Every finding on record at Holly Hill House

Based on record review and interviews, the facility failed to maintain a complete medical record on each resident by failing to ensure treatments were documented on the Electronic Treatment Administration Record (ETAR) for 1(#1) out of 3 sampled residents. Findings:Review of the facility's policy titled Wound Prevention Policy, last reviewed 04/2026, read in part: Policy Guidelines: 6. Documentation and Reporting: document all wound prevention measures, assessments, & interventions in resident service plan and medical records. Promptly report any changes or concerns. Review of Resident #1's electronic health record revealed she was readmitted to the facility on [DATE] with diagnoses of displaced fracture of left femur, and pressure ulcer left heel Stage 2.Review of Resident #1's July 2026 Physician order read in part:Left dorsum hand, bruise: monitor bruise for changes in size and color daily until resolved. Left elbow, bruise: monitor bruise for changes in size and color daily until resolvedLeft heel, Pressure: cleanse with wound cleanser, pat dry, apply Iodosorb gel to area, cover with ABD pad, wrap with Kerlix, secure with tape daily and PRN (as needed) until resolved every day (start date 06/27/2026) Rear left thigh, bruise: monitor bruise for changes in size and color daily until resolvedRight dorsum hand, bruise: monitor bruise for changes in size and color daily until resolvedRight lateral thigh, bruise: monitor bruise for changes in size and color daily until resolvedSacrum: cleanse with wound cleaner, pat dry, apply Zinc skin protectant to area, leave open to air, bid (twice daily) and prn for prevention, every day and evening shift for prevention. Front left trochanter hip, surgical incision: keep dressing clean, dry and intact. Monitor site every shift for signs/symptoms of infection, increase in pain, bleeding, redness, discharge, warmth/fever or foul odor from site. Notify MD of any changes.Bilateral heel protectors as tolerated while in bed every shift for prevention.Weight every day shift, every Tuesday for monitoring for 4 weeks (start date 06/16/2026)Review of Resident #1's July 2026 ETAR revealed the following orders had no nurse initials documented: On 07/03/2026 night shift: Front left trochanter hip surgical incision, and bilateral heel protectorsOn 07/04/2026 night shift: Front left trochanter hip surgical incision, and bilateral heel protectorsOn 07/06/2026 day shift: Front left trochanter hip surgical incision, bilateral heel protectors, Sacrum prevention treatment, left heel pressure treatment, left dorsum hand bruise, left elbow bruise, right left thigh bruise, right dorsum hand bruise, and right lateral thigh bruiseOn 07/07/2026 for day shift: Weight Review of skilled nurse notes dated for 07/06/2026, by S2AgencyLPN indicated in part that Resident #1's skin condition was assessed per ETAR, skin no signs of infection. On 08/10/2026 at 11:10 a.m., an interview and record review was conducted with S2AgencyLPN. She acknowledged she was the day shift nurse for Resident #1 on 07/06/2026. She stated that she had completed Resident #1's wound care and made a skilled nurses note regarding her care for the shift on 07/06/2026, but was unsure of why she had not signed the ETAR that day. On 08/11/2026 at 12:09 p.m., an interview and record review was conducted with S1DON. He confirmed that Resident #1's ETAR for July 2026 was incomplete. He was unsure as to why the nurse had not initialed as completed. He stated that the ETAR gives the nurse options to document as to not given, refused, sleeping, hospitalized , or other with the option to make a nurse note. He verbalized that the nurse should document at the time of completion.

Based on observations, interview, and policy review, the facility failed to maintain a clean and sanitary kitchen, as evidenced by:1. A buildup of thick black residue on the wall approximately six inches high for the length of the three compartment sink,2. a buildup of thick black residue on the wall approximately six inches high for the length of the dirty side dish table of the dishwasher,3. a buildup of food particles on three clean dish storage trays; and4. a buildup of black residue on the inside top panel of the kitchen ice machine.This deficient practice had the potential to affect 74 residents who ate out of the kitchen.Findings:A review of the facility's policy titled, Kitchen Sanitization with no review date, read in part, 1. The food service manager will monitor food safety and sanitation of the dietary department on a daily basis.On 04/13/2026 at 8:30 a.m., an initial tour of the kitchen was conducted with S6DMA who was responsible for the dietary department. During the tour, observations were made in the clean dish storage area, the dishwashing area, and of the ice machine. In the three-compartment sink and dishwasher area, a thick buildup of black residue was observed on the brick wall above the stainless steel backsplash. The residue extended approximately six inches in height along the entire length of the three-compartment sink. A similar accumulation of black residue was observed on the brick wall above the stainless steel backsplash along the length of the dirty side dish table of the dishwasher. S6DMA scratched the residue with her fingernail and stated, It's just dirty, confirming the substance was a buildup of soil and not a permanent stain. Continued observations revealed that clean dish storage, including dinner plates, bowls, and dessert plates, were stored upside down on trays that contained a buildup of old food particles. Further observations of the kitchen's ice machine revealed a buildup of black residue on the interior top panel. S6DMA acknowledged the clean dish storage surfaces should not contain old food particles and required cleaning. S6DMA also confirmed the ice machine was dirty and stated that the ice would need to be discarded and the machine needed to be cleaned immediately.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure to facility was free from pests in the kitchen dishwashing area. The deficient practice had the potential to affect 74 residents who resided in the facility and ate meals from the kitchen.Findings:Review of the facility's policy titled, Pest Control, with no review date, read in part: Facility wide pest control strategies are developed emphasizing kitchens, cafeterias.1. On-going measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice, and rats.On 04/13/2026 at 8:30 a.m., during a tour of the kitchen dishwashing area conducted with S5DM and S6DMA, four live, small, dark brown insects were observed crawling on the wall near the backsplash on the clean side of the dishwasher dish table. S5DM verified the insects were roaches and further confirmed the pest problem.On 04/13/2026 at 11:03 a.m., an interview was conducted with S1ADM and S2AIT responsible for the overall management of the facility. S1ADM stated that pest control services were provided on a monthly basis and included the kitchen area. Both S1ADM and S2AIT stated they were unaware of any pest concerns in the kitchen.On 04/13/2026 at 11:24 a.m., a second observation of the kitchen dishwashing area revealed one additional live, small dark brown insect crawling on the wall near the backsplash on the dirty side of the dishwasher dish table.

Based on observation, policy review, and interviews, the facility failed to implement and maintain an effective infection control and prevention program by failing to ensure ice scoops used for filling resident water pitchers were cleaned and sanitized daily. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings:A review of the facility's policy titled, Ice Handling and Storage with no review date, read as follows: 3. Scoops will be cleaned/sanitized daily.On 04/13/2026 at 9:40 a.m., an observation was made of the ice chest and ice scoop used for filling resident water pitchers with S9LPN. The ice scoop was stored in a clear plastic bag labeled with a date of 04/09/2026. S9LPN confirmed the date indicated the scoop had last been cleaned and sanitized four days prior and stated she was unsure of the required frequency for cleaning and sanitizing the scoops.On 04/15/2026 at 10:28 a.m., an interview was conducted with S4ADON who also served as the facility's Infection Preventionist and was responsible for oversight of the infection control program. S4ADON stated the ice chests and scoops were to be sent to the kitchen daily at the end of the evening shift for cleaning and sanitizing. She further stated that following cleaning, scoops were to be placed in a clear plastic bag and labeled with the current date. S4ADON confirmed the ice scoop observed on 04/13/2026 should have been cleaned and sanitized per policy but was not.

Based on observations, interview, and policy review, the facility failed to ensure garbage and refuse were disposed of properly. Findings:A review of the facility's policy titled, Garbage Disposal with no review date, read in part: All outside dumpsters will be maintained in clean and sanitary conditions. 8. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter.A review of S7RD's inspection report titled, Skilled Nursing Kitchen Observation dated 01/14/2026 revealed the following: 6. Dumpster/Dumpster area: needs attention, doors closed, around dumpster has quite a bit of trash and uncertain where it is coming from, clean dumpster area. A review of S7RD's inspection report titled, Skilled Nursing Kitchen Observation dated 03/18/2026 revealed the following: 6. Dumpster/Dumpster area, needs attention, clean dumpster area, and keep dumpster doors closed while not in use. On 04/13/2026 at 12:29 p.m., a concurrent observation and interview was conducted of the outside trash dumpster and surrounding dumpster area located at the north side of the facility with S1ADM and S2AIT who were responsible for the day to day management of the facility. The dumpster side door was open. Trash that consisted of used vinyl gloves, empty milk cartons, used plastic drinking cups, disposable cutlery, paper and plastic litter, a broken patio umbrella and multiple wooden pallets was strewn about on the ground surrounding the dumpster. S1ADM confirmed the trash was from the facility and should not have been on the ground.On 04/13/2026 at 2:30 p.m., an observation was made of the trash dumpsters located at the west side of the facility. A large bag of trash that contained soiled adult briefs and other items was on the ground in front of the dumpster. The side door to one of the dumpsters was open and both dumpster top lids were open.On 04/13/2026 at 3:30 p.m., observations of trash at both dumpster locations was made with S1ADM and S2AIT where open dumpster lids and doors were noted. Both S1ADM and S2AIT confirmed that it was the maintenance department's responsibility to maintain the dumpster areas, there should not have been any trash on the ground, and all dumpster lids and doors should have been closed.

Based on observation, interview, and record review, the facility failed to ensure dietary staff accurately measured nutritional supplements in accordance with residents assessed nutritional needs. This deficient practice had the potential to result in inadequate or inconsistent nutritional intake, altered nutritional status, and failure to meet the nutritional needs for 10 residents with supplements, being served the supplements from the kitchen. Findings:A review of the facility's policy Dietitian Responsibilities with no review date, read in part, Participation in developing and implementing an individualized plan of care to meet the nutritional needs of each resident. On 04/13/2026 at 11:50 a.m., an observation was made of S8DA preparing nutritional supplements for residents' noon meal. S8DA poured from a 32oz (ounce) container of MedPlus 2.0 supplement into 10, 5oz. cups without the use of a measuring device. A concurrent interview was conducted with S8DA. She stated that she had been instructed by S7RD to use the MedPlus 2.0 as the designated nutritional supplement for a list of residents who were to receive supplements but confirmed she had not received education or instruction regarding measuring the supplement portions. S8DA stated, I don't know, no one ever told me that I had to.On 04/13/2026 at 12:00 p.m., a phone interview was conducted with S7RD with S6DMA present. S7RD stated that the 10 residents who had been assessed and determined to require nutritional supplements should be served 4 ounces of the supplement. S7RD confirmed that dietary staff had not been educated on the proper measurement of supplements and acknowledged the issue, stating, I think you've found an area that needs to be improved. S7RD further confirmed that without measuring the supplement, there was no way to ensure the residents had received the proper nutrition as ordered per their diet.

Based on record review, observations, and interviews, the facility failed to ensure a resident's urinary drainage bag was below the resident's bladder according to facility policy for 1 (#13) out of 2 residents reviewed for urinary catheters or UTI (urinary tract infection). Findings:On 04/14/2026, a review of the facility's policy titled, Catheter Care, Urinary, dated 12/2024 read in part, The purpose of this procedure is to prevent catheter associated urinary tract infections. Maintaining unobstructed urine flow. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.A review of Resident #13's electronic health record revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses including, but not limited to, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, unspecified, and retention of urine.A review of Resident #13's physician orders revealed an order dated 02/20/2026 that read, Urinary catheter - Catheter 20F (French) suprapubic every shift related to obstructive and reflux uropathy, unspecified.A review of Resident #13's Care Plan Report revealed a focus area initiated on 05/02/2025 that read in part, The resident has a suprapubic catheter. The interventions included in part, Position catheter bag and tubing below the level of the bladder and away from entrance room door.On 04/14/2026 at 11:27 a.m., an observation was made of Resident #13 sitting in his wheelchair in the dining room. The resident's urinary catheter drainage tube was draped over the armrest of the wheelchair and the urinary drainage bag was inside the pouch of the backrest of the wheelchair, behind the resident's back, which was above the resident's bladder.On 04/14/2026 at 11:53 a.m., an interview was conducted with S10RN. She stated that Resident #13 had a suprapubic catheter. S10RN stated that she put Resident #13's urinary drainage bag in the pouch of the backrest of his wheelchair. She stated the urinary drainage bag should have been placed below the resident's bladder, but it was not.On 04/14/2026 at 11:57 a.m., an observation of Resident #13 was conducted with S11LPN. She confirmed the resident's urinary drainage bag was in the pouch of the backrest of the wheelchair and it should not have been. She stated it should have been placed in a privacy bag and placed below the resident's bladder.On 04/14/2026 at 12:00 p.m., an interview was conducted with S3DON. He stated a urinary drainage bag should be placed lower than the resident's bladder with a privacy cover over it. At this time an observation of Resident #13 was conducted with S3DON. He confirmed the urinary drainage bag was in the back pouch of the wheelchair, above the resident's bladder, and should not have been.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antibiotic medication for 1 (#5) out of 34 sampled residents.Findings:Review of Resident #5's Quarterly MDS, dated [DATE], revealed in part: Section N. Medications.N0415. High-Risk Drug Classes: Use and indication 1. Is taking. Check if the resident is taking any medication by pharmacological classification, during the last 7 days F. Antibiotic not checked.Review of Resident # 5's February 2026 electronic Medication Administration Record (MAR) revealed that he received Macrobid 100 mg (milligrams) (an antibiotic) daily from 2/1/2026 to 2/28/2026. On 4/15/2026 at 8:25 a.m., an interview and record review was conducted with S12RN. She reviewed Resident #5's Quarterly MDS dated [DATE], along with resident's February 2026 MAR, and confirmed Resident #5 received antibiotic medications and the MDS was not coded correctly.

