at that time, 12/28/22, there were staff accusing agency staff and that there were no staff names mentioned and what was told to him/her was after agency staff started working more bruises were observed on residents and that they were hearsay. Staff A stated that there were no reports submitted to the State Survey Agency (SSA) and that there was no formal investigation on the accusations made related to agency staff. Staff A also stated that the investigation related to the bruises was not reported to the SSA as the bruises were found to be related to wheelchair positioning. Interview with the Medical Examiner on 1/20/23 at aproximatley 1:30 p.m. revealed that an autopsy was performed and Resident #2 had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death. Resident #6 Review on 1/5/23 of Resident #6's nurse's notes revealed that on 12/26/22 Resident #6 was found to have a purple bruise above their right eye measuring about 6 centimeter (cm) length by 2 cm width, and periwound was yellow. Further review of the nurse's note dated 12/2622 revealed that Risk Management was noted. Review on 1/5/23 of the facility's incident report on Resident #6's bruise to right eye dated 12/26/22 at 9:22 a.m. revealed that the bruise to right eye had an unknown cause. Review on 1/5/23 of Resident #6's nurse's note revealed that on 12/27/22 at 1:55 p.m. Resident #6 has a bruise on right eye that he/she may have bumped their head on the cross bar of the hoyer lift. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A confirmed the above findings on Resident #6. Staff A was unable to provide any corrective actions in regards to re-educating staff on safe hoyer lift transfers. Interview on 1/6/23 at approximately 2:00 p.m. with Staff B and Staff A revealed that the facility's Abuse Policy did not contain timeframes of reporting alleged violations, reporting to SSA and other officials, responses, and corrective actions after investigations. 43408 Resident #1 Review on 1/5/23 at approximately 11:30 a.m. of facility investigation for Resident #1 alleged abuse dated 1/2/23, with a time stamp of 22:20 [10:20 p.m.], revealed the following: Resident #1 reported that they did not want the young [pronoun omitted] who took care of [pronoun omitted] today to take care of [pronoun omitted] again. Resident #1 reported that [the LNA] slapped his buttocks, smacked them with plastic bags, and laughed about it. Resident #1 described the LNA by approximate age and hair color. Resident #1 also stated I wish to die if I am going to be beat, and the LNA responded by stating I wish you would die too. Further review of the facility investigation revealed that the Director of Nursing (DON) and the Nurse Unit Manager were notified at the time of filling out the report. Two staff statements were attached to the investigation. The statements were from Staff F and Staff G. Review on 1/5/23 at approximately 11:45 a.m. of Resident #1's medical record revealed the following diagnosis on file: Dysphasia, oral pharyngeal phase, cognitive communication deficit, and acquired absence of the right and left leg below the knee. Further review of Resident #1's medical record revealed the following progress notes: 1/3/23 at 11:01 a.m., entered by Staff C (Nurse Unit Manager), I went and interviewed [Name omitted] and asked if anything had happened over the weekend [pronoun omitted] had no allegations [pronoun omitted] has no bruising. [Pronoun omitted] stated multiple times that [pronoun omitted] had no complaints. 1/3/23 at 11:11 a.m., entered by Staff E (Social Worker), .voices no concerns-[pronoun omitted] denies any complaints or concerns in any way, with interactions with staff or caregivers .writer reinforced that should resident ever have any concerns that [pronoun omitted] make them known . 1/4/23 at 7:06 a.m., entered by Staff A .upon interviewing resident by Nurse Unit Manager and Social Worker resident denied that anything happened over the weekend or at any time. [Pronoun omitted] has behavior care plan that [pronoun omitted] is resistive to care and accusatory. Upon review by nurse [pronoun omitted] had no apparent bruises or abrasions. Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed they spoke to Resident #1 on the morning of 1/3/23 regarding incident reported on 1/2/23. Staff C stated they did not speak to any other staff or residents regarding any concerns with LNA's. Staff C stated they were not aware of anything else for the investigation as they handed this off to Staff A. Staff C stated the two statements were obtained as they are the only young [pronouns omitted] that worked the Dementia Unit on the day of the accusation. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed they were notified of 1/2/23 incident involving Resident #1 around 10:30 a.m. on 1/3/23. Staff A stated that Resident #1 denied allegations so no further investigation or reporting was necessary. Staff A confirmed that no education was provided after the conclusion of this incident as nothing was identified as a concern. Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's Grievance Report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance was filed by Staff G for Resident #3 and given to Staff C. Further review of grievance revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (License Practical Nurse (LPN)), Staff A and Staff B and dated 12/28/22. Review on 1/5/23 at approximately 11:30 a.m. of facility nursing schedule for Dementia Unit for the night shift on 12/27/22 into 12/28/22 revealed one LNA on for the entire shift and one nurse. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. The LNA came in and said they were alone and had to help someone else and would be back. Resident #3 stated that he/she laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke back up and rang again and that is when the day LNA came in and helped him/her. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they had met with Resident #3 on the morning of 12/28/22 and resolved the situation by having the day LNA take care of him/her. Staff C confirmed that they did not initiate an investigation, no reporting sent to State Survey Agency (SSA), and did not identify the LNA in question but handed the grievance report off to the DON and was unaware of what occurred after that. Interview on 1/5/23 at approximately 2:00 p.m. with Staff B revealed they had no knowledge of any investigation for Resident #3's grievance report as it was marked resolved on 12/28/22. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22.

