Every finding on record at Royal Braintree Nursing and Rehabilitation Center

Based on observation, interview, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to develop and implement appropriate plans of action for resident concerns regarding food temperatures.Findings include:Review of the facility's policy titled Quality Assurance Performance Improvement Program, last reviewed in January 2025, indicated but was not limited to the following:-Quality Assurance and Performance Improvement (QAPI) principles will drive the decision making within our organization. Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided and all areas that affect the quality of life for persons living and working in our organization.-The QAPI committee will review data from areas of the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality.-Data to be monitored include but is not limited to complaints/facility-reported incidents and Resident/family input-resident council/grievance log.-The facility Administrator is responsible and accountable for developing, leading and closely monitoring our QAPI program.-All QAPI documentation to include tracking of committee activity, performance improvement projects (PIP), forms, resources and worksheets as needed.-Quality Assessment and Assurance (QAA) committee will have the responsibility for reviewing data, suggestions, and input from residents, staff, family members, and other stakeholders.-An important aspect of our PIPs is to determine the effectiveness of our performance improvement activities and whether improvement is sustained.-A systematic approach will be used to determine when an in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change.During initial screening on 2/5/26, the residents on the Windsor 2 unit expressed the following food concerns:- Food is awful, always comes up cold.- Food always comes up cold, never warm.- Food sucks, it's always cold.- Food always cold. Review of Resident Council Minutes and/or Food Committee Minutes from March 2025 to December 2025 indicated the following food concerns:-3/11/25: Cold food, inaccurate meals.-5/21/25: Cold food, inaccurate meals-7/14/25: Cold food-10/20/25: Cold eggs at breakfast, melted ice cream for dessert. The department response noted on the form indicated the Dietician and FSM were aware and would follow-up and a Quality Assurance and Performance Improvement (QAPI) for temperatures to follow. The form was signed by the Executive Director.-11/10/25: Minor concerns were raised regarding food temperatures. Food council meeting scheduled to address concerns.-12/17/25: Ice cream arriving melted when on meal carts.During a group meeting held on 2/10/26 at 10:00 A.M., the 12 residents in attendance shared the following information with the surveyors:-Meals on the units are served cool/cold and the food temperature is better when they eat in main dining room which is adjacent to the main kitchen.-Ice cream is always melted.-Two residents in attendance said they only order ham sandwiches because everything else comes up cold. -Residents report they do not always receive what they ordered. -The residents said they complain about cold food in Resident Council every month and no one ever follows up with them with how they are going to make it better.On 2/9/26 at the lunch meal and 2/10/26 at the breakfast meal, the survey team conducted test trays which validated the residents' concerns of cold food.During an interview on 2/11/26 at 1:39 P.M., the Food Service Manager (FSM) said she holds monthly Food Committee meetings with residents after the Resident Council Meetings. She said she is aware of the residents' ongoing complaints about food temperatures and accuracy of meals. She said she believes the problem with the food temperatures is due to the length of time it takes staff to distribute the meal trays once the food trucks get to the units. The FSM was unable to explain or provide any documentation of any projects initiated to address the residents' ongoing complaints of cold food and meal accuracy.During an interview on 2/11/26 at 2:30 P.M., the Administrator said he leads the QAPI Committee which meets quarterly as well as four monthly meetings during the year. He said the committee identifies areas of improvement utilizing [NAME] quality measures, five-star measures, a recent Joint Commission of Healthcare Organizations (JCAHO) survey and last year's recertification survey results. He said projects the committee has been working on in 2025 include long stay residents with pressure ulcers, and long stay residents with falls with major injuries. The Administrator said he was aware of the residents' ongoing complaints about cold food from the Resident Council and Minutes, however, has not initiated a QAPI project to address it.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend three of three QAPI meetings reviewed.Findings include:Review of the facility's policy titled Quality Assurance on (sic) Performance Improvement (QAPI) Program, dated as revised January 2025, indicated but was not limited to:-The facility Administrator is responsible and accountable for developing, leading and closely monitoring our QAPI program.-QAPI activities will be governed and monitored by the Quality Assurance and Assessment (QAA) committee which will include: -The Medical Director, or designee -The Director of Nursing Services -The Administrator, or corporate leadership in his/her absence -Infection Preventionist -Two additional staff membersReview of the facility's QAPI Attendee sign-in sheets for September 2025 indicated the Infection Preventionist was not in attendance.Review of the facility's QAPI Attendee sign-in sheets for December 2025 indicated the Infection Preventionist was not in attendance.Review of the facility's quarterly QAPI Attendee sign-in sheets for January 2026 indicated the Infection Preventionist was not in attendance.During an interview on 2/11/26 at 1:28 P.M., the Infection Preventionist said she does not attend QAPI meetings.During an interview on 2/11/26 at 2:30 P.M., the Administrator reviewed the September 2025, December 2025 and January 2026 QAPI attendance sheets and could not identify the IP's signature. He said it is hard to get everyone together to attend the meetings.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in 3 of 7 kitchenette refrigerators.Findings include:Review of the facility's policy titled Foods Brought by Family/Visitors, dated 1/2025, indicated but was not limited to the following:-Perishable foods must be stored in resealable contains with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date.-The nursing staff is responsible for discarding perishable foods on or before the use by date.-The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example mold growth, foul odor, past due packaging expiration dates).Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:3-501.17 Ready to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date of day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3-29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by-date based on FOOD safety.On 2/5/26 at 9:19 A.M., the surveyor reviewed the [NAME] unit kitchenette and observed the following:-One container of honey consistency thickened orange juice, opened and not marked with the date opened or use by date, in the refrigerator. Review of the container's label indicated the juice should be discarded within 10 days of opening.-One container of nectar consistency thickened apple juice, opened and not marked with the date opened or use by date, in the refrigerator. Review of the container's label indicated the juice should be discarded within 7 days of opening.-One container of nectar consistency thickened cranberry juice, opened and not marked with the date opened or use by date, in the refrigerator. Review of the container's label indicated the juice should be discarded within 7 days of opening.On 2/10/26 at 10:15 A.M., the surveyor reviewed the Windsor 2 unit kitchenette and observed the following:-A container of Vita [NAME] coconut water, opened and unlabeled, in the freezer-A container of Core water, opened and unlabeled, in the refrigerator-A can of Vanilla Coca Cola, opened and unlabeled, in the refrigerator-A plastic shopping bag containing a bowl of soup and a ladle, unlabeled, in the refrigeratorOn 2/11/26 at 11:12 A.M., the surveyor reviewed the Sunshine unit kitchenette and observed the following:-A disposable to-go style container containing a slice of cake-like product, unlabeledDuring an interview on 2/10/26 at 2:20 P.M., the Food Service Director (FSD) said there should be no unlabeled/undated personal food items in the unit kitchenettes. The FSD said she had checked the unit kitchenettes that morning and had not seen any unlabeled/undated items. The FSD said all thickened liquids should be labeled with the opened on and use by dates and she had created labels to put on the containers as a reminder for staff.

Based on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances/complaints brought forward from the Resident Council were addressed and resolved in a timely manner to ensure the residents felt their concerns were acted upon and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council Meetings, last reviewed December 2024, indicated but was not limited to the following:- The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the CouncilReview of the facility's policy titled Complaint/Grievance Policy and Procedure, dated September 2023, indicated but was not limited to the following:-Voiced grievances (e.g. those about treatment, care management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff.Review of Resident Council notes, Resident Council Department Response Forms and Food Committee Meeting Minutes representing five of seven units in the facility, provided by the facility, from March 2025 to December 2025, indicated resident food complaints as follows: -3/11/25: Cold food and incorrect meals. The Food Service Manager (FSM) noted cold food complaints and indicated the issue has a lot to do with how fast they hand out meal trays. The form was signed by the department head and the Executive Director.-4/1/25: No follow-up to the residents' complaints of cold food and incorrect meals brought forward during the 3/11/25 Resident Council and Food Committee meeting.-5/21/25: Cold lunch, not getting the right foods. No follow-up to the residents' complaints of cold food and incorrect meals brought forward during previous Resident Council and Food Committee meetings.-6/17/25: No follow-up to the residents' complaints of cold food and incorrect meals brought forward during the 5/21/25 Resident Council and Food Committee Meetings.-7/14/25: Cold food.-8/20/25: No follow-up to the residents' complaints of cold food brought forward during the 7/14/25 Resident Council meeting.-No September 2025 Resident Council or Food Committee minutes were provided to the survey team for review.-Food Committee Meeting minutes, dated 10/15/25, failed to indicate any follow-up to complaints voiced during the 7/14/25 meeting.-10/20/25: Cold eggs at breakfast, melted ice cream for dessert. The department response noted on the form indicated the Dietitian and FSM were aware and would follow-up and a Quality Assurance and Performance Improvement (QAPI) for temperatures to follow. The form was signed by the Executive Director.-11/10/25: Meeting conducted by the Administrator and Director of Nursing and minor concerns were raised regarding food temperatures.Food Committee Meeting Minutes, dated 11/20/25, failed to indicate the residents' concerns regarding food temperatures brought forward during the 11/10/25 Resident Council Meeting was addressed.-12/17/25: Ice cream arrives melted when delivered on meal carts. Meeting conducted by the Administrator; plan identified to review handling procedures to ensure products arrive properly frozen within 14-30 days.During a group meeting held on 2/10/26 at 10:00 A.M., the 12 residents in attendance shared the following information with the surveyors:-Meals on the units are served cool/cold and the food temperature is better when they eat in main dining room which is adjacent to the main kitchen.-Ice cream is always melted.-Two residents in attendance said they only order ham sandwiches because everything else comes up cold. -Residents report they do not always receive what they ordered. -The residents said they complain about cold food in Resident Council every month and no one ever follows up with them with how they are going to make it better.During an interview on 2/11/26 at 10:38 A.M., the Activity Director (AD) said she coordinates the monthly Resident Council meeting and documents the meeting minutes. She said when any concerns arise during the meeting, she usually completes a Resident Council Department Response form and gives it to the appropriate department head for follow-up. She said the FSM usually holds a Food Committee Meeting with residents on the same day as Resident Council. The AD said residents have brought forward complaints about cold food in Resident Council every month since she started working at the facility a year ago. She said she used to provide the FSM a completed Resident Council Department Response form with the residents' concerns on it. However, the residents still complain about cold food. The AD said she doesn't always document the residents' ongoing complaints of cold food voiced during the Resident Council minutes anymore and instead informs the Administrator directly. The AD said she was not aware of any changes made by the FSM or Administrator to address the residents' complaints of cold food.Review of the facility's grievance book failed to indicate any grievances were formulated for any ongoing concerns brought forth by resident council as a group. During an interview on 2/11/26 at 1:39 P.M., the FSM said she holds monthly Food Committee meetings with residents after the Resident Council Meetings. She said she is aware of the residents' ongoing complaints about food temperatures and accuracy of meals. She said she believes the problem with the food temperatures is due to the length of time it takes staff to distribute the meal trays once the food trucks get to the units. The FSM was unable to explain or provide any documentation of any approaches developed and implemented to address the residents' ongoing complaints of cold food and meal accuracy.During an interview on 2/11/26 at 2:30 P.M., the Administrator and surveyor reviewed the food complaints brought forward by residents during the Resident Council Meeting held on 2/10/26 as well as repeated complaints over the past year. He said he was aware of the ongoing food concerns but had not put a performance improvement plan in place to address it until the survey team identified food temperature issues from test trays. He said the FSM needs to work on these issues. He said they need to make sure concerns brought up during Resident Council are documented and brought through the grievance process to ensure they are addressed, and the problem is resolved.

Based on interviews and record review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#5), out of a total sample of 34 residents. Specifically, the facility failed to ensure resident specific, individualized care plans were developed to address the medical, physical, mental and psychosocial needs of a residents identified with a history of suicidal ideation/attempt/gestures. Findings include:Review of the facility's policy titled Comprehensive Care Plans, last revised May 2025, indicated but was not limited to:-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.-The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. the attending physician or non-physician practitioner designee involved in the resident's care, if able to participate in the development of the care plan.b. A registered nurse with responsibility for the resident.c. A nurse aide with responsibility for the resident.d. A member of the food and nutrition services staff.e. The resident and the resident's representative, to the extent practicable.f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.-The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment.-The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternate interventions will be documented, as needed.Resident #5 was admitted to the facility in October 2022 and had diagnoses including bipolar disorder, schizoaffective disorder and suicidal ideations.Review of the MDS assessment, dated 11/24/25, indicated Resident #5 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 4-6 days during the review period and had a diagnosis of suicidal ideation. The assessment indicated Resident #5 had an activated Health Care Proxy (HCP- someone designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions).Review of comprehensive care plans failed to indicate a care plan was developed to address the Resident's diagnosed history of suicidal ideation.Review of a Nurse Practitioner Note (NP), dated 1/24/25, indicated Resident #5 presented with agitation/suicide attempt. The nurse reported to the NP that Resident #5 threw a food tray at staff after breakfast because he/she didn't like the food. He/she was later seen by housekeeping staff holding a butter knife to his/her wrist as if contemplating to cut him/herself. The kitchen was immediately notified to remove all knives and sharp objects from his/her tray moving forward. The Resident told the NP that the people in the television wanted to hurt him/her and wanted him/her dead, so he/she was going to hurt him/herself before they got to him/her. The NP and consultant psychiatric NP assessed the Resident and adjusted his/her psychotropic medications, initiated 15-minute safety checks when the Resident is alone in his/her room, keep the television off in his/her room and no sharp objects.Further review of comprehensive care plans failed to indicate any care plan was developed for suicidal ideation/gestures/ideation following his/her actual suicide attempts/gesture/ideation on 1/24/25.Review of a Behavior Note, dated 11/1/25, indicated Resident #5 exhibited increased behaviors and verbalized wanting to pull the fire alarm. The nurse attempted to redirect the Resident when he/she pulled out a piece of broken glass and held it to his/her right wrist saying he/she was going to cut his/her wrist. The broken glass was immediately removed, the Resident was placed on 1:1, the physician was notified and ordered the Resident to be sent to the hospital for evaluation.Review of hospital documentation indicated Resident #5 was admitted to the hospital's geriatric psychiatry unit from 11/4/25 to 11/17/25 for evaluation and treatment of paranoid ideation and attempts at self-injurious behaviors. The documentation indicated that Resident #5 reported multiple psychiatric hospitalizations in the past, self-injurious behaviors in the past by cutting and reports of past suicide attempt 30 years ago. The Resident's psychiatric status was stabilized following an adjustment to his/her medication regimen and therapy utilizing DBT (Dialectical Behavior Therapy-a type of talk therapy for people who experience emotions very intensely) and discharged back to the facility on [DATE].Further review of comprehensive care plans failed to indicate any care plan was developed for suicidal ideation/gestures/ideation following his/her actual suicide attempts/gesture/ideation on 11/1/25.During an interview on 2/9/26 at 11:25 A.M., Certified Nursing Assistant (CNA) #1 said she provides care to Resident #5 on a regular basis. She said the Resident can be accusatory of staff believing they are taking his/her belongings. CNA #1 said she was never told that Resident #5 had ever attempted to hurt him/herself and has not seen anything about it on the CNA care card.During an interview on 2/9/26 at 11:44 A.M., Unit Manager (UM) #2 said she has been the UM on Resident #5's unit since January 2025. She said the Resident can be accusatory toward staff. UM #2 reviewed Resident #5's medical record and said the Resident has had two incidents of suicidal ideation with attempts of self-harm with a knife and broken glass. She said the Resident was sent out to the hospital in January after housekeeping found the Resident with a knife and threatening to cut his/her wrist and was sent out again in November after holding a piece of broken glass to his/her wrist and saying he/she was going to cut him/herself. The UM reviewed Resident #5's comprehensive care plans and said there is no care plan that addresses the Resident's suicidal ideations and/or suicide attempts/gestures.During an interview on 2/9/26 at 12:45 P.M., the Director of Nursing (DON) said a care plan should be developed for any resident that has a history of suicidal ideation/attempts and has an actual suicide attempt or gesture. The DON reviewed Resident #5's medical record including comprehensive care plans and said a care plan should have been developed with individualized interventions for Resident #5's history of suicidal ideation/attempts and actual suicide attempts/gestures and was not.

