Every finding on record at Oxford Rehabilitation & Health Care Center

Based on observation, record review, and interview the facility failed to appropriately monitor the effective use of a low temperature dish machine. Specifically, the facility failed to document the parts per million (PPM) of the sanitizing solution, to ensure effective sanitization. Findings include: Review of the current manufacturer's guidelines, for the facility's contracted dish machine maintenance company, indicated that chemical sanitization PPM should be checked with daily test strips. During an observation on 2/11/26 at 11:56 A.M., the dish machine in the kitchen ran a wash cycle at 126 degrees Fahrenheit and a rinse cycle at 176 degrees Fahrenheit. The staff member in the dish machine area said that the dish machine used chemicals to clean the dishes in the machine. During an interview on 2/11/26 at 12:00 P.M., the Food Service Director said that she believes the dish machine was a low temp machine and used chemicals to clean the dishes. The Food Service Director said that the last time she recorded the PPM, with a test strip, was over a month ago and was unaware that she needed to test the PPM of the machine. Review of the dish machine temperature log for February 2026 indicated wash temperatures between 150 and 156 degrees Fahrenheit and rinse temperatures between 180 and 182 degrees Fahrenheit. There was no indication that the facility tested the PPM of the chemical machine to assess proper sanitization. During an interview on 2/11/26 at 12:05 P.M., the Food Service Director said that the reason the temperature is so high is because she requested the maintenance company to increase the temperature, otherwise the machine would run at too low of a temperature. The Food Service Director was unaware that a low temperature machine is to be run between the temperatures of 120-140 degrees Fahrenheit and needed to be tested with PPM test strips. During an interview on 2/12/26 at 7:25 A.M., the service technician for the dish machine said that, for a low temperature machine, PPM should be recorded to ensure it is sanitizing properly.

Based on observations, record reviews and interviews, the facility failed to ensure a comfortable environment on two floors where residents reside. Specifically, the facility failed to ensure that the residents' comfort was maintained and comfortable temperatures were present, resulting in residents wearing jackets, hats, gloves inside and throughout the day and night, even when extra blankets and hot beverages were available. Findings include: a.) During the initial tour on the second-floor unit on 2/10/26 between 7:39 A.M., through 2/10/26 at 8:26 A.M, the surveyor observed several residents wearing winter gloves, winter hats, and winter coats, the surveyor received the following complaints from residents: - its friggen freezing. - I'm so cold, I am wearing gloves. The Haverhill Board of Health came in last week because they 'got lots of calls', look at the temperature in my room it is 58.7 degrees. The Maintenance man 'doesn't bleed the system' and it is 'too cold to shower'. - My room is so cold, there are no mice lately it is too cold in this room for mice. - It's freezing here and they are doing nothing. - We haven't had heat forever; I am wearing a hoodie it's cold like crazy. - it's cold in my room. On 2/10/26 at 8:30 A.M., the surveyor observed the temperature outside to be 18 degrees Fahrenheit (F). On 2/10/26 at 8:34 A.M., the surveyors requested to check room temperatures with a facility representative. The Administrator said that the low temps on the unit was because of extreme weather, and she said the Maintenance Director would obtain temperatures with the surveyors. On 2/10/26 at 9:01 A.M., the surveyor and the Maintenance Director obtained the following temperatures using an infrared thermometer: room [ROOM NUMBER]: 65.1 degrees Fahrenheit (F.) room [ROOM NUMBER]: 63.3 degrees F. room [ROOM NUMBER]: 64.2 degrees F. room [ROOM NUMBER]: 63.8 degrees F, and 59.3 degrees F on the exterior wall. room [ROOM NUMBER]: 61.1 degrees F, and 60.9 degrees F. room [ROOM NUMBER]: 68 degrees F. room [ROOM NUMBER]: 67.4 degrees F, and 68 degrees F. room [ROOM NUMBER]: 65.3 degrees F, and 63.6 degrees F. room [ROOM NUMBER]: 68.7 degrees F, and 64.5 degrees F. room [ROOM NUMBER]: 68.0 degrees F, and 68.0 degrees F. b.) During the initial tour of the second-floor units on 2/10/26 at 8:30 A.M., the following complaints were received by residents: - The heat does not work; it is always cold in here. - My room is always cold. - It is always cold in this building; the pipes are old. During a walkthrough of the second-floor unit on 2/10/26 at 9:29 A.M., with the Maintenance Director, the following room temperatures were obtained by using an infrared thermometer (temperature at bedroom door/temperature by bedroom window): room [ROOM NUMBER]: 66.2 F/ 66.0 F room [ROOM NUMBER]: 65.8 F/ 65.3 F room [ROOM NUMBER]: 64.0 F/ 68.0 F room [ROOM NUMBER]: 67.0 F – with a window heater on room [ROOM NUMBER]: 63.5 F/ 62.4 room [ROOM NUMBER]: 61.7 F/60.9 F room [ROOM NUMBER]: 63.6 F/ 63.3 F room [ROOM NUMBER]: 63.5 F/ 63.0 F During an interview on 2/10/26 at 9:43 A.M., the Maintenance Director said the building has large, drafty windows and there is not much that can be done about it. c.) During the initial tour and interviews on 2/10/26 at 8:47 A.M., with residents on the first floor (Rooms in the 100's) the following was observed and reported: -A resident with a portable electric heater that was on, in his/her room said the heater was brought in because the room was freezing. -A resident said he/she is cold, and that there has been no heat on this floor. The radiator in the room felt cold to touch. d). During a walk through with the Maintenance Director on 2/10/26 at 9:00 A.M., the following room temperatures were obtained: room [ROOM NUMBER]: 59 degrees F. room [ROOM NUMBER]: 65 degrees F. room [ROOM NUMBER]: 61 degrees F. e.) During the initial observations and interviews on 2/10/26 at 7:33 A.M., with residents on the first floor the following was observed and reported: -A resident with a portable electric space heater that was on in his/her room said the space heater was brought in because it has been very cold for weeks, and that we (nodding to his/her roommate) are wearing jackets to bed. The radiator on the wall was slightly warm to touch on the left side of the unit. The right side of the radiator was not warm to touch. -A resident said we have not had heat all winter. The resident said we just keep getting lip service about what they are doing to fix the heat. At night it is very cold and we use extra blankets. I have called AgeSpan (ombudsman program) about the heat and we still not see any improvement. When the surveyor touched the radiator in the room it had minimal heat on the left side and the right side of the radiator did not have any heat emanating from the unit. -A resident said we have a problem of it being cold here like my roommate said. -A resident was observed with a portable electric space heater that was on. The resident said when it gets to be under 68 degrees, he/she is uncomfortable, especially his/her legs because he/she has hardware in his/her legs. The radiator in the room had minimal heat emanating from the left side of the radiator and the right side had no warmth to touch. When the surveyor opened the door to another resident room, the room was cold. The resident in the room said they say (the room) is 67 degrees, but it is cold and has been cold all winter. -The next resident room was cold upon entry. A resident was observed covered in bed wearing a hood. The resident said it has been this way (cold) for a while now, they (staff) say they have fixed it, but it is still cold and it is not fixed. f.) During the initial observations and interviews on 2/10/26 at 10:52 A.M., with residents on the second floor the following was observed and reported by residents: -A resident observed in bed, small and frail in stature, wearing gloves and a coat in bed. The resident said I think there is something wrong with the heat. The room felt cold. -Another resident room was cold upon entering. -A resident said he/she is cold, and that there has been no heat on this floor During the Resident Group Meeting conducted with the surveyors on 2/10/26 at 1:20 P.M., seven out of eight residents who participated said they have concerns over the lack of heat in the building. The residents continued to say that the heat has been a concern for at least a couple of weeks, and it is always cold in the building. One resident said it is getting as cold as 58 degrees F. in his/her room. Further, the residents said they have observed staff members wearing jackets while working. Review of the Resident Council Concern Follow-Up document dated 1/29/26 indicated the nature of the concern: the rooms are very cold. First floor would like a portable heater and fix the latch on the first-floor day room window. Department Head Resolution: Weather sealed and screwed window shut. Despite the Department Head Resolution response residents continue to say they are cold both day and night. During an interview on 2/10/26 at 1:58 P.M., the Administrator said that the regulation for temperatures in a facility certified after 1990 are required to have temperatures between 71 degrees and 81 degrees Fahrenheit or that the residents are reasonably comfortable, when the temperature is 67 degrees Fahrenheit. The Administrator said she was made aware of the residents being cold early January. The Administrator said building is old with drafty windows and that the heating system is only about three years old. The Administrator said they have been temping the rooms, offering blankets and hot beverages. The Administrator said she was not sure if the heating service provider has been in to review the heating system operation. During an interview on 2/10/26 at 2:29 P.M., the Ombudsman said residents have been reporting they are cold since early January. The Ombudsman said the facility has patched spaces around the windows, and the air conditioning units, and that it remains cold to the residents. The Ombudsman said the residents tell her after the sun goes down it is very cold and the residents report to her, they wear hats, jackets and hoodies to bed. g.) During an interview and observation on 2/10/26 at 4:18 P.M., Administrator #2 said he came to the facility today from another facility to help and has not been in the facility recently. Administrator #2, using an infrared thermometer gun obtained the following temperatures: room [ROOM NUMBER], internal wall 59.6 degrees Fahrenheit, 69 degrees Fahrenheit on the radiator. The resident in the B bed, said he/she was cold. room [ROOM NUMBER] exterior wall 62.9 degrees Fahrenheit, behind the beds 64.7 degrees Fahrenheit. room [ROOM NUMBER] exterior wall 62.9 degrees Fahrenheit, wall above beds 67.8 degrees Fahrenheit, room [ROOM NUMBER] exterior wall 60 degrees Fahrenheit, slit wall across from beds 62.6 degrees Fahrenheit room [ROOM NUMBER], the resident in the room said it is cold and it gets colder at night. Exterior wall 59.8 degrees Fahrenheit, wall above the beds 60 degrees Fahrenheit, interior wall 62 degrees Fahrenheit. room [ROOM NUMBER] exterior wall 63 degrees Fahrenheit, interior wall behind the beds 66 degrees Fahrenheit, wall across from the beds 64.7 degrees Fahrenheit. The resident in the room said it should be warmer here. room [ROOM NUMBER] exterior wall 57 degrees Fahrenheit, wall behind the beds 60 degrees Fahrenheit, Wall across from the beds 59.3 degrees Fahrenheit. The resident in the room said it is ice cold in here. room [ROOM NUMBER] exterior wall 57.7 degrees Fahrenheit, behind the bed wall 61.8 degrees Fahrenheit, the wall across the beds 61.5 degrees Fahrenheit. room [ROOM NUMBER] exterior wall 63.5 degrees Fahrenheit, bed wall 64 degrees Fahrenheit, wall across from beds 65.6 degrees Fahrenheit. Administrator #2 said there seemed to not be enough flow through the radiators. Administrator #2 said all the rooms' ambient temperature would be a few degrees higher than the infrared thermometer readings. Administrator #2 said he could not deny the rooms were cool. During an interview on 2/10/26 at 8:33 A.M., Certified Nursing Assistant (CNA) #5 said he usually works the overnight shift. CNA #5 said the residents are cold, especially at night. CNA #5 said he was not sure if they were fixing the heat, and said the residents ask for more blankets, which he said he provided. During an interview on 2/10/26 at 4:51 P.M., CNA #1 (evening shift CNA) said that residents complain that the building is too cold especially when the sun goes down. During an interview on 2/10/26 at 4:52 P.M., CNA #2 (evening shift CNA) said that residents complain that the building is too cold. During an interview on 2/11/26 6:56 A.M., CNA #3 (night shift CNA) said that the facility has been cold a couple months, and residents have been complaining for months, he said they brought in a space heater in the hallway, and staff are encouraged to keep the residents' doors open but it only does so much. CNA #3 said that Resident rooms [ROOM NUMBERS] are extremely cold. During an interview on 2/11/26 at 3:47 P.M., the Maintenance Director said he was just taking into consideration that it was a cold winter with extreme outside temperatures, that the windows are drafty, and some beds were against the radiators as to why the facility was running cold. The Maintenance Director said he taped off drafts, and gaps around the air conditioners. The Maintenance Director said after Christmas more residents said they were cold and he started to record room temperatures. The Maintenance Director said he does not doubt it will get colder in the rooms at night. The Maintenance Director said he did not record the temperatures at nighttime. The Maintenance Director said he was not aware that nor did residents tell him they were sleeping in hats and coats. The Maintenance Director said the plumber was not called before yesterday and came out last night and said a circular pump was misfiring and this effected the water circulation into the radiators and was not pulling the hot water quickly enough. During an interview on 2/12/26 at 8:13 A.M., a resident said his/her room is warmer today and he/she finally did not feel like a cold slab of meat in a meat locker. During an interview on 2/12/26 at 7:00 A.M., a resident said, I don't know why it took you (surveyors) to come into the facility to get them to get someone here to fix the heat.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit ([NAME]), out of four units and for one Resident (#109) residing on the [NAME] Unit.Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on the [NAME] Unit:For Resident #109, the facility staff failed to wear Personal Protective Equipment (PPE) while providing high contact care for the Resident on EBP with a feeding tube.Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP), revised 7/2022, indicated the following:-It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or tarted multi-resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other germs.-EBP require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of MDROs. High -contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care, and wound care.Resident #109 was admitted to the facility in October 2025 with diagnoses including malignant neoplasm of lateral wall of oropharynx and gastrostomy status.Review of the most recent Minimum Data Set (MDS) assessment, dated 11/3/25, indicated that Resident #109 was cognitively intact as evidenced by a Brief Interview for Mental Stats (BIMS) score of 14 out of 15.On 2/11/26 at 9:16 A.M., the surveyor observed the following:-An EBP sign posted at the entrance of the Resident's doorway to the room.-A PPE bin with the necessary PPE required located in the hallway directly outside of the Resident's room.-Nurse #5 entered Resident #109's room with his/her medications. Nurse #5 was not wearing a gown or gloves. Resident #109 was wearing gloves and Nurse #5 explained to surveyor that he/she has been educated on how to administer his/her own medications and tube feeding with supervision from the nurse. Nurse #5 raised Resident #109's shirt with her bare hand and used her stethoscope to check his/her tube feeding for placement (attach a syringe to the port, inject 5-10 ml (milliliters) of air while listening for a whoosh over the stomach with a stethoscope. The Resident completed the remainder of the care independently with her supervision.-Resident #109's removed his/her syringe from his/her drawer without any covering or container when Nurse #5 and surveyor entered the room. The syringe was left on his overbed table without any cover or container when Nurse #5 and surveyor left the room.During an interview on 2/11/16 at 9:25 A.M., the surveyor discussed with Nurse #5 that Resident #109 is on EBP and that gloves and a gown are required. Nurse #5 said she did not think PPE was required as the Resident was administering his/her own medication.During an interview on 2/11/26 at 2:17 P.M., Unit Manager #1 said that Resident #109 is on EBP and the nurse should have worn a gown and gloves when caring for his/her tube feeding.During an interview on 2/11/26 at 12:43 P.M., the Infection Prevention Nurse said the nurse should have worn a gown and gloves when caring for Resident #109's feeding tube.During an interview on 2/12/26 at 9:12 A.M., the Assistant Director of Nursing (ADON) said Resident #109 was on EBP due to his/her tube feeding. The ADON said a gown and gloves should be worn when providing care for Resident #109.

Based on observation, record review and interview the facility failed to ensure for one resident #109, out of a total sample of 24 residents, that recommended services were implemented in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Evaluation Determination Summary. Specifically, Resident #109 was screened to meet PASRR criteria for SMI (serious mental illness) with recommended behavioral health services, individual psychotherapy. Findings include: Resident #109 was admitted in October 2025 and has diagnoses that include dysphagia, and gastrostomy status (a gastrostomy tube is surgically placed to provide direct access to the stomach for nutrition, hydration, and medication when oral intake is insufficient or unsafe), post-traumatic stress disorder, opioid use, anxiety disorder and schizoaffective disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #109 scored a 14 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. Review of Resident #109's clinical record indicated the following:-A Pre-admission Screening and Resident Review (PASRR) level II Evaluation Determination Summary, dated 12/8/25, which indicated Resident #109 meets the PASRR criteria for a SMI and nursing facility services are appropriate up to 90 days. Recommended behavioral health services including Individual Psychotherapy. Review of the Care plan with the Focus: Resident meets PASRR II level of determination due to schizoaffective d/o (disorder), anxiety d/o, major depressive d/o, opioid abuse, cocaine use, and PTSD (post-traumatic stress disorder). As part of the determination, PASRR mandates the implementation of the following specialized services during the resident's admission to the facility: DMH (Department of Mental Health) Clubhouse, Case Consultation, Individual Psychotherapy, Methadone, buprenorphine, buprenorphine/naloxone, or naltrexone, self-help skills, PT (physical therapy), OT (occupational therapy) and ST (speech therapy) evaluation expires 3/8/26. During an interview on 2/10/26 at 3:55 P.M., Resident #109 said he/she was not sure what DMH clubhouse was or if he/she was seen by individual therapy but was interested in knowing. Review of Resident #109's clinical record indicated the following:- A Social Service note dated 11/4/25 Referral sent to behavioral health therapist on this day. Further review of the clinical record failed to indicate Resident #109 was seen for individual psychotherapy in accordance with the PASRR level II determination summary. During an interview on 2/11/26 at 8:49 A.M., Unit Manager #1 said the individual talk therapist notes are located under miscellaneous in the clinical record. During a telephone interview on 2/11/26 at 8:53 A.M., the PASRR review specialist said the SNF (skilled nursing facility) staff should be aware of the level II determination including coordinating the recommended services including psychotherapy. During an interview with Social Worker #1 and Social Worker #2 on 2/11/26 at 10:16 A.M., Social Worker #1 said Resident #109 has been seen by the psychiatric nurse practitioner (NP) who would have offered Resident #109 individual therapy. SW #1 said the NP would not be the person to coordinate the PASRR level II recommended services. Social Worker #2 said they audited Residents last fall who had Level II recommendations.

Based on observation, record review and interview the facility failed for one Resident (#37), out of a total sample of 24 resident to provide standards of quality of care. Specifically, the facility failed to identify an alteration in Resident #37's skin resulting in a delay in providing treatment and monitoring to ensure it was not worsening. Findings include: Review of the facility's policy, titled Preventative Skin Care, dated April 2015 indicated it is the policy of this facility that routine preventative skin care be done by the C.N.A. (Certified Nursing Assistant) every shift for those residents at risk for altered skin integrity. Resident #37 was admitted to the facility in April 2021 and has diagnoses that include but are not limited to chronic diastolic heart failure, morbid obesity, muscle weakness and venous insufficiency. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition. Further, the MDS indicated Resident #37 as dependent on staff for care activities including bathing, toileting and dressing, is at risk for developing pressure injuries and had no venous ulcers. On 2/12/26 at 8:13 A.M., Resident #37's left lower shin was observed with small scab-like areas descending the shin, with dry patches of skin and a small open area. Resident #37 said he gets washed daily and cannot reach his/her legs. Review of Resident #37's clinical record indicated the following: -A weekly skin check dated 2/9/26, that did not identify any skin alterations for Resident #37. -Physician's orders dated 8/30/23 monitor for signs and symptoms for bleeding d/t (due to) being on Eliquis (a blood thinning medication), every shift and notify MD (medical doctor) if observed. Review of the care plan date initiated 6/7/2023 indicated Resident #37 has potential alteration in skin integrity related to decreased/impaired mobility or function, incontinence, poor nutrition, morbid obesity, Norton Plus Score. Goal: skin will remain intact target date 2/16/26. Review of the care plan date initiated 6/7/23 indicated Resident #37 has edema in: Left Lower Extremities, right lower extremities. Intervention dated 6/7/23 indicated observe for complications r/t edema, i.e. open areas, weeping of serous fluid, sx (symptom) infection date 6/7/23. Review of the care plan date initiated 6/7/23 indicated Resident #37 occasionally chooses not to participate in daily care needs, hygiene needs, frequently refuses ordered weights, therapies, and ultimately refuses to both ambulate and get out of bed. Review of the clinical record failed to indicate a treatment for the areas observed, nor a plan of care for monitoring the areas to promote healing and prevent worsening. During an interview on 2/12/26 at 9:59 A.M., CNA #6 said she took care of Resident #37 yesterday on the day shift. CNA #6 said Resident #37 requires two CNAs to provide daily care and at times he/she will not let staff touch his/her feet. CNA #6 said the Resident does use his/her other foot to scratch his/her skin or uses a reacher (a mechanical tool used to extend a person's reach) to scratch his lower leg. CNA #6 and the surveyor went to see Resident #37. CNA #6 said the areas of red scabs, dry patches and small open area were present yesterday and that the Nurses are aware of how his/her left leg looks. During an interview on 2/12/26 at 10:26 A.M., Unit Manager #1 was working on the medication cart. Unit Manager #1 said she was not aware until just now, when she was told by the CNA that Resident #37 has an alteration in his/her skin. Unit Manager said staff are required to let nursing staff know if there are changes of any kind to a resident's skin. Unit Manager #1 and the surveyor observed Resident #37's lower left leg. Unit Manager #1 said the areas on Resident #37's left lower leg are small scabs in a line, dry skin and an open area that she said is a possible skin tear. Unit Manager #1 said the Resident is at risk of bleeding due to being on blood thinner and has history of edema. During an interview on 2/12/26 at 10:56 A.M., the Nursing Staff Developer said she is also the nurse who does skin rounds. The Staff Developer Nurse said she would expect staff when they identify skin changes to report it to the nurse. The Staff Developer Nurse said she observed the Resident, and that he/she does scratch him/herself, he/she has a cluster of scratches, has dry skin areas and an open area that was not scabbed.

Based on observations, record review, and interviews, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment for three Residents (#75, #9, and #112), out of 24 total sampled residents. Specifically,1 For Resident #75, the facility failed to ensure a safe, hazard free environment when Resident #76 had an electric space heater in his/her room. 2. For Resident #9, the facility failed to ensure a safe, hazard free environment when Resident #9 had a small electric space heater in his/her room. 3. For Resident #112 the facility failed to ensure a safe, hazard free environment when Resident #112 had a small electric space heater in his/her room. Findings include: 1. Resident #75 was admitted to the facility in January 2025. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #75 scored 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. During an observation and interview on 2/10/26 at approximately 7:40 A.M., a small electric space heater was observed plugged in and running. The roommate said Resident #75 bought it. Resident #75 entered the room and said they were wearing jackets to bed because it was so cold. During a follow-up interview on 2/11/26 at 1:12 P.M., Resident #75 said the space heater was brought in by family a week or more ago. At this time the space heater was no longer observed in the room. 2. Resident #9 was admitted to the facility in October 2024. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #9 scored 14 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as cognitively intact. On 2/10/26 at approximately 7:50 A.M., Resident #9 was observed up in a chair in his/her room. A space heater was on and located near the foot of the bed. Resident #9 said when it gets to be under 68 degrees, he/she is uncomfortable because he/she has hardware in his/her legs. On 2/10/26 at 4:18 P.M., Administrator #2 and the surveyor observed the portable space heater in Resident #9's room. Administrator #2 said he did not know the policy on residents' having portable space heaters. On 2/11/26 at approximately 1:00 P.M Resident #9 said his/her family brought in the space heater about a week ago and that last night it was removed for safety reasons. During an interview 2/11/26 12:53 P.M., the Administrator said space heaters are not to be used by residents for safety reasons. 3. Resident #112 was admitted to the facility in August 2023 with diagnoses including Diabetes, chronic kidney disease, and anemia. Review of Resident #112's most recent Minimum Data Set (MDS) assessment, dated 1/9/26, indicated moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of 15. On 2/10/26 at 8:29 A.M. and 2/10/26 at 1:30 P.M., the surveyor observed Resident #112 sitting next to his/her bed with an electric heater on the nightstand set at 90 degrees. On 2/11/26 at 7:11 A.M., the surveyor observed Resident #112 lying in his/her bed with his/her eyes closed and the electric heater was not in view. During an interview on 2/11/26 at 12:20 P.M., Resident #112 said that at 10:30-11P.M. last night a man he/she did not know came in his/her room and attempted to remove his/her heater without introducing himself or explaining why he was removing it. The Resident said his/her spouse had bought that heater and he/she was not aware that there was any rule or regulation against using one. He/she would not allow the heater to be removed but stopped using it and placed it under his/her bed. The Resident complained of the room being cold without the use of the heater. During an interview on 2/11/26 at 12:56 P.M., the Administrator said that she was not aware that any residents had heaters in their rooms. She said that they are a safety risk to use in a resident's room. She was not aware of any policy they had about using a heater, but they follow the regulation. During an interview on 2/12/26 and 10:55 A.M., the Maintenance Director said he had heard that residents had been ordering space heaters on weekends but had not been told of anyone specific that they had them. He said it was his understanding that they are not allowed due to safety risk.

Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter (a tube placed through the suprapubic region into the bladder to drain urine) for one Resident (#51) out of a total sample of 24 residents. Specifically, the facility failed to ensure the size of Resident #51's catheter was the same size the physician ordered. Findings include: Resident #51 was admitted to the facility in June 2022 with diagnoses including stroke and neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated that Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Stats (BIMS) score of 15 out of 15. This MDS indicated Resident #51 had an indwelling catheter. Review of Resident #51's plan of care related to suprapubic catheter care, dated 7/27/22, indicated:- Resident has a supra pubic 18 x 30 ml (milliliters) catheter due to neurogenic bladder. Review of Resident #51's physician's order, dated 12/2/25, indicated:- Suprapubic Catheter- insert foley 16 French (size of catheter), with 30 ml balloon. Change catheter as needed for blockage or leakage. Review of Resident #51 urology office visit report, dated 1/28/26, indicated:-12/4/25- SPT (suprapubic tube) change, reports tubing was backed up, and he/she developed right testicle pain and swelling found to have right epididymo-orchitis (inflammation of both the epididymis and the testis) and treated at hospital and had SPT change16 French in on exam with balloon super inflated to 30mls he/she denies leakage issues. Will change with 18 French and 10mls in balloon.-1/5/26- SPT change. No issues.-1/28/26- SPT change 18 French. No issues. On 2/11/26 at 8:58 A.M., and on 2/12/26 at 9:00 A.M., the surveyor observed Resident #51 with an 18 French 5 cc balloon suprapubic urinary catheter. During an interview on 2/11/26 at 12:20 P.M., Resident #51 said that he/she goes out to his/her urologist to have the catheter changed every 3 weeks. He/she said that it has been changed at the facility by nursing when it has become blocked, but not recently. During an interview on 2/11/26 at 2:07 P.M., Unit Manager #1 said that nursing should be checking the size of catheter and balloon size when he returns from the hospital or urologist to make sure the order matches the size of catheter that is being used. She said that the urologist usually changes the catheter and replaces it with the same size. During an interview on 2/12/26 at 9:10 A.M., the Assistant Director of Nursing said nursing should implement the catheter size in accordance with the physician's order and that the consequences of inserting a size too large could potentially result in pain, infection, and necrosis.

Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for two Residents (#40 and #7) out of sample of 24 residents. Specifically,1 For Resident #40 the facility staff failed to ensure a physician's order was obtained for the administration and liter flow rate of oxygen to be administered. 2. For Resident #7 the facility failed to ensure that nursing consistently administered oxygen in accordance with the physician's orders. Findings include: Review of the facility policy titled Oxygen Administration dated as revised November 2020, indicated to deliver low flow oxygen, per the physician's order via nasal cannula. 1.Resident #40 was admitted to the facility in December 2025 with diagnoses including centrilobular emphysema. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident 40's cognition is cognitively intact as evidenced by a scored 15 out of 15 on the Brief Interview for Mental Status assessment. Further review indicated that Resident #40 used oxygen. On 2/10/26 at 8:28 A.M. and at 12:30 P.M., the surveyor observed Resident #40 walking in his/her room receiving oxygen (O2) via nasal cannula at 1 L/min (liters per minute). Resident #40 said he/she had just been in the hospital and needed to wear oxygen. On 2/11/26 at 2:04 P.M., the surveyor observed Resident #40 sitting in hallway receiving portable O2 via nasal cannula at 1L/min. On 2/12/26 at 7:57 A.M., the surveyor observed Resident #40 in his/her room wearing O2 via nasal cannula at 1L/min. Review of the physician's orders dated February 2026 failed to indicate an order for the administration of oxygen or to check oxygen saturation. Review of the care plan related to oxygen dated 12/19/25 indicated: -Administer oxygen as ordered and monitor its effectiveness by checking oxygen saturation, as indicated. Review of the Hospital Discharge summary dated [DATE] indicated: -COPD on home oxygen- continue home regime. -Wean oxygen to keep oxygen saturation 88-92%. During an interview on 2/12/26 at 7:57 A.M., Unit Manager #1 said Resident #40 should have a physician's order for the use of oxygen. She said he/she had returned from the hospital on 2/6/26 and the oxygen order must have been overlooked. During an interview on 2/12/26 at 9:10 A.M., the Assistant Director of Nursing said that there should be a physician's order for the use of oxygen. 2. Resident #7 was admitted to the facility in March 2022 with diagnoses including diabetes, asthma, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set assessment, dated 12/12/25, indicated Resident #7 had a severe cognitive impairment as evidenced by a Brief Interview of Mental Status score of 5 of 15. This MDS indicated Resident #7 required assistance with activities of daily living and he/she received oxygen therapy. Review of Resident #7's care plan related to Resident has altered respiratory status, dated as revised 7/3/25, indicated: - Oxygen as ordered for resident needs. Review of Resident #7's physician's order, dated 1/27/25, indicated: -Titrate oxygen (O2) 0-2 liters/minute (ltre/min) to maintain pulse ox greater than 89% every shift for dyspnea and sao2 (oxygen saturation) below 90. On 2/10/26 at 7:39 A.M., 2/10/26 at 11:54 A.M., 2/10/26 at 4:42 P.M., and on 2/11/26 at 6:52 A.M., the surveyor observed Resident #7 in bed, he/she was receiving oxygen via nasal cannula at a flow rate of 4 liters per minute (LPM). Resident #7's oxygen concentrator was out of reach, and he/she could not reach the concentrator. On 2/11/26 at 1:20 P.M., and 2/12/26 at 6:50 A.M., Resident #7 was not wearing any supplemental oxygen. On 2/12/26 at 7:50 A.M., the surveyor observed Resident #7 in bed not wearing any supplemental oxygen, the oxygen concentrator was turned off. The surveyor found Nurse #3, and she said that Resident #7 wears oxygen and Resident #7 sometimes takes the nasal cannula out of his/her nose and Nurse #3 said Resident #7 does not have the dexterity to shut the oxygen concentrator off him/herself. The surveyor and Nurse #3 entered Resident #7's room and Nurse #3 attempted to obtain Resident #7's oxygen saturation on room air as Resident #7 was not wearing oxygen. The surveyor observed Nurse #3 as she attempted to trouble shoot the pulse oximeter (a device clipped to the finger that measures blood oxygen saturation) to ensure the oximeter was working and Nurse #3 confirmed the pulse oximeter was working. Nurse #3 left the pulse oximeter on Resident #7's finger, and she said she would try to find a warm cloth to apply to Resident #7's finger to see if that would help get an oxygen reading. On 2/12/26 8:02 A.M., the Assistant Director of Nursing (ADON) entered Resident #7's room with a different pulse oximeter, the oximeter that Nurse #3 had left on Resident #7's finger was now reading 87-88%, and Resident #7 was on room air. The ADON's pulse oximeter began to read on 88-89% on room air. The ADON said that Resident #7 has cold fingers and sometimes the oximeter takes a little time for the oxygen saturation to read. The ADON said that she would need to administer oxygen to Resident #7 to maintain an oxygen saturation above 89%. Review of Resident #7's Medication Administration Record, dated 2/1/26 through 2/10/26, indicated nursing documented that they administered Resident #7 oxygen at a level above his/her physician's flow rate on 12 out of 30 shifts. During an interview on 2/12/26 at 9:33 A.M., the Quality Assurance (QA) Nurse said that nursing should implement oxygen orders based on the physician's orders. The surveyor and the QA Nurse reviewed the documentation in the medical record, and she said that Resident #7's order for oxygen is for 0 to 2 LPM and if nurses are administering oxygen above 2 LPM the nurses should notify the provider and obtain new orders with a higher flow rate range.

