Every finding on record at Sterling Place Healthcare & Rehabilitation Center

Based on interviews and record reviews, the facility failed to report a serious bodily injury of unknown origin ,resulting in a fracture, to the State Survey Agency within the required 2 hour timeframe for 1 (#64) of 2 residents reviewed for accidents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure, dated 03/25/2023, revealed, in part:Procedure:7. Reporting/Response: The facility employee or agent who becomes aware of injuries of unknown source shall immediately report the matter to the facility administrator. The administrator notifies the regional director and corporate nurse. The administrator shall immediately initiate a report in the State's Incident Management System and the facility's local enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation results in serious bodily injury. Review of Resident #64's Quarterly MDS Assessment with an ARD of 04/08/2026, revealed the resident had a BIMS of 10, which indicated he was moderately cognitively impaired. Further review revealed he was unable to accurately recall the current year, current month, current day of the week, and was unable to accurately recall three words previously told to him at the start of the assessment. Review of Resident #64's Nurse Note, dated 05/06/2026, revealed around 5:55 a.m., Resident #64 complained of pain to his right hip. Review of Resident #64's Progress Notes, dated 05/06/2026, revealed, he was seen at approximately 11:09 a.m. for new onset of pain to right shoulder, right hip and left ankle with order given to obtain STAT In-house X-Rays. Review of Resident #64's In-house X-Ray Results, obtained 05/06/2026 revealed, in part, an acute, mildly displaced fracture to the Right Superior Pubic Ramus. Review of Resident #64's Nurse Note dated 05/06/2026 at 12:14 p.m. revealed Resident #64 denied falling or any other type of incident. Resident #64's In-house X-Ray revealed an acute appearing fracture of the right superior pubic ramus. On 06/11/2026 at 11:14 a.m., an interview was conducted with S6CNA. S6CNA stated Resident #64 was lying in bed on the morning of 05/06/2026 and reported hip pain to her. S6CNA stated she was unaware of what caused Resident #64's pain. On 06/11/2026 at 11:49 a.m., an interview was conducted with S8CNA. She stated she worked on 05/05/2026 and the morning of 05/06/2026. She stated Resident #64 stayed in bed later than usual, then complained of pain to his right hip. She stated she was not aware of how his injury occurred. On 06/11/2026 at 2:01 p.m., an interview was conducted S5LPN. S5LPN stated on the morning of 05/06/2026, Resident #64 complained of pain to his right hip and she was not aware of what caused it. On 06/11/2026 at 2:09 p.m., an interview was conducted with S4DON. S4DON confirmed Resident #64 was identified to have a Right Superior Pubic Ramus fracture on 05/06/2026 and the facility was unable to determine how his injury occurred. S4DON confirmed she made S1ADM aware of Resident #64's injury and confirmed he was responsible for filing a report with the State Survey Agency. Review of the facility's self-reported incidents to the State Survey Agency revealed there was no report for Resident #64's Injury of Unknown Origin. On 06/11/2026 at 3:35 p.m., an interview was conducted with S1ADM. S1ADM stated an injury of unknown origin would be if a major injury occurred and neither the resident nor the staff knew how the injury occurred. S1ADM confirmed Resident #64 was identified to have a Right Superior Pubic Ramus fracture on 05/06/2026. S1ADM confirmed staff were unable to tell him how Resident #64's injury occurred. S1ADM confirmed the facility was not able to identify how Resident #64's injury occurred. S1ADM confirmed he did not file a SIMS Report within 2 hours of becoming aware of Resident #64's injury.

Based on observation, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety by failing to document temperatures on temperature logs. This had the potential to affect the 121 residents who were served by the kitchen.Findings:Review of the policy titled, Monitoring Temperatures of Cooked Foods with a revision date of 10/2018 revealed the following, in part:The temperature of potentially hazardous cooked foods will be monitored to ensure the foods are not in the danger zone (above 41F and below 135F).Procedures:3. Cooking and holding temperatures should be recorded on the Food Holding Temperature Log or other form .4. Storage temperatures should be recorded on the Food Holding Temperature Log or other form. Review of the policy titled, Food Storage Labeling with a revision date of 05/2023 revealed the following, in part:5. Storage temperatures are routinely monitored and documented using the appropriate temperature logs.6. Temperatures are recorded daily.Review of the document titled Temperature Log dated 06/06/2026 for the Dietary department revealed no documentation of the following, in part:Breakfast Temperatures before the tray line starts;Lunch Temperatures before the tray line starts;Afternoon Refrigerator and Freezer Temperatures;Dinner Temperatures before the tray line starts; andClosing Refrigerator and Freezer Temperatures. Review of the document titled Temperature Log dated 06/07/2026 for the Dietary department revealed no documentation of the following, in part:Morning Refrigerator and Freezer Temperatures;Breakfast Temperatures before the tray line starts;Lunch Temperatures before the tray line starts; Afternoon Refrigerator and Freezer Temperatures;Dinner Temperatures before the tray line starts; andClosing Refrigerator and Freezer Temperatures. On 06/12/2026 at 4:02 p.m., an interview was conducted with S3CM. S3CM stated the Temperature Logs are important because it is how the kitchen ensures the food is properly cooked, held, and served at a safe temperatures. S3CM stated the temperatures of the freezers and refrigerators are monitored to ensure the food has not spoiled and to prevent residents from getting sick. S3CM stated the kitchen's process is to document the temperatures on the logs to ensure everything is safe for the residents. S3CM confirmed the aforementioned findings on 06/06/2026 and 06/07/2026. S3CM confirmed the temperatures should have been documented on 06/06/2026 and 06/07/2026. On 06/11/2026 at 4:53 p.m., an interview was conducted with S2AA. S2AA reviewed the Temperature Logs for 06/06/2026 and 06/07/2026 and confirmed the aforementioned findings. S2AA confirmed the Temperature Logs should be completed. On 06/11/2026 at 4:19 p.m., an interview was conducted with S1ADM. S1ADM confirmed he expected the temperatures in the kitchen to be checked daily and with each meal. S1ADM confirmed the aforementioned findings and confirmed he expected the Temperature Logs to be completed.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 127 residents who were served from the kitchen. Findings: Review of the facility's policy titled, Food Storage Labeling, with a revision date of 10/2018, revealed, in part: The facility will store and label all foods to ensure safety and quality. 7. Food is stored in containers that are sealable, leak proof, durable, and undamaged. Review of the facility's policy titled, Food Service Operation Standards for Purchasing, Cooking and Storage, with a revision date of 10/2018, revealed, in part: 5. Thawing a. The preferred method is to thaw under refrigeration at a temperature of 40 degrees F or below. i. Store raw foods on the lowest shelf to prevent them from dripping or splashing onto other foods. On 06/16/2025 at 12:27 p.m., an initial tour of the kitchen was conducted with S2CSA. Observations were made of the following items: 14 fried chicken patties, dated 06/15/2025, uncovered, in walk-in cooler #1. 3, 10 pound packs of ground beef thawing on the counter, dripping blood into the sink containing raw, opened chicken thighs. On 06/16/2025 at 12:42 p.m., an interview was conducted with S2CSA. S2CSA stated all food stored in the walk-in cooler should be dated and covered appropriately. She stated frozen food should be thawed in a sink with cold water with nothing dripping on it. S2CSA confirmed the chicken patties in the walk in cooler were uncovered and the ground meat thawing on the counter, did drip red liquid onto the raw, opened chicken in the sink. On 06/16/2025 at 4:00 p.m., an interview was conducted with S3CSP. She stated food that was stored in the refrigerator/cooler should be covered and dated. S3CSP confirmed ground meat should not have been thawing on the counter and the drainage from the ground meat should not have dripped on the raw chicken.

Based on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 2 (#9 and #124) of 2 (#9 and #124) residents reviewed for weight loss. The facility failed to ensure weekly weights were completed as ordered. Findings: Resident #9 A review of Resident #9's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, and Cognitive Communication Deficit. Review of Resident #9's most recent Care Plan revealed Resident #9 was at risk for weight loss with an intervention of weighing resident as appropriate implemented on 10/20/2024. Review of Resident #9's Current Physician Orders revealed the following: 01/10/2025 Weekly weights Review of Resident #9's May 2025 through June 2025 weekly weights revealed no weight was obtained the week of 05/20/2025. Resident #124 A review of Resident #124's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. Review of Resident #124's most recent Care Plan revealed Resident #124 was at risk for weight loss with an intervention of weekly weights implemented on 02/04/2025. Review of Resident #124's Current Physician Orders revealed the following: 02/04/2025 Weekly weights Review of Resident #124's April 2025 through June 2025 weekly weights revealed no weight was obtained the following weeks: 04/29/2025, 05/13/2025, and 05/27/2025. On 06/23/2025 at 8:36 a.m., an interview was conducted with S14RD. She stated S15ADON was responsible for obtaining the weekly weights and sent the weekly weights for her to review. She confirmed Resident #9 and #124 should be weighed weekly as ordered, but were not. On 06/23/2025 at 9:40 a.m., an interview was conducted with S15ADON. She stated weekly weights were obtained by the CNA. She stated she reviewed the weekly weights and provided a copy to the Dietician, Nurse Practitioner and the Minimum Data Set Nurse. She confirmed Resident #9 and #124 should be weighed weekly, but were not. On 06/23/2025 at 12:09 p.m., an interview was conducted with S4DON. She stated Resident #9 and #124 should be weighed weekly. She confirmed Resident #9 was in the facility and not weighed on 05/20/2025. She further confirmed Resident #124 was at the facility and not weighed on the following weeks, 04/29/2025, 05/13/2025, and 05/27/2025.

Based on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status by failing to monitor, modify, and implement interventions after weight loss for 1 (#124) of 3 (#12, #98, and #124) residents reviewed for nutrition. The facility failed to ensure 1. Resident #124 was assessed for food preferences; and 2. Resident #124 was weighed weekly, treating providers were notified of weight loss, and new interventions were implemented. Findings: Review of the facility Policy titled, Weight Evaluation, dated 09/25/2024 revealed the following: Purpose: To review, monitor and maintain the resident's weight. Procedure: 2. The DON or designee with review weights weekly, monthly and as needed. 5. High risk residents will be discussed in high risk meeting. a. Recommendation with interventions will be made and discussed with the physician or designee. 7. DON/Designee will address weight in his/her notes and will give a list of those residents to Registered Dietician to review monthly and as needed. 8. DON or designee will address weight gain/loss with recommendations in the clinical record. 9. Family will be notified of weight gain/loss of any recommendations made by dietary, physician, therapy or nursing. 10. Care plan will be updated. A review of Resident #124's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. Review of Resident #124's current care plan revealed the following, in part: I am at risk for weight loss Interventions: 01/28/2025- Supplement as ordered 02/05/2025- Refer to RD, weekly weights, maintain current listing of food like and dislikes, offer bedtime snacks 02/19/2025- Protein supplement added 03/25/2025- Significant weight loss noted, continue plan of care 05/06/2025- Weight loss, decreased appetite, continue plan of care 05/20/2025- Weight loss, poor appetite, continue plan of care 06/03/2025- Weight loss, poor appetite 06/10/2025- Poor appetite, staff to assist with meals 06/17/2025- Weight loss, Resident sent to hospital Review of Resident #124's current Physician Orders revealed the following, in part: 01/29/2025- House Supplement 4 oz TID 02/04/2025- Weekly weights 02/19/2025- Liquid Protein Supplement 30 ml BID 03/19/2025- NSOT diet, mechanical soft texture, regular thin consistency. Review of facility's Monthly Weight Changes Log revealed S14RD was not notified of weight changes on the following weeks: 04/10/2025, 04/15/2025, 04/29/2025, 05/13/2025, and 05/27/2025. Review of Resident #124's weights from March 2025 to June 2025 revealed no weight was obtained on the following weeks: 04/29/2025, 05/13/2025, and 05/27/2025. Review of Resident #124's Dietician Notes revealed the following: 03/31/2025- Weight on 01/13/2025, 129#, readmit on 2/25/2025, weight 98.6#. Orders reviewed, NSOT mechanical soft diet, House Supplement 4 oz TID, and liquid protein 30 ml BID. PCP consider appetite stimulant. 04/14/2025- House Supplement 4 oz TID, liquid protein 30 ml BID. No recommendation diet change at this time. Nursing staff to encourage intake. Review of Resident #124's NP Progress notes from revealed 03/01/2025 to 05/20/2025 revealed no documentation of weight loss or treatment plan for weight loss Review of Resident #124's NP Progress note, dated 05/21/2025, revealed the following: Weight Loss Overview: Resident continues with significant weight loss. Weight on 01/13/2025 129#, weight on 02/18/2025 110.4# Resident currently on Mirtazapine 7.5 nightly, continue house supplement TID Current weight 86#, Resident #124 appears to be eating small amounts. ST evaluated and will continue to examine and treat. Palliative care was consulted during hospitalization but family refused at that time. Will again reassess with family at later time. Review of Resident #124's therapy notes revealed the following: 05/27/2025- ST evaluation requested due to weight loss and pocketing of food. 1. On 06/18/2025 11:11 a.m., an interview was conducted with S21CNA. She stated Resident #124 was able to feed herself at times but required encouragement and redirection with meals. She stated she did not have a big appetite and she was not aware of any foods Resident #124 liked or disliked. On 06/23/2025 at 9:21 a.m., an interview was conducted with S3CSP. She stated she met with Resident #124 due to a significant weight loss to assess food preferences. She stated she met with Resident #124 at the end of May or June and she did not voice any food preferences. She stated she did not reach out to the family for food preferences. She confirmed Resident #124 did not have any food preferences on her meal ticket. 2. On 06/23/2025 at 8:36 a.m., an interview was conducted with S14RD. She stated Resident #124 had a significant weight loss after returning from the hospital in February. She stated she made the following recommendations for Resident #124: 01/29/2025, house supplements TID, 02/19/2025, liquid protein BID and 03/31/2025 for the PCP to consider an appetite stimulant. She stated she expected the facility to weigh the resident weekly, assess resident's food preferences, offer night time snacks and provide her with a report of any weight changes. She confirmed she reviewed the facility's weekly weight log and Resident #124 was not listed on the log on the following dates: 04/10/2025, 04/29/2025, 05/13/2025, 05/27/2025 and 06/03/2025. She further confirmed if the resident was not on the weekly weight loss log she was unaware of any continued weight loss. On 06/23/2025 at 9:40 a.m., an interview was conducted with S15ADON. She stated she was responsible for obtaining Resident #124's weekly weights. She confirmed Resident #124 was not on the weight loss logs on the following dates: 04/10/2025, 04/29/2025, 05/13/2025, 05/27/2025 and 06/03/2025. On 06/23/2025 at 10:05 a.m., an interview was conducted with Resident #124's daughter. She stated she was involved in Resident #124's care. She stated facility staff had not reached out to discuss Resident # 124's food preferences or an appetite stimulant. On 06/23/2025 at 1:19 p.m., an interview was conducted with S23NP. She stated she was aware of Resident #124's weight loss on 05/21/2025 as noted in her NP notes. She confirmed she was not aware of weight changes 03/01/2025 to 05/20/2025. On 06/23/2025 at 12:09 p.m., an interview was conducted with S4DON. She stated S15ADON was responsible for obtaining the weekly weights and provided a copy of the weekly weight log to S14RD. She stated Resident #124 had a significant weight loss and had an order to weigh weekly. She confirmed Resident #124 was not on the weekly weight log provided to S14RD on the following dates: 04/10/2025, 04/29/2025, 05/13/2025, 05/27/2025 and 06/03/2025 and should have been. She confirmed between 02/19/2025 and 05/27/2025 no new interventions were initiated to address Resident #124's weight loss.