Based on interview and record review, the facility failed to be administered in a manner permitting all residents to maintain or attain their highest practicable well being. Findings include: Interview and record review revealed the facility failed to ensure that residents were free from abuse and neglect. Reference F600 Free from Abuse and Neglect. Interview, record review, and policy review, revealed the facility failed to develop and implement the facility's abuse policy for alleged abuse and neglect. Reference F607 Develop/Implement Abuse/Neglect Policies. Interview and record review revealed the facility failed to ensure that all alleged violations of abuse or neglect were thoroughly investigated. Reference F610 Invesitgate/Prvent/Correct Alleged Violations. Interview, observation, and interview revaeled the facility failed to ensure that the resident's environment remains as free of accident hazards. Reference F689 Free of Accident Hazards/Supervision/Devices Interview and record review revealed the facility failed to provide sufficient staff for the evening and night shift in accordance with their facility assessment. F725 Sufficient Staffing.

Based on interview and record review, it was determined that the facility failed to provide sufficient staff for the evening and night shift in accordance with the facility assessment for 11 days out of 4 weeks of nursing schedules reviewed (Resident identifier is #3). Findings include: Interview on 1/4/23 at approximately 1:30 p.m. with Anonymous #1 revealed that for the past 4 weeks, night shift (11:00 p.m. to 7:00 a.m. shift) has been staffed with one Registered Nurse (RN) or Licensed Practical Nurse (LPN) and one Licensed Nursing Assistant (LNA) on each unit. Anonymous #1 stated that the Reflection Unit has between 30-40 residents which most residents were dependent on staff with transfers, incontinence care, and personal care. Anonymous #1 also stated that the LNA would be responsible for all residents on the unit for care needed at night such as rounding and incontinent care. Interview on 1/5/23 at approximately 10:31 a.m. with anonymous #3 revealed that staffing was short on night shift. Anonymous #3 stated that there would be one nurse and one LNA on the unit and at times the LNA would go to the other unit to help out. Review on 1/5/23 of the facility's assessment with review date of 12/15/22 revealed that Part 1: Our Resident Profile Numbers 1.1 .There are two separate units in the facility. The Reflections Unit is a 49 bed secure memory unit, composed of mainly long term care residents with varying stages of dementia. Resident who are an elopement risk primarily also resident on this unit. 1.2. Indicate your average daily censes: 63.6. The average daily census is 80. Of theses residents the average daily Medicare A census is 10 .Staffing plan 3.2 Licensed nurses providing direct care .Total Number Needed or Average or Range .evening shift [3:00 p.m. to 11:00 p.m. shift] 1 RN and 3 LPNS [sic], night shift 1 RN and one LPN * [sic] an RN may be replaced with an LPN and an LPN may be replaced with an LMNA [Licensed Medication Nursing Assistant] this staffing changes with census and acuity requirements .Nurse aides .Total Number Needed or Average or Range .evening shift 8 LNAs, night shift 4 LNAS *subject to change based on acuity and census . Review on 1/5/23 of the facility nursing staff scheduled from 12/10/22 to 1/5/23 revealed the following nursing staff on the Reflection Unit: Evening Shift 12/11/22 1.5 LPNs (1 LPN from 3:00 p.m. to 7:00 p.m.), 3.5 LNAs, 12/12/22 1.5 LPNs (1 LPN from 3:00 p.m. to 7:00 p.m.), 2 LPNs call outs, and 3.5 LNAs, 12/13/22 1.5 LPNs (1 LPN from 3:00 p.m. to 7:00 p.m.), 1 LMNA from 7:00 p.m. to 11:00 p.m., 3.5 LNAs from 3:00 p.m. to 7:00 p.m., and down to 2 LNAs from 7:00 p.m. to 11:00 p.m. with a census of 63 residents, 12/17/22 1 LPN from 3:00 p.m. to 7:00 p.m., 1 LMNA for 3:00 p.m. to 7:00 p.m., 1 LMNA from 7:00 p.m. to 11:00 p.m., 4 LNAs from 3:00 p.m. to 7:00 p.m., and down to 2 LNA from 7:00 p.m. to 11:00 p.m., 12/23/22 5 LNAs 3:00 p.m. to 7:00 p.m., and down to 2 LNAs from 7:00 p M. to 11:00 p.m., 12/24/22 1 LPNs from 3:00 p.m. to 7:00 p.m., 1 LMNA, 5 LNA from 3:00 p.m. to 7:00 p.m., and down to 2 LNAs from 7:00 p.m. to 11:00 p.m., 12/25/22 2 LPNs from 3:00 p.m. to 7:00 p.m., down to 1 LPN from 7:00 p.m. to 11:00 p.m., 3 LNAs from 3:00 p.m. to 7:00 p.m., and down to 2 LNAs from 7:00 p.m. to 11:00 p.m., 12/26/22 2 LPNs from 3:00 p.m. to 7:00 p.m. and 1 LMNA from 7:00 p.m. to 11:00 p.m. (1 RN for the whole facility from 7:00 p.m. to 11:00 p.m. with no other licensed nurse), 12/27/22 1 LPN, 1 LPN from 3:00 p.m. to 7:00 p.m., 4 LNAs from 3:00 p.m. to 7:00 p.m. down to 2 LNAs from 7:00 p.m. to 11:00 p.m., and 2 LNA call outs, 12/28/22 2 LPNs from 3:00 p.m. to 7:00 p.m., and 1 LMNA from 7:00 p.m. to 11:00 p.m. (1 LPN for the whole facility with no other licensed nurse from 7:00 p.m. to 11:00 p.m.) with a census of 62 residents. Night Shift 12/11/22 1 LPN, 1 LNA, and 1 LNA call-out, 12/13/22 1 LMNA, 1 LNA, no call-out , and only 1 LPN scheduled for the night shift for the whole facility) with a census of 63 residents, 12/17/22 1 LMNA, 1 LNA, no call-out, and 1 LPN scheduled for the night shift for the whole facility, 12/23/22 1 LPN scheduled for the whole facility with no other scheduled licensed nurse, 12/24/22 1 LPN scheduled for the whole facility with no other scheduled licensed nurse, 12/25/22 1 LPN scheduled for the whole facility with no other scheduled licensed nurse, 12/27/22 1 LPN schedule for the whole facility, 1 LMNA, 1 LNA, 2 LNA call outs, and 1 LNA scheduled for 6:00 a.m. to 7:00 a.m., 12/30/22 1 LPN, 1 LMNA, and 1 LNA call-out. Interview on 1/6/23 at approximately 2:00 p.m. with Staff B (Administrator) confirmed the above findings on the facility assessment. Staff B stated that the census for the past 4 weeks has been between 60-64 residents. Staff B also stated that they have capped their census at 64 residents per the facility staffing. Further interview with Staff B also revealed that the facility assessment was based on a census of 80 residents, despite the facility assessment noted average daily census of 63.6 as mentioned above. Staff B was unable to provide an updated facility assessment to reflect the average daily census of 63.6. Interview on 1/6/23 at approximately 2:00 p.m. with Staff A (Director of Nursing (DON)) revealed that the facility has been short staff. Staff A stated that the night shift at times has 1 LNA on 1 unit and would prefer to have 2 LNAs. Staff A also stated that there were call-outs and Staff A was unable to provide protocols for nursing staff call-outs. Staff A was unable to provide updated defined nursing staff assignment ratios based on resident acuity and needs, and resident census. Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance report was filed by Staff G (LNA) for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide [LNA scheduled from 12/27/22 11:00 p.m. to 12/28/22 7:00 a.m.] told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. (morning) care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (LPN), Staff A and Staff B and dated 12/28/22. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. Resident #3 stated that the LNA came in and said they were alone and had to help someone else and would be back. Resident #3 also stated that he/she laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke up and rang their call light and that is when the day (7:00 a.m. to 3:00 p.m.) shift LNA came in and helped him/her. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22.