Based on observation, interviews, and record review, the facility failed to ensure one Resident (#11) was free from a significant medication error, out of a total sample of 24 residents. Specifically, for Resident #11, the facility failed to ensure nursing administered intravenous (IV) daptomycin (antibiotic medication) was administered to a resident with a diagnosis of bacteremia (blood infection).Findings include: Review of the facility policy titled Intermittent Medication Administration, dated as effective [DATE], indicated to safely administer intermittent infusion of medications or solution to a resident in a subacute setting. Procedure: 2. Verify the physician's order.7. Inspect medication or solution for leaking, cracks, particulate matter, clarity, and expiration date. If the product is expired or integrity is compromised, report and return to the pharmacy. Resident #11 was admitted to the facility in [DATE] with diagnoses including bacteremia, pulmonary embolism, anxiety, collapsed vertebra, pain, bipolar disorder, mood disorder, and post-traumatic stress disorder. Review of the most recent Minimum Data Set assessment, dated [DATE], indicated: C: Brief Interview of Mental Status score 15/15, which indicated Resident #11 was cognitively intact. N: antibiotic, coded as yes. O: IV medications, coded as yes. During an interview on [DATE] at 8:14 A.M., Resident #11 said he/she was admitted to the facility for IV antibiotics related to a blood infection. Resident #11 said on one evening the facility did not have his/her antibiotic medication and he/she did not receive the dose. The IV pole in Resident #11's room had an empty bag of daptomycin hanging that was dated do not administer after [DATE] (expired), Resident #11 said that the bag hanging was what she received last evening. Review of Resident #11's care plan related to IV therapy, dated as [DATE], indicated: -IV as ordered. Review of Resident #11's care plan related to infection with a resistant micro-organism bacteremia, dated as [DATE], indicated:-Antibiotics as ordered. Review of Resident #11's physician's orders dated [DATE], indicated: -Daptomycin Intravenous Solution Reconstituted (Daptomycin), Use 625 milligrams (mg) intravenously one time a day for Bacteremia for 25 Days. Review of Resident #11's Orders-Administration Note, dated [DATE], indicated:-Daptomycin Intravenous Solution Reconstituted, Use 625 mg intravenously one time a day for Bacteremia for 25 Days. Pending Delivery. Review of Resident #11's Medication Administration Record in the Electronic Health Record, dated [DATE], indicated the daptomycin was not administered as ordered. Review of the Infusion Medication Administration Record (a paper medical record, located in a binder at the nursing station), dated February 2026 indicated between [DATE] through [DATE] that nursing documented the daptomycin medication was administered as ordered. Review of the pharmacy delivery manifest, dated as [DATE] at 3:51 A.M., indicated the pharmacy delivered two doses of daptomycin for Resident #11. During an interview on [DATE] at 4:50 P.M., Nurse #1 said that Resident #11's daptomycin was not available for administration on [DATE] and she called the pharmacy and Nurse #1 said the pharmacy was supposed to come on the night run and deliver the daptomycin after her shift was over. Nurse #1 said she spoke with the night nurse (Nurse #2) and Nurse #1 said Nurse #2 agreed to hang the daptomycin when the medication arrived. Further Nurse #1 said that she only documents the daptomycin administration in the EHR (electronic health record) and she was not aware of any paper documentation. Nurse #1 said she did not document she notified the physician and she did not obtain a physician's order to administer the daptomycin available once delivered. During an interview on [DATE] at 6:53 A.M., Nurse #2 said she couldn't recall administering Resident #11's daptomycin on [DATE] when the medication arrived from the pharmacy on [DATE]. During a follow up interview on [DATE] at 7:30 A.M., Nurse #2 said she did not recall administering daptomycin and she said she did not administer the daptomycin. Nurse #2 reviewed the electronic health record (EHR), and she said that if she had administered the daptomycin she would have documented in the EHR. During an interview on [DATE] at 9:26 A.M., the Quality Assurance (QA) Nurse, said that Resident #11 missing a dose of daptomycin would be considered a significant medication error as the medication is used for a blood stream infection and not receiving the medication can result in the worsening of infection. The QA Nurse said the pharmacy only delivers two doses of daptomycin at a time because the daptomycin is only good for 2 days. The QA Nurse said that the facility has not fully integrated documenting IV administration into the EHR, and she said that nursing should continue to document in both the EHR and the paper flow sheets. During an interview on [DATE] at 9:51 A.M., the Infection Control Nurse said that nursing should document IV medication administration in both the paper records and in the EHR. During a follow up interview and subsequent observation and record review on [DATE] at 10:11 A.M., the QA Nurse and the surveyor reviewed the paper documentation for the daptomycin administration and the documentation in the EHR and she said she was not sure why the nursing initials did not match with each other and they should be the same initials in both records. During an interview [DATE] at 11:10 A.M., the Physician said Resident #11 is on daptomycin for his/her bacteremia and it is important he/she receives it daily. The Physician said that when the daptomycin wasn't administered on [DATE] the medication should have been given once the medication was available. The Physician said he was not aware that Resident #11 never received the dose on [DATE].

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed. Findings include: Review of the facility policy titled 'Medication Storage Room/Medication Cart Policy ', dated 2/2018, indicated:- Licensed personnel will be responsible for checking expiration dates on ordered medication, house stock medications, and supplies. On 2/10/26 at 9:15 A.M., the surveyor and Nurse #4 observed the following in the [NAME] floor medication cart:- One Symbicort inhaler, opened and undated.- One Humalog insulin pen, opened and was not labeled with name or date.- One Lantus insulin pen, opened and undated.- One Lispro insulin vial, opened and was not labeled with name or date. During an interview on 2/11/26 at 2:11 P.M., Unit Manager #1 said that Nurse #4 had informed her of the open, undated, and unlabeled inhaler and insulin. Unit Manager #1 said these medications have shortened expiry dates once opened and should have been dated but were not. During an interview on 2/12/26 at 9:10 A.M., the Assistant Director of Nursing said the inhaler and insulin have shortened expiry dates once opened and should have been dated once opened.

Based on observation and interview, the facility failed to properly dispose of garbage and refuse outside near the dumpster, potentially hindering pest management efforts. Findings include: During initial screening on 2/10/26, several residents complained of pest sightings, particularly mice in their bedrooms. During resident council on 2/10/26 at 1:15 P.M., 7 out of 8 residents complained about seeing mice in their rooms. Review of the pest control service report, dated 12/22/25, indicated the following: Theres pallets of trash outside on the ground, this attracts pests, need better trash program You have uncovered trash in the break room with the rear door open and trash outside. This is exactly why you have mice issues. Review of the pest control service report, dated 2/5/26, indicated a recommendation pending to clean dumpster and cover trash. During observations on 2/11/26 at 12:29 P.M. and 5:00 P.M., the dumpster outside was left open on the top and side and was filled with bags containing trash. During an observation on 2/12/26 at 7:25 A.M., the dumpster outside was left open on the top and side and was filled with trash. There were four trash bags left on top of pallets next to the dumpster. During an interview on 2/12/26 at 10:49 A.M., the Maintenance Director said that his assistant meets with the pest control contractor and believes most of the pest control issues stem from residents leaving food out in their rooms. The Maintenance Director said that he expects staff to close the dumpster when not in use.

Based on observation, record review and interviews, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified and ensured continuous evaluation of care delivery systems and to prevent continued concerns that affect the quality of life of the residents on all resident care units. Specifically, the facility failed to ensure a Quality Assurance Improvement plan was established when sources of concern were reported related to the residents being cold. Findings include: Findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) dated April 2015 indicated the (Organizations) Health Care Systems facilities will have effective Quality Assurance Performance Improvement programs to improve the quality of life, and quality of care and services delivered in facilities.During the survey conducted on 2/10/26 through 2/12/26 multiple residents residing in the facility on both floors said they have been reporting that they are cold most of the winter until 2/12/26, when they reported feeling more heat. During the survey, sources including the Ombudsman, resident interviews, staff interviews, and resident group note dated 1/29/26 indicated continuous concerns related to the cold environment, resulting in residents saying they wear coats and hats to bed. During an interview on 2/10/26 at 1:58 P.M., the Administrator said she was made aware in early January that the residents reported being cold. The Administrator said that she requested the Maintenance Director to take room temperatures a few times a week, for staff to offer residents blankets, and have hot beverage stations. During the QAPI task interview on 2/12/26 at 11:56 A.M., the Administrator said the QAPI committee meets the third Thursday of each month. The Administrator said the environment, including the operation of the heating system and residents reporting being cold, was not identified or discussed in the January QAPI meeting.

Based on record reviews and interviews the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments for three residents (#3, #5 and #109), out of a total sample of 24 residents. Specifically:1. For Resident #3 the MDS nurse failed to code a high-risk medication accurately. 2. For Resident #5, the MDS nurse failed to include a fall sustained by Resident #5 on the most recent MDS and, 3. For Resident #109, the MDS nurse failed to document the use of a gastrostomy tube (a tube used for enteral nutrition) These failures resulted in inaccurate MDS assessments being transmitted to the Centers of Medicare and Medicaid Services. Findings include: 2. Resident #5 was admitted to the facility in March 2016 and has diagnoses that include dementia, and non-traumatic brain dysfunction. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #5 scored a 1 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #5 as severely cognitive impaired. Further, the MDS indicated Resident #5 as dependent on staff for care activities including eating, toileting, bathing and dressing. Review of Resident #5's clinical record indicated the following: -A fall assessment dated [DATE] resulting in a score of 14 indicating the Resident is at risk of falling. -A progress note dated 1/6/26 that Resident #5 was found on the floor. Review of the fall incident report dated 1/6/26, indicated Resident #5's roommate came to staff to show the Resident was on the floor. Guardian, MD (medical doctor), Director of Nursing and Administrator aware. Review of the MDS with an assessment reference date of 1/23/26 failed to indicate Resident #5 was coded as having a fall since admission/entry or reentry or the prior assessment. Coding that Resident #5 did not have a fall, conflicts with the documentation of a fall on 1/6/26. During an interview on 2/11/26 at 3:22 P.M., MDS Nurse #2 said when she does an MDS assessment she reviews risk management to see if a resident had fallen since the last assessment and whether there was an injury. MDS Nurse #2 said Resident #5 did have a fall and it was missed on the MDS. MDS nurse #2 said she did not see the progress note that Resident #5 fell on 1/6/26. MDS Nurse #2 said MDS assessments should be accurate and that it was a mistake. 3. Resident #109 was admitted in October 2025 and has diagnoses that include dysphagia, and gastrostomy status (a gastrostomy tube is surgically placed to provide direct access to the stomach for nutrition, hydration, and medication when oral intake is insufficient or unsafe). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #109 scored a 14 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. On 2/11/26 at 8:19 A.M., Resident #109 was observed resting in bed. A syringe was on the bedside table. Resident #109 picked it up and said it is used to administer his/her medications and pointed to the gastrostomy tube in his/her stomach. Resident #109 said it has been there since he/she was admitted and a new syringe is used for the Jevity (nutritional supplement) daily. Review of Resident #109's physician orders indicated the following: - Jevity 1.5 Cal/fiber Oral Liquid (nutritional supplement), give 237 milliliters (ml) via g-tube one time a day for unable to meet needs with PO (by mouth eating) 12/8/26. (sic) Review of Resident #109's care plan indicated the focus as Resident has a gastric tube feeding (18fr (French)) d/t (due to) dysphagia, malnutrition, and poor P.O. intake, date initiated 11/2/25. Review of the admission Nutritional assessment dated [DATE] indicated Resident #109 has (G) tube feeding for supplemental bolus feeding. Review of the MDS dated [DATE] indicated the nutritional approach of a feeding tube, while a resident in the facility was coded as 'No'. During an interview on 2/11/26 at 11:57 A.M., MDS Nurse #1 and the surveyor reviewed the Medication Administration Record for October 2025 and November 2025 indicating Resident #109 was administered supplemental nutrition and medication via the g-tube. MDS Nurse #1 said she did not code the Resident as having a feeding tube on the MDS and that the MDS should be accurate. 1. Review of the Resident Assessment Instrument (RAI) manual, dated October 2025, indicated for coding section: N0415: High-Risk Drug Classes: Use and Indication 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day lookback period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room). Resident #3 admitted to the facility in June 2006 with diagnoses including vascular dementia, hemiplegia and hemiparesis, and atrial fibrillation. Review of Resident #3's most recent Minimum Data Set assessment, dated 11/18/25, indicated Resident #3 received a hypnotic medication. Review of Resident #3's active physician's orders and medication administration records during the MDS assessment reference date (ARD) failed to include documentation to support that Resident #3 received a hypotonic medication. Further review indicated Resident #3 received an anxiolytic medication (Ativan). During an initial interview on 2/11/26 at 10:04 A.M., MDS Nurse #1 said she codes every resident who receive hypnotic medication such as Ativan according to RAI manual and she said she review's the Massachusetts Circular letter 17-2-699 for medication classification that indicates that Ativan is a hypnotic medication. The surveyor requested MDS Nurse #1 to reach out to her regional MDS Nurse to re-review the coding for hypnotic medications and Ativan. During a follow up interview on 2/11/26 at 12:27 P.M., MDS Nurse #1 said she spoke with her regional MDS nurse, and she said that the Ativan should not have been coded as a hypnotic.

Based on observation, record review and interview, the facility failed to protect one Resident (#92), from neglect, out of a total sample of 25 residents. Specifically, the facility neglected to schedule a follow-up appointment for over ten months when a physician's order was written for a Gastrointestinal Doctor consult to determine a possible colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon directly into a bag or pouch) reversal procedure resulting in emotional distress. Findings include: Review of the facility policy titled Policy & Procedure Manual Abuse, Neglect and Exploitation, dated February 2023 indicated the following: - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. - Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Resident #92 was admitted to the facility in January 2024 with diagnoses including traumatic brain injury, colostomy status and adult failure to thrive. Review of Resident #92's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of 15 indicting moderate cognitive impairment. Further review of the Resident's MDS indicated that he/she has a colostomy and requires substantial/maximum assistance with toileting. During an interview on 2/24/25 at 8:36 A.M., Resident #92 said he/she wants his/her colostomy bag removed as he/she has had it for over one year and it really bothers him/her. The surveyor observed a colostomy bag on the lower left side of Resident #92's stomach. During a follow-up interview with Resident #92 on 2/26/25 at 10:00 A.M., Resident #92 said he/she wants his/her colostomy reversed and it is bullshit and it should have been reversed a long time ago. He/she continued to say it smells bad and it leaks sometimes. The Resident said he/she does not want to go out in public at times because it is embarrassing, especially if it smells. The Resident continued to say that he/she has been staying in his/her room more because of the colostomy bag. Review of Resident #92's Colostomy care plan dated 1/4/24 included interventions which indicated the following: Follow up with GI Consult if indicated. Refer to ostomy specialist as/if needed. Review of Resident #92's progress note written by the facility's Substance Abuse Counselor indicated the following: - Dated 2/23/24 at 2:55 P.M. - Check in with Resident on this day to learn he/she has not been seen by GI as he/she had requested in order to learn if his/her colostomy bag removed [sic]. This writer spoke with Unit Secretary to learn medical records need to be requested from an out of state hospital prior to establishing an appointment with GI near facility. Moreover, it was learned MD (medical doctor) need to order said appointment. Unit Secretary reports herself and medical records will follow up on Resident's request. Further review of the medical record failed to indicate any additional information regarding a follow up appointment with GI for colostomy removal was documented until 4/10/24, over a month after the Residents request on 2/23/24. Review of Resident #92's physician's order dated 4/10/24 indicated the following: GI consult for possible colostomy reversal. During a telephone interview on 2/26/25 at 10:19 A.M., the Medical Doctor (MD) said he saw Resident #92 two weeks ago with an ongoing plan to have a colostomy reversal. The MD said Resident #92 is in a good position to get his/her colostomy reversed but he/she needs to see a GI doctor first. During an interview on 2/26/25 at 8:44 A.M., Unit Secretary #1 said she is in charge of making appointments and managing paperwork for residents in the facility. She continued to say she has been attempting to make an appointment with a GI doctor but it is difficult since she does not have Resident #92's admission medical records. Unit Secretary #1 said she was unsure if the facility has obtained Resident #92's medical records yet. During an interview on 2/26/25 at 8:50 A.M., the Medical Records Coordinator said she does not believe that Resident #92's was admitted to this facility with his/her past medical records. The Medical Records Coordinator said when a resident is not admitted with their medical records they should be obtained as soon as possible. The Medical Records Coordinator said she believes Resident #92's medical records are in the facility but she needs to find them. During a follow-up interview on 2/26/25 at 10:15 A.M., the Medical Records Coordinator provided the surveyor with Resident #92's past medical records before he/she was admitted to the facility. The Medical Records Coordinator said she found them in a drawer in her office. Review of Resident #92's past hospital medical records included a cover sheet which indicated the following: - Purpose for which disclosure is to be made: Records needed to make an appointment to reverse colostomy. The cover sheet was signed and dated by Resident #92 on 8/20/24. Additionally, the coversheet had a stamped date of 8/26/24, had a date the documents were scanned on 8/27/24 and a printed dated of 8/29/24. The facility did not request to receive Resident #92's medical records from his/her previous medical facility until seven months since the progress note was written on 2/23/24 indicating that the medical records needed to be requested prior to establishing an appointment for a colostomy reversal with a GI doctor and over five months since the physician's order for a GI consult was developed. During a follow up interview on 2/26/25 at 10:28 A.M., just under two hours since the last interview, Unit Secretary #1 said she was able to get Resident #92 a pending appointment for a GI doctor in about 5 weeks from today, 22 minutes away from this facility. This was done after the facility provided the surveyor with Resident #92's medical records which were found in a drawer in the Medical Record Coordinator's office. During an interview with the Director of Nursing (DON) and Administrator in Training (AIT) on 2/27/25 at 8:33 A.M., they said referrals should be made as soon as possible but no specialty doctor would see Resident #92 until his/her medical records were available. The surveyor, DON and AIT reviewed the coversheet of Resident #92's hospital paperwork and they were not aware Resident #92's medical records were available in August, 2024. The DON said the facility had a delay in trying to contact a GI doctor for Resident #92's colostomy reversal and the facility dropped the ball on this and it should have been done sooner if the paperwork has been available since August. The DON and AIT said it is neglectful to not follow up on this concern. During a telephone interview with the interim Unit Secretary that was covering for Unit Secretary #1 while she was away from the building on 2/27/25 at 9:19 A.M., the interim Unit Secretary said she was in the role from September 2024 through January 2025. The interim Unit Secretary said Medical Records had Resident #92's hospital medical records before she started covering as interim Unit Secretary, but no one told her the paperwork was in the facility until right before Christmas time. Despite Resident #92's medical records being in the facility prior to September 2024 and despite the interim Unit Secretary being made aware that the medical records were in the facility just before Christmas time, an appointment with a GI doctor was not made until over ten months since the MD order was first written and one year since the resident first inquired about the colostomy reversal.

Based on observation and interview, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to ensure the dish machine was functioning properly and replace it with a new, functional dish machine. Findings include: During breakfast and lunch meals of the entire survey period from 2/24/25 through 2/27/25, residents were observed eating their meals out of Styrofoam take-out containers and with plastic cutlery. During the resident screening process on 2/24/25, multiple residents from the first-floor and second-floor units reported that all of their meals have been served in Styrofoam containers and with plastic cutlery for months. During the kitchen walk-through on 2/25/25 at 11:14 A.M., the Foodservice Director (FSD) said the dish machine has been broken and not functional for at least one month. The FSD then said there is a brand-new dishwasher in the hallway and we are waiting for it to get installed, the FSD continued to say it has been in the hallway for a lot longer than one month. The FSD then said since the dish machine has been broken the facility has been using Styrofoam containers and plastic utensils for all meals. During the kitchen walk-through, the surveyor observed a brand-new dish machine in the hallway still wrapped in plastic. The surveyor also observed the current dish machine not in use as it was not functioning properly. During an interview on 2/25/25 at 11:50 A.M., the Maintenance Director said the new dish machine in the hallway got delivered around November 2024 and we have received two quotes from different companies to install it. The Maintenance Director then said he thinks it would be a one-day job for installation. The Maintenance Director said he has sent the quotes to Accounts Payable but did not hear back at first and he has needed to keep following up. During the Resident Group Interview on 2/25/25 at 1:17 P.M., 15 out of 15 residents all said the dishwasher has been broken for months and they have been eating out of Styrofoam containers since Thanksgiving of 2024. Review of the work order invoices dated 8/16/24, 9/4/24 and 11/6/24 indicated that the facility had an outside company come into the facility to service the dish machine that is currently broken and not in use. Review of an invoice dated 11/22/24 indicated that the facility received an estimate for the installation of a new dish machine. During an interview with the acting Director of Nursing, Administrator and Administrator in Training on 2/25/25 at 12:55 P.M., the Administrator said the facility has received several quotes and the dish machine has been getting repairs since October, but it keeps breaking down. The Administrator continued to say that the residents have been continuously eating from Styrofoam containers and with plastic utensils for at least one month.

Based on observation and interview, the facility failed to provide a homelike environment during dining on 4 of 4 units. Specifically, the facility failed to ensure resident meals were served on standard dining ware and cutlery and instead were served Styrofoam boxes and plastic cutlery due to the dish machine being broken for approximately the last three months. Findings include: During breakfast and lunch meals of the entire survey period from 2/24/25 through 2/27/25, residents were observed eating their meals out of Styrofoam take-out containers and with plastic cutlery. During the resident screening process on 2/24/25, multiple residents from the first-floor units reported that all their meals have been served in Styrofoam containers and with plastic cutlery for months. One resident reported it is difficult to eat from plastic fork because the food will not stay on the utensils. Another resident on the first-floor reported that his/her food is always cold when delivered and it is likely from being in a Styrofoam box. During the resident screening process on 2/24/25, multiple residents from the second-floor units reported that all their meals are served in Styrofoam containers and with plastic utensils. Two residents reported they had resided in the facility for months and had always been served their meals with Styrofoam and plasticware. One Resident said that the facility used to serve meals with standard dining ware and cutlery, but since the dishwasher in the kitchen had broken down, they switched to disposable plateware for a few months. During the kitchen walk-through on 2/25/25 at 11:14 A.M., the Foodservice Director (FSD) said the dish machine has been broken and not functional for at least one month. The FSD then said there is a brand-new dishwasher in the hallway, and we are waiting for it to get installed, the FSD continued to say it has been in the hallway for a lot longer than one month. The FSD then said since the dish machine has been broken the facility has been using Styrofoam containers and plastic utensils for all meals. During the kitchen walk-through, the surveyor observed a brand-new dish machine in the hallway still wrapped in plastic. During an interview on 2/25/25 at 11:50 A.M., the Maintenance Director said the new dish machine in the hallway got delivered around November 2024 and we have received two quotes from different companies to install it. The Maintenance Director then said he thinks it would be a one-day job for installation. The Maintenance Director said he has sent the quotes to Accounts Payable but did not hear back at first and he has needed to keep following up. During the Resident Group interview on 2/25/25 at 1:17 P.M., 15 out of 15 residents all said the dishwasher has been broken for months and they have been eating out of Styrofoam containers. The residents continued to say they do not want to eat from Styrofoam containers and the plastic cutlery always break, they further said it was particularly awful at Thanksgiving and Christmas. Review of the work order invoices dated 8/16/24, 9/4/24 and 11/6/24 indicated that the facility had an outside company come into the facility to service the dish machine that is currently broken and not in use. Review of an invoice dated 11/22/24 indicated that the facility received an estimate for the installation of a new dish machine. During an interview with the acting Director of Nursing (DON), Administrator and Administrator in Training (AIT) on 2/25/25 at 12:55 P.M., the DON was not aware the dish machine has been broken. The DON, Administrator and AIT said residents eating from Styrofoam boxes with plastic utensils is not considered a homelike environment and they should be using standard dish ware and cutlery. The Administrator then said the facility has received several quotes and the dish machine has been getting repairs since October, but it keeps breaking down. The Administrator continued to say that the residents have been continuously eating from Styrofoam containers and with plastic utensils for at least one month. Refer to F908

Based on observations, interviews, and record reviews for two Residents, (#50 and #16), out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. When one out of two nurses observed made three errors out of 28 opportunities resulting in a medication error rate of 10.71%. Specifically: 1.) For Resident #50, Nurse #1 administered Linzess (oral medication for constipation) after a meal when the medication was ordered to be administered 30 minutes before a meal. 2.) For Resident #16, Nurse #1 administered the incorrect dose (two sprays instead of one) of a nasal spray (Azelastine HCL, used for allergies) and Nurse #1 failed to administer the correct fiber medication (psyllium husk instead of calcium polycarbophil). Findings include: Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated: 1. Verify medication order of the Medication Administration Record (MAR). 6. Compare the medication label to the resident's MAR. 9. Verify the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 1.) Resident #50 was admitted to the facility in January 2018 with diagnoses including anxiety, depression, and chronic idiopathic constipation. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/25, indicated that Resident #50 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 2/26/25 at 8:18 A.M., the surveyor observed Nurse #1 prepare and administer Resident #50's morning medications. Resident #50 said he/she had already eaten his/her breakfast and there was no longer a breakfast tray with the Resident. Nurse #1 prepared and administered the following: - Linzess 145 micrograms (mcg), 1 capsule. Review of the medication bottle indicated the following take this medicine on an empty stomach, at least 30 minutes before the first meal of the day. Review of Resident #50's physician's order, dated 1/29/24, indicated: - Linzess Oral Capsule 145 mcg, give one capsule by mouth one time a day for constipation. Additional directions indicate to administer the medication 30 minutes prior to breakfast. Additional Administration notes indicate 7:00 A.M. During an interview on 2/26/25 at 1:54 P.M., Nurse #1 reviewed Resident #50's Linzess order and medication bottle and she said that the Linzess is ordered 30 minutes prior to breakfast, but she did not administer the medication prior to breakfast. During an interview on 2/26/25 at 1:58 P.M., Unit Manager #2 said Resident #50's Linzess should be administered before breakfast. During an interview on 2/26/25 at 2:55 P.M., the Director of Nursing said nursing should administer medications as ordered. 2.) Resident #16 was admitted to the facility May 2016 with diagnosis including chronic obstructive pulmonary disease, diabetes, and irritable bowel syndrome. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 2/26/25 at 8:32 A.M., the surveyor observed Nurse #1 prepare and administer Resident #16's morning medications. Nurse #1 prepared and administered the following: - Azelastine HCL Solution 0.1%, 2 sprays in each nostril. - Psyllium Husk, one capsule. Further review of the medication bottle indicated the serving size was 5 capsules. Review of Resident #16's physician's order, dated 2/2/23, indicated: - Azelastine HCL Solution 0.1%, give one spay in both nostrils two times a day related to chronic obstructive pulmonary disease. - FiberCon Oral Tablet (Calcium Polycarbophil), give one tablet by mouth two times a day related to irritable bowel syndrome. During an interview on 2/26/25 at 8:33 A.M., Resident #16 said he/she took 2 sprays into each of his/her nostrils and that is how he/she takes the medication every day. During an interview on 2/26/25 at 1:56 P.M., Nurse #1 said Resident #16 should have only received one spray of the nasal spray in each nostril but did not. Nurse #1 said that she provided one capsule of the psyllium husk because that is what is provided by the facility. During an interview on 2/26/25 at 1:59 P.M., Unit Manager #2 said Resident #16's medications should be administered as ordered by the physician. Unit Manager #2 and the surveyor reviewed literature which indicated that psyllium husk and calcium polycarbophil are not the same medication. Unit Manager #2 said the facility should have the correct over the counter medications available for administration. During an interview on 2/26/25 at 2:57 P.M., the Director of Nursing said nursing should administer medications as ordered.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to 1. Ensure a treatment room containing resident-specific creams, lotions and other biologicals was locked while unattended on the first floor unit and 2. Ensure medication carts were locked while unattended by staff on the first and second floor units. Findings include: Review of the facility policy titled Medication Storage Room/Medication Cart Policy, dated and revised January 2025, indicated the following: - Medications are stored primary in a locked mobile medication cart which is accessible only to licensed nursing personnel. - Storage for other medications will be limited to a locked medication room. - The medication cart is to be kept locked at all times when not in use by the nurse. The medication cart is to be locked when stored in the medication room or some other location. 1. The surveyor made the following observations on the first-floor medication treatment room next to the nursing station: - On 2/24/25 from 8:28 A.M. through 8:42 A.M., the medication treatment room door was open, no staff were in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals. The surveyor was able to open and access the treatment cart inside the room. - On 2/24/25 at 12:11 P.M., the medication treatment room door was open, no staff were in the room and a resident was observed walking into the treatment room. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals. The surveyor was able to open and access the treatment cart inside the room. - On 2/25/25 at 6:49 A.M., the medication treatment room door was open, no staff were in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals. - On 2/26/25 at 7:52 A.M., the medication treatment room door was open, no staff were in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals. The surveyor observed a latex gloved stuffed into the latch of the door which was preventing the door from latching properly and locking. During an interview on 2/26/25 at 8:37 A.M., Unit Manager #1 said the treatment room contains creams, ointment, biologicals and other treatment materials for residents and it should be locked at all times. Unit Manager #1 continued to say the treatment cart inside the room is open because the door to the room should be locked. During an interview on 2/27/25 at 8:33 A.M., the Director of Nursing (DON) and Administrator in Training (AIT) said all medication carts, medication rooms and treatment rooms should be locked when unattended. 41105 2. The surveyor made the following observations: - On 02/26/25 at 11:43 A.M., the surveyor observed an unlocked and unattended medication cart on the first-floor unit. The surveyor was able to open and access the cart and staff were unaware. -On 2/25/25 at 6:49 A.M., the surveyor observed an unattended, unlocked medication cart on the second-floor unit. During an interview on 2/26/25 at 11:44 A.M., with Nurse #1, she said that the medication cart is supposed to be locked when unattended. During an interview on 2/27/25 at 8:33 A.M., the Director of Nursing (DON) and Administrator in Training (AIT) said all medication carts, medication rooms and treatment rooms should be locked when unattended.