Based on record review, observations, and interviews, the facility failed to ensure staff implemented a resident's established, individualized plan of care for 1 (Resident #1) of 3 sampled residents who required two person assistance with bed mobility.This deficient practice resulted in an actual harm for Resident #1 on 03/11/2026 at 1:45 p.m., when S4CNA failed to follow the resident's plan of care for using two person staff assistance. S4CNA provided bed mobility during ADL (activities of daily living) care for Resident #1 without assistance from another staff member resulting in the resident falling from her bed onto the floor sustaining an injury to her right lower extremity requiring hospitalization. Resident #1 was diagnosed as having a right periprosthetic fracture of the proximal tibia, a displaced fracture of the proximal right fibula, and a hematoma in the medial aspect of the proximal medial aspect of the lower leg measuring approximately 9cm (centimeters) x 2cm x 5 cm. The facility implemented a corrective action plan on 03/11/2026 which was completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Findings: A review of the facility's Activities of Daily Living policy with an approval date of 09/24/2025, revealed the following, in part: This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included severe morbid obesity, acquired absence of left leg above knee, cerebrovascular disease, and unspecified dementia. Review of Resident #1's quarterly MDS (Minimum Data Set) resident assessment with an ARD of 02/23/2026, revealed the following, in part:BIMS (Brief Interview for Mental Status) of 8 which indicated the resident was mildly cognitively impaired.Bed mobility (rolling left to right) defined as the ability to roll from a supine position to the left and right sides and return to supine in bed-Resident was assessed as requiring substantial to maximum assistance. This level of assistance indicated that the helper performs more than half of the effort, including lifting or supporting the trunk and/or limbs.Toileting hygiene -Dependent. This level of assistance indicated that the helper does all of the effort. Review of Resident #1's current Care Plan revealed the following, in part:Date Initiated: 01/04/2022Focus: The resident has an ADL self care performance deficit: left AKA (above knee amputation), impaired mobility.Intervention: Bed Mobility: The resident requires 2 or more staff participation to reposition and turn in bed. Review of Resident #1's Nursing Notes revealed the following, in part:3/11/2026 13:45 (1:45 p.m.) Note Text: This nurse heard resident yelling, upon entering room noted resident was sitting on the floor leaning on her L (left) side. Noted that R (right) leg was hyper extended while on floor. Instant bruising noted to R (right) ankle/top foot area. Skin tear to L (left) abdomen x's (times) 2 and R (right) center chest area. Resident lifted from floor using Hoyer lift x's 3. Successfully placed back in bed.O2 (oxygen) in place per NC (nasal cannula) . Resident c/o (complains of) pain.ambulance called for transport for post fall evaluation. Review of the resident's hospital records dated 03/11/2026 at 11:22 p.m. revealed Resident #1 sustained the following: 1. Acute mildly displaced and angulated comminuted periprosthetic fracture of the proximal tibia with the fracture line extending to the distal tip of the tibial prosthesis. 2. Acute mildly displaced fracture of the proximal fibula. 3. Hematoma in the medial aspect of the proximal medial aspect of the lower leg measuring approximately 9cm (centimeters) x 2cm x 5 cm. Review of the facility's Investigative Report revealed the following, in part:On 03/11/2026 at approximately 1:45 p.m., Resident #1 was being provided peri care by a CNA (Certified Nursing Assistant) turned to left side while in bed and continued to roll off the bed and had a fall that resulted in a tibia fracture. On 03/23/2026 at 11:30 a.m., Resident #1 was observed in bed with a leg immobilizer in place to her right leg. The resident was not interviewable to answer questions regarding the incident involving the fall with fracture. On 03/23/2026 at 12:50 p.m., an interview was conducted with S4CNA who confirmed that on 03/11/2026, she provided bed mobility and ADL care to Resident #1 without a second staff member present for assistance when the resident fell from her bed. She explained that when turning Resident #1 to change her brief, the resident grabbed onto the mobility rail to assist with the turning. The resident turned all the way out of the bed falling to the floor. S4CNA stated she had not referenced the residents Kardex (electronic record containing the resident's care plan) prior to providing care and bed mobility and was unaware that resident information regarding care requirements was available on the Kardex. On 03/23/2026 at 2:15 p.m., an interview was conducted with S3LPN. S3LPN affirmed both she and S4CNA were caring for Resident #1 on 03/11/2026. She stated she heard Resident #1 yell out and seconds later S4CNA called for help. S3LPN entered the Resident #1's room and saw the resident lying on her left side, on the floor, on the left side of her bed with only one staff member present in the room to which she identified as S4CNA. She observed dark bruising already developing to the resident's right ankle/top of foot area and her right leg/ankle was in an unnatural position indicating a probable injury. S3LPN stated she immediately called for S2DON's assistance. She explained they assessed the resident and returned her back to her bed and she initiated the emergency hospital transfer protocol. On 03/24/2026 at 8:34 a.m., a phone interview was conducted with S2DON who was responsible for nursing services provided at the facility. S2DON confirmed S3LPN called him to the resident's room after Resident #1's fall. S2DON explained that when he entered the resident's room, Resident #1 was on the floor on the left side of her bed. S2DON affirmed that Resident #1 already had visible bruising to her right lower leg. He stated that, with assistance from three staff members, they lifted the resident back into the bed using a mechanical lift and S3LPN called EMS (emergency medical services). S2DON explained that all staff were trained upon hire and PRN (as needed) on accessing and following resident plans of care/Kardex including to review care requirements before providing care. He stated that Resident #1 had been assessed as a 2 person staff assist with transfers and bed mobility since her admission in 2022. He further confirmed that during his investigation, S4CNA verbalized to him that she was performing this task without a second staff member present because she had been caring for this resident for so long that she thought she could just do it herself. S2DON stated the root cause of the resident's fall and injury was due to S4CNA failing to properly follow the resident's plan of care and requirement for two staff while providing ADL care and bed mobility. The facility implemented corrective actions immediately with reeducation for S4CNA and clinical staff on the current shift and again for the oncoming shift on 03/11/2026. He also stated that this reeducation included a return demonstration from staff on how to access the resident care plan/Kardex. S2DON stated the facility had no further incidents regarding ADL care and bed mobility since 03/11/2026. On 03/24/2026 at 1:25 p.m., an interview was conducted with S1ADM who was responsible for the overall management of the facility. S1ADM provided documentation of the facility's investigation regarding Resident #1's fall. She stated that on 03/12/2026, a 100% audit of all residents' plans of care was completed to identify all residents that required two person assistance. It was at that time S2DON stated residents were no longer at risk. She further explained that on 03/13/2026, staff monitoring was initiated by the interdisciplinary team for residents requiring two person assistance to validate safety and compliance. This monitoring will be done on randomly selected residents that require the use of two person assistance 3 times a week for the following 90 days. She further explained that all staff were trained during their orientation upon hire and as needed, regarding the resident plan of care and resident care requirements. A request was made for documentation that S4CNA had received this training. On 03/24/2026 at 1:50 p.m., S1ADM and S5HR, who provided S4CNA's personnel file. A hire date of 05/31/2022 was noted. S5HR provided the form that S4CNA signed on the date of her orientation as evidence that she had received the orientation handbook. S1ADM explained that education for resident plans of care and the Kardex was included in this orientation handbook. A copy of this handbook was provided at this time as well. It read as follows: Follow the Kardex and resident care plan for specific interventions - encourage and assist with repositioning, refer to Kardex and care plan for specifics. Point of Care Documentation - the resident's Kardex or plan of care with specific instructions on caring for the resident is also maintained in POC (plan of care) and are available for you to view at any time.A copy was S4CNA's transcript for continuing education was provided. It was noted that S4CNA completed a course titled, Repositioning in Bed on October 15, 2025 and again on November 14, 2025. The information provided in this continuing education course was also provided. In regards to positioning, it read as follows: For some people, it may need to be often, so it is important to refer to the individual's care plan for specific instructions. On 03/24/2026 at 3:06 p.m., S1ADM, provided documentation of a facility wide in-service that had been conducted on 10/15/2025. Procedures reviewed were two person transfers.task: check Kardex/service plan for appropriate transfer technique. S4CNA signature was observed on the sign in sheet as verification for having received this education. The skills demonstration checklist with this specifically stated task was dated 10/16/2025 and signed by S4CNA verifying she received the education. On 03/24/2026 at 3:40 p.m., a final phone interview was conducted with S4CNA. The signed education and in-services from hire, trainings from October 2025 and November 2025 that referenced following a residents plan of care, as well as the facility conducted in service were all reviewed and discussed. She confirmed to having received each one of these in-services/education agreeing that she remembered them. She now stated she looked at resident care plans, but just had not looked at hers (referring to Resident #1) in a long time. She further confirmed that she should have reviewed the resident's plan of care prior to administering care, but did not. Multiple Nurses and CNAs were interviewed from 03/23/2026 through 03/24/2026 on when and how to access a residents plan or care/Kardex. All staff interviewed were knowledgeable about the facility's policy and confirmed having received re-education with a return demonstration. Three random residents, who required assistance from two staff members for ADL care and bed mobility, were observed having two or more staff members enter the residents' room and provide ADL care from 03/23/2026 to 03/24/2026. No identified concerns were noted.During an interview on 03/23/2026 at 12:50 p.m., S4CNA confirmed that she received training after the incident on how and where to access this information, what information the kardex contained, and when to access it. On 03/24/2026 at 9:44 a.m., a follow up interview was conducted with S4CNA who correctly demonstrated how to access the resident's Kardex/care plan.The facility implemented the following actions to correct the deficient practice: I. Resident #1 assessed and sent for emergency evaluation and treatment. Investigation opened immediately on 03/11/2026.II. On 03/11/2026, S2DON and S6AIT initiated education and in-service for S4CNA and all clinical staff on the current shift and again for the oncoming shift. S4CNA was also retrained on following the resident's care plan and the facility's abuse policy and protocol. On 03/12/2026, a 100% audit of all residents plan of care completed to identify all residents that require two person assistance. It was at that time S2DON stated residents were no longer at risk. III. On 03/11/2026 initiated education of clinical staff that included a return demonstration had begun for all clinical staff and was completed on 03/12/2026.IV. On 03/13/2026, initiated staff monitoring by the interdisciplinary team on residents requiring two person assistance to validate safety and compliance. Monitoring will be done on randomly selected residents that require the use of two person assistance will be done 3 times a week for the following 90 days. The interdisciplinary team included S1ADM, S2DON, S6AIT, the assistant director of nursing, the two data collection nurses (MDS nurse), the nurse practitioner, and the staffing educator. Monitoring is ongoing.V. Facility's compliance date 3/13/2026.

Based on record review and interviews, the facility failed to implement a comprehensive person-centered plan of care that identified the resident's need for 1:1 (one on one) supervision to manage behaviors for 2 (#1, #3) out of 4 (#1, #2, #3 and #4) sampled residents.Findings:Resident #1Review of Resident #1's EMR (electronic medical record) revealed the resident was readmitted to the facility on [DATE] with a diagnoses not limited to depression, unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #1's EMR, progress notes revealed a progress note dated 07/26/2025 at 4:28 p.m.,. Resident #1 stated I'm going to go in my room and hang myself. At 4:30 p.m., S13LPN (Licensed Practical Nurse) notified S10NP (Nurse Practitioner) who gave an n/o (new order) for 1:1 r/t (related to) suicidal ideation. Resident #1 was placed immediately on 1:1 with S13LPN at nurses' station.Further review of the EMR progress notes revealed no evidence of 1:1 supervision of the resident from 07/26/2025 at 9:56 p.m. through 07/27/2025 at 9:30 a.m. Resident #1 was transferred out facility with transportation service to the behavioral hospital on [DATE] at 9:30 a.m. for behaviors.Resident #3Review of Resident #3's EMR revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder, current episode depressed, moderate; vascular dementia, severe, with psychotic disturbance, vascular dementia, severe, with agitation; major depressive disorder, recurrent, mild and anxiety disorder, unspecified.Review of Resident #3's EMR progress note's revealed on 08/09/2025 at 3:43 p.m., S10NP documented: Spoke with S4LPN on memory care unit. S10NP was advised that Resident #3 had become aggressive with Resident #2 and began striking Resident #2 in the face multiple times. Residents #1 and #3 were separated for safety. S10NP advised S4LPN to place Resident #3 on 1:1 and consult inpatient psych.Further review of Resident #3 EMR progress notes revealed no evidence of 1:1 supervision of the resident from 08/09/2025 at 3:20 p.m. until Resident #3 transferred out facility with transportation service to the behavioral hospital on [DATE] at 11:15 p.m.On 08/25/2025 at 12:35 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed she was aware of the incident of suicidal ideation of Resident #1 and the resident to resident altercation with Resident #2 and Resident #3. S3ADON reviewed Resident #1's EMR and confirmed the nursing documentation for Resident #1's 1:1 supervision was not documented in the EMR from 07/26/2025 at 9:56 p.m. through 07/27/2025 at 9:30 a.m., before Resident #1 was transferred out of the facility to the behavioral hospital. S3ADON also reviewed Resident #3's EMR and confirmed there was documentation in the progress note from S10NP for 1:1 supervision, but there was no documentation one to one supervision had been implemented for Resident #3 after the incident on 08/09/2025 at 3:20 p.m. until Resident #3 was transferred out of facility.On 08/26/2025 at 9:42 a.m., an interview was conducted with S10NP, she confirmed she was notified by the facility of the suicidal ideation for Resident #1 on 07/26/25 and gave a telephone order to initiate 1:1 supervision and consult inpatient psych. She also confirmed she had given a telephone order on 08/09/2025 to S7LPN for 1:1supervision after the resident to resident altercation for Resident #3 with a consult for inpatient psych care.

Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#1) out of 4 (#1, #2, #3 and #4) residents sampled. Findings: A review of Resident #1's admission record revealed an initial admission date of 07/17/2025 and a discharged with return anticipated date of 07/27/2025 with diagnoses that included but were not limited to, depression, Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #1's nurse's notes revealed on 07/27/2025 at 9:30 a.m., Resident #1 transferred out of the facility to the hospital with transportation service via stretcher. A review of the emergency transfer log noting the Ombudsman notifications from July 2025 revealed Resident #1's transfer to the hospital on [DATE] was not identified on the list. On 08/25/2025 at 12:35 p.m., an interview and record review was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed Resident #1 was transferred out of facility via a stretcher to the hospital on [DATE]. A review of the Emergency Transfer Log noting Ombudsman notification for July 2025 was conducted. S1ADON confirmed that the State Long-Term Care Ombudsman was not notified of Resident #1's facility-initiated transfer, and should have been.

Based on interview and record review, the facility failed to ensure an investigation of an allegation of abuse was thoroughly investigated for 1 (#4) of 3 (#2, #3, #4) sampled residents reviewed for abuse. Findings:Review of the facility's abuse, prevention and prohibition policy, with an approved date of 12/2024, revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals . Investigation: Resident abuse must be reported immediately to the administrator. The facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. 2. Initiate investigation including initial reporting to all required agencies.5. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, resident or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. 6. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on.Review of Resident #4's medical record revealed a re-entry admission date of 04/02/2025, with diagnoses that included in part Parkinson's disease without dyskinesia, without mention of fluctuations; unspecified dementia, unspecified severity, with other behavioral disturbance and delusional disorders.Review of Resident #4's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/08/2025 revealed a BIMS score of 00, which indicated severely cognitively impaired. Review of a facility's critical incident report revealed events occurred on 08/03/2025 at 6:00 p.m. and discovered on 08/03/2025 at 6:00 p.m. and was entered on 08/03/2025 at 7:43 p.m. Incident Investigation: completed by S1ADM (Administrator) on 08/07/2025 at 5:53 p.m. revealed the following in part, S1ADM wrote investigation findings: Resident #4 with a BIMS 99, did sustain a hematoma to the right side of head above the temple. The resident is unable to state or recall the origin of injury. The resident did not complain of pain. Resident was assessed with no further injuries noted. Resident was treated for injury. The injury was first noticed by hall CNA (Certified Nursing Assistant) and was reported to the nurse who examined and treated. Recognition of the injury was early afternoon. Nurse initiated all required protocol for the injury, including contacting physician and family. Charge nurse became aware of the injury approximately 6:00 p.m., and informed the regional nurse and Administrator of the injury. Administrator initiated the investigation and critical incident report.There is no video surveillance to view. There is no roommate to interview.There is no evidence to the origin of injury. Abuse cannot be substantiated. Included in the attachment is face sheet, statement, diagnosis of resident, summary of event, police case, nurses' notes, progress notes, skin assessment, SBAR (Situation, Background, Assessment and Recommendation), and in-service. Review of the SBAR communication form and progress note dated 08/03/2025 revealed in part, hematoma to right side of head above temple. Before getting resident up, CNA reported to this nurse that resident had a hematoma on right upper temporal area. Upon assessment, purplish raised bruising noted. Light blue bruising noted below area. Resident unable to let this nurse know how/when accident occurred.Resident family notified on 08/03/2025 at 10:55 a.m. and NP (Nurse Practitioner) notified on 08/03/2025 at 11:00 a.m.On 08/25/25 at 4:15 p.m., an interview was conducted with S8CNA, she reported she worked 11:00 p.m. - 7:00 a.m. on 08/02/2025. S8CNA stated she made her 1st round on Resident #4 with S9CNA. She stated when they entered the room she noticed a bruise to Resident #4's face and asked S9CNA what happened. S9CNA stated she did not know. S8CNA stated the resident did not complain of pain and could not tell them what had happened to her. S8CNA stated S9CNA reported it to nurse. She stated she did not know how Resident #4 had gotten the bruise. On 08/25/2025 at 4:30 p.m., during an interview with S9CNA, she stated she worked with S8CNA, on the night of 08/02/2025. S9CNA stated when they walked into Resident #4's room, S8CNA asked her what had happened to Resident #4's face. S9CNA, told her she did not know saying that was the first time she had seen it. S9CNA stated she reported to the nurse, S12LPN Licensed Practical Nurse), who was covering the unit at the time. S9CNA stated S12LPN's response was yeah ok. And nothing more was asked of her after that time from anyone at the facility.On 08/25/2025 at 6:33 p.m., 08/26/2025 at 9:14 a.m. and 11:44 a.m., attempts were made to contact S12LPN for phone interview, no answer, and unable to leave a message.On 08/26/2025 at 9:00 a.m., an interview was conducted with S5LPN who stated she was notified by S7CNA, of a bruise to the right side of Resident #4's face on the morning of 08/03/2025, before breakfast. She stated she did not report it to the administrative staff until later in the day. She stated she notified the NP and family mid/late morning of the bruise. She stated she did not know how the bruise occurred. She confirmed that no one had ever asked her to write a statement as to what had happened, nor had any administrative staff spoke to her about the incident. She confirmed she did not report the injury of unknown origin immediately.On 08/26/2025 at 10:12 a.m. and 08/27/2025 at 11:38 a.m., attempts were made to contact S11RN, but she did not answer. A message was left for a call back, but she had not returned the call prior to survey exit.On 08/26/2025 at 10:40 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing), she confirmed the times of administration notifications for the incident for Resident #4 were: S11RN (Registered Nurse) notified S3ADON on 08/03/2025 at 6:43 p.m. S3ADON notified S2DON (Director of Nursing) on 08/03/2025 at 6:47 p.m. and S2DON notified S1ADM on 08/03/2025 at 6:51 p.m. On 08/27/2025 at 10: 15 a.m., an interview was conducted with S1ADM (Administrator). He reported he was responsible for submitting the critical incidents. He stated when a reportable occurs the administrative team discuss the incident, if it is reportable within 2 hours the clinical team will gather with S1ADM to discuss and review the policy for steps to take. He stated S2DON and S3ADON were responsible for gathering the information and investigate and interview the staff and obtain written statements. He stated when he was ready to submit the completed investigation he asked if there was any other witness statements or investigations before submitting. On 08/27/2025 at 10:55 a.m., an interview was conducted with S1ADM. S1ADM and surveyor reviewed the incident investigation and abuse policy for the facility, specific to the investigation procedure. S1ADM confirmed the time on the critical incident report occurred was 6:00 p.m. A review of the facility's abuse policy was reviewed specific to investigation with surveyor and S1ADM. S1ADM confirmed the policy stated the investigation process would include: #5. Complete a thorough investigation.#6. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resided on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. He confirmed only one employee statement was included with the investigation, from S7CNA who reported the finding to S5LPN. S1ADM confirmed he did not speak to any other shift staff that had worked on 8/02/2025.

