Every finding on record at Maple View Health & Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #9) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to have a Level 1 prescreening PASARR on admission and failed to update the state agency when the level of care expired after 60 days. The findings include:Level of Care Notice of Action dated [DATE] identified Resident #9 was approved on [DATE] for 60 days of short term rehabilitation for monitoring post op pain for a hip fracture and post op urinary retention requiring a foley catheter. Based on the submission and information received, short-term care is appropriate. If the resident requires more time, the admitting nursing facility should submit an updated level of care screen near the end date of this approval. Resident #9 was admitted to the facility in [DATE]. Diagnoses included bipolar disorder current manic episode, fragile x chromosome disorder, severe intellectual disabilities, and violent behaviors.A physician's order dated [DATE] directed to administer Depakote delayed release 500 mg 3 times a day for bipolar disorder, Escitalopram Oxalate 5 mg once a day for depression, monitor antidepressant medication target behaviors (withdrawn and hitting staff) every shift. The psychiatric APRN note dated [DATE] identified Resident #9 has a significant history of intellectual disabilities secondary to fragile x syndrome and bipolar. The APRN indicated Resident #9 was aggressive with care and required 7 staff to assist in changing resident. The APRN indicated Resident #9 does better with male aides.The psychiatric APRN note dated [DATE] identified physical therapy requested Resident #9 to be seen due to this severe developmental disability. The APRN noted Resident #9 has severe intellectual disability secondary to fragile x and has been institutionalized for his/her entire life. The physical therapist, this APRN, and a group home aide were able to convince Resident #9 to sit up and get into the wheelchair. The care plan dated [DATE] identified Resident #9 had bipolar disorder. Interventions included the use of an antidepressant as ordered by the physician and monitor and record target behaviors of unsteady gait, tardive dyskinesia, and dry mouth. Additionally, Resident #9 has the potential for physically aggressive behaviors by hitting or biting staff related to his/her depression. The admission MDS dated [DATE] identified Resident #9 had moderately impaired cognition. Additionally, Resident #9 requires Level 2 PASARR due to serious mental illness and intellectual disability. Interview with SW #2 on [DATE] at 12:57 PM indicated she was responsible to review all the documentation for all new admissions for the PASARR and she prints the PASARR out of the state agency web site and files it in the resident's medical record. SW #2 was responsible for Resident #9s unit but was not assigned to that unit when Resident #9 was admitted . SW #2 indicated that she did not audit the medical records for her unit when she changed units to make sure they were accurate when she took the unit over. SW #2 indicated at that time the prior social worker was responsible for all the admission PASARR screenings for Level 1 and Level 2 PASARR's. After reviewing the clinical record, SW #2 indicated a PASARR was not in Resident #9's medical record. SW #2 went into the state agency web site and indicated Resident #9 had a level of care done on [DATE] and was approved for 60 days but that had expired on [DATE] and had not been updated. The resident did not have a Level 1 preadmission screening done and did not have an outcome from a Level 1 PASARR. SW #2 indicated it was missed because she had not see it and was not aware that it needed to be updated in 60 days. SW #2 indicated she was responsible to do it but did not. SW #2 indicated she just assumed Resident #9 would have been given a hospital exemption. SW #2 indicated the hospital filed only for the preadmission screen for a level of care which was approved for 60 days. SW #2 indicated the hospital did not make the referral for the Level 1 PASARR nor did the prior social worker on admission to the facility. SW #2 indicated a Level 1 PASARR that should have been done before admission or on admission, but it was not done so she will submit it today.Interview with SW #1 on [DATE] at 11:15 AM indicated Resident #9 only came in on admission with a level of care and did not have a preadmission prescreening Level 1 PASARR, so Resident #9 should not have been admitted without it. SW #1 indicated the social worker was responsible on admission to submit a prescreening PASARR for evaluation since Resident #9 did not already have one submitted by the hospital due to Resident #9 having the mental health diagnosis of bipolar, fragile x chromosome disorder, and severe intellectual disability. SW #1 indicated she does not know why it was not done on admission. Interview with SW #2 on [DATE] at 9:50 AM indicated she submitted the Level 1 prescreening PASARR on Monday [DATE] after surveyor inquiry.Review of the Pre-admission Screening and Resident Review (PASARR) Policy identified the PASARR process requires all applicants to a Medicaid certified nursing facility be screened for possible serious mental health disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level 1 and is completed prior to admission to the facility. Screenings are reviewed upon admission to identify residents with a possible mental disorder, intellectual disability or a related condition prior to admission to the facility. If a positive screen results in a Level 2 determination the facility will incorporate the recommendations from the PASARR Level 2 determination and the PASARR evaluation report into a resident's assessment, care planning, and transition of care. The facility social worker is responsible for making the referral to the appropriate state designated authority when a resident is identified as having an evident or possible mental disorder or intellectual disability. Review of the admission and Discharge Policy identified the facility will obtain the following information for accepting a resident referral: a physician order to admit resident to the skilled nursing facility, a medication list, a medical history and recent exam with any results, a PASARR signed by a registered nurse or social worker.

Based on review of clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #62) reviewed for accidents, the facility failed to provide adequate supervision during toileting to prevent a fall for a resident who was identified with severely impaired cognition and at high risk for falls. The findings include:The hospital admission history & physical form dated 8/2/25 at 10:33 PM identified Resident #62 had a history of atrial fibrillation, dementia, and congestive heart failure. Resident #62 was hypotensive with a blood pressure of 83/55 mm/Hg (normal range 120/80 mm/Hg). After intravenous (IV) fluids were administered, the resident's blood pressure was 112/64 mm/Hg. Resident #62 was disoriented, cachectic and was not in acute distress. Resident #62 had a chest x-ray with results indicating pneumonia. Resident #62 had received antibiotic and intravenous (IV) fluids in the emergency room. Resident #62 had been admitted to the hospital for acute kidney injury and pneumonia. Resident #62 was last seen by the home health aide at night at his/her home and then was found on the floor the next morning at his/her home. Resident #62 was admitted to the facility on [DATE] with diagnoses that included history of falling, dizziness, giddiness, pain, muscle weakness, hypotension, heart failure, atrial fibrillation, and severe dementia with anxiety.The care plan dated 8/6/25 identified Resident #62 had potential for fall with/without injury due to: weakness and history of fall at home. Interventions included appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when mobilizing in wheelchair. The admission MDS dated [DATE] identified Resident #62 had severely impaired cognition, required substantial/maximal assistance with toileting hygiene, toilet transfer, required extensive assistance with one-person physical assistance with transfer and toilet use.The occupational therapy Discharge summary dated [DATE] - 9/2/25 identified on 9/2/25, Resident #62 required partial/moderate assistance with toilet hygiene and toilet transfers. Additionally, required assistance of one for all activity of daily living (ADL'S) and toilet transfers.The reportable event form dated 8/24/25 at 3:15 AM identified Resident #62 was observed lying on his/her back on the floor next to his/her bed. An RN assessment and neurological check were performed with no injuries noted. The APRN and the resident representative were notified. An investigation was initiated. Interventions included low bed with floor mats.The fall evaluation form dated 8/24/25 identified Resident #62 was at high risk for falls. Resident #62 was confused at all times, had unsteady gait and balance, and does not use an assistive device for mobility. The task list report dated 8/24/25 identified Resident #62 was at high risk for falls.The reportable event form dated 9/6/25 at 8:15 PM identified Resident #62 was placed on the toilet in the bathroom by NA #1 and Resident #62 got up and fell. Resident #62 was alert and confused and transferred with one staff assistance with rolling walker. RN assessment and neurological check were performed with no injuries noted. The APRN, the resident representative were notified and an investigation was initiated. Intervention included to educate NA #1 not to leave Resident #62 when being toileted. The revised care plan dated 9/7/25 identified Resident #62 had potential for fall with/without injury due to: weakness, history of fall at home. Interventions dated 9/6/25 identified education for NA #1 to not leave Resident #62 alone when the resident is using the bathroom.The investigation statement form by NA #1 dated 9/6/25 identified that she last saw Resident #62 at 8:15 PM when she brought the resident to the bathroom. NA #1 indicated Resident #62 had voided. NA #1 indicated she transferred Resident #62 with assist time one. NA #1 indicated she was turning down the bed linen and Resident #62 got up from the toilet and fell. The investigation statement form by LPN #2 dated 9/6/25 at 8:15 PM identified it was reported to her that Resident #62 fell in the bathroom. LPN #2 indicated she observed Resident #62 sitting on the floor near the bathroom door. Resident #62 was alert and verbal. LPN #2 indicated Resident #62 denies hitting his/her head.The summary of investigation report dated 9/6/25 identified Resident #62 had a diagnosis of dementia. NA #1 assisted Resident #62 into the bathroom and while Resident #62 was sitting on the toilet the resident got up and fell. RN assessment was performed. The changes made to the plan of care was to educate NA #1 not to leave Resident #62 in the bathroom when being toileted. The conclusion was Resident #62 had an unwitnessed fall without injury. The fall unwitnessed form dated 9/6/25 at 8:15 PM identified NA #1 toileted Resident #62 in the bathroom and while the resident was sitting on the toilet, he/she got up and fell. NA #1 was educated not to leave Resident #62 in the bathroom when being toileted.Interview and review of the clinical record with the Rehabilitation Director on 12/3/25 at 12:06 PM identified on 9/2/25 Resident #62 was a partial/moderate assistance with toilet transfers and toilet hygiene (50% - 75% of the toilet hygiene to be perform by nursing staff). The Rehabilitation Director indicated for privacy issues the nursing staff is allowed to stand outside of the bathroom with the bathroom door crack or open enough for eyesight even with a confused resident. The Rehabilitation Director indicated that the nursing staff is to constantly visualize the resident and verbally speak to the resident. The Rehabilitation Director indicated the nursing staff is keeping in contact with the resident by peeking and knowing what the resident is doing at all times. Interview and review of the clinical record with the Assistant Director of Nursing Services (ADNS) on 12/3/25 at 12:23 PM identified that Resident #62's activity order prior to the 9/6/25 fall required partial/moderate assistance with one staff member for transfers and toileting. The ADNS indicated that during the facility's investigation, NA #1 reported she had toileted Resident #62 and that the resident remained in the nurse aide visual field at all times. The ADNS provided a reenactment in Resident #62's former room and indicated the resident occupied bed A, which was closest to the bathroom. The ADNS indicated all residents deserve privacy during toileting. The ADNS indicated on 10/9/25 the facility had initiated a Quality Assurance and Performance Improvement (QAPI) addressing resident safety and privacy in the bathroom. The ADNS indicated NA #1 has been educated. The ADNS indicated education is on-going.Interview with LPN #2 on 12/4/25 at 1:34 PM identified NA #1 informed her that Resident #62 had fallen. LPN #2 indicated NA #1 reported that she had put Resident #62 on the toilet and turned around to do something and Resident #62 fell. LPN #2 indicated she observed Resident #62 sitting on the floor near the bathroom door. LPN #2 indicated Resident #62 denied hitting his/her head. LPN #2 indicated she did not asked NA #1 where she was in the room when Resident #62 fell. LPN #2 indicated she notified RN #4 of Resident #62 fall. Although attempted an interview with NA #1 and RN #4 (RN supervisor) was not obtained.The facility fall prevention program policy identified the purpose of this program is to reduce the incidence of falls in residents identified at high risk. Participation in the program is determined by a resident's fall risk evaluation score, past history of falls, and recommendations from the nursing staff. Residents that are a risk for falls will be identified on the nurse aide kardex/assignment. Program participants are encouraged by staff to attend recreation therapy programs. Each resident will have an individual evaluation and care plan which will address their specific needs related to fall risk.All residents will be evaluated for risk for falls on admission, readmission, with a change of condition. Residents at high risk for falls will have intervention initiated to prevent falls. Interventions may include: Provide staff supervision of ADL's.