Based on interviews and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for one Resident, (#55), out of a total sample of 25 residents. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation dated February 2023, indicated but was not limited to the following: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation's Abuse also includes the deprivation of any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being instances of abuse of all residents irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse neglect and misappropriation of resident property and exploitation that achieves; B. Written procedures for investigations that include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing on the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation. Resident #55 was admitted to the facility in October 2022 with diagnoses including major depressive disorder, anxiety, repeated falls and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/25, indicated that Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. The MDS further indicated Resident #55 required supervision or touching assistance with walking. On 2/25/25 at 8:32 A.M., the surveyor reviewed two grievance forms for Resident #55 and dated 2/24/25. The grievance forms indicated the following: Grievance #1 indicated: On 2/22/25 (Resident in wheelchair) and Resident #55 and (third Resident) were in the elevator when it went to 2nd (floor). I was by the buttons when (Resident in wheelchair) told me to get out so he/she could get out. I was not in his/her way and I said you have plenty of room, then he/she told me I would be sorry when he/she rolled over my feet. I told him/her go ahead. It escalated by him/her calling me a bitch and other words. I responded by saying them back. That's when (third Resident) started laughing. (Resident in wheelchair) said he/she never liked me and I told him/her the same was mutual. (Third Resident) was blocking the elevator so I couldn't leave and go to my floor. I finally told him/her to please move and then he/she did. Grievance #2 indicated: On 2/23/25 the security guard started accusing me of starting with (Resident in wheelchair from Grievance #1) and wouldn't listen to me. He did it so unprofessional cause other residents heard him. He told me he was going to the Substance Abuse Counselor, Administrator In Training (AIT) and Social Worker to have me thrown out cause he believes (Resident in wheelchair). Grievance #1 and Grievance #2 was signed as received on 2/24/25 by Social Worker. The grievance form was signed and dated 2/25/25, by the AIT, Social Worker and Unit Manager #1 as reviewed and resolved. During an interview on 2/24/25 at 8:40 A.M., Resident #55 said he/she submitted two grievance forms to the social worker regarding an altercation with another resident in the elevator on 2/22/25. Resident #55 said the other resident threatened and rolled over his/her feet in the elevator. Resident #55 said he/she had a verbal altercation with the security guard on 2/23/25 and the security guard threatened to have him/her thrown out of the facility because he did not like the way Resident #55 was speaking to the resident in the elevator the day prior. Resident #55 said the security guard embarrassed and threatened him/her in front of other residents and said he doesn't like me. Resident #55 said he/she was upset and embarrassed by both situations and said he/she submitted a grievance form and told the Social Worker, but they won't do anything about it. Review of Resident #55 social service progress notes did not indicate any information regarding the reported grievances. The facility failed to provide any initial investigation into the allegations reported on 2/24/25. Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the allegation to the state agency. During an interview on 2/25/25 at 11:02 A.M., the Social Worker said she received two grievance forms from Resident #55 and said she did not feel they warranted to be reported as it was a verbal altercation between two residents and because she met with the security guard and gave the forms to the Administrator with the plan to perform customer service education with the security guard. The surveyor reviewed both grievance forms with the Social Worker. The Social Worker said she should have read the forms entirely and said threatening to roll over the resident's feet and threatening to have the Resident thrown out of the facility is concerning for verbal abuse. During an interview on 2/25/25 at 12:46 P.M., with the Administrator, AIT and the Director of Nurses (DON), the Administrator said he would expect the incidents to been investigated and reported. The AIT said she could not remember if she was notified last night or this morning and said she would expect any resident-to-resident altercations to be reported at the time of the event and investigated. The AIT said she did not receive a call over the weekend from staff regarding the resident to resident altercation. The AIT said she would expect measures to be taken to ensure residents feel safe and said the security guard should have been placed on administrative leave pending the investigation regarding suspected verbal abuse. The DON said they do not have any investigation information at this time and said they are starting the process now. During a follow-up interview on 2/27/25 at 10:25 A.M., the AIT said the security guard worked on 2/24/25 from 2:52 P.M., to 10:25 P.M., and said the Substance Abuse Counselor met with the security guard to go over customer service training on 2/25/25 and obtain a written statement. The AIT said she has not interviewed or met with the Security Guard as part of the investigation and that only the Substance Abuse Counselor has met with him. During an interview on 2/27/25 at 10:27 A.M., the DON said an investigation into the allegation should have been investigated immediately on the information that was reported and the grievances should have been reviewed per policy. Review of the Health Care Facility Reporting System (HCFRS) indicated the abuse allegation was submitted on 2/25/25; 24 hours after the allegation was made to the Social Worker. Refer to F609

Based on observation and interview, the facility failed to ensure a dignified dining experience for one Resident, (#52), out of a total sample of 25 residents. Specifically, the facility failed to ensure the needed assistance with a meal was provided resulting in a.) the Resident resorting to feeding him/herself with his/her hands and b. served the Resident in a Styrofoam dish with plastic utensils. Findings include: Resident #52 was admitted to the facility in July 2022 and has diagnoses that include vascular dementia and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that on the Brief Interview for Mental Status exam Resident #52 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #52 required supervision or touching assistance for eating. Review of the current Activities of Daily Living (ADL) care plan for Resident #52 indicated the following intervention: -Eating: max assist, dated as revised on 2/24/25. On 2/24/25 at 8:25 A.M., Resident #52 was observed in the unit dining room trying to feed him/herself eggs with the plastic fork provided by the facility. The meal was served in a Styrofoam container. As Resident #52 attempted to feed him/herself the eggs repeatedly fell off the fork into Resident #52's lap. Resident #52 ate the eggs with his/her hands from his/her lap. By 8:38 A.M., the floor underneath Resident #52 was covered in eggs. On 2/26/25 between 8:09 and 8:14 A.M., Resident #52 was seated in a chair in the unit dining room. Resident #52's body was leaning so far to the left that his/her left hand was an inch from the floor. As Resident #52 attempted to feed himself/herself eggs with a plastic food fork the eggs repeatedly fell to the floor. At 8:12 A.M., Resident #52 began eating the scrambled eggs with his/her hands. Throughout the observation the Director of Social Work stood within three feet of the resident facing him/her and did not intervene, offer assistance or find staff to assist the Resident. On 2/26/25 at 12:03 P.M., Resident #52 was observed seated in a chair in the unit dining room. A staff person served the lunch, partially set up the meal and then left the table to continue passing meals to other residents. The surveyor continued to make the following observations: -At 2:07 P.M., a staff person walked over to Resident #52, opened the milk container and poured it into Resident #52's cup, placed a chair beside him/her and walked away. -At 12:08 P.M., Resident #52 dropped food off the plastic fork he/she was using into his/her lap. -At 12:10 P.M., Resident #52 reached for cup of milk, and as he/she struggled to carry it to his/her mouth, Resident #52 rested his/her hand in meat and gravy, covering the underside of his/her palm covered in grave -At 12:11 P.M., Resident #52 used his/her hand to eat green beans. -At 12:11 P.M., Resident #52 used the meal ticket to his/her wipe mouth. -By 12:12 P.M., no staff had offered or assisted Resident #52 with the meal. During an interview on 2/27/25 at 8:36 A.M., Certified Nurse Assistant (CNA) #1 said that Resident #52 requires feeding assistance with meals. CNA #1 said that she knows the care Resident #52 needs based on his/her care card. CNA #1 showed the surveyor Resident #52's care which indicated he/she required substantial/ maximal assistance with eating. During an interview on 2/27/25 at 8:42 A.M., Unit Manager #2 said CNAs should provide the assistance based on the care card, Unit Manager #2 said that Resident #52 has been declining over the past few days, and he/she needs more assistance. Unit Manager #2 said that if the CNAs are not available the Nurse or anyone who is available, can assist during meals. The surveyor reviewed the surveyor's observations from 2/24/25 and 2/26/25 and Unit Manager #2 said that staff should intervene when the Resident is struggling. During an interview on 2/27/25 at 12:08 P.M., the Director of Nursing said that nursing should provide assistance with meals in accordance with the plan of care.

Based on observations, record review and interview, the facility failed to ensure Residents received oxygen according to professional standards of practice and in accordance with physician's orders for 1 Resident (#23) out of a total sample of 33 residents. Findings include: Resident #23 was admitted to the facility in June 2022 with diagnoses that include chronic obstructive pulmonary disease, acute and chronic respiratory failure, morbid obesity and heart failure. Review of Resident #23's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicated that he/she is cognitively intact. The MDS further indicated that Resident #23 requires total dependence on all activities of daily living and receives respiratory care. The surveyor made the following observations: *On 5/9/23 at 10:54 A.M., Resident #23 was observed lying in bed receiving oxygen (O2) at 3 liters via nasal cannula. *On 5/10/23 at 7:26 A.M., Resident #23 was observed lying in bed receiving oxygen at 4 liters via nasal cannula. *On 5/10/23 at 12:37 P.M., Resident #23 was observed lying in bed receiving oxygen at 3.5 liters via nasal cannula. Review of Resident #23's physician's orders dated 3/15/23 indicated the following: *Oxygen via n/c (nasal cannula) at 2 liters/minute Review of Resident #23's care plan for congestive heart failure dated 6/21/22 indicated the following intervention: *Provide O2 @ 2 liters/minute Review of Resident #23's nursing progress notes for the Month of May, 2023 indicated the following: *5/1/23 at 1:29 P.M.: Resident #23 on 3 liters of O2 n/c (nasal cannula) continuous *5/8/23 at 2:00 P.M.: He/she is at 3 liters of O2 *5/8/23 at 6:02 P.M.: Patient is awake and alert on 4 liter nasal cannula Review of Resident #23's documents titled Lab Results Report indicated the following: *Collection Date 4/10/23: CO2 (Carbon Dioxide) 42 mmol/L with a normal reference range of 22-33. This result was marked in red as HH indicating it is very elevated. *Collection Date 5/1/23: CO2 (Carbon Dioxide) 47 mmol/L with a normal reference range of 22-33. This result was marked in red as HH indicating it is very elevated. During an interview on 5/10/23 at 1:55 P.M. Certified Nursing Assistant (CNA) #1 and Nurse #1 said Resident #23's oxygen levels should be set to 2 liters. CNA #1 and Nurse #1 said Resident #23 is very confused right now because her CO2 levels are high and his/her oxygen saturation levels are low so they increased the oxygen rate to 3 liters to get his/her oxygen levels where it should be. During the interview CNA #1 checked Resident #23's oxygen flow rate and said it was currently at 5 liters. CNA #1 and Nurse #1 did not know why it was set to 5 liters. Nurse #1 said the facility should be following the physician's order of 2 liters/minute for Resident #23. During an interview on 5/10/23 at 2:40 P.M., the Director of Nursing said her expectation is for Resident #23's physician's orders to be followed. She continued to say the Resident is receiving too much oxygen which could result in excess CO2 in his/her system.

Based on observation, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status by not providing adequate evaluation and interventions to maintain body weight and prevent significant weight loss or gain for 4 Residents (#46, #69, #158, and #306), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Weight Monitoring, dated August 2015, indicated that if a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months) the IDT (interdisciplinary team), dietician, physician, and family are notified. Further review indicated that all residents with a significant weight loss are reviewed weekly by the IDT for appropriateness of the interventions implemented. Further review indicated newly admitted or readmitted residents are weighed weekly x 4. 1. For Resident #46, the facility failed to address a significant weight gain. Resident #46 was admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's most recent Minimum Data Set (MDS) assessment, dated 4/26/22, revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated he/she has minimal cognitive impairment. The MDS also indicated Resident #46 is independent with self-feeding. During an interview on 6/24/22 at 8:10 A.M., Resident #46 said he/she knew he/she was gaining weight because his/her clothes were all too tight to wear. Resident #46 said he/she had previously lost weight and had not wanted to gain this weight back. Resident #46 said nursing and/or the Dietitian had not spoken to him/her about the weight. Review of Resident #46's weight log indicated the following: - 1/5/22- 145.6 pounds (lbs.) - 2/8/22- 162 lbs. which is a significant weight gain of 11.26 % *The Resident was not weighed again until 6/23/22, at which time he/she weighed 190.6 lbs., an additional 17% weight gain. Review of Resident #46's medical record failed to indicate the physician, or the nurse practitioner was made aware of the weight gain. Review of Resident #46's medical record failed to indicate the Resident was seen by a Dietitian since January 2022, prior to the weight gain. During an interview on 6/23/22 at 8:31 A.M., Unit Manager #1 said all significant weight gains or losses are reported to the Dietitian, the IDT, and the physician. Unit Manager #1 said an assessment would be completed and a dietary intervention would be initiated. Unit Manager #1 said she was unaware of Resident #46's weight gain and if the physician had been notified. During an interview on 6/23/22 at 9:55 A.M., the Director of Nursing (DON) said the facility had been without a dietitian for a couple of months and a new Dietitian just started about a month ago. The DON said that while the facility was without a dietitian, the nursing staff was ensuring all dietary needs were met. The DON said that there was also a Regional Dietitian covering the needs of the residents in the facility. The DON said that risk meetings had not been occurring but had re-started in June 2022. The DON was unaware of Resident #46's significant weight gain and said if dietary notes were not in the Resident's chart, then he/she had most likely not been seen by the dietitian. During an interview on 6/24/22 at 10:22 A.M., the Regional Dietitian said she had not covered the nutritional needs of the facility when there was no dietitian. 2. For Resident #69, the facility failed to address a significant weight loss. Resident #69 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #69's most recent Minimum Data Set (MDS) assessment, dated 5/3/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she has moderate cognitive impairment. Review of Resident #69's weight log indicated that on 01/05/22, the Resident weighed 186.2 pounds and on 06/02/22 the Resident weighed 166.8 pounds, which is a significant weight loss of 10.42%. Review of Resident #69's medical record failed to indicate the physician, or the nurse practitioner was made aware of this weight loss. Review of Resident #69's medical record failed to indicate the Resident was seen by a Dietitian at the time of the weight loss. During an interview on 6/23/22 at 8:31 A.M., Unit Manager #1 said all significant weight gains or losses are reported to the Dietitian, the IDT, and the physician. Unit Manager #1 said an assessment would be completed and a dietary intervention would be initiated. Unit Manager #1 said she was unaware of Resident #69's weight loss and if the physician had been notified. During an interview on 6/23/22 at 9:55 A.M., the Director of Nursing (DON) said the facility had been without a dietitian for a couple of months and a new Dietitian just started about a month ago. The DON said that while the facility was without a dietitian, the nursing staff was ensuring all dietary needs were met. The DON said that there was also a Regional Dietitian covering the needs of the residents in the facility. The DON said that risk meeting had not been occurring but had re-started in June 2022. The DON was unaware of Resident #69's significant weight loss and said if dietary notes were not in the Resident's chart, then he/she had most likely not been seen by the dietitian. During an interview on 6/24/22 at 10:22 A.M., the Regional Dietitian said she had not covered the nutritional needs of the facility when there was no dietitian. 3. For Resident #158, the facility failed to address a significant weight loss. Resident #158 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #158's most recent Minimum Data Set (MDS) assessment, dated 5/10/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he/she has no cognitive impairment. The MDS also indicated Resident #158 is independent with self-feeding. Review of the medical record indicated weights as follows: -3/14/22- 209 pounds (lbs.) -4/6/22- 197 lbs. - upon re-admission from hospital, a 5.7% loss in 3 weeks. -6/1/22- 188.4 lbs. - upon re-admission from hospital, a 9.86% loss in 3 months. No further weights were documented in the medical record. Review of the medical record failed to indicate that upon re-admission from the hospital Resident #158 was weighed weekly x 4 weeks per the facility's policy. Further review indicated that Resident #158 only refused to be weighed one time, on 6/3/22. Review of the care plan, dated as initiated on 2/23/22, failed to indicate Resident #158 refused weights. Further review failed to indicate dietary interventions to address the significant weight loss. Review of the doctor's orders, dated 2/3/22 and 5/31/22, indicated a diet order for regular diet, regular consistency texture, thin (regular) liquids consistency for diet. Further review failed to indicate any dietary interventions to improve/maintain weight was put in place after Resident #158 experienced significant weight losses. Review of the medical record failed to indicate a dietitian's assessment of the significant weight loss. 4. For Resident #306, the facility failed to follow up on a significant weight loss. Resident #306 was admitted in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #306's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated cognitive impairment. The MDS also indicated Resident #306 requires extensive assistance with feeding. During an interview on 6/22/22 at 10:22 A.M., the surveyor observed Resident #306 lying in bed and said he/she had been here for a few months. During a review of Resident #306's medical record, a weight summary indicated: -6/21/22 -166.2 lbs. (16.10% significant weight loss since 2/9/22) -6/13/22- 168.2 lbs. -6/02/22 -169.0 lbs. -3/28/22- 160.6 lbs. (18.93% significant weight loss since 2/9/22) -3/23/22- 155.0 lbs. -2/16/22- 198.4 lbs. -2/09/22- 198.1 lbs. Further review of Resident #306's medical record indicated: -A care plan, dated 2/23/22, indicated Decreased self-feeding, dependent on staff with interventions including monitor/evaluate weight changes, Notify RD, Family, and physician of significant weight changes. -Dietary note, dated 3/28/22, indicated resident's documented weight of 155.0 lbs. appears to be an error, recheck weight as needed and reassess if needed. A weight recheck on 3/28/22 resulted in a weight of 160.6 lbs., 18.93% weight loss since weight on 2/9/22. No additional documentation was available regarding the weight loss. During an interview on 06/24/22 at 08:26 A.M., Unit Manager #2 said the only documentation regarding the weight loss was a dietary note indicating a possible error and to reassess. Unit Manager #2 was unable to find further documentation to support the weight loss and said the expectation would be for this to be addressed and followed up on.

Based on records reviewed, interviews, and review of Facility surveillance camera video footage, for one of three sampled residents (Resident #1) the Facility failed to ensure he/she was free from abuse by staff. On 07/21/21, Resident #1, who was known by staff to have exhibited inappropriate behaviors, came up behind Certified Nurse Aide (CNA) #1 and touched her buttocks. CNA #1 immediately swung her arm around slapping Resident #1 on his/her right upper arm. CNA #1 also swore at and in a threatening manner, told Resident #1 to not do that again. Findings include: The Facility's Policy titled, Abuse Prohibition Policy, dated December 2016, indicated the Facility had the responsibility to ensure that each resident had the right to be free from abuse. The Policy indicated physical abuse included hitting and/or slapping. The Policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. The Policy defined willful was the individual must had acted deliberately. Resident #1 was admitted to the Facility in April 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care (POC) related to a history of substance abuse, dated as revised 05/19/21, indicated he/she would remain free from inappropriate, disruptive, or abusive behaviors directed at others, staff interventions included encouraging him/her to seek staff assistance as needed. Review of Resident #1's POC related to psychosocial well-being, dated 05/11/21, indicated he/she had an alteration in psychosocial well-being and/or coping mechanisms related to nursing home placement and COVID-19 restrictions. The POC indicated staff were to direct problems regarding Resident #1, to staff members who could address them. Review of the Facility's Reportable Event Form, dated 07/21/21, indicated Resident #1 touched a CNA's (later identified as CNA #1) buttocks as he/she was self-propelling down the hallway, and CNA #1 reacted to the touch by swinging around and hitting Resident #1's arm with her hand. The Facility's Internal Investigation, dated 07/21/21, indicated that Resident #1 was self-propelling in his/her wheelchair on the unit and he/she smacked CNA #1 on the buttocks. The Investigation indicated Certified Nurse Aide (CNA) #1 reacted by shouting out at Resident #1, and then swung with an open hand and hit Resident #1 on the upper arm. The Investigation described CNA #1's behavior as a reflex of a fight or flight response, due to being touched inappropriately by Resident #1. During an interview on 09/01/21 at 7:30 A.M., Certified Nurse Aide (CNA) #2 said that after Resident #1 returned from the Hospital in July, he/she displayed verbal and sexually inappropriate behaviors towards others. CNA #2 said that sometime in July 2021, Resident #1 attempted to grab her breast with a reacher/grabber adaptive device. CNA #2 said she made a note in the CNA Communication Logbook. During an interview on 09/01/21 at 10:18 A.M., and throughout the Survey, the Nurse Supervisor said she is the Supervisor on the unit where Resident #1 resides. The Nurse Supervisor said that about a week prior to the incident on 07/21/21, Resident #1 returned to the Facility from the hospital with an altered mental status. The Nurse Supervisor said Resident #1 made remarks that consisted of sexual innuendoes for a few days, but he/she was easily redirected. The Nurse Supervisor said she was not notified of Resident #1 having displayed any sexually inappropriate behaviors towards others after he/she returned from the hospital. The Nurse Supervisor said the CNA Communication Logbook is used by the CNA staff to communicate significant information, such as falls or resident behaviors, which is used as an informal shift report communication tool, in addition to staff providing verbal reports to one another. The Nurse Supervisor said the CNAs are also expected to document significant incidents in the resident's electronic health record, report to the floor nurse, and to nursing management. The Nurse Supervisor said she reviews the CNA Communication Logbook every morning or every other morning when she is at the Facility. During an interview on 09/01/21 at 1:30 P.M., Resident #1 said he/she went behind CNA #1 one day, tapped her behind, and said then CNA #1 whacked me. Review of CNA #1's initial Written Witness Statement, dated 07/21/21, indicated at 11:00 A.M., she was standing at the nursing station reading the communication logbook, and as she was standing there someone (later identified as Resident #1) came from behind her and smacked her ass. The Statement indicated she (CNA #1) reacted and her reflex was to punch Resident #1 in the arm. The Statement indicated she (CNA #1) told Resident #1 not to do that again, asked him/her to please leave her alone and she then walked away from him/her. Review of CNA #1's second Written Witness Statement, also dated 07/21/21, indicated she was standing at the nursing station and someone (later identified as Resident #1) came up from behind her and smacked her bottom. The Statement indicated that with an open hand, she swung back and hit the person, without knowing who it was, until after she had turned around. The Statement indicated she spoke with the Director of Nurses (DON) and explained what happened and why she reacted to Resident #1 due to her reflex. During an interview on 09/02/21 at 12:34 P.M., Certified Nurse Aide (CNA) #1 said she had provided care to Resident #1 in the past. CNA #1 said that on 07/21/21, Resident #1 came up behind her and smacked her butt with his/her hand. CNA #1 said she got scared and reacted by hitting Resident #1's upper right arm with her right hand. CNA #1 said she yelled at him/her, and said she told Resident #1, Don't [OBSCENITY] ing do that again. CNA #1 said that two other staff members (later identified as Nurse #2 and the Unit Secretary) were near the nursing station, said she told them that Resident #1 touched her butt and that she turned around and hit him/her. CNA #1 said the staff members told her to write the incident in the CNA Communication Logbook and complete an incident report, which she did right afterwards. CNA #1 said the DON spoke with her that day around noon after he read the documentation in the CNA Communication Logbook. CNA #1 said she could tell it was a person who touched her buttocks because it was with an open hand, and it felt like the touch was intentional, not accidental. CNA #1 said she does not believe the way she responded was a mistake because someone touched her private area (buttocks), and said as for Resident #1, it was not the first time he/she tried to do something like that. Review of the Unit Secretary's Written Witness Statement, dated 07/21/21 and during an interview on 09/01/21 at 10:35 A.M., the Unit Secretary said she was at the nursing station around 11:00 A.M., and she heard CNA #1 say words to the effect of, what the heck, don't do that again. The Unit Secretary said and her written Statement indicated CNA #1 told her that Resident #1 had just smacked her butt. During an interview on 09/01/21 at 12:42 P.M., the Assistant Director of Nursing (ADON) said she watched the security camera footage as part of the Facility's Investigation and saw Resident #1 touch CNA #1's bottom and that she saw CNA #1 turn around and throw her arm behind her at the same time. During an interview on 09/01/21 at 12:20 P.M., the Director of Nurses (DON), said on 07/21/21 around 1:00 P.M., he learned of the incident with Resident #1 and CNA #1 by reading CNA #1's documentation of the incident in the CNA Communication Logbook during a risk management meeting. The DON said he was unable to find the CNA Communication Logbook, dated July 2021, (with CNA #1's documentation to the incident) at the time of Survey. The DON said that he asked CNA #1 to provide a second written statement to clarify additional information that she had shared during their conversation about the incident. The DON said the Facility suspended CNA #1 for physically making contact with Resident #1. Review of CNA #1's Timecard, dated 07/21/21, indicated that she was sent home from the Facility at 1:39 P.M., pending the Facility's investigation of the alleged abuse. On 07/21/21, CNA #1 remained working on the same floor that Resident #1's care unit is located on for approximately two hours after she hit him/her on the arm, putting Resident #1 at further risk of potential harm related to abuse. During an interview on 09/01/21 at 3:00 P.M., the Administrator said the nursing staff completed the investigation into the alleged physical abuse of Resident #1 by CNA #1. The Administrator said the date of the Survey was the first time he watched the Facility security camera video footage of the incident. Review of the video camera surveillance footage provided by the Facility, and date stamped 07/21/21 from 11:04 A.M. to 11:09:14, showed the nursing station area of Resident #1's unit. Review of the video camera surveillance footage showed the following: - 11:04:16 - CNA #1 was standing in the hallway, facing the nursing station. Resident #1 self-propels him/herself in a wheelchair into the view of the camera, he/she propels up behind CNA #1, and touches CNA #1's buttocks with his/her right hand. - 11:04:17 - CNA #1 swings her right arm around behind her, without looking, and hits Resident #1 on his/her upper right arm, and then she turns around. - 11:04:19 - Resident #1 grabs his/her right upper arm with his/her left hand. Resident #1 remains in the hallway near the nursing station. - 11:04:23 - Resident #1 grabs his/her right upper arm with his/her left hand again. Resident #1 remains in the hallway near the nursing station. - 11:04:30 - CNA #1 walks into the nursing station area and sits down, facing the resident care area hallway. - 11:06:22 - Resident #1 self-propels in his/her wheelchair and goes out of view of the security camera. - CNA #1 remains seated at the nursing station on the unit for approximately two minutes after she hit Resident #1.

Based on records reviewed and interviews, for one of three sampled residents (Resident #), a severely cognitively impaired resident, assessed as being at risk for elopement and who unsafe to leave the Facility unattended, the Facility failed to provide adequate supervision to Resident #1, when on [DATE], Resident #1, eloped from his/her locked unit, and was found on the ground outside of the Facility by a community member. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. Findings include: Resident #1's was admitted to the Facility in [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's medical record indicated his/her Health Care Proxy was invoked in [DATE], due to dementia and his/her inability to make or communicate his/her own health care decisions. The Elopement and Wandering Assessment, dated [DATE], indicated Resident #1 was at risk of an elopement as he/she expressed the desire to leave the Facility and exhibited exit seeking behaviors, such as trying the doors and packing his/her belongings. The Psychiatric Nurse Practitioner Note, dated [DATE], indicated Resident #1's exit seeking behaviors continued to persist. Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she had severe cognitive impairments and he/she used a wander guard bracelet due to his/her wandering behaviors. Resident #1's Plan of Care, dated [DATE], indicated that Resident #1 required staff redirection when he/she attempted to go down the stairs and/or the elevator in attempts to go to his/her daughters across the street. Resident #1's Plan of Care, dated [DATE], indicated Resident #1 was at risk for falls and required a walker to assist him/her with safe ambulation. The Interdisciplinary Team Meeting Note, dated [DATE], indicated Resident #1 had a wander guard bracelet in place. The Facility's Investigation, dated [DATE], indicated that at 10:15 P.M. Resident #1 was seen on the security camera using the alarm system number pad to successfully enter the alarm code to unlock, then open the door and exit the care unit. The Investigation indicated Resident #1 went down the stairs and he/she exited through an emergency fire exit, which was an alarmed door. The Investigation indicated that at approximately 10:30 P.M., the Security Guard was completing security rounds and when he opened the door to one of the stairways, he heard the emergency exit door's alarm sounding. The Investigation indicated a Dr.(NAME)(missing resident) page was initiated. The Investigation indicated Nurse #2 identified Resident #1 as the missing resident; and she went outside to search for Resident #1. The Investigation indicated that when Nurse #2 found Resident #1, he/she was already being attended to by the local Fire Department and Emergency Medical Technicians (EMT) and he/she was transferred to the hospital. Review of the report submitted to the Department of Public Health via the Health Care Facility Reporting System (HCFRS), dated, [DATE], indicated the local Fire Department found Resident #1 on the ground, approximately 200 feet from the Facility and he/she was transported to the Hospital Emergency Department for evaluation. The Hospital Record, dated [DATE], indicated Resident #1 presented to the hospital after a bystander found him/her in the community and that the Hospital notified the Facility that he/she was in the Emergency Department being evaluated. The Record indicated Resident #1 had a bruise on his/her hip. Resident #1's Nurse Progress Note, dated [DATE], indicated that the Security Guard went to Resident #1's care unit and said that an emergency exit door's alarm was sounding. The Note indicated staff completed a head count and Resident #1 was not in his/her bed. The Note indicated that Nurse #2 went to check outside of the building for Resident #1 and saw Resident #1 being attended to by Emergency Medical Technicians. During an interview on [DATE] at 11:00 A.M., Nurse #2 said Resident #1 frequently wanders and asked to leave the Facility to go see his/her family. Nurse #2 said that as soon as the Security Guard said a resident may be missing, she went right to Resident #1's room to check if he/she was still lying in bed. Nurse #2 said she left the Facility to go look for Resident #1 which is when she found him/her being attended to by emergency personnel down the road. Nurse #2 said she was unsure how Resident #1 eloped from the Facility. The physician progress notes [REDACTED].#1 had increased exit seeking behaviors and managed to leave the Facility on [DATE], had returned to the Facility, and that Resident #1 was not safe to leave the Facility by him/herself. The Facility's Policy, titled Elopement, dated July, 2015, indicated elopement is defined as the ability of a resident who was not capable of protecting him/herself from harm to successfully leave the Facility unsupervised and unnoticed and who may enter into harm's way. The Facility's Policy, titled Wander Management System, dated [DATE], indicated the Policy was used for residents at risk for elopement as assessed and determined by the interdisciplinary team. During an interview on [DATE] at 5:00 P.M., the Security Guard said he completed rounds at approximately 10:00 P.M. and he saw an emergency exit door open and the alarm was sounding. The Security Guard said he did not hear the alarm sounding while he was in the lobby because the door into the staircase was shut and the alarm was not loud enough to be heard. The Security Guard said he saw ambulance lights outside through the open door so he went to the three different floors/units and asked the staff to complete a head count due to concerns of a potentially missing resident. The Security Guard said that approximately ,[DATE] minutes had passed from when he saw the opened emergency exit door until a nurse (later identified as Nurse #2) identified Resident #1 as missing. The Security Guard they found Resident #1 down the street being attended to by EMT's. During an interview on [DATE] at 9:30 A.M., the Administrator said he reviewed the security camera footage as part of the Facility's investigation and he saw Resident #1 use the numbered key pad to successfully unlock the door after two or three attempts. The Administrator said Resident #1 exited the unit door and walked from the third floor to the ground floor, where he/she exited the emergency exit door egress and set off the alarm. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 returned to the Facility and his/her safety has been maintained since the elopement on [DATE]. B. All residents were re-assessed by the Assistant Director of Nurses (ADON) on [DATE], for the potential to by adversely affected by concern area, elopement from the Facility. C. On [DATE], the ADON completed Care Plan Audits for all residents in the Facility. D. All staff members were in-serviced by the ADON (from [DATE] to [DATE]) on the Facility's Elopement/Wandering Policy. E. Staff will continue to complete wander guard checks to ensure bracelets are not expired and working appropriately. F. The Facility changed the code to the alarm, and if a resident pushes on Unit Emergency Exit Door in an attempt to leave unit, an alarm will sound. G. The Facility added an additional alarm sensor on the Unit Emergency Exit door, that sounds when door is opened, even with code, and staff were in-serviced on addition of second alarm. H. The Facility had the volume of the Emergency Exit Door (egress door at bottom of stairs) increased so it can be heard by staff on Units, if activated. I. Concern area (elopement) addressed at QAPI and will continue to be discussed with the committee as needed for compliance and safety. J. The Director of Nurses/ADON is responsible for overall compliance.

Based on observation, record review, and interview, the facility failed to ensure residents identified as high risk for falls received adequate supervision to prevent falls, resulting in 3 falls with injury (two right rib fractures and 2 skin tears) for 1 Resident (#50) and a fall from bed during care for 1 Resident (#21) out of a total sample of 24 residents. Findings include: Review of the Facility's Fall Management Policy, revised August 2018, indicated the following: *A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly MDS cycle, when a significant change in status occurs, annually and following a fall. *The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. *Residents/patients who are identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with information made available at the time of admission to implement a safety related care plan. Residents/patients who are identified to be at risk on subsequent fall evaluations will be evaluated in accordance with nursing, medical and rehabilitation needs. *A fall risk will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological checks, range of motion and evaluation of cognitive status will be documented. *The interdisciplinary team will meet at the next morning meeting to review any falls. 1. Resident #50 was admitted to the facility in June 2014 with [DIAGNOSES REDACTED].#50 scored a 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment and he/she required assistance with mobility, transfers, bathing, dressing and toileting. Review of Resident #50's care card, (a form utilized to inform staff on how to care for a resident), indicated that Resident #50 requires 1 person assistance with toileting, transfers, bed mobility and ambulation. Review of Resident #50's Fall Risk Assessments dated 3/21/19, 6/10/19, and 8/23/19 indicated that he/she was identified as being at high risk for falls. A. Review of Resident #50's Fall Incident Report and Investigation form dated 11/1/19, indicated that at 7:40 P.M., staff found the resident on the floor next to his/her bed. Resident #50 told staff that he/she was trying to go to the bathroom. Interventions to be implemented after this fall to prevent further falls included 15 minute checks, bed to be checked and lowered, and to toilet resident ahead of need. Resident #50's fall care plan and care card failed to indicate the new interventions of 15 minute checks or a specific toileting plan. Review of Resident #50's clinical record failed to indicate any staff monitoring of his/her toileting needs. B. Review of Resident #50's Fall Incident Report and Investigation dated 11/8/19 indicated that at 11:45 P.M., a CNA observed Resident #50 fall while getting out of his/her bed. The report indicated that Resident #50 reported right rib pain and an X-Ray was ordered. Review of the X-Ray report dated 11/10/19, indicated that Resident #50 sustained acute fractures of the right posterior lateral sixth and seventh ribs. Review of Resident #50's 15 minute check log dated 11/8/19, indicated his/her 15 minute checks were not completed after 4:00 P.M. on 11/8/19. Resident #50 fell at 11:45 P.M. on 11/8/19. During an interview with the DON and the Administrator on 1/29/20, at 11:46 A.M., they said that the facility does not have a policy regarding 15 minute checks after a fall, and the length of time someone is on 15 minute checks varies on their risk level. The DON and the Administrator acknowledged that Resident #50 was on 15 minute checks at the time of the fall on 11/8/19, and could not explain why Resident #50's 15 minute checks were not completed after 4:00 P.M. The DON and the Administrator could not say what interventions regarding toileting were implemented for Resident #50 prior to Resident #50's fall on 11/8/19. C. Review of the Fall Incident Report and Investigation dated 12/29/19, indicated that at 4:30 A.M., Resident #50 was heard by staff yelling for help and he/she fell on the floor next to her bed and sustained a small skin tear on his/her right ear. Interventions implemented to prevent reoccurrence included 15 minute checks, leaving the bathroom light on, and placing Resident #50's call light within reach. Review of Resident #50's care plan and care card failed to indicate the interventions of leaving his/her bathroom light on or placing the call light within his/her reach. D. Review of Resident #50's Fall Incident Report and Investigation dated 1/23/20, at 10:00 A.M., indicated that Resident #50 was exiting his/her bathroom and fell sustaining a small skin tear to his/her right eye. Interventions implemented to prevent reoccurrence included a rehab evaluation for the possible use of a wheelchair. Review of Resident #50's clinical record failed to include a referral to or evaluation by rehab services in response to this fall. During an interview with Nurse #1 on 1/29/20, at 8:30 A.M., she said she was present when Resident #50 fell on [DATE]. Nurse #1 said that Resident #50 was exiting the bathroom in a hurry and fell . During an interview with CNA #2 on 1/29/20, at 9:57 A.M., she said that Resident #50 is a fall risk and requires extensive assistance with all activities of daily living. 2. For Resident #21, the facility failed to provide the assistance of 2 staff, per the resident's plan of care, with bed mobility, when providing personal care, in order to prevent a fall. Review of a fall incident report for Resident #21 dated 1/15/20, indicated that Resident #21 sustained a fall out of bed while rolling from side to side while having care provided by 1 nursing assistant. Resident #21 was admitted to the facility in January 2008, with [DIAGNOSES REDACTED]. Review of Resident #21's most recent Minimum (MDS) data set [DATE], revealed that Resident #21 had a Brief Interview for Mental Status score of 15 out of a possible 15, which indicated that he/she is cognitively intact. The Minimum Data Set also indicated that Resident #21 required extensive assistance from staff for all bathing and dressing needs. Review of Resident #21's functional mobility care plan dated 4/11/18, and last revised 1/27/20, indicated the following interventions: *Bed: turning side to side - # of staff 2. Review of Resident #21's fall care plan dated 4/11/18, and last revised 1/16/20, indicated the following interventions: *2 CNAs for care for patient safety During an interview on 1/29/20, at 1:07 P.M., the Director of Nursing confirmed that Resident #21's care plan indicated he/she should have had the assistance of 2 staff for care at the time of the fall.