Based on record reviews and interviews, the facility failed to ensure allegations of injury of known origin were reported immediately to the Administrator or his/her designated representation, and reported to the state agency not later than 2 hours after the allegation was identified for 1 (#4) out of 4 (#1, #2, #3 and #4) residents reviewed for timely reporting of critical incidents.Findings:Review of the facility's abuse, prevention and prohibition policy revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.Reporting/Response: 1. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrator's absence.Resident #4Review of Resident #4's critical incident report related to injury of unknown origin with bruising to the right side of head revealed the event occurred on 08/03/2025 at 6:00 p.m. The date the incident was discovered was documented as 08/03/2025 at 6:00 p.m. The date the report was entered was documented as 08/03/2025 at 7:53 p.m., with a report due date of 08/08/2025. Review of Resident #4's progress notes revealed in part, on 08/03/2025 at 10:16 a.m., the resident experienced a change in condition noted as a Hematoma to right side head above temple. S7CNA (Certified Nursing Assistant) reported to S5LPN that Resident #4 had hematoma on the right upper temporal area. Upon assessment, purplish raised bruising noted. Light blue bruising noted below area. Resident #4 unable to let S5LPN know how/when accident occurred.On 08/26/25 at 9:00 a.m., an interview was conducted with S5LPN. She stated she was notified by S7CNA of a bruise to the right side of the face on Resident #4, on the morning of 08/03/2025, before breakfast. She stated the bruise was found the morning of 08/03/2025, and she did not report it to the administrative staff until later in the day, sometime after lunch. She stated she did not know how the bruise occurred. S5LPN confirmed she did not immediately report the injury of unknown origin and should have.On 08/26/2025 at 10:40 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who stated the facility Administrator was responsible for reporting alleged violations to the state agency. She confirmed the facility's administrative staff were made aware of Resident #4's injury: S11RN (Registered Nurse) notified S3ADON on 08/03/2025 at 6:43 p.m. S3ADON notified S2DON (Director of Nursing) on 08/03/2025 at 6:47 p.m. and S2DON notified S1ADM on 08/03/2025 at 6:51 p.m. She confirmed Resident #4 had an injury of unknown origin that S5LPN failed to report immediately and that the incident was not reported to the state agency within 2 hours as required.On 08/27/2025 at 10: 15 a.m., an interview was conducted with S1ADM (Administrator). He reported he was responsible for submitting the critical incidents. He stated when a reportable occurs the administrative team discuss the incident, if it is reportable within 2 hours the clinical team will gather with S1ADM to discuss and review the policy for steps to take. He stated S2DON and S3ADON were responsible for gathering the information and investigate and interview the staff and obtain written statements. He stated when he was ready to submit the completed investigation he asked if there was any other witness statements or investigations before submitting.

Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by other residents for 1 (#2) out of 4 (#1, #2, #3 and #4) sampled residents. The facility failed to protect Resident #2 from physical abuse when Resident #3 slapped Resident #2 in the face on 08/09/2025. The deficient practice had the potential to effect a census of 79.Findings: Review of the facility's abuse, prevention and prohibition policy revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.Review of the facility's Incident Report for the past 90 days revealed one incident of resident to resident physical aggression for Resident #2 dated 08/09/2025 at 3:20 p.m. Resident #2Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with psychotic disturbance, anxiety disorder, and conductive hearing loss, bilateral.Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score that was unscored, indicating the resident could not participate in the interview. Resident #3 Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder, current episode depressed, moderate; vascular dementia, severe, with psychotic disturbance, vascular dementia, severe, with agitation; major depressive disorder, recurrent, mild and anxiety disorder, unspecified.Review of Resident #3's most recent Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 99, indicating her cognitive status could not be assessed.Review of the facility's Incident Report dated 08/09/2025 at 3:20 p.m., revealed the following in part: Incident Location: Common area/day roomPerson Preparing report: S4LPN (Licensed Practical Nurse)Incident Description: Today (08/09/2025) at 3:20 p.m., Resident #2 was involved in an incident where he was the victim of resident-to-resident physical aggression. Resident #2 was sitting at the dining room table and because he was blind, he feels his surroundings and was rubbing the table. S6CNA (Certified Nursing Assistant) stated Resident #2 touched a package of gram crackers that were on the table. S6CNA stated due to Resident #3 getting upset, S6CNA stated she removed the Resident #2 from the table. As she was pushing Resident #2 while in his wheelchair, Resident #3 went around S6CNA, stood in front of the Resident #2, and began to yell at the resident. Resident #3 slapped Resident #2 with her right hand on the left side of Resident #2's face. S4LPN (Licensed Practical Nurse) immediately went in front of the Resident #3 to allow S6CNA to take Resident #2 out of the sight of Resident #3.S4LPN noted a red area to the residents left upper cheek area. Level of Pain: 4.On 08/25/2025 at 11:30 a.m., an interview was conducted with S6CNA, she reported she was present when the resident to resident altercation occurred with Resident #2 (victim) and Resident #3 (accused). She stated she was standing in the hallway, at the dining room door, as she was conducting one on one care with another resident when she observed Resident #2 feeling on the table to put his cup of coffee down. S6CNA stated as Resident #2 passed his hand over a pack of graham crackers, Resident #3 was walking from the table to the door. S6CNA stated Resident #3 turned around and saw Resident #2 touch the crackers then Resident #3 began yelling at Resident #2. Resident #3 turned around moving toward Resident #2. S6CNA stated she went to Resident #2 and got between him and Resident #3 to stop Resident #3 from hitting on Resident #2. She stated she turned him away from Resident #3 and Resident #3 came around her and began slapping Resident #2 on the side of the face, yelling at the resident. She stated the nurse then came in and got between Resident #2 and #3 to stop resident #3 from hitting on Resident #2. On 08/25/2025 at 12:35 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed she was aware of the incident of the resident to resident altercation with Resident #2 and Resident #3. S3ADON confirmed Resident #2 was not protected from abuse. On 08/27/2025 at 10:00 a.m., an interview was conducted with S4LPN. She confirmed she was working when Resident #3 slapped Resident #2. She confirmed Resident #3 willfully intended to hit Resident #2 because the resident yelled and went toward Resident #2 to hit him, yelling as she hit him.

Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 88 residents residing in the facility. Findings: Review of a facility policy on 04/15/2025 at 3:00 PM titled, QAPI Policy with a revised date of 01/2024, revealed the following in part, the QAPI program takes a systematic, comprehensive and data-driven approach to maintaining and improve safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirements, understand the CMS (Center for Medicare and Medicaid services) survey process and regulations, provide a QAPI path to correcting issues. The QAPI program consist of monthly/quarterly meetings, daily quality activities, QAPI tasks and performance improvement plans. On 04/15/2025 at 1:30 p.m., a review of the facility's QAPI binder was conducted. There was no evidence of any monitoring for quality performance On 04/15/2025 at 1:40 p.m., a [NAME] interview was conducted with S1ADM (Administrator) and S2DON (Director of Nursing) to determine the QAPI monitoring process for the facility. S1ADM reported a QAPI meeting was held every morning, and that was how the facility monitored for quality assurance. S2DON confirmed he did not have any documentation to show monitoring of facility QAPI concerns.

Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day. Findings: Review of the facility's PBJ (Payroll Based Journal) RN Coverage Report for 01/01/2025 to 03/28/2025 revealed no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. Review of RN clock in hours for 01/01/2025 to 03/28/2025 revealed there were no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. On 04/14/2025 at 12:30 p.m., an interview was conducted with S1ADM (Administrator). S1ADM acknowledged the PBJ RN Coverage report for 01/01/2025 to 03/28/2025 revealed on 01/01/2025, 01/04/2025, and 01/05/2025 there was not 8 hours of RN coverage on those dates. He stated the RN scheduled to work did not show up for her scheduled shifts. He stated he was unaware at the time it occurred and did not find out about it until after the fact. S1ADM stated they must have 8 hours of RN coverage daily. On 04/15/2025 at 10:00 a.m., an interview and review of RN timesheets was conducted with S10HR (Human Resources). She stated 01/01/2025 was a holiday, and confirmed there was no indication that an RN was on staff for 8 hours that day. She stated a salaried RN may have worked, but would be unable to provide any documentation that showed they were clocked in for 8 hours. She reviewed the RN timesheets and confirmed that on 01/04/2025 and 01/05/2025 there was no RN hours for those dates. She reviewed the schedule and confirmed the scheduled RN had called in on both of those dates. On 04/15/2025 at 11:40 a.m., an interview was conducted with S2DON (Director of Nursing). He confirmed there was not 8 hours of RN coverage provided on 01/01/2025, 01/04/2025, and 01/05/2025. He stated the scheduled RN did not work her scheduled shift on those days. He further stated he was not aware at the time this occurred and didn't find out about it until he returned to work and reviewed the schedule.

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. Food storage: A. Refrigerated items: 1. One container of peaches not labeled with the date it had been prepared. 2. Two containers of brown gravy with meat not labeled with the date it had been prepared. 3. One container of white gravy not labeled with the date it had been prepared. 4. One bag of pepper jack cheese not labeled with the date it had been opened. 5. One bag of sausage not labeled with the date it has been opened. B. Freezer items: 1. One bag of fries opened and not labeled with the date it had been opened or placed in a closed bag. 2. One bag of mushrooms opened and not labeled with the date it had been opened or placed in a closed bag. C. Walk-in refrigerator items: 1. Two red bell peppers with texture changes in the refrigerator indicated the items were spoiled. This deficient practice had the potential to affect the 88 residents who consumed food from the kitchen. Findings: A review of the facility's policy titled, Labeling and Dating Foods (Date Marking) undated, read in part, All foods stored will be properly labeled according to the following guidelines. The policy also indicated general guidelines, once opened all ready to eat, potentially hazardous food will be re-dated . On 04/13/2025 at 10:00 a.m., an observation and interview was conducted with S7DM (Dietary Manager). S7DM stated any food items prepared in a container or bag should have been labeled with the preparation date. He stated the items in the freezer should have been in a sealed bag and labeled with the open date. He stated any vegetables with texture changes should have been discarded.

Based on record review and interview, the facility failed to have a resident's physician respond timely to a consulting pharmacist's recommendations for 4(#11, #27, #46, #58) of 5 (#11, #23, #27, #46, #58) residents reviewed for unnecessary medications. The facility had a total census of 88. Findings: Resident #11 Review of Resident #11's medical record revealed the resident was admitted to facility on 09/17/2021 with diagnoses including diabetes mellitus, bipolar, anxiety, schizoaffective disorder, major depressive disorder and dementia. Review of physicians' orders for April 2025 included the following order: 06/06/2024 - Seroquel 400mg orally every night. Review of the facility's Monthly Medication Review (MMR) forms from 05/2024 to 03/27/2025 for Resident #11 revealed the consulting Pharmacist wrote: 10/28/2024- lsf (letter sent to Facility). Review of a GDR (Gradual Dose Reduction) form dated 10/28/2024 revealed a recommendation for dose reduction for Seroquel 400mg hs (hour of sleep) (ordered 06/2024). The form had no documented signatures by the DON (Director of Nursing) or physician that the recommendation was reviewed. On 04/15/2025 at 8:47 a.m., an interview was conducted with S4ADON (Assistant Director of Nursing). She confirmed the GDR form had not been reviewed by the facility's DON or physician after receiving the recommendation from the pharmacist. 31426 Resident #58 Review of resident #58's medical record revealed resident was admitted to the facility on [DATE] with diagnoses including morbid obesity, mild cognitive impairment, insomnia, anxiety disorder, major depressive disorder, apraxia, unspecified anemia, and frontal lobe and executive function deficit. Review of resident #58's June 2024 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 50 mg daily to equal 150 mg; (start date 06/19/2024) Sertraline HCl oral tablet 50 mg, give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 100 mg to equal 150 mg daily; (start date 06/19/2024) Trazadone HCl oral tablet 50 mg, give 1 tablet by mouth at bedtime for sleep related to major depressive disorder; insomnia; (start date 06/18/2024) Wellbutrin SR oral tablet extended release 12 hour, give 100 mg by mouth at bedtime for depression related to major depressive disorder; (start date 06/18/2024) Buspirone HCl oral tablet 5 mg, give 1 tablet by mouth two times a day for anxiety related to anxiety disorder (start date 06/18/2024) Review of resident #58's April 2025 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth at bedtime for depression related to major depressive disorder; (start date 07/01/2024) Wellbutrin SR oral tablet extended release 12 hour, give 100 mg by mouth at bedtime for depression related to major depressive disorder; (start date 06/18/2024) Buspirone HCl oral tablet 5 mg, give 2 tablets by mouth two times a day for anxiety related to anxiety disorder; (start date 11/29/2024) Review of the facility's Monthly Medication Reviews (MMR) from 03/15/2024 through 03/27/2025 for resident #58 revealed the consulting pharmacist had sent lsf (letter sent to facility) with recommendations to the physician to evaluate the routine use and consider gradual dose reduction for resident #58's psychoactive medications on 06/21/2024 and 10/28/2024. Review of resident #58's Monthly Medication Review (MMR), conducted by the consulting pharmacist on 06/21/2024, read: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rational for the continued use. This resident is prescribed the following psychoactive medication (with corresponding start dates). Buspirone 5 mg bid (twice daily) (06/24/2024) Sertraline 150 mg qd (every day) (06/24/2024) Trazadone 50 mg hs (at hour of sleep/bedtime) (06/24/2024) Wellbutrin SR 100 mg hs (06/24/2024) Please also evaluate the concurrent use of two or more antidepressants Review of resident #58's Monthly Medication Review (MMR), conducted by the consulting pharmacist on 10/28/2024, read: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rational for the continued use. This resident is prescribed the following psychoactive medication (with corresponding start dates). Sertraline 100 mg hs (07/24/2024) Wellbutrin SR 100 mg hs (08/24/2024) Please also evaluate the concurrent use of two or more antidepressants Review of the Pharmaceutical Consultant Reports, dated 06/21/2024 and 10/28/2024, revealed neither had a signature or any comments from the Director of Nursing (DON) or physician, to indicate the pharmacist's suggestions had been reviewed and considered. On 04/15/2025 at 9:48 a.m., S3ADON (Assistant Director of Nursing) confirmed that Pharmaceutical Consultant Reports, dated 06/21/2024 and 10/28/2024, had no comments or physician signature. S3ADON verified that the reports had not been submitted to resident #58's physician for review. 46169 Resident #27 A review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, dementia, anxiety disorder, bipolar disorder, and major depressive disorder. A review of Resident #27's medical record revealed the following physician's orders in part, 08/06/2024 Divalproex sodium 500 mg give 1 tablet by mouth at bedtime for mood and 02/26/2025 Seroquel XR Extended Release 24 Hour give 250 mg by mouth at bedtime related to dementia. A review of the facility's Monthly Medication Review (MMR) form from 10/27/2024 and 12/20/2024 for Resident #27 revealed the consulting Pharmacist wrote: 10/27/2024 lsf psych and 12/20/2024 lsf Seroquel dx. A review of GDR dated 10/28/2024 revealed a recommendation for a dose reduction for Divalproex DR 500mg hs (8/24) and Seroquel XR 150mg hs (8/24). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. A review of GDR dated 12/20/2024 revealed a request for an appropriate diagnosis for the use of Seroquel XR 200mg hs. The following diagnoses are considered appropriate indicated a check mark for mood disorder (bipolar disorder). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. Resident #46 Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's medical record revealed the following physician's orders in part, 12/12/2024 that read, Lorazepam oral tablet 0.5 mg give 0.5 mg by mouth three times a day related to anxiety disorder. 12/06/2024 Venlafaxine ER (Effexor XR) 75mg give 1 tablet by mouth in the evening for major depressive disorder. A review of the facility's Monthly Medication Review (MMR) form from 10/27/2024 and 02/24/2025 for Resident #46 revealed the consulting Pharmacist wrote: 10/27/24 - lsf psych and 2/24/25 lsf 2aa. A review of GDR (gradual dose reduction) for 10/28/2024 revealed a recommendation for a dose reduction for Effexor XR 75mg hs (hour of sleep) (6/24) and Lorazepam 0.5mg q (every) 8hrs (hours) prn (as needed) anxiety (6/24). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. A review of GDR for 02/24/2025 revealed a recommendation to evaluate and verify the desire to utilize the following psychotropic medications: Lorazepam 0.5mg tid (three times a day) and Buspirone 10mg qpm (every evening). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. On 04/14/2025 at 3:20 p.m., an interview was conducted with S3ADON who confirmed the GDRs for Resident #27 and #46 had not been reviewed by the facility DON or physician after receiving the recommendation from the pharmacy.