Based on observation and interview, the facility failed to ensure residents received food at appetizing temperatures for two of two test trays completed.Findings include:During initial screening on 2/5/26, the residents on the Windsor 2 unit expressed the following food concerns:- Food is awful, always comes up cold.- Food always comes up cold, never warm.- Food sucks, it's always cold.- Food always cold. Review of Resident Council Minutes from October 2025 through December 2025 indicated the following food concerns:-10/20/25: Cold eggs at breakfast, melted ice cream for dessert.-11/10/25: Minor concerns were raised regarding food temperatures. Food Council Meeting scheduled to address concerns.-12/17/25: Ice cream arriving melted when on meal carts.Food Council notes from 10/15/25 and 11/20/25 failed to include information on food temperature concerns.During observation of breakfast meal passes on the Kensington 2 Unit, surveyors made the following observations:-On 2/6/26 at 8:00 A.M., the food truck containing meal trays for all residents on the unit, arrived at the unit. At 8:45 A.M., the food truck still contained four breakfast trays that had not been passed.-On 2/9/26 at 8:36 A.M., the food truck contained seven breakfast trays that had not yet been passed. At 8:57 A.M., the food truck contained three breakfast trays that had not been passed. The last tray from the food truck was passed at 9:05 A.M. On 2/9/26 at 11:24 A.M., the surveyor requested a test tray to the Windsor 2 unit and made the following observations: -At 12:59 P.M., the food truck containing the test tray left the kitchen for the Windsor 2 unit. -At 1:01 P.M., the food truck containing the test tray arrived on the Windsor 2 unit and staff began passing trays.- At 1:24 P.M., the last tray was delivered to a resident from the food truck.On 2/9/26 at 1:26 P.M., the surveyor and the Regional Food Service Director (FSD) completed the test tray together and the food temperatures (in degrees Fahrenheit (F) were as follows:- Marinated Chicken Thigh: 112F, tepid/lukewarm to taste- Mixed Vegetables: 118F, tepid/lukewarm to taste- Parmesan Noodles: 110 F, tepid/lukewarm to tasteDuring an interview on 2/9/26 at 1:28 P.M., the Regional FSD said all of the hot food items on the tray could have been warmer. The Regional FSD said he would expect all trays to be passed from the food truck within 15 minutes of the truck arriving to the unit.On 2/10/26 at 7:05 A.M., the surveyor requested a second test tray to the Kensington 2 unit and made the following observations:- At 7:54 A.M., the food truck containing the test tray left the kitchen for the Kensington 2 unit.- At 7:55 A.M., the food truck arrived on the Kensington 2 unit and staff began passing trays.- At 8:39 A.M., the last tray was delivered to a resident from the food truck.On 2/10/26 at 8:40 A.M., the surveyor and Regional FSD completed the test tray together and the food temperatures were as follows:- Oatmeal: 122F, tepid/lukewarm to taste- Scrambled Eggs with Cheese: 96F, cold to taste- Toast: 90F; cold temperature, soggyDuring an interview on 2/10/26 at 8:42 A.M., the Regional FSD and surveyor reviewed the second test tray results from the Kensington 2 unit. The Regional FSD said the eggs tasted good but were cool and the oatmeal was warmish. The Regional FSD said a tray pass of more than 40 minutes was too long. During an interview on 2/10/26 at 8:45 A.M., Unit Manager #1 said the Kensington 2 unit had a lot of residents who needed assistance with eating and staff could only assist so many residents at a time. Unit Manager #1 said she had asked for more help with the tray pass but hadn't gotten it and thought it might be better if trays for residents that required assistance with eating were sent to the unit on a different food truck and not all at once with the other trays.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with acceptable standards for one Resident (#94), out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #94's three inhaler medications were stored securely. Findings include:Review of the facility's policy titled Self-Administration of Medications, undated, indicated but was not limited to the following:- Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.- Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Review of the facility's policy titled Bedside Medication Storage, undated, indicated but was not limited to the following:- Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team.- For residents who self-administer medications the following conditions are met for the bedside storage to occur: 1) The manner of storage prevents access by other residents. Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to the following:- The facility stores all drugs and biologicals in a safe, secure, and orderly manner.- Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Resident #94 was admitted to the facility in December 2025 with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema and weakness. Review of Resident #94's Minimum Data Set (MDS) assessment, dated 12/24/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #94's Physician's Orders indicated but were not limited to:- 2/8/26: May have inhalers at bedside; may self-administer- 12/19/25: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (micrograms per actuation - dosage of medication delivered per puff); one puff inhale orally one time a day for COPD; administered by clinician at 10:00 A.M.- 12/19/25: Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT; one puff inhale orally four times a day for COPD; administered by a clinician at 10:00 A.M./1:00 P.M./7:00 P.M./9:00 P.M.- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT; 2 puff inhale orally every four hours as needed for shortness of breath (SOB); unsupervised self-administration On 2/5/26 at 10:36 A.M., the surveyor made the following observations:- Resident #94 was asleep in bed.- Resident #94's Albuterol inhaler and Combivent inhaler were on top of his/her bedside nightstand, not secured. On 2/5/26 at 11:58 A.M., the surveyor made the following observations:- Resident #94 was asleep in bed.- Resident #94's Albuterol inhaler and Combivent inhaler were on top of his/her bedside nightstand, not secured. On 2/10/26 at 11:20 A.M., the surveyor made the following observations:- Resident #94 was awake but lying in bed on his/her left side facing his/her nightstand. Resident #94's overbed table was positioned behind him/her.- Resident #94's Albuterol inhaler was on top of his/her bedside nightstand, not secured.- Resident #94's Trelegy inhaler and Combivent inhaler were on top of his/her overbed table in bags, not secured. During an interview on 2/10/26 at 11:20 A.M., Resident #94 said he/she can use their Albuterol inhaler independently and he/she keeps it on their nightstand. Resident #94 said he/she usually leaves the inhaler on top of nightstand but does not lock it away or secure it. Resident #94 said the Trelegy inhaler and Combivent inhalers are brought to him/her each day by the nurse to be administered and are not stored in his/her room. Resident #94 said the nurse must have forgotten to take the medications after he/she took them. On 2/10/26 at 1:50 P.M., the surveyor made the following observations:- Resident #94 was awake but lying in bed on his/her left side facing his/her nightstand.- Resident #94's Albuterol inhaler was on top of his/her bedside nightstand, not secured. On 2/11/26 at 8:10 A.M., the surveyor made the following observations:- Resident #94 was awake but lying in bed on his/her left side facing his/her nightstand.- Resident #94's Albuterol inhaler was on top of his/her bedside nightstand, not secured. Review of Resident #94's Self-Administration of Medication assessment, dated 1/15/26, indicated he/she was fully capable of self-administration and approved for self-administration of medications. The assessment failed to indicate any specific medications the Resident was able to administer by his/herself. During an interview on 2/11/26 at 8:20 A.M., Nurse #1 said Resident #94 is able to complete his/her Albuterol inhaler at bedside after being assessed and receiving education by staff regarding self-administration. Nurse #1 said Resident #94 receives two other inhaler medications during morning medication pass that are administered with the nurse. Nurse #1 said she was not sure if medications needed to be locked or safely secured at the bedside. Nurse #1 said she was told the Resident could have his/her medication at the beside and it could be kept out. Nurse #1 said if the medication needed to be secured or locked the order would reflect the storage of the medication. During an interview on 2/11/26 at 9:08 A.M., the Director of Nursing (DON) said Resident #94 has a rescue inhaler for shortness of breath that he/she was assessed for self-administration. The DON said Resident #94 was determined to properly complete self-administration of the rescue inhaler and it is able to be left at the bedside. The DON said the inhaler should be kept in the nightstand but does not need to be locked because it is a rescue inhaler that would need to be used quickly if the Resident required it. The DON and the surveyor reviewed the observations made throughout the survey. The DON said she would not expect the Trelegy or Combivent inhalers to be left at the bedside unsecured.

Based on interview and record review, the facility failed to maintain a safe environment, free of accident hazards for one Resident (#74), out of 35 sampled residents. Specifically, the facility failed to ensure Resident #74's smoking materials were stored securely, and a smoking assessment was completed. Findings include:Review of the facility's policy tilted Smoking Policy and Procedure, undated, indicated but was not limited to:- It is the policy of [Corporate Name] to provide a safe environment for residents, staff and visitors through the enforcement of a smoking policy designed to reduce risks to residents who smoke tobacco products, reduce the risks of passive smoking for others and reduce the risk of fire.- Independent Smoker: a resident who has been assessed by the IDT (Interdisciplinary Team) to be able to smoke safely in the designated area without staff supervision. The Independent Smoker will adhere to all guidelines for safe smoking outlined in this policy and, if there are any infractions, will be re-assessed for safe smoking. The resident must keep all lighting materials at the designated secure area.- All residents expressing the desire to smoke tobacco products or use E-Cigarettes will be assessed upon admission to the center, when there is a change in status and quarterly. Once the facility has assessed the resident, safety interventions will be implemented and added to the resident's plan of care.- A specific care plan will be designed to meet the individual needs of the resident and will be reviewed quarterly and/or with changes in condition. All appropriate safety interventions will be included in this care plan, such as smoking apron, adaptive device, etc.- Tobacco products will be stored in a box on each unit. Each box will have a written list of residents who need safety measures taped inside the box. Resident #74 was admitted to the facility in November 2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and nicotine dependence. Resident #74 was identified by the facility as an independent smoker. Review of the Minimum Data Set (MDS) assessment, dated 10/29/25, indicated Resident #74 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #74's Physician's Orders indicated but were not limited to:- 12/29/25: may go LOA (leave of absence) independently. Review of Resident #74's medical record failed to include an active comprehensive care plan related to smoking. Review of Resident #74's comprehensive care plans indicated he/she had a smoking care plan which was resolved on 12/6/24. Review of Resident #74's medical record failed to indicate a smoking assessment was completed. During an interview on 2/5/26 at 11:42 A.M., Resident #74 said he/she was an independent smoker and would sign themselves out three times a day after meals to smoke outside. Resident #74 said his/her cigarettes and lighter are kept in the top drawer of his/her dresser across from their bed. During an interview on 2/11/26 at 8:15 A.M., Resident #74 said he/she keeps his smoking materials, including lighter and cigarettes, in a sock in his dresser drawer. Resident #74 said no one was able to get the materials in the drawer and declined to let the surveyor observe the location of the smoking supplies. During an interview on 2/11/26 at 8:16 A.M., Nurse #1 said Resident #74 is an independent smoker who signs him/herself out in the unit binder when he/she leaves the facility to smoke. Nurse #1 said Resident #74 was assessed by staff for independent smoking and education was completed with him/her. Nurse #1 said Resident #74 is able to keep smoking supplies in his/her room and they are not kept by nursing staff. During an interview on 2/11/26 at 9:15 A.M., the Director of Nursing (DON) said Resident #74 is an independent smoker and was assessed by nursing staff for his/her safe ability to smoke. The DON said Resident #74's smoking supplies are to be locked up by the nursing staff and given to the Resident when he/she goes out to smoke. The DON said the Resident should return the supplies to the nursing staff when he/she returns to the facility after smoking. The DON and the surveyor reviewed the information gathered throughout the survey. The DON said smoking supplies should be locked and given to staff after returning from smoking and should not be kept in the Resident's dresser. The DON said Resident #74's smoking care plan was accidently resolved by staff and needs to be reinstated.

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one (Kensington 2 unit) of seven nursing units. Specifically, the facility failed to ensure staff provided a meaningful and engaging activity program, including materials for self-directed activity, for residents residing on the Kensington 2 unit (secured).Findings include:Review of the facility's policy titled Activities, last revised December 2025, indicated but was not limited to:-Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being.-Activities will be designed with the intent to:a. Enhance the resident's sense of well-being, belonging and usefulness.b. Create opportunities for each resident to have a meaningful life.c. Promote or enhance physical activity.d. Promote or enhance cognition.e. Promote or enhance emotional health.f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.g. Reflect a resident's interest and age.h. Reflect cultural and religious interests of the residents.i. Reflect choices of the residents.-Activities may be conducted in different ways:a. One-to-One Programsb. Person Appropriate-activities relevant to the specific needs, interests, culture and background, etc., for the resident they are developed for.c. Program of activities-to include a combination of large and small groups. One-to-one, and self-directed as the resident desires to attend.During the entrance conference on 2/5/26 at 8:51 A.M., the Administrator said the Kensington 2 (K2) Unit was a secure unit with several residents with a diagnosis of dementia.Review of the Matrix for Providers (Centers for Medicare and Medicaid Services document used to identify pertinent care categories) provided by the facility on 2/5/26, indicated 25 of 25 residents residing on the K2 unit had a diagnosis of dementia.On the following days of survey, the surveyor made the following observations of the K2 unit activity/dayroom:-2/5/26 from 2:00 P.M. to 2:25 P.M., seven residents were seated in the dayroom at tables with nothing to do. Two residents were wandering throughout the unit. Staff were in the vicinity, but there was no interaction with the residents. The television was on, but the sound was low and inaudible with only three residents facing the television. The activity calendar posted on the wall indicated Family Feud Trivia on the unit at 2:00 P.M. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity.During an interview on 2/6/26 at 11:22 A.M., Unit Manager #1 said they don't have materials or supplies to provide residents with independent activity. She said they could give them a pencil and coloring page, but Activities staff come up to the unit three times a day and provide activities for them.-2/9/26 from 9:15 A.M. to 10:14 A.M., 10 residents were seated in the dayroom at tables with no staff in the immediate vicinity and no staff interaction. The television was on, but only two residents were facing the television. Two residents were sleeping and eight residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity.- 2/10/26 at 9:30 A.M., nine residents were seated in the dayroom at tables with no staff in the immediate vicinity and no staff interaction. The television was off. A speaker positioned on top of a refrigerator in the dayroom was on and playing music but could only be heard by the surveyor when standing directly in front of the refrigerator. The activity calendar posted on the wall indicated room visits at 9:00 A.M. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity.-2/11/26 at 10:00 A.M., 12 residents were seated in the dayroom at tables with no staff in the immediate vicinity and no staff interaction. The television was not on. Two residents were sleeping. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity.During an interview on 2/11/26 at 10:38 A.M., the surveyor reviewed activity observations on the K2 unit with the Activity Director (AD). She said the activity staff only go up to the K2 unit a few times a day for a short period of time and no one else does anything with the residents. She said she is frustrated because there are no supplies available to put together busy boxes for the residents. She said she puts together a list of what she needs to fulfill the activity programming on the calendar and sends it to the Administrator and will get only about 50% of the items.-2/11/26 at 12:46 P.M., 14 residents were seated at tables in the dayroom. All residents were awake and sitting idly with nothing in front of them for self-directed activity. Unit Manager #1 was in the dayroom and instructed the Certified Nursing Assistants (CNA) to begin toileting each resident.During an interview on 2/11/26 at 12:47 P.M., the Unit Manager said activity staff would be coming up to the unit around 2:00 P.M., and residents would have something to do at that time.During an interview on 2/11/26 at 1:00 P.M., CNA #3 said she does not know if any supplies or materials are available to give to residents to use for independent activities instead of sitting idly with nothing to do.During an interview on 2/11/26 at 1:02 P.M., CNA #4 said she did not know if any activity supplies were available to give to residents. She asked UM #1 if there were any activity supplies available for residents to use and the UM said that activity staff are supposed to come up at 2:00 P.M. and they provide activities for them.During an interview on 2/11/26 at 12:51 P.M., Activity Aide #1 said there is a small closet outside of the unit where activity supplies are stored. She brought the surveyor through the unit door into a vestibule, then through another door to a landing at the top of a stairwell. She opened a door to a small closet and pointed out activity materials that are for use by all seven units in the facility, not just the K2 unit. Items stored on shelves in the closet included magazines, books, board games (inappropriate for cognitively impaired residents), a beach ball, a rubber ball, a bag of pool noodles and silk flowers. A fidget sensory busy board was leaning against the back wall of the closet behind the bag of pool noodles and balls. A large plastic storage bin with a secured lid contained several baby clothing items and three busy mats/sensory blankets. The Activity Aide said only activity staff have access to these items and other staff don't use them.

