Every finding on record at Torrington Center for Nursing & Rehabilitation LLC

Based on clinical record review, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #28) reviewed for Advanced Directives, the facility failed to implement advanced directives according to the resident's expressed wishes. The findings include:Resident #28 had diagnoses that included dementia, hyperlipidemia, and edema. The physician's orders signed monthly from 3/19/24 through 5/5/26 directed a Full Code (despite Resident #28's wishes from 4/7/25 to be a DNR).The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #28 had moderately cognitively impaired, was independent for transfers, toileting, and required partial moderate assistance for bathing. The Advanced Directive Consent/Acknowledgement Release Form dated 4/7/25 identified Resident #28 requested a Do Not Resuscitate (DNR).The Resident Care Plan (RCP) dated 4/12/26 identified Resident #28 had a code status of DNR per the physician's order with interventions that directed to ensure resident/family wishes are conveyed to any other facility should a transfer occur.Interview and clinical record review on 5/5/2026 at 11:45 AM with Registered Nurse (RN) #2 identified Resident #28 requested to be a DNR, but the physician's order directed a full code. RN #2 indicated supervisors are responsible for entering resident's code status orders. Interview and clinical record review on 5/5/2026 at 11:53 AM with RN#3 identified on 4/7/25 Resident #28's Advanced Directive consent form was signed, and the supervisor was responsible for updating the physician's order to reflect a DNR.Interview on 5/5/2026 at 12:20 PM with the Director of Nursing Services (DNS) identified on Resident #28 elected a DNR on 4/7/25, but the physician's order directed a full code. The DNS identified Resident #28's code status should have been changed from a full code to a DNR per the resident's expressed wishes. The DNS indicated that the supervisor is responsible for updating the physician's order when a resident's code status is changed.Subsequent to surveyor inquiry, Physician's orders dated 5/6/26 (395 days after Resident #28's wishes were to be a DNR Resident #28's code status was changed to a DNR.Review of facility Advanced Directives policy identified resident preferences regarding end-of-life decisions and medical decisions are always respected. Nursing reviews the advanced directive options and completes the form. The form is to be filed in the medical chart. A doctor's order is to be written in the electronic medical record. Advanced directives are to be reviewed quarterly by nursing in the Resident Care Plan meetings.

Based on review of the clinical records, facility documentation, and interviews for 3 of 3 residents (Resident #83, #84, and #85) reviewed for beneficiary notification, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to the residents upon being discharged from Medicare Part A with benefit days remaining. The findings include:1.Resident #83 was admitted to the facility on [DATE] with diagnoses that included atherosclerosis with gangrene of the left foot, below the knee amputation 17 years ago, and peripheral arterial diseaseThe Resident Care Plan (RCP) dated 11/7/25 identified Resident #83 was admitted for short term rehabilitation with a goal to discharge back to the community. Interventions including the social workers will utilize community resources to ensure safe discharge.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #83 had intact cognition and required supervision for toileting and transfers.The Physical Therapy discharge note dated 12/10/25 indicated Resident #83 was independent at the wheelchair level, required contact guard assistance with a rolling walker for household-distance ambulation, and required supervision for stair negotiation. The resident was discharged from skilled physical therapy services on this date due to achieving independence at the wheelchair level. The note further recommended continuation of physical therapy services in the home setting to address gait training, stair mobility, and safety with ambulation using a rolling walker.APRN #1's note dated 12/11/25 at 10:30 AM indicated Resident #83 was seen for medical clearance prior to planned discharge home. APRN #1 indicated at the time of discharge, Resident #83's pain was documented as manageable and the resident was medically cleared for discharge with no new adjustments to the pain management regimen. The discharge plan included home care services consisting of physical therapy, occupational therapy, and skilled nursing services for wound management.The Discharge Plan dated 12/11/25 indicated Resident #83 verbalized understanding of all information contained in the discharge summary. Resident #83 was discharged home with supportive services in place.Interview with Licensed Practical Nurse (LPN) #5, the MDS coordinator on 5/7/26 at 11:17 AM identified she was responsible for providing the Notice of Medicare Non-Coverage (NOMNC) at least 48 hours prior to discharge. LPN #5 identified a NOMNC was not provided to Resident #83 because the resident met therapy goals and requested discharge home.Interview with APRN #1 on 5/7/26 at 1:51 PM identified Resident #83's discharge was planned. APRN #1 indicated Resident #83 had met therapy goals, was medically cleared to return home, and was agreed to discharge. 