Every finding on record at Livewell Connecticut

Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the staff provided care in accordance with the plan of care and failed to ensure staff to reapproached the resident when resisted care. The findings include: Resident #1's diagnoses included dementia with behaviors, delusions, and major depression. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment, was dependent with ADLS, and independent with transfers and ambulation. The Resident Care Plan (RCP) dated 3/24/2026 identified a cognitive loss due to dementia, alteration in communication, and alteration in ADL function. Interventions directed to assist to make needs known, use Resident #1's personal life story to make connections, ask yes/no questions, assess ability to communicate related to confusion/mood state with each interaction, assist with ADLs, and if not interested in care to come back at a later time and try again. Facility Reportable Event dated 3/31/2026 at 6:30 PM identified NA #1 reported that she was in a room and Resident #1 and Resident #2 were both laying on the bed. NA #1 indicated she observed NA #2 enter the room and approach Resident #1. NA #2 told Resident #1, I'm not doing this s. tonight. NA #1 then stated she observed NA #2 reach out with one hand and grab Resident #1 by the ponytail close to his/her scalp and squeezed with a closed hand and stated to Resident #1, get the f. up and pulled Resident #1 from a position of laying on his/her side to a sitting position. Resident #1 began to resist physically and was mumbling incoherently. NA #2 continued to pull Resident #1 by the ponytail causing Resident #1 to get into a squat-like position next to the bed. Resident #1 then got up and NA #2 let go of Resident #1 and followed Resident #1 out of the room. Assessment identified no injury and no distress, and NA #2 was suspended pending an investigation. Nursing note dated 3/31/2026 at 7:42 PM identified Resident #1 was in bed resting quietly with no apparent discomfort, hair was in a ponytail with no loose hair strands or any redness/irritation noted at the hairline. Will continue to monitor. Nursing note dated 3/31/2026 at 8:15 PM identified an RN assessment was completed with no acute physical or emotional distress. Review of facility RE summary dated 4/2/2026 identified the facility investigation did not substantiate abuse occurred as Resident #1 had no physical harm, mental anguish or deprivation. Further there were two (2) additional staff that were outside the room when the event occurred that did not provide conclusive or corroborating evidence. Interview, review of NA #1 written statement, and facility documentation review on 4/23/2026 at 10:41 AM with NA #1 identified on 3/31/2026 she was standing in a resident's room, on side of the bed near the window and observed Resident #1 and Resident #2 were both lying on another resident's bed and the roommate was sleeping in the second bed in the room. Residents #1 and 2 were both lying on their sides, with Resident #1 closer to the headboard. NA #1 was facing the door when NA #2 walked into the room and said, I'm not doing this s-t tonight. NA #1 indicated NA #2 immediately approached Resident #1, held her arm out and grabbed Resident #1 by the ponytail, close to scalp end with a clenched fist, pulled Resident #1 up from laying position to a seated position on the bed. When Resident #1 attempted to lay back down, NA #2 pulled the ponytail again and pulled Resident #2 to a seated position again. NA #1 believed the force of NA #2 pulling Resident #1's hair caused Resident #1 to come off the bed into a low squatting position. Resident #1 yelled, mumbled and moved his/her arms while NA #2 held the ponytail. NA #2 stated, get the f-k up to Resident #1, who stood up and NA #2 released the ponytail. Resident #1 then left the room independently. NA #2 remained in room, and NA #1 stayed in room to assist Resident #2 out of bed, and reported the incident to the charge nurse, the supervisor and another nurse. NA #1 further indicated no one else could see into the room when the incident occurred. NA #1 stated she did not intervene or call for help due to shock at what happened. NA #1 stated it was her first time witnessing abuse and the first time working with NA #2. NA #1 stated when she exited the room she observed there were no staff in the immediate area (room or common area/hallway), and she had received abuse reporting education when she was hired recently, and she reported the incident as soon as possible. Interview and review of facility documentation on 4/23/2026 at 11:27 AM with NA #2 identified that Resident #1 and Resident #2 were found sleeping in another resident's bed and she wanted to get that resident into bed, she tried to get Resident #1 up and Resident #1 said, leave me alone, don't touch me, I want to sleep and stated she was pulling resident up by his/her back, trying to get resident into a sitting position so he/she could stand up. NA #2 stated she said, let's go, go with me, we got to go to your room and Resident #1 was trying to lay back down, the other aide was not helping, was just standing there and helping Resident #2. Resident #1 would not get up and NA #2 stated she was trying to get Resident #1 into a sitting position, once Resident #1 was up she walked Resident #1 to his/her room. NA #2 stated Resident #1 wears a ponytail at middle of his/her head, and the hair end touches residents' neck and indicated she touched hair only when she held Resident #1's neck. NA #2 further stated she had no issues with NA #1, who was new, and it was their first time working together. NA #2 stated Resident #1 often falls asleep in other resident's rooms, and at times gets up on own and other times needs to be taken back to his/her room. NA #2 denied the allegation of the verbal comments and indicated she did not tell Resident #1 to get the f-k up or we're not doing this s-t tonight. NA #2 indicated she did not consider reapproaching Resident #1 when he/she would not get out of the bed, as it was time for the resident whose bed it was to go to bed, and she did not ask NA #1 to help her with Resident #1 as NA #1 was busy with Resident #2. Interview and facility documentation review on 4/27/2026 at 9:33 AM with RN #1 identified he was the supervisor on 3/31/2026 when the alleged incident occurred. RN #1 stated NA #1 may not have been comfortable confronting a more experienced aide (NA #2), and stated that during interviews neither NA appeared to have ill will toward the other. RN #1 described NA #2 as having a direct demeanor that can seem cold and had worked with NA #2 for an extended period. RN #1 stated any action such as grabbing a resident by the ponytail or pulling a resident to force movement, and the alleged verbal comments would be inappropriate. Interview and record review with RN #2 (Director of Clinical Advancement) and the Administrator on 4/23/2026 at 1:39 PM, identified the allegation of abuse was made on 3/31/2026 at approximately 6:30 PM. NA #1 reported potential abuse by NA #2 to the charge nurse, and RN #1/supervisor was notified. NA #1 and #2 both provided different accounts of the incident, and both residents had dementia. Resident #1 and Resident #2 were found in another resident's bed, and the other resident was due to return to bed. Facility review of hall security video monitoring identified no sounds were heard (from the room/incident) before NA #1 was witnessed on the video to exit the room and speak with the charge nurse to report the allegation, approximately 10 minutes after the alleged incident occurred. The facility did not confirm Resident #1 was pulled by the hair or NA #2 made the statements alleged. NA #1 and NA #2 had never worked together previously and had no personal history. Interview identified NA #1 could have used a call bell to call for help, or could have used the staff-issued communication system that staff wear. Although the facility did not substantiate the allegation, NA #1's employment was terminated for not reporting the incident immediately, and NA #2's employment was terminated related to the incident. The DNS was not available for interview during the survey. Review of Nursing Home Resident's [NAME] of Rights Policy directed in part that residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality in an environment that promotes maintenance or enhancement of quality of life and privacy. Further, residents have the right to be free from verbal, sexual, physical or mental abuse, neglect, exploitation. Review of Certified Nursing Assistant Position (job) Description directed in part; focus on the well-being of all residents. Further the Position Description directed to respect the dignity of residents by respecting their right to refuse care (i.e. leaves and return later - does not insist on care being given.) and to respond with patience when the resident may be slow to respond. Review of the facility Compliance and Ethics - Code of Conduct directed in part, to provide an empathic approach to dementia care.

Based on review of facility documentation, review of facility policy, and interviews, the facility failed to provide documentation that their flushing program logs were maintained according to the facility's water management plan. The findings include: Review of the Facility Water Management Plan with the Director of Maintenance for the years 2023 through March 2025 on 3/26/25 at 11:45 AM identified the facility water management plan included flushing monthly, annual testing and that the facility also had a contract with a vendor for their water management program. The Director of Maintenance provided a log titled Domestic Hot Water Heaters Monthly Draining for 2024 in which only the months of January, February, March and April were checked off as completed. The Director of Maintenance identified that whenever the flush was completed it should have been signed off by the maintenance staff. In a notarized Affidavit statement dated 3/27/24 by the Maintenance staff (Maintenance #1) who was responsible for documenting and flushing the hot water domestic heater in 2024) identified he had completed the flushes as required and did not document the flushes at the time he completed them for the months of May 2024 through December 2024. Although a request was made on 3/27/25 and 3/28/25 for the flushing program logs from April 2023 through March 2025, the facility failed to provide such documentation and had only provided the monthly draining log of the hot water domestic heater. Review of the Annual Water Management Plan Revision and Updates dated 8/31/21 in which the Director of Maintenance identified that was current and in effect along with the Facility's Environmental Assessment and Procedure and water management binder with the Director of Maintenance on 3/27/25 at 12:58 PM identified the Water Management Plan in fact included a flushing program using the mitigations steps identified in facility's Environmental Assessment and Procedures which were hot water storage tank; facility ice machine; showers/tubs/faucets that are uncommonly used to be flushed for 3-5 minutes monthly, which should be documented and kept in the service section of their plan; and eyewash station to be flushed monthly for 3 minutes which should be documented and kept in the service section of their plan as well as to utilized the flushing program log provided. The Director of Maintenance identified that the boiler was drained monthly, ice machines were serviced semi-annually by an outside vender, eye washes were flushed and will provide paperwork, tubs were flushed when not in use and unused sink and shower heads are being flushed by housekeeping but would not be able provide a log for such flushing. A review of the service section of the plan failed to identify any servicing of the ice machine, flushes of the eyewash station or any flushing of uncommonly used areas such as showers, tubs, or faucets. He further identified the facility did not utilize the logs provided by the water management vendor as they had their own. Interview with Maintenance #1 on 3/27/25 at 12:58 PM identified he only flushes the boiler. In an interview with Housekeeping (Housekeeper #1) on 3/28/25 at 8:85 AM it was identified that bathrooms including showers are cleaned daily. Housekeeper #1 identified faucets in the showers are turned on for approximately 30 seconds when cleaning showers in bathroom that are not being used to rinse the showers and are turned on for a longer time to rinse showers that have being just used when cleaning. The housekeeper further identified they were not aware of flushing any unused faucet in the resident's bathroom. Interview with the Director of Maintenance on 3/28/25 at 9:15 AM identified that Maintenance #1 was trained to document in the logs whenever the boiler was flushed. He further identified that he was unable to provide documentation of the flushes for the tub and the eyewash stations as those tags were taken when they were removed during the construction. He did identify that he should document when flushes were completed but did not have the paperwork that he flushed any uncommonly used faucets, tubs, or showers. He also identified that not all the showers were being used even though each resident had their own showers in their room. Interview with the Administrator on 3/28/25 at 10:30 AM identified she was aware of the water management plan as she is a part of the committee and that it involves annual testing, quarterly meetings, boiler flushing, hot water faucet flushes in all areas, flushing of eyewash station and servicing of the ice machine. She identified that when areas are flushed it should be documented at the time of the flush. She identified that the facility was granted a waiver for no tubs on 8/30/23 and prior to the waiver flushes were done and documented on the tag on the tub which was removed when the tub was taken during construction. The Administrator also identified that the eyewash stations were flushed, and the tags were also removed with construction. She further indicated that if there were any unused faucets the Director of Maintenance was responsible for identifying those areas for flushing and documentation not the housekeepers. Review of the facility resident areas identified an eyewash station at the sink in both cleaning utility rooms were without tag to indicate flushes and/inspections. In a tour with the Administrator on 3/28/25 at 10:45 AM identified eyewash station in the cleaning utility room that was without tags which would indicate the flushes. She was asked when the eyewash stations were installed, and she responded that she would find out and get back to the surveyor. In an interview with the Administrator on 3/28/25 at 11:00 AM it was identified that the eyewash stations were installed in August of 2024 and according to the Director of Maintenance they were flushed but he was unable to provide documentation of the flushing. Interview with Person #1 (an expert of water management planning) on 3/28/24 at 12:57 PM identified it is best practice to document flushes as it shows the facility is meeting their control measures, water is moving, and it is important to maintain such documents as it shows mitigations. Review of the Water Management Policy identified facility should maintain the environmental assessment, sampling, and management plan and any associated sampling results on the facility premises for at least three years, such records should be made available to the local and the state department upon request. The facility Water Management plan Revision and Updates identified areas noted to be included in the flushing program are low flow areas (areas with minimum to no usage), purging of storage tanks and other desired location. Also, to document areas of compliance such as water flushing program eye wash station protocol.

