Every finding on record at Homewood Living Williamsport

Based on record reviews and interviews it was determined the facility staff failed to report allegations of abuse timely. This was evident for 3 (2708251, 2960881, 3133312) of 3 facility reported incidents reviewed. The findings include:Facility reported incident 2708251 was reviewed on 8/6/26 at 10:32 AM. The report indicated Resident #1 informed Physical Therapy Assistant (PTA) #6 on 1/5/26 that s/he was abused by 2 staff the previous day. In a written statement, PTA #6 indicated the date and time was 1/5/26 at 10:30 AM and she reported it to nursing after speaking with the social worker. The facilities initial report to the State Agency revealed the Director of Nursing (DON) was notified of the allegation at 1:00 PM on 1/5/26, 2 1/2 hours after the resident reported it to PTA #6. The facilities initial report was sent to the State Agency on 1/5/26 at 2:33 PM. 4 hours after PTA #6 was informed of the alleged abuse by Resident #1, not within the 2-hour reporting requirement. Facility documentation for incident 2960881 was reviewed on 8/6/26 at 1:47 PM. The report revealed that Resident #2 informed a family member s/he experienced abuse by staff during AM care on 3/21/26.Documentation in the facilities initial report and statements from Geriatric Nursing Assistant (GNA) #2, Licensed Practical Nurse (LPN) #4 and Nursing Supervisor #5, obtained during the facilities investigation, indicated that staff became aware of the incident at 9:45 AM on 3/21/26.An email receipt dated 3/21/26 at 12:35 PM revealed the initial report was not sent to the State Agency within the 2-hour requirement for reporting an allegation of abuse Facility reported incident 3133312 was reviewed on 8/7/26 at 9:28 AM. The report indicated the DON was notified by night shift staff of an incident between resident #3 and #4 on 8/3/26 at 5:32 AM. The email receipt for the initial report to the State Agency revealed it was sent on 8/3/26 at 8:56 AM, approximately 3 1/2 hours after staff initially reported the it to the DON. PTA #6 was not available for an interview.In an interview on 8/10/26 12:00 PM PTA #8 the Rehabilitation Department Director indicated the rehab staff receive abuse training through their company upon hire. She was asked what the policy/procedure was for reporting abuse. She explained that staff are to report anything they see, hear or suspect, to the DON, Administrator or HR immediately. She added that she knew there were timeframes for administration to submit reports to the State Agency. She indicated that she would report immediately, then complete a written report. In an interview on 8/10/26 at 12:04 PM the Human Resource (HR) Director #7 indicated that abuse/abuse prevention/reporting training was done through modules in an online training platform upon hire and annually. She also indicated that the DON did in person abuse presentation during orientation for newly hired staff. She indicated that the Rehab company was responsible for training and keeping records for training their staff and she did not keep records related to them but was able to immediately obtain their records as needed. The DON was interviewed on 8/10/26 at 12:10 PM. She indicated that she is the facilities Abuse Coordinator. She confirmed she was aware that alleged violations involving abuse were required to be reported to the state agency no later than 2 hours after the allegation was made. The above concerns were reviewed with her at that time. She acknowledged the reports were late and indicated she was the person responsible for completing the initial report forms. She indicated that it was difficult to submit them in a timely manner, especially if she was notified of an allegation when not in the building.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to the resident based on professional standards of practice. This was evident for 1 (Resident #3) of 5 residents reviewed for unnecessary medications. The findings include: Resident #3 was admitted into the facility in 2022 with diagnosis that includes but is not limited to lumbar radiculopathy, left shoulder pain, and rupture/tear of the left shoulder rotator-cuff. A review of Resident #3's electronic medication administration record (eMAR) for December 2025 was conducted on 1/7/26 at 1:56 PM. The review revealed an order for a narcotic pain medication scheduled to be taken as needed for pain. This medication was administered 14 times. The notes section of the eMAR revealed documentation from the nurses that indicated the resident's pain score, before med administration and the follow up pain score. However, the 12/7/25 at 10 AM administration did not indicate the before and follow-up pain score, the 12/12/25 at 4:56 PM administration had no follow-up pain score, the 12/23/25 at 1:23 PM administration did not indicate pain characteristics (pain score/severity, location of pain), and the 12/25/25 at 12:20 PM administration had no follow-up pain score. A subsequent review of Resident #3's medical record was conducted on 1/8/26 at 8:25 AM. The review revealed that there was no documentation to indicate that non-pharmacological interventions (NPI) were administered/attempted prior to administering the as needed pain medication. The Director of Nursing (DON) was interviewed on 1/8/26 at 12:50 PM. During the interview, she explained her expectations from the nursing staff in providing pain management, including NPI's and documentation. She reported that nurses are primarily responsible for all documentation for pain management including NPI's. However, nursing assistants also provide NPI's like warm blanket, positioning, a drink or food, and could document it themselves. The findings with Resident #3 were discussed with the DON and she indicated that she would review the resident's medical record to verify and report back to the surveyor. The facility's pain management policy was reviewed on 1/8/26 at 1:12 PM. The policy indicated that physicians order appropriate non-pharmacological intervention; and staff to provide comforting environment and appropriate physical and complementary interventions.on 1/8/26 at 2:27 PM, the Infection preventionist (IP) nurse reported that she was tasked by the DON to review Resident #3's medical record regarding the findings stated above. The IP nurse provided the surveyor with a printed report that indicated:all 14 administrations of the narcotic pain medication had no documentation for NPI's,late entry progress notes by the nurse dated 12/10/25 indicated the resident's pain score prior to pain medication administration but did not find a follow-up pain score for the 12/7/25 at 10 AM administration.12/12/25 at 4:56 PM administration had no follow-up pain score12/23/25 at 1:23 PM had no initial pain score12/25/25 at 12:20 PM administration had no follow-up pain score In a subsequent interview with the DON on 1/8/26 at 2:33 PM, the findings were reviewed, and the concern was discussed that the facility failed to ensure pain management was provided to Resident #3 based on professional standards of practice. The DON verbalized understanding and acknowledged the concern.

Based on observations, record reviews, and interviews, it was determined that the facility failed to follow an attending physician's order to administer oxygen to a resident. This was evident in 1 (Resident #94) of 1 resident reviewed for Respiratory Care during the survey. The findings include:On 1/5/2026 at 1:55 PM, Resident #94 was observed lying in bed and receiving oxygen via a nasal cannula connected to an oxygen concentrator set to 4 L/min (liters per minute).During a subsequent observation on 1/6/2026 at 9:01 AM, Resident #94 was in bed and continued to receive oxygen via nasal cannula at 4 L/min.A review of Resident #94's medical record contained an attending provider's order initiated on 12/23/25 for oxygen at 2L/min every shift for hypoxia.During an interview on 1/6/2026 at 10:07 AM, staff #10, the head nurse for the second-floor unit, was present in Resident #94's room with the surveyor. Staff was asked to confirm Resident #94's oxygen flow rate at that time; she reported it was set to 4 L/min. Staff #10 then stated that Resident #94 should receive 2 L of oxygen and changed it from 4 L after the surveyor's intervention.

Based on record review and interviews, it was determined that the facility failed to provide activities to residents based on their comprehensive assessment to support the physical, mental, and psychosocial well-being. This was evident for 1 (Resident #3) of 3 residents reviewed for activities.The findings include:Resident #3 had been a resident of the facility since early 2022. The resident was interviewed on 1/5/26 at 9:34 AM. During the interview, the resident stated, we are trapped like prisoners, we never get to go out.A review of Resident #3's most recent annual comprehensive assessment with a reference date of 9/3/25 was conducted on 1/6/26 at 12:25 PM. The review indicated that the resident had a normal cognitive status, and that it was very important for the resident to go outside to get fresh air when the weather is good. The resident's care plan for activities was also reviewed and revealed interventions that include please invite and encourage me to go outside when the weather permits dated 8/16/22. In Resident #3's electronic health record, the daily charting for activities was reviewed on 1/7/26 at 11:35 AM. Both group and individual activity categories were reviewed for 2025. The review revealed that the resident had 2 documented outdoor activities (6/7/25, 11/18/25) under group activity, and 2 outdoor activities (2/14/25, 12/22/25) under individual activity.In an interview with the Activity Director (Staff #12) and Activity assistant (Staff #14) on 1/7/26 at 1 PM, they reported that they have a lot of outdoor activities, especially during the summer months. The finding with daily charting for activities for Resident #3 was reviewed with both staff and both expressed that there were several instances where the resident would refuse to attend/join the outdoor activities. However, both staff reported that the refusals are not being documented. The concern was discussed that based on the comprehensive assessment, it was very important for the resident to spend time outdoors, but the medical records only had 4 instances showing outdoor activities for the resident for the entire year of 2025. Both staff verbalized understanding and acknowledged the concern.

Based on review of Resident Council meeting minutes, grievance logs, facility policy, and staff interviews, the facility interfered with residents' right to file grievances by failing to maintain and implement a functional grievance process. This was evident during the annual recertification survey. The findings include: Cross-referencing related findings from F565:Resident complaints documented in Resident Council meetings were screened by the activities staff and handled informally without being recognized or processed as grievances. The absence of a functional grievance system prevented residents' concerns from being formally filed, investigated, documented, or responded to. On 1/08/2026 at 11:59 AM, review of Resident Council meeting minutes from January-December 2025 identified resident complaints regarding call bell response times, food temperature and preferences, frequency of bed linen changes, and staff entering resident rooms without identifying themselves.On 1/08/2026 at 11:50 AM, review of the facility's grievance logs revealed no grievances for 2025, except for one incomplete entry dated 12/14/2025 with inconsistent resolution dates and no documentation of investigation or the response provided.On 1/08/2026 at 12:25 PM and 12:31 PM, Staff #12 stated resident concerns were only escalated as grievances if they were repeated more than once and raised by more than one resident. This practice prevented individual resident complaints from being recognized or filed as grievances.