2. Resident #84 was admitted to the facility on [DATE] with diagnoses that included gangrene, diabetes, and orthopedic aftercare following surgical toe amputation. The RCP dated 9/8/25 identified Resident #84 was admitted for short term rehabilitation with interventions that included the social worker will utilize community resources to ensure a safe discharge.The admission MDS dated [DATE] identified Resident #84 had intact cognition and required moderate assistance with upper body dressing and personal hygiene, and dependent on staff for toileting.A social service note written by SW #1 dated 12/15/25 at 12:26 PM indicated discharge planning was discussed with Resident #84, and he/she has arranged transportation home. SW #1 indicated upon discharge Resident #84 will receive home care services.APRN #1's note dated 12/16/25 at 8:00 AM indicated Resident #84 was seen for medical clearance for discharge to home. APRN #1 identified at the time of discharge, Resident #84 was medically stable with no acute medical concerns, and follow-up care had been arranged.A nurse's note dated 12/16/25 at 12:54 PM identified Resident #84 was discharged home with medications and services. Interview with LPN #5 ( MDS coordinator) on 5/7/26 at 11:17 AM identified she was responsible for providing the Notice of Medicare Non-Coverage (NOMNC) at least 48 hours prior to discharge. LPN #5 indicated she was aware Resident #84's discharge was planned. LPN #5 identified Resident #84 was not provided with a NOMNC because the resident agreed with the discharge. Interview with APRN #1 on 5/7/26 at 1:51 PM identified Resident #84's discharge was planned. APRN #1 indicated Resident #84 had met therapy goals, was medically cleared to return home, and was agreed to discharge.3. Resident #85 was admitted to the facility on [DATE] with diagnoses that included heart failure and a stroke affecting the right dominant side. The RCP dated 8/13/25 identified Resident #85 was admitted for short term rehabilitation with interventions that included the social workers will utilize community resources to ensure a safe discharge.The admission MDS dated [DATE] identified Resident #85 had intact cognition and required moderate assistance with toileting, dressing, and personal hygiene.A social service note written by SW #1 dated 11/17/25 at 12:16 PM indicated discharge planning was discussed with Resident #85, and he/she would not require home care services. SW #1 indicated Resident #85's primary care physician appointment was scheduled for 11/20/25 following discharge.APRN #1's note dated 11/18/25 at 9:15 AM indicated Resident #85 was seen for medical clearance for discharge to home. APRN #1 identified Resident #85 may discharge home without any services.The nurse's note dated 11/18/25 at 12:08 PM identified Resident #85 was discharged home at 12:00 PM with medications and paperwork. Interview with LPN #5 (MDS coordinator) on 5/7/26 at 11:17 AM indicated Resident #85 was independent, had met the therapy goals, and agreed to return home. LPN #5 identified the discharge was planned and resident-initiated; so, she did not provide the NOMNC notice 24 hours before Resident #85 was discharged .Interview with SW#1 on 5/7/26 at 1:41 PM identified Resident #85's discharge was planned after the resident met all therapy goals and found a safe place to live.Interview with APRN #1 on 5/7/26 at 1:51 PM identified Resident #85 had met therapy goals, received medical clearance to return home, and had a planned discharge.Although requested, the Notice of Medicare Non-Coverage policy was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1of 4 resident (Resident #2) reviewed for accidents, the facility failed to ensure a grievance was completed when the resident reported a delay in care and call bell response time. The findings include:Resident #2's diagnosis included conversion disorder with mixed symptoms, neuralgia, and hypertension.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #2 had intact cognition, was frequently incontinent of bowel and bladder, and required substantial assistance with personal hygiene, and dependent with transfers and toileting.