Based on review of clinical records, review of facility documentation and interviews for four sampled residents (Residents #22, #26, #30 and #49) who received psychiatric medications and received psychiatric services, the facility failed to ensure psychiatric visits were documented in a timely manner. The findings include: 1. Resident #22's diagnoses included dementia, anxiety disorder, and delusional disorder. The annual MDS assessment dated [DATE] identified Resident #22 had severely impaired cognition, required maximal assistance with dressing, personal hygiene, moderate assistance with bed mobility and transfers and ambulated using a walker with moderate assistance. The care plan dated 1/20/25 identified Resident #22 was receiving psychotropic medication related to vascular dementia with behavioral disturbances and major depressive disorder with interventions that included resident sees the psychiatric team routinely for care. The physician's order dated 3/19/25 directed for evaluation and ongoing treatment by psychiatry. Review of the psychiatry progress note dated 11/21/24 at 12:13 PM by APRN #1 identified she added a new medication Memantine (used to treat memory loss) 5mg for one week then to increase to 10 mg daily and she would reassess for further increase at next visit. Review of the clinical record failed to identify any further documentation from APRN #1 in Resident #22's medical record. Interview with APRN #1 on 3/25/25 at 3:10 PM identified her schedule varies as it relates to seeing patients: as stable patients are seen within 2 to 3 months and less stable patients are seen frequently within 2 to 4 weeks. APRN #1 identified she saw Resident #22 as recent as last month. When asked where she had documented her notes after her visits, she indicated that she was behind in her documentation, but the resident had been seen. In addition, APRN #1 identified that the expectation is that she enters her notes into the EMR after her visit. When asked if she had let the DNS/Administrator know how far behind she was, she indicated that she had not. She stated that she would get documentation entered in by the end of the day. In an interview with the DNS on 3/26/25 at 9:35 AM she identified that she was unaware that APRN #1 was behind in her documentation. The DNS added that her expectation is that all documentation is entered after each encounter is completed. The DNS identified that APRN #1's EMR does not interface with the facility's EMR, therefore she cuts and pastes her notes into the facility's EMR. Interview with the Medical Director of the Mental Health Specialist (MD #2) on 3/28/25 at 9:19 AM identified he expects that when a resident is seen by the provider the notes are put in the resident chart for continuity of care. Interview with APRN #2 on 3/28/25 at 10:41 AM identifies that she could communicate via texting system with the psychiatry APRN. She further identified she could only review the notes that were available, and it was expectation was that documentation to be completed timely. Subsequent to surveyor's inquiry APRN #1 entered notes in the EMR on 3/25/25 for visits with Resident #22 which had occurred on 12/3/24, 12/10/24, 12/31/24, and 1/21/25. Although requested, a facility policy for documentation was not provided. In an interview with the DNS on 3/28/25 at 10:30 AM identified the facility does not have a policy for documentation but it is the facility's practice to enter documentation into the EMR after each resident encounter. 2. Resident #26's diagnoses included Alzheimer's disease, adult failure to thrive, and pain. The quarterly MDS assessment dated [DATE], identified Resident #26 had severe cognitive impairment and was dependent for all personal hygiene and activities of daily living. The physician's order dated 3/19/25 directed to obtain a psychiatry evaluation and treatment as needed. The Resident Care Plan dated 3/21/25 identified Resident #26 received psychotropic medications. Interventions included psychiatric services as needed. Review of the 5/15/24 Behavioral Health note written by APRN#1 indicated that a follow-up re-assessment visit would be scheduled in 3 months. Review of the clinical record did not contain any further documentation from APRN #1. In an interview with APRN #1 on 3/25/25 at 3:10 PM she confirmed that she had seen Resident #26 in August and was behind in her documentation. She identified that the expectation is that she enters her documentation into the EMR after her visit. When asked if she let the DNS/Administrator know how far behind she was, she indicated that she had not. She noted that she would enter the documentation of the visit by the end of the day. In an interview with the DNS on 3/26/25 at 9:35 AM she identified that she was unaware that APRN #1 was behind in her documentation. Further she stated that her expectation is that all documentation is entered after each encounter is completed. The DNS identified that APRN #1's EMR does not interface with the facility's EMR, therefore she cuts and pastes her notes into the facility's EMR. In an interview with MD#2 on 3/28/25 at 9:19 AM identified that the expectation is when the resident is seen by the provider, the notes are put in the resident's chart for continuity of care. Subsequent to surveyor inquiry all notes were entered into the EMR on 3/26/25 for the following visits: 8/14/24, 8/28/24, 1/9/25, and 2/20/25. A documentation policy was requested; however, one was not provided as the facility does not have a policy for documentation. The facility practice is to enter documentation into the EMR after each resident encounter. 3. Resident #30's diagnoses included dementia with behavioral disturbances, nutritional deficiency, and chronic pain. The quarterly MDS assessment dated [DATE] identified Resident #30 had severely impaired cognition, was short tempered or easily annoyed, had disorganized thinking, exhibited verbal behavioral symptoms directed toward others, and was dependent on staff for all mobility and transfers. The care plan dated 2/11/25 identified Resident #30 was being monitored for psychotropic medications and behaviors with interventions that included: offer food or emotional support, seen by the psychiatric team as needed for care, attempt gradual dose reduction (GDR) as ordered by provider, monitor behaviors and response to medications, AIMS (Abnormal Involuntary Movement Scale) per facility policy and as needed, monitor medication for therapeutic effects and document target symptoms. The physician's orders dated 3/4/25 directed to administer the following medications: Quetiapine (antipsychotic medication) 25 mg give twice per day with 50 mg dose at 5pm and 9 pm Sertraline (antidepressant) 25 mg by mouth with food as part of a 37.5 mg dose once a day Nursing progress notes dated 11/19/24 at 6:59 PM identified the resident was seen by the psychiatric APRN with no new orders. Nursing progress notes dated 1/9/25 at 5:16 PM identified Resident #30 was seen that afternoon by the psychiatric APRN and indicated there were no new orders. Review of Resident #30's clinical record on 3/25/25 at 1:00 PM identified that the last noted documentation from the psychiatric APRN (APRN #1) was dated 11/20/24 and identified the resident was seen to assess mood/behavior and to review psychiatric medications. Review of the Psychiatric Referral Log identified Resident #30 was seen by the psychiatric APRN on 3/26/25. Review of the clinical record failed to identify documentation of the visit. Interview on 3/25/25 at 3:10 PM with APRN#1 identified that she documents her notes in a different computer system and is responsible for transferring the notes to the resident's clinical record. Further, she did not provide an explanation as to why the notes were not up to date in Resident #30's clinical record. She also noted that she had not communicated to anyone that she was behind with her documentation. Interview on 3/26/25 at 9:35 AM with the DNS identified that she was not aware that APRN#1's documentation was not completed. The DNS indicated that her expectation is that all documentation be entered into the computer when the resident is seen. The DNS further identified that APRN#1 used a different computer system to write her notes and that she was required to cut and paste the notes into the facility's EMR (electronic medical record). Interview on 3/28/25 at 9:19 AM with the Medical Director of the mental health specialists (MD #2) identified that the expectation for documentation is that when the resident is seen by the provider, the notes should be put in the resident's chart immediately to ensure continuity of care. Interview on 3/28/25 at 10:41 AM with APRN #2 identified that she is able to text with APRN#1 should she have questions. APRN#2 indicated that she can only read what is available and that communication with APRN#1 was minimal and that she usually received verbal report from nursing staff. Interview on 3/27/25 at 2:09 PM with APRN #1 identified her notes for Resident #30 had not been entered since 11/20/24 and was unable to identify why. APRN#1 indicated she had seen the resident, made some medication changes and that the resident had a gradual dose reduction and would upload the notes that night. APRN#1 indicated that she communicates with nursing staff regarding changes. Review of the medical record on 3/28/25 identified that APRN #1 entered notes into Resident #30's medical record at 11:41 PM on 3/27/25 for visits dated 1/9/25 and 2/20/25. 4. Resident #49's diagnoses included cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, The quarterly MDS assessment dated [DATE] identified Resident #49 had intact cognition, did not exhibit behavioral symptoms, and received antianxiety and antidepressant medication. The care plan dated 1/14/25 identified Resident #49 was taking psychotropic drugs and interventions included: attempt a gradual dose reduction (GDR) per regulations and as recommended by MD/APRN to see the psychiatric team as needed for care, monitor behavior and response to medication, monitor for side effects and therapeutic effects, provide coaching on appropriate behaviors. Physician's orders dated 3/19/25 directed evaluation and on-going treatment by psychiatry, note the presence of target behaviors of yelling, inappropriate sexual comments, and paranoia, at the end of each shift. Physician's orders included Duloxetine capsule delayed release (antidepressant) 60 mg once a day, Lorazepam (antianxiety) 0.5 mg tablet (give 1/2 tablet twice a day), Trazodone (antidepressant) 50 mg tablet 1/2 tablet once daily in addition to 1/2 tablet by mouth every 4 hours as needed for anxiety or agitation. Interview on 3/25/25 at 3:10 PM with APRN#1 identified that she documents her notes in a different computer system and is responsible for transferring the notes to the resident's clinical record. Further, she did not provide an explanation as to why the notes were not up to date in Resident #49's clinical record. She also noted that she had not communicated to anyone that she was behind with her documentation. Interview on 3/26/25 at 9:35 AM with the DNS identified that she was not aware that APRN#1's documentation was not completed. The DNS indicated that her expectation is that all documentation be entered into the computer when the resident is seen. The DNS further identified that APRN#1 used a different computer system to write her notes and that she was required to cut and paste the notes into the facility's EMR (electronic medical record). Interview on 3/27/25 at 11:40 AM with the Administrator and DNS identified the expectation for documentation is that it is to be completed in real time, or when the resident is seen the documentation should be completed. Additionally, the Administrator indicated that the facility did not have a policy that outlined expectations for documentation. Interview on 3/27/25 at 2:05 PM with APRN#1 identified she saw the resident frequently and indicated she did not have a reason for not having any documentation in the computer. Interview on 3/28/25 at 9:19 AM with MD#2 identified the expectation for documentation is that when the resident is seen by the provider, the notes should be put in the resident's chart to ensure continuity of care. Subsequent to surveyor's inquiry APRN#1 entered notes into the facility EMR on 3/27/25 for visits that occurred with Resident #32 on 12/10/24, 12/17/24, 12/31/24, 1/16/25, 1/21/25, 1/30/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25. 47900 48792

Based on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for three of five sampled residents (Resident #46, Resident #47, and Resident #50), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was offered and administered as required. The findings include: Resident #46 was admitted to the facility in November/2024 with diagnoses that included mild neurocognitive disorder, bipolar disorder, and Vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #46 had intact cognition. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >[AGE] years who had received the PPSV23 only (pneumococcal vaccine) at any age have an option to receive after one year the pneumococcal vaccine (PCV20 or PCV15). Review of Resident #46's Pneumococcal Vaccination history under the Preventative Health Care tab identified the resident had received the PPSV 23 (pneumococcal vaccine) on 2/13/2023 prior to his/her admission to the facility and no records of the Prevnar 13 vaccine (PCV 13) being administered previously. Review of the Authorization for Examinations, Laboratory Studies and test consent form which includes immunizations identified Resident #46's representative had given consent and received education regarding the pneumococcal vaccine on 10/16/24. Review of Resident #46 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. IP identified she had sent a consent to the resident's representative on 2/6/25 with no response but did not realize that on admission residents are provided with a consent form that includes vaccines consent along with education on admission. RN #3 was asked if she had any prior documentation since the resident admission in November that would indicate that she had made efforts to obtain vaccination history or consent from the resident representative which she responded that she only had the email sent on 2/6/25. RN #3 identified that the Resident #46 was eligible to receive PCV 20 after one year based on CDC pneumococcal vaccine schedule. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule. Resident #47 was admitted to the facility in July/2024 with diagnoses that included dementia, mood disturbance, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #47 had severely impaired cognition. The assessment further identified that the resident did not receive the pneumococcal vaccine with no reason as to why the vaccine was not offered. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >[AGE] years and had no prior vaccination of the pneumococcal vaccine are eligible for receiving the PCV20 vaccine or the PCV15 vaccine (pneumococcal vaccine) then after one year the PPSV23 vaccine. Review of Resident #47's Pneumococcal Vaccination history under the Preventative Health Care tab failed to identify any previous history/record of pneumococcal vaccination. Review of the Authorization for Examinations, Laboratory Studies and test consent form which includes immunizations identified Resident #47's representative had given consent and received education regarding the pneumococcal vaccine on 7/11/24 and had indicated that the last dose of pneumococcal was in 12/22. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. The IP identified she had no records of past vaccination for the resident and had sent a pneumococcal vaccination consent to the resident's representative on 2/6/25 but did not realize that on admission residents are provided with a consent form that includes vaccines consent along with education on admission. RN #3 was asked if she had any prior documentation since the resident admission in July that would indicate that she had made efforts to obtain vaccination history or consent from the resident representative which she responded that she only had the email sent on 2/6/25. RN #3 identified Resident #47 was eligible to receive PCV 20 based on CDC pneumococcal vaccine schedule. Interview with the DNS and the Administrator on 3/27/25 at 10:30 AM identified that the facility did not have a set timeframe to obtain vaccination history. The DNS identified that a nurses note would not be required to document that the facility was obtaining the vaccination history, but an internal tracking system should be utilized. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule. Resident #50 was admitted to the facility in August/2024 with diagnoses that included Alzheimer's disease, chronic pain syndrome, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #50 had moderately impaired cognition. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >[AGE] years have an option to receive the pneumococcal vaccine 20 (PVC 20) if they had already received both Prevnar 13 (PCV 13) at any age and/ pneumococcal vaccine (PPSV23) at or after age [AGE] years old and are eligible to receive after 5 years the PCV20 or another dose of the PPSV23 after shared decision with the provider and the patient. Review of Resident #50's Pneumococcal Vaccination history under the Preventative Health Care tab in the pneumococcal vaccine with a created date of 8/15/24 identified the resident had received the PPSV 23 (pneumococcal vaccine) on 11/12/2007 and Prevnar 13 vaccine (PCV 13) on 8/19/2015 which was prior to his/her admission to the facility. Review of the Authorization for Examinations, Laboratory Studies and test form which includes immunizations identified the Resident #50's representative had given consent and received education regarding the pneumococcal vaccine on 8/14/24. Review of Resident #46 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. The IP identified she had not offered any pneumococcal vaccine to Resident #50 because she was utilizing the CDC vaccine schedule that was dated 4/1/22, which based on the resident's vaccination history he/she was updated. However, based on the updated pneumococcal vaccine schedule, which she has been utilizing, the resident should have been offered the PCV 20 or another dose of PPSV 23. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule.