Based on interview, observation, and interview, it was determined that the facility failed to ensure that the resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for bruising (Resident identifier is #5). Findings include: Review on 1/5/23 at approximately 11:30 a.m. of the facility incident report dated 12/26/22, with a time of 11:25 a.m., revealed that staff noted scattered small bruises on residents left forearms and left upper arm. Review on 1/5/23 at approximately 11:45 a.m. of Resident #5's progress notes revealed the following entries: 12/26/22 at 11:35 a.m., entered by Staff H (Licensed Practical Nurse), Resident noted to have scattered bruising over left upper arm and forearm. Risk management completed. No signs/symptoms of pain or discomfort. 12/27/22 at 2:14 p.m., entered by Staff C (Nurse Unit Manager) IDT [interdisciplinary team] Skin: [name omitted] has small bruises on his/her LFA [left forearm] [pronoun omitted] may be bumping it on bed rails. Observation on 1/5/23 at approximately 12:55 p.m. of Resident #5 revealed multiple circular discolored areas to upper and lower left and right arm. Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they were made aware of the bruising to Resident #5 on 12/27/22. Resident #5 is known to flair arms a lot and it is possible they hit their arms on the side rails when they were in bed. Staff C denied any measures to prevent future bruising or injury being initiated to Resident #5 from the placement of the side rails. Interview on 1/6/22 at approximately 12:55 p.m. with Staff I (Licensed Nursing Assistant) revealed that Resident #5 routinely is seen hitting their arms and hands on the side rails and on their tray table if left in front of them.

