Every finding on record at New Horizons Care Center

Based on medical record review, staff interview, incident report review, and policy and procedure review, the facility failed to protect the resident's right to be from physical abuse by a resident for 1 of 4 sample residents (#3) reviewed for abuse. This failure resulted in actual harm to resident #3 who suffered fractures. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which included Alzheimer's dementia, anxiety disorder, and depression. Further review showed resident #3 (victim) was independent with mobility, including walking. Review of the quarterly MDS assessment dated [DATE] showed resident #2 (perpetrator) had severe cognitive impairment and diagnoses which included Alzheimer's dementia, and anxiety disorder. Further review showed resident #2 was independent with mobility, including walking. Review of the resident's behavioral care plan dated 10/2/25 showed the resident displayed physical and behavioral symptoms directed toward others, including hitting, pushing, and grabbing. Further review showed interventions which included Evaluate for signs of irritation when interacting with others and Attempt to redirect when . upset with others. The following concerns were identified:a. Review of the facility incident report dated 4/15/26 showed at 2:05 PM resident #3 was standing in the atrium and was uncomfortable with how close resident #2 was standing next to him/her. Resident #3 told resident #2 to leave or move and waved a hand in a swatting motion. Resident #2 then pushed resident #3 with both hands against resident #3's abdomen. Resident #3 fell backwards landing on his/her coccyx. The two residents were separated following the fall. Resident #3 expressed pain in both wrists, exhibited wrist swelling and bruising, and became unresponsive at which time emergency services was called. Further review showed resident #3 was sent to the emergency room for further evaluation.b. Review of the emergency room report dated 4/15/26 and timed 5:23 PM showed resident #3 had fallen and experienced a syncopal episode. The resident reported both wrists hurt bad and was unable to squeeze the physician's fingers.c. Review of the wrist X-ray report dated 4/15/26 and timed 7:35 PM showed resident #3 had a mildly displaced intra-articular fracture of the right distal radius, mildly displaced fracture of the left distal radius with intra-articular extension and fracture of the styloid process of the ulna.d. Interview with LPN #1 on 6/9/26 at 11:03 AM revealed she had witnessed resident #3 fall to the ground. Further, she revealed resident #2 had been walking around aggressively that day prior to him/her pushing resident #3.e. Interview with CNA #1 on 6/9/26 at 10:31 AM revealed she witnessed resident #2 push resident #3 and saw resident #3 land on his/her buttocks. She revealed It happened so fast; we didn't have time to redirect.f. Interview with the DON on 6/9/26 at 3:57 PM revealed staff were expected to redirect and follow care plans when the residents act out. 2. Review of the facility policy titled Resident to Resident Altercations last revised 9/3/2024 showed .1. Facility staff will monitor residents for aggressive / inappropriate behavior towards other residents. and .2. If two residents are involved in an altercation, staff will .a. separate the residents and institute measures to calm the situation. 3. Review of the facility policy titled Abuse Prevention Program last revised 9/3/24 showed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal. mental, sexual, or physical abuse, and physical or chemical restraint not required to treat resident's symptoms . As part of the residents' abuse prevention, the administration will .1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . or any individual.

Based on medical record review, and staff and resident representative interview, the facility failed to notify the responsible party following a change of condition in 1 of 3 sampled residents (#1) reviewed. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had severe cognitive impairment, and had diagnoses which included, Alzheimer's dementia, diabetes mellitus, and urinary incontinence. Further review showed the resident required staff assistance with bed mobility and personal cares. Review of a 7/30/25 Braden score assessment showed the resident was at severe risk for developing pressure ulcers. The following concerns were identified:a. Review of the nursing progress note dated 7/13/25 and timed 12:14 PM showed . There was a small opening on [his/her] coccyx. Wound was cleaned and a 4X4 Mepilex was applied.b. Review of the nursing progress note dated 7/14/25 and timed 12:23 PM showed . Spoke with wound care nurse. about residents coccyx wound. if worsening occurs to notify wound care nurse right away.c. Review of the nursing progress note dated 7/15/25 and timed 9:52 PM showed . Resident has a coccyx wound with calazime getting applied, when this LPN checked the residents wound it was tender and resident had a reaction when LPN was assessing it. Calazime was reapplied in a thin layer to open area.d. Review of the 7/30/25 document titled Care Plan Conference Summary showed the coccyx wound was discussed with the resident's representative. Review of the resident's medical record showed no evidence the resident's representative was notified of the wound prior to the care conference. 2. Interview with the wound care nurse on 6/9/26 at 8:59 AM confirmed the resident's representative was not notified of the coccyx wound prior to his/her care plan conference on 7/30/25. 3. Interview with the resident's representative on 6/9/26 at 8:45 AM confirmed she had not been notified of the coccyx wound prior to the care conference on 7/30/25. 4. Interview with the DON on 6/9/26 at 3:39 PM revealed staff were expected to notify the resident representatives Anytime there is a change of condition, from outside their norm.

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to notify family of changes for 1 of 3 sample residents (#1). The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15, which indicated s/he had moderate cognitive impairment, and diagnoses which included cerebral infarction due to occlusion. Review of the facility incident review showed the resident had a fall during a transfer on 2/16/25. The following concerns were identified: a. Review of a progress note dated 2/18/25 and timed 3:30 AM showed the resident's representative called the facility on 2/17/25 at 7:40 PM to express a concern that the resident had a fall on 2/16/25 that was not reported to her, and the resident may have hurt [his/her] wrist. Further review showed that following the call the resident was assessed by the nurse and had no obvious open areas, no deformities or swelling, no apparent guarding or motor deficits in any limb; close inspection of left wrist shows no grimace or overt signs of pain elicited upon passive manipulation and observed active motion of the wrist: there is a slight bluish-colored bruising with indistince margins at lateral aspect of the wrist and a small, dry scab approx 1cm [centimeter] long x 2mm [millimeter] wide on the dorsal aspect of the wrist and this does not appear to need a bandage. b. Review of a progress note dated 2/18/25 and timed 3:24 PM showed an x-ray of the resident's left wrist showed no fracture. c. Interview with CNA #1 on 4/2/25 at 10:31 AM revealed the resident pulled his/her right foot up during the transfer, and when s/he started to slide out of the sling, the CNA called for assistance and lowered the resident to the floor. Further interview revealed the resident had not lifted his/her foot before during a transfer. The CNA revealed she reported the incident to the nurse on duty at that time. d. Interview with the DON on 4/2/25 at 11:04 AM confirmed the resident's representative was not called after the fall, and the facility policy was to notify the resident's family after a fall. Further interview revealed the nurse on duty was a traveler and was not aware of the policy to notify family after an assisted fall. Further interview revealed immediate education was given to the nurse on the policy. e. Interview with the resident representative for resident #1 on 4/2/25 at 12:25 PM revealed that during a visit with the resident on 2/17/25 the resident had told her s/he had a fall during a transfer on 2/16/25. Further interview revealed the resident had a bruise on his/her wrist, and the representative was upset she had not been notified about the fall. 2. Review of the policy titled Resident Falls last reviewed on 5/1/23 showed .In the event of a fall, family members of residents will be notified as well as the provider if the resident sustains an injury or possible injury .**A fall is anytime a patient falls, or a patient would have fallen if staff would not have been there to assist the patient to the floor.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitored for 6 of 6 sample residents (#2, #9, #36, #44, #45, #47) and failed to ensure PRN orders for psychotropic medications were limited to 14 days for 1 of 6 sample residents (#44) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #44 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment and diagnoses which included Alzheimers/dementia with agitation and depression. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and the resident exhibited behaviors such as verbal behavior directed at others and wandering. Further review showed the resident received antipsychotic medication and antidepressent medication during the look-back period. Review of the physician orders showed the resident received olanzapine (antipsychotic) 7.5 milligrams (mg) by mouth twice a day, sertraline (antidepressant) 50 mg by mouth every day, and lorazepam (antipsychotic) 0.5 mg by mouth every day, PRN. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. b. Review of the physician's progress notes dated 10/23/24 showed the physician re-ordered the use of lorazepam 0.5 mg by mouth daily as needed, however there was no indication of a stop date. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimers/dementia, anxiety and depression. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and exhibited behaviors of inattention, disorganized thinking, physical behavior directed toward others, rejection of care, and wandering. Further review showed the resident received antipsychotic medication and antidepressent medication during the look-back period. Review of the physician orders showed the resident received lorazepam (antidepressant) 0.5 mg by mouth three times a day, quetiapine (antipsychotic) 150mg by mouth twice a day, and quetiapine (antipsychotic) 75mg by mouth at every lunch. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #45 had a BIMS score of 2 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's dementia, anxiety, and agitation due to dementia. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and the resident exhibited behaviors such as verbal behavior directed at others and wandering. Further review showed the resident received antipsychotic medication and antidepressant medication during the look-back period. Review of the physician orders showed the resident received sertraline (antidepressant) 50 mg by mouth daily and lorazepam (antianxiety) .5mg by mouth every day as needed (PRN) for agitation-sedation. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #47 had a BIMS score of 7 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimers/dementia, anxiety and depression. The MDS showed the resident had a mood score of 1, which indicated minimal signs or symptoms of depression, and exhibited behaviors of inattention, delusions, verbal behavior symptoms directed toward others, rejection of care, and wandering. Further review showed the resident received antipsychotic medication and antidepressant medication during the look-back period. Review of the physician orders showed the resident received quetiapine (antipsychotic) 100 mg by mouth twice a day, lorazepam (antianxiety) 1 mg by mouth at noon and 1 mg by mouth at night. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 51658 5. Review of the quarterly MDS assessment dated [DATE] showed resident #9 had a BIMS score of 14 out of 15, which indicated intact cognition, and diagnoses which included anxiety disorder, depression and insomnia. Review of the physician orders for the resident showed an order for venlafaxine (antidepressant) 150 mg daily and trazodone (antidepressant) 50 mg daily. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 35081 6. Review of the admission MDS assessment dated [DATE] showed resident #2 resident had short-term memory loss and diagnoses which included Alzheimer's dementia, anxiety disorder, and depression. Further review showed the resident didn't exhibit any behaviors during the look-back period. Review of the medication administration record showed the resident received fluoxetine (antidepressant) 20 mg daily, buspirone (antianxiety) 10 mg daily, lorazepam (antianxiety) 0.5 mg twice daily, and olanzapine (antipsychotic) 10 mg daily. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 7. Interview with the DON on 1/8/25 at 4:31 PM confirmed the facility had not identified and did not monitor medication specific target symptoms for the psychotropic medications. 8. Review of the policy titled Antipsychotic medication use/PRN psychotropic/ antipsychotic order procedure last reviewed 5/1/23 showed 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications .PRN orders for psychotropic drugs are limited to 14 days initially. PRN orders for anxiolytics and antipsychotics must be reviewed for appropriateness 14 days after initiation. Providers must document the rational [sic]/benefit for continuing this prn order in the clinical record and must also indicate when this order will be re-evaluated. 1. Stop dates will be put in when ordering PRN psychotropic. They will not exceed 14 days for initial order. If provider documents the continue [sic] need and extends the timeframe, order can be adjusted to fit the timeframe. Timeframe cannot be indefinite or lifetime, 2-12 months max. This can be repeated as deemed necessary .