Based on record review, observation, and interview, it was determined that the facility failed to ensure residents' grievances were identified, investigated, documented, and responded to. This was evident during the annual recertification survey when reviewing the facility resident council. The findings include: 1/08/2026 9:29 AM after an interview with R#3, permission was given to the surveyor to review the resident council meeting minutes, and Staff #12 provided the resident council meeting minutes for January - December 2025 for review. 1/08/2026 11:50 AM The surveyor asked Staff #13, identified as the facility's grievance officer, for copies of the grievance logs for the previous 12 months to correlate with the resident council meeting minutes that had been reviewed. Staff #13 provided the surveyor with the grievance log and the facility policy stating, We have not had any grievances for all of 2025. A binder was provided to the surveyor that contained 2024, 2025, and 2026 grievance logs. 1 entry existed for 12/14/2025 stating that unit manager submitted a grievance, with a resolution date of 12/16/2024. No details regarding the nature of the grievance were indicated, nor the facility's response to whom had submitted the grievance on the resident's behalf. 1/08/2026 11:59 AM The resident council meeting minutes for 2025 were provided by Staff #12, who assists residents in facilitating resident council meetings. The council minutes revealed resident concerns related to: call bell response times Resident expressed that he is not getting out of bed timely.expressed he has to wait for a CNA over 30 minutes (September, October 2025 resident council meeting)food temperature concerns/ food type preferences (March 2025 resident council meeting) food preferences ( for more vegetables) (March, October 2025 resident council meetings)Resident inquired why bed sheets are not changed more often than they currently were] (September, October 2025 resident council meetings)Resident frustration with when staff enter their rooms, they do not always state who they are or what they are in their room to do (November, December 2025 resident council meetings)On 1/08/2026 at 12:25 PM, Staff #12 was interviewed following the review of the resident council meeting minutes and asked, In your own words, can you tell me what your understanding of grievance is? Staff #12 stated, We would consider a situation a grievance if something comes up more than once during the resident council meeting, it will be escalated to [Staff#13], who is the grievance officer. The surveyor asked, So, for example, what about call bell response times? Staff #12 responded: [We] would take that to [the DON], and we will review. There are times when a call bell response time complaint is reviewed, and the log shows it is approximately 6 minutes. On 1/8/2026 at 12:26 PM, during the same interview with Staff #12, the Director of Nursing (DON) was present, and she stated that she is unsure how long call bell logs are accessible. Further stated that she does not know if she has access. The surveyor asked how other specific grievances or concerns, such as food or care concerns that are marked (resolved) in the resident council minutes, are addressed. Staff #12 provided an explanation of the collaboration from dietary services to address resident preferences. Though this is not indicated or followed up on in the facility's grievance log. 1/8/2026 at 12:28 PM, Staff #12 explains that concerns #4 and #5 from the resident council meeting minutes were addressed by Staff #12, writing the concerns from the resident down and providing them to the DON.1/8/2026 at 12:28 PM, the DON confirmed during the interview with Staff #12 that she addressed the concerns directly with the residents on the unit, letting them know they are able to request a bed linen change whenever they would prefer. However, there is no evidence that this was provided to the facility's grievance officer, that documentation supporting the grievance review was provided, or that a follow-up was provided. 1/8/2026 at 12:31 PM, at the conclusion of the interview, Staff #12 was asked, When do you consider something a resident or family member shares with you a grievance? Escalating a concern to a grievance and taking it to Staff #13 would be when it has been repeated more than once, involved more than one person. 1/08/2026 1:42 PM The Nursing Home Administrator (NHA) was interviewed and asked about the facility's process to give an overview of the current grievance process and policy. The NHA replied, We have a process that consists of offering surveys after admission and post-discharge. We provide comment and suggestion forms that can be submitted in the lobby, too. The surveyor asked the NHA, What can you tell [me] is considered a grievance? He stated, Any concern from the resident or representative that they feel was not adequately addressed or resolved. These could be things like. cold food, cleanliness, and medications.1/08/2026 1:50 PM during an interview with the NHA, he stated, a grievance could be anything that a resident or their representative or sponsor would feel is inadequate related to their care. 1/8/2026 at 2:13 PM, during the interview with the NHA, the surveyor reviewed the resident council meeting minutes and the binder provided by the grievance officer, which contained the 2024, 2025, and 2026 grievance logs. 1 entry existed for 12/14/2025 stating that unit manager submitted a grievance, with a resolution date of 12/16/2024. to understand if the NHA had been aware, or could provide further evidence that they had followed any portion of their policy:Filing Grievances/ Complaints 2001 MED-PASS, Inc. (Revised August 2008) Policy StatementOur facility will help residents, their representatives (sponsors), other interested family members, or resident advocates file grievances or complaints when such requests are made. Policy Interpretation and Implementation1. Any resident, his/her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other resident(s), staff members, theft of property, etc., in person or anonymously, without fear of threat or reprisal in any form. 2. Upon admission, residents are provided with written information on how to file a grievance or complaint. A locked box is at the front desk for anonymous grievances. 3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 4. The administrator has delegated the responsibility of grievance and/or complaint investigation to Social Services. 5. Upon receipt of a grievance, the Social Worker will investigate the allegation and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance/complaint.6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 7. The resident, or person filing the grievance/complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator, or his/her designee, will make such reports orally within 10 working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. 8. Should the resident not be satisfied with the result of the investigation or the recommended actions, he or she may file a written complaint to the local ombudsman office or to the state survey and certification agency. 1/8/2026 at 2:30 PM, there was no evidence within the policy provided to the surveyor specific to the facility, or indicative that the 'Filing Grievances/Complaints' policy had been more recently reviewed and revised, since the references were from 2008. According to The Centers for Medicare & Medicaid Services (CMS), the referenced federal survey tag numbers in the policy provided (F156, F165, F166, F224, F225, and F226) were officially replaced on November 28, 2017, during Phase 2 of the CMS Long-Term Care Requirements of Participation (RoP) overhaul.1/8/2026 at 3:29 PM, no further evidence was provided, and the NHA acknowledged the concern with resident grievances. 1/9/2026, at 10:10 AM, the surveyor shared the concerns regarding resident grievances with the DON prior to survey exit. No additional evidence was provided. Cross refer also to F585

Based on record review, observations, and interviews, it was determined that the facility failed to ensure that call devices were kept within residents' reach. This was evident in 1 (Resident #9) of 24 residents reviewed in the initial pool of the survey.The findings include:A call device is a communication tool that allows residents to alert staff when they need help.The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions.A record review for Resident #9 included an MDS assessment dated [DATE]. The MDS noted that Resident #9 had moderate cognitive impairment and was dependent on staff for most self-care needs. An observation on 1/5/2026 at 9:43 AM showed Resident #9 lying in bed with a call device clipped to the side of the bed. The Resident was asked about the call device; s/he attempted to reach for it but was unable to. The Resident added that reaching the call device was sometimes challenging. A review of Resident #9's care plans included an ADL (activities of daily living) care plan stating, Please keep my call light within my reach. However, an earlier observation noted that Resident #9's call device was out of reach.During a subsequent observation on 1/6/2026 at 9:03 AM, Resident #9's call bell was clipped to the side of the bed and unreachable. Staff #10, the unit manager for the second-floor unit, was with the surveyor in Resident #9's room, confirmed that the call device was not within the Resident's reach, and repositioned it after the surveyor's intervention. Staff stated that she would educate staff on placing Resident #9's call device within her/his reach.

Based on observation and interview, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by the failure to knock and request permission before entering a resident's room. This was evident for 1 (Resident #68) of 1 resident reviewed for dignity. The findings include:An observation on 1/6/2026 at 8:52 AM showed that Resident #68 had activated the call light for help. Staff #7, a geriatric nurse aid, entered Resident #68's room in response to the call light. However, the observation did not show that Staff #7 knocked on the resident's door or requested permission before entering the room.During an interview at that time, Staff #7 was asked whether she knocked on Resident #68's door before entering the Resident's room. Staff #7 confirmed that she did not and added that she simply wanted to answer the light.A record review later that day indicated that Resident #68 was alert, oriented, able to communicate his/her needs, and able to understand others.In an interview on 1/8/2026 at 1:57 PM, the director of nursing (DON) was informed of concerns that a staff member had entered a resident's room without knocking or requesting permission. DON stated that her expectation for staff was to knock on residents' doors and introduce themselves before attending to the call light.

Based on interviews, observations, and record reviews, it was determined that the facility failed to develop and implement infection prevention and control policies and procedures, as evidenced by staff not wearing appropriate personal protective equipment (PPE) before providing direct care to residents. This was evident in 2 (Resident #13 and #12) of 4 residents reviewed for pressure ulcers.The findings include:Enhanced Barrier Precautions (EBP) are infection-control interventions designed to reduce the transmission of infection in nursing homes. They involve wearing gowns and gloves during high-contact Resident care activities, such as dressing, bathing or showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with a central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring dressing. 1.) An interview with Resident #13's representative on 1/5/26 revealed that the Resident had a facility-acquired wound to the sacrum (tailbone) area. A review of Resident #13's medical record included a nursing note dated 12/31/25 that indicated the wound had increased in size and was draining. Continued review of Resident #13's treatment administration record included an attending provider's orders for daily wound dressings. Further review of the facility's infection control policy included a policy on enhanced barrier precautions. The review indicated that EBPs were required for residents with wounds and/or indwelling medical devices. It also stated that gloves and gown are applied before performing high contact resident care activities. During multiple observations on 1/5/26 and 1/6/2026, facility staff provided direct care to Resident #13. The observations showed that staff put on gloves before providing direct care; however, they did not show that staff put on gowns. During an interview on 1/6/2026 at 10:29 AM, Staff #10, a head nurse for the second-floor units, confirmed that Resident #13 had a wound; however, she was unsure whether EBP was indicated for Resident #13. In an interview on 1/6/2026 at 10:47 AM, staff #5, an infection prevention nurse, reported that, to inform staff which Resident was placed on EBP, an EBP signage was posted on the Resident's door, and a supply of gowns was placed on a small cart outside the Resident's room.However, earlier observations failed to show EBP signage on Resident #13's door or a supply of gowns outside the Resident's room.Staff #5 confirmed that Resident #13 should be placed on EBP and stated she would address it. An observation on 1/7/2026 at 9:30 AM showed an EBP signage on Resident #13's door, and a drawer containing gowns was noted outside the Resident's room after the surveyor's intervention. 2.) Resident #12 was admitted into the facility in early 2025. Current diagnosis includes but not limited to pressure ulcer of the sacral region. During the initial tour of the facility, the resident was observed on 1/5/26 at 10:20 AM. During the observation, there was no indication that the resident was on any kind of special precaution, including enhanced barrier precaution (EBP). Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). A review of the facility matrix document on 1/5/26 at 1:04 PM indicated that Resident #12 had a stage 3 pressure ulcer. Resident #12's medical record was reviewed on 1/6/26 at 9:06 AM. The review revealed the most current skin evaluation by the wound nurse (Staff #4) dated 12/30/25. The evaluation indicated that the resident's sacral wound started on 8/30/25. There was no order or documentation to indicate that an EBP was initiated when the wound was discovered. Staff #4 was interviewed on 1/6/26 at 12:27 PM. Staff #4 was accompanied by the Director of Nursing (DON) and the Infection Preventionist (IP) nurse. During the interview, Staff #4 indicated that they had an education/training with the local health department recently. Included in that training was education about EBP and she reported that having a chronic wound does not automatically warrant the use of EBP. A resident must have several criteria before an EBP was initiated. The criteria were heavily draining wound, history of infection, chronic wound, and size of the wound. Adding that they also must be mindful of the cost of putting a resident in a specialized precaution as this would entail added cost/fee to the resident. The DON confirmed that it was a corporate policy. A monthly 800$ fee was the charge for all residents put on EBP. Resident #12's medical record was reviewed with all 3 staff members on 1/6/26 at 12:35 PM. Staff #4 confirmed that the resident had a chronic wound. However, the resident was not placed on EBP because the dressing was always intact with no heavy drainage, always covered in clothing, and no history on infection from wound. Staff #4 also stated, we hesitate because of the cost and burden to the family (referring to the standard facility fee when placing a resident on EBP) The concern was discussed with all 3 staff members (DON, IP Nurse, and Wound Nurse) that federal guidelines on the use of EBP for residents with wounds do not indicate that the residents must meet several criteria to warrant the use of the precaution. The DON indicated that she was reviewing the notes from the prior training/education from the local health department and could not find the criteria as well. All 3 staff members verbalized understanding and acknowledged the concern. On a subsequent tour of the facility on 1/7/26 at 8:37 AM, an EBP sign was posted outside Resident #12's room including storage for gowns and gloves.

Based on medical record review, administrative record review, and staff interview; the facility failed to protect a vulnerable resident (resident #901) from a fall with major injury when facility nursing staff failed to delete an incorrect order for sleep medication (Ambien) from the resident ' s medical record. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident ' s medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with a rolling walker when the resident lost his/her balance and fell toward his/her left side, bruising the left side of the resident's forehead. The resident was assessed and ordered to be sent to a local hospital for evaluation by the primary provider. Surveyor review of a self-report (MD00190723) on 8/8/24 at 12:45pm, dated on 9/15/22, revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff that over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN #307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the medication after administration. On 9/10/22 at 9:38pm, RN #308 administered the resident's standing dose of Ambien of 6.25mg and the one-time dose 12.5mg of Ambien. Surveyor interview with the RN #310 on 8/8/24 at 2:08 pm revealed RN #310 assessed resident #901 after the 9/11/22 fall incident. RN #310 observed a red bump/bruise on the resident's left side of his/her head. RN #310 contacted the provider and was ordered to have the resident sent to the local hospital. The resident's family was also contacted. RN#310 started a medication review after the resident's fall because GNA #309, the facility nursing staff member who assisted the resident when he/she fell , noticed the resident was lethargic when he/she assisted the resident to the bathroom. RN #310 discovered that RN#308 administered a higher dose of the resident's sleep medication when he/she gave the resident the standing dose and a one-time dose of the sleep medication on 9/10/11 at 9:38pm. RN #310 also discovered that RN #307 transcribed a one-time dose of sleep medication from a provider phone order. RN #307 administered the one-time dose of the sleep medication on 9/8/22 and failed to discontinue the one-time dose after administration of the medication. Surveyor interview with the Director of Nursing (DON) on 8/9/24 at 8:30am confirmed the statements made by RN #310 and the fall incident report. The DON also stated the facility added steps to the order reconciliation process to avoid the mistake made in resident #901's medication order record. The facility now requires a nurse on the 11-7 shift on each floor of the facility to reconcile all resident orders for that floor daily. Any new orders must be written in an order book. This step is in addition to the nurse printing out all orders and reconciling all orders to the electronic record.

Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (resident #900) from physical abuse from a facility staff member. This was evident for 1 of 5 residents reviewed during a complaint survey. After the incident, the facility implemented effective and thorough corrective measures.The facility's plan and action were verified during this survey; therefore, this deficiency will be cited as past noncompliance. The date of correction is 2/20/23 The following terms are defined for comprehension of the investigative findings: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few] to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. The findings include: Medical record review on 8/7/24 at 9:25am revealed resident #900 was a memory-impaired long-term care resident as documented in the quarterly MDS assessment dated [DATE]. On 8/7/24 at 9:25am, surveyor review of facility reported incident intake MD#00189249, dated 2/19/23, revealed that on 2/19/23 resident #900 reported to facility nursing staff that I don't want to be hit anymore. On 8/7/24 at 9:30am, surveyor review of the facility investigation dated 2/19/23 revealed a witness statement by LPN #304 which stated that on 2/19/23, resident #900 reported that he/she did not want to be hit anymore. LPN #304 assessed the resident and observed that the resident had purple/red bruises on his/her right temple, right eyebrow, right hand, and left hand. LPN#304 also stated that he/she spoke to GNA #302 regarding the bruising on resident #900's body. GNA#302 admitted that he/she bumped the resident when he/she was attempting to clean barrier cream from the resident ' s face. On 8/8/24 at 9:00am, surveyor interview with the Director of Nursing (DON) revealed he/she interviewed GNA #302 on 2/19/23 at approximately 12:30am, and he/she confirmed that he/she bumped resident #900 when he/she was taking a tube of barrier cream from the resident. The DON also stated that he/she interviewed LPN #304 on 2/19/23 at approximately 12:15 am and was told that he/she spoke to resident #900 and the resident stated, I don't want be hit anymore. LPN #304 observed that the resident was covered with thick, white barrier cream on the right side of his/her face/ hair and bruises on the resident's right temple. LPN #304 escorted the resident to his/her bathroom where the resident was assessed and additional bruises were found on the resident's right eyebrow, top of left hand, and between the 4th and 5th finger on the right hand. The DON stated that LPN #304 also observed that the bruises were purple/red in color. The DON stated that he/she was also able to observe the bruises reported by LPN #304 and he/she agreed with the assessment. The DON stated that he/she took GNA #302 from the unit by 12:30am on 2/19/23 and escorted GNA #302 from the property by 1:30am. On 8/8/24 at 10:40am, the surveyor interviewed Human Resource Director #305. HR Director #305 was able to confirm that GNA #302 last day of pay was on 2/19/23 and GNA#302 worked until 1:30am. On 8/9/24 at 9:31am, surveyor interview with LPN #304 confirmed the details gathered from the DON. The surveyor asked LPN #304 how he/she made initial contact with resident #900. LPN #304 stated that he/she was preparing medications at the medicine cart on 2/19/23 at approximately 12:00am. The resident approached LPN #304 and stated, I don ' t want to be hit anymore. LPN #304 initially thought the resident was involved in a resident-to-resident altercation. LPN#304 stated that when he/she continued to question the resident about his/her statement, the resident was unable to tell him/her any information. LPN #304 then realized the resident had barrier cream all over his/her hair, face and hands. LPN #304 then took the resident to his/her bathroom to clean him/her up and then observed the bruises on the resident ' s face and hands. While LPN #304 was assisting resident#900, GNA #302 came into resident ' s room to speak to LPN #304 about other residents. LPN #304 stated that he/she told GNA #302 that he/she was unable to speak to him/her because the resident was injured in an altercation. LPN#304 stated that GNA#302 told him/her that not one hit the resident and he/she must have bumped the resident ' s glasses with my arm or hand when I was taking the barrier cream from her. LPN#304 then realized that the facial bruises were in the shape of the resident ' s glasses. LPN #304 realized at that moment that GNA #302 may have hurt the resident so he/she did not let the resident out of his/her sight until the DON came to the unit to take GNA#302 off the unit. On 8/9/24 at 11:00am, the surveyor then expressed concern to the Administrator and the DON that the facility failed to protect a cognitively impaired resident (resident #900) from physical abuse from a facility staff member. The DON stated that the facility self-initiated the following actions to correct and re-enforce facility abuse policy as of 2/19/23: 1.) The DON terminated GNA #302 from facility employment on 2/20/23. 2.) The facility reported GNA #302 to the State of Maryland ' s Board of Nursing after termination. 3.) All facility nursing staff were re-educated on abuse prohibition and neglect policies on 2/20/23 and any staff not educated on 2/21/23 were not allowed to work in the facility until re-educated on abuse prohibition and neglect policies.

Based on medical record review, administrative record review, policy review and staff interview; the facility failed to protect vulnerable residents (resident #901 & #174) from a significant medication error. This was evident for 2 of 30 residents reviewed during the survey. This deficient practice resulted in harm to resident # 901 who had a fall incident (accident) with major injury. The findings include: 1.) Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident's medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with a rolling walker when the resident lost his/her balance and fell toward his/her left side, bruising the left side of the resident's forehead. The resident was assessed and ordered to be sent to a local hospital for evaluation by the primary provider. Surveyor review of a self-report (MD00190723) dated 9/15/23 revealed the facility completed an investigation of the resident ' s fall and discovered the root cause of the resident ' s fall was over-administration of the resident ' s prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff that over-administered the resident ' s sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN #307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the medication after administration. On 9/10/22 at 9:38pm, RN #308 administered the resident's standing dose of Ambien of 6.25mg and the one-time dose 12.5mg of Ambien. Surveyor interview with the RN #310 on 8/8/24 at 2:08 pm revealed RN #310 assessed resident #901 after the 9/11/22 fall incident. RN #310 observed a red bump/bruise on the resident's left side of his/her head. RN #310 contacted the provider and was ordered to have the resident sent to the local hospital. The resident ' s family was also contacted. RN #310 started a medication review after the resident ' s fall because GNA #309, the facility nursing staff member who assisted the resident when he/she fell , noticed the resident was lethargic when he/she assisted the resident to the bathroom. RN #310 discovered that RN#308 administered a higher dose of the resident's sleep medication when he/she gave the resident the standing dose and a one-time dose of the sleep medication on 9/10/11 at 9:38pm. RN #310 also discovered that RN #307 transcribed a one-time dose of sleep medication from a provider phone order. RN #307 administered the one-time dose of the sleep medication on 9/8/22 and failed to discontinue the one-time dose after administration of the medication. 28604 2.) Review of R174's undated Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R174 was admitted to the facility on [DATE] with diagnoses that included disorder of bone and other cervical disc degeneration. R174 had the following drug allergies: Penicillin's, Avelox, Bactrim, and cephalosporins. Review of R174's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/22, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R174 was cognitively intact. It was recorded R174 had experienced occasional pain the last five days and had received opioids in the preceding seven days. Review of R174's Physician's Orders, dated 04/15/22 and located in the EMR under the Physician Orders tab, revealed an order for Oxycodone 5 mg [milligrams] tablet 0.5 tab (2.5 mg) by mouth every 8 hours for pain. Review of R173's Physician's Orders, dated 04/29/22 and located under the Physician Orders tab of the EMR, revealed an order for Oxycodone 5 mg tablet one by mouth every 4 hours as needed for moderate to severe pain. Review of R173's facility provided Controlled Substance Record, dated 05/09/22, revealed 26 medications noted at 11:00 PM on 05/09/22 count; resident on leave of absence (LOA) pulled in error. Review of the facility's investigative documents revealed the following nursing staff statements written on 05/10/22: Certified Medicine Aide (CMA) 1: On 05/09/22 at 1:00 PM, she pulled R173's medication card from the medication cart and administered R174 the wrong pain medication (Oxycodone 5.0 MG instead of Oxycodone 2.5 MG). Licensed Practical Nurse (LPN) 7: On 05/09/22 at 11:00 PM, during the change of shift count, she noticed R173's medication card was missing one Oxycodone which was not correct because he was out of the facility. During an interview on 08/08/24 at 2:49 PM, CMA1 confirmed she pulled R173's Oxycodone medication card from the medication cart and administered the pain medication to R174 in error. CMA1 stated she should have checked the medication card to ensure she had the right resident and correct medication, but she was distracted by coworkers at the time. LPN7 was unavailable for interview. During an interview on 08/08/24 at 3:36 PM, Director of Nursing (DON) 1 stated she was notified by LPN7 on 05/09/22 at 11:00 PM that one of R173's Oxycodone pills was missing from the medication card and R173 was in the hospital. DON 1 stated she completed the investigation on 05/10/22 and determined CMA1 pulled the wrong medication card from the cart in error and administered R174 Oxycodone 5 MG which was double the dose he/she was supposed to receive per the physician order. DON1 indicated R174 was assessed with no adverse reaction or change of condition and the physician was notified on 05/10/22. DON1 indicated she expected nursing staff to administer medications to the right resident. Review of the facility's policy titled, Administering Medications, revised April 2019 ad provided by the facility, revealed policy medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug .

Based on record review, staff interview, and policy review, the facility's administration failed to implement its Resident Immunization policy related to current Centers for Disease Control (CDC) recommendations to provide residents the opportunity to receive the Prevnar (Pneumococcal conjugate vaccine (PCV) 20) or the PCV15. Eight out of eight residents ((R) 14, R21, R10, R32, R35, R2, R19, and R36) reviewed for immunizations were not offered pneumococcal vaccinations in compliance with CDC recommendations, the facility had never had PCV20 available, and the facility failed to identify the potential for deficient practice in quality assurance. These failures had the potential to increase the risk of residents contracting pneumonia. Findings include: Review of a facility policy titled Resident Immunization dated 11/08/23 indicated . The facility will offer residents immunization against vaccine-preventable diseases that may be encountered in the facility and as recommended by the CDC Advisory Committee for Immunization Practices . Upon admission or shortly thereafter, each resident's status for influenza, pneumococcal . will be determined and recorded in the medical record . Residents will be offered pneumococcal vaccine (PPV) using these criteria . Primary physician will be contacted for pneumococcal vaccine for information if not received upon admission . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV 15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is not indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination . Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it . For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are completed. 1. Review of Influenza and Pneumococcal Immunizations. Cross Reference F883: Failure to offer eight residents ((R) 14, R21, R10, R32, R35, R2, R19, and R36), the opportunity to be vaccinated in accordance with CDC standards and failed to offer PCV20. 2. Review of Quality Assurance and Performance Improvement. Cross Reference F867: Failure to identify potential deficient practice for implementation of CDC recommendations for pneumococcal vaccinations. During an interview on 08/07/24 10:17 AM, the Consultant Pharmacist stated she brought up education on the PCV20 vaccination in the Quality Assurance (QA) meetings, but it was never addressed by the members of the QA meetings. The Consultant Pharmacist stated she called the facility's pharmacy to verify if PCV20 vaccines were ordered by the facility. The Consultant Pharmacist stated there were no orders placed by the facility for the PCV20. During an interview on 08/07/24 12:42 PM, the Medical Director confirmed he attended the monthly QA meetings and stated he remembered the Consultant Pharmacist addressed the CDC recommendations of the PCV20. The Medical Director was then informed the facility never ordered the PCV20 vaccination. The Medical Director stated he was aware that the PCV20 was the current standard vaccine and the residents who received the PCV15 and the PPSV23 did not need to be vaccinated for another five years. During an interview on 08/09/24 12:10 PM, the Director of Nursing (DON) 1 stated she did not know why the PCV20 was not picked up as potential deficient practice.

Based on interviews, review of the facility documentation, and policy review, the Quality Assessment (QA) committee failed to identify quality deficiencies related to the facility's infection control program and take corrective action to ensure that Prevnar (PCV) 20 was offered and provided in accordance with recognized national standards. This failure had the potential to affect all residents who were eligible for the PVC20 vaccine who currently live in the facility. Findings include: Review of a facility document titled Quality Assurance, dated 03/25/22, indicated the Consultant Pharmacist provided the QA committee members with the Centers for Disease Control and Prevention (CDC) recommendations of Prevnar20. During an interview on 08/07/24 at 10:17 AM, the Consultant Pharmacist confirmed she participated in the quarterly QA meetings. The Consultant Pharmacist stated during one QA meeting in 2022 she provided the QA members information on the Prevnar20 vaccination and the CDC recommendations. The Consultant Pharmacist was asked why the facility never implemented the CDC recommendations on the use of the Prevnar 20. The Consultant Pharmacist stated there was staff turnover with the Infection Preventionist (IP) position. The Consultant Pharmacist stated the facility never asked her to assist with the tracking of pneumococcal vaccines with the current resident population. The Consultant Pharmacist stated she called the facility's pharmacy to verify if PCV20 vaccines were ordered by the facility. The Consultant Pharmacist stated there were no orders placed by the facility for the PCV20. During an interview on 08/07/24 at 8:29 AM, the Director of Nursing (DON) 1 stated she was not sure why the facility missed the CDC recommendations for the PCV20 in the QA meetings. During an interview on 08/07/24 1:17 PM, Registered Nurse (RN) 1, who was also a nursing supervisor and attended the QA meetings, stated she did not remember the Consultant Pharmacist going over the CDC recommendations for the PVC20 vaccination. Review of a facility document titled Quality Assurance Program dated 08/2012 indicated . This facility shall develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality, and to resolve identified problems . To provide a means whereby negative outcomes relative to resident care and safety can be identified and resolved through an interdisciplinary approach .