Based on observation, interview, and policy review, it was determined that the facility failed to store food according to acceptable standard for food safety in 1 out of 1 main kitchens and 2 out of 2 unit kitchenettes observed. Findings include: Main Kitchen Observation on 12/7/22 at 9:20 a.m. of the facility's main kitchen with Staff B (Dietary Manager) revealed the following in a refrigerator: - 2 gallon container of apple juice (facility made from concentrate) in the refrigerator in the main kitchen with no date - Container of Balsamic Dressing opened 11/8/22 with a manufacturer's use by date of 8/17/22 Interview on 12/7/22 at 9:20 a.m. with Staff B confirmed that the apple juice should have been labeled and dated and the balsamic dressing should have been discarded. Observation on 12/7/22 at 9:25 a.m. of the main kitchen preparation area with Staff B revealed that a large red trash can was uncovered at the prep area while food was being prepared Interview on 12/7/22 at 9:25 a.m. with Staff B confirmed that the trash can should not be there and that is should have a cover on it. Observation on 12/7/22 at 9:27 a.m. of the walk-in refrigerator with Staff B revealed. - A green cluster of soft moist material was on the floor of the walk in refrigerator under the bottom rack, - One open package of hot dogs with no date, - Open package of sausage patties with hand written use by date of 12/4/22 on the package, - Cooked chicken breast in a clear container with use by date of 11/26/22 written on a facility sticker, - Open container of crushed pineapple with use by date of 11/25/22, - Open bag of melted shredded mozzarella cheese dated 10/17/22, - Unidentifiable contents in a container with use by date of 11/5/22, - A container of white soft content with a use by date of 10/21/22, - A container containing coleslaw with use by date of 11/26/22, - A container containing a pancake mixture with a use by date of 11/30/22, - A container of a greenish yellow liquid substance with no date of label, - (3) 16. 3 ounce sealed bags of salami with use by dates of 11/2022, - 1 large one gallon container of ranch dressing with a manufacturer's use by date of 9/26/22, - 4 large one gallon container of vinaigrette dressing with a manufacturer's use by date of 8/16/22, - 1 large one gallon container of creamy caesar dressing with a manufacturer's use by date of 5/25/22, - Unidentifiable contents in a container with no date, - 6 cantaloupes melons soft and leaking fluid substance, - 1 case of 22 soft moist green peppers with black spots visible on all of the peppers in the case, Interview on 12/7/22 between 9:27 a.m. to 9:40 a.m. with Staff B confirmed the above findings at the walk-in refrigerator. Staff B stated that the container of white soft content with a use by date of 10/21/22 was whip topping, the container with greenish yellow liquid with no date of label was soup and the unidentifiable contents in container with no date was stuffed cabbage. Observation on 12/7/22 at approximately 9:45 a.m. of the dry storage room in the main kitchen revealed the following: - 1 open package of orzo pasta 10 pound bag with no open date wrapped in plastic wrap, - 1 open Package of elbow pasta 10 pound bag with no open date wrapped in plastic wrap, - 1 open package of linguini pasta partially covered in plastic with exposed pasta with no open date, - 1 unopened case of 12 wheat bread dated 11/3/22 containing green fuzzy-like material on the bread, - 2 unopened bags of hot dog buns noted on the dry storage shelf with green fuzzy-like material on the buns, - 2 packages of hamburger buns with green fuzzy-like material on the rolls, - 20 unopened cartons of cream cheese with a manufacturer's use by date of 5/2022 Interview on 12/7/22 at 9:45 a.m. with Staff B confirmed that the above findings at dry storage room. New Horizon kitchenette Observation on 12/7/22 at 9:45 a.m. of the kitchenette in the New Horizon unit with Staff B revealed the following. - 1/4 loaf of bread with an expiration date of 9/21/22, - 14 cereal bars with a manufacturer's use by date of 12/6/22 and 2 cereal bars use by date of 10/12/22, - 1 bag of red grapes organic with no name or date on the bag, the red grapes were soft and some grapes were leaking fluid and wilted-like. Interview on 12/7/22 at 9:45 a.m. with Staff B confirmed the above findings at the horizon unit kitchenette. Reflection Unit kitchenette Observation on 12/7/22 at 9:50 a.m. of the kitchenette in the Reflections Unit with Staff B revealed the following. - 2 cartons (4 ounces each) of 1 percent low fat milk with use by dates of 12/6/22. Interview on 12/7/22 at 9:50 a.m. with Staff B confirmed the above findings at the reflection unit kitchenette. Facility was unable to provide a policy for food safety. Standard: Review on 5/24/22 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .

Based on observation, interview and record review, it was determined that the facility failed to follow physician's order for documentation urinary output for 5 out of resident reviewed for urinary catheters in a final survey sample of 18 residents. (Resident identifiers are ##22, #30, #33, #34, and #37.) Findings include: Resident #22 Review on 12/9/22 of Resident #22's physician's orders revealed an order to empty foley catheter bag and document output in the TAR every shift. Review on 12/9/22 of Resident #22's November TAR revealed that there was no documentation of output for the following dates: 11/20/22 evening shift 11/21/22 day and night shift 11/25/22 night shift 11/27/22 night shift 11/28/22 night shift 11/29/22 day shift Review on 12/9/22 of Resident #22's December TAR revealed there was no documentation of output for the following dates: 12/1/22 night shift 12/3/22 evening shift 12/4/22 day shift 12/5/22 evening and night shift 12/6/22 night shift 12/8/22 day and evening shift Interview on 12/9/22 at approximately 11:08 am with Staff E (Licensed Practical Nurse) confirmed that there was no documentation of output for those dates and that output should be documented on the TAR. Resident #30 Review on 12/9/22 of Resident #30's physician's orders revealed an order to empty Foley catheter bag and document output in the Electronic Medical Record (EMR) every shift. Review on 12/9/22 of Resident #30's November TAR revealed that there was no documentation of output for the following dates: 11/20/22 day and evening shift 11/21/22 day and night shift 11/25/22 evening shift 11/27/22 evening shift 11/28/22 evening shift 11/29/22 day shift Review on 12/9/22 of Resident #30's December TAR revealed there was no documentation of output for the following dates: 12/3/22 evening shift 12/4/22 day shift 12/5/22 evening and night shift 11/6/22 night shift 12/8/22 evening shift Interview on 12/9/22 at approximately 11:08 am with Staff E (Licensed Practical Nurse) confirmed that there was no documentation of output for those dates and that output should be documented on the TAR. Resident #33 Review on 12/9/22 of Resident #33's physician's orders revealed an order to empty Foley catheter bag and document output in the EMR every shift. Review on 12/9/22 of Resident #33's November TAR revealed that there was no documentation of output for the following dates: 11/3/22 day shift and night shift 11/8/22 night shift 11/9/22 evening shift 11/10/22 evening shift 11/11/22 evening shift and night shift 11/16/22 evening shift 11/25/22 evening shift 11/27/22 evening shift Review of Resident #33's December 2022 TAR revealed that there was no documentation of output for the following dates: 12/2/22 day shift 12/5/22 night shift 12/8/22 evening shift Interview on 12/9/22 at 10:46 a.m. with Staff A (Licensed Practical Nurse) confirmed there was no urinary output documented on the TAR for the dates listed, and that the output should be documented on the TAR. Resident #34 Review on 12/9/22 of Resident #34's medical record revealed the following physician's order: Empty foley catheter bag and document output every shift. Review on 12/9/22 of Resident #34's Treatment Administration Record (TAR), dated November 2022 revealed no documentation of output on the following dates: 11/2/22 night shift 11/3/22 night shift 11/6/22 day shift 11/8/22 night shift 11/9/22 evening shift 11/10/22 evening shift 11/11/22 evening and night shift 11/16/22 evening and night shift 11/21/22 evening shift 11/26/22 evening shift 11/27/22 day shift 11/28/22 evening shift 11/29/22 evening shift Review on 12/9/22 of Resident #34's TAR, dated December 2022 revealed no documentation of output on the following dates: 12/2/22 evening shift 12/4/22 evening shift 12/5/22 evening shift Interview on 12/9/22 at 10:46 a.m. with Staff A (Licensed Practical Nurse) confirmed there was no urinary output documented on the TAR for the dates listed, and that the output should be documented on the TAR. Resident #37 Review on 12/9/22 of Resident #37's physician's orders revealed an order to empty Foley catheter bag and document output in the EMR every shift. Review on 12/9/22 of Resident #37's November 2022 TAR revealed that there was no documentation of output for the following dates: 11/3/22 day shift and night shift 11/8/22 night shift 11/9/22 evening shift 11/10/22 evening shift 11/11/22 evening shift and night shift 11/16/22 evening shift 11/25/22 evening shift 11/27/22 evening shift Review of Resident #37's December 2022 Medication Administration Record (MAR) revealed that there was no documentation of output for the following dates: 12/5/22 night shift 12/8/22 evening shift Interview on 12/9/22 at approximately 10:46 a.m. with Staff A (Licensed Practical Nurse) confirmed that there was no documentation of output for the dates listed, and that the output should be documented on the TAR.