Based on records reviewed, observations, and interviews, for one of ten sampled residents (Resident #2), the Facility failed to ensure a resident was free from physical abuse by another resident. - On [DATE] at approximately 7:30 P.M., Resident #1 repeatedly struck Resident #2 in the head and face with a walker, causing significant head and facial injuries. Resident #2 received care from Emergency Medical Technicians (EMTs) for approximately one hour prior to arrival at hospital included cardiopulmonary resuscitation (CPR), the administration of [MEDICATION NAME] (a medication used to stimulate the heart), defibrillation (the administration of an electrical shock to return the heart to a normal rhythm), and intubation (the placement of a tube into a person's airway to help them breathe). - Resident #2 was pronounced dead approximately 20 minutes after his/her arrival to the Hospital Emergency Department as a result of the injuries he/she sustained. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Note, dated [DATE], indicated that Resident #1 had been recently hospitalized from another facility after he/she became more agitated and aggressive. The Note indicated that Resident #1 was administered antipsychotic medication for [MEDICAL CONDITION] and aggressive behaviors. Review of Resident #1's Patient Progress Note from the Facility's mental health provider, dated [DATE], indicated that Resident #1 was Spanish-speaking, and had a history of [REDACTED]. The Note indicated that the mental health provider would follow up as needed. Review of Resident #1's clinical record indicated there was no documentation to support that Resident #1 was assessed by the mental health provider after [DATE]. Review of Resident #1's Nursing Progress Note, dated [DATE], indicated that Resident #1 became agitated and physically threatening to a male Certified Nurse Aide (CNA). Review of Resident #1's Nurse Practitioner (NP) Note, dated [DATE], indicated that Resident #1 was hospitalized for [REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 exhibited verbal behavioral symptoms directed at others (such as threatening, screaming, or cursing at others), other behavioral symptoms not directed at others (such as pacing and rummaging), and wandered. The MDS also indicated that Resident #1 had severe cognitive impairment, and walked with the assistance of a walker. Review of Resident #1's Care Plans, printed on [DATE], indicated that there was no documentation to support that interventions were developed and implemented regarding Resident #1's known verbal behavioral symptoms, physically threatening behavior, or known history of agitation, aggression, paranoia, or combative behaviors. Resident #2 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #2's MDS, dated [DATE], indicated that Resident #2 exhibited verbal behavioral symptoms directed at others (such as threatening, screaming, or cursing at others), other behavioral symptoms not directed at others (such as pacing and rummaging), and wandered. The MDS also indicated that Resident #2 had moderate cognitive impairment, required the extensive assistance of two or more persons with bed mobility, the extensive assistance of one person with transfers from one surface to another, and required the use of a wheelchair for mobility. Review of Resident #2's Physician order [REDACTED]. The Surveyors interviewed Nurse #1 at 12:53 P.M. on [DATE]. Nurse #1 said that on [DATE] at approximately 7:30 P.M., she went to Resident #1's and Resident #2's bedroom because she heard a walker noise, or words to that effect, but could not define what that meant. Nurse #1 said she entered Resident #1's and Resident #2's bedroom and observed Resident #1 standing at the foot of Resident #2's bed, with his/her walker raised up in the air to about shoulder height. Nurse #1 said she observed blood on Resident #1's walker, and stepped into their bedroom further so she could visualize Resident #2, who's bed was partially obscured by a privacy curtain. Nurse #1 said she observed Resident #2 lying in bed on his/her back, with his/her face covered in blood, or words to that effect. Nurse #1 said she told Resident #1 to stop and to put the walker down, but that Resident #1 then turned toward her, with the walker still up in the air, and told her that he/she was going to hit Nurse #1. Nurse #1 said she left Resident #1's and Resident #2's bedroom to get help. Nurse #1 said she asked female staff, whose names she could not recall, to run down to Resident #1's and Resident #2's bedroom. Nurse #1 said she did not recall if she told them what she saw or why they needed to go down to Resident #1's and Resident #2's bedroom. The Surveyors interviewed CNA #1 at 3:25 P.M. on [DATE] and CNA #2 at 4:54 P.M. on [DATE]. CNA #1 and CNA #2 said Nurse #1 told them to go to Resident #1's and Resident #2's bedroom because there was something going on, that they were fighting, or words to that effect. CNA #1 and CNA #2 said they entered Resident #1's and Resident #2's bedroom and observed Resident #1 with his/her walker raised up in the air above his/her shoulders, standing to the right of Resident #2, who was lying in bed. CNA #1 and CNA #2 said Resident #1 then swung his/her walker downward, striking Resident #2 in the face with the walker. CNA #1 and CNA #2 said Resident #1 turned to them and said words to the effect of, now I have to kill you too, and walked towards them. CNA #1 and CNA #2 said they ran out of Resident #1's and Resident #2's bedroom and down to the nurses' station for help. CNA #1 and CNA #2 said Resident #2 was covered in blood, or words to that effect. CNA #1 said she observed that Resident #2 had cuts to his/her face, his/her face was covered in blood, there was a hole to his/her eyebrow area, that his/her eyes were closed, and his/her head was slumped to the side. The Surveyors interviewed CNA #4 at 3:41 P.M. on [DATE]. CNA #4 said he had previously provided care to Resident #2, but said that when he initially saw him/her after the incident, he did not recognize him/her because of the injuries and blood covering his/her face. The Surveyors interviewed Nurse #2 at 4:21 P.M. on [DATE]. Nurse #2 said that when she entered Resident #1's and Resident #2's bedroom after the alleged incident, she observed blood splatter on Resident #1's bed, the wall, and on Resident #2's pillow. Nurse #2 said she observed that Resident #2 had multiple injuries to his/her head and face, including a gash across the forehead, a split lip deep enough that she could visualize fat, and said that the right side of his/her head, nose, and mouth area appeared caved in, or words to that effect. Review of Resident #2's Emergency Medical Services (EMS) Patient Care Report, dated [DATE], indicated that observations of Resident #2 at the Facility included: - His/her airway was partially obstructed with blood, he/she had no pulse, was unresponsive, and his/her pupils were not reactive (nonreactive pupils are often associated with severe increases in increased pressure within the brain and/or severe brain damage); and, - He/she had severe head trauma and trauma to both hands, both eyes were swollen and closed, he/she had excessive bleeding and bruising to the face, and there was blood coming from his/her eyes, nose and mouth. The Report also indicated that the care provided to Resident #2 by Emergency Medical Technicians (EMTs) for approximately 54 minutes prior to arrival to the Hospital Emergency Department included the administration of CPR, seven doses of [MEDICATION NAME], approximately three defibrillations, and intubation. Review of Resident #2's Hospital Documentation, dated [DATE], indicated that Resident #2's injuries included: - A 10 centimeter (approximately four inches) stellate laceration (a star-shaped tear in the skin caused by [MEDICATION NAME] trauma) through the left eyebrow with crepitus (crackling or grating sound caused by bones rubbing against each other) felt in the laceration; - Pro[DIAGNOSES REDACTED] (protrusion) of the left eye with subconjunctival hemorrhage (one or more blood spots on the white of the eye) and hyphema (a pooling or collection of blood inside the space between the cornea and the iris, usually caused by [MEDICATION NAME] trauma); - Left maxillary (of or attached to a jaw or jawbone, especially the upper jaw) crepitus; and, - That he/she was neurologically unresponsive. The Documentation indicated that Resident #2 was pronounced dead at 9:04 P.M., approximately 20 minutes after his/her arrival to the Hospital Emergency Department.

Based on records reviewed and interviews, for two of ten sampled residents (Resident #1 and Resident #5), the Facility failed to ensure a comprehensive person-centered care plan was developed and implemented for each resident to meet their identified mental and psychosocial needs. - Resident #5 had a known history of verbally and physically abusive behaviors, exhibited signs and symptoms of those behaviors at the Facility, and expressed homicidal ideation (thoughts of homicide) toward staff and other residents at the Facility. Resident #5 verbally and physically abused his/her roommate(s) on 06/17/19 and 08/03/19; verbally abused staff and other residents and expressed homicidal ideation on 09/01/19; and, was placed on 15 minute checks on 09/20/19 for unspecified behaviors. - Resident #1 had a known history of delusions, verbal behavioral symptoms, physically threatening behavior, agitation, aggression, paranoia, and combative behaviors. Resident #1 was brought to the Hospital Emergency Department for evaluation following an altercation with another resident on 10/05/19, which resulted in serious bodily injury of the other resident. In addition, Resident #1's known primary language was not English, and an intervention was not initiated until approximately four months after his/her admission to the Facility to utilize Spanish speaking staff to reorient Resident #1 during episodes of inappropriate behaviors. Findings included: Review of the Facility's Comprehensive Care Plans policy, revised (MONTH) (YEAR), indicated that care plans were a combination of information including, but not limited to: acute/chronic events, behaviors and/or illness. The Policy also indicated that the care plan was evaluated and revised as needed, but at least quarterly. 1. Resident #5 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. [NAME] Review of Resident #5's Patient Progress Note from the Facility's mental health provider, dated 04/22/19, indicated that Resident #5 was admitted to the Facility following a psychiatric hospitalization . The Note indicated that Resident #5's history included: medication non-compliance, psychiatric hospitalization s for delusions (misconceptions or beliefs that are firmly held, contrary to reality) related to his/her refusal of [MEDICAL CONDITION] medications (medications which affect a person's mental state), self-harm, suicide attempt, and verbal and physical outbursts. Review of Resident #5's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she exhibited mood symptoms. Review of Resident #5's Patient Progress Note from the Facility's mental health provider, dated 05/08/19, indicated that Resident #5 denied having mental illness, was paranoid, and possibly exhibited delusions. Review of Resident #5's Nursing Progress Note, dated 06/17/19, indicated that Resident #5 was transferred to the Hospital Emergency Department for evaluation after physically abusing his/her roommate. Review of the Facility's Resident to Resident Incident Report & Investigation Form, dated 06/17/19, indicated that Resident #5 and one of his/her roommates argued about the room's air conditioner. The Report indicated that Resident #5 slapped his/her roommate, scratched the roommate on the upper chest, and embedded his/her fingernails into the roommate's chest area. The Report indicated that Resident #5 was transferred to the Hospital Emergency Department for evaluation of his/her aggressive behavior. Review of Resident #5's MDS, dated [DATE], indicated that Resident #5 exhibited verbal behavioral symptoms directed at others (such as threatening, screaming, or cursing at others), and other behavioral symptoms not directed at others (such as pacing and rummaging). Review of Resident #5's Nursing Progress Note, dated 08/03/19 (as a late entry), indicated that Resident #5 was transferred to the Hospital Emergency Department for evaluation after he/she verbally and physically abused one of his/her roommates and a staff person, and verbally abused his/her other roommate. Review of the Facility's Health Care Facility Reporting System (HCFRS) report, dated 08/03/19, indicated that on that date, Resident #5 began yelling at and arguing with a roommate, struck the roommate on his/her arm, and broke the roommate's computer. The Report indicated that Resident #5 was transported to the Hospital Emergency Department for evaluation and was found to be very agitated and confrontational. The Report indicated that Resident #5 was admitted to a psychiatric inpatient unit. Review of Resident #5's Nursing Progress Note, dated 08/12/19, indicated that Resident #5 was readmitted to the Facility from the Hospital's behavioral unit. Review of Resident #5's clinical record indicated that there was no documentation to support that the Facility developed and implemented a care plan to meet Resident #5's acute or chronic mental and psychosocial needs as identified on 04/22/19 and 05/08/19 by the Facility's mental health provider; as identified in the MDS dated [DATE]; or, after he/she verbally and physically abused his/her roommate(s) on 06/17/19 and 08/03/19. B. Review of Resident #5's Nursing Progress Note, dated 09/01/19, indicated that Resident #5 was verbally abusive to and expressed homicidal ideation toward staff and other residents. Review of Resident #5's Hospital Emergency Department Document, dated 09/01/19, indicated that Resident #5 presented to the emergency department for evaluation of aggressive behavior. Review of Resident #5's Resident Monitoring Tool - Frequent Checks, dated 09/20/19 through 09/22/19, indicated that Facility staff monitored him/her every 15 minutes due to behaviors. Review of Resident #5's Care Plans indicated that there was a care plan created on 08/21/19 regarding his/her physically abusive behaviors. However, the Behavior Care Plan did not include Resident #5's known verbally abusive behaviors or expressed homicidal ideation. Review of Resident #5's clinical record indicated that there was no documentation to support that the Facility evaluated and revised Resident #5's behavioral care plan after he/she verbally abused staff and other residents and expressed homicidal ideation on 09/01/19; or, after being placed on 15 minute checks on 09/20/19 for unspecified behaviors. 2. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. [NAME] Review of Resident #1's Admission Note, dated 06/06/19, indicated that Resident #1 had been recently hospitalized from another facility after he/she became more agitated and aggressive. The Note indicated that Resident #1 was being administered antipsychotic medication for [MEDICAL CONDITION] and aggressive behaviors. Review of Resident #1's Patient Progress Note from the Facility's mental health provider, dated 06/06/19, indicated that Resident #1 had a history of [REDACTED]. The Note indicated that the mental health provider would follow up as needed. Review of Resident #1's Nursing Progress Note, dated 06/09/19, indicated that Resident #1 became agitated and physically threatening to a male Certified Nurse Aide (CNA). Review of Resident #1's MDS, dated [DATE], indicated that Resident #1 exhibited delusions. Review of Resident #1's Nurse Practitioner (NP) Note, dated 06/14/19, indicated that Resident #1 was hospitalized for [REDACTED]. Review of Resident #1's MDS, dated [DATE], indicated that Resident #1 exhibited verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, and wandered. Review of Resident #1's Emergency Department Document, dated 10/06/19, indicated that Resident #1 was brought to the Hospital Emergency Department for evaluation following an altercation with another resident at the Facility. Review of Resident #1's Care Plans, printed on 10/07/19, indicated that there was no documentation to support that interventions were implemented regarding Resident #1's known delusions, verbal behavioral symptoms, physically threatening behavior, or known history of agitation, aggression, paranoia, or combative behaviors. B. Review of Resident #1's Baseline Care Plan, dated 06/05/19, indicated that he/she spoke only Spanish and required an interpreter. Review of Resident #1's Patient Progress Note from the Facility's mental health provider, dated 06/06/19, indicated that Resident #1 was Spanish-speaking. Review of Resident #1's MDS, dated [DATE], indicated that Resident #1 did not need or want an interpreter to communicate with a physician or health care staff. The Surveyors interviewed CNA #1 at 3:25 P.M. on 10/07/19, and interviewed Unit Manager #1 at 7:55 [NAME]M., Nurse #1 at 12:53 P.M., CNA #3 at 1:19 P.M., CNA #4 at 3:41 P.M., Nurse #2 at 4:21 P.M., and CNA #2 at 4:54 P.M. on 10/08/19. CNA #1, CNA #2, CNA #3, CNA #4, Nurse #1, Nurse #2, and Unit Manager #1 said Resident #1's primary language was Spanish. CNA #3, CNA #4, and Nurse #2 said they could not communicate with Resident #1 because they did not speak his/her primary language. Review of Resident #1's Care Plans indicated an intervention, initiated on 10/06/19, to utilize Spanish speaking staff to reorient Resident #1 during episodes of inappropriate behaviors. Review of Resident #1's Care Plans indicated there were no interventions identified by the Facility prior to 10/06/19 to address Resident #1's known communication needs.

Based on observations, interviews, and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent an injury, when Certified Nurse Aide (CNA) #1 heated a cup of coffee in the microwave on the unit, and Resident #1 spilled the hot coffee on his/her right thigh, causing a third degree burn. Findings include: The Facility's protocol titled, Reheating Food in the Microwave, undated, indicated, staff were to place an 8 ounce (oz) cup of coffee in the microwave for one minute to heat the coffee to 145 degrees Fahrenheit. The protocol indicated staff were to place a food thermometer in the coffee to check the temperature before serving. The Facility's Protocol, titled, General Thermometer Guidelines, undated, indicated Thermometers were to be calibrated regularly, before each shift, to ensure accuracy. The Protocol indicated when checking the temperature of food, the probe end of the thermometer should be inserted into the center of the food for at least 15 seconds. Resident #1 was admitted to the Facility in (MONTH) of 2019, [DIAGNOSES REDACTED]. The Occupational Therapy Treatment Encounter Note, dated 2/28/19, indicated Resident #1 required maximum assistance to open beverage containers, and needed all meals set up. The Nurse's Note, dated 3/30/19, indicated Nurse Supervisor #1 witnessed Resident #1 take the cover off his/her cup of coffee and spill it onto his/her lap. The Note indicated Resident #1 sustained a burn to his/her right anterior thigh with a small open blister. The Note indicate staff were re-educated to check the temperature of hot drinks prior to giving them to residents. The Nurse Practitioner's Note, dated 4/1/19, indicated Resident #1 had spilled boiling hot coffee, and had a burn wound on his/her right upper thigh as a result. The Wound Care Progress Note, dated 4/4/19, indicated Resident #1 had a cluster of third degree burn wounds to his/her right anterior thigh, which measured 5.5 centimeters (cm) long by 8.2 cm wide. The Surveyor interviewed Nurse Supervisor #1 at 1:06 P.M. on 5/2/19. Nurse Supervisor #1 said Resident #1 had poor dexterity, history of amputated thumb and index finger on the right hand, and was known to frequently drop objects and beverages. Nurse Supervisor #1 said that at approximately 8:30 A.M. on 3/30/19, she was walking past the dining room on the unit and observed Resident #1 attempt to pick up a cup of coffee and dropped the entire contents onto his/her right thigh. Nurse Supervisor #1 said Resident #1 cried out immediately when the hot coffee landed on his/her lap, and began rubbing it with a towel. Nurse #1 said she immediately brought Resident #1 to his/her room, removed Resident #1's clothing from the area, and observed a one centimeter (cm) round blister had developed. Nurse #1 said CNA #1 said she had checked the temperature of the coffee before serving it to Resident #1. Nurse Supervisor #1 said that on 3/30/19 after Resident #1 was burned with the hot coffee, she replaced the food thermometer in the kitchen on the unit with a new one, but did not check the food thermometer to be sure it was functioning properly. The Surveyor interviewed CNA #1 at 10:27 A.M. on 4/30/19. CNA #1 said that at approximately 8:30 A.M. on 3/30/19, Resident #1 asked her to heat up his/her coffee. CNA #1 said she heated Resident #1's coffee in the microwave on the unit for one minute, and used the food thermometer located in the kitchenette to measure the temperature of the coffee. CNA #1 said she placed the thermometer in the coffee for approximately six or seven seconds, and the temperature measured at 145 degrees Fahrenheit. CNA #1 said she placed a plastic cover on the coffee, placed the coffee cup on the table in front of Resident #1, told Resident #1 to be careful because the coffee was hot, and walked away. The Surveyor observed CNA #1, CNA #2, CNA #3, and Nurse #1 demonstrate use of the microwave and the food thermometer in the kitchenette on the unit on 4/30/19. Each staff member observed demonstrated how to heat a mug of coffee using the Facility's mug and water. -CNA #1 microwaved the mug of water for one minute and 10 seconds, removed the protective sheath from the food thermometer, inserted the food thermometer into the water, and waited approximately 10 seconds, until the needle stopped moving. The temperature read 140 degrees Fahrenheit. -CNA #2 inserted the wrong end of the thermometer into a mug of water, said it was too cold, heated the cup of water for one minute, removed the cup of water from the microwave, and inserted the correct end of the food thermometer, with the protective sheath still on the probe. CNA #2 said she would leave the food thermometer in the cup until the needle stopped moving, and said there was no set time to leave the food thermometer in the coffee. -CNA #3 placed a mug of water in the microwave, set the microwave to run for two minutes, and stopped the microwave after one minute and 34 seconds had passed. CNA #3 then inserted the food thermometer with the protective sheath still on the probe, waited until the needle stopped moving, and said the temperature of the mug of water was 135 degrees Fahrenheit. The Surveyor observed the temperature reading on the food thermometer was 144 degrees Fahrenheit. CNA #3 pointed to the 140 degree Fahrenheit mark on the food thermometer and said it was the mark that indicated 130 degrees Fahrenheit, or words to that effect, and said he would need to heat the coffee longer until it reached 145 degrees Fahrenheit. -Nurse #1 placed a mug of water in the microwave for one minute, removed the mug from the microwave, and inserted the probe of the food thermometer into the mug. Nurse #1 said she would wait approximately 30 seconds before reading the temperature of the food thermometer. The Surveyor observed, the food thermometer indicated the water was 140 degrees Fahrenheit. Nurse #1 said staff were trained to wait until the needle on the food thermometer stops, but were not trained to wait any specific amount of time, and said six or seven seconds would be enough time to measure the temperature of a cup of coffee. The Surveyor interviewed the Director of Nurses at 8:30 A.M. and throughout the day on 4/30/19. The Director of Nurses said there was no competencies done with staff regarding the proper use of food thermometers. The Director of Nurses said the Facility did not have a record of calibration of food thermometers, and that staff just took them out of the package and used them. The Director of Nurses said there was no way to know if the food thermometer was operating properly on 3/30/19.

Based on record review and staff interview, the Facility staff failed to maintain acceptable parameters of nutritional status through providing adequate interventions to maintain body weight and prevent weight loss for 1 Resident (#93) in a total sample of 21 residents. Findings include For Resident #93, the Facility staff failed to provide adequate interventions to maintain body weight and prevent a significant weight loss of 9.6 pounds in 1 month, 6.7%. Resident #93 was admitted to the facility in 05/2018 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #93 was cognitively intact with a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS), weighed 113 pounds with a significant weight loss and independent at meals. Review of the weight policy, dated (MONTH) (YEAR), indicates that: - Residents are to be weighed weekly if they have an unanticipated weight loss greater than 5% in one month. - If a significant weight loss/gain is identified (greater than 5% in 30 days or greater than 10% in 6 months), the interdisciplinary team, dietitian, physician, and family are notified. - All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate are monitored weekly. Review of the weight record for Resident #96 is as follows: - 1/3/19 : 141.4 pounds - 1/15/19: 131.8 pounds - 1/28/19: 130.8 pounds - 2/15/19: 127.1 pounds - 2/21/19: 113.3 pounds - 3/8/19: 113.8 pounds Review of Resident #93's most recent Quarterly Nutrition Assessment, dated 11/29/18, indicated that the Resident's weight had been stable and the Resident was eating greater than 76% of meals. Interventions that were in place included a house supplement, super foods (high calorie/protein foods), and two ice creams at lunch and dinner. The dietitian discontinued the house supplements on 11/29/18 due to refusal and because the Resident preferred the supplements he/she received from oncology (strawberry Boost supplement). On 1/15/19, a weight of 131.8 pounds was entered into the Electronic Medical Record (EMR), which indicated a significant 6.7% loss in one month. During review of Resident #93's Nurse Practioner progress note dated 1/23/19, there was no evidence to indicate that the weight loss was acknowledged. There was a current physician order [REDACTED].#93's weight loss, but did not implement any measurable interventions. Review of Resident #93's nutrition care plan initiated on 6/1/18 indicated the last intervention added was resident enjoys ordering take out food dated 1/31/19. The dietitian also wrote that the contracted behavioral health service was consulted. Review of the behavioral health consult dated 1/28/19, indicated there was no acknowledgement of Resident #93's significant weight loss in the consult note and no interventions were recommended regarding the weight loss. Review of Resident #93's oncology recommendation form, dated 2/5/19, indicated the consulting physician from the oncology center recommended that the Facility provide snacks in between meals and perform weekly weights due to a 15 pound weight loss, as recorded by the oncology center. The Facility ordered a dietary consult on 2/5/19. Review of the dietitian progress note, dated 2/5/19, indicated the Resident did not want to waste any more money ordering out food and that he/she wanted steak and eggs. The dietitian recommended a magic cup (supplement) at lunch and dinner. There was no evidence to indicate that Resident #93's food preferences were updated. On 2/12/19, Ensure Plus twice a day was ordered. On 2/21/19, a weight of 113.3 pounds was entered into Resident #93's EMR, indicating a significant weight loss of 28.1 pounds (19.8%) over a period of 7 weeks. During an interview on 3/14/19, at 10:12 A.M., the Director of Nursing (DON) said that the interdisciplinary team meets daily to discuss concerns regarding the residents and the care plans are updated during the meeting as interventions are discussed. During an interview with the dietitian on 3/14/19, at 11:14 A.M., when asked what interventions were put in place at the time the weight loss was identified, the dietitian said that she was waiting for the behavioral health consult to take place regarding concerns of depression and loss of appetite. She said there was a discussion of Resident #93 admitting to hospice because Resident #93 [MEDICAL CONDITION] and that decline was expected. She said that Resident #93 enjoyed ordering take out food. The dietitian also acknowledged Resident #93 should have been on weekly weights. During an interview on 3/14/19, at 1:22 P.M., the dietitian said that she could not find any updated preferences that occurred on 1/31/19.

Based on interviews and records reviewed, for 5 of 12 sampled residents (Resident #4, Resident #5, Resident #7, Resident #8, Resident #10), the Facility failed to investigate allegations of resident abuse, and failed to implement interventions to protect residents from ongoing abuse. - Resident #5 reported to Nurse #4 that on 4/9/18, Resident #4 forcefully, and without his/her consent, kissed him/her. There was no evidence of a thorough investigation or follow up by the Facility to protect Resident #5 from ongoing abuse by Resident #4. - On 2/10/18, Resident #7 went into another Resident's room and punched him/her three times on the chest. The Facility provided no evidence of an investigation including identification of the resident that was punched, and interventions to protect the unidentified resident and other residents. - On 10/19/18, the Administrator presented Surveyor #2 with a statement written by a dietary aide that indicated Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and Non Sampled Resident #13 confirmed Resident #8's allegation. On 10/22/18, the Facility provided no evidence that the allegation had been investigated, and had not attempted to identify and remove the accused CNA. - On 3/27/18, Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Facility provided no evidence that Resident #10's injuries were investigated. The Facility policy titled, Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated 4/2015, indicated: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. - Physical abuse includes hitting, slapping, pinching, and kicking. - Investigation would follow whenever there was an allegation, report, or reason to suspect abuse - The Policy also indicated that Immediate actions would include: - Removing the resident from the alleged abuser or remove the abuser from the resident - Perform a physical assessment of the resident if physical abuse is suspected - Provide any necessary interventions to ensure the resident's safety and well being - Provide emotional support and reassurance to the resident as needed. - Begin investigation within 24 hours of the discovery of the alleged abuse - Take all reasonable steps to protect the resident during the investigation. Resident #8 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/18, indicated Resident #8 was mildly cognitively impaired, did not ambulate, and required assist of two staff for transfers. Non Sampled Resident #13 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/8/18, indicated Non Sampled Resident #13 was cognitively intact. The handwritten Report, dated 10/19/18, indicated Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and that a nurse would generally jump in to stop the abuse, however he/she did not know to report this because he/she did not know the rules. The Report indicated Non Sampled Resident #13 confirmed Resident #8's allegation. The Administrator gave Surveyor #2 the handwritten Report at approximately 2:00 P.M. on 10/19/18. The Administrator said the Facility would begin an investigation, and said the accused CNA had not been identified at that time. Review of Resident #8's Medical Record at 11:10 A.M. on 10/22/18 indicated the Facility had not documented that Resident #8 had alleged abuse, or any follow up care including a skin assessment, or emotional support related to the abuse. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said that resident care after an abuse allegation would be to console the resident, perform a skin assessment to check for injuries, psychological assessment and care, and staff were to document observations, interventions, and assessments in the resident's electronic medical record. Surveyor #2 interviewed the Administrator at 4:38 P.M. on 10/22/18 (four days after the initial allegation of abuse). The Administrator said no further information including staff or resident statements had been gathered regarding Resident #8's allegation of physical abuse by staff, said the accused CNA had not been identified, and said the Facility had not begun to investigate Resident #8's allegation of abuse. Resident #5 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. The Care Plan, dated 10/17/18, indicated Resident #5 was at risk for unwanted sexual advances of others due to [MEDICAL CONDITIONS], and dementia. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #4 was cognitively intact, and had verbal behaviors. The Activities Care Plan, dated 1/2/18, indicated an intervention was initiated on 4/17/18 to verbally redirect Resident #4 when socially or sexually inappropriate. The Care Plan, dated 1/31/18, indicated Resident #4 was known to be inappropriate with staff of the opposite gender, however the Care Plan did not indicate Resident #4 was known to be sexually inappropriate with other residents, or interventions in place to prevent sexual advances toward residents of the opposite gender. The Facility's internal investigation, dated 4/25/18, indicated Resident #4 and Resident #5 were observed socializing together despite Resident #5's statement that he/she was afraid of Resident #4. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 said he/she had reported the incident to a CNA, but she did not know if that CNA had reported the incident to the Administrator or DON, and said she did not report the incident to the Unit Manager until the end of her shift, approximately five hours after Resident #4 reported the allegation of sexual abuse. Review of the Facility's investigation file, undated, indicated Resident #4 and Resident #5 were interviewed, however no other information was gathered such as witness statements or interviews. Review of Resident #5's medical record indicated there was no documentation to indicate follow up care for the incident, and no skin assessment was performed. Surveyor #2 interviewed the DON at 10:19 A.M. on 10/19/18. The DON said Nurse #4 should have reported the allegation of abuse immediately to herself or the Administrator, and the police should have been notified. The DON said the unidentified CNA who told Resident #5 to write a grievance should have reported the allegation of abuse to the nurse, and an investigation including witness statements should have been conducted. Resident #7 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Care Plan, dated 8/11/17, indicated Resident #7 was known to get into verbal and physical altercations with other residents. The Nurses Note, dated 2/10/18, indicated Resident #7 went into another Resident's room and punched him/her three times on the chest. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said there was not an investigation started or completed regarding Resident #7's physical assault toward an unknown resident, including witness statements, who the unknown resident was, if he/she sustained any injuries, received follow up care, or if the physician or family was notified. Resident #10 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #10 was cognitively impaired, required two staff assistance for transfers and bed mobility, and had impaired range of motion in both upper extremities. The Nurse Progress Note, dated 3/27/18, indicated Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Note indicated the DON was notified. Review of Resident #10's medical record indicated there was no documentation of follow up care provided regarding the abuse allegation. Surveyor #2 interviewed the DON at 11:30 A.M. on 10/31/18. The DON said there was no investigation about the finding of hand prints on Resident #10.