Based on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents right to request/refuse/discontinue treatment for 1 of 1 sample residents (#45) with a do not resuscitate (DNR) status. The findings were: 1. Review of the electronic medical record on 1/7/25 at 2:26 PM showed resident #45 had a DNR code status, however there was no evidence the resident elected the DNR code status. 2. Interview with the DON on 1/9/25 at 10 AM revealed the electronic medical record showed no sign of a declaration of code status. Further interview revealed the provider should have filled out the code status; however, it was not in the electronic medical record. 3. Review of the facility's policy DNR Policy updated 3/15/18 showed .1. At the time of admission the Social Services person or Charge Nurse shall determine if the resident has executed a Living Will or has a signed statement for DNR.5. The physician shall assume the responsibility for writing the DNR order by: a. Writing and dating the order on the Physician's order sheet b. The order will be updated every 30 days and signed by the Physician. 6. If the resident is mentally incompetent (determined by a Physician), the resident's guardian and/or the Durable POA for health care decisions (designated by the Living Will or by written statement from the resident prior to the mental incompetency) may make the DNR designation.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure an appropriate diagnoses and attempt removal of an indwelling urinary catheter for 1of 1 sample resident (#7). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out 15, which indicated the resident was cognitively intact, and no genitourinary diagnoses except renal insufficiency, renal failure, or end-stage renal disease. Further review showed the resident was independent with toileting hygiene, personal hygiene, and toilet transfer, was always continent of bowel, was not on a toileting program, and had an indwelling catheter placed. The following concerns were identified: a. Observation on 1/7/25 at 9:21 AM showed the resident was in his/her room and a catheter drainage bag was hanging on the side of the resident's trash can. b. Review of a hospital discharge note dated 6/13/24 showed the resident was discharged from the hospital to the facility following antibiotic therapy for 21 days. Further review showed .[S/he] will continue with Foley catheter secondary to urine incontinence and recurrent infection . c. Review of the physician orders showed no evidence of an appropriate diagnosis for the placement of a foley catheter. d. Interview with the DON on 1/8/25 at 4:16 PM revealed the resident previously had wounds on his/her legs and the catheter was placed to prevent infections in the legs. She revealed the facility had not attempted an external catheter or bladder retraining and she was aware the resident did not have an appropriate diagnosis for catheter placement. 2. Review of a facility policy titled Bowel & Bladder Training last revised on 8/15/18 showed .All residents who are admitted to [the facility] will be evaluated for Bowel and Bladder training The functions of the bowel and bladder conditions of each resident will be reassessed on a quarterly basis in conjunction with the care plan and MDS conferences, to assure the monitoring of these conditions and to enable prompt treatment if a problem should occur in bowel and bladder function .Residents will not qualify for Bowel or Bladder retraining if they have the following conditions: Multiple Sclerosis, Quadriplegia, neurogenic bladder, severe benign prostatic hypertrophy, comatose, Alzheimer's disease, combative and uncooperative to retraining, and if the resident is unable to cooperate due to being cognitively impaired .

Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received services to maintain good personal hygiene for 2 of 3 sample residents (#7, #33) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cerebrovascular accident, transient ischemic attack, or stroke and Parkinson's disease. Further review showed the resident required partial/moderate assistance with bathing and upper and lower body dressing. The following concerns were identified: a. Interview with the resident on 1/7/25 at 9:21 AM revealed s/he did not feel there was enough staff because s/he did not get showers regularly. b. Review of the bathing records for October, November, and December of 2024 and January of 2025 showed the resident went 6 days without a shower from 10/18/24 to 10/25/24, 11/22/24 to 11/29/24, 12/6/24 to 12/13/24, and 12/13/24 to 12/20/24. Further review showed the resident went 10 days without a shower from 12/27/24 to 1/7/25. There were no documented refusals for the resident. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #33 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included Parkinson's disease. Further review showed the resident required partial/moderate assistance with bathing and lower body dressing. The following concerns were identified: a. Interview with the resident on 1/7/25 at 11:03 AM revealed the facility only offered showers 2 days per week and at times s/he did not receive a shower because there was not enough staff. b. Review of the bathing records for October, November, and December of 2024 and January of 2025 showed the resident went 6 days without a shower from 10/1/24 to 10/9/24, for 9 days from 10/15/24 to 10/25/24, for 10 days from 10/25/24 to 11/5/24, for 6 days from 11/8/24 to 11/15/24, for 9 days from 11/19/24 to 11/29/24, for 6 days from 12/6/24 to 12/13/24 and 12/13/24 to 12/20/24, and for 10 days from 12/27/24 to 1/7/25. Further review showed the resident refused bathing on 10/4/24, 10/18/24, 10/29/24, 11/12/24, and 11/22/24 and there was no evidence the resident was offered bathing on another day. 3. Interview with the DON on 1/8/25 at 4:24 PM revealed residents should get at least 1 shower per week and ideally would have 2 showers per week. She confirmed showers were only provided on scheduled days and the facility did not have a plan to ensure bathing when the staff member who provided bathing was not available. 4. Review of the facility policy titled Resident Baths last revised on 6/15/18 showed .All residents will receive a full-body bath at least once a week. An exception to this may be made if the resident is so ill that it would not be in their best interest to insist. For residents who are ill or unable to tolerate the tub or shower bath, a bed bath is an acceptable substitute .3. All residents will be bathed more frequently as the desire, or if soiling has occurred that requires a tub bath or shower .10. We recognize that all residents have the right to refuse baths, clothing changes, and other measures of good hygiene. If any resident chooses not to accept these services, the CNA will inform the nurse in charge of that resident's care, of the refusal. The nurse will then have the responsibility of persuading the resident to accept care. If the resident still adamantly refuses the bath, the nurse will document in the resident's chart. Offers for the bath will be continued until the resident will accept .12. Residents will be scheduled for baths on two days per week, as has been the practice. If residents refuse a bath on one day, or if the care center staffing does not allow for baths on one of those days, it may be postponed until the next shift, the next day, or the next scheduled bath day. All schedules and cares give must always be in the best interest of care and comfort for the resident .

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 4 sample residents (#1, #3) reviewed for allegations of abuse. This failure resulted in actual harm to resident #1. The findings were: 1. Review of an incident dated 8/4/24 showed resident #2 punched resident #1 in the mouth with his/her fist. Further review showed resident #1 had a small cut and mild swelling. The following concerns were identified: a. Interview with RN #1 on 8/28/24 at 10:32 AM revealed resident #1 was demonstrating sundowners and was moving and straightening chairs. The RN revealed 2 residents near resident #1 asked the resident to leave the chairs alone and when s/he didn't, resident #2 stood up and popped resident #1 in the mouth. Further interview revealed resident #1 received an exterior abrasion, was upset, and was shocked. b. Interview with CNA #1 on 8/28/24 at 10:52 AM confirmed resident #1 was moving furniture and resident #2 punched resident #1 on the right side of his/her face. The CNA revealed resident #1 had bleeding and swelling to his/her face and s/he was cursing. The CNA revealed the resident continued to hold his/her face after it happened. Further interview revealed resident #2 was kind of dangerous, attacked staff, was aggressive without provocation, and usually goes after resident #1. c. Interview with CNA #2 8/28/24 at 10:22 AM revealed she did not observe the altercation; however, after it occurred, she observed the resident bleeding from his/her upper lip and would hold his/her face after the incident occurred. 2. Review of an incident dated 7/21/24 showed resident #3 walked up to resident #1, grabbed resident #1's face and resident #1 slapped resident #3 in the face. Review of Actions Taken to Prevent Incident in Future showed suggest scheduling Ativan twice per day for resident #3. The following concerns were identified: a. Interview with RN #1 on 8/28/24 at 10:32 PM revealed she did not witness the incident between the residents; however, the CNA reported both residents were shocked by the incident. b. Interview with CNA #3 on 8/28/24 at 10:48 AM revealed she was the only CNA on shift at the time of the incident and multiple residents were getting riled up. Resident #1 was sitting at the table, Resident #3 hit resident #1 in the face then resident #1 hit resident #3 in the face. Further interview revealed both residents were surprised by the incident. 3. Interview with the resident representative for resident #1 on 8/27/24 at 5:35 PM revealed he was unsure how the resident would have reacted to prior to current health state as the resident would not get into altercations; however, he revealed the resident would probably be surprised. 4. Interview with the resident representative for resident #3 on 8/27/24 at 6:02 PM revealed prior to the resident's current health state the resident would have been shocked and fearful if a similar incident had occurred. 5. Review of the policy titled Abuse Prevention Program last reviewed 5/1/23 showed .1. Protect our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .

Based on resident representative and staff interview, grievance review, state survey agency incident database review, and policy and procedure review, the facility failed to ensure allegations of abuse were reported for 1 of 4 sample residents (#3) reviewed for allegations for abuse. The findings were: 1. Interview with the resident representative for resident #3 on 8/27/24 at 6:02 PM revealed the resident's spouse reported a CNA had pushed the resident down onto a chair on 8/25/24; however, she did not think the facility believed the spouse. 2. Review of a Complaint/Grievance form dated 8/25/24 showed [Spouse of resident #3] said CNA pushed [resident] down to sit in chair. 2. Review of the state survey agency incident database showed no evidence an allegation of abuse was reported for resident #3 on or after 8/25/24. 3. Interview with CNA #4 on 8/27/24 at 6:21 PM revealed she was providing 1 to 1 care for resident #3 on 8/25/24. Further interview revealed the DON arrived at the facility and sent the CNA home due to an allegation of abuse; however, after the DON watched the camera footage, she was told there was no evidence she abused the resident. 4. Interview with the DON on 8/28/24 at 11:22 AM confirmed the spouse of resident #3 reported a staff member had pushed the resident down into a chair roughly; however, the spouse was unable to see if the CNA did anything. The DON revealed the CNA was sent home and an investigation was initiated. Further interview confirmed the allegation was not reported to the state survey agency. 5. Review of the policy titled Abuse Prevention Program last revised on 5/1/23 showed .7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure care plans were developed and implemented for 2 of 4 sample residents (#1, #2) following resident to resident altercations. The findings were: 1. Review of an incident dated 8/4/24 showed resident #2 punched resident #1 in the mouth with his/her fist. Further review showed resident #1 had a small cut and mild swelling. Review of an incident dated 7/21/24 showed resident #3 walked up to resident #1, grabbed resident #1's face, and resident #1 slapped resident #3 in the face. The following concerns were identified: a. Review of the care plan for resident #1 last updated 7/1/24 showed no resident specific interventions related to altercations on 7/21/24 or 8/4/24. b. Review of the care plan for resident #2 last updated 7/20/24 showed no resident specific interventions related to aggression toward other residents or staff and no updated interventions related to the altercation on 8/4/24. 2. Interview with CNA #1 on 8/28/24 at 10:58 PM revealed resident #2 was kind of dangerous, attacked staff, was aggressive without provocation, and usually goes after resident #1. Further interview revealed staff implemented things they knew about residents because resident specific interventions were not on the care plans. 3. Interview with the MDS assessment coordinator on 8/28/24 at 11:22 PM revealed care plans should communicate interventions to staff and care plans have been a struggle. Further interview revealed the facility did not complete any type of analysis following incidents and confirmed care plans were not updated with all identified interventions. 4. Review of the policy titled Resident to Resident Altercations last revised on 6/2/20 showed .If two residents are involved in an altercation, staff will .e. Review the events with Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents .g. Make any necessary changes in the care plan approaches to any or all of the involved individuals .

Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 resident (#58) reviewed for discharge to another nursing home or swing bed. The findings were: 1. Review of the 9/13/23 discharge MDS assessment for resident #58 showed s/he had been discharged to Another nursing home or swing bed and a return to the facility was not anticipated. The following concerns were identified: a. Review of the resident's medical record showed a 9/13/23 Facility Transfer form had been completed which indicated the resident had been transferred to a swing bed. Further review of the medical record showed no evidence a discharge summary had been completed. Interview with the DON on 10/17/23 at 5:19 PM confirmed the discharge summary had not been completed.

Based on review of the posted daily nurse staffing data and staff interview, the facility failed to ensure the daily posted nurse staffing information included all required elements. The census was 58. The findings were: 1. Review of the posted daily nurse staffing information for the dates 8/6/23 through 10/15/23 showed the following concerns: a. Review of the daily nurse information postings failed to include the number of RNs, LPNs, or CNAs on duty for each shift. 2. Interview with the DON on 10/19/23 at 9:02 AM revealed the facility was not aware of the requirement and confirmed the information posted was incomplete.