Based on interview, record review, and policy review, it was determined that the facility failed to implement an antibiotic stewardship program that includes a system to track and monitor antibiotic use. Finding Include: Interview on 12/08/22 at 9:20 a.m. with Staff D (Infection Preventionist) revealed that the facility did not have a method for tracking and monitoring the monthly antibiotic use for the facility. Further interview with Staff D revealed that the facility did not implement the facility's program for antibiotic stewardship nor are they currently tracking the symptoms for the use and lab sensitivities to determine if residents are on the appropriate antibiotic. Interview on 12/8/22 at 3:00 p.m. with Staff C (Director of Nursing) and Staff E (Administrator) confirmed that the antibiotic stewardship program was not in place. Review on 12//08/22 at 9:/20 a.m. of the Facility Policy Titled Antibiotic Stewardship updated 1/21/21 .Antibiotic Stewardship Program . - Optimizing the treatment of infections by ensuring that residents who require and antibiotic are prescribed the appropriate antibiotic, for the appropriate amount of time via the correct route using the lowest effective dose. - Reduce the risk of adverse events, including the development of antibiotic-resistant organism for unnecessary or inappropriate antibiotic use. - Maintenance of a facility wide system to monitor the use of antibiotics. Provide ongoing staff, resident and family education on the appropriate use of antibiotics. Standard: Review on 12/12/22 of Center of CDC (Center for Disease Control and Prevention) website titled, The Core Elements of Antibiotic Stewardship in Nursing Homes, review date June 11, 2020, revealed that .Infection and syndrome specific interventions to improve antibiotic use .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use .Infection prevention program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections Broad interventions to improve antibiotic use .Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .

Based on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 of 3 residents reviewed for pressure ulcers out of a final sample of 18 residents (Resident identifier #28). Findings include: Interview on 12/7/22 at approximately 9:45 a.m. with Staff A (Licensed Practical Nurse) revealed that Resident #28 has a pressure ulcer to his/her right heel. Observation on 12/7/22 at approximately 9:45 a.m. of Resident #28's right heel with Staff A confirmed that Resident #28 did have a Deep Tissue Injury (DTI). Review on 12/9/22 of Resident #28's progress note dated 11/22/22 revealed the following: IDT [InterDisciplinary Team] WOUND: [pronoun omitted] 1.3 x 1.1 DTI to right heel new order for skin prep booties on while in bed Daughter [pronoun omitted] aware of DTI will monitor. Review on 12/9/22 of Resident # 28's medical record revealed there was no other wound measurements or descriptions of the right heel DTI. Interview on 12/09/22 at approximately 12:15 p.m. with Staff C (Director of Nursing) confirmed that Resident #28's DTI was not assessed or measured after the initial identification of the DTI on 11/22/22. Review on 12/09/22 of facility policy titled Skin Body Audit, revised on 3/12/13, revealed Procedure: 1. The Licensed Nurse performs a weekly head to toe check of the residents skin, paying particular attention to : .Bony prominences (heels, tailbone, shoulder blades, elbows, back of head, etc .