Based on record reviews and interviews, the facility failed to ensure 2 (#44 and #56) of 5 (#42, #44, #56, #332, # and #381) resident's records had documentation indicating the resident either received or did not receive a pneumococcal immunization due to medical contraindication or refusal. Findings: Review of the facility's policy, titled, Vaccinations Influenza and Pneumococcal Immunizations Policy and Procedure, dated 09/18/2017, revealed, in part: Purpose: The facility will give the resident the opportunity to receive the pneumococcal vaccine, unless medically contraindicated, refused or was already immunized. Procedure: Pneumonia 2. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. 3. The resident's medical record includes documentation that indicates: b. That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization Resident #44 Review of Resident #44's clinical record revealed he was admitted to the facility on [DATE]. Further review record revealed a consent to receive pneumococcal vaccine, signed and dated 09/13/2024. Review of Resident #44's Immunization Audit Report revealed no documentation of pneumococcal immunization received from 09/13/2024 through 06/17/2025. On 06/18/25 at 2:12 p.m., an interview was conducted with Resident #44. He confirmed he has not refused vaccines and was not offered the pneumococcal vaccine last year. Resident #56 Review of Resident #56's clinical record revealed she was admitted to the facility on [DATE]. Further review revealed a consent to receive pneumococcal vaccine, signed and dated 09/13/2024. Review of Resident #56's Immunization Audit Report revealed no documentation of pneumococcal immunization received from 09/13/2024 through 06/17/2025. On 06/18/25 at 2:07 p.m., an interview was conducted with Resident #56. She confirmed she has not refused vaccines and was not offered the pneumococcal vaccine last year. On 06/18/25 at 2:18 p.m., an interview was conducted with S4DON. She stated vaccines are always available for those who have consented to receive vaccines. She confirmed Residents #44 and #56 did not refuse and did not receive the pneumonia vaccine and should have. On 06/18/2025 at 2:20 p.m., an interview as conducted with S9CORP. He confirmed residents not receiving vaccines six months after they have consented to receive vaccines is unacceptable.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 1 (#9) of 2 (#9 and #61) residents reviewed for call lights. Findings: Review of the facility's policy, Resident Call Light System, dated 09/14/2022, revealed the following, in part: Purpose: To provide a communication system with audible or visual signals to allow residents to call for staff assistance . Procedure 6. When providing care to residents, be sure to positon the call light conveniently within reach for the resident to use. A review of Resident #9's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Cognitive Communication Deficit. A review of Resident #9's Quarterly MDS with an ARD of 04/25/2025 revealed the resident was dependent on staff for transfers. On 06/17/2025 at 02:10 p.m., an observation was conducted of Resident #9. He was observed sitting up in his wheelchair with his call light not within his reach. On 06/17/2025 at 2:11 p.m., an interview was conducted with Resident # 9. Resident #9 stated he was ready to get back in bed but did not have a call light to notify the nurse he needed assistance. On 06/17/2025 at 2:32 p.m., an interview was conducted with S11CNA. She stated Resident #9 was dependent on staff for transfers, used the call light to alert staff when he needed assistance, and she confirmed the call light should remain within his reach. On 06/23/2025 at 12:09 p.m., an interview was conducted with S4DON. She confirmed Resident #9 used his call light to alert staff when he needed assistance and she confirmed the call light should remain within his reach.

Based on observations and interviews, the facility failed to ensure resident's room were clean and maintained in a sanitary manner for 1 (#117) of 3 (#20, #95, and #117) sampled residents investigated for environment. The facility failed to ensure Resident #117's room were properly cleaned and free of urine odor. The deficient practice had potential to affect all incontinent Residents in facility. Findings: An observation was made on 06/17/2025 at 9:35 a.m. of Resident #117's room and a strong odor of urine was noted. An interview was conducted on 06/17/2025 at 1:06 p.m. with Resident #117. Resident #117 stated he did not like to complain and became quiet when asked if he liked the environment of his room. An observation was made on 06/17/2025 at 03:53 p.m. of Resident #117's room and a strong urine odor was noted while standing in the hallway. An interview was conducted on 06/17/2025 at 03:58 p.m. with S18CNA. She stated Resident #117 had incontinent episodes. S18CNA entered Resident #117's room and confirmed a strong odor of urine was present. An interview was conducted on 06/18/2025 at 09:38 a.m. with S17CNA. She stated Resident #117 was incontinent of urine and required assistance with ADL's, including assistance with his bedside urinal. She stated he spilled his bedside urinal on a daily basis. She stated she notified her supervisor of the ongoing strong urine odor in Resident #117's room. An interview was conducted on 06/18/2025 at 10:55 a.m. with S16HK. She stated Resident #117's room never smelt good even after she cleaned it. She stated she notified S10HOU about the ongoing strong urine odor but S10HOU stated there was nothing that could be done. An interview was conducted on 06/18/2025 at 10:59 a.m. with S19LPN. She stated Resident #117 was incontinent of urine and required ADL assistance, including assistance with his bedside urinal. She stated he often spilled his bedside urinal on the floor and his room had a strong urine odor. She confirmed she had reported the ongoing strong urine odor to the CNA supervisor. An interview was conducted on 06/18/2025 at 1:00 p.m. with S10HOU. He stated he was aware Resident #117's hid his urine soiled linen in his close and staff removed the linens from the Residents' rooms at least twice a day. He confirmed he was not aware of an ongoing strong urine odor in Resident #117's room. An interview was conducted on 06/18/2025 at 01:40 p.m. with S10HOU inside Resident #117's room. He stated following the above interview, he investigated Resident #117's room and discovered a large amount of urine residue present under Resident 117's bed. He confirmed the urine was in the tile flooring, was soaked within the cracks of the plank flooring, and needed disinfectant and sanitizing. An interview was conducted on 06/18/2025 at 01:55 p.m. with S4DON. She was made aware of the environmental concerns of the ongoing strong urine odor in Resident #117's room. She stated she expected staff to notify maintenance, housekeeping or administrative staff of any unresolved strong urine odors found in any Residents' environment. She further confirmed staff had not reported to maintenance, housekeeping or administrative staff prior to today.

Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate a PASRR Level II determination and recommendations into a resident's MDS (Minimum Data Set ) for 1 (#42) of 2 (#42 and #99) residents reviewed for PASRR. Review of Resident #42's Clinical Record revealed an admission date of 06/20/2023 and diagnoses, which included Schizoaffective Disorder - Bipolar Type, Psychotic Disorder with Hallucinations, and Unspecified Psychosis. Review of Resident #42's BHSF Form 142 revealed she was approved for admission by Level II PASRR effective 11/20/2024. Review of Resident #42's Significant Change MDS with an ARD (Assessment Reference Date) of 01/08/2025 revealed question A1500, Resident evaluated for PASRR, was answered as no. An interview was conducted with S8MDS on 06/17/2025 at 2:14 p.m. S8MDS reviewed Resident #42's Significant Change MDS with an ARD of 01/08/2025, and confirmed it was coded Resident #42 did not have a Level II PASRR. S8MDS confirmed Resident #42 had a Level II PASRR at the time of the assessment, and the assessment was inaccurate. An interview was conducted with S4DON on 06/17/2025 at 2:20 p.m. S4DON reviewed the above mentioned Significant Change MDS, and BHSF Form 142 PASARR II determination. S4DON confirmed the Level II PASRR should have been coded on Resident 42's Significant Change MDS assessment, dated 01/08/2025, and was not.

Based on interviews and record review, the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled baths for 1 (#73) of 2 (#9 and #73) residents reviewed for ADLs. Findings: Resident #73 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of Resident #73's admission MDS assessment, with an ADR of 04/07/2025, revealed Resident #73 had a BIMS of 12 which indicated moderate cognitive function. Review of Resident #73's Current Care Plan revealed the following, in part: Focus: The resident requires limited to extensive staff assistance for ADL care. Interventions: Resident prefers morning baths. Review of Resident #73's ADL documentation revealed she was scheduled to receive baths on Monday, Wednesday, and Friday. Further review of ADL Documentation for 05/20/2025 - 6/15/2025 revealed no documentation of a bath/shower. On 06/18/25 at 9:02 a.m., an observation and interview was conducted with Resident #73. Resident #73 was observed in a brief with no other clothing in place. Resident #73 was observed wiping herself down with baby wipes. Resident #73 stated she had not received a bath or a shower in more than a month. She stated the whirlpool on the 4th floor was not clean, and she did not want to bathe in it. Resident #73 stated she asked S5CNA multiple times to take her to the 2nd floor shower. Resident #73 stated S5CNA told her she would not take her to the 2nd floor, and to ask another CNA. On 06/18/2025 at 9:15 a.m., an interview was conducted with S5CNA. S5CNA confirmed she cared for Resident #73. She stated Resident # 73 refused a bath in the 4th floor whirlpool and asked to go to the 2nd floor for a shower, but she had not taken her to the shower room. She confirmed if a resident wanted a shower, the request should be honored and had not been. On 06/18/2025 at 9:10 a.m., an interview was conducted with S6CNA. S6CNA confirmed if a resident did not want a bath in the 4th floor whirlpool, the resident could be taken to the 2nd floor for a shower. She stated a resident request for a shower should be honored. On 06/18/2025 at p.m., 12:50 p.m., an interview was conducted with S7LPN. She confirmed she was caring for Resident #73. S7LPN stated Resident #73 did not refuse care, and she had not been notified of Resident #73 refusing baths, or staff's denial of shower requests. On 06/18/2025 at 1:00 p.m., an interview was conducted with S4DON. S4DON stated CNA staff were expected to provide ADL assistance, which included baths to all residents according to the schedule and as needed, if requested. S4DON reviewed Resident #73's ADL documentation. S4DON confirmed the documentation dated 05/20/2025 to 06/17/2025 indicated no documentation Resident #73 received or refused a bath/shower. She further confirmed if a Resident requested a shower instead of a whirlpool bath, the request should have been accommodated, and was not.

Based on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment for 1 (#12) of 2 (#12 and #41) residents reviewed for activities. This had the potential to affect any of the 125 residents' residing in the facility. Findings: Review of the Clinical Record for Resident #12 revealed he was admitted to the facility on [DATE] with diagnoses which included Unspecified Diastolic Heart Failure, Dementia, and Anxiety Disorder. Review of the Care Plan for Resident #12 revealed the following, in part: Problem: I will attend activities of my choice/preference Interventions: establish and record the resident's interest by talking with the resident, caregivers and family on admission. Review of the Clinical Record Notes revealed the following, in part: 06/11/2025- Activity Preferences: How important is it to listen to music you like: very important. Other preferred music genres: all kinds. How important is it to do your favorite things: very important. On 06/16/2025 at 1:23 p.m., an observation was conducted of Resident # 12 lying in his bed with the lights and television turned off. Resident #12 stated he was bored. Resident #12 stated, I like to listen rock and roll music. On 06/17/2025 at 9:35 a.m., an observation was conducted of Resident # 12 lying in his bed with lights and television turned off. On 06/17/2025 at 12:27 p.m., an observation was conducted of Resident # 12 sitting in his chair in his room eating lunch. Resident #12 stated he did not go down for activities and liked to stay in his room. Resident #12 stated he liked to listen to all genres of music. On 06/17/2025 at 2:32 p.m., an interview was conducted with S11CNA. She stated Resident # 12 did not participate in any activities and reported being bored. S11CNA stated she was not aware of any activities Resident #12 enjoyed. On 06/18/2025 at 1:58 p.m., an interview was conducted with S13AD. She stated she was over the facility activities for the residents. She stated Resident #12 did not attend any activities out of his room and liked to stay to himself. She stated she was unaware Resident #12 liked music and did not know any activities he enjoyed. On 06/23/2025 at 10:25 a.m., an interview was conducted with S12SSD. She stated Resident #12 did not attend any activities out of his room and liked to stay to himself. She stated Resident #12 loved listening to music. She confirmed the facility should provide an activity with music for Resident #12 in his room. On 06/23/2025 at 12:09 p.m., an interview was conducted with S4DON. She confirmed if a resident did not like to leave his room, staff should provide activities in his room which, included listening to music.

Based on observations, interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to affect 126 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Storage Of Refrigerated Food revealed the following: Policy: The facility will ensure the quality and safety of refrigerated food through acceptable storage practices. Procedure: 4. All non-hazardous, opened foods are labeled with name of food and date stored 5. Foods are labeled with date to be discarded or the date stored. An observation was made on [DATE] at 8:45 a.m. of the facility's walk-in refrigerator with S10AM. The following was observed: - 6 8 oz plastic containers of whole milk with expiration date of [DATE] An observation was made on [DATE] at 8:50 a.m. of the facility's refrigerator #2 with S10AM. The following was observed: - 1 plastic package of opened turkey with no discard date An observation was made on [DATE] at 8:55 a.m. of the facility's dry food storage room with S10AM. The following was observed: - 1 open plastic bag of yellow cake mix, with no discard date - 1 open bag of powdered sugar box, unsealed, with no discard date - 1 16 oz plastic container of chili powder, unable to read open date, no discard date An interview was conducted on [DATE] at 9:00 a.m. with S10AM. She confirmed the above observations. She confirmed the above food items were available for resident use. She confirmed all expired food items should have been discarded. She confirmed all opened food items should have a label including both opened and expiration dates. An interview was conducted on [DATE] at 5:45 p.m. with S1ADM. S1ADM confirmed all food storage items should be labeled and checked for both opened and expiration dates.

Based on interviews and record reviews, the facility failed to ensure resident MDS assessments accurately reflected the resident's status for 4 (#11, #68, #100, and #119) of 8 (#10, #11, #23, #68, #100, #109, and #119) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations. Findings: #11 Review of Resident #11's Clinical Record revealed an admitted [DATE] with diagnoses which included Dementia, Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder. Further review revealed an approved Level II PASRR. Review of Resident #11's Annual MDS with ARD of 06/19/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #68 Review of Resident #68's Clinical Record revealed an admitted on 06/20/2023 with diagnoses which included Generalized Anxiety Disorder, Depression, and Bipolar Disorder. Further review revealed an approved Level II PASRR. Review of Resident #68's Annual MDS with ARD of 06/19/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #100 Review of Resident #100's Clinical Record revealed an admitted [DATE] with diagnoses, which included, in part, the following; Schizoaffective Disorder; Schizophrenia; Major Depressive Disorder. Further review revealed an approved Level II PASRR. Review of Resident #68's Annual MDS with ARD of 06/26/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #119 Review of Resident #119's Clinical Record revealed an admitted [DATE] with diagnoses which included Schizophrenia. Further review revealed an approved Level II PASRR. Review of Resident #119's Annual MDS with ARD of 11/28/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. On 07/31/2024 at 11:03 a.m., an interview was conducted with with S5MDS. He confirmed he was responsible for Resident #100's annual MDS assessments. He stated comprehensive MDS assessments should include if the resident has a state level II PASRR. He confirmed Resident #100 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have. On 07/31/2024 at 11:04 a.m., an interview was conducted with S4MDS. She stated she was responsible for Residents #11, #68 and #119 annual MDS assessments. She stated comprehensive MDS assessments should include if the resident has a state level II PASRR. She confirmed Residents #11, #68 and #119 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have. On 07/31/2024 at 4:44 p.m., an interview was conducted with S2DON. She confirmed the MDS assessments should be accurate for all residents. 44590