Based on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was labeled, dated ,and stored properly for 4 (Resident #20, #30, #63 and #237) out of 4 (Resident #20, #30, #63 and #237) sampled residents reviewed for respiratory care. Findings: Resident #20 Review of Resident #20's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease and SOB (shortness of breath). Review of Resident #20's current physician's orders that read in part, 03/31/2025 - Oxygen Tubing - Change weekly every night shift every Thursday; 03/31/2025 - Oxygen (O2) - clean O2 concentrator filter with water and allow to air dry weekly every night shift every Thursday; 03/31/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday; 03/31/2025 - OXYGEN 2L (liters) via N/C (nasal cannula) - every shift; 03/31/2025 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) give 3 ml inhale orally every 6 hours for SOB/Wheezing. On 04/13/2025 at 9:58 a.m., an observation of Resident #20's oxygen concentrator revealed a humidifier dated 04/04/2025 and there was no date or label on the O2 tubing. On 04/13/2025 at 12:00 p.m., an observation of Residents #20's oxygen was conducted with S6LPN. She confirmed the tubing for Resident #20's oxygen was not dated. S6LPN confirmed the tubing should have been dated and changed every week. Resident #63 Review of Resident #63's electronic medical record revealed she was admitted to the facility on [DATE] with diagnosis including chronic kidney disease. Review of Resident #63's current physician's orders that read in part, 03/31/2025 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB and 04/14/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday. On 04/13/2025 at 10:20 a.m., an observation of Resident #63's nebulizer tubing/mask in a storage bag with no label or date in the nebulizer supplies or storage bag. On 04/13/2025 at 12:05 p.m., an observation of Resident #62's nebulizer tubing and mask was conducted with S6LPN. S6LPN confirmed Resident #63's nebulizer tubing, and mask, and the storage bag was not dated. She confirmed the tubing should have been dated when it is changed. Resident #237 Review of Resident #237's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including Heart failure, shortness of breath, obstructive sleep apnea. Review of Resident #63's current physician's orders that read in part,0 4/07/2025 - Oxygen Tubing - change weekly every night shift every Thursday; 04/07/2025 - Oxygen - clean O2 concentrator filter with water and allow to air dry weekly every night shift every Thursday; 04/07/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday; 04/07/2025 - OXYGEN 2L via Nasal cannula every shift. On 04/13/2025 at 10:09 a.m., an observation of Resident #237's oxygen tubing revealed there was no label or date on oxygen tubing and O2 was patent at 2L/NC without a humidifier. On 04/13/2025 at 12:05 p.m., an observation and immediate interview of Resident #237's oxygen was conducted with S6LPN. S6LPN confirmed the tubing for his oxygen was not dated and that there was no humidifier in use with the concentrator to administer oxygen to resident. She confirmed the tubing should have been dated when changed and changed every week. On 04/14/2025 at 2:30 p.m., an interview was conducted with S3ADON, she confirmed oxygen should be administered using humidified oxygen and the tubing for the oxygen and nebulizer should be changed every week on Thursday's and documented on the MAR (Medication administration record). She confirmed the oxygen tubing change for Resident's #20, #63 and #237 was not documented on their MAR. 41868 Resident #30 Review of Resident #30's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, pulmonary edema, shortness of breath, pleural effusion, and malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of Resident #30's current physician's orders read in part: Oxygen at 3L (liters) per Nasal Cannula continuously, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (milligrams)/ml (milliliters) 1vial inhaled orally three times a day. On 04/13/2025 at 10:30 a.m., an observation of Resident #30's oxygen concentrator revealed a humidifier with no date. There was no date on the nasal cannula oxygen tubing. Resident #30's nebulizer mask was laying on the table next to the bed. It was dated 03/24/2025 and was not stored in a bag. On 04/13/2025 at 11:45 a.m., an observation of Residents #30's oxygen concentrator and nebulizer mask was conducted with S6LPN (Licensed Practical Nurse). She confirmed the nasal cannula oxygen tubing was not dated, and the humidifier was not dated. S6LPN confirmed they should have been dated and changed every week. S6LPN confirmed Resident #30's nebulizer mask was labeled 03/24/2025 and was not stored in a bag. She stated the nebulizer mask should be changed weekly and stored in a bag when not in use.

Based on observation, interviews, and record reviews, the facility failed to maintain dignity for 2 (Resident #27 and #61) out of 29 sampled residents by failing to provide residents with metal utensils and non-disposable drinking cups during dining. Findings: A review of the facility's policy titled, Resident Rights Policy with a last review date of 12/2024, read in part, Each resident in this community has the right and will be afforded he right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. Resident #27 A review of Resident #27's Quarterly MDS (Minimum Data Set) dated 11/13/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 12, indicating his cognition was moderately impaired. On 04/13/2025 at 12:09 p.m., an observation was conducted of dining. Resident #27 was observed consuming lunch using plastic utensils and drinking out of a disposable cup. On 04/13/2025 at 12:25 p.m., an interview was conducted with Resident #27. He stated some of the residents have been receiving plastic utensils and disposable drinking cups for approximately two months now for all meals. He stated he does not like using plastic utensils and would rather use metal utensils and he would like to drink out of a non-disposable cup. Resident #61 A review of Resident #61's Quarterly MDS dated [DATE] revealed she had a BIMS of 15, indicating her cognition was intact. On 04/13/2025 at 1:17 p.m., an interview was conducted with Resident #61. She stated that she is the Resident Council President and all concerns are discussed during monthly meetings. She stated some residents have been receiving plastic utensils and disposable drinking cups for about two months now due to the kitchen not having enough metal utensils and non-disposable drinking cups. She stated she received plastic utensils and a disposable drinking cup for lunch today. She stated she would like to use metal utensils and a non-disposable cup for all meals. On 04/13/2025 at 1:24 p.m., an interview was conducted with S8DA (Dietary Aide). She confirmed that some residents received plastic utensils and disposable drinking cups for all meals due to the kitchen not having enough for all residents. On 04/13/2025 at 2:30 p.m., an interview was conducted with S7DM (Dietary Manager). He stated that plastic utensils and disposable drinking cups were used during meals for some residents. He stated the facility recently purchased and received non-disposable cups, metal silverware, and plates for the facility and that they do have enough metal utensils and non-disposable drinking cups for all residents. He confirmed that metal utensils and non-disposable cups should be used for all meals. On 04/13/2025 at 3:20 p.m., an interview with S1ADM (Administrator). He confirmed during all meal services for residents only metal utensils and non-disposable drinking cups should be provided to residents and not plastic utensils or disposable drinking cups.

Based on observations, interviews, and record reviews; the facility failed to protect the resident's right to be free from abuse for 3 (#1, #2, #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The facility failed to protect: 1. Resident #1 from sexual abuse by Resident #2. 2. Resident #2 from physical abuse by Resident #5. 3. Resident #3 from physical abuse by Resident #4. This deficient practice resulted in: 1. psychosocial harm for Resident #1 on 03/02/2024 at 4:42 p.m., when Resident #2 grabbed her breasts. Resident #1 was observed startled by staff at the time of the incident. The resident's responsible party stated that she would have been panicked, very fearful, and not happy at all. 2. physical harm for Resident #2 on 03/14/2024 at 8:54 p.m., when Resident #5 struck Resident #2 on the top of his head with a cane resulting in a laceration that required sutures. 3. physical harm for Resident #3 on 03/09/2024 at 1:42 p.m., when Resident #4 hit Resident #3 in the eye that resulted in a contusion to the area with subsequent complaints of headaches and pain. Findings: On 04/08/2024, a review of the facility's Abuse Neglect Policy dated 01/2024 read in part: Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents .The facility prohibits mistreatment, neglect, or abuse of residents .The resident must not be subjected to abuse by anyone. 1. A record review of Resident #2's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses in part: Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, Disorder of Adult Personality and Behavior. A record review of Resident #2's quarterly MDS (Minimal Data Set) dated 03/08/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) that could not be completed due to the resident rarely understood. A staff assessment for mental status was conducted and indicated the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #2's progress notes revealed the following: 03/02/2024 4:42 p.m .observed in dining room physical inappropriately touched another resident's (Resident #1) breast. A review of Resident #2's care plan, failed to identify the resident's diagnosis of Sexual Dysfunction. Review of Incident Report, dated 03/02/2024 at 16:24 (6:24 p.m.), revealed the section titled Incident Description read: Resident observed inappropriately touching a female resident (Resident #1) on the breast. Immediate Action Taken read: Redirected to another area away from female resident and supervisor, doctor, and family notified, one on one staff assigned to resident in his room, psych med increased until physician can assess resident for behavior. Further review of the incident report revealed a witness stated written by S8CNA (Certified Nursing Assistant) stating Resident #1 was startled and upset at first. On 04/04/2024 at 1:15 p.m., an observation was made of Resident #2 sitting in his wheelchair propelling self in and out of dining areas in the memory care unit, in view and observation of staff. An attempt for an interview was made at that time but was unsuccessful as he did not respond to any questions or conversation. On 04/04/2024 at 3:15 p.m., an interview was conducted with S1ADON (Assistant Director of Nursing). S1ADON confirmed the incident in which Resident #2 grabbed Resident #1 breasts. She stated that the doctor was immediately notified of the incident; a medication change was immediately put into place, and Resident #2 was immediately placed on 1 on 1 observation. The doctor also assessed Resident #2 the next morning. S1DON stated the medication change was effective and he has had no other incidents of sexually inappropriate behavior. 04/08/2024 at 3:40 p.m. and on 04/09/2024 at 4:00 p.m.,phone interview attempts with S8CNA were unsucessful. On 04/08/2024 at 4:00 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed she was the nurse on duty for 03/02/2024 when Resident #2 grabbed Resident #1's breast. She stated the incident was immediately reported to her by the S8CNA. S8CNA reported to her that Resident #2 reached and grabbed the female's breast from behind her. She stated they immediately separated the two residents, redirected Resident #2, and initiated 1-on-1 observation for Resident #2. She then notified the administrator; the police; the doctor; responsible parties for both involved residents; and completed an incident report. On 04/09/2024 at 2:20 p.m., a phone interview was conducted with the Resident #1's RP (Responsible Party). He stated that his grandmother would have panicked, would not have been happy at all and would have been very fearful if the incident with Resident #2 had occurred prior to her Dementia diagnosis. On 04/09/2024 at 4:00 p.m., an interview was conducted with S6ADM (Administrator). S6ADM acknowledged he was aware of the sexual abuse incident that occurred on 03/02/2024 perpetrated by Resident #2 onto Resident #1. 44269 2. Review of Resident #5's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses, in part: Cerebral Infarction, Vascular Dementia-Unspecified Severity with Other Behavioral Disturbance, Sepsis, Metabolic Encephalopathy, and Acute Cystitis with Hematuria. Review of Resident #5's 5- Day MDS Assessment with an ARD (Assessment Reference Date) of 03/07/24 revealed a BIMS score of 09 indicating moderate cognitive impairment. Review of Resident #5's nursing progress notes dated 03/14/2024 at 8:54 p.m. per S3LPN (Licensed Practical Nurse) revealed Resident #5 being sent to hospital for behavior, hit roommate (Resident #2) in the head with his walking stick because Resident #2 bumped in Resident #5's bed and woke him up. Review of a form titled Incident Report revealed the incident occurred and was discovered on 03/14/2024 at 8:30 p.m. and entered into the state's electronic reporting system on 03/14/2024 at 8:43 p.m. Resident #2 was identified as the victim with an injury sustained of a laceration that required evaluation in the ER (emergency room ) and the accused was identified as Resident #5 for an allegation of physical abuse. Further review of the Incident Report dated 03/14/2024 revealed Resident #5 was laying in his bed when his roommate, Resident #2, was trying to get by and bumped into Resident #5's bed. Resident #5 then hit Resident #2. Resident #5 is being sent to the hospital for psychological evaluation and Resident #2 is being sent to ER. Police have been notified. Review of S3LPN's handwritten statement revealed: Resident #2 was hit in the head by Resident #5; his roommate. Reason - he bumped his bed and keeps going in/out of his room waking him up and stares at him all day at 8:35 p.m. Review of S8CNA's (Certified Nursing Assistant) typed statement read: I was in the dining room with other residents when the nurse informed me that Resident #5 stated he hit Resident #2 in the head with his cane. I went down to the residents' room and observed Resident #2 laying on the bed bleeding from his head. I put a towel on the wound while the nurse called for help. On 04/08/2024 at 3:40 p.m., 04/09/2024 at 8:20 a.m., and 4/09/2024 at 4:30 p.m., interview attempts with S8CNA were unsuccessful. On 04/08/2024 at 5:15 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was working the night of 03/14/2024 when the incident occurred between roommates Resident #2 and Resident #5. She stated Resident #5 came up to her at the nursing station and casually informed her that he had hit Resident #2 in the head with his cane and there was a lot of blood in their room. S3LPN assessed Resident #2 and observed a laceration on top of his head that required ER visit for sutures. Resident #5 was no longer in the facility. He had been discharged to home with family after the incident occured. 3. Review of Resident #3's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses in part: Acute Respiratory Failure, Muscle Wasting and Atrophy, Liver Cell Cancer, Anxiety Disorder, Atrial Fibrillation and Cerebral Vascular Accident. Review of Resident #3's Significant Change MDS assessment revealed a BIMS score of 15 indicating he was cognitively intact. Resident #3 was unable to be interviewed due to actively transitioning on hospice services. Review of Resident #4's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses in part: Unspecified Dementia- Unspecified Severity with Other Behavioral Disturbance, Major Depressive Disorder- Recurrent Severe with Psychotic Symptoms, Anxiety Disorder and Bipolar Disorder. Review of Resident #4 quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating his cognition was intact. Review of Resident #3's nursing progress notes revealed an entry dated 03/09/2024 at 1:42 p.m. per S4LPN: This Resident in dining room visiting with other residents when another resident started cursing and yelling. This resident told him to be quiet. Other resident did not stop cursing and this resident got up and went to his table and told him again to be quiet. Other resident then put fist up and said come on This resident states go ahead and hit me. Other resident then hit this resident in the eye. No other fighting noted. Very light pink area noted to this resident's outer eye. This resident is not complaining of pain. Family here and aware. Review of a form titled Incident Report revealed the incident occurred and was discovered on 03/09/2024 at 11:30 a.m. and entered into the state's electronic reporting system on 03/09/2024 at 12:52 p.m. Resident #3 was identified as the victim with an injury of redness to his eye. Resident #4 was identified as the accused for allegation of physical abuse. Further review of the Incident Report dated 03/09/2024 revealed Resident #4 and Resident #3 were playing bingo in the dining room. Resident #4 spoke ugly to another resident (Resident #6) so Resident #3 was defending her asking Resident #4 to stop speaking to her like that. Resident #4 then wheeled in his wheelchair to Resident #3 and hit Resident #3 in the eye. Resident #3's eye is red. Review of a handwritten statement per a family member of an unidentified resident/volunteer dated 03/09/2024 revealed, in part: I call 1 game of bingo and Resident #4 started after that game of Bingo was over and Resident #4 went off on Resident #6. Resident #4 told her to shut the f#@% up and that's when Resident #3 got up from his chair and Resident #4 was telling him to come on and Resident #3 went by Resident #4 and hit Resident #4 on the corner of his eye. Review of a handwritten statement per S10CNA dated 03/09/2024 revealed: Witnessed Resident #4 and Resident #3 getting into it. The 2 residents was passing licks (hitting/slapping) so she and the kitchen workers stopped them and Resident #4 was removed from the dining room .The kitchen staff told me that Resident #4 wanted to move Resident #6 and Resident #3 said get your hands off of her and Resident #4 said don't mess with me old man and Resident #3 then hit Resident #4. Review of S11NP's progress note (Nurse Practitioner) dated 03/15/2024 revealed Resident #3 was assessed for complaints of a headache and eye pain. S11NP's assessment revealed with recent contusion right eye, now with complaints of eye pain and headaches. Resident is currently alert, appropriate. Able to follow commands with normal eye movement, slight fading discoloration to eyelid; resident c/o (complaint of) pain to right eye periorbital and headache with pain level of 3/10. Skin inspection revealed redness to right periorbital area; Assessment and Plan= New Diagnoses: Headache and contusion right eye and plan to complete neuro (neurological) vital signs, prn (as needed) pain meds, may need further work up if any changes & continue hospice services. On 04/09/2024 at 10:10 a.m. an interview was conducted with Resident #4. The resident stated he felt safe living at the facility. The resident explained he recalled the incident last month when he was playing bingo in the dining room when Resident #3 started swinging at him so Resident #4 swung back striking Resident #3 in the eye. On 04/09/2024 at 11:35 a.m., an interview was conducted with S10CNA. S10CNA stated she recalled the incident between Resident #4 and Resident #3 on 03/09/2024 and confirmed she was working that day when the two were with other residents in the dining room playing bingo. She explained that the kitchen staff told her that Resident #4 wanted to move Resident #6 and Resident #3 said get your hands off of her and Resident #4 said don't mess with me old man and Resident #3 said hit me and then that's when the fight started. Resident #4 punched Resident #3 in the eye with his fist. S10CNA recalled Resident #3's eye was red. On 04/09/2024 at 1:00 p.m., an interview was conducted with S4LPN. S4LPN stated she was familiar with Resident #3 and Resident #4. She stated she was working on 03/09/2024 when she was informed Resident #4 hit Resident #3 in the eye during Bingo in the dining room. She stated that Resident #3 had redness noted to his eye and required in house monitoring only.