Based on review of medical records, staff interview and policy review the facility failed to protect the resident's right to be free from physical abuse by other residents for 1 of 8 sample residents (#7) reviewed for resident-to-resident abuse. This failure resulted in harm to resident #7, who sustained bruising from altercations with other residents. The findings were: 1. Review of the [DATE] admission MDS assessment for resident #7 showed the resident was admitted on [DATE] and had diagnoses which included arthritis, Alzheimer's disease, anxiety disorder, depression, cervical disc disorder with radiculopathy and other chronic pain. Further review showed the resident was unable to be understood and unable to complete a BIMS interview. The following concerns were identified: a. Review of the nursing progress note dated [DATE] at 12:50 AM showed This Resident entered a room that belongs to someone else and the other resident hit this Resident with [his/her] cane repeatedly on the legs. CNA intervened and prevented further abuse. Several bruises are noted on this Resident's legs. This Resident was agitated after altercation and continued to wander .On call provider gave one time 5 mg Haldol order which was given for this Resident's safety . b. Further review of the nursing progress note dated [DATE] at 5:08 AM showed .Bruising noted to head at hairline and [left] arm with multiple bruises in various places on [his/her] body . c. Review of the nursing progress note dated [DATE] at 3:43 PM showed .This afternoon resident has been very busy, wandering the halls, slamming doors, going in other residents rooms, etc. Resident has been hard to redirect at times. Resident continues to walk the halls . d. Review of the nursing progress note dated [DATE] at 3:12 PM showed This resident was sitting on the edge of a couch in the atrium and one of the men on the unit saw [resident #7] as [s/he] was sitting in a recliner across from this resident and he stood up and grabbed [resident #7's] arms and told [resident #7] [s/he] needed to get out of here. This RN went over and got him away from [resident #7] and other staff came to help and the man resident was yelling to get [him/her] gone. This [resident] when assessed on [his/her] arms, had a small thumb sized bruise on [his/her] right mid forearm and also a thumb sized bruise on [his/her] left wrist area . e. Review of the nursing progress note dated 3:43 PM on [DATE] showed [resident #7] was walking in the atrium and went in front of [another resident] and this resident stood up and pushed [his/her] walker into [resident #7] causing [him/her] to fall down . 2. Review of the care plan for resident #7 which was created at the resident's admission on [DATE] showed a lack of updated interventions for protecting the resident from injury due to wandering and resident to resident altercations. 3. Interview on [DATE] at 3:55 PM with the resident care coordinator revealed the resident spends time looking for his/her deceased spouse, displays exit-seeking behavior, goes into others' rooms and is difficult to redirect. 4. Interview with RN #1 on [DATE] at 9:33 AM revealed the main goal in keeping the resident safe was trying to keep him/her away from other residents that are touchy or react unpredictably. 5. Review of the undated Resident's Admit Package showed under Resident Rights Residents have the right to be free from verbal, sexual, physical or mental abuse; punishment for behaviors or involuntary seclusion. 6. Interview on [DATE] at 3 PM with the DON verified residents had a right to be safe from all abuse. The DON stated investigation on these cases was difficult because of the level of dementia of all of the residents. The DON confirmed the information in the nursing progress notes was all of the documentation there was on the incidents. The DON stated the facility should have tried harder to prevent the altercations.

Based on observation, resident interview, staff interview, and policy review the facility failed to ensure food temperatures were maintained at an acceptable temperature for 1 of 3 units (Pod 2). The findings were: Observation on 8/17/22 at 11 AM showed covered food was in the steamer table ready for staff to plate. Further observation showed plated food was delivered to Pod 2 at 12 PM. At 12:15 PM one of the last trays was served to the residents. The last tray of food was checked by the dietary manager. The meat temperature was measured at 102 Fahrenheit (F) and the vegetables at 120 degrees F. Interview at that time with the dietary manager confirmed the temperatures were lower than they should be. Further, she stated the cook takes the temperature of the food prior to serving the plates. The food temperature is not checked again after that initial check. Once the trays are loaded in the carts they go directly to the different pods. Once delivered to the pod, it is the nursing staff that serves the trays to the residents. Interview with resident #31 on 8/16/22 at 1:19 PM revealed the food was cold, and did not taste good. Interview with dietitian on 8/17/22 at 3:41 PM revealed the facility needed to recheck the food temperature once it gets out to the residents. It is something we need to improve on. Review of the policy Food Temperatures last reviewed 12/29/21, showed Food temperatures will be within state guidelines . 4. The Dietary Supervisor will monitor and take appropriate steps if temperatures are not in acceptable ranges.

Based on observation, medical record review, staff interview, and review of policy and procedures the facility failed to develop and implement a comprehensive person-centered care plan or 1 of 6 residents (# 18) reviewed for behavior indicators. The findings were: 1. Review of the care plan for resident #18, dated 6/10/22, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 7/9/22 at 11:44 PM showed [Res #18] and another resident wanting to go out outside after supper. Review of the progress note dated 7/12/22 at 6:24 PM showed Resident has attempted at least 5 times during 3p-7p shift to go out the patio doors. Resident has attempted to get on the elevator twice, stating [s/he] needed to go downstairs and outside to look for [her/his] phone. Review of the progress note dated 7/13/22 at 9:11 PM showed Resident wanting to go out on the patio or downstairs this evening; no extra staff to go with [her/him]. Complains to other residents which makes them angry also. Trying to get on elevator to get downstairs. Intervention by this RN. Resident did go over to [special care unit] and then could not get back out the doors. Heard banging on the doors by this RN. Review of the progress note dated 7/16/22 at 8:28 PM showed Resident consistently trying to get out patio doors. Wants to be outside. The following concerns were identified: a. Observations performed on 8/15/22 through 8/17/22 showed resident #18 frequently tried to get on the elevator with staff and visitors. b. Review of the care plan for resident #18 last dated 6/10/22 showed the only behavior indicator to be [S/he] tends to take things that don't belong to [her/him]. c. Interview with the DON on 8/17/22 at 4:47 PM revealed the resident attempted to elope frequently. It was further revealed this behavior should have been addressed in the care plan, along with interventions. d. Review of Policy and Procedure CCN-100-46 last reviewed on 12 /28/21, showed It will be the policy of the New Horizons Care Center to have a care plan on each resident admitted to the Care Center. These will be reviewed and revised quarterly and more often if the resident's condition warrants it.

Based on medical record review, staff interview, review of the facility's incident report, and policy and procedure review, the facility failed to ensure a thorough investigation of abuse allegations, and failed to ensure protection for 1 of 1 allegations (involving resident #11) made between 8/1/21 and 10/26/21 . The findings were: 1. Review of the 9/29/21 quarterly minimum data set (MDS) assessment revealed resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of 5 of 15. Continued review showed the resident required total dependence of two staff members for bed mobility, and extensive assistance of two staff members for transfers and toilet use. The following concerns were identified: a. Interview with certified nurse aide (CNA) #1 on 10/27/21 at 11:25 AM revealed during shift change on the night of 10/19/21 at approximately 10:30 PM, she needed assistance with resident #11, who had crawled out of bed and was seated on the floor towards the center of the room. She requested the help of CNA #2, and noted CNA #2 appeared very grouchy and irritated at that time. She stated they entered the room, and before she could help, CNA #2 walked over behind the resident, stated We are not doing this[OBSCENITY]tonight!, grabbed the resident under his/her arms, dragged the resident back over to his/her bed, lifted him/her up, and sat him/her on the edge of the bed without the assistance of CNA #1. At that point the resident stated s/he needed to use the restroom. CNA #1 further stated CNA #2 positioned the resident's wheelchair next to the bed, and again grabbed the resident under his/her arms and lifted him/her into the chair without the assistance of CNA #1. The two staff members then took the resident to the bathroom and transferred him/her to the toilet. When the resident had finished, the resident attempted to stand up from the toilet him/herself, insisting s/he wanted to try and perform the task him/herself. CNA #1 stated CNA #2 was standing back against the wall and making abrasive comments to the resident at that time, stating . come on, if you can do it then just stand up! CNA #1 then assisted the resident to standing position, performed perineal care, and guided the resident back to his/her wheelchair. CNA #1 stated CNA #2 wanted to put the resident back into bed, but CNA #1 stated she . did not think that was a good idea or safe after watching how [CNA #2] was acting . CNA #1 then brought the resident out to the common area, near the area where staff gave report. At that time, the resident was visibly agitated and upset, and began expressing his/her frustrations in Spanish. CNA #3, who spoke Spanish, noticed how upset the resident was, approached the resident, and attempted to calm him/her down. CNA #3 translated and stated to the staff present in the area the resident stated s/he was . being thrown around like a rag doll by the girl in blue scrubs . CNA #3 then asked the resident in Spanish who was .throwing [him/her] around? and the resident pointed at CNA #2. b. Interview with CNA #3 on 11/8/21 at 11:07 AM revealed on the night of 10/19/21, she had just come on shift and was awaiting report at approximately 10:45 PM, and observed CNA #1 and CNA #2 bringing resident #11 to the common area where she was waiting. CNA #3 stated she noticed the resident was visibly very upset, and expressing herself in Spanish. She further stated the resident was saying s/he wanted to go back to his/her room, and . all I wanted to do was go pee. She further stated the resident expressed . I want to go to bed but the girl in blue threw me around like a rag doll . and continued to ask why s/he was in the common area and not in his/her room. CNA #3 then retrieved a snack and juice for the resident in an attempt to calm him/her down. CNA #3 stated after getting the snacks, she wanted to take the resident to a different area to help deescalate the situation. Upon turning the wheelchair around, the resident noticed CNA #2 standing in the area, pointed at her stating That's the girl throwing me around like a rag doll!, and began getting upset again. CNA #3 then took the resident away from the area, and after CNA #1 finished giving report, the two staff members toileted the resident and put him/her to bed. c. Review of the resident's medical record showed no documentation referencing the allegation, no documentation of vital signs or an assessment of the resident had been performed. Review of the facility's incident report regarding this allegation showed no evidence any assessment had been made of the resident. d. Interview with registered nurse (RN) #1 on 11/3/21 at 7:14 PM revealed he came to the unit close to shift change, and observed CNA #2 who . seemed very upset and agitated, and heard her say she was 'sick of this[OBSCENITY]' as she walked through the unit. He stated after passing some medications, he returned to the common area and observed a group of CNAs having . an intense discussion . After completing a few more tasks, he stated he was approached by CNA #1 and informed of the incident. RN #1 further stated that while staff were giving report, resident #11 was in the common area very upset, and was talking to CNA #3 in Spanish. Further, when CNA #3 began to wheel the resident out of the area, the resident was expressing things in Spanish and strongly pointing at CNA #2. He stated he notified the on-call supervisor, and was directed to have CNA #1 file a complaint on behalf of the resident. Further interview revealed he did not perform an assessment of the resident after the alleged incident occurred, and was not directed to do so by the on-call supervisor when he notified her. He also stated he was not directed to make staffing adjustments, did not make any himself, and CNA #2 was still allowed to care for the resident after the alleged incident had occurred. e. Review of facility document Investigation Flowsheet Staff to Resident Abuse, Neglect, or Misappropriation of Resident Property for this incident, which was undated showed the incident was .reported to supervisor and the nurse said apparently stated [sic] that [the resident] didn't want [CNA #2] taking care of [him/her]. Supervisor wasn't aware of the abuse allegations. f. Review of the facility policy entitled Abuse Prevention Program, last reviewed 8/15/19, showed .residents have the right to be free from abuse . This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . Further review showed . the administration will: Protect our residents from abuse by anyone including . facility staff, other residents consultants, volunteers staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . Identify and assess all possible incidents of abuse . Protect residents during abuse investigations.

Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure range of motion (ROM) services were provided as ordered for 3 of 6 sample residents reviewed (#33, #35, #36) for restorative needs. The findings were: 1. Review of the 5/5/21 quarterly MDS assessment showed resident #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had short term and long term memory problems, range of motion impairment on both sides to the upper and lower extremities, required extensive physical assistance of 2 or more people for bed mobility, transfers, and toilet use, required total physical assistance of 1 person for personal hygiene, eating, and locomotion on unit, and required total physical assistance of 2 or more people for dressing. Observation on 6/22/21 at 9:11 AM showed the resident lying in bed on top of the bedding and a lift sling, fully clothed. Further observation showed the resident had a foam positioning wedge under his/her right side, heel lift boots on his/her bilateral feet, and a positioning cushion was placed in the resident's wheelchair. Review of a Restorative Therapy Referral dated 2/17/21 showed the resident was to receive therapy services 2 to 3 times per week to maintain range of motion. Further review showed the treatment was gentle PROM [passive range of motion] to shoulder, elbow, fingers. Encourage AROM [active range of motion] in BUE [bilateral upper extremities] first. (Both Shoulders etc) .PT [physical therapy] order: Gentle passive range of motion to bilateral lower extremities . The following concerns were identified: a. Review of the Restorative Care Flow Record dated May 2021 showed the resident did not receive restorative range of motion therapy from 5/1/21 to 5/9/21 and the document was marked closed for that time period. b. Review of the Restorative Care Flow Record dated June 2021 showed the resident did not receive restorative range of motion therapy from 6/4/21 to 6/14/21. Further review showed no indication why services were not provided. c. Interview with the restorative nurse on 6/23/21 at 3:39 PM confirmed the resident was on a restorative therapy program for passive range of motion and revealed the restorative therapy gym was closed at that time due to the facility's COVID outbreak status and residents were not allowed to go to other units. Further interview revealed residents should receive restorative care in their rooms when the gym was not available and some missed days were due to restorative staff working in other areas due to staffing challenges. 2. Review of the 2/3/21 quarterly MDS assessment showed resident #33 was cognitively intact with a BIMS score of 15/15. The assessment further showed range of motion impairment on one side for the lower extremities. Review of the 4/16/21 Restorative Therapy Referral documentation showed the resident participated 2 times per week related to decreased mobility and right shoulder pain. The treatment plan included walking with the restorative staff, and encouragement to ride the Nustep exercise bike. The following concerns were identified: a. Interview with the resident on 6/22/21 at 2:11 PM revealed s/he used to ride the bike and still would if it were available. She verified the bike was unavailable due to the facility being in a quarantine status. The bike was located in another unit of the facility, and due to the quarantine, they were not allowed to go between units. b. Interview with the restorative nurse on 6/23/21 at 2:38 PM confirmed the resident was on a plan to walk with the restorative aides and they were to encourage the resident to ride the Nustep exercise bike. The nurse further confirmed other than on 6/3/21 the restorative program and gym had been closed for the month of June due to the outbreak status in the facility. She confirmed making the equipment available during quarantine had not been considered. 3. Review of the 2/10/21 quarterly MDS assessment showed resident #36 was cognitively intact with a BIMS score of 13/15, and showed range of motion impairment on both sides of the lower extremities. Review of the 6/2/20 Restorative Therapy Referral documentation showed the resident participated 3-5 times per week related to decreased mobility and balance. The treatment plan included the resident riding the Nustep exercise bike as tolerated. The following concerns were identified: a. Interview with the resident on 6/22/21 at 9:46 AM revealed s/he walked with a walker, and the aides were able at times to walk with him/her. However, s/he voiced concerns due to not being able to get the proper exercise because the bike was upstairs. The resident confirmed the bike was on a different unit and it was not available during the outbreak. b. Interview with the restorative nurse on 6/23/21 at 2:38 PM confirmed the resident was on a plan to ride the Nustep bike. The nurse further confirmed other than on 6/3/21 the restorative program and gym had been closed for the month of June due to the outbreak status in the facility. She confirmed making the equipment available during quarantine had not been considered.

Based on medical record review and staff interview, the facility failed to ensure 1 of 1 (#37) sample residents were free from unnecessary as needed (PRN) [CONDITION(S)] medications. The findings were: Review of the 2/8/21 admission MDS assessment showed resident #37 was admitted to the facility on [DATE] with diagnoses that included adult attention deficit [CONDITION(S)] disorder (ADHD), aggressive behavior of adult, dementia of the Alzheimer's type, [CONDITION(S)], generalized anxiety disorder, loss of memory, and mixed dementia. The following concerns were identified: a. Review of current physician orders showed an order with a start date of 6/8/21 for Lorazepam 0.5mg [milligrams] PO [by mouth] q6Hr [every 6 hours] PRN [as needed] . However, there was no end date or expiration date noted on the order. b. Review of monthly pharmacy medication regimen review documentation showed medication reviews had been performed monthly since the resident's admission in February 2021. Further review showed the medication review had been completed for June 2021 without identification of the irregularity related to the PRN antipsychotic medication order. c. Review of the MAR for June 2021 showed the resident received a PRN dose of lorazepam on 6/22/21. d. Interview with the DON on 6/24/21 at 11 AM revealed she was not completely aware of, or had a full understanding of the guidance around PRN antipsychotic medications. She further revealed she was not aware of any additional pharmacy or physician documentation related to this medication order. The DON then confirmed the lorazepam medication order did not have an end or expiration date.

Based on medical record review, review of facility-reported incidents, staff interview, and policy and procedure review, the facility failed to ensure thorough investigations were completed for 2 of 2 incidents of alleged sexual abuse (involving residents #6, #7). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required extensive assistance with mobility, transfers, and toilet use. The resident had a BIMS score of 7/15 indicating severe cognitive impairment and was unable to be interviewed. The following concerns were identified: a. Review of an incident reported by the facility to the State Survey Agency showed on 4/8/21 a staff member observed resident #4 in the atrium with resident #7. Resident #4 was rubbing resident #7's breast and saying, Oh that's nice. Review of the nursing progress notes for 4/8/21 showed a single note timed at 7:28 PM indicating resident #7 had been assessed following an interaction in the atrium. b. Interview with the DON on 5/14/21 at 9:20 AM revealed the incident had occurred and was investigated per protocol. The DON and the social services director conducted the investigation. It was further revealed the incident was determined to be sexual abuse, but no records of the investigation had been kept. 2. Review of the significant change MDS assessment dated [DATE] showed resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of an incident reported by the facility to the State Survey Agency showed on 4/23/21 a CNA witnessed resident #4 with his/her hands on resident #6's genital area while sitting at the dining table. b. Review of the nursing progress notes for 4/23/21 at 10:38 AM showed It was reported that this resident may have been inappropriately touched by another resident. Resident removed from harm and staff notified to keep other resident away from [her/him]. The only other note related to the incident was when the family was notified of the incident on 4/26/21 at 10:32 AM. c. Interview with the DON on 5/14/21 at 9:20 AM revealed the incident had occurred and was investigated per protocol. The DON and the social services director conducted the investigation, however, no records of the investigation had been kept. 3. Review of the policy titled, New Horizons Abuse Investigation and Reporting with an issue date of 7/25/19 showed It is the policy of New Horizons Care Center that all reports of resident abuse .shall be promptly reported .and thoroughly investigated by facility management . and .4. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator .

Based on medical record review, review of facility-reported incidents, staff interview, and policy and procedure review, the facility failed to ensure residents were free from unwanted sexual contact for 2 of 6 sample residents (# 6, #7) reviewed that were involved in resident to resident altercations. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 was most recently readmitted to the facility on [DATE]. The resident had a BIMS score of 15, indicating the resident was cognitively intact. The resident ambulated independently and was not coded as having any behaviors. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required extensive assistance with mobility, transfers, and toilet use. The resident had a BIMS score of 7/15 indicating severe cognitive impairment and was unable to be interviewed. The following concerns were identified: a. Review of an incident reported by the facility to the State Survey Agency showed on 4/8/21 a staff member observed resident #4 in the atrium with resident #7. Resident #4 was rubbing resident #7's breast and saying, Oh that's nice. Review of the nursing progress notes for 4/8/21 showed a single note timed at 7:28 PM indicating resident #7 had been assessed following an interaction in the atrium. b. Interview with the DON on 5/14/21 at 9:20 AM revealed the incident had occurred and was investigated per protocol. The DON and the social services director conducted the investigation. It was further revealed the incident was determined to be sexual abuse, but no records of the investigation had been kept. 3. Review of the care plan for resident #4 showed it was updated 4/14/21 with new behavior interventions that included set boundaries, supervise interactions with other residents, hourly checks on resident to ensure other resident safety, and to not let other vulnerable residents visit without supervision. 4. Review of the significant change MDS assessment dated [DATE] showed resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of an incident reported by the facility to the State Survey Agency showed on 4/23/21 a CNA witnessed resident #4 with his/her hands on resident #6's genital area while sitting at the dining table. b. Review of the nursing progress notes for 4/23/21 at 10:38 AM showed It was reported that this resident may have been inappropriately touched by another resident. Resident removed from harm and staff notified to keep other resident away from [her/him]. The only other note related to the incident was when the family was notified of the incident on 4/26/21 at 10:32 AM. c. Interview with the DON on 5/14/21 at 9:20 AM revealed the incident had occurred and was investigated per protocol. The DON and the social services director conducted the investigation, however, no records of the investigation had been kept. 5. Further review of resident #4's medical record showed no evidence hourly checks were completed as indicated by the resident's care plan. Interview with CNA #1 on 5/14/21 at 10:10 AM revealed that the hourly checks on resident #4 were done, but there was no place that they were documented. 6. Review of the policy and procedure titled Abuse Prevention Program dated 7/25/19 showed As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone.

