Every finding on record at St. Elizabeth Rehabilitation & Nursing Center

Based on observations and interview it was determined that the facility staff failed to maintain infection control practices. This deficient practice was evidenced in 20 of 24 PPE carts observed outside of residents' rooms and 1 (#1) of 2 residents with urinary drainage bags assessed during the complaint survey.The findings include:1. On 08/20/26 at 10:15 am during observation rounds the surveyor observed PPE carts outside of the residents' room on the second and third floors.On 08/21/26 at 11:42 am the surveyor observed PPE carts on the floor outside of room [ROOM NUMBER] on the first floor. On the second floor there was a PPE cart on the floor outside Rooms 218, 219, 224, 225, 228, 230, and 232. On the third floor there were a PPE carts on the floor outside Rooms 310, 315, 319, 320, 321, 322, 324, 325, 326, 328, 329, and room [ROOM NUMBER]. During an interview with Director of Nursing #2 the surveyor reported that most of the PPE carts were on the floor and other PPE carts had wheels. The surveyor asked why the PPE carts were on the floor. DON #2 verbalized they didn't realize the carts were on the floor and they would make sure they take care of the issue. 2. On 08/25/26 at 3:54 pm the surveyor observed Resident #1 in a Geri-Chair on the third floor in the dayroom. The resident's urinary drainage bag was on the floor on the right side of the Geri-Chair. The surveyor made Activities Director #7 aware the urinary drainage bag was on the floor.

Based on medical record review and interviews it was determined that the facility staff failed to document when a resident received a shower. This deficient practice was evidenced in 1 (#2) of 1 Task section reviewed during the complaint survey.The findings include:On 08/20/2026 10:34 AM A review of the electronic health record (EHR) revealed the Resident #2 was scheduled to receive a shower on Monday & Thursday during the 7:00 am - 3:00 pm shift. On 08/20/26 review of the Task Section in PCC (Point Click Care) EHR for the months of June and August 2026 revealed the staff were not documenting that the resident received a shower. According to the documentation the resident was receiving a bed bath. On 08/20/26 at 1:33 pm during an interview with Geriatric Nursing Assistant (GNA) #4 the surveyor asked when a resident receives a shower, where was the task documented. GNA #4 verbalized the staff documents in PCC which is the electronic health record. The surveyor asked, when a resident receives a shower, did the staff shampoo the residents' hair. GNA #4 verbalized they notify the nurse when the residents' hair is shampooed. At 1:53 pm during an interview with GNA #5 they said they document in PCC and on the shower sheet when a resident receives a shower. They usually shampoo the residents' hair twice a week; they document a note in PCC when their hair is shampooed. A review of Resident #2 Task Section in the EHR revealed on 08/13 and 08/17 the documentation did not indicate that the resident received a shower. Director of Nursing #2 was made aware the documentation was not clear in the electronic health record when the resident received a shower.

Based on a review of the facility's investigation and interview it was determined that the facility staff failed to complete a thorough investigation when a resident had a drug overdose. This deficient practice was evidenced in 1 (#3) of 1 facility investigation reviewed during the complaint survey.The findings include:On 08/20/26 at 2:27 pm a review of the facility's investigation revealed on 08/09/26 at 9:00 am Resident #3, had a drug overdose and was administered Narcan x 1 dose. The assignment sheet was not included with the documents in the investigation file.On 08/20/26 at 2:38 pm during an interview with Administrator #1 the surveyor asked how they determine what staff needed to be interviewed. Administrator #1 verbalized they interview the staff that worked during the time of the incident including the staff assigned to the resident, the manager on duty, supervisor, and the concierge. The surveyor made Administrator #1 aware, according to the staffing sheet, all the staff who worked on the unit were not interviewed. Administrator #1 verbalized they interviewed the staff who were in the immediate area. On 08/20/26 at 2:50 pm the surveyor received a copy of the assignment sheet and compared the staff who worked on the unit to the statements in the investigation. According to the assignment sheet and statements, a statement was not included in the investigation from Geriatric Nursing Assistant (GNA) #5, GNA #11, GNA #12, Registered Nurse (RN) #13, and Licensed Practical Nurse (LPN) #14. During interview, Administrator #1 verbalized they interviewed the staff who worked on the hall where the resident was located. The surveyor made Administrator #1 aware GNA #5 was assigned to the hall where the resident was located, but a statement was not included with the investigation. There were statements from other staff who worked on the unit but not all the staff.

Based on medical record review and interviews it was determined that the facility nursing staff failed to document according to professional nursing standards. This deficient practice was evidenced in 2 (#2, #3) of 3 resident records reviewed during the complaint survey. The findings include:The Maryland Nurse Practice Act guide and governs nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 B (3) (c) (i) The LPN contributes to the nursing assessment by recording data in a manner which is complete, timely, and accurate. 1. On 08/20/26 at 11:05 am a review of Resident #2's electronic health record revealed the resident was sent to the hospital for further medical evaluation for complications with their gastrostomy tube (G-tube). A review of the Transfer Form revealed Licensed Practical Nurse (LPN)#3 failed to document the resident's admission diagnosis, the resident's urinary catheter and the reason why the catheter was inserted was not documented. LPN #3 documented the resident had a leaking hole instead of documenting the resident's gastrostomy tube had a hole that caused the tube to leak. The surveyor spoke with LPN # 3 via telephone at 12:26 pm, the surveyor asked why Resident #2 was sent to the hospital. LPN#3 verbalized when they went to administer the resident's medications, tube feeding was in the bed, and they noticed a hole in the gastrostomy tube when they attempted to administer medications through the G-tube. The surveyor asked LPN #3 why they didn't document the admitting diagnosis and the resident's suprapubic urinary catheter. LPN#3 verbalized they didn't pay attention to that because it didn't have anything to do with the situation. The surveyor asked why another nurse completed the SBAR (Situation/Background/Assessment/Recommendation) Form. LPN #3 verbalized LPN #8 knew what was going on and completed the form on their behalf.On 08/26/26 at 9:35 am during a telephone interview with LPN #8 the surveyor asked why pertinent questions on the SBAR/Change in Condition Form were not answered. The residents' code status and urinary catheter were not documented. The residents' pain was documented as 2/10 with the date 08/17/26 at 2:10 pm. LPN #8 verbalized not remembering which questions were missed but believes they should have been answered as it had been some time since they worked with the resident. They assessed the resident's pain by looking at their facial expression; from what they saw, the resident did not have pain. 2a. On 08/20/26 at 2:27 pm a review of the facility's investigation regarding an incident of a drug overdose by Resident #3 revealed the incident occurred on 08/09/26 around 9 am. Licensed Practical Nurse #6 was the assigned nurse who administered Naloxone HCL intranasally. A review of Resident #3's medication administration record revealed LPN #6 documented Naloxone HCL was administered to the resident on 08/08/26 at 8:34 am and the order was written on 08/11/26, which was two days later.On 08/21/26 at 1:44 pm the surveyor asked if Resident #3 had an overdose more than once. LPN #6 verbalized the resident overdosed once. The surveyor asked LPN #6 if Resident #3 overdosed once why did they document Naloxone HCL was administered on 08/08/26 at 8:34 am. LPN #6 verbalized Resident #3 overdosed one time that they are aware of; Director of Nursing #2 made them aware they didn't sign off the medication after it was administered. Instead of immediately documenting the medication was given on 08/09/26 they signed it off on 08/08/26 which was the incorrect date.2b. On 08/25/26 at 4:34 pm a review of Resident #3's Transfer Form that was completed when they were transported to the hospital revealed LPN #6 documented the resident was transferred to the hospital on [DATE] at 2:12 pm. On the second page of the Transfer Form LPN #6 documented report was given to the ER Nurse on 08/09/26 at midnight. During an interview with LPN #6 the surveyor asked was the recorded time when the ER Nurse received report correct. LPN #6 verbalized if the time was not changed when the form was completed the time would default to midnight. The time was not correct.On 08/26/26 at 9:48 am a review of the facility's policy for Documentation in the Medical Record revealed documentation should be accurate, relevant, and complete containing sufficient details about the residents' care and/or responses to care. In addition, documentation should be timely.

Based on observation and staff interview, it was determined that the facility failed to ensure that refrigerated food items were consistently labeled and dated with preparation and expiration dates to maintain sanitary storage conditions and prevent the potential for serving unsafe food. This deficient practice was identified during the initial and follow-up tours of the kitchen during the recertification survey. The findings include: On 02/19/2026 at 7:52 AM, during the initial tour of the kitchen, the surveyor met with Dietary Technician (Staff #32). At 8:03 AM, during observation of the walk-in refrigerator identified by Staff #32 as grocery storage, the surveyor observed eight bags of cabbage without labels or dates, one mixed tray of carrots and cabbage that was unlabeled and undated, two trays of sliced tomatoes without labels or dates, and two bags of carrots with a Best Used By January 27, 2026 date. When interviewed, Staff #32 stated that unlabeled groceries were usually prepared the same day or the day before and acknowledged that they should have been dated. Regarding the cabbage, he stated it was supposed to have an expiration date. When informed that the carrots were past the Best Used By date, he stated it was an oversight and that the items would be removed.On 02/19/2026 at 8:15 AM, the Lead [NAME] (Staff #21) met with the surveyor and Staff #32 in front of the walk-in refrigerator and was asked for dual observation. Staff #21 confirmed that the items had no labels or dates and stated that the items would be discarded. The items were then removed from the refrigerator.On 02/25/2026 at 12:57 PM, during a follow-up visit to the kitchen with the Certified Dietary Manager (CDM), the surveyor again observed two unlabeled and undated bags of carrots in the grocery refrigerator. The surveyor also observed two trays of tuna fish and one tray of sliced tomatoes stored in another refrigerator without labels or dates. The CDM acknowledged the findings and stated the items would be removed immediately.On 02/26/2026 at 7:49 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the concerns identified during the kitchen tours. Both acknowledged the findings.

Based on observations, record review, and interviews, it was determined that the facility failed to provide respiratory care services for residents that meets professional standards. This was evident for 6 residents (Resident #161, #121, #162,#118, #160, and #2 ) out 9 reviewed for respiratory services during the annual survey. The findings Include:1) On 02/19/2026 at 9:29 AM, during the initial tour of the facility, Resident #161 was observed lying in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 4.5 liters per minute (LPM). On 02/19/2026 at 11:30 AM, review of the resident's electronic health record (EHR) revealed no active physician order for oxygen therapy or oxygen flow rate. An order dated 02/18/2026 stated: Change, Date & Initial O2 tubing & Humidifier bottle weekly & PRN every night shift every Wed for Infection Prevention. No order specifying oxygen flow rate was identified at that time. On 02/19/2026 at 1:35 PM, review of the hospital Discharge summary dated [DATE] revealed the resident was discharged on 3 LPM of oxygen. On 02/19/2026 at 1:47 PM, an interview was conducted with Licensed Practical Nurse (LPN #12). When asked what the ordered oxygen flow rate was for Resident #161, LPN #12 stated the resident was receiving 2 LPM. When asked when the order was obtained, she stated that the outgoing nurse had reported during shift report that the resident was on 2 LPM. When asked who entered the oxygen order into the EHR, LPN #12 reviewed the record and stated there was no physician order for oxygen. She further stated there should have been an order specifying the oxygen flow rate. On 02/19/2026 at 1:50 PM, during dual observation with LPN #12, the oxygen concentrator was observed set at 4.5 LPM. LPN #12 adjusted the oxygen flow rate to 2 LPM at that time. On 02/19/2026 at 1:57 PM, an interview was conducted with the Unit Manager (LPN #10). When asked what the prescribed oxygen flow rate was for Resident #161, she stated it should be reflected in the physician orders. After reviewing the EHR, she confirmed there was no oxygen flow rate order present in the resident's record. She stated the order should have been entered, as oxygen was noted in the hospital discharge summary. At that time, LPN #12 informed the Unit Manager that she did not locate an order and did not further investigate because she relied on shift report indicating the resident was receiving 2 LPM. On 02/20/2026 at 9:03 AM, follow-up review of the resident's physician orders revealed a new order stating: Oxygen at 3 LPM via nasal cannula continuous every shift. Notify provider if oxygen saturation is less than 90%. On 02/20/2026 at 9:31 AM, follow-up observation of Resident #161 revealed the oxygen concentrator was set at 4 LPM. On 02/20/2026 at 9:51 AM, during a dual observation with Registered Nurse (RN #13), the oxygen was confirmed to be running at 4 LPM. When asked what the prescribed oxygen flow rate was, RN #13 stated the resident had shortness of breath and she had been informed during shift report that the resident was to receive 4 LPM. When asked to verify the physician order, she reviewed the EHR and stated the order was for 3 LPM. RN #13 then adjusted the oxygen flow rate to 3 LPM. On 02/20/2026 at 10:02 AM, a follow-up interview was conducted with the Unit Manager (LPN #10). When asked about the process for shift-to-shift reporting, she stated outgoing nurses were responsible for providing accurate information regarding residents' needs and treatments. When informed that Resident #161 had been receiving 4 LPM based on shift report despite a 3 LPM physician order, she acknowledged that the error involved inaccurate reporting by outgoing nurses and failure of incoming nurses to verify physician orders. She stated nursing staff would receive in-service education regarding verification of physician orders. 02/24/2026 10:52 AM in an interview with the DON, when asked for expectations regarding oxygen flow rates, she stated that there had to be a physician order in place which is expected to be followed by the nurses. On 02/24/2026 at 11:01 AM, when concerns regarding the absence of oxygen orders and the administration of incorrect oxygen flow rates were discussed with the DON, she acknowledged it as a concern. 2) On 02/19/2026 at 8:59 AM, during the initial tour of the facility, Resident #121 was observed receiving oxygen at 3 liters per minute (LPM) via nasal cannula. The oxygen tubing in use was not dated or labeled to indicate when it had last been changed. On 02/20/2026 at 9:39 AM, a follow-up observation of Resident #121 revealed the resident continued to receive oxygen at 3 LPM via nasal cannula. The oxygen tubing remained undated and unlabeled. The attached humidifier bottle was observed to be empty. On 02/20/2026 at 9:42 AM, Licensed Practical Nurse (LPN #15) participated in a dual observation and confirmed that the oxygen tubing was not dated or labeled and that the humidifier bottle was empty. When asked when the tubing had last been changed, LPN #15 stated she did not know due to the absence of a date on the tubing. When asked about the facility's expectation regarding oxygen tubing maintenance, LPN #15 stated that the tubing should be dated and labeled after each change. LPN #15 stated she would replace the tubing and humidifier bottle immediately. 3)On 02/20/2026 at 1:14 PM, Resident #162, identified as a new admission, was observed receiving oxygen at 2 LPM via nasal cannula. Observation of the oxygen tubing did not reveal any date or labeling indicating when the tubing had been changed. On 02/24/2026 at 9:10 AM, a follow-up observation in Resident #162's room revealed the oxygen tubing remained undated and unlabeled. On 02/24/2026 at 9:16 AM, LPN #15 was called for dual observation and confirmed that the oxygen tubing was not dated or labeled. LPN #15 stated that it should have been dated and labeled and indicated she would do so immediately. On 02/24/2026 at 10:50 AM, during an interview, the Director of Nursing (DON) was asked about the facility's expectation regarding the dating of oxygen connecting tubing. The DON stated that oxygen tubing should be changed and dated weekly on Wednesdays and as needed. On 02/24/2026 at 11:01 AM, when concerns regarding the absence of oxygen orders and the administration of an incorrect oxygen dose were discussed with the DON, she acknowledged it as a concern. 4) On 02/19/2026 at 9:11 AM, during the initial tour of the facility, Resident #118 was observed receiving oxygen via a nasal cannula. The oxygen tubing was not dated or labeled to indicate when it had been changed. On 02/20/2026 at 9:40 AM, a follow-up observation of Resident #118 revealed the resident continued to receive oxygen via nasal cannula. The oxygen tubing was still not dated and labeled. On 02/20/2026 at 9:43 AM, Licensed Practical Nurse (LPN) #9 was brought into Resident #118's room and shown that the oxygen tubing was not labeled. He stated that the oxygen tubing should be changed weekly depending on the order and that the oxygen tubing should have been labeled and dated after it was changed. On 02/20/2026 at 9:44 AM, During an Interview with the 3rd floor Unit Manager, she stated and confirmed that oxygen tubing should be changed weekly and that after the staff changed the tubing they are expected to label and date the tubing. At this time she was made aware of the concern. 5) On 02/19/2026 at 9:19 AM, during the initial tour of the facility, Resident #160 was observed receiving oxygen via a nasal cannula. The oxygen tubing was not dated or labeled to indicate when it had been changed. On 02/20/2026 at 9:40 AM, a follow-up observation of Resident #160 revealed the resident continued to receive oxygen via nasal cannula. The oxygen tubing was still not dated and labeled. On 02/20/2026 at 9:43 AM, Licensed Practical Nurse (LPN) #9 was brought into Resident #160's room and shown that the oxygen tubing was not labeled. He stated that the oxygen tubing should be changed weekly depending on the order and that the oxygen tubing should have been labeled and dated after it was changed. On 02/20/2026 at 9:44 AM, During an Interview with the 3rd floor Unit Manager, she stated and confirmed that oxygen tubing should be changed weekly and that after the staff changed the tubing they are expected to label and date the tubing. At this time she was made aware of the concern. 6a) On 02/19/2026 at 8:21 AM, an observation in Resident #2's room revealed that his/her oxygen was set at 2 liters of oxygen. The surveyor asked Resident #2 what his/her oxygen is supposed to be set at, and Resident #2 stated that it was supposed to be at 3 liters. On 02/19/2026 at 8:26 AM, during an interview with Licensed Practical Nurse (Staff #8) he/she asked Resident #2 what his/her oxygen should be set at, and Resident #2 stated 3 liters and Staff #8 then proceeded to adjust the flow rate to 3 liters. On 02/26/2026 at 10:13 AM, record review revealed that Resident #2 had an active physician's order for oxygen at 3 liters. 6b) On 02/19/2026 at 8:21 AM, an observation in Resident #2's room revealed that his/her oxygen tubing was unlabeled. On 02/19/2026 at 8:26 AM, an interview with Licensed Practical Nurse (Staff #8) revealed that the expectation was that the oxygen tubing should have been labeled. On 02/20/2026 at 9:38 AM, a second observation in Resident #2's room revealed that his/her oxygen tubing remained unlabeled. On 02/20/2026 at 9:45 AM, an interview with Registered Nurse (Staff #16) revealed that the expectation was that the oxygen tubing should have been labeled. On 02/20/2026 at 11:44 AM, a third observation in Resident #2's room revealed that his/her oxygen tubing was labeled. On 02/24/2026 at 9:03 AM, the concerns were brought up with the Director of Nursing and she indicated that she understood.

