Every finding on record at Stone Bridge Center for Health & Rehabilitation

Based on clinical record reviews, facility documentation, facility policies, and interviews for two of three residents (Resident #2 and #3) reviewed for resident rights, the facility failed to maintain comfortable temperature levels within the range of 71 to 81 degrees Fahrenheit (F). The findings include: 1.Resident #2's diagnoses included dementia, anemia, diabetes mellitus, restlessness-agitation, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen (12/15), indicative of moderate cognitive impairment and required assistance with ADL's (activities of daily living). The Resident Care Plan (RCP) dated 4/10/26 identified impaired cognitive function/thought process related to dementia. Interventions directed if increased confusion noted, to place resident on UTI (urinary tract infection) monitoring for three days, monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level ofconsciousness, and mental status. Nursing note dated 4/15/26 at 19:57 (7:57 PM) identified new order to transfer to hospital for stroke-like symptoms. Review of the Emergency Medical Services (EMS) Run Sheet dated 4/15/26 at 6:08 PM identified EMS was called to the facility for Resident #2 who was weak with changes to his/her speech reported by facility staff. Resident #2 usually can ambulate to the bathroom on his/her own, but today was unable to stand on his/her own, speech slower to staff today, beginning one hour prior, and denied pain. the Run Sheet noted it is severely hot on the xxxx floor where Resident #2 resides and his/her skin is dry with tenting and hot to the touch, and EMS transferred Resident #2 to the hospital. Review of the Emergency Department admission Documentation dated 4/15/26 at 8:36 PM identified Resident #2 arrived from the facility for weakness and difficulty walking with left lower extremity weakness and had difficulty following commands. EMS reported that the facility was hot and the thermostat temperature at the facility was 90 degrees Fahrenheit. Over the last few days, the facility did not have any air conditioning and the temperature within the building went up to about 90 F. approximately one (1) and a half hours after Resident #2's arrival at the hospital, he/she was awake, alert, talkative and oriented at baseline. Hospital findings indicated consistent with possible heat exhaustion and diagnosed with a urinary tract infection (UTI) with antibiotic administration. The report further indicated, in view of the lack of any other findings, Resident #2 did not warrant admission to the hospital at this point in time, however, it indicated that the hospital will be unable to send Resident #2 back to the facility on 4/15/26 because there was still no air conditioning. Plan to keep Resident #2 overnight until tomorrow and once the conditions are better, Resident #2 can be safely discharged back to the facility on oral antibiotics. Nursing note dated 4/16/26 at 20:27 (8:27 PM) identified Resident #2 returned this afternoon from the hospital, on oral antibiotic for UTI. 2.Resident #3's diagnoses included chronic obstructive respiratory failure, dementia, emphysema, diabetes mellitus, and anxiety disorder. The Resident Care Plan (RCP) dated 3/17/26 identified Resident #3 has a deficit in self-care function due to dementia, COPD, and chronic respiratory failure requiring supplemental oxygen. Interventions directed to administer medications as ordered The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of fifteen out of fifteen (15/15), indicative of being cognitively intact, required moderate assistance with ADL's (activities of daily living) and was independent with ambulation. Review of the EMS Run Sheet dated 4/15/26 at 11:46 AM identified EMS was called to the facility for Resident #3 who was acting lethargic for the past four (4) days per staff and baseline was reported as energetic and ambulatory. Staff reported a poor intake and recent weight loss. The Run Sheet noted that the 3rd floor of the facility where the resident resides was exceptionally hot and Resident #3 had a fan at the foot of the bed blowing air on him/her. Staff reported the facility air conditioning had been broken, but it is allegedly now fixed and operational. EMS transferred Resident #3 to the hospital. Nursing note dated 4/15/26 at 15:41 (3:41 PM) identified transfer to hospital for respiratory distress. Review of the hospital Emergency Department admission Documentation dated 4/15/26 at 4:56 PM identified Resident #2 presented to the hospital for the evaluation of generalized weakness, decreased oral intake and weight loss of 25 lbs since December. Resident #2 also states he/she is having chronic diarrhea since December. Per facility report, they noticed altered mental status from baseline, decreased oral intake, poor hygiene, weight loss around 25 lbs in the past 4 months. Resident #3 resided on the xxxxx floor of the facility where the air conditioning was not working and Resident #3 felt hot to the touch. Review of the facility daily punch log for 4/15/26 identified the following department heads and supervisory staff were present and working within the facility on 4/15/26: the Business Office Manager (BOM), Director of Social Services (DSS), Program Coordinator (PC), Administrator, MDS Director (MDS #1), Maintenance Worker (MW #1), Director of Human Resources (DHR), Assistant Director of Nursing Services (ADNS), Director of Housekeeping Services (DHK), and Director of Admissions (DOA). Review of The Weather Channel historical weather data for 4/15/26 identified weather conditions described as summer-like warmth with humid conditions. The report identified a daytime high temperature of 84 degrees Fahrenheit and an overnight low temperature of 54 degrees Fahrenheit. Review of the photo submitted by Person #1 identified an image dated 4/15/26 at 6:44 PM depicting a Honeywell thermostat located on Resident #2 and Resident #3's nursing unit with a temperature reading of 90 degrees F. The thermostat display appeared to have a maximum readable temperature of 90 degrees F, indicating the actual environmental temperature may have been 90 degrees F or above. Review of the Honeywell thermostat manual identified that the device utilizes two dials/indicators: one representing the set (desired) indoor temperature and the other reflecting the current ambient indoor temperature. Interview with RN #1 on 5/21/26 at 9:45 AM identified that on 4/15/26, Resident #2 exhibited symptoms concerning a possible stroke, prompting RN #1 to notify APRN #1, who directed to send Resident #2 to the hospital for evaluation. RN #1 stated the facility environment was noted to be hot on that date but was unable to provide an exact temperature reading. RN #1 stated the hot temperatures put residents at increased risk for dehydration and staff provided residents with water and ice-filled pitchers for hydration. Interview with Resident #4 on 5/21/26 at 10:00 AM identified that during an unknown period of time in April 2026, the temperatures on the unit felt excessively hot, which interfered with his/her ability to sleep comfortably. Resident #4 further identified he/she received a fan until approximately two weeks prior to the interview (beginning of May). Interview with LPN #4 on 5/21/26 at 10:20 AM identified that during April 2026, on an unknown date, the temperatures on Resident #2 and Resident #3's unit were excessively hot. LPN #4 stated he/she did not believe the air conditioning system was malfunctioning, however, the facility had not yet activated or set up the air conditioning units for the season. LPN #4 further stated the temperatures on the unit were approximately 90 degrees F. Interview with the Director of Maintenance (DOM) on 5/21/26 at 11:45 AM identified that during April 14 to 16, 2026, the facility experienced an abnormal heat wave and staff provided extra hydration, portable air conditioning units were installed in the dining rooms, and fans were distributed to residents considered most at risk for heat-related illness. The DOM stated a complaint was received from the local health department regarding hot room temperatures, and the facility typically changes the HVAC system over to air conditioning in May, however due to the hot temperatures, the air conditioning was started early on 4/17/26 (two days after Residents #2 and #3 were sent to the hospital). interview identified although facility temperatures were recorded on 4/16 and 4/17/26, no temperatures were provided for 4/15/26. Interview with Person #1 on 5/21/26 at 11:55 AM identified when he/she entered Resident #2's room, he/she noted the temperature to be excessively hot and he/she notified the staff. Person #1 viewed the thermostat and identified it read a current temperature of 90 degrees F. Person #1 stated Resident #2 was hot with dry skin and poor skin turgor, and he/she believed Resident #2 was exhibiting signs and symptoms consistent with heat exhaustion. Review of the facility undated Heat and Humidity Policy directed in part, the facility will ensure to every possible extent that the effect of heat and humidity on residents, staff, and visitors is limited. The facility is fully, centrally air-conditioned with individual room AC units and roof top HVAC units for the common areas. The effects of heat and humidity may be detrimental to an individual's well-being. Therefore, the following guidelines and procedures will be in effect whenever summer weather causes extremes in temperature (approximately 90 degrees), in order to make the internal environment of the facility as comfortable as possible and the residents free from side-effects of the heat.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for elopement, the facility failed to ensure elopement risk assessments were performed timely for a resident that eloped from the facility without staff knowledge. The findings include: Resident #1's diagnoses included schizoaffective disorder, Wernicke's encephalopathy, diabetes mellitus, and epilepsy. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicating of being cognitively intact, had no wandering behaviors and ambulated independently. The Resident Care Plan (RCP) dated 4/9/26 identified Resident #1 had impaired thought processes related to schizoaffective disorder, suicidal ideations, Wernicke's encephalopathy, and alcohol dependence. Interventions directed to provide cues, reorient, and supervise as needed. Facility reportable event dated 4/17/26 identified at approximately 1 PM, nursing staff were nursing alerted by staff that Resident #1 was walking up the driveway. Resident #1 went all the way to the road where another staff member was with him until other staff came to keep resident safe. Resident #1 agreed to come back to building, psychiatric APRN was notified and a new elopement assessment was completed with a wander guard placed. Clinical record review identified the most recent documented elopement risk assessment for Resident #1 was completed on 11/2/24 (one year, five months and fifteen days prior to the elopement), at which time the resident was assessed as not being at risk for elopement. Record review failed to identify any additional elopement risk assessments were conducted prior to the incident on 4/17/2026. Facility Reportable Event Summary dated 4/22/26 identified Resident #1 was not previously identified as an elopement risk. On 4/17/26 Resident #1 was sitting on a bench outside the facility with other residents and was wearing a tee shirt with a brown jacket, jeans, and sneakers. Prior to going outside, Resident #1 told a staff member that a friend was coming to pick him/her up and they were going to the diner. The staff member asked if the friend was planning on coming inside to sign him/her out and Resident #1 responded yes. The staff member had concerns about this story and watched Resident #1 outside from the receptionist's desk and when the staff member was able to leave the desk, she went down the hall to inform another staff member of her concerns. Approximately five minutes later the staff member went outside to check on Resident #1, but he/she was not there. The employee asked another resident outside if he/she saw Resident #1 and the other resident stated he/she walked up the hill. The employee returned inside the building and reported this to multiple other staff members. Four (4) staff members immediately went up the hill to locate Resident #1 and when they reached the road, an off-duty staff member was already with Resident #1 and Resident #1 stated he/she was walking to the diner to wait for a friend to pick him/her up. Resident #1 returned to the facility with no injuries identified, and a new elopement assessment was completed. Interview with the Director of Nursing (DON) on 5/20/26 at 12:15 PM identified nursing staff are responsible for completing resident elopement risk assessments within the electronic medical record system upon admission, readmission, and with a change in resident condition. Interview identified although the staff member who had the conversation with Resident #1 before he/she went outside indicated they had concerns about Resident #1's story and watched him/her from the receptionist desk before going to tell other staff, interview failed to identify why the staff member had concerns, why another staff member did not supervise Resident #1 when the employee left the reception desk, and why an elopement assessment had not been completed for Resident #1 since 11/2/24, one (1) year, five (5) months and fifteen (15) days prior to the elopement. Review of the Elopement Policy dated 12/2025 identified an elopement is an unauthorized absence of a resident from the facility who is unable to make decisions due to mental capacity or guardianship. Residents will be accounted for. The facility will evaluate and identify residents who are at risk for elopement from the facility by completing the Elopement Risk Evaluation in PCC. A risk evaluation will be done on new admissions and with a change of resident's condition.

Based on review of clinical records, review of facility documentation, review of facility policy and interviews for two of four sampled residents (Resident #61 and #228) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during transport, which resulted in an accident and failed to ensure the resident was transferred as ordered with assist of one and the utilization of a walker, which resulted in a right lower leg laceration sustained as a result of the improper transfer from the wheelchair to the bed. The findings include: 1. Resident #61's diagnoses included cerebral infarction, narcolepsy, anemia, peripheral vascular disease, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #61 had intact cognition and was dependent on staff for transfers, was non-ambulatory, and was dependent on staff for wheelchair mobility. The care plan dated 3/4/25 identified Resident #61 had a deficit in functional mobility related to cerebral infarction with left side weakness. Care plan interventions directed to transfer using a mechanical lift, was non-ambulatory and needed extensive assistance with bed mobility. The Situation, Background, Assessment, and Recommendation (SBAR) nurse's note dated 4/25/25 at 1:34 PM identified Resident #61's left leg was caught under the wheelchair while being transported by the Recreation Aide (RA #1) without using the leg rests. The nursing notes also identified Resident #61 had a medical history of cerebral infarction, narcolepsy, and type 2 diabetes mellitus. The assessment did not identify medical condition changes and did not complain of left leg pain. The recommendation was to encourage Resident #61 to use the wheelchair leg rests when being transported in the wheelchair. The facility accident and incident report dated 4/25/25 at 3:15 PM identified RA #1 was transporting Resident #61 in a wheelchair from the activity program to the resident room without the wheelchair leg rests. It also identified Resident #61 was holding both of his/her legs up during the wheelchair transport and his/her left leg lowered and went under the wheelchair. Interview with RA #1 on 5/28/25 at 11:30 AM identified Resident #61 had an accident on 4/25/25 after he/she requested assistance to bring him/her back to his/her room after participating in the activity program. She identified that the accident happened during transporting Resident #61 in the nursing hallway while both legs was elevated and suddenly Resident #61's left leg was caught under the wheelchair. She identified that the wheelchair leg rests were not in use when the accident occurred. She identified that the wheelchair leg rests must be used when staff is transporting a resident in a wheelchair. She further identified that she received education from the facility after the incident to ensure the wheelchair leg rests were in place prior to transporting the resident in a wheelchair. Interview with the DNS on 5/29/25 at 10:30 AM identified that leg rests should be utilized when the staff is transporting a resident in a wheelchair. She also identified that an accident and/or injury could occur when the wheelchair leg rests are not used during the wheelchair transport. She further identified RA #1 did not use the wheelchair leg rests when she transported Resident #61 in the wheelchair and his/her left leg went under the wheelchair. She further identified that the RA #1 received education after the incident to ensure the leg rests was utilized in a wheelchair during wheelchair transportation. A facility policy for wheelchair transport was requested but a policy was not provided. 2. Resident #228's diagnoses include dementia, atrial fibrillation, anemia and feeding difficulties. The quarterly MDS assessment dated [DATE] identified Resident #228 had severely impaired cognition (BIMS of 3), required maximal assistance with toileting hygiene, upper and lower body dressing, personal hygiene, and transfers, required moderate assistance with bed mobility, did not ambulate and was dependent for wheelchair mobility. The care plan dated 11/8/24 identified Resident #228 had a deficit in self-care function with interventions that included the use of a two wheeled walker (assistive device). Review of the Nurse Aide care card in effect for the month of January 2025 identified Resident #228 required the assistance of one staff for transfers utilizing the rolling walker with wheelchair to follow. The physician's order for the month of January 2025 directed the assistance of one for toileting, transfers, and ambulation utilizing a rolling walker with wheelchair to follow closely. The reportable event report dated 1/10/25 at 7:00 PM identified that during a transfer from the wheelchair to the bed Resident #228 sustained a laceration to the left lower leg. The report noted that NA #1 transferred Resident #228 from the wheelchair to the bed and then noticed blood on the resident's pant leg, and when she pulled up the pant leg, she noticed a laceration to the right lower leg. The report further noted that the charge nurse and nursing supervisor were immediately notified, pressure was applied to the wound, the APRN was notified, and the resident was sent to the acute care hospital emergency department via ambulance. Additionally, the report noted that the wound was not measured at that time due to maintaining pressure to the wound until emergency personnel arrived at the facility. The reportable event report identified a written statement by NA #1 dated 1/10/25 that identified that while transferring Resident #228 from the wheelchair to the bed she noticed a gash on the lower right leg and alerted the charge nurse and the supervisor. The statement further identified that during the transfer the wheelchair was locked in preparation of the transfer. She noted that during the transfer Resident #228 hugged her and they both stood up, turned and sat on the bed. The documentation further noted Resident #228 was calm throughout the transfer and was not resistive during the transfer. Review of the acute care hospital discharge instructions dated 1/11/25 identified Resident #228 was diagnosed with a leg laceration and was given one dose of Keflex 500mg (antibiotic) at 4:00AM on 1/11/25. The wound evaluation dated 1/15/25 identified the laceration to the front right lateral lower leg occurred on 1/10/25, measured 10.3 centimeters (cm) in length and 1.5 cm in width and required 28 staples. The evaluation further noted the wound did not have depth, undermining, or tunnelling noted. Interview with NA #1 on 5/28/25 at 10:22 AM identified Resident #228 was wheeled from the dining room to his/her room in preparation for bed. NA #1 identified Resident #228 was exhausted, soaking wet and was unable to stand independently. She identified that Resident #228 was a stand pivot assist of one staff member utilizing a rolling walker. She further identified that she did not use the rolling walker because the resident was unable to follow her direction. NA #1 was asked if residents were supposed to hug her during a transfer and should gait belts be used during transfers. NA #1 responded that residents should not be hugging her and if there was not a note in her statement regarding the use of a gait belt then she probably had not used the gait belt during the transfer. Additionally, NA #1 identified that she did not ask anyone for assistance with the transfer or notify the charge nurse that the resident appeared exhausted. She noted that because the resident was a stand pivot transfer, and weighed approximately 90 pounds, she felt she could transfer him/her on her own. Interview with the DNS and the Regional Clinical Nurse (RN #1) on 5/28/25 at 12:05 PM identified that the investigation of the incident identified NA#1 did not use the rolling walker during the transfer as required. The DNS noted that the utilization of the walker would have allowed the resident to step out, turn and pivot to avoid his/her leg from rubbing against the prongs connecting the leg rest. The DNS identified after re-enacting the transfer with the resident wearing protective shin sleeves. She further identified that the investigation identified that Resident #228's right leg rubbed against the two metal pieces that stick out to lock the leg rest in place, she noted that blood was observed on the metal prongs. The DNS further noted NA #1 did not use a gait belt and residents should not be hugging the staff during a transfer and when a resident is not able to be transferred as ordered, the charge nurse should be notified, because a resident can be downgraded in transfer status (meaning the resident can be transferred by two if necessary) but they should not be upgraded (meaning transferred not as ordered with assistive devices when that is what is ordered to just doing as was done with Resident #228). She added that education and disciplinary action was taken toward NA #1 regarding this incident and education was provided to NA #1 as well as all staff on transfers as this was a serious injury that had occurred. Interview with the Charge Nurse (LPN #2) on 5/28/25 at 1:32 PM identified she was the nurse on duty when the incident occurred and was notified by NA #1 of the right lower leg laceration. LPN #2 identified Resident #228 was in bed, and the injury looked like it had just happened as the blood was red, did not appear coagulated, and the blood was pooling inside of the wound. The Competency One Assist Transfer Technique skills identified the steps to take when transferring with one assist include: prepare the chair by removing the leg rest and lock the brakes; apply the gait belt on resident and stand in front of the resident with one foot between the resident's feet, the other foot on the outside edge of the resident foot, and then grasp the gait belt on either side and have the resident place his/her hands on your shoulders/upper arm, followed by gently rocking on the count of 3 and stand with resident and sit resident on the bed then remove the gait belt. Review of the Activities of Daily Living (ADL) policy identified that staff provide assistance to complete ADL activities per the person-centered evaluation and care plan such as functional mobility which is the ability to get from place to place while performing ADLs, either under one's own power or with the assistance of a wheelchair or other assistive device.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #17 and Resident #95) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed/and administered to the resident when requested. The findings include: 1. Resident #17 was admitted to the facility in December of 2024 and had diagnoses that included Alzheimer's disease, atrial fibrillation, and chronic systolic congestive heart failure. The quarterly MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition. The assessment further identified that Resident #17 had not received the pneumococcal vaccine as it was not offered. Review of the Consent Form for Pneumococcal Vaccination Series (PCV/PPSV23) identified Resident #17 gave the facility permission to administer/complete the pneumococcal series as directed by the Center for Disease Control and Prevention (CDC) guidelines and physician on 12/10/24. Review of Resident #17's clinical records with the Infection Preventionist (LPN #1) on 5/29/25 at 12:03 PM failed to identify that he/she had received any of the pneumococcal vaccines while at the facility. The records also did not contain any documentation that the resident had refused the vaccine. Interview with LPN #1 on 5/29/25 at 12:03 PM identified Resident #17 should have received the vaccine if he/she had given consent to the vaccine administration. She identified it was the Infection Preventionist's (IP) responsibility to review the consent form, obtain a physician's order, order the vaccine and ensure that it was administered to the resident. She further identified that she was not working at the facility during the time the resident had requested the vaccine, and it was the responsibility of the previous IP nurse to ensure the resident had received the vaccine. Review if the Pneumococcal Vaccination policy identified all residents admitted to this facility will be evaluated to determine if they have received Pneumococcal Vaccination. The facility will offer pneumococcal immunization, unless immunization is medical contraindicated, or the resident has already been immunized upon resident and or responsible party consent, the PCV15, PCV 20 vaccine and the PPSV23 will be offered per the CDC guidelines as indicated. 2. Resident #95's diagnoses included type 2 diabetes mellitus, Alzheimer's disease, chronic kidney disease stage 3 and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #95 had severely impaired cognition. The assessment further identified that Resident #95 had not received the pneumococcal vaccine as it was not offered. Review of Resident #95's clinical records with the Infection Preventionist (LPN #1) on 5/29/25 at 12:03 PM failed to identify that he/she had any prior vaccination history of the pneumococcal vaccines or was offered the vaccine while at the facility. The records also did not contain any documentation that the resident had refused the vaccine. Interview with LPN #1 on 5/29/25 at 12:03 PM identified that all resident is offered the pneumococcal vaccine on admission by the admitting nurse, which is then reviewed by the Infection Preventionist (IP). The IP nurse is responsible for reviewing the consent, obtaining the physician's order, order the vaccine and then it would be administered to the resident. She identified that she was not working at the facility during the time the Resident #95 was admitted , and it was the responsibility of the previous IP nurse to ensure the resident was offered and assessed for the pneumococcal vaccine. Review if the Pneumococcal Vaccination policy identified all residents admitted to this facility will be evaluated to determine if they have received Pneumococcal Vaccination. The facility will offer pneumococcal immunization, unless immunization is medical contraindicated, or the resident has already been immunized upon resident and or responsible party consent, the PCV15, PCV 20 vaccine and the PPSV23 will be offered per the CDC guidelines as indicated.

Based on observation, review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #53) with a diagnoses of Alzheimer's disease, the facility failed to notify the resident's responsible party (Person #1) when a new medication (Namenda) was added to the medication regimen. The findings include: Resident #53's diagnoses included Alzheimer's disease and dysphagia The annual MDS assessment dated [DATE] identified Resident #53 had severely impaired cognition and was independent with ambulation and bed mobility. The APRN's note dated 11/6/24 identified Person #1 was against the use of Namenda and did not want any new medications to be added to Resident #53's medication regimen. The APRN's note dated 11/22/24 identified that education was provided to Person #1, who continued to refuse the use of Namenda. The APRN's note dated 12/5/24 identified Person #1 continued to refuse the use of Namenda, despite education. The APRN's note dated 12/27/24 identified Person #1 declined use of Namenda. The physician's order dated 2/21/25 directed Namenda 5mg to be administered twice daily by mouth. Review of the medication administration record (MAR) for the period of 2/22/25 through 2/28/25 identified Namenda 5mg was administered to Resident #53 twice daily. Review of nurses 'notes dated from 2/21/25 through 2/28/25 failed to identify Person #1 was notified of the new order for Namenda. Review of the MAR for the month of March 2025 identified Resident #53 was administered Namenda 5mg twice daily. Review of the MAR for the month of April 2025 identified Resident #53 was administered Namenda 5mg twice daily. Review of the MAR for the month of May 2025 identified Resident #53 was administered Namenda 5mg twice daily. Observation on 5/29/25 at 10:44 AM identified Resident #53 seated in the dining area at a table appearing to be asleep while there was a recreation activity in progress. Review of the MAR for June 2025 identified Namenda 5mg twice a day was administered on 6/1/25 and on 6/2/25 (AM does only). Interview on 6/2/25 at 12:47 PM with Person#1 identified that he/she was unaware that Resident #53 had an order and was being administered Namenda, because he/she had verbalized to many people that after reviewing the medication uses and side effects, he/she was of the opinion that it would not benefit Resident #53. Person#1 identified she had not spoken to the doctor, but when she spoke with APRN#1 she made it clear she did not want the medication added to the medication regimen. Person#1 indicated she expected that the facility would notify her of any changes in order to have input regarding the medication management and identified that no one from the facility had notified her about the addition of the Namenda and that during Resident #53's care conference held in May, she was not notified about any changes or additions. Interview on 6/2/25 at 12:37 PM with LPN #4 identified that when the physician/APRN adds an order to the computer it needs to be approved. The person who approves the order should notify the responsible party. She further noted that the Namenda order was approved by the RN supervisor, but there was no documentation that she notified Person #1. Interview on 6/2/25 at 12:46 PM with the DNS indicated the doctor entered the order into the electronic medical record and an RN supervisor approved the order. The expectation is that the RN Supervisor who approves the order also notify the family (responsible party). The DNS further identified there should be a progress note written to identify the family was notified. Interview on 6/2/25 at 1:01 PM with the ADNS identified she is sometimes asked to represent nursing during a care conference meeting. The ADNS indicated If there were no changes, then I don't list out the medications, but can be reviewed if the family has questions. The ADNS identified she looks in the chart to see any dates of anything discontinued or completed. Looking through Resident#53's chart, the ADNS did not identify the Namenda as a new medication and indicated she does a quick review of the chart and does not go back to the previous care conference. Although requested, the facility failed to provide a facility policy regarding notification of changes.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for the one sampled resident (Resident #103) reviewed for abuse, the failed to ensure the resident was free from mistreatment sustained from a resident-to-resident altercation. The findings include: Resident #103 was admitted to the facility March 2025. Diagnoses included left knee effusion, muscle weakness, dementia, anxiety and difficulty walking. The admission MDS assessment dated [DATE] identified Resident #103 had severe cognitive impairment, had behaviors that were not directed at others, displayed wandering behaviors, required moderate to total dependence with activities of daily living, did not ambulate and utilized a wheelchair. Physician's orders dated 3/5/25 directed administration of anti-depressant medications and monitoring of side effects and behavior of sadness. The care plan dated 3/11/25 identified Resident #103 had a deficit in functional mobility and was non-ambulatory with use of a wheelchair. The care plan additionally identified Resident #103 had some agitation with long term care placement with an intervention that included safely housed on designated unit. A reportable event report dated 3/19/25 at 4:10 PM identified Resident #103 was seated in a wheelchair in his/her room when Resident #112 entered the room and sat in a chair. Resident #103 identified that he/she asked the him/her to leave and then Resident #112 stood up and went over to Resident #103 and slapped him/her in the face. The report further identified that Resident #103 was assessed and did not sustain any injuries from the altercation. A DNS note dated 3/19/25 at 6:00 PM identified the same incident as stated in the reportable event report and noted Resident #103 felt safe and requested the room door be closed. A nursing progress note dated 3/20/25 at 3:51 PM identified a stop sign was placed in the doorway of Resident #103's doorway but was refused by Resident #103. A social service progress note dated 3/21/25 at 11:10 AM identified the social worker met with Resident #113 as a follow up to the incident with another resident and had no signs of distress. Resident #112 was admitted to the facility 10/21/24 with a diagnosis of Alzheimer's disease with mood disturbance. Nursing progress note dated 10/22/24 at 8:56 AM identified Resident #112 wandering into other residents' rooms most of the night and noted Resident #112 was redirected and did not change behaviors and was very easily agitated. Nursing progress note dated 10/24/24 at 12:20 PM identified Resident #112 hit a nurse aid (NA) at the nurse's station, unprovoked. The note indicated Resident#112 punched her left arm and back, took the computer desk and tried to throw it at her. Resident #112 called the NA a vulgar name and was medicated for agitation. Nursing progress note dated 10/28/24 at 7:56 AM identified Resident #112 was trying to enter other resident's rooms and got agitated and verbally abusive when staff tried to interfere. Nursing progress note dated 10/28/24 at 3:46 PM identified Resident #112 continued to wander into other resident's room and refused care. Nursing progress note dated 11/24/24 at 8:18 AM identified Resident #112 was anxious and restless last night and walking in and out of other resident's room, became agitated when staff tried to redirect, and was medicated with Trazodone and slept from 3-7am. Nursing progress note dated 12/3/24 at 9:10 AM identified Resident #112 was awake most of the night and walking in hallway trying to enter other residents' rooms. Nursing progress note dated 1/4/25 at 7:12 AM identified Resident #112 wandered all night and sat in chairs on different units to nap and would become agitated when redirected by staff. The significant change MDS assessment dated [DATE] identified Resident #112 had severely impaired cognition, exhibited physical and verbal behaviors directed toward others, including rejection of care, wandering, and was independent with ambulation. The assessment further identified that behaviors triggered as a focus area to be care planned for and the indication on the assessment was that it would be included on the care plan. The care plan dated 2/21/25 identified Resident #112 was dependent on staff for meeting emotional, intellectual and social needs related to cognitive deficits with interventions that included: allow resident to explore the environment in a safe manner, introduce to other residents with similar backgrounds, interests, and encourage/facilitate interaction, offer a quiet place if overstimulated during activities. The care plan further identified Resident #112 had the potential to be verbally/physically aggressive related to dementia, mental/emotional illness/psychosis. Interventions included: monitor behaviors every shift, staff to remain near the resident while on one-to-one observation but allow a small amount of space to avoid triggering negative behaviors and intervene before agitation escalates; guide away from source of distress and if response is aggressive, staff to walk calmly away and approach later. The care plan did not address the resident's behavior of wandering. The nursing note dated 3/10/25 at 6:02 PM identified Resident #112 was positive for influenza A and was resistive to wearing mask or face guard. The nursing note dated 3/11/25 at 8:17 AM identified Resident #112 was placed on droplet precautions but continued to ambulate in the hallway and became agitated when staff tried to encourage mask. The nursing note dated 3/11/25 at 6:05 PM identified Resident #112 had difficulty with remaining in room due to significant confusion and behaviors. The care plan (revision) dated 3/14/25 identified Resident #112 wanders all over the nursing unit and in and out of other resident's rooms. Care plan interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, and identify patterns of wandering. The care plan further identified the resident had impaired cognitive function with an intervention of 1 to 1 monitoring due to aggression with residents which was added on 3/19/25. The nursing progress note dated 3/19/25 at 5:24 PM identified Resident #112 wandered into the other resident room and when asked to leave, hit the other resident (Resident#103) in the face on the left side with an open hand. The note indicated Resident#112 was immediately placed on 1 to 1 monitoring and was sent to the acute care emergency department for evaluation. Nursing progress note dated 2/8/25 at 10:47 PM identified refusals of care and verbally swearing and aggressive to staff. The nursing note dated 3/19/25 at 5:24 PM identified Resident #112 wandered into Resident #103's room and when asked to leave, hit Resident#103 in the face on the left side with an open hand. The note further indicated Resident #112 was placed on immediate 1 to 1 monitoring, the APRN was notified, and Resident #112 was sent to the acute care hospital emergency department to be evaluated. Interview on 5/28/25 at 10:25 AM with LPN#5 identified staff sometimes call Resident #112's family member who is sometimes able to assist with redirection. LPN#5 indicated Resident #112 refuses medications, changes and treatments. LPN#5 identified that when Resident #112 does not get medicated due to refusals, it effects the resident's behaviors on the following shifts. Interview on 6/2/25 at 1:27 PM with the Regional Director of Nursing Services identified the facility does not complete A and Is for residents who assault/hit staff members unless the staff member was injured and required treatment. Facility policy for abuse identified that each resident has the right to be free from abuse.