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #2 was frequently incontinent of bowel/bladder function. Interventions included providing incontinence care, incontinence care products as needed, and monitoring changes in continent status.Interview with Resident #2 on 5/4/2026 at 12:50 PM identified on 4/17/26 he/she experienced issues with Nurse Aide (NA) #2 during the 3:00 PM-11:00 PM shift. Resident #2 identified two nurse aides are required to transfer him/her to the commode. Resident #2 indicated after ringing the call bell for toileting assistance, NA #2 did not respond promptly, but NA #2 finally came to the doorway and said she was assisting another resident and would return afterward. Resident #2 indicated when NA #2 finally returned he/she was on a virtual appointment and asked NA #2 to return after the appointment ended. Resident #2 indicated he/she became incontinent while waiting for assistance form NA #2. Resident #2 indicated the supervisor, Registered Nurse #5 (RN), who worked the 3:00 PM-11:00 PM shift on 4/17/26, was made aware he/she had to call NA #2 multiple times for assistance with care. Resident #2 identified RN #5 and NA #2 offered care, but he/she was upset and declined care from both, so RN #5 sent NA #3 to provide care, which Resident #2 accepted.Interview with NA #3 on 5/6/2026 at 3:07 PM identified RN #5 called him to the unit to assist with Resident #2's care on 4/17/26 during the 3:00 PM to 11:00 PM shift. NA #3 indicated he did not know the reason for the call at that time. NA #3 identified Resident #2 had been incontinent, and he provided care to the resident.Interview with NA #2 on 5/6/2026 at 3:15 PM identified on 4/17/26 when Resident #2 rang the call bell she was assisting another resident. NA #2 indicated she went to Resident #2's room and informed the resident that she would return after finishing care for the other resident. NA #2 indicated when she returned, Resident #2 was on a virtual appointment and became upset, requesting assistance from another nurse aide. NA #2 indicated she informed RN #5 about the situation, and both she and RN #5 offered care to Resident #2. NA #2 indicated Resident #2 refused care from them and accepted care from NA #3.Interviews with the Director of Nursing Services (DNS) and the Administrator on 5/6/2026 at 3:44 PM indicated that they were unaware of any incident involving Resident #2 and NA #2 on 4/16/26 or 4/17/26. The DNS and Administrator identified staff should have completed documentation, including a grievance report, notified the DNS of the incident, and changed the NA assignment.Interview with RN #5 on 5/6/2026 at 4:31 PM identified on 4/17/26 Resident #2 was upset about the care received from NA #2 due to delayed responses to the call bell. RN #5 identified she did not file a grievance or report the incident to the Administrator or Director of Nursing Services (DNS) because she changed Resident #2's assignment that evening and believed that action was sufficient. RN #5 identified she knows the policy and should have filed a grievance, documented the incident, and reported it to the DNS.Review of the Grievance log indicated there was no grievance on file dated 4/17/26 for Resident #2.Subsequent to surveyor inquiry, the DNS and Administrator initiated an accident and incident investigation.Review of facility Grievance Policy dated 1/19/18 directed, in part, all resident and responsible parties have a right to voice their grievances and to make recommendations for changes in services and/or policies (verbally or in writing) to administration, medical, nursing, or ancillary departments. Grievance is federally defined as a complaint regarding treatment, care, management of funds, lost clothing, and violation of rights. These communications are generally held confidentially and are investigated without fear or reprisal. Responses to expressed concerns are made in an orderly and timely process and are documented.Review of facility Supervisor Communication Protocol policy dated 1/19/28 directed, in part, that the RN Supervisor shall promptly report significant resident care, operational, staffing, regulatory, safety, and clinical concerns to appropriate leadership to ensure timely intervention, regulatory compliance, resident safety, and continuity of care. Any event, issue, condition, or occurrence that may negatively impact resident safety, resident rights, quality of care, staffing operations, regulatory compliance, or facility operations. The RN Supervisor shall immediately notify appropriate leadership of concerns that exceed routine nursing management responsibilities or require escalation of interventions, investigation, or regulatory reporting. The RN Supervisor shall report resident voiced concerns and will immediately notify the DNS, Administrator, and appropriate state agencies as directed by the facility policy. The RN supervisor shall document nature of concern, date, time identified, assessment findings, individuals notified, time of notifications, interventions implemented, follow-up actions, and resident outcomes.