Based on observation and interview, the facility failed to ensure that food was served to residents at an appropriate and palatable temperature to ensure quality and safety. This deficient practice was identified during test tray observation on 1 (second floor) out of 2 floors during the facility's recertification survey.The findings include:On 02/19/2026 at 8:40 AM, during an interview, Resident #63 reported that food was consistently cold when delivered to his/her room.On 02/19/2026 at 9:50 AM, during an interview, Resident #92 stated that meals were cold and stale upon delivery.On 02/24/2026 at 11:09 AM, the surveyor conducted an observation of the lunch tray line for the first floor. Dietary Aide Staff #19 was observed plating meals for residents dining in the main dining room.On 02/24/2026 at 11:44 AM, the surveyor inquired regarding the service schedule for residents who preferred to dine in their rooms. Dietary Aide Staff #19 stated that she would begin preparing those trays only after completing meal service for residents in the dining room.On 02/24/2026 at 11:52 AM, the first meal cart departed the dining room for the unit.On 02/24/2026 at 12:39 PM, as the final meal cart was being prepared, the surveyor requested that the Certified Dietary Manager (CDM) include a test tray on the final cart designated for the first floor.On 02/24/2026 at 12:41 PM, the final meal cart departed from the dining room. The surveyor and the CDM followed the cart to the unit to conduct a test tray observation. The cart was parked in the hallway while the Administrator-in-Training and the Geriatric Nursing Assistant (GNA) transported trays from the cart to residents' rooms. The final tray was delivered at 12:49 PM.On 02/24/2026 at 12:50 PM, the CDM tested the food on the test tray using the facility's food thermometer. The recorded temperatures were as follows: peanut butter pie, 72.2 F; cola-glazed ham, 104.4 F; baked sweet potato, 113 F; green beans, 116 F; and carrots, 117 F.When he/she was asked regarding the facility's expected food temperatures, the CDM stated that hot food items were required to be served between 125 F and 135 F, and cold food items at 41 F or below. When he was informed of the concern regarding the recorded food temperatures, the CDM acknowledged the concern.On 02/25/2026 at 12:49 PM, the concern with the food temperature for residents on the second floor was presented to the Nursing Home Administrator (NHA) and the Director of Nursing (DON).

Based on record review and staff interview, it was determined that the facility failed to ensure that residents and/or their representatives were provided with written notice of hospital transfer and information regarding the facility's bed-hold policy. This was found evident for 2 (Residents #14 and #5) out of 2 residents reviewed for hospitalization during the facility's recertification survey. The findings include: On 02/23/2026 at 12:59 PM, review of Resident #14's electronic health record revealed that the resident was transferred to the hospital on [DATE] with diagnoses of anemia and altered mental status.On 02/23/2026 at 1:58 PM, a review of the resident's clinical record was conducted to determine whether the facility had provided and documented written notice of the hospital transfer and the facility's bed-hold policy to the resident and/or responsible party. The record did not contain documentation of a notice of transfer.On 02/23/2026 at 2:40 PM, review of Resident #5's electronic health record revealed that the resident was discharged to the hospital on [DATE] due to acute respiratory failure with hypoxia. Documentation indicated the resident had experienced repeated hospitalizations for pneumonia and hypoxia.On 02/23/2026 at 3:08 PM, Resident #5's clinical record was reviewed for evidence of written notice of transfer and documentation that the resident and/or representative had been informed of the facility's bed-hold policy. No documentation of a notice of transfer or bed-hold policy disclosure was found in the medical record.On 02/24/2026 at 8:55 AM, an interview was conducted with the Director of Nursing (DON) regarding the facility's process for hospital transfers and discharges. The DON stated that when a resident is transferred to the hospital, the facility obtains a physician order, completes e-Interact/SBAR documentation, and notifies the family. When asked about the expectation for providing notice of transfer and bed-hold policy information, the DON stated that a bed hold is completed for every hospital transfer and that the family is notified.On 02/24/2026 at 8:57 AM, the DON was requested to provide documentation demonstrating that notice of transfer and bed-hold policy information had been provided for Residents #5 and documentation demonstrating that notice of transfer for Resident #14.On 02/24/2026 at 9:54 AM, the DON returned and stated that there was no documentation of the notice of transfer or the bed-hold policy for Resident #5 and notice of transfer for Resident #14. The DON further stated there was no other documentation available to demonstrate that the required notification had been provided. When asked whether the notice of transfer and bed-hold policy should have been provided, the DON stated that it is the facility's policy to notify the resident and/or family of the transfer and to offer the bed-hold policy. When informed that the lack of documentation was a concern, the DON acknowledged the concern.

Based on observations, record reviews, and interviews it was determined that the facility failed to develop and/or update the comprehensive care plan to include oxygen therapy. This was evident for 1 (Resident #2) out of 5 residents observed for respiratory care during the annual survey. A care plan is a simple written plan that explains how to take care of a resident's health and daily needs. It lists what the resident needs help with, what their goals are, and what caregivers should do to help them. It makes sure everyone helping the resident knows the same plan so the care stays organized and consistent. The findings include: On 02/19/2026 at 8:21 AM, an observation of Resident #2 revealed that the resident was receiving oxygen therapy. On 02/19/2026 at 10:13 AM, record review revealed Resident #2 had an active physician's order for oxygen. Further review of the comprehensive care plan revealed no goals, or interventions addressing oxygen therapy, including administrations, monitoring or safety precautions. On 02/24/2026 at 8:58 AM, an interview with the Director of Nursing revealed that the expectation was that residents receiving oxygen therapy had this addressed in the comprehensive care plan. On 02/24/2026 at 9:03 AM, the concern was addressed with the Director of Nursing, and she indicated that she understood.

Based on record review and interviews, it was determined that the facility failed to accurately and completely document a resident's pain as ordered by the physician. This was evident for 1 (Resident #119) of 1 resident reviewed for pain management. The findings include: On 02/24/2026 at 9:29 AM, a review of the resident #119's medical records revealed an order that stated, Has the elder experienced pain during the last 8 hours. If yes, complete a progress note. On 02/24/2026 at 9:45 AM, a review of the resident's treatment administration record (TAR) for January and February of 2026 revealed an assessment task that stated Has the elder experienced pain during the last 8 hours. If yes, complete a progress note. The task documentation revealed several assessments that indicated the resident had pain. On 02/24/2026 at 10:04 AM, a review of the resident's progress notes failed to reveal any documentation related to the resident's pain assessment. On 02/24/2026 at 10:25 AM, during an interview with the Director of Nursing (DON), she stated that her expectation of the nursing staff was to assess the resident for pain and then to document the pain assessment in a progress note per the physician's order. At this time the surveyor asked the DON to provide proof of the pain progress notes. On 02/24/2026 at 10:42 AM, during a follow up interview with the DON. She stated that she was not able to locate any pain progress notes. She then stated that there should be progress notes related to the resident's pain assessment because the order stated to do so. At this time she was made aware of the concern of missing pain assessment documentation and not following the physician's orders.

Based on observations, record reviews, and interviews with facility staff, it was determined that the facility failed to ensure residents were served meals according to the predetermined menu that incorporated resident preferences. This was evident for three residents (Residents #2, #63, and #163) out of four residents reviewed for concerns related to the food menu during the facility's recertification survey. The findings include:On 02/19/2026 at 8:14 AM, during the initial tour of the facility, Resident #2 stated that the meal served did not match the meal ticket. The surveyor observed a hard-boiled egg, a piece of ham, and bread on the resident's plate. The resident's meal ticket indicated juice, oatmeal, scrambled eggs, bacon, cranberry orange muffin, fruit, milk, and coffee.On 02/19/2026 at 8:40 AM, during the continued tour, Resident #63 stated that he/she was not receiving pre-ordered meals due to unavailability of the meals ordered. When asked how long this had been occurring, the resident stated it had been for a while.On 02/20/2026 at 7:20 AM, a review of the day's lunch menu indicated the main entree as potato-crusted fish with rice pilaf, seasoned greens, roll with margarine, and chocolate cake with frosting. The alternate entree was Salisbury steak with gravy, mashed potatoes with gravy, and Italian blend vegetables.On 02/20/2026 at 12:32 PM, during a follow-up interview with Resident #63, the surveyor observed mashed potatoes, carrots, peas, and a bread roll on the resident's plate. When asked whether this was the preferred meal, the resident stated he/she had requested rice pilaf as listed on the menu, but mashed potatoes were served, which were part of the alternate entree. The resident also stated that cake with frosting was not served. When asked for the meal ticket, the resident stated it could not be located.On 02/20/2026 at 1:07 PM, during a follow-up interview with Resident #2, the resident stated that an alternate meal tray consisting of Salisbury steak with gravy, mashed potatoes with gravy, and vegetables had been provided. The resident stated a preference not to have gravy; therefore, the meal tray was returned.On 02/24/2026 at 11:36 AM, during a dining observation, the surveyor observed Resident #163 with a regular potato, cornbread, carrots, peas, peanut butter pie, and a beverage on the table. When asked whether the preferred meal was received, the resident stated it was a regular potato rather than the baked sweet potato listed and added that he/she would eat it. The resident provided the meal ticket, which indicated cola-glazed ham, baked sweet potato, Italian blend vegetables, cornbread with margarine, peanut butter pie, and a beverage.On 02/24/2026 at 12:54 PM, during an interview with the Certified Dietary Manager (CDM), when asked if residents meal preferences were followed, he stated that residents were supposed to receive what was listed on the menu or according to their meal preferences which the facility followed. When informed that a resident reported the menu listed baked sweet potatoes, but a regular potato was served instead, the CDM stated sweet potatoes were available but remained in the oven at lunchtime; therefore, regular potatoes were served. When asked whether residents were informed of the delay and offered a choice, he stated they were not informed and acknowledged they should have been notified of the delay and offered an alternative option rather than being served what was available.On 02/25/2026 at 12:49 PM, the concern was presented to the Nursing Home Administrator (NHA), the Director of Nursing (DON) and they acknowledged the concern.