Based on medical record review, observation, staff interview, review of employee training records, review of the State Survey Agency incident reporting logs, and review of facility investigation documentation, the facility failed to ensure residents were free from abuse for 2 of 6 abuse allegations (both involving resident #1) reviewed. This failure resulted in harm to resident #1, who sustained bruising. The findings were: Review of the 5/8/19 MDS assessment showed resident #1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills for daily decision making, was rarely or never understood, and rarely or never understood others. The resident was totally dependent on staff assistance with dressing and eating, and required extensive staff assistance with bed mobility, transfers, and toilet use. The resident was coded as having physical, verbal, and other behaviors 1 to 3 days during the 7-day look-back period. Further, the resident did not receive anti-coagulant medication. The following concerns were identified: 1. Review of the State Survey Agency reporting logs showed a 7/28/19 incident, reported by the facility on 8/1/19, with an allegation of abuse. The incident report showed an allegation CNA #4 .grabbed (the resident)and told (him/her) to 'shut the [***] up.' Further review showed the facility had contacted the Department of Family Services (DFS), and DFS will completing (sic) this investigation and we are awaiting the outcome of that investigation. Interview with CNA #3 on 8/2/19 at 5 PM revealed she had witnessed the alleged abuse. The CNA stated on 7/28/19 around 4:15 PM the resident was .yelling, crying and (CNA #4) was jerking on (the resident's) arm to get (her/him) out of bed and telling (him/her) to shut up. CNA #4 then threw the resident hard into the wheel chair. Observation on 8/2/19 8:45 AM showed the resident had three round bruises of a deep purple color, consistent with finger imprints, that measured approximately 1 centimeter each and were located on the right arm just above the elbow. Interview with CNA #2 on 8/2/19 at 2:55 PM revealed There weren't any bruises there Friday (7/26/19) during (the resident's) shower, but there sure were on Monday (7/29/19). Interview with the DON on 8/2/19 at 2:30 PM revealed CNA #4 had been placed on suspension pending the outcome of facility and DFS investigations. During a phone interview on 8/2/19 at 5:50 PM CNA #4 revealed she didn't .know why they called and told me not to come to work. The CNA volunteered she had completed a one-person transfer of the resident over the weekend, and stated, It was not the [MEDICATION NAME] transfer. Additionally, the CNA stated (Resident #1) is very vocal and gets on everyone's nerves. Review of the online educational record for CNA #4 showed Abuse and Restraints training was completed on 10/31/18. 2. Review of the State Survey Agency incident reporting logs showed a 7/20/19 incident, reported by the facility on 7/22/19, with an allegation of abuse. The incident report showed RN #1 told the facility the resident had a history of [REDACTED]. CNA #1 got the resident up for dinner, and at that time, the resident was crying and moaning. The RN provided the resident with pain medication, and asked CNA #1 to feed the resident ice chips, as that was know to calm the resident and help him/her stop crying. The CNA responded she didn't understand why, because .it wouldn't do any good. While assisting with feeding the ice chips to the resident, the CNA stated I can't stand this (man/woman). This was said in front of the resident and in a public area. The report showed the facility interviewed the CNA, and she admitted to making the statements. The CNA received a three day suspension, would no longer be working with the resident, and was scheduled to attend abuse training. Review of the nursing note dated and timed 7/20/19 at 4:30 PM showed RN #1 assigned CNA #1 to feed the resident ice cubes. The RN reported CNA #1 stated that she didn't understand why because it wouldn't do any good, and then later stated I can't stand this (man/woman). This was spoken in front of resident and in a public area. Further, the note showed these statements upset the resident. Interview with RN #1 on 8/02/19 at 10:34 AM confirmed the CNA said she didn't understand why because it wouldn't do any good and I can't stand this (man/woman). The RN further stated the resident was visibly upset by the statement. During a phone interview with CNA #1 on 8/2/19 11:20 AM she acknowledged that she made the statements. She further acknowledged she knew it was a violation to do so, but stated no way the resident could have even heard me. Review of the online educational record for CNA #1 showed Abuse and Restraints training was completed on 10/31/18.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to protect residents from abuse for 1 of 5 sample resident (#53) who were involved in abuse allegations. The findings were: Review of the 5/22/19 behavior monitoring documentation showed resident #64 was physically aggressive to resident #53. The note showed .(s/he) punched (resident #64) in the face and knocked (him/her) to the ground. There were no additional details regarding possible injuries on the behavior monitoring documentation, however, review of the 5/25/19 timed at 3:11 AM nurse's note showed resident #53 had bruising noted on his/her .left hip from waistline down to the mid-thigh region. It is unknown when or how this injury occurred. Review of the undated fall committee meeting minutes showed resident #53 was reviewed for the injury and it was determined to be a result of the incident when the resident was pushed by an external force. The following concerns were identified: a. Review of the records failed to show a report or investigation was done related to the physical abuse. b. Review of the medical record failed to show a nursing assessment was completed related to the bruising identified on the resident on 5/25/19. c. Interview on 6/26/19 at 10:33 AM with RN #2 and RN #3 revealed there were no reports made or investigations done related to the resident to resident altercations. d. Review of the undated facility policy and procedure titled Resident-To-Resident Altercation showed .k. Report incidents, findings, and corrective measures to appropriate agencies outlined in our facility's abuse reporting policy. Review of the 2/13/19 revised Abuse Prevention Plan for Care Center and Swing Bed showed requirements for reporting and investigation which included .7 .While protecting the welfare of all residents, reports of abuse are investigated immediately and reported to the appropriate authorities . The policy went on to show the State Survey Agency was included as an agency required to be notified.

Based on medical record review, staff interview, and review of fall investigation documentation, the facility failed to ensure interventions for fall prevention were consistently implemented and failed to conduct a post-fall assessment to determine any additional interventions for 1 of 4 sample residents (#1) with falls. The resident had another fall which resulted in a fracture. The findings were: 1. Review of the 3/29/17 initial MDS assessment for resident #1 showed s/he required limited assistance for transfers and ambulation, and had not had any falls since admission. Review of the 3/27/17 fall risk assessment showed the resident was at risk for falls with a score of 16 (a score of 10 or higher is at risk). Review of fall investigation documentation showed the resident had a fall on 3/25/17 trying to get into the w/c. Further review showed the resident had falls on 4/1/17 and 4/4/17; in both falls, the resident's feet got tangled in the walker while ambulating or transferring. Both investigations showed the resident had a restorative program. The following concerns were identified: a. Review of the care plan dated 3/29/17 showed an intervention for fall prevention was Strengthening thru restorative. Review of the restorative therapy referral dated 3/24/17 revealed the resident had a restorative plan to maintain mobility and walking. The plan was for ambulation 3-5 times per week with a front-wheeled walker (FWW) and gait belt. Review of restorative documentation for March (after 3/24/17) and April 2017 (until 4/12/17) showed services were only documented on 4/3, 4/5, and 4/11. During an interview on 4/26/17 at 11:37 AM the DON stated the resident ambulated independently at times and CNAs would also ambulate the resident, although there was no CNA documentation to confirm. However, she stated the resident's restorative plan should have been followed. b. Review of a nursing note dated 4/10/17 revealed the resident's family member called the nurse asking about a resident fall. The nurse was not aware of a fall. The nurse spoke to a CNA who witnessed the fall. According to the CNA and resident, the walker rolled out from underneath the resident while the resident was transferring. The resident was put on twice a day vital signs for 3 days, and the nurse inspected the walker. The walker was found to be in good condition and safe to use. Further review of the medical record and review of fall documentation showed no evidence a post-fall assessment was completed to determine potential causes for the fall and to identify any new interventions. During an interview on 4/26/17 at 12:14 PM the DON stated she was not aware of the fall until the family member voiced a grievance. She further stated it was the responsibility of the nurse to do the fall report, and she confirmed there was not a fall report for this fall. c. Review of nursing notes and fall investigation documentation showed the resident had another fall on 4/12/17. The resident stated the walker got away from him/her while walking. The resident was taken to the hospital where x-rays showed a left hip fracture.

Based on observation, staff interview, review of manufacture instructions, and medical record review, the facility failed to ensure fall review/investigations were completed and/or timely for 2 of 5 sample residents (#52, #59) with falls. This failure resulted in actual harm for 1 resident (#59). In addition, the facility failed to ensure 1 of 4 observations of lift transfers were done safely which affected resident #47. The findings were: 1. Review of the 4/16/16 quarterly MDS showed resident #59 had [DIAGNOSES REDACTED]. The resident was independent with ADLs and had a brief interview for mental status (BIMS) score of 12 which indicated moderate impairment. Review of nurses notes showed the resident had falls on 2/12/16, 2/25/16, 2 falls on 2/26/16, 3/8/16, 3/20/16, 3/29/16, 4/7/16, 4/30/16, and 5/4/16. Review of the 1/13/16 fall risk care plan with a review date of 4/14/16 showed the interventions to prevent falls were for staff to know the resident's whereabouts, to provide frequent rounding, ensure the resident used a walker/scooter, and to help with ADLs as needed. The fall on 3/29/16 resulted in a fracture of the resident's right fibula. The following concerns were identified: a. Review of the fall review for the 3/29/16 fall showed the resident was found on the floor of his/her bathroom. The fall review showed there had been 4 falls in the last month. The interventions in place at the time of the fall were: clutter free environment, call light in reach, frequent observations, good lighting, and appropriate footwear. The fall review showed there were major injuries sustained from this fall which included a fractured right fibula. Recommendations on the fall review showed remind resident to call for help. However, it was also noted the resident doesn't like to ask for help. The date of the fall team investigation was 4/4/16, 6 days after the fall, and there was no evidence the fall team analyzed the details of this fall and previous falls to determine meaningful interventions. There were no recommendations made by the team, and review of the care plan failed to show any changes were made related to fall prevention. b. Review of the 2/12/16 fall review showed the resident was found on the floor of the room. The fall review showed there had been no falls in the last month. The interventions in place at the time of the fall were: clutter free environment, good lighting, and call light within reach. The fall review further showed there were no injuries, a restorative plan was initiated, and the resident was educated on wearing his/her oxygen. The date of the fall team investigation was 2/22/16, 10 days after the fall, and there were no recommendations or care plan updates related to this fall investigation. c. Review of the 2/25/16 fall review showed the resident was opening the door, got dizzy, and fell . The fall review showed there had been no falls in the last month. However, review of nursing notes showed a fall occurred on 2/12/16. The interventions in place at the time of the fall were: clutter free environment, good lighting, and good footwear. The fall review further showed there were no injuries and the resident was educated on wearing his/her oxygen. The date of the fall team investigation was 2/29/16, 4 days after the fall and the resident had fallen 2 additional times prior to this fall review. Further, there were no recommendations or care plan updates related to the fall teams findings/review. d. Review of the 2/26/16 fall review showed at 2 AM the resident was found on the floor of the room. The fall review showed there had been no falls in the last month. However, review of nursing notes showed falls on 2/12/16, 2/22/16 and 2/25/16. The interventions in place at the time of the fall were: clutter free environment, appropriate footwear, and frequent observations. The fall review further showed there were minimal injuries and the resident was educated on calling for assistance when experiencing dizziness and unsteadiness. The date of the fall team investigation was 2/29/16, 3 days after the fall, and the team did not make recommendations or care plan updates related to this fall investigation. e. Review of the 2/26/16 fall review showed another fall occurred this day at 2:45 AM. The resident was found on the floor of the room. The fall review showed there had been no falls in the last month. However, according to nursing notes, this was the second fall this day, and there were 3 falls earlier in the month (2/12, 2/22, 2/25). The interventions in place at the time of the fall were: clutter free environment, call light in place, and frequent observations. The fall review further showed there were no injuries and the resident was educated and sent to the emergency room . The date of the fall team investigation was 2/29/16, 3 days after the fall, and there were no recommendations or care plan updates related to the team's fall investigation. f. Review of the 3/8/16 fall review showed the resident stated s/he fell off the toilet. The fall review showed there had been 4 falls in the last month. The interventions in place at the time of the fall were: good lighting, good footwear, and frequent observations. The fall review further showed there were minimal injuries and the resident was seen by the physician, continues to be independent, refuses restorative, and labs were ordered. The date of the fall team investigation was 3/21/16, 13 days after the fall, and there were no recommendations or care plan updates related to the team's fall investigation. g. Review of the 3/20/16 fall review showed the resident was found on the floor of his/her room, had been ambulating and stated his/her legs became weak. The fall review showed there had been 4 falls in the last month. The interventions in place at the time of the fall were: light source on and call light within reach. The fall review further showed there were no injuries and the physician was notified, labs were drawn, and rapid flu swab and duo nebs were ordered for pneumonia. The date of the fall team investigation was on 3/21/16, and there were no recommendations or care plan updates related to this fall investigation. h. Review of the 4/7/16 fall review showed the resident was found on the floor of room after sneezing. The fall review showed there had been 3 falls in the last month. The interventions in place at the time of the fall were: good footwear, clutter free environment, and frequent observations. The fall review further showed there were minimal injuries and the resident was reminded to use the call light. The date of the fall team investigation was 4/11/16, 4 days after the fall, and there were no recommendations or care plan updates related to this fall investigation. i. Review of the 4/30/16 fall review showed the resident was found on the floor in his/her room after using the toilet. The fall review showed there had been 3 falls in the last month. The interventions in place at the time of the fall were: good footwear, call light in reach, appropriate lighting, frequent observations, and resident instructed. There was not further information on what the resident was instructed for. The fall review further showed there were minimal injuries that included a laceration above the eye. Recommendations on the review showed staff felt the resident was hungover as family provided beer and the resident drank several prior to the beer being removed. The date of the fall team investigation was 5/2/16, 3 days after the fall, and the recommendation was to ask family not to bring beer to the resident's room. Further, there were no care plan updates related to these recommendations. j. Review of the 5/4/16 fall review showed the resident was found on the floor of room after ambulating in room. The fall review showed there had been 5 falls in the last month. The interventions in place at the time of the fall were: appropriate footwear, call light in place, frequent observations, and light source on. The fall review further showed there were no injuries and the resident refused his/her oxygen. The date of the fall team investigation was 5/16/16, 12 days after the fall, and the fall was reviewed with the physician and orders were received to reduce oxycodone and limit the resident to 2 beers after 2 PM. Review of the care plan failed to show these recommendations were included to help prevent further falls. k. Interview with the DON, RN #1, and RN #2 on 5/26/16 at 9:45 AM revealed the resident was becoming more confused and having increased falls. Further, they verified when the team reviewed the details of the falls, recommendations were not always made. In some cases, the DON felt some interventions that may have been tried were not documented on the care plan. 2. Review of nurses notes showed resident #52 had falls on 5/12/16, 5/17/16, 5/22/16, 5/23/16, and 5/24/16. Review of the fall risk care plan showed a problem date of 5/12/15. The interventions to prevent falls were ensuring access to a walker at all times, ensuring the room was clutter free, and assistance with ADLs especially personal hygiene and bathing and toileting. The last date the care plan was reviewed was 2/10/16. The following concerns were identified: a. Review of the fall review for the 5/12/16 fall showed the resident attempted to transfer him/herself to the bathroom. The fall review showed there had been no falls in the last month. The interventions in place at the time of the fall were: bed in low position, clutter free environment, appropriate footwear, and frequent observations. The fall review further showed there were no injuries, and no new interventions initiated by staff at the time of fall. The date of the fall team investigation was 5/16/16 and there were no recommendations or care plan updates related to this fall investigation. b. Review of the 5/17/16 fall review showed there had been no falls in the last month. Although review of nursing notes showed a fall occurred on 5/12/16. The resident had attempted to self transfer out of the wheelchair and was found on the floor in the front hallway. There were no injuries noted. There were no new interventions put in place at the time of the fall, and the date of the investigation was shown to be 5/23/16, 6 days after the fall. There were no care plan updates or recommendations made. c. Review of the 5/22/16 fall review showed there had been no falls in the last month, although nursing notes showed 2 falls in the month (5/12, 5/17). The resident had attempted to self transfer to the bathroom and was found on the floor. There were no injuries noted and neuro checks were completed. Recommendations/interventions initiated at the time of the fall included more frequent toileting. The date of the investigation was shown to be 5/23/16 with no care plan update or recommendations made. d. Review of the 5/23/16 nurse's note timed at 12:54 PM showed the resident was found on the floor by the toilet. At that time the resident complained of groin pain. The note further showed the resident did not have any bruising or other complaints of pain and nursing would continue to monitor. The physician and family were notified. There was no investigation notes provided and there was no evidence of updates or review to the care plan. e. Review of the 5/24/16 nurse's note showed the resident was found on the floor of his/her room. There were no injuries noted. There was no additional documentation related to this fall provided. 3. Interview with the DON and RN #1 on 5/26/16 at 9:40 AM verified the fall reviews and investigations did not always include new interventions/recommendations and the care plans were not reviewed or updated to reflect changes with each fall. 4. Observation on 5/24/16 at 10:21 AM showed CNA #3 and CNA #4 transferred resident #47, with an EZ Way Smart Stand mechanical lift, from the resident's wheelchair to the toilet. The lifting device used a sling system that was placed behind the resident and secured around the resident's trunk. When the resident was placed on the toilet, CNA #3 locked the lift brakes. At 10:28 AM CNA #3 stated Yesterday (s/he) almost fell out. The CNAs left the room at that time, leaving the resident secured to the lift with the brakes locked. At 10:36 AM, 8 minutes later, the CNAs returned to the room, unlocked the lift brakes, and assisted the resident off the toilet. The following concerns were identified: a. Review of the EZ Way Smart Stand lift instructions received from the facility on 5/26/16 at 11 AM showed .Safety notes .The only time you should lock the wheels of the EZ Way Smart Stand when in use is when raising or lowering a patient during ambulation. Refer to the instructions for using the EZ Way Smart Stand for ambulation on page 7 . b. Interview with the DON, RN #1, and RN #2 on 5/26/16 at 9:45 AM revealed resident #47 had a cognitive deficit and anyone with a cognitive deficit would not be safe to be left unattended while attached to the lift.