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #54 and Resident #79) reviewed for hospitalizations, the facility failed to provide written notifications regarding the bed-hold policy at the time the residents were sent to the hospital and failed to ensure the Office of the State Long-Term Care Ombudsman was notified of resident transfers. The findings include:1.Resident #54 had diagnoses that included stage 4 chronic kidney disease, acute respiratory failure with hypoxia, and dementia. The Resident Care Plan (RCP) dated 7/08/2025 identified Resident #54 was expected to be discharged to another facility. Interventions included the social worker would utilize community resources to ensure a safe discharge and the interdisciplinary team would work together to discharge the resident at the appropriate time. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 had a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment and Resident #54's goal for discharge was to be discharged to another facility. a.The social service note dated 10/24/2025 written by Social Worker (SW) #1 identified Resident #54 was transferred to the hospital and placed on a 15-day bed hold. Review of the clinical record for Resident #54 was unable to provide documentation to reflect the facility provided written information regarding the bed-hold policy, including the duration of the bed hold or that the Office of the State Long-Term Care Ombudsman was notified. b. The quarterly MDS assessment dated [DATE] identified Resident #54 had a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment and Resident #54's goal for discharge was to be discharged to the community. The social service note dated 4/28/2026 written by SW #1 identified Resident #54 was transferred to the hospital and placed on a 15-day bed hold. Review of the clinical record for Resident #54 was unable to provide documentation to reflect the facility provided written information regarding the bed-hold policy, including the duration of the bed hold or that the Office of the State Long-Term Care Ombudsman was notified. Interview with SW #1 on 5/07/2026 at 10:42 AM identified she did not notify the Office of the State Long-Term Care Ombudsman that Resident #54 was transferred to the hospital on [DATE] and 4/28/2026. SW #1 stated she did not provide written notice of a bed hold to Resident #54 on 10/24/2025 and 4/28/2026. SW #1 indicated she did not provide the bed hold information or notify the Ombudsman because she had not been trained and was unaware of the facility policy. Interview on 5/07/2026 at 11:37 AM with the Director of Nursing Services (DNS) identified on 10/24/2025 and 4/28/2026 at the time of hospital transfer Resident #54 was not provided with written information on the bed hold policy. The DNS further identified on 10/24/2025 and 4/28/2026 SW #1 did not notify the Office of the State Long-Term Care Ombudsman of Resident #54's transfers. 2. Resident #79 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of rectum, paraplegia, Type 2 Diabetes Mellitus, depression, portal hypertension, schizophrenia, and metabolic encephalopathy The admission Minimum Data Set (MDS) dated [DATE] identified Resident #79 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicative of intact cognition and Resident #79's goal for discharge was to be discharged to the community. The nurse's note dated 4/1/26 at 5:43 AM written by Registered Nurse (RN) #6 identified Resident #79 complained of non-specific rectal pain, refused pain medication, and he/she requested to be transferred to the hospital. RN #6 identified she notified the on-call APRN and Resident #79 was transferred to the hospital. Review of the clinical record for Resident #79 was unable to provide documentation to reflect the facility provided written information regarding the bed-hold policy, including the duration of the bed hold or that the Office of the State Long-Term Care Ombudsman was notified. Interviews with the Administrator and DNS on 5/4/26 at 12:55 PM identified a copy of the bed hold policy should be provided to a resident at the time of transfer to the hospital. The DNS identified the charge nurse is responsible for providing the bed hold policy at the time of transfer. The DNS identified a bed hold notice was not provided to Resident #79 at the time of transfer to the hospital on 4/1/26 because it was not completed. The Administrator and DNS identified the social worker is responsible for notifying the Office of the State Long-Term Care Ombudsman when a resident is transferred to the hospital. The DNS and Administrator identified that SW #1 should have notified the Office of the State Long-Term Care Ombudsman on 4/1/26 that Resident #79 was transferred to the hospital. Interview with SW #1 on 5/4/26 at 1:00 PM identified she did not notify the Office of the State Long-Term Care Ombudsman when Resident #79 was transferred to the hospital on 4/1/26. SW #1 indicated she was unaware she was responsible for notifying the