Based on review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #112) with behaviors, the facility failed to ensure the care plan was comprehensive in addressing the resident's behavior of wandering into other residents' rooms, although the behavior was identified on the admission MDS and behaviors triggered, and it was noted that behaviors would be included on the comprehensive care plan. The findings include: Resident #112 was admitted to the facility 10/21/24 with a diagnosis of Alzheimer's disease with mood disturbance. Nursing progress note dated 10/22/24 at 8:56 AM identified Resident #112 wandering into other residents' rooms most of the night and noted Resident #112 was redirected and did not change behaviors and was very easily agitated. Nursing progress note dated 10/24/24 at 12:20 PM identified Resident #112 hit a nurse aid (NA) at the nurse's station, unprovoked. The note indicated Resident#112 punched her left arm and back, took the computer desk and tried to throw it at her. Resident #112 called the NA a vulgar name and was medicated for agitation. Nursing progress note dated 10/28/24 at 7:56 AM identified Resident #112 was trying to enter other resident's rooms and got agitated and verbally abusive when staff tried to interfere. Nursing progress note dated 10/28/24 at 3:46 PM identified Resident #112 continued to wander into other resident's room and refused care. The admission MDS assessment dated [DATE] identified the resident had severely impaired cognition, behaviors that included physical and verbal abuse, and wandering that does not significantly intrude on the privacy activities of others, had no range of motion impairments and was independent with ambulation. The assessment further identified the resident triggered for behavioral symptoms with the decision made to include on the comprehensive care plan. The comprehensive care plan dated 11/1/24 did not identify the resident's behavior of wandering or contain interventions that addressed the resident's wandering behaviors specifically the behavior of wandering into other residents' rooms. Nursing progress note dated 11/24/24 at 8:18 AM identified Resident #112 was anxious and restless last night and walking in and out of other resident's room, became agitated when staff tried to redirect, and was medicated with Trazodone and slept from 3-7am. Nursing progress note dated 12/3/24 at 9:10 AM identified Resident #112 was awake most of the night and walking in hallway trying to enter other residents' rooms. Nursing progress note dated 1/4/25 at 7:12 AM identified Resident #112 wandered all night and sat in chairs on different units to nap and would become agitated when redirected by staff. The significant change MDS assessment dated [DATE] identified Resident #112 had severely impaired cognition, exhibited physical and verbal behaviors directed toward others, including rejection of care, wandering, and was independent with ambulation. The assessment further identified that behaviors triggered as a focus area to be care planned for and the indication on the assessment was that it would be included on the care plan. The care plan dated 2/21/25 identified Resident #112 was dependent on staff for meeting emotional, intellectual and social needs related to cognitive deficits with interventions that included: allow resident to explore the environment in a safe manner, introduce to other residents with similar backgrounds, interests, and encourage/facilitate interaction, offer a quiet place if overstimulated during activities. The care plan further identified Resident #112 had the potential to be verbally/physically aggressive related to dementia, mental/emotional illness/psychosis. Interventions included: monitor behaviors every shift, staff to remain near the resident while on one-to-one observation but allow a small amount of space to avoid triggering negative behaviors and intervene before agitation escalates; guide away from source of distress and if response is aggressive, staff to walk calmly away and approach later. The care plan did not address the resident's behavior of wandering. Interview on 5/28/25 at 10:38 AM with LPN #5 identified that the LPNs and nursing supervisors can add problems and interventions to the care plan, she further identified that Resident #112's behavior of wandering into other resident's rooms should have been including on the comprehensive care plan. She noted that the nursing supervisor or the MDS Coordinator should have added it. Additionally, she noted that the staff attempts to redirect Resident #112 when attempts to enter other residents' rooms are made. Interview on 6/2/25 at 11:47 AM with the DNS identified that when Resident #112 is aggressive or wandering into other resident rooms, staff should intervene and redirect, attempt to keep the resident in sight and attempt distant supervision. The DNS indicated Resident #112's wandering into other resident rooms should have been added when the resident was admitted based on the Interview on 6/2/25 at 1:05 PM with the ADNS, who added the care plan intervention of wandering that was dated 3/14/25, identified she could not with 100% certainty explain why the wandering intervention was added at that time, but indicated Resident #112 was wandering in and out of other resident rooms. The baseline/comprehensive person-centered care plan policy identified that the comprehensive person-centered care plan will be periodically reviewed and revised by a team of qualified persons after each assessment or reassessment or episodically as the plan of care changes. The policy indicated that the comprehensive person-centered care plan would be kept current by all disciplines on an ongoing basis and that disciplines would be responsible for updating the care plan when there was a new problem that requires intervention. The facility failed to care plan for Resident #112's behavior of wandering after identifying the behavior on two comprehensive assessments and identify that behaviors would be included on the care plan and although the care plans included some of the behaviors identified on the assessments. They did not address the wandering behavior.

Based on clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #125) reviewed for discharge, the facility failed to ensure the Ombudsman's office was provided with the required notification of the transfer. The findings include: Resident #125's diagnoses included acute osteomyelitis of left foot and ankle and type 2 diabetes mellitus with diabetic neuropathy. The admission MDS assessment dated [DATE] identified Resident #125 had intact cognition, required moderate assistance with toileting hygiene, upper and lower body dressing, personal hygiene, bed mobility and transfers and utilized a walker with ambulation. The Social Worker (SW #1) progress note dated 3/20/25 at 3:04 PM identified she met with Resident #125 to review his/her discharge for 3/21/25 and indicated that transportation was booked. The note further identified Resident #125 was reluctant to use homecare services and was informed that a referral was made. RN #4's progress note dated 3/21/25 at 12:58 PM identified Resident #125 was discharged home with health services set up, and medications and discharge instructions were reviewed with the resident with no questions. A request was made on 6/2/25 for the Ombudsman's report of transfers and discharges for the last four months. The Social Worker (SW #1) conveyed that she was behind in reporting to the Ombudsman's office. A review of the documentation provided by the facility identified that the last report sent to the State Ombudsman's office regarding resident admissions, discharges, and transfers was last completed in February 2025. Review of the facility's admission, discharge, and transfer report for the past three months identified the following: for the month of February, there were forty-one residents discharged and/or transferred from the facility; for the month of March, there were forty-one residents discharged and/or transferred from the facility; for the month of April, thirty-four residents were discharged and/or transferred from the facility. Interview with SW #1 on 6/2/25 at 11:34 AM identified she is responsible for sending reports of each month's transfers and discharges to the Ombudsman's office. SW #1 indicated that she was unaware that the reports should be sent on a monthly basis. She identified that she would send in a couple of months at a time via the ombudsman's reporting portal but had fallen behind recently. Interview with the Administrator on 6/2/25 at 12:08 PM identified it was the responsibility of SW #1 to submit the report via the ombudsman's portal on a monthly basis. The report should contain the residents that were discharged for any reason and/or transferred for any reason. She further identified she was not aware of SW #1 being behind in sending the monthly report. On 6/2/25 (after surveyor inquiry) the facility updated the Ombudsman's office of all discharges and transfers that occurred during the period of February/2025 through May/2025. An interview with the Administrator on 6/2/25 at 12:08 PM identified that the facility does not have a written policy regarding notification of discharges and transfers to the Ombudsman office, but it was the facility's practice and the social worker's responsibility to submit the report monthly.

Based on review of clinical records, review of facility documentation, review of facility policy and procedures, and staff interview for 13 of 13 residents (Resident #'s 11, 17, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, and 33), reviewed for allegations of abuse, the facility failed to document, report and investigate allegations of abuse to provide for protections for the health, welfare and rights of each individual resident. The findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included ataxia and chronic obstructive pulmonary disease. Review of the clinical record identified admission notes dated 8/22/22 which indicated the resident was admitted at 5:15 P.M. from the hospital and had been in the emergency department since 8/20/22. Additionally, review identified the resident requested that all assessments be deferred until after s/he had the opportunity to shower and have dinner. Further notes dated 8/22/22, 10:38 P.M. identified during the shower, the resident became upset related to the water temperatures and expressed that s/he was going home. The resident was discharged and an Against Medical Advice (AMA) discharge was processed. A social service progress note dated 8/30/22 identified that a referral was made to Adult Protective Services related to the AMA discharge. A subsequent progress note dated 9/7/22 identified the social worker received a telephone call from Adult Protective Services (APS) indicating that Resident #4 had reported to APS s/he was treated inappropriately when at the facility, was put in a shower that was cold and was told s/he could not leave the shower. Attempts to interview the social worker who spoke with adult protective services were unsuccessful. During an interview with Social Worker #1 on 6/20/24 at 2:30 P.M., she stated that she was not working in the facility at the time of this event, however, indicated that the social worker who spoke with APS should have referred this incident to nursing. During an interview with DNS #2 (DNS at the time of the incident) on 6/11/24, she stated she could not recall the event. Although during an interview and review of the clinical record with DNS #1 (DNS at the time of the investigation) on 7/3/24, she stated that an investigation regarding an allegation of resident abuse should have been initiated, review of the clinical record and facility documentation failed to identify an investigation had been initiated. 2. Resident #17 was admitted with diagnoses of neuropathy, low back pain, weakness, and protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that Resident #17 was cognitively intact, exhibited no behaviors, required limited assistance with transfers, and extensive assistance for bed mobility, toileting, and hygiene. An RCP dated 4/25/23 identified that Resident #17 required assistance with activities of daily living related to deficits in balance, strength, weakness, intractable back pain, and ambulation. Interventions included allowing the resident to make choices, breaking tasks down to simpler sub tasks, and explaining the purpose and expected task to the resident. Additionally, there were no RCP's regarding behaviors, resident to staff interactions, or allegations of abuse. A Grievance Sheet dated 4/2/23 identified Resident #17 reported that NA #2 was rough with him/her when she put him/her in bed and that NA #2 put her fist on the Resident's back while using the bathroom, requesting he/she did not want NA #2 caring for him/her. SW #1 reported she followed up with emotional support for Resident #17 and that there had been no additional concerns. Review of progress notes from 4/2/23 through 4/9/23 failed to identify any documentation regarding any allegations towards staff and/or the residents mood. Interview with Resident #17 on 6/13/24 at 11:42 AM indicated that s/he was unable to recall the events mentioned in the grievance. Although interview with SW #1 on 6/20/24 at 11:57 AM identified she had documented on the grievance form for Resident #17 that she followed up with the resident for emotional support and there were no further concerns, she reported the encounters were not documented in the clinical record. Subsequent to surveyor inquiry, the incident was reported as an allegation of abuse-neglect on 6/10/24 and an investigation was initiated. 3. Resident #19 was admitted to the facility with diagnoses that included fibromyalgia, anxiety, and weakness. A quarterly MDS assessment dated [DATE] identified no cognitive impairment, no exhibited behaviors, required extensive assistance for bed mobility and personal hygiene, and was totally dependent for transfers and toileting. A corresponding RCP identified a problem with ADL's related to deficits in mobility, balance, strength, ambulation, weakness, endurance, and cognition. Interventions included staff providing verbal cues and reassurance with transfers due to fear of falling. A Grievance Sheet dated 4/2/23 identified Resident #19 reported NA #2 is rude and will not answer the call bell. The Grievance Sheet indicated that coaching was provided to the nursing assistants with the social worker following up. A subsequent SW progress note dated 4/3/23, 4:08 P.M. indicated Resident #19 reported s/he is not a fan of NA #2. A second Grievance Sheet dated 4/11/23 indicated the Resident reported to the Therapeutic Recreation Director at 12:35 P.M. s/he had not been provided care that day. Pursuant to the report, care was provided. Although the Grievance Sheet identified SW #3 provided follow up, review of the progress notes failed to identify progress notes and/or interventions to address the incident. Further, an investigation was not conducted to determine who the nursing assistant was and that failed to provide the care. Resident #19 was unavailable for interview. Attempts to interview SW #3 were unsuccessful. Subsequent to surveyor inquiry, the incident was reported as an allegation of abuse-neglect on 6/13/24 and an investigation was initiated. 4. Resident #18 was admitted with diagnoses of spinal stenosis of the lumbar region, weakness, low back pain, and adjustment disorder. The quarterly MDS dated [DATE] identified that Resident #18 was cognitively intact, exhibited no behaviors, and required extensive assistance with bed mobility, transfers, personal hygiene, and toileting. The RCP dated 4/4/23 identified that Resident #18 required assistance due to decreased mobility of right lower extremity due to a history of right knee surgery in the past, as well as a right knee dislocation. Interventions included staff assistance of 2 with the mechanical lift, with a knee immobilizer applied to the right lower extremity. Additionally, the RCP identified that Resident #18 is incontinent of bowel and bladder. Interventions included offering the bedpan and/or commode and providing incontinent care every two hours and as needed. Review of the 'Grievance Sheet' dated 4/2/23 reported that NA #2 doesn't answer the call bell and that you will see her once and then she disappears for the remainder of the shift. It identified that NA #2 was not happy when Resident #18 requested the bedpan. Review of the clinical record failed to identify any further follow-up from social services regarding the incident. Interview with Resident #18 on 6/21/24 at 1:00 PM identified that he/she did not remember the details of the incident, reporting that sometimes NA #2 makes rude comments but that he/she didn't have a problem with her recently. He/she indicated that if a staff member appeared angry when he/she requested something, it would make him/her feel as if they did something wrong and that they were in trouble. Further review of the clinical record and facility documentation failed to identify an allegation of abuse-neglect had been reported and/or investigated until 6/13/24, subsequent to surveyor inquiry. 5. Resident #21 was admitted with diagnoses of type 2 diabetes mellitus, congestive heart failure, weakness, unsteady in the feet, difficulty walking, dysphagia, feeding difficulties, history of falls, anxiety and depression. A quarterly MDS assessment dated [DATE] identified that Resident #21 was cognitively intact, exhibited no behaviors, required limited assistance with bed mobility, transfers, and toileting and required extensive assistance with hygiene. The RCP dated 4/30/24 identified Resident #21 had deficits that required support with bathing, grooming, dressing, and toileting related to generalized weakness and a history of pain. Additionally, the RCP identified that Resident #21 had a history of refusing care from some staff, displays accusatory behavior toward staff at times, and yells at staff at times. Interventions included that the resident was an assist of 2 with care, monitor for triggering events and avoid them in the future, decrease visual or auditory stressors when over stimulated, if agitated during activity stop the activity and try again later, and staff to listen and be supportive. Review of a 'Grievance Sheet' dated 7/25/22 identified Resident #21 reported waiting for over two hours from 9:00 PM to 11:00 PM on 7/22/22 for the NA to assist with care, and that he/she is not happy when the NAs tell him/her that they only have X number of other residents to take care of before they can attend to him/her. The response stated the social worker met with the resident and reviewed his/her requests for timely responsive care and the DNS and Administrator are aware of requests. Review of a 'Grievance Sheet' dated 3/27/24 identified Resident #21 reported that dishes are not removed timely following meals and that he/she would like to store food from meals in the refrigerator. The facility response recorded, identified the DNS provided education on timely removal of meal trays and if a resident wishes to store leftover food, they must label it prior to storing it in the refrigerator. Although the grievance identified broadly that the dishes weren't picked up, surveyor interview with the Resident on 6/6/24 at 12:44 PM identified that NA #2 was the staff member that refused to pick up trays and store the food in the refrigerator as requested by Resident #21. Resident #21 further stated that NA #2 would turn off the call bell and state that the resident needed to ask the NA assigned to his/her care for assistance. Surevyor interview with Resident #21 on 6/6/24 at 12:44 PM identified that he/she had filed previous grievances regarding not receiving care timely, NA #2 shutting off call bells and not providing care and refusing to take dinner trays and store leftover food in the fridge. He/she reported that NA #2 treats him/her differently now by refusing to help him/her and telling him/her to ask his/her assigned NA, not bringing items it for him/her that she brings in for others and he/she feels as if they are being retaliated against. Review of a Resident Rights Survey/Audit conducted by facility staff related to a 9/4/23 facility investigation regarding NA #2, identified Resident #21 reported that NA #2 sometimes if I ask her to do something she refuses, Further review of the clinical record and facility documentation failed to identify a follow up or facility investigation until 6/13/24, and subsequent to surveyor inquiry. 6. Resident #33 was admitted with diagnoses that included sickle cell, depression, weakness and polyneuropathy. A MDS assessment dated [DATE] indicated the resident was moderately cognitively impaired, exhibited no behaviors, and was independent with all ADL's. A corresponding RCP identified a problem with cognition, interventions included keeping the call bell within reach. Review of a Resident Rights Survey/Audit that was conducted from a 9/4/23 facility investigation regarding care and services provided by NA #2, identified Resident #33 reported that if s/he had a concern, s/he would not feel comfortable reporting it if related to NA #2. Resident #33 further identified if you piss her off, she's not nice. Further review of the clinical record and/or facility documentation failed to identify any follow up or facility investigation regarding a resident allegation that is suggesting verbal abuse or retaliation. 7. Resident #22 was admitted with diagnoses of weakness, lack of coordination, bilateral age-related cataracts, major depressive disorder, and anxiety. A quarterly MDS assessment dated [DATE] identified that Resident #22 was cognitively intact, exhibited no behaviors, required limited assistance with transfers, and extensive assistance for bed mobility, toileting, and hygiene. An RCP identified that Resident #22 had deficits related to generalized weakness, a history of repeated falls and deficits in ambulation. Interventions included an assist of 1 staff for activities of daily living, assist with gathering and setting up clothing, toiletries, and equipment, and encourage self-performance, praise all attempts, allow sufficient time for task completion, and assist as needed. Additionally, the RCP identified that Resident #22 had episodes of anxiety and was prescribed anti-anxiety medication. Interventions included discussing positive coping mechanisms such as relaxation/breathing techniques to aid in lessening anxiety and encourage resident to verbalize thoughts and feelings related to anxiety. Interview with Resident #22 on 6/6/24 at 12:54 PM identified that he/she has requested not to have NA #2, as she has an attitude and is very moody, reporting you never know what you're going to get. He/she indicated that she slams stuff down and lets you know that she's annoyed when you ask for anything but stated he/she hasn't dealt with her lately, as she's never here anymore. The staff says she calls out a lot. Resident #22 reported that he/she is not afraid of NA #2, but that she causes him/her anxiety and doesn't like how NA #2 treats the residents. During an interview with LPN #1 on 6/6/24 at 12:08 P.M., she identified that she has worked with NA #2 for a long time and there had been previous complaints from residents about how she acted and conversed with them that could have constituted abuse or neglect. LPN #1 indicated that NA #2 had made rude statements on several occasions and that there were 4 residents (Resident's #17, #22, #24, and #23) that didn't want NA #2 to care for them. Although the facility was aware of NA #'s 2's inapproprate interactions and the request from Resident #22 that NA #2 not be assigned to assist with Resident #22's care, the facility failed to investigate the alleged concerns. 8. Resident #23 was admitted with diagnoses of peripheral vascular disease, left sided hemiplegia/hemiparesis, type 2 diabetes mellitus, weakness, depression, and anxiety. A quarterly MDS dated [DATE] identified that Resident #23 was cognitively intact, exhibited no behaviors, and required extensive assistance for bed mobility, transfers, and toileting. The RCP dated 4/23/24 identified that Resident #23 required assistance with bathing, dressing, and transfers due to functional deterioration related to hemiplegia post CVA, PVD, CKD stage 3, Gout, and OA of hips. Interventions included extensive to total assist with activities of daily living, allow resident to make choices, and to ask and encourage the resident to participate to the full extent that he/ she is able. Additionally, the RCP identified that Resident #23 displays behaviors of hoarding, making inappropriate comments, diet noncompliance at times, refusing to get out of bed at times, and has a history of accusations regarding not receiving his/her Ambien (narcotic sleep medication) at bedtime. Interventions included education with resident regarding the risks of not waiting for staff assistance, education with resident that his/her threatening behavior is inappropriate, staff to listen to resident and be supportive, and staff to provide for the immediate safety of the resident. Interview with Resident #23 on 6/13/24 at 12:50 PM identified that he/she filed a grievance on NA #2 a few years ago and he/she has not allowed her to care for him/her since, reporting her attitude is rude and demeaning, stating she barks orders from the doorway, acting like [NAME], and refuses to answer the call bell. He/she indicated they have waited over an hour for the call bell to be answered on numerous occasions and has been told by NA #2 that he/she needs to wait until his/her assigned NA can come to assist. Review of a 'Grievance Sheet' dated 8/22/21 reported that he/she is treated unfairly by NA #2, as she causes him/her anxiety due to her refusals to give him/her linens or soup when she services the other residents. Review of progress notes from 8/21/21 through 8/30/21 failed to identify any documentation regarding any allegations verbalized by Resident #23 towards staff and/or chnages in the residents mood. Review of the personnel file for NA #2 identified the date of hire as 11/4/2002. Review identified multiple education sessions related to the employee's attitude and her approach with residents. Multiple coaching sessions, final warnings, and counseling sessions (total of 16 since 2003) identified NA #2 had been disrespectful to residents, neglectful, abusive with her language with residents and rough with care. Review of facility documentation dated 9/12/23 between DNS#2 and the Human Resources Manager identified that a termination of employment will not be supported. Instead, the employee will be provided with a final written warning and offer clear guidance/re-training on expectations. Interview with DNS #2 on 6/6/24 at 12:35 PM identified that she would have terminated NA #2 a long time ago, indicating that she had sent numerous involuntary separation attempts to corporate for review, but she was met with a lot of resistance and they were all rejected. She reported that there had been several complaints from residents regarding NA #2, but when they would discuss the incidents with NA #2, she would state, I thought it was okay, we were cool and would not admit any wrongdoing. She also indicated she had received employee complaints against NA #2 stating that she was not a team player and had an attitude with them as if they were bothering her when asking for assistance. She identified that NA #2 had been suspended after the 9/4/23 incident for at least 5 days. DNS #2 further stated during that time, she monitored NA #2, however, was unable to provide documentation of such monitoring. NA #2 was terminated on 6/13/24. Interviews with Social Worker #1, LPN # 1 and the DNS were conducted related to the concerns presented from Resident #'s 17, 18, 19, 21, 22, 23, 24 and #33 regarding care and services. During an interview with LPN #1 on 6/6/24 at 12:08 P.M. she stated that she has worked with NA #2 for a long time and there had been previous complaints from residents about how she acted and conversed with them. LPN #1 indicated that NA #2 had made rude statements on several occasions and that there were 4 residents (Resident's #17, #22, 23 and #24 ) that didn't want NA #2 to care for them. Interview with SW #1 on 6/7/24 at 12:57 P.M. identified that abuse includes physical, sexual, psychosocial, financial and verbal abuse, which includes derogatory statements, yelling, and inappropriate words. Further interview indicated that she brings the grievances to the morning meeting and the DNS determines how they should be managed. Additionally, she could not explain why these incidents were managed as grievances and not as allegations of abuse or neglect. A subsequent interview with SW #1 on 6/20/24 at 11:57 AM identified that prior to 4/2/23 when multiple incidents related to NA #2's interactions with residents was reported, she would have been surprised to hear that residents were afraid of NA #2. However, following 4/2/23 when she received 3 grievances related to NA #2, she would not have been surprised to hear additional residents voice concerns that they were afraid of NA #2. She further stated that after a resident allegation of abuse in September of 2023, a survey audit was conducted of all residents soliciting the quality of care and services provided by NA #2. SW #1 stated that several residents had reported concerns, however, stated that she did not follow up on the concerns as the DNS did not direct her to. Interview with the DNS on 6/11/24 at 12:06 P.M. she identified that the Social Worker is probably the Grievance Officer. She further stated that when there are concerns, they are transferred to nursing. She further stated that she could not speak to why the process failed as she was not the DNS during that time frame. 9. Resident #29 was admitted with diagnoses of congestive heart failure, adjustment disorder, atrial fibrillation, and weakness. The 5-day MDS dated [DATE] identified that Resident #29 was cognitively intact, exhibited no behaviors, and required extensive assistance with bed mobility, personal hygiene, and toileting and required total assistance with transfers. The RCP dated 2/6/24 identified that Resident #29 had an activities of daily living deficit related to mobility, ambulation, balance, strength, generalized weakness, and recent hospitalization . Interventions included mechanical lift transfers with staff assist of 2, no ambulation, and provide assistance and/or cueing to maximize the current level of functioning. Additionally, the RCP identified that Resident #29 has a history of behaviors including refusal of care, calling 911, and wanting to be discharged from the facility and then changing his/her mind. Interventions included psychiatric evaluation and consultations as indicated, education on the importance of care and the possible adverse effects of not receiving care and staying in bed for prolonged periods, and staff to introduce themselves to the resident and explain what they are going to do using a calm and gentle approach, working slowly, and asking for the resident's cooperation with the task. Review of the 'Grievance Sheet' dated 4/10/23 identified that Resident #29 reported his/her wheelchair was pushed deliberately by the NA into his/her roommate's wheelchair, which subsequently hit the closet door. Interview with Resident #29 on 6/13/24 at 11:45 AM identified that she could recall the 4/10/23 incident, reporting that a NA heaved a sitting chair that was in between 2 wheelchairs on his/her side of the room. He/she indicated that the incident made her feel weary, and he/she did not want the NA taking care of him/her after that stating he/she did not trust NA to take care of them safely. Review of progress notes from 4/6/23 through 4/24/23 identified that although the incident occurred on 4/6/23, there was no documentation in the clinical record until 4/12/23 at 3:31 PM, which was documented as a late entry Social Service Interim Progress Note. During multiple interviews on 6/21/24, and 6/24/24 with the Social Worker and the DNS, they stated an investigation of the incident was not conducted therefore they could not identify who the NA was. 10. Resident #20 was admitted to the facility with diagnoses of congestive heart failure, chronic respiratory failure, weakness, and anxiety. A bowel and bladder assessment dated [DATE] indicated Resident #20 was continent of bladder and bowel function. A MDS assessment dated [DATE] identified no cognitive impairment (BIMS of 15), no episodes of behavioral issues or changes in mood, and the resident was continent of bladder and bowel function. An RCP dated 1/25/24 identified behavior problems with a history of accusatory behaviors with interventions that included monitoring every shift for accusatory behaviors and provide two caregivers when providing care. Review of the accusatory behavior tracking/monitoring notated on the treatment administration record identified no accusatory behavior was noted from 1/26/24 through 1/29/24. A nursing progress note dated 1/30/24, 23:01 identified the resident was agitated when the aides did not attend to him/her timely and reported it took over an hour for assistance. A Grievance Sheet dated 1/30/24 indicated Resident #20 reported the call light was not answered for an hour which resulted in urinary incontinence. Review of the investigation's statements included a statement from a nursing assistant which indicated Resident #20 was yelling. When the nurse aide responded to Resident #20, it was noted the resident had been incontinent. Assistance to the commode was provided and Resident #20 reported to the nurse aide that she had urine running down the leg. A follow up progress note from social services dated 1/31/24 identified the resident expressed concerns with response to call bells and indicated the intention that the response would improve with staff education. Although a grievance form was completed, the facility failed to manage the incident as an allegation of abuse-neglect and failed to identify and interview other staff and residents who might have knowledge of the allegation, failed to determine if abuse had occurred and failed to document what changes or improvements were needed to prevent any further incidents or allegations as directed by the facility abuse policy. 11. Resident #26 was admitted with diagnoses of congestive heart failure, respiratory failure, iron deficiency anemia, chronic venous hypertension, and atrial fibrillation. A MDS assessment dated [DATE] identified the resident had no cognitive impairment, was depressed at times, required limited assistance with bed mobility, and dependence for hygiene and bathing. The MDS further identified the resident was always incontinent of bowel function, and occasionally incontinent of urinary function. A corresponding RCP identified the resident required assistance with activities of daily living related to weakness and endurance with interventions that included allowing the resident to make choices. The RCP further indicated the resident was incontinent of bowel and bladder function with interventions that included offering the bed pan or toileting assistance and incontinent care every 2 hours and when necessary. Additionally, the RCP identified the resident is at risk for skin breakdown related to incontinence with interventions that included offer turning and repositioning every 2 hours and when necessary and toileting and incontinent care as needed. A [NAME] skin assessment dated [DATE] identified the resident had redness to the coccyx. Review of the behavioral tracking, noted on the treatment administration record identified no behaviors were present. A nursing progress note dated 3/27/23, 07:19 and at 08:36 identified the resident reported that s/he rang the call bell and did not have any response for 8.5 hours. Further review of the progress notes identified the resident was discharged on [DATE]. A Grievance Sheet dated 3/27/23 identified Resident #26 complained that when the call bell was activated last night, s/he had to wait 8.5 hours. It further notated that on the 3-11 shift, skin cream had not been applied. Investigation statements were obtained which identified the resident was sleeping when the resident was checked and unless the resident rings, residents are not disturbed. Although a grievance form was completed, the facility failed to manage the incident as an allegation of abuse-neglect and failed to identify and interview other staff and residents who might have knowledge of the allegation, failed to determine if abuse had occurred and failed to document what changes or improvements were needed to prevent any further incidents or allegations as directed by the facility abuse policy. 12. Resident #27 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, gout, morbid obesity, ileus, and difficulty walking. A MDS assessment dated [DATE] identified the resident had no cognitive impairment, required extensive assistance for activities of daily living, total dependence with assist of 2 for transfers, frequently incontinent of bowel function, and occasionally incontinent of bladder function. A corresponding RCP, with the care conference conducted on 11/21/23 identified the resident requires assistance with ADL's related to deficits in balance, mobility, ambulation and weakness. Additionally, the RCP identified functional mobility goals with interventions that included assistance of 2 persons with a Hoyer lift for transfers. Review of a resident grievance dated 12/6/23 identified an incident that occurred on the 3-11 shift on 12/3/23. The Grievance Sheet identified Resident #27 reported to the charge nurse while providing care, a NA transferred the Resident out of bed with the Hoyer lift and did not have the assistance of 2 for the transfer. It was further noted the NA had head phones on and was listening to music while providing care to the resident. Further, the NA applied 2 briefs to the resident which were removed by the charge nurse. The follow up response identified the nurse aide was from an agency and would not be permitted back to the facility. Further review of the medical record failed to identify any progress notes and/or follow-up progress notes related to the incident. During an interview with Resident #27 on 6/21/24 at 1:30 P.M., the resident stated that s/he recalled the incident and stated that during the transfer they were nervous and could have been injured. Resident #27 stated at that time, the NA had on headphones and was listening and singing along with the music being played and was not listening to the resident. Although a grievance form was completed, the facility failed to manage the incident as an allegation of abuse-neglect and failed to identify and interview other staff and residents who might have knowledge of the allegation, failed to determine if abuse had occurred and failed to document what changes or improvements were needed to prevent any further incidents or allegations as directed by the facility abuse policy. 13. Resident #28 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dysphagia, and gastritis. An MDS assessment dated [DATE] identified the resident had no cognitive impairment, required extensive assistance with transfers, frequently incontinent of bladder and bowel function, is at risk of developing pressure ulcers and had one, stage 4 pressure ulcer. Further, the MDS identified the resident as receiving a scheduled pain medication and reported pain frequently. An RCP dated 10/11/23 identified a potential for pain related to chronic pain with interventions that included assist with position changes as needed to achieve optimal level of comfort. Review of progress notes from 10/9-10/11/23 identified a stage 4 pressure ulcer to the sacrum that measured 4.5 centimeters (cm) by 5 cm and a skin tear to the left lower leg that measured 1.5 cm by 0.5 cm and was draining copious amounts of serosanguineous drainage. Review of a resident grievance dated 10/11/23 identified the resident was dissatisfied with the therapy session on this date. S/he stated that the sessions last 20-30 minutes and then is left to sit in the chair afterwards. It was further noted that the resident wants to control the amount of time she spends outside of his/her comfort zone. The investigation statements dated 10/11/23 identified the resident reported on a previous occasion being in pain for greater than an hour. The resident reported specific to this incident, s/he felt marooned and in a puddle of pain A follow up progress note with the SW dated 10/11/23 noted the resident was alert and oriented and was placed in the wheel chair for more time than expected. It was further noted that when s/he refuses to do somethin [TRUNCATED]