Based on observation, interview, and review of facility policies, the facility failed to ensure protective equipment (PPE) was available for laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or residents with pathogens which could potentially lead to the development of infectious diseases. Findings include: During a tour of the soiled laundry room on 08/09/24 at 8:41 AM, gloves were observed but no gowns. An immediate interview was conducted with Housekeeper 1, and she confirmed when she handled the soiled linens from the floors, she did not don (put on) a gown and only used gloves. The Director of Housekeeping/Laundry (DHL) was present during this interview and confirmed the same information. The DHL stated the laundry staff would retrieve the bagged soiled laundry from a bin and then place the bag open end first into the washing machine. The DHL stated there was no contact between the soiled laundry and the laundry staff. During an interview on 08/09/24 at 8:44 AM, Director of Nursing (DON) 1 confirmed the laundry staff only used gloves when handling soiled laundry. During an interview on 08/09/24 at 9:48 AM, the Infection Preventionist (IP) stated she did not go into the soiled laundry room and was not aware the laundry staff were not donning gowns while handling soiled linens. Review of a facility policy titled Laundry and Bathing, Soiled, dated 09/2022 indicated, . Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting) .

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer eight of eight residents (Resident (R) R14, R21, R10, R32, R35, R2, R19, and R36) reviewed for immunizations and/or their representatives the opportunity for the resident to be vaccinated in accordance with nationally recognized standards out of a current facility census of 69. This practice had the potential to increase the risk for the residents to contract pneumonia. (Cross Reference F835 and F867) Findings include: Review of a facility policy titled Resident Immunization dated 11/08/23 indicated . The facility will offer residents immunization against vaccine-preventable diseases that may be encountered in the facility and as recommended by the CDC Advisory Committee for Immunization Practices . Upon admission or shortly thereafter, each resident's status for influenza, pneumococcal . will be determined and recorded in the medical record . Residents will be offered pneumococcal vaccine (PPV) using these criteria . Primary physician will be contacted for pneumococcal vaccine for information if not received upon admission . Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV 23 [Pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . For adults who received PCV13 at any age and PPSV23 after age [AGE] years . use shared clinical decision-making to decide whether to administer PCV20 . 1. Review of a facility provided document titled Profile Face Sheet indicated R21 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document for R21 titled Consent for Immunization, dated 10/03/22, indicated a section titled Pneumococcal Vaccine. Under this section were blank (incomplete) areas which would identify if the resident received, was offered, or declined the opportunity to be vaccinated with PCV20. Review of a facility provided document titled Immunization Report for Residents indicated R21 received a PCV13 on 10/05/22. 2. Review of a facility provided document titled Profile Face Sheet indicated R10 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Consent for Immunization, dated 10/26/23, indicated a section titled Pneumococcal Vaccine. Under this section were blank areas which would identify if the resident received, was offered, or declined the opportunity to be vaccinated with PCV20. Review of a facility provided document titled Immunization Report for Residents indicated R10 was not offered the opportunity to be vaccinated with PCV20 and had not received any prior pneumococcal vaccinations. 3. Review of a facility provided document titled Profile Face Sheet indicated R36 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Consent for Immunization, dated 09/25/23, indicated a section titled Pneumococcal Vaccine. Under this section, revealed R36's representative consented to the pneumococcal vaccine. The consent did not identify which pneumococcal the resident's representative was offered. Review of a facility provided document titled Immunization Report for Residents dated 02/01/21 indicated R36 received the PPSV23 vaccination. There was no other evidence the resident was provided the opportunity to be offered the PCV20. 4. Review of a facility provided document titled Profile Face Sheet indicated R35 was admitted to the facility on [DATE]. he resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Consent for Immunization dated 09/26/23 indicated a section titled Pneumococcal Vaccine. Under this section, revealed R35's representative consented to the pneumococcal vaccine. The consent did not identify which pneumococcal the resident's representative was offered. Review of a facility provided document titled Immunization Report for Residents dated 08/12/20 indicated R35 received the PPSV23 vaccination. There was no other evidence the resident was provided the opportunity to be offered the PCV20. 5. Review of a facility provided document titled Profile Face Sheet indicated R14 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Immunization Report for Residents indicated R14 received PCV13 on 07/20/18 and the PPSV23 on 07/10/08. There was no other evidence, in the clinical record, to show R14 and/or her representative was offered the PCV20. There was no evidence in the clinical records, which indicated shared clinical decision making was conducted by the medical provider with the resident and/or their representative. 6. Review of a facility provided document titled Profile Face Sheet indicated R19 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Consent for Immunization dated 05/05/22 indicated R19's representative consented to the resident to be vaccinated with the pneumococcal vaccine. This document revealed the resident received an unknown pneumococcal on 10/18/18. Review of a facility document titled Immunization Report for Residents indicated R19, received the PCV13 vaccine on 10/18/18. There was no other evidence, in the clinical record, to show R19 and/or her representative was provided the opportunity to be offered the PCV20 or PPSV23. 7. Review of a facility provided document titled Profile Face Sheet indicated R2 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Consent for Immunization dated 09/25/23 indicated R2's representative consented to a pneumococcal vaccine. The consent failed to identify which pneumococcal was offered. Review of a facility provided document titled Immunization Report for Residents indicated R2 received the PCV13 on 02/02/15 and the PPSV23 on 10/01/09. There was no other evidence, in the clinical record, to show R2 and/or her representative was offered the PCV20. There was no evidence in the clinical records, which indicated shared clinical decision making was conducted by the medical provider with the resident and/or their representative. 8. Review of a facility provided document titled Profile Face Sheet indicated R32 was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of their admission. Review of a facility provided document titled Resident Vaccination dated 09/17/20 that R32 gave consent to receive a pneumococcal vaccination. Review of a facility provided document titled Immunization Report for Residents indicated R32 received the PCV13 on 01/08/15 and the PPSV23 on 07/30/12. There was no other evidence, in the clinical record, to show R32 and/or her representative was offered the PCV20. There was no evidence in the clinical records, which indicated shared clinical decision making was conducted by the medical provider with the resident and/or their representative. During an interview on 08/07/24 at 10:17 AM, the Consultant Pharmacist stated she called the facility's pharmacy to verify if PCV20 vaccines were ordered by the facility. The Consultant Pharmacist stated there were no orders placed by the facility for the PCV20. During an interview on 08/07/24 at 8:35 AM, the Infection Preventionist (IP) reviewed the residents' immunization records and stated she would assume if they were offered and administered the PCV20, it would be reflected in the immunization records and confirmed it was not. The IP stated the Admission Coordinators went over the vaccination consents with all new admissions, uploaded, and scanned and placed in the electronic medical records (EMR). The IP stated then a physician's order would be obtained. During an interview on 08/07/24 at 12:34 PM, the Admission Coordinator confirmed she obtained vaccination consents. The Admission Coordinator stated once the consent has been obtained, the document was uploaded into the resident's EMR. The Admission Coordinator stated she was unaware if the uploaded consent would alert nursing to obtain a physician's order for a pneumococcal vaccination. During this interview, the Admission Coordinator stated the information on the pneumococcal vaccine was included in the facility's Admission Packet. During this interview, the Admission Coordinator presented the educational piece for the Pneumococcal vaccine and confirmed this was the educational document provided to each resident and/or their representative. A review of the facility's admission packet contained a document titled Pneumococcal polysaccharide vaccine (PPSV23) dated 04/24/15. During an interview on 08/07/23 at 12:42 PM, the Medical Director stated he was aware of the PCV20 vaccination and stated this was the standard for long-term care to offer and to administer. During an interview on 08/07/24 at 1:17 PM, the Director of Nursing (DON) 2 for a sister facility stated there were no triggers to alert clinical staff to obtain a physician order for the pneumococcal vaccine when it was scanned into the EMR. During an interview on 08/09/24 at 12:10 PM, DON2 stated the facility missed identifying the need for the PCV20 vaccine.

Based on record review, interview, and policy review, the facility failed to ensure five staff (Geriatric Nursing Assistant (GNA) 4, GNA5, and GNA6); (Licensed Practical Nurse (LPN) 9) and (Registered Nurse (RN) 3) of five random nursing staff reviewed for staffing were trained in the facility's Quality Assurance Performance Improvement (QAPI) Program. Findings include: Review of a facility policy titled Staff Development Program, dated May 2019, indicated All personnel must participate in initial orientation and regularly scheduled in-service training classes . The primary objective of our facility's staff development program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care . Required training topics include the following: Elements and goals of the facility QAPI program . Review of documents provided by the facility titled Relias [an on-line training program] revealed the following: 1. CNA4's date of hire was 11/02/23 and her training failed to address the facility's QAPI program. 2. CNA5's date of hire was 03/02/23 and her training failed to address the facility's QAPI program. 3. CNA6's date of hire was 06/27/24 and her training failed to address the facility's QAPI program. 4. LPN9's date of hire was 02/07/24 and her training failed to address the facility's QAPI program. 5. RN3's date of hire was 10/03/23 and his training failed to address the facility's QAPI program. During an interview on 08/08/24 at 3:59 PM, Director of Nursing (DON) 1 confirmed the staff were not yet trained on the facility's QAPI program. The DON stated, We were ready to implement the QAPI training to staff when COVID hit the facility, and it went by the wayside. My goal is to have QAPI included in the yearly Relias Training that is completed online.

Based on interview, record review, and Resident Assessment Instrument (RAI) Manual review, the facility failed to follow the RAI's transmission requirements, which indicate that within 14 days after a facility completes a resident's assessment a facility must electronically transmit encoded, accurate, and complete ''Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System, for one (Resident (R) 25) of one supplemental residents reviewed for Resident Assessment. Specifically, it had been over 120 days since the discharge ''MDS'' was completed and the ''MDS'' had not been transmitted to the CMS System. Findings include: Review of R25's undated ''Face Sheet'' located in the electronic medical record (EMR) under the ''Dashboard'' tab, revealed R25 was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (CHF) and pneumonia. Review of R25's admission ''Minimum Data Set (MDS)'' located in the EMR under the ''MDS'' tab with an ''Assessment Reference Date (ARD)'' of 04/01/24 revealed R25's ''Brief Interview for Mental Status (BIMS)'' score was four out of 15 which indicated R25 was severely cognitively impaired. Review of R25's ''Progress Note,'' dated 04/21/24 and located in the EMR under the ''ID Notes'' tab, revealed, ''Resident was discharged at 10:30 am with medications to [another facility]. Discharge instructions were given to resident along with son and daughter. Staff assisted resident out of the building along with his/her family without incident.'' During an interview on 08/09/24 at 10:39 AM, the MDS Coordinator (MDSC) showed on her computer, that R25's discharge ''MDS'' with an ARD of 04/21/24 was completed but had not been submitted. MDSC stated that no reports were provided through the EMR to let her know that the MDS was not submitted, and no other staff were auditing the system to ensure that MDSs were submitted timely. The MDSC acknowledged the MDS was not submitted and should have been submitted within seven days from the MDS lock date. During an interview on 08/09/24 at 1:24 PM, the Director of Nursing (DON) stated she expected the MDSC to complete and submit the MDS timely per the RAI Manual and to check to ensure that the MDS were submitted. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, revealed ''. 09. Discharge Assessment-Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) .''