Office of the State Long-Term Care Ombudsman of resident hospital transfers. Review of the facility Transfer/Discharge policy dated 1/1/2025, directed in part, that before the facility transfers the resident the facility must notify the resident and their representative of the transfer or discharge and the reason for the move in writing in a language that the resident understands. The regional Long- Term Care Ombudsman will be notified through the long-term care portal. Review of facility Bed Hold policy dated 1/19/2018, directed in part, that upon admission and in advance of any transfer, the resident and their representative shall be provided with a copy of the facility's bed hold policy, specifics of any state Medicaid bed-hold coverage, and written notice regarding the duration of the bed hold and the resident's rights regarding readmission.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to implement a system to consistently and accurately account for controlled drugs' receipt and disposition to enable an accurate reconciliation and that an account of all controlled drugs was maintained and periodically reconciled and failed to ensure controlled drug records were in order. The findings include:Interview with the Director of Nursing Services (DNS) on 5/5/2026 at 11:42 AM indicated she began employment at the facility approximately 8 months ago and had been conducting bimonthly controlled drug audits since that time. The DNS provided bimonthly controlled drug reconciliation audits dated from September 2025 through April 2026. The DNS was unable to locate any controlled drug audit documentation for the period of 9/1/2024 through 8/31/2025 (11 months).Interviews with the DNS and Administrator on 5/6/26 at 7:52 AM identified bimonthly controlled drug audits of all controlled drugs should be completed twice per month. The DNS and Administrator further identified the audits and inventory records should be maintained at the facility. Review of facility Pharmacy Controlled Substance policy dated 1/1/25 directed to conduct monthly audits of all controlled substance records, maintain inventory logs for each controlled substance, shift to shift count verifications by two nurses, and discrepancy reports for any count variances with immediate follow up and to retain records per state requirements (minimum 2 years per Drug Enforcement Agency-DEA).

Based on interviews, review of facility policy, and review of 2 of 3 Nurse Aide (NA #2 and NA #5) personnel files, the facility failed to ensure performance evaluations were completed at least every 12 months. The findings include: 1.NA #2's personnel file identified she was hired on 5/9/24 and one staff performance evaluation was completed on 2/4/2026. There was no documented annual performance evaluations completed for 2025. 2.NA #5's personnel file identified she was hired on 1/3/24 and had one staff performance evaluation on 1/1/2026. There was no documented annual performance evaluations completed for 2025. Interview with the Director of Nursing Services (DNS) on 5/11/2026 at 8:22 AM revealed she began completing annual performance evaluations in January 2026. The DNS indicated she was not sure which ones had been completed and had given the completed ones to Human Resources. Interview with the Administrator on 5/11/26 at 8:28 AM identified he was unable locate any annual performance evaluations for NA #2 and NA #5 for 2025. Interview with Human Resources (HR) on 5/11/26 at 8:34 AM identified he did have employee performance evaluations and did not recall receiving any completed employee performance evaluations. Review facility Staff Performance Evaluations policy dated 1/1/25 directed in part, it was the policy of the facility to conduct regular staff performance evaluations to promote quality resident care, employee development, accountability and compliance with federal, state and facility standards. The purpose was to establish a consistent process of evaluating employee performance, identifying strengths and areas for improvement, and supporting professional growth. Employees shall receive annual performance evaluations and evaluations as needed on the job performance or when any disciplinary concerns arise.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of four (4) residents (Resident #3) reviewed for change in condition, the facility failed to notify the physician when a resident was exhibiting behaviors that included agitation, anxiety, and aggression. The findings include: Resident #3 had diagnoses that included paranoid schizophrenia, antisocial personality disorder, conversion disorder with seizures or convulsion, and unspecified dementia with severe anxiety. A physician's order dated 10/7/24 directed to administer trazodone (a medication used for anxiety, depression, and insomnia) 50 milligrams (mg) every 6 hours as needed for anxiety. The 5-day MDS dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of eleven (11) indicative of moderately impaired cognition with