Based on review of the clinical record, facility documentation, facility policy, and interviews for seven of thirteen residents, (Resident #'s 1, 3, 21, 23, 17, 27, and 28), reviewed for allegations of inappropriate staff to resident interactions, the facility failed to ensure the residents were treated with respect and dignity. The findings include: 1. Resident #1's diagnoses included Parkinson's disease, adjustment disorder, cerebral ischemic attack, difficulty in walking, depression and Alzheimer's disease. The Psychological Supportive Care progress note dated 12/27/19 identified Resident #1 with an adjustment difficulty (illness, decline, loss), inappropriate behaviors and interactive skills, short tempered and was easily annoyed. Interventions included coping skills training, supportive psychotherapy and validation therapy. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition and required limited-one person assistance with transfer and walking in the room. The care plan dated 1/21/20 identified Resident #1 with a problem related to behavior and mood patterns. Interventions directed to encourage the resident to verbalize feelings and concerns, assist to identify strengths and encouraged to focus on them, and to give realistic, positive feedback. The Psychiatric Evaluation and Consultation dated 1/27/20 identified Resident #1 was seen for a follow up to assess mood/behavior and to complete a medication review. The resident was alert and oriented with some confusion, was calm and cooperative and had a disorganized thought process. No symptoms of agitation noted. The consultation further identified they would continue to follow mood and behavior and staff should report to the psychiatric group any change in mood/behavior. A Reportable Event Form dated 2/4/20 identified Physical Therapy Assistant (PTA) #2 reported that staff member (NA #1) said to Resident #1 Sit. Sit down. Sit your ass down! Sit down. You're gonna fall. You're gonna end up on the floor .and I'm gonna choke you. NA #1 was removed from the building pending investigation. The physician and family were notified, and the police were called. Review of a Summary Report dated 2/13/20 identified Resident #1 with periods of forgetfulness at times and stated that NA #1 was her/his friend. Further review identified that the facility was unable to substantiate the allegation of verbal abuse. However, the interaction between NA #1 and Resident #1 was inappropriate. NA #1 received education directing to maintain a professional relationship with residents. Interview with NA #1 on 6/6/24 at 11:57 A.M. and NA #1's written statement related to the 2/4/20 incident with Resident #1 was reviewed. NA #1 confirmed that she was making Resident #1's bed when the resident stood up and started to walk away from her/his chair, and she stated to the resident Sit down. Sit your ass down. You're going to fall, and I'm going to choke you. NA #1 further identified that the resident just had a shower, was unsteady while walking and was not supposed to walk without help; and to stop the resident she said those words but only jokingly. NA #1 identified that she should have stopped making the bed and assisted the resident to walk or to sit down and not to use those words while speaking to the resident. Interview with PTA #2 on 6/11/24 at 12:28 P.M. identified she was waiting by the elevator and witnessed NA #1 being verbally abusive to Resident #1. NA #1 sounded frustrated and angry, she was speaking to the resident in a very stern voice and aggressive manner. PTA #2 further identified that NA #1 was not joking while directing the resident to sit down. The resident was sitting in her/his chair, slumped down, leaning forward, confused and spoke a different language. PTA #2 further identified that she immediately reported the incident to her supervisor because NA #1 used inappropriate words and threatened the resident. Interview and facility investigation review related to the 2/4/20 incident with current DNS on 6/11/24 at 2:20 P.M. identified NA #1 was verbally abusive to Resident #1. The DNS further identified no one person, no facility staff should use impolite, offensive or threatening words while speaking to a resident. Interview and review of facility documentation related to the 2/4/20 incident with MD #1 on 6/18/24 at 11:15 A.M. identified NA #1 was verbally abusive to Resident #1 and her employment should have been terminated at that time. 2. Resident #3's diagnoses included malignant neoplasm (cancer) of the esophagus, vertigo (sensation of spinning, often described as dizziness), weakness, difficulty in walking, depression, epilepsy (seizures), and suicidal ideation. The MDS assessment dated [DATE] identified that Resident #3 was cognitively intact, had no behavioral issues, and required limited assistance with transfers, and extensive assistance for bed mobility and locomotion on and off the unit. Review of a Reportable Event document dated 9/4/23 identified that Resident #3 voiced concerns after requesting that NA #2 move papers for him/her to the other side of the room and NA #2 threw them across the room, in which they landed on the floor, and NA #2 refused to pick them up, stating, I don't want to be here, and left the room. Review of facility documentation dated 9/4/23 identified Investigation Statements from LPN #1, NA #2, NA #4, and RN #8 and identified the following. a. Statement from LPN #1 identified that a NA called her to Resident #3's room and upon entering the room, the resident requested she close the door and proceeded to tell her that NA #2 threw papers across the room and they landed on the floor. Resident #3 reported he/she told NA #2 that the papers were on the floor and she responded, I know and walked out of the room. Resident #3 stated he/she was concerned that the roommate would attempt to pick up the papers and would fall down. Staff picked up the papers and LPN #1 notified the nursing supervisor. b. Statement from NA #2 identified that she threw papers across the room and did not pick them up, indicating she knew it was wrong. c. Statement from NA #4 identified that Resident #3 reported to her that he/she was very upset with NA #2 because they requested that she move papers to the roommates bed or windowsill and she instead just threw them on the floor. When Resident #3 asked NA #2 why she threw the papers she replied stating, I don't want to be here. d. Statement from RN #8 identified that she was asked by LPN #1 to speak to Resident #3 following an incident where he/she had asked NA #2 to return some newspapers to her roommate that she had borrowed, and NA #2 threw the papers onto the floor next to the bed. When Resident #3 asked NA #2 why she threw the papers, NA #2 responded that she didn't want to be there and proceeded to leave the room. Interview with LPN #1 on 6/6/24 at 12:08 P.M. identified that she has worked with NA #2 for a long time and there had been previous complaints from residents about how she acted and conversed with them that could have constituted abuse or neglect. LPN #1 indicated that NA #2 had made rude statements on several occasions and that there were 4 residents (Resident's #17, #22, #24, and #23) that didn't want NA #2 to care for them. Interview with NA #2 on 6/6/24 at 3:03 PM identified that Resident #3 had requested she put some papers that she had borrowed from her roommate back onto her roommate's bed, but instead she threw them on the floor and would not pick them up, and when asked why she did that she reported that she was just having fun and indicated that it wasn't meant to hurt anybody. She later identified that she was sick of residents expecting her to stop what she was doing to help them or bring them things, stating I'm not doing that. They need to ask their own aide. Interview with NA #4 on 6/7/24 at 12:11 P.M. identified that she was able to recall the 9/4/23 incident regarding Resident #3, reporting that Resident #3 was a lovely person who never complained about anything, but on that afternoon, s/he walked up to the nurse's station independently and was very upset. Resident #3 reported to her that he/she had requested that NA #2 put some papers back on his/her roommates bed and she picked them up and threw them, and they landed on the floor, and NA #2 then refused to pick them up and left the room. She stated that Resident #3 was very worried that his/her roommate would slip on the papers and fall and was scared of NA #2, so she called LPN #1 to the room to report the incident and then picked up the papers and placed them on the resident's bed. Additionally, NA #4 identified that she has worked with NA #2 for [AGE] years and she has a very bad temper, further stating that if NA #2 doesn't like a resident, she will do anything to avoid them, including changing the NA assignment, picking and choosing who she wants to care for. She also reported that there are 4 residents that refuse care from NA #2, but was only able to identify Resident #17 and #21 by name as 2 of the 4 resident's. Although attempted, an interview with RN #8 was unable to be obtained. A nursing progress note dated 9/4/23 at 10:17 P.M. identified that APRN #2 was notified of the incident regarding Resident #3 and NA #2, and new orders were obtained to monitor mood, sleep, and appetite for 3 days as well as to obtain a psych consult. The authorities were notified, and a case number was obtained. Resident #3 reported being very angry with NA #2. The Resident Care Plan (RCP) dated 9/5/23 identified that Resident #3 voiced concerns related to how a NA made him/her upset. Interventions included a psychiatric evaluation, facility social worker to provide follow-up visits, and staff to monitor for changes in mood, mentation, sleep, and appetite. Review of Psychiatric Evaluation and Consultation dated 9/7/23 identified that Resident #3 was seen for an allegation where Resident #3 reported that a NA threw something on the floor that he/she had requested she place on the roommate's bed and refused to pick it up. The report indicated that Resident #3 was able to account for the incident with the NA and he/she stated that the NA was rude and disrespectful towards him/her. Review of facility audits from the 9/4/23 investigation identified 2 resident audits alleging abuse/ neglect (Resident #21, #33) by NA #2. Review of the personnel file for NA #2 identified the date of hire as 11/4/2002. Review identified multiple education sessions related to the employee's attitude and her approach with residents. Multiple coaching sessions, final warnings, and counseling sessions (total of 16 since 2003) identified NA #2 had been disrespectful to residents, neglectful, abusive with her language with residents and rough with care. Review of facility documentation dated 9/12/23 between DNS#2 and the Human Resources Manager identified that a termination of employment will not be supported. Instead, the employee will be provided with a final written warning and offer clear guidance/re-training on expectations. Interview with DNS #2 on 6/6/24 at 12:35 P.M. identified that she would have terminated NA #2 a long time ago, indicating that she had sent numerous involuntary separation attempts to corporate for review, but she was met with a lot of resistance, and they were all rejected. She reported that there had been several complaints from residents regarding NA #2, but when they would discuss the incidents with NA #2, she would state, I thought it was okay, we were cool and would not admit any wrongdoing. She also indicated she had received employee complaints against NA #2 stating that she was not a team player and had an attitude with them as if they were bothering her when asking for assistance. She identified that NA #2 had been suspended after the 9/4/23 incident for at least 5 days. DNS #2 further stated during that time, she monitored NA #2, however, was unable to provide documentation of such monitoring. NA #2 was terminated on 6/13/24. Additionally, DNS #2 reported that the social workers were responsible for following up with Resident #3 after the incident. Review of the clinical record failed to document any social worker follow up after the 9/4/23 incident. Interview and clinical record review with SW #1 (Director of Social Services) on 6/7/24 at 12:57 P.M. identified that a reportable event alleging abuse/neglect that involves a staff member will trigger social work staff to conduct personalized resident rights audits. She reported that the prior DNS had requested she conduct the audits as part of the reportable event investigation, but that there was no formal process for the audits or a process on what questions were asked. SW #1 reported that she conducted the audits and then reviewed them with the prior DNS, but stated she was not asked by the prior DNS to follow up any further. Additionally, she identified that staff refusing to help a resident with any services they request would be classified as neglect. She reported that Resident #3 had indicated that she had no prior problems with NA #2 until 9/4/23, stating that day she was out of place. Interview with the DNS on 6/11/24 at 12:06 P.M. identified that she was not employed at the facility at the time of the 9/4/23 allegation and reported that she had not been made aware that NA #2 had a history of progressive discipline and that residents had made allegations of abuse/neglect against her in the past. She indicated that since starting the DNS position in March of 2024, she has had complaints from other staff reporting that NA #2 is not a team player and changes the NA assignment so that she can pick and choose who she wants to care for, and stated she had spoke with NA #2 about it, but reported she was not aware of any allegations of abuse/neglect towards the residents from NA #2 since her employment started. Further, the DNS identified that after reviewing the 9/4/23 incident, it would not surprise her if staff and residents notified her that NA #2 has a temper. Re-review of the personnel file for NA #2 failed to identify any verbal coaching or discipline following the 9/4/23 incident. A subsequent interview with SW #1 on 6/20/24 at 11:57 AM identified that she had received grievances from other residents regarding rough care, refusal of care, and her attitude in the past (4/2/23) and was not surprised to hear additional residents voice concerns that they were afraid of NA #2. She further stated that after the resident allegation of abuse on 9/4/23, a survey audit was conducted of all residents soliciting the quality of care and services provided by NA #2. SW #1 stated that several residents had reported concerns, however, stated that she did not follow up on the concerns as the DNS did not direct her to. An interview with Resident #3 was unable to be obtained. 3. Resident #21 was admitted with diagnoses of type 2 diabetes mellitus, congestive heart failure, weakness, unsteady in the feet, difficulty walking, dysphagia, feeding difficulties, history of falls, anxiety and depression. A quarterly MDS assessment dated [DATE] identified that Resident #21 was cognitively intact, exhibited no behaviors, required limited assistance with bed mobility, transfers, and toileting and required extensive assistance with hygiene. The RCP dated 4/30/24 identified Resident #21 had deficits that required support with bathing, grooming, dressing, and toileting related to generalized weakness and a history of pain. Additionally, the RCP identified that Resident #21 had a history of refusing care from some staff, displays accusatory behavior toward staff at times, and yells at staff at times. Interventions included that the resident was an assist of 2 with care, monitor for triggering events and avoid them in the future, decrease visual or auditory stressors when over stimulated, if agitated during activity stop the activity and try again later, and staff to listen and be supportive. Review of the 'Grievance Sheet' dated 7/25/22 identified Resident #21 reported waiting for over two hours from 9:00 PM to 11:00 P.M. on 7/22/22 for the NA to assist with care, and that he/she is not happy when the NA's tell him/her that they only have X number of other residents to take care of before they can attend to him/her. The response stated the social worker met with the resident and reviewed his/her requests for timely responsive care and the DNS and Administrator are aware of requests. Review of the 'Grievance Sheet' dated 3/27/24 identified Resident #21 reported that dishes are not removed timely following meals and that he/she would like to store food from meals in the refrigerator. The facility response recorded stated the DNS provided education on timely removal of meal trays and if a resident wishes to store leftover food, they must label it prior to storing it in the refrigerator. Although the grievance identified broadly that the dishes weren't picked up, interview with Resident #21 on 6/6/24 at 12:44 P.M. identified that NA #2 was the staff member that refused to pick up trays and store the food in the refrigerator as requested by Resident #21. Resident #21 further stated that NA #2 would turn off the call bell and state that the resident needed to ask the NA assigned to his/her care for assistance. Interview with Resident #21 on 6/6/24 at 12:44 P.M. identified that he/she had filed previous grievances regarding not receiving care timely, NA #2 shutting off call bells and not providing care and refusing to take dinner trays and store leftover food in the fridge. He/she reported that NA #2 treats him/her differently now by refusing to help him/her and telling him/her to ask his/her assigned NA, not bringing items it for him/her that she brings in for others and he/she feels as if they are being retaliated against. Review of the Resident Rights Survey/Audit conducted from a 9/4/23 facility investigation regarding NA #2, Resident #21 reported that NA #2 sometimes if I ask her to do something she refuses. 4. Resident #23 was admitted with diagnoses of peripheral vascular disease, left sided hemiplegia/hemiparesis, type 2 diabetes mellitus, weakness, depression, and anxiety. A quarterly MDS dated [DATE] identified that Resident #23 was cognitively intact, exhibited no behaviors, and required extensive assistance for bed mobility, transfers, and toileting. The RCP dated 4/23/24 identified that Resident #23 required assistance with bathing, dressing, and transfers due to functional deterioration related to hemiplegia post Cerebral Vascular Accident (CVA), Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD) stage 3, Gout, and Osteoparthritis (OA) of the hips. Interventions included extensive to total assist with activities of daily living, allow the resident to make choices, and to ask and encourage the resident to participate to the full extent that he/ she is able. Additionally, the RCP identified that Resident #23 displays behaviors of hoarding, making inappropriate comments, diet noncompliance at times, refusing to get out of bed at times, and has a history of accusations regarding not receiving his/her Ambien (narcotic sleep medication) at bedtime. Interventions included education with the resident regarding the risks of not waiting for staff assistance, education with the resident that his/her threatening behavior is inappropriate, staff to listen to the resident and be supportive, and staff to provide for the immediate safety of the resident. Interview with Resident #23 on 6/13/24 at 12:50 P.M. identified that he/she filed a grievance related to NA #2 a few years ago and he/she has not allowed her to care for him/her since, reporting her attitude is rude and demeaning, stating she barks orders from the doorway, acting like [NAME], and refuses to answer the call bell. He/she indicated they have waited over an hour for the call bell to be answered on numerous occasions and has been told by NA #2 that he/she needs to wait until his/her assigned NA can come to assist. Review of the 'Grievance Sheet' dated 8/22/21 reported that he/she is treated unfairly by NA #2, as she causes him/her anxiety due to her refusals to give him/her linens or soup when she services the other residents. Review of progress notes from 8/21/21 through 8/30/21 failed to identify any documentation regarding any allegations towards staff and/or the residents mood. Further review failed to identify any follow up investigation had been conducted following Resident #23's concerns with interaction that s/he had with NA#2, but rather NA #2 was no longer assigned to Resident #23's care. Review of the personnel file for NA #2 identified the date of hire as 11/4/2002. Review identified multiple education sessions related to the employee's attitude and her approach with residents. Multiple coaching sessions, final warnings, and counseling sessions (total of 16 since 2003) identified NA #2 had been disrespectful to residents, neglectful, abusive with her language with residents and rough with care. Review of facility documentation dated 9/12/23 between DNS#2 and the Human Resources Manager identified that a termination of employment will not be supported. Instead, the employee will be provided with a final written warning and offer clear guidance/re-training on expectations. Interviews with Social Worker #1, LPN # 1 and the DNS were conducted related to the concerns presented from Resident #'s 17, 18, 19, 21, 22, 23, 24 and #33 regarding care and services. During an interview with LPN #1 on 6/6/24 at 12:08 P.M. she stated that she has worked with NA #2 for a long time and there had been previous complaints from residents about how she acted and conversed with them. LPN #1 indicated that NA #2 had made rude statements on several occasions and that there were 4 residents (Resident's #17, #22, 23 and #24 ) that didn't want NA #2 to care for them. Interview with SW #1 on 6/7/24 at 12:57 P.M. identified that abuse includes physical, sexual, psychosocial, financial and verbal abuse, which includes derogatory statements, yelling, and inappropriate words. Further interview indicated that she brings the grievances to the morning meeting and the DNS determines how they should be managed. Additionally, she could not explain why these incidents were managed as grievances and not as allegations of abuse or neglect. Interview with the DNS on 6/11/24 at 12:06 P.M. she identified the Social Worker is probably the Grievance Officer. She further stated that when there are concerns with care, they are transferred to nursing. She further stated that she could not speak to why the process failed as she was not the DNS during that time frame. 5. Resident #17 was admitted with diagnoses of neuropathy, low back pain, weakness, and protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that Resident #17 was cognitively intact, exhibited no behaviors, required limited assistance with transfers, and extensive assistance for bed mobility, toileting, and hygiene. An RCP dated 4/25/23 identified that Resident #17 required assistance with activities of daily living related to deficits in balance, strength, weakness, intractable back pain, and ambulation. Interventions included allowing the resident to make choices, breaking tasks down to simpler sub tasks, and explaining the purpose and expected task to the resident. Additionally, there were no RCP's regarding behaviors, resident to staff interactions, or allegations of abuse. A Grievance Sheet dated 4/2/23 identified Resident #17 reported that NA #2 was rough with him/her when she put him/her in bed and that NA #2 put her fist on the Resident's back while using the bathroom, requesting he/she did not want NA #2 caring for him/her. SW #1 reported she followed up with emotional support for Resident #17 and that there had been no additional concerns. Further review failed to identify any follow up investigation had been conducted following Resident #17's concerns with interaction that s/he had with NA#2, but rather NA #2 was no longer assigned to Resident #17's care. Review of progress notes from 4/2/23 through 4/9/23 failed to identify any documentation regarding any allegations towards staff and/or the residents mood. During an interview with LPN #1 on 6/6/24 at 12:08 P.M. she stated that she has worked with NA #2 for a long time and there had been previous complaints from residents about how she acted and conversed with them. LPN #1 indicated that NA #2 had made rude statements on several occasions and that there were 4 residents (Resident's #17, #22, 23 and #24 ) that didn't want NA #2 to care for them. Interview with Resident #17 on 6/13/24 at 11:42 AM indicated that s/he was unable to recall the events mentioned in the grievance. Interview with the SW #1 on 6/20/24 at 11:57 AM identified, although she had documented on the grievance form for Resident #17 that s/he followed up with the resident for emotional support and there were no further concerns, s/he reported the encounters were not documented in the clinical record. 6. Resident #27 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, gout, morbid obesity, ileus, and difficulty walking. A MDS assessment dated [DATE] identified the resident had no cognitive impairment, required extensive assistance for activities of daily living, total dependence with assist of 2 for transfers, frequently incontinent of bowel function, and occasionally incontinent of bladder function. A corresponding RCP, with the care conference conducted on 11/21/23 identified the resident required assistance with ADL's related to deficits in balance, mobility, ambulation and weakness. Additionally, the RCP identified functional mobility goals with interventions that included assistance of 2 persons with a Hoyer lift for transfers. Review of a resident grievance dated 12/6/23 identified an incident that occurred on the 3-11 shift on 12/3/23. The Grievance Sheet identified Resident #27 reported to the charge nurse while providing care, a NA transferred the Resident out of bed with the Hoyer lift and did not have the assistance of 2 for the transfer. It was further noted the NA had head phones on and was listening to music while providing care to the resident. Further, the NA applied 2 briefs to the resident which were removed by the charge nurse. The follow up response identified the nurse aide was from an agency and would not be permitted back to the facility. Further review of the medical record failed to identify any progress notes and/or follow-up progress notes related to the incident. During an interview with Resident #27 on 6/21/24 at 1:30 P.M., the resident stated that s/he recalled the incident and stated that during the transfer s/he was anxious and could have been injured. Resident #27 stated at that time, the NA had on headphones and was listening and singing along with the music being played and was not listening to the resident and any concerns s/he verbalized regarding the unsafe hoyer lift transfer. 7. Resident #28 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dysphagia, and gastritis. An MDS assessment dated [DATE] identified the resident had no cognitive impairment, required extensive assistance with transfers, was frequently incontinent of bladder and bowel function, is at risk of developing pressure ulcers and had one, stage 4 pressure ulcer. Further, the MDS identified the resident as receiving a scheduled pain medication and reported pain frequently. An RCP dated 10/11/23 identified a potential for pain related to chronic pain with interventions that included assist with position changes as needed to achieve optimal level of comfort. Review of progress notes from 10/9-10/11/23 identified a stage 4 pressure ulcer to the sacrum that measured 4.5 centimeters (cm) by 5 cm and a skin tear to the left lower leg that measured 1.5 cm by 0.5 cm and was draining copious amounts of serosanguineous drainage. Review of a resident grievance dated 10/11/23 identified the resident was dissatisfied with the therapy session on this date. S/he stated that the sessions last 20-30 minutes and then is left to sit in the chair afterwards. It was further noted that the resident wants to control the amount of time s/he spends outside of his/her comfort zone. The investigation statements dated 10/11/23 identified the resident reported on a previous occasion being in pain for greater than an hour. The resident reported specific to this incident, s/he felt marooned and in a puddle of pain A follow up progress note with the SW dated 10/11/23 noted the resident was alert and oriented and was placed in the wheel chair for more time than expected. The progress note further identified the resident reported that when s/he refuses to do something, therapy makes faces and gestures with their hands. The facility policy and procedure for Grievances identified if the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown source the incident shall be investigated and reported pursuant to the facility policy on abuse prohibition. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 2/2023, identified, it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined verbal abuse as including the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. The policy further directed the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on clinical record review, review of facility documentation, review of policy and procedures for 24 of 24 residents (Resident #'s 16, 29, 32, 34, 35, 36, 37, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, and 57) ) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, seizures, gastro-esophageal reflux disease, hyperlipidemia, adjustment disorder and hypertension. Physician orders directed Pepcid 40 milligrams (mg), one time a day for gastro-esophageal reflux disease; Senna 8.6 mg, one time a day for constipation; Keppra, 100 mg, two times a day for anti-convulsions and Acyclovir (antiviral medication) 400 mg, one time a day for prophylaxis. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Pepcid, Senna, Acyclovir and Keppra were scheduled for administration at 8:30 A.M., the medication was not administered until 1:06 P.M. (4 hours and 36 minutes late). 2. Resident #29 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, chronic diastolic heart failure, mood disorder, and venous hypertension. Physician orders directed normal saline nasal spray, 1 spray to each nostril every morning and at bedtime for dry nose; Jardiance 10 mg, once a day for diabetes; Omega 3-1000 mg, 2 capsules once a day; Miralax powder 17 grams, once a day for constipation; Fluticasone Furoate -Vilanterol Aerosol Powder Breath Activated 200-250 micrograms, one puff once a day for COPD; Vitamin B-Complex, one tablet once a day as a mineral supplement; Depakote Delayed Release 250 mg, 2 tablets twice a day for mood disorder; Allopurinol 100 mg, once a day for gout; Calcium Citrate 200 mg, 1 tablet twice a day as a supplement; Eliquis 5 mg, two times a day for atrial fibrillation; Pepcid 20 mg, once a day for gastro-esophageal reflux disease (GERD); Wellbutrin XL 300 mg, once a day for depression; Tylenol Extra Strength 500 mg, 2 tablets, twice a day for pain; and Liquid Protein, 30 milliliters, once a day. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although normal saline nasal spray, Jardiance, Omega 3, Miralax powder, Fluticasone Furoate -Vilanterol Aerosol Powder Breath Activated, Vitamin B-Complex, Depakote Delayed Release, Eliquis, Allopurinol, Calcium Citrate, Pepcid, Wellbutrin XL, Tylenol Extra Strength, Liquid Protein were scheduled for administration at 8:30 A.M., the medication was not administered until 12:57 and 12:58 P.M. (4 hours and 27 minutes and 4 hours and 28 minutes late). 3. Resident #32 had diagnoses that included schizophrenia, COPD, spinal stenosis, seizures, cardiomegaly, and GERD. Physician orders directed Abilify 15 mg, once a day for schizophrenia; Senna Plus, 1 tablet two times a day for constipation; Furosemide 20 mg, one table daily for congestive heart failure; Sertraline HCL 100 mg, once day for depression; Phenobarbital 32.4 mg, once day for seizures; Keppra 100 mg, two times daily for a seizure disorder; and Umeclidinium -Vilanterol Inhalation Aerosol Powder Breath Activated, once daily for COPD. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Abilify, Senna Plus, Furosemide 20 mg, Sertraline, and Umeclidinium -Vilanterol Inhalation Aerosol Powder Breath Activated, were scheduled for 8:30 A.M. the medications were not administered until 11:19 A.M to 12:23 P.M. (2 hours and 41 minutes and 3 hours and 53 minutes late). 4. Resident #34 had diagnoses that included Alzheimer's disease, dysphagia, chronic kidney disease, and atherosclerotic heart disease. Physician orders directed Isosorbide Mononitrate ER 30 mg, once a day for coronary artery disease. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Isosorbide Mononitrate ER was scheduled for 9:30 A.M., the medication was not administered until 1:11 P.M. (3 hours and 41 minutes late). 5. Resident #35 had diagnoses that included Type 2 diabetes, essential hypertension, and osteoarthritis. Physician orders directed Namenda 10 mg two times a day for behavioral disturbance and dementia. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Namenda was scheduled for 9:30 A.M., the medication was not administered until 12:06 P.M. (2 hours and 36 minutes late). 6. Resident #36 was admitted with diagnoses that included Alzheimer's disease, Type 2 diabetes mellitus, dysphagia, depressive disorder, and convulsions. Physician orders directed Lexapro 20 mg one time a day for depression; Polyethylene Glycol powder 17 grams once a day for constipation; Keppra 750 mg twice a day for seizures; Labetalol HCL 50 mg twice a day for hypertension; and Baclofen 5 mg, 2 tablets twice a day for a hand contracture. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Lexapro, Polyethylene Glycol powder, Keppra, Labetalol and Baclofen were scheduled for 9:30 A.M., the medications were not administered until 1:22 P.M., 2:27 P.M. and 2:31 P.M. (3 hours and 52 minutes late-4 hours and 1 minute late). 7. Resident #37 was admitted with diagnoses that included metabolic encephalopathy, heart failure, Alzheimer's disease, hypertensive emergency, and a pressure ulcer of the sacral region. Physician orders directed Lasix 30 mg, two times a day related to heart failure. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Lasix 30 mg, was scheduled for administration at 9:30 A.M., the medication was not administered until 12:19 P.M. (2 hours and 49 minutes late). 8. Resident # 39 had diagnoses that included metabolic encephalopathy, unspecified dementia, hypothyroidism, Alzheimer's disease, and congestive heart failure. Physician orders directed Sertraline HCL 50 mg, once daily for depression; Aspirin Delayed Release 81 mg, once daily for history of venous thrombosis and embolism; Potassium Chloride Extended Release 10 milliequivalents, once daily for low potassium; Calcium-Vitamin D Minerals, 600-400 mg units; Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 micrograms, one puff daily for COPD; Eliquis 2.5 mg, twice daily for history of venous thrombosis and embolism; Tiotropium Bromide Monohydrate Inhalation 18 micrograms, inhale orally once time a day for hypoxia; Memantine HCL 10 mg, once daily for dementia; Diltiazem HCL 30 mg, twice a day for heart failure; Risperdal 0.5 mg, two times a day for dementia; and Lasix 40 mg, once daily for congestive heart failure. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Sertraline, Aspirin Delayed Release 81 mg, Potassium Chloride Extended Release, Calcium-Vitamin D Minerals, Breo Ellipta Inhalation Aerosol Powder Breath Activated, Eliquis 2.5 mg, Tiotropium Bromide Monohydrate Inhalation, Memantine HCL, Diltiazem HCL 30 mg, Risperdal 0.5 mg, and Lasix 40 mg, was scheduled for administration at 9:30 A.M., the medication was not administered until 1:14 P.M. and 2:51P.M. (3 hours and 44 minutes to 5 hours and 21 minutes late). 9. Resident #40 was admitted to the facility on [DATE] with diagnoses that included interstitial pulmonary disease, hypoxemia, obstructive and reflux uropathy, and essential hypertension. Physician orders directed Magnesium Oxide 400 mg, two times a day as a mineral supplement. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Magnesium was scheduled for administration at 9:30 A.M., the medication was not administered until 1:19 P.M. 3 hours and 49 minutes late). 10. Resident #41 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, type 2 diabetes mellitus, major depressive disorder, and pain in the left shoulder. Physician orders directed Morphine Sulfate Oral Solution, 20mg/ml. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Morphine Sulfate was scheduled for administration at 8:30 A.M., the medication was not administered until 10:32 A.M. (2 hours and 2 minutes late). 11. Resident #42 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, atrial fibrillation, peripheral vascular disease, mood disorder, and cerebral aneurysm. Physician orders directed Lidocaine External Patch 4%, apply to right hip once a day for pain; Amiodarone HCL 100 mg, once daily; Lasix 1.5 tablet, once daily for congestive heart failure; Aspirin 81 mg, once daily for atrial fibrillation; Coreg 12.5 mg, twice a day for hypertension; and Eliquis 2.5 mg, two times a day for atrial fibrillation. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Lidocaine External Patch 4%, Amiodarone HCL, Lasix, Aspirin, Coreg, and Eliquis were scheduled for administration at 9:30 A.M., the medication was not administered until 11:59 A.M. (2 hours and 29 minutes late). 12. Resident #44 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, heart failure, Parkinson's disease with dyskinesia, and hypertension. Physician orders directed Miralax 17 grams, once every other day; Tylenol Arthritis Pain Tablet Extended Release 650 mg, 2 times a day for pain; Lidocaine patch 4%, apply to right and left knee and back daily for pain. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Miralax, Tylenol Arthritis Pain Tablet Extended Release, and Lidocaine patch were scheduled for administration at 9:30 A.M., the medication was not administered until 11:02 A.M. and 11:10 A.M. (1 hours and 32 minutes and 1 hour and 40 minutes late). 13. Resident #46 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, chronic diastolic heart failure, and atrial fibrillation. Physician orders directed Flonase Suspension 50 micrograms, 1 spray to both nostrils daily; Lasix 40 mg, daily for congestive heart failure; Tramadol HCL 50 mg, 2 times a day for pain; Senna 8.6 mg, 2 tablets daily for constipation; and Eliquis 2.5 mg two times a day for atrial fibrillation. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Flonase Suspension, Lasix, Tramadol HCL, Senna, and Eliquis were scheduled for administration at 9:30 A.M., the medication was not administered until 1:23 P.M. and 1:31 P.M. (3 hours and 23 minutes and 4 hours and 1 minute late). 14. Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, squamous cell carcinoma, senile degeneration of the brain, adjustment disorder, pemphigus, and pain in the left shoulder. Physician orders directed Prednisone 20 mg, one time a day for pemphigus; Niacinamide 500 mg, once daily for pemphigus; and Doxycycline Monohydrate 100mg, twice daily for pemphigus. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Prednisone 20 mg, Niacinamide, and Doxycycline Monohydrate were scheduled for administration at 9:30 A.M., the medication was not administered until 12:21 P.M. (2 hours and 51 minutes late). 15. Resident #48 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, severe protein-calorie malnutrition, gastrointestinal hemorrhage, and contracture of the hip. Physician orders directed Miralax 17 grams, once daily for constipation; Zoloft 25 mg, once daily for skin picking; and Refresh Tears 2 drops in both eyes twice daily. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Miralax, Zoloft, and Refresh Tears were scheduled for administration at 9:30 A.M., the medication was not administered until 12:07 P.M. (2 hours and 37 minutes late). 16. Resident #49 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, hyperlipidemia, peripheral vascular disease, disorder of the adrenal gland, depressive disorder, and cerebral infarction. Physician orders directed Norvasc 5 mg, once daily; Aspirin 81 mg Delayed Release, one tab once for peripheral vascular disease; Rifaxmin Oral Tablet 550 mg, once daily for encephalopathy; Senna 8.6 mg, two tablets for constipation; Clopidogrel Bisulfate 75 mg, once daily for peripheral vascular disease; Trazodone HCL 50 mg, give one half of a tablet for depressive disorder; Sertraline HCL 100 mg, one and one half tablet once daily for depression, Polyethylene Glycol Powder 17 grams, once daily for constipation; Thera M Plus, one tablet daily for supplement; Lactulose 15 milliliters, three time a day for constipation; and Lidocaine External Patch 4%, apply to bilateral knees daily. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Norvasc, Aspirin, Rifaxmin, Senna, Clopidogrel Bisulfate, Trazodone HCL, Sertraline HCL, Polyethylene Glycol Powder, Thera M Plus, Lactulose, and Lidocaine External Patch were scheduled for administration at 8:30 A.M., the medication was not administered until 10:16 A.M. to 10:22 A.M. (1 hour and 46 minutes late - 1 hour and 52 minutes late). 17. Resident # 50 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, COPD, hypothyroidism, hypertension, major depressive disorder, and peripheral vascular disease. Physician orders directed Senna S 8.6-50 mg, one tablet once daily for constipation; and Zoloft 50 mg, once daily for major depression. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Senna and Zoloft were scheduled for administration at 9:30 A.M., the medication was not administered until 1:07 P.M. (3 hours and 37 minutes late). 18. Resident #51 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, gastrostomy, seizures, schizoaffective disorder, and hypertension. Physician orders directed Aspirin 81 mg, once daily following cerebral infarction; Famotidine 20 mg, once daily for GERD; Finasteride 5 mg, once daily; Nitrofurantoin Macrocrystal 50 mg, once daily for urinary tract infection prophylaxis; Seroquel 50 mg, one and none half tablets for schizoaffective disorder; Keppra 250 mg, twice daily for seizures; Cilostazol 100 mg, twice daily for arterial disease; Baclofen 5 mg, three times a day for contracture; Tylenol 650 mg, three times a day for pain and Gabapentin 100 mg, two times a day for neuropathy pain. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Aspirin, Famotidine, Finasteride, Nitrofurantoin Macrocrystal, Seroquel, Keppra, Cilostazol, Baclofen, Tylenol, Gabapentin were scheduled for administration at 8:30 A.M., the medication was not administered until 1:02 P.M. to 2:48 P.M. (4 hours and 32 minutes to 6 hours and 18 minutes late). 19. Resident #52 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic heart failure, chronic atrial fibrillation, chronic kidney disease, hypertension, benign prostatic hyperplasia (BPH) , contracture, and Parkinson's disease. Physician orders directed Carvedilol 3.125 mg, twice daily for heart failure; Pantoprazole Sodium Delayed Release 40 mg, once daily for GERD; Lasix 20 mg, once daily for heart failure; Finasteride 5 mg, once daily for BPH; Levsin 0.125 mg, twice daily for secretions; Eliquis 5 mg, twice daily for atrial fibrillation; Lisinopril 5 mg, once daily for heart failure; Zoloft 25 mg, once daily for depression; Cyanocobalamin 1000 micrograms, one daily for anemia; and Multivitamin, one tablet daily as a supplement. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Carvedilol, Pantoprazole Sodium Delayed Release, Lasix, Finasteride, Levsin, Eliquis, Lisinopril 5 mg, Zoloft, and Cyanocobalamin were scheduled for administration at 8:30 A.M., the medication was not administered until 11:16 A.M. (2 hours and 46 minutes late). 20. Resident #53 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, Alzheimer's disease, hypothyroidism, major depressive disorder, GERD, and hypertension. Physician orders directed Fiber Oral Tablet, one tablet daily for constipation; Miralax 17 grams, one packet daily for constipation; Metformin HCL 1000 mg, twice daily for diabetes mellitus; Farxiga 10 mg, once daily for diabetes mellitus; Rivastigmine Tartrate 1.5 mg, twice daily for Alzheimer's disease; Zoloft 100 mg; once daily for depression; and Lantus Insulin 4 units, once a day for diabetes mellitus. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Fiber Oral Tablet, Miralax, Metformin HCL, Farxiga, Rivastigmine Tartrate, Zoloft, and Lantus Insulin were scheduled for administration at 8:30 A.M., the medication was not administered until 11:11 A.M. to 11:56 A.M. (2 hours and 41 minutes late to 3 hours and 26 minutes late). 21. Resident #54 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, atrial fibrillation, hyperlipidemia, aneurysm of the carotid artery, stage 3 chronic kidney disease, and adjustment disorder with depressed mood. Physician orders directed Lidocore External Patch 4%, apply to right knee daily for pain and Apixaban 2.5 mg, two times a day for atrial fibrillation. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Lidocore and Apixaban were scheduled for administration at 8:30 A.M., the medication was not administered until 2:33 P.M. and 2:50 P.M. respectively (4 hours and 3 minutes late to 4 hours and 20 minutes late). 22. Resident #55 was admitted to the facility on [DATE] with diagnoses that included fracture of the left acetabulum, dementia, chronic kidney disease, major depressive disorder, hypertension, arteriosclerotic heart disease, and hemiplegia following cerebral infarction. Physician orders directed Aspirin 81 mg daily for hemiplegia, Donepezil HCL 10 mg once daily for dementia, and Cholecalciferol 25 micrograms daily for Vitamin D deficiency. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Aspirin, Donepezil HCL, and Cholecalciferol were scheduled for administration at 8:30 A.M., the medication was not administered until 12:09 P.M. (3 hours and 39 minutes late). 23. Resident #56 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hydroureter, dementia, hypotension and impaction of the intestine. Physician orders directed Senna 8.6 mg daily for constipation; Miralax 17 grams, daily for constipation; Hiprex 1 gram, daily for urinary track infection; Carbidopa-Levodopa 25-100mg, give 1.5 tablet daily for Parkinson's; Sodium Chloride 1 gram, daily for orthostatic hypotension; Fludrocortisone Acetate 0.1 mg, daily for orthostatic hypotension; Nuplazid 34 mg, once daily for hallucinations; Pepcid 20 mg, daily for GERD; and Midodrine HCL 10 mg, three tine a day for orthostatic hypotension. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although, Senna, Miralax, Hiprex, Carbidopa-Levodopa, Sodium Chloride, Fludrocortisone Acetate, Nuplazid, Pepcid, and Midodrine HCL were scheduled for administration at 8:30 A.M., the medication was not administered until 11:00 A.M. to 11:42 A.M. (2 hours and 30 minutes late to 3 hours and 12 minutes late). 24. Resident #57 was admitted to the facility on [DATE] with diagnoses that included seizures, intellectual disabilities, peripheral vascular disease, hypertension, and chronic lymphocytic leukemia. Physician orders directed Miralax 17 grams, daily for constipation; Zoloft 50 mg, daily for depression; Saline Nasal Spray 0.65% in both nostrils every day; Metoprolol Succinate ER 50 mg, daily for hypertension; Cyanocobalamin 1000 micrograms, daily for Vitamin B-12 deficiency; and Topiramate 100 mg, 1.5 tablets twice daily for seizures. Review of the facility Medication Admin Audit Report dated 11/26/23 identified that although Miralax, Zoloft, Saline Nasal Spray, Metoprolol Succinate ER, Cyanocobalamin, and Topiramate were scheduled for administration at 9:30 A.M., the medication was not administered until 1:20 P.M. to 2:38 P.M. (3 hours and 50 minutes late to 5 hours and 8 minutes late). Review of the facility documentation/investigation dated 12/1/23 identified on 11/26/23, the morning medication administration pass on an entire resident unit was delayed due to the late arrival of the nurse assigned to the 7-3 shift on the affected unit. Further review identified the night nurse remained on the unit however, did not initiate the medication administration. The investigation further identified that the incident resulted in a greater than 2 -3 hour delay on the administration time for all residents on the unit. During an interview with the Director of Nurses on 7/3/24 at 1:30 P.M., she stated that there was a disconnect in communication. She further stated the 11-7 nurse who stayed over, should have started the morning medications. Additionally, she stated the RN supervisor should have been also checking on the unit to ensure the day nurse duties had been started. The facility policy and procedure for Oral Medication Administration dated June 2015 directed in part, Verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route.