Based on observations, review of the clinical record, review of facility policy, and interviews for 1 of 5 sampled residents, (Resident #35), reviewed for unnecessary medications, the facility failed to attempt a gradual dose reduction (GDR). The findings include: Resident #35's diagnoses included unspecified dementia, bipolar disorder, non-traumatic brain dysfunction, and depression. The annual MDS assessment dated [DATE] identified Resident #35 was severely cognitively impaired, had minimal depression, required extensive assistance with bed mobility, transfers, and wheelchair use. Review of the Resident Face Sheet identified that Person #1 was the resident's power of attorney for financial and health care decisions. The Resident Care Plan dated 2/15/2023 identified Resident #35 had memory deficits and required assistance with care and direction throughout the day to feel connected, secure, and aware of his/her identity. In addition, the care plan identified that Resident #35 was under routine care of a psychiatrist secondary to cognitive changes and bipolar depression. Care plan interventions included: assess for the effectiveness of drug treatment, monitor, and report any adverse signs or symptoms including, sedation, anticholinergic, extrapyramidal symptoms, and a gradual dose reduction should be attempted unless contraindicated by the physician. The monthly physician's orders for March/2023 identified orders that directed Seroquel (antipsychotic medication) 50mg three times a day (9am, 1pm, 5pm) and Seroquel 75mg at bedtime for mood disorder. Further review of the orders identified that the origination date of the order was 2/3/22. A psychiatric note dated 8/10/22 identified that Person #1 wished to continue with the Seroquel as ordered and noted that staff had no reports of new behaviors. It further noted that as the resident continued to decline, it might be possible to attempt a very gradual taper of the Seroquel and noted that per Person #1's wishes, the Seroquel would be continued as ordered. A note dated 9/28/22 also noted that Seroquel would be continued due to Person #1's wishes. A psychiatric note dated 12/21/22 noted that Seroquel would be continued and that a gradual dose reduction of the medication would not be considered at that time. A nurse's note dated 2/5/23 at 6:56 PM identified Resident #35 was asleep all day, ate and drank, but the 5:00 PM 50mg dose of Seroquel was held due to sedation. The APRN's note dated 2/7/23 at 11:20 AM identified Resident #35 appeared sleepier, and Person #1 was not open to reducing Seroquel given life-long symptoms. The facility will continue to revisit and discuss medication reductions at each care plan meeting. The care plan conference note dated 2/15/23 identified Resident #35 could be difficult to keep awake during meals. A psychiatric note dated 3/1/23 identified that the resident had increased daytime somnolence and noted that Person #1 was reluctant to consider decreasing the dose of the Seroquel. The note further identified that the resident would likely tolerate the decrease in the Seroquel dosing. In addition, the documentation noted to continue the Seroquel for now and staff would plan to discuss possibly decreasing the Seroquel with Person #1. Observation on 3/23/23 at 11:23 AM identified Resident #35 seated in a tilt and space wheelchair, the wheelchair was tilted back in a reclined position. Resident #35 had her/his eyes closed appearing to be asleep. Constant observations on 3/28/23 from 9:10 AM through 12:42 PM identified Resident #35 seated in his/her reclined wheelchair in the day room, appearing to be asleep during the entire observation. During the observation period Resident #35 was not approached or spoken to by facility staff, and not repositioned. At 12:43 PM, RN #5 was noted to administer medications, and although the medications were administered, Resident #35 was difficult to rouse and immediately appeared to fall back to sleep. At 1:05 PM, NA #6 moved Resident #35 from a reclined to an upright position and then transported the resident to the dining table, without waking. Constant observations on 3/28/23 from 9:10 AM through 1:05 PM (total of three hours and fifty-five minutes) identified that Resident #35 had her/his eyes closed and appeared to be asleep for most of the time other than when medications were administered. Observation on 3/28/23 at 1:40 PM identified Resident #35 appeared to be unable to be awakened for lunch with gentle touch and patting. NA #3 and NA #6 identified that Resident #35 was too lethargic to utilize his/her usual method of transfer (a mechanical sit to stand lift), to safely be placed on the toilet to void. They utilized a total mechanical lift (Hoyer) to place the resident in the bed to provide care. Review of nursing notes dated 3/28/2023 at 6:14 PM indicated that after breakfast until around lunch time Resident #35 had increased fatigue. Interview with the registered nurse supervisor (RN#3) on 3/28/23 at 9:50 AM identified that when staff notices a resident declining, the family and physician are notified, and it should be considered if the decline is due to disease process or if a medication review and reduction should be considered. A psychiatric note dated 3/29/23 completed by APRN#1 indicated Resident #35 had increased sleepiness during the day, and may tolerate a taper of medication (Seroquel). The note further noted a plan to decrease the am dose of Seroquel to 25mg and reassess it in 1-2 weeks. A physician's order dated 3/29/23, directed to discontinue Seroquel 50 mg three times daily, and begin Seroquel 25 mg every morning and Seroquel 50 mg twice daily at 1:00 PM and 5:00 PM. A note on the physician's order indicated that Person #1 had declined the change. Review of the medication administration record identified that the order was not transcribed (the medication dosages were not changed). Interview with APRN#1 on 3/30/23 at 9:28 AM indicated that if any resident, in general was stable and subsequently clinically declined, the medication is often able to be reduced. Additionally, she noted that staff observed that Resident #35 was slowing down a little bit and that it was reasonable to decrease the dose, but APRN #1 indicated that Person #1's permission to decrease the dose was necessary prior to making the change. APRN #1 indicated that if a resident's representative refused a gradual dose reduction, then there was no professional responsibility to make a dose change. APRN#1 further identified that it would negate her responsibility because the resident's representative had input and that they make the resident's decision. In addition, APRN #1 indicated that if Person #1 was not involved, a dose reduction would have been appropriate, and as Resident #35's, medical provider a Seroquel dose was clinically indicated. APRN#1 identified that she would touch base with Person #1 and indicated that the facility Medical Director may need to become involved in making the decision. Interview with Person #1 identified that Resident#35 had psychosis exacerbations and depression throughout his/her life, and indicated that Resident #35 had always been sleepy. Person #1 indicated that Seroquel did not cause the sleepiness and denied that Resident #35 had a diagnosis of dementia.

Based on observation, review of facility policy, and interview for 1 sampled resident (Resident #40) with an indwelling catheter, the facility failed to ensure a privacy cover was utilized to conceal a urinary containment bag. The findings include: Resident # 40's diagnoses included benign prostatic hyperplasia, unspecified dementia, and urinary retention. The quarterly MDS assessment dated [DATE] identified Resident #40 had severe cognitive impairment and required total assistance with toileting, personal hygiene, and dressing. A physician's order dated 3/17/23 directed catheter care and to maintain foley catheter to gravity drainage. The Resident Care Plan dated 3/23/23 identified Resident #40 utilized a urinary containment device with interventions that included to provide Resident #40 with privacy to maintain dignity with any personal care. Observation on 3/27/23 at 9:37 AM identified Resident #40 was in the unit television room seated in a wheelchair with an uncovered urinary containment bag that was hooked to the side of the wheelchair. The urinary containment bag contained amber colored urine, that was potentially visible to staff, residents, and visitors. Interview with RN #13 on 3/27/23 at 9:37AM identified Resident #40 had an uncovered containment bag filled with urine that was visible. RN# 13 indicated that he was unaware if the facility had a policy to keep Resident #40's urinary bag covered to ensure dignity and privacy. A review of the facility's Foley Catheter policy identified that privacy covers for drainage bags are recommended for the resident's privacy and dignity.

Based on observation, review of the clinical record, review of facility policy and interviews for 1 of 2 sampled residents, (Resident #35) reviewed for positioning, the facility failed to ensure a resident was repositioned in a timely fashion. The findings include: Resident #35's diagnoses included unspecified dementia with behavioral and mood disorders, non-traumatic brain dysfunction, depression, and bipolar disorder. The annual MDS assessment dated [DATE] identified Resident #35 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, and toilet use. The assessment further noted that Resident #35 was totally dependent on staff for locomotion and was always incontinent of bowel and bladder. The Resident Care Plan dated 2/15/2023 identified Resident #35 had memory and speech impairments, required assistance with personal care, and was at risk for pressure ulcer development. Care plan interventions included: check the resident for turning and positioning at least three times per shift. Intermittent observations on 3/23/23 from 11:23 AM through 1:15 PM identified Resident #35 seated in his/her wheelchair in a reclined position with eyes closed. Constant observations from 9:10 AM through 12:42 PM on 3/28/23 identified Resident #35 seated in his/her wheelchair in a reclined position in the day room. During the observation period, Resident #35 was not approached by facility staff, not repositioned, and not spoken to or removed from the day room area. At 12:43 PM, RN #5 administered medications to Resident #35 but failed to provide further care. At 1:05 PM NA #6 moved Resident #35 to the dining table. At 1:10 PM NA #6 moved Resident #35 from a reclined to an upright position. Constant observations on 3/28/23 from 9:10 AM through 1:10 PM failed to indicate that Resident #35 was repositioned, checked for incontinence, or provided with incontinent care for approximately 4 hours. Following the observation period RN #8 was made aware at 1:17 PM of the failure of staff to provide Resident #35 with incontinent care and/or repositioning. Observation on 3/28/23 at 1:40 PM identified Resident #35 appeared lethargic. NA#3 and NA#6 determined Resident #35 was unable to utilize his/her usual method of transfers (a mechanical sit to stand lift) to be placed on the toilet, instead NA #3 and NA #6 assisted Resident #35 to bed with the use of a mechanical lift (total lift) to provide care. Although Resident #35's incontinent brief was dry, Resident #35's buttocks and upper legs were noted to be reddened with notable indentations patterned after the waffle cushion that she/he was seated upon. In addition, the skin along the resident's upper back and spine was reddened and blanchable. NA#6 indicated that Resident #35 might answer when asked about incontinence but was unable to initiate asking for assistance. NA #6 further identified that repositioning was considered complete when the wheelchair was reclined or there was a change in position, and that all staff were responsible to ensure repositioning. NA#6 stated she did not know how many times Resident #35 had been repositioned since she/he was placed in the dayroom around 7:00 AM through the time NA #6 placed Resident #35 at the dining table at 1:10 PM. NA #6 indicated that she did not know why the resident was not repositioned or provided incontinent care but conveyed that it was the responsibility of the nurses' aides. Interview with RN #8 on 3/28/23 at 9:50 AM identified incontinent care is provided to residents 3 to 4 times per shift and as needed and Nurse Aides provide incontinent care first thing in the morning, on arrival at or around 7:00 AM. Further, RN #8 identified that some residents prefer to sleep later, but that would be reflected in the resident's care plan. Review of the facility's Bowel and Bladder Assessment policy identified that residents will be toileted and/or checked 3-4 times each shift. Review of the facility's policy for Prevention of Pressure identified that for prevention of pressure ulcers, a minimum of incontinence care, and turning and repositioning is provided at least every 2 hours and as needed.

Based on staff interview and clinical record review for 1 sampled resident (Resident #58) reviewed for Hospice, the facility failed to ensure the Minimum Data Set (MDS) assessments were coded accurately related to Hospice status. Resident #58's diagnoses included unspecified dementia, dysphagia, protein calorie malnutrition and anemia. Physician orders dated 11/18/22 directed a Hospice consultation. Hospice notes dated 11/29/22 through 3/21/23 identified Resident #58 was receiving Hospice services. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired and required extensive assistance of 2 with bed mobility, transfers and toilet use, extensive assist of 1 for dressing and hygiene, supervision set up of 1 for eating, but failed to identify Section O was coded as Resident #58 receiving Hospice services (despite Resident #58 receiving Hospice services). The Quarterly MDS assessment dated [DATE] identified Resident #58 was severely cognitively impaired and required extensive assistance of 2 with bed mobility, dressing and hygiene, total dependence for transfers and toilet use and extensive assist of 1 for dressing and hygiene. Additionally, the MDS identified Resident #58 required limited assistance of 1 for eating, but failed to identify Section O was coded as Resident #58 receiving Hospice services (despite Resident #58 receiving Hospice services). On 3/28/23 at 7:58 AM, interview and record review with RN #2 (who completes MDS') identified that Resident #58 was on Hospice services at the time of the Annual and Quarterly MDS and that she should have coded both MDS' for hospice services. Additionally, RN #2 identified that she reviews the clinical record prior to completing the MDS, and must have overlooked that Hospice services were being received. Subsequent to surveyor inquiry on 3/28/23, a correction was completed and submitted for the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE], Section O-Hospice, which identified Resident #58 was on Hospice services.