Based on records reviewed and interviews for seven of twelve residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, and Resident #10) the Facility failed to implement their own policy, failed to investigate allegations of sexual and physical abuse, failed to prevent ongoing and further abuse, failed to protect residents from abusive acts of other residents. -On 10/6/18 Resident #1, whom the Facility had been informed was a potential sex offender, was observed with his/her mouth on the breast of Resident #3, who had a [DIAGNOSES REDACTED]. This put Resident #3 at risk for the potential for sexual abuse. Although witnessed by a staff member who intervened, no investigation was conducted, no report was made to Administration, police or DPH, no effort was made to protect other residents from abuse from 10/6/18-10/13/18, when a second incident of sexual abuse involving Resident #1 and another resident (Resident #2) occurred. -On 10/13/18, Resident #1 was observed with his/her hand on the breast of Resident #2, who was cognitively impaired. The incident was not immediately reported until 10/15/18 and no effort to immediately intervene to protect others from abuse was made. - On 4/10/18, Resident #5 reported to Nurse #4 that on 4/9/18, Resident #4 forcefully, and without his/her consent, kissed him/her. There was no evidence of a thorough investigation or follow up by the Facility to protect Resident #5 from ongoing abuse by Resident #4. The allegation was not reported to the Department of Public Health within the two hour reporting requirement. - On 2/10/18, Resident #7 went into another Resident's room and punched him/her three times on the chest. The Facility provided no evidence of an investigation, and the incident was not reported to the Department of Public Health. - On 10/19/18, Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and Non Sampled Resident #13 confirmed Resident #8's allegation. On 10/22/18, the Facility provided no evidence that the allegation had been investigated, and had not attempted to identify and remove the accused CNA. - On 3/27/18, Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Facility provided no evidence that Resident #10's injuries were investigated. The incident was not reported to the Department of Public Health until 10/31/18, approximately seven months after the injuries were found. Findings Include: The Facility Policy, titled, Abuse Prevention Policy, dated 8/2016, indicated: -The Facility would identify events, occurrences, patterns and trends of potential abuse for residents -Identify, correct, and intervene in situations where abuse, mistreatment, neglect, and/or misappropriation of resident property occur. - Any incident of actual or suspected abuse must have an incident report completed. - Supervisory personnel were responsible to ensure that the initial investigation regarding the incident occurred timely and appropriate interventions were put into place to ensure resident safety or protect the resident from additional harm. - Interventions would include obtaining statements from witnesses and interviewing the resident when possible. - To protect the residents from harm, immediate actions would include: - Remove the resident from the alleged abuser or remove the abuser from the resident. Separate residents in a resident to resident altercation. - Perform a physical assessment of the resident if physical abuse is suspected, and provide emotional support and reassurance to the resident. 1. A Department of Public Health (DPH) Incident Report Form, submitted via the Health Care Reporting System, on 10/15/18, indicated that on 10/6/18 it was alleged that Resident #1 was observed by a staff member to be orally stimulating Resident #3's breasts. A Police Report, dated 10/17/18, indicated that at 6:39 P.M. on 10/15/18, the Facility reported that Resident #1 had inappropriately touched another resident (Resident #2) and when Police arrived at the Facility, they were informed by the Administrator that when the Facility was investigating an incident (which occurred on 10/13/18), they discovered Resident #1 had inappropriately touched another resident (Resident #3) on 10/6/18. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #1 was admitted in (MONTH) of (YEAR), he/she was cognitively intact, and had the ability to ambulate on the Unit. A Quarterly MDS, dated [DATE], indicated that Resident #3 had medical [DIAGNOSES REDACTED]. A Resident Incapacity Form, signed by Resident #3's Physician in 11/2017, indicated that Resident #3 lacked the capacity to make, or to communicate health care decisions due to his/her [DIAGNOSES REDACTED]. A Psychological Therapy Assessment Note, dated 10/4/18, indicated that Resident #3 had impaired intellectual functioning, poor insight, and poor judgement. A written Statement, undated (later determined to reference 10/6/18) and signed by Certified Nurse Aide #4 (CNA), indicated that when CNA #4 entered Resident #1's room, she observed Resident #3 supine (face up) on another resident's bed, Resident #3's top was pulled up to show his/her breast, and Resident #1, who was shirtless, was beside Resident #3, sucking on his/her breast. There was no indication that any immediate interventions were initiated to protect Resident #3 or other residents from abuse; or that law enforcement or DPH were notified timely. The Facility did not obtain any statements from staff until 10/15/18, nine days later. Surveyor #1 interviewed Nurse #1 at 11:15 A.M. on 10/22/18. Nurse #1 said that, on 10/6/18, a CNA #4 informed him that Resident #3 was in Resident #1's room and when he went into Resident #1's room approximately 10 minutes later, he observed Resident #1 sitting on his/her bed using his/her computer tablet and Resident #3 was sitting on the other bed next to Resident #1's bed and they were facing each other. Nurse #1 said he never heard anyone report any sexual allegations to him related to Resident #1 and Resident #3 so he did not report any incident to the Nursing Supervisor. Surveyor #1 interviewed the Unit Manager at 12:50 P.M. on 10/22/18. The Unit Manager said he was not aware of the Progress note, dated 7/18/18, that indicated the Facility was informed that Resident #1 may be required to register as a sex offender. The Unit Manager said he was not aware of the reason why the Police were called on 10/15/18. The Unit Manager said he did not know about an incident involving Resident #1 and Resident #3 on 10/6/18. The Unit Manager said that, on 10/15/18, he was informed by CNA #3 that Resident #1 was observed talking to Resident #2 and Resident #1 attempted to take Resident #2 back to Resident #2's room. There was no Care Plan in Resident #1's Medical Record that was established, prior to the sexual abuse allegations reported to Administration on 10/15/18, that indicated that Resident #1 had the potential to for sexual abuse or had the potential for sexually inappropriate behaviors. There was no Care Plan in Resident #3's Medical Record, prior to the sexual abuse allegations reported to Administration on 10/15/18, that indicated that Resident #3 exposed himself/herself in public and was at risk for sexual abuse. 2. A DPH Incident Report Form, submitted to DPH on 10/15/18, indicated that on 10/13/18, it was alleged that Resident #1 was observed, by a staff member, to be in the day room touching Resident #2's arms and heading towards his/her breasts (later determined actually touched breast). An MDS, dated [DATE], indicated that Resident #2 was cognitively impaired and had a Brief Interview for Mental Status (BIMS) score of 2 (a score of less than 12 indicates cognitive impairment). A written Statement, dated 10/15/18 and signed by Certified Nurse Assistant (CNA) #3, indicated that on at approximately 9:30 A.M. on 10/13/18, CNA #3 went into the TV room, observed Resident #1 seated next to Resident #2 rubbing Resident #2's arm. The Statement indicated that Resident #1 then proceeded to touch Resident #2's breast and CNA #3 intervened. The Statement indicated that Resident #1 went back to his/her room, CNA #3 reported the incident to a nurse (later determined Nurse #2), and CNA #3 brought Resident #2 to CNA #3's desk. There was no documentation to indicate that any investigation was initiated or that immediate corrective action was implemented to protect residents from abuse. Surveyor #1 interviewed Nurse #2 at 12:14 P.M. on 10/22/18. Nurse #2 said that when she worked on 10/13/18, no staff member informed her about any sexual allegations related to Resident #1 and Resident #2. Surveyor #1 interviewed CNA #3 at 11:18 A.M. on 10/25/18. CNA #3 said that, on 10/13/18, she observed Resident #1 sitting next to Resident #2 in the day room and Resident #1 was rubbing Resident #2's arm then proceeded to put his/her hand over Resident #2's shoulder towards his/her breast. CNA #3 said she separated them and told Nurse #2 about what happened. Surveyor #2 interviewed the Nursing Supervisor at 12:11 P.M. on 10/25/18. The Nursing Supervisor said that when she supervised on 10/6/18 and 10/13/18, staff did not report any incidents to her that involved Resident #1, Resident #2, or Resident #3. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the allegations that involved Resident #1, Resident #2, and Resident #3, until 10/15/18. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she was not notified until 10/15/18 about the alleged sexual abuse that involved Resident #1 and Resident #3 on 10/6/18 and the alleged sexual abuse that involved Resident #1 and Resident #2 on 10/13/18. The DON said that staff should have informed her and the Police at the time the incidents occurred. 3. Resident #5 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. The Care Plan, dated 10/17/18, indicated Resident #5 was at risk for unwanted sexual advances of others due to [MEDICAL CONDITIONS], and dementia. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #4 was cognitively intact, and had verbal behaviors. Review of Resident #4's Medical Record indicated: -On 2/27/18, a Nurse's Note indicated Non Sampled Resident #21 accused Resident #4 of requesting a sexual favor in exchange for candy. -On 3/17/18, a Nurse's Note indicated Resident #4 made sexually inappropriate comments to staff and residents of the opposite gender, and required frequent intervention to redirect behaviors. -On 3/22/18, a Nurse's Note indicated Resident #4 called another resident a homo and then charged at other residents while yelling. The Note indicated Resident #4 was transferred to the Hospital. -On 3/31/18, Resident #4 was verbally abusive and cursing at other residents in a very loud tone, and was unable to be redirected. -On 4/14/18, a complaint was received from another resident that Resident #4 had made sexually inappropriate remarks to a family member, and redirection for Resident #4 remained ineffective. There was no documentation to indicate interventions were initiated to prevent abuse of other residents in response to these incidents. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. The Facility's Internal Investigation, dated 4/25/18, indicated Resident #5 said he/she was afraid of Resident #4. The Investigation indicated Resident #4 and Resident #5 continued to socialize together after the incident. There was no documentation to indicate witness statements from staff or other residents were obtained, or that a plan was in place to ensure Resident #5's well being, or increased supervision for either Resident #4 or Resident #5. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 said he/she had reported the incident to a CNA, but she did not know if that CNA had reported the incident to the Administrator or DON, and said she did not report the incident to the Unit Manager until the end of her shift, approximately five hours after Resident #4 reported the allegation of sexual abuse. Surveyor #2 interviewed the Director of Nurses (DON) at 10:07 A.M. and throughout the day on 10/19/18. The DON said Resident #4's plan of care should have been updated to include interventions to provide increased supervision, and Resident #5's plan of care should have been updated to provide emotional support and increased supervision. The DON said Local Police were notified of the sexual assault by Resident #4 towards Resident #5 in (MONTH) (YEAR), six months after the allegation was made. 4. Resident #7 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Care Plan, dated 8/11/17, indicated Resident #7 was known to get into verbal and physical altercations with other residents. The Nurses Note, dated 2/10/18, indicated Resident #7 went into another Resident's room and punched him/her three times on the chest. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said there was no investigation started or completed regarding Resident #7's physical assault toward an unknown resident, including witness statements, who the unknown resident was, if he/she sustained any injuries, received follow up care, or if the physician or family was notified. 5. Resident #8 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/18, indicated Resident #8 was mildly cognitively impaired, did not ambulate, and required assist of two staff for transfers. Non Sampled Resident #13 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/8/18, indicated Non Sampled Resident #13 was cognitively intact. The statement handwritten by a dietary aide, dated 10/19/18, indicated Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, that it happened all the time, and that a nurse would generally jump in to stop the abuse, however he/she did not know to report this because he/she did not know the rules. The Report indicated Non Sampled Resident #13 confirmed Resident #8's allegation. The Administrator gave Surveyor #2 the handwritten Report at approximately 2:00 P.M. on 10/19/18. The Administrator said the Facility would begin an investigation, and said the accused CNA had not been identified at that time. Review of Resident #8's Medical Record at 11:10 A.M. on 10/22/18 indicated the Facility had not documented that Resident #8 had alleged abuse, or any follow up care including a skin assessment, or emotional support related to the abuse. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said that resident care after an abuse allegation would be to console the resident, perform a skin assessment to check for injuries, psychological assessment and care, and staff were to document observations, interventions, and assessments in the resident's electronic medical record. Surveyor #2 interviewed the Administrator at 4:38 P.M. on 10/22/18 (four days after the initial allegation of abuse). The Administrator said no further information including staff or resident statements had been gathered regarding Resident #8's allegation of physical abuse by staff, said the accused CNA had not been identified, and said the Facility had not begun to investigate Resident #8's allegation of physical abuse by staff. 6. Resident #10 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #10 was cognitively impaired, required two staff assistance for transfers and bed mobility, and had impaired range of motion in both upper extremities. The Nurse Progress Note, dated 3/27/18, indicated Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Note indicated the DON was notified. Review of Resident #10's medical record indicated there was no documentation of follow up care provided regarding the abuse allegation. Surveyor #2 interviewed the DON at 11:30 A.M. on 10/31/18. The DON said there was no investigation about the findings of hand prints on Resident #10, and no report was sent to the Department of Public Health.

Based on records reviewed and interviews for seven of twelve sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #10), the Facility failed to identify and address quality of care concerns for residents who demonstrated sexually inappropriate and physical behaviors which put them at risk for abuse of other residents, failed to identify residents who were at risk for being abused, failed to recognize, report, and investigate signs of and allegations of abuse, and failed to address quality of care concerns related to Physician notification in the presence of a significant change of status. Findings Include: 1. On 10/6/18 Resident #1, whom the Facility had been informed was a potential sex offender, was observed with his/her mouth on the breast of Resident #3, who had a [DIAGNOSES REDACTED].#3 at risk for the potential for sexual abuse and at risk for abusive behaviors. 2. On 10/13/18 Resident #1 was observed with his/her hand on the breast of Resident #2, who was cognitively impaired. A Police Report, dated 10/17/18, indicated that at 6:39 P.M. on 10/15/18, the Facility reported that Resident #1 had inappropriately touched another resident (Resident #2) and when Police arrived at the Facility, they were informed by the Administrator that when the Facility was investigating an incident that involved Resident #1 and Resident #2 (which occurred on 10/13/18), they discovered another incident in which Resident #1 had inappropriately touched another resident (Resident #3) on 10/6/18. Surveyor #2 interviewed the Nursing Supervisor at 12:11 P.M. on 10/25/18. The Nursing Supervisor said that when she supervised on 10/6/18 and 10/13/18, staff did not report any incidents to her that involved Resident #1, Resident #2, or Resident #3. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the allegations that involved Resident #1, Resident #2, and Resident #3, until 10/15/18. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she was not notified until 10/15/18 about the alleged sexual abuse that involved Resident #1 and Resident #3 on 10/6/18 and the alleged sexual abuse that involved Resident #1 and Resident #2 on 10/13/18. The DON said that staff should have informed her and the Police at the time the incidents occurred. 3. Resident #5 reported to Nurse #4 that on 4/9/18, Resident #4 forcefully, and without his/her consent, kissed him/her. There was no evidence that a thorough investigation or follow up by the Facility to protect Resident #5 from ongoing abuse by Resident #4. The allegation was not reported to the Department of Public Health within the two hour reporting requirement. 4. On 2/10/18, Resident #7 went into another Resident's room and punched him/her three times on the chest. The Facility provided no evidence of an investigation, was unable to identify the resident who had been punched by Resident #7, and the incident was not reported to the Department of Public Health. 5. On 10/19/18, the Administrator presented Surveyor #2 with a statement written by a dietary aide that indicated Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and Non Sampled Resident #13 confirmed Resident #8's allegation. On 10/22/18, the Facility provided no evidence that the allegation had been investigated, and had not attempted to identify and remove the accused CNA. 6. On 7/19/18 Resident #9 and a CNA informed Nurse #3 that Resident #9 was unable to move his/her arms. Nurse #3 did not inform Resident #9's Physician and did not write a Progress Note on 7/19/18 that indicated that she completed a neurological assessment on Resident #9. On 7/20/18 Nurse #4 observed Resident #9's left arm flaccid and did not notify Resident #9's Physician and did not write a Progress Note on 7/20/18 that indicated that she completed a neurological assessment on Resident #9. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that the Facility had no concerns related to Resident #9's care prior to his/her transfer to the hospital. 7. On 3/27/18, Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Facility provided no evidence that Resident #10's injuries were investigated. The incident was not reported to the Department of Public Health until 10/31/18, approximately seven months after the injuries were found. The Facility Quality Assurance Performance Improvement Meeting Minutes, from (MONTH) through (MONTH) of (YEAR), did not indicate that the Facility identified, addressed, or put a self-identified Performance Improvement Plan in place for quality of care concerns related to: -potential sexual and physical abusive behaviors which put others at risk for harm. -staff identification of signs or symptoms of potential abuse. -reporting potential signs and symptoms of abuse or abuse allegations in a timely manner. -failure to evaluate changes of condition -failure to document changes of condition -failure to notify Physicians of changes in condition in a timely manner

Based on records reviewed and interviews for one of twelve sampled residents (Resident #9), the Facility failed to promptly notify Resident #9's Physician of a significant change in his/her status in a timely manner, when on 7/19/18, Resident #9 informed staff on the 3:00 P.M. to 11:00 P.M. shift, that he/she could not move and on 7/20/18 staff observed that Resident #9 was unable to move his/her left arm. Findings Include: The Facility Policy titled Condition: Significant Change, dated 4/2015, indicated that professional staff will communicate with the Physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which was essential to quality care management. An Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #9's medical [DIAGNOSES REDACTED]. A Physician's Note, dated 6/18/18, indicated that Resident #9 had the ability to move all extremities. A Nurse Progress Note, timed at 10:37 A.M. and dated 7/20/18, indicated that Resident #9 stated that he/she was unable to feel his/her left arm and he/she was unable to squeeze the Nurse's hand, Resident #9 was unable to lift or move his/her left arm. The Progress Note indicated that Resident #9's blood pressure was 180/109 (hypertensive), his/her heart rate was elevated, and Resident #9 was transferred to the hospital. A Nurse Progress Note, timed at 5:30 P.M. and dated 7/20/18, indicated that an ambulance arrived at the Facility sometime after 10:00 A.M. (which was two and a half hours after Nurse #4 observed Resident #9's flaccid left arm). The Progress Note indicated that Resident #9 had been unable to move his/her arms and the, 7/19/18, 11:00 P.M.-7:00 A.M. shift had reported that Resident #9 had been awake all night. A Nurse Progress Note, dated 7/25/18 (five days after Resident #9 was transferred to the Hospital) and labeled as a late entry, indicated that at approximately 7:30 P.M. on 7/19/18, Nurse #3 was informed by a Certified Nurse Aide that Resident #9 could not move. The Late Entry Progress note indicated that Resident #9's speech was garbled which was his/her baseline, Nurse #3 took Resident #9's blood pressure and heart rate, and asked Resident #3 to move his/her arms and legs, which he/she was able to do. This was not consistent with the Nurse Progress Note dated as written on 7/20/18. The Late Entry Progress Note indicated that Nurse #3 rechecked Resident #9 at 9:30 P.M., Resident #9 was sleeping comfortably, and the information was passed to the on-coming 11:00 P.M. -7:00 A.M. nurse. A Nurse Progress Note, dated 7/31/18 (eleven days after Resident #9 was transferred to the Hospital), indicated that at 7:30 A.M. on 7/20/18, CNA #1 questioned Nurse #4 about what happened to Resident #9's left arm. The Progress Note indicated that when Nurse #4 went to assess Resident #9 she observed that Resident #9's left arm was flaccid and that Resident #9 told Nurse #4 that he/she had told the Nurse about it the previous day. The Progress Note indicated that she informed another staff member to follow up after she clocked out of the Facility at approximately 7:50 A.M. on 7/20/18. Surveyor #1 interviewed Nurse #3 at 1:05 P.M. on 10/24/18. Nurse #3 said that when she worked on the 3:00 P.M.-11:00 P.M. shift on 7/19/18, she was told by a CNA that Resident #9 could not move and insisted that something was wrong with Resident #9. Nurse #3 said when she went into Resident #9's room, he/she was able to take his/her scheduled medications which indicated to her that Resident #9 could move his/her arms and did no further assessment of his/her ability to move his/her arms. Nurse #3 said that Resident #9 told her that he/she was unable to move his/her arms. Nurse #3 said that although she went back into the room later in the shift to check on Resident #9, she did not perform a neurological assessment. Nurse #3 said that she had no reason to call Resident #9's Physician. Nurse #3 said that [MEDICAL CONDITION] (also known as a TIA, blood flow to part of the brain stops for a short period of time and is a warning sign that stroke may happen in the future) could include symptoms such as weakness, decreased speech, and inability to follow instructions and that the symptoms could pass with no real deficits, but Resident #9 showed no signs other than what the CNA reported to her, or words to that affect. Surveyor #1 interviewed Nurse #4 at 2:07 P.M. on 10/24/18. Nurse #4 said that between 7:30 and 7:45 A.M. on 7/20/18, CNA #1 informed her that Resident #9's arm was limp. Nurse #4 said she went to check on Resident #9 and observed that he/she was not able to move his/her arm and fingers without moving them with the other hand. Nurse #4 said that Resident #9 told her that he/she had reported his symptoms to staff the previous day. Nurse #4 said she thought Resident #9 may have had a stroke but did not feel that it was an emergency because Resident #9 was not in pain, did not have any mental status change, and he/she had no blurred vision. Nurse #4 said that if Resident #9 had a stroke (condition that occurs when blood flow to the brain is cut off) it would be an emergent situation because there was a time frame of 20 minutes from which the first signs and symptoms of stroke required medical attention. Nurse #4 said if Resident #9 had reported his/her symptoms on the previous day, his/her 20 minutes was up 24 hours ago. Nurse #4 said that she did not call Resident #9's Physician because she had her bags packed to go home, nobody from management was on the unit and said that she informed other staff members to follow up on it. Nurse #4 said she did not document that she completed a neurological assessment on Resident #9 on 7/20/18 but wrote a late entry Progress Note (7/31/18) because someone at the Facility asked her to write a Progress Note. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that any changes in mobility or with flaccidness, Nurse's should have completed a head to toe assessment and called Resident #9's Physician to notify him of their assessment findings. A Hospital Emergency Department (ED) Medical Records Report, dated 7/20/18, indicated Resident #9 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].

Based on records reviewed and interviews for four of twelve sampled residents (Resident #1, Resident #3, Resident #4, and Resident #5), the Facility failed to develop and implement person-centered Care Plans for residents with the potential for sexually and physically abusive behaviors and who were at risk for being sexually abused. Findings Include: The Facility Policy titled, Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention Policy, dated 4/2015, indicated that interventions to ensure resident well-being will be identified by the interdisciplinary team and included in the resident's care plan. Resident #1: 1. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #1 was admitted in (MONTH) of (YEAR), he/she was cognitively intact, and had the ability to ambulate on the Unit. A Progress note, dated 7/18/18, indicated that the Facility received a call from a Family Member who questioned if Resident #1 registered as a sex offender and informed the Facility that Resident #1 had been required to register as a sex offender in another state. The Progress Note indicated that the information was passed on to the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Surveyor #1 interviewed the Assistant Director of Nursing (ADON) at 11:39 A.M. on 10/24/18. The ADON said she was aware of the phone call made to the Facility, on 7/18/18, regarding Resident #1 was potentially a sex offender. The ADON said that the Facility checked online to see if Resident #1 was a registered sex offender and they did not see his/her name online. The ADON said there was no further follow up to confirm if what they were told was valid and she did not ask Resident #1 about any history of being a sexual offender. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she did not see the Progress Note, dated 7/18/18, that referred to a phone call to inform the Facility that Resident #1 had been required to register as a sex offender in another state. The DON said that she was never informed by anyone about the call. A Department of Public Health (DPH) Incident Report Form, submitted via the Health Care Reporting System, on 10/15/18, indicated that on 10/6/18 it was alleged that Resident #1 was observed by a staff member to be orally stimulating Resident #3's (who lacked capacity to make decisions) breasts. There was no Care Plan in Resident #1's Medical Record that was established, prior to the sexual abuse allegations reported to Administration, including the DON and ADON, on 10/15/18, that indicated that Resident #1 had the potential to sexually abuse or had the potential for sexually inappropriate behaviors. Resident #3: 2. A Resident Incapacity Form, signed by Resident #3's Physician in 11/2017, indicated that Resident #3 lacked the capacity to make, or to communicate health care decisions due to his/her [DIAGNOSES REDACTED]. There was no indication in Resident #3's Medical Record that indicated that Resident #3 was evaluated and determined to have the capacity to consent to sexual activity. A Quarterly MDS, dated [DATE], indicated that Resident #3 had medical [DIAGNOSES REDACTED]. A Psychological Therapy Assessment Note, dated 10/4/18, indicated that Resident #3 had impaired intellectual functioning, poor insight, and poor judgement. A Progress Note, dated 2/24/18, indicated that Resident #3 exposed himself/herself to other residents and staff. A Progress Note, dated 2/25/18, indicated that Resident #3 disrobed in in the hallway and wandered from room to room. A Progress Note, dated 3/6/18, indicated that Resident #3 was sexually inappropriate, exposed himself/herself in the hallway and wandered into other resident's rooms on multiple occasions. A Progress Note, dated 3/15/18, indicated that Resident #3 exposed himself/herself and walked in the hall with a small towel that exposed his/her buttocks and genital area. The Progress Note indicated that Resident #3 laughed inappropriately and ignored staff's attempts at redirection. A Progress Note, timed at 12:45 A.M. and dated 10/6/18 (prior to the time of the alleged sexual abuse allegation), indicated that Resident #3 exhibited [MEDICAL CONDITION], was frequently observed entering a resident's room of the opposite sex, and Resident #3 was difficult to direct. A written Statement, undated and signed by Certified Nurse Aide #4 (CNA), indicated that when CNA #4 entered Resident #1's room, she observed Resident #3 supine (face up) on another resident's bed, Resident #3's top was pulled up to show his/her breast, and Resident #1, who was shirtless, was beside Resident #3, sucking on his/her breast. Surveyor #1 interviewed CNA #1 at 10:25 A.M. on 10/22/18. CNA #1 said Resident #3 wandered around on the unit, frequently went into Resident #1's room, and would disrobe in public. CNA #1 said he didn't think that Resident #3 was aware of what he/she was doing and said when he saw Resident #3 in other resident rooms he redirected Resident #3 out of the room. Surveyor #1 interviewed Nurse #1 at 11:15 A.M. on 10/22/18. Nurse #1 said that, on 10/6/18, a CNA #4 informed him that Resident #3 was in Resident #1's room and when he went into Resident #1's room approximately 10 minutes later, he observed Resident #1 sitting on his/her bed using his/her computer tablet and Resident #3 was sitting on the other bed next to Resident #1's bed and they were facing each other. Nurse #1 said he never heard anyone report any sexual allegations to him related to Resident #1 and Resident #3 so he did not report any incident to the Nursing Supervisor. Nurse #1 said that he was not aware if Resident #1 had the potential to sexually abuse. Nurse #1 said there were several residents on the Unit who had dementia, were cognitively impaired, wandered, and were unable to verbalize concerns. Surveyor #1 interviewed Nurse #2 at 12:14 P.M. on 10/22/18. Nurse #2 said Resident #3 frequently wandered into resident rooms and required re-direction. The Unit Manager said Resident #3 made attempts to take his/her t-shirt off in the hall, consistently wandered into resident's rooms, gravitated towards people of the opposite sex, and said that he had observed Resident #3 wander into Resident #1's room in the past. The Unit Manager said his role as a Unit Manager included oversight of resident care and he assisted with care plan development and implementing interventions after incidents occurred. Surveyor #1 interviewed the DON at 2:15 P.M. on 10/22/18. The DON said she was not aware that Resident #3 had behaviors of disrobing in public. There was no Care Plan in Resident #1's Medical Record that was established, prior to the sexual abuse allegations reported to Administration on 10/15/18, that indicated that Resident #1 had the potential to sexually abuse or had the potential for sexually inappropriate behaviors. There was no Care Plan in Resident #3's Medical Record, prior to the sexual abuse allegations reported to Administration on 10/15/18, that indicated that Resident #3 exposed himself/herself in public and was at risk for sexual abuse. Resident #5: 3. Resident #5 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. The Care Plan, dated 10/17/18, indicated Resident #5 was at risk for unwanted sexual advances of others due to [MEDICAL CONDITIONS], and dementia. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #4 was cognitively intact, and had verbal behaviors. The Activities Care Plan, dated 1/2/18, indicated an intervention was initiated on 4/17/18 to verbally redirect Resident #4 when socially or sexually inappropriate. The Care Plan, dated 1/31/18, indicated Resident #4 was known to be inappropriate with staff of the opposite gender, however the Care Plan did not indicate Resident #4 was known to be sexually inappropriate with other residents, or interventions in place to prevent sexual advances toward residents of the opposite gender. Review of Resident #4's medical record indicated: -On 2/27/18, a Nurse's Note indicated Non Sampled Resident #21 accused Resident #4 of requesting a sexual favor in exchange for candy. -On 3/17/18, a Nurse's Note indicated Resident #4 made sexually inappropriate comments to staff and residents of the opposite gender, and required frequent intervention to redirect behaviors. -On 3/22/18, a Nurse's Note indicated Resident #4 called another resident a homo and then charged at other residents while yelling. The Note indicated Resident #4 was transferred to the Hospital under section 12. -On 3/31/18, Resident #4 was verbally abusive and cursing at other residents in a very loud tone, and was unable to be redirected. -On 4/14/18, a complaint was received from another resident that Resident #4 had made sexually inappropriate remarks to a family member, and redirection for Resident #4 remained ineffective. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 was known to have boy/girlfriend relationships with residents of the opposite gender, and said she was not aware of the extent of the relationships or if Resident #5 was involved in kissing or otherwise sexual acts with other residents. Nurse #4 said she did not know if Resident #5 had a plan of care in place with interventions to protect him/her and other residents from unwanted sexual advances. Surveyor #2 interviewed the DON at 10:07 A.M. on 10/19/18. The DON said Resident #4 and Resident #5's care plans should have been updated immediately after Resident #4's allegation of Resident #5's sexual assault to include interventions to increase supervision. There was no documentation to indicate Resident #4's and Resident #5's Care Plans were updated and interventions were implemented to prevent, and protect from, sexual abuse.

Based on records reviewed and interviews for six of twelve sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #10), the Facility failed to ensure that allegations of resident-to-resident physical and sexual abuse were immediately reported to the Administrator or designee, and the Department of Public Health within the two hour requirement. -On 10/6/18 Resident #1, whom the Facility had been informed was a potential sex offender, was observed with his/her mouth on the breast of Resident #3, who had a [DIAGNOSES REDACTED]. This put resident #3 at risk for the potential for sexual abuse. -On 10/13/18 Resident #1 was observed with his/her hand on the breast of Resident #2, who was cognitively impaired. - On 4/10/18, Resident #5 reported to Nurse #4 that on 4/9/18, Resident #4 forcefully, and without his/her consent, kissed him/her. The allegation was not reported to the Department of Public Health within the two hour reporting requirement. - On 2/10/18, Resident #7 went into another Resident's room and punched him/her three times on the chest. The incident was not reported to the Department of Public Health. - On 3/27/18, Resident #10 was found with bright red hand prints on his/her chest and abdomen. The incident was not reported to the Department of Public Health until 10/31/18, approximately seven months after the injuries were found. Findings Include: The Facility Policy titled Accident and Incident (A&I) Specific Reporting Department of Public Health Reportable Event, dated 4/2015, indicated that the Administrator, Director of Nursing, or their designee assumes responsibility for the immediate notification to the Department of Public Health (DPH) and local Police Department in all cases of physical abuse, alleged or confirmed. The Facility Policy titled Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention Policy, dated 4/2015, indicated that all Facility staff members were expected to identify and report any potential or actual occurrences of abuse immediately. The Policy indicated that DPH was to be immediately notified via oral communication, electronically transmitted report or facsimile. The Facility Policy titled Abuse Prohibition Policy, dated 8/2016, indicated that Supervisor will notify the Administrator and/or Director of Nursing (DON) when an abuse allegation is made. Review of the Facility Policies related to Abuse, indicated that the Policy's were not updated to include reporting time frames as indicated in Section 1150B of the Social Security Act for individuals reporting a reasonable suspicion of a crime, which indicated that each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 1. A DPH Incident Report Form, submitted via the Health Care Reporting System (HCFRS), on 10/15/18, indicated that on 10/6/18 it was alleged that Resident #1 was observed by a staff member to be orally stimulating Resident #3's breasts. The Report was submitted nine days after the incident occurred. This was not consistent with the Facility Policy titled Accident and Incident Specific Reporting Department of Public Health Reportable Event. A written Statement, undated (later determined to reference 10/6/18) and signed by Certified Nurse Aide #4 (CNA), indicated that when CNA #4 entered Resident #1's room, she observed Resident #3 face up on another resident's bed, Resident #3's top was pulled up to show his/her breast, and Resident #1, who was shirtless, was beside Resident #3, sucking on his/her breast. This was not reported to Police until nine days after the incident. The Statement indicated that CNA #4 called Resident #3 out of the room, she walked with Resident #3 over to Nurse #1 to inform him/her about the incident. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the 10/6/18 allegations that involved Resident #1 and Resident #3 until 10/15/18. The Administrator said the Facility notified DPH at that time. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she could not recall who informed her about the 10/6/18, alleged sexual abuse that involved Resident #1 and Resident #3 but said she was informed on 10/15/18, by a staff member during her investigation of another abuse allegation involving Resident #1 and another resident. 2. A DPH Incident Report Form, submitted via HCFRS on 10/15/18, indicated that on 10/13/18, it was alleged that Resident #1 was observed, by a staff member, to be in the day room touching Resident #2's arms and heading towards his/her breasts. This was not consistent with the Facility Policy titled Accident and Incident Specific Reporting Department of Public Health Reportable Event. A written Statement, dated 10/15/18 and signed by Certified Nurse Assistant (CNA) #3, indicated that on at approximately 9:30 A.M. on 10/13/18, CNA #3 went into the TV room, observed Resident #1 seated next to Resident #2 rubbing Resident #2's arm. The Statement indicated that Resident #1 then proceeded to touch Resident #2's breast and CNA #3 intervened. The Statement indicated that Resident #1 went back to his/her room, CNA #3 reported the incident to a nurse, and CNA #3 brought Resident #2 to CNA #3's desk. Surveyor #1 interviewed CNA #3 at 11:18 A.M. on 10/25/18. CNA #3 said that, on 10/13/18, she observed Resident #1 sitting next to Resident #2 in the day room and Resident #1 was rubbing Resident #2's arm then proceeded to put his/her hand over Resident #2's shoulder towards his/her breast. CNA #3 said she separated them and told Nurse #2 about what happened. A Police Report, dated 10/17/18, indicated that at 6:39 P.M. on 10/15/18, the Facility reported that Resident #1 had inappropriately touched another resident (Resident #2) and when Police arrived at the Facility, they were informed by the Administrator that when the Facility was investigating an incident that involved Resident #1 and Resident #2 (which occurred on 10/13/18), they discovered another incident in which Resident #1 had inappropriately touched another resident (Resident #3) on 10/6/18. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the 10/13/18 allegation that involved Resident #1 and Resident #2 until 10/15/18. The Administrator said the Facility notified DPH at that time. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she was not informed of the allegation of sexual abuse that involved Resident #1 and Resident #2 on 10/13/18. The DON said she was notified about the alleged sexual abuse by CNA #3 on 10/15/18. 3. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 said he/she had reported the incident to an unknown CNA, but she did not know if that CNA had reported the incident to the Administrator or DON, and said she did not report the incident to the Unit Manager until the end of her shift, approximately five hours after Resident #4 reported the allegation of sexual abuse. Surveyor #2 interviewed the DON at 10:07 A.M. on 10/19/18. The DON said Nurse #4 should have reported the allegation to the DON or to the Administrator immediately, and said the unknown CNA should have reported the allegation to the nurse on duty immediately. The HCFRS Report, dated 4/25/18, indicated the allegation was not reported to DPH until fifteen days after the allegation was made, and was not reported to local Police until (MONTH) (YEAR), approximately six months after the allegation of sexual abuse. 4. The Nurses Note, dated 2/10/18, indicated Resident #7 went into another Resident's room and punched him/her three times on the chest. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said there was not an investigation started or completed regarding Resident #7's physical assault toward an unknown resident, including witness statements, who the unknown resident was, if he/she sustained any injuries, received follow up care, or if the physician or family was notified. 5. The Nurse Progress Note, dated 3/27/18, indicated Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Note indicated the DON was notified. Review of Resident #10's medical record indicated there was no documentation of follow up care provided regarding the abuse allegation. Surveyor #2 interviewed the DON at 11:30 A.M. on 10/31/18. The DON said there was no investigation about the findings of hand prints on Resident #10, and no report was made to the Department of Public Health.