Based on observation, interview, medical record and policy review, it was determined that the facility failed to ensure the resident environement remained free of accident hazards for 1 of 1 residents reviewed for smoking in a facility with 4 smokers and a census of 58 residents. (Resident identifier is #12.) Findings include: Interview on 10/5/21 at approximately 10:00 a.m. with Resident #12 revealed that Resident #12 was a smoker. During the interview it was observed that Resident #12 had cigarettes on their bedside table. Review on 10/6/21 of Resident #12's smoking assessment, dated 8/4/21 revealed: .8. Does resident need the facility to store the lighter and cigarettes. 0. no (was checked off) Review on 10/6/21 of Resident #12's BIMS (Brief Interview for Mental Status) dated, July 7, 2021 revealed: .CO500. BIMS Summary Score: 11 Review on 10/7/21 of the Brief Interview for Mental status (BIMS) calculator dated, November 2015 revealed: BIMS score interpretation .scores between 8 and 12, moderate impairment, . Interview on 10/6/21 at approximately 12:10 p.m. with Staff B (Licensed Practical Nurse) revealed that Resident #12 goes out to smoke multiple times of day and night, [pronoun omitted] makes [pronoun omitted] own cigarettes and rolls them in [pronoun omitted] room, [pronoun omitted] is supposed to drop [pronoun omitted] lighter off with us but does not always do it. Observation on 10/6/21 at approximately 2:30 p.m. revealed a pack of cigarettes on his/her side table in his/her bedroom. Interview on 10/6/21 at approximately 2:30 p.m. with Resident #12 revealed, I must have forgot to give them to the nurse again. Review on 10/7/21 of Resident #12's care plan does not address where Resident #12's smoking materials should be kept in the facility. Review on 10/7/21 of the facility policy titled, [NAME] Terrace Smoking Policy, undated revealed: 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in designated areas only, and that smoking articles of any kind (includes, cigarettes, cigars, vapor, e-cigarettes and [MEDICATION(S)] related product) are to be stored in the nurses' station (or area designated by the facility) and not permitted to be stored in resident living or sleeping quarters. 5. Smoking/[MEDICATION(S)] device articles: All residents who smoke or utilize a [MEDICATION(S)] device regardless of their classification, will not be permitted to keep any smoking articles/paraphernalia in their room. This includes but is not limited to the following: a. cigarettes .6. Purchasing and/or storage of smoking/[MEDICATION(S)] device articles: .All [MEDICATION(S)] articles for residents will be stored at the nurses' station (or facility designated area) in a safe area with restricted access, such as the medication room or locked box. Interview on 10/7/21 at approximately 9:45 a.m. with Staff G (Administrator in Training) revealed that Resident #12 did not have a lock box in his/her room designated for smoking materials.

Based on observation, interview, policy and manufacturer's review it was determined that the facility failed to label medications with an opening date and dispose of expired medications in 1 out of 1 medication rooms and 2 out of 2 medication carts reviewed. Findings include: Reflections Unit medication storage room. Review on 10/5/21 at approximately 12:15 p.m. of the medication storage room on the Reflections Unit revealed the following: 1 vial of [MEDICATION(S)] was opened and not labeled with a date of opening or an expiration date 1 [MEDICATION(S)] lock flush 500 units/5 ml (milliliter) expiration 9/30/21 3 [MEDICATION(S)] lock flushes 50/5 ml expiration 1/31/20 1 [MEDICATION(S)] lock flush 50/5 ml expiration 9/19/21 Interview on 10/5/21 at approximately 12:15 p.m. with Staff A (Licensed Practical Nurse) confirmed that the vial of [MEDICATION(S)] was opened and not dated. Staff A confirmed that the 5 [MEDICATION(S)] lock flushes were expired. Review on 10/5/21 of the [MEDICATION(S)] (Mantoux) manufacturers instructions, product information date April 2016 revealed: .Storage. A vial of [MEDICATION(S)] which has been entered and in use for 30 days or more should be discarded. Reflections Medication Cart #2 Observation on 10/5/21 at approximately 12:25 p.m. revealed: Resident #50's Novolog insulin pen was opened and not dated with an opening date or an expiration date. Interview on 10/5/21 at approximately 12:25 p.m. with Staff A, confirmed Resident #50's Novolog insulin pen did not have a date of opening on it. Review on 10/6/21 of the manufacturers instructions for Novolog, revised 02/2015 revealed: .16.2 Recommended Storage .Table 9 .3 ml Novolog [MEDICATION(S)]. In-use (room temperature) 28 days New Horizons Medication Cart #3 Observation on 10/5/21 at approximately 12:30 p.m. of the New Horizons Medication Cart #3 revealed: Resident #27's [MEDICATION(S)] injectable pen 18 mg (milligram)/3 ml was opened and was not dated with an opening date or an expiration date . Interview on 10/5/21 at approximately 12:30 p.m. with Staff B (Licensed Practical Nurse) confirmed Resident #27's [MEDICATION(S)] injectable pen did not have a date of opening on it. Staff B also confirmed that Resident #27 did receive his/her scheduled dose this morning from this injectable pen. Review on 10/6/21 of the [MEDICATION(S)] injection manufacturers instructions, revised 11/20 revealed: .Medication Guide .The [MEDICATION(S)] pen you are using should be thrown away 30 days after you start using it . Review on 10/6/21 of the facility policy titled, ID1: Storage of Medications revealed: .Procedures .Expiration Dating (Beyond-use dating) .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1.) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturers recommends another date or regulations /guidelines require different dating .