Based on medical record review and interview with staff and resident it was determined that the facility staff neglected his assigned patients and failed to provide care to them causing identified harm to a resident when the care was refused to be administered. This resulted in psychosocial harm to Resident #2 and was evident during the review of a facility reported incident reviewing documented neglected care of 13 (Residents #2, #29, #33, #39 #40 #30, # 31, #32, #34, #35, #36,# 37, and # 38 ) of 13 residents reviewed during the complaint survey. The findings include: 1. A review on 8/27/25 at 8:45 AM of the facility investigation into the allegation of neglect for Resident #2 revealed allegations that the resident repeatedly requested throughout the nightshift on 7/6/25 assistance for incontinent care. However, according to all available statements, documentation and interviews, staff GNA #7 failed to ever provide that care.Staff ADON # 8 made a statement in the investigation and again on 8/27/25 that the charge nurse from the night shift reported to her on the morning of 7/7/25, concerns that GNA #7 was not providing care to Resident #2 even after repeatedly being asked by said charge nurse. Staff ADON #8 approached Resident #2 on the morning of 7/7/25 after the night shift and found him/her soiled and took a picture of what was left by GNA #7 for the investigation packet. The image in the packet showed Resident #2 in a soiled brief with evidence of stool on the resident's leg and bed. ADON #8 then proceeded to change Resident #2 into a new brief. ADON #8 documented that when she changed Resident #2's brief, the resident's perineal and buttock area were excoriated which was a new occurrence. An order was placed to apply Calmoseptine to the perineal and buttock area after each incontinent episode and the facility DON was notified of the findings. Review on 8/28/25 at 8:30 AM revealed Resident #2 scored with a brief interview of mental status (BIMS) of 13 on admission, meaning that s/he is cognitively intact. S/he was also assessed on the 7/2/25 MDS as being dependent on staff for toileting hygiene. A comprehensive review of GNA #7's documentation from the night of 7/6/24 was completed. Review of the ‘documentation survey report', where GNAs document the care that they provide to residents revealed that form documents the level of care and assistance that a GNA provides a resident for specific activities of daily living. According to the documentation survey report the following was identified as documented by GNA #7 on the nightshift 11-7 am on 7/6/24 into 7/7/24 regarding Resident #2: 1, M, 1 for bowel, NA for bladder. This coding meant that he changed the resident, s/he was dependent for care, incontinent of bowel and there was no urine in the brief when he changed the resident documented at 6:59 AM. A review of Resident #2's medical record revealed that s/he was seen on 7/16/25 by the facility psychiatrist secondary to the incident that occurred on 7/6/25. Resident #2 expressed to the psychiatrist that s/he had intermittent thoughts of hopelessness and stated, I personally would rather die than continue. The assessment continued to document that the resident was frustrated surrounding the events of ‘perceived neglect' and was exacerbating [his/her] emotional vulnerability. There were recommendations to continue support, and s/he was provided with a crisis line for support. Resident #2 was seen again on 7/17/25 with notes that a safety plan would be implemented.The Administrator was interviewed on 8/27/25 and 8/28/25 regarding the status of the ‘safety plan' that was identified and recommended for Resident #2 in the psychiatry notes from admission to the incident that occurred on 7/6/25. As of exit, there was no safety plan provided to the survey team for Resident #2 after the recommendations from the facility psychiatrist and with collaboration from the facility for Resident #2.Resident #2 was interviewed on 8/28/25 at 8:45 AM. S/he was very tearful during the interview regarding the incident that occurred on 7/6/25 and stated s/he had told GNA #7 at the beginning of the (11pm-7am) shift that [s/he] really needed to be changed and he stated, ‘well no we will have to wait until the morning.' S/he stated that s/he was scared as he would just stand there and not do anything and is still scared as the facility has yet to follow up directly with him/her about the status of the employee and if he is ever coming back and if he will ever care for him/her again. S/he further stated that the excoriation on his/her buttocks has gotten worse and is painful. The DON and NHA were interviewed on 8/28/25 regarding this after the interview with Resident #2. The DON stated that she had followed up and met with the resident, however, could not verify what she told the resident or when she followed up with the resident.2. Record review of Resident #29 on 8/27/25 at 11:21 AM revealed MDS assessments showing on 7/7/25; a BIMS of 15 and according to section ‘GG' that assesses functional abilities, Resident #29 was documented as always incontinent of bowel and occasionally incontinent of urine and requires supervision assistance with the wheelchair/walker. Review of an interview with Resident #29 documented in the facility investigation noted that s/he was ‘ignored on purpose and given the silent treatment' according to question #3 on the psychological abuse questionnaire that was given out on 7/10/25 after the abuse allegations reported on 7/7/25 from Resident #2. Resident #29 further reported that on the 11-7 shift that [s/he] was not offered toileting or incontinent care. The Resident stated that [s/he] can go to the bathroom but was not offered help. According to the documentation survey report for Resident #29, GNA #7 documented that s/he was ‘NA' for bowel and bladder, meaning that s/he was unavailable. However, reviews of the progress notes revealed that the resident was in the facility at that time. 3. Review on 8/28/25 of GNA #7's documentation for the remainder of the residents on his assignment from the night of 7/6/25 revealed the following: GNA #7 documented the same thing for-Resident # 33, 39 and #40 as was documented for Resident #2; 1, M, 1 for bowel, NA for bladder. This coding meant that he changed the resident, s/he was dependent for care, incontinent of bowel and no urine in the brief when he changed the resident also documented at 6:59 AM. The following residents were documented as ‘RU,' (not available) for 7/6/25 or ‘NA' (not applicable): Resident #30, 31, 32, 34, 35, 36, 37, 38 all signed off on the documentation survey report between 6:50 AM and 6:59 AM. Further review revealed that GNA #7 worked the 11-7 AM shift on 7/4, 7/5 and 7/6 and that this documentation and lack of care occurred over 3 consecutive days.A review of the above identified resident's progress notes and statuses revealed that the residents noted as ‘NA' or unavailable were all present in the facility. The 13 identified, according to their completed MDS's surrounding the time of the incident revealed that they all required some sort of dependence and support from staff for care from partial to complete for toileting. Review of the employee file for GNA #7 on 8/27/25 at 10:30 AM revealed that GNA #7 was recently hired on 6/12/25 and completed orientation with basic abuse education and training completed on 6/14/25 with skills orientation completed on 6/18/25. The DON and NHA were interviewed regarding these concerns on 8/27/25 at 11:58 AM. They were asked about the thoroughness of the investigation, including completing a skin assessment of the residents. The DON stated that an order was put in for Resident #2 related to the excoriation. However, it was brought to their attention that there is no record or documentation of the excoriation anywhere in the medical record, only the ordered treatment. In addition, there were no assessments of the other identified residents and their skin status from the incident. The DON and the NHA were also unaware that GNA #7 had coded residents that were in the facility as ‘NA' and ‘RU.Cross reference, F585, F609, F610, F656

Based on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to prevent avoidable falls. This was found to be evident for 1 (Resident #7) out of 2 residents reviewed for accidents during the survey. The fall resulted in actual harm to Resident #7. The findings include:On 8/21/25 at 10 AM, review of Resident #7's medical record revealed the resident was admitted to the facility with diagnosis that included but not limited to dementia, polyarthritis, and contracture of muscle. On 8/26/25 at 11 AM, a review of the admission Minimum Data Set Assessment (MDS), section GG0100 with an Assessment Reference Date of 11/21/24 revealed the resident's Upper extremity (shoulder, elbow, wrist, hand) and Lower extremity (hip, knee, ankle, foot) were impaired on both sides. The resident was dependent for toileting, shower/bathe, dressing and personal hygiene. On 11/21/24 the MDS 3.0 Section C - Cognitive Patterns revealed A Brief Interview for Mental Status (BIMS) was conducted. The staff assessment for mental status revealed both short- and long-term memory problems and that the resident had severely impaired cognitive skills for daily decision making.On 8/26/25 at 12PM a review of the care plan that addressed the resident's requirement for assistance with activities of daily living revealed the following intervention, which was initiated on 05/30/2024, that Resident #7 will need assistance/escort to activity functions.On 8/21/25 at 10 AM, a review of the complaint #347680 revealed that, on 11/13/2024, the resident was pushed out of the dining room while in a wheelchair , after breakfast, by GNA # 4. While GNA # 4 was pushing the Resident in the wheelchair, the resident fell forward hitting her/his head on the floor. On 11/13/2024 at 12:42, the electronic medical record revealed a Nursing note that the resident had a sustained laceration to forehead. The area was cleansed with NSS, pressure applied to stop bleeding and dressing applied. The resident was then transferred to the hospital at 0850 for further evaluation per the physician's order. On 11/13/24 the resident was returned to the facility from the hospital with a report of closed head injury, skin tears and abrasion. The laceration could not be approximated with sutures because of missing skin tissue.On 8/21/25 at 11:55 am an interview with the Director of Physical Therapy (PT) revealed that if a resident is being wheeled to PT by staff a footrest is needed for the wheelchair. If the resident can self-propell then no footrest is needed. If a resident is receiving a wheelchair leg rests are provided and the resident can keep them in the room. The Director of PT did not remember Resident # 7. On 12/2/2024 the physician ordered PT to evaluate the wheelchair and positioning for resident #7. The Director of Physical Therapy (PT) stated that he could not confirm or deny that the evaluation occurred.8/21/25 at 12PM the Director of nursing revealed that if a resident is being wheeled by staff a footrest is needed for the wheelchair. If the resident can be self-propell then no footrest is needed. The DON did not remember the incident with Resident # 7. The DON gave the surveyor in-service education for the importance of leg rest during residents' transfer that was provided for staff dated 11/14/24.On 8/26/25 at 11:30 am the DON reported that she could not find a summary of the investigation, witness statement, or a root cause analysis/conclusion for Resident #7's fall.On 8/25/25 at 10:59 AM a telephone interview with GNA # 4 recalled when Resident # 7 fell from the wheelchair. GNA #4 remembered the resident had tennis shoes on but did not remember if the wheelchair had leg rests. GNA #4 stated that the resident put his/her feet down while being wheeled to the other room and his/her feet went under the wheelchair, and he/she fell forward. On 8/26/25 at 10:19 AM interview with Unit manger # 6 recalled when Resident # 7 fell from the wheelchair. The unit manager did not witness the fall, but heard the noise from the fall and investigated. The Unit Manager confirmed that the wheelchair did not have leg rests attached. On 8/26/25 at 12:58 PM, surveyor reviewed with the Director of Nursing the concern that the fall resulted in harm to Resident #7.On 8/28/25 at 12:30 PM at the time of exit conference the Administrator handed the surveyor a plan of correction that was incomplete and the Wheelchair leg rest policy which stated; when residents are transported by staff (pushed in wheelchair): leg rest and footplates shall be in place with both feet supported to prevent dragging, injury, or entrapment.

Based on record review and interview, it was determined the facility staff failed to identify and provide needed care and services by 1) failing to respond timely when residents activated their call bells for assistance, and 2) failing to provide Gastrostomy Tube site care. This was evident for 1 (Resident #5) of 17 residents reviewed for Quality of Care during the complaint survey.The findings include:1) Complaint 2592016 was reviewed on 8/26/25 at 9:00 AM. The complaint included but was not limited to allegations that on numerous occasions staff failed to respond for over an hour after residents activated their call bells for assistance. This concern was confirmed with the complainant during a telephone interview on 8/26/25 at 9:03 AM.On 8/27/25 at approximately 8:00 AM, the Administrator was asked to provide the surveyors with the call bell logs. Review of 3rd floor call bell logs for a 1-week period from 8/1/25 - 8/7/25 revealed 114 occasions in which resident call bells were ringing for more than 30 minutes. On 31 of the 114 occasions staff failed to answer the call bells for more than 1 hour.The facility policy for Call Lights: Accessibility and Timely Response included but was not limited to: 10. All staff members who see or hear an activated call light are responsible for responding within a reasonable timeframe.During an interview on 8/28/25 at 1:14 PM the Director of Nursing (DON) was was asked to identify a reasonable timeframe for staff to answer resident call bells. She stated: at least within 15 minutes. If they're with another resident, about 25 minutes. She added that everyone working in the facility can answer call bells, if it's something they can't address, they should notify the nurse and tell the resident to turn the bell back on, if no one returns within 10 minutes. She was asked if the facility had identified any issues related to timeliness of staff answering call bells. The Administrator, who was also present, responded that the facility recently had a Town Hall meeting where answering call bells timely was discussed. When asked how they identified the need to address answering call bells timely, the DON stated, we looked at trends. She was asked to explain how they looked for trends and what trends they identified. She did not provide an answer but instead provided several examples of why call bells might not be answered timely. The Administrator attempted to explain the question to the DON, then indicated to the surveyor that he would sometimes stand in the hallway during his rounds, observing to see if call lights were on for a long time.They were made aware of the call bell audit review findings at that time.2) A percutaneous endoscopic gastrostomy (PEG) tube is a thin, flexible tube inserted through the skin and into the stomach. It provides a direct route for administering food, fluids, and medications and is used in patients who cannot swallow safely. TAR's (Treatment Administration Records) and MAR's (Medication Administration Records) are used to convey the physicians' orders to the nurse and are signed (initialed) off to document each time the nurse administered the prescribed treatment or medication.Complaint 2592016 included a concern that staff did not clean the area around Resident #5's PEG tube on a regular basis and that on numerous occasions it was covered in gunk.In an interview on 8/28/25 Staff #16, the Assistant Director of Nursing indicated that care of a PEG tube site should be documented on the TAR.Resident #5's medical record was reviewed on 8/28/25 at approximately 2:40 PM. A physician's order was written on 5/22/25 to Cleanse PEG tube site with soap and water and cover with dry gauze every night shift. The order was renewed for July 2025. However, the order was not included on Resident #5's July 2025 TAR or MAR (Medication Administration Record). The resident was transferred to the hospital on 7/28/25. No order was written for PEG tube care upon Resident #5's return to the facility on 7/30/25. The August 2025 physician orders, TAR, and MAR did not include PEG tube site care.In an interview on 8/28/25 at 3:05 PM, the DON (Director of Nursing) indicated that the nurse is responsible for performing routine PEG tube site care and that if there was an order it should be on the TAR. She confirmed that if a Resident had a PEG tube there should be a physician order for PEG tube care. During an interview on 8/29/23 at 9:53 AM, Staff #17 the 3rd floor Nurse Manager was made aware, reviewed Resident #5's medical record, and confirmed the above findings.The Administrator, DON and Corporate Administrator were made aware of these findings on 8/29/25 at 2:00 PM.

Based on medical record and statement from Staff # 13, the facility failed to notify Responsible party after the Resident fell on 8/23/24. This was evident for 1 (Resident # 21) out of 1 resident reviewed during the complaint survey. Findings include:On 8/23/24 Resident #21 was lowered to the floor by Staff # 13. Resident #21 was assessed and put back to bed. The Resident's daughter came to visit and noticed he/she was slumped to the left side of wheelchair and left ankle was swollen. Resident # 21 had a history of blood clots and asked that resident be checked for blood clots and have his/her left lower ankle be x-rayed. On 8/25/24 Lower left ankle was x-rayed and venous doppler was done. Results were the same as before, mild degeneration changes done on 8/26/24. On 8/26/24 Resident #21 could not stand or put pressure on his/her foot. The Resident was sent out 911 to hospital on 8/26/24 and noted to have a left hip fracture. The Resident had it repaired and was sent back to facility.The Responsible party was not notified of the fall that occurred until 8/26/24 when she went to the hospital. DON and administrator aware and stated they spoke with Staff # 13 asking about a fall that resident had on 8/23/24. Staff #13 stated she lowered resident to the floor so she did not consider this a fall so she never reported this. Staff was counselled on 9/5/24 on importance of reporting all incidents.

Based on interviews with resident, staff and review of the grievance process it was determined that the facility failed to give adequate responses to grievances presented by a resident/family regarding an allegation of neglect. This was found evident in the review a facility reported incident of neglect that was also a reported grievance from Resident #2 reviewed during the complaint survey.The findings include:A review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed admission to the facility in June of 2025 for therapy and antibiotics. On the nightshift of 7/6/25 into 7/7/25 Resident #2 put on their call-light repeatedly asking for help to be changed out of a soiled brief. According to a grievance form completed by Resident # 2's family on 7/9/25, GNA #7 failed to provide any activities of daily living on the night shift for Resident #2. According to the response and resolution on the form the employee was terminated, however, there is nothing noted that there was follow up with the family or the resident. Resident #2 was interviewed on 8/28/25 at 8:42 AM. Resident #2 was very tearful and revealed that at that moment s/he was still very upset and scared as according to the resident there was no follow up and s/he did not know if the GNA that neglected him/her that night was coming back. Interview with the facility DON and NHA on 8/28/25, the DON stated that she had followed up with the resident regarding the incident that occurred on 7/6/25 however, she was unable to provide any documentation that there was follow-up.According to the facility grievance policy 10. e. The grievance official will keep the residents appropriately appraised of progress towards resolution of the grievances. f.the Grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation.

Based on record review and interview it was determined the facility staff 1) failed to determine on admission if a resident had an advance directive and provide information about the right to formulate an advance directive; and 2) failed to identify a primary decision-maker for a resident determined not to have decision-making capacity. This was evident for 1 (Resident #5) of 17 residents reviewed for Quality of Care and Treatment during the complaint survey. The findings include:1) Resident #5's medical record was reviewed on 8/25/25 at 12:30 PM. An admission BIMS (Brief Interview of Mental Status) cognitive screening tool dated 5/25/25 revealed Resident #5 score was 14. A score of 13-15 is categorized as cognitively intact. The admission Record revealed the resident was his/her own Responsible Party. The section of the admission record titled, Advance Directive was blank.No documentation was found in the resident's medical record to indicate the facility staff determined if Resident #5 had an Advance Directive on admission, that they informed the resident of his/her right to establish an Advance Directive and provided him/her assistance if he/she wished to establish one.2) The record review also revealed that Resident #5 experienced changes in his/her condition including but not limited to increased confusion. On 8/5/25 2 physicians assessed Resident #5 and certified that s/he lacked the capacity to make informed medical decisions. Further review of the medical record failed to reveal who was responsible for making decisions on Resident #5's behalf nor how they identified Resident #5's decision maker.On 9/29/25 at 9:20 AM the Surveyor requested all documentation related to Resident #5's Advance Directives and determination of decision maker.On 9/29/25 at 11:10 AM the Administrator indicated that the resident did not bring Advance Directives with him/her on admission. He was made aware of the above concerns and asked to provide evidence that the facility offered the resident an opportunity and assistance to develop advanced directives upon admission and documentation reflecting the determination of a surrogate decision maker for Resident #5.He returned at 1:48 PM on 8/29/25 and indicated that he was unable to find any additional documentation and added that the facility's Social Worker at that time no longer worked in the facility.