48333 Based on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning, and transitions of care for 3 (#14, #100, and #109) of 8 (#10, #11, #14, #23, #68, #100, #109, and #119) residents reviewed for PASRR. Findings: Review of facility's Policy and Procedure, dated 10/31/2014, revealed the following, in part: Policy: The Facility is required to ensure that the Specialized Service Recommendations indicated on the PASRR/ Level 2 are implemented and documentation of the recommended services is recorded in the resident's clinical record. If the recommended services are refused, the facility should ensure the refusal of such services is documented in the residents' clinical record. Resident #14 Review of Resident #14's Clinical Record revealed an admitted [DATE] with diagnoses, which included, in part, the following: Generalized Epilepsy, Anxiety Disorder, Schizophrenia, Depression, Slurred Speech, and Schizoaffective Disorder. Review of Resident#14's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/2024, indicated resident #14 had a Brief Interview of Mental Status (BIMS) of 5, which indicated resident was severely cognitively impaired. Review of Resident #14's BHSF Form 142, dated 03/12/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 03/12/2024 through 03/11/2025. Review of Resident #14's OBH-PASRR Level II Summary and Determination Notice, dated 03/11/2024, effective 03/12/2024 through 03/11/2025, revealed, in part, the following: Recommended Lesser Services: Medication Education; Training in ADLs; Training in independent living skills; Structured leisure activities; and Evaluation for a diagnosis of dementia. Review of Resident #14's Care Plan revealed no documented care plan present for any of the following services: Medication Education, Training in ADLs, Training in independent living skills, or evaluation for a diagnosis of dementia. An interview was conducted on 07/31/2024 at 9:00 a.m. with Resident #14. He stated he would be willing to participate in the following: medication education, training in ADLs, training in independent living skills, and structured leisure activities, but these services were never offered to him. An interview was conducted on 07/31/2024 at 9:43 a.m. with S16SSD. She confirmed she was responsible for ensuring Level II PASRR recommended services were offered and carried out for each resident. She stated she offered the above services to Resident #14 but he refused. She confirmed she could not provide documented evidence to indicate Resident #14 refused the services. An interview was conducted on 07/31/2023 at 11:03 a.m. with S3MDS. She reviewed Resident #14's care plan and confirmed it did not include the recommended services from his Level II PASRR and should. She confirmed if services were refused, the care plan should reflect that and it did not. Resident #100 Review of Resident #100's Clinical Record revealed an admitted [DATE] with diagnoses, which included, in part, the following; Schizoaffective Disorder; Schizophrenia; and Major Depressive Disorder. Review of Resident #100's most recent MDS, with an ARD of 06/26/2024, indicated resident had a BIMS of 12, which indicated resident was cognitively intact. Review of Resident #100's BHSF Form 142, dated 04/22/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 04/22/2024 through 04/21/2025. Review of Resident #100's OBH-PASRR Level II Summary and Determination Notice, dated 04/22/2024, effective 04/22/2024 through 04/21/2025, revealed, in part, the following: Recommended Lesser Services: Training in independent living skills; and Structured leisure activities. Specialized Services Recommendations: Community Psychiatric Support and Treatment (CPST); and Psychosocial Rehabilitation (PSR) - Group. Review of Resident #100's Clinical Record revealed no documented evidence to indicate the facility offered or implemented any of the following: Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group. Review of Resident #100's Care Plan revealed no documented care plan present for any of the following services: Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group. An interview was conducted on 07/30/2024 at 1:32 p.m. with Resident #100. She confirmed she would enjoy participating in Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group because she enjoyed doing new things and being around other people. She confirmed she did not recall being offered any of those services in the past and if she had, she would not have refused them. An interview was conducted on 07/31/2024 at 9:50 a.m. with S16SSD. She stated she offered the above services to Resident #100 but she refused. She confirmed she could not provide documented evidence to indicate Resident #100 refused the services. An interview was conducted on 07/30/2024 at 11:03 with S5MDS. He reviewed Resident #100's careplan and confirmed it did not include the recommended services from her Level II PSARR and should. He confirmed if services were refused, the care plan should reflect that and it did not. Resident #109 Review of Resident #109's Clinical Record revealed an admitted [DATE] with diagnoses which included, in part, the following; Anxiety Disorder. Review of Resident #109's most recent MDS, with an ARD of 12/28/2023, indicated resident had a BIMS of 11, which indicated resident was moderately cognitively intact. Review of Resident #109's BHSF Form 142, dated 04/30/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 05/01/2024 through 04/30/2025. Review of Resident #109's OBH-PASRR Level II Summary and Determination Notice, dated 04/30/2024, effective 05/01/2024 through 04/30/2025, revealed, in part, the following: Recommended Lesser Services: Structured leisure activities. Specialized Services Recommendations: CPST. Review of Resident #109's Care Plan revealed no documented care plan present for any of the following services: Structured leisure activities and CPST. An interview was conducted on 07/30/2024 at 1:30 p.m. with Resident #109. She confirmed she did not recall being offered any of the services identified in her Level II PASRR in the past and if she had, she would not have refused them. An interview was conducted on 07/31/2024 at 9:50 a.m. with S16SSD. She stated she offered the above services to Resident #109 but she refused. She confirmed she could not provide documented evidence to indicate Resident #109 refused the services. An interview was conducted on 07/30/2024 at 11:03 with S5MDS. He reviewed Resident #109's careplan and confirmed it did not include the recommended services from her Level II PSARR and should. He confirmed if services were refused, the care plan should reflect that and it did not. An interview was conducted on 07/31/2024 at 9:57 a.m. with S1ADM. He confirmed he would expect residents to be offered and careplanned for all services recommended by their Level II PASRRs. He confirmed he would expect staff to document when those services were offered, especially if the services were refused by the resident.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#40 and #119) of 2 (#40 and #119) residents reviewed for ADL's. The facility failed to clean and trim fingernails for Residents #40 and #119. Findings: #40 Review of Resident #40's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia following Cerebral Vascular Accident Affecting Left Non-Dominant Side, Lack of Coordination, and Type 2 Diabetes Mellitus. Review of Resident #40's Annual MDS with an ARD of 06/19/2024 revealed Resident #40 had a BIMS of 8, which indicated moderate cognitive impairment. Further review revealed Resident #40 was dependent on staff for ADL's. Review of Resident #40's July Physician Orders revealed the following: 11/17/2023 Assess and trim fingernails and toenails monthly and as needed. On 07/29/2024 at 8:39 a.m., an observation was conducted of Resident #40. Her fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. She stated she would like her nails trimmed and cleaned. On 07/30/2024 at 8:52 a.m., an observation was conducted of Resident #40 eating breakfast in her bed. Her fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. On 07/30/2024 at 9:54 a.m., an interview was conducted with S8CNA. She stated she was assigned to Resident #40 and provided her morning ADL care on 07/29/2024. She stated the wound care nurse was responsible for cleaning and trimming fingernails and she did not clean the nails during her morning ADL care on 07/29/2024. On 07/30/2024 at 1:08 p.m., an interview was conducted with S17LPN. She stated the floor nurse would assess fingernails weekly during the scheduled skin assessment. She confirmed she never assessed, cleaned, or trimmed Resident #40's fingernails. She further confirmed she worked on 07/28/2024 and was assigned to complete the scheduled skin assessment and did not provide nail care. #119 Review of Resident #119's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Weakness, and Generalized Arthritis. Review of Resident #119's Quarterly MDS with an ARD of 07/17/2024 revealed Resident #119 had a BIMS of 3, which indicated severe cognitive impairment. Further review revealed Resident #119 required supervision assistance for ADLs. Review of Resident #119's July Physician Orders revealed the following: 11/28/2023 Assess and trim fingernails and toenails monthly and as needed. On 07/29/2024 at 8:33 a.m., an observation was conducted of Resident #119 laying in his bed. His fingernails are noted to be 1/2 cm long with black stuff under multiple fingernails. He stated he would like his nails trimmed and cleaned. On 07/30/2024 at 8:31 a.m., an observation was conducted of Resident #119 laying in his bed. His fingernails are noted to be 1/2 cm long with black stuff under multiple fingernails. He stated he would like his nails trimmed and cleaned. On 07/30/2024 at 9:54 a.m., an interview was conducted with S7CNA. She stated she was assigned to Resident #119 and provided his morning ADL care today. She stated the wound care nurse was responsible for cleaning and trimming fingernails and she did not clean the nails during her morning ADL care this morning. On 07/30/2024 at 10:17 a.m., an interview was conducted with S6WC. She stated she assessed and trimmed fingernails for all residents monthly. She stated the assigned floor nurse was responsible for weekly fingernail assessment and care if needed. She further stated CNAs should be cleaning under the nails during baths. On 07/30/2024 at 10:19 a.m., an observation of Resident #40 and #119 was conducted with S6WC. She confirmed Resident #40's fingernails were dirty and should have been trimmed. She stated the staff nurse should assess fingernails weekly and trim them or inform her if they are not comfortable. She stated she was not made aware Resident #40's fingernails needed trimming. She further confirmed Resident #119's fingernails were dirty and should have been cleaned during morning ADL care. She stated it was a normal length for him because sometimes he did not like them cut short. On 07/31/2024 at 4:44 p.m., an interview was conducted with S12DON. She stated CNA's were responsible for cleaning under the fingernails during morning ADL care and nurses assessed fingernail care weekly with the scheduled skin assessment. She confirmed fingernails should not have black under them and should be trimmed as needed.

Based on observations and interviews, the facility failed to maintain a safe, functional, sanitary and comfortable environment for 5 of 5 (a, b, c, d, e) rooms observed for environmental concerns. The facility failed to ensure maintenance of: 1. The walls, door frame and facing, and ceiling tiles in Room a; 2. Water entering the interior of Room a; 3. Water entering from windows and from ceiling above electrical outlet in Room b; 4. Ceiling tiles and prevention of sagging, black discolorations for Room c; 5. The walls and flooring of Room d; 6. Sanitary conditions for cleaning station, eye wash station, and ceiling tiles of Room e Findings: Room a On 07/29/2024 at 8:45 a.m., an observation was made of Room a. One ceiling tile was hanging and not in place above the television. There was black, spotty staining noted at the top of all walls where the ceiling is joined in the room and around the door frame. The door facing had a green, fuzzy staining on it. There was one corner ceiling tile in the bathroom with stains/discoloration. On 07/30/2024 at 10:08 a.m., an observation was made of Room a. One ceiling tile was hanging and not in place above the television. There was black, spotty staining noted at the top of all walls where the ceiling is joined in the room and around the door frame. The door facing had a green, fuzzy staining on it. There was one corner ceiling tile in the bathroom with stains/discoloration. On 07/30/2024 at 11:00 a.m., an observation was made of Room a with S12DON present. An interview was conducted with S12DON at that time. S12DON confirmed the above observations and stated Room a looked like water had dripped around the door and top of the walls. S12DON confirmed she was unaware of the findings. On 07/30/2024 at 3:35 p.m., an interview was conducted with S1ADM. He confirmed S12DON informed him of the above findings. S1ADM confirmed black staining on the walls was not comfortable and homelike. Room b On 07/29/2024 at 9:25 a.m., an observation was made of Room b. On the interior wall to the left of the window and air conditioning unit, water lines were noted 15 inches wide from the ceiling halfway down the wall. On the interior wall to the right of the window and air conditioning unit with Resident #66's bed against it, the bead board on the bottom half of the wall was warped with water lines present. Two half dollar sized holes were on the exterior wall with a black substance surrounding them and extending outward to the rest of the wall. The sheet rocked upper half of the wall contained signs of water damage with water mark stains of varying colors throughout with peeling and bubbling. The bead boarded bottom half of the wall contained two electrical outlets, one outlet was in use running the room's air conditioner and one outlet was not in use. 100% of the bead board, including the areas immediately surrounding the electrical outlets, were warped and had water mark stains of varying colors. The baseboards on the exterior wall were laying on the floor, not attached to the wall. The metal trim surrounding the window contained rust throughout. The window glass contained dried water lines coming from the top of the window downward toward the room's air conditioner located directly beneath the window. On 07/29/2024 at 9:25 a.m., an interview was conducted with Resident #66. She confirmed Room a had been in rough shape since she moved in this past January. She confirmed she made numerous complaints in attempt to get it fixed since she moved in. She stated every time it rained, water came in from around the window and from the ceiling tiles along the exterior wall. She stated any time she spoke with anyone at the facility, they told her the repairs would have to wait until her floor was remodeled because they weren't doing anything until then. On 07/30/2024 at 1:40 p.m., an observation was conducted of Room b. On the interior wall to the left of the window and air conditioning unit, water lines were noted 15 inches wide from the ceiling halfway down the wall. On the interior wall to the right of the window and air conditioning unit with Resident #66's bed against it, the bead board on the bottom half of the wall was warped with water lines present. Two half dollar sized holes were on the exterior wall with a black substance surrounding them and extending outward to the rest of the wall. The sheet rocked upper half of the wall contained signs of water damage with water mark stains of varying colors throughout with peeling and bubbling. The bead boarded bottom half of the wall contained two electrical outlets, one outlet was in use running the room's air conditioner and one outlet was not in use. 100% of the bead board, including the areas immediately surrounding the electrical outlets, were warped and had water mark stains of varying colors. The baseboards on the exterior wall were laying on the floor, not attached to the wall. The metal trim surrounding the window contained rust throughout. The window glass contained dried water lines coming from the top of the window downward toward the room's air conditioner located directly beneath the window. On 07/30/2024 at 3:20 p.m., an interview was conducted with S18CNA. She confirmed she was regularly assigned to Resident #66. She confirmed during periods of heavy rain or high wind and rain, she had seen water come in from around the window in Room a and run down the walls and around the air conditioner. She confirmed staff had mopped water up from the floor along the exterior wall. She confirmed she reported the issue to maintenance in the past but was told it wouldn't be fixed until the remodel of the third floor took place so she quit reporting it. On 07/30/2024 at 3:40 p.m., an observation was made of Room b with S15M. An interview was conducted with S15M at that time. He stated he was not aware of the damage to Room a. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. On 07/30/2024 at 4:00 p.m., an observation was made of Room b with S14MS. An interview was conducted with S14MS at that time. He stated he was not aware of the damage to Room b. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. On 07/30/2024 at 4:00 p.m., an observation was made of Room b with S1ADM. An interview was conducted with S1ADM at that time. He stated he was not aware of the damage to Room b. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. He confirmed the facility was aware of some on-going issues with exterior windows leaking but it was a big process to get them resealed and was going to cost a bunch of money so it had not been done yet. He confirmed resident rooms should be maintained for safety and in good repair at all times and Room b was not. Room c On 07/29/24 at 10:10 a.m., an observation was made of Room c. There were five water stained ceiling tiles in the hallway between the kitchen and dry storage room. One ceiling tile had green/black discolorations, softball size, and the entire tile was sagging downward toward the floor. S14MS was walking through the hallway during the observation, and an interview was conducted with S14MS. S14MS verified the ceiling tiles were an ongoing challenge. He confirmed the ceiling tiles should have been changed. Room d On 07/29/2024 at 8:45 a.m., an observation was made of Room d with a 4x10 inch piece of vinyl wood floor plank missing. The wall on the right side of the room had black and greenish widespread circles and was fuzzy in spots. On 07/30/2024 at 10:55 a.m. an observation was made of vinyl floor plank still missing 4x10 piece and wall on right side of room black and greenish widespread circles fuzzy in spots had been freshly painted over. Room e On 07/31/2024 at 10:15 a.m., an observation was made of Room e with S25HK and S9HKS. There was a large amount of debris/dirt in the sink with an eye wash station. The floor was covered with dirt and debris, and in the right back corner of Room e, there was a drain with raised edges. The drain area had blackish colored, sludge, water with a foul smell. S9HKS said Room e had been a long time issue. S9HKS pointed to the floor drain area and said that is where housekeeping staff dump all dirty water mop buckets. There were three large opened ceiling areas with missing tiles and visible ceiling wiring. S25HK stated the ceilings had been open for the past three days. S9HKS stated the above issues had been reported to S1ADM and requested for improvements to the area, but they had not been done. On 07/31/2024 at 5:45 p.m., an interview was conducted with S1ADM. He stated S9HKS notified him earlier today of observations made in Room e. He stated he was aware of the cleanliness/sanitation issue, foul odor, and flooring dirty with sludge around the drain. He stated he was aware of the eye wash station location in this room. S1ADM stated the condition of Room e was not acceptable.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 128 residents who currently reside in the facility. Findings: An observation was made on 07/29/2024 at 8:45 a.m. of a small roach crawling across floor in main kitchen food preparation area. An observation was made on 07/29/2024 at 8:48 a.m. of a dead roach, close to clean pans. Further observations revealed small, black, grains of rice size particles on the main kitchen floor. An interview was conducted with S10AM on 07/29/2024 at 8:50 a.m. She stated that kitchen staff were responsible for making Management aware of pest observations. S10AM verified insect sightings in kitchen areas had been reported to Administration. An observation was made on 07/29/2024 at 8:55 a.m. of dead insects and small, black particles on the floor in food storage room. An observation was made on 07/29/2029 at 8:49 a.m. of a small spider crawling inside main kitchen area. S10AM verified recent insect and pest control issues. An observation was made on 07/29/2024 at 9:10 a.m. midway down the short side of Hall 3 of a cockroach, 3 inches in length, crawling on the lid of the yellow rolling bin utilized for dirty linens. The dirty linen bin was located in the hallway 3 feet from the clean linen cart. An interview was conducted on 07/29/2024 at 9:12 a.m. with S25CNA. She confirmed a roach was crawling on the lid of the yellow rolling bin utilized for dirty linens and roughly 3 feet from the clean linen cart. An observation was made on 07/29/2024 at 12:00 p.m. of a large cockroach crawling on the ceiling approximately 1ft. from door entry into dry food storage room. An observation was made on 07/30/2024 at 11:10 a.m. of a fly hovering over steam table during food temperature checks. S26C was observed waving her arms rapidly over the prepared food service table to shoo the fly away. An interview was conducted on 07/31/2024 at 5:45 p.m. with S1ADM. He stated he was aware there was a pest problem and increased pest control services were needed.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, the following: Purpose: Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. No one shall abuse a resident. The policy applies to covered individuals (the owner, operator, employees, managers, vendors, agency staff, agents or contractors) Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal, . abuse of a resident, . mistreatment of a resident . I. Types of Abuse: Abuse: is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or anguish. Our policy presumes that abuse of any resident, ., causes physical harm, pain or mental anguish. Verbal Abuse: is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend or disability. Examples: Name-calling, cursing or yelling at a resident in anger. Threats of harm. II. Procedures 2. Training. Guidelines for Employees: If a resident starts to show signs of aggressive or catastrophic behavior verbally or physically, remain calm. Do not engage in an argument with the resident. Exit the area to prevent an incident. Resident #98 Review of Resident #98's Clinical Record revealed an admitted [DATE] with diagnoses which included, in part, the following; Anxiety Disorder; Dementia; Cognitive Communication Deficit; Unspecified Psychosis. Review of Resident #98's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 5, which indicated resident had severe cognitive impairment. Review of the facility's Incident Report, dated 05/29/2024, revealed, in part, the following: Date/Time of Incident: 05/29/2024 at 7:27 a.m. Incident Type: Verbal Contact-Staff Resident Involved: Resident #98 Staff Involved: S23LPN Description of Incident: Verbal altercation between Resident #98 and S23LPN. S23LPN and Resident #98 were on the elevator alone when Resident #98 touched S23LPN's hair. As elevator opened, S23LPN was observed to be very upset with Resident #98 and they began arguing loudly using inappropriate language and curse words towards each other. Both S23LPN and Resident #98 continued to become increasingly agitated as they cursed at each other louder and louder. Staff members present on the 3rd floor intervened to pull S23LPN into a supply room away from Resident #98 in attempt to deescalate the situation. Resident #98 calmed down until S23LPN exited the supply room and began cursing at him again, which in turn re-escalated the situation. Staff from the 2nd floor heard the commotion and came up to assist with de-escalation and removed S23LPN from the floor. Witnesses: S13ADON, S19ADON, S20CNA, S21UC, S22LPN, S23LPN, and S24LPN. Review of the facility's Incident Report submitted to the State Survey Agency revealed, in part, the following: Date Occurred: 05/29/2024, 7:50 a.m. Accused Allegations: Verbal Abuse Resident Victim: Resident #98 Accused: S23LPN Allegation Findings: Substantiated. Review of a signed Witness Statement written by S19ADON, dated 05/29/2024, revealed, in part, the following: At approximately 7:28 a.m., S19ADONwas sitting at her desk when she overheard S23LPN and Resident #98 involved in a verbal altercation. S19ADON recalled hearing S23LPN telling Resident #98 that he should not have touched her hair. S23LPN stated that if she let him slide, he would try to touch other things. Other words were exchanged between the two that S19ADON could not hear. S23LPN walked to the supply room as Resident #98 yelled 'F**k You' and threw a book at S23LPN from the nurses station. S23LPN turned around and they both were yelling offensive words, such as, N***a, Black B***h, F***k you. S13ADON, S22LPN and other staff members came up to 3rd floor because they heard the commotion from the 2nd floor. S13ADON took S23LPN into the supply room while others were trying to get Resident #98 into his room. However, Resident #98 would not leave from the nurses' station. S23LPN then came out still talking to Resident #98 and S13ADON took her back into the supply room. Resident #98 hit the supply room door causing myself and another nurse to run out of the office to assist. Resident #98 stated he was going to get his people to kill S23LPN and anyone who gets in his way. Resident #98 then stated he was going to stab her with a pen that he had in his hand. S13ADON and others finally got S23LPN in the elevator. Review of a signed Witness Statement written by S22LPN, dated 05/29/2024, revealed, in part, the following: Loud voices were heard coming from the third floor. S13ADON and S22LPN immediately ran up the stairs to the third floor and witnessed Resident #98 and S23LPN having a verbal altercation. S22LPN did not know how the incident started but she did witness S23LPN shouting don't put your f***king hands on me. As S22LPN walked up to Resident #98 to calm him down he stated I was just moving her hair. It was in her face. Resident #98 then continued to go back and forth with S23LPN arguing. S22LPN heard Resident #98 say F**k you black b***h and S23LPN said no, you are the black b***h. F**k you. Resident #98 then stated I'll get my people from the park to come f**k you up. S23LPN shouted I got people to f**k you. S22LPN was able to calm Resident #98 down as S13ADON brought S23LPN in the supply room. When S23LPN came out the supply room she overheard Resident #98 saying I was moving her hair so S23LPN stated I don't care, don't f**king touch me. Resident #98 and S23LPN continued the verbal argument until Resident #98 charged at S23LPN without hitting her and the verbal argument continued with cursing from both parties before S23LPN entered the elevator to go to the 4th floor. Review of a signed Witness Statement written byS20CNA, dated 05/29/2024, revealed, in part, the following: S20CNA stated she was on the second floor and heard the shouting commotion getting louder on the third floor so she rushed upstairs. She stated as she exited the elevators she heard S23LPN shouting F**k you to Resident #98. Review of a signed Witness Statement written by S21UC, dated 05/29/2024, revealed, in part, the following: While on the 3rd floor, she saw Resident #98 get off the elevator. S23LPN was by the nurses' station when Resident #98 touched her. She stated S23LPN told him not to touch her. She said I have asked you before not to touch me. She stated the exchange went back and forth and eventually escalated to both Resident #98 and S23LPN cursing and shouting at each other. An interview was conducted on 07/31/2024 at 3:00 p.m. with S13ADON. She stated she was working on the 2nd floor on the morning of 05/29/2024 when the incident between S23LPN and Resident #98 occurred. She stated she heard shouting from the 3rd floor that continued to get louder so she went up to determine what was occurring. She stated when she arrived to the 3rd floor, S23LPN and Resident #98 were shouting and cursing at each other but still had space between them. She confirmed S23LPN was shouting profanities at Resident #98 causing the situation to escalate rather than attempting to deescalate as she had been trained to do. She stated she immediately grabbed S23LPN and pulled her into the supply room to separate the two in attempt to deescalate the situation. She stated a few minutes later when S23LPN exited the supply room, she immediately began fussing and cursing at Resident #98 which got him agitated all over again. S13ADON stated she and the other staff then pulled S23LPN onto the elevator to get her out of there. She confirmed she would consider a staff member shouting and/or cursing at a resident to be abuse. An interview was conducted on 07/31/2024 at 3:22 p.m. with S24LPN. She stated she was working as a nurse on the 3rd floor on the morning of 05/29/2024 when the incident between S23LPN and Resident #98 occurred. She stated she saw the elevator open on the 3rd floor with S23LPN and Resident #98 inside and both exited. She stated S23LPN approached the nurses' station and she could tell she was not happy. S24LPN stated S23LPN informed her Resident #98 put his hand in her hair and she didn't appreciate it. She stated S23LPN was visibly upset and becoming agitated, as was Resident #98. She stated Resident #98 told S23LPN I didn't mean anything by it. She stated S23LPN began telling Resident #98 to keep his hands to himself. Resident #98 called S23LPN names and cursed at her. S23LPN began shouting curse words at Resident #98. She confirmed she would consider it abuse if a staff member shouted or cursed at a resident for any reason. An interview was conducted on 07/31/2024 at 3:40 p.m. with S2AADM. She confirmed S13ADON made her aware of the verbal altercation between S23LPN and Resident #98 immediately after it occurred. She confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. An interview was conducted on 07/31/2024 at 3:33 p.m. with S1ADM. He confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. He confirmed S13ADON notified him, S2AADM and S12DON of the altercation between S23LPN and Resident #98 immediately after the event occurred.