Based on record review, review of facility policies and procedures, and interviews with facility staff for 1 sampled resident, (Resident #4), who required specialized rehabilitative services, the facility failed to conduct a timely speech therapy evaluation in the presence of weight loss and failed to perform a provider directed physical therapy evaluation for heel offloading with a knee contracture in the presence of a facility acquired left heel pressure injury. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), no signs of pain, and severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted weight loss, a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and no indication of a mechanically altered diet (e.g., pureed food, thickened liquids) is noted. The Resident Care Plan (RCP) dated 3/5/21 identified Resident #4 was at risk for skin breakdown and required extensive assistance from 2 staff members for moving, turning and positioning while in bed. Additionally, the RCP identified a potential for an impaired nutritional status. The RCP further noted significant weight loss dates of 11/19/19 and 11/12/20 and included an intervention to refer to a speech therapist for a swallow evaluation as needed. Review of the clinical record identified there were no referrals to speech therapy for the significant weight loss dates of 11/19/19 and 11/12/20. Review identified Resident #4 last received speech therapy from 6/7/19-7/1/19 and was discharged on a regular diet with thin liquids and supervision a. An APRN progress noted dated 3/3/21 at 1:23 P.M. identified weight loss and interventions to include a speech therapy consult. Review of the facility Weights and Vitals document identified a weight of 146.8 lbs on 2/25/21 and a weight of 165.1 lbs on 1/29/21 identifying a significant weight loss of 11% (18.3 pounds) in just under 4 weeks. Review of the March 2021 Order Listing Report identified a provider order dated 3/22/21 which directed a speech therapy consult for a possible diet downgrade. The speech evaluation was conducted 98 days later on 6/9/21. Review of the Speech Therapy SLP Evaluation and Plan of Treatment document dated 6/9/21 identified a treatment certification duration of 85 days with oral function therapy and swallowing function eval listed under the plan of treatment with a treatment frequency of 3 times per week. The document noted Resident #4's prior level of functioning as a regular consistency diet and thin liquids, and presently on a mechanical soft consistency with thin liquids. The clinical impressions of the evaluation are as follows: Patient demonstrates a moderate oropharyngeal dysphagia characterized by reduced mastication, poor bolus formation, pocketing, oral residue, increased oral transit time, delayed swallow reflex, coughing on thins by cup and straw, inconsistent ability to suck from a straw, wet voice on thins, multiple swallows. Recommend downgrade to puree consistency with nectar thick liquids, aspiration precautions. Feed by small bites/sips alternated, no straw, slow rate with pauses to allow for multiple swallows. An interview and clinical record review with Speech Therapist #1 on 6/25/24 at 2:15 P.M. identified there was no referral made to speech therapy for an evaluation until 6/9/21 (98 days after the provider order). Speech Therapist #1 indicated a speech therapy evaluation performed in the month of June, after requested by a provider in the month of March, is not an acceptable time frame for evaluation. An interview with APRN #1 on 7/3/24 at 10:50 A.M. indicated they did not know of the delay in speech therapy evaluation and would not follow up with the facility after ordering a speech therapy evaluation because they assume no news is good news. b. On 6/1/21 a provider progress note identified Resident #4 had a left knee muscle contracture that caused the left heel to dig into the mattress and further notes discussed having PT evaluate for offloading with knee contracture. Although the progress note identified the need for a PT evaluation for positioning, the facility was unable to provide documentation of this evaluation. An interview and clinical record review with the Director of Rehabilitation Services on 6/25/24 at 2:00 P.M. identified there was no documentation in therapy notes reflecting an evaluation or treatment related to offloading with a knee contracture. The interview further identified that in 2021 the facility did not have a communication tool for other departments to refer to therapy services and that referrals may have been discussed during the facility's daily clinical meeting. Review of the Pressure Injury/Non Pressure Wound Risk Management policy includes the following in reference to immobile residents: Heels are extremely vulnerable and must be elevated completely off the bed and\or chair surface. Use pillows, positioning devices, and or suspension boot devices.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two of six sampled residents (Residents #8 and #31) reviewed for allegations of abuse, the facility failed to immediately report the allegation of abuse to the state agency and no later than two (2) hours after being notified of the alleged abuse in accordance with facility policy. The findings include: 1. Resident #8 was admitted to the facility with diagnoses that included cerebral infraction, hypertension, cognitive communication deficit and Wernicke's encephalopathy. The admission MDS dated [DATE] identified Resident #8 had intact cognition, was frequently incontinent of bladder, was always incontinent of bowel and required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The care plan dated 8/25/21 identified the resident exhibited behavior problems and refused to get out of bed. Interventions directed to introduce yourself to the resident and explain what you are going to do, use calm, gentle approach, work slowly and ask the resident for cooperation with task. The Grievance Sheet dated 10/13/21 identified a staff member (OT #2) went to Resident #8 to provide therapy. Resident #8 reported that her/his NA (NA #9) was being evil to her/him last night, during the 3 P.M. to 11 P.M. shift on 10/12/21. The resident stated she/he needed to go to the bathroom and NA gave her/him attitude that escalated to the NA stating, I cannot wait to quit, so you guys can take care of each other, so you guys can see how hard it is. The NA also checked the residents brief and said the residents brief was wet but not wet enough to change. Review of the Psychiatric Evaluation & Consultation notes dated 10/14/21 identified Resident #8 was oriented to time, place and person with relevant thought process. The resident reported feeling crappy and complained of headache. The resident reported that her/his sleep and appetite were good, and that she/he already received pain medications. The resident did not endorse anxiety and depression at that time. The psychiatric note further identified that supportive therapy and counseling were provided, and coping skills were reviewed. Review of NA #9 written statement dated 10/14/21 identified that she answered Resident #8's call bell and the resident started to complain that she/he was waiting for an hour. NA #9 wrote that she apologized and proceeded to check the resident and the resident was dry, then she assisted the resident with a bedpan. Further review identified that NA #9 denied saying that she was going to quit and for the residents to care for themselves. Interview with DNS on 6/18/24 at 1:20 P.M. identified the previous DNS should have reported all alleged incidents of abuse to the state agency immediately, and no longer than two hours after the allegation according to facility policy. Subsequent to surveyor inquiry, a Reportable Event Report was submitted to the State Agency on 6/18/24. Interview and OT #2's written statement dated 10/13/21 and reviewed with OT #2 on 6/20/24 at 1:03 P.M. identified Resident #8 was upset while telling her about NA #9 being evil with attitude and refused to change her/his brief. OT #2 identified that she immediately reported the resident's concern to her supervisor because she would not want her family member to be treated like that and wanted the facility to investigate what had happened and if it was an abuse or not. OT #2 further identified she wanted residents to feel safe and comfortable while at the facility. Interview and facility documentation review with NA #9 on 6/20/24 at 2:45 P.M. identified she could not remember what had happened with Resident #8 at that time. Interview and review of facility documentation related to the Grievance Sheet for Resident #8 dated 10/13/21 with previous Administrator #2 on 6/24/24 at 2:15 PM identified she could not remember the incident and was unable to explain why a Reportable Event Form was not completed and the alleged abuse event was not reported to the state agency on 10/13/21 as per facility policy. Further interview identified this allegation was completed as a grievance because most likely it was more of an employee issue. 2. Resident #31 was admitted to the facility with diagnoses that included dementia, non-traumatic brain dysfunction, adjustment disorder, anxiety, depression and cognitive communication deficit. The care plan dated 12/14/22 identified Resident #31 with a potential for behavior and mood patterns. Interventions directed staff to assist the resident to identify strengths and encouraged to focus on them and to give realistic, positive feedback. The quarterly MDS dated [DATE] identified Resident #31 had moderately impaired cognition, had no behavioral symptoms, and required limited assistance with bed mobility, transfer, walking and locomotion. Review of a psychological services note dated 3/4/22 identified Resident #31 had endorsed heightened anger and shame at the present related to an interpersonal conflict with a particular staff member, resulting in increased stress and discomfort with facility staff. The resident shared a number of recent negative interactions with a staff member, often demonstrating perseveration and heightened anxiety. The resident's feelings were validated and the resident wass engaged in supportive psychotherapy. The resident required frequent redirection, was offered psychoeducation regarding appropriate conflict and anxiety management, exploring appropriate coping strategies, and encouraging daily practice. The note further identified that the resident's concerns were discussed with the social worker for further investigation and follow-up. The Grievance Sheet dated 3/4/22 identified on 3/4/22 the psychologist reported to SW #3 that Resident #31 had a complaint about NA #9, who worked with her/him. SW #3 met with the resident who stated that NA #9 had been giving her/him a very difficult time and has a chip on her shoulder. The resident stated that she/he was in the room next door visiting her/his friend who asked her/him to look for a bracelet in her/his nightstand drawer. NA #9 saw Resident #31 looking in the drawer and made a big deal about it, even after the resident stated that she/he was asked to look. Resident #31 stated that NA #9 has had an attitude with her/him on several occasions and would prefer NA #9 no longer work with her/him. The resident stated that she/he prefers NA #9 to work in another state. A further interview identified that Resident #31 was actually afraid of this one. Review of a follow up statement dated 3/8/22 (four days after the facility was notified of the allegation) and written by SW #3 identified Resident #31 stated that she/he did not want to run into NA #9 at the facility. When asked if she/he had seen NA #9 since the complaint, the resident responded, No; I haven't seen her; I have been staying in my room. When asked if she/he was staying in her/his room to avoid running into NA #9, the resident responded, Yes. The resident further stated that she/he did not think that NA #9 would do anything to her/him physically however she/he did not want to deal with her attitude. The resident stated, she walks around like she invented a cure for cancer. Review of NA #9 written statement dated 3/8/22 (four days after the facility was notified of the allegation) identified that she witnessed Resident #31 going through another resident's drawer and asked the resident what she/he was doing. The resident responded that the other resident asked her/him to look for something. Then Resident #31 became defensive. NA #9 stepped away and notified the nurse. Review of LPN #6 written statement dated 3/8/22 (four days after the facility was notified of the allegation) identified that NA #9 notified her that Resident #31 was going through another resident's drawer. LPN # 6 observed that Resident #31 was still going through the drawer. The resident refused to leave, and LPN #6 explained that it was not nice to go through someone else's drawers. Resident #31 left the room. Review of facility documentation identified NA #9 received in-service including Customer Service Training and Fear of Retaliation on 3/8/22. Further review identified NA #9 was coached on professional behaviors and dealing with difficult behaviors on 3/8/22. Interview and facility documentation review with NA #9 on 6/20/24 at 2:45 P.M. identified she could not remember what had happened with Resident #31 at that time. During further interview NA #9 stated some residents are accusatory; I respect all residents and I know that they need our care. Interview with RN #6 on 6/24/24 at 12:40 P.M. identified during review of old grievance records dated 3/4/22, statements were found with an allegation of potential abuse from NA #9 to Resident #31 with the resident stating she/he was afraid of NA #9. RN #6 further identified this accusation of alleged abuse should have been reported immediately to the state agency and investigated to determine if residents were safe. RN #6 further identified NA #9 was suspended and investigation was initiated at this time. Subsequent to surveyor inquiry, a Reportable Event Report was submitted to the State Agency on 6/24/24. Interview and facility documentation review with previous Administrator #2 on 6/24/24 at 2:15 P.M. identified if the facility thought that it was an abuse allegation, she would have reported it to the state agency, as per facility policy. The facility practice was to report all allegations of abuse as soon as possible, investigate and then send a follow-up summary to the state agency. Further interview and review of facility documentation for Resident #31 identified that at this time Administrator #2 was unable to determine if the grievance completed for the resident was allegation of abuse or not. Administrator #2 could not remember the incident and was unable to explain why a Reportable Event Form was not completed and the allegation was not reported to the state agency for Resident #31 on 3/4/22, although the facility investigation started four days after the facility was notified of the allegation. Interview and facility documentation review with previous DNS #2 on 6/26/24 at 2:30 P.M. identified, although on 3/8/22 she signed the Grievance Sheet for Resident #31 dated 3/4/22, she did not report the allegation to state agency because the investigation was probably completed by another staff member. Previous DNS #2 was unable to remember the allegation but based on the information presented during interview, she would have probably reported the allegation of abuse at that time. Further interview identified she would have followed the advice of a previous corporate leader on what to do. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 2/2023, identified reporting of all alleged violations should be reported to the administrator, state agency, adult protective services and to all other required agencies such as law enforcement when applicable, immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or result in serious bodily injury.