Based on records reviewed and interviews for three of 12 sampled residents (Resident #1, Resident #2, and Resident #3) the Facility failed to report allegations of possible sexual abuse to local Police and the Department of Public Health (DPH) as required: -On 10/6/18 Resident #1, whom the Facility had been informed was a potential sex offender, was observed with his/her mouth on the breast of Resident #3, who had a [DIAGNOSES REDACTED]. -On 10/13/18 Resident #1 was observed with his/her hand on the breast of Resident #2, who was cognitively impaired. - On 4/10/18, Resident #5 said that on 4/9/18, Resident #4 had forcefully kissed him/her without his/her consent. Findings Include: Federal regulations require that the Facility must develop and implement written policies and procedures that: Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to reporting to one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. The Facility Policy titled Accident and Incident (A&I) Specific Reporting Department of Public Health Reportable Event, dated 4/2015, indicated that the Administrator, Director of Nursing, or their designee assumes responsibility for the immediate notification to the Department of Public Health (DPH) and local Police Department in all cases of physical abuse, alleged or confirmed. 1. A DPH Incident Report Form, submitted via the Health Care Reporting System (HCFRS), on 10/15/18, indicated that on 10/6/18 it was alleged that Resident #1 was observed by a staff member to be orally stimulating Resident #3's breasts. The Report was submitted nine days after the incident occurred. This was not consistent with the Facility Policy titled Accident and Incident Specific Reporting Department of Public health Report. A written Statement, undated (later determined to reference 10/6/18) and signed by Certified Nurse Aide #4 (CNA), indicated that when CNA #4 entered Resident #1's room, she observed Resident #3 face up on another resident's bed, Resident #3's top was pulled up to show his/her breast, and Resident #1, who was shirtless, was beside Resident #3, sucking on his/her breast. This was not reported to Police until nine days after the incident. 2. A DPH Incident Report Form, submitted via HCFRS on 10/15/18, indicated that on 10/13/18, it was alleged that Resident #1 was observed, by a staff member, to be in the day room touching Resident #2's arms and heading towards his/her breasts. This was not consistent with Federal Regulations that requires the Facility to immediately report, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. A written Statement, dated 10/15/18 and signed by Certified Nurse Assistant (CNA) #3, indicated that on at approximately 9:30 A.M. on 10/13/18, CNA #3 went into the TV room, observed Resident #1 seated next to Resident #2 rubbing Resident #2's arm. The Statement indicated that Resident #1 then proceeded to touch Resident #2's breast and CNA #3 intervened. The Statement indicated that Resident #1 went back to his/her room, CNA #3 reported the incident to a nurse (later determined Nurse #2), and CNA #3 brought Resident #2 to CNA #3's desk. Surveyor #1 interviewed CNA #3 at 11:18 A.M. on 10/25/18. CNA #3 said that, on 10/13/18, she observed Resident #1 sitting next to Resident #2 in the day room and Resident #1 was rubbing Resident #2's arm then proceeded to put his/her hand over Resident #2's shoulder towards his/her breast. CNA #3 said she separated them and told Nurse #2 about what happened. A Police Report, dated 10/17/18, indicated that at 6:39 P.M. on 10/15/18, the Facility reported that Resident #1 had inappropriately touched another resident (Resident #2) and when Police arrived at the Facility, they were informed by the Administrator that when the Facility was investigating an incident that involved Resident #1 and Resident #2 (which occurred on 10/13/18), they discovered another incident in which Resident #1 had inappropriately touched another resident (Resident #3) on 10/6/18. The Facility failed to report incidents of Resident #1 inappropriately touching and sexually abusing other residents to the Police within 24 hours of the occurrences. This was not consistent with Federal Regulations that require that each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the allegations that involved Resident #1, Resident #2, and Resident #3, until 10/15/18. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she was not notified until 10/15/18 about the alleged sexual abuse that involved Resident #1 and Resident #3 on 10/6/18 and the alleged sexual abuse that involved Resident #1 and Resident #2 on 10/13/18. The DON said that staff should have informed her and the Police at the time the incidents occurred. 3. Resident #5 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Activities Care Plan, dated 1/2/18, indicated an intervention was initiated on 4/17/18 to verbally redirect Resident #4 when socially or sexually inappropriate. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 said he/she had reported the incident to an unknown CNA, but she did not know if that CNA had reported the incident to the Administrator or DON, and said she did not report the incident to the Unit Manager until the end of her shift, approximately five hours after Resident #4 reported the allegation of sexual abuse. Surveyor #2 interviewed the DON at 10:07 A.M. on 10/19/18. The DON said Nurse #4 should have reported the allegation to the DON or to the Administrator immediately, and said the unknown CNA should have reported the allegation to the nurse on duty immediately, and said the incident was not reported to local police until (MONTH) (YEAR).

Based on records reviewed and interviews for seven of 12 sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, and Resident #10) and one Non Sampled Resident (Non-sampled Resident #13), the Facility failed to protect residents from alleged abuse. -On 10/6/18 Resident #1, whom the Facility had been informed was a potential sex offender, was observed with his/her mouth on the breast of Resident #3, who had a [DIAGNOSES REDACTED]. This put Resident #3 at risk for the potential for sexual abuse. Although the above referenced incident involving Resident #1 and Resident #3 was observed by a staff member who indicated she informed a nurse, no immediate interventions were implemented to protect other residents. -On 10/13/18 Resident #1 was observed with his/her hand on the breast of Resident #2, who was cognitively impaired. - On 4/9/18, Resident #5 reported to Nurse #4 that Resident #4 forcefully, and without his/her consent, kissed him/her. There was no evidence of a thorough investigation or follow up by the Facility to protect Resident #5 from ongoing abuse by Resident #4. There was no immediate intervention implemented to protect Resident #5 from abuse. - On 2/10/18, Resident #7 went into another Resident's room and punched him/her three times on the chest. The Facility provided no evidence of an investigation of the incident of resident to resident abuse and was unable to provide the Surveyors with the identity of the Resident who was punched by Resident #7. - On 10/19/18, Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and Non Sampled Resident #13 confirmed Resident #8's allegation. As of 10/22/18, the Facility provided no evidence that the allegation had been investigated, and had not attempted to identify and remove the accused CNA. - On 3/27/18, Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Facility provided no evidence that Resident #10's injuries were investigated. Findings Include: The Facility Policy titled Abuse Prohibition Policy, dated 8/2016, indicated that the Facility was responsible to ensure that each resident has the right to be free from abuse. The Policy indicated that the Facility would identify events, occurrences, patterns and trends of potential abuse for residents and would protect residents from harm during an investigation of alleged abuse. The Facility Policy titled Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention Policy, dated 4/2015, indicated that all Facility staff members were expected to identify and report any potential or actual occurrences of abuse immediately. A Police Report, dated 10/17/18, indicated that at 6:39 P.M. on 10/15/18, the Facility reported that Resident #1 had inappropriately touched another resident (Resident #2) and when Police arrived at the Facility, they were informed by the Administrator that when the Facility was investigating an incident (which occurred on 10/13/18), they discovered Resident #1 had inappropriately touched another resident (Resident #3) on 10/6/18. 1. A Department of Public Health (DPH) Incident Report Form, submitted via the Health Care Reporting System, on 10/15/18, indicated that on 10/6/18 it was alleged that Resident #1 was observed by a staff member to be orally stimulating Resident #3's breasts. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #1 was admitted in (MONTH) of (YEAR), he/she was cognitively intact, and had the ability to ambulate on the Unit. A Quarterly MDS, dated [DATE], indicated that Resident #3 had medical [DIAGNOSES REDACTED]. A Resident Incapacity Form, signed by Resident #3's Physician in 11/2017, indicated that Resident #3 lacked the capacity to make, or to communicate health care decisions due to his/her [DIAGNOSES REDACTED]. There was no indication in Resident #3's Medical Record that indicated that Resident #3 was evaluated and determined to have the capacity to consent to sexual activity. A Psychological Therapy Assessment Note, dated 10/4/18, indicated that Resident #3 had impaired intellectual functioning, poor insight, and poor judgement. A Progress note, dated 7/18/18, indicated that the Facility received a call from a Family Member who questioned if Resident #1 registered as a sex offender and who informed the Facility that Resident #1 had been required to register as a sex offender in another state. The Progress Note indicated that the information was passed on to the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Surveyor #1 interviewed the Unit Manager at 12:50 P.M. on 10/22/18. The Unit Manager said he was not aware of the Progress note, dated 7/18/18, that indicated the Facility was informed that Resident #1 may be required to register as a sex offender. Surveyor #1 interviewed the Assistant Director of Nursing (ADON) at 11:39 A.M. on 10/24/18. The ADON said she was aware of the phone call made to the Facility, on 7/18/18, regarding Resident #1 was potentially a sex offender. The ADON said that the Facility checked online to see if Resident #1 was a registered sex offender and they did not see his/her name online. The ADON said there was no further follow up to confirm if what they were told was valid and she did not ask Resident #1 about any history of being a sexual offender. A Progress Note, dated 2/24/18, indicated that Resident #3 exposed himself/herself to other residents and staff. A Progress Note, dated 2/25/18, indicated that Resident #3 disrobed in in the hallway and wandered from room to room. A Progress Note, dated 3/6/18, indicated that Resident #3 was sexually inappropriate, exposed himself/herself in the hallway and wandered into other resident's rooms on multiple occasions. A Progress Note, dated 3/15/18, indicated that Resident #3 exposed himself/herself and walked in the hall with a small towel that exposed his/her buttocks and genital area. The Progress Note indicated that Resident #3 laughed inappropriately and ignored staff's attempts at redirection. A Progress Note, timed at 12:45 A.M. and dated 10/6/18 (prior to the time of the alleged sexual abuse allegation), indicated that Resident #3 exhibited [MEDICAL CONDITION], was frequently observed entering a resident's room of the opposite sex, and Resident #3 was difficult to direct. Surveyor #1 interviewed Nurse #2 at 12:14 P.M. on 10/22/18. Nurse #2 said Resident #3 frequently wandered into resident rooms and required re-direction. Surveyor #1 interviewed CNA #1 at 10:25 A.M. on 10/22/18. CNA #1 said Resident #3 wandered around on the unit, frequently went into Resident #1's room, and would disrobe in public. CNA #1 said he didn't think that Resident #3 was aware of what he/she was doing and said when he saw Resident #3 in other resident rooms he redirected Resident #3 out of the room. Surveyor #1 interviewed Nurse #3 at 1:05 P.M. on 10/24/18. Nurse #3 said Resident #1 came out of his/her room not fully dressed and went into rooms of residents of opposite sex, staff need to redirect him/her, and said she did not think that Resident #3 had the ability to realize what he/she was doing. Surveyor #1 interviewed Nurse #4 at 2:07 P.M. on 10/24/18. Nurse #4 said Resident #3 was deemed incompetent and had poor judgement. Nurse #4 said Resident #3 disrobed and veered toward residents of the opposite sex and said that, in the past, she observed Resident #3 take his/her shirt off as he/she stood in front of a resident's room who was of the opposite sex. The Unit Manager said Resident #3 made attempts to take his/her T-shirt off in the hall, consistently wandered into resident's rooms, gravitated towards people of the opposite sex, and said that he had observed Resident #3 wander into Resident #1's room in the past. The Unit Manager said he did not know about an incident involving Resident #1 and Resident #3 on 10/6/18. The Unit Manager said his role as a Unit Manager included oversight of resident care and he assisted with care plan development and implementing interventions after incidents occurred. There was no Care Plan in Resident #1's Medical Record, prior to 10/15/18, that indicated that Resident #1 had the potential to sexually abuse or had the potential for sexually inappropriate behaviors. There was no Care Plan in Resident #3's Medical Record, prior to 10/15/18, that indicated that Resident #3 exposed himself/herself in public and was at risk for sexual abuse. A written Statement, undated (later determined to reference 10/6/18) and signed by Certified Nurse Aide #4 (CNA), indicated that when CNA #4 entered Resident #1's room, she observed Resident #3 face up on another resident's bed, Resident #3's top was pulled up to show his/her breast, and Resident #1, who was shirtless, was beside Resident #3, sucking on his/her breast. The Statement indicated that CNA #4 called Resident #3 out of the room, she walked with Resident #3 over to Nurse #1 to inform him/her about the incident. A written Statement, dated 10/16/18 and signed by Nurse #1, indicated that between 11:30 A.M. and 1:00 P.M. on 10/6/18, he was informed by a CNA that Resident #3 was in Resident #1's room. The Statement indicated that Nurse #1 went into Resident #1's room, saw Resident #3 sitting on another resident's bed next to Resident #1 and Nurse #1 redirected Resident #3 out of Resident #1's room. Surveyor #1 interviewed Nurse #1 at 11:15 A.M. on 10/22/18. Nurse #1 said that, on 10/6/18, a CNA #4 informed him that Resident #3 was in Resident #1's room and when he went into Resident #1's room approximately 10 minutes later, he observed Resident #1 sitting on his/her bed using his/her computer tablet and Resident #3 was sitting on the other bed next to Resident #1's bed and they were facing each other. Nurse #1 said he never heard anyone report any sexual allegations to him related to Resident #1 and Resident #3 so he did not report any incident to the Nursing Supervisor. There was no indication that the Facility staff initiated any immediate interventions to protect Resident #3 or other residents from abuse in response to the 10/6/18 staff witnessed abuse. 2. An MDS, dated [DATE], indicated that Resident #2 was cognitively impaired and had a Brief Interview for Mental Status (BIMS) score of 2 (a score of less than 12 indicates cognitive impairment). A DPH Incident Report Form, submitted to DPH on 10/15/18, indicated that on 10/13/18, it was alleged that Resident #1 was observed, by a staff member, to be in the day room touching Resident #2's arms and heading towards his/her breasts (later determined actually touched breasts). A written Statement, dated 10/15/18 and signed by Certified Nurse Assistant (CNA) #3, indicated that on at approximately 9:30 A.M. on 10/13/18, CNA #3 went into the TV room, observed Resident #1 seated next to Resident #2 rubbing Resident #2's arm. The Statement indicated that Resident #1 then proceeded to touch Resident #2's breast and CNA #3 intervened. The Statement indicated that Resident #1 went back to his/her room, CNA #3 reported the incident to a nurse (later determined Nurse #2), and CNA #3 brought Resident #2 to CNA #3's desk. Surveyor #1 interviewed CNA #3 at 11:18 A.M. on 10/25/18. CNA #3 said that, on 10/13/18, she observed Resident #1 sitting next to Resident #2 in the day room and Resident #1 was rubbing Resident #2's arm then proceeded to put his/her hand over Resident #2's shoulder towards his/her breast. CNA #3 said she separated them and told Nurse #2 about what happened. A written Statement, dated 10/15/18, and signed by Nurse #2, indicated there was no incident involving Resident #1 and Resident #2 reported to her on 10/13/18. Surveyor #1 interviewed Nurse #2 at 12:14 P.M. on 10/22/18. Nurse #2 said that when she worked on 10/13/18, no staff member informed her about any sexual allegations related to Resident #1 and Resident #2. Surveyor #2 interviewed the Nursing Supervisor at 12:11 P.M. on 10/25/18. The Nursing Supervisor said that when she supervised on 10/6/18 and 10/13/18, staff did not report any incidents to her that involved Resident #1, Resident #2, or Resident #3. Surveyor #1 interviewed the Administrator at 8:00 A.M. on 10/19/18. The Administrator said that she was not made aware of the allegations that involved Resident #1, Resident #2, and Resident #3, until 10/15/18. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that she was not notified until 10/15/18, when CNA #3 informed her about the alleged sexual abuse that involved Resident #1 and Resident #3 on 10/6/18 and the alleged sexual abuse that involved Resident #1 and Resident #2 on 10/13/18. The DON said that staff should have informed her and the Police at the time the incidents occurred. 3. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #4 was cognitively intact, and had verbal behaviors. The Activities Care Plan, dated 1/2/18, indicated an intervention was initiated on 4/17/18 to verbally redirect Resident #4 when socially or sexually inappropriate. The Care Plan, dated 1/31/18, indicated Resident #4 was known to be inappropriate with staff of the opposite gender, however the Care Plan did not indicate Resident #4 was known to be sexually inappropriate with other residents, or interventions in place to prevent sexual advances toward residents of the opposite gender. Review of Resident #4's medical record indicated: -On 2/27/18, a Nurse's Note indicated Non Sampled Resident #21 accused Resident #4 of requesting a sexual favor in exchange for candy. -On 3/17/18, a Nurse's Note indicated Resident #4 made sexually inappropriate comments to staff and residents of the opposite gender, and required frequent intervention to redirect behaviors. The identity of the other residents involved was unknown. -On 3/22/18, a Nurse's Note indicated Resident #4 called another resident a homo and then charged at other residents while yelling. The identity of the other residents involved was unknown. The Note indicated Resident #4 was transferred to the Hospital. -On 3/31/18, Resident #4 was verbally abusive and cursing at other residents in a very loud tone, and was unable to be redirected. -On 4/14/18, a complaint was received from another resident that Resident #4 had made sexually inappropriate remarks to a family member, and redirection for Resident #4 remained ineffective. There was no documentation to indicate that immediate interventions were initiated to protect other residents from sexual abuse in response to these incidents. The Nurse Progress Note, dated 4/10/18, indicated, at approximately 2:00 A.M., Resident #5 told Nurse #4 that on 4/9/18 Resident #4 had called him/her over, grabbed him/her, and began forcefully kissing him/her. The Note indicated Resident #5 said he/she was afraid of Resident #4, and the Resident #4 had hit him/her with a chair in the past. The Note indicated Resident #5 said he/she had reported the forceful kiss to a CNA who told Resident #5 to write a grievance about the event. The Note indicated Nurse #4 reported the allegation to the Unit Manager in the morning at the conclusion of her shift. The Facility's Internal Investigation, dated 4/25/18, indicated Resident #5 said he/she was afraid of Resident #4. The Investigation indicated Resident #4 and Resident #5 continued to socialize together after the incident. There was no documentation to indicate witness statements from staff or other residents was obtained, or that a plan was in place to ensure Resident #5's well being, increased supervision for either Resident #4 or Resident #5, or that the allegation was reported to law enforcement. Surveyor #2 interviewed Nurse #4 at 9:09 A.M. and at 11:05 A.M. on 10/25/18. Nurse #4 said Resident #5 told her at approximately 2:00 A.M. on 4/10/18 that on 4/9/18, while waiting for smoke break, Resident #4 had called him/her over, and when Resident #5 bent forward to hear what Resident #4 was going to say, Resident #4 grabbed Resident #5 and forcefully kissed him/her. Nurse #4 said she knew Resident #5, and had a good relationship with Resident #5. Nurse #4 said Resident #5 said he/she was embarrassed, emotionally hurt, and said he/she said felt staff were mocking him/her. Nurse #4 said Resident #5 said he/she had reported the incident to a CNA, but she did not know if that CNA had reported the incident to the Administrator or DON, and said she did not report the incident to the Unit Manager until the end of her shift, approximately five hours after Resident #4 reported the allegation of sexual abuse. Nurse #4 said Resident #5 was known to have boy/girlfriend relationships with residents of the opposite gender, and said she was not aware of the extent of the relationships or if Resident #5 was involved in kissing or otherwise sexual acts with other residents. Nurse #4 said she did not know if Resident #5 had a plan of care in place with interventions to protect him/her from unwanted sexual advances. Surveyor #2 interviewed the Director of Nurses (DON) at 10:07 A.M. and throughout the day on 10/19/18. The DON said Resident #4's plan of care should have been updated to include interventions to provide increased supervision, and Resident #5's plan of care should have been updated to provide emotional support and increased supervision. The DON said local Police were notified of the sexual assault by Resident #4 towards Resident #5 in (MONTH) (YEAR), six months after the allegation was made, while performing an audit after an investigation performed by Department of Public Health. 4. Resident #7 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Care Plan, dated 8/11/17, indicated Resident #7 was known to get into verbal and physical altercations with other residents. The Nurses Note, dated 2/10/18, indicated Resident #7 went into another Resident's room and punched him/her three times on the chest. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said there was no investigation started or completed regarding Resident #7's physical assault toward an unknown resident, including witness statements, who the unknown resident was, if he/she sustained any injuries, received follow up care, or if the physician or family was notified. There was no indication the allegation of physical abuse was reported to the Department of Public Health. 5. Resident #8 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/18, indicated Resident #8 was mildly cognitively impaired, did not ambulate, and required assist of two staff for transfers. Non Sampled Resident #13 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/8/18, indicated Non Sampled Resident #13 was cognitively intact. The handwritten Report, dated 10/19/18, indicated Resident #8 reported on 10/19/18 that he/she had been punched by a CNA, and that this happened all the time, and that a nurse would generally jump in to stop the abuse, however he/she did not know to report this because he/she did not know the rules. The Report indicated Non Sampled Resident #13 confirmed Resident #8's allegation. The Administrator gave the Surveyor the handwritten Report at approximately 2:00 P.M. on 10/19/18. The Administrator said the Facility would begin an investigation, and said the accused CNA had not been identified at that time. Review of Resident #8's Medical Record at 11:10 A.M. on 10/22/18 indicated the Facility had not documented that Resident #8 had alleged abuse, or any follow up care including a skin assessment, or emotional support related to the abuse. Surveyor #2 interviewed the DON at 3:02 P.M. on 10/22/18. The DON said that resident care after an abuse allegation would be to console the resident, perform a skin assessment to check for injuries, psychological assessment and care, and staff were to document observations, interventions, and assessments in the resident's electronic medical record. Surveyor #2 interviewed the Administrator at 4:38 P.M. on 10/22/18 (four days after the initial allegation of abuse). The Administrator said no further information including staff or resident statements had been gathered regarding Resident #8's allegation of physical abuse by staff. The Administrator said the accused CNA had not been identified, and said the Facility had not begun to investigate Resident #8's allegation of physical abuse by staff. 6. Resident #10 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #10 was cognitively impaired, required two staff assistance for transfers and bed mobility, and had impaired range of motion in both upper extremities. The Nurse Progress Note, dated 3/27/18, indicated Resident #10 was found with bright red hand prints on his/her chest and abdomen. The Note indicated the DON was notified. Review of Resident #10's medical record indicated there was no documentation of follow up care provided regarding the abuse allegation. Surveyor #2 interviewed the DON at 11:30 A.M. on 10/31/18. The DON said there was no investigation about the findings of hand prints on Resident #10, and no report was sent to the Department of Public Health.

Based on records reviewed and interviews for one of 12 sampled residents (Resident #9), the Facility failed to promptly notify Resident #9's Physician of a significant change in his/her status in a timely manner, when on 7/19/18, Resident #9 informed staff on the 3:00 P.M. to 11:00 P.M. shift, that he/she could not move and on 7/20/18 staff observed that Resident #9 was unable to move his/her left arm. Findings Include: The Facility Policy titled Condition: Significant Change, dated 4/2015, indicated that professional staff will communicate with the Physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which was essential to quality care management. An Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #9's medical [DIAGNOSES REDACTED]. A Physician's Note, dated 6/18/18, indicated that Resident #9 had the ability to move all extremities. A Nurse Progress Note, labeled as a late entry for 7/19/18, (and dated 7/25/18, five days after Resident #9 was transferred to the Hospital), indicated that at approximately 7:30 P.M. on 7/19/18, Nurse #3 was informed by a Certified Nurse Aide that Resident #9 could not move. The Late Entry Progress note indicated that Resident #9's speech was garbled which was his/her baseline, Nurse #3 took Resident #9's blood pressure and heart rate, and asked Resident #3 to move his/her arms and legs, which he/she was able to do. This was not consistent with the Nurse Progress Note dated as written on 7/20/18. The Late Entry Progress Note indicated that Nurse #3 rechecked Resident #9 at 9:30 P.M., Resident #9 was sleeping comfortably, and the information was passed to the on-coming 11:00 P.M. -7:00 A.M. nurse. A Nurse Progress Note, dated 7/20/18, indicated that Resident #9 stated that he/she was unable to feel his/her left arm and he/she was unable to squeeze the Nurse's hand, Resident #9 was unable to lift or move his/her left arm. The Progress Note indicated that Resident #9's blood pressure was 180/109 (hypertensive), his/her heart rate was elevated, and Resident #9 was transferred to the hospital. A Nurse Progress Note, dated 7/20/18, indicated that an ambulance arrived at the Facility sometime after 10:00 A.M. The Progress Note indicated that Resident #9 had been unable to move his/her arms and the, 7/19/18, 11:00 P.M.-7:00 A.M. shift had reported that Resident #9 had been awake all night. A Nurse Progress Note, dated 7/31/18, (eleven days after Resident #9 was transferred to the Hospital), indicated that at 7:30 A.M. on 7/20/18, CNA #1 questioned Nurse #4 about what happened to Resident #9's left arm. The Progress Note indicated that when Nurse #4 went to assess Resident #9 she observed that Resident #9's left arm was flaccid and that Resident #9 told Nurse #4 that he/she had told the Nurse about it the previous day. The Progress Note indicated that she informed another staff member to follow up after she clocked out of the Facility at approximately 7:50 A.M. on 7/20/18. Surveyor #1 interviewed Nurse #3 at 1:05 P.M. on 10/24/18. Nurse #3 said that when she worked on the 3:00 P.M.-11:00 P.M. shift on 7/19/18, she was told by a CNA that Resident #9 could not move and insisted that something was wrong with Resident #9. Nurse #3 said when she went into Resident #9's room, he/she was able to take his/her scheduled medications which indicated to her that Resident #9 could move his/her arms and did no further assessment of his/her ability to move his/her arms. Nurse #3 said that Resident #9 told her that he/she was unable to move his/her arms. Nurse #3 said that although she went back into the room later in the shift to check on Resident #9, she did not perform a neurological assessment. Nurse #3 said that she had no reason to call Resident #9's Physician. Nurse #3 said that [MEDICAL CONDITION] (also known as a TIA, blood flow to part of the brain stops for a short period of time and is a warning sign that stroke (condition that occurs when blood flow to the brain is cut off) may happen in the future) could include symptoms such as weakness, decreased speech, and inability to follow instructions and that the symptoms could pass with no real deficits, but Resident #9 showed no signs other than what the CNA reported to her, or words to that affect. Surveyor #1 interviewed Nurse #4 at 2:07 P.M. on 10/24/18. Nurse #4 said that at between 7:30 and 7:45 A.M. on 7/20/18, CNA #1 informed her that Resident #9's arm was limp. Nurse #4 said she went to check on Resident #9 and observed that he/she was not able to move his/her arm and fingers without moving them with the other hand. Nurse #4 said that Resident #9 told her that he/she had reported his symptoms to staff the previous day. Nurse #4 said she thought Resident #9 may have had a stroke but did not feel that it was an emergency because Resident #9 was not in pain, did not have any mental status change, and he/she had no blurred vision. Nurse #4 said that if Resident #9 had a stroke (condition that occurs when blood flow to the brain is cut off) it would be an emergent situation because there was a time frame of 20 minutes required for which the first signs of and symptoms require medical attention. Nurse #4 said if Resident #9 had reported his/her symptoms on the previous day, his/her 20 minutes was up 24 hours ago. Nurse #4 said that she did not call Resident #9's Physician because she had her bags packed to go home, nobody from management was on the unit and said that she informed other staff members to follow up on it. Surveyor #1 interviewed the Director of Nursing (DON) at 2:15 P.M. on 10/22/18. The DON said that any changes in mobility or with flaccidness, Nurse's should have completed a head to toe assessment and called Resident #9's Physician to notify him of their assessment findings. A Hospital Emergency Department (ED) Medical Records Report, dated 7/20/18, indicated Resident #9 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].