Based on record review and interviews, the facility failed to ensure an allegation of abuse was reported immediately, but no later than 2 hours, after the allegation was made to the state survey agency for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, the following: Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal, . abuse of a resident, . mistreatment of a resident, Contact the Administrator immediately. Employees should immediately report their knowledge related to abuse allegations to the Administrator. The Administrator shall immediately initiate a report to the state survey agency and the facility's local law enforcement agency; but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse ( . verbal abuse .). Review of Resident #98's Clinical Record revealed an admitted [DATE] with diagnoses which included, in part, the following; Anxiety Disorder; Dementia; Cognitive Communication Deficit; Unspecified Psychosis. Review of the facility's Incident Report, dated 05/29/2024, revealed, in part, the following: Date/Time of Incident: 05/29/2024 at 7:27 a.m. Incident Type: Verbal Contact-Staff Resident Involved: Resident #98 Staff Involved: S23LPN Description of Incident: Verbal altercation between Resident #98 and S23LPN. S23LPN and Resident #98 were on the elevator alone when Resident #98 touched S23LPN's hair. As elevator opened, S23LPN was observed to be very upset with Resident #98 and they began arguing loudly using inappropriate language and curse words towards each other. Both S23LPN and Resident #98 continued to become increasingly agitated as they cursed each other louder and louder. Staff members present on the 3rd floor intervened to pull S23LPN into a supply room away from Resident #98 in attempt to deescalate the situation. Resident #98 calmed down until S23LPN exited the supply room and began cursing at him again, which in turn re-escalated the situation. Staff from the 2nd floor heard the commotion and came up to assist with de-escalation and removed S23LPN from the floor. Witnesses: S13ADON, S19ADON, S20CNA, S21UC, S22LPN, S23LPN, S24LPN Review of the facility's Incident Report submitted to the State Survey Agency revealed, in part, the following: Date Occurred: 05/29/2024, 7:50 a.m. Date Reported: 05/29/2024, 1:11 p.m. Accused Allegations: Verbal Abuse Resident Victim: Resident #98 Accused: S23LPN Review of a signed Witness Statement written by S22LPN, dated 05/29/2024, revealed, in part, the following: Loud voices were heard coming from the third floor. S13ADON and S22LPN immediately ran up the stairs to the third floor and witnessed Resident #98 and S23LPN having a verbal altercation. S22LPN did not know how the incident started but she did witness S23LPN shouting don't put your f***king hands on me. As S22LPN walked up to Resident #98 to calm him down he stated I was just moving her hair. It was in her face. Resident #98 then continued to go back and forth with S23LPN arguing. S22LPN heard Resident #98 say F**k you black b***h and S23LPN said no, you are the black b***h. F**k you. Resident #98 then stated I'll get my people from the park to come f**k you up. S23LPN shouted I got people to f**k you. S22LPN was able to calm Resident #98 down as S13ADON brought S23LPN in the supply room. When S23LPN came out the supply room she overheard Resident #98 saying I was moving her hair so S23LPN stated I don't care, don't f**king touch me. Resident #98 and S23LPN continued the verbal argument until Resident #98 charged at S23LPN without hitting her and the verbal argument continued with cursing from both parties before S23LPN entered the elevator to go to the 4th floor. An interview was conducted on 07/31/2024 at 3:00 p.m. with S13ADON. She confirmed she was present for the altercation on 05/29/2024 that occurred shortly after 7:30 a.m. between S23LPN and Resident #98. She stated she was on the 2nd floor and heard shouting from the 3rd floor that continued to get louder. She stated when she arrived to the 3rd floor, S23LPN and Resident #98 were shouting and cursing at each other but still had space between them. She confirmed S23LPN was shouting profanities at Resident #98 causing the situation to escalate rather than attempting to deescalate as she had been trained to do. She stated she immediately grabbed S23LPN and pulled her into the supply room to separate the two in attempt to deescalate the situation. She stated a few minutes later when S23LPN exited the supply room, she immediately began fussing and cursing at Resident #98 which got him agitated all over again. She stated she and the other staff then pulled S23LPN onto the elevator to get her out of there. She confirmed as soon as she was able to remove S23LPN from the 3rd floor and deescalate the situation, she immediately notified S1ADM, S2AADM and S12DON of what occurred. An interview was conducted on 07/31/2024 at 3:33 p.m. with S1ADM. He confirmed he was responsible for submitting the facility's incident reports to the state agency. He confirmed any allegation or suspicion of resident abuse should be reported within 2 hours, including allegations of verbal abuse from a staff member. He confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. He confirmed S13ADON notified him, S2AADM and S12DON of the altercation between S23LPN and Resident #98 immediately after the event occurred. He confirmed he did not submit an incident report to the state agency within 2 hours of being notified of the altercation from S13ADON.

Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment in 12 of 12 (a, b, c, d, e, f, g, h, i, j, k, and l) rooms observed for environmental concerns. Findings: On 06/07/2024 at 12:10 p.m., an environmental tour was conducted with S2MAIN. S2MAIN confirmed the following findings: Room a -There was an approximate 1 gap in the right hand top corner between the air conditioner unit and the wall mount harness; Room b -Wires were hanging from the bottom of the telephone jack face plate cover; Room l -A hole was in the ceiling tile above the toilet; Room c -The edge of the bead board/paneling above the air conditioner unit was peeling away from the wall; Room d -An approximate 1/2 gap was between the air conditioner unit and the wall mount harness with outside light visible; -The edge of the bead board/paneling above the air conditioner unit was peeling away from the wall; Room e -The bathroom vanity's laminate covering had peeled away from the right side. The bottom edge of the vanity's laminate covering was broken and rough; Room f -Stained ceiling tiles were near the window along the wall; -The cover of the air conditioner's power button was missing and the button covers for the temperature controls, mode, and speed were damaged; Room g -A rectangular hole was in the wall above the resident's bed on the right side wall; -A wall socket face plate cover was peeling from the wall near the resident's bed on the right side wall; -A wall socket face plate cover was broken on the wall near the bathroom; Room h -Ceiling tiles x2 were drooping above the resident's bed; -A ceiling tile was drooping over the toilet; Room k -A wall socket near the air conditioner unit was missing a face plate cover; Room i -The slats on the air conditioner unit were broken; Room j -An approximate 1/4 gap was between the air conditioner unit and the wall mount harness with outside light visible; and, -A wooden block was on the floor supporting the left hand side of the air conditioner unit. On 06/11/2024 at 12:10 p.m., an interview was conducted with S1ADM. S1ADM stated he was made aware of the aforementioned findings by S2MAIN and confirmed the findings should not be that way. On 06/11/2024 at 1:57 p.m., an observation was made of a bed in Room l with S1ADM. The head board of the bed was sitting on the bed frame leaning at an angle. The head board was missing one of the two metal brackets which allowed the headboard to be attached to the bed. S1ADM confirmed the head board was missing the bolts which held the brackets in place to support the head board to the bed frame. S1ADM confirmed the head board should not be like that.