Based on record review and review of facility policies and procedures for 1 sampled resident (Resident #4) who had a diagnosis of diabetes and was at risk for skin breakdown and for one sampled resident (Resident #14) who was incontient of urine, required incontinence care, and often refused incontinent care, the facility failed to develop a comprehensive care plan for foot care for an individual with a diagnosis of diabetes and failed to develop a comprehensive care plan with person centered interventions for incontinence care and care refusals. The findings include: 1. Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), had no signs of pain, and was severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The Resident Care Plan (RCP) dated 3/5/21 identified Resident #4 as at risk for skin breakdown, requiring extensive assistance from 2 staff members for moving, turning and positioning while in bed, and an intervention to offer turning and repositioning approximately every 2 hours and as needed. The RCP included diabetes as a focus area but no interventions listed for diabetic foot care or monitoring. An Infection Preventionist progress note dated 5/7/21 identified a new pressure injury to the left heel. Although attempted, an interview with the Infection Preventionist was not obtained. A Nursing Supervisor progress note dated 5/16/24 by RN #2 identified a pressure injury to the right heel. Although attempted, an interview with RN #2 was not obtained. The facility Diabetic Foot Care policy states diabetic foot care is to be provided by qualified nursing staff. Review of the clinical record identified Resident #4 was transferred to the hospital on 6/11/21 and underwent above knee amputation on 6/17/21. Hospital documents dated 6/11/21 noted Resident #4's wound as both a decubitus ulcer (pressure injury) and a diabetic foot ulcer. Review of the clinical record identifed Resident #4 had a diagnosis of diabetes on admission to the facility and failed to identify a plan of care for diabetic foot monitoring or care throughout admission to the facility. 2. Resident #14 was admitted to the facility with diagnoses that included dementia with behavior disturbance, memory impairment, and bilateral knee pain. The Occupational Therapy Discharge Summary dated 4/1/21 indicated Resident #14's level of assistance varies. Factors impacting level of assistance include: time of day, level of fatigue and poor safety awareness. A bladder and bowel assessment dated [DATE] indicated Resident #14 was continent. The MDS assessment dated [DATE] indicated Resident #14 required supervision/set up only for toileting, was occasionally incontinent and had severely impaired cognition (brief interview for mental status (BIMS) score of 4). A care plan dated 7/28/21 included a focus, initiated on 10/19/20, of declining personal care and a revision on 6/11/21 to include refusal of a shower and care. The care plan did not include personalized interventions to manage care refusals. No additional interventions were added to the care plan when revised 6/11/21. The care plan also included an intervention to not leave resident unattended in the bathroom. An email dated 7/13/21 by Person #4 identified the mattress and sheets were soaked in urine at two recent visits, there was no mattress cover on the mattress, and the room smelled offensively of urine. A grievance form dated 7/13/21 indicated the housekeeping supervisor replaced the mattress and housekeeping scheduled a room cleaning for 7/15/21. On 7/13/21 Social Worker #2 sent an email response to the grievance dated 7/13/21 and indicated Resident #14 often refuses assistance and likes to feel independent. Although attempted, an interview with SW #2 was not obtained. The nurse aid care card dated 7/21/21 has Resident #14 listed as continent of bowel and bladder. The nurse aid flow sheets reviewed from June 2021 to July 2021 indicated varying continence and incontinence episodes in addition to 123 of 183 shifts with no documentation of continence care indicating care was not provided. Behavioral health services evaluations from June 2021 to July 2021 have no indication of care refusal concerns. Review of progress notes from June 2021 to July 2021 indicated 2 instances of Resident #14 refusing personal care. The interview with Housekeeper #1 on 6/6/24 at 1:00 P.M. indicated the facility has several different types of mattresses and all mattresses should have a blue fluid resistant (not waterproof) cover. The interview with Person #4 on 6/12/24 indicated the soiled mattress that was removed from Resident #14's room was white, indicating the absence of a fluid resistant cover. The facility policy titled: Bladder and Bowel Continence Evaluation and Management Planning states, residents/patients who are incontinent of urine or bowel will be identified, evaluated and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for two of four residents (Resident #4 and #7) who were at risk for the development of pressure ulcers, the facility failed to promote the prevention of pressure ulcer/injury development; failed to promote the healing of existing pressure injuries (including prevention of infection to the extent possible); and failed to prevent development of an additional pressure ulcer/injury; and failed to conduct an initial skin assessment as a baseline when a reddened area of the left hip was identified to determine if the area was healing or deteriorating. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), had no signs of pain, and was severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted a weight loss, a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and no indication of a mechanically altered diet (e.g., pureed food, thickened liquids) was noted. a. The Resident Care Plan (RCP) dated 3/5/21 identified Resident #4 was at risk for skin breakdown, requiring extensive assistance from 2 staff members for moving, turning and positioning while in bed, and included interventions to offer turning and repositioning approximately every 2 hours and as needed, and to offload heels. Further, the RCP had diabetes as a focus area but no interventions listed for diabetic foot care or monitoring. The RCP noted Resident #4 had a potential for impaired nutritional status, lists significant weight loss dates of 11/19/19 and 11/12/20, and included interventions for referral to a speech therapist for swallow evaluations as needed, and an intervention for weekly weights. An Infection Preventionist progress note dated 5/7/21 identified a new pressure injury to the left heel and further noted the charge nurse will notify the family. There was no documentation of family notification in the clinical record. A Nursing Supervisor progress note dated 5/16/21 by RN #2 identified a suspected deep tissue injury to the right heel measuring 7 cm x 3 cm appearing dark black and purple in color with a dry top layer and lifting wound edges. Physical therapy notes dated 5/12/21, 5/13/21, 5/17/21, 5/27/21, 5/30/2021, and 6/6/21 note both verbal and non-verbal expressions of pain. An APRN progress note dated 5/13/21 noted pain with ambulation. A nurse progress note dated 5/13/21 noted Resident #4 cried out in pain pointing at the left leg. A nurse supervisor progress note dated 5/16/21 identified Resident #4 was calling out in pain during a wound assessment. Review of the clinical record identified there were 5 pain assessments performed in May of 2021 and 1 pain assessment performed in June of 2021 prior to a hospitalization . Although progress notes dated 5/7/21 and 5/16/21 identified new pressure injuries, the RCP was not updated to include the facility acquired wounds and lacked revisions related to the new and worsening wounds. Despite multiple progress notes identifying Resident #4 was experiencing pain, documentation of wound deterioration, and changes in pain regimen, the plan of care was not updated to assess pain and the (RCP) lacked revisions pertaining to pain related to the new and worsening wound. The last revision made to the RCP related to pain was on 9/14/20. b. On 4/28/21, LPN #1 added a new nursing order for heel booties to bilateral heels every shift while in bed. The nursing order did not indicate removing the boots on a schedule to assess skin integrity and there was no documentation of rationale or physician notification for the new intervention. A skin evaluation performed on 5/6/24 by LPN #8 indicated there were no new alterations in skin. During an interview with LPN #8 on 6/26/24 at 1:51 P.M., LPN #8 indicated when performing a skin evaluation, they check between the toes and under the heel for alterations in skin integrity. Interview with LPN #1 on 6/24/24 at 1:30 P.M. indicated heel booties are ordered when heels are reddened or boggy and that removing heel boots every shift to assess skin integrity is a standard part of the order. LPN #1 stated she/he would know to remove the boots every shift but if the order did not direct to do so, other nurses would probably not c. On 5/17/21 at 3:15 P.M., Registered Dietician #1 assessed Resident #4 and added 2 new interventions to provide additional protein in the setting of new and worsening pressure injuries. This assessment was performed 10 days after the first wound was acquired and 1 day after the second wound was acquired. Both wounds were facility acquired. Review of the clinical record identified there was an order for weekly weights and review of the Weights and Vital Summary for May 2021 and June 2021 identified missing weights for three consecutive weeks: 5/20/21, 5/27/21 and 6/3/21. d. Although the RCP identified turning and repositioning every 2 hours with extensive assistance of 2 staff members, review of the clinical record identified during the month of May, assistance with bed mobility was documented on 30 out of 93 shifts. 18 shifts documented total dependence for bed mobility, 11 shifts documented extensive assistance for bed mobility, and 1 outlier shift documented supervision with bed mobility. There was no documentation for bed mobility for the remaining 63 shifts indicating assistance with bed mobility was only provided 32% of the time. Of the documented shifts, only 5 occurred during the 3 P.M. to 11 P.M. and 11 P.M. to 7 A.M. shifts when Resident #4 would have spent the most time in bed. Although requested, the facility was unable to provide any additional documentation for turning and repositioning and was unable to provide the nurse aid care card. e. On 6/1/21 a provider progress note identified Resident #4 had a left knee muscle contracture that caused the left heel to dig into the mattress and further notes discussed having PT evaluate for offloading with knee contracture. Although the progress note identified the need for a PT evaluation for positioning, the facility was unable to provide documentation for this evaluation. Review of the clinical record identified Resident #4 was transferred to the hospital on 6/11/21 and underwent an above knee amputation on 6/17/21. Hospital documents dated 6/11/21 noted Resident #4's wound as both a decubitus ulcer (pressure injury) and a diabetic foot infection. Although attempted, an interview with the Infection Preventionist was not obtained. Although attempted, an interview with RN #2 was not obtained. An interview and clinical record review with the Director of Rehabilitation Services on 6/25/24 at 2:00 P.M. identified there was no documentation in therapy notes reflecting an evaluation or treatment related to offloading with a knee contracture. The interview further identified that in 2021 the facility did not have a communication tool for other departments to refer to therapy services and that referrals may have been discussed during the facility's daily clinical meeting. Review of the facility Prevention and Management of Pressure Injuries policy in reference to avoidable versus unavoidable pressure injuries, states avoidable means that the resident developed a pressure injury and that the facility did not do one or more of the following: evaluate the residents clinical condition and pressure injury risk factors, define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the intervention; or revise the interventions as appropriate. The facility failed to turn and reposition Resident #4 according to the plan of care prior to and after the development of pressure injuries. After the development of the first pressure injury on 5/7/21, the facility failed to conduct a timely nutritional assessment. he facility failed to conduct a physical therapy evaluation for offloading of the left heel in the presence of a knee contracture and failed to appropriately assess pain which could have further impaired mobility and positioning efforts. 2. Resident #7's diagnoses included anemia, polyneuropathy, hypertension, weight loss, Alzheimer's disease and dementia. The quarterly MDS assessment dated [DATE] identified Resident #7 had severely impaired cognition, required extensive assistance in bed mobility, transfer, dressing, and total dependence with personal hygiene. Additionally, the MDS identified the resident was at risk of developing pressure ulcers/injuries and a pressure reducing device for chair and bed was in use and had applications of ointments/medications. The resident was receiving hospice care. The care plan revised 12/27/21 identified Resident #7 was at risk for skin break down due to decreased mobility. Interventions directed to inspect the skin for redness, irritation or breakdown during care. The care plan further identified Resident #7 with an actual impairment of skin integrity MASD (moisture-associated skin damage) to the bilateral buttocks. Interventions directed to monitor and document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to the physician. The Home Health and Hospice Visit Documentation Log dated 12/28/21 identified Resident #7 was in bed. The coccyx wounds were open and bleeding which was reported to the charge (nurse) for wound evaluation. The resident had barrier on it but may benefit from Triad (Zinc oxide-based paste). The note further identified the resident with Redding of left hip, on pillows to relieve pressure. The Hospice Visit Summary dated 12/28/21 at 11:40 A.M. identified Resident #7 was in bed sleeping, the resident was confused and drowsy. No signs and/or symptoms of pain or discomfort noted. The Hospice NA reported to the Hospice RN, the resident had a skin tear on her/his buttock. Upon assessment the Hospice RN also noted the resident's left hip was red and some areas were non-blanchable, the facility nurse was notified and would follow up with the APRN. The nurse's note dated 12/28/21 at 4:25 P.M. identified Resident #7 with an open areas to the buttocks, and the resident was seen by APRN #1 and the hospice nurse. A new treatment of Xeroform Gauze Dressing (primary dressing maintains a moist wound environment), ProSource (liquid protein) and an air mattress was ordered. The note further identified that the resident was in bed and was turned from side to side. The nurse's note failed to reflect documentation that the resident's newly noted reddened, non-blanchable area of the left hip was assessed to include characteristics of the injury. The APRN #1 Progress Note dated 12/28/21 at 4:42 PM identified Resident #7 with a stage II pressure ulcer on coccyx. On exam some maceration was noted to the resident's buttocks, with 2 small open areas in the middle, stage II pressure ulcers. The resident was receiving Triad cream to the affected area. The note further identified, no pain to the resident's coccyx area was noted. Additionally, the progress noted identified the treatment for the stage II coccyx pressure ulcer directed cleansing the area with normal saline, followed by Xeroform, followed by dry protective dressing daily and to order an air mattress for the resident. Further review failed to reflect documentation that the resident's newly noted left hip skin injury was assessed, and new interventions ordered. A nurse's note dated 12/30/21 at 8:36 A.M.(two days after left hip reddened area was noted by the hospice nurse), identified Resident #7's left hip was noted to be an intact, dark maroon area. The area measured 8 centimeters (cm) by 13 cm with the area firm to touch, with a warm, non-blanchable center. The surrounding skin was dark pink and blanchable. The physician was notified and gave a new order to offload the resident's left hip every shift, turn and reposition every two hours, and apply Opti-foam (foam wound) dressing daily to area. The nurse's note dated 12/30/21 at 5:51 P.M. identified Resident #7 was seen by the APRN for a new DTI (deep tissue pressure injury) to his/her left hip. The resident was turned and repositioned throughout the day. The air mattress was on the bed and the family was updated. The APRN #1 Progress Note dated 1/14/22 identified on exam an open area was noted to Resident #7's left hip with drainage and surrounding area with some erythema. Further review identified the progress note indicated the treatment was changed to cleanse left hip area with normal saline, followed by Alginate (absorbs wound fluid, maintains moist environment and minimize bacterial infections) and a dry protective dressing daily. The wound care consult dated 1/20/22 identified that the stage two pressure injury ulcer to the buttock and deep tissue pressure injury to left hip continued to improve. Further review identified a left hip deep tissue pressure injury that measured 2.5 cm by 2.5 cm by 0 cm depth with non-blanchable deep red, maroon or purple discoloration, and the wound bed had 76% to 100% epithelization. There was no drainage noted and the resident had no pain. The wound care consultant recommended to continue current treatment plan. Interview and clinical record review with MD #1 on 6/18/24 at 11:10 A,M, identified the facility should have conducted a wound assessment and measurements of all the wounds to identify appropriate treatment and any changes that had occurred within the two days since the non-blanchable, reddened area was identified. Interview with APRN #2 on 6/18/24 at 11:54 A.M. identified she should have been notified of Resident #7's left hip redness on 12/28/21. If notified she would have assessed the area, determine specific treatment and document in the resident's clinical record at that time. Interview and clinical record review with DNS on 6/18/24 at 12:37 P.M. was unable to explain why Resident #7's clinical record lacked documentation pertaining to left hip deep tissue pressure injury when the resident's reddened area was identified by the hospice nurse on 12/28/21. DNS further identified that left hip deep tissue pressure injury assessment should have been conducted and documented on 12/28/21. Review of the facility policy on Prevention and Management of Pressure Injuries directed residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Care plans are developed based on individual resident's goals and decisions for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. 50890

Based on clinical record review, review of facility policies and procedures, and interviews with facility staff for 1 sampled resident who was assessed as a nutritional risk (Resident #4), the facility failed to provide a timely nutritional assessment for a resident with a documented pressure injury. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), no signs of pain, and severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted weight loss, a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and no indication of a mechanically altered diet (e.g., pureed food, thickened liquids) was noted. The RCP dated 3/5/21 identified Resident #4 had a potential for impaired nutritional status, identified significant weight loss with dates of 11/19/19 and 11/12/20 and included an intervention for weekly weights. Review of the clinical record identified a progress noted dated 5/17/21 at 3:15 P.M., which identified Registered Dietician #1 assessed Resident #4 and added 2 new interventions to provide additional protein in the setting of new and worsening pressure injuries. This assessment was performed 10 days after the first wound was acquired and 1 day after the second wound was acquired. Both wounds were facility acquired. Although the RCP dated 3/5/21 identified the potential for impaired nutrition with interventions that included weekly weights, review of the facility's Weights and Vital Summary document for May 2021 and June 2021 identified missing weights for three consecutive weeks: 5/20/21, 5/27/21 and 6/3/21. Further review of the weight documentation identified a weight of 148.4 pounds on 6/10/21, representing a 10.1% weight loss in approximately 4 months. The facility policy titled Pressure injury/Non-Pressure Wound Risk Management states Nutritional assessments are done routinely and as needed by a registered dietician if there are new wound issues. The facility policy titled Policy for Nutrition with Weight Loss/Wounds states It is the policy of this facility to evaluate food consumption, weight, and hydration status to determine if further intervention is needed and A resident with wounds will have a comprehensive assessment completed by the dietician and a plan will be developed. Although attempted, an interview with Registered Dietician #1 was not obtained. However, an interview with Registered Dietician #2, the facility's current dietician, on 6/24/24 at 1:00 P.M. indicated a timely notification to the registered dietician for a new or worsening wound is 24-48 hours, taking weekends into consideration. An interview with the DNS on 6/24/24 at 11:30 A.M. identified a registered dietician should be notified of a new or worsening wound within 24 hours to allow for a timely nutritional assessment and subsequent changes to the plan of care.

Based on clinical record reviews, staff interviews, and review of facility documentation for three of six residents reviewed for social service needs (Resident #1, #8 and #31), the facility failed to ensure the residents were assessed after allegations of abuse were reported: 1. Resident #1's diagnoses included Parkinson's disease, adjustment disorder, cerebral ischemic attack, difficulty in walking, depression and Alzheimer's disease. The Psychological Supportive Care progress note dated 12/27/19 identified Resident #1 with adjustment difficulty (illness, decline, loss), inappropriate behaviors and interactive skills, short tempered and easily annoyed. Interventions included coping skills training, supportive psychotherapy and validation therapy. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, required limited one person assistance with transfer and walking in the room. The care plan dated 1/21/20 identified Resident #1 with behavior and mood patterns. Interventions directed to encourage the resident to verbalize feelings and concerns, assist to identify strengths and encouraged to focus on them, and to give realistic, positive feedback. The Psychiatric Evaluation and Consultation dated 1/27/20 identified Resident #1 was seen for a follow up to assess mood/behavior and to complete medication review. The resident was alert and oriented with some confusion, was calm and cooperative and had a disorganized thought process. No symptoms of agitation noted. Will continue to follow mood and behavior. Staff to report to psych for any change in mood/behavior. A Reportable Event Form dated 2/4/20 identified PTA #2 reported that staff member (NA #1) said to Resident #1 Sit. Sit down. Sit your ass down! Sit down. You're gonna fall. You're gonna end up on the floor .and I'm gonna choke you. NA #1 was removed from the building pending investigation. The physician and family were notified, and the police were called. Review of Summary Report dated 2/13/20 identified Resident #1 with periods of forgetfulness at times and stated that NA #1 was her/his friend. Further review identified that the facility was unable to substantiate the allegation of verbal abuse. However, the interaction between NA #1 and Resident #1 was inappropriate. NA #1 received education directing to maintain a professional relationship with Residents. Interview with NA #1 on 6/6/24 at 11:57 AM and NA #1's written statement related to the 2/4/20 incident with Resident #1 was reviewed. NA #1 confirmed that she was making Resident #1's bed when the resident stood up and started to walk away from her/his chair, she stated to the resident Sit down. Sit your ass down. You're going to fall, and I'm going to choke you. NA #1 further identified that the resident just had a shower, was unsteady while walking and was not supposed to walk without help and to stop the resident she said those words but only jokingly. NA #1 identified that she should have stopped making the bed and assisted the resident to walk or to sit down and not to use those words while speaking to the resident. Interview with PTA #2 on 6/11/24 at 12:28 PM identified she was waiting by the elevator and witnessed NA #1 being verbally abusive to Resident #1. NA #1 sounded frustrated and angry, she was speaking to the resident in a very stern voice and aggressive manner. PTA #2 further identified that NA #1 was not joking while directing the resident to sit down. The resident was sitting in her/his chair, slumped down, leaning forward, confused and spoke a different language. PTA #2 further identified that she immediately reported the incident to her supervisor because NA #1 used inappropriate words and threatened the resident. Interview and facility investigation review related to the 2/4/20 incident with current DNS on 6/11/24 at 2:20 PM identified NA #1 was verbally abusive to Resident #1. The DNS further identified nobody, no facility staff should use impolite, offensive or threatening words while speaking to a resident. Interview and facility documentation review related to the 2/4/20 incident with MD #1 on 6/18/24 at 11:15 AM identified NA #1 was verbally abusive to Resident #1 and her employment should have been terminated at that time. The clinical record failed to reflect any psychosocial support by Social Service department was provided by when Resident #1 with history of agitated behaviors and chronic psychiatric illness was witnessed being mistreated by NA #1. 2. Resident #8's diagnoses included cerebral infraction, hypertension, cognitive communication deficit and Wernicke's encephalopathy. The admission MDS dated [DATE] identified Resident #8 had intact cognition, was frequently incontinent of bladder, was always incontinent of bowel and required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The care plan dated 8/25/21 identified the resident exhibited behavior problems and refused to get out of bed. Interventions directed to introduce yourself to the resident and explain what you are going to do, use calm, gentle approach, work slowly and ask the resident for cooperation with task. The Grievance Sheet dated 10/13/21 identified staff member (OT #2) went to Resident #8 to provide therapy. Resident #8 reported that her/his NA (NA #9) was being evil to her/him last night, during 3 PM to 11 PM shift on 10/12/21. The resident stated she/he needed to go to the bathroom and NA gave her/him attitude that escalated to the NA stating, I cannot wait to quit, so you guys can take care of each other, so you guys can see how hard it is. The NA also checked the residents brief and said the residents brief was wet but not wet enough to change. Review Psychiatric Evaluation & Consultation notes dated 10/14/21 identified Resident #8 oriented to time, place and person with relevant thought process. The resident reported feeling crappy and complained of headache. The resident reported that her/his sleep and appetite were good, and that she/he already received pain medications. The resident did not endorse anxiety and depression at that time. The psychiatric note further identified that supportive therapy and counseling were provided, and coping skills were reviewed. Review of NA #9 written statement dated 10/14/21 identified that she answered Resident #8's call bell and the resident started to complain that she/he was waiting for an hour. NA #9 wrote that she apologized and proceeded to check the resident and the resident was dry, then she assisted the resident with a bedpan. Further review identified that NA #9 denied saying that she was going to quit and for the residents to care for themselves. Interview and OT #2's written statement dated 10/13/21 review with OT #2 on 6/20/24 at 1:03 PM identified Resident #8 was upset while telling her about NA #9 being evil with attitude and refused to change her/his brief. OT #2 identified that she immediately reported the resident's concern to her supervisor because she would not want her family member to be treated like that and wanted the facility to investigate what had happened and if it was an abuse or not. OT #2 further identified she wanted residents to feel safe and comfortable while at the facility. The clinical record failed to reflect any psychosocial support by Social Service department was provided when Resident #8 was visibly upset and reported NA #9 was evil with attitude and refused to change her/his brief. Although attempted, an interview with previous Social Worker #4 was not obtained. 3. Resident #31's diagnoses included dementia, non-traumatic brain dysfunction, adjustment disorder, anxiety, depression and cognitive communication deficit. The care plan dated 12/14/22 identified Resident #31 with potential for behavior and mood patterns. Interventions directed staff to assist the resident to identify strengths and encouraged to focus on them and to give realistic, positive feedback. The quarterly MDS dated [DATE] identified Resident #31 had moderately impaired cognition, had no behavioral symptoms, required limited assistance with bed mobility, transfer, walking and locomotion. Review of Psychological Services note dated 3/4/22 identified Resident #31 endorsed heightened anger and shame at present related to interpersonal conflict with a particular staff member, resulting in increased stress and discomfort with facility staff. The resident shared number of recent negative interactions with a staff member, often demonstrating perseveration and heightened anxiety. The resident's feelings were validated and engaged the resident in supportive psychotherapy. The resident required frequent redirection, offering psychoeducation regarding appropriate conflict and anxiety management, exploring appropriate coping strategies, and encouraging daily practice. The note further identified that the resident's concerns were discussed with social worker for further investigation and follow-up. The Grievance Sheet dated 3/4/22 identified on 3/4/22 psychologist reported to SW #3 that Resident #31 had a complaint about NA #9, who worked with her/him. SW #3 met with the resident who stated that NA #9 had been giving her/him a very difficult time and has a chip on her shoulder. The resident stated that she/he was in the room next door visiting her/his friend who asked her/him to look for a bracelet in her/his nightstand drawer. NA #9 saw Resident #31 looking in the drawer and made a big deal about it, even after the resident stated that she/he was asked to look. Resident #31 stated that NA #9 has had an attitude with her/him on several occasions and would prefer NA #9 to no longer work with her/him. The resident stated that she/he prefers NA #9 to work in another state. A further interview identified that Resident #31 was actually afraid of this one. Review of follow up statement dated 3/8/22 (four days after the facility was notified of the allegation) and written by SW #3 identified Resident #31 stated that she/he did not want to run into NA #9 at the facility. When asked if she/he had seen NA #9 since the complaint, the resident responded, No; I haven't seen her; I have been staying in my room. When asked if she/he was staying in her/his room to avoid running into NA #9, the resident responded, Yes. The resident further stated that she/he did not think that NA #9 would do anything to her/him physically however she/he did not want to deal with her attitude. The resident stated, she walks around like she invented a cure for cancer. Review of NA #9 written statement dated 3/8/22 (four days after the facility was notified of the allegation) identified that she witnessed Resident #31 going through another resident's drawer and asked the resident what she/he was doing. The resident responded that the other resident asked her/him to look for something. Then Resident #31 became defensive. NA #9 stepped away and notified the nurse. Review of LPN #6 written statement dated 3/8/22 (four days after the facility was notified of the allegation) identified that NA #9 notified her that Resident #31 was going through another resident's drawer. LPN # 6 observed that Resident #31 was still going through the drawer. The resident refused to leave, and LPN #6 explained that it was not nice to go through someone else's drawers. Resident #31 left the room. Review of facility documentation identified NA #9 received in-service including Customer Service Training and Fear of Retaliation on 3/8/22. Further review identified NA #9 was coached on professional behaviors and dealing with difficult behaviors on 3/8/22. Interview and facility documentation review with NA #9 on 6/20/24 at 2:45 PM identified she could not remember what had happened with Resident #8 and Resident #31 at that time. During further interview NA #9 stated some Residents are accusatory; I respect all residents and I know that they need our care. The clinical record failed to reflect any psychosocial support by Social Service department was provided when the resident reported mistreatment, was afraid of NA #9 and was identified with increased stress and discomfort with facility stay because of the interaction with NA #9. Interview, review of the clinical records and facility policy with Director of Social Services on 6/24/24 at 1:50 PM identified residents should be assessed and provided support for at least 3 days after an allegation of abuse or neglect to ensure residents were not psychologically harmed. Further interview identified this was the responsibility of the Social Worker. Interview and review of Resident #31's clinical record with Social Worker #3 on 6/26/24 at 12:34 PM identified regardless of the allegation being reported to the state agency or documented as a grievance, the resident's clinical record should have documentation showing an assessment was completed and that support was provided. Social Worker #3 further identified that normally she would follow up with residents immediately after an allegation of mistreatment was reported but she did not document all her interactions with Resident #31 as she should have done. Facility policy and procedure Abuse, Neglect and Exploitation directed the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further identified the resident will be monitored for potential negative outcomes for 72-hours post incident occurrence and this will be documented in the clinical record. The social worker will provide counseling and support to the resident involved for three (3) days, excluding weekends and holidays. This will be documented in the clinical record.