Based on clinical record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident was transferred in accordance with physician's orders to prevent an injury. The findings include: Resident #1 was admitted to the facility with diagnoses that included Alzheimer's, depression, and [CONDITION(S)]. The Physician's orders dated 8/3/2021 directed to transfer Resident #1 with two staff assist to adaptive wheelchair with head rest, Rojo cushion, bilateral elevating leg rests, and pelvic positioning belt. Review of the clinical record identified Physical Therapy (PT) recommended to discontinue use of a Sara life and change Resident #1's transfer status to transfer with two (2) staff due to safety concerns with use of the Sara lift for Resident #1. The Annual Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment, was non-ambulatory, had no behaviors, required one staff assist for personal hygiene, and was dependent on two (2) staff for repositioning and transfers. The Resident Care Plan (RCP) dated 9/20/2021 identified an alteration in mobility. Although interventions directed to transfer Resident #1 using a Sara lift, physician orders dated 8/3/2021 directed to transfer with assist of two (2) staff. Review of facility incident report dated 9/24/2021 at 2:45 PM identified after NA #1 and NA #2 transferred Resident #1 into bed they discovered a bump on Resident #1's right forehead. The report further identified Resident #1 was transferred via use of a [NAME] Lift. Resident #1 was assessed by RN #1, and RN #1 noted a light/blue purple raised area measuring 4 centimeters (cm) by 3.5 cm by 0.3 cm in size. The injury review form identified Resident #1's head was vulnerable to trauma during transfers with the [NAME] lift and he/she may have banged his/her head on the nightstand or headboard during the transfer with the [NAME] lift. The investigation summary identified Resident #1 hit his/her head during a transfer using the [NAME] Lift on 9/24/2021 at 1 PM that resulted in a bump and bruise to his/her head. Review of written statement written by NA #1 dated 9/26/2021 identified that on 9/24/2021 she transferred Resident #1 with NA #2 using a [NAME] lift; she thought Resident #1 required use of the lift and she did not check the care plan. Review of NA #2's written statement dated 9/29/2021 identified she was providing care for another resident, and she did not assist NA #1 with the transfer. Nurse's note dated 9/25/2021 at 4:19 PM identified Resident #1 was noted to have a lump on the right thigh, the supervisor was notified and assessed Resident #1. Resident #1 complained of right leg pain and Tylenol was administered with good effect. The physician was notified with no new orders obtained. Review of facility incident report dated 9/26/2021 identified a lump was observed on Resident #1's right inner thigh on 9/25 and on 9/26/2021 a bruise measuring 7 centimeters (cm) diameter was noted on Resident #1's right inner thigh. Additionally, MD #1 was notified, and Tylenol was administered for discomfort with good effect. Resident #1 was unable to explain what caused the injury and interventions included to monitor for safety. The DNS identified the area was vulnerable to trauma during transfers with the [NAME] Lift. The investigation summary identified that on 9/26/2021 Resident #1 developed increased discomfort and was assessed by APRN #1 with new orders for an x-ray of the right leg and x-ray results identified a right distal femur fracture. Review of the X-ray report dated 9/27/2021 identified an acute fracture of the right distal femur with moderate displacement and modest osteopenia. The APRN progress note dated 9/27/2021 identified a question of a hematoma to the right medial thigh tender to touch and limited ROM was noted. Additionally, Resident #1 had facial grimacing when touched and pain and ordered Tylenol 650 milligrams (mg) every eight (8) hours for seven (7) days for pain. The progress note written by APRN #1 dated 9/29/2021 identified Resident #1 had acute pain due to trauma and ordered [MEDICATION(S)] 50 mg by mouth every six (6) hours scheduled for seven (7) days. The note further identified Resident #1 had modest [CONDITION(S)] joint disease/[CONDITION(S)], a history of [CONDITION(S)] and was at high risk for pathological fractures due to multiple comorbidities and risk factors which included low calcium intake, vitamin d deficiency, and inadequate physical activity. Interview with NA #1 on 10/28/2021 at 11:20 AM identified she and NA #2 transferred R#1 into bed on 9/24/2021 at approximately 1 PM using a [NAME]. Additionally, NA #1 identified she did not know Resident #1 had orders to stand pivot transfer with the assistance of two persons; she thought Resident required the [NAME] lift and she did not check the care plan because she was assisting NA #2 (assigned to Resident #1) with the transfer. NA # 1 indicated the lift pad (size unknown) was placed under Resident #1. Resident #1 then held the lift bar while they then guided him/her in the [NAME] lift. NA #2 used the electronic controls to move Resident #1 from the chair into the bed and Resident #1 was cooperative during the transfer. NA #1 indicated after the transfer she stepped out of the room for a few minutes and when she returned to the room to provide incontinent care to Resident #1 by herself, she noticed a bump and bruise on Resident #1's head, and she did not know how it happened. Further, NA #1 indicated when she was notified of Resident #1's fractured leg, she did not know how that occurred. Interview with the DNS on 10/28/2021 at 11:34 AM identified she concluded that Resident #1 bumped his/her head on the [NAME] lift because the bump was immediately present after NA #1 and NA #2 transferred Resident #1 into bed after lunch on 9/24/2021. Additionally, she did not know how the femur fracture occurred other than Resident #1 was at risk for pathological fractures because of a history of [CONDITION(S)] and indicated that bumps happen during transfers. Further, she indicated that although NA #2 denied that she assisted NA #1 with the transfer, she was unable to she was unable to explain the discrepancies in the statements obtained from NA #1 and #2 of who performed the transfer. Review of the clinical record and facility documentation identified that although the physician's orders directed to pivot transfer Resident #1 with two staff, staff did not follow the physician's orders and transferred Resident #1 using a [NAME] lift. Additional review of the clinical record identified Resident #1 did not require surgical intervention; he/she remained at the facility on palliative care with pain medication as indicate. Interview with NA #2 on 10/28/2021 at 12:56 PM identified she fed Resident #1 breakfast and lunch, did not provide any other resident care, and did not notice any bump or bruise of Resident #1's right forehead. Further, although NA #1 indicated NA #2 assisted with Resident #1's transfer into bed about 1 PM, NA #2 indicated that she was providing care for another resident and did not assist with the transfer. She indicated that she did not know how Resident #1 sustained either the bump on his/her head or femur fracture. Interview with The Radiologist/MD #2 on 10/29/2021 identified that while osteopenia placed Resident #1 at a higher risk for fractures due to thin bones, the type of fracture identified on 9/27/2021 was not pathological fracture or spontaneous in nature. He indicated that the type of fracture Resident #1 sustained was likely the result of impact or force that was greater than a usual transfer or repositioning. Although requested, a facility policy was not provided regarding following physician's orders. Review of facility NA Job Description, directed in part, to transfer resident in accordance with their assignment. The facility policy entitled [NAME] Lift identified in part to ensure two staff members perform this procedure.

Based on clinical record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident was provided incontinent care and repositioning timely. The findings included: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's orders dated 8/3/2021 directed to transfer Resident #1 with two staff assist to adaptive wheelchair with head rest, Rojo cushion, bilateral elevating leg rests, and pelvic positioning belt. The Annual Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment, was non-ambulatory, had no behaviors, required one staff assist for personal hygiene, and was dependent on two (2) staff for repositioning, toilet use, and transfers. The Resident Care Plan (RCP) dated 9/20/2021 identified a problem with urinary incontinence and an alteration in mobility (inability to walk). Interventions directed to assist with toileting, provide incontinent care three (3) to four (4) times during each shift and as needed, and to transfer Resident #1 using a Sara lift. Review of facility incident report dated 9/24/2021 at 2:45 PM identified NA #1 and NA #2 transferred Resident #1 back to bed when they discovered a bump on Resident #1's right forehead. the report further identified Resident #1 transferred via use of a [NAME] Lift. Resident #1 was assessed by RN #1, and RN #1 noted a light/blue purple raised area measuring 4 centimeters (cm) by 3.5 cm by 0.3 cm in size. The injury review form identified Resident #1's head was vulnerable to trauma during transfers with the [NAME] lift and he/she may have banged his/her head on the nightstand or headboard during a transfer with the [NAME] lift. Interview and facility documentation review with NA #2 on 10/28/2021 at 8:56 AM identified she was the NA assigned to Resident #1 on 9/24/2021 during the day shift. She indicated that Resident #1 was already washed, dressed and out of bed when she arrived to the unit shortly after 7AM that at the start of her shift. Further, she indicated that she did not provide any care to Resident #1 between 7 AM and 1 PM other than feeding him/her breakfast and lunch because she was busy helping other residents. Although the facility incident report indicated that she assisted NA #1 to transfer Resident #1 back into bed after the bump was identified, she could not recall assisting with the transfer. Further she indicated that during the shift, she did not provide Resident #1 with any incontinent care or repositioning between 7 AM and 1 PM. She indicated that she checked Resident #1's brief at 10 AM by placing her fingers inside the top of the brief while Resident #1 was in his/her wheelchair in the lounge and the brief was dry at the time; she did not open the brief or reposition Resident #1. NA #2 indicated that although she was aware that Resident #1 required incontinent care and repositioning every two hours when in bed, she was not sure what was required when Resident #1 was in his/her wheelchair and she did not notify the nurse that she was unable to provide care because whe was busy helping other residents. Interview with the DNS on 10/28/2021 at 1:25 PM identified NA #2 should follow the plan of care for providing incontinent care and repositioning (provide incontinent care and repositioning every two hours). Review of the Nurse Aide Job Description directed in part, the nursing assistants care for elders in a manner conducive to their comfort, and perform nursing assistant duties as instructed, and in accordance with policies and procedures. Additionally, the Job Description further directed the nursing assistant was to provide toileting and incontinent care timely. Review of the facility policy entitled Incontinent Care directed in part, that incontinent care is performed by nursing staff on all residents following an episode of incontinence and as needed. Review of the policy entitled Positioning directed in part, that each resident who is unable to turn themselves will be repositioned based on the plan of care.

Based on facility documentation review, facility assessment review and staff interviews for a review of staffing, the facility failed to ensure staff were trained and had annual competencies regarding use of Mechanical Lifts. The findings include: Review of the Facility Assessment, section entitled Competencies directed in part, that Nurses and Certified Nursing Assistants would demonstrate safe lift techniques on orientation with the lifts used within the facility and education was provided as deemed necessary. Additionally, the facility training program included an orientation process and ongoing training based on staff need and resident characteristics. The Facility Assessment further directed the Inservice training for nurse aides must be no less than 12 hours annually and ensure the competence of the nurse aides and included transfers/lifts. Further, audits are conducted with staff and reeducated when necessary. Review of the Safe Lifting and Transfer Agreement/education forms signed and dated 9/25/2021 by NA #2, and signed and dated on 10/18/2021 by NA #1 identified for resident safety, two staff members were required to assist with mechanical lift transfers and to ensure use of the appropriate type of lift as directed by the resident's plans of care and NA assignments. Further, if a NA identified a change in a resident's ability, they must notify the nurse. Review of the attached competency forms were blank and were not signed by either NA #1 or NA #2, or an instructor to demonstrate that NA #1 and NA #2 had completed a transfer competency. Interview with NA #1 on 10/28/2021 at 11:20 AM identified she had received education/training on the use of mechanical lifts upon hire three (3) years ago and had not received any additional training since that time. Interview with the DNS on 10/28/2021 at 11:34 AM identified mechanical lift training was completed on hire and as needed and random audits were conducted on all shifts. Interview with NA #2 on 10/28/2021 at 12:56 PM identified she had mechanical lift training upon hire two (2) years ago and had not received additional training after that time. Although surveyor requested documentation of random mechanical lift audits, the facility did not provide audits for surveyor review. Although requested, a facility policy was not provided.