Based on observation, staff interview, and review of infection control documentation, the facility failed to effectively implement measures to prevent the spread of a known GI illness occurring within the facility. The initial number of residents affected with GI illness was 12, five of 13 sample residents (#11, #12, #13, #14, #17) and 7 non-sample residents (#3, #28, #34, #39, #40, #54, #60). Failure to implement precautions timely and effectively resulted in harm to 8 additional residents (#15, #25, #26, #36, #59, #61, #62, #65) who became infected with the illness as of 4/8/15. The census was 71. The findings were: Upon entrance to the facility on [DATE] at 4:35 PM, the DON stated that some residents and staff were experiencing GI symptoms. Review of the infection tracking information on 4/6/15 showed there were 11 residents (#3, #11, #12, #13, #14, #17, #28, #34, #39, #54, #60) who had symptoms including nausea, vomiting and diarrhea. The onset date of the symptoms showed the first residents affected were identified on 4/4/15. Observation during a tour of the facility on 4/6/15 from 4:55 PM to 5:30 PM revealed there was no personal protective equipment (PPE) or signage outside of any resident rooms. Interview with the IP on 4/6/15 at 5:45 PM verified the residents experiencing symptoms were located in the two upper level units of the facility (the secure unit, and the 7/8 unit). The IP then verified other than keeping the upper and lower level residents separated, there were no isolation precautions in place. In addition, she stated at that time formal education had not been provided to staff, just verbal reminders regarding good hand hygiene practices. Furthermore, the IP stated there were some employees with symptoms of the illness and the facility did not have specific requirements for when they could return to work. She revealed at that time the outbreak had not yet been reported to any State officials. The following concerns were identified: a. Observations on 4/7/15 at 8 AM showed residents in the 7/8 unit were located in the dining area being served breakfast. At 8:12 AM resident #13 had an episode of emesis while seated at the table. CNA #3 who was assisting the resident used the clothing protector to absorb the small amount of emesis and failed to remove the soiled clothing protector from the resident or to perform hand hygiene prior to continuing to assist the resident. b. Observation on 4/7/15 at 8:15 AM showed resident #40 was taken away from the table where he was dining with other residents. The resident was placed at an adjacent table alone with a vomit basin because s/he was feeling nauseous. c. Interview on 4/7/15 at 8:15 AM with LPN #5 the 7/8 unit nurse verified there were more residents getting ill, and none of the residents were on isolation. She then stated she had not been educated on any procedures related to the outbreak. d. Observation on 4/7/15 at 7:45 AM showed resident #17 had door signage which stated, "Please speak with a nurse before visiting your loved one." At that time the resident was at the main secure unit dining area eating breakfast. The observation showed there were three additional residents at the same dining table. e. Observation on 4/7/15 at 8 AM showed LPN #3 performed a medication pass in the secure unit. The LPN was observed to wear one pair of gloves while administering medications to a number of residents. At no time was she observed to change gloves or wash hands. Interview with LPN #3 on 4/7/15 at 8:30 AM confirmed she should have changed gloves and washed hands as appropriate during the medication pass. f. Observation on 4/7/15 beginning at 7:45 AM showed resident #25 sitting at the dining table in the common room vomiting into his/her clothing protector. At that time, CNAs #2 and #4 responded by wheeling the resident back to his/her room. Both CNAs then donned gloves. The resident vomited again into the clothing protector and onto the floor before stating that s/he felt better. CNA #2 wiped the resident's face with a washcloth, removed her gloves, and did not perform hand hygiene before providing the resident a cup of water. CNA #4 bagged the soiled washcloth and clothing protector. She then removed her gloves, donned new gloves, and used paper towels to wipe up vomit off the floor. No hand hygiene was performed between gloving. She placed the soiled paper towels in the resident's trash can. She then removed her gloves, did not perform hand hygiene, donned new gloves, and selected a clean shirt from the resident's closet. Both CNAs then assisted the resident with changing clothes and getting into bed. Both CNAs then used hand sanitizing gel after leaving the resident's room. g. Interview with housekeeper #1 on 4/7/15 at 10:15 AM verified she had not been provided any instruction to modify her cleaning process. The housekeeper stated the hand rails in each area were wiped with a disinfectant product once per week. h. Review of the list provided showed 7 employees (5 CNAs and 2 licensed nurses) were out ill with GI symptoms as of 4/9/15. Interview with the IP on 4/9/15 at 11:30 AM verified the employees needed to be free from symptoms for 72 hours before they would be allowed back to work. i. Interview with the medical director on 4/8/15 at 4:20 PM revealed he was not aware of the scope of the outbreak. The medical director learned during the interview there were 19 residents affected. Further the medical director verified his expectation would be for the residents' physicians to be notified about those experiencing acute illness within the day of onset of symptoms. In addition, the physician verified the residents needed to be assessed for their symptoms and details needed to be documented related to the condition of the residents. He further stated his expectation was for a daily update related to the status of those affected in the facility. j. When the updated resident infection control information was reviewed on 4/8/15 at 3:55 PM there were 8 additional residents (#15, #25, #26, #36, #59, #61, #62, #65) who were now identified with symptoms of the GI illness since the initial 4/6/15 information.