Based on observations, review of the facility grievance file, facility policy and interviews, the facility failed to ensure grievances were responded to in a timely manner regarding appropriate food temperatures for consumption. The findings include: Review of the Resident Council Minutes for 2/21/24 and 3/25/24 identified residents' reported concerns that meals were not served at the appropriate temperature. Inservice education on 4/2/24 indicated Nursing staff are aware to reheat food in the microwave when residents request or complain their food is cold or not warm enough. No plan was discussed for non-verbal residents. Interview with a resident on 5/8/24 at 1:30 PM identified food continues to arrive to units cold. Residents attribute the cold food temperatures to the delay in staff passing out the food. Observation on 5/9/24 at 12:00 PM of food identified food arriving on 2nd floor unit. Observation On 5/9/24 at 12:38 PM identified the last meal given to the resident on the 2nd floor. A temperature check of the last try was completed at 12:40 PM by surveyor and Registered Nurse (RN #3). The temperature of the meal served to a resident on 2nd floor identified the following: 123.8 degrees Fahrenheit (Normal Range Holding Food 135 degrees Fahrenheit; RN #3 temperature indicated 120 degrees Fahrenheit. On 5/9/24 at 12: 55 PM Interview with RN #3 indicated for non-verbal/ cognitively impaired residents, the facility should be able to tell if the food is cold by looking at it or hovering hand over meal to feel for temperature. On 5/9/24 at 1:15 PM Interview with Director of Nursing Services (DNS) indicated staff are responsible for ensuring foods are at the correct temperature prior to serving residents. She indicates for nonverbal/ cognitively impaired residents' staff should be able to tell if the food is at the appropriate temperature prior to serving. Interview on 5/13/24 at 10:14AM with Grievance Officer (Administrator) indicated he was aware of the concerns regarding the food temperature, and conducted an in service, on what to do for residents who complain. He indicated for non-verbal/ cognitively impaired residents, food temperatures are checked based on the temperatures of the plate or hovering their hand over it. Facility policy notes the appropriate method of testing temperatures, includes using various types of thermometers (Bimetallic Stemmed Thermometer, Thermistors, and thermocouples Thermometer) Etc. Facility policy Grievances notes in part the Grievance Officer is responsible for ensuring that all grievances are responded to in a timely manner.

Based on observations, clinical record review, policy review and staff interviews for 1 of 1 resident reviewed for choices (Resident #71), the facility failed to honor a family member's choice regarding having the resident out of bed to a chair by 11:00 AM. The findings include: Resident #71's diagnoses included early-onset Alzheimer's disease and seizure disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 with short-term and long-term memory impairments and noted dependence with eating, toileting, and transferring to and from a bed to a chair. The MDS further identified Resident #71 as incontinent of bladder and bowel. The care plan dated 4/22/24 identified Resident #71 had little, or no group activity involvement related to dementia and behaviors. Interventions included: assisting/escorting to activity functions and indicated resident preferred socializing with nursing staff and spouse. The care plan also noted at risk for Activities of Daily Living (ADL) self-care performance deficit related to dementia. Interventions included: transferring the resident out of bed with the assistance of two staff members and a mechanical lift. The care plan for communication problems related to dementia. Interventions included anticipating and meeting the residents' needs. A psychiatric follow-up note dated 5/1/24 identified Resident #71 was non-verbal and did not respond to his/her name or to family. Additionally, the psychiatric follow-up indicated that the resident's spouse visits daily. On 5/7/24 at 3:00 PM, an interview with (Person # 3) identified the resident does not get out of bed in the morning. Person # 3 further indicated s/he would like Resident # 71 to be get out of bed in the morning by 11:00 AM so s/he could take the resident outside for a walk when s/he visits 11:30 AM to 1:30 PM. Person #3 indicated s/he have complained and spoken to staff about this concern and the resident is still not consistently out of bed by the time s/he arrives to visit. On 5/8/24 at 9:34 AM, an observation identified the resident in bed with a gown on. An observation at 11:29 AM identified Resident # 71 in bed and dressed. An observation at 11:35 AM was made of Nurse Aide (NA#2) pushing a mechanical lift into the resident's room. A follow-up interview with Person # 2 on 5/8/24 at 11:40 AM indicated s/he arrived to visit Resident # 71 at 11:15 AM and found the resident in bed. Person # 3 further indicated that it takes time for staff to transfer the resident using the mechanical lift, which takes time away from the time s/he could spend visiting with the resident. On 5/8/24 at 2:18 PM, an interview with NA #1 indicated staff tried to put the resident in the chair at the same time every day. NA#1 indicated that around 11:00 AM the resident is regularly incontinent of urine and stool, so staff will wait for the incontinent episode before moving the resident to the chair. NA#1 further indicated if the resident is transferred to the chair before the resident's incontinent episode, the staff would have to use the mechanical lift to transfer the resident back to the bed to be cleaned and then once again to the chair. On 5/8/24, an interview with NA #2 identified NA#2 was new to the facility and unaware Resident # 71 had a specific time to get up. NA#2 indicated she started getting things ready to get the resident up out of bed when Person # 3 arrived and told her the resident should be taken out of bed to chair. NA#2 also indicated that part of her workflow is to help the residents who are ambulatory to get out of bed first and then the residents who require assistance from another staff member but have no set time to get up. On 5/8/24 at 2:31 PM, an interview with LPN#3 indicated Person # 3 arrives to visit every day around 11:00 AM or 11:15 AM and when it is warm outside, Person # 3 would take the resident outside and sit on a bench. Additionally, LPN#3 indicated the resident tends to be incontinent of stool around 11:00 AM, and if staff were to get the resident up before then the resident would be incontinent of stool while in the chair. Additionally, LPN#3 indicated when Person # 3 arrives and notices that the resident is incontinent of stool while on the chair, Person # 3 complains about the resident being cleaned. On 5/13/24 at 10:00 AM, an interview with the Director of Nursing Services (DNS) indicated staff take Resident #71 out of bed every day and staff know the resident should be out of bed before Person # 3 arrives and if Resident # 71 is still in bed with Person # 3 arrives s/he becomes upset.

Based on observations, clinical record reviews, facility policy and interviews for the 2 of 2 residents (Resident # 77 and Resident #80) reviewed for oxygen, the facility failed to administer oxygen as prescribed. The findings included: 1. Resident #77 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation, dysphagia, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #77 as cognitively intact and required two persons to assist in bed mobility, transfers and one person assist with eating. The MDS also indicated Resident #77 experience shortness of breath/ trouble breathing when lying flat and required oxygen therapy. The Resident care plan dated 4/13/24 for chronic respiratory failure with hypoxia. Interventions included oxygen via nasal cannula at 2-3 L per minute and to monitor for respiratory distress. A physician's order dated 4/13/24 directed oxygen at 2 or 3 liters per minute continuous via nasal cannula. Observation on 5/08/24 at 9:08 AM identified Resident # 77 in the room with nasal cannula in, however, tube was not connected to the oxygen machine. The oxygen machine was 4 liters. Interview with LPN #1 on 5/8/24 at 9:15 AM indicated Resident # 77 was connected to her/his oxygen machine when LPN # 1 did her rounds at 7:30 AM. However, LPN #1 could not explain why the resident was connected to the oxygen. LPN #1 was unable to explain why Resident# 77 oxygen was set at 4 litter. LPN #1 also indicated nursing supervisor/ APRN are allowed to set litter per physician's order. During the interview Resident #77 expressed she was experiencing shortness of breath (SOB). LPN #1 indicated when resident expresses SOB, there is an as needed order for a nebulizer to assist. After inquiry, the resident's orders were revised on 5/8/24 to reflect oxygen 4 liters when needed, titrate up as needed up to 5 liters and to keep oxygen saturation greater than 93 percent. 2. Resident #80's diagnoses included Chronic Diastolic Hear Failure, hypertensive heart disease with heart failure, and Chronic Obstructive Pulmonary Disease (COPD). A physician's order dated 3/5/24 directed to administer oxygen at 2 liters per minute via nasal cannula for shortness of breath or oxygen saturation levels of less than 90%. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #80 as severely cognitively impaired and required extensive assistance with transfers, eating and toileting. The Resident Care Plan updated on 3/19/24 identified Resident #80 had altered respiratory status/difficulty breathing. Interventions included oxygen settings via nasal cannula as ordered. Observation on 5/08/24 09:55 AM identified Resident # 80's oxygen liter flow rate was set at 4 liters. Interview and observation with LPN #2 on 5/8/24 at 10:00 AM identified Resident # 80's oxygen set at 4 liters and the order was for 2 liters. LPN #2 also was unable to explain why the oxygen level was set at 4 liters. After inquiry, LPN #2 set the resident's oxygen flow rate at 2 liters. Although requested, a facility policy for Oxygen was not provided. The Administrator indicated they do not have a policy for oxygen, the staff are directed to follow the physician's order for oxygen flow rate. 49100