Based on review of facility documentation, facility policy and interview the facility failed to ensure 2 nurses (RN #1 and LPN #1) worked in the facility with current active nursing licenses. The findings include: Review of information received from the DPH Practitioner's Licensing and Investigation Section identified that RN #1 and LPN #1, who were employed at the facility, had not renewed their nursing licenses since 2018, 3 years. Review of RN #1's employee file identified RN #1's license expired on [DATE] and had not been renewed. Review of LPN #1's employee file identified LPN #1's license expired on [DATE] and had not been renewed. Interview with the Administrator on [DATE] at 9:45 AM identified she became aware on [DATE] that RN #1 was working under an expired nursing license. RN #1 had reported to facility staff that she had received notification from the Department of Public Health (DPH) that her license had expired. Subsequently, the DNS, Human Resource (HR) staff members and the Administrator immediately reviewed all nursing licenses to ensure they were not expired. Results of the facility's review identified that LPN #1's nursing license had expired on [DATE]. No other nursing staff licenses were expired. Both RN #1 and LPN #1 were immediately suspended on [DATE] and instructed to re-instate their licenses in order to return to work. Additionally, members of the QAPI committee met ([DATE]) and initiated corrective measures to prevent reoccurrence. The Administrator identified that tracking of licenses was reassigned to the HR Coordinator. Interview with Scheduler #1 on [DATE] at 10:45 AM identified she was responsible for keeping the current nursing licenses. Scheduler #1 indicated she was instructed to organize the licenses according to each nurse's birth month. Additionally, Scheduler #1 identified that nurses were responsible for keeping their licenses up to date, and that she had not been instructed to track or monitor when licenses were due to be renewed. Further, there was no formal tracking system in place. Interview with the Director of Human Resources (HR) on [DATE] at 10:55 AM identified that initially they had assumed that Scheduler #1 had received instruction to track the expiration of nursing licenses. The Director of HR identified they realized there was no tracking process in place after RN #1 alerted facility about her expired license and an audit revealed LPN #1 also had an expired license. The Director of HR identified their process was reviewed and updated and was now the responsibility of the HR Coordinator. Attempts to contact RN #1 and LPN #1 were unsuccessful. Review of the facility's Nursing Licensure Compliance Plan, which was implemented on [DATE], identified that nurses are responsible to annually update required licenses. The Human Resource Coordinator will track licensure on a monthly basis in an excel spreadsheet to ensure the nursing license remains in active status. (Status will be checked the month prior to each nurse's birth month and the month of, to ensure the renewal was processed). Tracking is kept in an excel spreadsheet and audited monthly. Any discrepancies found will be immediately shared with the nurse and reported to the Director of Nursing and Administrator. Should a nurse let their license lapse they will be immediately removed from the schedule and put on suspension until it is active.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of five sampled residents (Residents #54 and #60) reviewed for unnecessary medications, the facility failed to monitor for target behaviors or assess the potential side effects related to the use of antipsychotics. The findings include: a. Resident #54's diagnoses included [CONDITION(S)], Dementia, Spondylolisthesis, lack of coordination, generalized weakness, and cognitive communication deficit. A physician's order dated 12/23/2019 directed to provide [MEDICATION(S)] 50mg (antipsychotic) three times a day. The Admission Minimum Data Set, dated dated dated [DATE] identified that Resident #54 was cognitively intact. Physician's orders dated 12/31/2019 directed the activity level for Resident #54 as an assist of 1 staff member for transfer. The Resident Care Plan (RCP) dated 12/24/2019 identified that Resident #54 utilized [CONDITION(S)] medications due to dementia. Interventions included to monitor medications for serious side effects as well as therapeutic effects, documenting target symptoms on the nurse's psychoactive flow sheet. The RCP further identified that Resident #54 was at risk for falls due to the diagnosis of [CONDITION(S)], with interventions of transfer and ambulate with rolling walker with assist of 1 staff. Review of Resident #54's medical record failed to reflect documentation of target behavior monitoring from 12/24/2019 to 1/16/2019. A physician's order dated 1/13/2019 directed to provide [MEDICATION(S)] 50mg (antipsychotic) three times a day. Target Behavior monitoring sheets dated 1/16/19 to 1/31/19 identified Resident #54's target symptoms as night terror and identified no demonstration of this behavior for day and evening shifts. The Target Behavior monitoring sheets dated 1/16/19 to 1/31/19 lack documentation for the night shift. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 1/29/2020 identified that Resident #54 had Dementia with depression and behavioral disturbances currently presenting with symptoms of increased depression. Target Behavior monitoring sheets dated 2/1/2020 to 3/3/2020 identified Resident #54's target symptoms as night terror and identify no demonstration of this behavior for day and evening shifts. The Target Behavior monitoring sheets dated 2/1/2020 to 3/3/2020 failed to reflect documentation for the night shift. Review of Resident #54's medication administration records for December, 2019, January, February, and March, 2020 identified Resident #54 received all scheduled doses of medication. Facility policy for Psychoactive Medication Use identified that facility staff should monitor the resident's behavior as per facility policy using a behavioral chart or behavioral assessment record for resident's receiving [CONDITION(S)] medication. b. Resident #60 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, major depressive disorder, [CONDITION(S)], anxiety, and Alzheimer's disease. A physician's order dated 6/19/19 directed to administer [MEDICATION(S)] 12.5 milligrams (mg) by mouth once per day at 11:00 AM, [MEDICATION(S)] 25 mg by mouth once per day at 4:00 PM, and [MEDICATION(S)] 50 mg by mouth three times per day. A physician's order dated 6/19/19 directed to obtain orthostatic blood pressures once per month before the 11th of the month. A physician's order dated 6/21/19 directed to administer [MEDICATION(S)] 10mg once per day. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was severely cognitively impaired and required extensive assistance with personal hygiene and dressing. In addition Resident #60 received antipsychotic and antidepressants daily over the last 7 days. The Resident Care Plan (RCP) dated 6/20/19 identified Resident #60 received [CONDITION(S)] medication. Interventions directed to monitor medication for therapeutic effects and document how Resident #60's target symptoms were doing, on the nurse's psychoactive flow sheet. A review of Resident #60's blood pressure log from 7/1/2019 through 2/29/2020 identified orthostatic blood pressures were not obtained per physician's order for the months of July 2019, November 2019, and February 2020. A pharmacy consultation report dated 7/2/19 identified Resident #60 received an antipsychotic, [MEDICATION(S)] with a recommendation to please update the medical record to include a list of symptoms or target behaviors (e.g., hallucinations, scratching) including their impact on the resident with desired outcomes. The psychiatry progress note dated 7/10/19 identified Resident #60 was seen to assess medications with recommendations to continue all medications to allow for longer period of adjustment before attempting gradual dose reduction (GDR). A pharmacy consultation report dated 8/5/19 identified REPEATED RECOMMENDATION from 7/2/19 for Resident #60 who received an antipsychotic, [MEDICATION(S)] recommendation please update the medical record to include a list of symptoms or target behaviors (e.g., hallucinations, scratching) including their impact on the resident with desired outcomes. The psychiatry progress note dated 8/14/19 identified Resident #60 could be irritable and anxious at times. In addition, Resident #60 was easily distracted, easily over stimulated, he/she was alert with poor judgement, and had impaired memory. Assessment and plan medications well tolerated, would not consider GDR at this time, continue all medications, and reassess in 2 months. The psychiatry progress note dated 10/23/19 identified Resident #60 had a general decline with increased sleepiness at times. Assessment and plan, no recent behavior symptoms, overall decline may tolerate GDR. Plan to discontinue [MEDICATION(S)] 12.5 mg daily morning dose, continue other medications, and reassess in 2-3 weeks. A physician's order dated 10/23/19 directed to discontinue [MEDICATION(S)] 12.5mg by mouth at 11:00 AM once per day. The psychiatry progress note dated 11/13/19 identified since discontinuing [MEDICATION(S)] 12.5mg daily morning dose, Resident #60 has had increased irritability and frustration, was more resistive to care, and was occasionally combative. Assessment and plan due to increased symptoms since morning dose of [MEDICATION(S)] discontinued, restart [MEDICATION(S)] 12.5mg daily morning dose, continue all other medications, and reassess in 2-4 weeks. A physician's order dated 11/13/19 directed to administer [MEDICATION(S)] 12.5mg by mouth once per day every morning. The psychiatry progress note dated 12/4/19 identified Resident #60 was combative at times toward staff, with an improvement in mood. Assessment and plan, mood improved, would not consider any changes at this time, continue medications, and reassess in 1 month. The significant change MDS assessment dated [DATE] identified Resident #60 was severely cognitively impaired and required extensive assistance with personal hygiene, dressing, transfers, and locomotion. In addition Resident #60 received antipsychotic and antidepressants daily over the last 7 days. The psychiatry progress note dated 1/8/2020 identified Resident #60 was having difficulty with ambulation and feeding self with increased confusion. Assessment and plan, did not tolerate prior attempt to discontinue [MEDICATION(S)] 12.5mg morning dose decline is anticipated with advancing dementia current medications well tolerated. Continue all medications as ordered for now, reassess in 6-8 weeks, and at that time will consider decreasing [MEDICATION(S)]. The Resident Care Plan dated 1/9/2020 identified Resident #60 received [CONDITION(S)] medication. Interventions directed to monitor medication for therapeutic effects and staff to document how Resident #60's target symptoms were doing on the nurse's psychoactive flow sheet. The psychiatry progress note dated 2/19/2020 identified Resident #60 had occasional periods of increased anxiety. Assessment and plan, given occasional symptoms would not consider GDR of medications as they continue to be of benefit continue all medications. Interview and clinical record review with Licensed Practical Nurse (LPN) #1 on 3/3/2020 at 1:51 PM identified any resident prescribed [CONDITION(S)] medications has target behaviors monitored every shift. LPN #1 would expect Resident #60 to have a behaviors monitored every shift, however he/she was unable to provide documentation to reflect that Resident #60 had a current behavior monitoring flowsheet nor any prior month flow sheets to reflect behavior monitoring since Resident #60's admission on 6/19/19. In addition LPN #1 indicated during the working shift all nurses including herself/himself are responsible for documenting behaviors on the flowsheet. LPN #1 could not explain why Resident #60 has not had any target behaviors monitored. Interview with the Director of Nurses (DNS) on 3/3/2020 at 2:17 PM indicated any resident on [CONDITION(S)] medications has target behaviors monitored every shift by the nurse working that shift. The DNS would expect a specific target behavior or behaviors to be monitored and documented on the flowsheet kept in the white binder at the nurses stations. In addition the DNS was unable to provide documentation to reflect orthostatic blood pressures were obtained in July 2019, November 2019, or February 2020 for Resident #60. Subsequent to surveyor inquiry LPN #1 started a Psychoactive Medication Flowsheet for Resident #60 dated 3/3/2020 with a target behavior of hallucinations. Review of facility orthostatic blood pressure policy identified orthostatic blood pressures are obtained monthly on elders who are on psychoactive medication to monitor for possible adverse effects. Review of the facility's [CONDITION(S)] medication use policy identified staff should be monitoring the resident's behavior using the psychoactive medication flowsheet every shift with the identified target behaviors.

Based on observation, review of the clinical record, interviews, and review of facility policy, for one of three residents reviewed for pressure ulcers, (Resident #28), the facility failed to ensure offloading of heels as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #28's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #28's admission Minimum Data Set (MDS) dated [DATE] identified Resident #28 had severe cognitive impairment, was totally dependent on one staff for bed mobility, was at risk for developing pressure ulcers, and had no pressure ulcers. A Braden skin assessment dated [DATE] identified a score of 18 indicating Resident #28 was at risk for pressure sore development. The care plan dated 2/27/20 identified Resident #28's right toe was reddened and the left toe was noted with a suspected deep tissue injury (DTI). Interventions included heel float boots while in bed. Wound assessment dated [DATE] identified Resident #28 with a DTI to the left great toe measuring 3 cm x 0.2 cm. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 2/27/20 identified the Advanced Practice Registered Nurse (APRN) was updated regarding Resident #28's red, blanchable right great toe and suspected DTI to left great toe. The note further identified to see new orders for skin prep, non-skid socks, heel float boots, and bed cradle. Observation and interview with Nurse Aide (NA) #4 on 3/4/20 at 6:29 AM identified that Resident #28's heels were not elevated. Resident #28 was wearing gripper sock and his/her heels were directly on the bed surface, were not offloaded with heel float boots, and no heel float boots were found in the room. Observation and interview on with Licensed Practical Nurse (LPN) #3 on 3/4/20 at 6:32 AM identified Resident #28 was without the benefit of heel float boots or offloading of heels and no heel float boots in the room. LPN #3 identified Resident #28 had orders for heel float boots and further identified that she/he would expect offloading of heels. Interview with LPN #3 on 3/4/20 at 6:33 AM identified that Resident # 28 had current orders for heel float boots while in bed, identified that Resident # 28 should have been wearing them, and LPN #3 was calling therapy at the time to obtain boots. Resident care card copies for NA use were provided to the surveyor by the Assistant Director of Nurses (ADNS) and LPN #3 on 3/4/20 at 6:38 AM. The care card did not reflect the need for heel float boots. Interview with NA #6 on 3/4/20 at 6:44 AM identified NA #6 did not know Resident # 28 was to have boots or elevated heels. NA #6 further identified the care card packet, taken from his/her pocket and dated 2/27/20 (same date as provided to surveyor), did not identify to use heel float boots for Resident #28. Interview with NA #4 on 3/4/20 at 6:50 AM identified that the care card packet he/she used dated 2/27/20, did not direct the use of heel boots for Resident #28. Interview and record review with the ADNS, with LPN #3 present, on 3/4/20 at 6:52 AM identified that the care cards get updated weekly on Thursdays by the unit secretary. LPN #3 identified that the master copy of care cards was updated, but the copies for staff were not updated. The ADNS identified that until the care cards have the weekly update, the information is given in report and staff can write in this information. The ADNS identified that this was missed for Resident #28, and identified that nursing staff are responsible for this. The facility policy for Pressure Ulcer/Non-Pressure Ulcer Risk Management identified: Determine the cause of the pressure ulcer and remove the causative agent if possible. Interventions may include: Maintain activity and mobility as follows for immobile residents: Heels are extremely vulnerable and must be elevated completely off the bed or chair surface. Use pillows, positioning devices and/or suspension boot devices.