Based on records reviewed and interviews for two of three sampled residents (Resident #2 and #3), the Facility failed to ensure that upon admission, they developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.Findings include:Review of the Facility Policy titled Baseline Care Plans, dated as last revised 05/2025, indicated that a baseline plan of care for each resident is to include the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care. The Policy further indicated that the baseline care plan be developed within 48 hours of admission and supervising staff should verify within 48 hours that a baseline care plan has been developed.1) Resident #2 was admitted to the Facility in 9/2025, diagnoses include a history of a Traumatic Brain Injury (TBI) with seizure disorder, multiple falls, acute urinary retention with an indwelling catheter (flexible tube inserted into the bladder to drain urine) in place, and cirrhosis (severe scarring of the liver from long term damage) secondary to alcohol use.Review of Resident #1 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;-Acute urinary retention with an indwelling catheter in place;-Need for Enhanced Barrier Precautions (infection control measure during high-contact resident care, especially for those with devices);-High risk for falls related to seizure disorder; and-Titration of antipsychotic medication.Review of Resident #2's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented to address these areas of concern within 48 hours of his/her admission.2) Resident #3 was admitted to the Facility in 11/2025, diagnoses chronic obstructive pulmonary disease, pneumonia, Normal Pressure Hydrocephalus (NPH, an excess of cerebrospinal fluid builds up in the ventricles) dysphagia (difficulty swallowing) with the need for a gastrostomy tube (tube inserted into stomach to provide nutrition), and pressure injury. Review of Resident #3 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;- Pneumonia with antibiotic and oxygen use;-Gastrostomy Tube in place for Nutrition.-Need for Enhanced Barrier Precautions;-Anticoagulation therapy; and-Actual Pressure Injury and continued risk for skin breakdown.Review of Resident #3's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented, or that the Comprehensive Care Plans addressed these areas of concern were in place within 48 hours of admission.During an interview on 12/02/25 at 2:16 P.M., the Unit Manager said that she was not aware that Residents # 2 and #3 did not baseline care plans completed and said that it was a team effort to complete the baseline care plans starting with the admitting nurse.The Unit Manager said that as a team, the management staff are to review a new admission chart the next day at morning meeting to ensure that the baseline care plans are completed.During an interview on 12/02/25 at 4:07 P.M., the Assistant Director of Nurses (ADON) said that she was unaware that Resident #2 and Resident #3's baseline care plans had not been completed.The ADON said that the admitting nurses are responsible for initiating the baseline care plan for the residents and each section should be filled out. The ADON said that the team is to review the baseline care plans the day after admission (or as close to) for completion. During an interview on 12/02/25 at 4:54 P.M., the Director of Nurses (DON) said that she was not aware of Residents #2, and #3 baseline care plans were incomplete and had not addressed their immediate care needs.The DON said that it is the Facility's expectation that the admitting nurse is to initiate the resident's baseline care plan and said, along with the other disciplines complete the Baseline care plan within 48 hours of admission.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), whose Hospital Discharge Summary included instructions related to voiding trials and the removal of his/her indwelling catheter (flexible tube inserted into the bladder to drain urine), the Facility failed to ensure he/she underwent a voiding trial and was assessed timely for potential removal of the catheter, which resulted in the extended use of an indwelling device.Findings include:Resident #2 was admitted to the Facility in 9/2025, diagnoses include a history of a Traumatic Brain Injury (TBI) with seizure disorder, multiple falls, acute urinary retention with an indwelling catheter in place, and cirrhosis (severe scarring of the liver from long term damage) secondary to alcohol use.Review of Resident #2's Hospital Discharge summary, dated [DATE], indicated that an indwelling catheter had been placed secondary to acute urinary retention. The Discharge Summary indicated to attempt a voiding trial once discharged from the acute hospital and remove the indwelling catheter as able.Review of Resident #2's admission Minimum Data Set (MDS) assessment, dated 10/02/25, indicated he/she had an indwelling catheter. Review of Resident #2's Care Plan titled Indwelling Catheter, dated 10/16/25, indicated he/she had a urinary catheter, however the care plan failed to include interventions related to conducting voiding trials and attempting to remove the indwelling device.Review of Resident #2's Physician Assistant Progress Note, dated 10/20/25, indicated to follow-up with urology for any voiding trials.Review of Resident #2's medical record indicated that there was no documentation to support nursing staff communicated with urology, attempted a voiding trial or removed the indwelling catheter as indicated in his/her Hospital Discharge Summary.During an interview on 12/02/25 at 12:29 P.M., Resident #2 said he/she had no idea why he/she still has an indwelling catheter in place and wondered when they would be taking the tube out!During an interview on 12/02/25 at 12:42 P.M., Nurse #9 said that she does not know why Resident #2 had an indwelling catheter in place and said that she does not know why they have not attempted to remove Resident #2's indwelling catheter.During an interview on 12/02/25 at 4:54 P.M., the Director of Nurses (DON) said that she was not aware that Resident #2 had instructions on his/her discharge summary to attempt a voiding trial and to remove his/her indwelling catheter as able.The DON said that it is the Facility's expectation that nursing read each resident's discharge summary and verify all orders upon admission. The DON said that all indwelling catheters should be removed in a timely manner unless otherwise indicated by a physician.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure thickened beverage items were properly dated and stored in three of seven kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Review of the facility's policy titled Food Receiving and Storage, undated, indicated but was not limited to: Policy: Food shall be stored in a manner that complies with safe food handling practices. Policy interpretation and implementation: Food items and snacks kept on the nursing units must be maintained as indicated below: -All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses' station and labeled with a use by date; -Beverages must be dated when opened and discarded after 24 hours; -Other opened containers must be dated and sealed or covered during storage. The surveyor made the following observations: 11/12/24 at 10:37 A.M. (Windsor 1 Unit): -one opened thickened cranberry juice container, undated. Manufacturer label stated: after opening, may be kept up to seven days under refrigeration; 11/12/24 at 2:55 P.M. (Kensington 1 Unit): -two opened containers of thickened dairy beverage, undated. Manufacturer label stated: Discard if not used within four days of opening; 11/13/24 at 9:02 A.M. (Kensington 1 Unit): -three opened containers of thickened apple juice, undated. Manufacturer label stated: after opening, may be kept up to seven days under refrigeration; -two opened containers of thickened dairy beverage, undated. Manufacturer label stated: Discard if not used within four days of opening; 11/13/24 at 9:13 A.M. (Windsor 1 Unit): -one opened thickened cranberry juice container, undated. Manufacturer label stated: after opening, may be kept up to seven days under refrigeration; 11/14/24 at 12:45 P.M. ([NAME] Unit): -two opened containers of thickened juice, undated. Manufacturer label stated: after opening, may be kept up to seven days under refrigeration. During an interview on 11/14/24 at 3:45 P.M., the Food Service Director (FSD) and surveyor observed one opened container of thickened juice on the Windsor 1 Unit. The FSD said he expected the staff member who opened the thickened juice container to have written the date the beverage was opened. Additionally, the FSD said he expected all thickened beverage to be dated with an opened date and for staff to utilize the manufacturer's recommendations for length of storage.

Based on observations, interviews, and records reviewed, the facility failed to ensure a reasonable accommodation was made for seven Residents (#150, #101, #49, #148, #65, #102, and #93), on the Sunshine Unit with a census of 35. Specifically, the facility failed to ensure the call system was accessible to the Residents to call for staff assistance. Findings include: Review of the facility's policy titled Resident Call System, undated, indicated but was not limited to: -When in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers. 1. On the following dates and times, the surveyor observed Resident #150 without a means of directly contacting caregivers. The surveyor observed Resident #150 in bed with the call light clipped to itself and hanging against the wall, not within the Resident's reach, with no hand-held device (i.e., hand bell) observed: -11/12/24 at 10:53 A.M., -11/12/24 at 3:35 P.M., -11/13/24 at 9:11 A.M., -11/13/24 at 11:36 A.M., -11/13/24 at 2:08 P.M., -11/13/24 at 4:40 P.M., -11/14/24 at 8:05 A.M., and -11/14/24 at 3:18 P.M. 2. On the following dates and times, the surveyor observed Resident #101 without a means of directly contacting caregivers. The surveyor observed Resident #101 in bed with the call light cord draped over a wall mounted monitoring device above the headboard, not within the Resident's reach, with no hand-held device observed: -11/12/24 at 10:52 A.M., -11/12/24 at 3:35 P.M., -11/13/24 at 9:11 A.M., -11/13/24 at 11:36 A.M., -11/13/24 at 2:08 P.M., -11/14/24 at 8:05 A.M., and -11/14/24 at 3:18 P.M. 3. On the following dates and times, the surveyor observed Resident #49 without a means of directly contacting caregivers. The surveyor observed Resident #49 in bed with the call light cord draped over a wall mounted monitoring device above the headboard, not within the Resident's reach, with no hand-held device observed: -11/12/24 at 10:06 A.M., -11/12/24 at 3:34 P.M., -11/13/23 at 9:12 A.M., -11/13/23 at 11:34 A.M., -11/13/23 at 2:14 P.M., -11/13/23 at 4:43 P.M., and -11/14/24 at 3:19 P.M. 4. On the following dates and times, the surveyor observed Resident #148 without a means of directly contacting caregivers. The surveyor observed Resident #148 in bed with the call light cord clipped to itself and hanging against the wall, not within the Resident's reach, with no hand-held device observed: -11/12/24 at 9:57 A.M., -11/12/24 at 1:46 P.M., -11/12/24 at 3:36 P.M., and -11/13/24 at 4:44 P.M. 5. On the following dates and times, the surveyor observed Resident #65 without a means of directly contacting caregivers. The surveyor observed Resident #65 in bed with the call light cord draped over a wall mounted monitoring device above the headboard, not within the Resident's reach, with no hand-held device observed: -11/12/24 at 10:03 A.M., -11/12/24 at 1:39 P.M., and -11/12/24 at 3:30 P.M. 6. On 11/12/24 at 9:57 A.M., the surveyor observed Resident #102 without a means of directly contacting caregivers. The surveyor observed Resident #102 in bed with the call light cord clipped to itself and hanging against the wall, not within the Resident's reach, with no hand-held device observed. 7. On 11/12/24 at 9:52 A.M., the surveyor observed Resident #93 without a means of directly contacting caregivers. The surveyor observed Resident #93 in bed with the call light cord clipped to itself and hanging against the wall, not within the Resident's reach, with no hand-held device observed. During an interview on 11/14/24 at 4:08 P.M., Certified Nursing Assistants (CNA) #2, #3, and #4 said the facility staff know a resident needs help when they ring the call light. CNAs #2, #3, and #4 said all residents should be able to reach their call light when in their room. During an interview on 11/14/24 at 4:06 P.M., Nurse #1 said she knew when a resident needed help because they used the call light. Nurse #1 said residents should always have access to a call light. During an interview on 11/14/24 at 5:03 P.M., the Assistant Director of Nurses (ADON) said residents should always have the call light within reach. The surveyor and the ADON observed Residents #101, #150 and #49 in bed with their call lights out of reach. The ADON said the call lights should have been within reach. During an interview on 11/14/24 at 5:07 P.M., Regional Nurse #2 said all residents should have access to their call lights and a means of contacting staff when in their rooms.

Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident rooms were maintained in good repair (without holes, painted) and homelike on one unit (K2) out of seven. Findings include: Review of the facility's policy titled Royal Health Group Preventative Maintenance Program, undated, indicated but was not limited to: -A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functioning, sanitary, and comfortable environment for residents, staff, and the public. -The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 11/13/24 at 8:30 A.M. on the K2 unit, the surveyor observed: -room [ROOM NUMBER]-B: Missing a privacy curtain; and a hole in the wall with paint cracking -room [ROOM NUMBER]-B: Blinds with four areas of brown stains -room [ROOM NUMBER]-B: Ripped floor mats exposing the foam inside; and a broken footboard on the bed -room [ROOM NUMBER]-B: A hole in the windowsill with paint chipping and peeling; and a broken window that would not close with four towels placed in the open window to decrease a cold draft in the room During an interview on 11/13/24 at 8:59 A.M., Certified Nurse Aide (CNA) #5 said maintenance requests for repairs are written in a logbook on the unit for someone from maintenance to review. During follow-up visits to the unit on 11/14/24 at 9:54 A.M., and 11/14/24 at 3:10 P.M., the same observations were made by the surveyor on the K2 unit as during the initial tour on 11/13/24. During an interview on 11/14/24 at 9:43 A.M., the Maintenance Director said he recently just started at the facility, and they have begun rolling out the implementation of the TELS system as of 11/11/24. He said he rounds on the units regularly and he wasn't aware of any issues on the K2 unit. Review of the TELS log indicated the need for repairs were not reported. During an interview on 11/14/24 at 9:49 A.M., Nurse #2 said she was not aware there were any repairs that needed to be requested on the unit. She said if she notices something she will put it in the log and she depends on the staff providing care in resident rooms to report issues. During an interview on 11/14/24 at 12:06 P.M., the Administrator said he was aware the building needed repairs and there were quite a few unfinished work orders from the previous maintenance director. He said the current Maintenance Director has only been in the role for a week. During an interview with observation on 11/14/24 at 3:10 P.M., the Administrator and Regional Nurse #2 toured the K2 unit with the surveyor. The Administrator and Regional Nurse #2 agreed that the fall mats, walls, windows, and other broken items should have been identified and repair. The Administrator said one possibility for the lack of repairs could be fatigue from the staff from making multiple requests to the previous maintenance director with no follow-up. He said sometimes we just get used to how something appears. The Regional Nurse #2 said the environment should be sanitary and in good repair for the residents to experience a homelike environment.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#67) was provided a therapeutic diet as ordered, in a total sample of 34 residents. Specifically, Resident #67, with weight loss, was not provided fortified food as ordered. Findings include: Review of the facility's policy titled Fortified Food Program, undated, indicated the following: -the goal of the fortified food program is to provide a higher calorie and higher protein food item to residents -a fortified food is typically a food from the regular diet with additional ingredients which provide extra calories and/or protein without increasing the volume of food offered to the resident Resident #67 was admitted to the facility in April 2024 with diagnoses of dementia and failure to thrive. Review of the care plan indicated Resident #67 had a nutritional problem related to decreased appetite with a goal of maintaining adequate nutritional status. The care plan interventions included having fortified foods with all meals. Review of the Physician's Orders indicated that an order was written on 10/16/24 for a house diet, regular texture, with fortified foods with all meals and Magic Cup (high calorie, ice cream-like nutritional supplement) with lunch and dinner. Review of the weights for Resident #67 indicated the Resident weighed 109.5 pounds (lbs.) on 7/10/24 and 99.5 lbs. on 8/28/24, a loss of 9.13% in six weeks. Review of the weights indicated the Resident weighed 102.0 lbs. on 9/3/24 and 99.8 lbs. on 10/1/24. Review of the medical record indicated Resident #67 had been hospitalized for five days in October 2024. Review of the Quarterly Nutritional Assessment, dated 10/18/24, indicated Resident #67 was at nutritional risk related to a diagnosis of dementia and variable intake of food and the Resident would continue to have fortified foods at all meals. On 11/13/24 at 1:18 P.M., the surveyor observed Resident #67 in the unit dining room having lunch of seasoned fish, noodles, and cauliflower. Review of the meal ticket indicated Resident #67 was to have fortified mashed potatoes. There were no fortified foods observed with the Resident's meal. On 11/14/24 at 9:18 A.M., the surveyor observed Resident #67 in the unit dining room having breakfast of pancakes, sausage link, cold cereal and fruit cup. Review of the meal ticket indicated Resident #67 was to have fortified hot cereal of choice. There were no fortified foods observed with the Resident's meal. On 11/14/24 at 1:24 P.M., the surveyor observed Resident #67 in the unit dining room having lunch of seasoned chicken, macaroni and cheese, and brussels sprouts. Review of the meal ticket indicated Resident #67 was to have fortified mashed potatoes and Magic Cup. There were no fortified foods or Magic Cup observed with the Resident's meal. During an interview on 11/14/24 at 1:25 P.M., Nurse #3 said fortified foods were usually the oatmeal in the morning and the mashed potatoes. The Nurse observed the meal for Resident #67 and said she could not be sure if anything on the plate was fortified because there were no mashed potatoes. She said she had no way of knowing if the kitchen made additional food items fortified. She said she noticed the Resident's meal did not come with a Magic Cup and she had called down to the kitchen for them to send some up to the unit. During an interview on 11/14/24 at 2:26 P.M., the Registered Dietitian said the facility utilized oatmeal/hot cereal for a fortified food at breakfast and mashed potatoes for lunch and dinner. She said the facility did not have any other fortified foods. She said Resident #67 was a high nutritional risk and had been experiencing weight loss and should be getting fortified foods. She said the kitchen should be putting the fortified foods on to the meal trays as indicated on the tray tickets. She said the kitchen was responsible for putting the Magic Cups on the meal trays and this should be included if indicated on the tray ticket.