Based on observations, interviews, and record reviews, the facility failed to ensure residents remained safe from abuse of other residents (#3) and from staff for 3 (#3, #2, #6) of 6 (#1-#6) sampled residents investigated for abuse. The facility failed to: 1. Identify and implement appropriate measures to help protect residents from abuse by other residents in the facility and staff, 2. Ensure all incidents of alleged resident abuse were immediately reported to the Administrator and acted upon, and 3. Ensure all residents were protected from abuse by allowing abusive staff to continue to work with residents. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 7/1/19 at 1:20 p.m., when the resident who had severe cognitive impairment and was a known wanderer, was found in Resident #4's bed. Resident #4's hand was observed inside of Resident #3's brief fondling her genitalia. Once this incident was discovered by S3CNA, Resident #3 was immediately removed from Resident #4's room. In addition, staff to resident physical abuse occurred on 7/3/19 to Residents #2, #3, and #6 by S1CNA and was observed by S7CN[NAME] S7CNA reported the abuse of the residents to S12Former CNA Supervisor, however S1CNA was allowed to continue working her shift. On 7/11/19, S2CNA was observed to slap Resident #3 on the hand. The facility did not ensure Residents #3, #2, and #6, who resided in the locked unit, were free from physical and/or verbal abuse by the staff and/or another resident. This deficient practice continued at a potential for more than minimal harm for the remaining 96 residents residing in the facility. S8ADM and S4DON were notified of the Immediate Jeopardy at 11:07 a.m. on 8/1/19. The Immediate Jeopardy was removed on 8/2/19 at 3:45 p.m. The facility presented an acceptable Plan of Removal. Through observations, interviews, and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit: - Immediate re-education of 100% of all staff, including administrative staff, on the Abuse Policy was started on 8/1/19. This re-education will focus on identifying abuse, timely reporting, and to whom to report. This re-education will be completed at a minimum of 70% by 8/2/19 at 2pm. No staff will be allowed to work until this re-education has been completed. - Immediate re-education of all clinical staff throughout whole facility regarding 1:1 (one-to-one) supervision, q (every) 1 hour and q 15 minute supervision began starting 8/2/19. - (Locked Unit) residents were interviewed by DON (Director of Nursing) specifically to assess if they felt safe and if the workers were nice to them. This was completed at 10:00am. Clinical staff will continue to interview residents throughout entire nursing facility to assess if they feel safe and if staff treats them nice. This will be completed by 8/5/19. - We have reviewed the residents and level of care on the (Locked Unit) and staffing has been implemented to meet the needs of the residents. - The 1:1 resident was discharged to a facility closer to his family earlier in the week on 7/30/19. Dr. _____, Resident #3's psychiatrist, was consulted on 8/2/19 and decided along with the IDT (Interdisciplinary Team) to change her monitoring from 1:1 to q 15 minute checks. Care plan revised on 8/2/19. - Dementia training has been initiated with all staff and will continue to be part of orientation for all (facility) employees. No staff member will be allowed to work without dementia training. Mandatory dementia training has been scheduled for 8/6/19, 8/10/19, and 8/20/19. In addition (Locked Unit) training will be provided to any staff prior to them working in the (Locked Unit). Signed by S4DON. Dated 8/2/19. Findings: Record review of the policy entitled Abuse, Prevention and Prohibition revealed the following, in part: The facility will educate anyone upon hire and at least annually of the Prevention and Prohibition policy including definitions pertaining to abuse and neglect. The facility's abuse programs includes the following . 2. Prevention - . Resident's behaviors will be monitored for changes which trigger abusive behaviors . Intervention strategies will be implemented to prevent occurrences of abuse. 3. Identification - .The subcommittee will identify situations which may contribute to abuse, such as staffing, supervision, and resident behaviors. They will verify staff mileage and awareness of facility's abuse plan and ensure facility's employees understand their responsibility for timely reporting. 6. Protection - removal of perpetrator. If the perpetrator is an employee, they shall immediately be barred from contact with residents. The administrator and/or the DON will relay this suspicion. When another resident is the alleged perpetrator . changes in room assignments. Safety of the residents is the primary concern. 7. Reporting/Response - The facility employee or agent who becomes aware of abuse shall immediately report the matter to the facility administrator . All alleged violations of abuse will be reported immediately to administration. Resident to Resident Abuse Resident #4 was admitted on [DATE] with diagnoses, in part, of dementia with behavior disturbances, major [MEDICAL CONDITION], recurrent unspecified convulsions, and [MEDICAL CONDITION]. A review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/15/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. Resident #3 was admitted on [DATE] with diagnoses, in part, of [MEDICAL CONDITION] with behavioral disturbance, delusional disorder, [MEDICAL CONDITION] disorder, unspecified [MEDICAL CONDITION], and [MEDICAL CONDITION]. A review of the Quarterly MDS with an ARD of 5/9/19, revealed a BIMS score of 99, indicating the resident was unable to be interviewed. Review of the resident's current care plan dated 7/17/19 revealed the resident was almost always non-verbal, and had a history of [REDACTED]. The interventions put in place for the wandering were redirection and increased supervision. Review of the investigative report dated 7/1/19 revealed Resident #3 was sexually abused by Resident #4 on that same day and further revealed the following: On 7/1/19 at 1:20 p.m., it was reported to S4DON by S5LPN that (Locked Unit) Resident #3 had been found lying across Resident #4's bed while he was standing over her with his hand in her brief fondling her genitalia. Further review of the investigation revealed the allegation was substantiated by the facility administration on 7/9/19 with a summary as follows, in part: Resident #4 was sent out to ______ (local psychiatric hospital unit) on the same day it was discovered that he had put his hand in Resident #3's brief. Resident #3 is almost always nonverbal. Increased supervision was put in place for the Certified Nursing Aides (CNAs) to take turns knowing where Resident #4 is at all times. Resident #3 was placed on every 15 minute checks. Review of the Progress Notes dated 7/1/19 revealed Resident #4 was placed on 1:1 Supervision and was transferred to the hospital for admission at 4:00 p.m. Review of the (Locked Unit) Resident Increased Supervision form for Resident #4, created by S4DON, on 7/2/19, revealed This is to be completed everyday on each shift for administrative records. Resident is to be 1:1 until further notice. This form was created while the resident was hospitalized until 7/8/19. Resident #4 was readmitted from the hospital to his same room across the hall from Resident #3 on 7/8/19. He was placed on 1:1 Supervision. Review of Resident #4's Increased Supervision forms revealed that 1:1 supervision was not initiated on 7/8/19 when he returned from the hospital as Care Planned. The Supervision forms dated 7/11/19 through 7/29/19, revealed missing staff signatures on 7/13, 7/14, 7/16, 7/19, 7/20, 7/21, 7/26, 7/27, 7/28, and 7/29 on both day and night shifts. Further review revealed missing Supervision forms for 7/22, 7/23, 7/24. Review of the (Locked Unit) Resident Increased Supervision forms for Resident #3, dated 7/11/19 through 7/29/19 revealed the resident was to be observed once every 15 minutes beginning 7/11/19. The forms had missing staff signatures on 7/13, 7/14, 7/16, 7/19, 7/20, 7/27, 7/28, 7/29 on both day and night shifts. S11CNA stated that she did not sign the increased supervision log, because she didn't actually do 1:1 due to lack of staffing. During an interview with S4DON, on 7/29/19, at 10:25 a.m., she stated that the facility had no policy for staffing in the (Locked Unit) or for any part of the facility. S4DON provided the facility Census which revealed that there were 21 residents in the Locked Unit and 96 total residents in the facility. During an interview for clarification on 8/1/19 at 10:40 a.m., both S8ADM and S4DON stated there was no policy for increased supervision, 1:1 supervision, or staffing. On 7/30/19 from 6:05 a.m. through 7:45 a.m., Resident #3 was observed in her room, located across the hall from Resident #4's room, with no supervision. On 7/30/19 from 6:00 a.m. through 6:40 a.m., Resident #4 was observed in his room with no supervision. During an interview on 7/30/19 at 7:28 a.m., S20InterimCNASup stated she went into Resident #4's room at 6:40 a.m. and got him up. S20InterimCNASup further stated there was no staff in the room when she went in to get him up. She defined 1:1 supervision for a resident is for the resident to be in sight and arms reach at all times. S20InterimCNASup confirmed Resident #4 was not being provided 1:1 supervision by staff. On 7/30/19 at 12:15 p.m., an interview was conducted with S4DON and S8ADM. They both verified they were unable to meet the needs of Resident #4 and Resident #3 (who were both on 1:1 supervision) while taking care of the other 19 resident's needs. S4DON and S8ADM both verified that there were 2 scheduled CNAs at night because they believed the night time to be more peaceful. S8ADM reviewed the blank and incomplete monitoring forms for Residents #3 and #4 and stated he should have been more vigilant to ensure they were complete. During an interview on 8/1/19 at 5:21 a.m., S3CNA confirmed she witnessed Resident #4 standing over Resident #3 with his hand inside Resident #3's brief, fondling her genitalia. Resident #3 was in Resident #4's bed with her head pushed up against the wall. She asked Resident #4, What are you doing? Resident #4 replied, Playing with her. Then, S3CNA instructed Resident #4 he could not do that. Resident #4 stated, I can if she is in my bed. S3CNA immediately removed Resident #3 from Resident #4's bed and walked her down the hall when they met S5LPN. S3CNA told the nurse what she witnessed between Resident #3 and Resident #4 in his room. S5LPN instructed S3CNA to bring Resident #3 into the shower room, for a head to toe assessment. S3CNA stated Resident #3's brief was soiled with bowel and urine, so she performed perineal care. S3CNA confirmed that the resident admitted to fondling Resident #3's genital area. During a phone interview with S5LPN on 8/1/19 at 8:25 a.m., she confirmed the incident that occurred between Residents #3 and #4 on 7/1/19. She stated she conducted a body audit of Resident #3 and found no visible injuries. She also stated that there had never been enough staff to cover any 1:1 (within 10 feet) or increased supervision at night. On 8/1/19 at 8:25 a.m. an interview was conducted with S9LPN. She stated that there has never been enough staff to cover any 1:1 (within 10 feet) or increased supervision at night. Review of another investigative report dated 7/16/19 revealed that on 7/16/19 at 7:10 p.m., S11CNA witnessed Resident #1 strike Resident #3 on the left forearm for attempting to grab Resident #1's book. Further review revealed the incident was reported to S8ADM on 7/16/19 at 7:13 p.m. On 7/30/19 at 6:10 a.m., an interview with S11CNA confirmed the 7/16/19 incident between Residents #3 and #1. S11CNA stated Resident #3 tends to agitate the others when she messes with their stuff. S11CNA immediately separated the two residents. Throughout the survey process, multiple interviews with staff on the unit revealed Resident #3 was a known wanderer who often wandered into other residents' rooms. There was no evidence that the care plan interventions, which included redirection and increased supervision, were put in place for the resident's wandering. The resident continued to wander and was later abused by others. Staff to Resident Abuse Resident #6 was admitted on [DATE] with the diagnoses, in part, of dementia with and without behavior disturbances, [MEDICAL CONDITION], depression, [MEDICAL CONDITION], anxiety, and [MEDICAL CONDITION]. A review of the Significant Change MDS, ARD 7/23/19, revealed a BIMS score of 99 (resident was unable to be interviewed). Resident #2 had [DIAGNOSES REDACTED]. A review of the Quarterly MDS, ARD 6/13/19 revealed a BIMS score of 12 (indicating moderate cognition). Review of an investigative report revealed that the facility discovered on 7/8/19, that Residents #3, #2, and #6 were verbally and physically abused by S1CNA (on 7/3/19 and 7/4/19 per S7CNA interview). The incident is described as follows, in part: Reported to S6SDN (Staffing Development Nurse) by S7CNA that another CNA, S1CNA was abusive to residents in the (Locked Unit). S1CNA was suspended from work until further notice. Review of the investigative report entered on 7/9/19 at 4:37 p.m. revealed S7CNA witnessed S1CNA verbally and physically abuse 3 Residents (#2, #3, and #6) on 7/3/19 and 7/4/19. S7CNA reported S1CNA pushed Resident #6's head into the pillow. S1CNA pulled on Resident #3 in a rough manner and cursing at her as she was getting her up. S1CNA was cursing towards Resident #2. Review of the investigative report dated 7/11/19 revealed that at 4:10 a.m. that same day, S9LPN and S11CNA witnessed S2CNA slap Resident #3 on the top of her left hand. S2CNA had made several failed attempts to redirect Resident #3 from reaching for another resident's chair. S2CNA reported that she tapped Resident #3 on the top of the hand. S8ADM was notified on 7/11/19 at 6:00 a.m., by the Assistant Director of Nurses (ADON). S2CNA was removed from the facility at 6:15 a.m. (2 hours and 5 minutes after the incident) as revealed from the time sheets dated 7/10/19 - 7/11/19. A telephone interview was conducted on 7/29/19 at 2:59 p.m. with S7CN[NAME] S7CNA recalled reporting that S1CNA physically and verbally abused Resident #6. S7CNA stated that on 7/3/19, she and S1CNA were in the room with Resident #6 trying to change her wet brief when the Resident tried to stop her from changing her brief by grabbing her arm. When Resident #6 grabbed S7CNA's arms, the Resident's fingernails dug into her skin, so S1CNA grabbed the Resident's arms with one hand. S1CNA then shoved her head into the pillow. S7CNA recalled telling S1CNA that was uncalled for, for her to shove her head into the pillow S1CNA then let go of Resident #6 and she stormed out of the room. S7CNA recalled reporting the incident to her Supervisor, S12FormerCNA Supervisor that same morning, 7/3/19, at 4:45 a.m. During a telephone interview on 7/29/19 at 2:29 p.m., S7CNA stated she walked out of a resident room into the hallway on 7/3/19, where she overheard S1CNA talking to Resident #2 out of line. S7CNA stated she heard S1CNA tell Resident #2 to shut up you crazy ass woman and told her that she stinks. S7CNA recalled walking down the hallway and saw her Supervisor, S12FormerCNA Supervisor that same morning, 7/3/19, at 4:45 a.m. She mentioned to her what S1CNA did to both residents (#6, #2) earlier that morning. On 7/29/19 at 2:29 p.m., S7CNA stated that on 7/4/19 during the night shift, S1CNA verbally abused Resident #3 when she was trying to make her go to bed, handled her roughly by shoving on her, told her that she smelled bad, and she needed to get up right now. S7CNA notified S12FormerCNA Supervisor that same morning, 7/4/19, at about 4:45 a.m. S7CNA recalled S6DSN, calling her to work a night shift. S7CNA stated she told S6DSN that she did not want to work with S1CNA because she witnessed S1CNA physically and verbally abuse Residents #6, #2, and #3. S7CNA stated she did not notify Administration because it occurred on the night shift. S7CNA had reported the incidents to S12FormerCNA Supervisor both nights that the abuse occurred with Resident #6 and Resident #2 on 7/3/19 and Resident #3 on 7/4/19. S7CNA stated she reported the abuse that occurred to Resident #2, #3, and #6 on 7/3/19 and 7/4/19 to the new CNA Supervisor (S6DSN) two days later on 7/6/19. An interview was held on 7/30/19 at 11:28 a.m. with S6SDN. S6SDN recalled that on 7/9/19, S7CNA reported to her abuse that she witnessed with 3 Residents (#6, #3, and #2) that occurred on 7/3/19 and 7/4/19. S7CNA told S6SDN, She had already reported this immediately to S12Former CNA Supervisor on 7/3/19 and on 7/4/19 (both days). S6SDN stated S1CNA should have been removed from the floor immediately and not allowed to finish working her shift on 7/3/19 and then return to work on 7/4/19 for a 12 hour shift from 7:00 p.m. to 7:00 a.m.