Based on review clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident # 160 and Resident #259) reviewed for abuse, the facility failed to report allegations of abuse to other regulatory agencies. The findings included: 1. Resident #160's diagnoses included pancytopenia (significant reduction in the number of almost all blood cells), alcoholic cirrhosis of liver with ascites (abnormal fluid in the abdomen) and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #160 as cognitively intact, requiring one person to assist with bed mobility, transfers, and personal care. The RCP dated 4/17/23 identified Resident #160 as dependent on staff for meeting emotional, intellectual, physical, social needs and noted cognitive dysfunction. Interventions directed to ensure activities are compatible with physical/mental capabilities, provide assist of one with activities of daily living and to monitor report changes in cognitive function. A facility Reportable Event dated 4/22/23 at 3:29PM identified on 4/22/23 at 1:30PM Resident #160 reported to Registered Nurse, RN #4, that the charge nurse, Licensed Practical Nurse, LPN #6 last evening during the 3:00 PM-11:00 PM shift, LPN #6 told Resident #160 she wished s/he would fall, crack her/his head, and die. A nurse's note dated 4/22/2023 at 4:06 PM identified Resident #160 reported the nurse told him/ her that she wished the resident would fall and crack his/her head and die. The state agency, local law enforcement, Conservator of Estate and Advanced Practice Registered Nurse (APRN) were notified. The APRN ordered urinalysis due to confusion to rule out a urinary tract infection (UTI). A Reportable Event Summary dated 4/24/23 identified Resident #160 alleged on 4/22/23 LPN #6 threatened him/her and was verbally abusive. Resident #160 was confused, anxious and paranoid at the time. Resident # 160 verbalized all the other residents on the unit were dead. Investigation initiated immediately. LPN #6 was removed from the schedule. LPN #6 denied any verbal abuse. Resident's laboratory results revealed critical levels and abuse was not substantiated. A review of the investigative report did not include documented notification to other regulatory agencies. An interview with Person #3 at 5/10/24 at 10:14 AM identified that although allegations of abuse submitted for residents in long term care were referred to state agency for investigation, all allegations of potential abuse were required to be reported to other regulatory agencies when an incident occurs. An interview with the Director of Nursing Services (DNS) on 5/13/24 at 11:25 AM other regulatory agency was only notified if an allegation of abuse was substantiated. In the case of Resident #160, abuse was not substantiated. Rather, a symptom of a medical condition. A review of the facility policy for Abuse dated 12/2023 directed the Administrator, DNS or designee assume the responsibility for notification of the incident and preliminary internal investigation results to include the state agency and other regulatory agencies per individual state reporting requirements. Attempts to interview RN #4 and LPN #6 were unsuccessful. 2. Resident #259's diagnoses included dementia, visual hallucinations, and major depressive disorder. The care plan dated 8/30/22 identified Resident # 259 as cognitively impaired, impaired thought process related to dementia. Interventions included cueing, reorienting, and supervising as needed, keeping the resident's routine consistent, and providing as consistent caregivers as possible. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #259 with moderate cognitive impairment and noted the resident required extensive assistance from one person for dressing and personal hygiene. The resident was independent with ambulation. A facility Reportable Event dated 9/10/22 identified at 10:30 PM, Resident #259 alleged (Nurse Aide (NA#4) was rough with her/him and called the resident names during care. The Reportable Event indicated the facility notified the local police, immediately suspended NA#4 pending the investigation, consulted psychiatry, performed a body audit, and ensured two staff members provided care to the resident. The incident was reported to the state agency on 9/11/22 at 12:00 AM, within the two-hour mandatory window for initial reporting of alleged abuse. The facility's summary of the investigation dated 9/12/22 identified the facility did not have a reasonable cause to suspect abuse had occurred. A nursing progress note by the nursing supervisor (RN#5) dated 9/11/22 at 12:41AM indicated a body assessment was performed, and no injuries were noted. Additionally, the progress note indicated that police arrived, the resident's provider and family were notified, and the facility DNS was notified. On 5/9/24 and 5/10/24, attempts to contact NA#4 during the survey were unsuccessful. On 5/9/24 and 5/10/24 attempts to contact RN#5 were unsuccessful. An interview with the DNS on 5/9/24 at 2:00 PM indicated NA#4 was sent home when the allegation was first known. Additionally, the DNS indicated the allegation was not reported to other regulatory agency because the facility did not substantiate the allegation as an incident of abuse and the facility would only report to the other regulatory services if the facility's investigation concluded that abuse may have occurred. On 5/10/24 at 10:14 AM, an interview with Person #3 indicated the allegation of abuse for Resident #259 was the other regulatory agencies at Department of Social Services on 9/12/22 by the local police department. Person #3 indicated long-term care facilities are expected to report allegations of abuse within 24 hours to the other regulatory agency. A review of facility policy for abuse identified the facility would notify the state agency immediately but no later than 2 hours to report allegations of abuse. The facility abuse policy further indicated that staff would need to see state-specific guidelines for verbal notification of all abuse (alleged or confirmed) to the state health department and other regulatory agencies per individual state reporting requirements. 48880

Based on clinical record review, facility documentation, facility policy and interviews for one (1) sampled resident (Resident #1) who was reviewed for quality of care, the facility failed to ensure an injury of unknown origin was reported to the State Agency within the required time frame. The findings include: Resident #1's diagnoses included dementia, congestive heart failure and schizoaffective disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living and required two (2) person assistance with turning and repositioning when in bed, total assistance with getting in and out of the bed and chair. The Resident Care Plan dated 11/17/22 identified Resident #1 had a self-care deficit related to confusion and dementia. Interventions directed to transfer with an assist of two (2) via the Hoyer lift. The nurse's note dated 3/10/23 at 1:00 PM identified Resident #1's right lower leg was noted to be swollen, Resident #1 was alert and verbal with no signs of discomfort, and the Supervisor was updated. The nurse's note dated 3/10/23 at 6:23 PM identified a new order was obtained for a venous ultrasound to rule out a deep vein thrombosis (DVT) and an x-ray of the right lower extremity. The Facility Reported Incident form dated 3/13/23 at 4:15 PM identified it was discovered Resident #1 had right ankle swelling, an x-ray was ordered to rule out DVT and the x-ray results revealed a right ankle fracture, etiology unknown. The report identified that the incident was reported on 3/12/23 at 8:00 PM to the State Agency. An interview with the Director of Nurses (DON) on 4/20/23 at 12:18 PM identified injuries of unknown origin were to be submitted to the State Agency within two (2) hours of discovery. The DON indicated that while she believed the supervisor may have had difficulty at the time with submission, she was unable to provide documentation that the effort to submit the injury was reported. The DON indicated she submitted the report once she was made aware. A review of the facility policy for abuse identified a two (2) hour requirement to report to Department of Public Health following identification of an injury of unknown source.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of two sampled residents (Resident #1) who were reviewed for mistreatment, the facility failed to put immediate measures in place when an observation of potential resident to resident sexual abuse was identified. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long-term memory problems, rarely or never made decisions regarding tasks of daily life, and required supervision when walking in the room and on the unit. The Resident Care Plan dated 7/12/22 identified Resident #1 had a behavioral problem related to wandering into other resident rooms. Interventions directed to minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention such as redirection. Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Care Plan dated 5/25/22 identified Resident #1 had a behavioral problem related to dementia. Interventions directed periodic checks, to ensure no female resident was in the room. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life, required extensive assistance with turning and repositioning while in bed and with locomotion on unit. The nurse's note dated 8/3/22 at 10:44 PM identified around 9:45 PM a nurse aide reported observing Resident #1 touching Resident #2's genitalia in Resident #2's room and the charge nurse immediately went to Resident #2's room, observed Resident #1 walking in Resident #2's room, removed Resident #1 to the nurse's station and notified the supervisor. The Facility Reported Incident form dated 8/3/22 at 10:51 PM identified Resident #1 was observed touching Resident #2's genital. The Summary Report form dated 8/4/22 at 4:31 PM identified Resident #1 was observed in Resident #2's room, sitting on the bed and touching Resident #2's genitalia under his/her clothes. No injuries or any discomfort was noted, the residents were separated immediately, Resident #1 was redirected out of Resident #2's room and every fifteen (15) minute checks were initiated to ensure Resident #1 was not entering into other resident rooms. Interview with the 3-11PM nurse aide, Nurse Aide (NA) #1, on 9/6/22 at 3:20 PM identified she was walking down the hall, looked into Resident #2's room and noticed Resident #1 sitting on Resident #2's edge of bed while Resident #2 was lying in bed in the prone position. NA #1 indicated Resident #1 was sitting by Resident #2's feet, however, the bed sheet was bundled obstructing NA #1's view, so she entered the room and realized Resident #1's left hand was under the sheet in the area of Resident #2's genital. NA #1 identified she asked Resident #1 to come out of the room and she pulled Resident #1's hand, pulled the bed sheet and noticed Resident #2's brief was down and not covering the genital area. NA #1 identified she tried to remove Resident #1 from Resident #2's room, however, Resident #1 would not get up or move, so she left the room and went to get the charge nurse. NA #1 identified when she returned to Resident #2's room with the charge nurse, Resident #1 had gotten up, was walking toward the door and just walked out of the room. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 9/6/22 at 3:08 PM identified NA #1 notified him of seeing Resident #1 in Resident #2's room and Resident #1 touching Resident #2's genitalia. LPN #1 indicated he immediately went into Resident #2's room and noticed Resident #1 was almost at the door and he made sure Resident #1 was removed completely from Resident #2's room. Interview with the Director of Nurses (DON) on 9/6/22 at 3:45 PM identified the expectation was for the facility staff to separate the residents immediately, to ensure both residents were safe and then report the incident to the charge nurse. Review of the abuse policy directed that each resident had the right to be free from abuse. Immediate action directed to protect resident from alleged abuse.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #64) reviewed for hospitalization , the facility failed to notify the Ombudsman within acceptable parameters when the resident was transferred and/or discharged to the hospital. The findings include: Resident #64's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified Resident #64 had moderately impaired cognition with short and long term memory deficits, required extensive assistance with bed mobility, limited assistance with transfers and supervision with ambulation and utilized a walker. A nurse's note dated 12/21/21 at 3:59 AM identified that at 3:00 AM Resident #64 had increased agitation, attempted to hit staff with a rolling walker and was verbally abusive towards his/her roommate. The staff was unable to redirect the resident and the roommate was temporarily moved to another room. The note further identified that Resident #64 attempted enter the room that the roommate was moved to, the APRN was updated and an order was obtained that directed for the resident to be sent to the hospital for evaluation. Resident #64 was transferred to the hospital at 3:50 AM and the resident's responsible party was updated. A nurse's note dated 12/21/21 at 4:00 PM identified Resident #64 arrived at the facility at 2:30 PM via stretcher accompanied by two ambulance attendants. A nurse's note dated 12/23/21 at 2:26 PM identified Resident #64 was agitated and unable to understand due to a language barrier. The resident's responsible party was present and translated that Resident #64 was upset because he/she thought that his/her roommate had taken his/her sugar. Per the responsible party Resident #64 sat on the floor, yelled and refused to be assisted up off the floor. Resident #64 was transferred to the hospital at 1:15 PM for evaluation. Responsible party present and aware. A nurse's note dated 12/31/21 at 3:21 PM identified Resident #64 arrived at the facility via stretcher accompanied by two ambulance attendants. Review of the facility's tracking system utilized to send notices to the Ombudsman's office of resident transfers and discharges identified that the last notifications made to the Ombudsman was August of 2021. Interview on 2/17/22 at 1:30 PM with the Administrator identified he was unable to provide documentation that the Ombudsman was notified of the Resident #64's transfers to the hospital. He indicated that he was unaware that the Ombudsman was not notified when Resident #64 was transferred to the hospital. Interview on 2/17/22 at 1:46 PM with the Social Worker identified she had been employed with the facility for two months and was unaware that the previous Social Worker had not sent the resident transfer and discharge notices for the months of October, November or December of 2021 to the Office of the State Long-Term Care Ombudsman. She further failed to identify why she had not sent out the notices for the month of January but indicated that she would address the issue. Review of the facility's protocol addressing discharge and transfer notices identified that the forms were updated in January of 2022. It identified that the forms should be sent out timely to the correct address of the Ombudsman.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #73) reviewed for Hospice, the facility failed to develop a comprehensive care plan to address the resident's hospice needs. The findings include: Resident #73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order dated 1/6/22 directed for a hospice evaluation. The significant change MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with ADL's, was incontinent of bowel and bladder and was receiving hospice care. Interview on 2/16/22 at 1:32 PM with RN #1 indicated the MDS Coordinator updates the care plan when there is a change in condition. Interview on 2/17/22 at 11:59 AM with RN #2 (MDS Coordinator) indicated it is her responsibility to update the care plan when there is a change in condition. Additionally, RN #2 indicated Resident #73's care plan was not updated to address hospice care and the coordination between the facility and hospice. Interview on 2/17/22 at 12:07 PM with the DNS identified the care plan is updated when there is a change in condition and it is the responsibility of the supervisors, charge nurses, social services and the MDS Coordinator to update the care plan. A review of the facility policy title Baseline/Comprehensive care person centered care plan indicated the comprehensive person centered care plan (CPCCP) will be periodically reviewed and revised by a team of qualified persons after each assessment or reassessment. Additionally, the policy identified the CPCCP will be reviewed and revised following a significant change in status and completion of significant change in MDS. The policy further states that the IDT will periodically review and revise the CPCCP based on the MDS assessment and reassessments and upon any change in status and intervention initiated will be dated at the time of the implementation. Subsequent to surveyor inquiry the care plan was updated to reflect Resident #1 was receiving hospice services.