Based on interviews and record reviews, the facility failed to provide services and assistance to maintain bladder continence for 1 (#1) of 2 (#1 and #5) continent residents reviewed. This deficient practice resulted in an actual harm for Resident #1, a continent resident, on 08/19/2023 at 5:53 a.m. when she attempted to go to the restroom and fell in her room. Resident #1 was admitted to the facility on [DATE] after a left knee replacement surgery which required one person assist with utilization of a walker for mobility. On 08/19/2023 at 4:27 a.m., Resident #1 began asking S5CNA for assistance to the restroom. S5CNA failed to assist Resident #1 to the restroom. On 08/19/2023 at 5:53 a.m., Resident #1 fell on the floor hitting her face after attempting to go to the restroom to prevent urination on herself. Resident #1 sustained a cut on her nose and was transferred to a local hospital and diagnosed with a Right Frontal Scalp Hematoma with Diffuse Ecchymosis noted around both eyes. Findings: Review of the Clinical Record for Resident #1 revealed she was admitted to the facility on [DATE] for short-term, skilled nursing services following a Left Knee Replacement Surgery on 08/14/2023. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 12 indicating Resident #1 was moderately cognitively impaired. Further review revealed Resident #1 required 1 person physical assistance with transfers and ambulation, utilized a walker for mobility, and was continent of bowel and bladder. Review of the Physician Orders for Resident #1 dated 08/18/2023 revealed, in part, the following: Eliquis 2.5mg tablet, give 1 tablet by mouth twice daily. Aspirin 81mg tablet, give 1 tablet by mouth daily. Review of the current Care Plan for Resident #1 dated 08/18/2023 revealed, in part, the following: Problem: I am at risk for falls related to limited mobility from recent knee surgery. Approaches: Place me on the fall program. Review of the Nurses' Notes dated 08/18/2023 - 08/19/2023 for Resident #1 revealed, in part, the following: 08/18/2023 at 12:39 p.m. - Resident #1 had a Total Left Knee Replacement on 08/14/2023. Resident is continent of bowel and bladder. Resident #1 ambulates with a walker. 08/19/2023 at 1:05 p.m. - The ward clerk came to second floor during morning medication pass to notify S3LPN that the ambulance was on the phone regarding resident. S3LPN was informed that resident contacted 911 requesting an ambulance because she was on the floor in her room. The resident was observed on the floor in sitting position beside the bed. A hematoma was noted on the middle of her forehead. An abrasion was noted on bridge of her nose. When asked, resident stated she was trying to go to the bathroom by herself and fell . S3LPN notified the on call nurse practitioner. S3LPN notified transport for transfer to local hospital for further evaluation and treatment. S3LPN contacted the responsible party and updated them. S3LPN notified the Administrator and DON of fall and transfer to the local hospital. Review of Resident #1's Hospital Records dated 08/19/2023 revealed, in part, the following: CT scan of the Head revealed Right Frontal Scalp Hematoma. Diffuse Ecchymosis noted around both eyes upon assessment. An interview was conducted on 09/05/2023 at 11:00 a.m. with S2DON and S1AADM. Both stated they reviewed video camera footage together on 08/19/2023 and created a timeline. S2DON stated video camera footage dated 08/19/2023 of Resident #1's doorway revealed the following: 4:27 a.m. Resident #1 initiated her call light. 4:31 a.m. S3LPN answered call light and was seen speaking with S5CNA. 4:35 a.m. S5CNA entered Resident #1's room, turned call light off, and remained in room for less than 1 minute. 4:40 a.m. Resident #1 initiated her call light. 4:46 a.m. S5CNA entered Resident #1's room, turned call light off, and then immediately exited Resident #1's room. 5:51 a.m. S7UC was seen speaking with S3LPN at the nurses' station. 5:53 a.m. S3LPN entered Resident #1's room. S5CNA and S6CNA remained at Resident #1's doorway. An interview was conducted on 09/05/2023 at 11:30 a.m. with S7UC. S7UC stated she received a phone call from 911 dispatch on the early morning of 08/19/2023 stating Resident #1 called them after she had fallen in her room. S7UC stated 911 dispatch reported Resident #1 stated she had asked for assistance to the bathroom multiple times before she fell . S7UC stated she notified S3LPN. An interview was conducted on 09/06/2023 at 9:46 a.m. with Resident #1. She stated after using the call light twice for assistance to the bathroom, S5CNA told her she wanted to wait for someone to help her. She stated she needed one person to assist her with use of her walker. She stated she needed to use the bathroom extremely bad, so she tried to walk to the bathroom with the use of the bedside rolling table. She stated she tripped on the bedside table and fell on to the floor, hitting her face. She stated she was very upset because she came to the facility to get help with ambulation and assistance, which she did not receive. She stated S5CNA could have gotten her walker and assisted her to the bathroom or provided her with a bedpan. She stated 1 hour was too long for staff to expect a resident to wait to use the bathroom. She stated she did not want to urinate on herself while waiting. An interview was conducted on 09/06/2023 at 9:17 a.m. with S5CNA. S5CNA stated Resident #1 used the call light in the early morning of 08/19/2023 when she required assistance going to the bathroom. S5CNA stated she needed help getting Resident #1 up due to Resident #1's new surgical incision, and she was unsure of Resident #1's requirements for transfers. S5CNA stated she then asked S6CNA for assistance, however, S6CNA was busy assisting other residents. S5CNA stated she waited for S6CNA to finish but before she got back into Resident #1's room, S3LPN received a phone call stating Resident #1 had fallen. S5CNA stated she and S6CNA entered Resident #1's room, and Resident #1 was sitting on the floor. S5CNA stated she was aware of other staff members available to assist her, but she failed to ask. S5CNA confirmed Resident #1 waited over 1 hour for assistance to the bathroom, and she should not have. An interview was conducted on 09/06/2023 at 10:00 a.m. with S6CNA via telephone. S6CNA stated on the morning of 08/19/2023, Resident #1 asked S5CNA to assist her to the bathroom. S6CNA stated she was busy changing briefs on other residents when S5CNA asked her for assistance. S6CNA stated she was unsure how long she was busy assisting other residents when they received a call that Resident #1 called 911. S6CNA stated she and S5CNA found Resident #1 sitting on the floor in her room. S6CNA stated Resident #1 had a cut on her nose and a bump on her head. S6CNA stated Resident #1 had to wait too long for toileting assistance. An interview was conducted on 09/06/2023 at 10:18 a.m. with S3LPN. S3LPN stated Resident #1 used the call light in the early morning of 08/19/2023, and stated she needed to use the bathroom. S3LPN stated she immediately notified S5CNA that Resident #1 needed to use the bathroom. S3LPN stated S5CNA stated she would handle it. S3LPN stated Resident #1 required 1 person with use of her walker for transfers due to her recent knee replacement surgery. S3LPN stated about 1 hour or so later, S7UC arrived on the unit stating 911 notified her Resident #1 called 911 because she was on the floor in her room after a fall. S3LPN stated she went to Resident #1's room and found her sitting on the floor with a hematoma on her forehead and bleeding from the bridge of her nose. S3LPN stated the resident then told her she asked twice to use the bathroom, and S5CNA told her both times she was waiting for someone to help her. S3LPN stated Resident #1 told her she used the bedside table to try to get to the bathroom and fell . S3LPN stated if S5CNA would have asked her for assistance, she would have immediately helped her. S3LPN stated she was available the entire time and was unaware S5CNA had not assisted Resident #1. S3LPN confirmed Resident #1 received blood thinners, which increased her risk for bleeding. An interview was conducted on 09/06/2023 at 10:30 a.m. with a representative from 911 dispatch. She reviewed the call from the early morning of 08/19/2023. She stated at 5:48 a.m. 911 was called by Resident #1, who stated she was a resident at this nursing facility. She stated Resident #1 reported she was on the floor in her room and needed help. She stated at 5:49 a.m., 911 dispatch called the nursing facility and notified them of the call. An interview was conducted on 09/05/2023 at 11:00 a.m. with S2DON and S1AADM. S2DON stated after Resident #1's incident, S5CNA explained she was nervous about helping Resident #1 alone to the bathroom due to her fresh knee incision. S2DON stated S5CNA told her she asked S6CNA for assistance, however, S6CNA was busy assisting other residents. S2DON stated Resident #1 reported she got tired of waiting so she attempted to go to bathroom utilizing the bedside table and tripped and fell . S2DON stated Resident #1 had a hematoma on her forehead and an abrasion located on the bridge of her nose. S2DON confirmed Resident #1 required 1 person physical assistance with use of her walker during ambulation. S2DON confirmed S5CNA should have asked S3LPN for assistance. S2DON and S1AADM confirmed the wait time of Resident #1 trying to get assistance to the bathroom was too long, and her fall could have been avoided.

Based on interviews and record review, the facility failed to ensure weekly skin/body audits, consistent with professional standards of practice, were conducted in order to prevent the development of avoidable pressure ulcers for 1 (#1) of 3 (#1, #3, R1) sampled residents reviewed for pressure ulcers. An Immediate Jeopardy situation occurred for Resident #1 on [DATE] at 10:00 a.m. when S5CNAS identified pressure ulcers to Resident #1's sacral area, left great toe and right foot. Prior to the discovery of these pressure ulcers, Resident #1 had no [DIAGNOSES REDACTED]. S4WCN discovered a fourth new pressure ulcer to Resident #1's right hip on [DATE] at 3:23 p.m. Resident #1 was transferred to a local hospital on [DATE] and diagnosed with [REDACTED]. The facility's administrative staff did not implement measures for monitoring the nursing staff to ensure skin/body audits were being performed through direct observation on all residents in the facility. This deficient practice continued at a potential for more than minimal harm for the 5 residents of which were considered high risk for pressure ulcers and 10 residents of which were considered moderate risk for pressure ulcers. The Administrator was informed of the Immediate Jeopardy on [DATE] at 9:50 a.m. The Immediate Jeopardy was removed on [DATE] at 4:00 p.m. when the facility presented an acceptable plan of removal. Through observation, interview and record review, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented. 1. Corrective actions for alleged deficient practice were accomplished for Resident #1 by the following: a. Root Cause Analysis and Performance Improvement Project initiated [DATE]. i. All residents assessed to obtain baseline skin status (initiated [DATE], completed [DATE]) ii. In-service nurses on body audit protocol (to include primary utilization of standard body audit schedule as primary source of reference) completed [DATE] and [DATE], [DATE], [DATE], and [DATE]. iii. DON and or designee completed weekly audits of medical records to ensure body audits completed and in compliance. iv. Re-evaluated Root Cause Analysis and Performance Improvement Project [DATE] 1. Audited electronic health record to ensure it was configured correctly. 2. In-service nurses and CNA on body audits expectation (to include utilization of standard body audit schedule as primary source of reference) and protocols on [DATE], [DATE] and [DATE]. 3. DON and or designee monitored completion and compliance of body audits by direct visual observation and record review. 2. All residents are potentially at risk from this alleged deficient practice. 3. Measure put into place to prevent this alleged deficient practice from re-occurring a. Root Cause Analysis (RCA) and Performance Improvement Project initiated and completed as above (with numerous in-services listed above) b. DON and or designee will utilize and complete nurse competency with all nurses to ensure nurse competent of body audit protocol and procedure (began [DATE] projected completion [DATE]) c. DON and or designee will utilize and complete CNA competency with all CNA to ensure CNA is competent of skin observation and procedure (Began [DATE] Projected completion [DATE]) 4. Facility will monitor its performance to ensure sustained compliance by the following a. DON and or designee will observe by direct visual observation nurse performing random resident body audits three times week (Began [DATE] Projected completion: to be decided) b. DON and or designee will observe by direct visual observation CNA skin observations on random residents three times a week (Began [DATE] Projected completion: to be decided) c. DON and or designee will perform by record review documentation of completion of body audits on random residents three times a week (Began [DATE] Projected completion: to be decided) d. Additional in-servicing and or progressive disciplinary action will occur if further noncompliance is noted Findings: Review of the facility's protocol entitled Skin Protocol revealed the following, in part: Purpose: To maintain health skin integrity, to prevent skin breakdown, to heal skin breakdown and prevent further skin breakdown. Policy: Each resident will be assessed on admission, re-admission, quarterly, annually, with any significant change in condition, and as needed for potential skin breakdown. Discussion regarding the acceptable level of risk must be based on the individual assessment and resident's needs, with input from the resident and interdisciplinary team. Procedure: 6. Daily skin monitoring by CNA's to be completed with weekly nursing audit. High risk/Severe risk: 1. Residents will be reviewed and added to high risk to be monitored weekly. Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE]. She had diagnoses that included [MEDICAL CONDITION] following Cerebral Infarction affecting left non dominant side, Dementia, Cognitive Communication Deficit, Mild Protein Calorie Malnutrition, Unspecified [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Disorder, Dysphagia following Cerebral Infarction, and COVID-19. Review of Resident #1's MDS with an ARD of [DATE] revealed the resident had a BIMS score of 9 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 required extensive one-person physical assistance with bed mobility, transfers, eating, and toilet use. She was totally dependent for dressing, personal hygiene and bathing. Resident #1's skin condition was coded as at risk for developing pressure ulcers/injuries and coded as no for having one or more unhealed pressure ulcers/injuries. A review of Resident #1's Care Plan revealed the following, in part: Problem: I am at risk for skin breakdown related to bowel and bladder incontinence and decreased mobilization. Goal: I will have minimal to no skin breakdown. (target date:[DATE]) Approaches: Observe my skin when providing routine care. I need a full skin evaluation as appropriate. Review of Braden Risk Assessment Report provided by the facility for Resident #1 revealed the following: Assessment completed on [DATE] and [DATE] Risk score- 12 Risk level- High (indicates high risk for pressure ulcers) Review of the Skin Inspection Report for Resident #1 provided by the facility revealed the following in part: [DATE] - No skin/body audits completed for the month of [DATE]. [DATE] - No skin/body audits completed week of [DATE], [DATE], [DATE]. Review of S4WCN's notes for Resident #1 revealed the following, in part: [DATE] at 12:42p.m. Assessed by wound care nurse. New unstageable pressure wound noted to sacrum/buttocks area. Measurements are 9.0 cm x 8.6 cm. Eschar 90%, Slough 10% with a small amount of serosanguineous drainage. SDTI noted to left great toe and SDTI noted to right lateral foot. [DATE] at 3:23p.m. Pressure ulcer/right buttock assessed by wound care nurse. New wound noted to right hip. Review of the Wound Healing Progress Report for Resident #1 revealed the following: [DATE] Pressure ulcer left great toe: 0.8cm x1.3cm (unstageable due to suspected deep tissue injury) [DATE] Pressure ulcer right pad of foot; right lateral foot: 3.0cm x 0.50cm (unstageable due to suspected deep tissue injury) [DATE] Pressure ulcer sacrum; buttocks; 9.0cm x 8.6cm x 0.0cm (unstageable due to slough/eschar) [DATE] Pressure ulcer right buttock; right hip 7.0cm x 8.0cm (unstageable due to suspected deep tissue injury) Review of the Wound Care Specialist's professional services progress notes, for Resident #1, dated [DATE] revealed the following: Wound #1 - Sacral is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 14.0cm length x 9.0cm width x 0.1 cm depth, with an area of 126 sq cm and volume of 12.6 cubic cm. Adipose is exposed. There is a large amount of serous drainage noted which has a mild odor. The wound margin is well defined. The peri wound skin exhibited: moist. Wound #2- Right lateral foot is an acute deep tissue pressure injury persistent non-blanchable deep red, maroon or purple discoloration. Pressure ulcer and has received a status of not healed. Initial wound measurements are 2.0cm length x 4.1cm width x 0.01 cm depth with area of 8.2sq cm and a volume of 0.082cubic cm. The wound margin is flat and intact. The periwound skin exhibited: dry/scaly. Local pulse is weak. Wound #3- Left toe 1st is an acute deep tissue pressure injury persistent non blanchable deep red, maroon or purple discoloration Pressure ulcer and received a status of not healed. Initial wound measurements are 2.0cm width x 0.01 cm depth with an area of 4.0sq cm and a volume of 0.04 cubic cm. The wound margin is well defined. The periwound skin exhibited: dry/scaly. Wound #4 - Right hip is an acute deep tissue pressure injury persistent non- blanchable deep red. Maroon or purple discoloration pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 7.0cm length x 8.0cm width x 0.01 cm depth with an area of 56 sq cm and a volume of 0.56 cubic cm. No drainage noted pain level of ,[DATE]. The wound margin is flat and intact. Peri wound skin exhibited: dry/ scaly. Procedure: Wound #1 (pressure ulcer) is located on the sacral area. A skin/subcutaneous tissue level excisional/surgical debridement with a total area debrided of 25.2 sq cm was performed by the facility's wound care specialist. Subcutaneous was removed along with devitalized tissue: slough. A minimal amount of bleeding was controlled with pressure. The procedure was tolerated well with a pain level of 0 throughout, a pain level of 0 following the procedure. Post Debridement Measurements: 14.0cm length X 9.0cm width x 0.2cm depth; with an area of 126 sq cm and a volume of 25.2 cubic cm. Review of nurses notes dated [DATE] for Resident #1 revealed the following: [DATE] at 4:28 p.m. Resident not responding to verbal stimuli. Hypotensive. [DATE] at 5:21 p.m. Around 4:15 p.m. during rounds resident noted lying in bed unresponsive to verbal or tactile stimuli; Vital signs obtained Blood pressure: ,[DATE], Respiration: 16 Pulse: 39 Temperature: 97.3 O2Sat: 70% RA, oxygen applied. Send to ER for evaluation and treatment. Resident transferred via ambulance to local hospital. Review of Resident #1's hospital records revealed the following in part; admitted date: [DATE] Admitting complaint: [MEDICAL CONDITION] 74 -year old female from local nursing home presents to Emergency Department with SOB x 6 hours. Patient was somnolent on arrival. Vitals at that time showed blood pressure 70's/20's, Heart rate 30's, O2 saturation 70's on room air. Impression/ Plan: [MEDICAL CONDITION] secondary to unstageable sacral decubitus ulcer Possible aspiration pneumonia and concern for osteo[DIAGNOSES REDACTED] of the left great toe. Acute hypoxic [MEDICAL CONDITION]-[MEDICAL CONDITION] vs aspiration pneumonia vs PE. AKI - pre-renal Unstageable sacral decubitus Hospital Medicine discharge: [DATE] [DIAGNOSES REDACTED].>[MEDICAL CONDITION] with septic shock secondary to infected sacral decubitus Possible Aspiration pneumonia/ pneumonitis with acute [MEDICAL CONDITION] AKI secondary [MEDICAL CONDITION] [MEDICAL CONDITION] with lactic acidosis Hospital course: [MEDICAL CONDITION] with septic shock secondary to infected sacral decubitus. Patient was admitted from local nursing home with altered mental status and found to be in septic shock secondary to infected sacral decubitus. Condition/ Discharge to: Hospice unit in guarded condition. An interview was conducted on [DATE] at 1:00 p.m. with the son of Resident #1. He said his mother had been in a local nursing home since [DATE]. He said she was diagnosed with [REDACTED]. He said she was admitted to the hospital on [DATE] with [MEDICAL CONDITION] related to the pressure ulcer to her sacrum. He said his mother had a pressure ulcer on her right buttock, right foot, left great toe and sacrum area. He said his mother never had a pressure ulcer since admit to the facility in 2017. He said his mother was discharged from the hospital to a hospice unit and died on [DATE]. He said his mother was totally dependent on the staff for ADL's. An interview was conducted on [DATE] at 8:50 a.m. with S4WCN. She said she had been informed of Resident #1's pressure ulcers on [DATE]. She said she assessed Resident #1 on [DATE] and found three unstageable pressure ulcers. She said the pressure ulcers were located on Resident #1's left great toe, right foot and sacral/buttock area. She said the sacral wound was 9.0 cm x 8.6cm. She said on [DATE] she observed a new pressure ulcer to the resident's right hip. She reviewed Resident #1's medical record and confirmed, since admission in 2017, Resident #1 had no previous pressure ulcers prior to [DATE] and [DATE]. S4WCN confirmed she had not been consulted or treated the resident for a pressure ulcer prior to [DATE]. An interview was conducted on [DATE] at 9:00 a.m. with the facility's wound care specialist. She said she was notified on [DATE] by S4WCN regarding new pressure ulcers to the left great toe, right foot and sacral/buttock area on Resident #1. She said she was made aware on [DATE] that Resident #1 had a new pressure ulcer to the right hip. She said prior to [DATE], she had not been consulted for wound care for Resident #1. She reviewed the medical record and verified Resident #1 had resided in the facility since [DATE] and she had not had an issue with skin breakdown prior to [DATE]. An interview was conducted on [DATE] at 8:50 a.m. with S5CNAS. She stated Resident #1 was dependent on ADL's and could make her needs known only by answering yes or no but could not hold a conversation. She said on [DATE] at 10:00 a.m., she discovered a pressure ulcer to Resident #1's sacral area while she provided a bed bath. She described the pressure ulcer as an open area to the sacral region that was quarter size. She said the skin around the ulcer was red but did not have drainage or odor. S5CNAS said she also observed a pressure ulcer to her left great toe and right foot on [DATE]. She said the CNA staff were responsible for inspecting resident's skin during care and notifying the nurse when there was a change in a resident condition including skin breakdown. She confirmed, prior to [DATE], she had never been informed or observed skin issues regarding Resident #1. An interview was conducted on [DATE] at 9:00 a.m. with S6LPN. She said on [DATE], S5CNAS informed her Resident #1 had a pressure ulcer to her sacral area. She said she notified S4WCN. She said she had not been informed of skin issues by a CNA regarding Resident #1 prior to [DATE]. She said she worked prn and had observed Resident #1's skin twice while she resided on the COVID unit. She said she could not recall if she completed a skin/body audit on Resident #1 while she resided on the COVID unit. She said the nursing staff were required to do weekly skin/body audits. She reviewed Resident #1's medical record and confirmed a skin/body audit had not been completed in July or August of 2020. An interview was conducted on [DATE] at 3:00 p.m. with S3ADON. She said she had been the ADON for 3 months, and prior to, was the staff development educator. She said she knew Resident #1 well. She said Resident #1 was dependent on ADL's. She said Resident #1 could not make her needs known but did hand motions to indicate an answer to yes or no questions. She said she was aware Resident #1 had multiple pressure ulcers that were discovered on [DATE]. She confirmed Resident #1 did not have pressure ulcers prior to the discovery on [DATE]. She said the nursing staff were required to obtain skin/body audits weekly and report any new findings. She said the facility's administration initiated a root cause analysis after Resident #1 expired on [DATE]. She explained the facility determined the nursing staff had not been performing skin/body audits on the residents each week. She said S2DON and administrative staff were now electronically monitoring to ensure skin/body audits were entered into the clinical record weekly. An interview was conducted on [DATE] at 4:00 p.m. with S1CN. He stated, after Resident #1 was transferred to the hospital on [DATE], he identified that the nursing staff were not performing weekly skin/body audits on the residents. He said a root cause analysis was initiated on [DATE], after Resident #1 expired, and nursing staff were in-serviced on performing weekly skin/body audits. He said S2DON began monitoring to ensure the completion of skin/body audits each week for all residents in the facility. He stated on [DATE], S2DON still found the facility to be out of compliance with performing weekly skin/body audits on all residents. He explained at that point staff were re-in-serviced on completing weekly skin/body audits and administrative staff began monitoring to ensure the skin/body audits were electronically entered into the resident's clinical record each week. He verified the nursing staff was noncompliant with obtaining weekly skin/body audits on residents in the facility.