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: 1. Ensure and/or implement written policies and procedures for 1:1 resident supervision or for every 15 minute resident checks/rounds, 2. Ensure there was adequate staff available to work with the residents, and 3. Ensure the facility's abuse policies were properly implemented by the staff. 4. Ensure the facility had a functioning Quality Assurance Program in response to incidents of abuse and staffing. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 7/1/19 at 1:20 p.m., when the resident who had severe cognitive impairment and was a known wanderer, was found in Resident #4's bed. Resident #4's hand was observed inside of Resident #3's brief fondling her genitalia. Once this incident was discovered by S3CNA, Resident #3 was immediately removed from Resident #4's room. In addition, staff to resident physical abuse occurred on 7/3/19 to Residents #2, #3, and #6 by S1CNA and was observed by S7CN[NAME] S7CNA reported the abuse of the residents to S12Former CNA Supervisor, however S1CNA was allowed to continue working her shift. On 7/11/19, S2CNA was observed to slap Resident #3 on the hand. The facility did not ensure Residents #3, #2, and #6, who resided in the locked unit, were free from physical and/or verbal abuse by the staff and/or another resident. S8ADM and S4DON were made aware of the Immediate Jeopardy at 11:07 a.m. on 8/1/19. The Immediate Jeopardy was removed on 8/2/19 at 3:45 p.m. The facility presented an acceptable Plan of Removal. Through observations, interviews, and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit: - Immediate re-education of 100% of all staff, including administrative staff, on the Abuse Policy was started on 8/1/19. This re-education will focus on identifying abuse, timely reporting, and to whom to report. This re-education will be completed at a minimum of 70% by 8/2/19 at 2pm. No staff will be allowed to work until this re-education has been completed. - Immediate re-education of all clinical staff throughout whole facility regarding 1:1 (one-to-one) supervision, q (every) 1 hour and q 15 minute supervision began starting 8/2/19. - (Locked Unit) residents were interviewed by DON (Director of Nursing) specifically to assess if they felt safe and if the workers were nice to them. This was completed at 10:00am. Clinical staff will continue to interview residents throughout entire nursing facility to assess if they feel safe and if staff treats them nice. This will be completed by 8/5/19. - We have reviewed the residents and level of care on the (Locked Unit) and staffing has been implemented to meet the needs of the residents. - The 1:1 resident was discharged to a facility closer to his family earlier in the week on 7/30/19. Dr. _____, Resident #3's psychiatrist, was consulted on 8/2/19 and decided along with the IDT (Interdisciplinary Team) to change her monitoring from 1:1 to q 15 minute checks. Care plan revised on 8/2/19. - Dementia training has been initiated with all staff and will continue to be part of orientation for all (facility) employees. No staff member will be allowed to work without dementia training. Mandatory dementia training has been scheduled for 8/6/19, 8/10/19, and 8/20/19. In addition (Locked Unit) training will be provided to any staff prior to them working in the (Locked Unit). Signed by S4DON. Dated 8/2/19. This deficient practice continued at a potential for more than minimal harm for the remaining 96 residents residing in the facility. Findings: Cross reference F600. Record review of the policy entitled Abuse, Prevention and Prohibition revealed the following, in part: The facility will educate anyone upon hire and at least annually of the Prevention and Prohibition policy including definitions pertaining to abuse and neglect. The facility's abuse programs includes the following . 2. Prevention - . Resident's behaviors will be monitored for changes which trigger abusive behaviors . Intervention strategies will be implemented to prevent occurrences of abuse. 3. Identification - .The subcommittee will identify situations which may contribute to abuse, such as staffing, supervision, and resident behaviors. They will verify staff mileage and awareness of facility's abuse plan and ensure facility's employees understand their responsibility for timely reporting. 6. Protection - removal of perpetrator. If the perpetrator is an employee, they shall immediately be barred from contact with residents. The administrator and/or the DON will relay this suspicion. When another resident is the alleged perpetrator . changes in room assignments. Safety of the residents is the primary concern. 7. Reporting/Response - The facility employee or agent who becomes aware of abuse shall immediately report the matter to the facility administrator . All alleged violations of abuse will be reported immediately to administration. Record review of the facility's abuse programs includes the following component, in part: Identification - The facility has in place a Quality Assurance Performance Improvement (QAPI) committee that meets at least quarterly. Committee includes the administrator, DON (Director of Nursing), medical director, and other facility staff. Abuse will be reviewed and discussed at each compliance subcommittee meeting to ensure that the program is followed and effective. The subcommittee will identify situations which may contribute to abuse, such as staffing, supervision, and resident behaviors. They will verify staff mileage and awareness of facility's abuse plan and ensure facility's employees understand their responsibility for timely reporting Record review of Monthly QA (Quality Assurance) Meeting agenda and minutes for 7/9/19, revealed the Administrator was responsible reviewing the quality data for allegations of abuse, including number of allegations, number of investigations completed, and identify patterns and trends. Further review of the minutes contained the subject Allegations of Abuse with no information or documentation of abuse allegations listed. During an interview with S4DON, on 7/29/19, at 10:25 a.m., she stated that the facility had no policy for staffing in the (Locked Unit) or for any part of the facility. S4DON provided the facility Census which revealed that there were 21 residents in the Locked Unit and 96 total residents in the facility. During an interview for clarification on 8/1/19 at 10:40 a.m., both S8ADM and S4DON stated there was no policy for increased supervision, 1:1 supervision, or staffing. On 7/30/19 at 12:15 p.m., an interview was conducted with S4DON and S8ADM. They both verified they were unable to meet the needs of Resident #4 and Resident #3 (who were both on 1:1 supervision) while taking care of the other 19 resident's needs. They both verified that there were 2 scheduled CNAs at night. S8ADM reviewed the blank and incomplete monitoring forms and stated he should have been more vigilant to ensure they were complete. An interview on 8/1/19, at 11:07 a.m., was conducted with S8ADM and S4DON during which they confirmed that each had knowledge of the incidents involving Residents #2, #3 and #6. S8ADM and S4DON agreed these incidents were egregious acts that should have implemented an immediate corrective action plan and monitoring through the QAPI.