Based on observation of the Dietary Department, review of facility policy, and staff interviews, the facility failed to appropriately store and/or label open food items and/or failed to ensure staff donned a beard cover. The findings include: a. A tour of the kitchen on 1/28/19 at 9:45 AM with the Registered Dietician (RD) identified a walk in freezer contained one non labeled and/or dated bag of carrots, peas, four cakes, and four pies. Additionally, the walk in refrigerator contained one non dated open crock of whole grain mustard, one opened jar of cherries, one non labeled/non dated container of sliced red and green vegetables, and one non dated opened container of capers. Furthermore, observation of the dry storage room identified one deeply dented six pound can of peas and one deeply dented six pound can of sauerkraut. Interview with the RD during the tour of the kitchen on 1/28/19 at 9:50 AM identified the carrots, peas, cakes, peppers, mustard, cherries, and capers should have been labeled and were not. The RD indicated all food should have been labeled to identify the content of the food if it was not in the original container. Opened food items should be labeled with the date it was opened, and the date to be used by. The RD removed and disposed of the food items that were not labeled and/or dated from the freezer and refrigerator. The RD identified that the cooks and/or kitchen aides were responsible for ensuring the food was labeled when opened. Furthermore, the RD indicated food in dented cans should not to be utilized as it could be contaminated. The dented cans should have been placed in the Food Director office to return to the vendor. The RD identified when food is stocked, the aide stocking it was responsible for removing all dented cans. Although the RD could not identify why the food was not labeled, dated or why the dented cans were in dry storage, he/she did identify it had been a busy time in the kitchen as the facility just received a delivery of food, the Director of Food Services was out sick, and the dishwasher required repair. Interview with the Director of Food Services on 1/29/19 at 8:40 AM identified food items stored in the refrigerator and freezer should be labeled, dated properly to ensure the food is safe for consumption. Furthermore, the food in dented cans should not be utilized. Review of facility policy for Food Storage identified any left over food items should be evaluated and those that can be re-used or saved for incorporation into future production are to be wrapped, dated and labeled. The policy failed to direct a system for food cans that were compromised by dents. b. Observation of Dietary Aide #1 on 1/29/19 at 8:40 AM identified he/she had facial hair (a beard/mustache) and was in the kitchen, by the food preparation area washing his/ her hands in the sink without the benefit of a beard restraint. Interview with Dietary Aide #1 on 1/29/19 at 8:41 AM identified although he had worked at the facility for one year, his facial hair was new and indicated he did not know he needed to don a beard cover while in the kitchen. Interview with Director of Food Services on 1/29/19 at 8:41 AM identified that Dietary Aide #1 was provided with education at the time of his orientation directing facial hair be covered, however, the Dietary Aide had been clean shaven until recently. The Director of Food Services identified Dietary Aide #1 required his facial hair be covered and provided him with a facial hair covering. Review of facility policy identified that facial hair longer than an eyebrow or eyelash shall be covered in the kitchen.

Based on observation, a review of the clinical record, a review of facility documentation, a review of facility policy, and interviews, for two sampled residents reviewed for a clean and homelike environment (Resident #54 and #90), the facility failed to ensure resident's wheelchairs were kept clean and/or in good repair. The findings include: a. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 with severe cognitive impairment, independence with eating, and the use of a wheelchair for mobility. A physician's orders [REDACTED].#54 out of bed to an adaptive wheelchair with a pelvic positioning device. Observation on 1/28/19, 1/30/19 and 1/31/19 identified Resident #54 sitting in a wheelchair at a table. The pelvic positioning device was noted with multiple white dried stains. b. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #90 with severe cognitive impairment, requiring total assistance with locomotion on or off the unit, and the use of a wheelchair for mobility. A physician's orders [REDACTED].#90 out of bed to a custom wheelchair. Observation on 1/28/19, 1/30/19 and 1/31/19 identified Resident #90 sitting in wheelchair with his/her arm on the wheelchair arm rests. The wheelchair armrest was observed with cracked areas on both the right and left armrest exposing white mesh padding. Interview and observation of Resident #54 and Resident #90 with Licensed Practical Nurse (LPN) #2 on 1/31/19 at 10:19 AM identified Resident #54's pelvic positioning device with dry stains. LPN #2 indicated that third shift nurse aides were responsible to clean the wheelchairs every night, and if the wheelchair was very soiled then the maintenance department would power wash the wheelchair. Observation of Resident #90's wheelchair identified visible tears. LPN #2 indicated that Occupational Therapy (OT) was responsible for equipment, and as a nurse LPN #2 was unaware he/she was responsible to report tears on the wheelchair. Interview and observation with OT #1 on 1/31/19 at 10:30 AM identified the pelvic positioning device appeared to have food on the seat belt and multiple dry white stains were also noted. OT #1 indicated when wheelchairs were heavily soiled, maintenance was responsible to deep clean them. The nurse aide was responsible to wipe the chair. OT #1 indicated that it looked like the the armrest on Resident #90's wheelchair had worn and the mesh on the padding was exposed. Interview and observation with Registered Nurse (RN) #2 on 1/31/19 at 11:07 AM identified that night shift nurse aides were responsible to check the wheelchair for cleanliness nightly. RN #2 identified Resident #90's wheelchair armrests were cracked. RN #2 indicated that all staff was responsible to report anything out of ordinary and place documentation into the daily repair log. Interview and observation with OT #2 on 1/31/19 11:37 AM identified that Resident #90's wheelchair armrests were due for replacement as it was an infection control issue. OT #2 indicated that it was a shared responsibility, staff members were responsible to check wheelchairs for cleanliness. Customized wheelchairs and adaptive wheelchairs were reviewed quarterly and annually. OT #2 indicated the procedure was for the nurse aide or any other staff member who noticed an unclean or damaged wheelchair to report that information to the nurse. The nurse in turn would report the problem to the maintenance department. Subsequent to surveyor inquiry Resident #54's pelvic positioning device and Resident #90 wheelchair armrests were replaced on 1/31/19.

Based on a clinical record review, staff interviews, a review of facility documentation, and a review of facility policies and procedures, for five of eight residents reviewed for mistreatment (Residents #20, #46, #51, #77, and #110) the facility failed to report the results of the investigations to the state agency timely. The findings include: a. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 with severe cognitive impairment, was independent with transfers and ambulation in the room and on the unit, had verbal behavioral symptoms toward others, and had behaviors not directed towards others. The resident care plan (RCP) dated 1/10/19 identified memory challenges and assistance needed with care and direction throughout the day to feel connected, secure, and aware of identity. Interventions included making eye contact, approach slowly so I do not startle and include me in on decisions about my life, care and activities, and every fifteen minute observational checks. The reportable event(s) dated 1/10/19 at 4:00 PM identified the facility was made aware that Resident #20 was involved in an interaction with Resident #110 on 1/10/19 at approximately 1:30-2:00 PM. Resident #20 was observed walking by holding Resident #110's hand and entered Resident # 20's room, shut the door, and touched Resident # 110's chest (over his/her shirt) area. Staff intervention included immediate removal of Resident #110 from Resident #20's room. Further review of the reportable event documentation identified the facility actions included every fifteen minute observational checks and police, physician, and family notifications. b. Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #110 with short and long term memory deficits, with modified independence for daily decision making, with disorganized thinking, requiring supervision with a one person physical assist for eating, ambulation in the room, corridor, and for locomotion on unit. The RCP dated 1/10/19 identified memory challenges as a problem with interventions that included assistance with care and direction throughout the day to feel connected, secure and aware, make eye contact, approach slowly so I don't startle and include the resident on decisions about care and activities. The reportable event dated 1/10/19 at 4:00 PM identified Resident #110 was involved in an resident to resident altercation with Resident #20 on 1/10/19 at approximately 1:30 to 2:00 PM. Resident #110 was observed walking hand in hand with Resident #20's hand. Both residents were observed entering Resident #20's room. Resident #20 shut the door, and touched Resident #110's chest over his/her shirt area. Staff intervention included immediate removal of Resident #110 from Resident #20's room. Further review of the reportable event documentation identified the facility actions included a body audit, a social service visit, and police, physician and family notifications. c. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #46 had severe cognitive impairment and required the physical assistance of one staff with ambulation in the corridor and on the unit. The nursing care plan dated 11/13/18 identified Resident #46 was administered antipsychotic medication daily due to cognitive losses and was monitored for sexually inappropriate behaviors. Interventions directed staff to be aware that Resident #46 may attempt to touch female elders and to monitor Resident #46 when he/she sat next to female residents. d. Resident # 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #51 had severe cognitive impairment, and was independent with ambulation in the corridor and on the unit. The RCP dated 11/19/18 identified Resident #51 was at risk for injury due to [DIAGNOSES REDACTED].#51's whereabouts on the unit. e. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident # 77 had moderate cognitive impairment, and was independent with ambulation in the corridor and on the unit. The RCP dated 12/3/19 identified Resident #77 had no safety awareness, may be in other residents personal spaces, may pick up other resident's belongings and carry them around, walk into other residents's rooms, and likes to hug and be close to other elders. Interventions directed to redirect resident as needed, keeping in mind that the resident may want to kiss/hug people who might not like it. The reportable event form dated 1/10/19 at 4:00 PM identified that Person #1 made the facility aware of an interaction between Resident #46 and Resident #51 last Thursday or Friday (1/3/18, 1/4/18). Person #1 saw Resident #46 sitting in a wheelchair with his/her back against the nurse's station. Resident #51 was walking by Resident #46 and Resident #46 took Resident #51 by the hand. Person #1 reported he/she saw Resident #46 pull Resident #51 toward him/her, tried to kiss Resident #51, and put his/her hand on Resident #51's pants. The reportable event form dated 1/10/19 at 4:00 PM identified that at 4:00 PM Person #1 made the facility aware that he/she witnessed an interaction between two resident several weeks ago. Person #1 witnessed Resident #46 on the couch in the family/TV room. Resident #77 came in and sat down on the couch next to Resident #46. Person #1 observed Resident #46 touch Resident #77 chest over his/her shirt. Person #1 got up and took Resident #77 by the hand and walked Resident #77 out of the room. Review of the facility documentation failed to identify the results of investigations related to resident to resident interactions dated 1/10/19 were reported within five working days to the state agency. Interview with the Director of Nursing (DNS) on 1/31/19 at 12:12 PM indicated she was in the process of sending the conclusion of the investigations to the state agency, however the survey team entered the facility on 1/28/19. The DNS identified she had not submitted the conclusion as the investigative process took a long time to put together due to it's complex nature. The DNS indicated the report should have been submitted within five working days of the incident and/or within five working days subsequent to the facility's knowledge of the incident and was not.