Based on clinical record reviews, review of facility documentation and interviews for one of five sampled residents (Resident #17) reviewed for pneumococcal immunizations, the facility failed to ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization and the administration of the pneumococcal vaccine. The findings include: During a review of the facility's infection control program, a sample of five residents' vaccination records were reviewed on 2/17/22 to determine immunization status for Covid-19, influenza and pneumonia. The review identified that Resident #17's consent form for the pneumococcal vaccinations was not complete and the vaccinations had not been administered. Further review identified Resident #17 was admitted to the facility in August of 2021. Interview on 2/17/22 at 10:35 AM with the IP identified Resident #17's pneumococcal immunization history was not available from his/her PCP, and the resident's family was not sure if Resident #17 had received them in the past. In addition, the IP identified that the information should have been documented in the resident's chart and a follow up should have been done. The IP further identified that it was an oversight on her part and noted that the focus of the facility at that time was on ensuring influenza and COVID-19 vaccinations were administered. She further noted that there was a push-back on the pneumococcal immunizations. The IP nurse also indicated that the RN supervisors are also expected to follow-up on the immunization status. Interview on 2/17/22 at 12:35 PM with the DNS identified that it is her expectation that during the admission's process the nursing supervisor should ask the family about the resident's vaccination status, obtain the consent, obtain the physician's order for the administration of the vaccine and pass the information along to the IP nurse. Review of the facility policy for Pneumococcal Vaccination identified that All residents admitted to the facility will be evaluated to determine if they have received Pneumococcal Vaccination upon admission, the facility will offer residents on admission the pneumococcal vaccine upon resident and/or responsible party consent. Additionally, the facility policy directed to obtain resident's vaccination history, obtain informed consent from the resident/designated representative (if resident unable to consent), obtain order from the physician and administer vaccine as per ACIP/CDC guidelines. Subsequent to surveyor inquiry, the IP nurse conducted an in-service for the nursing supervisors regarding ensuring immunization consents were appropriately filled out, refusals documented, and to follow-up routinely if consent was not obtained initially.

Based on review of the clinical record and interviews for two of five residents reviewed for vaccination (Resident #1 and #3), the facility failed to ensure a complete and accurate record. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] identified the resident had severe cognitive impairment. A COVID-19 Facility Vaccination Form for Resident #1 identified on 5/6/21 the resident's responsible party refused the COVID-19 vaccination for Resident #1. The printed name of the legal representative was left blank. The form areas to complete if the declination was verbal were left blank, this area included an area to document the printed name of the person providing verbal declination and staff member signature (person who received the verbal consent, per form). An additionally form area for staff member signature was also left blank. The second page of the form identified under Documented Efforts to Obtain COVID-19 Vaccination identified on 5/6/21 the efforts were Will re-educate and follow up. Comments for this date identified We are undecided. The second page of the form further identified on 7/3/21 the area for efforts was left blank and Comments noted Continue to refuse. There were no areas on this second page to identify who was contacted, or which staff had made the effort or obtained a verbal refusal or consent, for any dates. Interview and record review with the Director of Nursing Services (DNS) on 8/3/21 at 2:30 P.M. identified the forms were not completed correctly and identified there is no specific facility policy for completion of consent forms; however, he/she would expect forms to be completed correctly or completely. The DNS also indicated she/he would expect that documentation would include all necessary information. The DNS further indicated this is the nurse's responsibility, specifically the responsibility of the Infection Preventionist of RN #1 to ensure. The DNS identified the resident representative was contacted regularly by the facility with ongoing follow up related to vaccination, and the resident representative was contacted several times specifically related to vaccination consent, as per facility policy and indicated the resident representative refused vaccination each time. Interview and record review with Registered Nurse (RN #1) on 8/3/21 at 2:40 P.M. identified RN #1 had spoken to the resident's representative on 5/6/21 and 7/3/21 and reviewed the vaccination education and offered the COVID-19 vaccination, in attempts to receive consent for COVID-19 vaccination for Resident #1. However, the responsible party continued to decline vaccination, indicating they would consider vaccination after the resident had gotten stronger/recovered from hospitalization s. RN #1 identified that he/she had not filled out the COVID-19 Facility Vaccination form correctly or completely. RN #2 identified he/she had incorrectly signed the form for the resident's representative, had not filled out the information for the verbal consent area of the form, and did not document what efforts were made on 7/3/21. RN #1 identified that the reason for this was that he/she was new to the facility and the role, and further identified that it was his/her responsibility to ensure this was done. The facility policy for COVID-19 Vaccination for Residents identified in part: The facility will obtain a signed consent form for the administration of the COVID-19 vaccine from the resident or the resident's designated health care representative. Telephone consent is acceptable. The resident or resident representative is provided the opportunity to refuse that vaccine and to change their decision about vaccination at any time. The facility will track consents of all residents. All new and re-admissions will be evaluated by the nurse and/or physician for previous immunizations and will be offered the vaccine if appropriate and available. The facility policy further identified: The resident's medical record will include the following documentation (in part): Resident or representative will be provided education regarding benefits and potential side effects of the COVID-19 Vaccine. Resident will either accepted and received the vaccine or will not receive the vaccine due to medical contraindications, prior vaccination, or refusal. Date of the education and offering will be noted. Name of the Representative that received the education and accepted or refused the vaccine will be noted. 2.Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified the resident had no cognitive impairment. A COVID-19 Facility Vaccination Form for Resident #3 on 8/3/21 identified a report that the resident had the COVID-19 vaccination, and the reporter could not recall the location. Although page 2 of the form reflected dates of efforts and actions, page one of the forms was left blank in the areas that does not reflect date, or the name or signatures of the resident. Because of the missing information, it was not clear if the resident was the respondent for the form information. There was no staff member signature to indicate who has obtained the information. Though page 2 reflects discussions with resident and family, no representative name is reflected. There were no specific areas on this second page to identify who was contacted, or which staff had made the effort. Interview and record review with the DNS on 8/3/21 at 2:30 P.M. identified there is no specific facility policy for completion of consent forms; however, he/she would expect forms to be completed correctly and would expect documentation would include all necessary information, this is the nurse's responsibility, specifically the responsibility of the Infection Preventionist RN #1 to ensure. Interview and record review with RN #1 on 8/3/21 at 3:30 P.M. identified RN #1 identified he/she had not filled out the COVID-19 Facility Vaccination form completely. RN #1 identified that the reason for this was that he/she was new to the facility and the role and further identified that it was his/her responsibility to ensure this was done. The facility policy for COVID-19 Vaccination for Residents identified: The facility will obtain a signed consent form for the administration of the COVID-19 vaccine from the resident or the resident's designated health care representative. Telephone consent is acceptable. The resident or resident representative is provided the opportunity to refuse the vaccine and to change their decision about vaccination at any time. The facility will track consents of all residents. All new and re-admissions will be evaluated by the nurse and/or physician for previous immunizations and will be offered the vaccine if appropriate and available. The facility policy further identified: The resident's medical record will include the following documentation (in part): Resident or representative was provided education regarding benefits and potential side effects of the COVID-19 Vaccine via fact sheet, medical contraindications, prior vaccination, or refusal. Date of the education and offering. Name of the Representative that received the education and accepted or refused the vaccine.