Based on medical record review, staff interview and review of incident reports, the facility failed to ensure effective supervision and interventions to prevent falls for 6 of 12 sample residents (#4, #14, #25, #26, #33, #79). As a result, serious avoidable injuries occurred to sample residents #4, #25, #33, and #79. The findings were: 1. Review of the medical record for resident #4 showed s/he had [DIAGNOSES REDACTED]. Review of the history and physical dated 11/18/11 showed the resident was admitted to the nursing home in 2008 and has had a gradual decline in both motor and cognitive skills. Review of the 9/21/12 annual MDS assessment showed the resident required limited assistance with one person physical assist for walking and for locomotion. In addition, section G0300 of this MDS assessment showed the resident was "Not steady, only able to stabilize with human assistance" for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer. Review of incident information showed the resident had fallen 5 times since September 2012. The resident fell twice on 9/10/12 both times while trying to independently sit in a chair, on 9/21/12 the resident was found in his/her own room on the floor with a minor injury, a skin tear to the left elbow; additionally, when the resident was found on the floor, s/he was incontinent of bowel and bladder. On 10/13/12 the resident was found on the floor of another resident's room with no injury noted. On 10/28/12 the resident was witnessed to fall while standing face-to-face with another resident. This fall resulted in a fractured hip and surgical intervention. Review of the CAA for falls dated 9/25/12 showed the resident was at risk and had a history of [REDACTED]. In addition, the CAA analysis of findings was inconsistent with the data in the MDS assessment showing the resident ambulated by self with the use of an assistive device. The analysis identified the risk as "fall with injury." A decision was made to proceed with a care plan. The following concerns were identified with the failure to develop effective interventions to help prevent falls: a. Review of the care plan showed alteration in ADLs and risk of falls was initiated on 12/6/10. The goal was to have "No injury fall over the next 90 days" the review date on the care plan showed 9/25/12. There were several interventions listed which failed to be specific. These included: "assist with transfers when possible...anticipate needs...guide resident with ambulation when needed...monitor when wandering." Further review of the care plan showed there were no dates associated with interventions to show what had been added or changed related to the resident's recurrent falls. b. Review of the fall investigation worksheets and the occurrence report for the 10/28/12 fall which resulted in a broken hip, showed the resident fell while ambulating. It further showed the resident ambulates without assist, and the fall was witnessed. According to this 10/28/12 report, the witness was a housekeeping staff member. The investigation worksheet and the report failed to identify the lack of monitoring and supervision for the resident by direct care staff. This resident had been identified on the 9/21/12 annual MDS assessment as being unsteady and needing physical assistance for walking. The interdisciplinary team review of the fall was completed on 11/1/12; However, review of this form showed the area for discussing the interventions used to prevent falls for this resident was blank. According to the previous IDT fall review dated 10/18/12, the IDT recommended to "monitor when wandering." c. Interview with the MDS coordinator on 11/7/12 at 10:30 AM verified the care plan failed to specifically identify how wandering would be monitored. d. Interview with the DON on 11/7/12 at 10:40 AM verified staffing in the secure unit had been problematic for the past several months. 2. Review of 7/6/12 annual MDS assessment for resident #25 showed s/he had [DIAGNOSES REDACTED]. According to the 7/6/12 timed at 4 PM nurses note, the resident was dependant on staff for ADLs requiring extensive assistance with bed mobility, transfers, ambulating, dressing, eating, toileting, personal hygiene, and bathing. The note further showed the resident was quite unsteady and was a fall risk and "very frail." Observation on 11/6/12 at 2:50 PM showed the resident was seated in his/her recliner next to the bed. The recliner was automated with a remote to lower the foot rest, and to raise up the seat to ease getting up into a standing position. The remote for the chair was situated next to the resident in the chair. However, the chair was not plugged into the wall which disabled the remote. Interview with CNA #1 on 11/6/12 at 2:55 PM revealed the resident was not safe to use the remote, because of previous falls, so they unplugged it. She further revealed the aides would plug it back in to lower and raise the foot rest for the resident because there was not any manual lever. Review of the alteration in ADLs and risk for falls care plan dated 8/9/11 for the resident showed interventions that included extensive to total assist with ADLs...assess pain daily...room free of clutter...chair alarm...low bed...floor mat alarm and check on him/her frequently. The review date on the care plan was 7/10/12. There were not any specific dates associated with the interventions. Continued review of the care plan showed a new problem for alteration in comfort related to Parkinson's and falls was developed on 7/10/12. These interventions included anticipate needs, and keep chair remote out of reach. Review of the fall incident reports and IDT reviews showed the resident had sustained two falls both of which were related to getting up from the chair while unassisted. One fall was on 7/12/12, another was on 9/6/12. Review of the 7/12/12 nurses note for the 6 PM to 10 PM shift, and the 7/13/12 untimed nurses note showed the fall on 7/12/12 resulted in a serious injury to the resident's left eye which required sutures and ocular surgery. The following concerns were identified with implementing effective strategies to prevent falls: a. Review of the 7/12/12 fall investigation worksheet showed the fall occurred at 5 PM on 7/12/12, the fall was unwitnessed and staff were alerted by the resident's chair alarm going off. The resident was found on the floor between the recliner and the bedside table. The worksheet failed to describe if the resident had been in control of the chair remote, possibly contributing to the fall. Further, the worksheet failed to include any information from the resident related to what had happened to cause the fall. b. Review of the IDT (interdisciplinary treatment team) fall review for the 7/12/12 fall with serious injury failed to include any documentation regarding the 7/10/12 care plan intervention to keep the chair remote out of the reach of the resident. The interventions in place were listed as: chair alarm, call bell in reach, low bed and floor alarm. The area to show "were they in use" (the interventions) showed a "yes" next to the line for chair alarm, and the lines for the other interventions listed were left blank. In addition the recommendations/new interventions were not specific to the resident or well defined. The documentation showed the team recommended, "all interventions in place-monitor." c. Review of the 9/6/12 fall investigation worksheet showed the resident raised the chair to the highest position and slid out of the recliner. Review of the occurrence report for the 9/6/12 fall showed the fall was unwitnessed and there was no injury. Review of the undated IDT fall review showed the team failed to document the portion of the form related to the interventions that were or were not in place at the time of the fall. Additionally, there was no answer to the question to update the care plan. The recommendations/new interventions section showed the team decision was, "keep control out of reach." 3. Review of the 6/14/12 hospital history and physical for resident #79 showed s/he had [DIAGNOSES REDACTED]. Review of the 7/6/12 initial MDS assessment showed the resident required extensive assistance with bed mobility, transfer and ambulation. Continued review of this assessment showed the resident was not steady and was only able to stabilize him/herself with staff assistance. Finally, review of this assessment showed the resident required the use of a walker or wheel chair due to lower extremity limitation in range of motion. The following concerns with supervision and fall prevention management were identified: a. Review of the 6/28/12 nursing notes timed at 7:10 AM showed the resident was found lying on the floor by the side of his/her bed. Review of the falls investigation worksheet dated 6/28/12 showed recommendations for a chair and bed alarm and a low bed. Further review of the 6/28/12 timed at 7:10 AM nursing notes showed a chair alarm was placed. Review of these nursing notes showed no evidence an alarm was placed on the resident's bed. Review of the 7/6/12 fall assessment showed the resident was at risk for falls and the interventions in place included a low bed and use of a walker. There was no evidence a chair or bed alarm was in place at this time. b. Review of the 8/28/12 physical therapy evaluation showed the resident had experienced a decline in ambulation. Review of the 10/6/12 nursing notes timed at 3:15 AM showed the resident was found sitting between the bed and bathroom and was incontinent of feces. This fall was unwitnessed but staff noted the resident's walker was in the bathroom out of his/her reach. Review of the 10/11/12 interdisciplinary team fall review showed the call bell was not in place. Review of the current care plan, dated 7/2/12, showed the resident was at risk of falls. Interventions included monitor for needs, call bell in reach, keep walker and wheelchair available for locomotion, keep room free of clutter, encourage socialization, help with ADLs as needed. Review of the emergency room report showed this fall resulted in a skull fracture with subsequent death of the resident. 4. Review of the medical record for resident #33 showed s/he was admitted with [DIAGNOSES REDACTED]. This resident resided in the secured dementia unit. Review of the 3/2/12 annual MDS assessment showed the resident was not steady when walking or turning around while walking but was able to steady him/herself without staff assistance. In addition, according to this MDS assessment the resident had lower extremity limitations and required the use of a walker. Review of the CAA dated 3/6/12 showed the resident did not wear shoes and therefore required gripper socks due to being at risk for falls. The following concerns were identified: a. Review of the 5/12/12 nursing notes and the May 2012 fall report showed the resident had a fall with minor injury to the right knee on 5/12/12 at 2:40 PM. Review of the 5/12/12 falls investigation worksheet did not indicate whether or not the resident was wearing gripper socks as instructed in the care plan. Review of the interdisciplinary post fall assessment dated [DATE] showed the only recommendation was to "monitor" and there were no changes to the care plan. b. Review of the 6/14/12 nursing notes timed at 1:55 AM showed the resident had a fall and sustained fractured ribs. Review of the interdisciplinary post fall assessment, undated, showed the recommendation was again to "monitor" and encourage to use the walker. No changes were made to the care plan c. Interview with the DON on 11/7/12 at 10:40 AM verified staffing in the secure unit had been problematic for the past several months. 5. Review of the 8/16/12 physician note showed resident #14 had [DIAGNOSES REDACTED]. The resident resided on the secure dementia unit. According to the fall reports from April 2012 through October 2012, the resident had 16 falls with all but 3 unwitnessed. The following concerns with safety management and supervision to prevent falls were identified: a. Review of the 2/10/12 quarterly MDS assessment showed the resident required extensive assistance with bed mobility and transfers, did not ambulate, and required total assistance with locomotion on or off the unit. In addition the resident was not steady when moving from a seated to standing position, moving on and off the toilet and for surface to surface transfers. Finally, the assessment showed the resident required a wheel chair for mobility. Review of the 4/15/12 nursing notes timed at 3:30 PM showed the resident was found lying on the floor in the atrium. Review of the 4/15/12 falls investigation worksheet showed the only intervention recommended was "monitoring." b. Review of the 5/4/12 annual MDS assessment showed the resident required extensive assistance with bed mobility, transfers, and ambulation. The resident required total assistance with locomotion on or off the unit and continued to have an unsteady gait and required human assistance for stabilization. The MDS showed the resident now used a walker or a wheel chair. Review of the 5/3/12 nursing notes timed at 5:15 AM showed the resident was found crawling on the floor in front of the recliner s/he had been sitting in. Review of the fall investigation worksheet showed a possible cause for the fall was the resident had been administered a routine rectal suppository earlier. Continued review of the worksheet showed a recommendation to more closely supervise the resident after being administered a rectoral suppository "(staff permitting!)." Review of the medical record also showed the resident fell out of the wheel chair on 5/16/12 at 8:20 AM after lunging forward. On 5/22/12 at 5:40 AM the resident stood up out of the wheel chair and crumbled to the floor. Review of the falls investigation worksheet showed recommendations to "put in recliner (not) WC (wheel chair) when unattended." According to the aforementioned MDS assessment, the resident required extensive assistance with mobility and ambulation. c. Review of the fall investigation worksheets for June 2012 showed the resident had falls on 6/5/12 at 7:15 AM from the wheel chair and on 6/9/12 at 2:40 PM from the recliner. The falls investigation worksheet for both of these falls had recommendations to "monitor." No new interventions were put into place. On 6/14/12 at 4:15 PM the resident had a fall from the recliner. Review of the 6/14/12 falls investigation worksheet showed the recommendation "Do not leave alone." d. Review of the 6/15/12 fall investigation showed the resident fell on [DATE] at 5:30 PM when s/he pushed the locked wheel chair away from the table and slid onto the floor. The recommendation noted on the falls investigation worksheet after this fall was for a one to one during dining. However, the resident again pushed his/her locked wheel chair away from the table on 6/25/12 at 6:15 PM, slid to the floor, and experienced pain as a result from this fall. There was no evidence in the medical record the resident was on a one to one for dining during this fall. Recommendations by the interdisciplinary fall team after this fall included do not lock the brakes on the wheel chair while at the table and to wear gripper socks. e. Review of the July 2012 fall investigations showed the resident was found on the floor in front of a tipped over recliner. The recommendation noted on the falls investigation worksheet showed "more staff" and "someone to sit in atrium while CNAs get other (residents up)." Review of the interdisciplinary team evaluation showed the resident did not have gripper socks or shoes on as recommended from a previous fall. f. The resident had another fall on 7/5/12 at 11 PM, again s/he slid out of the recliner. Review of the interdisciplinary team review showed the resident was not wearing the recommended gripper socks at the time of the fall. g. Review of the 7/21/12 nursing notes timed at 5:10 PM showed the resident's chair alarm was going off while the CNAs were toileting another resident. When the CNAs were able to assist the resident s/he was on the floor; having fallen out of his/her wheel chair. h. Review of the 7/27/12 timed at 5:30 PM falls investigation worksheet showed the resident was found in the family room seated on the floor between his/her wheel chair and a recliner. Review of the fall notes showed the chair alarm clip came off the resident's shirt and did not alarm to alert staff. The 5/8/12 care plan showed the resident should have extensive assistance with ambulation, should wear gripper socks and staff should "monitor as much as possible." i. Review of the 8/2/12 quarterly MDS assessment showed the resident needed extensive assistance with mobility, transfers, and ambulation and was totally dependent upon staff for locomotion on and off the unit. Also, the resident had an unsteady gait that s/he could not stabilize without staff assistance. Review of the medical record showed the resident had a fall on 8/29/12 at 4:45 PM. Review of the falls investigation worksheet showed the resident attempted to lay down in bed and when s/he got up out of the wheel chair the clip on the alarm slipped off his/her shirt and did not alarm. Review of the 8/8/12 care plan showed interventions for fall prevention that were added included making sure the alarm clip was secure and extensive to total assistance. j. Review of the October 2012 fall reports showed the resident had a fall on 10/8/12 at 6:50 PM. Review of the falls investigation worksheet showed the alarm sounded but by the time staff arrived to assist the resident s/he was lying on the floor in front of the wheel chair. No recommendations were noted on the worksheet. On 10/11/12 at 9 PM the resident leaned forward in the wheel chair and fell forward onto the floor. k. Interview with the DON on 11/7/12 at 10:40 AM verified staffing in the secure unit had been problematic for the past several months. 6. Review of the medical record showed resident #26 had [DIAGNOSES REDACTED]. Review of the March 2012 fall report and March 2012 nursing notes showed the resident had a fall on 3/4/12 with a minor injury. Review of the 3/23/12 quarterly MDS assessment showed s/he wandered less and was no longer independent with mobility. Review of this MDS assessment showed the resident required limited assistance of one staff member for ambulation. Review of the nursing notes and fall report for April 2012 showed the resident had additional falls on 4/15/12 and 4/16/12, both unwitnessed and without injury. Review of the 6/15/12 quarterly MDS assessment showed the resident continued to wander but no longer required assistance with ambulation, even though s/he had falls on 5/25/12 and 6/10/12 both unwitnessed. Review of the 9/7/12 significant change MDS assessment showed the resident required extensive assistance with mobility and the use of a wheel chair. Review of the August and September 2012 nursing notes and fall reports showed the resident had falls on 8/18/12 with minor injury, on 8/21/12 without injury, on 9/3/12 without injury, and on 9/6/12 without injury. Review of the 10/12/12 significant change MDS assessment showed the resident wandered and was again independent in mobility. Review of October 2012 nursing notes and the October 2012 fall report showed the resident had falls on 10/13/12, 10/18/12 and 10/28/12. Review of the current care plan showed the potential for falls was identified as a problem on 3/27/12 and showed interventions were to monitor when wandering and to check the resident frequently. Also included as interventions were "encourage to slow down if running, monitor when agitated, keep room free of clutter, medication as ordered, and do not leave unattended in the bathroom." Review of the care plan showed there were no dates associated with interventions to show what had been added or changed related to the resident's recurrent falls. The following concerns with safety and supervision to prevent falls were identified: a. Review of the 9/3/12 post fall assessment showed the resident was left in the bathroom alone while the CNA obtained gloves and other supplies. Review of the 9/3/12 nursing notes timed at 8:20 PM verified the resident was left unattended in the bathroom by the staff member. Review of the current care plan showed the resident was not to be left unattended in the bathroom. b. Review of the post fall assessment for 9/6/12 showed the resident was seated in a wheel chair with a chair alarm in place when s/he stood up, turned, then sat on the floor. According to the 9/6/12 nursing notes timed at 6:30 PM, the "chair alarm strings were too long causing a delayed response from (the) chair alarm. Strings shortened to appropriate length..." c. Review of the post fall assessment from the fall on 10/13/12 at 1 PM showed the resident was walking with another resident. According to the 9/7/12 significant change MDS assessment, the resident required extensive assistance with ambulation and should not have been walking without staff assistance. d. Review of the 10/12/12 significant change MDS assessment showed the resident wandered and was again independent in mobility. Review of October 2012 nursing notes and the October 2012 fall report showed the resident had falls on 10/13/12, 10/18/12 and 10/28/12. Review of the October 2012 nursing notes showed no evidence the resident was being monitored frequently while wandering as instructed on the care plan. e. Review of the medical record and fall documents showed this resident had 12 falls within eight months, six were unwitnessed even though the care plan indicated the resident should be monitored frequently while wandering or ambulating. f. Interview with the MDS coordinator on 11/7/12 at 10:30 AM verified the care plan failed to specifically identify how wandering would be monitored. g. Interview with the DON on 11/7/12 at 10:40 AM verified staffing in the secure unit had been problematic for the past several months. 7. Interview with the nurse manager on 11/6/12 at 9:55 AM revealed the facility was aware of the large number of falls within the facility. She said most were in the evenings and they had tried to put preventions in place but residents continued to fall. The nurse manager said the facility had just ordered and received hip protectors in order to minimize injury when residents had falls.