verbal behavioral symptoms directed towards others, and during the last 7 days Resident #3 was taking high-risk drugs which included antipsychotics and antidepressants. The care plan dated 10/14/24 identified that Resident #3 has a potential alteration in mood due to diagnoses of antisocial personality disorder, paranoid schizophrenia, and anxiety with interventions that directed to monitor and document changes in mood and behavior. A review of APRN #2's (psych) note dated 10/14/24 at 1:30 P.M. identified Resident #3 continues trazodone as needed as ordered. APRN #2 identified Resident #3 shared that h/she is reticent to PRN [as needed] trazodone. APRN #2 indicated she provided Resident #3 with medication education, Resident #3 was encouraged to let the nursing staff know if h/she feels like h/she is having increased anxiety, and h/she will notify nursing staff if h/she is experiencing increased anxiety. The nurse's note dated 10/15/24 at 3:31 A.M. written by Licensed Practical Nurse (LPN ) #2 identified that Resident #3's behaviors continued, and Resident #3 was throwing staff's personnel belongings on the floor. The resident was re-directed and educated Resident #3 multiple times during the shift, and Resident #3 responded with vulgar language. The nurse's note dated 10/15/24 at 10:13 P.M. written by LPN #4 identified Resident #3 continues with behaviors, Resident #3 is verbally aggressive towards staff and other residents. LPN #4 identified Resident #3 was not easily redirected. The nurse's note dated 10/16/24 at 6:49 A.M. written by LPN #6 identified Resident #3 was self-propelling in h/her wheelchair with a very rapid on the unit. LPN #6 identified Resident #3 sat and stared at her using side-to-side hand gestures across h/her throat while pointing at her using threatening comments and foul language. LPN #6 identified Resident #3 was talking to h/herself with a rapid voice and directing anger at staff. LPN #6 identified Resident #3 turned up the volume on the television to the point it was waking neighboring residents. LPN# 6 indicated when she requested that Resident #3 turn the volume down Resident #3 attempted to hit her. LPN #6 identified during the shift Resident #3 had numerous confrontations with staff and when attempts were made to educate Resident #3 h/she would curse. The nurse's note dated 10/16/24 at 9:55 A.M. written by Registered Nurse (RN) RN #1 identified Resident #3 had a verbal and physical altercation with another resident and was placed on one to one supervision. RN #1 identified Resident #3 continued with agitation and aggression was sent to the emergency room . A review of Resident #3's Medication Administration Records dated 10/15/24 and 10/16/24 revealed Resident #3 did not receive as needed trazodone 50 mg for anxiety. An interview with APRN #2 on 2/27/25 at 2:00 P.M. identified on 10/15/24 and 10/16/24 when Resident #3 was verbally aggressive, using vulgar language, threatening staff, and throwing items on the floor she was not notified. APRN #2 identified her expectation is when a resident is exhibiting these types of behaviors she is notified. APRN #2 identified on 10/15/24 and 10/16/24 when Resident #3 had changes in h/her behaviors she should have been notified. An interview with the Director of Nursing Services (DNS) on 2/27/25 at 2:30 P.M. identified her expectations are when a resident is exhibiting any changes in mood or behaviors the provider is notified. The DNS identified on 10/15/24 and 10/14 when Resident #3 was verbally aggressive, using vulgar language, threatening staff, and throwing items on the floor APRN #2 should have been notified. Although attempted, interviews with LPN #2, LPN #4, and LPN #6 were not obtained. Review of facility change in condition policy dated 9/16/2018 identified it is the policy to ensure that changes in residents' conditions are reported to the providers and families and the facility must immediately inform the resident, consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of four (4) residents (Resident #4) reviewed for abuse, the facility failed to ensure a resident who was exhibiting verbal and physical behaviors did not physically abuse another resident. The findings include: 1. Resident #3 had diagnoses that included paranoid schizophrenia, antisocial personality disorder, conversion disorder with seizures or convulsion, and unspecified dementia with severe anxiety. The 5-day MDS dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of eleven (11) indicative of moderately impaired cognition with verbal behavioral symptoms directed towards others, and during the last 7 days was taking high-risk drugs that included antipsychotics and antidepressants. The care plan dated 10/14/24 identified that Resident #3 has a potential alteration in mood due to diagnoses of antisocial personality disorder, paranoid schizophrenia, and anxiety with interventions that directed to monitor and document changes in mood and behavior. The nurse's note dated 