Based on interviews and observation 1.) the The Facility was found to be negligent in the matter of quality of life of residents and failed to utilize it's resources to maintain the water temperatures in the facility so that the resident's could bathe in comfortable temperatures on 2 of 2 resident care floors. The Nursing Home Maintenance Staff identified the problem and the Administrator/Management Company did not remedy the hot water failure, resulting in diminished quality of life for residents for a duration of at least 21 days; and 2). Based on direct observations by the Surveyor, review of the medical record, review of the Facility investigation and interviews, the Facility failed to Prevent 1 Resident (#45) from being verbally and physically abused by a hospice certified nurse aide (CNA) #7. Findings include: 1. In an interview on 1/30/18 at 8:34 A.M., the Facility Administrator informed the Surveyor that they have been having water temperature issues with the water tank and temperatures being low. The water tank that affects the resident's area bathrooms and showers. On 1/30/18 at 9:00 A.M. the Ombudsman came to the facility. He said that he had bumped in to residents who complained that they haven't had hot water for showers in a few weeks. On 1/30/18 at 9:30 A.M., a resident, who is cognitively intact, told this surveyor that the facility hasn't had hot bathing water for them in a few weeks. On 1/30/18 at 3:00 P.M., the Resident Group Meeting took place with the Ombudsman and Federal Surveyor oversite. At this time the residents in attendance said that they had cold water in the showers/bathing areas on both units. They were unable to specify an exact amount of time but did say for a couple of weeks. In an interview with the Physical Plant Manager at the facility on 1/30/18 at 1:00 P.M., he said that he has had problems with the water tank that provides hot water to resident's units for a few weeks. He said that he reached out to the Corporate Resource Manager for help. He was able to produce emails that the Corporate Resource Manager and the Facility Administrator became aware of water temperature issues beginning on 12/20/17. He then said they had consults from different plumbers to get an idea of the root cause of the problem. He was able to produce a quote from a plumbing company on 1/19/18 with a possible solution to the problem. He was unsure of the status of the quote as Corporate had not approved the work yet. During this conversation, the Adminstrator entered the Physical Plant Manager's office and said that he is aware of the water temperature issue but his hands are tied because he doesn't make the final decision and allocate resources in his position. In a telephone interview with the Corporate Resource Manager on 1/3/18 at 1:30 P.M., he said that he wasn't aware when he learned of the water issues. He further said that he knew there was an issue with hot water, but not cold water. On 1/31/18 at 7:00 A.M., the Administrator said that they were able to internally fix the water temperatures at 10:45 P.M. on 1/30/18. On 1/31/18 at 8:30 A.M. 2 Residents one who is cognitively intact and one resident, who staff have determined to have modified independence in new situations, said that the water temperature is so too cold to bathe in. As of 1/31/18 at 3:34 P.M. the water tanks were still not functioning properly and the resident care area water temperatures remained too low for personal care. A physical plant employee and a surveyor obtained temperatures of the water in the 6 shower rooms that are designated for resident use. First floor temperatures in Resident bathing areas were as follows: -Shower room by room [ROOM NUMBER] was 72.5 degrees -Shower room by room [ROOM NUMBER] was 80.4 degrees -Shower room by room [ROOM NUMBER] was 88 degrees Second floor temperatures in Resident bathing areas were as follows: -Shower room by room [ROOM NUMBER] was 65 degrees -Shower room by room [ROOM NUMBER] was 73 degress -Shower room by room [ROOM NUMBER] was 94 degrees On 1/31/18 a timeline was created by the Facility Administrator as to the length of time the Facility and Corporate office was aware of the water not reaching comfortable temperatures for resident use. This timeline started on 12/20/17 and ended on 1/31/18. This left the resident's with inconsistent and uncomfortable temperatures of water for bathing/handwashing for 21 days. On 2/2/17 2 Residents, both being cognitively intact, told the Surveyor that they were so happy to finally have hot water for showers. 2. On 1/30/18 at 11:45 A.M. the Surveyor heard Resident #45 calling out Help me! Help me! Help me! You're hurting me! several times. When the Surveyor did not observe any staff persons entering the room to assist the Resident, the Surveyor entered the room and observed Hospice Certified Nurse Aide #7 aggressively trying to open the Resident's contracted fingers and hand to wash it. The Resident was pushing his/her hands up against CNA #7's hands in what appeared to be him/her trying to get her to stop. The Resident kept yelling, You're hurting me! The Surveyor heard Hospice CNA #7 say to the Resident - if you don't let me wash your hands, you won't have dinner today. The Surveyor immediately asked CNA #7 to leave the room with the Surveyor. The Surveyor reported the incident to the Director of Nursing (DON). The Surveyor witnessed CNA #7 speak with other CNA's about the incident in the hallway. The Surveyor asked CNA #7 to leave the hallway and stop speaking about the incident where others could hear. The DON initiated the Facility's abuse investigation and removed CNA #7 from the building. Review of the Facility's Abuse Prohibition Policy dated 12/2016 indicated that the residents had the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation. The section titled: Definitions- Abuse/Potential Abuse: indicated that abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary; to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as defined in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to humiliation, harassment and threats of punishment or deprivation. The identification of any incident of abuse or neglect must be reported and an internal investigation completed. Immediate actions require that the resident is removed from the alleged abuser and a physical assessment completed. The resident will also receive any necessary interventions to insure the resident's safety and well being and emotional support and reassurance will be provided to the resident. Review of the Resident #45's medical record indicated the Resident was admitted in 8/2017 with [DIAGNOSES REDACTED]. Hospice services were initiated on 1/26/18. The Resident was totally dependent on staff for activities of daily living. The Director of Rehabilitation (an Occupational Therapist) was interviewed on 02/05/18 at 3:14 P.M. and he said that the Resident has very poor vision and is very hard of hearing. The Director of Rehabilitation said that he has worked with the Resident in the past and has had success in working with him/her if he approached in a slow and relaxed manner. The Director of Rehabilitation said the Resident needed much encouragement to complete rehabilitative exercises. The Director of Rehabilitation said that he was not aware if there were instructions on the correct method to wash the Resident's contracted hand. Review of the Resident's care plan did not indicate that the Resident will become calmer and may allow more personal care if approached in a calm, slow manner. During interviews with the Certified Nurses Aides (CNA) #1, #2, #3 and #4 on 1/31/18 at 11:00 A.M., they admitted that they have not been in-serviced on the correct method of cleaning the resident's contracted hand. They said they only washed the Resident's hand from the outside and tried not to separate the contracted fingers. Review of the Resident's care plan also indicated there was no information on washing the Resident's contracted hand. The Rehabilitation Director, at the conclusion of the interview with the Surveyor, said he will be in-servicing the staff and the hospice staff on the care of washing the resident's hands. The facility will create a care plan regarding washing of his hands. Review of the Facility's Internal Investigation dated 2/5/18 indicated that the Hospice Service concluded that CNA #7 was found to have a viable offense of abuse toward Resident #45 and she was terminated. Staff at the Facility were educated on Verbal and Mental Abuse - Will not be tolerated under any circumstance on 1/31/18 and 2/1/18.

Based on records reviewed and interviews, the Facility failed to ensure that the Medical Director was responsible for the implementation of resident care policies and procedures, and the coordination of care for residents with substance use disorders at the Facility. The Facility failed to ensure that the Medical Director was consulted to assist in the development of admission and discharge policies; assessments; and, supervision required for residents with substance abuse/use or addiction, prior to the admission of residents, with this known need, to the Facility. The Facility also failed to ensure the Medical Director's oversight of clinician services as they pertained to residents with substance abuse/use or addiction. Findings include: Records reviewed indicated that the Medical Director was the primary care physician at the Facility, for Resident #4, who was being treated for [REDACTED]. Surveyor #1 and Surveyor #4 interviewed the Medical Director at 12:45 P.M. and 2:54 P.M. on 04/28/17. The Medical Director said he was aware the Facility had a large population of residents with [DIAGNOSES REDACTED]. The Medical Director said he had not been consulted by the Facility on the care and treatment of [REDACTED]. The Medical Director said he was not aware if the Facility had a clinician who specialized in the treatment of [REDACTED]. The Medical Director said he attended quarterly quality assurance meetings at the Facility and did not remember discussing topics related to alcohol and substance use related issues. The Medical Director said that the Facility mainly admitted residents with histories of substance use disorders for their underlying medical issues and not to address the substance use disorder. Surveyor #1 and Surveyor #4 interviewed the Nurse Practitioner (NP) at 1:46 P.M. on 04/28/17. The NP said she only treated the medical or clinical needs of residents with substance use disorders, not their substance use disorder or addiction needs. The Medical Director said he had never had a discussion with the Facility about residents who attended a local [MEDICATION NAME] treatment center for the treatment of [REDACTED]. Surveyor #1 and Surveyor #4 interviewed the Director of Nursing (DON) at 9:13 A.M. on 05/01/17. The DON said the Medical Director was not involved in the development, revisions or implementation of the Facility's policy and procedures pertaining to the care and treatment of [REDACTED].

Based on records reviewed and interviews, the Facility failed to ensure all staff were provided with the necessary competencies and training to care for and promote the safety and well-being of residents with substance use disorders prior to admitting residents with this known ailment. The Facility provided information to Surveyors, on 4/5/2017, regarding residents residing at the Facility with [DIAGNOSES REDACTED]. - Between 03/29/17 and 04/25/17, there were 3 documented overdoses at the Facility (Resident #5, Resident #11 and Resident #13), and 4 documented incidents of residents impaired by alcohol (NS E and NS G). Findings include: Unit Manager #1 provided Surveyor #1 with a list, on 4/5/2017, of Facility residents who had known [DIAGNOSES REDACTED]. Surveyor #1 interviewed The Staff Development Coordinator and Unit Manager #1 at 4:10 P.M. on 04/05/17, Nurse #3 at 8:26 A.M. on 04/06/17, Nurse #1 at 11:55 A.M. on 04/06/17, Nurse #4 at 12:55 P.M. on 04/06/17, Certified Nurse Aide (CNA) #6 at 1:12 P.M. on 04/06/17, Nurse #5 at 1:33 P.M. on 04/06/17 and CNA #8 at 4:18 P.M. on 04/06/17. The Staff Development Coordinator, Unit Manager #1, Nurse #1, Nurse #3, Nurse #4, Nurse #5, CNA #6 and CNA #8 said the Facility had not provided staff with education regarding substance use disorders. Nurse #1, Nurse #3 and Nurse #4 said they did not feel comfortable caring for residents with [DIAGNOSES REDACTED]. The Staff Development Coordinator and Unit Manager #1 said, on 4/5/2017, the Facility had no formal education for staff regarding the use of [MEDICATION NAME] (medication used to treat a narcotic overdose in an emergency situation) and said the education was provided informally, or words to that effect. The Staff Development Coordinator and Unit Manager #1 said, on 4/5/2017, the Facility had not provided and therefore did not have any documentation of competencies or trainings regarding the care and treatment of [REDACTED]. Nurse #1 said she had not received education from the Facility on the administration and use of [MEDICATION NAME]. Nurse #3 said she had not received any education from the Facility on the administration and use of [MEDICATION NAME], and she had taken it upon herself, or words to that effect, to read about [MEDICATION NAME] administration. Nurse #5 said security and staff education were needed at the Facility to keep everyone safe and to provide the care the residents needed. On 04/27/17, the DON provided Surveyor #4 with a list of residents with substance use disorders. The list indicated that 45 of 116 residents, 38 on Unit #1 and 7 on Unit #2 (approximately 39% of the Facility's resident population), had a known substance use disorder. The DON said there had been an influx of residents with substance use disorders into the Facility since the beginning of 2017. Surveyor #4 interviewed Nurse #11 at 7:47 A.M. on 04/27/17. Nurse #11 said she thought she had received training on substance use disorders and related topics late last year (2016), but could not recall exactly. Surveyor #4 interviewed Nurse #12 at 8:09 A.M. on 04/27/17. Nurse #12 said she received training on the administration of [MEDICATION NAME] and addiction approximately 2 to 3 weeks prior to the date of interview. Surveyor #4 interviewed the Director of Social Services at 12:58 P.M. on 04/27/17. The Director of Social Services said the Facility had inadequate resources, and the staff lacked the necessary training, to properly care for residents with substance use disorders. Surveyor #4 interviewed CNA #10 at 4:01 P.M. on 04/27/17. CNA #10 said she heard there was an in-service at the Facility about addiction and how the brain worked, but did not attend as she was not scheduled to work that day. CNA #10 said she had not received training from the Facility related to substance use disorders and related topics, and was not aware of any future scheduled training. Surveyor #4 interviewed the Human Resources (HR) manager at 11:08 A.M. on 05/01/17. The HR manager said she felt that the Facility was admitting residents, such as those with substance use issues, without some of the staff being adequately trained on how to meet those residents' needs. The HR manager said some staff felt uncomfortable caring for residents with substance use issues because they did not have adequate training. Surveyor #1 and Surveyor #4 interviewed the Administrator at multiple times throughout the dates of survey. The Administrator said the Facility was in the process of conducting training on substance use disorder and related topics. The Administrator said it was difficult to educate staff on the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts because there were less staff on duty, and so it was difficult to remove them from resident care duties for education purposes. The Administrator said that the Licensed Drug Abuse Counselor (LDAC) used by the Facility for purposes including training, had been at the Facility on the evening of 04/24/17 to conduct in-services. On 04/27/17 at 11:46 A.M., Surveyor #4 requested all in-service materials, including attendance records, for any trainings conducted on substance use disorders and related topics for the previous year. Surveyor #4 was provided with the following in-service attendance sheets: - Emergency [MEDICATION NAME] Policy & Procedure, dated 03/03/16, attended by 12 of 37 licensed nurses listed on the attendance sheet. This was not consistent with the information provided to Surveyor #1 on 4/5/2017 which indicated the Facility had not conducted any competencies or trainings regarding the use of [MEDICATION NAME] and therefore could not provide Surveyor #1, on 4/5/2017, with any documentation of [MEDICATION NAME] training. -Code White: Policy & Procedure For Suspected Opioid Overdose & Clinical Competency, dated 05/25/16. This was not consistent with the information provided to Surveyor #1 on 4/5/2017 which indicated the Facility had not conducted any competencies or trainings regarding the substance use disorders and therefore could not provide Surveyor #1, on 4/5/2017, with any documentation of [MEDICATION NAME] training. - Proper Administration of [MEDICATION NAME], dated 04/06/17 through 04/20/17 and attended by 24 licensed nurses; - Substance Abuse Training, dated 04/10/17 and attended by 65 licensed and unlicensed staff which included unlicensed nursing staff from: social services, dietary, maintenance, rehabilitation, housekeeping, laundry, activities, reception and admissions. A Nursing Staff Contact List indicated the Facility had 66 nursing staff members (licensed and unlicensed) in addition to agency (temporary) nursing staff working at the Facility. - There were no educational materials provided for any in-service education conducted after 04/10/17 pertaining to competencies or trainings regarding substance use disorders.

Based on records reviewed and interviews, for 4 of 17 sampled residents (Resident #5, Resident #8, Resident #11 and Resident #13) and 3 of 9 non-sampled residents (NS E, NS G and NS I), the facility failed to provide the necessary supervision and interventions to prevent and treat substance abuse, or an elopement from the Facility. - On 12/24/16, NS I was transferred to the hospital for evaluation after consuming alcohol and exhibiting an altered mental status, aggressive behavior, and suicidal thoughts. - On 3/18/17, Resident #8, who was cognitively impaired, required continual supervision with walking, and had a history wandering, was observed alone outside by another resident. Staff located Resident #8 walking beyond the Facility, down the sidewalk of a busy main road with heavy traffic volume. - On 3/29/17, nursing staff assessed Resident #5 as having altered mental status, low blood pressure and inability to stand. Nursing documentation indicated Narcan was not available to administer to Resident #5 and he/she was sent to the hospital emergency room , where Resident #5 was administered Narcan for an opioid (narcotic) overdose. - On 03/29/17 and 04/01/17, NS G admitted to consuming alcohol at the Facility. - On 04/06/17, nursing staff administered Resident #13 Narcan and transferred him/her to the hospital, where he/she was treated for [REDACTED]. - On 03/30/17, 04/22/17 and 04/24/17, NS E admitted to consuming alcohol at the Facility. - On 04/25/17, Resident #11 admitted to self-injecting heroin and was transferred to the hospital, where he/she was administered Narcan for an overdose. Findings include: Surveyor #1 interviewed the Licensed Drug Abuse Counselor (LDAC) at 12:23 P.M. on 04/10/17. The LDAC said she had heard that there was a concern of residents bringing drugs into the Facility. The LDAC said she would never recommend that residents with substance use disorder leave the Facility unaccompanied. Surveyor #4 interviewed Nurse #11 at 7:47 A.M. on 04/27/17. Nurse #11 said she had heard residents talk about having access to drugs at the Facility, but could not recall who the residents were. Nurse #11 said that when Resident #11 was being sent to Hospital #1 on 04/25/17 after he/she reported self-injecting heroin, he/she asked why he/she was being sent out to the hospital when other residents were doing the same thing. Surveyor #4 interviewed Nurse #13 at 12:19 P.M. on 05/03/17. Nurse #13 said she had heard reports of residents sharing medications, and so it was difficult to identify the residents actively using substances in the Facility. Nurse #13 said that if the residents were sharing medications, toxicology reports would not necessarily be helpful as the shared medication(s) could be of the same medication type and so the resident's toxicology report would show as positive anyway. Nurse #13 said she had notified administration every time she had seen, heard, or received a report of residents allegedly using substances at the Facility. Surveyor #4 interviewed the Maintenance Director at multiple times throughout the dates of survey. The Maintenance Director said he had found a bottle of rum hidden outside in the housing where the Facility's generator was kept. Surveyor #4 interviewed CNA #10 at 4:01 P.M. on 04/27/17. CNA #10 said she understood that residents with substance use disorders had rights, but that the rights of those residents were jeopardizing the safety of themselves and other residents. Surveyor #1 and Surveyor #4 interviewd Unit Manager #1 at multiple times throughout the dates of survey. Unit Manager #1 said she had received reports from residents in the Facility that there were residents exchanging medications, but that because the reporting residents declined to provide names, the reports were difficult to substantiate. Unit Manager #1 said staff had a general concern about residents sharing or trading medications. Unit Manager #1 said that the current in-services on substance use disorders and related topics was not adequate, that staff did not know what to do or how to report if they saw concerning behavior, such as impaired residents. Surveyor #1 and Surveyor #4 interviewd the Administrator and Director of Nurses (DON) at multiple times throughout the dates of survey. The Administrator and DON said they were unaware of staff reports of finding liquor bottles on Facility property, including in resident rooms and in common areas. The Administrator and DON said that the Facility had no written process for what staff was to do if they observed a resident who was impaired. The Administrator and DON then said that the Facility did have a written process, and nurses were educated on the process in March 2017. Surveyor #1 and Surveyor #4 requested copies of the written process and education, which as of 05/10/17, had not been received. 1. Resident #5 was admitted to the Facility in November 2016 with [DIAGNOSES REDACTED]. The Substance Abuse Care Plan, dated 11/12/16, indicated that Resident #5 had a history of [REDACTED]. The Care Plan indicated that Resident #5 had the potential for complications such as recurrence of substance use and goals included that Resident #5 would have no alcohol or drugs hidden in his/her room or brought to him/her by visitors/others. The Care Plan did not include interventions in regards to how staff were to determine whether Resident #5 had alcohol or drugs hidden in his/her room or in his/her possession, or how staff were to prevent visitors/others from making drugs or alcohol accessible to, or bringing Resident #5 drugs or alcohol. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and dressing. The physician's orders [REDACTED]. The Situation, Background, Assessment, Recommendation (SBAR) Form, dated 03/29/17 at 4:27 A.M. indicated Resident #5 was being sent to the hospital for lethargy, change in mental status, weakness, low blood pressure and decreased oxygen saturation (measure of oxygen in the blood). The SBAR Form indicated Nurse #3 documented she was unable to administer Narcan (medication used to treat narcotic drug overdose) to Resident #5 because it was not available. The Hospital Emergency Department Report, dated 03/27/17, indicated Resident #5 was diagnosed with [REDACTED]. The Nursing Note, dated 03/29/17 at 10:30 A.M., indicated Resident #5 returned from the hospital after an opiate overdose. Unit Manager #1 provided Surveyor #1, in the late afternoon on 04/05/17, with a list of Facility residents who had known histories of substance use disorders. The list indicated 35 of 54 residents on Unit 1's Midnight Census Report, dated 04/04/17, had substance use disorders. Surveyor #1 interviewed Nurse #3 at 8:26 A.M. on 04/06/17. Nurse #3 said Resident #5 had a fall on 03/29/17, so she assessed Resident #5 and observed that he/she was out of it, or words to that effect, and Resident #5's eyes appeared pinpoint. Nurse #3 said she was going to administer Narcan to Resident #5, but there was no Narcan available. Nurse #3 said she called for emergency medical transportation, and the emergency medical technicians (EMTs) administered Narcan to Resident #5 and transported him/her to the hospital emergency department. Nurse #3 said the Facility had a high population of residents with known histories of substance use disorders, especially on her nursing unit. Nurse #3 said she had not been provided with any education or training from the facility about caring for residents with substance use disorders. Nurse #3 said the nursing unit had been stocked with Narcan, so she did not know why there was no Narcan available at the time she needed it for Resident #5. Surveyor #1 interviewed Nurse #4 at 12:55 P.M. on 04/06/17. Nurse #4 said she worked on the morning of 03/30/17, and was informed by Nurse #3 during morning report of Resident #5's incident of a narcotic overdose. Nurse #4 said Nurse #3 informed her that there was no Narcan available on the nursing unit. Nurse #4 said she and Nurse #3 then went to look for Narcan, but could not find any Narcan on the nursing unit. Nurse #4 said the Facility had a high population of residents with known histories of substance use disorders, and the Facility had not provided any education or training about caring for residents with substance use disorders. Surveyor #1 interviewed the Staff Development Coordinator and Unit Manager #1 at 4:10 P.M. on 04/05/17, Nurse #1 at 11:55 A.M. on 04/06/17, CNA #6 at 1:12 P.M. on 04/06/17, Nurse #5 at 1:33 P.M. on 04/06/17, CNA #8 at 4:18 P.M. on 04/06/17. The Staff Development Coordinator, Unit Manager #1, Nurse #1, Nurse #5, CNA #6 and CNA #8 said the Facility had not provided staff with education regarding substance use disorders. Surveyor #1 interviewed the Assistant Director of Nursing (ADON) at 2:17 P.M. on 04/06/17. The ADON said she was not aware of Resident #5's overdose incident. There was no documentation at the time of survey that on 03/29/17, there was Narcan available in the Facility to treat Resident #5 in the event of his/her narcotic overdose. 2. The Facility's Elopement Policy, dated 04/2015, indicated that a Care Plan would be developed and implemented for any resident at risk for elopement. The Neuropsychological Evaluation, dated 06/03/14, indicated Resident #8 had impaired memory, limited insight, poor judgement, and his/her ability to reason was severely impaired. The Behavior Care Plan, initiated on 11/08/16, indicated Resident #8 had a history of [REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #8 had moderate cognitive impairment and required supervision with ambulation. The Elopement Risk Screen, completed on 01/30/17, did not indicate that Resident #8 lacked the cognitive ability to make relevant decisions, and did not indicate that Resident #8 paced or wandered aimlessly. The form indicated that Resident #8 did lose track of his/her room. The form indicated that if any questions were answered Yes, the Resident was at risk for elopement and individualized plan of care was to be developed. The Quarterly/Annual Social Service Assessment, dated 02/07/17, indicated Resident #8 had impaired judgement, was restless, and wandered. The Interdisciplinary Team Meeting Sheet, dated 02/07/17 and signed by the Interdisciplinary Team, indicated Resident #8 was not at Risk for elopement. Surveyor #2 interviewed the ADON at 1:43 P.M. on 4/10/17. The ADON said Resident #8 was confused and wandered while on the unit. The ADON said Resident #8 was at risk for elopement, and an elopement care plan should have been completed. The ADON said an elopement care plan was not developed when the elopement assessment screen was completed. The ADON later presented Surveyor #2 with an elopement care plan, initiated and dated 04/10/17, which was one of the dates of survey, that indicated Resident #8 was an elopement risk. Surveyor #2 interviewed the Maintenance Assistant at 2:20 P.M. on 04/10/17. The Maintenance Assistant said that on 03/18/17 sometime before lunch, he was told by other residents that Resident #8 was outside. The Maintenance Assistant said he went to look for Resident #8 and found him/her past the Facility, walking down the sidewalk that runs along Route 125, a main road along the side of the Facility. The Maintenance Assistant said he was unsure how Resident #8 exited the Facility. The Maintenance Assistant said Main Street was busy with traffic at the time. The Maintenance Assistant said Resident #8 appeared confused, and so he assisted him/her back into the Facility and notified nursing Staff. 3. Resident #11 was admitted to the Facility in April 2017 with [DIAGNOSES REDACTED]. The Nurse's Note, dated 04/05/17, indicated that a staff member found a bag full of prescription medication bottles in Resident #11's belongings. Surveyor #4 interviewed Unit Manager #1 at multiple times throughout the dates of survey. Unit Manager #1 said the prescription medications included medications consistent with Resident #11's home medications prior to admission to the Facility, but also included methadone (a medication used for the treatment of [REDACTED].#11 told her he/she had been on prior to admission. The Nurse's Note, dated 04/25/17, indicated that Resident #11 was found unresponsive in his/her wheelchair in his/her room. The note indicated that staff was able to arouse Resident #11 with painful stimuli, and Resident #11 reported injecting heroin. Surveyor #4 interviewed Nurse #1 at 8:22 A.M. on 04/27/17. Nurse #1 said that on 04/25/17, staff called her to report that Resident #11 was unresponsive. Nurse #1 said Resident #11 was responsive when she arrived at his/her room, so she asked him/her what he/she had taken. Nurse #1 said Resident #11 told her he/she took heroin that a visitor had brought to him/her. Nurse #1 said she conducted a room search after obtaining Resident #11's permission and a physician order. Nurse #1 said she located and confiscated items including: syringes, a spoon with residue on it, a lighter, and prescription bottles with unknown contents. Surveyor #4 and the DON reviewed the confiscated items at 9:10 A.M. on 04/27/17. The DON said that as of that date, she had not had the pills found in Resident #11's possession identified by the Facility's pharmacy. The reviewed items included: - a transparent tan colored bottle with an undated, worn prescription label from a chain pharmacy with Resident #11's name on it, for methadone 10 milligram (mg) tablets. The bottle contained: one dark pink, round pill with ABG imprinted on one side, and 30 imprinted on the other side, identified by Surveyor #4 via the internet as a 10 mg tablet of morphine; 7 white, round pills with 54 142 imprinted on one side, and scored (a line used to make dividing the pill easier) on the other side, identified by Surveyor #4 via the internet as 10 mg tablets of methadone. - a clear prescription bottle with a peeling, but legible label from a second pharmacy, with Resident #11's name on it, for 10 mg tablets of cetirizine (an allergy medication). The bottle contained: 30 white, oval tablets with 4H2 imprinted on one side, identified by Surveyor #4 via the internet as 10 mg tablets of cetirizine; and, 2 white, rectangular pills with 10 imprinted on one side, unable to be identified by Surveyor #4. Surveyor #4 interviewed Resident #11 at multiple times throughout the dates of survey. Resident #11 said he/she would not confirm or deny self-injecting a substance, or what that substance was. Resident #11 then said the substance and syringes were brought to him/her at the Facility, and he/she was not sure what he/she had self-injected. Resident #11 said the medications in the prescription bottles were one morphine pill, methadone tablets, and valium (a benzodiazepine medication used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms). Surveyor #4 interviewed the Director of Social Services at 12:58 P.M. on 04/27/17. The Director of Social Services said she spoke with Resident #11 after his/her overdose. The Director of Social Services said Resident #11 told her he/she self-injected heroin, which he/she bought from a friend. The Director of Social Services said Resident #11 told her that he/she purchased the syringes from the pharmacy down the street from the Facility. The DON said the receptionist was responsible to ensure that all visitors signed in and out of the Facility. The DON said that on 04/25/17, Resident #11 had 2 visitors, but neither signed in or out because the receptionist was not at the front desk. The DON said the Facility had a security guard from approximately 8:00 P.M. to 8:00 A.M., and the receptionist was supposed to be in at 8:00 A.M. so that there was always someone at the front desk. The DON said the receptionist was responsible to ensure that all visitors signed in and out of the Facility. Surveyor #4 interviewed the Human Resources (HR) manager at 11:08 A.M. on 05/01/17. The HR manager said a staff member or security guard was always supposed to be at the reception desk, especially if there were residents in the lobby. At multiple times throughout the dates of survey, Surveyor #1 and Surveyor #4 observed the reception desk without a staff member or security guard present, for upwards of 36 minutes at a time, with residents observed in the lobby area with and without visitors. Hospital #1's Emergency Department documentation, dated 04/25/17, indicated that Resident #11 was treated for [REDACTED]. The laboratory results indicated Resident #11's toxicology report was positive for the presence of methadone and Fentanyl (an opioid pain medication). Resident #11's Physician Orders, dated for 04/01/17 through 04/30/17, indicated that he/she had an order in place to be administered methadone, but did not have an order to be administered Fentanyl. 4. Resident #13 was admitted to the Facility in February 2016 with [DIAGNOSES REDACTED]. The Nurse's note dated 04/06/17 at 5:30 P.M., indicated that staff was called to Resident #13's room. The note indicated that Resident #13 appeared to be impaired, and was hard to arouse, diaphoretic (sweating), with shallow breathing, and cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The note indicated that Narcan was administered and 911 was called. Written statements, dated 04/06/17, indicated that Resident #13 was administered Narcan due to symptoms of a possible substance overdose including increased lethargy (sleepiness or unresponsiveness), decreased respirations and a low blood pressure. The statements indicated that Resident #13 responded to the Narcan, and was transported to the hospital. Hospital #1's Emergency Department documentation, dated 04/06/17, indicated that Resident #13 was treated for [REDACTED].#13's toxicology report was positive for the presence of methadone. Unit Manager #1 said Resident #13 said his/her overdose was related to an increase in his/her methadone dosing from the methadone clinic. Unit Manager #1 said the Facility had no way to confirm that information from the methadone clinic, despite multiple telephone calls to the clinic. 5. NS E was admitted to the Facility in August 2016 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Nurse's Note, dated 03/30/17, indicated that the nurse was notified that NS E smelled of alcohol. The note indicated that a room search was conducted with NS E's consent, and one empty and one full vodka bottles were found in his/her nightstand. There was no documentation at the time of survey that the physician was notified of the results of the search of NS E's room. The physician's orders [REDACTED]. The Nurse's Note, dated 04/22/17, indicated that NS E appeared impaired and was questioned about drinking alcohol because of the heavy stench of alcohol in the room. The note indicated that NS E admitted to drinking alcohol, and a physician's orders [REDACTED]. The note indicated that the DON was aware. There was no documentation at the time of survey to indicate the incident that necessitated the physician's orders [REDACTED]. Nurse #13 said that on 04/22/17, she observed NS E to be inebriated. Nurse #13 said she found empty liquor bottles in NS E's room, and NS E told her that he/she was drunk. Nurse NS E said she also found multiple nip bottles (small bottles containing approximately 1.7 ounces of liquor), which NS E said he had consumed that day. Nurse #13 said she discussed addiction services with NS E, who refused services and told her that he/she was going to continue drinking alcohol. Nurse #13 said she notified administration, the Administrator and/or DON, of the events, and provided them with the empty liquor bottles. Nurse #13 said she spoke with the DON about NS E being intoxicated in the Facility, as she wanted guidance on how to address NS E's substance use. The DON denied being aware of NS E's inebriation in the Facility on 04/22/17. The Nurse's Note, dated 04/23/17, indicated that NS E returned from the hospital, and his/her alcohol level was 206 (equivalent to 0.206; the legal limit in Massachusetts is 0.08) The Telephone Order, dated 04/24/17, indicated to send NS E to the emergency room for medical clearance, and a toxicology screen and evaluation because NS E had been consuming alcohol. The Administrator said that as long as the resident was of legal age, they had the right to consume alcohol and staff could not prevent them from doing so. 6. NS G was admitted to the Facility in January 2017 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Nurse's Note, dated 03/29/17, indicated that NS G received intravenous (IV) hydration because of nausea and vomiting. The Nurse Practitioner's (NP) Note, dated 03/29/17, indicated that NS G admitted to buying alcohol and consuming it the day before (03/28/17). The note indicated that NS G reported the vomiting began after he/she consumed the alcohol, so the NP ordered IV hydration. The note indicated that the NP explained to NS G that his/her problems were most likely related to his/her recent drinking, and that the NP was able to smell alcohol on NS G's breath during her visit with him/her on 03/29/17. The Nurse's Note, dated 04/01/17, indicated that NS G smelled of alcohol. The note indicated that NS G consented to a room search, which yielded an empty vodka bottle in NS G's bedside trash. The note indicated that NS G admitted to consuming alcohol. Nurse #13 said that a few days prior to 04/01/17, NS G was so intoxicated that he required the administration of IV fluids at the Facility. Nurse #13 said that on 04/01/17, empty liquor bottle were found in NS G's room. Nurse #13 said NS G refused addiction services, and told her that he/she liked to drink. The Administrator denied being giving drug or alcohol paraphernalia by staff or residents. The Administrator said empty nip bottles had been found at the Facility, and were known to belong to NS G. 7. NS I, was admitted to the Facility in August 2016 with [DIAGNOSES REDACTED]. Nurse #13 said that prior to the Christmas holidays, she and the physician had discussed concerns that, NS I, was consuming alcohol during leaves of absence. Nurse #13 said she was informed a few days later that, NS I, had the right to leave the Facility, with or without a physician's orders [REDACTED]. Nurse #13 said, NS I, was so intoxicated, he/she was unable to tell staff where he/she was. Nurse #13 said she was notified of, NS I's, whereabouts by a prior resident, who also reported that the police had been called in response to, NS I's, intoxication. Nurse #13 said she called the police, who confirmed that they had received complaints about, NS I, being intoxicated. Nurse #13 said, NS I, arrived back at the Facility many hours later, but had no idea how he/she had gotten there. Nurse #13 said, NS I, had to be sent to the hospital, as he/she became violent and threatened to kill himself/herself. The Telephone Order, dated 12/24/16, indicated to obtain a urine and blood toxicology screen, and to send NS I to the emergency room if he/she appear unsafe or became violent. The NP's Note, dated 01/09/17, indicated that, NS I, had a alcohol drinking problem during the holidays, and was heavily drunk on Christmas Eve.