Based on record review and interviews it was determined the facility staff failed to report incidents within required timeframes. This was evident for 2 (#21 and #2) of 12 residents reviewed for neglect and 2 (#15 and #4) of 6 residents reviewed for abuse during the complaint survey. The findings include:1) On 8/23/24 Resident #21 was lowered to the floor by staff # 13. Resident #21 was assessed and put back to bed. The Resident's daughter came to visit and noticed the resident was slumped to the left side of wheelchair and left ankle was swollen. Resident # 21 had a history of blood clots and asked that resident be checked for blood clots and have his/her left lower ankle be x-rayed. On 8/25/24 Lower left ankle was x-rayed and venous doppler was done. Results were the same as before, mild degeneration changes done on 8/26/24. On 8/26/24 resident could not stand or put pressure on foot. Resident was sent out 911 to hospital on 8/26/24 and noted to have a left hip fracture. It was repaired and the resident was sent back to facility. Responsible party was not notified of the fall that occurred until 8/26/24 when he/she went to the hospital. DON and administrator aware and stated they spoke with Staff # 13 asking about a fall that resident had on 8/23/24. Staff #13 stated she lowered resident to the floor so she did not consider this a fall so she never reported this. Staff was counselled on 9/5/24 on importance of reporting all incidents. Staff # 13 never reported a fall or lowering a patient to the floor that day on 8/23/24. There were no nursing notes. When administrator and DON found out Staff # 13 lowered a resident to the floor on 9/5/24 there was still no investigation done and no one else was interviewed on how resident received a broken hip. When administrator and DON were asked these questions, there was no response. 2) On 8/26/25 at 11:31 AM, a review of a facility’s self-reported incident, 347659, alleged that Resident #15 reported an allegation of possible sexual abuse to a family member, who then reported the allegation to the facility staff. The facility’s investigation documented that the facility staff became aware of the incident on 11/16/24 at 3:00 PM. Further review of the facility’s documentation revealed an email confirmation that documented the facility's initial self-report was submitted to the state survey agency, the Office of Health Care Quality (OHCQ) on 11/17/24 at 6:02 PM. The facility failed to report the allegation of abuse immediately, but not later than 2 hours after the allegation was made. The concerns with the late reporting of an allegation of abuse was discussed with the Director of Nurses (DON) on 8/29/25 at 1:25 PM. The DON acknowledged the concerns and offered no further comments at that time. 3) Review on 8/27/25 at 8:45 AM of the facility reported incident regarding Resident #2 involving an allegation of neglect revealed that the facility was aware of the allegation on the morning of 7/7/25, however, did not make a report until 7/10/25 to the Office of Health Care Quality (OHCQ) as there was an official grievance completed by the family on 7/9/25. This concern was reviewed with the facility DON and NHA (Nursing Home Administrator) on 8/27/25 at 1:24 PM. Although the facility had initiated an internal investigation, there was not a formal report to OHCQ for 48 hours post the finding of a resident being neglected for activities of daily living. 4) Facility reported incident 347683 was reviewed on 8/27/25 at 1:00 PM. The report indicated that on 5/11/25 at approximately 2:45 PM Resident #4's family member reported that the resident stated “bum, bum, bum.” The facility reported an allegation abuse to the state agency, and the police were notified. The facility investigation included statements from several staff members. A statement from Staff #19 a GNA (Geriatric Nursing Assistant) dated 5/11/25 7-3 indicated that on Saturday 5/10/25 she arrived at 7 AM and checked on residents. She stated: [Resident #4] was very upset, crying, and doing a hand movement gesture waving back and forth saying something happened, but I couldn’t understand him/her, and it kept making [him/her] more upset. So, I said don’t worry I’ll be back”, “but [s/he] didn’t say anything the rest of the day”. Staff #19 added “today” the resident’s family member reported Resident #4 made similar remarks to them. There was no evidence that Staff #19 reported the resident’s distress or report that “something happened” immediately to a nurse or supervisor on 5/10/25. On 8/29/25 at 12:32 PM Staff #3 the Corporate Administrator (former NHA of the facility) and the current NHA were made aware of these findings. The Corporate Administrator indicated that agitated and upset behavior was baseline for Resident #4 and not unusual. However, the facility’s summary from the investigation indicated - Resident #4 had “no signs of mood disturbance at this time. However, s/he does have a history per nursing staff. There have been no mood or behavior disturbance reported at this time.”

Based on record review and interview with facility staff it was determined that the facility staff failed to thoroughly investigate allegations of abuse and neglect. This was evident for 2 (Residents #15 and #4) of 6 residents reviewed for abuse and for 1 (Resident #2) of 12 residents reviewed for neglect during the complaint survey. The findings include:1) On 8/26/25 at 11:31 AM, a review of a facility’s self-reported incident, 347659, alleged that Resident #15 reported an allegation of possible sexual abuse to a family member, who then reported the allegation to the facility staff. The facility’s investigation documented that staff became aware of the incident on 11/16/24 at 3:00 PM. The facility’s follow-up investigation report on 11/21/24 documented that Resident #15 was moderately cognitively impaired and resided on the memory care unit. The self-report further documented that Resident #15 was interviewed by the DON (Director of Nurses) and there were no witnesses to the allegation. The facility’s investigation concluded that the allegation of sexual abuse was not verified, there was no evidence to show that any sexual assault had occurred, and interviews with family, the resident and staff did not show any evidence of sexual activity. The self-report documented that Resident #15 was assessed by the physician on 11/18/24, that lab work was ordered to determine any underlying medical condition that might be related to the resident’s allegation, and the medical work was unremarkable. Continued review of the facility’s investigation and review of Resident #15’s medical record failed to reveal evidence that a physical assessment of Resident #15 had been conducted on 11/16/24, when the facility staff became aware of the resident’s sexual abuse allegation. Further review of the facility’s investigation revealed no resident interviews were conducted during the facility’s investigation of the alleged sexual abuse. A review of the facility’s midnight census report for 11/16/24 documented that on that date, 22 residents resided on Unit A-1 (Noah’s Place), including Resident #15. Continued review of facility’s documentation failed to reveal evidence that during the facility’s investigation of the alleged sexual abuse, interviews had been conducted with any of the residents who resided on the same nursing unit Resident #15. In addition, there was no evidence that during the alleged sexual abuse investigation, vulnerable residents who resided on the same unit as Resident #15 had been assessed for potential abuse. On 8/29/25 at 1:31 PM, the concerns with failing to complete a thorough investigation were discussed the Nursing Home Administrator (NHA), the Corporate Administrator, and the Director of Nurses (DON). The DON acknowledged the concerns at that time and stated residents were not interviewed because of their cognitive status, and indicated resident assessments should have been completed and documented in the facility’s self-report 2) Review on 8/27/25 at 8:45 AM of the facility reported incident regarding Resident #2 involving an allegation of neglect revealed that the facility DON was made aware of an allegation of neglect on the morning of 7/7/25. The facility initiated an investigation and GNA (Geriatric Nursing Assistant) #7 was suspended. A review at this time of the facility investigation revealed that the facility ADON (Assistant Director of Nursing), was so concerned about that status she found Resident #2 in that she took a picture of him/her in their soiled brief prior to initiating activities of daily living and changing the resident into a new brief. When the ADON changed Resident #2 she noted that Resident # 2's sacrum was red and excoriated and immediately ordered Calmoseptine, a multipurpose moisture barrier cream to help with the excoriation. Further record review failed to reveal any documented skin assessment showing the presence of the sacral excoriation. Surveyor reviewed the medical records of the 12 other residents on GNA#7's assignment. The documentation survey report was reviewed and revealed that GNA #7 documented the same thing for-Resident # 33, 39 and #40 as was documented for Resident #2; 1, M, 1 for bowel, NA for bladder, even though it was established care was not provided for Resident #2. This coding meant that he changed the resident, s/he was dependent for care, incontinent of bowel and no urine was in the brief when he changed the resident, all documented between 6:51-6:59 AM. The remaining residents on his assignment were documented as ‘RU,’ (not available) for 7/6/25 or ‘NA’ (not applicable): Resident #30, 31, 32, 34, 35, 36, 37, 38 all were signed off on the documentation survey report between 6:50 AM and 6:59 AM. Further review revealed that GNA #7 worked the 11-7 AM shift on 7/4, 7/5 and 7/6 and that this documentation and lack of care occurred over 3 consecutive days. The DON and NHA were interviewed regarding these concerns on 8/27/25 at 11:58 AM. They were asked about the thoroughness of the investigation, including completing a skin assessment of the residents and/or assessments of the other identified residents and their skin status from the incident. The DON and the NHA also verbalized that they were unaware that GNA #7 had coded 8 residents that were in the facility as ‘NA’ and ‘RU' for ADL care over 3 nights. 3) Review of facility reported incident 347683 on 8/29/25 at 12:02 PM revealed that on 5/11/25 at approximately 2:45 PM Resident #4’s family member reported that the resident stated “bum, bum, bum.” The facility reported an allegation of abuse to the state agency and the police and conducted an investigation. The facility’s investigation included 11 statements from staff. Staff did not identify the date or shift to which their statement pertained in 9 of the 11 statements. Review of the nursing staffing schedule for Sarah’s Circle where Resident #4 resided revealed there were no statements from 7 staff who worked on the unit on 5/9/25 and 5/10/25. The census on Sara’s Circle on 5/9/25 and 5/10/25 was 32 – 33 residents. Physical Abuse interviews were conducted with only 4 of the 32/33 residents. There were no physical assessments of residents who were not interviewable. These concerns were reviewed with the Administrator, DON & Corporate Administrator on 8/29/25 at 2:00 PM.

Based on medical record review, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the Brief interview of mental status (BIMS) assessment completed on the minimum data set (MDS). This was evident for 1 of 5 residents (Resident #2) reviewed during the complaint survey. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. BIMS (mandatory, cognitive screening tool used in long-term care facilities to identify and monitor cognitive changes in residents upon admission and periodically thereafter)Review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed that on admission to the facility in 2025, the resident signed the admission contract and was identified as their own representative. The facility social worker also completed a BIMS assessment on admission on [DATE] and Resident #2 scored a 13 meaning that s/he was cognitively intact. However, further review of the medical record for Resident #2 revealed that the submitted MDS assessments for section ‘C' cognitive status since admission all noted that the BIMS for Resident #2 was not assessed or rated and should be scored by the facility staff. The facility social worker who completed all the BIMS assessments and MDS assessments was interviewed on 8/28/25 at 11:35 AM. She stated that she was not sure and could not recall and would like to review her notes.Follow-up from the facility social worker at approximately 12:30 PM on 8/28/25 revealed that yes there was an error in documentation on the submitted MDS related to Resident #2 related to the coded BIMS and that another resident's information was entered under him/her and that it will be corrected.

Based on observation, medical record review, review of the facility's investigation reports, and interviews with staff, it was determined that the facility failed to supervise and provide a secure environment for a resident residing in a secure unit. These failures contributed to the resident eloping and placed the resident at increased risk for serious harm. This was evident for 1 (Residents #374) of 3 residents reviewed for elopement. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance. The findings include: On 10/4/24 at 9:18 AM, the surveyor reviewed the medical record for Resident #374. The review revealed that Resident #374 was admitted to the facility in late 2020 and had a past medical history that included, but was not limited to, vascular dementia , and other abnormalities of gait and mobility. The surveyor reviewed the care plans for Resident #374. A care plan initiated on 11/30/20 stated, that Resident #374 has a diagnosis of dementia and presents with memory impairments. Listed as an intervention was; cue, reorient and supervise as needed. On 12/8/20 an additional care plan was initiated that stated, Resident is an elopement risk/wanderer and exhibits exit seeking behaviors related to vascular dementia; disoriented to place, impaired safety awareness, resident wanders aimlessly and significantly intrudes on the privacy or activities of others. On 5/13/22 a care plan was initiated that stated Resident #374 had a behavior problem related to unspecified dementia. On 1/20/23 Resident #374 had another care plan added that stated, Resident has poor safety awareness related to cognitive function/dementia or impaired thought processes, dementia, impaired cognitive function, impaired decision making. Interventions for this care plan listed to check frequently on the Resident when in his/her room and ensure orders for safety precautions are in place. On further review, the surveyor noted that there were several progress notes written regarding Resident #374's wandering and inappropriate behaviors. On 5/20/22 a progress note was written by Certified Registered Nurse Practitioner in Psychiatric Mental Health (CRNP-PMH) Staff #34, that stated, Resident #374 lacked judgment and insight regarding everyday activities. A progress note written by the Social Service Staff #34 on 6/9/23 stated Resident #374 continues to wander on the secure unit. The note further stated that staff will continue to provide redirection as needed. The surveyor next reviewed a progress note dated 6/23/23, that described an event where Resident #374 exited the patio gate with his/her walker and walked through the grass, down the hill, to the hospital. The note further stated that Resident #374 was returned to the unit by the Unit Manager and an assessment was completed with no injuries noted. On 10/4/24 at 11:01 AM, the surveyor reviewed the facility's investigation file. The review revealed that Resident #374 was attending an outdoor activity on the patio. The patio was attached to the locked unit. During the activity, the activity staff was assisting another resident, at which time it was determined that Resident #374 was able to open the gate to the enclosed patio and leave the gated area. The hospital notified the facility at 2 PM, that Resident #374 was located at the hospital and at 2:10 PM Resident #374 was returned to the facility. The report further concluded that the locking mechanism to the gate was open and disarmed due to a fire drill that was conducted the day before. On 10/7/24 at 8:15 AM, the surveyor observed the courtyard connected to the secured unit. The gate was secured and there was no ability for a Resident to leave the gated courtyard. The hospital ' s parking lot was able to be seen from the courtyard. To get there a person would have to walk down a grassy hill which would lead you to the parking area connected to the hospital. On 10/07/24 at 9:29 AM, the surveyor interviewed the Activities Assistant Staff #28, who was working with residents in the locked unit. During the interview, Staff #28 stated that she had just started the job a few weeks ago and due to the constant rain, no activities had been held into the courtyard. When asked what the protocol was for activities conducted in the courtyard staff #28 stated that the activities person should first check the gate to make sure it is locked. She further stated she and an additional person would obtain a census for the residents that were scheduled to attend the activity and would take attendance before and after the activity. She stated that two people were required to supervise the residents. On 10/7/24 at 2:02 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated the facility staff that supervised the outdoor activity when Resident #374 eloped was no longer working at the facility. She further stated while investigating the incident it was determined that the gate within the enclosed fence that surrounded the patio was unlocked due to a fire drill that was conducted the day before. The DON stated that education was provided to activities staff and nursing on the protocol for activities conducted on the patio. Also, she stated that education was provided to the maintenance staff that included checking the gate after all fire drills and/or power outages. On 10/10/24 at 7:30 AM, the surveyor interviewed the Maintenance Manager Staff #12. During the interview Staff #12 stated that after the elopement incident with Resident #374, his staff were educated on the protocol to check the magnetic locks after every fire drill or power outage. On 10/10/24 the surveyor reviewed the corrective action the facility provided to the surveyor. An in-service was completed on 6/23/23 with the maintenance staff that included the education training to check all exits after fire drills. An in-service was completed for staff on the protocol for resident safety during outside activities on the locked unit. The education included: 1. directions to split up residents into two different groups with two staff members. 2. Activity and nursing staff to check the gate prior to outside activities to ensure that it ' s locked during activities. 3. Collaboration with nursing staff with a roll call at the beginning of an activity and the end of an activity to make sure all the residents are accounted for. 4. Activity staff and nursing staff have been educated on the steps to protect our patients from leaving the facility unaccompanied during outside therapeutic activities. This education was completed on 6/26/23. The facility was in substantial compliance as of 6/26/2023.