Based on observation, facility policy reviews, and interviews of infection control practices as it related to COVID-19, the facility failed to follow infection control guidelines/facility policy for visitor screening upon entrance to a facility. The finding includes: 1. Observation on 6/7/2020 at 8:42 AM, identified Radiology Technician #1 entered the facility and proceeded onto the patient care unit without the benefit of having temperature taken and screening for potential COVID exposure. Observation on 6/7/2020 at 8:59 AM identified Radiology Technician #1 exiting the nursing unit and entering facility lobby. Interview at this time identified, Radiology Technician #1 had entered the nursing unit, performed an x-ray on one resident. Radiology Technician #1 indicated she was never approached or asked to have her temperature taken or screened for COVID related symptoms or exposure, and then left the unit when her task was completed. Radiology Technician #1 further stated other times she has entered the building her temperature is obtained before entering, and she was not sure where anyone was when she entered the building,. Radiology Technician #1 indicated she was provided access to the building through the front entrance by a Nursing Assistant (NA). 2. Observation on 6/7/2020 at 8:45 AM, identified Phlebotomist #1 entered the facility and proceeded to enter the first floor nursing unit without the benefit of having temperature taken and screening for potential COVID exposure. Interview with Phlebotomist #1 on 6/7/2020 at 9:15 AM with the Nursing supervisor identified that no one had taken her temperature upon entry and that she did not get her temperature taken until she entered the nursing unit and informed the nurse that she still needed her temperature taken because no one was in the lobby when she entered. Interview with the Nursing Supervisor on 6/7/2020 at 9:00 AM identified that temperatures were to be completed on everyone entering the building. She further identified that she had been informed by staff that this State Agency (SA) Nurse Consultant, and the national guardsmen were both screened, and temperatures were taken upon entrance. This SA Nurse Consultant informed the Nursing Supervisor that was not the case, and that Radiology Technician #1 and Phlebotomist #1 were also let into the building without temperatures or additional evaluation complete. Nursing Supervisor identified that she had been busy taking care of a resident on the second floor of the building at the time Radiology Technician #1, and Phlebotomist #1 entered the building. Interview with the Infection Control Registered Nurse (ICRN) #1 and Administrator at 6/7/2020 at 9:40 AM identified that temperatures and screening for everyone entering the building should be completed upon entrance, and that there should have been a nursing assistant present in the lobby to take temperatures that day prior to the receptionist arriving and assuming that duty. Policy for Resident and Healthcare Personnel Symptom Screening dated 5/1/20 identified temperature screening and surveillance questionnaire would be completed upon arrival to facility and prior to entering work areas.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #56) reviewed for food, the facility failed to ensure food was served at a safe and palatable temperature. The findings include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#56 with a general diet. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition, was continent of bowel and bladder and required set up only for eating. The care plan dated 7/17/19 identified Resident #56 had a problem or potential nutritional problem related to [DIAGNOSES REDACTED]. Interview with Resident #56 on 8/19/19 at 1:59 PM identified that he/she was frustrated because the food served was on the cold side instead of hot. Resident #56 identified that he/she had shared these concerns with nursing staff and also voiced concerns via the resident council meetings but continued to be served cold meals. Interviews during the survey with 2 anonymous residents indicated a concern with food being served cold. Observation of the tray line on 8/21/19 at 12:36 PM identified Cook #2 did not take the temperature of a tray of fish after it was removed from the oven. Cook #2 was observed serving the fish on the tray line to the dietary aides as they prepared resident meals. Interview and temperature check (test tray) of food with the Director of Dietary identified the test tray left the kitchen in a dietary cart with resident meals on 8/21/19 at 12:37 PM and arrived on 1 North at 12:40 PM. Following distribution of the last resident tray from the dietary cart, food temperatures were recorded: orzo 140 -141 degrees Fahrenheit (F), beets 120 F, and fish 115 F. The Director of Dietary identified that the food items were cold, and indicated that the food items should be 145 F to ensure food items are safe to consume and noted although she agreed with the temperatures obtained during testing of the food items on the test tray, she was surprised the food was cold. The Director of Dietary identified that it was her expectation that the cook take the temperature of food items before food is served on the tray line to ensure the items were cooked and not a potential cause of food borne illness. Interview with Cook #2 on 8/21/19 at 1:10 PM identified that she checked the temperature of the food items when she took out the initial tray of fish and documented the temperature on the temperature sheet. Cook #2 identified it was her practice to take the temperature of any food item that came out of the oven prior to serving it on tray line and she recalled checking the temperature of the fish prior to serving it for resident consumption. Cook #2 identified that the temperature of the orzo was 172 F, the beets 174 F and the fish 172 F. Interview with the Administrator on 8/21/19 at 3:07 PM identified that the Director of Dietary agreed that orzo, beets and fish from the test tray were cold. The Administrator identified that although the cook took the temperature of the food items prior to serving them on the tray line, she may not have given the thermometer enough time to reset between temping of different food items. Review of the facility dining policy identified the facility will prepare foods in a manner so as to prevent cross-contamination. The policy further identified that hot foods will be held at 140 degrees F. Review of residents' bill of rights identified that residents have the right to receive quality care and services with reasonable accommodations of individual needs and preferences, except when your health and/or safety or the safety of other individual needs would be endangered by such accommodations.

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to maintain food preparation areas in a clean and/or sanitary manner. The findings include: 1. Observation on 8/19/19 at 9:40 AM of the kitchen with Dietary Aid #1 identified that sanitizing solution, used by kitchen staff, is obtained from a dispenser above the 3 bay sink. Dietary Aide #1 indicated the sanitizing solution is utilized in the food preparation areas by the cook staff, in the dishwashing room by the dietary aids, and there was a spray container with sanitizer located in the chemical room of the kitchen. The initial test of the solution contained in the spray bottle utilized for sanitizing surfaces in the kitchen and housed in the chemical closet contained less than 100 Parts Per Million (ppm). Dietary Aid #1 identified that he had not tested the solution on 8/19/19, and was not certain when it had last been tested . Dietary Aid #1 identified he had utilized the solution to clean surfaces in the kitchen earlier in the morning and did not know who was responsible to check the level of sanitization in the solution. Dietary Aid #1 identified he had not checked the ppm of the sanitizer for several weeks. Interview on 8/19/19 at 9:45 AM with Dietary Aid #2 identified the sanitizing solution should be 200 ppm or greater. Additionally, she had obtained the sanitizer for the cook from a dispenser in the dishwashing room earlier in the morning but had not tested it. Upon surveyor request, Dietary Aid #2 tested the sanitizing solution in a bucket obtained from the dispenser above the three bay sink in the dish room, and identified it was less than 200 ppm. Dietary Aid #2 identified this solution should be greater than or equal to 200 ppm and indicated she was not certain who was responsible for checking the level of sanitizer and noted she had not checked tit for several weeks. Interview with Cook #1 on 8/19/19 at 9:47 AM identified that although she had utilized the sanitizing solution in the bucket at the cook preparation table earlier in the morning, she did not test the ppm of the sanitizing solution that morning and was not certain who is responsible to test the sanitation solution. Cook #1 identified that Dietary Aid #2 had provided the bucket of sanitizer for her use at the beginning of the morning. At surveyor request, Cook #1 tested the sanitizing solution in the red bucket in the cook preparation area and it contained less than 100 ppm sanitizer. Cook #1 identified that the solution should be 200 ppm or greater to ensure the sanitizer would be effective in preventing food borne illnesses during the preparation of resident meals. Interview with Dietary Aid #1, #2 and Cook #1 on 8/19/19 at 9:50 AM identified that the level of sanitizer had not been tested on [DATE], and that staff had not tested the sanitizing solution since the most recent inspection by the local health department earlier in the summer. Dietary Aid #1, #2 and Cook #1 identified the sanitizer solution should have been tested to ensure it was effective as a sanitizer to prevent infection of residents. Additional testing of the sanitizing solution after emptying the solutions in the spray bottle, red bucket in the kitchen, and in the dishwashing sink, and refilling the sanitizer in the bucket identified the solution contained less than 100 ppm of the chemical sanitizing solution. Interview on 8/19/19 at 10:48 AM with Dietary Aid #2 identified that subsequent to surveyor tour of the kitchen, she had worked with the director of maintenance to ensure the tubing connecting the sanitizer solution to the sink water was not kinked. Additionally, Dietary Aid #2 identified that the facility had changed vendors for the sanitizing solution recently and she found a different brand of test strips in the Dietary office. Furthermore, Dietary Aid #2 identified that the new sanitizing solution she had prepared tested 200 ppm or greater with the new test strips. Interview on 8/20/19 at 7:57 AM with the Administrator identified that in the absence of the Director of Dietary, the cook was in charge of the kitchen. Additionally, the Administrator identified that the dishwasher was expected to check the level of sanitizer in the kitchen 3 times a day as was the facility policy, to ensure resident food was handled in in a manner to prevent food borne infection. Interview with the Director of Dietary on 8/20/19 at 8:07 AM identified that in her absence, the cook was in charge of the kitchen. The Director of Dietary identified that each morning the dishwasher is responsible to fill a container in the dish room with the sanitizer and to test it to ensure the level is 200 ppm, thereby effective in sanitizing the dish room areas. Additionally, the Cook is responsible to fill a bucket with sanitizing solution, and to test the sanitizer's ppm to ensure it was effective for use in the kitchen preparation areas where resident's food was prepared. The sanitizer spray bottle in the chemical room should be tested as well to ensure the ppm indicated the solution was effective in sanitizing. The Director of Dietary the sanitizing solutions should be changed at least 3 times a day. The Director of Dietary identified that the facility did not require staff to document the sanitizer solution had been tested and/or changed. Review of cook job description identified duties included storing all food items and supplies according to procedure in a safe and sanitary manner. Additionally, the cook was to operate, clean and sanitize any equipment or work surfaces according to procedure in a safe and sanitary manner. Review of the dietary aide job description identified duties included preparing, washing sanitizing and properly handling dishes, utensils or pots and pans according to procedure in a safe and sanitary manner. Additionally, the dietary aid was to operate, clean and sanitize any equipment or carts utilized according to procedure in a safe and sanitary manner. Review of facility policy for infection control identified that sanitizing solution must be changed at least 3 times a day. 2. Observation of tray line with second surveyor on 8/21/19 at 12: 20 PM identified Cook #1's hair net was positioned so it covered the top of her head, and just above her ears. Cook #1's hair protruded approximately 3 inches from under the hairnet as she assisted Cook #2 to plate food on the tray line. Additionally, although Cook #2 had a hair net in place, approximately 2 ½ inches of long wavy bangs hung on her forehead, and approximately 5 inches of hair strands were observed in front of both ears outside of the hair net, as she worked on the tray line. Dietary Aid #3 had a hair net in place and approximately 3 inches of bangs hung out of the hair net framing her face as she worked on the tray line. Interview with the Dietary Director on 8/21/19 at 1:15 PM identified that staff is expected to wear hair nets when working in the kitchen. The Director of Dietary identified her expectation was that the staff hair was contained within the hair net to ensure sanitary food service. Review of facility policy for dietary dress code identified that all employees must wear a hat, hair net, beard restraint (used as a barrier for any length of hair) when in the kitchen.

Based on observations, review of facility documentation, facility policy and interviews, the facility failed to ensure the environment was maintained in a clean, comfortable, and homelike manner. The findings include: Observations on 8/20/19 at 2:05 PM with the Administrator identified the following: Missing, cracked and/or chipped tiles on North One in rooms #128 and 130. Damaged and/or peeling base molding on North One in resident room [ROOM NUMBER]. Missing, cracked and/or chipped tiles on East Two in room [ROOM NUMBER]. Soiled and/or stained personal resident hampers on North One in rooms #117, 118, 119, 121, 123 and 125. Moderate amount of dust and/or debris buildup on the wall fan in the beauty salon, which was noted to be on at that time. Damaged, broken and/or debris buildup noted for wheelchairs in room [ROOM NUMBER], 117 and 127. Holes behind the headboards in rooms #117 and 130. Bathroom threshold in room [ROOM NUMBER] with chipped tiles, and black tape across, with some of the black tape missing. Window sill in room [ROOM NUMBER] has a hole present, and there is rust at the base of the inner window framing, and sill is missing compound/sheet rock. Interview with the Administrator on 8/20/19 at 2:05 PM identified he was aware of some of the issues identified and indicated there is a maintenance log on each unit to be used by staff. The Administrator indicated cleaning of the residents personal hampers is the responsibility of housekeeping on a daily basis. When hampers need to be replaced, the housekeeper will inform the Director of Environmental Services and/or the Administrator. Review of the Director of Environmental Services job description identified he/she performs periodic inspections of the building and grounds to ensure proper repair, cleanliness, and laundry service quality. The Director of Environmental Services places orders for necessary supplies in accordance with department budget, and performs other duties as needed to ensure that a clean environment is maintained. Review of the Director of Engineering/Maintenance job description identifies he/she oversees all aspects of the physical plant, mechanically and structurally, inside and out. Review of the Housekeeper job description identifies he/she is responsible for performing routine tasks to ensure the cleanliness of assigned areas of the facility. Review of the wheelchair cleaning policy indicated to scrub all parts of wheel/geri chairs with solution of heavy duty cleaner and water. Use long handed brush and green scouring pads for heavy soil. Use stainless steel polish on all chrome areas. Repeat process until all wheel/geri chairs are done.