Based on interviews and record reviews, the facility failed to ensure there was adequate supervision and monitoring for 1 (#65) of 17 (#2, #8, #25, #39, #52, #65, #68, #73, #81, #86, #90, #92, #109, #110, #120, #125, #480) residents who were assessed by the facility as an elopement risk. This deficient practice resulted in an immediate jeopardy situation for Resident #65 on 06/13/18 at 8:30 a.m. when the resident, who was cognitively impaired, eloped from the facility unnoticed by the staff. The resident had been assessed by the facility on 06/04/18 as being an elopement risk. Resident #65 was found sitting on a bench by a maintenance man at a local school, located approximately 1.2 miles from the nursing home. The police were notified by the school's maintenance man and the resident was returned to the facility on [DATE] at 11:54 a.m. The immediate jeopardy for Resident #65 ended when he was returned by the local police to the nursing facility on 06/13/18 at 11:54 a.m. On 07/13/18 at 9:30 a.m. the Administrator was informed of the Past Noncompliance at Immediate Jeopardy level that began on 06/13/18 at 8:30 a.m. and ended on 06/13/18 at 11:54 a.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of Resident #65's clinical record revealed he was a ninety-one year old male with [DIAGNOSES REDACTED]. A review of the most recent MDS with an ARD of 05/22/18 revealed Resident #65 had a BIMS score of 5, indicating severe cognitive impairment. The MDS also revealed Resident #65 used a walker for mobility and needed limited assistance for walking and locomotion on and off the unit. He exhibited ROM impairment to one side (lower extremity) and bilateral upper extremities. A review of the Resident #65's care plan revealed the following: 05/31/17=I am at risk for falls related to unsteady gait and poor safety awareness. 06/09/17=I have severe cognitive loss. I require staff to anticipate my needs, cue me to location of my room and to come inside for meals. 06/09/17=I have had a [MEDICAL CONDITION]. I have residual right side [MEDICAL CONDITION], impaired cognition and difficulty expressing my ideas/thoughts and may need extra time to make my needs known. 06/04/18=I am an elopement risk related to I am a wanderer and I wear a wander guard. 06/13/18=I have been placed on the secure unit because I eloped. An interview was conducted with S10CNA on 07/11/18 at 10:39 a.m. She said she was on duty and assigned to Resident #65 on the morning he eloped. S10CNA stated Resident #65 liked to sit outside hall d. She stated Resident #65 was not considered to be an elopement risk and she was not aware of him trying to leave the facility or grounds. She denied checking to see if his wander guard bracelet was in place on the morning of 06/13/18. She stated she recalled bringing him to the main dining room for breakfast. She further stated a new nurse, S9LPN, was working his hall that morning and that she (S9LPN) routinely worked a different hall. She further stated staff was allowed to enter the code on hall d doors so that Resident #65 could exit the facility and sit outside. She explained he was allowed to sit outside unsupervised. She further explained that all other residents that wore wander guard bracelets had to be supervised by staff when outside. S10CNA explained rounds were made every 2 hours by the staff and all residents should be checked on during these rounds. S10CNA was asked to explain how Resident #65 went unnoticed for 2-3 hours on the morning of 06/13/18. She explained that when breakfast was over, the CNAs began bathing the residents. She stated the staff would have been looking for him again at lunch, but before they noticed he was gone, the police had already called the facility. An interview was conducted with S9LPN on 07/11/18 at 11:01 a.m. She explained she was assigned to work hall b on 06/13/18 and she was not familiar with the residents residing on that hall. S9LPN stated she was told Resident #65, who resided on hall b, liked to take his medicines and sit on the porch with other residents. S9LPN recalled administering Resident #65's medications that morning. She said he then went about his own business. Again, she stated she was not familiar with Resident #65 and was not aware he was an elopement risk or if he wore a wander guard bracelet. S9LPN said staff, both CNAs and LPNs, should check on residents at least every two hours. An interview was conducted with S1Adm on 07/12/18 at 2:04 p.m. He explained Resident #65 was admitted to the facility in (MONTH) (YEAR) and had developed a daily routine of sitting outside hall d or by himself in his room. The administrator said the resident had a BIMS score of 5 and that this score was based on the resident's short term memory loss. He further explained the resident was stable and could ambulate within the building (to and from the dining room, to the courtyard area and to his room) with use of his walker. S1Adm stated Resident #65 had no issues, until 06/04/18, when he was observed by staff ambulating with his rolator (rolling walker) toward the gate that exited the parking lot of the facility to the street. He explained a staff member brought him back into the facility. At that time, Resident #65 was made an elopement risk and a wander guard bracelet was placed on his ankle. S1Adm further explained the facility received phone call from the local police department on 06/13/18 at approximately 11:30 a.m. He said the police officer asked if Resident #65 resided at the facility and that the resident had been picked up at a local elementary school approximately 4 blocks away from the facility. S1Adm reviewed the facility's camera footage and stated the police brought the resident back to the facility at 11:54 a.m. S1Adm said another wander guard bracelet was placed on the resident. He explained that later that afternoon, the resident was once again observed by staff ambulating toward the exit doors of hall d. He stated he feared the resident may again be able to remove the wander guard bracelet and the decision was made to transfer the resident to the secure unit of the facility. S1Adm was asked if residents who had been identified as an elopement risk needed more frequent monitoring. He responded, Yes, if they demonstrate signs or signals indicating they are prone for elopement. He further explained that based on Resident #65's daily needs, three hours unnoticed was not inappropriate. Again he explained the resident had not expressed wanting to leave or been observed pulling on exit doors etc. S1Adm explained the facility staff was busy with their morning duties which included tending to other residents in the dining room for breakfast then performing their baths. S1Adm was asked if there was a policy in place to indicate how often residents should be visually monitored. He responded there was no policy in place and nothing was written to indicate a resident needed to be checked on every hour or even every two hours. He further explained that it was resident specific and depended upon each resident's individual needs. S1Adm further stated he felt the staff would have realized Resident #65 was missing when he was not in the dining room for lunch and/or medication pass. S1Adm stated a QA plan was written upon the resident's return to the facility which included a full-staff in-service that covered the topics of elopement and wander guards. He stated this in-service was scheduled and conducted on 06/22/18 at 2:00 p.m. Throughout the survey, nine LPNs and ten CNAs were interviewed. These staff members were knowledgeable of the facility's elopement policy and procedures as well as observation/monitoring of the placement of the wander guard bracelets on the residents. The facility has implemented the following actions to correct the deficient practice on 06/13/18: 1. Resident #65 was relocated to the secure care unit, where the doors remain locked at all times. 2. An audit was made of all wander guard bracelets in use to ensure that they operated properly. 3. An audit was performed on all magnetic door locking devices to ensure they worked properly. 4. A Quality Assurance (QA) plan was devised to stipulate that the wander guard bracelet and magnetic door lock checks would be conducted three times weekly. 5. A full staff in-service was scheduled to review elopement precautions and procedures. In-service scheduled for 06/22/18 at 2:00 p.m. The facility will audit the in-service sign in sheets to determine which employees have not yet received this training. The outstanding employees will be outreached trained on elopement precautions by (MONTH) 20, (YEAR). This training presentation includes a detailed review of the monitoring and supervision expected for those residents determined to be at risk for elopement. 6. A review of all residents care-planned to wear wander guard bracelets was made by the care management team to re-determine the validity of the order. As a result, several wander guard orders were discontinued, as certain residents no longer presented a threat for elopement.