Based on observations, record reviews, and interviews the facility failed to: 1. accurately assess residents with limited mobility for 2 of 3 residents (#17, #59) reviewed for range of motion from a sample of 39 stage two residents. This resulted in actual harm for resident #59 when the facility failed to accurately assess the resident's joint mobility and failed to intervene when the resident sustained [REDACTED]. 2. assess the resident's vital signs (#41, #53), [MEDICAL CONDITION] status (#41), weekly weights (#53) for 2 of 39 stage two sampled residents. 3. accurately assess a resident's dental status (#120) for 1 of 3 residents reviewed for dental status and services from a total sample of 39 stage two residents. 4. assess a resident after receiving [MEDICAL TREATMENT] (#62) for 1 of 1 stage two residents receiving [MEDICAL TREATMENT] from a census of 88. 5. assess the use of a hypnotic (#57) for 1 of 3 residents reviewed for the use of psychoactive medications from a stage two sample of 39. Findings: Resident #59 Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Admission Nursing Assessment revealed the resident had no limitations to her extremities. Multiple observations were made of the resident on 2/14/11 and 2/15/11 between the times of 9:00 a.m. and 4:00 p.m. At each observation the resident was found to have her hands in a closed fist position. Review of the quarterly MDS(s) dated 2/8/10 and 5/6/10 revealed the resident had no limitations in her range of motion. Further review of the MDS(s) revealed the resident was not receiving PT, OT, Nursing Rehabilitation, or Restorative Care. Review of the Contracture Assessment(s) dated 2/12/10 and 5/6/10, revealed the resident scored a "20". This indicated she was a "high risk" for developing contractures. This also cued the assessing nurse to "update the Care Plan with preventative interventions to minimize risk, refer to Rehab Services (PT/OT) to complete contracture profile, and refer to Rehab Services for treatment and ongoing functional maintenance plan." Review of the annual MDS dated [DATE] revealed the resident had no limitations in her range of motion. Further review of the MDS revealed the resident was not receiving PT, OT, Nursing Rehabilitation, or Restorative Care. Review of the Resident Assessment Protocol (RAP) Summary dated 8/2/10 revealed that ADL functional/rehabilitation potential triggered. Review of the RAP care plan note revealed the resident was extensive to total care with ADLs due to muscle weakness and debility. That she was not receiving rehab or restorative care because she was with hospice and that she had no functional loss noted in ROM to extremities. A box was checked at the end of the note that indicated this was addressed within the Care Plan. Review of the MDS (s) dated 10/18/10 and 1/13/11 revealed Section G0400. Functional Limitation in Range of Motion. The resident was coded as "0" which indicated "no impairment" to the upper extremities (shoulder, elbow, wrist, hand). Review of Section O0500. Restorative Nursing Programs revealed the resident received no passive range of motion, active range of motion, or splint/brace assistance. Further review of the Contracture Assessment(s) dated 7/26/10, 10/14/10, and 12/7/10, the resident scored an "18". This indicated the resident was at a "moderate risk" for development of contractures. This cued the nurses to "update the Care Plan with preventative interventions to minimize risk and referral to Restorative Nursing for program evaluation." Review of the Care Plan revealed the following: Problem (start date of 12/3/08): Alteration in ADL's/physical functioning. At risk for decline related to: general muscle weakness, debility, [MEDICAL CONDITION]. Approaches (goal date 4/16/11): Refer for Restorative Nursing evaluation as needed. Rehab Services referral. Further review of the Care Plan included that the resident was "At risk for Contractures/Muscle Wasting/Loss of Mobility". This was included beneath the Problem of "restraint use". The only Approach applicable to the risk for contractures was "Physical Therapy referral". Review of a Quarterly Occupational Therapy Screen Form dated 12/29/10 and completed by S8COTA revealed directions to enter a "Y" for "yes" and an "N" for "no" to the questions. Each of the questions was asked in relation to functional deficits that included: bathing, bed mobility, dressing, personal safety, feeding, grooming, joint mobility, leisure activity, positioning, continence, and toilet hygiene. All of the questions were answered with an "N" to indicate a "no" response. The questions included the following: Is there a change of condition? Does the potential exist for this patient to decline further without intervention? Within the "Comments" section was written "no change in status". S8COTA marked an "X" by the selection of "Occupational Therapy evaluation NOT indicated." Review of the hospice Nursing Comprehensive Update/Visit Note included the section "Musculoskeletal". This section included the following documentation: 12/3/10: "Generalized weakness noted, hands squeezed shut; will open but with resistance." 12/5/10: "Holds hands in tightly closed fists-except pointer finger on right hand-it remains out stretched. Can open hands with assist-does resist." 12/6/10: "Holds hands in tightly closed fists-will open if assisted, but resists doing so." 12/13/10: "Contractures to bil hands/fingers" 12/27/10: "Contractures: bil hands/fingers. Holds hands tightly in fists." 1/7/11: "Holds hands in tightly closed fists with pointed fingers sticking out. Resists attempts to straighten fingers-but can do so." 1/11/11: "Contractures: bil hands clutched in fists tightly- pointers to each hand remain out stretched." 1/20/11: "Contractures to bil hands clutched in fists tightly with pointers to each hand out stretched." 1/26/11: "Contractures to bil hands/fingers" 1/31/11: "Contractures to bil hands/fingers..." 2/11/11: "Contractures to bil hands/fingers" 2/14/11: "Contractures to bil hands..." An interview was held with S15LPN on 2/16/11 at 10:30 a.m. She explained that the hospice nurse will inform the nursing staff of any changes with the resident that was observed during her visit. She stated the hospice nurse visits the resident once a week and documented an assessment. She stated the nursing staff would sign off on the hospice nursing assessments. On 2/16/11 at 1:00 p.m. an observation was made of the resident's bilateral hands/fingers with S15LPN. The resident was observed to have closed fists with the exception of the second finger and thumb on each hand. The resident was resistant to the nurse as she tried to pry open each of her closed fists. The LPN further stated that she had been an employee at the facility for 2 1/2 years and the resident's hands had always been in that condition. An interview was held with S5 and S6, both MDS/Care Plan Nurses, on 2/16/11 at 1:10 p.m. Each observed the resident's hands and verified she had bilateral hand contractures. Each stated they worked together on the MDS(s) and Care Plans. S5MDS/Care Plan Nurse reviewed resident #59's Care Plan and verified there was no reflection of the resident's bilateral hand contractures even though she had been assessed as moderate to high risk for the development of contractures. An interview was held with S5MDS/Care Plan Nurse on 2/17/11 at 7:35 a.m. She reviewed each of the MDS(s) dated 2/ 8/10, 5/6/10, 8/2/10, 10/18/10, and 1/13/11. She verified that the MDS(s) were inaccurate because they did not identify the resident's bilateral hand contractures. On 2/17/11 at 8:30 a.m. an interview was held with S8COTA. She stated the resident had not been evaluated for therapy since she began working at the facility in September 2010. She stated the screening form dated 12/29/10 was only done to screen the resident for the need for therapy and at that time the resident had not had any changes and was not a candidate for therapy. She could not recall the status of the resident's hands during the screening. An interview was held with S9OT on 2/17/11 at 8:35 a.m. She stated the resident was evaluated this morning, but refused to participate in the evaluation. She verified the resident's hands were in a tightly closed fist. She further stated that she could not say this was "contractures". She stated the resident became agitated during the screening and refused to allow full assessment. Review of the Occupational Therapy Screen Form dated 2/17/11 revealed the resident was screened for a change in ROM status. The screening was performed by S9OT. The following documentation was noted: "OT screened to assess for contractures to bilateral hands....AROM digits 1-2 bil hands but unable to actively open 3-5 digits...OT noted resistance and combative behavior when attempting to open 3-5th digits. Plan to check with hospice regarding ROM program to prevent further contracture risk." S9OT further documented "Plan to check with hospice regarding ROM/Splinting Program, Spoke to nursing and nursing to apply carrot hand positioning device bil hands to prevent further deformity." On 2/17/11 at 3:20 p.m. a telephone interview was held with the hospice nurse whom cared for resident #59. She stated she had been caring for the resident over a year. She said the resident had some movement to her thumbs and second fingers, but had always had the contractures to her third, fourth, and fifth fingers. She explained that when she had documented the resident had opened her hand with encouragement, she said she only meant the resident would relax enough for her to place the pulse ox on her third finger. An observation was made on 2/18/11 at 8:00 a.m. of the resident sitting upright in her wheelchair in front of the nurses' station. She was observed to have "Carrot" orthotic hand rolls to each of her hands. These orthotic rolls were shaped like a carrot with one end slender and the other end larger. The resident was only able to hold the smallest part of the Carrot orthotic roll due to the limited range of motion in each of her hands. An interview was held on 2/18/11 at 8:30 a.m. with S2DON. She verified the resident had bilateral hand contractures. She agreed that the facility failed to assess the resident's joint mobility and update the plan of care to include the appropriate interventions. Resident #17 Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Admission Nursing Assessment revealed the resident had no limitations to her extremities. Multiple observations were made of the resident on 2/14/11 and 2/15/11 between the times of 9:00 a.m. to 4:00 p.m. The resident was observed to have her left hand in a closed fist position. When the resident asked if she could open her hand, she would look at her hand as if to understand what was being asked of her, but was unable to actually open her hand. The resident had limited movement to her right hand and during the observations was observed to make movements with the right hand that were not purposeful. There were no observed voluntary leg or feet movements made by the resident throughout the observations. Review of the hospice admission note dated 10/26/10 revealed the resident's left hand was contracted and her bilateral lower extremities were "stiff and rigid". Further review of the hospice notes revealed the following: 10/27/10: Musculoskeletal: Contractures: left hand and bilateral lower extremities very stiff/rigid 1/24/11: Musculoskeletal: Contractures: Weakness: contractures to all extremities 1/31/11: Musculoskeletal: Weakness: contractures to all extremities 2/11/11: Musculoskeletal: Contractures: Weakness: holds bilateral hands/fingers in tightly clutched fists. Review of the significant change MDS dated [DATE] revealed the resident had no upper extremity impairments. Review of the most recent MDS dated [DATE] revealed a Section G0400. Functional Limitation in Range of Motion: no impairment of the upper extremity (shoulder, elbow, wrist, hand). Review of the February 2011 physician's orders [REDACTED]. Off 2 hours QD. Inspect skin for redness, swelling. Review of the most recent Contracture assessment dated [DATE] revealed the resident scored a "17". This indicated the resident was at a "moderate risk" for development of contractures. This cued the nurses to "update the Care Plan with preventative interventions to minimize risk and referral to Restorative Nursing for program evaluation." Review of the Care Plan revealed the following: Problem: Total care with all ADL needs. Approach: 7/16/10: Left hand brace to resident every day, take off 1-2 hours QD to allow inspection for redness, swelling, and irritation. Refer to PT/OT for high risk for contractures, positioning devices, PROM needs. An observation was made with S22LPN on 2/16/11 at 2:00 p.m. The resident was observed awake and lying in bed. The resident was able to move her right hand slightly, but the movement was not purposeful. Her left hand was observed to have a rolled washcloth in it. The nurse was able to move the resident's left hand and fingers just slightly before the resident complained of pain. The nurse verified the resident did have a left hand splint ordered but the splint was not in place. The nurse stated the splint currently could not be found. She stated she had spoke with the OT and was told the rolled towel would suffice until the splint was found. The resident had no voluntary movement to her legs or feet. An observation was made on 2/17/11 at 12:45 p.m. of the resident sitting upright in a Geri Chair in the dining room. The resident was observed to have her left hand in a closed fist position. She was being fed her lunch meal by facility staff. On 2/17/11 at 3:20 p.m. a telephone interview was held with the hospice nurse that cared for resident #17. She stated she had been caring for the resident since her admission in October 2010. She stated the resident was admitted to hospice with the contracture to her left hand. An interview was held on 2/17/11 at 4:15 p.m. with S6MDS/Care Plan Nurse. She verified the most recent contracture assessment was dated 9/10/10 and that she had performed the assessment and it revealed the resident could move only 3 extremities. S6 stated that the extremity she had assessed as being immovable by the resident was not the left hand but was one of her legs. S6 stated that at the time of the assessment, the resident was having problems with one of her knees not extending entirely. S6 reviewed the MDS(s) dated 11/3/10 and 12/16/10 and verified the MDS(s) did not reflect the resident's left hand contracture or the use of a left hand brace. An interview was held on 2/18/11 at 8:50 a.m. with S2DON. She stated she was aware of the MDS(s) being inaccurate for resident #17. Resident #41 Resident #41 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Summary written 10/10/10 revealed the following: Resident #47 was admitted to OT/PT services for gait distance, transfers, muscle strength, safety, standing balance, ADL's and was making significant progress until she was admitted to hospital on [DATE]. Review of the Physician order [REDACTED]. Monitor B/P daily Vital signs every shift while SNF Review of the Care Plan dated 8/30/10 revealed the following: Problem: Potential for [MEDICAL CONDITION] Approaches: Give meds as ordered. Elevate leg as resident will tolerate while up in chair. Watch for s/s of congestion, [MEDICAL CONDITION] or other problems. According to the Plan of Care-nursing was the discipline that should provide the above care. Review of the Care Plan dated 8/30/10 revealed the following: Problem: Risk for SOB, Chest Pains, [MEDICAL CONDITION], Elevated B/P as resident has [MEDICAL CONDITION] Apporaches: Observe feet and hands for [MEDICAL CONDITION] Encourage resident to be OOB daily and exercise Encourage resident to keep feet elevated if [MEDICAL CONDITION] occurs Review of the Daily Skilled Nursing Notes dated 9/10/10 at 9:30 a.m. revealed the following: Resident c/o SOB. O2 sat 95% on room air. Resident placed on O2 at 2 l/min. Resident had orders to go to the ER for evaluation but refused to go even after Ambulance transportation had been called and arrived. Review of the Daily Skilled Nursing Notes for 9/11/10 revealed the following: 12 a.m.-resting quietly on rounds with no complain of discomfort. PO fluids encouraged on rounds and in reach at bedside. Requires extensive assist of one person for repositioning in bed. Usually remains in bed during these hours. Continue SNF for nursing therapy. 8:00 p.m.-Awake, alert, resting quietly in bed. Watching TV. No complaints voiced at present. Foley in place with clear yellow urine noted in tubing. Continent of bowels, request bedpan-takes meds whole, regular diet, feeds self. Call light in reach, encouraged to call PRN. There was no documented evidence that the resident was assessed for SOB during the assessments done for the resident the following day. There was no documented evidence that the staff was following the comprehensive care plan in assessing the resident which included observing feet and hands for [MEDICAL CONDITION]. There were no documented vital signs in the skilled nursing notes. Review of the Skilled Nursing Notes dated 9/12/10 at 4:08 a.m. revealed the following: Awake, c/o SOB-says she is having [MEDICAL CONDITION]. O2 sat 96%. B/P 184/100, 72, 26. T 96. O2 started at 2l/min per nasal cannula for respiratory distress. 4:20 am-MD notified of respiratory distress, resident insisted she was in [MEDICAL CONDITION] and wishing to go to the hospital-New order noted to send to hospital ER to evaluate SOB. 6:25 a.m.--notified by hospital that resident would be admitted with probable [MEDICAL CONDITION]. Review of the hospital History and Physical revealed the following: O2 sat 97% on 3 liters/nasal cannula, her current B/P was 167/71. Lungs with diminished breath sounds bilaterally and multiple crackles in both lung bases up to the lower third of the lungs. Extremities: 1+ [MEDICAL CONDITION] up to mid calf. Her BNP was elevated 49, 958 Assessment/Plan: [MEDICAL CONDITION], acute and chronic diastolic dysfunction Hypertension-poorly controlled at this time An interview was conducted with S2DON on 2/17/11 at 1:10 p.m. She reviewed the skilled nursing notes for Resident #41 for dates of service 8/23/10 (admission) to 9/12/10 (hospitalized ). She verified that the nurses were not assessing the resident according to the comprehensive plan of care or physician's orders [REDACTED]. Resident #53 Resident #53 was an [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Weights weekly x 4 weeks then monthly Vital signs q shift while SNF Review of the Nursing Summary dated 11/5/10 at 5:30 p.m. revealed the following: Resident difficult to arouse-B/P 164/85, P 88, O2 sat 95% taken. Didn't wake to eat supper, temp taken at 6:30 p.m.--100.3, Tylenol given. 1:00 a.m.-Resting quietly in bed with eyes closed, call light in reach. Incontinent care every 2 hours and PRN per staff. There are no documented vital signs for the 11-7 shift and no assessment of the resident's mental status during the 11-7 shift. The resident was not assessed every shift as directed by the physician. Review of the Nursing Summary dated 11/6/10 at 8:20 a.m. revealed the following: Patient up in wheelchair in dining room area, son at his side. Pt observed by staff and son to be able to swallow small amount of food. Pt also had facial drooping on the right side-also unable to move right arm. Patient was non-verbal, staring off to the left. Able to follow small short commands and able to grip with left hand, no grip noted to right hand. Pt's son states he may have had a stroke. Call placed to MD-verbal order given to send pt to ER via ambulance. 8:55 a.m. -- Ambulance arrived to transport pt to local hospital. An interview was conducted with S3ADON on 2/18/11 at 1:25 p.m. She reviewed the admit physician orders [REDACTED]. some notes had no vital signs for either shift. She verified that if the vital signs were done they should be documented on the skilled nursing note. She also verified that the nurses were not assessing the resident adequately prior to his hospitalization . She further stated that vital signs should have been documented on the nursing notes. Resident #120 Resident #120 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] in Section C 0400 (b) revealed that the resident was able to recall things. Review of the Admission Nursing assessment dated [DATE] revealed that the resident had an oral exam and it was noted that he has his own teeth and that they were in poor condition. Review of the Comprehensive Nutritional assessment dated [DATE] revealed that he had his own teeth. Review of the 2/11 Physician order [REDACTED]. On 2/17/11 at 3:45 p.m. an interview was conducted with Resident #120. He stated that he had not seen a dentist since he had been at the facility and that he probably should because his teeth needed to be pulled. He stated that he couldn't chew his meat, he just "gnawed" on his it. He stated that he was on a Regular Diet. Review of the Interdisciplinary Plan of Care for Dental Problems dated 11/12/10 revealed that the resident had some natural tooth loss. Approaches: 1. Oral exam upon admission. 2. Social services to schedule dentist visits as needed. 3. Observe for verbal and nonverbal signs of pain/discomfort. 4. Assess oral cavity as ordered and as needed for any oral/dental problems. Review of the Comprehensive Plan of Care for Alteration in Communication related to difficulty making self understood and understanding others dated 11/12/10 revealed the following: Approaches: Anticipate care/needs. Review of the Comprehensive Nutritional assessment dated [DATE] revealed that the staff was suppose to check all the areas that applied to the resident. Review of the document noted that the resident had his own teeth. Further review of the document revealed that (1) few teeth or lost dentures or (3) poor condition or difficulty in chewing was not circled. On 2/18/11 at 8:50 a.m. an interview was conducted with S5MDS/Care Plan Nurse. She verified that the MDS dated [DATE] in Section L revealed that the resident had no obvious or likely cavities or broken natural teeth and that the resident was assessed inaccurately. She stated that (D) should have been checked for obvious or likely cavity or broken natural teeth and it would have triggered a chewing care plan. On 2/18/11 at 9:08 a.m. an interview was conducted with S3ADON. She verified that the MDS Assessment in Section L dated 11/24/2010's that was signed by her was inaccurate. She stated that S5MDS/Care Plan Nurse assessed did the MDS assessment and she just signed behind her. On 2/17/11 at 3:50 p.m. an interview was conducted with S24Social Services. She verified that she did not make a dentist appointment for the resident. She stated that the only time she made dental appointments for a resident was if a staff member gave her a referral form. She stated that she did see the resident and noted that he had missing teeth, but further said that he had not complained about his teeth hurting. On 2/17/11 at 4:00 p.m. an interview was conducted with S5MDS/Care Plan Nurse. She stated that the resident never complained of any problems to the staff and verified that he was never seen by the dentist. On 2/18/11 at 7:30 a.m. an interview was conducted with S7Dietary Manager. She verified that the resident was on a Regular Diet and that he had several missing teeth. She stated that the resident had never complained about any dental problems. She verified that the Comprehensive Nutritional Assessment did note that the resident had his own teeth and that the choices with (1)few teeth or lost dentures or (3) poor condition or difficulty in chewing had not been circled. Resident #62 Resident #62 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. On 2/18/12 at 7:21 a.m. an interview was conducted with Resident #62. He denied being in pain or having complications. He stated that he goes out to [MEDICAL TREATMENT] around 9:00 a.m. Review of resident's February 2011 Physician Order's revealed that he received [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. Review of the [MEDICAL TREATMENT] Communication Form dated 2/16/11 revealed that the resident gets [MEDICAL TREATMENT] from at a center in the community. Further review of the form revealed no nurse's assessment for Post [MEDICAL TREATMENT] Facility Information for weights, vital signs, access of site dressing condition and/or if any problems or concerns upon return to the facility from 1/19/11 to 2/16/11. On 2/18/11 at 10:30 a.m. an interview was conducted with S5MDS/Care Plan Nurse. She stated that according to the comprehensive plan of care that the resident was to have no blood pressures or needle sticks in his left arm and that the sign was posted on the resident's door and at the head of his bed. Review of the resident's room revealed no sign posted regarding blood pressures or needlesticks to his left arm. On 2/18/11 at 10:58 a.m. an interview was conducted with S6MDS/Care Plan Nurse, S2DON and S1Administrator. They all verified that the resident did not have a sign posted in his room for no blood pressures or needlesticks to his left arm. On 2/18/11 at 11:00 a.m. an interview was conducted with S2DON. She verified that there was no nurses' assessment for the resident when he returned from [MEDICAL TREATMENT] from 1/19/11 to 2/16/11. On 2/18/11 at 11:10 a.m. an interview was conducted with S22LPN. She stated that she could not recall if ever there was a sign in the resident's room notifying staff not to check blood pressures in the left arm or needlesticks. She stated that she never filled out the Post [MEDICAL TREATMENT] Facility Information Form because she was never in-serviced on doing that. She verified that she does not assess the resident's weight, vital signs or access site upon his return from [MEDICAL TREATMENT] and that any charting that she does on the resident would be in her nursing notes. Review of the Nurse's Notes revealed the following: 2/11/11-6:15 a.m.-resident left the facility via van for [MEDICAL TREATMENT] and returned at 1:20 p.m. 2/16/11-9:00 a.m.-resident left the facility via van for [MEDICAL TREATMENT] and returned to 2:20 p.m. Resident #57 Resident #57 was a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. Review of the February 2011 physician's orders [REDACTED]. Review of the Pharmaceutical Consultant Report revealed no dose reduction for [MEDICATION NAME] 15mg q hs for [MEDICAL CONDITION]. Medication was ordered on [DATE]. Review of the Consent for Psychoactive Medication Therapy dated 1/14/08 revealed a consent for [MEDICATION NAME] for Depression [MEDICATION NAME] 1 q hs prn. Review of the Interdisciplinary Plan of Care revealed that the resident has a [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care for Sedative/Hypnotic dated 11/19/10 revealed the following: Dx: [MEDICAL CONDITION] 1/26/11-Resident takes [MEDICATION NAME] Goals: Will be free of significant side effects of medication as evidenced by over the next 90 days. Approaches: Observe for significant side effects of Sedative/Hypnotic medication:Sedation/Drowsiness/Morning Hangover/Ataxia (drunk walk). Special attention if given with other sedative or hypnotics. On 2/16/11 at 10:45 a.m. an interview was conducted with S23LPN. She stated that they document the side effects of the Sedative/Hypnotic on a Psychoactive Medication Monthly Flow Record. She stated that they leave them blank if its none. Review of the February 2011 Psychoactive Medication Monthy Flow Record revealed no documentation. Review of the Social Progress Notes dated 7/30/10 revealed that the resident had repeated health complaints daily about [MEDICAL CONDITION] and change in her usual sleep pattern 5 days a week. Review of the Nurse's Notes dated 1/26/11 at 2:30 p.m revealed that the resident's daughter visited the facility for a Care Plan meeting and requested that the resident have a new sleeping pill... Review of the Physician order [REDACTED]. On 2/16/11 at 10:13 a.m. an interview was conducted with S24Social Services. She stated that they typically update when they do care plans if they haven't been when new orders are written. She stated that her and S2DON did the forms. She verified that the Consent for Psychoactive Medication Therapy form was suppose to be updated and that she assumed they missed one. She stated that nothing had been tried since she started in September. She stated that if it was something going on with the resident that was sporadic, she may try another intervention, but if its more than that the nursing staff tells her to make a note for the physician. On 2/16/11 at 11:00 a.m. an interview was conducted with Resident #57. She stated that she had been in the facility going on 4 years and she had been [MEDICATION NAME] a while but it would be 1:00 am or 2:00 am in the morning before she would fall asleep, so she requested that her sleeping pill be changed to something else. She stated that the more she tried to go to sleep, she just couldn't. She stated that it was nothing in particular that kept her awake.