Based on administrative and medical record review and interviews with the resident and facility staff it was determined the facility failed to keep residents safe and free from accidents that resulted in injury for Resident #5 due to a transfer by an aide that did not use a sit to stand mechanical lift required for the resident transfer. Resident #5 fell and fractured their right hip, resulting in harm to the resident. This was found to be evident for 1 of 3 residents (Resident #5) reviewed for falls during a complaint survey conducted at the facility. Findings include: During this survey the investigation was extended to include Resident #5 who was reviewed for falls. 1. Resident #5 was transferred by an aide that did not use a sit to stand mechanical lift that was required for the resident transfer. The Minimum Data Set (MDS) is a federally funded mandated process used for the clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Resident #5 was admitted to the facility with the following but not a limited Diagnosis: [REDACTED]. Review of the MDS on 11/18/20 with ARD (Assessment Reference Date) of 7/23/20 revealed under the section for Functional Status (G0110) Activities of Daily Living (ADL) Assistance (b) Transfer: Resident #5 was coded 3 extensive assistance and requires 2-person physical assist support. On 11/18/20 the facility provided a copy of a progress note with an incident dated 10/15/20 at 20:38 as follows: GNA #5 was placing Resident #5 in bed and s/he slipped out of the chair to the floor on his/her right hip. Found resident laying on his/her back and complaining of a small to moderate amount of pain to the right hip. The resident was checked for Range of Motion and spoke of no pain after the exam. The facility's undated No Lift Policy was reviewed on 11/18/20 and listed under Procedure for use of Sit/Stand Mechanical Lift and under (1b) Equipment/Personnel indicates Two (2) or more caregivers. An interview was conducted with the Director of Nursing (DON) on 11/18/20 at 2:00 PM. The DON stated that the GNA assigned to work with Resident #5 on 10/15/20 worked with an agency that the facility uses to assist with staffing needs. The DON went on to say that Resident #5 required 2 persons to physically assist with transfers and a sit to stand mechanical lift is required for all transfers. The DON further explained the GNA did not get another staff to assist her with the transfer and did not use the required mechanical sit to stand lift to transfer the resident. As a result, the resident fell and sustained a fracture to the right hip. An interview was conducted with Resident #5 on 11/19/20 at 9:15 AM with the DON present. The resident was alert and oriented x 3. The resident was asked if they had a recent fall and s/he responded, yes about a month ago. The resident went on to say that an aide transferred him/her from the wheelchair to the bed and did not use the lift machine that is usually used. Resident #5 further stated that s/he fell and broke their right hip and had to have surgery. The resident stated that usually two aides assist him/her using a sit to stand machine that helps with lifting, but only one aide transferred him/her and did not use the equipment. On 11/19/20 the facility provided the surveyor with a typed statement from the assigned GNA indicating the following: On 10/15/20 I was trying to transfer (Resident #5) from the chair to the bed and his/her left side gave away and we went to the floor. I lowered him/her down then called for the nurse. The ADL self-care performance care plan initiated on 1/11/19 was reviewed on 11/19/20. Listed under interventions and transfers are as follows: STS (Sit to Stand) machine with two staff assist. The facility obtained an x-ray on 10/16/20 of the resident right femur and upon review on 11/19/20 it revealed the following findings: Proximal and distal [MEDICAL CONDITION] changes. Contour deformity of the femoral neck laterally. Obscuration secondary to the posterior acetabular rim. Impression: Limited positioning prevents exclusion of the femoral neck impaction fracture. Recommend CT. Review of the Transfer Summary Report [REDACTED]. In another interview with the DON on 11/19/20 at 9:30 AM she was asked how the facility ensures that agency staff can perform required skills to competently care for the residents. The DON stated that the facility does not complete competencies on agency staff and that the agency is responsible for ensuring that their staff are competent and ready to work on the floor when they come to the facility. The DON further explained that each of the caregivers has an IPAD for documentation and that they can access the resident care plan as well. She stated that inside of each resident closet is a form that lists care notes to include resident's specific needs such as ambulation, incontinence needs, eyeglasses, and Transfers. An interview was conducted on 11/19/20 at 10:15 AM with the Head of Clinicians #7 from the staffing agency. She was asked to explain the agency process for ensuring that their staff are competent to provide the skilled level requirements to work in the facility. She stated that during onboarding, the time in which applicants are being considered for hire, the agency does a proficiency assessment. The assessment involves a list of skill sets in which the applicant must meet and if they do, a check is placed next to that competency level box. If their experience and skills meet the criteria and all areas are checked, the staff is hired. If the staff does not check all the boxes indicating they have experience and meets the skill set, they are not considered for hire. The clinician stated that every applicant must have a minimum of 1 year of long-term care experience. The surveyor requested a copy of GNA #5's skills checklist from the agency. On 11/19/20 at 11:30 AM the DON submitted a copy of Long-Term Care Nursing Aide Skills Checklist dated 3/14/20 for GNA #5. Upon review, there was a check in each box indicating the staff scored a 4 for the following areas: Transfer Techniques for Gait Belt, Weight Bearing, Hoyer/Easy-Stand, Two-Person Transfer, Pivot, and Wheelchair. A score of 4 = Expert, able to act as a resource to others. The DON stated that she was unsure why the GNA did not use the equipment and attempted to transfer the resident alone. The DON stated the facility notified the agency and requested that the GNA be placed on the do not return list due to her carelessness and lack of concern regarding the resident safety.