10/15/24 at 3:31 A.M. written by Licensed Practical Nurse (LPN ) #2 identified that Resident #3's behaviors continued, and Resident #3 was throwing staff's personnel belongings on the floor. The resident was re-directed and educated Resident #3 multiple times during the shift, and Resident #3 responded with vulgar language. The nurse's note dated 10/15/24 at 10:13 P.M. written by LPN #4 identified Resident #3 continues with behaviors, Resident #3 is verbally aggressive towards staff and other residents. LPN #4 identified Resident #3 was not easily redirected. The nurse's note dated 10/16/24 at 6:49 A.M. written by LPN #6 identified Resident #3 was self-propelling in h/her wheelchair with a very rapid on the unit. LPN #6 identified Resident #3 sat and stared at her using side-to-side hand gestures across h/her throat while pointing at her using threatening comments and foul language. LPN #6 identified Resident #3 was talking to h/herself with a rapid voice and directing anger at staff. LPN #6 identified Resident #3 turned up the volume on the television to the point it was waking neighboring residents. LPN# 6 indicated when she requested that Resident #3 turn the volume down Resident #3 attempted to hit her. LPN #6 identified during the shift Resident #3 had numerous confrontations with staff and when attempts were made to educate Resident #3 h/she would curse. The nurse's note dated 10/15/24 at 3:31 A.M. written by Licensed Practical Nurse (LPN ) #2 identified that Resident #3's behaviors continued, and Resident #3 was throwing staff's personnel belongings on the floor. The resident was re-directed and educated Resident #3 multiple times during the shift, and Resident #3 responded with vulgar language. The nurse's note dated 10/15/24 at 10:13 P.M. written by LPN #4 identified Resident #3 continues with behaviors, Resident #3 is verbally aggressive towards staff and other residents. LPN #4 identified Resident #3 was not easily redirected. The nurse's note dated 10/16/24 at 6:49 A.M. written by LPN #6 identified Resident #3 was self-propelling in h/her wheelchair with a very rapid on the unit. LPN #6 identified Resident #3 sat and stared at her using side-to-side hand gestures across h/her throat while pointing at her using threatening comments and foul language. LPN #6 identified Resident #3 was talking to h/herself with a rapid voice and directing anger at staff. LPN #6 identified Resident #3 turned up the volume on the television to the point it was waking neighboring residents. LPN# 6 indicated when she requested that Resident #3 turn the volume down Resident #3 attempted to hit her. LPN #6 identified during the shift Resident #3 had numerous confrontations with staff and when attempts were made to educate Resident #3 h/she would curse. A review of Resident #3's Medication Administration Records dated 10/15/24 and 10/16/24 revealed Resident #3 did not receive as needed trazodone 50 mg for anxiety or that the physician was notified of the residents aforementioned behaviors. The nurse's note dated 10/16/24 at 9:55 A.M. written by Registered Nurse (RN) RN #1 identified Resident #3 had a verbal and physical altercation with another resident and was placed on one to one supervision. RN #1 identified Resident #3 continued with agitation and aggression was sent to the emergency room . A nurse's note dated 10/16/24 at 9:55 A.M. written by RN #1 identified Resident #3 had a verbal and physical altercation with another resident and was placed on one to one. RN #1 identified Resident #3 continued with agitation and aggression was sent to the emergency room . 2. Resident #4 had diagnoses that included borderline personality disorder, delusional disorder, anxiety, and major depressive disorder. The annual MDS dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicative of intact cognition and during the last 7 days was taking high-risk drugs that included antipsychotics, antidepressants, antianxiety. The care plan dated 9/26/24 identified Resident #4 at potential risk of an alteration in mood state as evidenced by depressive symptoms and mental health conditions with interventions that directed to monitor for verbal expressions of distress and observe mood, behavior, appetite and sleep pattern document any changes, psych services as needed, and social worker to provide additional support as appropriate. The nurse's note dated 10/16/24 at 7:59 A.M. written by RN #1 identified Resident #4 was involved in an altercation with Resident #3. RN #1 identified Resident #4 was hit in the right shoulder with an open hand as Resident #3 yelled at Resident #4 for h/her to move. RN #1 indicated Resident #4 denied any pain and no injuries were noted. Review of the facility's accident and incident report dated 10/16/24 at 9:24 A.M. identified at 7:45 A.M. an incident of resident-to-resident abuse without injury occurred in the lobby between Resident #3 and Resident #4. The Speech Therapist (SLP) #1 witnessed Resident #3 hit Resident #4 with an open