Based on interview and record review, it was determined that the facility failed to ensure that the facility electronically transmit, encoded, accurate and complete MDS (Minimum Data Set) within 14 days after a facility completes a resident's assessment for 4 out of 19 residents reviewed for MDS records. (Resident identifiers are #1, #2, #3 and #4.) Findings include: Resident #1 Review on 10/6/21 of Resident #1 MDS records revealed a MDS dated [DATE] for discharge return not anticipated/end of PPS (Prospective Payment System) part A stay with MDS completion date of 7/19/21, submit by date of 8/2/21, and a status of export ready. No record that this MDS was transmitted to CMS. Interview on 10/6/21 at 12:26 p.m. with Staff C (MDS coordinator) confirmed that the above MDS has not been transmitted. Resident #2 Review on 10/6/21 of Resident #2's medical records revealed that Resident #2 was discharge home on 6/9/21. Review on 10/6/21 of Resident #2's MDS records revealed no record of an MDS for Resident #2's discharge. Interview on 10/6/21 at approximately 12:27 p.m. with Staff C confirmed the above findings for Resident #2. Resident #3 Review on 10/6/21 of Resident #3's MDS records revealed an MDS dated [DATE] for end of PPS part A stay and an MDS dated [DATE] for death in facility with completion dates of 7/26/21. There were no records that both the above mentioned MDS for Resident #3 were transmitted to CMS. Interview on 10/6/21 at approximately 12:28 p.m. with Staff C confirmed the above findings for Resident #3. Resident #4 Review on 10/6/21 of Resident #4's MDS record revealed an MDS dated [DATE] for a discharge return not anticipated with a completion date of 7/19/21, submit by date of 8/2/21, and a status of export ready. There was no record that the above mentioned MDS for Resident #4 was transmitted to CMS. Interview on 10/6/21 at approximately 12:29 p.m. with Staff C confirmed the above findings for Resident #4.

Based on observations, review of Facility's food storage policilies and procedures, and interview the Facility failed to ensure that outdated foods and improperly stored foods were removed from the 2 kitchenettes that each serve 1 of the 2 nursing units in the Facility. Findings include: Observations made on 12/14/16 in the kitchenette that serves the New Horizons Nursing Unit at this facility revealed several items that were either out of date or undated: 2 loaves of bread were observed to be in the cupboard across from the refrigerator. One was a partial loaf of white bread with a date of 12/6/16. The surface of the bread appeared to be dry. It was in its original plastic wrapper, unsealed with the plasic wrapped around the remainder of the loaf. There was also a partial loaf of wheat bread with a date of 11/27/16 that was in its original plastic wrapper, unsealed with the plasic wrapped around the remainder of the loaf. It too, appeared to be dry. There were 2 medium sized coffee cups each partially full with a residents name on them one dated 12/11/16 and the other with no date. There was an undated plastic storage container of a substance that appeared to be soup. It had a residents name written on the container. There was an undated fruit plate in the bottom left front corner of the refrigerator. there was a small black covered bowl of red jello with illegible markings. Also observed, was an undated, covered breaded haddock plate with a residents name in place. Observations made on 12/15/16 in the kitchenette that serves the Reflections Unit at this facility revealed several items that were either out of date or undated: There was a partially full 48 oz. container of Thickened Lemon Flavored Water with a 9/26/16 delivery date on top, no open date or use by date was observed. The facility threw this out on 12/15/16. There was a half full bottle of bottled water with no open date observed toward the back of the refrigerator shelf. A factory package containing cheese bearing a resident's name was observed in a left hand drawer of the refrigerator. The package was open to air and the cheese was drying out and getting darker where it stuck out through the open package. A partially full box of cranberry cocktail located on the door had a use by date of 12/11/16. It was thrown out by Facility staff on 12/15/16. A partially full prune juice container was on the door with a use by date of 12/11/16. It was also discarded 12/15/16. An 8 oz. Ginger Ale was open, undated, approximately half full and sitting on top of the refrigerator, in the center at the edge of the door seal for the freezer. Review, 12/15/16, of a printed food storage policy Revised July 7, 2016 and provided by Facility management, reads in part: Procedure- Foods will be labeled and dated and monitored, including but not limited to leftovers, so it is used by its use-by dae, or frozen (where applicable) or discarded. Normally this date would be 3 days from its label date. Always follow the most basic rule, when in doubt, throw it out. On interview 12/15/16 Staff D, Food Service Director stated: Generally food items are kept in the refrigerator 3 days after opening.

Based on record review and interview the facility failed to ensure 16 of 424 blood glucose monitoring results for the high control range on the Reflections unit , from September 1, 2016 to December 15, 2016 were within the specified high range parameters, failed to ensure 1 of 424 high control range parameters was transcribed properly and failed to ensure, on the New Horizons unit, that glucose test strips were dated when opened. Findings include: Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #1 was 212-264, the high control range test result was 355, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #1 was 196 - 245, the high control range test result was 330, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #1 was 196 - 245, the high control range test result was 330, above the stated parameters with no corrective action documented. On 9/2/16 the indicated high control range for glucometer #1 was 199 - 249, the high control range test result was either 271 or 291, either of which is above the stated parameters with no corrective action documented. On 9/30/16 the indicated high control range for glucometer #1 was 208 - 259, the high control range test result was 271, above the stated parameters with no corrective action documented. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #2 was 212-264, the high control range test result was 356, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #2 was 196 - 245, the high control range test result was 340, above the stated parameters with no corrective action documented. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #3 was 214-267, the high control range test result was 368, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #3 was 212 - 265 the high control range test result was 330, above the stated parameters with no corrective action documented. On 10/5/16 the indicated high control range for glucometer #3 was 208 - 259, it appears on the log sheet, incorrectly, as 208 - 359. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/1/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 250, above the stated parameters with no corrective action documented. On 12/2/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 252, above the stated parameters with no corrective action documented. On 12/3/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 256, above the stated parameters with no corrective action documented. On 12/4/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 373, above the stated parameters with no corrective action documented. On 12/5/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 260, above the stated parameters with no corrective action documented. On 12/6/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 254, above the stated parameters with no corrective action documented. On 12/7/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 255, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #4 was 212-265, the high control range test result was 350, above the stated parameters with no corrective action documented. On interview 12/15/16 with Staff A, LPN (Licensed Practical Nurse) Reflections Unit Coordinator confirmed there were some high control test results outside of the stated high control test ranges.