Based on observations, review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 2 residents (Resident #101) reviewed range of motion, the facility failed ensure physician's orders [REDACTED]. The findings include: Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The occupational therapy evaluation dated 6/7/19 identified Resident #101 had a left hand contracture and would tolerate a left hand splint for 2 hours with no signs of redness, irritation and/or pain, in order to maintain skin integrity. The occupational therapy discharge summary dated 7/4/19 recommended to utilize a left resting hand splint as per 24 hour positioning plan, with use of splint after morning care and remove at night prior to evening care. A physician's orders [REDACTED]. The quarterly MDS dated [DATE] identified Resident #101 had severely impaired cognition, required extensive assistance of 2 persons with bed mobility, transfers, dressing, and personal hygiene. Additionally, Resident #101 required extensive assistance of 1 person for eating and was dependent on staff for locomotion off the unit. Review of the (MONTH) and (MONTH) 2019 MAR/TAR dated 7/4/19 through 8/20/19 failed to reflect the left resting hand splint had been applied, and/or that skin integrity and CMS had been assessed. Review of the hand splint wearing schedule form, undated, directed staff to check the splint for cleanliness, check arm and hand for redness and swelling. Observation of Resident #101 on 8/20/19 at 9:47 AM identified the left hand and arm splint was in place. Interview with the ADNS on 8/21/19 at 9:05 AM identified that the nurse aides are responsible for the application and removal of splints. Additionally, the ADNS identified that while it was the responsibility of the nurse to complete the skin assessment, the nurse aide should check the skin and report changes to the nurse. Further, the ADNS indicated there was no documentation related to application or removal of the splint, or skin integrity and CMS assessments for the left hand/arm under the splint. Interview with NA #1 on 8/21/19 at 9:11AM identified she applies the splint to Resident #101's left hand, however does not document this in the medical record. Interview with LPN #1 on 8/21/19 at 9:31 AM identified the nurse aide is responsible for applying and removing the splint, and the nurse is responsible for completing the skin and CMS assessments. Additionally, LPN #1 identified the skin and CMS assessment was usually documented in the TAR however, she did not know why it had not been done. Further, LPN #1 identified the nurse who transcribed the order for the splint should have triggered the care plan, and TAR with the intervention to complete CMS and skin integrity assessments. Although requested, the facility did not provide a policy on splint management or CMS assessments. Review of the policy for general skin care identified casts, braces, splints must be checked for any irritation or pressure to the skin every shift and documented in the TAR. Additionally the policy identified to monitor for color, sensation and movement. Although Resident #101 had orders for a left hand splint, documentation failed to reflect the splint had been applied 7/4/19 through 8/20/19, or that skin integrity and CMS of the left hand/arm had been assessed.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #28) required extensive assistance with transfers, the facility failed to ensure residents telephone and call bell where within reach when he/she was out of bed in the wheel chair. The findings include: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, was frequently incontinent of bladder and always incontinent of bowel. Additionally, Resident #28 required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene. The care plan dated 8/13/19 identified Resident #28 was at risk for falls related to poor safety awareness, and had 6 falls since (MONTH) 2019. Interventions included to anticipate and meet the resident's needs, be sure the call bell is within reach, encourage the resident to use the call bell for assistance as needed. Observation on 8/19/19 at 10:30 AM identified Resident #28 was seated in a wheelchair in the center of the room between the beds. The call bell was out of the resident's reach, located at the head of the bed near the pillow. The resident's telephone, with large print numbers, was out of the resident's reach on the other side of the bed near the window on the nightstand. During observation the telephone was ringing and the resident was unable to reach the telephone to answer it. Resident #28 was noted to be looking at the telephone while it was ringing. Observation on 8/20/19 at 12:15 PM identified Resident #28 was seated in a wheelchair in the center of the room between the beds, and the call bell was attached to side rail behind the resident out of his/her reach. The resident's telephone was on the other side of the bed near the window, on the nightstand. Resident #28 was not able to reach either the call bell or the phone. Observation and interview on 8/21/19 at 2:00 PM with LPN #3 identified Resident #28's call bell and telephone were out of the resident's reach. LPN #3 indicated she is not aware whether or not Resident #28 uses the telephone, however, was noted to move the call bell and phone within the resident's reach. Interview on 8/21/19 at 2:05 PM with Resident #28 indicated he/she does use the telephone once in a while when his/her family calls. Review of the nurse aide electronic care card identified to place the call bell within reach when the resident is in the room. Additionally, provide for the overall safety of all residents. The facility policy on residents' bill of rights indicates the resident has the right to reasonable access to a telephone that you can use without being overheard.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #28 and 45) reviewed for urinary catheter, the facility failed to ensure the resident's dignity when staff left urinary collection devices uncovered and visible. The findings include: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, was frequently incontinent of bladder and always incontinent of bowel. Additionally, Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. The care plan dated 8/13/19 identified Resident #28 had an indwelling catheter due to [MEDICAL CONDITION]. Interventions included to monitor and document signs/symptoms of discomfort on urination and frequency, and intake and output as per facility policy. Position catheter bag and tubing below the level of the bladder and away from entrance room door. A physician's orders [REDACTED]. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified an unlabeled leg bag and urinal hanging on the grab bar. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom, were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) in the shared bathroom identified an unlabeled leg bag and urinal hanging on the grab bar. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Observation on 8/21/19 at 10:00 AM and 1:50 PM identified Resident #28 was in a wheelchair in his/her room. A urinary collection bag attached to Resident #28's wheelchair was visible without the benefit of a privacy cover. Observation and interview on 8/21/19 at 2:00 PM with the Charge Nurse, (LPN #3) indicated the resident's urinary collection bag should be covered for privacy. Additionally, LPN #3 indicated the resident is supposed to have a leg bag on when he/she is out of bed. Observation and interview on 8/21/19 at 2:10 PM with NA #4 indicated she was not aware of the physician's orders [REDACTED]. Additionally, NA #4 indicated Resident #28 did not have a privacy cover on when she came in, and she did not apply a privacy cover. 2. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #45 had severely impaired cognition, required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene. Additionally, Resident #45 ambulated in the room with supervision. A physician's orders [REDACTED]. The care plan dated 7/3/19 identified Resident #45 had an indwelling catheter for [MEDICAL CONDITION]. Interventions included to change the catheter per physician's orders [REDACTED]. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified hanging on the grab bar was an unlabeled leg bag and urinal. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) indicated hanging on the grab bar was an unlabeled leg bag and urinal. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Observation on 8/22/19 at 10:30 AM identified Resident #45 lying in bed with a urinary catheter collection bag, which contained urine, attached to the bed frame, and visible from the hallway without the benefit of a privacy cover. Observation and interview on 8/22/19 at 10:35 AM with LPN #5 indicated Resident #45's urinary collection device was visible from hallway and did not have a privacy cover. LPN #5 indicated that the urinary collection bag should have a privacy cover, however, upon a room search, LPN #5 was unable to find a privacy cover in Resident #45's room. Review of the nurse aide electronic care card indicated to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, check tubing for kinks. Although requested, a policy on urinary catheter care, including labeling/privacy cover use and storage of urinary collection devices was not provided.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #39) reviewed for advance directives, the facility failed to ensure the advanced directive consent form and resident care plan reflected resident's current wishes. The findings include: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A consent form dated [DATE] identified Resident #39 met with staff who explained and discussed the potential benefits and risks of cardiopulmonary resuscitation and other means of resuscitation, the use of life support systems, and methods of artificial provision of nutrition and hydration. Resident #39's choices regarding the administration of life support systems were documented as follows; administer CPR, artificial respiration, artificially provided nutrition and hydration. A physician's orders [REDACTED].#39 was readmitted with a code status change. The order directed to discontinue the order to provide CPR and implement DNR (do not resuscitate) status. The quarterly MDS dated [DATE] identified Resident #39 had severely impaired cognition. The care plan dated [DATE] identified to honor Resident #39's advance directive (full code). Interview with RN #3 on [DATE] at 1:15 PM identified that the advance directive in the paper record (full code), the physician's code status order in the electronic medical record (DNR) and the resident care plan (full code) should all match. RN # 3 could not explain the discrepancy. Interview with the ADNS on [DATE] at 2:00 PM identified that Resident #39's code status was changed after his/her readmission to facility in (MONTH) of 2019, and was now DNR. Additionally, the ADNS indicated she usually addressed the advance directives with new and readmissions, but it must have been overlooked. Interview with the DNS on [DATE] at 10:30 AM identified that it was the responsibility of the unit managers and/or supervisors to ensure the advance directives were addressed and completed on all admissions and readmissions, and the DNS indicated they should be done timely. Although requested, documentation was not provided to indicate a discussion regarding Resident #39's advanced directives change dated [DATE] took place. Review of the facility's advance directive policy identified that nursing is responsible for completing the advance directives form with the resident or family within the first 72 hours. All DNR information, including signed consent, copy of current progress note that addresses the DNR and copy of original MD order will be put together in a plastic sleeve and placed in the advance directives section. Although a consent form dated [DATE] identified Resident #39 choice regarding the administration of life support systems was to receive CPR, artificial respiration, artificially provided nutrition and hydration, a physician's orders [REDACTED].#39 was readmitted to the facility with a code status of DNR. Additionally, the clinical record lacked documentation to indicate a discussion regarding the change to Resident #39's advance directives from full code to DNR took place.