Based on interview and record review, the facility failed to assess triggers for a Resident (#22) with a history of trauma, to avoid potential re-traumatization, out of a total sample of 34 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as revised in November 2023, indicated the following: -the commitment to recognize events in resident's past that may have been traumatic and may continue to have a negative, upsetting or emotionally difficult impact on their lives -as part of the admission process a specific assessment will be done consisting of several questions that are worded to assesses past experiences and not trigger the episode -once the initial assessment has been completed by Social Services a choice can be made to proceed or not to proceed to a psych referral based on responses -if a resident has a history of trauma that is documented or if they have triggered from the assessment the Social Worker (SW) and Interdisciplinary team (IDT) need to immediately formulate a plan of care to assist the resident in coping within the facility -the plan of care needs to be specific and include anything that has been shared that could trigger a memory of the incident -staff education should be done to identify any resident reactions that may indicate past trauma and what to do with that information Resident #22 was admitted to the facility in June 2015. Review of the medical record indicated a new diagnosis of post-traumatic stress disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) in December 2023. Review of the care plans indicated Resident #22 had a trauma history with a goal of being comfortable during their stay. The interventions included: staff assistance with referral to psychiatric services as needed, assistance with monitoring for signs and symptoms of anxiety, hyperarousal or panic and requiring staff assistance with monitoring for signs and symptoms of depression including low self-esteem and trust issue. Review of the nursing progress note, dated 12/18/23, indicated Resident #22 had reported a sexual assault to his/her daughter and the daughter informed staff that Resident #22 had a history of sexual assault. Review of the social service progress note, dated 12/19/23, indicated Resident #22 said something happened a long time ago and emotional support was provided. Review of the Trauma Assessment, dated 12/26/23, indicated the following responses: Have you ever had a life-threatening medical condition: No Have you ever experienced something that made you feel threatened in the past or present: yes Have you ever had nightmares about something that happened to you or that you witnessed happen to someone else: yes What was your childhood like: ok If married or in serious relationship, what was that relationship like: NA Do you often feel on edge or that you are outside looking in on yourself: no Proceed to referral: Yes Review of the Follow-up Psychiatric Evaluation from the consultant Psychiatrist indicated delusional, believes foster staff may be here trying to harm him/her. During an interview on 11/15/24 at 9:05 A.M., Social Worker #1 said she had completed the Trauma Assessment for Resident #22 and had met with the Resident in December 2023. She said the Social Workers were responsible for completing the Trauma Assessment to determine if there was a history of trauma and then refer to psych services if needed, but did not inquire about triggers that may re-traumatize a Resident. She said the nurses would inquire about triggers for trauma, especially when related to sexual assault. She said Resident #22 was very conversant and was able to make his/her needs known. She said she did not inquire with the Resident if there was anything in particular which may be upsetting or trigger the trauma and would have to check with nursing to see if this was done. The surveyor and the Social Worker reviewed the Psychiatric Evaluation from 12/21/23. The Social Worker said she did not know what foster staff meant or if the Resident was ever in foster care. During an interview on 11/15/24 at 9:45 A.M., the Assistant Director of Nurses said the process for trauma informed care was for the Social Workers to complete the assessment to determine if there was a history of trauma and if there were triggers so that staff could be aware. She said if a resident has trauma, the triggers need to be identified so that staff can be educated on the triggers to avoid any additional re-traumatization. She reviewed the Trauma Assessment for Resident #22 and said the assessment did not indicate the type of trauma or the triggers and was not elaborate. She reviewed the care plan for Resident #22 and said the care plan did not include the trauma information or triggers. She said the facility staff would need to know what to do to keep the resident safe and the information wasn't available in this assessment or care plan.