Based on review of facility policy, interviews, and review of employee files for 6 of 6 Nurse Aides (NA #1, NA #2, NA #3, NA #4, NA #5 and NA #9), the facility failed to ensure performance evaluations were completed in a timely manner. The findings include: 1. Review of NA #1's employee file identified that date of hire was 2/8/2016 and last Employee Performance Evaluation was completed on 3/2/21. 2. Review of NA #2's employee file identified that date of hire was 11/4/2002 and last Employee Performance Evaluation was completed on 10/25/2017. 3. Review of NA #3's employee file identified that date of hire was 8/8/11 and last Employee Performance Evaluation was completed on 10/8/2020. 4. Review of NA #4's employee file identified that date of hire was 3/24/03 and last Employee Performance Evaluation was completed on 10/10/2020. 5. Review of NA #5's employee file identified that date of hire was 12/11/17 and last Employee Performance Evaluation was completed on 9/30/2020. 6. Review of NA #9's employee file identified that date of hire was 3/30/20 and last Employee Performance Evaluation was completed on 11/3/2020. Interview and facility documentation review with the current DNS on 6/11/24 at 10:35 AM identified the DNS and the Administrator were responsible for ensuring that the NA evaluations were completed, and they were no longer employed with the facility. The interview further identified that although performance evaluations should be completed every year, the DNS was unable to explain why they were not completed timely. Further interview with the current DNS identified she was presently responsible for completing annual evaluations and she will review compliance. Review of the facility Performance Appraisal policy directed that Department Heads and Supervisors will complete performance appraisals upon the following occasions: by the end of the first three months of employment and prior to the anniversary date of employment. The policy further identified that in evaluating employees, Department Heads and Supervisors will consider such factors as the experience and training of the employee, the expectations as set forth in the job description, and the employee's attainment of previously set objectives and goals. Other factors that normally will be considered include, but are not limited to, knowledge of the job, quantity and quality of work, promptness in completing assignments, cooperation, initiative, reliability, attendance, judgement, and acceptance of responsibility. Review of Philosophy of a Performance Appraisal identified an employee performance appraisal should be a mutual planning effort, where together you strive to meet both the facility's needs for trained and capable staff, and the individual's need for growth, achievement, and security. 48879

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for one resident (Resident #13) reviewed for facility transportation, the facility failed to include and have available consultations from outside vendors available in the paper or electronic chart and have nursing documentation available regarding outside consultations. The findings include: Resident #13's diagnoses included malignant neoplasm (abnormal tissue growth) of the right breast, epilepsy (seizures), anxiety disorder, unsteadiness on feet, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact, exhibited no behaviors, and required extensive assistance for bed mobility, transfers, toileting, and personal hygiene. The Resident Care Plan dated 5/13/22 identified Resident #13 was diagnosed with breast cancer and was undergoing chemotherapy. Interventions included to follow-up with the oncologist as ordered and treatments/diagnostics as ordered. Interventions included following up with the orthopedic physician as recommended/ scheduled, immobilizer in place as ordered, applying and removing the brace as ordered, and rehab therapy as ordered to increase function and mobility. Review of the facility transportation schedule identified that Resident #13 had outside consultative appointments scheduled on 1/3/22, 1/5/22, 1/10/22, 1/13/22, 1/21/22, 1/25/22, 1/26/22, 1/31/22, 2/16/22, 2/22/22, 3/14/22, 3/16/22, 4/7/22, 4/8/22, 4/11/22, 4/12/22, 4/13/22, 4/14/22, 4/15/22, 4/18/22, 4/19/22, 4/20/22, 4/21/22, 4/22/22, 4/25/22, 4/26/22, 4/27/22, 4/28/22, 4/29/22, 5/2/22, 5/3/22, 5/4/22, 5/5/22, 5/6/22, 5/9/22, 5/11/22, 5/13/22, 5/16/22, 5/19/22, 5/25/22, 5/27/22, 5/31/22, 6/1/22, 6/2/22, and 6/24/22. Review of the clinical record failed to identify any consultant documentation or notes documented in the clinical record for 14 out of the 45 above dates (1/5/22, 1/21/22, 1/25/22, 4/21/22, 4/22/22, 4/26/22, 4/28/22, 4/29/22, 5/2/22, 5/3/22, 5/4/22, 5/6/22, 5/13/22, and 5/19/22). Subsequent to surveyor inquiry, the facility provided consultative documentation indicating that Resident #13 had outside Radiation Oncology appointments on 1/10/22 and 1/21/22 and had a cardiology appointment on 1/25/22. Interview with the Unit Secretary on 6/26/24 at 9:42 A.M. identified that she is responsible for the transportation schedule and scheduling any resident appointments, indicating that she prepares and sends a W10 (inter-agency patient report), labs, a medication list and advanced directives with each resident that goes out for an appointment. She reported that for chemo and dialysis residents, the facility sends a resident specific binder, but that the outside providers refuse to use them, so she must call the office to get a consult report. She also reported that when the Radiation Oncology office was contacted, they stated that radiation doesn't trigger a medical report, therefore there is no consult to send back with the resident or to the facility. She indicated that she had been on leave in 2022 so she was not able to identify if the resident missed any appointments but reported she had talked with the facility driver ([NAME]) and he could not recall Resident #13 missing any medical appointments. The Unit Secretary further noted that the facility has 2 vans and 2 drivers and if one calls out, they will rearrange the appointments in order of priority, and if not able they will then reach out to other vendors to try and secure transportation. If they are unable to secure transportation, she will call the nursing supervisor, the floor nurse, and then the family to let them know that she will have to reschedule the appointment. Re interview with the Unit Secretary on 6/26/24 at 12:16 P.M. identified that the appointment on 1/5/22 for Resident #13 was canceled due to an ice storm, and that the appointment on 5/19/22 was canceled, as radiation was being held due to skin irritation. Interview with RN #1 on 6/26/24 at 10:48 A.M. identified that the nursing staff is responsible for documenting in the electronic health record when a resident leaves for an appointment, and when they return. She indicated if there's a change in status upon return, nursing will then notify the facility provider to assess the resident. Interview with the DNS on 6/26/24 at 12:37 P.M. identified that she expects the nursing staff to write a nursing note in the clinical record regarding when and where a residents goes out to an outside appointments and also when they return, as well as any recommendations and who the recommendations were communicated to. Additionally, she indicated she would expect that all consultations be retained in the clinical record, and if a resident returned without a consult, it is the responsibility of either the charge nurse or the unit secretary to contact the outside office to get the consultative notes. A Consultant Services policy dated 4/2015 identified, in part, that a consultant's report or some form of documentation pertaining to the results will be retained in the clinical record. A Nursing Documentation policy dated 2/2016 identified, in part, that all resident record forms are kept in the resident's medical record. At the time of discharge all nurses notes are included in the completed hard copy discharge chart.

Based on clinical record review, review of facility policies and procedures, and interviews with facility staff for 1 of 2 residents who were reporting/demonstrating pain, (Resident #4), the facility failed to assess pain for a resident with a deteriorating facility acquired pressure injury and failed to assess efficacy of the pain regimen. The findings include: 1. Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), experienced a weight loss, and was severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted Resident #4 was rarely/never understood and had no signs of pain. The Resident Care Plan (RCP) dated 3/5/21 identified Resident #4 was at risk for skin breakdown, required extensive assistance from 2 staff members for moving, turning and positioning while in bed, and included interventions to offer turning and repositioning approximately every 2 hours and as needed, and to offload heels. Further review identified a RCP had been initiated on 6/2/19 and reviewed on 3/5/21 addressing pain. Review of the clinical record identified an Infection Preventionist progress note dated 5/7/21 which identified a new pressure injury to the left heel and a Nursing Supervisor progress note dated 5/16/21 by RN #2, identified a suspected deep tissue injury to the right heel measuring 7centimeters (cm) x 3cm appearing dark black and purple in color with a dry top layer and lifting wound edges. An APRN progress note dated 5/13/21 noted pain with ambulation and a nurse progress note dated 5/13/21 noted Resident #4 cried out in pain, pointing at the left leg. Review of the Physical therapy notes on the following dates referenced both verbal and non-verbal expressions of pain: 5/12/21: Resident #4 was unable to perform standing activities due to left heel pain; 5/13/21: Upon standing, Resident #4 would indicate increased left heel pain and sit back down and stated it hurts but unable to quantify pain; 5/17/21: Resident #4 indicated pain during therapy but was unable to quantify; 5/27/21: Resident #4 indicated bilateral heel pain but was unable to quantify; 5/30/2021: Resident #4 complained of left lower extremity pain upon movement; and 6/6/21: Resident #4 was unable to quantify pain but would state no, no, no and indicated increased pain. A provider order dated 5/13/21 directed Acetaminophen 975 milligrams (mg), 3 times a day. A previous order dated 6/1/19 for Acetominphen 650mg every 6 hours as needed for elevated temperature was discontinued. A Nurse Supervisor progress note dated 5/16/21 noted Resident #4 was calling out in pain during a wound assessment. Physician orders dated 5/16/21 directed Tramadol 25mg as needed every 6 hours for mild pain and Tramadol 50mg every 6 hours for moderate-severe pain. A subsequent physician order dated 5/27/21 directed Tramadol 25mg, 2 times per day and the Tramadol 25 mg that was ordered on 5/16/21 on an as needed basis every 6 hours was changed to as needed every 8 hours. Review of the clinical record identified there were 6 pain assessments performed in May of 2021 and 1 pain assessment performed in June of 2021 prior to a hospitalization . The pain evaluations conducted on 5/7/21, 5/12/21, 5/25/21 indicated Resident #4 is able to vocalize pain and answered no to experiencing pain. The pain evaluation conducted on 5/16/21 indicated Resident #4 is unable to vocalize pain and conducted the non-verbal pain evaluation sleeting the hurts a whole lot facial expression. The pain evaluations conducted on 5/18/21 and 6/1/21 indicated Resident #4 is able to vocalize pain and rated the present pain at a level 5 out of 10 and a level 6 out of 10 respectively. Although adjustments were made to the pain medication regimen, review of the clinical record failed to identify ongoing pain monitoring or assessment to monitor pain and efficacy of the pain regimen. The facility Pain Management Policy includes: the facility will assess the potential for pain, recognize the onset or presence of pain, assess pain using a standardized pain scale of 0-10 and/or nonverbal pain scale, develop and implement interventions/approaches to pain management, both pharmacological and nonpharmacological, and monitor appropriately for effectiveness and/or adverse reactions. An interview with the DNS on 6/24/24 at 11:30 A.M. identified pain assessments should be performed every shift for all residents, especially for a resident with a new or worsening wound. 50890

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #81) reviewed for abuse, the facility failed to ensure adequate supervision for a resident with a history of wandering to prevent the resident from getting into another resident's bed, and for one of six residents reviewed for abuse (Resident #39) the facility failed to ensure the resident was free from verbal abuse by a staff member. The findings include: 1. a. Resident #81 was admitted to the facility to unit 2B (second floor), with diagnoses that included dementia and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 had severe cognitive impairment, was independent with ambulation, and had no behaviors during the prior seven (7) days. The Resident Care Plan (RCP) dated 10/18/2022 identified Resident #81 ambulated/wandered throughout the unit and entered other resident's rooms and would take other resident's belonging/objects at times. Interventions directed to redirect out of other resident rooms, assist Resident #81 to find his/her own room/bathroom as needed, and to offer reading materials in effort to redirect out of peers rooms. Social worker (SW) note dated 10/18/2022 identified Resident #81's quarterly care plan meeting was held and Resident #81 had a history of wandering in other resident rooms and on the unit. Review of the Behavior Monitoring Flowsheets for wandering into peers rooms identified Resident #81 wandered into other resident rooms on 10/5, 10/11 and 10/12/2022, and was redirected. b. Resident #98 was admitted to the facility to unit 2 A (second floor), with diagnoses that included benign neoplasm of meninges, dementia and adjustment disorder. Physician's order dated 8/21/2022 directed assist of one for transfers/ambulation in room and hall using no assistive device. The admission MDS dated [DATE] identified Resident #98 had severe cognitive impairment, was frequently incontinent of bowel and bladder, and had no wandering behaviors. The RCP dated 9/3/2022 identified Resident #98 had behavior problems and had functional mobility. Interventions directed ambulate with one staff and rolling walker, monitor for triggering events and avoid them in the future, calm/gentle approach, redirect with eating, drinking, talking/music, and decrease visual/auditory stressors when overstimulated, Wandering and Elopement risk assessment dated [DATE] identified Resident #98 paced or wandered aimlessly and lost track of his/her room. Review of facility incident report dated 10/29/2022 at 9:20 PM identified Resident #98 was found in bed on his/her knees over Resident #81. Resident # 81 was naked, and Resident #98 was without pants and one side of his/her brief was undone. The residents were immediately separated, assessments were conducted, responsible parties, physicians, and the police were notified. Resident #81 was transferred to the hospital for an evaluation. Incident summary indicated an APRN follow up identified no concerns per hospital documentation, Resident #81 returned to the facility and had no signs of distress noted. Residents were monitored, with no pain or injury identified after the incident. Review of the hospital record dated 10/29/2022 identified Resident #81 had no signs of trauma or penetration. Review of the clinical record identified Resident #81 returned to the facility and was placed on every 15-minute checks. Interview with NA #1 on 3/13/2023 at 1:50 PM identified on 10/29/2022 she last observed Resident #81 walking in the hallway of unit 2C - center part of the nursing unit - (not the hallway where Resident #98's room was) Resident #98 in his/her room approximately 10 minutes before the residents were observed in the bed. NA #1 indicated she entered Resident #98's room and saw Resident #81 lying in his/her bed wearing a sport-type bra and no pants or brief (Resident #81's brief was on the floor). NA #1 indicated she observed Resident #98 kneeling over Resident #81 without wearing any briefs (they were on the floor), and he/she had one leg out of his/her pants. NA #1 indicated she did not observe Resident #81 and #98 have intimate contact and she assisted Resident #98 to get off the bed to separate the residents, and she called for help. Resident #98 dressed him/herself and NA #1 covered Resident #81, and the nurse entered the room to take over. Interview with LPN #1 at 3/13/2023 at 2:10 PM identified she was Resident #98's nurse and heard NA #1 calling for help. She identified the residents were separated when she entered Resident #98's room and RN #1 was present. LPN 31 indicated Resident #81 did not know what was going on, and although Resident #81 had a history of wandering on the second floor and other residents had reported to her that Resident #81 entered their rooms in the past, she did not recall finding Resident #81 in other resident's rooms prior to the incident. Interview with RN #1 on 3/13/2023 at 2:20 PM identified she was the supervisor on 10/29/2022 and responded to the incident between Residents #81 and 98. When she arrived on the unit the residents were separated, Resident #81 was transferred to the hospital for evaluation and Resident #98 was placed on one-to-one (1:1) supervision. RN #1 further indicated Resident #81 had a history of sitting with male residents and of walking back and forth in the halls. Interview with the DNS on 3/13/2023 at 2:15 PM identified Resident #81 should not have been in Resident #98's room. She indicated although Resident #81 had a history of sitting with male residents and was occasionally observed holding male residents hands she did not think it was sexual in nature but friendly behavior; Resident #81 did not have a prior history of sexual behavior. Review of the facility second floor plan identified Resident #81's room was in A wing and Resident #98's room was in B wing, and the rooms were 75 feet apart from one another. Follow up interview with NA #1 on 3/15/2023 at 9:46 AM identified when she observed Resident #81 walking in the hallway prior to the incident, Resident #81 was dressed (wearing street clothes, not a johnny gown). NA #1 indicated Resident #81 usually went to bed around 9 or 9:30 PM. NA #1 further indicated that when she observed Resident #81 in the center hallway about 10 minutes prior to the incident, she did not re-direct Resident #81 because it was Resident #81's normal behavior to wander around the unit, and Resident #81 required staff to monitor/keep their eye on to monitor Resident #81. Follow up interview with the DNS on 3/15/2023 at 10:15 AM identified residents who wander on the 2nd floor typically congregate in the middle of the unit (Unit C) and there should be a staff member present to monitor the residents who require supervision with ambulation. She identified she would expect residents who are wandering to be redirected, and Resident #81 should not have been in Resident #98's room/bed. Interview further identified although Resident #81 did not have a prior history of sexual behavior, Resident #81 should not have been able to wander into Resident #98's bed. 2. Resident #39 was admitted to the facility with diagnoses that included Alzheimer's, dementia, major depressive disorder, dysphagia and mood disorder. The quarterly MDS dated [DATE] identified Resident #39 had moderate cognitive impairment and walked independently with supervision. Care plan dated 12/8/2022 identified Resident #39 had a mood problem related to major depression, schizoaffective disorder and history of substance abuse. Interventions directed to administer medications as ordered, behavioral consults as needed, monitor/record/report to the physician as needed patterns of depressions, anxiety, and psychiatry evaluations as ordered. Psychiatric progress note dated 12/19/2022 identified there were no inappropriate behaviors reported by staff for Resident #39, mood was at baseline and a plan to continue current regimen. Review of facility incident report dated 12/27/2202 identified staff witnessed a NA use profane language directed toward Resident #39. The report indicated Resident #39 was in the hallway and ST #1 and Housekeeper #1 witnessed NA #7 use profanity towards Resident #39. The witnesses took Resident #39 to his/her room and NA #7 was sent home. Resident #39 was seen by the APRN, and the conservator, MD and police were notified. The Report further indicated the facility substantiated the verbal abuse and NA #7's employment was terminated. Psychiatric note dated 12/27/2022 identified Resident #39 described the events that occurred as a staff member said multiple profane things which he/she did not like. Resident #39 was provided support and validation of feelings. A new order was given for Trazodone 25 mg every 8 hours PRN for 14 days for any breakthrough anxiety was ordered. Physician's order dated 12/27/22 directed trazodone 50 mg half tablet every 8 hours as needed for anxiety and to monitor behavior, insomnia, restlessness, anxiety or changes in appetite every shift for three days. Interview with ST #1 on 3/15/2023 at 4:05 PM identified on 12/27/22 he was in another resident's room when he heard a loud commotion. He identified NA #7 always has a loud voice so did not think anything of it at first. He then heard NA #7 use foul language (swearing) and tell Resident #39 to shut up. ST #1 identified he immediately went to the hall and Resident #39 and NA #7 were nose to nose and he separated NA #7 and Resident #39. He further identified his concern was for Resident #39 as Resident #39 was shaken up. ST #1 walked Resident #39 back to his/her room and gave him/her water and coffee to help calm him/her. He and Housekeeper #1 then notified the supervisor of the event. Interview with the DNS on 3/15/2023 at 3:00 PM identified staff are not to swear, use foul language or tell residents to shut up. Review of the Resident's Bill of Rights Policy directed in part, residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality. The Policy further directed residents have the right to be free from verbal, sexual, physical, or mental abuse. Review of the undated facility Abuse, Neglect and Exploitation Policy directed in part, verbal abuse means the use or oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. It further identified the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse.