Based on observations, record reviews and interviews, the facility failed to ensure that residents receive adequate supervision to prevent accident hazards for 2 (#2, #3) of 8 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8). The facility failed to: 1) Ensure adequate supervision for a cognitive impaired resident (#3) which resulted in her drinking an antimicrobial agent ([MEDICATION NAME]). An immediate jeopardy situation occurred on 03/12/18 at 3:34 p.m. when Resident #3, a cognitively impaired resident grabbed a bottle of [MEDICATION NAME] from behind the nurses' charting station and ingested the [MEDICATION NAME]. The hall nurse found Resident #3 down hall b with a bottle of [MEDICATION NAME] in one hand and lid in the other hand. The resident had pink ring around her mouth. The resident was transferred to the Emergency Department on 03/12/18 at 4:30 p.m. after she complained of burning to her throat and had nausea and vomiting. The resident was admitted to the ICU (Intensive Care Unit) on 03/12/18 at 8:30 p.m. and intubated on 03/13/18. The resident was diagnosed with [REDACTED]. The Administrator was notified of the Immediate Jeopardy on 04/16/2018 at 4:52 p.m. The facility submitted an acceptable plan of removal on 04/17/2018 at 2:40 p.m. The plan of removal included the following: The facility will designate staff members, such as the administrator, DON, administrative nurses, and weekend supervisors to randomly make visual observations of all residents' access areas at least three times daily to ensure that hazardous materials are not left unattended and within access to the residents. These areas shall include, but are not limited to: Linen carts Whirlpool rooms Storage closets, such as housekeeping chemical closet, hazardous waste closet Counter tops of nurses stations and charting areas Unattended medication carts Medication rooms Nurses stations Resident rooms The attached spreadsheet will be used to document these hazardous materials checks. It should be noted on the attached spreadsheet that the administrative team conducted a full facility sweep early on 4/17/2018 to include all aforementioned areas and all hazardous items were removed and secured in the administrator's office. These confiscated items will be properly stored in a secured area or disposed of. Also, self-locking lever devices were installed on the housekeeping chemical supply closets to prevent access by unauthorized persons. The facility audit sheets will be maintained in the binder in the administrator's office and reviewed daily by the administrator and his designees. Also, the Director of Nurses and Administrator will conduct staff in-services of all personnel to re-educate them on the requirement that hazardous materials shall not be left within residents' access. The Immediate Jeopardy ended for Resident #3 when an acceptable Plan of Removal was activated in the facility on 04/17/2018. 2) Ensure adequate supervision and implementation of new interventions to prevent reoccurring falls for a cognitively impaired resident (#2). The deficient practice resulted in an actual harm for Resident #2 when she was pushed by another resident and fell on [DATE] resulting in a left [MEDICAL CONDITION]. The facility failed to supervise Resident #2 and implement new interventions resulting in her falling on 02/04/18 and 02/10/18. Resident #3 was diagnosed with [REDACTED]. Resident #2 was diagnosed with [REDACTED]. Resident #2 returned to the facility on [DATE]. On 02/13/18, Resident #complained of pain to her right knee. She was diagnosed with [REDACTED]. While hospitalized , the family was informed by the physicians that the resident was unable to proceed with surgical interventions due to her age, advanced Dementia, and repeated hospitalization s for falls and orthopedic injuries. At that time, the family opted to place the resident on hospice services at an in-patient hospice facility. The facility failed to supervise Resident #2 and implement new interventions resulting in her falling on 02/04/18 and 02/10/18. The deficient practice continues at a scope and severity of a potential for harm for the 7 other wandering, cognitively impaired sampled residents (#1, #2, #3, #5, #6, #7, #8). Findings: Resident #3 Record review for Resident #3 revealed she was an [AGE] years old female with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of MDS (Minimum Data Set) with an ARD (01/26/18) revealed in part: Section C-Cognitive Patterns C0500: BIMS resident interview: summary score of 7 indicating the resident had severe cognitive impairment Section E- Behavior E0900: Wandering: presence and frequency 3. Behavior of this type occurred daily Section G- Functional Status revealed resident required limited assistance with one person in areas of bed mobility, transfer, dressing, eating, toileting, bathing and personal hygiene. Section K- Swallowing/Nutritional Status K0300B: Weight (in pounds) -130 Review of MDS (Minimum Data Set) with an ARD (04/04/18) revealed in part: Section C-Cognitive Patterns C0500: BIMS resident interview: summary score of 0 indicating resident had severe cognitive impairment Section E- Behavior E0900: Wandering: presence and frequency 3. Behavior of this type occurred daily Section G- Functional Status revealed resident required extensive assistance with two persons physical assist in areas of bed mobility, transfer, toileting and personal hygiene. Resident #3 required extensive assistance with one person in dressing, eating, bathing and personal hygiene. Section K- Swallowing/Nutritional Status K0300B: Weight (in pounds) -108 Review of the current Care Plan revealed in part: Problem Onset: 05/19/16 I exhibit behaviors r/t dx: Alzhemer's and [MEDICAL CONDITION] disorder. I wander in the hallway via my w/c I repeat the same sentence, I just don't know what to do. She is not easily redirected. 10/3/17. I continue to repeat same thing as listed above 1/18/2018 I continue with the same behaviors Goal & Target Date: I will show a decrease in my behaviors within the next 90 days 5/10/18 Approaches: Place me in area where observation is possible Social Services to evaluate and visit with me as needed Activities staff to visit with me and provide diversional activities Approach me with a calm and quiet demeanor Monitor and document my behavior Allow me opportunities to make choices and participate in care Praise me for demonstrating desired behavior Administer my behavior medications as ordered by my physician Talk with me in calm voice when behavior is disruptive 4/12/17 Apply my wander guard and monitor it Q shift Review of Resident #3's Incident Report revealed in part: Incident Date: 3-12-18 time 3:34 p.m. Location of Occurrence: Nurses station Incident Reported by: S14LPN Immediate Action Taken First Aid given by: S14LPN Date: 3-12-18 Time: 3:34 p.m. Type of Aid: Gave clear fluids, assessed mouth Temp: 98.7; Pulse: 82; B/P: 138/84 Notified- Physician- NP; 3-12-18 at 4:03 pm; Responded- 3-12-18 at 4:03 pm Family- member, 3-12-18 .No answer Other- Poison Control Center; 3-12-18 at 4:00 pm; Responded- 3-12-18 at 4:00 pm Taken to Hospital: local hospital Trans by: Ambulance; Date: 3-12-18 at 4:30 pm Mobility: w/c self-wheeled Other current conditions: Inability to understand directions, Confusion/Disorientation boxes were checked. Narrative of incident and descriptions of injuries: Alzheimer resident grabbed a bottle of [MEDICATION NAME] from behind the nurses' station and ingested a small amount before nurse saw her with bottle in one hand and lid in the other. Pink ring around mouth. Witness by: RN/DON 3-12-18 Witnessed via camera footage for investigative purposes and got accurate time and location. Review of ER record revealed in part the following: DOS: 03/12/2018 at 17:46 (5:46 p.m.) BP: 141/94; 03/12/2018 at 22:19 (10:19 p.m.) Pulse: 90; 03/12/2018 at 22:19 (10:19 p.m.) Temp: 96.5F; 03/12/2018 at 17:53 (5:53 p.m.) Resp: 20; 03/12/2018 at 22:19 (10:19 p.m.) O2 saturation at 94% (3 l/m) (Nasal/Cannula); 03/12/2018 at 22:19 (10:19 p.m.) Free Text Summary: Patient is an [AGE] year old female with history of CKD ([MEDICAL CONDITION]),[MEDICAL CONDITION](Hypertension), Dementia, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION] presenting from nursing home after she drank about 6 ounces of [MEDICATION NAME]. Patient stated having nausea and vomiting and complaining of burning to her throat. She became increasingly agitated. Ambulance contacted poison control. Per report patient had O2 saturation at 83% on room air and started on 10L nonrebreather. Resident was admitted to Emergency Department. Physical Exam- General: Awake, patient responds to voice and alert but unable to respond to questions Neuro: Patient responds to voice and alert but unable to respond to questions, moves all extremities While Resident #3 was in ER the following lab tests were conducted that included Arterial Blood Gas, Alcohol Serum and CBC with differential, and chest X-ray. The Impression from chest X-ray revealed Right lower lobe infiltrate Reveal of Progress Note fromER on [DATE] revealed in part: Time: 06:35 PM Note: Spoke to staff at poison control. Updated on patient's status. Recommendations given to EMS (Emergency Medical Service) earlier were supportive care, check electrolytes including renal and liver function. Patient may need an upper GI (Gastrointestinal) scope to evaluate for ulcerations and being monitored for signs of hemorrhagic gastritis. Monitor for [MEDICATION NAME] in urine as [MEDICATION NAME] contains [MEDICATION NAME] alcohol. On 03/12/2018 at 20:38 (8:39 p.m.) Resident was admitted to ICU for [REDACTED]. Resident #3 was treated with [MEDICAL CONDITION], IV antibiotics, IV fluids, admission to the ICU. On 03/13/2018 at 13:15 (1:15 p.m.), Resident #3 was intubated. Resident also had catheter intervention on 03/13/18. She was fed via NG (Nasal Gastric) tube during her hospital stay due to her at risk for aspiration. Resident was extubated and catheter was discontinued on 03/15/18. Review of the hospital Discharge Summary dated 03/23/2018 revealed in part: [DIAGNOSES REDACTED].>Acute hypoxic [MEDICAL CONDITION] s/t aspiration pneumonia/PNA s/t (secondary to) emesis from [MEDICATION NAME] ingestion, Aspiration pneumonitis/PNA (Pulmonary Nodular [DIAGNOSES REDACTED]), AKI (Acute Kidney Injury), Acute [MEDICAL CONDITIONS], Right lobe infiltrate. Resident #3 failed the pharyngogram test conducted on 03/20/18. Review of Speech therapy notes revealed resident was silently aspirating with any consistency of food or liquid. Further review of facility's departmental notes revealed in part: Entry on 11/3/2017 3:34 PM [MEDICATION NAME] 1 mg tablet, one tablet PO Q 12 PRN administered. Resident unable to hold still. Constantly propelling self in wheelchair around facility and taking things off nurses' carts. Repeating the same sentence continuously. Slamming door multiple times. Entry on 11/6/2017 3:45 PM [MEDICATION NAME] 1 mg tablet, one tablet PO Q 12 PRN administered. Resident anxious, restless, slamming room door repeatedly statements. Entry on 12/26/17 4:22 PM [MEDICATION NAME] 1 mg tablet, one tablet PO Q 12 PRN administered. Resident is restless, slamming room door repeatedly, making repetitive statements, anxious, unable to hold still. Entry on 1/2/2018 9:27 PM [MEDICATION NAME] 1 mg tablet, one tablet PO Q 12 PRN administered. Resident difficult to redirect, making repetitive statements and actions, wandering, taking other resident's and staff belongings. Entry on 3/12/2018 11:13 PM Resident was stopped by nurse with a bottle of [MEDICATION NAME]. The Resident had the bottle in one hand and the lid in the other hand. The Resident had a pink ring around her lip, nurse smelled her breath. Resident was taken to her room and monitored. Informed S2DON. Notified poison control, spoke with poison control staff, with orders to give clear liquids, no milk, monitor for irritation around and inside the mouth, upset stomach, difficulty swallowing and if coughing gets worse. Notified NP with orders to send to ER. Acadian ambulance was called around 4:25 p.m. Notified family member with no answer. Resident complaint burning to the throat, N/V (nausea/vomiting) noted X3. Acadian ambulance arrived at 4:35 p.m. Resident transferred to a local hospital via stretcher. Resident continued with N/V while being transferred to the ambulance. On 04/12/18 at 9:35 a.m., an interview was conducted with S20CNA. She said she took care of Resident #3 for 2 months. She said the resident had been sick and sleeping a lot due to the recent incident where she drank some [MEDICATION NAME]. She said the resident just returned from the hospital on [DATE] due to a decline in health status and pneumonia. On 04/12/18 at 9:40 a.m., an interview was conducted with S4ADON. She reported that the resident was able to roll herself in her wheelchair and went to hall b nurses' charting station and drank the [MEDICATION NAME] cleanser. There was no witness of the incident, but the S1ADM and S2DON were able to witness via the camera footage and concluded that the resident actually drank the [MEDICATION NAME] cleanser. She said the resident was sent toER on [DATE] and returned on 03/23/18 to facility. On 04/13/18 at 9:40 a.m., an observation of Resident #3 revealed she was lying on bed in a fetal position in her bed at the lowest position. She was unresponsive when called by name. There was a floor mat next to her bed. There was an O2 concentrator by her bed, not being used. An interview was conducted with hall nurse S7LPN at that time. She said the resident refused to have the O2 nasal cannula in her nose. She said the resident constantly took it off when staff tried to place the nasal cannula on her. On 04/13/18 at 9:00 a.m., interview conducted with S2DON. She explained that the nurse on the hall S14LPN report to her that Resident #3 had grabbed a bottle of [MEDICATION NAME] from behind the nurse's station and ingested a small amount of the cleanser. She said she completed the incident report. She said she had no knowledge who left the [MEDICATION NAME] cleanser at the nurses' charting station. She said probably the evening staff had left it at the nurses' charting station the night before when the staff used it on another resident who recently had surgery. On 04/13/18 at 9:50 a.m., an interview was conducted with S4ADON. She said the resident had no family to contact after the incident and had a decline. She said before the incident on 03/12/18 the resident was alert and rolled herself in the wheelchair and made her needs known. She said the resident had a good appetite and ate well. She said the resident had a history of [REDACTED]. She said after the incident the resident was weak and lethargic. She said when she visited the resident now, she said she did not think the resident recognized her, but told her that she was not doing well and asked her to pray for her. On 04/13/18 at 12:00 p.m., an observation of Resident #3 revealed S20CNA was trying to feed the resident lunch in her room. She said the resident was eating in the feeder's dining room and had to be fed. She said she was feeding the resident when the resident was eating in the feeder's dining room and she ate all her food. She said the resident even tried to feed herself. The resident did not show any signs of coughing or pocketing the pureed in her mouth then. She said after the resident ingested the [MEDICATION NAME] cleanser on 03/12/18 and was hospitalized , she observed a drastic change in the resident health status. She said this morning the resident ate a few bites of pureed eggs, some grits and pureed bread. She said the resident ate about 5% of meals served. S20CNA said the resident drank about 8 ounces of nectar thickened milk and refused the orange juice. O2 concentrator was observed next to resident's bed not being in used. She explained the resident did not like the O2 nasal cannula in her nose. She explained that the resident kept removing it. A review of the hospital discharged summary revealed Resident #3 had a pharyngogram completed on 03/20/18. A review of Speech therapy notes from the hospital revealed resident was silently aspirating with any consistency of food or liquid. On 04/13/18 at 12:30 p.m., S20CNA was observed feeding the resident lunch. She tried to feed the resident some pureed potato salad, fish and green beans and resident would take a few bites and refused to eat after that. Resident was observed coughing a lot during feedings and in between feedings. S20CNA said the resident would have a bad cough when she touched her and cleaned her. The resident kept telling the CNA that she was full. She said before the incident when the resident was well, she could tell you she was full and push herself away from the table. She said before the incident on 03/12/18, when she came in at 6A, she would give the resident a bed bath on Tuesday, Thursday, and whirlpool on Monday, Wednesday and Friday. She said when she put the resident in her w/c she would propel herself all over the building and talk to staff. She said the resident would say, I don't know what to do . pray for me. She said when the incident happened on 03/12/18, she was busy attending to the other residents getting them ready for supper. She said the resident just got up from her nap. She was in her w/c and rolled herself to the nurses' station and drank the [MEDICATION NAME]. She said resident does not sit still in the TV room or in her room. She said the resident could put weight on her legs to assist with transferring. And now the resident is not doing that anymore. She said now when the resident in the w/c, she would lean forward and ask for help, and could not roll herself anymore. She said the resident had not been out to hospital in (MONTH) (YEAR) or (MONTH) (YEAR) that she could recall. She said when she tried to get the resident to the side of the bed to comb her hair, the resident was weak and flopped back to the bed to lie in the fetal position since she came back from the hospital after drinking the [MEDICATION NAME]. She said the resident would come behind you and pull your shirt and laugh and giggle. She said the resident would say, you pray for me or help me, help me. She said she was feeding the resident in feeder's dining room since (MONTH) (YEAR) and saw the resident was eating well and was not aware that the resident had been to hospital. She said there was no indication that the resident had any illness prior to 03/12/18. On 04/13/18 at 1:05 p.m. interview with S7LPN. She said she had been working on hall b taking care of the resident since 8/2018. She said prior to the resident drinking the cleanser, resident would roll herself in the w/c going into resident's rooms and getting in another resident's bed. She said the resident would take plastic cups, water, or Hi Cal off the nurse cart because she was able to stand out of her w/c. She said she could not recall that the resident had been out to hospital or had any illness in the last 6 months. She said the resident just had behavior issues. She said around Sept (YEAR), resident went to the hospital for her heart. She said resident now pockets her pureed food in her mouth. On 04/13/18 at 3:50 p.m. an interview was conducted with S36RD. She said she had been working in the facility for 8 years. She said before the incident on 03/12/18, resident was very hyper, impulsive, alert and able roll herself up and down the hall way. She said the resident would repeat phrases, like I don't know what to do. Pray for me She said the resident came in the rehab room she would grab anything in her sight. She said you have to constantly keep an eye on her. She said other staff members knew she grabbed things in her sight. She said she had seen the resident grab a hand cleanser from the rehab counter. She said after the resident drank the [MEDICATION NAME] cleanser she saw a drastic change in the resident health status and a decline. She said the resident was not alert, not eating or drinking and in bed all the time. She said the last time the resident came for OT (Occupational Therapy) and ST (Speech Therapy) was on 09/24/2014. S36RD said the resident was unable to follow any commands and had reached her maximum potential. She said the resident did not have any swallowing problems then in 2014. On 04/13/18 at 3:15 p.m., an interview was conducted with S9LPN. She said the resident was alert with some episodes before the incident. She said the resident would roll herself in the wheelchair and was able to ask for something to drink when she was working on the hall. She said she works 7A-3P, Monday to Friday. She said the resident had a decline in health status since returned from hospital and she had not been her usual self. On 04/13/2018 at 3:23 p.m., an interview with S32CNA. He said Resident #3 used to feed herself in the feeder's dining room and he just had to provide supervision. He said after the incident he saw a big decline in the resident in areas of ADLs. He said the resident was no longer active, alert and was not moving round in the w/c like she used to. On 4/13/18 at 3:33 p.m., an interview with S24LPN. She said on 03/12/18, the nurse who was working on the hall saw the resident had a bottle of [MEDICATION NAME] cleanser in her hand and grabbed it from her. She said the nurse asked her how much she drank, she said the resident looked up, smiled and said quite a bit. She said the nurse took it from her immediately and called the on-call doctor and also contacted the poison control. She said the resident grabbed the cleanser when she was going down the hall, and the nurse rolled the resident back to hall b to monitor her after she called the poison control center. She said prior to the incident the resident was alert, happy and rolling around in the building. She said the resident never sit still and able to get and walk a few steps. She said resident would grab something on the cart and ask for something to drink. She said there was drastic decline in the resident's behavior and eating following the incident. On 04/16/18 at 9:12 a.m., an interview was held with S33RN. She had been working in the facility since (MONTH) (YEAR). She said Resident #3 was alert, confused, rolled around in the w/c self-propelled. She said resident was very friendly, cheerful and tried to communicate with staff. She said the resident would say, I don't know what in the world to do. She said after 03/23/18, the resident was still coming down the hall and had a major decline a few days later. She said the resident did not eat or drink much anymore and was hosptalized on [DATE] with an altered mental status. On 04/16/18 at 10:04 a.m. an interview with S34HK. She said Resident #3 was rolling herself in the w/c up and down the hall, alert and would be talking to herself. She said she saw tried to reach for her housekeeping cart. On 04/16/18 at 10:23 a.m., an interview with S18CNASupervisor. She said she had been working in the facility since 1991. She said she did not see the resident drank the [MEDICATION NAME] from the nurses' station where she sat. She said Resident #3 would get in the morning and roll herself around to the feeder's dining room for breakfast, lunch and supper with staff supervision and direction. She said the resident would say, Pray for me all the time. She said the resident always complained about being thirsty and wanted something to drink. She said the resident would try to reach for something if she saw a bottle or cup on the counter. She said after the incident she saw a major decline in the resident. She said the resident was very different in every aspects of her ADLs. She said she had not seen any of the resident's family come to visit her since admission. On 04/16/18 at 10:46 a.m. an interview with S22CNA. She said she had been working in the facility for [AGE] years. She said Resident #3 rolled around and wants everyone to pray for her. She said the resident would walk some with staff assistance and could stand on the scale to be weighed monthly. She said the resident always asked for juice or water to drink. She said the resident was confused, but able to respond to simple questions. She said she witnessed the resident's ADLS had declined after the incident and that was it. She said, The resident was just a sweet and lovable person. She said she tried to find the family online but had no luck. She said she gave up. On 04/16/18 at 11:02 a.m., an interview with S13LPN. She said the resident wandered around on the hallways, and would get into other resident's beds, can be easily redirected. She said the resident would say, I don't know what in the world to do, pray for me. She said she doesn't see the resident up anymore in w/c. She said when she goes in the resident's room to do wound care, she said she mostly heard the resident say, I don't know what in the world to do. She said she had never seen any family come to see the resident. On 04/16/18 at 11:25 a.m., an interview was held with S35AD. She said Resident #3 used to roll around the halls, round and round in circle through the building, and every now and then the resident tried to stand up and ambulate to the dining table. She said the resident was eating meals in the feeders' dining room. She said resident had some decline, more confused, but still getting up and going about in her w/c. She said after the incident the resident has become less responsive, in bed all the time, eating and drinking less. She said the resident had to be redirected constantly during activity session. She said the resident would repeat the same thing. I don't know what in the world to do, pray for me. She said the resident never sat still in the activity session/during meals. She said staff would frequently redirect her to come back to the table in her w/c. She said the resident was a happy person, laughed and told jokes. She said the resident would always visit her at her office, asking for coffee with thickener or snacks. She said she was sad to see the resident with such drastic decline after the incident. On 04/16/18 at 11:58 a.m., an interview conducted with S3ADON. She said the resident was alert, in w/c with pommel cushion for support. She said you could have a conversation with her, but her answer is mostly, I don't know what to do. Pray for me. She said the resident was able to roll herself throughout the facility and to the dining room. She said the resident ate in the feeder's dining room and ate well. She said the resident could feed herself with staff providing cueing and prompts. She said the resident sometimes needed staff assistance and wandered off. She said staff would provide minimum assistance with ADLS. She said resident was incontinent. She said the resident was progressively having swallowing problems and received pureed food with nectar thickened liquid. She said she was not in the building when Resident #3 ingested the [MEDICATION NAME]. She said the resident would have a plastic cup in her hand and ask the hall nurse for milk/her supplement. She said the resident would try to grab the cup from the nurses' carts. She said everyone was supposed to provide the resident close supervision at all times. On 04/16/18 at 12:46 p.m., an interview with S11LPN/MDS. She said the resident had some type of change since returned from the hospital. She said the resident tried to take cups off the nurses' carts and sometimes she would come up to a staff asking for something to drink. She said the resident had a gradual decline since (MONTH) (YEAR) and more decline after the incident on 3/12/18 incident. On 04/16/18 at 2:00 p.m., an interview with S2DON. She said the NP said the resident was diagnosed with [REDACTED]. She said the ingestion of Hibicliens was not the cause of the resident's decline, but the aspiration pneumonia. On 04/17/18 at 10:45 a.m., a telephone interview was held with poison control center regarding the [MEDICATION NAME] cleanser revealed that the chemical was not toxic if ingested unless the person aspirates, then it is toxic to the lungs. Resident #2 Review of the record revealed Resident #2 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Quarterly MDS with 11/21/17 ARD revealed a BIMS of 4 which indicated severe cognitive impairment. She was coded as requiring limited one person assistance with all ADLs except toilet use; she required extensive assistance. She was coded as being frequently incontinent of urine and occasionally incontinent of bowel. She was coded as not having any falls prior to admit or within a month of the review date 11/21/17. Review of the Significant Change MDS with ARD of 1/31/18 revealed they were unable to complete a BIMS test. She was coded requiring extensive one to two person assistance with ADLs. She was coded as being frequently incontinent of urine and occasionally incontinent of bowel. She was coded as having limited range of movement impairment on one side. She was coded as not having any falls. Her [DIAGNOSES REDACTED]. Review of Resident Incident Report dated 1/21/18 at 4:35 p.m. and completed by S15LPN revealed: Incident Type: Pt (patient) Contact- resident Type of Injury: Hematoma, Fracture Narrative of incident and description of injuries: Summoned to Secure Unit by S38CNA. Pt noted lying on floor. Informed by CNA that pt (patient) was pushed by another resident and patient lost balance falling onto left side and then hitting head on floor. Pt noted to have large hematoma to left posterior head. Pt. complaining of pain to left leg and hip area. Pt. left foot with + pedal pulse but noted notable shorter that right leg. Did not move pt. at that time. Immediate Actions Taken: Pt. assessed. VS taken. On Call NP called, order to send to ER received; ambulance called for transfer. Sent to local hospital ER for evaluation. 24 Hour Follow-up: Resident admitted to the hospital with [REDACTED]. Narrative of Investigation (completed by S2DON): Resident was ambulating in hallway and when she got close to another resident's door, that resident pushed her down. Resident #2 hit her head on the floor obtaining a hematoma. She also c/o pain to her left leg and hip area. One leg was shorter than the other. Ambulance called, arrived and took her to the ER. She had a fx to her left hip and was admitted for a hip replacement. Resident #2 was pushed down by another resident with a behavioral outburst. Residents were separated and the other resident was fine once no one was close to her doorway. Review of Resident Incident Report dated 2/3/18 at 7:04 a.m. and completed aby S6MDS/LPN revealed Incident Type: Roll from bed Type of Injury: Skin Tear Narrative of incident and description of injuries: Resident rolled out of bed on to floor. Stated she thought she was dreaming to get up and go to bathroom and bumped elbow on AC Unit. Received a skin tear. Able to move all other extremities to best as possible. No complaints of pain noted. Assessed resident and applied wound care and placed resident back in bed. Skin tear left elbow 3.0x2. (TRUNCATED)