Based on observation, interview, and record review, the facility failed to ensure that for two Residents (#86 and #232), of a total sample of 34 residents, that Minimum Data Set (MDS) assessments accurately reflected the residents' status. Findings include: 1. Resident #232 was admitted to the facility in September 2024 with diagnoses which included a fall requiring rehabilitation. Review of the MDS assessment, dated 9/26/24, indicated, under the Physical Restraint section, P0100, that bed rails were not used. Review of the Physician's Orders, dated 9/16/24, indicated that bed rails were to be used daily. From 11/12/24 to 11/14/24, the surveyor observed each day of the survey that Resident #232's bed rails were in place and up, on the left and right upper part of the Resident's bed. During an interview on 11/13/24 at 10:52 A.M., Nurse #4 said that the Resident used bed rails daily. Nurse #4 reviewed the assessment dated [DATE] and said it was inaccurate because bed rails were used daily and the assessment should have been coded 2 Used daily instead of 0, Not used. 2. Resident #86 was admitted to the facility in January 2022 with diagnoses which included cerebrovascular accident (CVA). Review of the MDS assessment, dated 10/7/24, indicated, under Bowel and Bladder Section H, that the Resident did not have an indwelling catheter. On 11/12/24 at 11:30 A.M., the surveyor observed Resident #86 to have a Foley catheter in place. Review of Resident #86's record indicated that he/she utilized a urinary catheter for urinary drainage. Review of the current Physician's Order indicated: -16 French Foley catheter with a 10 milliliter (ml) balloon -Nursing to perform catheter care every shift, fluid output monitoring every shift, and irrigate with normal saline as needed. During an interview on 11/14/24 at 10:45 A.M., Unit Manager #3 said the MDS assessment, dated 10/7/24, was inaccurate, as it did not code the Resident for having an indwelling Foley catheter. Unit Manager #3 said Resident #86 has had the Foley catheter in place for months, going back to when the Resident developed a Stage 2 coccyx pressure ulcer following a hospitalization in April 2024.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), who experienced a decline in condition with weakness, and who had a new physicians order in effect on 4/24/23 at the start of the evening shift, for nursing obtain a urine sample STAT (obtain sample immediately) for testing, the Facility failed to ensure nursing notified the provider when 24 hours later, they had been unable to obtain the sample. Findings include: Review of the Facility's Policy titled, Change in a Resident's Condition or Status, undated, indicated that the Nurse will promptly notify the resident's physician when there has been a significant change in the resident's medical, physical, emotional, mental condition or status. The Policy indicated that the Nurse will notify the physician when there has been a need to alter the resident's medical treatment significantly and except in medical emergencies, notifications will be made within 24 hours of a change in the resident's medical, mental change in condition or status. Review of the Facility's Policy titled, Charting and Documentation, dated as revised October 2022, indicated that any changes in the resident's medical, physical, functional or psychosocial condition, treatments or services performed shall be documented in the resident's medical record and notification of the physician and family. Resident #1 was admitted to the Facility in September 2022, diagnoses included Alzheimer's disease, atherosclerosis disease, hypothyroidism, hyperlipidemia, thrombocytopenia (shortage of platelets in the blood, which increases the risk of bleeding) and COVID-19. Review of Resident #1's Physician's Order, dated 04/24/23 at 4:08 P.M., indicated to collect urine for urinalysis and culture and sensitivity STAT (to be obtained immediately). Review of a Nurse Progress Note, dated 4/24/23 at 11:01 P.M., written by Nurse #1, indicated that Resident #1 was weak and had a new order for STAT labs and a urine culture. The Note indicated that the labs were obtained, and results were pending. The Note further indicated that the urine was attempted twice to be obtained, but was not successful in obtaining a urine. During an interview on 11/20/23 at 2:16 P.M., Nurse #1 said that she worked on 4/24/23 during the 3:00 P.M. to 11:00 P.M. shift. Nurse #1 said that Resident #1 was weak and had a change in condition during her shift. Nurse #1 said that the Nurse Practitioner (NP) ordered STAT labs and STAT urine sample for urinalysis and culture and sensitivity. Nurse #1 said that she was unable to obtain a urine sample during her shift. Nurse #1 said that she reported this information to the 11:00 P.M. to 7:00 A.M. shift nurse. Nurse #1 said that she did not notify the physician or NP that she was unable to obtain a urine sample during her shift. Review of a Nurse Progress Note, dated 4/25/23 at 6:38 A.M., written by Nurse #3, indicated that Resident #1 was restless all night, repeatedly removed his/her oxygen nasal cannula and removed his/her clothes multiple times. The Note indicated that despite multiple attempts his/her urine sample for urinalysis and culture and sensitivity was unable to be obtained. During a telephone interview on 12/05/23 at 6:55 A.M., Nurse #3 said that she worked on the 11:00 P.M. to 7:00 A.M. shift on 4/24/23 (the shift after Nurse #1 had worked). Nurse #3 said that she was unable to obtain Resident #1's urine and said she reported that information to the 7:00 A.M. to 3:00 P.M. nurse. Nurse #3 said that she did not notify the physician or NP that she was unable to obtain the urine during her shift. During a telephone interview on 12/04/23, Nurse #4 said that she worked on the 7:00 A.M. to 3:00 P.M. shift on 4/25/23. Nurse #4 said she could not recall if she notified the physician or NP that she was unable to obtain a urine sample on Resident #1. Nurse #4 said that if she had notified the physician or NP, there would be a nurse's note written in Resident #1's medical record to indicate that she notified the physician or NP. Review of a Nurse Progress Note, dated 4/25/23 at 3:28 P.M., written by Nurse #4, indicated that she attempted to obtain a urine sample on Resident #1 and was unable to obtain the urine. Further review of Nurse #4's Progress Note, dated 4/25/23, indicated there was no documentation to support that the Physician or NP were notified that she was unable to obtain Resident #1's urine sample During a telephone interview on 12/04/23 at 8:35 A.M., Nurse #2 said that she worked on the 3:00 P.M. to 11:00 P.M. shift on 4/25/23. Nurse #2 said that she could not recall if she notified the physician or NP that she was unable to obtain a urine sample on Resident #1. Nurse #2 said that if she did notify the physician or NP, there would be a nurse's note written in Resident #1's medical record to indicate that she notified the physician or NP. Review of a Nurse Progress Note, dated 4/25/23 at 9:26 P.M., written by Nurse #2, indicated that she was unable to obtain a urine sample on Resident #1. Further review of Nurse #2's Progress Note, dated 4/25/23, indicated there was no documentation to support that the Physician or NP were notified that she was unable to obtain Resident #1's urine sample Review of Resident #1's Medical Record indicated there was no documentation to support that nursing staff notified the physician or NP that they were unable to obtain a urine sample for Resident #1. Review of Resident #1's Medical Record indicated there was no documentation to support that the STAT urine sample that was ordered on 4/24/23 was ever obtained. During an interview on 12/06/23 at 10:21 A.M., the Director of Nursing (DON) said that Resident #1's urine sample that was ordered on 4/24/23 was never obtained by nursing and said that neither the physician or the NP were notified. The DON said it was her expectation that nursing notified the physician or NP that they were unable to obtain a urine sample so further orders could be obtained.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a physicians order for STAT (to be obtained immediately) bloodwork, the Facility failed to ensure abnormal laboratory results were promptly reported to his/her Health Care Providers (Physician or Nurse Practitioner (NP). On 04/24/23 Resident #1's laboratory results were reported to the Facility by the laboratory via their electronic medical record system, Point Click Care (PCC), however the results were not reported to his/her Health Care Provider until the following day. Findings Include: Review of the Facility's Policy, titled Lab and Diagnostic Test Results - Clinical Protocol, dated as revised October 2022, indicated the following: -the physician will order lab testing, the staff will arrange for the tests and the laboratory will report test results to the facility; -the nurse will review all results and communicate the results to the physician; -the nurse will identify the urgency of communicating with the physician based on the seriousness of any abnormality; -nursing staff will consider situations requiring prompt physician notification such as: the result is something that should be conveyed to a physician regardless of other circumstances-the abnormal result is problematic regardless of any other factors, whether the resident's clinical status is unclear or worsening; -if resident has signs and symptoms of acute illness or condition change and he/she is not stable or improving, the nurse will notify the physician promptly; -the Facility staff should document information about when, how, and to whom the information was provided and the response in the Progress Notes of the medical record. Resident #1 was admitted to the Facility in September 2022, diagnoses included Alzheimer's disease, atherosclerosis disease, hypothyroidism, hyperlipidemia, thrombocytopenia (shortage of platelets in the blood, which increases the risk of bleeding) and COVID-19. Review of Resident #1's Physician's Order, dated 04/24/23 at 4:14 P.M., indicated to obtain STAT labs for Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and Thyroid Stimulating Hormone (TSH). Review of Resident #1's Laboratory Report, dated 4/24/23, indicated the blood sample was collected on 4/24/23 at 6:00 P.M. The Laboratory Report indicated that Resident #1 had multiple abnormal laboratory results that flagged. The Laboratory Report indicated that Resident #1's abnormal laboratory results were reported to the facility on [DATE] at 11:25 P.M. During a telephone interview on 12/05/23 at 8:33 A.M., the Laboratory Customer Service Representative said Resident #1's blood laboratory results for 4/24/23 had multiple abnormal labs that flagged as abnormal labs and was reported to the Facility via fax on 04/24/23 at 11:25 P.M. Review of a Nurse Progress Note, dated 4/24/23 at 11:01 P.M., written by Nurse #1, indicated that Resident #1 was weak and had a new order for STAT labs and a urine culture. The Note indicated that the labs were obtained, and results were pending. During an interview on 11/20/23 at 2:16 P.M., Nurse #1 said that she worked on 4/24/23 during the 3:00 P.M. to 11:00 P.M. shift. Nurse #1 said that Resident #1 was weak and had a change in condition on 4/24/23 during her shift. Nurse #1 said that the Nurse Practitioner (NP) ordered STAT labs and a urinalysis and urine for culture and sensitivity. Nurse #1 said that the labs were drawn during her shift but that the results of his/her bloodwork were not received during her shift. Nurse #1 said that she reported this information to the 11:00 P.M. to 7:00 A.M. shift nurse. Review of a Nurse Progress Note, dated 4/25/23 at 6:38 A.M., written by Nurse #3, indicated that Resident #1 was restless all night, repeatedly removed his/her oxygen nasal cannula and removed his/her clothes multiple times. During a telephone interview on 12/05/23 at 6:55 A.M., Nurse #3 said that she worked on the 11:00 P.M. to 7:00 A.M. shift on 4/24/23 (the shift after Nurse #1 had worked). Nurse #3 said she did not recall being told during the change of shift report with Nurse #1 that Resident #1 had STAT labs drawn. Nurse #3 said that if he/she had abnormal labs, she would have notified the Physician or NP. Review of the Facility Staffing Schedule, dated 04/24/23, indicated that Nurse #3 was scheduled on the unit where Resident #1 resided for the 11:00 P.M. to 7:00 A.M. shift. Review of Resident #1's Medical Record indicated there was no documentation to support that nursing reported the abnormal blood laboratory results to his/her Physician or Nurse Practitioner until 4/25/23 during the 7:00 A.M. to 3:00 P.M. shift. During an interview on 11/20/23 at 1:09 P.M., the Director of Nursing (DON) said that her expectation is that nursing reports any abnormal labs to the physician or nurse practitioner immediately so that further orders can be obtained.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had lost his/her upper dentures in October 2022, the Facility failed to ensure he/she had a timely dental consultation for the replacement of his/her upper dentures. Resident #1 was not seen by the dentist until July 2023 for the fabrication of the upper dentures, nine months after the loss of his/her upper dentures. Findings Include: Review of the Facility's Policy, titled Dental Services, dated May 2023, indicated the following: -routine and emergency dental services are available to meet the resident's oral health services; -facility will contract with a Consultant Dentist to provide services on site; -dentures will be protected from loss or damage, to the extent practicable, while being stored; -if dentures are lost, residents will be referred for dental services within three days; -if the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay. Resident #1 was admitted to the Facility in September 2022, diagnoses included Alzheimer's disease, atherosclerosis disease, hypothyroidism, hyperlipidemia, thrombocytopenia (shortage of platelets in the blood, which increases the risk of bleeding) and COVID-19. Review of Nurse Progress Note, dated 10/06/22, indicated that Resident #1's daughter called the facility to report that his/her upper dentures were missing. Review of a Speech Therapy Evaluation and Plan of Treatment, dated 10/19/22, indicated that Resident #1 lost his/her upper dentures and diet was downgraded to ground textured diet. During an interview on 11/20/23 at 12:10 P.M., the Speech Language Pathologist (SLP) said that Resident #1 lost his/her upper dentures in October 2022. The SLP said that she evaluated Resident #1 in October 2022 when his/her upper dentures were lost and said she recommended a ground textured diet for him/her due to his/her lost upper dentures. The SLP said that no one ever notified her that Resident #1 had received upper dentures and said Resident #1 was still currently on a ground textured diet. Review of Resident #1's Medical Record indicated there was no documentation to support that the Facility notified the Dentist they contracted with, of Resident #1's lost upper dentures until eight months after they were lost. Review of a Dental Consult, dated 6/02/23, indicated that Resident #1 was seen for an initial examination. Review of a Dental Consult, dated 7/19/23, indicated that Resident #1 presented with a complaint of lost upper dentures. The Consult indicated that fabrication of new upper dentures to aid in eating was recommended for Resident #1. Review of a Dental Consult, dated 10/04/23, indicated that Resident #1 had alginate impressions taken for fabrication of new upper dentures and denture Step one completed. During an interview on 12/04/23 at 12:42 P.M., the Administrator said his expectation is that whenever dentures are lost, the Dental Service is contacted timely and new dentures are made for the resident a timely manner. The Administrator said that no resident should be waiting over a year for new dentures. During an interview on 12/04/23 at 12:47 P.M., the Director of Nurses (DON) said that a grievance regarding Resident #1's lost upper dentures should have been completed in October 2022. The DON said that the dental process for dentures takes a while and said that it was her expectation that Resident #1 would see the dentist as soon as possible to start the denture process. The DON said she could not explain why that did not happen and said Resident #1 should not have waited nine months to have the denture process begin. The DON said that Resident #1 should finally have his/her upper dentures sometime in January 2024.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was provided with necessary care and services, including an assist of two staff persons when being transferred in a mechanical lift, when Certified Nurse Aide (CNA) #1 transferred Resident #1 using a mechanical lift without another staff member present to help her, Resident #1 fell out of mechanical lift on to the floor, sustained a head injury and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Food and Drug Administration (FDA)'s Patient Lifts Safety Guide, undated, indicated that using the wrong sling or attaching the sling incorrectly may result in serious injury or death. The Guide indicated the use of two staff persons during resident-transfers with mechanical lifts to ensure residents' safety. The Facility's Abuse Policy, revised 02/15/19, indicated that the failure to provide treatment and services to maintain resident's health and safety constituted neglect. Resident #1 was admitted to the Facility in (MONTH) 2014, medical history included generalized muscle weakness, falls, [MEDICAL CONDITION], difficulty in walking, heart failure and Dementia. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL) Function / Rehabilitation Potential, dated 2/19/19, indicated that Resident #1 was dependent on staff members to provide ADL care due to his/her limited functional status. Plan of Care interventions included that Resident #1 to have two staff members when transferring him/her with the mechanical lift. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 5/1/19, indicated that Resident #1 was totally dependent with ADL care and that he/she required the assistance of two staff persons with transfers and bed mobility. The Facility's Incident Report, dated 6/23/19, indicated that Resident #1 was observed lying on the floor in his/her bedroom, that Resident #1's head and neck were on the metal base of the mechanical lift and that blood was noted under his/her head and neck. A Nurse Progress Note, dated 6/23/19, indicated that at approximately 8:05 P.M., this writer (Nurse #1) heard a bang sound come from Resident #1's room, and upon entering the room, found Resident #1 on the floor. The Note indicated that Resident #1's head and neck were on the metal base part of the mechanical lift and that Certified Nurse Aide (CNA) #1 was found in the room, alone with Resident #1. The Note indicated that blood was found under Resident #1's head and neck and that he/she was transferred to the hospital. The Hospital Discharge Summary, dated 6/23/19, indicated that Resident #1 was diagnosed with [REDACTED]. A Nurse Progress Note, dated 6/24/19, indicated that Resident #1 had a bruise on the back of his/her head measuring 3.8 centimeters (cm) by 2.7 cm. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 07/03/19. Nurse #1 said she was on the medication cart in the hallway on 6/23/19 when she heard a loud sound from Resident #1's room, that went to the room and found Resident #1 on the floor and that CNA #1 was alone with him/her. Nurse #1 said she saw blood on the floor underneath Resident #1's head. Nurse #1 said Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) # 1 at 10:20 A.M. on 07/02/19. CNA #1 said she took Resident #1 into his/her room at approximately 8:00 P.M. on 06/23/19 to perform evening care. CNA #1 said Resident #1 fell from the mechanical lift to the floor during the transfer and he/she hit her head. CNA #1 said she knew she needed a second staff member when doing a mechanical lift transfer and said she transferred Resident #1 alone because other staff members were busy providing care to other residents. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 10:00 A.M. on 7/2/19. CNA #3 said she cared for Resident #1 in the past and said she was aware that his/her care plan interventions included having two staff members present when transferring Resident #1 with the mechanical lift. The Surveyor interviewed the Staff Development Coordinator (SDC) at 11:15 A.M. on 7/2/19. The SDC said that it was facility policy and procedure to have two staff members transfer residents whenever the mechanical lift device was used. The SDC said she in-serviced the nursing staff that resident should be left safe in bed until help arrived, rather than be transferred with the mechanical lift by one person, in order to prevent falls. The SDC said all CNAs are trained on how to use the mechanical lift device prior to providing care to residents, and said CNA's must pass a return demonstration before placement on the units and providing direct care Review of the Director of Nurses Written Statement, dated 6/23/2019, indicated during her interview with Certified Nursing Aide (CNA) #1, CNA #1 said Resident #1 fell from the mechanical lift when he/she was approximately three feet high off the floor, during transfer from the chair to bed. The DON statement indicated Resident #1 fell on his/her back and hit his/her head on the metal base bar of the mechanical lift. The Statement indicated CNA #1 failed to follow and implement Resident #1's Care Plan by transferring him/her with the mechanical lift without a second staff member. The Surveyor interviewed the Director of Nurses (DON) at 12:20 P.M. on 7/2/19. The DON said she asked CNA #1 to demonstrate what happened during the mechanical lift transfer, and said CNA #1 failed to demonstrate correct placement of the mechanical lift slings straps. The DON said CNA#1 failed to cross the mechanical lift sling straps around Resident #1 appropriately and said Resident #1 most likely slid between the straps and fell . The DON said as a safety precaution for falls, every resident who needed a mechanical lift for transfers must have two staff members available to perform the transfer.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required a two person assist with mechanical lift transfers, the Facility failed to ensure staff implemented and followed interventions in his/her plan of care related to Activities of Daily Living and Functional Rehabilitation, when Certified Nurse Aide (CNA) #1 transferred Resident #1 by herself, without another staff member present, and Resident #1 fell during the mechanical lift-transfer, sustained a head injury and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Facility Policy titled, Managing Falls and Fall Risk, revised (MONTH) (YEAR), indicated the staff, with the input of the attending Physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The Food and Drug Administration (FDA)'s Patient Lifts Safety Guide, undated, indicated that using the wrong sling or attaching the sling incorrectly may result in serious injury or death. The guide indicated the use of two staff persons during resident-transfers with mechanical lifts to ensure residents' safety. Resident #1 was admitted to the Facility in (MONTH) 2014, medical history included generalized muscle weakness, falls, [MEDICAL CONDITION], difficulty in walking, heart failure and Dementia. Review of Resident #1's Plan of Care related to ADL Functional / Rehabilitation, updated 2/19/19, indicated that Resident #1 was dependent on staff members to provide activities of daily living (ADL) due to his/her limited functional status. Plan of Care interventions included that two staff members are to assist resident with transfers via the mechanical lift. Review of Resident's #1 Quarterly Fall risk Assessment, dated 4/22/19, indicated his/her score was 10, which indicated he/she was at high risk for falls. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was totally dependent on staff for assistance with activities of daily living (ADLs) and that he/she needed the assistance of two staff persons with transfers and bed mobility. The Facility's Incident Report, dated 6/23/19, indicated that Resident #1 was observed lying on the floor in his/her bedroom, that Resident #1's head and neck were on the metal base of the mechanical lift and that blood was noted under his/her head and neck. A Nurse Progress Note, dated 6/23/19, indicated that at approximately 8:05 P.M., the writer (Nurse #1) heard a sound from Resident #1's bedroom, went to Resident #1's room and found him/her on the floor. The Note indicated that Resident #1's head and neck were on the metal base part of the mechanical lift and Certified Nurse Aide (CNA) #1 was alone in the room with Resident #1. The Note indicated that blood was found under Resident #1's head and neck and that he/she was transferred to the hospital. The Hospital Discharge Summary, dated 6/23/19, indicated that Resident #1 was diagnosed with [REDACTED]. A Nurse Progress Note, dated 6/24/19, indicated that Resident #1 had a bruise to the back of his/her head measuring 3.8 centimeters (cm) by 2.7 cm. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 07/03/19. Nurse #1 said she was on the medication cart in the hallway on 6/23/19 when she heard a loud sound come from Resident #1's room, went to the room and found Resident #1 on the floor and said that CNA #1 was alone with in the room with Resident #1 at that time. The Surveyor interviewed Certified Nurse Aide (CNA) # 1 at 10:20 A.M. on 07/02/19. CNA #1 said at approximately 8:00 P.M. on 06/23/19, she took Resident #1 into his/her room to perform personal care. CNA #1 said while she was transferring Resident #1 with the mechanical lift, Resident #1 fell from the mechanical lift onto the floor during the transfer and hit his/her head. CNA #1 said she knew she needed a second staff member to perform mechanical lift transfers and said that she transferred Resident #1 alone because other staff members were busy providing care to other residents. The Surveyor interviewed the Staff Development Coordinator (SDC) at 11:15 A.M. on 7/2/19. The SDC said that it was Facility policy and procedure to have two staff members transfer residents whenever the mechanical lift device was used. The SDC said she in-serviced the nursing staff that residents should be left safe in bed until help arrived, rather than be transferred with the mechanical lift by one person, in order to prevent falls. The SDC said all CNAs are trained on how to use the mechanical lift device, including the need for two staff persons, and said CNA's must pass a return demonstration on mechanical lift use, before placement to provide care on the units. Review of the Director of Nurses (DON), written witness Statement, dated 6/23/2019, indicated that when interviewed, Certified Nursing Aide (CNA) #1 told the DON that Resident #1 fell from the mechanical lift while he/she was approximately three feet high off the floor, during transfer from the chair to bed. The Statement indicated that CNA #1 demonstrated incorrect placement of the mechanical lift straps and that CNA #1 recreated how Resident #1 fell on his/her back and hit his/her head on the base of the mechanical lift. The Statement indicated CNA #1 did not follow Resident #1's Plan of Care when she transferred him/her without a second staff member to assist. The Surveyor interviewed the Director of Nurses (DON) at 12:20 P.M. on 7/2/19. The DON said she asked CNA #1 to demonstrate what happened during the mechanical lift transfer with Resident #1. The DON said CNA #1 failed to demonstrate correct placement of the mechanical lift sling straps. The DON said CNA #1 failed to cross the mechanical lift sling straps around Resident #1 correctly and said that Resident #1 likely slid between the straps and fell . The DON said as a safety precaution for falls, every resident who needed a mechanical lift for transfers must have two staff members available when the transfers are being done.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required assistance of two staff persons when being transferred via a mechanical lift, the Facility failed to ensure Resident #1 was free of incidents and/or accident(s) when Certified Nurse Aide (CNA) #1 transferred Resident #1 via the mechanical lift, by herself, did not get another staff member to assist her, and Resident #1 fell during transfer from a mechanical lift, sustained a head injury and was transferred to the hospital. Findings include: The Facility Policy titled, Managing Falls and Fall Risk, revised (MONTH) (YEAR), indicated the staff, with the input of the attending Physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The Food and Drug Administration (FDA)'s Patient Lifts Safety Guide, undated, indicated that using the wrong sling or attaching the sling incorrectly may result in serious injury or death. The guide indicated the use of two staff persons during resident-transfers with mechanical lifts to ensure residents' safety. Resident #1 was admitted to the Facility in (MONTH) 2014, medical history included generalized muscle weakness, falls, [MEDICAL CONDITION], difficulty walking, heart failure and Dementia. Review of Resident #1's Plan of Care related to ADL Functional / Rehabilitation, updated 2/19/19, indicated that Resident #1 was dependent on staff members to provide activities of daily living (ADL) due to his/her limited functional status. Plan of Care interventions included that two staff members are to assist resident with transfers via the mechanical lift. Review of Resident's #1 Quarterly Fall risk Assessment, dated 4/22/19, indicated his/her score was 10, which indicated he/she was at high risk for falls. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was totally dependent on staff for assistance with activities of daily living (ADLs) and that he/she needed the assistance of two staff persons with transfers and bed mobility. The Facility's Incident Report, dated 6/23/19, indicated that Resident #1 was observed lying on the floor in his/her bedroom, that Resident #1's head and neck were on the metal base of the mechanical lift and that blood was noted under his/her head and neck. A Nurse Progress Note, dated 6/23/19, indicated that at approximately 8:05 P.M., the writer (Nurse #1) heard a loud sound from Resident #1's bedroom, that Nurse #1 rushed there and found him/her on the floor. The note indicated that Resident #1's head and neck were on the metal part of the mechanical lift and Certified Nurse Aide (CNA) #1 was found in the room alone with Resident #1. Nurse #1 documented that blood was found under Resident #1's head and neck and that he/she was transferred to the hospital. The Hospital Discharge Summary, dated 6/23/19, indicated that Resident #1 was diagnosed with [REDACTED]. A Nurse Progress Note, dated 6/24/19, indicated that Resident #1 had a bruise at the back of his/her head measuring 3.8 centimeters (cm) by 2.7 cm. The Surveyor interviewed the Staff Development Coordinator (SDC) at 11:15 A.M. on 7/2/19. The SDC said that it was facility policy and procedure to have two staff members transfer residents whenever the mechanical lift device was used. The SDC said she in-serviced the nursing staff that residents should be left safe in bed until help arrived, rather than be transferred with the mechanical lift by one person, to prevent falls. The SDC said all CNAs are trained on how to use the mechanical lift device, and must pass a return demonstration before placement on the units to provide care. The Surveyor interviewed Nurse #2 at 9:50 A.M. on 7/2/19. Nurse #2 said that Nurse #1 called her into Resident #1's bedroom for assistance because Resident #1 had fallen. Nurse #2 said she saw blood on the floor and that she called 911 and Resident #1 was transferred to the hospital. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 07/03/19. Nurse #1 said she was on the medication cart in the hallway on 6/23/19 when she heard a loud sound from Resident #1's room, went to the room and found Resident #1 on the floor and said that CNA #1 was alone with him/her. Nurse #1 said she saw blood on the floor underneath Resident #1's head. The Surveyor interviewed Certified Nurse Aide (CNA) # 1 at 10:20 A.M. on 07/02/19. CNA #1 said she took Resident #1 into his/her room at approximately 8:00 P.M. on 06/23/19 to perform personal care. CNA #1 said she as she was transferring Resident #1 from the chair to the bed with the mechanical lift, Resident #1 fell from the mechanical lift to the floor and hit his/her head. CNA #1 said she knew she needed a second staff member to perform mechanical lift transfer and said she transferred Resident #1 alone because other staff members were busy providing care to other residents. Review of the Director of Nurses (DON), written witness Statement, dated 6/23/2019, indicated that when interviewed, Certified Nursing Aide (CNA) #1 told the DON that Resident #1 fell from the mechanical lift while he/she was approximately three feet high off the floor, during transfer from the chair to bed. The Statement indicated that CNA #1 demonstrated incorrect placement of the mechanical lift straps and that CNA #1 recreated how Resident #1 fell on his/her back and hit his/her head on the base of the mechanical lift. The Statement indicated CNA #1 did not transfer Resident #1 with a second staff member present to assist. The Surveyor interviewed the Director of Nurses (DON) at 12:20 P.M. on 7/2/19. The DON said as a safety precaution for falls, every resident who needed a mechanical lift for transfers must have two staff members available.