Based on observation, review of the clinical record and staff interview for one sampled resident (Resident #206), reviewed for assaultive behavior, the facility failed to provide adequate nursing supervision to ensure the safety of residents and a hazard free environment resulting in the finding of immediate jeopardy. The findings include: Resident #206 [DIAGNOSES REDACTED]. The discharge summary dated 8/18/16 identified the resident was admitted to the psychiatric hospital via a Physicians Emergency Certificate (PEC) because he/she was a danger to self or others. The discharge summary further identified the resident had unpredictable aggressive episodes for some time prior to admission. Admission physician orders dated 8/18/16 directed to administer Buspirone (anxiolytic)30mg daily, Depakote Sprinkles 500mg twice daily at 9:00AM, 5:00PM and 1000mg at 9:00PM, Lexapro 10mg daily, Gabapentin 100mg at 9:00PM, Lorazepam 0.5mg twice daily, Trazodone 50mg three times daily at 1:00P, 5:00P and 9:00PM, Mirtazapine 15mg at 9:00PM, and Trazodone 50mg every 4 hours as needed for agitation/insomnia. The nursing admission assessment dated [DATE] identified the resident ambulated independently, was alert, had long term memory impairment and severely impaired decision making ability. The care plan dated 8/18/16 and last revised on 8/27/16 identified the resident received psychotropic medications, had dementia and exhibited behaviors such as wandering, verbal abuse, disruptive, resistance to care with the potential for physical abuse. Interventions included to intervene as needed to ensure the safety of residents and others, medications as ordered and monitor for changes in mood/behavior. The care plan further identified an intervention (not dated) to stay with resident when increased agitation. The nurse's note dated 8/18/16, the day of admission, identified the resident wandered in and out of other residents ' rooms. Additionally, at 11:00PM the resident continued to wander into other residents rooms and was attempting to hit and kick other staff. The nurses ' notes dated 8/19/16, 8/20/16, 8/22/16, 8/23/16, 8/24/16 and 8/25/16 identified the resident required redirection for wandering behaviors which included going into other residents' rooms. The nurse's note dated 8/20/16 identified that at 8:00PM, the resident was agitated and going into every room. When the NA tried to re-direct the resident, the resident hit the NA in the stomach. At 10:00PM, the resident was put in a chair with a lap tray. The nurse's note dated 8/24/16 at 2:00PM identified the resident continued to wander in and out of other resident rooms and taking other residents belongings, was resistive at times, and was hitting at staff. The nurse ' s note dated 8/24/16 at 11:00PM identified the resident kept wandering to other residents rooms, refused to be changed, and was trying to kick staff when approached. Review of the MAR failed to reflect Trazadone 50 mg, medication ordered for agitation was administered. The nurse's note dated 8/25/16 at 8:15PM identified the resident was noted sleeping on the bed in Resident #134's room. The nurse ' s note identified Resident #134 was afraid to enter his/her room. When approached by staff to leave the room, Resident #206 became combative and chased LPN #2 around with a rolling walker. Other residents who witnessed the incident expressed fear and requested that the police be called. Resident#206 grabbed a footrest from another residents chair and wanted to hit staff. The resident followed LPN #2 around the unit, trying to hit and kick him/her. Subsequent to physician notification, the resident was sent to the hospital for an evaluation via 911. The care plan dated 8/25/16 identified the resident was sent to the ED for increased agitation with an intervention to redirect the resident away from residents' rooms as needed. Interview with LPN #3 on 8/30/16 at 3:40PM identified that on 8/25/16 at approximately 8:00PM, he/she was made aware by NA#4 that Resident #206 was in Resident #134's room lying on the empty bed. LPN#3 extended his/her arm to assist the resident out of the bed and Resident #206 attempted to punch him/her in the face, but hit his/her inner upper arm. LPN#3 sustained a bruise. LPN#3 indicated that staff asked him/her to attempt to assist the resident out of the room because they were afraid to approach the resident. Interview with NA#4 on 8/30/16 at 4:00PM identified that Resident #206 was found by Resident #134 in his/her room. Resident #134 indicated he/she was afraid to enter and reported the incident to staff. NA#4 indicated that he/she would not approach the resident because Resident#206 was unpredictable. NA#4 notified LPN#3, who entered the room, put his/her hand out to assist the resident and the resident punched LPN #3 almost in the face but when LPN #3 attempted to avoid the punch, he/she was hit in the arm. Interview with LPN #2 on 8/30/16 at 3:50PM identified he/she was unaware on 8/25/16 that the resident was in Resident #134's room on the bed. Additionally, after the resident was removed from Resident #134's room, Resident #206 attempted to punch him/her. The resident proceeded to chase LPN#2 around the unit, at one point with a leg rest in hand. Emergency 911 was called and the resident was sent to the hospital. LPN#2 indicated that the resident had been aggressive since admission and had tried to hit him/her. The nurse's note dated 8/26/16 at 5:00PM identified the resident returned from hospital, urinated on the floor, grabbed a jonnie and attempted to hit staff members. The note indicated the supervisor was notified, the family was able to calm the resident and medication was administered and resident was noted in the lounge napping on and off. The nurse's note dated 8/27/16 9:00AM identified the resident was aggressive, throwing things at the staff, slapped medications out of a nurse's hand and refused to take ordered medications. The resident took a carton of milk and threw it. Resident #206 was trying to open the fire alarm box and was hitting the wall, going in other resident ' s room and taking their things. Staff were unable to calm the resident down. The resident was physically and verbally abusive to the point that staff were scared. MD#1 examined the resident and ordered to transfer the resident to the hospital. Nurses note dated 8/27/16 at 4:15PM identified the resident returned from hospital, was more calm, had no aggression was taking medications and walking around and taking everything he/she sees. The care plan update dated 8/27/16 identified if unsafe, redirect and utilize the medications as per physician orders. The accident/incident report dated 8/29/16, untimed, identified that Resident #206 hit and kicked a nurse and pushed Person #2 into a wall. A statement by LPN#1 dated 8/29/16 identified that while passing morning medication, he/she heard someone calling for help from the lounge area. When LPN#1 went down to the lounge, he/she observed Resident #206 in the lounge facing Person #2, pushing a table at him/her and yelling. An addendum statement by LPN#1 identified that approximately 5-10 minutes prior to the escalated behavior, Resident #206 had been arguing with Resident #134 about his/her attempt to enter Resident #134's room. As LPN#1 passed the resident, Resident #206 struck LPN #1's left side then turned down the hallway, banging the medication cart as he/she went by. Resident#206 told Resident #134 he/she would knock him/her down if he/she couldn't go into Resident# 134's room. Interview with LPN#1 on 8/30/16 at 12:10PM identified that on 8/29/16 during the medication administration, Resident #206 was observed in the doorway of Resident #134's room arguing with the resident. Resident #206 threatened Resident #134 indicating he/she would knock the resident down if he/she told him/her to get out of the room. LPN#1 indicated he/she walked passed Resident #206 into the room and when he/she walked by Resident #206, the resident punched him/her in the back with his/her fist. Resident #206 appeared angry and proceeded to pound his/her fists on the medication cart. LPN#1 shut Resident #134's door and directed a nurse aide to get the supervisor. Interview with Person #2 on 8/30/16 at 10:00AM identified that on 8/29/16 at 9:40AM, Person #2 was in the second floor lounge. Resident #206 was in the hallway outside the door yelling at LPN#1, who was standing at the medication cart in the hallway in the room next to the lounge. The resident was pounding on the medication cart then entered the lounge and began yelling at Person #2 with profanity. Resident #206 prevented Person #2 from exiting the lounge. Resident #206 moved closer to Person #2 while continuing to threaten and yell profanities. Person #2 attempted to talk to the resident to calm him/her in order to be able to leave the lounge. The resident would not allow Person #2 to exit and continued to yell. The resident then raised his/her arm in a fist at Person #2's face and above his/her head. Resident #206 grabbed Person #2's forearms and pushed him/her backwards and against the window. Person #2 yelled for help two times, however, no staff members responded or were in the area. Resident #206 yelled at Person #2 to stop yelling for help. Person #2 again yelled for help two more times and a visitor, Person #3, came to the lounge and began waving his/her arms and called for the staff to come help. LPN #1, NA #7 and NA #6 responded to the lounge and the resident began pushing a cart with a basin of water on top of it into Person #2. Resident #206 was still blocking the exit and Person #2 could not exit the lounge. Staff were able to assist the resident aside so Person #2 could exit the lounge. Resident was then observed threatening staff and trying to push a wheelchair into staff members. Emergency 911 was called and the resident was sent to the hospital for an evaluation. Interview on 8/30/16 at 12:20PM with RN#1, who was the nursing supervisor on 8/29/16, identified that he/she heard someone yelling for help and a nurse aide came to the desk to report that LPN#1 needed assistance. LPN#1 reported that Resident #206 was exhibiting behaviors and hit him/her in the back. RN#1 indicated that Resident #206 was wandering on the unit and that many staff members were around at that time. RN#1 indicated that he/she directed staff to watch the resident because the resident had already hit/kicked a nurse and he/she did not want him/her to injure a resident. RN#1 indicated a specific staff member was not assigned to stay with the resident to provide supervision, but all staff were to keep an eye on the resident. RN #1 was unable to identify how all staff would be able to watch the resident when they were assigned to provide care to other residents. Interview with NA#7 on 9/1/16 at 9:05AM identified that the morning of 8/29/16 he/she was feeding a resident when he/she heard yelling in the hall. NA #7 went out into the hall and saw Resident #206 in the doorway of Resident #134 with LPN #1. LPN#1 was trying to keep Resident #206 from entering Resident #134's room. As LPN #1 walked by Resident #206, he/she hit LPN#1 in the back. LPN #1 told NA#6 to go and get LPN#4, Resident #206's nurse. LPN #1 was able to close Resident #134's door and after that NA#7 indicated he/she went back to feed the resident he/she was feeding prior to the incident. NA#7 indicated he/she did not see RN#1 after this incident, nor did he/she hear RN#1 direct staff to stay with or watch Resident #206. NA#7 indicated he/she went back to feeding the other resident and a few minutes later, while in a room feeding, heard Person #3 calling for help. NA#7 responded to the area, and at that time, Resident #206 had Person #3 in the lounge. LPN#1 directed NA#7 to go and get RN#1. NA#7 indicated RN#1 did not direct him/her to stay with and/or watch Resident #206 after the first incident with LPN#1. Interview with NA#6 on 9/1/16 at 9:15AM identified that the morning of 8/29/16 he/she was down the other end of the hall when he/she heard LPN#1 screaming for help. NA#6 responded and observed Resident #206 with the milk cart outside of Resident #134's room. NA#6 indicated that he/she thought that RN#1 went to the desk to do the paperwork to send Resident #206 to the hospital because of the incident. NA#6 indicated he/she went back to picking up the breakfast trays and was down near the nurse ' s station when he/she heard someone screaming for help. NA#6 responded and observed Resident #206 with Person #3 in the lounge. NA#6 indicated that at no time did RN#1 direct him/her to stay with and/or watch Resident #206 after the first incident with LPN#1. ¡@ Interview with the DNS on 8/30/16 at 1:05PM identified that after the resident struck the nurse and had the altercation with Resident #134, he/she should have been placed on a 1:1 observation until he/she was transferred to the hospital. Additionally, the DNS indicated that prior to the interaction on 8/29/16, the resident was constantly watched by staff and staff knew where the resident was at all times. Review of the facility policy on 1:1 observation identified residents that require constant observation for their safety or the safety of others will be placed on one to one observation. The nursing supervisor and/or administrator may place a resident on one to one if the safety of the resident or others is in jeopardy. Guidelines for one to one are; unsafe wandering on unit or off, resident assault - physical or sexual, suicide watch, agitation - when the resident is at risk for injury. The supervisor will designate a staff member to do the one to one, DNS/Administrator will be notified, in addition to the attending physician and family, a nurse ' s note is written detailing the reason, including specific behavior, duration of one to one, and that the attending physician was notified. The care plan and the nurse aide card will be updated immediately, and resident/reason/and duration of one to one will be documented on 24 hour report. One to one instructions included that staff will remain with the resident at all times, a replacement staff is required if staff have to leave the resident even if for a few minutes. ¡@ ¡@ The facility failed to provide adequate nursing supervision to a resident who exhibited aggressive physical behaviors ensuring the safety of residents resulting in the finding of immediate jeopardy.¡@ ¡@ ¡@ ¡@ ¡@ ¡@ ¡@ ¡@