Based on review of the facility reported incidents, investigative review and interview with facility staff it was determined that the facility failed to 1. Protect residents against incident of neglect and abuse, 2. Ensure allegations of misappropriation are investigated and reported to the state agency, 3. Ensure measure are put in place to prevent further incidents of abuse 4. Ensure allegations of abuse are thoroughly investigated. This was evident in 17 of 17 residents (#10, #9, #11, #30, #14, #21, #36, #32, #10, #12, #25, #1, #7, #31, #12, #33, #15) reviewed for abuse. On (MONTH) 19, (YEAR) at 6:00 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to thoroughly investigate allegations into abuse, protect residents after an allegation was made and to provide education to staff after an allegation of abuse was made. The immediate jeopardy was removed at 8:45 PM on (MONTH) 19, (YEAR) after acceptance by the survey team and the Office of Health Care Quality. After removal of the immediacy, the deficient practice continued with a scope and severity of F with potential for more than minimal harm for the remaining residents. The findings include: BIMS (Brief Interview for Mental Status) is an assessment tool used to determine a resident's cognitive status. The BIMS results in a score of 0-15 with scores of 13-15 indicating resident is cognitively intact; 8-12 moderately impaired; and 0-7 severely impairment. Review of the job description for Neighborhood Guide, dated (MONTH) (YEAR), revealed the following: Job Duties/Responsibilities .Provide orientation, on-site training, and evaluations for Neighborhood team members and volunteers .provide coverage as needed .Minimum Qualifications/Requirements: Associate's degree in nursing or related field. Holds a GNA certification .Skills/Competencies: Responsible for the delivery of care to address the cognitive, physical, and emotional needs of the elder population. 1. Facility failed to protect residents against incidents of neglect and abuse. Resident (#10, #9, #11) A. Review of the facility reported incident on 1/16/18 occurring on 6/6/17 revealed that Resident #10 alleged s/he called for assistance to use the bathroom for more than 2 hours. Call log showed that the resident pushed his/her call bell 5 times between 4:30 PM and 6:30 PM and did not receive assistance. review of the resident's medical record revealed [REDACTED]. Facility investigation into the allegation revealed after reviewing call bell logs and interview with staff that the resident indeed did call for assistance and the call light was turned off by another staff, geriatric nursing assistant (GNA) #47. GNA #47's statement regarding the incident was: she turned off the call light and told the residents assigned GNA (GNA #35) s/he needed assistance and did not help the resident, this was around 4-4:30 PM. The facility investigation revealed that assigned staff, GNA #35, stated that he was assisting other staff and residents and could not get to him/her. Interview with the facility Quality Assurance (QA) staff on 1/16/18 at 9:36 AM revealed that everyone is supposed to help each other, that is the expectation. The resident was not assisted into bed to use the bedpan until after dinner at 6:30 PM. Per resident's care plan: Void at first urge. Do not hold urine for extended amount of time secondary to risk for recurrent urinary tract infections, in addition to meeting resident's general needs. The facility was unable to substantiate neglect and stated that the employee would be re-educated. The facility was unable to provide any documentation that the employee was formally educated. Additionally, the facility was notified that the state agency found this incident to be substantiated for neglect. B. Review on 11:26 AM on 1/16/18 of a facility reported incident occurring on 5/1/17 revealed an allegation that Resident #9 made against geriatric nursing assistant (GNA) #12. According to the facility reported incident, the Resident alleged that on the night shift prior, his/her GNA had abruptly awakened him/her by roughly pushing on (his/her) shoulder. The roommate was interviewed regarding the incident and stated that Resident #9 and GNA #12 got into it last night. Resident #9's most recent BIMS assessment was a 15/15 on 2/14/17 and was noted as stable according to the facility investigation. Resident #9 alleged that s/he was wet and the GNA refused to change him/her and that (the resident) sat for 4 hours in a wet bed and she only came back when (the resident) stated, 'I'm going to tell your boss.' During the facility interview the elder stated, she is not nice, why she won't help me? The roommate was also interviewed and stated that s/he heard the GNA state after Resident #9 said s/he was wet, Don't tell me that, you will stay like that until I come back. Facility determined through their investigation, even though the employee denied being rude or abusive, that her behavior was contrary to (facility) expectations when interacting with residents . and was terminated. C. Review of the facility reported incident on 1/6/18 at 2:45 PM regarding Resident #11 revealed the resident reported that a geriatric nursing assistant (#13) had not provided care in a timely fashion. Through the facilities investigation they determined: 'Review of the information revealed that the resident did not receive care for more than two hours and the GNA did not respond appropriately.' The GNA directly assigned to Resident #11's employment was terminated. Surveyor review of the investigation revealed that on 5/4/17 GNA #13 was assigned to Resident #11. Resident #11 reported that at around 10:30 AM s/he reported to GNA #15 that Resident #11 needed assistance going to the bathroom. GNA #15 reported to GNA #14 who then at 11:15 AM (45 minutes later) reported to GNA #13, the residents assigned GNA, that the resident needed assistance to use the bathroom. At 12:05 PM Resident #11 reported to GNA #14 that she/he was now sitting in his/her bowel movement and had yet to be assisted. GNA #14 told Resident #11 that she had to leave the floor for lunch and will let his/her assigned GNA know when she sees her. GNA #14 reported that he/she did not see the assigned GNA so he/she reported Resident #11's concerns to the nurse on duty. Review of the nurse's statement (Staff #10) revealed that when he/she went to do wound care on Resident #11 at 1:30 PM and it was evident that the resident needed changed and she along with GNA #14 changed the resident. Although this incident occurred during the facilities compliance window, this incident type was not addressed in their plan of correction. 2. Failed to ensure allegations of misappropriation of resident property were thoroughly investigated and reported to local law enforcement. Resident (#30 and #14) D. On 1/19/18 review of a facility report revealed that on 11/27/17 Resident #30 reported missing money. review of the resident's medical record revealed [REDACTED]. Review of the investigative documentation revealed a statement from Geriatric Nursing Assistant (GNA) #22 who took the original report on 11/27/17. Review of this statement revealed the incident occurred on 11/25/17. Further review of the investigation revealed statements from two GNAs who worked with the resident on 11/25/17. Further review of the Resident Grievance/Complaint Form revealed that the Resident #30 reported that, someone took (Resident #1's) money from out of (his/her) nightstand and left the envelope that the money was in. It was about $53 . On 1/19/17 at 2:30 PM during an interview with GNA #22, who is the Neighborhood Guide, it was revealed that the money that was missing was actually Resident #1's money. GNA #22 was not aware if any interview was conducted with Resident #1 or not, although indicated that Resident #1 was present during his/her interview with Resident #30. GNA #22 also revealed that he had conducted the investigation and then met with the Administrator. He/She also reported that if there was a report of a missing item/money today on his unit, he/she would be the individual to conduct the investigation. Review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy (revision date 3/10/17) revealed the following: Investigation regarding misappropriation: complete an active search for missing item(s) including documentation of investigation. The investigation will consist of at least the following: vi. An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. On 1/19/17 after further review of the investigative documentation and interview with GNA #22 it was determined that there had been no interviews with the nurses who worked with the resident on 11/25/17 or with any housekeeping or maintenance staff that may have had contact with the resident on 11/25/17. Further review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy (revision date 3/10/17) revealed the following: Additional Investigation Protocols: g. Law Enforcement: I. All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. No evidence was found that local law enforcement had been notified. On 1/24/18 at 2:50 PM surveyor reviewed the concern with the Assistant Director of Nursing that law enforcement had not been contacted. E. On 1/18/18 review of Resident #14's facility report revealed that on 5/2/17 the resident's responsible person (RP) reported that the resident was missing coins that he/she gave the resident to use in the vending machines. review of the resident's medical record revealed [REDACTED]. Review of the facility investigative documentation revealed that the Neighborhood guide (GNA # 9) obtained a statement from the resident's responsible person. Further review of the investigative documentation failed to reveal any statements from the resident or any other staff members including housekeeping. The GNA revealed that staff was interviewed but they were unable to provide any useful information. Further review of the investigation failed to reveal that the GNA followed the abuse policy and procedures and law enforcement was not called. During an interview with GNA #9 on 1/18/18 she revealed that he/she did not have any training on how to investigate. The surveyor asked if he/she interviewed the resident, housekeeping or anyone else that may have entered the resident's room she said no and that he/she did not have any copies of the interview that he/she did with the GNA's. Furthermore, the GNA reported that the papers in the folder were all that she had. 3. The facility failed to implement measures to prevent further incidents of abuse, neglect, or misappropriation of property. These measures included failure to re-educate staff on abuse after allegations were made, failure to remove employees from working with a resident again after an allegation of abuse was made, and failure to report abuse allegations. (Residents #21, #11, #36, #32, #10, and #12) F. On 1/18/18 review of a facility report revealed that on 6/2/17 Resident #19 reported that the day shift GNA (Staff #23) had been verbally abusive towards the resident. Further review of this report revealed as of 5/12/17 the resident was coded as cognitively intact. The final report, submitted to the state survey and certification agency on 6/8/17, revealed that the facility is able to determine that (GNA #23) did not verbally abuse (resident). Further review of the Final Report section of this report revealed that the Neighborhood Guide #9 started an investigation of this concern and during this investigation, Neighborhood Guide #9 had spoken with other residents that were assigned to GNA #23. Further review of the investigation documentation failed to reveal any documentation of any interviews conducted by the Neighborhood Guide with other residents on GNA #23's assignment. The only interviews found in the investigative documentation were two hand written statements from the accused GNA and an interview with Resident #19 and Resident #21, which were completed by the Social Worker (Staff #25). Further review of Resident #21's medical record revealed that on 1/12/18 the resident's BIMS was 15 indicating the resident is cognitively intact. Further review of the Final report section revealed that Resident #21 expressed concern regarding the care that GNA #23 provided, stating that the GNA is rough. No mention was found in this report regarding verbal abuse. Review of the 6/5/17 interview with Resident #21 revealed the following: ' . (GNA #23) said to me, 'I'm not putting that cream on you, you don't need it, Big Baby. I don't want to get her fired, I just want a different aid SS (Social Service #25) offered emotional support and assured Elder this matter would be taken care of.' On 1/19/17 at 12:45 PM Social Worker #25, after reviewing the 6/5/17 statement she had written regarding the interview with Resident #21, confirmed that the resident reported being called a Big Baby and that this constituted verbal abuse. Further review of facility report revealed that the facility did not substantiate that the GNA abused Resident #21 but that center leadership (neighborhood guide) provided re-education of resident rights and Per (Resident #21) GNA #23 will not be assigned to (Resident #21). On 1/18/18 review of staffing sheets revealed GNA #23 was assigned to Resident #21 on 6/10/17 and 6/11/17. This information was reviewed with the Director of Nursing (DON) who confirmed that GNA #23 was: clearly assigned to the resident. Surveyor also reviewed the concern that there was no documentation of re-education of resident rights with GNA #23 after the allegations had been made. As of 1/19/18 at 4:30 PM no evidence that resident rights education had been provided to GNA #23 after the (MONTH) allegation. Evidence of Abuse training on 6/10/17 was provided. The facility also provided evidence that the GNA had received Resident Rights education in (MONTH) (YEAR), which was prior to the report of neglect and verbal abuse made in June. The allegation of verbal abuse made by Resident #21 was not reported to state survey and certification agency at all. On 1/18/18 at 11:48 AM surveyor reviewed the concern that Resident #21's abuse allegations had not been reported separately with the DON. G. Review of the facility reported incident on 1/6/18 2:45 PM regarding Resident #11 revealed the resident reported that a GNA (staff #13) had not provided care in a timely fashion. Through the facility's investigation they determined Review of the information revealed that the resident did not receive care for more than two hours and the GNA did not respond appropriately. The GNA directly assigned to Resident #11's employment was terminated. Surveyor review of the investigation revealed that on 5/4/17 GNA #13 was assigned to Resident #11. It was determined through the facility's investigation, that two other GNA's (#14 and #15) were notified, by answering of the call bell, of the residents need to use the bathroom and had not attempted to assist the resident and instead notified the assigned GNA that the resident needed assistance. This caused as delay in care of over 2 hours in which the residents ended up siting in his/her own bowel movement. The facility determined the assigned GNA was neglectful however, no education was provided to the other two GNA's that failed to respond to the needs of the resident when they answered the call bell and or were notified of the resident's needs. As per facility expectation according to the QA nurse on 1/16/18 at 9:36 AM that everyone is supposed to help each other, regarding patient care. Although this incident occurred during the facility's compliance window, this incident type was not addressed in their plan of correction. H. Review of the facility reported incident regarding Resident #36 revealed that the resident alleged that staff RN #45 was inappropriate and repeatedly touched him/her on the lips on the morning of 7/12/17, to force him/her to take morning medications. Although the facility did not substantiate the allegation, the resident who scored a BIMS of 15/15 on his/her 7/17/17 assessment, felt the interaction was inappropriate. The facility final report was for the staff RN #45 to receive re-education on customer service and resident rights. The facility however, was unable to provide any proof that staff RN #45 had any re-education. However, the Director of Nursing (DON) could only verbally state that he/she educated her as the employee refused to sign anything. The DON was asked if he/she herself documented anything regarding the interaction and training and the DON stated no, just the plan of the education in her personnel file during interview on 1/17/18. I. Review of the facility reported incident regarding Resident #32 revealed that the resident alleged that Employee #26 dragged him/her across the floor into the bathroom. Although the facility could not substantiate the allegation, the family requested that the alleged employee no longer provide care for Resident #32. A review of the staffing sheets concurrently with the employee's time card on 1/19/18 at 1:40 PM revealed that the employee was scheduled to work with the resident the days he/she worked. In addition, assignment sheets were missing for other days that the employee was scheduled. This was reviewed with the Quality Assurance nurse who had no further information or documentation that the employee did not care for the resident or that formal education was provided. J. Review of the facility reported incident occurring on 6/6/17 revealed that Resident #10 alleged she called for assistance to use the bathroom for more than 2 hours. review of the resident's medical record revealed [REDACTED]. Facility investigation into the allegation revealed the resident did call for assistance 5 times between 4:30 PM and 6:30 PM, all which were answered, however no care or assistance was provided to the resident until after 6:30 PM. Interview with staff regarding the incident even concurred that the call bell was answered, however, no activities of daily living (ADL) care was provided to the resident. During the facility investigation, the assigned GNA stated that he was assisting other staff and residents and could not get to Resident #10. Interview with the facility QA on 1/16/18 at 9:36 AM revealed that everyone is supposed to help each other, that is the expectation. The statement from GNA #47 regarding the incident was reviewed: '(he/she) turned off the call light and told the residents assigned GNA she needed assistance and did not help the resident, this was around 4:00 PM - 4:30 PM. The resident was not assisted into bed to use the bedpan until after dinner at 6:30 PM. Per resident's care plan: Void at first urge. Do not hold urine for extended amount of time secondary to risk for recurrent urinary tract infections, in addition to meeting resident's general needs. Call log shows that the resident pushed his/her call bell 5 times between 4:30 PM and 6:30 PM and did not receive assistance. The facility was unable to substantiate neglect and stated that the employee would be re-educated. The facility was unable to provide any documentation that the employee was formally educated. Additionally, the facility was notified that the state agency found this incident to be substantiated for neglect. K. Resident #12's facility reported incident was reviewed on 1/18/17, this review revealed that on 11/21/17 the resident alleged that GNA #34 frightened her/him and was rough while doing care and that the resident did not want the GNA to be assigned to her/him. Review of the facility reported incident that occurred on 11/21/17 failed to reveal a Resident Abuse Investigation Report Form. The facility obtained a statement from the perpetrator but failed to obtain any additional statements from other residents or employees. Further review of the incident documentation revealed that the resident verbalized that he/she did not want the GNA assigned to her/him again or to provide care. Review of the facility staffing revealed that on 11/26/17 the GNA was assigned to the resident even though the resident had stated that he/she did not want the GNA assigned to her/him again. During an interview with the Director of Nursing (DON) on 1/18/18 the surveyor asked about the facility's process when an allegation is made against a GNA and the resident is requesting not to have that GNA care for them. She revealed that the facility honors the resident's request and does not assign the GNA to the resident. The surveyor asked how long will the resident's request be honored, and she replied until the resident changes their mind. All findings discussed with the DON, administrator, QA nurse and nurse educator at the survey exit on 1/19/18 4. Failure to thoroughly investigate injury of unknown origin and allegations of abuse. (Residents #25, #1, #7, #31, #12, #33, #15) On 1/17/18 at 3:40 PM the Administrator reported that the Neighborhood Guides are responsible for investigations of injuries of unknown origin. He then confirmed that the guides are GNAs, and then stated the investigations were in conjunction with the unit (nurse) manager. On 1/17/18 at 4:20 PM surveyor reviewed the concern with the Director of Nursing (DON) that the Administrator had reported that the Neighborhood Guides were conducting investigations into injuries of unknown origin. The DON reported that since they had a mock survey she and the unit managers had been leading the investigations. On 1/19/18 the DON confirmed that no formal plan was in place to address this issue regarding abuse investigations which had been identified during the mock survey. On 1/25/18 the Quality Assurance nurse reported that the report from the mock survey was received 12/20/17 and that abuse investigations had been identified as an issue and there still was no plan in place to address the concerns identified as of this survey and the time the immediacy was called. It is important to note that this mock survey was conducted by a private contracted agency. L. Review of a facility report revealed that on 8/24/17 Resident #25 was observed with bruises to body during AM care and that the resident was unable to offer an explanation as to how the bruises were caused. Further review of this report revealed the following was observed by the charge nurse and the DON: large dark bruises noted to the right flank (side), inner aspect of right upper arm, and outer aspect of right lower extremity. Several small bruises noted to bilateral lower extremities as well. Review of the medical record revealed that on 5/25/17 the resident was assessed as being severely cognitively impaired as evidenced by a BIMS of 3. Review of the final report revealed: Nursing leadership conducted interviews with assigned nursing staff on the shifts during the 48 hours prior to the observation of the bruises. Statements were found from several GNAs and one nurse. Further review of the investigative documentation failed to reveal staffing information. On 1/18/18 review of Floor Staffing documentation revealed 3 nurses (Staff #28, #29 and #31) had worked with the resident during the 48 hours prior to the report of the bruises. No statements were found from any of these three nurses. On 1/19/18 at 12:23 AM surveyor reviewed the concern with the DON that the investigation failed to reveal documentation from 3 of the nurses who had cared for the resident during the 48 hours prior to the observation of the bruises. M. Review of a facility report revealed that on 8/30/17 an MRI showed that Resident #1 had a left tibia fracture. The resident had a fall on 6/29/17 but x-rays at that time had been negative for fracture. Review of the medical record revealed a [DIAGNOSES REDACTED]. On 1/18/18 at 9:10 AM the Administrator confirmed that when the initial report was sent to the survey and certification agency on 8/31/17 the fracture was considered an injury of unknown origin. He also confirmed that the final report was submitted on 9/5/17 as a paragraph in an email, rather than on the Self-Report Form. Further review of the facility investigation failed to reveal any interviews of the resident or staff on or after 8/30/17 regarding possible causes of the resident's fracture. This concern was reviewed with the Administrator on 1/18/18 who reported he would look for additional documentation. As of exit on 1/19/18 no additional documentation had been provided. Further review of the 6/29/17 incident report revealed the following note written by the nurse: Per neighborhood guide, elder while returning from the pavilion {his/her} foot got caught on the front door carpet an (his/her) leg gave was and was on the floor. I tripped on the carpet in front of the main door into the building and my legs gave way and I fell . On 1/24/18 further review of the medical record revealed a 7/22/17 physician note which included: The patient sustained a mechanical fall while trying to get to (his/her) wheelchair. On 2/15/18 at 11:10 AM surveyor reviewed the concern with the Assistant Director (ADON) that the 7/22/17 note referenced a fall that did not correspond with the description of the 6/29/17 fall and had not been identified during the injury of unknown origin investigation. It remained unclear if there was an additional fall, as the facilities investigation was incomplete. N. Review of the facility reported incident related to Resident #7 on 1/19/18 at 10:45 AM, revealed an allegation of sexual abuse occurring on 10/9/17. The resident stated someone had touched her private area in the middle of the night and s/he was not sure who it was. review of the resident's medical record revealed [REDACTED]. Further review of the facility reported incident revealed that the facility failed to interview the GNA that was assigned to the resident on the night the allegation of sexual abuse was alleged. The assigned nurse and 1 other GNA that worked that night were interviewed however, no other staff or residents were interviewed regarding this allegation. O. Review on 1/19/18 of a facility reported allegation of abuse occurring on 6/6/17 revealed a family complaint regarding staff RN #33. The allegation was that it was reported to the family from another visiting family member that the evening supervisor staff RN #33 was rude and yelled at her/his (family member, resident #31). review of the resident's medical record revealed [REDACTED]. Review of the facility investigation revealed that it was the Neighborhood Guide that completed the investigation and only staff were interviewed. No residents or other family members were interviewed regarding the concerns and allegations that were brought to the attention of the facility by the resident's family. P. On 1/18/18 Resident #33 facility reported incident was reviewed. This review revealed that on (MONTH) 16, (YEAR) the resident's family member reported to the neighborhood guide (geriatric nursing assistant) that the resident verbalized that someone yelled at him/her and forced him/her to go back to his/her room in which the resident did not want to return to the room. Further review of the investigation obtained by the neighborhood guide (GNA #16) revealed that the resident verbalized that when he/she fell out the bed that is when the alleged incident occurred. Review of the medical records reveal that on 6/1/17 the resident had a fall. Review of the facility investigation revealed staff assignments for 6/16/17 when the allegation was reported but failed to have staffing assignments for 6/1/17 when the alleged incident occurred. Review of the investigation documentation revealed a statement from the geriatric nursing assistant who was assigned to give care to the resident on 6/16/17. Further review of the investigation failed to reveal any statements from geriatric nursing assistants that was assigned to the resident on 6/1/16 when the alleged incident occurred. The facility failed to provide additional interviews with the resident's roommate and all staff working on the date of the allegation. During an interview with Neighborhood guide (GNA #16) the surveyor asked her to review the investigation that she had completed for this resident. Surveyor asked if she was aware that the resident had a fall. Even though it was documented in the investigation, she replied 'not really. The surveyor asked if there was any additional interview with staff on 6/1/17. The GNA replied, 'if it is not there then it wasn't done.' No other documentation or investigation was provided to the survey team at the time of the survey exit. Q. On 1/18/18 Resident #12's facility reported incident was reviewed. This review revealed that on 9/17/17 the resident reported that the GNA who took care of her/him the prior evening threw the resident on the bed causing pain to her/his arm. Review of the investigation from the facility reported incident that occurred on 9/17/17 failed to reveal a 'Resident Abuse Investigation Report Form', it had employee statements. Review of statement #1 failed to have who the person reported it to, the date and time. Statement #2 was written on a piece of paper and taped to the employee statement, statement #3 failed to have the resident's name and statement #4 had a statement but failed to have all the other required information that should have been included in the statements per the form. Further review of the facility reported incident failed to have any documentation of the investigation of the allegation of someone throwing the resident on the bed causing pain to the resident's arm. During an interview with the Quality Assurance nurse (Staff #3) on 1/18/18 the surveyor requested any additional documents from the investigation. He/She revealed that no other documentation could be found. R. On 1/17/18 Resident #15 facility reported incident was reviewed. This review revealed a statement written by the charge nurse, Staff #33, about the incident that occurred on (MONTH) 14, (YEAR). Review of the statement revealed that Staff #33 was asked to report to the nursing unit, upon arrival to the unit GNA #32 informed her that Resident #15 was saying that the assigned GNA #32 failed to provide care. Review of the statement revealed that Staff #33 did not immediately go to the resident's room but listened to GNA #32 tell her side of the incident. The charge nurse revealed that after GNA #32 finished, she went to speak with the resident. Staff #33 documented that the resident revealed that the GNA refused to change her/him after dinner and that the GNA also put the nurses call light on the floor out of reach. The charge nurse asked the resident if she/he was comfortable and the resident replied yes. Review of the abuse investigation form completed by Neighborhood Guide #16 revealed that the resident verbalized that the assigned GNA refused to change her/him after dinner and when care was provided the GNA put the call light on the