Based on interview and record review, for one of three sampled residents (Resident #1), Owner #1 abused Resident #1, on 3/7/17 after Resident #1 questioned Owner #1 about removing a paper sign from his/her bedroom door, Owner #1 told Resident #1 that he didn't care who Resident #1 was, there was no tape on his walls, and to get back in his/her [***] ing room and sit down, while pointing a finger in Resident #1's face. Findings include: The Surveyor interviewed Nurse #1 at 9:00 A.M. on 3/24/17. The Facility Internal Investigation was reviewed and contained a written statement, dated 3/8/17 from Nurse #1. Nurse #1 said and her written statement indicated that on 3/7/17, Owner #1 toured the Terrace unit with the Office Manager and the Director of Business Systems. Nurse #1 said that when Owner #1 approached Resident #1's room and began to remove a paper sign requesting that staff members knock from Resident #1's door, Nurse #1 told Owner #1 that the sign was OK and staff members knew about it. Nurse #1 said that Owner #1 told her that he did not care what nutcase was in the room, there was no tape allowed on his walls. Nurse #1 said and her written statement indicated that Resident #1 opened his/her bedroom door and asked Owner #1 who he was and what he was doing with Resident #1's paper sign. Nurse #1 said and her written statement indicated that Owner #1 stated words to the effect, I don't care who you are, no tape on my walls, get back in your room and sit down. Nurse #1 said and her written statement indicated that Owner #1 pointed a finger in Resident #1's face when he made the statement. Nurse #1 said and her written statement indicated that after Owner #1 left the unit, Resident #1 approached the nurses' station, was very upset and asked that the police be called about the incident. Nurse #1 said the voices of Resident #1 and Owner #1 were loud during the exchange and she said that Owner #1's tone and finger pointing could have been intimidating to Resident #1. The Surveyor interviewed Resident #1 about the alleged incident. Resident #1 said that he/she heard a scratching sound on his/her door and when he/she opened the door there was a foreboding man in a suit removing the sign from his/her door. Resident #1 said that he/she asked the man who he was and the man said words to the effect, never mind who the [***] I am and get back in your room. Resident #1 said that the man kept repeating no tape on my walls and would not answer Resident #1's questions. Resident #1 said that the man was rude, foreboding and verbally abusive. The Surveyor interviewed the Advocate at 10:00 A.M. on 3/28/17 and his/her written statement dated 3/7/17 was reviewed. The Advocate said and his written statement indicated that he was meeting privately with Resident #1 when they heard the scratching sound on Resident #1's bedroom door. The Advocate said and his written statement indicated that when Resident #1 opened his/her bedroom door, Owner #1 yelled at Resident #1 to get back into his/her [***] ing room. The Advocate said and his written statement indicated that Resident #1 asked the man who he was and what he was doing and the man told him not to worry about who he was and to get back into his/her room. The Advocate said that Owner #1's tone was angry and rude and Owner #1 was pointing around the unit with his finger, although the Advocate did not see Owner #1 point his finger at Resident #1. The Advocate described the interaction as inappropriate and he said that he felt intimidated by Owner #1's behavior. The Surveyor interviewed Owner #1 at 12:30 P.M. on 3/24/17. Owner #1 said that he was touring the Terrace unit on 3/7/17 when he saw a paper sign on Resident's bedroom door and he removed the sign despite being advised not to by Nurse #1. Owner #1 said most people don't have paper signs in their homes and he did not want them on the walls of his Facility. Owner #1 said Resident #1 opened the door and confronted Owner #1 about removing the sign and Owner #1 said he very firmly told Resident #1 to go back into his/her room. Owner #1 said that he was not upset and did not use profanity with Resident #1. Owner #1 said he could not recall whether he identified himself to Resident #1.

Based interview and record review, for one of three sampled Residents (Resident #1) the Facility failed to report an allegation of abuse that when Resident #1 questioned what Owner #1 was doing outside his/her room, Owner #1 told Resident #1 to get back into his/her [***] ing room to the Department of Pubic Health within two hours. Findings include: The Surveyor interviewed the Director of Nurses at 1:00 P.M. on 3/29/17. The Director of Nurses said that on 3/7/17, Nurse #1 called her and said that Resident #1 was very upset about an incident in which Owner #1 removed a sign from his/her bedroom door. The Director of Nurses said that she went to Resident #1's unit, and on her way, ran into Owner #1. The Director of Nurses said that she told Owner #1 that Resident #1 was upset about the sign being removed and they went together to Resident #1's room. The Director of Nurses said that she observed while Owner #1 knocked on Resident #1's door and explained to Resident #1 his reason for removing the paper sign from the bedroom door. The Director of Nurses said that during the conversation, Resident #1 told Owner #1 that he/she knew his/her rights and complained that Owner #1 had told Resident #1 to get back in his/her [***] ing room during their earlier interaction. The Director of Nurses said that she initiated an investigation into Resident #1's complaint, but at that time, she thought that the incident was best handled as a Grievance regarding Resident #1's complaint that Owner #1 removed a paper from his/her bedroom door. The Surveyor interviewed Nurse #1 at 9:00 A.M. on 3/24/17 and the Facility Internal Investigation, which contained a written statement from Nurse #1 dated 3/8/17 was reviewed. Nurse #1 said and her written statement indicated that when Owner #1 approached Resident #1's room and began to removed a paper sign requesting that staff members knock from Resident #1's door, Nurse #1 told Owner #1 that the sign was OK and staff members knew about it. Nurse #1 said that Owner #1 told her that he did not care what nutcase was in the room, there was no tape allowed on his walls. Nurse #1 said and her written statement indicated that when Resident #1 opened his/her bedroom door and asked Owner #1 what he was doing with Resident #1's paper sign, Owner #1 stated I don't care who you are, no tape on my walls, get back in your room and sit down. Nurse #1 said and her written statement indicated that Owner #1 pointed a finger in Resident #1's face when he made the statement. Nurse #1's written statement indicated that after Owner #1 left the unit, Resident #1 approached the nurses' station and was very upset and asked that the police be called about the incident. The Surveyor interviewed Nurse #1 at 9:00 A.M. on 3/24/17. Nurse #1 said the voices of Resident #1 and Owner #1 were loud during the exchange and she said that Owner #1's tone and finger pointing could have been intimidating to Resident #1. The Director of Nurses said that when she reviewed Nurse #1's written statement on 3/8/17, she realized that Resident #1 was alleging an incident of abuse and she changed the focus of her investigation from a grievance to an allegation of abuse. The Director of Nurses said and review of the internal investigation indicated that the Director of Nurses reported the alleged incident to the Department of Public Health on 3/8/17, about twenty four hours after the alleged incident.

Based on interview and record review, for one of three sampled Residents (Resident #1) the Facility failed to ensure staff adequately supervised the premise. At 2:35 A.M. on 2/9/17, an Unknown Male Intruder with a penile erection was found naked in Resident #1's bathroom standing six inches behind Resident #1. At that time, Resident #1's room which had been in its usual immaculate state thirty minutes earlier, was in disarray, as documented in photographs taken by police officers and attached to the Police Report as follows: a section of rubber baseboard had been removed from inside Resident #1's closet and behind a bureau; clothes and clothes hangers had been removed from Resident #1's closet and strewn about the floor in his/her room; jewelry had been strewn about his/her bed side table; a ladder had been positioned against the Facility exterior wall beneath Resident #1's bathroom window, and, damage had been done to the exterior of Resident #1's bedroom windows. Although the nurses' station is eighteen feet from the door to Resident #1's room, as measured by the Director of Maintenance, and CNA #1 and Nurse #1 stated that the nursing unit was quiet and they were at the nurses' station or making rounds on the nursing unit between 2:00 A.M. and 2:30 A.M., CNA #1 and Nurse #1 failed to hear the Unknown Male Intruder damaging Resident #1's windows and baseboard, removing items from Resident #1's closet and drawers and strewing them about the room, and undressing himself in Resident #1's room. Although Resident #1's impaired mental status limited his/her ability to recall and understand the alleged incident, an unimpaired individual would experience mental anguish when an Unknown Male Intruder damaged and caused disarray to items in their room and stood naked with a penile erection six inches behind him/her while he/she was alone and clothed only in a nightgown. Findings include: Resident #1's most recent Annual Minimum Data Set Assessment Form, dated 1/18/17, indicated that his/her cognitive status was severely impaired. The Surveyor interviewed Resident #1 at 10:00 A.M. on 2/11/17. Resident #1 said that he/she did not recall an incident in which there was an intruder in his/her room. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:20 P.M on 2/13/17. CNA #1 said, and review of the Schedule indicated, that she worked at the Facility on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. CNA #1 said that she made rounds on Resident #1's unit about every thirty minutes during the shift and saw Resident #1 asleep in his/her bed several times. CNA #1 said Resident #1 was asleep and his/her room was in its usually immaculate condition at 2:00 A.M. when CNA #1 made rounds. CNA #1 said that around 2:30 A.M. she punched out but remained on Resident #1's unit for her break. The Surveyor interviewed Nurse #1 at 5:00 A.M. on 2/9/17. Nurse #1 said and review of the Schedule indicated that she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. Nurse #1 said that when CNA #1 took her break at 2:30 A.M. Nurse #1 took over rounds on Resident #1's unit. Nurse #1 said that around 2:35 A.M. she heard the sound of Resident #1 talking in Resident #1's room. Nurse #1 and CNA #1 said that Resident #1 always started to talk when he/she needed to use the bathroom. Nurse #1 said that she told CNA #1 that she heard Resident #1 talking in Resident #1's room and CNA #1 said that she would take Resident #1 to the bathroom. CNA #1 said when she got to the doorway to Resident #1's room, the room was dark but the light was on in Resident #1's bathroom. CNA #1 said she noticed that clothes were strewn about Resident #1's room, which was very unusual as Resident #1 normally kept his/her room immaculate. CNA #1 said she walked toward the lit bathroom and saw Resident #1 and an Unknown Male Intruder in Resident #1's bathroom. CNA #1 said Resident #1 was dressed in a short night gown and was upright, facing the toilet with his/her back to the Unknown Male Intruder. CNA #1 said Resident #1's night gown was short but long enough that CNA #1 could not see whether Resident #1's incontinence brief was in place. CNA #1 said that the Unknown Male Intruder was completely naked, was facing Resident #1 about six inches away from his/her body and had a penile erection. CNA #1 said that Unknown Male Intruder looked at her and stated words to the effect of I'm sorry and I'm embarrassed. CNA #1 said that she immediately left Resident #1's room and reported the presence of the naked Unknown Male Intruder to Nurse #1, leaving Resident #1 alone with the Unknown Male Intruder. Nurse #1 said that immediately after CNA #1 entered Resident #1's room to take Resident #1 to the bathroom, CNA #1 came to the nurses' station and said that there was a naked man in Resident #1's bathroom. Nurse #1 said that she asked CNA #1 whether the man was from the Facility and CNA #1 told her words to the effect, no the Unknown Male Intruder was a young man. Nurse #1 said that she called the closest nursing unit and asked another nurse to come to Resident #1's unit immediately. The Surveyor interviewed Nurse #2 at 1:00 P.M. on 2/14/17. Nurse #2 said and review of the Schedule indicated that she worked at the Facility during the 11:00 P.M. to 7:00 A.M. shift, which started on 2/8/17 and ended on 2/9/17. Nurse #2 said that around 2:30 A.M. Nurse #1 called her and asked her to come to Resident #1's unit quickly. Nurse #2 said that she immediately went to Resident #1's unit and saw Nurse #1 seated at the nurses' station. Nurse #2 said that Nurse #1 told her that there was an Unknown Male Intruder in Resident #1's room. Nurse #2 said that at first she thought Nurse #1 meant that there was a male resident in Resident #1's room and Nurse #1 clarified that the Unknown Male Intruder was a man that Nurse #1 and CNA #1 did not know. Nurse #2 said that at that time, she became aware of CNA #1's presence and CNA #1 was stating words to the effect, oh my God and he was naked and how did he get in there. Nurse #2 said that she told CNA #1 and Nurse #1 to calm down and instructed Nurse #1 to take her cell phone around the far corner of the nurses' station where the Unknown Male Intruder would not hear her and to call 911. Nurse #2 said that she began to call other nursing units in order to alert the Nurse Supervisor. Nurse #2 said that at some point she became aware of blue lights and/or sirens and she sent CNA #1 off the nursing unit to let the police officers into the Facility. The Surveyor interviewed the Nurse Supervisor at 6:30 P.M. on 2/11/17. The Nurse Supervisor said and review of the Schedule indicated that she worked in the Facility during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. The Nurse Supervisor said that when she was alerted to the presence of the Unknown Male Intruder, she immediately went to Resident #1's unit. The Nurse Supervisor said that when she arrived on Resident #1's unit, she went to the doorway of Resident #1's room, she saw Resident #1 seated in his/her wheelchair in the doorway to his/her bathroom and there was an Unknown Male Intruder wearing only jeans standing at the foot of Resident #1's bed. The Nurse Supervisor said the Unknown Male Intruder appeared to be snooping around Resident #1's things. The Nurse Supervisor said that she asked the Unknown Male Intruder who he was and what he was doing there and the Unknown Male Intruder made several different statements about being in Resident #1's room redecorating it and being a friend of Resident #1's family member. The Nurse Supervisor said that Resident #1 was calm, said that he/she did not know the Unknown Male Intruder and said that the Unknown Male Intruder needed to leave his/her room. The Nurse Supervisor said that, at one point, Resident #1 tried to hand the Nurse Supervisor his/her soiled incontinence brief which appeared to have been in Resident #1's lap. The Surveyor asked the Nurse Supervisor whether Resident #1 removed his/her brief and the Nurse Supervisor said she did not know. The Nurse Supervisor said that she did not think that the incontinence brief had been in place on Resident #1 when the Nurse Supervisor entered the room otherwise Resident #1 would have had to stand or shift in his/her wheelchair in order to remove it. The Nurse Supervisor said that she did not want to take her eyes away from the Unknown Male Intruder and she told Resident #1 to place the incontinence brief on the floor. The Nurse Supervisor said that police arrived to Resident #1's unit within a minute or two of her arrival and handcuffed the Unknown Male Intruder. The Police Report, dated 2/9/17, was reviewed. The Surveyor interviewed Police Officer #1 at 11:50 A.M. on 2/14/17 and Police Officer #2 at 12:15 on 2/14/17. The Police Report indicated that at 2:43 A.M., police officers arrived at the Facility. The Police Report indicated and Police Officer #1 said that he and Police Officer #2 entered the Facility through the unlocked front door and met CNA #1 inside of the Facility. The Police Report indicated that CNA #1 led Police Officer #1 and Police Officer #2 to Resident #1's room where the shirtless, Unknown Male Intruder was standing in the doorway. The Police Report indicated that the Unknown Male Intruder was dressed in loose fitting jeans and did not appear to be wearing any underwear. The Police Report indicated that Resident #1 was also present in the room seated in a wheelchair near the bathroom door. The Police Report indicated that police officers interviewed the Unknown Male Intruder about how he came to be in Resident #1's room. The Police Report indicated the Unknown Male Intruder told the police officers that he was at a friend's house nearby the Facility and after a fight with his girlfriend, he came to the Facility to clean up. The Police Report indicated that the Unknown Male Intruder told the police officers that Resident #1, who the Unknown Male Intruder called by an incorrect first name, was a family member of his girlfriend. The Police Report indicated that the Unknown Male Intruder appeared to the police officers to be 'under the influence of some type of substance' and the Unknown Male Intruder told the police officers he had taken medications earlier in the evening. The Police Report indicated that family members of Resident #1 were contacted and did not know the Unknown Male Intruder. The Police Report indicated that the staff members on duty in the Facility were questioned and did not know the Unknown Male Intruder. The Police Report indicated that the police officers asked the Unknown Male Intruder how he got into the Facility and the Unknown Male Intruder told the police officers that he came in through the closest door. The Police Report indicated that Police Officer #2 observed that there was a door across from Resident #1's bedroom door which led to a stairwell. The Police Report indicate that staff members showed the police officers that a code had to be entered into a key pad in order to enter the stairwell from Resident #1's unit, but to enter Resident #1's unit from the stairwell only a button needed to be depressed. The Surveyor observed the button on the wall next to the door leading to Resident #1's unit from the stairwell and there was a sign which indicated that the button needed to be pressed in order to enter Resident #1's unit. Police Officer #2 said and the Police Report indicated that when Police Officer #2 descended the stairwell to a basement corridor he observed a utility door which exited to the outside. Police Officer #2 said and the Police Report indicated that the utility door was unsecured and Police Officer #2 exited without pushing the handle. Police Officer #2 said and the Police Report indicated that the utility door led outside to a stairwell which exited to an alley alongside the Facility. Police Officer #2 said and the Police Report indicated that at the top of the exterior stairwell, he observed a ladder positioned up against the Facility right beneath Resident #1's bathroom window. Photographs taken by the police and attached to the Police Report show the ladder beneath Resident #2's bathroom window. The Surveyor interviewed the Director of Maintenance at 9:00 A.M. on 2/11/17. The Director of Maintenance said that the ladder found beneath Resident #1's bedroom on 2/9/17 belonged to the Facility and was stored outside of the Facility. Police Officer #2 said and the Police Report indicated that he found the Unknown Male Intruder's jacket and a bag containing prescription medication bottles, some with the Unknown Male Intruder's name on them on the ground next to the ladder. Police Officer #2 said and the Police Report indicated that Police Officer #2 found a piece of plywood that was positioned to make a platform beneath Resident #2's bedroom window and the screen on the bedroom window was broken and damaged. Police Officer #2 said and the Police Report indicated that it appeared as though someone attempted to pry Resident #1's bedroom window open. Photographs taken by the police and attached to the police report show the plywood platform, the damaged window exterior, the ladder and the Unknown Male Intruder's jacket and bag with medication bottles. Police Officer #2 said and the Police Report indicated Police Officer #2 descended the exterior stairwell back to the basement utility door. Police Officer #2 said and the Police Report indicated that although there was no exterior handle, Police Officer #2 was able to easily open the door and gain access to the Facility. The Director of Maintenance said that the utility door was used to exit the Facility daily by staff members in the Maintenance Department, but was not used by residents or other staff members to enter or exit the Facility. The Director of Maintenance said that if the crash bar on the door did not fully latch when the door closed, the door could be pried open from the outside to gain entry into the basement. The Police Report indicated that Resident #1's room was inspected by police officers and photographs were attached to the police report. The Police Report indicated that Resident #1's room was observed to be a complete mess with clothes on the floor and damage to the wall in Resident #1's. Photographs show clothes strewn about the room and a section of rubber baseboard removed from inside Resident #1's closet and behind Resident #1's bureau. The Police Report indicated that a pair of men's boxer shorts and a men's size large sweatshirt were found among Resident's clothes. The Police Report indicated that Resident #1 was sent to the hospital for a sexual assault examination. The Detective was interviewed at 2:00 P.M. on 2/14/17. The Detective said and the Police Report indicated that he visited the Facility on 2/10/17. The Detective said and the Police Report indicated that the Director of Nurses pointed out some marks on the upper right and left part of the inside of the window frame in Resident #1's bathroom window and a mark on the lower right side of the inside of the window frame. Photographs of the marks were attached to the Police Report. The Detective said that the upper marks appeared to be dirt left behind from the Unknown Male Intruder's hands when he climbed in through Resident #1's bathroom window and the lower mark appeared to have been a mark left by the Unknown Male Intruder's sneaker. The Surveyor asked CNA #1 and Nurse #1 whether they heard the Unknown Male Intruder place a ladder against the side of the Facility and attempt to pry open Resident #1's bedroom window and they said that they did not. The Surveyor asked CNA #1 and Nurse #1 whether they heard the Unknown Male Intruder enter Resident #1's room, whether through the unsecured basement utility door and stairwell or through Resident #1's bathroom window and they said that they did not. The Surveyor asked CNA #1 and Nurse #1 whether they heard the Unknown Male Intruder removing Resident #1's clothes from his/her closet and throwing the clothes about on his/her floor and they said that they did not. The Surveyor asked CNA #1 and Nurse #1 whether they heard the Unknown Male Intruder removing the rubber baseboard from the closet and behind the bureau in Resident #1's room and they said that they did not. The Surveyor asked CNA #1 and Nurse #1 whether they heard the Unknown Male Intruder removing his clothes and going into the bathroom with Resident #1 and they said that they did not. CNA #1 and Nurse #1 said that although they were at the nurses' station about eighteen feet from Resident #1's bedroom, as measured by the Director of Maintenance, they did not hear the sounds of the Unknown Male Intruder. CNA #1 and Nurse #1 said they were able to hear Resident #1's talking while they were at the nurses station and when CNA #1 entered Resident #1's room and she found the naked Unknown Male Intruder.