Based on records reviewed and interviews, for 7 of 13 sampled residents with substance use disorders (Resident #5, Resident #6, Resident #7, Resident #11, Resident #12, Resident #13 and Resident #14) and 5 of 6 Non-sampled (NS) residents with substance use disorders (NS E, NS F, NS G, NS H and NS I), the facility failed to ensure that a comprehensive assessment was completed so that the resident received appropriate treatment and services for substance use issues/disorders. ~ For 5 of 13 sampled residents with substance use disorders (Resident #5, Resident #6, Resident #7, Resident #11 and Resident #14) and 2 of 6 non-sampled residents with substance use disorders (NS E and NS F) the facility failed to ensure that an Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at the time of admission; ~ For 6 of 13 sampled residents with substance use disorders (Resident #5, Resident #7, Resident #11, Resident #12, Resident #13 and Resident #14) and 5 of 6 non-sampled residents with substance use disorders (NS E, NS F, NS G, NS H, and NS I), the facility failed to ensure an Addictive Behavior and Substance Use History Addendum form was completed by the Licensed Drug Abuse Counselor (LDAC) at the time of admission, or that a reassessment was conducted after reported substance use; and, ~ For 4 of 6 non-sampled residents with substance use disorders (NS E, NS F, NS G, and NS I), the facility failed to ensure that there were current care plans in place to address the residents' substance use issues. Between 03/29/17 and 04/25/17, Resident #5, Resident #11 and Resident #13 had known overdoses at the Facility, and NS E and NS G had 2 incidents each of known alcohol consumption at the Facility. Findings include: Surveyor #1 and Surveyor #3 interviewed the Licensed Drug Abuse Counselor (LDAC) at 12:23 P.M. on 04/10/17. The LDAC said she only did evaluations on residents with substance abuse and/or alcohol histories at the time of their admission to the Facility, and completed substance abuse care plans on those residents. The LDAC said she was notified of residents with substance use disorders by the Director of Nurses (DON). The LDAC said that on the date of interview with Surveyor #1 and Surveyor #3, she conducted staff training on addiction as a disease. The LDAC said she came to the facility on Mondays, but could come on weekends if needed. Surveyor #4 interviewed the Director of Social Services at 12:58 P.M. on 04/27/17. The Director of Social Services said the nursing department was responsible for completing the substance use history assessment, and that an assessment was also completed by the Facility's LDAC, who was only in the Facility on Mondays. Surveyor #1 and Surveyor #4 interviewed the DON at multiple times throughout the dates of survey. The DON said that nursing staff were responsible for completing the Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form at the time of a resident's admission. The DON said the form was only completed on those residents with a known history, and was implemented when she started her employment at the Facility in July 2016. The DON said there was no process in place for the Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form to be completed if it was determined after admission that a resident had a substance use history, or for residents to be reassessed during admission to the Facility. Surveyor #1 and Surveyor #4 interviewed the Nurse Practitioner (NP) at 1:46 P.M. on 04/28/17. The NP said she only treated the medical or clinical needs of residents with substance use disorders, not their substance use disorder or addiction needs. 1. For 5 of 13 sampled residents with substance use disorders (Resident #5, Resident #6, Resident #7, Resident #11 and Resident #14) and 2 of 6 non-sampled residents with substance use disorders (NS E and NS F) the facility failed to ensure that an Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at the time of admission. - Resident #5 was admitted to the Facility in November 2016 with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that an Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at the time of Resident #5's admission to the Facility. The DON said no initial assessment was completed by nursing because Resident #5 did not have a known history of substance use. The Substance Use care plan, dated 11/12/16, indicated that Resident #5 had a history of [REDACTED]. - Resident #6 was admitted to the Facility in October 2016 with [DIAGNOSES REDACTED]. The Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form, dated 05/02/17, was not completed until approximately 7 months after Resident #6's admission to the Facility. - Resident #7 was admitted to the Facility in January 2017 with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that the Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at the time of Resident #7's admission to the Facility. - Resident #11 was admitted to the Facility in April 2017 with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that the Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at the time of Resident #11's admission to the Facility. Hospital #1's Emergency Department documentation, dated 04/25/17, indicated that Resident #11 was treated for [REDACTED]. There was no documentation at the time of survey that Resident #11 was reassessed by nursing after his/her reported overdose on 04/25/17. - Resident #14 was admitted to the Facility in November 2015 and discharged in April 2017, with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that the Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form was completed at any time during Resident #14's admission to the Facility. - NS E was admitted to the Facility in August 2016 with [DIAGNOSES REDACTED]. The Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form, dated 08/24/16, was completed 13 days after NS E's admission to the Facility. - NS F was admitted to the Facility in January 2017 with [DIAGNOSES REDACTED]. On 05/04/17, Surveyor #4 was provided with an Evaluation/Assessment For Residents With Known Substance Abuse Issues/Disorders form, dated 12/10/16, 46 days prior to NS F's admission to the Facility. There was no documentation at the time of survey of an initial evaluation by nursing for NS F's current admission to the Facility. 2. For 6 of 13 sampled residents with substance use disorders (Resident #5, Resident #7, Resident #11, Resident #12, Resident #13 and Resident #14) and 5 of 6 non-sampled residents with substance use disorders (NS E, NS F, NS G, NS H, and NS I), the facility failed to ensure an Addictive Behavior and Substance Use History Addendum form was completed by the Licensed Drug Abuse Counselor (LDAC) at the time of admission, or that a reassessment was conducted after reported substance use. - A Hospital Emergency Department Report, dated 03/27/17, indicated that Resident #5 was diagnosed with [REDACTED]. The Addictive Behavior and Substance Use History Addendum form, dated 04/10/17, was not completed until approximately 5 months after Resident #5's admission to the Facility, and 2 weeks after Resident #5's reported opioid overdose. - The Addictive Behavior and Substance Use History Addendum form, dated 02/12/17, was not completed until approximately one month after Resident #7's admission to the Facility. - The Director of Social Services said the LDAC had not completed an initial assessment on Resident #11, as there was no known substance use history. The Addictive Behavior and Substance Use History Addendum form, dated 04/10/17, indicated Resident #11 was assessed and denied a history of substance use. Hospital #1's Emergency Department documentation, dated 04/25/17, indicated that Resident #11 was treated for [REDACTED]. There was no documentation at the time of survey that Resident #11 was reassessed by nursing or the LDAC after his/her reported overdose on 04/25/17. The Director of Social Services said she did not know if the LDAC had seen Resident #11 after his/her reported overdose, as the LDAC was not scheduled to come to the Facility again until Monday (05/01/17). The DON said that there was no plan to have Resident #11 evaluated by the LDAC after his/her reported overdose. On 05/02/17, the DON said the LDAC had not seen Resident #11 the prior evening when she had been at the Facility and had not re-assessed Resident #11 after his/her reported overdose. - Resident #12 was admitted to the Facility in February 2016 with [DIAGNOSES REDACTED]. The Addictive Behavior and Substance Use History Addendum form, dated 06/21/16, indicated that Resident #12 had refused services. There was no documentation at the time of survey of any attempts to reassess Resident #12 for services. - Resident #13 was admitted to the Facility in February 2016 with [DIAGNOSES REDACTED]. The Addictive Behavior and Substance Use History Addendum form, dated 03/13/17, was not completed until approximately 13 months after Resident #13's admission. Hospital #1's Emergency Department documentation, dated 04/06/17, indicated that Resident #13 was treated for [REDACTED]. There was no documentation at the time of survey that Resident #13 was reassessed by nursing or the LDAC after his/her reported overdose on 04/06/17. - There was no documentation at the time of survey that an Addictive Behavior and Substance Use History Addendum form was completed at any time during Resident #14's admission to the Facility. - The Addictive Behavior and Substance Use History Addendum form, dated 04/03/17, was not completed until approximately 8 months after NS E's admission to the Facility. The Nursing Home Encounter Form, dated 04/11/17, indicated that staff reported an alcohol bottle was found at NS E's bedside. The Nurse's Note, dated 04/22/17, indicated that NS E appeared impaired and admitted to drinking alcohol. There was no documentation at the time of survey that NS E was reassessed by the LDAC after admitting to consuming alcohol. - On 05/04/17, Surveyor #4 was provided with an Addictive Behavior and Substance Use History Addendum form, dated 12/19/16, 37 days prior to NS F's admission to the Facility. There was no documentation at the time of survey of an evaluation by the Facility's LDAC for NS F's current admission to the Facility. - NS G was admitted to the Facility in January 2017 with [DIAGNOSES REDACTED]. On 05/04/17, Surveyor #4 was provided with an Addictive Behavior and Substance Use History Addendum form, dated 04/03/17, 62 days after NS G's admission to the Facility. - NS H was admitted to the Facility in November 2016 with [DIAGNOSES REDACTED]. There was no documentation at the time of survey of an Addictive Behavior and Substance Use History Addendum form completed at any time since NS H's admission to the Facility. - NS I was admitted to the Facility in August 2016 with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that an Addictive Behavior and Substance Use History Addendum form was completed at any time during NS I's admission to the Facility. 3. For 4 of 6 non-sampled residents with substance use disorders (NS E, NS F, NS G and NS I), the facility failed to ensure that there were current care plans in place to address the residents' substance use issues. - The Nurse's Note, dated 03/30/17, indicated that the nurse was notified that NS E smelled of alcohol and a room search indicated one empty and one full vodka bottles were found in his/her nightstand. The Nursing Home Encounter Form, dated 04/11/17, indicated that staff reported an alcohol bottle was found at NS E's bedside. The Nurse's Note, dated 04/22/17, indicated that NS E appeared impaired and admitted to drinking alcohol. There was no documentation at the time of survey that NS E's Substance Use care plan was updated after the incident on 03/30/17, 04/11/17, or 04/22/17. - On 05/04/17, Surveyor #4 was provided with a Substance Abuse care plan, dated 12/19/16, 37 days prior to NS F's admission to the Facility. There was no documentation at the time of survey of the implementation of a Substance Use care plan for NS F's current admission to the Facility. - The Nurse Practitioner's (NP) Note, dated 03/29/17, indicated that NS G admitted to buying alcohol and consuming it the day before (03/28/17). The Nurse's Note, dated 04/01/17, indicated that NS G smelled of alcohol. The note indicated that NS G consented to a room search, which yielded an empty vodka bottle in NS G's bedside trash. The note indicated that NS G admitted to consuming alcohol. On 05/04/17, Surveyor #4 was provided with a Substance Abuse care plan, dated 04/03/17, 62 days after NS G's admission to the Facility, and 6 days after NS G's admitted alcohol consumption. - Surveyor #4 interviewed Nurse #13 at 12:19 P.M. on 05/03/17. Nurse #13 said that on Christmas Eve, NS I incessantly called the Facility while out on a leave of absence and was so intoxicated, he/she was unable to tell staff where he/she was. The NP's Note, dated 01/09/17, indicated that NS I had an alcohol drinking problem during the holidays, and was heavily drunk on Christmas Eve. The NP's note, dated 01/18/17, indicated that at Christmas time, NS I was treated at the hospital for [MEDICAL CONDITION] and dependence, and detoxification. The Telephone Order, dated 01/18/17, indicated that NS I was to start Vivitrol (a medication used to treat addiction to drugs or alcohol) on 01/29/17. The Substance Use care plan, dated 08/04/16, indicated that it was reviewed on 11/15/16 and 02/04/17, but there was no documentation at the time of survey that the care plan was reviewed or revised in response to NS I's consumption of alcohol in 12/2016.

Based on records reviewed and interviews, for 1 of 17 sampled residents (Resident #5), the Facility failed to provide the necessary treatment for [REDACTED].#5 who had a known history of substance use disorder. On 3/29/17 at approximately 4:27 A.M., Resident #5 was assessed by nursing to have altered mental status, low blood pressure and inability to stand. Nursing documentation indicated [MEDICATION NAME] was not available to administer to Resident #5 and he/she was sent to the hospital emergency room . Hospital documentation indicated Resident #5 was diagnosed with [REDACTED]. Findings include: Resident #5 was admitted to the Facility in November 2016 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and dressing. The Substance Abuse Care Plan, dated 11/12/16, indicated that Resident #5 had a history of [REDACTED]. The Care Plan indicated that Resident #5 had the potential for complications such as recurrence of substance use. The Care Plan did not include interventions to implement in the event of a substance use recurrence. A Situation, Background, Assessment, Recommendation (SBAR) Form, dated 3/29/2017 at 4:27 A.M. indicated Resident #5 was being sent to the hospital for lethargy, change in mental status, weakness, low blood pressure and decreased oxygen saturation (measure of oxygen in the blood). The SBAR Form indicated Nurse #3 documented she was unable to administer [MEDICATION NAME] (medication used to treat narcotic drug overdose) to Resident #5 because it was not available. A Hospital Emergency Department Report, dated 3/27/2017, indicated Resident #5 was diagnosed with [REDACTED]. A Nursing Note, dated 3/29/2017 at 10:30 A.M., indicated Resident #5 returned from the hospital after an opiate overdose. Unit Manager #1 provided the Surveyor, in the afternoon on 4/5/2017, with a list of residents who had known histories of substance use disorders. The list indicated 35 of 54 residents on unit 1 had medical histories of substance use disorders. The Surveyor interviewed Nurse #3 at 8:26 A.M. on 4/6/2017. Nurse #3 said Resident #5 had a fall on 3/29/2017, she assessed Resident #5 and he/she was out of it, or words to that effect, and Resident #5's eyes appeared pinpoint. Nurse #3 said she was going to administer [MEDICATION NAME] to Resident #5 and there was no [MEDICATION NAME] available. Nurse #3 said she called for emergency medical transportation and the emergency medical technicians (EMT's) administered [MEDICATION NAME] to Resident #5 and transported him/her to the hospital emergency room . Nurse #3 said the Facility had a high population of resident's with known histories of substance use disorders, especially on Nursing Unit 1. Nurse #3 said she had not been provided with any education or training from the facility about caring for residents with substance use disorders. Nurse #3 said the nursing unit had been stocked with [MEDICATION NAME] and did not know why there was no [MEDICATION NAME] available at the time she needed it for Resident #5. The Surveyor interviewed Nurse #4 at 12:55 P.M. on 4/6/2017. Nurse #4 said she worked the morning of 3/30/2017 and during morning report, Nurse #3 informed her of Resident #5's incident of a narcotic overdose. Nurse #4 said Nurse #3 informed her there was no [MEDICATION NAME] available on the nursing unit. Nurse #4 said she went to look for [MEDICATION NAME] with Nurse #3, on the morning on 3/30/2017, and she could not find any [MEDICATION NAME] on the nursing unit. Nurse #4 said the Facility had a high population of resident's with known histories of substance use disorders and the Facility had not provided any education or training about caring for residents with substance use disorders. The Surveyor interviewed The Staff Development Coordinator and Unit Manager #1 at 4:10 P.M. on 4/5/2017, Nurse #1 at 11:55 A.M. on 4/6/2017, CNA #6 at 1:12 P.M. on 4/6/2017, Nurse #5 at 1:33 P.M. on 4/6/2017, CNA #8 at 4:18 P.M. on 4/6/2017. The Staff Development Coordinator, Unit Manager #1, Nurse #1, Nurse #5, CNA #6 and CNA #8 said the Facility had not provided staff with education regarding substance use disorders. The Staff Development Coordinator and Unit Manager said the Facility had no formal education for the Facility staff regarding the use [MEDICATION NAME] and said the education was provided informally, or words to that effect. The Staff Development Coordinator and Unit Manager said the Facility had not provided staff with education regarding caring for residents with substance use disorders, and therefore, did not have any documentation of education for staff on substance use disorders or the administration and use of [MEDICATION NAME]. Nurse #1 said she had not received education from the Facility on the administration and use of [MEDICATION NAME]. Nurse #3 said she had not received any education from the Facility on the administration and use of [MEDICATION NAME] and she had taken it upon herself, or words to that effect, to read about [MEDICATION NAME] administration. Nurse #5 said security and staff education were needed at the Facility to keep everyone safe and to provide the care the residents needed.

Based on records reviewed and interviews for 1 of 5 sampled residents (Resident #1) the Facility failed to ensure staff provided Resident #1, with the assistance required to ensure safe transfers, ambulation and toileting to prevent falls. Resident #1's plan of care indicated he/she was at risk for falls and required 2 person assistance with bed mobility, transfers, toilet use and ambulation. On 7/29/2016, Resident #1 was being assisted with ambulation and toileting by 1 Certified Nursing Assistant (CNA) when he/she fell backward resulting in hospitalization and fractured cervical spine. Findings include: The Massachusetts Board of Registration in Nursing (BORN): 244 CMR 3.00: Register Nurse and Licensed Practical Nurse Section 3.05: Delegation and Supervision of Selected Nursing Activities by Licensed Nurses to Unlicensed Personnel indicates: The qualified licensed nurse (Registered Nurse/Practical Nurse) within the scope of his/her practice is responsible for the nature and quality of all nursing care that a patient/client receives under his/her direction. Assessment/ identification of the nursing needs of a patient/client, the plan of nursing actions, implementation of the plan, and evaluation of the plan are essential components of nursing practice and are the functions of the qualified licensed nurse. (2) General Criteria for Delegation. Delegation of nursing activities to unlicensed persons shall comply with the following requirements: (b) The qualified licensed nurse must make an assessment of the patient's/client's nursing care needs prior to delegating the nursing activity. Resident #1's Plan of Care, dated 6/3/2016, indicated Resident #1 required 2 person assistance for bed mobility, transfers, ambulation and toilet use. A Physical Therapy Discharge Summary, dated 6/16/2016, indicated Resident #1 was discharged from skilled therapy services on 6/15/2016, was at risk for falls and his/her level of assistance varied as a result of Resident #1's medical condition and level of fatigue. A Occupational Therapy Discharge Summary, dated 6/16/2016, indicated Resident #1 was recommended for Hospice (end of life care) services, discharged from skilled occupational therapy services on 6/16/2016, and his/her level of assistance varied as a result of Resident #1's medical condition, mental status, time of day and level of fatigue. A Significant Change Minimum Data Set Assessment, dated 6/16/2016, indicated Resident #1's [DIAGNOSES REDACTED]. The Resident Daily Flow Sheet for the month of 7/2016 indicated staff documented Resident #1 was dependent in the evening for ambulation and required 2 assist for ambulation. A Licensed Nursing Summary, dated 7/19/2016, indicated Resident #1 had difficulty walking and required the physical assist of two for walking mobility and transfers. An Accident/Incident Report, dated 7/29/2016 indicated Resident #1 fell while being assisted to the bathroom with 1 assist. This was not consistent with Resident #1's Plan of Care, Significant Change Minimum Data Set Assessment, dated 6/16/2016 and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required 2-person assistance for bed mobility, transfers, ambulation and toilet use. An Accident/Incident Report, dated 7/29/2016, indicated Resident #1 was being assisted by 1 person with ambulation to the bathroom when he/she fell backward hitting his/her head on the floor and was transferred to the hospital. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016 which indicated Resident #1 required a 2 person assist for ambulation and toileting. Surveyor #1 and Surveyor #2 interviewed Nurse #1 at 3:20 P.M. on 8/31/2016. Nurse #1 said Resident #1 attempted to get him/herself out of the geri chair (reclining chair with wheels) on 7/29/2016 and he asked CNA #2 to assist Resident #1. Nurse #1 said CNA #2 assisted Resident #1, by herself, to transfer out of the geri chair and to ambulate to the bathroom. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting. Nurse #1 said Resident #1 fell backwards hitting his/her head on the floor. Nurse #1 said he assessed Resident #1, called the Physician and family and Resident #1 was sent to the hospital. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 3:48 P.M. on 8/31/2016. CNA #2 said Resident #1 was seated, on 7/29/2016, in his/her geri chair in the hall on the nursing unit and appeared anxious and needed to go to the bathroom. CNA #2 said she had provided care to Resident #1 several times. CNA #2 said Resident #1's level of assistance could vary. CNA #2 said she thought Resident #1 sometimes required the assist of 1 person, sometimes required the assist of 2 people depending on Resident #1's mental status and weakness. CNA #2 said she assisted Resident #1, by herself with a gait belt, to transfer out of the geri chair and ambulate to the bathroom. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting. CNA #2 said Resident #1 turned quickly and she was unable to prevent Resident #1 from falling backward and hitting his/her head on the floor. CNA #2 said Resident #2's cognitive and functional status would vary, sometimes requiring the assistance of 1 person and sometimes requiring the assistance of 2 people. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting Surveyor #1 interviewed the Director of Nursing Services (DON) at 1:58 P.M. on 9/12/2016. The DON said Resident #1's functional ability and level of assistance would fluctuate and the staff could determine the level of assistance Resident #1 needed at the time. This was not consistent with Resident #1 MDS assessment or Resident #1's Plan of Care. The DON said a CNA would decide for themselves if Resident #1 required the assistance of 1 or 2 people. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting. The decision to use 1 or 2 staff is outside the scope of a CNA and not consistent with the Massachusetts Board of Registration in Nursing (BORN): 244 CMR 3.05 (2) (b) The qualified licensed nurse must make an assessment of the patient's/client's nursing care needs prior to delegating the nursing activity. The DON said Resident #1 was more unpredictable than behavioral, or words to that effect. The DON said Resident #1 did not have any documentation of Resident #1's behaviors being monitored because Resident #1 did not have behavioral issues and was not care planned for behavioral issues. The DON there was no documentation of 15 minute checks ever being done with Resident #1. The DON said if there was no documentation of 15 minute checks for Resident #1, then they had not been done. Surveyor #1 interviewed Nurse #2 at 10:05 A.M. on 9/16/2016. Nurse #2 said Resident #1 required the physical assistance of 2 people, sometimes 1 person. Nurse #2 said Resident #1's level of assistance depended on if Resident #1 was sick or not, or words to that effect. Surveyor #1 interviewed the Director of Rehabilitation Services at 12:54 P.M. on 9/16/2016. The Director of Rehabilitation Services said Resident #1's functional ability could fluctuate a lot during the day, or words to that effect, and Resident #1's level of assistance would vary depending on his/her functional ability. Surveyor #1 interviewed the Unit Manager at 1:11 P.M. on 9/16/2016. The Unit Manager said Resident #1's functional ability would fluctuate and he/she required the assistance of 1 or 2 people with a gait belt depending on his/her functional or cognitive status which could vary throughout the day/night. The Unit Manager said Resident #1 had a bad knee, or words to that effect, and Resident #1's knee could give out on her at any given moment or words to that effect. The Unit Manager said Resident #1 required supervision all the time and was compulsive. A Hospital Emergency Department (ED) Report, dated 7/29/2016, indicated Resident #1 had sustained a fall at the Facility on 7/29/2016 and was diagnosed at the hospital with cervical spine fracture.

Based on records reviewed and interviews for 1 of 5 sampled residents (Resident #1), who sustained 5 falls in a 30 day period of time, had a [DIAGNOSES REDACTED]. On 7/29/2016, Resident #1 was being assisted with ambulation and toileting by 1 Certified Nursing Assistant (CNA) when he/she fell backward resulting in hospitalization and fractured cervical spine. Findings include: Resident #1's Plan of Care, dated 6/3/2016, indicated Resident #1 required 2 person assistance for bed mobility, transfers, ambulation and toilet use. A Physical Therapy Discharge Summary, dated 6/16/2016, indicated Resident #1 was discharged from skilled therapy services on 6/15/2016, was at risk for falls and his/her level of assistance varied as a result of Resident #1's medical condition and level of fatigue. There was documentation to indicate the how much assistance Resident #1 required when his/her medical condition and level of fatigue varied. An Occupational Therapy Discharge Summary, dated 6/16/2016, indicated Resident #1 was recommended for Hospice (end of life care) services, discharged from skilled occupational therapy services on 6/16/2016, and his/her level of assistance varied as a result of Resident #1's medical condition, mental status, time of day and level of fatigue. There was documentation to indicate the how much assistance Resident #1 required when his/her medical condition, mental status, time of day and level of fatigue varied. A Significant Change Minimum Data Set Assessment, dated 6/16/2016, indicated Resident #1's [DIAGNOSES REDACTED]. A Licensed Nursing Summary, dated 7/19/2016, indicated Resident #1 had difficulty walking and required the physical assist of two for walking mobility and transfers. An Accident/Incident Report, dated 6/26/2016 indicated Resident #1 fell from his/her chair at 9:50 A.M. on 6/29/2016. The Accident/Incident Report indicated staff documented recommendations, on the report, to prevent further falls which included Activities to keep Resident #1 busy and 15 minute checks. There was no documentation to indicate 15 minute checks were completed or for how long the 15 minute checks were to be done. There was no documentation to indicate Resident #1's Plan of Care was updated with the recommendations on the Accident/Incident Report, or other interventions, after Resident #1's fall on 6/29/2016. The Resident Daily Flow Sheet for the month of 7/2016 indicated staff documented Resident #1 was dependent in the evening for ambulation and required 2 assist for ambulation. An Accident/Incident Report, dated 7/3/2016 indicated Resident #1 had transferred him/herself to the bathroom at 11:45 A.M. on 7/3/2016 and sustained a fall. The Accident/Incident Report indicated staff documented recommendations to prevent further falls which included: Physical Therapy (PT) Consult and continuous supervision with ambulation. This was not consistent with Resident #1's Plan of Care and Significant Change Minimum Data Set Assessment which indicated Resident #1 required a 2 person assistance with ambulation. There was no documentation to indicate Resident #1's Plan of Care was updated with the recommendations on the Accident/Incident Report, or other interventions, after Resident #1's fall on 7/3/2016. An Accident/Incident Report, dated 7/11/2016 indicated Resident #1 fell from his/her chair at 4:30 P.M. on 7/11/2016. The Accident/Incident Report indicated staff documented recommendations, on the report, to prevent further falls which included: medicate before behavior issues. There was no documentation to indicate Resident #1's Plan of Care was updated with the recommendations on the Accident/Incident Report, or any other interventions, after Resident #1's fall on 7/11/2016. An Accident/Incident Report, dated 7/17/2016 indicated Resident #1 fell from his/her chair at 9:00 P.M. on 7/17/2016. The Accident/Incident Report indicated staff documented recommendations, on the report, to prevent further falls which included: 15 minute checks and keep in supervised area. There was no documentation to indicate 15 minute checks were done for Resident #1. An Accident/Incident Report, dated 7/29/2016 indicated Resident #1 fell while being assisted to the bathroom with 1 assist and was transferred to the hospital. This was not consistent with Resident #1's Plan of Care, Significant Change Minimum Data Set Assessment, dated 6/16/2016 and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required 2-person assistance for bed mobility, transfers, ambulation and toilet use. Surveyor #1 and Surveyor #2 interviewed Nurse #1 at 3:20 P.M. on 8/31/2016 and 1:40 P.M. on 9/12/2016. Nurse #1 said Resident #1 attempted to get him/herself out of the geri chair (reclining chair with wheels) on 7/29/2016 and he asked CNA #2 to assist Resident #1. Nurse #1 said CNA #2 assisted Resident #1 by herself to transfer out of the geri chair and to ambulate to the bathroom. Nurse #1 said he thought Resident #1 required the assistance of 1 person for ambulation and toileting. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016, Significant Change Minimum Data Set Assessment, dated 6/16/2016, and Licensed Nursing Summary, dated 7/19/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting. Nurse #1 said Resident #1 fell backward when walking into the bathroom with CNA #2 on 7/29/2016, hit his/her head on the floor and was sent to the hospital. Nurse #1 said he had completed the Resident #1's Accident/Incident Report on 7/3/2016. Nurse #1 confirmed he did not update Resident #1's Plan of Care after his/her fall on 7/3/2016. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 3:48 P.M. on 8/31/2016. CNA #2 said that on 7/29/2016, she assisted Resident #1, by herself with a gait belt to transfer and ambulate to the bathroom. CNA #2 said she had provided care to Resident #1 several times. CNA #2 said Resident #1's level of assistance could vary. CNA #2 said she thought Resident #1 sometimes required the assist of 1 person, sometimes required the assist of 2 people depending on Resident #1's mental status and weakness. This was not consistent with Resident #1's Plan of Care, dated 6/3/2016 and Significant Change Minimum Data Set Assessment, dated 6/16/2016, which indicated Resident #1 required a 2 person assist for ambulation and toileting. CNA #2 said Resident #1 turned quickly as she assisted Resident #1, on 7/29/2016, into the bathroom and she was unable to prevent Resident #1 from falling backward and hitting his/her head on the floor. Surveyor #1 interviewed the Director of Nursing Services (DON) at 1:58 P.M. on 9/12/2016 and at 12:28 P.M on 9/16/2016. The DON said resident falls were reviewed every morning at the Interdisciplinary Team (IDT) meeting. The DON said it was her expectation for a resident's plan of care to be updated by the nurse at the time of each resident fall and the interventions kept in place and followed until the next IDT meeting and, if needed, the care plan would be updated by the supervisor after the meeting. The DON said Resident #1 did not have any documentation of Resident #1's behaviors being monitored because Resident #1 did not have behavioral issues and was not care planned for behavioral issues. The DON said Resident #1 was more unpredictable than behavioral, or words to that effect. The DON there was no documentation of 15 minute checks ever being done with Resident #1 and said if there was no documentation of 15 minute checks for Resident #1 then they had not been done. The DON said PT consults were conducted after any resident fall. The DON said PT consults, after a resident fall, were not always documented. The DON said Resident #1 did not have a formal PT consult after each fall in June and July and said PT eyeballed Resident #1, or words to that effect, after each fall and made verbal recommendations. The DON then recanted and said the Rehabilitation Director had eyeballed Resident #1, or words to that effect, after each fall in June and July and had no recommendations. Surveyor #1 interviewed Nurse #2 at 10:05 A.M. on 9/16/2016. Nurse #2 said after any resident fall, the nurse should update the resident care plan at that time. Nurse #2 said if 15 minute checks were implemented they would be initiated by the nurse and the CNA's would document 15 minute checks for 24 hours. Surveyor #1 interviewed the Supervisor at 10:48 A.M. on 9/16/2016. The Supervisor said resident care plans should be updated after each resident fall by the nurse. The Supervisor said she had never been asked to update a resident care plan after a fall and had never been asked to update a resident care plan after IDT meetings following a resident fall. Surveyor #1 interviewed the Director of Rehabilitation Services at 12:54 P.M. on 9/16/2016. The Director of Rehabilitation Services said he screened Resident #1 after each fall and made verbal recommendations to nursing. The Director of Rehabilitation Services said his recommendations would be in the nursing notes and on Resident #1's plan of care. There was no documentation in the nursing notes or Resident #1's plan of care to indicate any recommendations by Physical or Occupational Therapy were made, implemented or followed. Surveyor #1 interviewed the Unit Manager at 1:11 P.M. on 9/16/2016. The Unit Manager said resident care plans should be updated immediately by the nurse after any resident fall and the interventions should be followed. The Unit Manager said if 15 minute checks were implemented they would be initiated by the nurse and the CNA's would document 15 minute checks for 72 hours. A Hospital Emergency Department (ED) Report, dated 7/29/2016, indicated Resident #1 had sustained a fall at the Facility on 7/29/2016 and was diagnosed at the hospital with cervical spine fracture.

Based on record review and interviews, the facility failed to follow identified safety interventions to prevent falls for 1 sampled resident (#6) in a total sample of 23 residents. Findings include: . Review of Resident #6's clinical record on 9/4/12, indicated that the resident was admitted to the facility in February, 2012, with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), dated [DATE], indicated that the resident had no cognitive impairments and required the physical assistance of one staff member for transfers and ambulation. Review of the Fall Assessment, dated 6/2/12 and 6/18/12, indicated that the resident was at high risk for falls. Review of the resident's plan of care for prevention of falls, dated 6/21/112, included: *the resident's bed was to be in the lowest position possible when in bed. *encourage the use of the call light. *provide assistance with transfers. *provide proper footwear. *a bed alarm when he/she in bed. Review of the Incident Report, dated 7/7/12 at 3:00 A.M., indicated that the resident's bed alarm sounded and the resident was found sitting on his/her buttocks on the floor. The report indicated that the resident attempted to transfer to the bathroom without assistance, urinated on the floor, and slipped to the floor because the floor was wet with urine. The report further indicated that the resident did not sustain an injury. Review of the resident's fall prevention plan of care, dated 7/7/12, included: *gripper socks were to be worn to bed. *encourage the use of the call light to request assistance. Review of the Incident Report, dated 7/14/12 at 1:45 A.M., indicated that the resident's alarm sounded and he/she was found on lying on his/her back on the floor after attempting to self ambulate. The Report indicated that the resident was wearing regular socks on his/her feet and not the gripper socks, as indicated in the fall prevention care plan dated 7/7/12. The Report further indicated that the resident had no safety awareness, was alert, confused, and oriented to self only, and did not use the call light to ask for assistance. The Report indicated that the resident complained of pain in his/her head after striking his/her head. The Report further indicated that the resident asked the staff for a bedpan while lying on the floor. The Report indicated that the physician was notified, and the physician ordered the resident to be transferred to the hospital for an evaluation. The Report indicated that the resident was admitted to the hospital with [REDACTED]. During an interview with the Director of Nurses (DON) on 9/4/12 at 10:30 A.M., she said that the resident was not wearing gripper socks as per the plan of care. She said that the resident was more confused prior to the second fall and would not have remembered to use the call light to ask for assistance.