Based on interview, record review, and policy review, the facility failed to provide education for two staff members to possess the competencies and skill sets necessary to ensure residents were free of medication errors for two of four residents (Resident (R) 174 and R15) reviewed for medications in a total sample of 26 residents. These failures resulted in the residents receiving the wrong dose of medications. Findings include: 1. Review of R174's undated Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R174 was admitted to the facility on [DATE] with multiple diagnosis including other disorder of bone, cervical disc degeneration and arthritis. Review of R174's Physician's Orders, dated 04/16/22 and located under the Physician Orders tab of the EMR, revealed an order for oxycodone hydrochloride (HCL) immediate release (IR) 5 milligrams (MG) tablet take 1/2 tablet (2.5 MG) by mouth every 8 hours and every 6 hours as needed (PRN) for severe pain. Review of R173's Physician's Orders, dated 05/17/22 and located under the Physician Orders tab of the EMR, revealed an order for oxycodone 5 MG tablet take one by mouth every 6 hours as needed for pain. Review of the facility's document titled Medication Error Report, undated, provided by the facility, revealed the type of error was the wrong dose and wrong resident. The description of the error was R174 received 5 MG of oxycodone from R173's medication card of oxycodone when Certified Medicine Aide (CMA) 1 pulled the wrong medication card from the medication cart. During an interview on 08/08/24 at 2:49 PM, CMA1 confirmed she administered the wrong medication to R174 due to removing R173's medication card from the medication cart in error on 05/09/22. CMA1 stated R174's card was next to R173's card in the medication cart but she should have checked the card to ensure it was the right resident and right medication before administering the medication. CMA1 stated she was tested every two years on medication administration to continue her medicine aide certification but did not receive education and was not observed passing medications from the staff development coordinator (SDC) until after the incident. During an interview on 08/08/24 at 3:36 PM, Director of Nursing (DON) 1 acknowledged there had been several SDCs over the years and the former SDC was expected to provide education on medication administration and conduct observations of medication administration for all nursing staff. DON1 stated she could not find documentation that medication administration education was provided, and observations of medication administration were performed for CMA1 prior to the medication error on 05/09/22. Review of the facility-provided undated document titled, Medication Technicians Observational Checklist revealed CMA1 was observed administering medications to the correct resident, right medication, right time, correct route, correct dose, and correct time in 2023 and 2024; however, CMA1's medication administration performance was not observed in 2022. Review of the facility-provided job description titled, Certified Medicine Aide, revealed Job Summary: Provide the activities of daily living care to the residents under license staff supervision and provides administers non-parenteral medications. Essential Functions: . 11. Prepares, administers, and records medications as physician-ordered and in accordance with certification regulations . 2. Review of R15's undated Face Sheet located in the electronic medical record (EMR) under the Dashboard tab, revealed R15 was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes mellitus (DM). Review of R15's Physician Orders, located in the EMR under the Physician Orders tab, revealed an order dated 08/03/24 for Lantus Solostar U-100 insulin 100 unit/milliliters (ML) (3 ML) subcutaneous pen [insulin glargine, a long acting insulin] - 5 [five] units subcutaneous every day for DM. During an observation on 08/09/24 at 8:53 AM, Licensed Practical Nurse (LPN) 3 was observed to administer R15's insulin pen (a pen contains the vial of insulin inside the pen and has a mechanism where the dose to be administered is set on a dial at the top of the pen, and only that amount can then be injected). LPN3 was not observed to prime the pen prior to dialing the dose to five units and was observed to remove the pen from the insertion site after administration without waiting. During an interview on 08/09/24 at 9:22 AM, LPN3 confirmed she did not prime the pen prior to dialing the dose to five units and did not hold the pen in R15's abdomen for five seconds after depressing the plunger. LPN3 stated she was not trained to prime the pen and hold the pen in the abdomen for five seconds. During an interview on 08/09/24 at 9:49 AM, the Infection Preventionist (IP) stated she assisted the staff development coordinator (SDC) with staff education and verified LPN3 did not attend the skills fair conducted in March 2024. The IP stated that a medication administration observation was completed on 05/13/24 but it did not include insulin pen administration. The IP indicated she expected nursing staff to prime the pen to two units before administering the insulin to ensure the needle worked and hold the pen in the abdomen for 10 seconds after depressing the plunger to ensure all the insulin was administered. During an interview on 08/09/24 at 10:27 AM, the Director of Nursing (DON) stated she expected the nursing staff to administer insulin correctly according to the manufacturer's guidance and she was not aware that LPN3 had not been trained on insulin pen administration. Review of the insulin pen guidance titled How to use your Lantus SoloStar Pen, undated, provided by the facility, revealed . Step 3. Perform a Safety Test Dial a test dose of 2 [two] units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle . Step 5. Inject your Dose clean site with an alcohol swab. Keep the pen straight. Insert the needle into your skin. Use your skin. Use your thumb to press the injection button all the way down. When the number in the dose window returns to zero as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose). Release the button and remove the needle from your skin . Review of the facility-provided document titled, Facility Assessment Tool, dated December 2023, revealed . A.1. Function - Sufficiency Analysis Summary . Staff training/Education and competencies [the facility] provides an ongoing educational program for the development and improvement of all co-workers. The staff training and education program is designed to ensure knowledge competency for all staff. Education is provided through a combination of online training and using the Relias Learning System, peer monitoring and classroom sessions. Competencies are based on the care and services needed by the resident population. Each job description identifies the required education and credentials for the job. Competencies are verified upon orientation and as needed. Competencies are based on current standards of practice and may include knowledge and test, knowledge and return demonstration, knowledge and observed behaviors, and annual performance evaluation. Annual nursing competencies include . medication administration observations .

Based on medical record review, administrative record review, and staff interview; the facility failed to maintain an accurate resident (resident #901) medication order history. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of a self-report (MD00190723) on 8/8/24 at 12:45pm, dated 9/15/22, revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN # 307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the medication after administration. On 9/10/22 at 9:38pm, RN#308 administered the resident's standing dose of Ambien of 6.25mg and the one-time dose 12.5mg of Ambien. Surveyor review of resident #901's medication administration record (MAR) for September 2022 revealed the one-time dose order transcribed by RN#307 was used to administer 12.5mg of Ambien to the resident on 9/8/22, 9/9/22, and 9/10/22. Surveyor interview with the Director of Nursing (DON) on 8/9/24 at 8:30am confirmed the accuracy of the medication error report and the 9/2022 MAR. The DON stated that the facility added steps to the order reconciliation process to avoid the mistake made in resident #901's medication order record. The facility now requires a nurse on the 11-7 shift on each floor of the facility to reconcile all resident orders for that floor daily. Any new orders must be written in an order book. This step is in addition to the nurse printing out all orders and reconciling all orders to the electronic record.

Based on observation, record review, and interview, it was determined that facility staff failed to provide an environment that was free of abuse. This was evidenced by: 1) sexual abuse perpetrated by Resident #7, resulting in harm to Resident #10 and Resident #6. This was evident for 2 of 3 residents (#10 and #6) reviewed for resident to resident abuse. 2) a staff member withheld goods and services from 8 residents (#12, #13, #14, #15, #16, #17, #18, and #19) by not administering medications to them. This was evident for 1 of 2 staff (staff #17) reviewed for staff to resident abuse. It was determined that there was no evidence of any observable clinical outcomes related to the lack of medication administration. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident which provides the facility with the information necessary to develop a plan of care. A care plan is a guide that addresses the unique needs of each resident. It is used to assess and plan for the resident's care needs and to evaluate the effectiveness of the resident's care. Brief Interview of Mental Status (BIMS) test is used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 1) On 5/19/21 at 1:55 PM, surveyor reviewed the facility's investigation file for an incident that occurred on 2/9/20 between Resident #7 and Resident #10. According to the documentation Licensed Practical Nurse (LPN) #12 had been passing medications in the dining room area when LPN #12 observed Resident #7 with his/her hand down the front of Resident #10's pants and attempting to put his/her hand up Resident #10's shirt. LPN #12 intervened and moved Resident #10 to the opposite end of the dining room from Resident #7. A few minutes later, LPN #12 noticed that Resident #10 had made their way back over to Resident #7 who was observed by LPN #12 trying to place his/her hand down Resident #10's pants again and the other hand up Resident #10's shirt. In response to this incident, resident #7 had been placed on 15 minute checks (which is when staff check and document the whereabouts of a resident every 15 minutes). LPN #12 reported the incident to the Registered Nurse (RN) Supervisor #10, who had reported it to the previous Director of Nursing (DON) #4. However, DON #4 failed to report the sexual abuse to the State agency and local law enforcement. A medical record review on 5/19/21 at 9:28 AM, for Resident #7 revealed Resident #7 had been admitted on [DATE], from another nursing home. Review of the admission documentation, dated 8/1/19, revealed that Resident #7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS with the Assessment Reference Date (ARD) of 8/8/2019, revealed Section C which had documentation that Resident #7 scored a 3/15 on the BIMS, which indicated Resident #7 had severe cognitive impairment. Review of a progress note from an attending physician that was dated 5/14/20, revealed documentation that the resident had the following diagnoses, but not limited to: senile dementia without behavioral disturbances and Generalized Anxiety Disorder. Also, documented that Resident #7 had been followed by a psychiatrist for making some sexual comments and had some agitation at times. Further review revealed a care plan, initiated on 8/9/19, for Resident #7's sexually inappropriate statements and touching other residents. LPN Assessment Coordinator #16 had initiated a goal for Resident #7 to have a decrease in socially inappropriate behaviors to less than 3 times a week. Review of the interventions revealed that the facility staff had failed to document the level of supervision required to ensure the safety of all residents residing in close proximity to Resident #7. A medical record review for Resident #10 on 5/21/21 at 2:46 PM, revealed a history and physical dated 4/20/20. The attending physician documented that Resident #10 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 2/11/20, section C that Resident #10 had been severely impaired for daily decision making skills. In addition, a form titled Resident's Ability to Understand Their Rights and Responsibilities had been signed by the attending physician on 2/9/16, which deemed Resident #10 as having been incapable of understanding any information contained on a document and would not have been able to sign the form. Further review revealed that Resident #10 had not had a physical assessment by a nurse or physician or nurse following the sexual abuse on 2/9/20. Also, there was no evidence that Resident #10 had been referred to psychiatric services and/or social services. On 5/19/21 at 2:24 PM, surveyor reviewed the facility's investigation for an incident that occurred on 3/15/20, between Resident #7 and Resident #10. According to the investigation Geriatric Nursing Assistant (GNA) #23 had observed Resident #7 with his/her hands down the front of Resident #10's nightgown fondling Resident #10's breast. Staff intervened and separated Resident #7 and Resident #10. This incident occurred while Resident had been on 15 minute checks. In response to this incident, facility staff had been informed to continue 15 minute checks for Resident #7 and when out of bed Resident #7 was to have a 1:1 observation. However, review of the 15 minute check sheet revealed Resident #7 had been out of bed on several occasions with no evidence that a 1:1 had been assigned. In addition, during an interview with the current DON #2, it was revealed that there had been no evidence that Resident #7 had a 1:1 assigned to him/her at those times. On 3/16/20 at 2:15pm, Resident #7 was transferred to another unit. A medical record review on 5/21/21 at 2:46 PM, revealed that Resident #10 did not have physical assessment by a clinical provider following the sexual abuse on 2/9/20. Also, there was no evidence that Resident #10 had been referred to psychiatric services and/or social services. An interview with LPN #12 on 5/20/21 at 12:25 PM, revealed that he/she had been aware of Resident #7's sexually inappropriate behaviors at the time of Resident #7's admission. LPN #12 also stated that Resident #7 would propel self around the unit independently. During an interview with GNA #8 on 5/20/21 at 12:45 PM, GNA #8 reported she had been aware of Resident #7's sexually inappropriate behaviors. GNA #8 reported that there had been no additional education and/or training provided to staff to address management of Resident #7's sexually inappropriate behaviors. An interview with RN supervisor #10 on 5/20/21 at 1:25 PM, revealed that Resident #7 had been targeting Resident #10 and that there had been multiple incidents that staff had intervened before Resident #7 had been able to inappropriately touch Resident #10. The surveyor attempted to interview the Director of Nursing (DON) #4, who was Director of Nursing at the time of these incidents, and was unsuccessful. 2) On 5/9/21 at 10:53 AM, surveyor reviewed the facility's investigation file for an incident on 8/8/20, between Resident #7 and Resident #6. According to the investigation, GNA #11 had walked into Resident #6's room and found Resident #6 lying in bed with Resident #7 sitting beside the bed with his/her hand down the front of Resident #6's brief. GNA #11 immediately removed Resident #7 from Resident #6's room. Resident #7 had been moved to the unit on 3/16/20, and had been on 15 min checks. However the checks had been discontinued on 3/28/20. A medical record review for Resident #6 on 5/19/21 at 9:28 AM, revealed a progress note dated 9/8/20, written by the attending physician, which documented that Resident #6 had been blind and hard of hearing. The attending also, documented that Resident #6 had appeared ready to die. Review of additional physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a MDS with an ARD of 10/1/20, which staff documented in Section C for Cognitive Patterns that Resident #6 had been interviewed and scored a BIMS of 99, which indicated that Resident #6 had either answered the questions incorrectly or had not answered them at all. Another question in Section C, Made decisions regarding task of daily life which staff documented a 3 - severely impaired - never/rarely made decisions. In addition, during the medical record review, there had been no evidence that Resident #6 had a documented physical assessment in relation to the incident of sexual abuse on 8/8/20. An interview with GNA #11 on 5/20/21 at 1:40 PM, revealed he/she had not been aware of Resident #7's inappropriate sexual touching of other residents. GNA #11 had recalled that Resident #7 had been difficult to keep track of due to Resident #7 propelling self around the unit and had been going in and out of other residents' rooms. The surveyor had confirmed this statement through a medical record review which showed evidence that staff had been documenting this behavior in the progress notes. On 5/21/21 at 7:45 AM, an interview with the current DON #2, revealed that he/she had not felt that Resident #7's inappropriate sexual touching of other residents could be fully avoidable due to Resident #7 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the attending physician/Medical Director on 5/25/21 at 9:15 AM, revealed that on a rare occasion a resident had been admitted with sexually inappropriate behaviors and staff had been expected to increase supervision of that resident. Attending physician/Medical Director stated that the facility had not had the capability to lock residents down, so the facility had done the best that they can. On 5/20/21 at 2:23 PM, an interview with the Nursing Home Administrator (NHA), Director of Clinical Services, and current DON, revealed the NHA had been aware of each incident. NHA stated that the previous DON #4 had taken care of the incidents of sexual abuse and that he/she had reviewed the incidents after the DON had concluded them. When NHA had been asked about the 2/9/20, incident of sexual abuse perpetrated by Resident #7 on Resident #10 and why it had not been reported to the state agency and local law enforcement, he/she stated that the previous DON #4 had decided that there had been no skin to skin contact, so therefore it had not been reportable. 3) On 5/19/21 at 4:18 PM, surveyor reviewed the investigation file for an incident of staff to resident abuse on 3/4/21. According to the investigation two Certified Medicine Aides (CMA) #18 and #19 reported to the current DON #2 on 3/3/21 or 3/4/21 that they had a suspicion that Licensed Practical Nurse (LPN) #17 had not been passing medications to all the residents who had been assigned to his/her care. Although the current DON #2 had received an allegation of resident abuse for LPN #17, DON #2 failed to remove LPN #17 from resident care until an investigation had been completed. On 3/4/21, DON #2 reviewed the security cameras and was unable to determine whether LPN #17 had administered medications to the residents assigned to him/her. On 3/4/21, DON #2 and UM #9 conducted a count of the medications in the medicine cart for 8 (#12, #13, 14, #15, #16, #17, #18, and #19) of the 21 residents assigned to LPN #17. DON #2 reported that this had been in effort to determine if LPN had not been administering the medications. On 3/5/21, after LPN #17 had returned the medication cart to the medication room at approximately 12:00 PM, the current DON #2 and ICP #3 conducted another count of for those 8 residents' medications in the medicine cart and compared them to the counts they had found the day before. It had been determined that all 8 residents had not received their morning medications on 3/5/21. On 3/5/21, after the counts had been checked, the DON, Nursing Home Administrator (NHA), and Human Resources Director confronted LPN #17 regarding the abuse. According to DON #2, it was during this meeting that LPN #17 stated that he/she was going to resign instead of being fired. An interview with CMA #18 on 5/21/21 at 10:18 AM, revealed that he/she had been working with LPN #17 for a few months. CMA #18 had noticed that LPN #17 would stand at the medication cart and play with the computer mouse for a while and had not been getting in the drawers of the cart to get out medications out of the cart to administer them. CMA #18 reported that he/she had noticed this about 1-2 days prior to going to the DON #2 on 3/3/21. CMA #18 continued to watch LPN #17 before going to the current DON #2 to report LPN #17. CMA #18 reported that it had become more obvious that LPN #17 had not been giving medications to all the residents on the assignment. Reportedly, staff member #18 reported to the DON on 3/3/21 after his/her shift had ended and provided a written statement to the DON. An interview with CMA #19 on 5/21/21 at 10:34 AM, revealed that on more than one occasion he/she had suspicion that LPN #17 had not been passing medications to all the residents assigned to him/her. CMA #19 stated that he/she had passed medications on that assignment before and it had taken much longer than LPN #17 had taken. CMA #19, could not recall the date, but he/she had reported these suspicions to the UM #9 a week prior to the report he/she had given to the current DON #2 on 3/3/21. An interview with CMA #20 on 5/21/21 at 10:40 AM, revealed that he/she had worked on the unit that LPN #17 had been assigned on 3/3/21 and 3/4/21. CMA #20 reported that he/she had worked with LPN #17 and CMA #20 had some suspicion that LPN #17 had not been giving out the medications to the residents. Then one day, approximately a week prior to 3/4/21, CMA #20 had noticed the medication cart had not been moved at all that day by LPN #17. CMA #20 had planned to go to the current DON #2 with CMA #18 and #19, but had to leave directly after his/her shift. CMA #20 stated he/she told DON #2 that he/she had been willing to report what he/she had observed with LPN #17 on another day. However, CMA #20 reported that DON #2 had not come to her about the allegations and had not asked for a statement. An interview with the UM #9 on 5/21/21 at 11:19 AM revealed that the day CMA #19 had reported a concern to him/her about LPN #17. UM #9 had just had a conversation with LPN #17 who had informed him/her that he/she (LPN #17) had not made it to the other pod to administer medications. Reportedly, this led UM #9 to believe that this had been what CMA #19 had meant when he/she had made the report of medications not having been administered to all residents assigned. No further investigation had been done at that time by UM #9. An interview with the current DON #2 on 5/24/21 at 7:45 AM, revealed that the first time he/she had been made aware of an allegation of abuse by LPN #17 had been on 3/4/21 at 3:30 PM, when CMA #18 and #19 had come to his/her office. DON #2 reported that at that time he/she reviewed the cameras and had a suspicion that something had not looked right while watching staff member #17 pass out the medications. DON #2 reported that it had looked like staff member had punched out the medications into the plastic cup, but then staff member would hide the cup when he/she had carried it to the room. Secondly, DON #2 stated it had been suspicious the amount of time LPN #17 had been in the residents' rooms because it had not been long enough to have had administered the medications. DON #2 reported that at one point LPN #17 had been in the dining room area passing out the medications and it had been suspicious that LPN #17 had not administered any medications to the residents in the dining hall eating. However, DON #2 reported that he/she had not had enough information to suspend LPN #17. When asked if he/she had reported to local law enforcement DON #2 responded that he/she had not due to no adverse effects had occurred with the 8 residents reviewed. On 5/26/21 at 12:00 PM, the surveyor reviewed the medications that had been documented as being missed or given late on 3/5/21, for the 8 (#12, #13, 14, #15, #16, #17, #18, and #19) residents identified. It had been determined that there were no observable clinical outcomes related to the lack of medication administration. During this interview, NHA and Director of Clinical Services reported that they had felt that the facility needed to collect this evidence before suspending LPN #17 for an allegation of abuse by 2 other staff members. Cross Reference F608, F609, F610, and F689.