Based on interview and record review, for one of three sampled Residents (Resident #1), the Facility failed to ensure staff immediately removed Resident #1, a cognitively impaired resident, to a safe environment in accordance with the established Facility Abuse Policy when a naked Unknown Male Intruder with a penile erection was found in Resident #1's bathroom standing approximately six inches behind Resident #1 who was wearing a short nightgown. Nurse Supervisor #1 said that around 2:35 A.M. on 2/9/17, a staff member from another nursing unit notified her by phone that there was a naked Unknown Male Intruder in Resident #1's room, but when she arrived to Resident #1's unit about a minute later, Nurse #1 and Nurse #2 were near the nurses' station and Resident #1 was left alone in his/her room with the Unknown Male Intruder. Findings Include: The dateless Facility Abuse Policy indicated that if the circumstances require it, the Director of Nursing Services or his/her designee, shall remove a resident suspected of being the subject of an alleged violation of the Facility prohibition on abuse to an environment where the resident's safety can be protected. Resident #1's most recent Annual Minimum Data Set Assessment Form, dated 1/18/17, indicated that his/her cognitive status was severely impaired. The Surveyor attempted to interview Resident #1 at 10:00 A.M. on 2/11/17. Resident #1 said that he/she did not recall an incident in which there was an intruder in his/her room. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:20 P.M on 2/13/17. CNA #1 said, and review of the Schedule indicated, that she worked at the Facility on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. The Surveyor interviewed Nurse #1 at 5:00 A.M. on 2/9/17. Nurse #1 said and review of the Schedule indicated that she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. Nurse #1 said that around 2:35 A.M. she heard the sound of Resident #1 talking in Resident #1's room. Nurse #1 and CNA #1 said that Resident #1 always started to talk when he/she needed to use the toilet. Nurse #1 said that she told CNA #1 that she heard Resident #1 talking in Resident #1's room and CNA #1 said that she would take Resident #1 to the bathroom. CNA #1 said that when she got to the doorway of Resident #1's room, the room was dark but the light was on in Resident #1's bathroom. CNA #1 said she noticed that clothes were strewn about Resident #1's room, which was very unusual as Resident #1 normally kept his/her room immaculate. CNA #1 said clothes were not strewn about Resident #1's room when CNA #1 checked Resident #1 during the 2:00 A.M. rounds. CNA #1 said she walked toward the lit bathroom and saw Resident #1 and a naked Unknown Male Intruder with a penile erection in the bathroom. CNA #1 said Resident #1 was dressed in a short night gown and was upright, facing the toilet with his/her back to the Unknown Male Intruder. CNA #1 said that the Unknown Male Intruder was completely naked with a penile erection and was facing toward Resident #1's back standing about six inches away from him/her. CNA #1 said that Resident #1's nightgown was short but long enough so that CNA #1 could not see whether Resident #1's incontinence brief was in place. CNA #1 said that the naked Unknown Male Intruder looked at her and stated words to the effect of I'm sorry and I'm embarrassed. CNA #1 said that she immediately left Resident #1's room and reported the presence of the naked Unknown Male Intruder to Nurse #1, leaving Resident alone with the Unknown Male Intruder. Nurse #1 said that immediately after CNA #1 entered Resident #1's room to take Resident #1 to the bathroom, CNA #1 came to the nurses' station and said that there was a naked man in Resident #1's bathroom. Nurse #1 said that she asked CNA #1 whether the man was from the Facility and CNA #1 told her that the man was not and that the Unknown Male Intruder was a young man. Nurse #1 said that she called the closest nursing unit and asked another nurse to come to Resident #1's unit immediately. CNA #1 said she stood at the nurses' station on the side closest to Resident #1's room while Nurse #1 called another Facility nursing unit. Nurse #1 said that she thought CNA #1 stood outside of Resident #1's room while she placed the telephone call to the other Facility unit, but Nurse #1 said she did not give CNA #1 any specific instruction to watch Resident #1 or the Unknown Male Intruder. The Surveyor interviewed Nurse #2 at 1:00 P.M. on 2/14/17. Nurse #2 said and review of the schedule indicated that she worked at the Facility during the 11:00 P.M. to 7:00 A.M. shift which started on 2/8/17 and ended on 2/9/17. Nurse #2 said that around 2:30 A.M., Nurse #1 called her and asked her to come to Resident #1's unit quickly. Nurse #2 said that she immediately went to Resident #1's unit and saw Nurse #1 seated at the nurses' station. Nurse #2 said that she did not recall where CNA #1 was when she arrived to Resident #1's unit. Nurse #2 said that Nurse #1 told her that there was an Unknown Male Intruder in Resident #1's room. Nurse #2 said that at first she thought Nurse #1 meant that there was a male resident in Resident #1's room and Nurse #1 clarified that the man was someone that she and CNA #1 did not know. Nurse #2 said that at that time, she became aware of CNA #1's presence and CNA #1 was stating words to the effect, oh my God and he was naked and how did he get in there. Nurse #2 said that she told CNA #1 and Nurse #1 to calm down and instructed Nurse #1 to take her cell phone around the far corner of the nurses' station where the Unknown Male Intruder would not hear her and to call 911. Nurse #2 said that she began to call other nursing units in order to alert the Nurse Supervisor to the presence of the Unknown Male Intruder. Nurse #2 said that at some point she became aware of blue lights and/or sirens and she sent CNA #1 to the front door to let the police officers into the Facility. The Surveyor interviewed the Nurse Supervisor at 6:30 P.M. on 2/11/17. The Nurse Supervisor said that when she was alerted to the presence of the Unknown Male Intruder, she immediately went to Resident #1's unit. The Nurse Supervisor said that when she arrived on Resident #1's unit, Nurse #1, Nurse #2 and CNA #1 were at the nurses' station. The Nurse Supervisor said that when she went to the doorway of Resident #1's room, she saw Resident #1 seated in his/her wheelchair in the doorway to his/her bathroom and there was a shirtless, Unknown Male Intruder with a penile erection standing at the foot of Resident #1's bed. The Surveyor asked the Nurse Supervisor whether any staff member was with Resident #1 and she said no Resident #1 was alone in his/her room with the Unknown Male Intruder. Although Resident #1's impaired mental status limited his/her ability to recall and understand the alleged incident, an unimpaired individual would experience mental anguish when left alone with a naked Unknown Male Intruder with a penile erection standing six inches behind him/her while clothed only in a nightgown in Resident #1's bathroom, despite a Facility Policy which indicated residents suspected of being the subject of an alleged violation of the Facility prohibition on abuse should be removed to an environment where the resident's safety can be protected.

Based on record review, observation, resident interview and staff interview, the facility failed for 1 resident (#3) of a total sample of 28 residents, to ensure that each resident not experience an avoidable psychosocial difficulty. The findings included: For Resident #3, the facility failed to ensure that the resident was offered a room that would accommodate the resident in the manner that the resident was accustomed when the facility decided to change the function of the resident's current unit. When the resident began experiencing worsening depression and anxiety after the transfer, the facility failed to promptly identify a space where the resident would be comfortable. Resident #3 had [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 5/15/13 indicated that the resident was cognitively intact and needed assistance from facility staff to complete the activities of daily living. A "Notice of Room/Roommate Change," dated 3/21/13, indicated that the resident would be moved from Kensington 2 to a specific room on Buckingham on 4/18/13. The notice indicated that the resident agreed to the change and would be moving with the current roommate. The notice read "Note: Appeal rights are not applicable when the movement of a resident within the same facility is from one certified bed to another bed with the same certification." A letter, dated 3/21/13, addressed to residents and family residing on the Windsor 1 and Kensington 2 units, indicated that "To continue to improve the quality of life for our residents, we will be combining the two units and moving some of your loved ones to Buckingham. This will now be a long term care unit. The move is planned for the week of April 29." Per review of the resident's medical record, Resident #3 was transferred from the facility Kensington 2 unit to the Buckingham unit on 4/18/13 "as explained on a letter sent 3/21/13." A physician's progress note, dated 5/2/13, indicated that the resident was unhappy with the room change and was having worsening anxiety. A social service note, dated 5/3/13, reported that the resident was unhappy with the room change and was having storage issues and would like a room change in the future. Social Worker #1 wrote that he/she was working with Resident #3 to "donate" some belongings. The Social Worker #1 wrote that the resident's "mood is fair." On 5/13/13, the facility psychotherapist wrote that the resident disliked the new living space due to the smaller size of the room. On 6/4/13 Social Worker #1 wrote that the resident had complaints regarding the room change. Social Worker #1 wrote that the resident's former room was larger, but that the resident was "better suited on this unit for independence." Social Worker #1 wrote that there was no open bed availability on the current unit to switch to a bigger room and that the resident did not want to return to the prior unit due to it being converted to a dementia unit. On 6/24/13, the facility psychotherapist wrote that the resident described his/herself as "Terrible. Wants a room change." The resident was upset with the smaller size of the room compared to the last room. On 6/27/13, the facility psychiatric nurse practitioner wrote that the resident remained unhappy with the room change and that the small size of the room caused the resident to continually bang his/her legs. During the initial tour of the facility on 7/30/13, room [ROOM NUMBER] on the Buckingham unit, a large 2 bed room, was noted to be empty. During the group meeting on 7/31/13 at 11:00 A.M., Resident #3 was among several residents that complained about the facility wide room changes. Residents said that they had no choice in the matter and had no choice about the room to which they were moved. During interview on 8/6/13 at 11:00 A.M., the resident said that he/she had resided on the Kensington 2 unit in the same room for approximately 3 years. The resident said that he/she was approached by Social Worker #1 about a room change in April 2013. The resident could not recall the exact date. The resident said that he/she was told that both he/she and the roommate would be moved together from the Kensington 2 unit to the Buckingham unit. The resident said that he/she was never told there was any choice in the matter. The resident said that he/she had no idea what the new room looked like until his/her belongings were moved on 4/18/13. The resident cried while telling the story. The resident said that issues with regard to less storage space and ability to move about the room were reported to facility staff immediately. The resident explained "I don't have much. I've lost everything I've ever had. I'd like to keep the things I have here." The resident said that he/she had a history of [REDACTED]. The resident said that Social Worker #1 said that the resident would be placed on a waiting list for a new room. The resident said that, as of the date of the interview 8/6/13, no room had been offered to the resident. The resident was informed by the surveyor that room [ROOM NUMBER] on the Buckingham unit was vacant during the initial tour of the facility. The resident said that he/she was aware that several rooms were vacant at various times since the transfer to the Buckingham unit. The resident said that he/she had been denied transfer to those rooms because they were "reserved for rehab." During interview on 8/6/13 at 12:30 P.M., Social Worker #1 said that the resident was on a waiting list for a room change. Social Worker #1 said that no rooms had been offered to the resident since the resident requested a room change in April 2013.