Based on medical record review, resident and staff interviews, it was determined that the facility failed to 1. have a system in place to keep a resident (Resident #46) safe from actual and potential psychosocial and physical harm from another resident who was identified as a wanderer with documented unpredictable behaviors (Resident #179). This failure resulted Resident #46 being left in the same environment for an extended period of time with Resident #179, after being hit by Resident #179 and expressing fear and increased anxiety. The facility also failed to report allegations of abuse to the state survey and certification agency (#9, #181, and #159). This was evident for 4 of 29 Residents reviewed during Stage 2 of this survey. The findings include: Resident #179 was admitted to the facility's non-secure Abram's Avenue unit in May 2016 with [DIAGNOSES REDACTED]. Per the 5/17/16 Minimum Data Set (MDS) assessment, at that time Resident #179 required extensive assistance of one staff for bed mobility, transfers; limited assistance for locomotion on/off unit, and he/she was noted as unsteady with walking and needing the assistance of one. Further record review revealed on 6/11/16 Resident #179 was transferred from the Abram's Unit to Sarah's Circle and became roommates with Resident #46. Review of Resident #46's medical record on 2/8/17 revealed that he/she was [AGE] years old with [DIAGNOSES REDACTED]. Review of Resident #46's Minimum Data Set (MDS) Assessment with assessment reference date (ARD) of 9/7/16 revealed that he/she was dependent on staff for all personal care needs and required a one person assist to transfer to a chair. It was further documented that in a 6/23/16 nursing progress note that Resident #179 defecated on his/her bed, on the floor in his/her room and in the hallway and, was found wandering half naked in the hallway. On 6/24/16, thirteen days after Resident #179's transfer to Sarah's Circle, it was first documented that Resident #179 continued getting out of bed at night and was found wandering into other residents' rooms, getting into their beds, going through their personal belongings and being verbally abusive to the other residents and staff members. The progress note for Resident #179 dated 9/21/16 at 3:14 PM documented the following: Was started on [MEDICATION NAME][MEDICATION NAME] q (every) 12 hrs. 9/14 after a weekend of delusions, going out on the balcony, refusing redirection, aggression, screaming. Roommate was quite frightened by her. She settled down for a few days but this past weekend acted out the same behavior in the evening . Resident #179's MDS with ARD of 9/7/16 documented that he/she required the limited assistance of one staff for transfers, bed mobility, locomotion on/off unit, and her/his walking was noted to be un-steady. He/she was also noted to be at risk for falls and a falls care plan dated 9/27/16 was in place for a one person assist with transfers. On 9/25/16 the medical record revealed that another nursing home resident in a room across the hall from Resident #179's room, reported to staff that Resident #179 came into his/her room and got into his/her bed. They argued and Resident #179 disconnected his/her TV by pulling the cord and then grabbed him/her by the wrists. Resident #179 was removed from the room by a staff member and directed back to his/her room. An incident report written by RN #1 on 10/13/16 at approximately 12:54 AM stated the following: Elder's (Resident #46) bed alarm went off and he/she was crying stating that his/her roommate came over and told him/her to get out of the bed then hit him/her in the stomach. Resident Description: The (lady/man) (pointing to his/her roommate) came over and told me to get out of the bed because it was (his/her) bed. I told (he /she) no it wasn't (his/her) bed and (he/she) got mad and hit me in the stomach. (He/she) then went to (his/her) bed. When the staff entered the room Resident #179 began using foul language towards the staff and Resident #46 as staff were directing Resident #179 to return to his/her own bed. At 12:54 AM on 10/13/16, RN #1 documented in Resident #46's medical record, Elder received routine Tylenol. Medical director made aware. Will continue to monitor. Resident #179 remained in the same room throughout that night with Resident #46. RN #1 also documented on 10/13/16 for Resident #179, staff continues to monitor moods and behaviors. Review of Resident #179's medical record did not show evidence of a documented and specific monitoring plan during this time. The Psychiatric Nurse Practitioner (NP) was made aware of the incident by phone on 10/13/16 by the day shift Licensed Practical Nurse Clinical Manager #1 (LPN CM #1). A note was written indicating that the NP reviewed Resident #179's medications and that Resident #179 would continue to do share days in she secure unit when he/she was awake. It was noted in the medical record that Resident #179 began doing share days on the secure unit on 9/27/16. However, resident #179 remained in the room with Resident #46 during the evening hours with no additional supervision. The Psychiatric NP visited the facility on 10/19/16 and saw both Resident #46 and Resident #179. The 10/19/16 Psychiatric NP note for Resident #46 documented the following: Reason for encounter/ Chief complaint- anxiety from roommate. Elder is sharing a room with another elder who has been quite anxious and agitated recently, including striking Elder (Resident #46). He/she has expressed fear to staff. Other elder is being taken to another unit during the day until another bed is available and is awaiting admission to inpatient psychiatric hospitalization . In addition, on 10/19/16 the facility social worker (SW #1) documented a conversation with Resident #179's daughter requesting permission to transfer Resident #179 to a Geriatric Psychiatric (Geri psych) facility: I told her there were regs to follow and we cannot chemically restrain elder although she poses a physical threat to other elders. On 10/20/16 the Psychiatric NP documented a follow-up on assessment note written 10/19/16 that, at that time Resident #179 was propelling through the unit, yelling, angry. He/she went to bed but did not remain there, up again, required 1:1 (a one on one observation/a staff member had to remain with Resident #179 throughout the night due to behavior concerns) all night. During a monthly medication review by the pharmacist in October 2016 for Resident #46, it was documented, No dose reduction possible in [MEDICAL CONDITION]'s (antianxiety medication) secondary to roommate stress. An interview with LPN CM #1 on 2/9/17 at 2:10 PM confirmed that Resident #46 and Resident #179 remained roommates until 10/24/16 when Resident #179 was transferred to a Geri psych facility. On 11/29/16 Resident #179 returned to the facility and was admitted to the secure dementia unit where he/she remained until 1/3/17. On 1/3/17 he/she was transferred to the hospital for an acute condition. He/She returned on 1/6/17 and was readmitted to the secured unit. On 1/11/17 he/she was transferred back to Sarah's circle the third floor of this facility (non-secure unit), the same unit where Resident #46 resided. During an interview with Resident #46 on 2/8/17 at 9:00 AM Resident #46 revealed that he/she was very fearful of his/her previous roommate (Resident #179) who had hit him/her. He/She stated that Resident #179 had been gone for a while but while out in the hallway recently, Resident #46 stated he/she saw Resident #179 again. Resident #46 reported that he/she was fearful when he/she goes out of his/her room for activities. Resident #46 stated that he/she had made the staff aware of his/her fears but, I feel like they don't care. During an interview with the Administrator on 2/9/17 at 1:17 PM he reported that Resident #179, was transferred to a Geri psych facility for approximately 7 to 10 days for Medication management. When asked if there was any discussion or plan to move Resident #179 to another room or unit after the hitting incident on 10/13/16, the Administrator replied, They were not roommates, he/she was across the hall. This surveyor informed the Administrator that there was documentation that confirmed that the two residents were roommates, and the administrator again stated, They were not roommates, I am going to have to look back at it, but I don't think they were roommates. The medical record for Resident #179 indicated that medications continued to be adjusted, however an interview with the Clinical Manager #1 (CM #1) on 2/9/17 at 2:10 PM revealed that no additional staff were added to monitor and maintain a safe environment for Resident #179 or other residents on the unit. CM #1 stated, We just had our regular staff. CM#1 also stated that Resident #179, would wander into the dining room and open multiple packets of condiments and eat them. During the same interview, when asked if there was any discussion or plan to move Resident #179 to another room or unit after the hitting incident with Resident #46, CM #1 replied, that decision wasn't made then. CM #1 was then asked to clarify that Resident #46 and Resident #179 remained roommates for 13 days following the hitting incident. CM #1 replied, Yes, he/she remained his/her roommate for weeks. When CM #1 was asked if he/she was concerned about Resident #179's behaviors and safety he/she replied of the wandering, yes and getting into things. When (he/she) was wandering into other elders rooms, the verbal thing bothered me. That's why I spoke to the Psych NP to see if there was something we could do. Surveyor asked CM #1, after the incident on 10/13/16 with medication changes and behavior monitoring were there any changes observed with Resident #179. CM#1 replied, There were good days and bad days with behavior and wandering. When questioned about Resident #179's return to this unit, CM #1 stated that after the hospital stay Resident #179 went to the secure dementia unit but then came back upstairs. Since he/she's been back up here Resident #179 has stayed in his/her room . During a follow up interview with the Administrator on 3/2/17 at 3:41 PM when asked why Resident #179 was not moved to the secure dementia unit after the incident with Resident #46, the Administrator stated, We didn't have an available bed. We didn't have a safe person downstairs to switch (him/her) with. We would take (him/her) back up at night when (he/she) was good and tired. Resident #46 consented to this agreement. There was no documentation of agreement to this plan from Resident #46 or his/her guardian found in the medical record, or provided to the survey team at the time of the survey. Cross Reference F309 2) During an interview with Resident #159 on 2/8/17 at 10:09 AM, the resident was asked Has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? Resident #159 stated, about 6 months ago the night girl was helping me to get to bed and she pulled on my arm really hard and when I told her to watch it she got really nasty. I told the nurse (Licensed Practical Nurse Clinical Manager 1), she is the supervisor and she told the doctor and they took a picture because I had a really big dark bruise. I think the girl got fired and got her just dues. The facility had documentation that they investigated the incident and the employee had been terminated for the incident, however the facility failed to report of the results of this investigation as required to the State Survey and Certification Agency. 3) On 2/8/17 facility documentation of the investigation related to MD 980 was requested from the Nursing Home Administrator. The Nursing Home Administrator affirmed that an investigation was conducted and stated, the Ombudsman came to see Resident #9 so we didn't report it to your office. On 2/8/17 at 2:30 PM findings were acknowledged with the Assistant Director of Nursing (ADON). When asked about facility investigation and reporting protocol, the ADON replied he/she receives information regarding alleged incidents and conducts an investigation. The ADON also stated he/she then forwards investigative information to the Administrator. The ADON states that he/she is not sure what happens after that. 4) Following medical record review and staff interviews, it was determined that on 8/26/16 at 6:00 PM Resident #181 was seen choking Resident #152 in the hallway of the Noah Unit. Medical records revealed that Licensed Practical Nurse (LPN) #2 had to remove Resident #181's hands from around Resident #152's neck. During an interview with the administrator he/she confirmed that this incident was not reported to the State Survey and Certification Agency within 24 hours of the incident.