Based on record review and staff interview, it was determined that the facility staff failed to provide adequate supervision to prevent a resident with known sexually inappropriate behaviors from perpetrating sexual abuse on other residents. This was evidenced by Resident #7 making nonconsensual sexual contact with Resident #10 in February 2020 and again in March 2020, and then with Resident #6 in August 2020. The facility's failure to provide adequate supervision for Resident #7 resulted in actual harm to both Resident #10 and Resident #6. The deficient practice was evident for 1(#7) of 1 resident reviewed for sexual abuse. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident which provides the facility with the information necessary to develop a plan of care. A care plan is a guide that addresses the unique needs of each resident. It is used to assess and plan for the resident's care needs and to evaluate the effectiveness of the resident's care. Brief Interview of Mental Status (BIMS) test is used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 1) On 5/19/21 at 9:00 AM, surveyor reviewed the facility's investigation file for an incident that occurred on 2/9/20 between Resident #7 and Resident #10. According to the documentation, Licensed Practical Nurse (LPN) #12 was passing medications to the residents and observed Resident #7 trying to pull up Resident #10's shirt, and put his/her hand down the top of Resident #10's pants. LPN #12 intervened and Resident #10 was taken to another table across the dining room. LPN #12 went back to passing medications. A few minutes later LPN #12 noticed that Resident #10 had made their way back to Resident #7. By the time LPN #12 had made it over to them, Resident #7 had already put his/her hand under the bottom of Resident #10's shirt and had been trying to put his/her other hand down the top of Resident #10's pants again. The intervention was to place Resident #7 on 15 minute checks (an intervention that requires staff to check on a resident every 15 minutes and document where they are and/or what they are doing). Registered Nurse (RN) Supervisor #10 had been notified who in turn had notified the previous Director of Nursing (DON) #4. DON #4 failed to report the incident to the state agency and local law enforcement. Review of the 15-minute check sheets revealed that 15 minute checks were initiated on 2/9/20 at 2:30 PM. A medical record review on 5/19/21 at 9:28 AM, for Resident #7 revealed an admission packet dated 8/1/19 that included documentation from a previous nursing home that Resident #7 had a history of sexually inappropriate behaviors towards staff and residents. Review of the admission MDS with the Assessment Reference Date (ARD) of 8/8/2019, revealed Section C which had documentation that Resident #7 scored a 3/15 on the BIMS. This indicated severely impaired cognition. Review of a progress note from an attending physician that was dated 5/14/20, revealed Resident #7's diagnoses included but were not limited to: senile dementia without behavioral disturbances and Generalized Anxiety Disorder. The note, also documented that Resident #7 had been followed by a psychiatrist for making some sexual comments and had some agitation at times. Review of the care plan revealed that Resident #7 had the following care plan initiated 8 days after admission, I [Resident #7] have socially inappropriate behaviors, such as sexually inappropriate statements or touching others inappropriately. I [Resident #7] need staff to help me understand why my behaviors are inappropriate and redirect me as needed. I [Resident #7] also refuse care at times and can be combative and curse at staff. I [Resident #7] need staff to re-approach me intermittently until I am agreeable for care to be completed. The goal for Resident #7 stated, I [Resident #7] would like to have a decrease # of behavior occurrences (Refusal of care, sexually inappropriate comments or actions) (<3 episodes a week) through next review. The following interventions had been initiated; 1. Please intervene as needed to ensure my safety and the safety of others, 2. Please talk to me in a calm manner, 3. Please divert my attention from stimulus, 4. Please assist me to a quiet locations, 5. Please help me understand why my behavior is socially inappropriate/disruptive, 6. Please provide/invite to a program of activities for me that minimizes the potential of my behavior, 7. Please administer/monitor effectiveness/side effects of my medication, 8. Please arrange a consultation for me with a Psychiatrist or Psychologist, 9. Please redirect me to more appropriate activity. This care plan had not included interventions that addressed a need for supervision of Resident #7. However, following the incident on 2/9/20, staff had noted in the evaluation notes that Resident #7 had an increased behaviors of a sexual nature and had been placed on 15-minute safety checks. Review of the physician's orders on 5/19/21 at 10:53 AM, revealed that Resident #7 was admitted with the following medications ordered: an Antiepileptic [a medication used to treat [CONDITION(S)] disorders but also used for treating behaviors for sexual dysfunction, a second Antiepileptic for mood disorder, and an antidepressant [used to treat depression and anxiety] for major depressive disorder and had remained on those medications. A form titled Resident's Ability to Understand Their Rights and Responsibilities had been signed by the attending physician on 8/1/19, which deemed Resident #7 incapable of understanding any information contained on a document and did not have capacity to sign documents. Further review revealed a referral form completed by the attending physician on 2/17/20, requesting the Psychiatrist evaluate Resident #7. The attending physician noted the following information, Staff report: On 2/9/20 [Resident #7] with his/her hand under another [female] resident's shirt, and was trying to put his/her hand down the top of his/her pants. The two were separated. The other resident made his/her way back over, and [Resident #7] was seen again with his/her hand under his/her shirt, and trying to put his/hand down the top of his/her pants. On 2/15/20, [Resident #7] asked the nurse to go to bed with him/her and tried to touch [the nurses] arm. A few minutes later he/she told another staff member, come here so I [Resident #7] can grab your [buttocks]. No behaviors reported so far today. (2/17/20) The Psychiatrist had seen Resident #7 on 2/18/20, and documented for this visit that Resident #7 had been, alert and oriented to self. Neutral mood and affect. No distress. Coherent speech. No [CONDITION(S)]. Judgement and insight poor. A medical record review for Resident #10 on 5/21/21 at 2:46 PM, revealed a history and physical dated 4/20/20, completed by the attending physician. Resident #10 had a diagnosis of Dementia with behavioral disturbances and had been bound to a wheelchair. Review of the MDS with an ARD of 2/11/20, section C that Resident #10 had been severely impaired for daily decision making skills. A form titled Resident's Ability to Understand Their Rights and Responsibilities had been signed by the attending physician on 2/9/16, which deemed Resident #10 had been incapable of understanding any information contained on a document and would not have been able to sign. Further review of the medical record revealed Resident #10 had no documentation regarding an assessment following the incident on 2/9/20. An interview with LPN #12 on 5/20/21 at 12:25 PM, revealed that he/she had assessed Resident #10 after the incident on 2/9/20, but had not documented the assessment in Resident #10's medical record. LPN #12 stated that Resident #7 propelled his/her self around the unit at times and that it would have been rare for at least one staff member not to be in the dining room area at all times throughout the day. An interview with GNA Staff #8 on 5/20/21 at 12:45 PM revealed that he/she recalled being informed of Resident #7's socially inappropriate behaviors. However, GNA Staff #8 had not been given any education or instructions regarding how to manage those behaviors. GNA Staff #8 reported that it had been difficult to complete 15 minute checks on any resident when they had been assigned, so GNA Staff #8 had placed Resident #7 in the common area in order to be able to complete the checks. 2) Review of the second investigation file revealed a self-report form dated 3/16/20 at 2:00 PM. The form documented that on 3/15/20, at approximately 8:45 PM Resident #7 had been observed to have his/her hand down Resident #10's nightgown and was touching Resident #10's breast. Resident #7 had supervision orders for 15 minute checks when this incident occurred. According to a statement provided by Registered Nurse (RN) Staff #10, he/she had been called to the unit at approximately 8:45 PM and the staff reported that Resident #7 had been found fondling [Resident #10's] [breast]. However, according to the facility self-report form, this incident of sexual assault was not reported to the Director of Nursing (DON) Staff #4 until the following day 3/16/20. In addition, staff failed to document the time it had been reported. The intervention for Resident #7 noted on the self-report and in Staff #10's statement was to have a 1:1 assigned to Resident #7 when out of bed. However, review of the 15-minute check sheet revealed the Resident had been out of bed on 3/15/20 from 8:45 pm - 9:30 pm and on 3/16/20 from 1:30 PM until 2:15 PM with documentation that Resident #7 had been in the dining room. An interview conducted on 5/25/21 at 1:48 PM with current DON #2 confirmed that there had been no evidence of a 1:1 being assigned to Resident #7 while he/she had been out of bed after incident of sexual abuse on 3/15/20 and 3/16/20. A record review for Resident #7 on 5/19/21 at 9:28 AM, revealed Resident #7 remained on the same unit as Resident #10 until Resident #7 was moved to another unit 17 hours after the second incident of sexual abuse. Further review of the medical record revealed that the care plan for socially inappropriate behaviors had no updated goal and/or interventions after the incident on 3/15/20. An evaluation note dated 4/23/20, entered by LPN Assessment Coordinator #16, documented Resident #7 had met the goal, after two incidents of sexual abuse perpetrated on the same resident. The goal had been documented as I [Resident #7] would like to have a decrease # of behavior occurrences (Refusal of care, sexually inappropriate comments or actions) (<3 episodes a week) through next review. LPN Assessment Coordinator #16 further documented that staff were to continue current plan of care and goal. A record review for Resident #10 on 5/21/21 at 9:45 AM, revealed that Resident #10 had no evidence of a medical assessment or evaluation by social services after the second incident on 3/15/20. Resident #10 had a consultation with Psychiatrist on 4/28/20, 6 weeks after the incident, which made no mention of either incident of sexual abuse. Record review for Resident #7 on 5/19/21 at 9:28 AM, revealed behavior notes that, while on the new unit, Resident #7 continued to have sexually inappropriate behaviors and started to wander in and out of other resident's rooms on the unit. The 15 minute checks had been discontinued on 3/28/20. The notes had been as follows: 5/30/20 - Progress note that stated Resident #7 asked a nurse to come to him/her so Resident #7 could feel her. She told Resident #7 it was unacceptable and she noted resident unable to comprehend. 6/8/20 - Progress note that resident asked a GNA to climb on top of him/her and keep him/her warm. Also, rubbing CNAs buttocks. Resident #7 was redirected. 6/22/20 - Staff noted in a progress note that Resident had been propelling self around the unit. (Usually noted resident to be in their room or in dining room). 6/25/20 - staff noted resident to be propelling self on unit. 6/26/20 Progress noted that Resident was combative with staff during care on day shift. Then noted again for evening shift. 6/30/20 - staff noted that Resident had been wandering in hallway propelling own wheelchair and occasionally entering other resident rooms, easily redirected by staff. 7/3/20 - Staff noted resident propelling self in hallway. 7/4/20 - Staff noted in progress note that Resident approached a staff member asking her to go into the woods and have sex with Resident. 7/5/20 - Staff noted that Resident had been wandering in and out of other Residents' rooms and had been easily redirected. 7/18/20 Staff noted that resident had been propelling self in and out of other resident's rooms. Stated easily redirected. 7/24/20 Staff noted that resident had been propelling self in and out of other resident's rooms and was easily redirected. However, there had been no evidence that facility staff had evaluated these behavior notes to determine if Resident #7 needed an increase in supervision to ensure the safety of other residents given the past incidents of sexual abuse. Review of the facility's investigation file for a self-reported incident dated 8/8/20, revealed a statement written by staff member #11 who reported that on 8/8/20 at 9:55 AM, he/she had went to Resident #6's room for morning rounds and found Resident #7 sitting beside Resident #6's bed with his/her hand down the front of Resident #6's pants. GNA #11 immediately removed Resident #7 from the room and reported the incident to the nurse. Resident #7 had been placed on every 15-minute checks. The incident had been reported to the state agency and local law enforcement was contacted via fax. Statements were obtained from staff of the incident. Resident #7 and Resident #6 remained on the same unit after the incident. Further review revealed the same care plan for inappropriate social behaviors with no updates to the interventions. The evaluation notes for Resident #7 on 10/30/20, stated Resident #7, after a 3rd episode of sexual abuse perpetrated on another resident, had met his/her goal although Resident #7 had continued to have inappropriate sexual behaviors at times and that staff were to continue current plan of care and current goal. A medical record review for Resident #6 on 5/18/21 at 9:28, revealed a History and Physical conducted by the attending physician dated 1/4/20, that documented in the last several months Resident #6 had an infection that required a brief hospitalization and since that time Resident #6 had a downhill course and appears ready to die. Resident had been blind and hard of hearing. Further review of progress notes from 4/2020 - 11/2020, revealed that Resident #6 spent a lot of time in bed and would keep his/her eyes closed. Further review revealed that after the sexual abuse perpetrated on 8/8/20, Resident #6 had not had a physical assessment and had not been seen by a physician. There had been no evidence that Resident #6 had been referred for psychiatric services or for onsite social services. An interview with GNA #11 on 5/20/21 at 1:40 PM, revealed that Resident #7 had been a hard Resident to keep track of because he/she had been wandering in and out of other resident's room all day on 8/8/20. GNA #11 reported that he/she had not received a report that Resident #7 had socially inappropriate behaviors such as touching other residents. GNA #11 had reported that Resident # 7 had made inappropriate remarks to him/her while he/she had provided incontinence care for Resident #7. On 5/21/21 at 7:45 AM, an interview with the current DON #2, revealed that he/she had not felt that Resident #7's inappropriate sexual touching of other residents could be fully avoidable due to Resident #7 diagnosis of Dementia with behavioral disturbances and a BIMS score of 3/15 which had indicated severe cognitive impairment. An Interview with the attending physician, who had been the Medical Director, on 5/25/21 at 9:15 AM, revealed that on a rare occasion a resident had been admitted with sexually inappropriate behaviors. In these situations staff had been expected to increase supervision of that resident. The attending physician stated that the facility had not had the capability to lock residents down, so the facility had done the best that they could. The attending physician reported that it would have been difficult to determine Resident #7's capacity to consent to sexual activity. However, when asked about Resident #6 and Resident #10, the attending physician stated they did not have the capacity to consent to sexual activity at the time of the incidents. When asked the rationale for moving Resident #7 to another unit with vulnerable residents, the attending physician stated that the facility thought that the residents on that unit had been more able to report any issues. An interview with Nursing Home Administrator (NHA), Director of Clinical Services, and current DON #2 on 5/25/21 at 2:57 PM, revealed that the facility had not developed a written policy for a 1:1 observation assignment. The NHA reported that if a resident required 1:1 observation then during the morning huddle meeting all staff would have been informed of the need for a 1:1 observation and all told to keep increase supervision for that resident. When asked the rationale for moving Resident #7 to another unit with vulnerable residents, the NHA reported that the facility had felt that the residents housed on that unit would have had the ability to ward off Resident #7's inappropriate touching and/or report any incidents of Resident #7 touching them. An interview with the Social Services Director on 5/27/21 at 12:36 PM, revealed he/she had not provided any services for Resident #10 and Resident #6 after they had been sexually abused. She reported that allegations of abuse had been handled by the DON. She reported that Resident #10 had been nonverbal, with a history of crying, and would have not been able to express his/her needs to her. The Social Services Director reported that her involvement with Resident #7 had been after the incident on 3/15/20, which had prompted a room change. The Social Services Director stated that the unit managers had known the residents very well and she had depended on them to refer Residents as needed. The findings were reviewed with the NHA, Director of Clinical Services, and DON at time of exit on 5/27/21 at 5:00 PM. (Cross Reference F600, F609, and F610)