Based on observations, clinical record reviews, facility documentation review, facility policy review, and interviews for 20 of 23 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, and 23) reviewed for assistance with activities of daily living, the facility failed to ensure adequate staffing levels to ensure resident care and services were provided timely. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included cerebrovascular disease, diabetes, urinary tract infection, Alzheimer's disease, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition with short and long-term memory problems, was always incontinent of bladder and bowel, was at risk for pressure ulcers, required extensive assistance with bed mobility, total assistance with toilet use, and transferred with two staff physical assist. The Resident Care Plan (RCP) dated 11/8/2022 identified Resident #1 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to offer bedpan/toilet assistance every two (2) hours and as needed, provide incontinence care approximately every two (2) hours and as needed, to observe for signs of redness/inflammation/breakdown, apply barrier cream if indicated and to the keep brief loose. Observations on 1/13/2022 at 11:52 AM identified Resident #1's incontinence brief, removed by NA #2, was saturated from front to back with dark color urine and a small amount of black-colored dried bowel movement noted on Resident #1's buttock area. A strong urine odor was noted when the brief was opened, and some of the inside of the incontinent brief was sticking to Resident #1's skin. Further observation identified multiple areas on Resident #1's buttock area that were painful to touch, the resident was flinching and was saying ouch, pain during incontinence care provided by NA #2. Resident #1 was assessed by RN #2 and identified with new alterations in skin integrity: the left buttock had a linear discoloration wound identified as a suspected deep tissue injury that measured 5 centimeters (cm) by 0.5 cm; the right buttock had a linear discoloration wound with deep tissue injury that measured 1.4 cm by 0.4 cm; the left upper buttock had a friction/skin tear that measured 5 cm by 0.5 cm by 0.1 cm with a small amount of serosanguinous drainage (yellowish fluid with small amounts of blood) identified as moisture associated dermatitis (inflammation or skin erosion caused by prolonged exposure to moisture); and the scrotum was red moisture associated dermatitis with intact skin. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide any care to Resident #1 prior to 11:52 AM. NA #2 identified she had not checked or changed Resident #1's brief and was unable to complete any round of incontinence care because she had 18 total residents on her assignment. NA #2 indicated that in addition to Resident #1, she still had five other residents (Resident #3, #4, #5, 6 and #7) that she was unable to provide any care since 8 AM when she arrived at work; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to any residents on her assignment) and it was now time for lunch to be served. Interview with RN #2 on 1/13/2023 at 12:10 PM identified Resident #1 had no open areas on his/her buttocks prior to those observed on 1/13/2023. RN #2 was notified that Resident #1 had new open and redden areas to his/her buttocks that looked like either he/she was sitting for a long time on the bedpan or the rolled up, wet diaper that had become stuck to Resident #1's skin had caused the injuries. RN #2 further identified that she was not aware that incontinent care was not provided through the morning shift (she was helping on another unit), and indicated the facility management was aware of short staffing. Interview with NA #5 on 1/15/2023 at 3:30 PM identified she worked during 11:00 PM to 7:00 AM shift on 1/12 into 1/13/2023, and she started her incontinent rounds for all residents on her unit about 6:00 AM. NA #5 identified Resident #1 received incontinent care and had his/her brief last changed on 1/13/2023 between 6:00 and 6:30 AM. NA #5 further identified Resident #1 had no discomfort, open areas, or redness on his/her buttocks at the time incontinent care was provided last (over 5 hours and 22 minutes between incontinence care was provided). Interview with wound consultant MD #2 on 1/17/2023 at 1:20 PM identified she assessed Resident #1's buttock wounds on 1/17/2023 and identified that they looked dermatological, and they were improving. MD #2 indicated the wounds were acute, and after removing pressure, friction, and wetness, they would heal. MD #2 identified the wounds on Resident #1's buttock happened very quickly and a few hours was a long time for Resident #1 to not be repositioned and/or exposed to a wet diaper, especially with trauma from the bulging. MD #2 further indicated the wet brief that was possibly rolled up and/or stuck to Resident #1's skin made the injury worse. 2. Resident #2's diagnoses included urinary tract infection, Parkinson's disease, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #10 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility and toilet use. The RCP dated 11/1/2022 identified Resident #2 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed, inspect skin for redness, irritation, or breakdown during care, and to turn and reposition approximately every two (2) hours. Observation on 1/13/2023 at 11:45 AM identified NA #2 was completing morning care with Resident #2. Observation identified Resident #2's incontinent brief was saturated with urine. NA #2 identified she started work at 8:00 AM, she had 18 residents on her assignment and she still had six (6) residents to provide care to. NA #2 stated she finished helping with breakfast and now she was going from room to room as fast as she could. 3. Resident #3's diagnoses included adult failure to thrive, hemiplegia and dementia. The quarterly MDS assessment dated [DATE] identified Resident #9 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, had an unstageable pressure injury, and required total assistance with bed mobility, toilet use, personal hygiene, and transferred with two staff physical assist. The RCP dated 11/1/2022 identified Resident #3 was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed, to inspect the skin for redness/irritation/breakdown during care, apply incontinence protective barrier, and to turn and reposition approximately every two (2) hours. Observation on 1/13/2022 at 12:15 PM identified Resident #3's incontinent brief was saturated with urine and soft stool, and an undated dressing to on Resident #3's buttock with visible dark stool under the unsealed lower area of the dressing. NA #2 identified she was unable to provide any care for Resident #3 since she started work at 8 AM, until 12:15 PM because she had 18 residents on her assignment to provide care for. Interview with LPN #1 (unit charge nurse) on 1/13/2023 at 12:15 PM identified Resident #3 had a large necrotic buttock ulcer. Interview further identified although LPN #1 was aware NA #2 had 18 residents to provide care for, LPN #1 indicated she was unaware that NA #2 was unable to provide care for all the residents on her assignment timely. LPN #1 indicated she had to administer resident medications, but if NA #2 had notified her, that resident care was not provided timely, she would help with resident care as much as possible between her other duties. LPN #1 further stated, at the end of my shift, every resident has received care. 4. Resident #4's diagnoses included chronic kidney disease, prostatic hyperplasia, cerebrovascular disease, Parkinson's disease, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #4 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required total assistance from staff for bed mobility, toilet use and transfer with two staff physical assist. The RCP dated 11/8/2022 identified Resident #4 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to observe for nonverbal clues of needing to use bathroom, observe for signs of redness/inflammation/apply barrier if indicated, and to inspect for skin breakdown during care. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident #4 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #5's brief and was unable to complete a round of incontinent care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. 5. Resident #5's diagnoses included overactive bladder, dementia, cord compression, schizophrenia, and anxiety. The annual MDS assessment dated [DATE] identified that Resident #5 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, required total assistance with dressing, toilet use, transfer with 2 staff physical assist and extensive assistance with bed mobility. The RCP dated 10/25/2022 identified Resident #5 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care and toileting every two (2) hours and as needed, to inspect the skin for redness, irritation, or breakdown during care, and to turn and reposition approximately every two (2) hours. Review of APRN Progress Note dated 1/13/2023 at 2:30 PM identified that Resident #5 was receiving Lasix (diuretic medication) for congestive heart failure, was a Hoyer lift (mechanical lift) for transfers, and often refused transfers out of bed. Interview with NA #2 on 1/13/23 at 3:05 PM identified Resident #5 was repositioned and received incontinent care just before 1:00 PM. NA #2 indicated Resident #5 was incontinent of large amount of urine and the brief was saturated when changed. NA #2 indicated although her shift began at 8 AM, she did not have time to provide repositioning or incontinent care prior to 1 PM (5 hours after her shift began) because she had 18 residents on her assignment, and she did not have time. 6. Resident #6's diagnoses included retention of urine, traumatic brain injury, contracture, and lumbar fusion. The RCP dated 10/18/2022 identified Resident #6 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to observe for signs of redness or inflammation and apply barrier if indicated and provide incontinent care approximately and to reposition Resident #6 every two (2) hours and as needed, and to check for skin breakdown. The quarterly MDS assessment dated [DATE] identified Resident #6 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk for pressure ulcers, required extensive assistance with toilet use and total assistance with bed mobility. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident #6 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #6's brief and was unable to complete a round of incontinence care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. Review of Progress Notes dated 1/13/2023 at 9:23 PM identified Resident #6 was bed bound and had a new unstageable pressure wound on the lower back, measuring 1 cm by 1.5 cm by 0.2 cm. 7. Resident #7's diagnoses included urinary infection, Alzheimer's, dementia, and dysphagia. The quarterly MDS assessment dated [DATE] identified Resident #7 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required total assistance with toilet use, bed mobility and personal hygiene and transfer with two staff physical assist. The RCP dated 12/13/2022 identified Resident #7 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care approximately every two (2) hours and as needed, and to turn and reposition every two (2) hours. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident #7 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #7's brief and was unable to complete a round of incontinence care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. 8. Resident #8's diagnoses included diabetes, adjustment disorder, osteoarthritis, cataract, and obstructive pulmonary disease. The annual MDS assessment dated [DATE] identified Resident #8 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility, toilet use and transfer with two staff physical assist. The RCP dated 11/8/2022 identified Resident #8 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care approximately every two (2) hours and as needed, and to turn and reposition every two (2) hours. Resident #9's diagnoses included dementia, urinary tract infection and malnutrition. The RCP dated 1/6/2023 identified Resident #9 was at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and to provide toilet and/or incontinence care as needed. Resident #10's diagnoses included Parkinson's disease, diabetes, dysphagia, and peripheral vascular disease. The RCP dated 1/10/2023 identified Resident #10 was incontinent of bowel and bladder. Interventions directed to provide incontinent care every 2 hours and as needed. Clinical record review identified Resident #10 had impaired cognition, required maximum staff assistance for toileting and bed mobility. The wound documentation dated 1/9/2023 identified resident #10 had a friction ulcer on the coccyx that measured 0.5 cm by 0.8 cm. Resident #11's diagnoses included Parkinson's disease, dementia, cataract, peripheral vascular disease, and gastric ulcer. The quarterly MDS assessment dated [DATE] identified Resident #11 had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required total assist with toilet use, transfer with two staff physical assistance, and extensive assist with bed mobility. The Resident Care Plan (RCP) dated 11/22/2022 identified Resident #11 was incontinent of bowel and bladder, and at risk for skin breakdown. Interventions directed to offer turn and reposition every two (2) hours and to provide incontinent care. Resident #12's diagnoses included personality disorder, urinary retention, urinary tract infection and seizures. The quarterly MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility, toilet use and two-person physical assistance with transfers. The RCP dated 12/21/2022 identified Resident #12 had an alternation in skin integrity. Interventions directed to turn and reposition every two (2) hours and toilet/provide incontinent care as needed. Resident #13's diagnoses included urinary tract infection, dementia, schizoaffective disorder, Alzheimer's disease, diabetes, and dysphagia. The admission MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required limited assistance with toilet use, personal hygiene, and supervision with bed mobility. The RCP dated 12/5/2022 identified Resident #13 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and to provide incontinent care every two (2) hours. Resident #14's diagnoses included urinary tract infection. Urine retention, metabolic encephalopathy, dysphagia, and alcohol abuse. The 5-day MDS assessment dated [DATE] identified Resident # 14 had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required total assistance with toilet use, transfer with two staff physical assistance and extensive assistance with bed mobility. The RCP dated 10/24/2022 identified Resident #14 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed and to turn and reposition every two (2) hours. Resident #15's diagnoses included urinary tract infection, dementia, psychosis, dysphagia, and adult failure to thrive. The quarterly MDS assessment dated [DATE] identified Resident #15 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required supervision with toilet use, dressing and personal hygiene. The RCP dated 10/25/2022 identified Resident #15 was at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and toileting or incontinence care as needed. Resident #16's diagnoses included dementia, nutritional deficit, and alcohol abuse. The quarterly MDS assessment dated [DATE] identified Resident #16 had moderate cognitive impairment, was occasionally incontinent of bladder and required supervision with transfer, dressing and toilet use. The RCP dated 1/5/2023 identified Resident #16 was at risk for skin breakdown and was occasionally incontinent of bladder. Interventions directed to monitor skin for breakdown during care and to provide toileting assistance every two (2) hours. Resident #17's diagnoses included dementia, chronic kidney disease, cataract, cerebral infarction, and dysphagia. The annual MDS assessment dated [DATE] identified Resident #17 had severe cognitive impairment, was occasionally incontinent of bladder, was at risk for skin breakdown, and required supervision with toilet use, bed mobility and extensive assistance with personal hygiene. The RCP dated 11/1/2022 identified Resident #17 was at risk for skin breakdown and was occasionally incontinent of bowel and/or bladder. Interventions directed to observe skin for breakdown during care, and to assist with toileting before leaving his/her room. Resident #18's diagnoses included urinary tract infection, dementia, multiple fractures, osteoporosis, and glaucoma. The admission MDS assessment dated [DATE] identified that Resident #18 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required limited assistance with toilet use, extensive assistance with bed mobility and personal hygiene. The RCP dated 1/11/2023 identified Resident #18 was at risk for skin breakdown and was incontinent of bowel and bladder. Interventions directed to turn and reposition every two (2) hours, and to provide incontinence care every two (2) hours and as needed. Follow up interview with NA #2 on 1/13/2023 at 3:05 PM identified she was unable to provide morning care or incontinent care every two (2) hours for Residents #8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18. NA #2 identified her assignment included ten (10) residents that required total assistance for hygiene and incontinent care, and eight (8) residents that required assistance with hygiene and incontinent care. NA #2 indicated it was impossible to provide care for the 18 residents on her assignment timely; she indicated the facility could not expect one (1) NA to provide incontinent care to 18 residents every two (2) hours as required in accordance with the resident's plans of care. As of 11:45 AM, NA #2 was able to provide care to twelve (12) residents leaving six (6) Residents without care, and those remaining six (6) residents received care by 1 PM. Further, NA #2 indicated she had not provided every two (2) hour incontinent care and repositioning for any of the residents on her assignment. NA #2 indicated no other staff assisted with providing resident care or feeding her residents, and she did answer any call bells for any residents that were able to call for assistance. Interview with NA #1 on 1/13/2023 at 11:30 AM identified she worked 7 AM to 3PM shift on the 2nd floor (assigned on the same unit with NA #2) and she was unable to assist NA #2 with resident care. NA #1 indicated she had 17 residents on her assignment, and it was difficult to get everything completed timely. Interview and facility documentation review with the Interim DNS on 1/13/2023 at 2:00 PM identified that the facility had a census of 129 residents. The Interim DNS further indicated that although the facility needed 13 to 14 NAs to staff the 7 AM to 3 PM shift to provide resident care in accordance with the resident needs, and on 1/13/2023 the facility had 8 NAs working the shift. Review of the resident roster identified the second floor had 71 residents with 4 NAs (ratio 1 NA to 18 residents). The Interim DNS stated that she was aware that the NA staffing levels were not what was needed to provide care to the residents, and she was working with a nursing agency to obtain additional staff and was working to hire more facility staff. Although the Interim DNS indicated she was aware the shift had less than the required NAs to provide resident care, the Interim DNS was unable to explain what measures she implemented/steps she took to ensure residents received care timely during the shift, or NA #2 received assistance with her assignment. Interview with the Administrator on 1/13/2023 at 3:30 PM identified although he was aware of the low staffing pattern involving NAs, and he indicated he was working on obtaining additional staff, he was unable to verbalize how NA #2 was provided with direction/assistance with her assignment or what steps were taken to ensure the facility had adequate staffing on each shift to ensure residents received care timely. The Administrator further identified that the facility does not have a staffing policy. 9. Resident #22's diagnoses included quadriplegia, dysfunction of bladder, anxiety, and depression. The quarterly MDS assessment dated [DATE] identified Resident #22 had intact cognition, was always incontinent of bowel, was at risk for developing pressure ulcers, had two (2) stage IV pressure ulcers, required extensive assistance with bed mobility, total assistance with toilet use and dressing, and transferred with two person's physical assist. The RCP dated 12/27/2022 identified Resident #22 was incontinent of bowel, required straight catheterization of the bladder and was at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed, inspect skin for redness, irritation, or breakdown during care, and to turn and reposition every two (2) hours. Interview with Person #2 on 1/17/2023 at 12:40 PM identified Resident #22 required staff assistance for personal needs. Person #2 indicated he/she visits frequently, indicated the facility was understaffed; and during visits had often observed long call bell response time (described over two hours) and he/she would have to leave Resident #22 to go search for staff. Person #2 further described many times Resident #22 did not receive staff assistance with personal hygiene and showers (missed many showers), and he/she provided personal hygiene for Resident #22 frequently. 10. Resident #23's diagnoses included urinary tract infection, kidney stones, cerebrovascular accident, obesity, and hypertension. The annual MDS assessment dated [DATE] identified Resident #23 had intact cognition, was occasionally incontinent of bladder, was at risk of developing pressure ulcers, required extensive assistance with bed mobility and personal hygiene, limited assistance with toilet use, and transfer with two staff physical assist. The RCP dated 10/25/2022 identified Resident #23 was incontinent of bladder and had fragile skin. Interventions directed to provide incontinent care every two (2) hours and as needed, inspect skin during care and provide specialty air mattress. Interview with Resident #23 on 1/17/2023 at 1:30 PM indicated a lack of facility staff, most often during the 7 AM to 3 PM shift. Resident #23 described he/she frequently had to wait a long time for his/her call bell to be answered, food was delivered cold, and often missed scheduled showers. He/she further described: imagine you are sitting in a wet and cold diaper for hours, you get urinary tract infection because there was no staff to change you and when the NA comes into your room, she tells you I am here by myself and have 20 residents, so you have to wait. Resident #23 indicated he/she can leave his/her room to look for staff, but not all residents can do that. Further interview identified that residents had voiced concerns during Resident Council meetings regarding the lack of staff and resident care not provided timely, and the facility blamed the staffing shortage on the pandemic. Interview with NA #8 on 1/17/2023 at 2:15 PM identified she worked in the facility frequently, and indicated she had difficulty completing her assignment timely when she had 18 to 20 residents on her assignment. NA #8 identified she was unable to complete resident rounds every 2 hours. She further indicated some residents stayed in bed, incontinent care was not provided, and for those residents she was able to get out of bed, she was not able to put them back to bed for repositioning or a nap. NA #8 indicated she needed assistance with her assignment and she did not have any other staff available to assist her. Interview with NA #7 on 1/18/2023 at 2:00 PM identified she worked in the facility frequently and in the past had 17 to 20 residents on her assignment during her shifts. She indicated it was impossible to provide toileting or incontinent care for the residents every two (2) hours. NA #7 indicated she often works without adequate staffing and has many residents on her assignment that she is not able to provide resident care timely. Review of Facility Assessment Tool, revised on 2/18/2022, directed in part: daily discussions with unit staffing to assess the needs of the building, provide updates regarding resident needs with nursing leadership and the scheduler will make staffing adjustments. On 1/13/23, the Department requested an immediate action plan to address the findings of Immediate Jeopardy. The facility's removal plan submitted on 1/13/2023 identified the facility has hired new staff and will continue its efforts in staff recruitment and retention. Audits will be conducted daily until substantial compliance is achieved to ensure adequate staffing is scheduled per the facility census, and the audits will be summitted to the QA committee for review. In addition, the facility has voluntarily agreed to stop new admissions.

Based on observations, clinical record reviews, facility documentation review, facility policy review, and interviews for 18 of 18 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18) reviewed for care and services, the facility failed to ensure the needs of all residents were met timely, in accordance with their plan of care resulting in neglect. The failures to provide care as required resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included cerebrovascular disease, diabetes, urinary tract infection, Alzheimer's disease, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition with short and long-term memory problems, was always incontinent of bladder and bowel, was at risk for pressure ulcers, required extensive assistance with bed mobility, total assistance with toilet use, and transferred with two staff physical assist. The Resident Care Plan (RCP) dated 11/8/2022 identified Resident #1 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to offer bedpan/toilet assistance every two (2) hours and as needed, provide incontinence care approximately every two (2) hours and as needed, to observe for signs of redness/inflammation/breakdown, apply barrier cream if indicated and to the keep brief loose. Observations on 1/13/2022 at 11:52 AM identified Resident #1's incontinence brief removed by NA #2 was saturated from front to back with dark color urine and a small amount of black-colored, dried bowel movement on Resident #1's buttock area. A strong urine odor was noted when the brief was opened, and some of the inside of the incontinent brief was sticking to Resident #1's skin. Further observation identified multiple areas on Resident #1's buttock area that were painful to touch, the resident was flinching and was saying ouch, pain during incontinence care provided by NA #2. Resident #1 was assessed by RN #2 and identified with new alterations in skin integrity: the left buttock had a linear discoloration wound identified as a suspected deep tissue injury that measured 5 centimeters (cm) by 0.5 cm; the right buttock had a linear discoloration wound with deep tissue injury that measured 1.4 cm by 0.4 cm; the left upper buttock had a friction/skin tear that measured 5 cm by 0.5 cm by 0.1 cm with a small amount of serosanguinous drainage (yellowish fluid with small amounts of blood) identified as moisture associated dermatitis (inflammation or skin erosion caused by prolonged exposure to moisture); and the scrotum was red moisture associated dermatitis with intact skin. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide any care to Resident #1 prior to 11:52 AM. NA #2 identified she had not checked or changed Resident #1's brief and was unable to complete any round of incontinence care because she had 18 total residents on her assignment. NA #2 indicated that in addition to Resident #1, she still had five other residents (Resident #3, #4, #5, 6 and #7) that she was unable to provide any care since 8 AM when she arrived at work; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to any residents on her assignment) and it was now time for lunch to be served. Interview with RN #2 on 1/13/2023 at 12:10 PM identified Resident #1 had no open areas on his/her buttocks prior to those observed on 1/13/2023. RN #2 was notified that Resident #1 had new open and redden areas to his/her buttocks that looked like either he/she was sitting for a long time on the bedpan or the rolled up, wet diaper that had become stuck to Resident #1's skin had caused the injuries. RN #2 further identified that she was not aware that incontinent care was not provided through the morning shift (she was helping on another unit), and indicated the facility management was aware of short staffing. Interview with NA #5 on 1/15/2023 at 3:30 PM identified she worked during 11:00 PM to 7:00 AM shift on 1/12 into 1/13/2023, and she started her incontinent rounds for all residents on her unit about 6:00 AM. NA #5 identified Resident #1 received incontinent care and had his/her brief last changed on 1/13/2023 between 6:00 and 6:30 AM. NA #5 further identified Resident #1 had no discomfort, open areas, or redness on his/her buttocks at the time incontinent care was provided last (over 5 hours and 22 minutes between incontinence care was provided). Interview with wound consultant MD #2 on 1/17/2023 at 1:20 PM identified she assessed Resident #1's buttock wounds on 1/17/2023 and identified that they looked dermatological, and they were improving. MD #2 indicated the wounds were acute, and after removing pressure, friction, and wetness, they would heal. MD #2 identified the wounds on Resident #1's buttock happened very quickly and a few hours was a long time for Resident #1 to not be repositioned and/or exposed to a wet diaper, especially with trauma from the bulging. MD #2 further indicated the wet brief that was possibly rolled up and/or stuck to Resident #1's skin made the injury worse. 2. Resident #2's diagnoses included urinary tract infection, Parkinson's disease, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #10 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility and toilet use. The RCP dated 11/1/2022 identified Resident #2 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed, inspect skin for redness, irritation, or breakdown during care, and to turn and reposition approximately every two (2) hours. Observation on 1/13/2023 at 11:45 AM identified NA #2 was completing morning care with Resident #2. Observation identified Resident #2's incontinent brief was saturated with urine. NA #2 identified she started work at 8:00 AM, she had 18 residents on her assignment and she still had six (6) residents to provide care to. NA #2 stated she finished helping with breakfast and now she was going from room to room as fast as she could. 3. Resident #3's diagnoses included adult failure to thrive, hemiplegia and dementia. The quarterly MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, had an unstageable pressure injury, and required total assistance with bed mobility, toilet use, personal hygiene, and transferred with two staff physical assist. The RCP dated 11/1/2022 identified Resident #3 was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed, to inspect the skin for redness/irritation/breakdown during care, apply incontinence protective barrier, and to turn and reposition approximately every two (2) hours. Observation on 1/13/2022 at 12:15 PM identified Resident #3's incontinent brief was saturated with urine and soft stool, and an undated dressing on Resident #3's buttock was visible with dark stool under the unsealed lower area of the dressing. NA #2 identified she was unable to provide any care for Resident #3 since she started work at 8 AM, until 12:15 PM because she had 18 residents on her assignment to provide care for. Interview with LPN #1 (unit charge nurse) on 1/13/2023 at 12:15 PM identified Resident #3 had a large necrotic buttock ulcer. Interview further identified although LPN #1 was aware NA #2 had 18 residents to provide care for, LPN #1 indicated she was unaware that NA #2 was unable to provide care for all the residents on her assignment timely. LPN #1 indicated she had to administer resident medications, but if NA #2 had notified her, that resident care was not provided timely, she would help with resident care as much as possible between her other duties. LPN #1 further stated, at the end of my shift, every resident has received care. 4. Resident #4's diagnoses included chronic kidney disease, prostatic hyperplasia, cerebrovascular disease, Parkinson's disease, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #4 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required total assistance from staff for bed mobility, toilet use and transfer with two staff physical assist. The RCP dated 11/8/2022 identified Resident #4 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to observe for nonverbal clues of needing to use bathroom, observe for signs of redness/inflammation/apply barrier if indicated, and to inspect for skin breakdown during care. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident 4 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #4's brief and was unable to complete a round of incontinent care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. 5. Resident #5's diagnoses included overactive bladder, dementia, cord compression, schizophrenia, and anxiety. The annual MDS assessment dated [DATE] identified that Resident #5 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, required total assistance with dressing, toilet use, transfer with 2 staff physical assist and extensive assistance with bed mobility. The RCP dated 10/25/2022 identified Resident #5 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care and toileting every two (2) hours and as needed, to inspect the skin for redness, irritation, or breakdown during care, and to turn and reposition approximately every two (2) hours. Review of a APRN Progress Note dated 1/13/2023 at 2:30 PM identified that Resident #5 was receiving Lasix (diuretic medication) for congestive heart failure, was a Hoyer lift (mechanical lift) for transfers, and often refused transfers out of bed. Interview with NA #2 on 1/13/2023 at 3:05 PM identified Resident #5 was repositioned and received incontinent care just before 1:00 PM. NA #2 indicated Resident #5 was incontinent of large amount of urine and the brief was saturated when changed. NA #2 indicated although her shift began at 8 AM, she did not have time to provide repositioning or incontinent care prior to 1 PM (5 hours after her shift began) because she had 18 residents on her assignment, and she did not have time. 6. Resident #6's diagnoses included retention of urine, traumatic brain injury, contracture, and lumbar fusion. The RCP dated 10/18/2022 identified Resident #6 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to observe for signs of redness or inflammation and apply barrier if indicated and provide incontinent care approximately and to reposition Resident #6 every two (2) hours and as needed, and to check for skin breakdown. The quarterly MDS assessment dated [DATE] identified Resident #6 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk for pressure ulcers, required extensive assistance with toilet use and total assistance with bed mobility. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident #6 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #6's brief and was unable to complete a round of incontinence care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. Review of Progress Notes dated 1/13/2023 at 9:23 PM identified Resident #6 was bed bound and had a new unstageable pressure wound on the lower back, measuring 1 cm by 1.5 cm by 0.2 cm. 7. Resident #7's diagnoses included urinary infection, Alzheimer's, dementia, and dysphagia. The quarterly MDS assessment dated [DATE] identified Resident #7 had severe cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required total assistance with toilet use, bed mobility and personal hygiene and transfer with two staff physical assist. The RCP dated 12/13/2022 identified Resident #7 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care approximately every two (2) hours and as needed, and to turn and reposition every two (2) hours. Interview with NA #2 on 1/13/2023 at 12:00 PM identified although her shift started at 8 AM, she did not provide care to Resident #7 prior to 12 noon (4 hours after her shift began). NA #2 identified she had not checked or changed Resident #7's brief and was unable to complete a round of incontinence care because she had 18 total residents on her assignment to provide care to; she indicated no other staff helped her provide care for the residents assigned to her (no other staff provided care to the residents on her assignment) and it was time for lunch to be served. 8. Resident #8's diagnoses included diabetes, adjustment disorder, osteoarthritis, cataract, and obstructive pulmonary disease. The annual MDS assessment dated [DATE] identified Resident #8 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility, toilet use and transfer with two staff physical assist. The RCP dated 11/8/2022 identified Resident #8 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care approximately every two (2) hours and as needed, and to turn and reposition every two (2) hours. Resident #9's diagnoses included dementia, urinary tract infection and malnutrition. The RCP dated 1/6/2023 identified Resident #9 was at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and provide toilet and/or incontinence care as needed. Resident #10's diagnoses included Parkinson's disease, diabetes, dysphagia, and peripheral vascular disease. The RCP dated 1/10/2023 identified Resident #10 was incontinent of bowel and bladder. Interventions directed to provide incontinent care every two (2) hours and as needed. Clinical record review identified Resident #10 had impaired cognition, required maximum staff assistance for toileting and bed mobility. The wound documentation dated 1/9/2023 identified resident #10 had a friction ulcer on the coccyx that measured 0.5 cm by 0.8 cm. Resident #11's diagnoses included Parkinson's disease, dementia, cataract, peripheral vascular disease, and gastric ulcer. The quarterly MDS assessment dated [DATE] identified Resident #11 had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required total assist with toilet use, transfer with two staff physical assistance, and extensive assist with bed mobility. The Resident Care Plan (RCP) dated 11/22/2022 identified Resident #11 was incontinent of bowel and bladder, and at risk for skin breakdown. Interventions directed to offer turn and reposition every two (2) hours and to provide incontinent care. Resident #12's diagnoses included personality disorder, urinary retention, urinary tract infection and seizures. The quarterly MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment, was always incontinent of bladder and bowel, was at risk of developing pressure ulcers, and required extensive assistance with bed mobility, toilet use and two-person physical assistance with transfers. The RCP dated 12/21/2022 identified Resident #12 had an alternation in skin integrity. Interventions directed to turn and reposition every two (2) hours and toilet/provide incontinent care as needed. Resident #13's diagnoses included urinary tract infection, dementia, schizoaffective disorder, Alzheimer's disease, diabetes, and dysphagia. The admission MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required limited assistance with toilet use, personal hygiene, and supervision with bed mobility. The RCP dated 12/5/2022 identified Resident #13 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and to provide incontinent care every two (2) hours. Resident #14's diagnoses included urinary tract infection. Urine retention, metabolic encephalopathy, dysphagia, and alcohol abuse. The 5-day MDS assessment dated [DATE] identified Resident # 14 had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required total assistance with toilet use, transfer with two staff physical assistance and extensive assistance with bed mobility. The RCP dated 10/24/2022 identified Resident #14 was incontinent of bowel and bladder and at risk for skin breakdown. Interventions directed to provide incontinent care every two (2) hours and as needed and to turn and reposition every two (2) hours. Resident #15's diagnoses included urinary tract infection, dementia, psychosis, dysphagia, and adult failure to thrive. The quarterly MDS assessment dated [DATE] identified Resident #15 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required supervision with toilet use, dressing and personal hygiene. The RCP dated 10/25/2022 identified Resident #15 was at risk for skin breakdown. Interventions directed to turn and reposition every two (2) hours, and toileting or incontinence care as needed. Resident #16's diagnoses included dementia, nutritional deficit, and alcohol abuse. The quarterly MDS assessment dated [DATE] identified Resident #16 had moderate cognitive impairment, was occasionally incontinent of bladder and required supervision with transfer, dressing and toilet use. The RCP dated 1/5/2023 identified Resident #16 was at risk for skin breakdown and was occasionally incontinent of bladder. Interventions directed to monitor skin for breakdown during care and to provide toileting assistance every two (2) hours. Resident #17's diagnoses included dementia, chronic kidney disease, cataract, cerebral infarction, and dysphagia. The annual MDS assessment dated [DATE] identified Resident #17 had severe cognitive impairment, was occasionally incontinent of bladder, was at risk for skin breakdown, and required supervision with toilet use, bed mobility and extensive assistance with personal hygiene. The RCP dated 11/1/2022 identified Resident #17 was at risk for skin breakdown and was occasionally incontinent of bowel and/or bladder. Interventions directed to observe skin for breakdown during care, and to assist with toileting before leaving his/her room. Resident #18's diagnoses included urinary tract infection, dementia, multiple fractures, osteoporosis, and glaucoma. The admission MDS assessment dated [DATE] identified that Resident #18 had severe cognitive impairment, was occasionally incontinent of bowel and bladder, was at risk of developing pressure ulcers, and required limited assistance with toilet use, extensive assistance with bed mobility and personal hygiene. The RCP dated 1/11/2023 identified Resident #18 was at risk for skin breakdown and was incontinent of bowel and bladder. Interventions directed to turn and reposition every two (2) hours, and to provide incontinence care every two (2) hours and as needed. Follow up interview with NA #2 on 1/13/2023 at 3:05 PM identified she was unable to provide morning care or incontinent care every two (2) hours for Residents #8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18. NA #2 identified her assignment included ten (10) residents that required total assistance for hygiene and incontinent care, and eight (8) residents that required assistance with hygiene and incontinent care. NA #2 indicated it was impossible to provide care for the 18 residents on her assignment timely; she indicated the facility could not expect one (1) NA to provide incontinent care to 18 residents every two (2) hours as required in accordance with the resident's plans of care. As of 11:45 AM, NA #2 was able to provide care to twelve (12) residents leaving six (6) Residents without care, and those remaining six (6) residents received care by 1 PM. Further, NA #2 indicated she had not provided every two (2) hour incontinent care and repositioning for any of the residents on her assignment. NA #2 indicated no other staff assisted with providing resident care or feeding her residents, and she did answer any call bells for any residents that were able to call for assistance. NA #2 identified I put my hands on every resident, even if it was for a little bit; although care was not provided timely and every two (2) hour checks were not completed, no resident was left unattended. NA #2 indicated she did her best, she was running and it was hard to get everything done with 18 residents on the assignment. Interview with NA #1 on 1/13/2023 at 11:30 AM identified she worked 7 AM to 3PM shift on the 2nd floor (assigned on the same unit with NA #2) and she was unable to assist NA #2 with resident care. NA #1 indicated she had 17 residents on her assignment, and it was difficult to get everything completed timely. Interview and facility documentation review with the Interim DNS on 1/13/2023 at 2:00 PM identified that the facility had a census of 129 residents. The Interim DNS further indicated that although the facility needed 13 to 14 NAs to staff the 7 AM to 3 PM shift to provide resident care in accordance with the resident needs, on 1/13/2023 the facility had 8 NAs working the shift. Review of the resident roster identified the second floor had 71 residents with 4 NAs (ratio 1 NA to 18 residents). The Interim DNS further identified that it was her expectation that NAs would check and change/reposition all residents at least every two (2) hours. The Interim DNS stated that she was aware that the NA staffing levels were not what was needed to provide care to the residents, she was working with a nursing agency to obtain additional staff, and was working to hire more facility staff. She further indicated that she expected that NAs to ask the nurses, rehabilitation staff, and other staff for help when they were unable to provide care timely. Although the Interim DNS indicated she was aware the shift had less than the required NAs to provide resident care, the Interim DNS was unable to explain what measures she implemented/steps she took to ensure residents received care timely during the shift, or NA #2 received assistance with her assignment. Interview with the Administrator on 1/13/2023 at 3:30 PM identified although he was aware of the low staffing pattern involving NAs, he did not expect residents to wait to have incontinence care provided and expected NA's to ask for help when needed to ensure that all residents were provided care timely. Although the Administrator indicated he was working on obtaining additional staff, he was unable to verbalize how NA #2 was provided with direction/assistance with her assignment or what steps were taken to ensure residents received care timely. Review of facility Abuse Prohibition Policy identified in part, neglect was the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Policy further directed each resident has the right to be free from neglect. Review of the facility Certified Nursing Assistant Job Description directed in part, the primary purpose of Certified Nursing Assistant job position was to provide assigned residents with routine daily nursing care promptly in accordance with established nursing care procedures, and as directed by the licensed staff nurse. Review of the facility Nursing Supervisor Job Description directed in part, to meet the nursing needs of the residents and to conduct oversight of the NA performance. On 1/13/23, the Department requested an immediate action plan to address the findings of Immediate Jeopardy. The facility's removal plan submitted on 1/13/2023 identified the facility has hired new staff and will continue its efforts in staff recruitment and retention. Audits will be conducted daily until substantial compliance is achieved to ensure adequate staffing is scheduled per the facility census, and the audits will be summitted to the QA committee for review. All licensed staff were educated regarding Skin/Infection Control Policy, weekly body audits and identification of skin impairments, and incontinent care. Audits of every resident's skin will be conducted to ensure concerns are addressed immediately, and the results of the audits will be presented to the facility QA committee. In addition, the facility has voluntarily agreed to stop new admissions.