Based on review of the medical record, facility documentation, and interview with staff and resident's family, it was determined that the facility staff failed to accurately report X-ray results to the physician, delaying timely medical treatment for [REDACTED]. In addition, staff failed to conduct thorough and accurate assessments and document pain and leg swelling for 1 of 2 (#4) residents reviewed. The findings include: Resident #4 was admitted to the facility for rehabilitation on 5/7/14 following hospitalization for a fall with a right [MEDICAL CONDITION], resulting in a surgical repair. The physician's admission history and physical assessment dated [DATE] indicated that the resident was a high fall risk due to cognitive and sensory impairment, unsteady gait, decreased vision, four or more drug prescriptions, and a history of falls. The nursing admission assessment, dated 5/7/14, indicated that the resident had a history of [REDACTED]. Review of the medical record, on 6/12/14, revealed a nursing note, written on 5/16/15 at 5:50 PM, that stated "resident found on floor laying on back in resident's room, evening shift, oriented x 3, no apparent injury, moves all extremities, no c/o (complaints of) pain. Action: resident got off floor w/staff assistance; head to toe assessment completed with no other issues noted, continue to observe, reviewed use of call light, assistance w/transfers, rehab notified of fall/found on floor." According to the medical record, the resident had a second fall on 5/17/14 at 10:30 AM. The nursing note for 5/17/14 at 11:55 AM stated that the resident was found on the floor in his room, lying on his back near the dresser. The resident was placed back in bed with a lift and neuro checks were started every 15 minutes x 5 times and every 30 minutes x 6 times. The documented neuro checks that the nurse did state, "LEG (R) Does not succumb to resistance" which indicated that the nurse moved the resident's leg 11 times in the first 4 1/2 hours after the fall. Review of the May 2014 Medication Administration Record (MAR) revealed that the resident received Tylenol 325 mg (milligrams) (2) tablets at 11:00 AM for pain, which was right after the fall. Review of the documented pain assessment, which was completed at 11:30 AM on 5/17/14, indicated that the resident had a pain level of "8" before and now has a pain level of "10". Pain level assessments rate pain from 1 to 10 with 10 being the most pain. The assessment noted that the medication was ineffective and the resident continued to complain of pain. Review of the telephonic physician's orders [REDACTED]. There was no time documented as to when the physician was notified and the order was received. Review of Licensed Practical Nurse (LPN) #2's written statement to the facility stated "the patient's pain medication was not effective so I checked the MAR and saw that his [MEDICATION NAME] was discontinued. I paged (Physician #1) to make her aware of the fall and the pain medicine not effective. I left the floor around 12:00 PM to get lunch and LPN #3 was aware that I had a call to (Physician #1). When I came back to the floor around 12:45 PM LPN #3 was on the phone to (Physician #1). Orders were rec'd (received) for [MEDICATION NAME] 4 mg x 1 dose and [MEDICATION NAME] 2 mg q 6 hrs prn, x-ray of right hip, knee and ankle". "LPN #3 gave (Resident #4) the 1 time dose of [MEDICATION NAME] at 2:00 PM." Review of the MAR revealed that Resident #4 did receive his one time dose of [MEDICATION NAME] 4 mg at 2:00 PM. Physician #1 was interviewed on 6/12/14 at 9:20 AM, regarding Resident #4. Physician #1 stated "the incident happened on a Saturday and they called me and I ordered the X-ray." Physician #1 was asked "when you gave the [MEDICATION NAME] order at 12:45 PM for a 1 x dose now, when did you expect the medicine to be given to the resident?" Physician #1 stated "as soon as I gave the order." Physician #1 stated "if they call me and say the patient is in pain I expect the medication to be given right away." The surveyor confirmed, on 6/12/14 at 11:55 AM, during an interview with Registered Nurse (RN) #1, that the [MEDICATION NAME] was in the emergency drug supply box. RN #1 also stated that she would call physician back to get a different drug, if the drug was not available. Resident #4 received the one time dose of pain medication 1 hour and 15 minutes after it was ordered, and after the resident was assessed to have a pain level of "10" on a 1 to 10 pain scale. Further review of the medical record revealed that a pain assessment was done on 5/17/14 at 3:11 PM, which stated, "Tylenol 325 mg given for pain. pain level before med : 8 at right lower leg. Pain level after med 10 Med ineffective continues to complain of symptoms are worse Physician notified; orders rec'd continue to observe, encourage to rest, repositioned." Continued review of LPN #2's written statement revealed the x-ray company "arrived around 3:30 PM." Resident #4's medical record revealed that another pain assessment was done on 5/17/14 at 6:23 PM. It stated "[MEDICATION NAME] 2 mg given for pain. pain level before med 9, after med 2, improved but still present." LPN #2's written statement continues "We rec'd a call from (x-ray company) to notify me that the x-ray results had been faxed in. So I read results and notified (Physician #1) of the results." Review of the Radiology Report dated 5/17/14 revealed the following: "Exam: Hip uni-lat complete Results: Fixated [MEDICAL CONDITION] is in good alignment with intact hardware. Non-fixated mid-shaft femur fracture is mildly displaced. The bones appear diffusely demineralized. Skin staples noted. Conclusion: Recent mid-shaft fracture of femur." "Exam: Knee AP or Lat Results: The knee joint is in alignment, but there is narrowing of the joint space due to mild [MEDICAL CONDITION] changes. There is mild [MEDICAL CONDITION] spurring involving tibial spine and femoral condyles. No fracture of dislocation is seen. No joint effusion is seen. Peripheral [MEDICAL CONDITION] disease noted. Conclusion: Mild [MEDICAL CONDITION]" Review of the nursing notes written on 5/18/14 at 4:49 AM stated " f/u (follow up) incident day #2: no new symptoms, no [MEDICAL CONDITION] (swelling), redness or warmth, no laceration, no bruising. At 4:51 AM, made negative statements (hopelessness, dispair) today. Verbalizations: "help, help", agitated, made disruptive noises, yells and shouts". "Behavior change: behavior status has deteriorated since the last assessment at 4:53 am." A Pain assessment was done on 5/18/14 at 2:07 PM PM, that stated [MEDICATION NAME] 2 mg was given for a pain level before med of 7, but there was no documentation if the medication was effective. Nothing documented afterwards. Another documented pain assessment on 5/19/14 at 1:16 AM stated "Tylenol 325 mg pain level before 5 location: "all over." There was no documentation on effectiveness of medication. Nursing note written on 5/19/14 at 2:29 AM, "f/u incident day #3: fall. Follow up assessment: injury, no new symptoms, no [MEDICAL CONDITION], redness or warmth, no bruising. Documented pain assessment on 5/19/14 at 5:05 AM [MEDICATION NAME] 2 mg given for pain 5 right hip. There was no follow-up. The next 2 pain assessments were written 3 days later as late entries to the medical record. Pain assessment written on 5/22/14 at 10:3 as "late entry for 5/19/14 at 3 AM. symptoms reduced to 1" and on 5/22/14 at 10:55 PM for "late entry 5/19/14 6 AM symptoms reduced to 2." Review of the physician follow up visit note of 5/19/14 at 12:17 PM, revealed "Resident seen on 5/16 and today; had delusion again on [MEDICATION NAME]; the pain meds were adjusted; he had a fall on 5/17 and c/o (complained of) right knee and ankle; MD was called several times during the weekend for this issue; X-rays (-) for fx (negative for fracture); due to severity of the pain, [MEDICATION NAME] prn was started." The note continues "pain at right knee when changing position". "right ankle is swollen, (+) pain on minor movement." "Assessment/Plan: 1) pain; add cold compression to right knee; cont Tylenol + [MEDICATION NAME] + ledoderm and [MEDICATION NAME] prn; will monitor closely." Physician #1 stated, on 6/12/14 at 9:20 AM, "when I saw his leg on that Monday I knew something was not right, the way it looked, swollen. That is why I ordered another x-ray." Spoke to Geriatric Nursing Assistant (GNA) #3 on 6/12/14 at 11:36 AM to ask if she took care of Resident #4. GNA #3 stated she took care of him on Monday, 6/19/14 during the day shift. GNA #3 stated "he had on and off confusion, got better and then got confused again. He would talk off the wall, he would think something is on the bed and try to pick it up but it wasn't' there." GNA #3 stated "Yes, he was considered a falls risk. He had a lower bed but didn't have a chair alarm because he barely got up, only to therapy. He did have to have help turning in bed. I saw him try to get out of the bed a lot, more so in the beginning. I went in and helped him lay back down and let the nurse know. I noticed swelling in his leg on Monday and at the touch of his foot, he would yell. I let the nurse know and they told me they did an x-ray and nothing was wrong, but I said something was wrong because he kept yelling and would yell if I touched his foot to say he was in pain." When the surveyor asked GNA #3 if she got report from the 11-7 GNA that he had swelling or was in pain, she stated "I was only told that he had a fall. For the rest of the day I washed him in bed. Me and the physical therapist tried to get him out of bed in a wheelchair but he was in too much pain. The physical therapist noticed the swelling. That was around 1:30 PM, and then I went on break. He was in a lot of pain, no hallucinations but a lot of pain." Review of the nursing documentation for Monday, 5/19/14, does not reveal any documentation about pain, the physician's visit, or any swelling in the right leg until the 3:45 PM nursing note that stated "Resident is alert and verbal, post fall day 3/3, pain management continues, cold compress to right knee day 1/5, continue to monitor." There is no documentation in the nursing note regarding another x-ray being ordered by the physician. Review of the second x-ray that was done on 5/19/14 revealed, "Exam: Femur AP and Lat Results: Acute mid shaft diaphyseal [MEDICAL CONDITION] identified with modest displacement. The fracture is below the level of the femoral stem. The remainder of the femur is intact. Conclusion: Midshaft femur fracture no change with May 17, 2014." The 5/19/14 9:59 PM nursing note stated "change noted, resident s/p x-ray of right femur which shows midshaft femur fracture" Physician notified, see new orders." The time of transfer to the emergency room was 11:00 PM. Review of the physician's progress note for 5/20/14 at 10:55 AM, stated "follow up visit: Addendum: late entry for second visit on 5/19." "(+) pain at right knee on movement; labs reveal elevated WBC (white blood count) with left shift. Given the swelling/pain at right LE (lower extremity), x-ray was again ordered; BCx and repeat CBC with diff were also ordered; case d/c'ed (discussed) with dgt (daughter), made aware of the management and plan, she was in agreement. Resident was sent to ER (emergency room ) for eval after x-ray revealed right femur fx." LPN #2's written statement continued " I read the conclusion of the results but did not read the conclusion of each result, which actually showed a fracture." The note stated "The neighborhood was very busy with several family requests, along with attempting to complete my duties, and answering the requests. I got very busy which may have lead me to misread the x-ray." LPN #2 was interviewed by the surveyor, on 6/12/14 at 10:49 AM, regarding the incident. LPN #2 stated "I only worked Saturday and did a double shift which was 16 hours. This was the first time taking care of him (Resident #4) on that day. I didn't know the activity at the time. Heard the boom, I don't know what he was trying to do at that time. I had been in there giving morning meds, the GNA got him out of bed and did ADLS (activities of daily living) and he was sitting in the wheelchair and then I gave him his meds. He was hallucinating a lot, a moment before the fall he was saying a train was coming and he had to get out of the way, that is why the doctor switched his medicines because they were making hallucinations worse. He had been having a lot of visual hallucinations. The last time I saw him he was sitting in the wheelchair. I was concerned that is why he was in wheelchair." "He fell between 10:30 and 11:00. The unit was a very busy unit, very overwhelming on that day." The family's major concern, they were concerned with him hallucinating that he would fall out of bed. The GNAs were aware of him hallucinating." "I told the GNAs that (Resident #4) is having hallucinations and we have to keep an eye on him but it was early on the shift and they were trying to get residents out of bed and there wasn't another staff to help out and be one on one with him. I didn't know the extent of it until after the fall. That was the first time taking care of him and it was 4 hours into the shift. Yes, I knew he was recovering from a fractured right hip." "He went to sleep for a short while after the [MEDICATION NAME]. Before I left to go home he got his meds. I thought the pain was coming from the previous fall and the surgery that he just had. I did assess his leg and I didn't notice any difference and he just came back from hip surgery. I kept thinking the pain was from the previous surgery. He did not have any swelling at that time." "After he fell he was placed back in bed and never got out of bed. I helped turn and position. I don't remember exact time, at one point when he kept complaining of pain, I repositioned him with a pillow on his lower back trying to help relax him." During an interview with Resident #4's daughter on 6/12/14 at 9:30 AM she stated "he was drugged up and slept. When he was awake he complained of tremendous pain. He woke up to eat. My father was crying he was in so much pain, my father doesn't cry." "On that Saturday they told me they were just giving him pain meds. He did not have an ice pack until the doctor saw his leg on that Monday. My brother kept arguing with the nurse that they need to do something because he was in so much pain. My father layed there for 60 hours with a fractured femur and in a lot of pain before he was sent to the hospital." During an interview of the Director of Nursing on 6/12/14 at 8:25 AM, he stated "the nurse missed the fracture. It is the way it is reported on the x-ray results. I had a conversation with the x-ray company about changing the way it is reported, such as putting in bold print." Medical treatment was delayed for at least 2 1/2 days due to the fact that the nurse failed to read the complete results of the X-rays which showed a fracture; subsequently, LPN #2 did not report the fracture to the physician.

Based on a review of the electronic medical record, administrative records, and interviews with the facility staff, it was determined that the facility staff failed to provide care in accordance with the resident's plan, the lift policy, to follow procedures/practices related to falls/incidents/or lowering of a resident to the floor, and timely reporting of an incident which delayed treatment. The resident sustained [REDACTED]. This was evident for 1 (# 9) of 2 residents reviewed for falls during a complaint survey. The findings include: A review of medical and administrative records for investigation of a complaint, intake # MD 402, was conducted on 6/11/14 thru 6/13/14. The complainant alleged that Resident # 9 suffered two broken legs while at the facility. Resident # 9 [DIAGNOSES REDACTED]. An interview was conducted with the Neighborhood Guide on 6/11/14 at 1:45 PM. Also present were the Clinical Manager, the Director of Nursing (DON), and the Administrator. The Neighborhood Guide stated that she did the investigation of the incident with Resident # 9. She stated that, on 4/24/14 on the evening shift, two Geriatric Nursing Assistants (GNAs) were assisting Resident # 9 back to her room in the shower chair. She stated that the two GNAs tried to place the Hoyer lift pad behind the resident. The resident began to fall forward. The Neighborhood Guide stated that the two GNAs grabbed Resident # 9 underneath each of her arms and lowered the resident to the floor. The resident's legs were folded underneath her at the knees. The Clinical Manager interjected while the Neighborhood Guide was giving an account of the event. She stated that two separate events occurred with Resident # 9 and the two GNAs. The Clinical Manager stated that, on 4/24/14 in the evening, GNA #1 and GNA #2 turned Resident # 9 on her side while in bed, and placed the lift pad underneath her. The resident became disruptive, rolled off her side, and flung her legs. GNA # 1 and GNA #2 were able to grab the resident under each of her arms to prevent her from falling. The resident hit her left leg on the side rail. She went on to say that after Resident # 9 was brought back to her room in the shower chair, another incident occurred. GNA #1 and GNA # 2 placed the lift pad behind the resident and she fell forward from the shower chair, having to be lowered to the floor. She stated that the resident's knees were underneath her when she was lowered to the floor. Review of administrative records and the statement written by GNA # 1 on 4/26/14, revealed that, on Thursday, 4/24/14, she and GNA #2 were giving Resident # 9 a shower in the evening. Prior to completion of the shower, Resident # 9 was being turned side to side while on the pad. GNA # 1's statement goes on to say that she and GNA # 2 did not realize that the resident wasn't fully secured. " We were trying desperately to prevent her from falling on the floor; however, we were not fast enough to prevent the fall/her from lowering to the floor. (GNA # 1 has a line marked through the fall on her statement). Review of the statement written by GNA # 2 on 4/25/14 revealed that, on 4/24/14 she and GNA # 1 assisted Resident # 9 to and from the shower chair. GNA # 2's statement goes on to say, "we went to roll Resident # 9 over to place the Hoyer pad, she rolled off her side. We caught her in time, pulled her back up, and proceeded to put the Hoyer pad back under her. The bottom rail was still up and she hit her left leg on it". GNA # 2's statement further revealed that, after the shower, she and GNA # 1 went to put the Hoyer pad under Resident #9's bottom and under her legs, and Resident # 9 fell forward with her legs under her. GNA #2 and GNA # 1 grabbed Resident #9 under her arms and lowered her to the floor, then lifted her back into the chair. They then Hoyer lifted her back into the bed. The resident was irate and yelling while most of this transpired. Review of the nurse's notes, on 6/12/14, revealed that an incident was documented on 4/25/14 at 6:00 AM, for bruising that was noted to Resident # 9's bilateral lower anterior legs. The incident revealed a statement by the resident, "I fell in the shower last night, and fell off the shower chair." According to the incident investigation, four staff gave statements on 4/25/14 at 6:00 AM that bruises were noted this AM to Resident # 9's bilateral shin areas, tender to touch. Staff educated that when lowered to the floor, it is still a fall and an incident sheet is required along with an assessment note. The investigation intervention: " pain evaluated and skin evaluated, bilateral leg bruising, on the top of right shin a small scratch. " X-Rays ordered. Review of the X-Ray report done on 4/25/14 in the AM showed the following, " There is considerable swelling over the medial aspect of the right knee, there is slight depression of the tibial plateau and is uncertain whether this represents an old healed fracture or a recent nondisplaced fracture. There also is noted moderate arthritic changes. " X-ray report of left ankle shows the following, " diffuse osseous demineralization is present. Minimally displaced oblique fracture of the distal fibula is present. Possible extension of syndemosis. X-ray of left knee shows there is a fracture through the tibial plateau without significant displacement; this involves the medial aspect of the joint. There appears to be osteoporosis. Review of the physician's orders on 6/12/14 at 1:30 PM revealed that Resident # 9 is currently prescribed Tramadol 25 mg (milligram) po (by mouth) bid (twice a day) for headache. Tramadol had been increased on 4/24/14 9:42 AM to 50 mg po bid for severe pain. Review of physician's notes revealed that the resident had an emergency room visit on 4/25/14 at 1:54 PM. The notes indicated that Resident # 9 had a fall yesterday and bilateral lower extremities severely bruised. Resident reported severe pain in both legs. Plan: Fracture of left tibia, fibia and patella bone, send to ER (emergency room ) for treatment plan. Acute pain stat dose of Oxycodone 5 mg x 1 prior to ER. An interview was conducted with Physician # 1 on 6/12/14 at 1:00 PM. The physician stated that she was aware of the X- ray results of Resident # 9's fractures. The physician was asked if the resident was able to flex, extend or bend her knees. The physician stated that bending her knees would be difficult due to the resident legs with stiffness at the knees. A phone interview was conducted with GNA # 2 on 6/12/14 at 3:30 PM, and she stated that she assisted GNA # 1 with putting Resident # 9 in the shower chair and she was positioned at the resident's side. She stated that she placed the lift pads underneath the resident's legs. GNA # 2 reported that the resident was irate, screaming, yelling, and shaking back and forth. She stated that the resident kept sliding down, so she and GNA # 1 lowered the resident to the floor. She further stated that the resident's legs were underneath her. She offered, " the resident is very heavy." She stated they put the resident back into the chair, as the resident continued to be irate and resistive. She said that GNA # 1 reported the incident to the Nurse# 1 after they were finished with her care. During an interview with the Assistant Director of Nursing (ADON) on 6/13/14 at 1:20 PM, the surveyor asked for a copy of all assessments that were done for Resident # 9. When the ADON returned at 1:35 PM, she stated that the assessments done for Resident # 9 would be included with the nurse notes. There was no documentation of an assessment completed or a pain assessment, however, a late entry that was dated 4/25/14 at 3:45 PM noted, "GNA # 1 made Nurse # 1 aware that Resident # 9 was lowered to the floor when she tried to get out of shower chair. Went to do assessment on elder no bruises or redness noted to any areas of the body". A phone interview was conducted with Nurse # 1 on 6/13/14 at 11:00 AM, and she stated that GNA # 1 reported that the resident was lowered to the floor. She stated that there were no bruises when she examined her. Review of the resident's care plan on 6/12/14 revealed that Resident #9 has problems with poor choices and refuses care, including turning and positioning. The documented approach on the care plan, dated 3/24/14, is for nurses and nurse aides to acknowledge Resident #9's right to refuse. Review of the policy for use of a mechanical lift indicated that the following information should be reported to the nurse: problems occurring during the lifting procedure, if elder refuses to be moved, and or, complaints made by the elder. GNA # 1 and GNA # 2 did not follow the facility policy, as they did not report the resident's disruptive behavior during the transfer. Review of the resident's medical record, review of the facility policy for use of the mechanical lift, written statements from staff, and interviews of staff, revealed that GNA #1 and GNA # 2 continued to provide care and attempted to transfer Resident # 9, in spite of disruptive behaviors (flung her leg over), irate verbalizations (yelling and screaming) and resistance to care (shaking back and forth). GNA # 1 and GNA # 2 did not acknowledge the resident's right to refuse, nor did they report to the nurse the problems that were occurring during the transfer. After the resident was lifted back into the chair and the care was complete by the GNAs, the nurse was notified. Resident #9 sustained an injury with multiple fractures.