Based on facility report review, medical record review, and staff interview, it was determined that the facility staff failed to ensure that safety interventions were followed and that the physician was provided sufficient notification regarding a recent fall with injury This is evident for 1 (#272) of 2 residents reviewed for provision of quality of care. These failures resulted in a finding of actual harm for Resident #272. The findings include: Review of the facility's investigation report MD# 351 revealed that, on 4/12/19 at 8:30 AM, Charge Nurse and Unit Manager observed Resident #272 on the floor, blood on the head and a bruised rug burn noted on forehead. Review of the investigation revealed that the resident's floor mat was not in place at the time of the fall. Review of the progress note, written by Licensed Practical Nurse (LPN) #2 on 4/12/19 at 10:05 AM, revealed that Resident #272 was found on the floor in a pool of blood that had come from his/her nose. At 10:56 AM, LPN #2 noted a bruise to the resident's right eye during a follow up assessment. At 11:09 AM, LPN #2 documented that she faxed physician #13 (the on-call physician) about the fall. However, review of the document faxed at 10:26 AM failed to indicate that the resident had bled or was noted with a bruise, or sustained a carpet burn injury or that the fall mat was not in place. Further review revealed that the notification did not require a return call from the physician to the facility. A progress note, written by LPN #2 on 4/12/19 at 1:06 PM, revealed that the resident was found unresponsive and sent to an acute care hospital for evaluation. A record review on 6/24/19 at 1:10 PM, revealed a summary of Resident #272's emergency room visit, dated 4/12/19. Resident #272 had a Computed [NAME]ography (CT Scan) of the head on 4/12/19, which revealed a [MEDICAL CONDITION] bone (the forehead) with a hematoma (which is collection of blood out the blood vessel) and swelling in the brain and evidence that the brain shifted from one side to the other. A second CT scan was done of the sinuses on 4/12/19 that revealed the fracture in the frontal bone extended to the sinus cavity and included the bone around the right eye. Further review of the summary documented that the neurosurgeon felt that surgery could not be done and the resident was placed in hospice (end of life) care. A progress note, written on 4/13/19 at 8:30 AM by LPN #11, documented that Resident #272 passed away on 4/12/19 at 11:50 PM. A medical record review on 6/24/19 at 1:35 PM, revealed a physician's orders [REDACTED]. Further review revealed a care plan as of 4/12/19, with a focus of, I (Resident #272) am at risk for falls related to poor safety awareness I have a history of falls. With a goal, I (Resident #272) would like to be free of falls at my next 90 day review. Interventions included a fall mat for safety and a bed alarm. Interview with the Unit Manager (UM) staff #1 on 6/25/19 11:21 AM revealed that, after the resident was found on the floor that morning, she provided the initial assessment then stayed and closely monitored the resident. She went on to say that she was aware of the development of the bruised right eye, nose, and forehead. However, further review of the medical record failed to indicate that the UM re-assessed the resident until 1:06 pm or tried to contact the physician personally that day. During an interview with the LPN #2, on 6/25/19 at 12:00 PM, she indicated that she would have called the physician after the fax was sent. However, she was unable to submit documentation to support that this was done. An interview with the Director of Nursing (DON) , on 6/25/19 at 3:48 PM, revealed her expectations would be that the physician be notified by phone regarding a resident's fall with details of the fall and the extent of the injuries. The DON acknowledged that this incident should have been reported to regulatory agencies and then investigated. Although LPN #2 indicated that the physician was updated at 1:52 PM, an interview with Physician #13 on 7/18/19 at 3:22 pm indicated that she was not made aware of the fall or the injuries, at the time of receipt of the resident's transfer to the hospital. In addition, she stated that, based upon the circumstances surrounding the fall and injuries sustained, she would have probably sent the resident to the hospital right away if notified of this information at the time of fall.