Based on review of the clinical record, observations, interviews, and review of facility documentation, for three of six residents (Resident # 296) reviewed for accidents, the facility failed to ensure the resident was transferred via mechanical lift with two staff members in accordance to the plan of care and for one of three residents (Resident # 89) reviewed for elopement the facility failed to prevent and elopement . The findings included: 1. Resident #296's diagnoses included dementia, difficulty walking, and abnormality of gait, fracture of left femur following insertion of implant or prosthesis, and weakness. NA #5's Clinical Competency Evaluation for Transferring a Resident Using a Mechanical Lift, dated 10/20/20, identified NA #5 passed the clinical competency elements, including: Checks the resident's care card for correct mechanical lift, sling size. A transferring quiz dated 10/20/20 identified NA#5 correctly answered no for the question: If you are unaware of the resident's transfer status, should you transfer them anyway? A physician's order dated 11/8/20 directed Hoyer lift transfers assist of two, left leg to be supported during transfers. The admission MDS assessment dated [DATE] identified the resident had severe cognitive impairment and required extensive assistance of two staff for transfers. The care plan dated 11/19/20 identified the resident had alteration in musculoskeletal status related to periprosthetic femoral fracture, interventions included: total dependence with Activities of Daily Living (ADL). The Resident's Care Card directed Hoyer (mechanical lift) assist of two staff, staff to provide support. The nurse's note dated 12/8/21 identified: Injury to left shin. Approximately 2:15 P.M .according to staff, resident was transferred from bed to wheelchair, in wheelchair staff observed with bleeding from the resident's left shin. On observation this author noted a golf ball-sized chunk of flesh missing from the resident's left shin as if the skin was torn open with muscle exposed and a missing portion of flesh where skin and flesh should have been. The resident present as alert and verbal, oriented to self and place, responds appropriately to questions and cues, reports moderate pain to area and was noted with anxiety related to the event. Resident # 296 was provided reassurance with positive effect, about 50 Cubic Centimeters (CC) of blood on a towel held in place by staff, the APRN was notified and staff was directed to transfer the resident to the hospital for an evaluation . Resident # 296's representative was notified and in agreement with an order to send to the resident to the hospital. Emergency Medical Technical (EMT) transferred the resident to the stretcher, identification bracelet on resident person. EMT report given and was notified of the resident's use of [MEDICATION(S)] (Anticoagulant) and recovery from COVID-19 status. No signs or symptoms of acute distress. Temperature-98.3, pulse-70, respirations-20 (indicating vital signs with normal range) blood pressure-106/65 (120/80 normal range), oxygen saturation-95% (within normal range) on room air. Facility Reportable Event form dated 12/8/20 identified the resident was transferred from bed to wheelchair by one NA (NA #5) which caused Resident # 296 to sustain a large flesh injury to the resident's left shin with muscle visible and further identified the resident was transferred to the hospital emergency department. Hospital Emergency Department documentation dated 12/8/20 identified the resident was transferring to wheelchair when he/she struck a piece of metal causing a large laceration to the resident's midshaft anterior left lower leg. The documentation further identified: Patient with isolated trauma to the leg, laceration requiring repair. Fascia was closed with a total of five 4-0 [MEDICATION(S)] sutures. Skin layer was closed with a total of 19 interrupted Prolene sutures. Laceration is approximately 12 Centimeter in length and roughly circular in nature, a flap/avulsion (skin flap) type injury. Disposition: noted discharged . Discharge instructions directed dressing changes at least daily and suture removal in 14 days. Interview with NA #5 on 4/21/21 at 1:16 P.M. identified NA #5 did transfer the resident by himself/herself when the resident sustained the injury to the left shin. NA #5 further identified she/he should not have transferred the resident by himself/herself. NA #5 identified the resident should have been transferred with a mechanical lift and assistance of two staff which was noted on the care card; however, the resident had been transferred to the unit that day and NA #5 believed he/she had been told the resident required one person for transfer. NA #5 identified he/she had failed to check the care card prior to the transfer because he/she did not know if the care card was on the unit at that time, but later found out the care card was in place on the unit. NA #5 identified review of the care card is required prior to transferring a resident, and further identified it is the NA's responsibility to notify nursing if the aide had any questions. Interview with the DNS on 4/22/21 at 3:01 P.M. identified NA #5 should not have transferred the resident by himself/herself; the aide should have checked the care card but did not. The DNS identified the facility has no specific policy for transfers, the expectation is that staff will follow prescriber's orders and follow the plan of care. Interview and review of the personnel file of NA #5 with the Director of Human Resources on 4/23/21 at 12:09 P.M. identified NA #5 had no discipline in the file, was hired at this facility by the former facility owners with a date of hire 2/8/16, and NA #5 had background screening done by the former company. The facility developed a plan of correction to correct the deficient practice by 12/30/21(Date of Completion) with the following interventions: that included: Education to Nurse Aides (NAs) on 12/8/20 through 12/15/20 regarding Patient Transfers and Ambulation Orders, NA # 5 received immediate on the job training regarding transferring clinical competency (transferring a resident using a mechanical lift) and a quiz. Audits were conducted from 12/9/20 through 1/3/21 regarding mechanical lift transferring and monitoring. Quality Improvement plan noted action steps which identified: in services to staff to follow the plan of care prior to providing any care to residents, facility wide audit to ensure that all care cards reflect current transfer status, all nurse aides will be brought up to date on all annual competency for transfer by 12/30/21. 2. Resident #89 was admitted to the facility on [DATE] with diagnoses that included dementia and cerebral infarction. The elopement and wandering assessment dated [DATE] identified Resident #89 was not at risk for wandering or elopement. A quarterly Minimum Data Set, dated dated dated [DATE] identified Resident #89 had severe impairment in decision making, required extensive assistance of one to two staff with activities of daily living, utilized a walker or wheelchair, and did not exhibit wandering behaviors. A nurse's note dated 8/24/20 at 1:59 PM indicated Resident #89 made it to the first floor, (Resident #89's room was on the second floor), returned and Wanderguard now on chair. The elopement and wandering assessment dated [DATE] identified the resident was at risk for wandering and elopement (Resident #89 was previously not a risk for elopement). The Resident Care Plan was dated 8/25/20 was revised to include a problem with being at risk to try to leave the nursing facility with pacing, roaming/wandering in/out of peer rooms. Interventions included assist to find own room/bathroom as needed, encourage participation in positive meaningful activity programs of choice, establish and maintain daily routine, provide diversional activities and Wanderguard applied. A Reportable Event form dated 9/27/20 at 7:15 PM indicated the Nursing Supervisor was alerted by a Dietary staff member that Resident #89 was laying on his/her right side in the parking lot with the wheelchair next to him/her. Facility investigation identified Resident #89 was last seen on the unit at approximately 7:00 PM, entered the elevator, and exited the building through the art/community room fire door located on the first floor. Resident #89 complained of right arm and head pain, was transferred to the emergency room , x-rays and CT scan were negative, and Resident #89 returned to the facility at baseline with no sustained injury or memory of the event. The investigation also indicated, although the resident had a prior history of elopement (from 8/24/20), a Wanderguard was not in place on 9/27/20. Interview and observation of the art/community room fire door with Maintenance Worker #1 on 4/21/21 at 11:40 AM indicated when Resident #89 pushed on the fire door to exit the art/community room, the alarm would have sounded at the second and third floor nursing stations and the alarm would have had to be cancelled by someone at the alarm panel in the art/community room. Maintenance Worker #1 further indicated if Resident #89 had a Wanderguard in place, the Wanderguard would have alarmed at the elevator on the second floor and at the fire door. Review of the security round sheet dated 9/27/20 indicated the door was checked for operation at 8:30 AM. Interview with the acting DNS on 4/21/21 at 11:40 AM indicated the investigation did not determine who shut the alarm off. In-services from 9/29/20 to 10/2/20 were held regarding the elopement policy and door alarms with the content of everyone being responsible to check alarms going off and searching outside for wandering residents when alarm is active. Interview and review of the medical record with the acting DNS on 4/22/21 at 2 PM failed to identify monitoring of the Wanderguard on the 8/2020 Treatment Administration Record. In addition, review of the record failed to identify when and the reason the Wanderguard was removed, although the acting DNS indicated the resident still should have had the Wanderguard in place during the 9/27/20 event. Review of the Wandering Management System policy indicated the system was used for residents/patients at risk for elopement as assessed and determined by the interdisciplinary team. The bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed.

Based on observations, review of the clinical records, facility policy and/or procedures and interviews for one of 20 residents observed for identification bracelets (R#111), and/or for one of two resident's reviewed for positioning (R #3), the facility failed to ensure that care and/or services were provided in accordance to the resident's plan of care, and/or for one of two sampled residents reviewed for non-pressure wounds (R#31), the facility failed to initiate interventions to alleviate pressure to the foot wounds, and/or failed to obtain a wound consult in a timely manner, and/or failed to initiate an "urgent" consult with a surgeon. The finding included: 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission skin/body assessment dated [DATE] noted multiple scabs on left and right anterior lower legs, a 2 x 2.6 x 0.4 cm open area with a moderate amount of yellow slough on the right Achilles area, red, blanchable heels, the left 2nd toe with a 0.6 x 0.6 cm open area with scant yellow slough, the 4th toe right foot with a 0.6 x 0.6 cm scab, and the 5th toe right foot with a 1.0 x 0.7 cm scab. The history and physical dated 11/14/14 identified 2+ non-pitting, [MEDICAL CONDITION] and mild cyanosis, cold to touch and hairless, left second toe with dorsal wound and overlying [MEDICATION NAME] which is slightly open. Toes on right foot with scattered eschars involving toes 2 and 4, right Achilles tendon has ulcer long and elliptical with at least 0.5 in depth with yellowish slough covering majority of wound bed and draining clear liquid. Decreased sensation over both feet. Plan: will have wound care consultant evaluate wounds and appropriate dressings. Right Achilles tendon with yellowish slough in bed will need to be debrided. The initial assessment by the wound care physician on 11/25/14 noted that right Achilles tendon/ankle area had " tendon already exposed on physical examination. Recommend urgent surgical assessment for reconstruction/coverage with either STSG or flap " . The wound measured 8 by 3.5 by 0.6 cm. The next assessment by the wound care physician dated 12/16/14 noted as follows: " necrotic Achilles tendon exposed. Pt does not need to go to a " wound clinic " . Pt needs to be seen by a surgeon for consideration for intra-op debridement and possible STSG/flap " NOT " wound clinic. Discussed with floor nurse extensively. Nurse acknowledged surgical consult request and will proceed with arrangement for surgical consult. " At that time the wound had declined to 10 by 4 by 1 cm with 50% necrotic tissue. On 1/22/15 at 11:20 AM, review of the paper record, computer entries, and interview with the IC/wound nurse failed to provide any documentation that the resident ' s heels were offloaded and/or that pressure reducing interventions were put in place upon admission with wounds present to the feet. Further review failed to provide documentation that the wound physician had assessed the wound for proper care and treatment from admission on 11/13/14 through 11/25/14 at which time the wound had significantly declined. 2. Resident #111's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was cognitively intact and independent for all activities of daily living. Physician monthly orders for January 2015 directed the following medications to be consumed by mouth: Chewable Aspirin 81 mg (milligrams) at 9:00 A.M. Calcium [MEDICATION NAME] 750 mg at 9:00 A.M. [MEDICATION NAME] Sodium 200 mg at 8:30 A.M. [MEDICATION NAME] 300 mg 9:00 A.M. [MEDICATION NAME] Mononit Extended Release 90 mg at 9:00 A.M. Losartan Potassium 100 mg at 8:30 A.M. Iron 325 mg tablet at 8:30 A.M. [MEDICATION NAME] 10 mg at 8:30 A.M. [MEDICATION NAME] 8 mg at 8:30 A.M. [MEDICATION NAME] Acid 40 mg at 8:30 A.M. Venlafaxinine Extended Release 150 mg at 9:00 A.M. On 1/22/15 at 11:40 A.M. during observation of residents on unit 3 for name identification bracelets with RN# 3, it was identified that a medication cup containing several types of medications had been left at the resident's bedside on the overbed table. RN #3 indicated at the time of the observation that R #111 was LPN #3's patient (resident). During an interview, review and comparison of all medications found at the resident's bedside with the physician orders, R #111's MAR (medication administration record) and pill cards with LPN #3 on 1/22/15 at 11:45 A.M., identified an omission of eleven of the resident's medications during the morning med pass. LPN #3 indicated that as he/she was attempting to administer the resident his/her medications, he/she was called away to provide assistance to a student nurse who was toileting a resident in another room. After providing assistance to the student nurse, LPN#3 indicated that he/she had forgotten to finish R #111's medication pass. On 1/22/15 at 12:10 P.M. an interview with the DON indicated that when LPN #3 left the resident's room, R #111's medications were not to have been left with the resident at his/her bedside. On 1/23/15 at 2:45 P.M. an interview with the Administrator indicated that when a student nurse requires assistance with caring for a resident, the expectation would be that the Clinical Nurse Instructor remain available to assist the student nurse with the resident until the task has been completed. 3. Resident #3's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was severely cognitively impaired required total assistance from staff for all activities of daily living, had unsteady sitting balance and utilized a (customized) wheelchair. The RCP dated 11/5/14 identified a problem with impaired mobility. Interventions included head rest for adaptive wheelchair and provide customized wheelchair. Observation of the resident on 1/20/15 at 3:28 P.M. and on 1/22/15 at 2:00 P.M. identified that although the resident was positioned in a customized wheelchair with a headrest in place, it was noted that the resident's head was leaning towards the right side of his/her body causing the resident to lack proper positioning while utilizing his/her head rest. A review of the clinical record identified that at the time of the resident's admission on 3/13/03, the resident was noted as having poor positioning and poor postural alignment, no sitting balance, or trunk strength with a goal to fit resident for a customized wheelchair to further prevent mal-alignment of the resident's joints. Upon further review of the clinical record for a more recent positioning and/or customized wheelchair assessment and/or screen for R#3 it was noted that documentation was lacking within recent years that the resident had been screened and/or assessed for positioning and/or for the continued use of a customized wheelchair. On 1/23/15 at 11:15 A.M. and 1:20 P.M. an interview and review of the clinical record for R #3 with the Rehab director indicated that the resident's most recent screen and/or assessment was performed in the year 2011 and that the resident was to have been provided an assessment and/or screen for positioning and/or continued use of the CWC with head rest, quarterly and/or every 4-5 months.

Based on clinical record reviews, observations, interviews and review of a policy and procedure for four of six residents in the survey sample reviewed for pressure sores (R #107, 142, 137, 100), the facility failed to ensure a splint ordered for a wrist fracture was evaluated and/or assessed for proper fit by specialized rehab services which resulted in a pressure sore, and/or failed to treat wounds with the appropriate treatment, and/or failed to assess wounds appropriately, and/or failed to initiate interventions to prevent heel breakdown in residents at risk due to hip surgery. The findings include: 1. Resident #107 ' s [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated R # 107 had severe cognitive deficits, required extensive assist with transfer, did not walk, and was total care with locomotion. A care plan dated 6/8/14 indicated the resident was at risk for altered skin integrity related to hand getting stuck in wheelchair. Interventions included splint in place and occupational therapy (OT) to evaluate wheelchair and hand positioning. An x-ray report dated 6/8/14 indicated there was suggestion of a [MEDICAL CONDITION] styloid which may extend to the articular surface. A physician's orders [REDACTED]. Check placement and skin integrity every shift. Review of a change of condition flow sheet dated 6/7/14 through 7/6/14 noted the right hand was monitored for circulation, movement, sensation, and swelling. A physician's orders [REDACTED]. Review of OT notes dated 6/10/14 through 6/13/14 indicated the resident was provided with a tilt in space wheelchair with good support and upright posture. The notes failed to document an evaluation and/or assessment of the splint on the right hand. A nurse ' s note dated 7/6/14 indicated a fluid filled blister was noted between the 2nd digit on the right hand. The nurse aide and Person #1 in the room indicated the splint was too tight at times and pushed into the resident's skin. A physician's orders [REDACTED]. An interview on 1/22/15 at 7:30 AM with the Director of Rehab indicated although s/he was not the treating OT for R #107, the standard of practice would be for OT to evaluate and assess any splint used on a resident for proper fit, placement, comfort, and schedule. An interview on 1/22/15 at 9:22 PM with MD # 1 indicated he/she had instructed RN # 1 to apply a trough-style splint to the right hand with the expectation that OT would see the resident the next day to assess and/or evaluate the splint. An interview on 1/22/15 at 10:45 AM with RN # 2 indicated he/she applied the splint to the resident's right hand. The splint was a hard plastic and/or metal. He/she did not refer the resident to OT at that time. An interview on 1/22/15 at 10:50 AM with the DNS indicated although there was no written policy on splints, he/she would have expected OT to evaluate the splint being used on R # 107 to ensure it fit properly. 2. Resident #142's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident was without cognitive impairment, and required extensive assistance with ADL ' s including bed mobility and transfers. Nurse ' s notes dated 12/27/14 identified the resident was readmitted to the facility after repair of a right [MEDICAL CONDITION]. Although 4 blistered areas were noted near the right hip incision site, no pressure ulcers were identified on the resident's heels. Physician orders [REDACTED]. Nurse ' s notes identified on 1/5/15 at 8:45 PM, a 2x2 cm intact blister was noted on the right inner heel when applying the skin prep. The physician was notified and directed to continue the application of skin prep, utilize a left heel Posey boot while in bed, a right heel lift boot at all times, and place an alternating air mattress on the bed. An initial evaluation of the wound done by the wound care specialist on 1/7/15 identified a blood filled, unstageable pressure ulcer on the right heel that measured 4cm x 3 cm. On 1/20/15 the wound remained blood filled and measured 3 cm x 2.5 cm. Interview and review of the clinical record on 1/23/15 at 9:30 AM with RN#4 failed to provide documentation that interventions to offload pressure to the resident's heels had been initiated on admission to prevent the development of the right heel pressure ulcer. 3. Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission body assessment dated [DATE] identified the resident had two open wounds on the buttocks area. The first was noted on the proximal medial area of the buttock measuring 0.5 cm (centimeters) by 0.3 cm in size and pink in color. The second wound was identified on the distal medial area of the buttocks measuring 1.3 cm by 0.7 cm pink with scant areas of yellow slough. The RCP dated 7/31/14 identified a problem with skin integrity related to two opened areas on buttocks. Interventions included assist to change position every two hours, observe skin and record changes. Interventions added on 8/5/14 included a wound consult, GEO mat, cushion and treatment as ordered. Nurses ' notes dated 7/31/14 identified the resident with an air overlay-new mattress and that DermGran (a barrier cream) was ordered by the physician for the treatment of [REDACTED]. An admission MDS assessment dated [DATE] identified the resident was without cognitive impairment, required extensive assistance from staff for bed mobility and transfers, and was had one stage III pressure ulcer present at the time of admission. The wound care specialist assessed the wounds on 8/5/14 and identified one stage III pressure wound on the buttocks/sacral area measuring 1.1 cm x 0.7 cm x 0.3 cm. Recommendations included gel cushion to chair, group -2- mattress, limit sitting to 60 minutes, off-load wound and reposition per facility protocol. On 1/22/15 at 12:30 P.M., an interview and review of the clinical record with the DON indicated that although the resident was identified as having two open wounds to the buttocks at the time of the admission assessment, [MEDICATION NAME] (R) ointment was ordered for both wounds on 7/30/14 and he/she wasn't sure of when the two wounds became one due to the lack of nursing documentation on the condition of the wounds. On 1/22/15 at 1:00 P.M. an interview and review of the clinical record with the ICN/Wound Nurse/RN #4 indicated that the resident was initially assessed at the time of admission with two open areas on the buttocks which were measured and described as being pink in color (Wound #1) and with scant yellow slough (Wound #2) with [MEDICATION NAME](R) ointment as the treatment ordered for both wounds. RN #4 further indicated that because [MEDICATION NAME] (R) is a barrier cream and utilized for wounds with partial thickness skin loss (i.e. stage I - stage II), the cream is not recommended for wounds that are noted as having yellow areas of slough. The Wound Nurse further noted that although documentation was lacking to reflect that the resident's wounds were 'staged' at the time of the admission, a review of the Wound Specialist evaluation on 8/5/14 identified the resident had a stage III (i.e. full thickness tissue loss) wound to the sacrum and/or buttocks area with light serous drainage and yellow necrotic tissue. It was further noted that in lieu of the resident being identified as having a stage III wound, recommendations were made by the wound specialist to discontinue [MEDICATION NAME] (R) barrier cream, and to initiate Santyl (R) ointment which is a debridement agent and to apply a protective dressing to cover the resident's wound. On 1/22/15 at 3:35 P.M. an interview and review of the clinical record with RN # 6 indicated that he/she was responsible for assessing the resident as having two opened areas to the buttocks area at the time of admission and although he/she measured and provided a description of the wounds, he/she did not stage the wounds because it was the physician's and/or wound specialist responsibility as per the facility's policy. The nurse further noted that although the physician was not on hand to assess the resident's wound at the time of admission, he/she obtained a treatment order for [MEDICATION NAME] to treat the resident's wounds because that is what is usually ordered for all open wounds based on the facility's protocol. According to the facility's skin assessment and surveillance policy and/or protocol identified in part, that the initial documentation will include type of ulcer, location, stage, size, color, drainage, odor, wound bed and surrounding tissue description, tunneling, exudates, undermining or sinus tract and date acquired, and all ulcers and wounds will be reviewed by the attending physician, APRN, or medical director for a definitive diagnoses, Stage II (wounds) with partial thickness loss of dermis presenting with a shallow open ulcer with a red, pink wound bed without slough; inform physician of ulcer and of initiation of protocol: [MEDICATION NAME] (R) ointment every shift and prn or other appropriate treatment as ordered by the physician. 4. Resident#100's [DIAGNOSES REDACTED]. A five-day MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance for bed mobility, total dependence for transfers, frequent urinary incontinence and absence of a pressure sore. The care plan dated identified altered skin integrity with interventions that included pressure relieving devices for bed and chair. Nurse ' s notes dated 1/18/15 at 9:00 PM identified a 1 cm x 1 cm black raised area in the upper right buttock near the gluteal fold that was tender to touch. On 1/19/15, nurse ' s notes identified that an open blister was observed and that the APRN was updated. Hospice Social Worker notes dated 1/21/14 indicated that the nurse reported an opened blister on the right upper buttock and that orders to treat the area had been obtained. Observation on 1/23/15 at 10:15 am with LPN#4 identified an open area the size of a quarter with slight drainage and a clean wound bed. Review of the medication administration kardex with LPN#4 identified that although an order dated 1/18/15 directed to monitor the area daily, a treatment order was not evident/documented. In addition, documentation of an assessment had also not been completed. Assessment of the area on 1/23/15 at 10:45 am with the APRN and ICN indicated that the area measured 1.2 cm x 2 cm and was now a Stage II pressure ulcer. The APRN directed to cleanse the area with normal saline followed by Derma Gran ointment after each pericare. Interview with the APRN and DNS on 1/23/15 at 1:30pm identified that the APRN was notified and assessed the area on 1/19/14. The APRN indicated that it was a blister that popped and that she then gave directions at the time to apply [MEDICATION NAME] ointment after each pericare. Clinical record review however failed to provide documentation of any treatment applications until after surveyor inquiry and/or until five days after the blister was noted as open.

Based on clinical record reviews, review of facility documentation and staff interviews for five of eight sampled residents ( Residents # 15, # 32, # 80, # 120 and # 171) reviewed for resident to resident abuse, the facility failed to protect the residents from resident to resident abuse. The findings include: 1. Resident # 15's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive dysfunction, required extensive assist with transfers, limited assist with walking, and extensive assist with locomotion on the unit. A nurse's note dated 10/10/13 at 12:30 P.M. indicated Resident # 186 wheeled up to Resident # 15 in the hallway and touched his/her thighs and put his/her hands between his/her legs and touched his/her stomach before the resident could get away. Resident # 186 was removed from the area and continued on every 15 minute checks. A Resident Care Plan (RCP) dated 10/11/13 identified a problem with potential for alteration in mood/behavior related to being inappropriately touched by a male peer on 10/10/13. Interventions included monitor mood for changes and encourage expression of feelings. A social service note dated 10/11/13 indicated Resident #15 had no recall of the recent event. Resident does not appear to be physically or emotionally impacted by recent event. 2. Resident # 32's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive dysfunction, required extensive assist with transfers, did not walk, and was dependent on staff for locomotion. A RCP dated 10/10/13 identified a problem with potential for alteration in mood related to being inappropriately touched by a male peer. Interventions included monitor mood. A nurse's note dated 10/10/13 at 2:30 P.M. indicated Resident # 186 wheeled up to Resident # 32 and touched his/her breasts. Resident #186 was removed from the dining room and continued on every 15 minute checks. A social service note dated 10/11/13 indicated the resident's dementia was at baseline and that the resident does not appear to be in any distress at this time. 3. Resident # 80's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] indicated the resident had severe cognitive dysfunction, required limited assist with transfers and walking, and extensive assist with locomotion on the unit. A nurse's note dated 11/14/13 at 8:20 PM indicated Resident # 186 was witnessed in the dining room putting his/her hands up R # 80's leg toward the groin and attempting to put his/her hands down R # 80's nightgown. Resident # 186 was removed from the area and placed on a 1:1 observation A RCP dated 11/15/13 identified a problem with potential for alteration in mood/behavior related to inappropriately being touched by a male peer on 11/14/13. Interventions included monitor mood and behaviors. A social service note dated 11/15/13 indicated the Resident # 80 had no recall of the recent event. Resident does not appear to be negatively impacted by the altercation. 4. Resident # 120's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated the resident had severe cognitive dysfunction, required limited assist with transfer and independent with walking. A RCP dated 10/11/13 identified a problem with potential for alteration in mood related to being inappropriately touched by a male peer. Interventions included monitor mood for changes and provide 1:1 emotional support. A nurse's note dated 10/11/13 at 11:30 A.M. indicated Resident #186 was witnessed in Resident #120's room with his/her hands between his/her legs (private area). Resident # 186 was removed from the area. A social service note dated 10/11/13 indicated Resident #120 had disorganized/unintelligible speech at time of meeting. 5. Resident # 171's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive dysfunction, required total care with transfers, did not walk and total care with locomotion. A nurse's note dated 11/14/13 at 4:10 P.M. indicated R # 186 was witnessed in R # 171's room with his/her hand on R # 171's bare chest while shirt was rolled up. A subsequent nurses note dated 11/15/13 indicated the resident was assessed after the incident and had no visible signs or symptoms of trauma or emotional distress. A RCP dated 11/15/13 identified a problem with potential for alteration in mood/behavior due to incident with male peer on 11/14/13. Interventions included provide 1:1 emotional support and monitor behavior. A review of the clinical records of Residents # 15, # 32, # 80 # 120 and # 171 and interview on 2/19/14 at 10:45 A.M. with the ADNS indicated although he/she was aware of Resident #186's sexual behaviors toward other residents, attempts were made to protect other residents by distracting Resident #186 and adjusting his/her medications. However, although interventions were in place, the facility failed to develop appropriate interventions to address Resident # 186's continued inappropriate sexual behavior toward other residents and/or failed to prevent further abuse exhibited by Resident #186's inappropriate sexual behavior.