Based on record review and staff interview, the facility failed to ensure that the facility adhered to professional standards of quality for not following the physician's orders [REDACTED]. (Resident identifiers are #1, #15) Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's order [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Findings include: Review of Resident #1's medical record revealed that weekly skin assessments ordered by the physician on 10/19/16 for preventive measures were not completed on a weekly basis. The skin assessment for 12/14/16 was not signed off as completed. Review of Resident #15's medical record revealed that weekly skin assessments were not signed off as completed on 10/25/16, 11/14/16, 11/29/16, 12/14/16. At approximately 10:15 AM interview with Staff A, LPN (Licensed Practical Nurse), Unit Manager confirmed that the facility did not complete the above mentioned skin assessments.

Based on record review and interview, it was determined that the facility failed to keep one resident free of a significant medication error, in a survey sample of 16 residents, resulting in that resident being temporarily hospitalized and intubated. (Resident identifier is #15.) Findings include: Review of Resident #15's nurses notes reveals that a medication error occurred on 12/15/15 and resident was transported to the emergency room . A subsequent nurses note of 12/18/15 revealed the resident was intubated for a day and a half and returned from the hospital on [DATE]. Interview with Staff G, Administrator, on 1/15/16 revealed that Staff J, who made the medication error was working at the facility only a few months, and that training when Staff J was hired was a weak point. As a result of the medication error, Staff J reviewed education materials and took an exam and was monitored when they first passed meds again. Staff G related that now Staff J is all clear and no further monitoring is to be done. Record review of the Medication Pass Observation document reveals it was done on 12/21/15.

Based upon observations made on survey, staff interview and resident record review the facility failed to offer the feeding and dining assistance necessary to prevent weight loss and a decline in nutrition for 1 of 17 sampled residents. (Resident identifier is #12). Findings include: On 4/7/15 Resident #12 was observed from approximately 11:50 a.m.-12:30p.m. in the assisted dining room of the Reflections Unit sitting by herself with her food tray in front of her on an over the bed tray. Resident #12 made no effort throughout the meal to feed herself and staff failed to intervene through either cueing, encouraging or by assisting Resident #12 in eating any of the food placed before her for this meal. When her mealtray was removed Resident #12 hadn't eaten any of her food. On 4/8/15 Resident #12 was observed from approximately 11:55a.m.-12:35p.m. in the assisted dining room of the Reflections Unit sitting by herself with her food tray in front of her on an over the bed tray. Resident #12 was seen taking a couple sips of milk by herself but otherwise made no effort to eat the food which had been placed before her. No staff member made any attempt to cue, encourage or assist Resident #12 in eating until the survey team brought it to their attention. Then a staff member helped feed Resident #12 and she ate the food when it was offered by staff one bite at a time. The unidentified LNA who fed Resident #12 stated that Resident #12 needed a person to assist her during meals. The facility according to Resident #12's comprehensive care plan identified Resident #12 as being "at risk for nutritional decline" because of in part Resident #12's "chronic poor appetite" and "variable intakes of food." The facility intervention designed to address this according to Resident #12's comprehensive plan of care was to provide Resident #12 with "feeding/dining assistance" which observations confirm hasn't been implemented resulting in a significant 22.6 pound weight loss for this resident. A review of Resident #12's medical record revealed the following from the progress note of the dietician dated 8/15/14 "Weight stable, will D/C Boost+" supplement. There were no further dietary progress notes or interventions documented in Resident #12's medical record after 8/15/14 which addressed subsequent weight losses by Resident #12. Staff B (Administrator) revealed during an 4/9/15 interview that from 9/4/14 through 10/13/14 the facility was without the services of a registered dietician. From July 2014 through January 2015, according to Resident #12's medical record Resident #12 experienced an 8.6 lb weight loss going from 110.6 pounds to 102 pounds respectively. From January 2015 Resident #12's weight declined further from 102 lbs. to 88lbs in February 2015 a total of 22.6 pounds since July 2014.

Based upon observations, staff interview and resident record review the facility failed to implement the comprehensive plan of care for 1 of 17 sampled residents.(Resident identifier is #12). Findings include: On 4/7/15 Resident #12 was observed from approximately 11:50 a.m.-12:30p.m. in the assisted dining room of the Reflections Unit sitting by herself with her food tray in front of her on an over the bed tray. Resident #12 made no effort throughout the meal to feed herself and staff failed to intervene through either cueing, encouraging or by assisting Resident #12 in eating any of the food placed before her for this meal. When her mealtray was removed Resident #12 hadn't eaten any of her food. On 4/8/15 Resident #12 was observed from approximately 11:55a.m.-12:35p.m. in the assisted dining room of the Reflections Unit sitting by herself with her food tray in front of her on an over the bed tray. Resident #12 was seen taking a couple sips of milk by herself but otherwise made no effort to eat the food which had been placed before her. No staff member made any attempt to cue, encourage or assist Resident #12 in eating until the survey team brought it to their attention. Then a staff member helped feed Resident #12 and she ate the food when it was offered by staff one bite at a time. The unidentified LNA who fed Resident #12 stated that Resident #12 needed a person to assist her during meals. A review of Resident #12's medical record revealed that the facility had identified Resident #12 at risk of being nutritionally compromised in part because of her history of having a "chronic poor appetite" and "variable intakes of food." The facility intervention designed to address this according to Resident #12's comprehensive plan of care was to provide Resident #12 with "feeding/dining assistance." Observations confirm that this hasn't been implemented resulting in Resident #12 sustaining a significant 22.6 pound weight loss.