Based on resident interview, medical record review, and staff interview, it was determined that the facility staff failed to protect a resident from an accident with injury. The failure of staff to follow the standard of care while turning a resident in bed resulted in the resident rolling out of bed and sustaining a knee and femur fracture. The facility staff also failed to follow a second resident's plan of care during a transfer which resulted in a fall without injury. This was evident for 2 (#23, #40) of 8 residents reviewed for falls. The findings include: 1) Review of the medical record for Resident #23, on 1/18/18 at 8:13 AM, revealed that Resident #23 had a [DIAGNOSES REDACTED]. The left hand also had a contracture. A contracture is an abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching which can lead to permanent disability. It can be caused by inadequate exercising of the joint in patients with paralysis. Resident #23 was recently in the hospital, from 12/31/17 to 1/7/18, due to acute hypoxemic [MEDICAL CONDITION], pneumonia, reactive airway disease, SIRS (systemic [MEDICAL CONDITION] response syndrome), along with other chronic diagnosis. After the resident returned from the hospital, the attending physician documented in Resident #23's medical record that the resident was Incapable due to cognitive dysfunction as of 1/11/18. During an interview with Resident #23 ,on 1/17/18 at 10:49 AM, Resident #23 stated he/she was just in the hospital due to a fall. The resident was observed with bruising to the right arm and on top of the right hand. The resident stated, my body hurts from the fall. Review of the medical record revealed that Resident #23 had a fall on 1/16/18 at 4:15 A.M while a Geriatric Nursing Assistant (GNA) was rendering care. This was 5 days after returning to the facility following hospitalization as stated above. Nursing documentation stated the resident was using the enabler bar and was holding on when the enabler bar moved. It was noted that the resident had a 3 cm (centimeter) purple bruise to the right hip. The resident was transferred to the hospital on [DATE] at 4:33 AM. A second note, written on 1/16/18 at 6:20 AM, stated GNA had turned the resident and resident grabbed the enabler and it was unsteady and he/she rolled off the side of the bed to the floor. Documentation revealed that the resident complained of right leg and knee pain. Review of the emergency room documentation, dated 1/16/18 at 13:20, revealed the clinical impression for Resident #23 was 1. Right distal femur fracture and 2. Right knee fracture. A splint device was applied to the resident's right leg and the resident was transferred back to the facility where the resident was to follow-up with orthopedics. A Fall's risk assessment was done, on 1/16/18 at 6:39 AM, after the fall by Staff #3 who documented the resident had intermittent confusion/poor safety awareness/impulsive. The assessment also documented the resident was chair bound, balance was decreased due to muscular coordination and was deemed a low risk for falls. An interview was conducted with the DON on 1/18/18 at 10:37 AM. The DON stated I didn't feel the enabler was involved at all. I had the GNA come in and I got a statement and we reenacted what happened and the GNA indicated the leg had come off the bed, had slid down and the resident indicated the bar was wobbly. I believe the legs got off the bed, were heavy and took him/her off the bed. The DON continued the GNA received education because I indicated to the supervisor if he/she was in the room alone, he/she needed to turn the resident towards him/her instead of away from him/her. We started education in house. Review of the in-house education given to the surveyor revealed 20 of the 46 GNAs had been in-serviced. The in-service education stated when you are assisting a resident in bed with care by yourself ALWAYS turn them toward you. This decreases the risk of the resident rolling OOB (out of bed). If you are ever uncomfortable providing care to a resident, you are encouraged to get a second person. An enabler is not to help the resident stay in bed. The sole purpose of the enabler is to assist the resident with mobility, increasing their independence. If you have questions, please ask your unit manager or shift supervisor. On 1/18/18 at 12:38 PM, Staff #3 was interviewed about the fall and stated that Staff #2 was turning and positioning the resident with no assistance and that the resident was usually a 1 assist. Staff #3 stated the resident will help with turning but is pretty much paralyzed on the left side. Staff #3 stated the resident said the enabler bar moved back and forth slightly. Staff #3 stated that he/she personally checked the enabler bar and it moved back and forth slightly. I thought it was the resident's perception of how loose the grab bar was and that the resident wasn't comfortable with the grip. Staff #3 also stated that after the resident came back from the hospitalization for pneumonia that the resident was more confused than normal and the night of the fall had baseline confusion and had issues with comprehension. On 1/19/18 at 7:45 AM, Staff #2 was interviewed regarding the fall. Staff #2 stated I was changing his/her Attends and linen pad. At 4:20 AM, the resident was wet so I got everything ready before I rolled him/her. I rolled him/her towards the enabler because his/her right side was the stronger side and he/she can hold on and he/she said the enabler was shaky and wobbly and I was trying to get everything under him/her. I wanted to roll him/her back towards me and he/she let go of the enabler and his/her feet went over the edge of the bed. The surveyor inspected the enabler bar and the bar was 4 inches wide and was located near the head of the bed on the left side of the bed. There were no side rails attached to the bed. The interview continued; normally I do him/her by myself because in the computer they have him/her as a 1 person assist. I wanted to get him/her changed and grab someone to help me pull him/her up in bed and he/she let go and his/her legs went and he/she fell on the floor. They said the enablers are not there to prevent someone from falling out of bed and it is for their bed mobility. They said that I should have rolled him/her toward my way instead of away from myself. The way I was taught in school they still had the side rails and that is not the same as enabler and I was taught to have them use their stronger side. I normally have 17 residents assigned to me. On Maplewood, I have to turn, position and change about 9 or 10 residents. About 5 or 6 of the residents, I need assistance with, and it would be easier to do rounds with 2 people. The surveyor asked if Staff #2 didn't feel comfortable doing a resident alone would Staff #2 get help. The response was In some cases I need to make a decision if I need help or not. I usually go by what's in the system. Review of Resident #23's MDS with an assessment reference date (ARD) of 11/19/17, Section G, Functional Status indicated that the resident was coded a (3) extensive assistance with the support (3) which meant a 2 plus person assist with bed mobility. The resident was also coded as having functional limitation for the upper extremity and no functional limitation for the lower extremity (which was an error - Cross Reference F641) as the resident had paralysis on the entire left side of the body, upper and lower. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and-or Medicaid-certified long-term care facility. The MDS contains items that measure physical, psychological and psychosocial functioning. The items in the MDS give a multidimensional view of the patient's functional capacities and helps staff to identify health problems and develop a plan of care to meet the resident's needs. Review of Resident #23's Activities of Daily Living (ADL) functional care plan dated 1/8/18 documented enabler x 1 for bed mobility. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of the GNA Resident Care Guide, that was initiated on 1/7/18, documented transfers and ambulation/mobility: Hoyer for all transfers with 2 staff. Uses w/c (wheelchair). Has left sided paralysis, left hand contracted, left foot turns inward. Bathing/hygiene/dressing: one assist d/t (due to) left sided paralysis, left hand contracture, and left foot turned inward. Left hand splint when OOB, remove splint q shift when worn. Safety, enabler x 1 for bed mobility due to increased congestion - keep out of bed as much as possible. Review of the GNA care log for (MONTH) 8-16, (YEAR) documented bed mobility as extensive assistance with 1 person. Review of the GNA care log for the month of (MONTH) (YEAR) had varied documentation from 1 person assist to 2 person assist for bed mobility. Out of the 31 days for day shift, 15 of the days, the resident required 2 or more staff for bed mobility, which was 48% of the time. Out of the 30 days for evening shift, (resident was discharged to hospital on [DATE] in the afternoon) 22 of the evenings the resident required 2 or more staff for bed mobility which was 73% of the time. The night shift documented 0 nights that the resident required 2 or more staff members for bed mobility. There was no clarity or rationale on a day to day basis as to how the decision was made to determine the level of assistance Resident #23 required for bed mobility. The MDS assessment should drive the care the resident is to receive and the MDS assessment documented that the resident was a 2 person assist for bed mobility. In addition, a functional pathway assessment that was in the paper medical record, which was completed on 10/26/17 documented bed mobility as a 3/3 which was extensive assist with 2 person, transfer 4/3 which was total dependence with 2 person. On 8/4/17 bed mobility was documented again as 3/3 and on 5/23/17 the resident also was an extensive assist with 2 plus person assistance. The DON and MDS Coordinator advised the surveyor on 1/18/19 at 2:15 PM that the functional pathway assessment was an MDS work tool. When the resident was readmitted from the hospital on [DATE] after pneumonia a physical therapy (PT) evaluation was done. PT documented on 1/8/18 that the resident was at baseline with dependence for transfers with Hoyer lift and was non-ambulatory. Nursing, GNA, PT and spouse did not feel PT was indicated as no changes in status existed for PT to address. On 1/19/17 at 2:00 PM the Physical Therapist was interviewed and asked how the resident should have been turned while in bed. The Physical Therapist stated the GNA should have turned towards them self, especially for this resident. 2) Review of the medical record for Resident #40 revealed documentation that the resident had a fall on 10/16/17 while being transferred by a GNA from the chair to the wheelchair. The GNA statement on the incident form stated went into resident room to transfer him/her to bathroom. When I helped him/her stand up (with gait belt on) to transfer him/her to w/c and help him/her to BR, his/her knees buckled on him/her. The resident was not hurt. The incident report only had 1 GNA in the room with the resident. Review of the MDS with an ARD of 9/117 and 12/1/17 coded the resident as a 3 which was extensive assist with 3 which was 2 person physical assistance. Review of GNA daily charting for (MONTH) (YEAR) documented the resident was extensive assistance (3) with 2 person assist (3). Review of the care plan I have [MEDICAL CONDITION] and I am dependent on staff for the completion of my ADLS bathing, dressing and personal hygiene needs. My mobility is limited due to my [MEDICAL CONDITION] and OA ([MEDICAL CONDITION]). I am able to feed myself but at times I need staff to assist me due to tremors of my hands. The care plan evaluation documented transfer/ambulate with 2 assist walker. The 12/14/17 evaluation stated transfers and ambulates with 2 assist and use of walker. The potential for fall care plan stated transfer/ambulate with gait belt/walker/2 assist. Facility staff failed to follow the care plan.

Based on review of a facility reported incident, medical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent a fall that injured a resident. This is evident for 1 of 3 resident's reviewed during this survey. (Resident #1) The findings include. Review of the entity reported incident investigation revealed that resident #1 fell upon return from restroom on 12/11/2016 at approximately 7PM. The resident was found to have a laceration 9 cm x 3.5 cm (with large flap of skin rolled back on itself) on his leg. Resident was sent to hospital and returned with 17 sutures to the wound. Based on review of the quarterly comprehensive MDS (Minimum Data Set) assessments ,dated 10/17/2016 and 1/15/2017, revealed that resident #1 was assessed to have a severe impairment of cognition and requires extensive assistance for most activities of daily living including bed mobility, transfers, and ambulation. The resident was assessed to require the assistance of 1 staff person to transfer and ambulate. Review of the resident #1's plan of care instructs staff to utilize a gait belt (wrapped around a resident's waist) for assistance with transfers and ambulation. The facility has policy and procedures for Gait Belt Usage; Gait belts are to be used to assist staff to safely transfer or ambulate residents that have the ability to bear weight. The purpose for use of a gait belt is stated as; to provide for safe ambulation and transfer assistance, protect the resident from accidental trauma to the skin; and provide a sense of security to the resident. Review of resident #1's plan of care revealed a written approach/intervention; I need one assist with my ambulation initiated on 4/28/2016, and another approach/intervention of use lift sheets and gait belt for bed mobility and transfers, dated 7/28/2016. The fall incident report indicated that a Geriatric Nursing Assistant (GNA) (GNA #1) was with resident #1 at the time of the fall to floor. The facility had identified that the GNA did not utilize a gait belt to assist the resident in transfer from the toilet and ambulation to bed. The GNA assigned to perform resident #1's care did not have a gait belt on her person and reported that the gait belt issued to her was in her locker at the time of the fall. Review of GNA#1's personnel file revealed that the GNA had signed twice I understand Homewood's lift free policy and gait belt policy and agree to follow them in order to residents and employee safe from injury as possible. The acknowledgement forms were signed on 10/11/2016 and 10/17/2016. The poor practice by GNA violated facility procedures to keep residents safe.