Based on clinical record review, review of facility documentation, and interview, the facility failed to provide care and services to prevent a pressure ulcer for 1 of 2 residents (Resident #2) reviewed for pressure ulcers. The Findings include: Resident #2's [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility on [DATE]. The Admission Care Plan dated 6/11/16 identified skin was intact but Resident #2 was at risk for breakdown due to skin fragility, incontinence, fracture, and impaired mobility. Interventions included to provide a pressure reducing mattress, monitor skin during morning and evening care and monitor skin before and after removing assistive/adaptive device - boot left lower extremity. physician's orders [REDACTED]. The Admission Assessment ((MDS) dated [DATE] identified Resident #2 was cognitively intact (BIMS 15), required extensive assistance of 2 staff with bed mobility, transfers and toilet use, required extensive assistance of 1 staff with bathing, dressing, grooming, ambulation and locomotion on and off unit, and was independent with eating after set up. Additionally, there were no unhealed pressure ulcers noted. Review of the Nursing Admission Evaluation identified a boot on left leg and no identified pressure ulcers. Review of the Nurse's Notes from 6/11/16 through 6/23/16 identified the left boot was in place however there was no documentation addressing the condition of resident's skin. Review of the Weekly Skin Assessments dated 6/14/16 and 6/21/16 identified no change in skin condition. Review of the Orthopedic Consultation Report dated 6/24/16, 13 days after admission, identified there was now skin breakdown to the left lateral foot and heel. Recommendations included dressing changes daily and the need to support and offload areas of pressure. Review of the physician's orders [REDACTED]. The corresponding Treatment Administration Record (TAR) identified dressing changes daily to left foot and heel however there were no times or shifts identified that would indicate when the dressing change was to be completed. Instead, documented in the hour column of the TAR was For Your Information (FYI). Further, the TAR lacked nursing signatures for the daily dressing change. Review of the Nurse's Notes from 6/24/16 through 6/26/16 identified that although there was documentation indicating the dressing to the left foot was changed daily, it failed to reflect evidence that the left lateral foot and heel pressure ulcers were accurately assessed and measured. Review of the Weekly Pressure Ulcer Flow Sheet identified both pressure ulcers were acquired on 6/24/16, however the first entry for wound assessment was dated 6/27/16. The flow sheet identified a left lateral foot unstageable pressure ulcer measuring 5 centimeters (cm) long by 4cm wide by 0.1cm deep with small amount serosanguinous drainage, wound bed 20% slough and 80% red/necrotic tissue. The left heel was identified with an unstageable pressure ulcer measuring 3cm long by 3cm wide by 0.1cm deep, small amount serosanguinous drainage, wound bed 20% slough and 80% red/necrotic tissue. treatment for [REDACTED]. Interview and review of the clinical record with RN #1 on 8/31/16 at 10:00AM identified that the unstageable pressure ulcers to Resident #2's left foot were identified during the orthopedic follow-up appointment on 6/24/16, 13 days after admission. When asked if the nurses were checking Resident #2's skin daily, RN #1 indicated they were, however could not produce any documentation to support this other than the 2 weekly skin checks completed on 6/14/16 and 6/21/16. Additionally, RN #1 indicated that he/she classified the pressure ulcers as being hospital acquired because they were caused by the boot to the resident's left foot which Resident #2 was admitted with. Interview with MD #2 on 8/31/16 at 3:50PM identified that Resident #2 had a stable fracture to the left 1st metatarsal and the boot's function was to provide support for ambulation. Additionally, that the boot should have been removed for bathing and that the skin under the boot should have been assessed at least daily. Furthermore, that if skin checks were being done daily, the pressure ulcers might have been identified sooner. Interview and review of the clinical record with the DNS on 9/1/19 at 8:30AM identified she could not explain why there was no documentation to support that the resident's skin had been checked daily prior to the orthopedic follow-up appointment on 6/24/16, when MD #2 identified skin breakdown. Additionally, it was his/her expectation that once the pressure ulcers were identified by MD #2 on 6/24/16, a thorough wound assessment including measurements and description should have been completed. Furthermore, it was his/her expectation that nurses should contact the physician when clarification of orders are needed. Review of the facility' Pressure Ulcer General Prevention Protocols identified, in part, that all residents will have a skin integrity check daily by the nursing assistant. Additionally, that changes in skin integrity assessed by the nursing assistant will be reported immediately to the licensed nurse.

Based on record review and staff interview for 1 of 6 sampled residents reviewed for falls (R#58) the facility failed to provide supervision to prevent a fall with injury. The findings include: Resident #58's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident as severely cognitively impaired, requiring extensive assistance of two staff members for bed mobility, toileting and hygiene. The MDS further identified the resident required extensive assistance of one staff member for transfers, dressing, eating and walking. A fall risk assessment dated [DATE] identified the resident a high risk for falls. A care plan dated 9/10/12 identified a risk for falls related to a history of falls. Interventions included to keep bed in low position, toilet per toileting plan and anticipate needs. Physician orders [REDACTED]. Physical therapy notes dated 10/4/12 identified assistance required with gait via contact guard and rolling walker. The physical therapy notes further identify the resident had functional limitations of decreased cognition, decreased functional mobility that impaired safety. Nurses notes dated 10/11/12 at 6:10 AM identified the NA toileted R#58, the resident got up suddenly, lost his/her balance and fell . The resident hit her/his head on the corner of the sink before the NA could prevent it. The resident sustained [REDACTED]. The resident was transferred to the emergency department. Nurses notes dated 9/12/12 at 2:50 PM identified the resident returned to the facility. Hospital discharge summary dated 10/11/12 diagnosed the resident with a closed spinal/cervical fracture without spinal cord injury. A cervical collar was in place upon re-admission to the facility. Interview with NA#1 on 9/6/13 at 6:07 AM identified that on 10/11/12 she assisted the resident to the toilet. NA#1 further identified that she told the resident not to get up from the toilet, and left the bathroom to go to the resident's chair in the bedroom to obtain underclothes. NA#1 stated that as she was leaving the bathroom to enter the room, she heard the resident fall from the toilet. Interview with the Physical Therapist on 9/5/13 at 11:30 AM, and review of PT notes identified that based on the evaluation dated 9/11/12 and 10/4/12, the resident was not to be left alone and the NA was to be near the resident while providing care.

Based on clinical record review and staff interview for one of three sampled residents reviewed for falls (R#188), the facility failed to notify the physician in a timely manner. The findings include: Resident #188 ' s [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as moderately, cognitively impaired and independent with bed mobility, transfers, walking, and eating. The resident required limited assistance with dressing and personal hygiene. A fall risk assessment dated [DATE] identified the resident a high risk for falls. A RCP dated 10/23/11 identified a problem with falls with interventions that included to utilize a pad alarm when out of bed, to provide non-skid socks and to encourage resident to sit at the nurse's station. A physician's orders [REDACTED]. A nurse's note dated 11/27/11 at 9:00 AM identified the resident was lying prone on the floor beside the bed, with the left side of the head against the baseboard heater. A moderate amount of blood was observed from the left nares. The resident was noted to sustain a 4 cm raised area to the left temporal area. The skin surrounding the bump was red and redness was noted to the left eye. A neurological assessment completed 11/27/11 at 9:15 AM to 11/30/11 on the 11:00 PM to 7:00 AM shift noted that pupils were not able to be assessed because the resident refused and nurse's note dated 11/28/11 from 7:00 AM to 3:00 PM noted the left eye was closed, bruised and with swelling extending to the left face area. A nurse's note dated 11/27/11 at 9:30 AM identified that a message was left with the physician's service, the responsible party and "awaiting a call back." However the physician did not return the phone call until 11/28/11, after the facility notified him of the resident's condition. Interview with MD #1 on 7/26/12 at 11:35 AM identified that he could not remember if he was on call that weekend, but had he been notified the resident sustained [REDACTED]. Interview with RN# 2 on 7/26/12 at 12:06 PM identified that she did not call the physician back on 11/27/11 because the resident "was at his baseline." Interview with the DNS on 7/26/11 at 1:40 PM identified that the physician was to have been re-notified by the RN after he did not call back within 1 to 2 hours.

Based on clinical record reviews, facility documentation and interviews for 2 of 3 sampled residents (Residents #1 and 3) with memory and cognition problems, the facility failed to ensure that the residents had adequate supervision and/or was free of environmental hazards to prevent an accident. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified that the resident was at high risk for falls. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated that Resident #1 had both short term and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance from staff with transfers and had a recent fall (within 31-180 days). A physical restraint review was done on 4/15/10 and determined that a Velcro seatbelt was necessary as part of the resident's care due to Resident's #1's impulsiveness which impeded safety awareness and judgement due to dementia. An interview with Nurse Aide (NA) #1 on 9/15/10 at 10:45AM indicated that on 7/12/10 at approximately 7:00 PM, he/she assisted the resident out of bed to the wheelchair after the resident was trying to get out of bed. NA #1 placed Resident #1 in the hallway with a chair alarm and Velcro seatbelt on the resident. Review of facility documentation indicated that on 7/12/10 at approximately 8:00PM, the resident was found on the floor with the chair alarm sounding. The resident was transferred tot he hospital and admitted with a scalp laceration and a right femur fracture. Facility documentation indicated that Resident #1 had been seen releasing the Velcro seatbelt in the recent past. NA #1 indicated that he/she was aware that the resident had been releasing the seatbelt and had made attempts to stand/transfer without assistance and "seemed restless". NA#1 indicated that the nurse was not informed of Resident's #1 restlessness. The resident was last seen by NA #1 at 7 PM. An interview with LPN #1 on 9/15/10 at 11:35 indicated that he/she was not aware that Resident #1 had been releasing the seatbelt and making attempts to stand without assistance. 2. Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated that Resident #3 had both short and long term memory problems, moderately impaired cognitive skills for daily decision making, exhibited daily wandering behaviors, and was independent in locomotion. Facility documentation indicated that on 8/22/10 at approximately 7:10 PM, Resident #3 drank a bottle of body wash and was observed spitting. An interview with Nurse Aide #3 on 8/15/10 at 3:30 PM indicated that on 8/22/10 he/she left a bottle of body wash in the hallway of the dementia unit when he/she went to assist another resident. NA #3 indicated while he/she was assisting another resident, Resident #3 took the bottle of body wash and drank it. Resident #3 was evaluated at the hospital on [DATE] and no injuries were identified. The resident returned to the nursing home later that evening. An interview with the Director of Nurses on 9/15/10 at 12:08 and review of facility documentation identified that staff has been in-serviced on not leaving chemical products unattended on the units.