Based on observation, a review of the clinical record, staff interviews, a review of facility documentation, and a review of the facilities policies and procedures, for one sampled resident (Resident #40) reviewed for positioning and mobility, the facility failed to ensure heel float boots were applied according to physician's orders [REDACTED].#46) reviewed for an allegation of mistreatment, the facility failed to consistently complete every fifteen minute observational checks as per the physician's orders [REDACTED].#46 and #51), the facility failed to conduct an assessment subsequent to an allegation of mistreatment. The findings include: a. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had severe cognitive impairment, was not resistant to care, was frequently incontinent of bowel and bladder and required total assistance with bed mobility, transfers, locomotion, dressing eating, and personal hygiene The Resident Care Plan (RCP) dated 1/24/19 identified a risk of injury related to dementia and directed to place heel float boots on the resident. A physician's orders [REDACTED]. The care card dated 1/28/19 directed heel float boots on at all times. Observations on 1/29/19 at 11:53 AM identified Resident #40 in an adaptive wheelchair in the common area waving his/her bare left foot in the air while the right foot was stationary supported by the wheelchair. Observations on 1/30/19 at 1:10 PM identified Resident #40 in adaptive wheelchair in the common area with socks on his/ her feet absent the heel float boots. Interview and review of the clinical record with Licensed Practical Nurse (LPN) #1 on 1/30/19 at 1:13 PM and observation of Resident #40 noted that although Resident #40 did not have heel float boots on, the physician's orders [REDACTED].#40 at all times. LPN #1 was unable to identify the reason Resident #40 did not have heel float boots on. Interview and review of the care card with Nurse Aide (NA) #1 on 1/30/19 at 1:18 PM identified that although she knew Resident #40 required heel float boots, she understood they were to be on only when Resident #40 was in bed. Upon review of Resident #40's care card, NA #1 identified Resident was to have had heel float boots applied at all times. Although requested, 1/30/19 at 3:50 PM from the Director of Nurses (DNS), a facility policy was not provided. b. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #46 had severe cognitive impairment and required supervision of one staff with ambulation. The reportable event dated 1/10/19 at 4:00 PM identified that Person #1 made the facility aware of an interaction between Resident #46 and Resident #51 last Thursday or Friday (1/3/19 or 1/4/19). Person #1 saw Resident #46 sitting in a wheelchair with his/her back against the nurse's station. Resident #51 was walking by Resident #46 and Resident #46 took Resident #51 by the hand. Person #1 reported he/she saw Resident #46 pull Resident #51 toward him/her and tried to kiss Resident #51 and put his/her hand on Resident #51's pants. The reportable event form dated 1/10/19 at 4:00 PM identified at 4:00 PM Person #1 made the facility aware that he/she witnessed another interaction between two residents several weeks ago. Person #1 witnessed Resident #46 on the couch in the family/TV room. Resident #77 came in and sat down on the couch next to Resident #46. Person #1 observed Resident #46 touch Resident #77's chest over his/her shirt. Person #1 got up and took Resident #77 by the hand and walked Resident #77 out of the room. A physician's orders [REDACTED]. The RCP dated 1/10/19 identified Resident #46 was at risk of injury due to cognitive losses. Interventions directed to monitor Resident #46 every fifteen minutes around the clock for thirty days then re-evaluate. Review of the observational flow sheets failed to identify every fifteen minutes checks were conducted on 1/13/19 from 7:45 AM to 11:15 PM. Interview and review of the clinical record with NA #1 on 1/31/19 at 1:22 PM identified that NA #1 worked on 1/13/19 from 8:00 AM to 8:30 PM and Resident #46 was on her/his assignment. Review of the fifteen minute observational checks dated 1/13/19 identified Resident #46 was out of bed at 7:30 AM and was asleep at 11:30 PM. The fifteen minute observational checks documentation failed to identify Resident #46 was monitored every fifteen minutes from 7:45 AM to 11:15 PM. NA #1 indicated he/she was unaware Resident #46 had to be monitored every fifteen minutes around the clock. Interview with RN #1 on 1/31/19 at 1:25 PM identified the nurse aide was responsible to monitor and document every fifteen minutes observations and the nurse was responsible to ensure the observational checks and documentation was completed. RN #1 identified it was his/her mistake that Resident #46 was not monitored from 7:45 AM to 11:15 PM. RN #1 and NA #1 identified prior to 1/10/19 Resident #46 was monitored every fifteen minutes at night only and indicated that was likely the reason they did not ensure observational checks were completed during the day. Review of the every fifteen minutes checks facility procedure identified, every fifteen minutes checks were to be recorded and documented in a timely manner. The nurses aide would show the nurse the observational check sheet to confirm completion. The nurse would also check that observations were conducted as ordered throughout the shift to ensure compliance. c. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #51 had severe cognitive impairment and was independent with ambulation. The RCP dated 11/19/18 identified Resident #51 was at risk for injury due to [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#51 to ambulate ad lib. The reportable event dated 1/10/19 at 4:00 PM identified that Person #1 made the facility staff aware of an interaction between Resident #46 and Resident #51 last Thursday or Friday (1/3/19 or 1/4/19). Person #1 saw Resident #46 sitting in a wheelchair with his/her back against the nurses station. Resident #51 was walking by Resident #46 and Resident #46 took Resident #51 by the hand. Person #1 reported he/she saw Resident #46 pull Resident #51 toward him/her and tried to kiss Resident #51 and put his/her hand on Resident #51's pants. The nurse's note dated 1/11/19 at 11:00 AM (late entry for 1/10/19 at 4:00 PM) identified that at 4:00 PM Person #1 made the facility staff aware of an interaction between Resident #46 and Resident #51 last Thursday and Friday (1/3/19 or 1/4/19). Person #1 saw Resident #46 sitting in a wheelchair with his back against the nursing station. Resident #51 was walking by Resident #46 and he/she took his/her by the hand. Person #1 witnessed Resident #46 pull Resident #51 toward him/her and tried to kiss him/her and Resident #46 put his/her hand on Resident #51's pants. Person #1 stated to staff I think you might want to separate Resident #46 and Resident #51. Person #1 did not share what he/she observed to staff. Interview with Person #1 on 1/30/19 at 3:00 PM identified he/she reported the incidence that was witnessed to facility staff because he/she did not want the same thing happen to his/her family member who resides at the facility. Person #1 identified that Resident #46 was sitting in his/her wheelchair to the side of the nurse's station, and the nurse that was sitting at the nurse's station could not see the residents. Resident #51 was walking around and Resident #46 placed one hand on Resident #51's genital area and attempted to kiss the resident. Review of the clinical record failed to identify that Resident #51 was assessed and/or a body audit was conducted when the resident to resident altercation was identified on 1/10/19. Interview with Director of Nursing (DNS) on 01/30/19 at 4:53 PM identified a body audit and/or assessment was not conducted because too much time had passed from the time of notification, to the time of the incidents. Further interview with the DNS identified when a resident to resident altercation was identified timely, a body audit should be conducted and documented in nurse's notes. The facility failed to conduct body audits subsequent to allegations of mistreatment to assess for injury. The facility policy entitled Resident to Resident Altercation Guidelines directed in part to stop the altercation, ensure everyone was safe, to assess the resident's involved, provide first aide if needed, and document the information in the medical record.

Based on a clinical record review, staff interviews, and a review of facility documentation for three of three sampled residents reviewed for hospitalization (Resident #264, Resident #265 and Resident #266), the facility failed to ensure the Ombudsman was notified timely of the resident's transfers to the hospital. The findings included: a. Resident #264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #264 with severe cognitive impairment and required total dependence with most activities of daily living (ADL's). Review of the nurses notes dated 7/24/18 identified Resident #264 was transferred to the hospital and was admitted with [DIAGNOSES REDACTED]. Review of facility documentation identified that the notice to the Ombudsman was send on 11/2/18. b. Resident #265 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident #265 with severe cognitive impairment, with independence with bed mobility and transfers, and required extensive assistance with dressing and personal hygiene. A review of the nurses notes dated 11/2/18 identified Resident #265 was transferred and admitted to the hospital for the treatment of [REDACTED].#256 returned back to the facility on [DATE]. Review of nurses notes dated 11/7/18 identified Resident #265 was readmitted to the hospital on [DATE] with respiratory distress. Review of facility documentation identified the notice to the Ombudsman was send on 1/17/19 for both admissions. c. Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified Resident #266 with moderate cognitive impairment and required limited assistance with transfers and locomotion on unit. Review of nurse's notes dated 8/1/18 identified Resident #266 was transferred and admitted to the hospital with [REDACTED]. Review of facility documentation identified the notice to the Ombudsman was send on 11/2/18. Interview with the Administrator on 1/30/19 at 1:37 PM identified written notifications of the residents hospital transfer were not sent to the Office of the State Long-Term Care Ombudsman every thirty days as required, as the facility believed it was acceptable to notify the Ombudsman every three to four months.

Based on clinical record review and staff interview for two of three residents in the survey sample reviewed for constipation (R#11, R#417) the facility failed to monitor and/or implement interventions to prevent a fecal impaction and/or implement physician orders [REDACTED]. The findings include: 1. Resident # 11's ( R # 11's) [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] indicated R # 11 had short and long-term memory problems, required total care with toileting, and was continent of bowel. A resident care plan dated 8/1/17 identified a problem with not meeting fluid goals. Interventions included to monitor medication side effects, including constipation. physician's orders [REDACTED]. A physician's orders [REDACTED]. A Physician's progress note dated 10/05/17 indicated the resident's constipation was stable on Senna. A Physician' order dated 10/10/17 directed to start [MEDICATION NAME] sulfate 5 mg by mouth (po) three times a day, 1/2 hour prior to care. A Physician's progress note dated 10/10/17 indicated the resident continued with a poor po intake. Review of the BM flow record and Medication Administration Record [REDACTED]. The flow record and/or MAR indicated [REDACTED]. On 10/23/17 R # 11 had milk of magnesia 30 cc po followed by [MEDICATION NAME] 30 cc po which resulted in no BM 10/23/17 or 10/24/17. Nurse's note dated 10/25/17 at 4:30 PM indicated R # 11 had increased discomfort. Resident bearing down as if to have a BM. The resident's abdomen was soft, non-distended, and no discomfort on palpation. Bowel sounds were heard in all 4 quadrants. The Physician was notified and directed a [MEDICATION NAME] suppository every 3 days for 21 days. The MAR indicated [REDACTED]. No results were recorded. Nurse's note dated 10/26/17 at 10:30 PM indicated R # 11 was pale, diaphoretic, and moaning. The resident was brought to the bathroom and assisted to the toilet. A hard stool was coming out of his/her rectum, but was unable to pass through. The resident's abdomen was firm, but not distended. A rectal prolapse formed due to the resident trying to evacuate the stool. The Physician was notified who directed the resident be sent to the emergency room for evaluation. Nurse's note dated 10/26/17 at 2:30 AM indicated R # 11 returned from the emergency room with no new orders. The emergency room nurse reported, via the telephone, that the Physician was able to disimpact the stool and R # 11 passed a large BM. Review of the clinical record and interview with RN # 1 on 12/04/17 at 9:19 AM indicated there are 3 records that document when a resident has a bowel movement. He/she identified after R # 11 was sent to the emergency roiagnom on [DATE] that the nurse's were not looking at the correct record to determine if the resident had a BM. He/she further indicated the nurse's were inserviced on monitoring the BM's in the clinical record (not the other 2 records). Review of the 3 records used to document BM's dated 10/01/17 through 10/25/17 noted no documentation related to the size and/or consistency of stool. RN # 1 indicated they have no guidance on documenting that information. He/she indicated the nurse aides know the residents and know if the BM is not their normal BM and would notify the nurse. RN # 1 was unable to provide documentation utilized by a licensed nurse which would could be used as a guide to assess R#11's stools from 10/01/17 to 10/25/17 to include size and consistency of stool. RN # 3 further indicated the transition from 8 - hour shifts to 12 - hour shifts for licensed staff had effected the documentation and monitoring of resident BM's. An inservice training record dated 10/25/17 indicated an inservice was conducted on constipation, factors related to constipation, assessment, and interventions to prevent constipation. A meeting form dated 11/09/17 with licensed staff noted a review of the bowel regimen expectations. 2. Resident # 417 ' s [DIAGNOSES REDACTED].# 417 as rarely or never understood, had moderately impaired cognitive skills for decision making, totally dependent for toilet use and was frequently incontinent of bowel. The Resident Care Plan (RCP) dated 9/13/2017 identified a problem of incontinence related to dementia. Interventions included, in part, to encourage sitting on the toilet when needed, and to provide prune juice and [MEDICATION NAME] as ordered. physician's order [REDACTED]. Use first: Milk of Magnesia 400 mg/5 ml oral suspension, administer 30 ml by mouth once daily as needed for constipation, if no results, see [MEDICATION NAME] order. Use second: [MEDICATION NAME] 10g/15 ml solution, administer 30 ml by mouth once daily as needed for constipation, may repeat in eight hours if first dose is ineffective; if no results in eight hours, see [MEDICATION NAME] suppository order. Use third: [MEDICATION NAME] 10 mg suppository, one suppository per rectum once as needed for constipation, if no result, call the physician the next day shift. Nurse's notes dated 9/19/2017 through 10/21/2017 failed to reflect use of any as needed (prn)bowel protocol medications or address bowel function. Nursing flow sheets dated 9/24/2017 to 10/23/2017 identified no bowel movements from the 3 - 11 shift on 9/26/2017 through 7 - 3 shift on 10/4/2017 (nineteen shifts), and identified no bowel movements from the 3 - 11 shift on 10/13/2017 through the 11 - 7 shift on 10/16/2017 (eight shifts). The (MONTH) MAR indicated [REDACTED]. The MAR further identified administration of Milk of Magnesia 30 ml by mouth, on 10/21/2017, however, this was not identified on the MAR, PRN medication administration record. This record identified administration of Milk of Magnesia 30 ml by mouth on 10/22/2017, with no time of administration or effect noted. Nurse aide monthly bowel record documentation for September, (YEAR) was not available. Nurse aide monthly bowel record documentation for October, (YEAR) identified no bowel movements from the 3 - 11 shift on 10/13/2017 through the 11 - 7 shift on 10/16/2017 (eight shifts). Interview with APRN #1 on 12/01/17 at 11:55 AM identified that he/she would expect nurses to implement the bowel regime as ordered and if not effective, to then notify him/her or the physician. Interview and record review with RN #1 on 12/04/17 at 10:45 AM identified that nursing flow sheets dated 9/24/2017 to 10/23/2017 identified no bowel movements from the 3 - 11 shift on 9/26/2017 to the 7 - 3 shift on 10/04/2017 (nineteen shifts) and identified no bowel movements from the 3 - 11 shift on 10/13/2017 through the 11 - 7 shift on 10/16/2017 (eight shifts). RN #1 identified that it is nursing' s responsibility to have identified the issue and implement physician's orders [REDACTED]. RN #1 identified there is no facility policy regarding constipation or bowel protocols other than to follow the physician's orders [REDACTED]. RN #1 identified that there were changes in nurse staffing to twelve hour shifts in (MONTH) (YEAR), however, the bowel data and protocol implementation continued with eight hour shifts, and may have contributed to confusion regarding implementation.