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician and Responsible Party of a significant change in a resident's condition for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. This deficient practice resulted in actual harm when a cognitively impaired resident, with a [DIAGNOSES REDACTED]. On 07/26/16, Resident #3 became lethargic and his medications were held. On 07/27/16 Resident #3 began to refuse medications. Resident #3 continued with a decline in his medical condition. The facility staff did not report a change in condition to the physician for intervention and treatment and on 07/29/16, Resident #3 was transported to a local hospital at the family's insistence due to them noticing a change in Resident #3's condition. Resident #3 was transferred to another local hospital, and required surgical intervention. Resident #3 did not receive immediate medical attention, since the staff did not report a change in condition to the physician for intervention and treatment. Findings: Review of the facility's policy on Change in Condition Policy and Procedure revealed, in part, the licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition; the resident's primary physician or designated alternated will be contacted promptly of a significant change in the resident's physical, mental, or psychosocial status and documented in resident's record; and the resident and or the resident's designated medical contact or guardian will also be notified. Review of medical record revealed Resident #3 was admitted to the facility on [DATE] to the Special Care Secure Unit with diagnoses, in part, of Dementia, Anxiety disorder, Mood disorder, and Wandering. Review of Resident #3's current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/16 Section C revealed, in part, Resident #3 ' s cognitive skills for daily decision making was severely impaired and never or rarely made decisions. Review of Section G of the same MDS revealed Resident #3 required Supervision and Setup help only with walking in the room and in the corridor; and limited assistance with one person assistance with eating. Review of Resident #3 ' s care plan revealed, in part, a plan of care was developed for cognitive loss related to a [DIAGNOSES REDACTED].#3 was not able to complete the Brief Interview for Mental Status (BIMS) assessment. Approaches included, in part, report any changes to Resident #3's doctor and family. Further review of care plan did not a documented revision for the recent changes noted in activities of daily living assistance required or changes in Resident #3's condition. Review of the 24 Hour Nursing Report Form dated 7/26/16 revealed, in part, Resident #3 was sluggish on the 7AM to 3PM shift. Review of Resident #3's July 2016 electronic Medication Administration Record [REDACTED]#3 ' s 8:00AM, 12:00PM, 3:00PM, and 8:00PM medications and nutritional supplement were not given due to the resident ' s refusal. Review of Resident #3's May and June MAR indicated [REDACTED]. In interview on 8/8/16 at 2:16PM S5/Aide indicated she noticed a change in Resident #3's condition. S5/Aide indicated Resident #3 required assistance of 2 staff members for walking, he did not attempt to get up on to walk through the unit as he did before. S5/Aide indicated Resident #3 would sit and stare and required staff members to feed him. S5/Aide indicated she reported the changes to the nursing staff. In interview on 8/9/16 at 1:10PM S6/Nurse Practitioner indicated he was not notified of Resident #3's medication being held due to lethargy or Resident #3 ' s refusal of medication. In interview on 8/9/15 at 5:00PM Resident #3's RP indicated she was not notified of Resident #3's medication being held due to lethargy and was not made aware of the Resident #3's refusal of medication until after his transfer to the hospital. In interview on 8/10/16 at 9:15AM S2/DON indicated there was no documented evidence of the Physician or Responsible Party being notified of Resident #3's change in condition, holding of medication, or refusal of medication. S2/DON indicated the physician and responsible party should have been notified. Review of Resident #3's Department Notes dated 7/29/16 at 2:38PM revealed, in part, that Resident #3 was transported to a local hospital at the family ' s request due to significant changes in Resident #3's physical functioning and responsiveness. Review of Emergency Department Notes from a local hospital dated 7/29/16 at 1:32PM revealed, in part, a CT scan was completed and showed Resident #3 had a subdural hemorrhage and will be transferred to another local hospital because Resident #3 is critically ill and requires a higher level of care and surgical intervention. Review of the second local hospital's medical records dated 7/30/12 at 2:12AM revealed, in part, Resident #3 required surgical intervention of a right craniotomy due to a subdural hematoma. There was no documented evidence and the facility did not present any documented evidence that Resident #3's Physician or Responsible Party was notified of Resident #3's change in condition, holding of medication, or refusal of medication.

Based on interviews and record review, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1(#3) of 3 residents(#1, #3 , #5) with a diagnose of dementia from a sample of residents (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). This deficient practice resulted in actual harm on 7/26/16 when a cognitively impaired resident, with a [DIAGNOSES REDACTED]. On 07/26/16, Resident #3 became lethargic and his medications were held. On 07/27/16 Resident #3 began to refuse medications. He continued with a decline in his medical condition and on 07/29/16, Resident #3 was transported to a local hospital at the family's insistence due to them noticing a change in Resident #3's condition. Findings: Review of the facility's policy on Change in Condition Policy and Procedure revealed, in part, the licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition; the resident's primary physician or designated alternated will be contacted promptly of a significant change in the resident's physical, mental, or psychosocial status and documented in resident's record; and the resident and or the resident's designated medical contact or guardian will also be notified. Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] to the Special Care Secure Unit with diagnoses, in part, of Dementia, Anxiety Disorder, Mood disorder, and Wandering. Review of Resident #3's current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/16 Section C revealed, in part, Resident #3's cognitive skills for daily decision making was severely impaired and never or rarely made decisions. Review of Resident #3's care plan revealed, in part, a plan of care was developed for cognitive loss related to a [DIAGNOSES REDACTED].#3 was not able to complete the Brief Interview for Mental Status (BIMS) assessment. Approaches included, in part, report any changes to Resident #3's doctor and family. There were no revisions or updates addressing recent declines in Resident #3 ' s condition. Review of Restorative Program documentation revealed, in part, Resident #3 was sick on 7/23/16 and was unable to participate in the restorative program and Resident #3 refused to participate in the Restorative program on 7/25/16, 7/26/16, and 7/28/16. Review of the facility's Problem List documentation form dated 7/25/16 revealed, in part, Resident #3 was noted as having muscle stiffness, increased sleeping and not ambulating. Review of the 24 Hour Nursing Report Form dated 7/26/16 revealed, in part, Resident #3 was sluggish on the 7AM to 3PM shift and his RP was concerned about Resident #3 moving slower. Review of Resident #3's July 2016 electronic Medication Administration Record [REDACTED]#3's 8:00AM, 12:00PM, 3:00PM, and 8:00PM medications and nutritional supplement were not given due to the resident ' s refusal. Review of an untitled document revealed on 7/28/16 Resident #3's Responsible Party (RP) informed the facility staff of changes in Resident #3's condition. The RP reported concerns of Resident #3 sleeping a lot more and Resident #3 not wanting to ambulate. In interview on 8/8/16 at 10:23AM S2/DON indicated Resident #3 started requiring increased assistance with activities of daily living about a week ago which medical staff felt it was the progression of his Dementia. In interview on 8/8/16 at 2:16PM S5/Aide indicated she noticed a change in Resident #3 about 5 days ago. S5/Aide indicated Resident #3 would just sit still made not attempts to get up and move around as usual. In interview on 8/9/16 at 9:04AM S4/LPN indicated Resident #3 was declining in physical function and staff thought it was from Resident #3's progression of his Dementia. In interview on 8/9/16 at 1:10PM S6/Nurse Practitioner (NP) indicated the facility staff requested Resident #3 be evaluated on 7/25/16 due to Resident #3's family concerns of a rapid decline. S6/NP indicated he did not see any acute changes in Resident #3's condition to warrant further evaluation at the time. In interview on 8/9/16 at 5:00PM Resident #3's Responsible Party (RP) indicated the family started noticing a change in Resident #3's condition around 7/24/16. Resident #3's RP indicated she reported her concerns about Resident #3's rapid decline and she was told by the staff it was the progression of his dementia that was causing his change in condition. In interview on 8/11/16 at 11:20AM S7/RN indicated she had spoken to Resident #3's RP and wife in regards to his declining condition. S7/RN indicated Resident #3 physical functioning changed and he required more assistance with transfers and ambulation. S7/RN indicated she also noted Resident #3 was sleeping more and was not ambulating and she communicated those issues to S6/NP by writing this information on the Resident Problem List form on 7/25/16. Review of the Resident Problem List form does not address the continuing decline of Resident #3 after 7/25/16. Review of Resident #3's Department Notes dated 7/29/16 at 2:38PM revealed, in part, that Resident #3 was transported to a local hospital at the family's request due to significant changes in Resident #3's physical functioning and responsiveness. Review of Emergency Department Notes from a local hospital dated 7/29/16 at 1:32PM revealed, in part, a CT scan was completed and showed Resident #3 had a subdural hemorrhage and will be transferred to another local hospital because Resident #3 is critically ill and requires a higher level of care and surgical intervention. Review of the second local hospital's medical records dated 7/30/12 at 2:12AM revealed, in part, Resident #3 required surgical intervention of a right craniotomy due to a subdural hematoma.