Based on observations, record review, and interviews the facility failed to ensure that interventions were implemented to maintain a resident's highest level of mobility for 2 of 3 sampled residents reviewed for range of motion from 39 stage two sampled residents. (#17, #59) This resulted in actual harm to resident #59 when the facility failed to implement interventions to prevent a decline in the resident's range of motion once the resident was determined to be at risk for the development of contractures. Findings: Resident #59 Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Admission Nursing Assessment revealed the resident had no limitations to her extremities. Multiple observations were made of the resident on 2/14/11 and 2/15/11 between the times of 9:00 a.m. to 4:00 p.m. At each observation the resident was found to have her hands in a closed fist position. Review of the Contracture Assessment(s) revealed that on 2/12/10 and 5/6/10 the resident scored a "20". This indicated she was a "high risk" for developing contractures. This also cued the assessing nurse to "update the Care Plan with preventative interventions to minimize risk, refer to Rehab Services (PT/OT) to complete contracture profile, and refer to Rehab Services for treatment and ongoing functional maintenance plan." Further review of the Contracture Assessment(s) revealed that on 7/26/10, 10/14/10, and 12/7/10, the resident scored an "18". This indicated the resident was at a "moderate risk" for development of contractures. This cued the nurses to "update the Care Plan with preventative interventions to minimize risk and referral to Restorative Nursing for program evaluation." Review of the Care Plan revealed the following: Problem (start date of 12/3/08): Alteration in ADL's/physical functioning. At risk for decline related to: general muscle weakness, debility, [MEDICAL CONDITION]. Approaches (goal date 4/16/11): Refer for Restorative Nursing evaluation as needed. Rehab Services referral. Further review of the Care Plan included that the resident was "At risk for Contractures/Muscle Wasting/Loss of Mobility". This was included beneath the Problem of "restraint use". The only Approach applicable to the risk for contractures was "Physical Therapy referral". Review of a Quarterly Occupational Therapy Screen Form dated 12/29/10 and completed by S8COTA revealed directions to enter a "Y" for "yes" and an "N" for "no" to the questions. Each of the questions was asked in relation to functional deficits that included: bathing, bed mobility, dressing, personal safety, feeding, grooming, joint mobility, leisure activity, positioning, continence, and toilet hygiene. All of the questions were answered with an "N" to indicate a "no" response. The questions included the following: Is there a change of condition? Does the potential exist for this patient to decline further without intervention? Within the "Comments" section was written "no change in status". S8COTA marked an "X" by the selection of "Occupational Therapy evaluation NOT indicated." Review of the hospice Nursing Comprehensive Update/Visit Note included the section "Musculoskeletal". This section included the following documentation: 12/3/10: "Generalized weakness noted, hands squeezed shut; will open but with resistance." 12/5/10: "Holds hands in tightly closed fists-except pointer finger on right hand-it remains out stretched. Can open hands with assist-does resist." 12/6/10: "Holds hands in tightly closed fists-will open if assisted, but resists doing so." 12/13/10: "Contractures to bil hands/fingers" 12/27/10: "Contractures: bil hands/fingers. holds hands tightly in fists." 1/7/11: "Holds hands in tightly closed fists with pointed fingers sticking out. Resists attempts to straighten fingers-but can do so." 1/11/11: "Contractures: bil hands clutched in fists tightly- pointers to each hand remain out stretched." 1/20/11: "Contractures to bil hands clutched in fists tightly with pointers to each hand out stretched." 1/26/11: "Contractures to bil hands/fingers" 1/31/11: "Contractures to bil hands/fingers..." 2/11/11: "Contractures to bil hands/fingers" 2/14/11: "Contractures to bil hands..." On 2/16/11 at 1:00 p.m. an observation was made of the resident's bilateral hands/fingers with S15LPN. The resident was observed to have closed fist with the exception of the second finger and thumb on each hand. The resident was resistant to the nurse as she tried to pry open each of her closed fists. The LPN further stated that she had been an employee at the facility for 2 1/2 years and the resident's hands had always been in that condition. An interview was held with S5 and S6, both MDS/Care Plan Nurses, on 2/16/11 at 1:10 p.m. Each observed the resident's hands and verified she had bilateral contractures. Each stated they worked together on the MDS(s) and Care Plans. S6MDS/Care Plan Nurse stated she had overseen the restorative nursing program since September 2010 and resident #59 had not received restorative nursing since then. She stated the resident was on hospice and was visited by the hospice aide five days a week and the hospice aide should provide range of motion when she visited the resident. S5MDS/Care Plan Nurse reviewed the Care Plan and verified there were no interventions in place to prevent the resident from forming contractures. An interview was held with the S2DON on 2/16/11 at 3:50 p.m. She stated she had reviewed the resident's clinical record and thinned records, but was unable to locate any documentation that indicated the facility had identified the resident's contractures. She stated she observed the resident's hands and felt that the resident was refusing to open her hands, but did not feel the resident's hands were contracted. She verified she had seen the hospice documentation that identified the resident as having bilateral hand contractures. On 2/16/11 at 4:00 p.m. an observation was made with S11LPN of resident #59 as she was lying in bed. The resident's bilateral hands were observed to have her third, fourth, and fifth fingers in a tightly closed fist. When the LPN attempted to open the resident's closed hands, she would display facial grimacing and withdraw her hand while saying "no". When the resident asked if this was painful, she responded "yes". S11LPN stated she had been an employee for 2 1/2 years and the resident's hands had always been contracted with limited movement to her thumbs and second fingers. S2DON was requested to the resident's room on 2/16/11 at 4:05 p.m. Upon the DON entering the room, the resident's hands remained in the same position (tightly closed fist) as observed with S11LPN. The DON observed the resident's bilateral hands and stated that she was capable of opening her hands, but refused to. The resident was asked to open her hands and there was slight movement noted to her thumbs and second fingers, but the remaining fingers did not move, and remained in a tightly closed fist. An interview was held with S12CNA on 2/16/11 at 4:15 p.m. with S2DON present. She stated she had been an employee for 2-3 months and the resident had always had her hands in the closed position. The CNA said she had not provided the resident with any type of range of motion exercises. She stated the resident will use her thumb and first finger to pick up things at times, but requires total assistance with her meals. On 2/16/11 at 4:20 p.m. an interview was held with S13CNA. She stated she had been an employee since August 2010. She stated the resident's hands had been in that condition since she began working at the facility. S13CNA stated she had not provided the resident with range of motion exercises because restorative nursing does that. On 2/17/11 at 7:10 a.m. an interview was held with S10LPN. She stated she had worked with the resident for approximately 6 months and the resident's hands were always in a closed fist position. She stated she had never attempted to open the resident's hands or to provide range of motion to the resident's hands. On 2/17/11 at 7:15 a.m. an observation was held with S14CNA of resident #59's hands. The resident was noted to be lying in bed with her hands in the closed position. The resident's left hand had her second finger extended but the resident refused to open her hands for the CNA. When the CNA attempted to open the resident's hands, the resident withdrew and stated "no". The resident's eyes filled with tears and when asked if this hurt her, she replied "yes". An interview was held with S5MDS/Care Plan Nurse on 2/17/11 at 7:35 a.m. She stated that she had reviewed the thin records and was unable to locate any facility documentation related to the resident's contractures. She stated the only documentation found related to the contractures was by the hospice nurse. She verified the facility had failed to recognize the resident's hand contractures. On 2/17/11 at 8:30 a.m. an interview was held with S8COTA. She stated the resident had not been evaluated for therapy since she began working at the facility in September 2010. She stated the screening form dated 12/29/10 was only done to screen the resident for the need for therapy and at that time the resident had not had any changes and was not a candidate for therapy. She could not recall the way the resident's hands looked during the screening. An interview was held with S9OT on 2/17/11 at 8:35 a.m. She stated the resident was evaluated this morning, but refused to participate in the evaluation. She verified the resident's hands were in a tightly closed fist. She further stated that she could not say they were "contractures". She stated the resident became agitated during the screening and refused to allow full assessment. Review of the Occupational Therapy Screen Form dated 2/17/11 revealed the resident was screened for a change in ROM status. The screening was performed by S9OT. The following documentation was noted: "OT screened to assess for contractures to bilateral hands....AROM digits 1-2 bil hands but unable to actively open 3-5 digits...OT noted resistance and combative behavior when attempting to open 3-5th digits. Plan to check with hospice regarding ROM program to prevent further contracture risk." S9OT further documented "Plan to check with hospice regarding ROM/Splinting Program, Spoke to nursing and nursing to apply carrot hand positioning device bil hands to prevent further deformity." On 2/17/11 at 11:00 a.m. an observation was made of the resident sitting upright in her wheelchair. The resident's bilateral hands were in the closed fist position. Another observation was made on 2/17/11 at 12:20 p.m. of the resident being fed her lunch by staff in the dining room. The resident made no attempt to feed herself. An interview was held with the Nurse Practitioner on 2/17/11 at 2:45 p.m. She verified that the resident was under her care. She stated the resident had declined over the last several months to the point of becoming completely dependent on staff. She was unable to recall if the resident had hand contractures, but defined contracture as an immovable joint. On 2/17/11 at 3:20 p.m. a telephone interview was held with the hospice nurse that cared for resident #59. She stated she had been caring for the resident over a year now. She said the resident had some movement to her thumbs and second fingers, but had always had the contractures to her third, fourth, and fifth fingers. She explained that when she had documented the resident had opened her hand with encouragement, she said she only meant the resident would relax enough for her to place the pulse ox on her third finger. An observation was made on 2/18/11 at 8:00 a.m. of the resident sitting upright in her wheelchair in front of the nurses' station. She was observed to have "Carrot" orthotic hand rolls to each of her hands. These orthotic rolls were shaped like a carrot with one end slender and the other end becoming larger. The resident only was able to hold the smallest part of the Carrot orthotic roll due to the limited range of motion in each of her hands. An interview was held on 2/18/11 at 8:30 a.m. with S2DON. She verified the resident had bilateral hand contractures. She stated the facility had failed to recognize the contractures and implement interventions to prevent the occurrence. Resident #17 Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Admission Nursing Assessment revealed the resident had no limitations to her extremities. Multiple observations were made of the resident on 2/14/11 and 2/15/11 between the times of 9:00 a.m. and 4:00 p.m. The resident was observed to have her left hand in a closed fist position. When the resident asked if she could open her hand, she would look at her hand as if to understand what was being asked of her, but was unable to actually open her hand. The resident had limited movement to her right hand and during the observations was observed to make movements with the right hand that were not purposeful. There were no observed voluntary leg or feet movements made by the resident throughout the observations. Review of the February 2011 physician's orders [REDACTED]. Off 2 hours QD. Inspect skin for redness, swelling. Review of the most recent Contracture assessment dated [DATE] revealed the resident scored a " 17 " . This indicated the resident was at a "moderate risk" for development of contractures. This cued the nurses to "update the Care Plan with preventative interventions to minimize risk and referral to Restorative Nursing for program evaluation." Review of the Care Plan revealed the following: Problem: Total care with all ADL needs. Approach: 7/16/10: Left hand brace to resident every day, take off 1-2 hours QD to allow inspection for redness, swelling, and irritation. Refer to PT/OT for high risk for contractures, positioning devices, PROM needs. The Care Plan also included a Problem of "At risk for Contractures/Muscle Wasting/Loss of Mobility" . This problem was included within the "Restraint Use" Care Plan and had the listed Approach of "Physical Therapy referral (PT/OT)" . Further review of the Care Plan revealed the Comprehensive Plan of Care for Restorative Care (PROM and bed mobility) dated 5/17/10 and with goal dates of 8/17/10 and 12/22/10. The page was lined through as to indicate the Plan of Care was no longer in use. Review of the Restorative Program/Care Plan Records dated for October, November, and December, 2010, revealed the resident received PROM to all extremities twice a day. Within the December 2010 record there was documentation of the resident being discharged from the program because she was on hospice. There was no documentation found within the clinical record that the resident was seen by PT or OT. Review of the hospice admission note dated 10/26/10 revealed the resident's left hand was contracted and her bilateral lower extremities were "stiff and rigid" . Further review of the hospice notes revealed the following: 10/27/10: Musculoskeletal: Contractures: left hand and bilateral lower extremities very stiff/rigid 1/24/11: Musculoskeletal: Contractures: Weakness: contractures to all extremities 1/31/11: Musculoskeletal: Weakness: contractures to all extremities 2/11/11: Musculoskeletal: Contractures: Weakness: holds bilateral hands/fingers in tightly clutched fists. An observation was made with S22LPN on 2/16/11 at 2:00 p.m. The resident was observed awake and lying in bed. The resident was able to move her right hand slightly, but the movement was not purposeful. Her left hand was observed to have a rolled washcloth in it. The resident was able to move her left hand and fingers just slightly before complaining of pain to the nurse. The nurse verified the resident did have a left hand splint ordered but the splint was not in place. The nurse stated the splint currently could not be found. She stated she had spoke with the OT and was told the rolled towel would suffice until the splint was found. The resident had no voluntary movement to her legs or feet. On 2/17/11 at 8:30 a.m. an interview was held with S8COTA. She stated the therapy company had been with the facility since September 2010 and that resident #17 had not been seen by the therapy department since then. An observation was made on 2/17/11 at 12:45 p.m. of the resident sitting upright in a Geri Chair in the dining room. The resident was observed to have her left hand in a closed fist position. She was being fed her lunch meal by facility staff. On 2/17/11 at 3:20 p.m. a telephone interview was held with the hospice nurse that cared for resident #17. She stated she had been caring for the resident since her admission in October 2010. She verified the documentation of contractures. She stated the resident was admitted to hospice with the contractures. An interview was held on 2/17/11 at 4:15 p.m. with S6MDS/Care Plan Nurse. She stated that resident #17 was discharged from the restorative nursing program in December 2010. She stated that residents were usually removed from the program when admitted to the hospice program. S6 verified the most recent contracture assessment was dated 9/10/10 and that she had performed the assessment and it revealed the resident could move only 3 extremities. S6 stated that the extremity she had assessed as being immovable by the resident was not the left hand but was one of her legs. S6 stated that at the time of the assessment, the resident was having problems with one of her knees not extending entirely. S6 reviewed the resident's clinical record and verified there were no interventions in place to prevent further decline in the resident's joint mobility. An interview was held on 2/18/11 at 8:50 a.m. with S2DON. She verified that resident #17's contractures had been identified by the hospice nurse. She stated she was aware that the resident was discharged from the restorative program in December 2010 and there had been no further interventions put into place to prevent the resident's joint mobility from declining.