Based on record review, interview with the resident and interview with staff, the facility failed to ensure that residents were not subjected to abuse or mistreatment, that allegations of abuse or mistreatment were immediately investigated, that immediate action was taken to protect residents from potential abuse during the investigation and that allegations of abuse and mistreatment were immediately reported to the Administrator and to the State Agency, for one resident (#28) in a total sample of 28. Findings include: For Resident #28, the facility failed to investigate an allegation of mistreatment immediately and thoroughly, failed to take immediate action to protect this resident and other residents in the facility following an allegation of mistreatment by a nurse, and failed to immediately report the allegation of mistreatment to the Administrator and the State Department of Public Health as required by state statute. Resident #28 had lived at the facility for several years and had [DIAGNOSES REDACTED]. A Cognitive/Neuropsychological Assessment was completed for the resident on 6/22/13, based on identified issues including refusal to follow treatment plans, impaired ability to care for self medically and grossly impaired insight. The assessment found the resident to be oriented in all spheres but with marked deficits in attention, short-term memory and abstract reasoning, and suggested that the resident did not have the capacity to make reasoned, informed decisions about care and welfare. The most recent annual Minimum Data Set (MDS) assessment, with a reference date of 6/26/13, indicated that the resident had no problems with communication or comprehension, had no cognitive or memory deficits and no symptoms of [MEDICAL CONDITION]. The MDS also noted that the resident required extensive assistance with personal care, and required supervision with mobility. On 8/6/13 at 11:05 A.M. the resident requested to speak with the surveyor because he/she was upset and worried. During the interview, the resident said that Nurse #1, who worked at the facility, singled the him/her out and was mean to him/her. The resident said Nurse #1 did things to make him/her upset. For example, the resident said that Nurse #1 gave him/her the wrong information about the resident's blood sugar reading to get the him/her upset that the blood sugar was out of normal range and the resident would have to get an insulin injection. The resident also said that on one occasion, Nurse #1 opened the bathroom door while the resident was seated on the toilet and stood there staring at the resident for several minutes, and, even though the resident was yelling at Nurse #1 to get out, Nurse #1 would not leave. When asked, the resident said he/she could not remember specific dates that these things happened. The resident said he/she reported his/her concerns about Nurse #1's actions and behavior to Nurse #3 on the unit about a week or so prior but couldn't remember the exact date. The resident said that on Friday 8/2/13 he/she was told by nursing staff, though did not specify who said it, that Nurse #1 would not be working on the floor any longer and so would not be taking care of the resident. The resident said that on Saturday 8/3/13 on the 3:00 P.M. to 11:00 P.M. shift, the day after being assured that Nurse #1 would not be caring for the resident, Nurse #1 came into the resident's room and threatened him/her. The resident said that Nurse #1 had switched assignments with another staff nurse for that shift and so was the nurse assigned to care for the resident. According to the resident's story to the surveyor, Nurse #1 argued with the resident and told him/her to shut off the television, and threatened that if the resident did not do what he/she was told, Nurse #1 would send the resident to the hospital. The resident said he/she yelled at Nurse #1 and told him/her to get out of the room. The resident said he/she then asked the other nurse on the unit (Nurse #2) to call the nursing supervisor because the resident did not want Nurse #1 to give medications to him/her. The resident said the supervisor came to the unit, and asked the resident what was going on, but did not do anything about the situation. The resident said he/she had spoken about the problem with Nurse #2, Social Worker #2 and one of the activities staff (not specifically identified). The resident said the Director of Nursing had not come to speak with him/her but that the Assistant Director of Nursing had talked to the resident. At the end of the interview, the resident told the surveyor that he/she was scared of retaliation, and was very afraid of Nurse #1. The resident said he/she was scared they would kick him/her out of the facility. No evidence was found or presented that demonstrated that the Nursing Supervisor, Nurse #2, Social Worker #2, activity staff or the Assistant Director of Nurses, all of whom knew of the resident's concerns and were mandated reporters, made any report of the resident's allegations of abuse against Nurse #1 immediately to the Administrator or to the State Survey Agency, Department of Public Health, as required by law. Following the resident's reported allegation of abuse, the facility failed to put any interventions in place to prevent further potential abuse of Resident #28 or of any other resident on that unit or in the facility. On 8/6/13 at 11:15 A.M., the surveyor asked the Director of Nurses for information and/or investigation related to the resident's allegations. The Director of Nurses said that she was not aware of the incident and she would check on it. On 8/6/13 at 11:20 A.M., the surveyor went to the Director of Nurses' office, where she was found to be meeting with the Administrator and Social Worker #2. The Assistant Director of Nursing came into the room a few minutes later. Again, the surveyor asked the Director of Nurses if there was any information and if the investigation had been initiated. The Director of Nurses said that Nurse #1 had to change the resident's tubing, and that this had to be done on the 11:00 P.M. to 7:00 A.M. shift, so she did not understand what the problem was. The surveyor said that the resident had made several different allegations, but did not make any reference to a problem with changing tubing. The Director of Nurses said he/she was not aware of any other allegations. The Administrator offered no information related to the allegations. At that point, the Assistant Director of Nursing said that Nurse #1 only worked at the facility on a per diem basis, so she had not been able to speak with Nurse #1. The Assistant Director of Nurses said she had talked with Nurse #1 briefly by telephone and was planning to call Nurse #1 again by the end of the week to set up an appointment for Nurse #1 to come in and talk with her about the situation. The Assistant Director of Nursing said that as of this time, no investigation had been started related to the resident's reported allegation. Further, the Assistant Director of Nursing said he/she had not spoken with the resident about the alleged abuse. Social Worker #2 then said that he/she had only heard of the allegation the previous Friday (8/2/13) and had spoken to the resident. Social Worker #2 said that this conversation with the resident was in the Social Service notes in the resident's record. The record was reviewed immediately following this discussion, and it was noted that the last Social Service progress note written was dated 7/30/13. A review of the Social Service notes back to April 2013 when the resident was transferred to the unit failed to yield any reference to allegations made by the resident about Nurse #1. The nursing notes were also reviewed from 7/1/13 through 8/6/13, and no reference was made to the resident's allegations. Review of the nursing notes revealed that a note was written on 8/2/13 for the 7:00 A.M. to 3:00 P.M. shift, and the next consecutive note was written 8/4/13 at 7:00 A.M. for the 11:00 P.M. to 7:00 A.M. shift. These notes did not contain any documentation of a problem with Nurse #1 and the resident, or any information that the resident had requested to speak with the nursing supervisor. On 8/6/13 at 11:30 A.M., Social Worker #2 approached the surveyor and said that he/she had not talked to the resident on Friday 8/2/13 as previously stated. Social Worker #2 said that the resident had spoken with Nurse #3 on 8/2/13, who had then advised Social Worker #2 of the issue. As of the time of that interview with the surveyor, Social Worker #2 had never discussed the allegations with the resident. Social Worker #2 said that Nurse #3 had spoken with Social Worker #2 on Friday 8/2/13, and Nurse #3 said the resident reported that Nurse #1 singled the resident out and was mean. Social Worker #2 said there were no Social Service notes in the record as stated previously to the surveyor. Social Worker #2 said that she told the Assistant Director of Nursing what Nurse #3 had related, and the Assistant Director of Nursing said she was going to switch sides for Nurse #1's assignment. Social Worker #2 said that the resident complained again on Monday 8/5/13 that Nurse #1 had been assigned to give the resident care over the weekend, and the Assistant Director of Nursing told Social Worker #2 that Nurse #1 must have switched assignments. During interview on 8/6/13 at 1:15 P.M., Nurse #3 said the resident had told him/her that there were problems with Nurse #1, and that Nurse #1 was mean and singled him/her out. Nurse #3 said he/she told Social Worker #2 about the resident's complaint. When asked when the resident told him/her about the problem, Nurse #3 consulted the calendar that was on the nurses' station desk and said to the surveyor that it was 7/29/13. The surveyor asked Nurse #3 to confirm the date and Nurse #2 said yes, that was when the resident had told him/her about the problem with Nurse #1. Based on interview with the resident on 8/6/13, and with the Assistant Director of Nursing on 8/6/13, no further action by facility staff was taken after the resident again complained on 8/5/13 and alleged continued abuse by Nurse #1. Despite these interviews, it was unclear who had actually spoken with the resident on 8/5/13. Review of the time sheets as worked for the previous three weeks revealed that Nurse #1 had worked as follows: -Saturday, 7/20/13, 3:00 P.M. to 11:00 P.M. shift and 11:00 P.M. to 7:00 A.M. shift, Buckingham Unit (where Resident #28 resided) -Friday, 7/26/13, 11:00 P.M. to 7:00 A.M. shift, Terrace Unit -Sunday, 7/28/13, 3:00 P.M. to 11:00 P.M. shift, Buckingham Unit -Saturday, 8/3/13, 3:00 P.M. to 11: P.M. shift, Buckingham Unit These dates were consistent with the statements of the resident and Nurse #3. During interview on 8/6/13 at 2:00 P.M. with the Administrator, the Director of Nursing, Director of Social Service and the Corporate Consultant, they said that no investigation had been initiated prior to the inquiry by the surveyor on 8/6/13 at 11:15 A.M. None of these administrative staff provided evidence that they had any direct involvement with the resident or the alleged incidents.

Based on observation, record review and interview with staff, the facility failed to provide adequate restorative nursing services to maintain the resident's optimal ambulation and transfer ability that had been achieved during his/her skilled rehabilitation treatment for one resident (#6), out of total sample of 28. Findings include: Resident #6 had resided at the facility since December 2010 and had [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 6/10/13, and review of the prior MDS, dated [DATE], indicated the resident was cognitively impaired, exhibited some behavioral symptoms and required maximum assistance of two staff for transfers, dressing and hygiene. The MDS indicated the resident did not ambulate and a wheelchair was used for his/her mobility. Review of the Physical Therapy notes, indicated the resident received skilled services from 3/21/13 through 6/7/13. Resident #6 was referred for Physical Therapy services for bilateral lower extremities contractures that were decreasing the resident's overall functional mobility, including mobility and transfers. When the resident began treatment with physical therapy, the therapy initial evaluation indicated he/she presented with decreased strength, decreased standing balance, abnormal posture and decrease ambulation tolerance. The resident's prior level of function indicated he/she required some assistance for transfers, activities of daily living and ambulation. The assessment indicated the resident's primary locomotion was a wheelchair, but he/she had been able to ambulate with a rolling walker. Review of the Physical Therapy notes from 3/21/13 through 6/7/13, indicated the resident had made steady progress in skilled physical therapy. The progress notes indicated on 3/21/13, 3/27/13, 3/28/13, 4/1/13, 4/2/13, 4/3/13, 4/4/13, 4/19/13, 4/10/13, 4/12/13, 4/24/13, 4/28/13, 5/1/13, 5/3/13, and 6/3/13 the resident ambulated (50 to 200 feet) with a rolling walker and stand by assist. The progress notes indicated that the bilateral contractures were impeding the resident's ability to ambulate at a functional level. The physical therapist on 4/25/13 initiated and obtained multipodus boots to improve the resident's standing balance, posture, transfers and ambulation, but not at a functional level. The subsequent progress notes indicated the resident had difficulty following commands and had some inconsistencies in his/her performance, but was still showed improvement with transfers and short distance ambulation. In addition, the therapy staff provided care giver education to staff (5/7/13, 5/30/13 and 6/7/13) to maintain mobility, transfers and proper use of the multipodus boots. The physical therapy discharge note dated 6/7/13, indicated the resident was able to ambulate short distances with a rolling walker, transfer with minimal assistance and the bilateral ankle contractures showed improvement. The goals were to maintain minimal assistance for transfers, ensure the staff consistently applied the bilateral multipodus boots to prevent further decline in ankles and to maintain some ambulation. Review of activities of daily living care plan, dated 6/24/13, indicated the resident was dependent on two staff for transfers and did not ambulate. Review of the activity of daily living (ADL) flow sheets for June 2013 and July 2013 indicated the resident did not ambulate and required the assistance of two staff for transfers. Review of the Resident's Kardex, which was not dated, failed to indicate the resident's transfer ability/status and the multipodus boots, but did indicate the resident's mobility was at a wheelchair level with assistance of one staff. On 8/1/13 at 3:30 P.M. and on 8/2/13 at 2:00 P.M., the surveyor observed the resident in a wheelchair. On both occasions the resident was wearing the bilateral multipodus boots. During interview on 8/2/13 at 2:10 P.M., CNA #1 (certified nursing assistant) said Resident #6 did not ambulate and he/she was a Hoyer (mechanical lift) transfer. The CNA said that about a month ago transferring the resident had become unsafe without the mechanical lift. He/he said the resident could not go from a lying position to a sitting position and was noted to be stiff. The CNA said he/she had notified the nurses and they had changed the transfer from a two person assist to the Hoyer. The CNA said it was the nurses' decision to alter the resident's transfer status and to implement the use a mechanical lift. She said that the rehabilitation service was involved in a change, but not always. During interview on 8/2/13 at 2:30 P.M., Unit Manager #2 said the resident could not ambulate. The Unit Manager said that the staff did not transfer the resident with a Hoyer lift, but required assistance of two staff for transfers. After reviewing the physical therapy notes from 3/20/13 through 6/7/13 with Unit Manager #2 and Occupational Therapist #1 on 8/2/13 at 2:40 P.M., the Manager and Therapist said that at discharge on 6/7/13, the resident had been ambulating short distances and required minimal assistance for transfers. CNA #1 joined the discussion and restated the resident was a mechanical lift transfer and that the change in status had occurred a month ago. The Unit Manager questioned the documentation on the ADL flow sheets and the CNA said he/she had made a mistake and had coded the flow sheet incorrectly. The CNA said it should be a mechanical transfer not a two person assist. Unit Manager #2 said that the facility did not have a functional or restorative maintenance program, but the expectation was for staff to maintain the resident's functioning ability following services. The Unit Manager and Occupational Therapist #1 said that if any resident has a change and/or decline in ambulation or transfers, a request to evaluate the resident should be given to the rehabilitation department, so that the resident can be evaluated. A request to evaluate the resident had not been made.