Based on staff interview, physician interview, and medical record review, the facility failed to notify the physician of changes in condition which created an immediate jeopardy for 1 of 14 sample residents (#72) who experienced a significant change in condition. The findings were: Review of the medical record for resident #72 showed s/he experienced multiple episodes of coughing/choking during meals while being fed by staff over the past year. Additionally, this same resident experienced eight episodes of [MEDICAL CONDITION] activity over the past year. Continued review of the medical record showed the physician was only notified of one episode of [MEDICAL CONDITION] activity (7/22/10) and was not notified at all of the resident's coughing/choking episodes. Interview with a family member on 12/15/10 at 9:06 PM revealed the family was not notified of any coughing/choking episodes or [MEDICAL CONDITION] activity. Refer to Federal citation F309 for details related to this immediate jeopardy situation. The immediate jeopardy was abated on 12/16/10 at 10:32 AM.

Based on observation, staff interview, and medical record review, the facility failed to provide care and services to identify risk factors or potential treatment goals for 1 of 8 sample residents (#72) with swallowing issues. In addition, the facility failed to ensure 1 of 4 sample residents (#72) who were on anti-[MEDICAL CONDITION] medications received the care and services to identify risk factors or potential treatment interventions for [MEDICAL CONDITION] activity. The facility's failure to provide services related to the resident's swallowing difficulty as well as for potential choking related to an unaddressed [MEDICAL CONDITION] activity resulted in an immediate jeopardy situation. The findings were: 1. Regarding swallowing difficulties and potential for aspiration: Review of the 4/22/10 annual and the 7/22/10 quarterly MDS assessments for resident #72 showed s/he had swallowing and chewing problems. Review of the 10/20/10 quarterly MDS assessment showed the resident received a mechanically altered diet and was totally dependent on staff for feeding. Observation of the resident on 12/14/10 from 7:53 AM to 8:25 AM revealed the resident was seated in a reclined position while being fed by a CNA. The resident's head was extended back toward the chairback. During the observation the resident coughed three times while being fed, and an upper airway rattling, or gurgling noise was heard. Observation of the resident on 12/14/10 from 5:30 PM to 6:06 PM during the evening meal showed the resident was again seated in a reclined position while a CNA fed him/her. The resident's head was again observed to be extended back toward the chairback. This observation also showed the resident coughed during the meal, and an upper airway rattling was heard. The following concerns were identified related to the lack of assessment and care provided to the resident in regard to his/her swallowing difficulties: a. Review of the nurses' notes revealed the following: 1. on 2/16/10 at 6 PM the resident choked on sputum during dinner, 2. on 2/22/10 at 8 AM the resident was fed by staff and had "a lot of coughing".... 3. on 3/2/10 at 10 AM "loose moist cough." 4. on 3/20/10 at 2 PM resident had "very cool moist cough." 5. on 3/21/10 at 2 PM the resident continued with "very moist cough." 6. 6/2/10 at 2 PM the the resident had loose moist cough. 7. on 6/11/10 at 2 PM the resident had a loose moist cough. 8. on 6/18/10 at 9 AM the resident had a loose moist cough.. 9. on 8/13/10 at 6 AM the resident had loose cough. 10. on 8/20/10 at 10 AM the resident chokes easily and had a "very loose moist cough." 11. on 11/13/10 at 10 AM, the resident had difficulty swallowing and a loose moist cough. 12. on 12/26/10 at 12 noon the resident had loose moist cough. 13. on 11/27/10 at 8 AM the resident had loose moist cough. 14. on 11/28/10 at 12 noon the resident was coughing. b. Review of the nutrition risk assessments dated 2/2/10, 4/21/10, 7/20/10, and 10/21/10 showed the resident had swallowing and chewing problems. The dietitian recommended a mechanical soft diet with ground meat. c. Interview with CNA #6 on 12/15/10 at 4:05 PM revealed he was aware the resident had difficulty swallowing at times during meals. When asked what he would do during the resident's coughing/choking episodes; the CNA said he would cover the resident's mouth to make sure s/he did not "spew food" on other residents. When asked if he thought it would help to sit the resident up straighter in the chair the CNA said, "Yes, I should have done that." Interview with CNA #4 on 12/15/10 at 4:13 PM revealed she knew to sit the resident up during coughing/choking episodes. However, observation of breakfast on 12/14/10 from 7:53 to 8:25 AM showed the CNA did not reposition the resident upright despite three episodes of coughing and choking. d. Review of the medical record showed no evidence a swallowing evaluation was ordered or performed even though dietary had identified swallowing as a problem for this resident on the 2/2/10 nutritional assessment. Interview with the resident's physician on 12/15/10 at 2:10 PM verified he was unaware of the resident's swallowing difficulties and, therefore, no swallowing evaluation had been ordered for this resident. e. According to The Lippincott Manual of Nursing, Seventh Edition, 2001 residents with difficulty swallowing should be referred to a speech therapist to determine what consistency of food is safe for the resident to swallow; and techniques such as sitting upright, tucking and turning the head to facilitate swallowing (pp. 180-181). The manual also documented a resident's cough should be evaluated in relationship to food intake (p. 196). From the time the problem was identified on 2/2/10 until the survey in December 2010, there was no evidence the facility had consulted a speech therapist despite the resident's documented history of swallowing difficulties. 2. Regarding potential choking and/or aspiration during [MEDICAL CONDITION] activity: Review of the nursing notes for resident #72 showed the following entries: a. 1/28/10 at 4:20 AM, CNA summoned nurse due to the resident appearing to be having a [MEDICAL CONDITION]. vital signs were normal. b. 2/28/10 at 8 AM, question [MEDICAL CONDITION] during breakfast c. 5/1/10 at 6 AM [MEDICAL CONDITION] episode d. 6/13/10 at 5 AM [MEDICAL CONDITION] during pericare, scant blood visible in saliva, has small cut on left outer tongue. e. 6/25/10 at 4:50 AM [MEDICAL CONDITION], clinic notified at 10:15 AM f. 9/24/10 at 5 AM, body limp, foam coming from mouth [MEDICAL CONDITION]. no vital signs taken. g. 10/30/10 at 7 AM [MEDICAL CONDITION], aspirated, suctioned h. 11/4/10 at 2 AM, [MEDICAL CONDITION] activity, snoring with gurgling sounds, unable to suction, head of bed elevated. Review of the entire medical record showed, with the exception of one time (6/25/10), the physician was not notified of the resident having [MEDICAL CONDITION] activity. When interviewed on 12/15/10 at 2:10 PM, the resident's physician stated he was unaware the resident was having [MEDICAL CONDITION] activity so often (eight times during an eleven month period). He stated that was a serious problem. The physician stated the resident was on the anticonvulsant, [MEDICATION NAME], but it was primarily used to control the resident's behaviors. Interview with a family member on 12/15/10 at 9:06 PM revealed the resident had no history of [MEDICAL CONDITION]. Review of the nursing notes and vital sign flowsheets revealed vital signs were not taken at the time of each [MEDICAL CONDITION], and there was no evidence the resident was monitored. Interview with the resident's nurse practitioner on 12/16/10 at 8:20 AM revealed the [MEDICAL CONDITION] activity was most likely due to the resident's end stage [MEDICAL CONDITION]. She stated the providers should be notified so the [MEDICAL CONDITION] could be managed. The nurse practitioner said she would expect staff to at least monitor vital signs and the level of conscious every fifteen minutes for 3 to 4 hours to ensure the resident did not aspirate or choke on any fluids. According to Smith, Duel and Martin in "Clinical Nursing Skills,"Seventh Edition, 2008: a resident having a [MEDICAL CONDITION] should be placed on his or her side with a pillow at the head of the bed in order to to keep the head flexed slightly forward and prevent the tongue from occluding the airway. The resident's side rails should be in the raised position and staff should remain with the resident during the [MEDICAL CONDITION] to ensure the airway is not occluded and afterward to ensure s/he has an uneventful postictal period. Finally, the physician should be notified (p. 154). On 12/15/10 at 4 PM the interim administrator and DON were notified of the immediate jeopardy situation. On 12/15/10 at 4:55 PM, the DON stated she had educated the evening staff regarding this resident's coughing/choking concerns and how to intervene. Observation of that evening meal showed the resident again had coughing /choking episodes, but staff sat him/her upright as directed. In addition, the resident was placed in more of an upright position in the recliner and pillows were placed to support the resident's head to promote a more forward position. Review of the resident's care plan showed it was updated to reflect proper feeding assistance. On 12/16/10 at 8:10 AM, the DON notified the survey team that a swallowing evaluation was ordered for 5 PM on that day, and a thorough medical evaluation was scheduled by the resident's nurse practitioner at 9 AM on that day. An all staff mandatory in-service regarding proper positioning was scheduled to be completed by 10/22/10. Until the mandatory in-service was completed, each staff working with this resident was to be instructed individually prior to feeding the resident. In addition, the facility planned to have a licensed staff member monitor each meal on each unit until the mandatory in-service was completed. The completion of the nurse practitioner's physical examination, the scheduled swallowing evaluation, the updating of the care plan, in-service education and monitoring of each meal by a licensed staff member (RN, LPN, COTA, RD) abated the immediate jeopardy situation on 12/16/10 at 10:30 AM.