Based on clinical record review, review of facility documentation and interviews for 1 of 1 sampled resident reviewed for pressure ulcers ( R#104) the facility failed to develop/implement new interventions to prevent pressure ulcer development once a decline in mobility was identified. The findings include: Resident # 104's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified R#104 as independent with bed mobility and required minimal assist with ambulation with the use of a walker. A Braden Scale dated 1/26/16 identified the resident with a score of 21 (low risk for developing pressure ulcers). A RE dated 3/07/16 at 8:05 PM identified the resident was found on the floor on his/her buttocks and was subsequently transferred to the hospital and admitted with a fractured right hip. The resident underwent [REDACTED]. Physician orders [REDACTED]. A significant change MDS assessment dated [DATE] identified the resident as cognitively impaired and required extensive assistance with bed mobility, was not ambulatory and had intact skin. Review of a pressure ulcer flow sheet dated 3/29/16 identified the resident with a deep tissue injury (DTI) to his/her right heel measuring 1.0 cm by 0.8 cm. physician's orders [REDACTED]. A physician's orders [REDACTED]. A Braden scale completed on 3/31/16 identified that the resident with a score of 16 ( indicating mild risk for pressure ulcers). Interview with RN#3, Unit Manager and review of the clinical record on 5/04/16 at 2:00 PM identified that prior to the femur fracture the resident ambulated with the assist of 1 and could reposition him/herself in bed. However, after the femur fracture he/she required assistance with his/her bed mobility. Furthermore, although the resident had an anti-pressure mattress upon re-admission from the hospital on [DATE], it was the same mattress the resident had on his/her bed prior to his/her decline in mobility. RN#3 further identified that the clinical record failed to reflect any new interventions were implemented to address the resident's decline in bed mobility, nonambulatory status, and/or increased risks noted on the Braden scale until the heel lift boot were ordered on [DATE] after the DTI was acquired on 3/29/16 (19 days after readmission). Review of the facility's Pressure Ulcer policy identified to provide total pressure relief on the heels by utilizing positioning or padding devices to keep heels off the bed.

Based on review of the clinical record, facility documentation, facility policies/procedures, Police Report, Ambulance Dispatch Report and interviews for one of five sampled residents reviewed for abuse (Resident #125), the facility failed to implement measures to ensure the resident was free from physical and verbal abuse resulting in an injury. The findings include: Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] identified short and long term memory deficit, moderately impaired cognition, independence with transfers and walking and wandering behavior that occurred daily. The Accident/Incident Report and investigation dated 3/30/14 at 10:00 PM identified staff observed Resident #93 push and strike Resident #125. LPN #2 identified that at 10:00 PM, Resident #93 opened the door to his/her room holding Resident #125 by the back of his/her collar. Resident #93 was yelling and swearing at Resident #125 to get out of here. When staff tried to intervene, Resident #93 pushed the staff away and Nurse Aide ( NA) #4 was struck with an open hand in the face by Resident #125. Resident #93 then began yelling at staff, "If anyone comes closer, I am going to kill him." Resident #93 pushed Resident #125 who fell to the ground face first. Licensed Practical Nurse ( LPN) #2 was concerned Resident #125 hit his/her head and continued to try to convince Resident #93 to allow staff to tend to Resident #125. Resident #93 was standing over Resident #125 and hit him/her on the side of the head. According to the facility witness report, LPN #2 saw Resident #93 hit Resident #125 three (3) times. As staff tried to assist Resident #125, Resident #93 lunged at the staff. After hitting Resident #125 three times, Resident #93 held Resident #125 by the back of his/her collar. Resident #93 was shouting to call the police. The security guard came to the unit to see if he could assist in the situation, but Resident #93 yelled at him telling him "he was not a cop, where is your gun." Nursing Supervisor Registered Nurse (RN ) #1 arrived at the same time as the security guard and began making telephone calls to the Administrators and Physician to report the problem and receive instructions while two nurses and four nurse aides remained with Resident #93 who eventually stopped yelling and let go of Resident #125 and went to his/her room. A written statement, obtained by the facility, by NA #4 dated 3/29/14 (stated by facility was actually written on 3/30/14) identified that Resident #125 entered Resident #93's room and Resident #93 opened the door and pushed him/her out of the room. Resident #125 was going to fall and NA #4 tried to assist the resident and was slapped in the face by Resident #125. Resident #93 was on Resident #125 and starting hitting him/her and holding him/her down on the floor. Resident #93 was screaming that he/she was going to kill Resident #125. A written statement by NA #5 dated 3/30/14 identified she/he saw Resident #93 holding Resident #125 by the neck. We attempted to calm down Resident #93, but Resident #93 repeatedly hit Resident #125 and began to choke him/her. When we attempted to pull Resident #93 off of Resident #125, he/she became aggressive towards us and attempted to hit us. A written statement by NA #6 dated 3/30/14 identified he/she observed Resident #93 holding Resident #125 by the neck. NA #6 stated she/he told Resident #93 to calm down, he/she pushed me and when staff attempted to get Resident #93 off of Resident #125 he/she became aggressive to us and hit us. A physician order [REDACTED].#125 to the emergency room for evaluation. The Ambulance Dispatch Report dated 3/30/14 identified Emergency Medical Services (EMS) received a call from the facility at 10:54 PM for an assault with multiple victims. Upon arrival in the facility, facility staff reported Resident #125 was assaulted by another resident. Resident #125 was thrown to the ground striking his/her head on the hard floor and was choked and kicked. The facility staff stated the resident who assaulted Resident #125 would not allow staff near the resident for approximately ten (10) minutes stating he/she would kill Resident #125 if they approached. The report identified Resident #125 was assessed to have a large bump on the top of the head and noticeable bilateral ligature bruising at the base of the anterior neck. The Ambulance Dispatch Report dated 3/30/14 at 11:17 PM identified upon arrival to the facility Resident #93 was in a fight with another resident and choked the resident. Resident #93 was agitated and combative and was being transported to the emergency room for an evaluation of homicidal ideation. Review of the Police Report dated 3/30/14 identified Officer #1 was dispatched to the facility because of a report that a patient had been assaulted by another patient. Officer #1 arrived at the facility on 3/30/14 at approximately 11:13 PM (incident is reported to have occurred at 10:00 PM). Upon arrival, Officer #1 spoke to LPN #2 who was one of the on duty staff members at the facility. LPN #2 identified Resident #125 entered Resident #93's room and Resident #93 became upset. Resident #93 pushed Resident #125 out of the room and into the nursing station outside the room. Resident #93 grabbed Resident #125 by the neck and began punching her/him in the head. LPN #2 reported that Resident #125 had a large lump on the head that was received from the altercation. Officer #1 documented that due to the fact both individuals involved in the incident are patients at the facility that specialized in Alzheimer's and suffer from dementia, no further police action was taken. The Inter-Agency Report completed by the facility and not dated, identified the resident was attacked by another resident, thrown to the ground, punched and neck grabbed. Additionally, the facility report indicated the resident's head was hit hard. Neurological checks were initiated that were normal. The resident also had a bump on the top of the head and ice was applied. The Hospital Discharge Summary dated 3/31/14 identified Resident #125 was assaulted by another resident at the facility, was grabbed over his/her neck, thrown to the ground and punched. Physical examination identified ecchymosis over the left parietal region and the right lateral lower neck with diffuse cervical spine tenderness. Resident #125 also complained of a headache. The hospital Inter-Agency Report dated 3/31/14 identified Resident #125 was diagnosed with [REDACTED]. A subsequent nurse's note dated 3/31/14 at 3:40 PM identified a large scratch remained on the right side of the resident's lower neck. The nurse's note dated 4/1/14 at 11:30 PM identified the resident was more lethargic, holding his/her forehead with facial grimace and Tylenol 650 Milligrams ( MG) was given at 5:35 PM with seemingly good effect. Interview on 10/1/14 at 8:30 AM with the Director of Nursing Services ( DNS) regarding the incident on 3/30/14 identified that the facility's first response would not be to send the resident out to the hospital, but to use de-escalation techniques. Interview with Nursing Supervisor (RN) #1 on 10/1/14 at 10:15 AM identified he/she was called to the unit and upon arrival, Resident #125 was on the ground and Resident #93 was standing over the resident saying " If you or anyone comes near me "I will kill him/her". RN #1 stated staff attempted to help Resident #125 but no one could get close enough because Resident #93 was swinging at staff. RN #1 stated that Resident #125 was on the floor for no more than 20 minutes before Resident #93 left the area. RN #1 indicated 911 emergency response was not activated because typically the facility does not send residents out to the hospital after an altercation. RN #1 indicated Resident #93 was unpredictable at that time and he/she was waiting for the physician to call back. Interview with Licensed Practical Nurse (LPN) #2, the charge nurse, on 10/1/14 at 1:55 PM identified Resident #93 pulled Resident #125 to the ground and was observed hitting and punching the resident. LPN #2 indicated it was impossible for the staff on duty to get Resident #93 away from Resident #125 because Resident #93 was threatening to kill staff and Resident #125 if we got near him/her. LPN #2 indicated he/she observed Resident #93 kneeling in reach of Resident #125, who was lying on his/her back. LPN #2 stated that although Resident #93 did not continually hit Resident #125 while he/she was lying on the ground, he/she could not say exactly how long the incident occurred, but possibly was 10 minutes. LPN #2 indicated the nursing supervisor was responsible to decide whether 911 emergency response would be activated. Interview with NA #8, in the presence of the Administrator and the DNS on 10/2/14 at 2:04 PM identified he/she wanted to be honest even though she/he may lose their job. When NA #8 returned to the unit on 3/30/14, Resident #125 was on the ground. NA #8 stated this incident was a little too much and he/she was really scared for him/herself, the nurses, and the resident. Additionally, NA #8 stated we were all scared and didn't have the capability to restrain the resident without the paramedics. Interview with Medical Doctor ( MD) #3 (Resident #125's attending physician) on 10/3/14 at 10:44 AM identified that in a situation where Resident #125 was thrown to the ground, striking his/her head on the floor, was choked and kicked by another resident, MD #3 expected facility staff to call the police and continue to try to talk to Resident #93. Interview with MD #1 (Resident #93's attending physician) on 10/3/14 at 11:26 AM identified he/she does not remember specifics of the call received from the facility on 3/30/14 regarding the incident, however, MD #1 stated he/she remembered it was a violent incident and stated he/she expected facility staff to call the police immediately because it was a safety issue. Additionally, MD #1 stated that nurses are within their scope to call 911 before speaking to the physician. Review of the facility Systemic Medical Emergency policy such as an acute psychiatric disturbance, identified to remove residents and visitors from immediate area, provide supervision from a safe distance until help arrives, notify physician and responsible party, notify psychiatric consultant, record all observations and interventions in the medical record and call 911, if applicable after other interventions not helping. Review of facility documentation and the clinical record failed to reflect facility staff implemented emergency measures to protect Resident #125 when Resident #93 choked, hit, threatened to kill the resident and did not allow staff to provide assistance and/or conduct an assessment of Resident #125 during and immediately after a physical assault and verbal abuse.

Based clinical record review, review of facility documentation and staff interviews, for one of four sampled residents reviewed for falls (Resident #114), the facility failed to ensure the resident was free of an accident with injury. The findings include: Resident # 114's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment, memory problems and required extensive assistance of one staff person for dressing, toileting and personal hygiene. The care plan dated 2/4/13 identified the resident was at risk for injury due to dementia. Interventions included ambulating with assistance of one staff and gait belt and assistance of two staff for transfers from bed to chair. The fall risk care plan further identified the use of a seat alarm to alert staff of independent transfers. A facility ' s Report Event (RE) and investigation dated 2/15/13 identified that Resident # 114 while in the bathroom, stood up, fell to the floor landing on his/her back. The investigation indicated the resident was unattended when the fall occurred. An assessment noted the resident was unable to bear weight on the right leg when attempted to stand and that external rotation was noted when the resident was returned to bed. The resident was transferred to the emergency room for an evaluation and diagnosed with [REDACTED]. Interview with Nurse Aide (NA#1) who provided care to the resident on 2/15/13, on 11/4/13 at 3:15 P.M. identified she/he brought the resident to the bathroom for morning care at 5:15 A.M. on 2/15/13. NA #1 indicated that each morning on the 11-7 shift, he/she would bring the resident into the bathroom at approximately 5:00 A.M. to provide care as the resident was frequently incontinent of stool. NA# 1 indicated that she/he left the resident alone in the bathroom to inform LPN #1 the resident was ready for application of medication to her buttocks. Upon returning to the bathroom she found the resident on the floor on his/her back. Review of NA #1 ' s employee file identified a performance review dated 9/18/13 in which the DNS and RN supervisor noted as a goal to never leave residents in the bathroom unattended. Interview with Registered Nurse (RN) #1 on 10/29/13 at 10:15 A.M. identified the expectation is for the nurse aides to remain with the resident at all times because the resident had a behavior of independently attempting to transfer.