hand on the shoulder, the residents were immediately separated, Resident #4 was placed on one-to-one monitoring and transferred to the emergency room for evaluation. The facility summary dated 10/21/24 identified on 10/16/24 when Resident #3 tried to enter the therapy gym early in the morning, it was closed, due to not being able to use the gym Resident #3 became agitated and Resident #3 approached Resident #4 striking h/her on the shoulder with an open hand in the lobby, Resident #3 and Resident #4 did not have a prior history of altercations with each other. The facility identified that abuse was substantiated. Interview with SLP #1 on 2/27/25 at 10:25 A.M. identified on 10/16/24 at approximately 7:45 A.M. Resident #3 and Resident #4 were sitting in their wheelchairs in the lobby in front of the doors to the gym. SLP #1 identified Resident #3 tried to enter the gym, but the doors were locked. SLP #1 identified Resident #3 said something to Resident #4 and as Resident #4 went to move out of to move out of Resident #3's way, Resident #3 with an open hand struck Resident #4 on h/her left shoulder. SLP #1 indicated she immediately separated the residents and notified RN #1. Interview with RN #1 on 2/27/25 at 11:45 A.M. identified on 10/16/24 she was notified by SLP #1 that Resident #3 hit Resident #4 with an open hand on h/her shoulder by the doors to the gym in the lobby. RN #1 indicated she assessed Resident #4 no injuries were noted, and Resident #4 denied any pain. RN #1 indicated Resident #3 was placed on one-to-one monitoring until the ambulance arrived and transported Resident #3 to the hospital. Interview with the Director of Nursing on 2/27/25 at 2:30 P.M. identified that her expectations are when a resident is exhibiting any changes in mood or behaviors the provider is notified. The DNS identified on 10/15/24 and 10/14 when Resident #3 was verbally aggressive, using vulgar language, threatening staff, and throwing items on the floor APRN #2 should have been notified. On 10/16/24 SLP #1 witnessed Resident #3 with an open hand hit Resident #4 on h/her left shoulder. The DNS indicated the residents were immediately separated; Resident #3 was placed on one to one until h/she was transferred to the hospital. The DNS indicated Resident #4 had no injuries, and Resident #4 denied any pain. The DNS identified based on the investigation the allegation of resident-to-resident abuse was substantiated Resident #3 did hit Resident #4 on h/her left shoulder without being provoked. Review of facility abuse policy dated 9/16/18 identified; in part; it is the policy of the facility to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation, and retaliation. Physical abuse is the intentional infliction of physical pain, bodily harm, or physical coercion.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for behaviors, the facility failed to ensure a comprehensive care plan with appropriate interventions was implemented for a resident who exhibited physical and verbal behaviors. The findings include: Resident #3 had diagnoses that included paranoid schizophrenia, antisocial personality disorder, conversion disorder, and unspecified dementia with severe anxiety. A physician's order dated 10/1/24 directed to monitor target behavior at the end of each shift marking the frequency and intensity. Review of a nurse's note dated 10/8/24 at 10:45 A.M. written Licensed Practical Nurse (LPN) #5 identified she heard yelling coming from Resident #3's room. LPN #5 indicated Resident #3 was cursing to h/herself because h/she lost remote to the television. LPN #5 identified when assisting Resident #3 h/she threatened to kill and strangle her. LPN #5 indicated Resident #3 was placed on a one-to-one at this time for safety. Review of a nurse's note dated 10/8/24 at 10:48 A.M. written by LPN #5 identified Resident #3 declined to take as needed trazodone during and after the event and redirection was ineffective. Review of a nurse's note dated 10/8/24 at 10:55 A.M. written by LPN #5 identified 911 was activated due to Resident #3's threats and the police were requested. Review of a nurse's note dated 10/8/24 at 11:28 A.M. written by Registered Nurse (RN) #2 identified Resident #3 was agitated, threatening staff and remained one to one supervision. RN #2 identified 911 was activated and Resident #3 was transported to the emergency room . Review of a nurse's note dated 10/8/24 at 7:09 P.M. written by RN #3 identified Resident #3 returned from the emergency department with a no harm letter and Resident #3 is not considered a danger to self or others. The care plan dated 10/10/24 identified that Resident #3 had a potential alteration in mood due to diagnoses of antisocial personality disorder, paranoid schizophrenia, and anxiety with interventions that directed to monitor and document changes in mood and behavior. The care plan failed to identify a concern related to Resident #3's behaviors and include personalized interventions to manage behaviors. Review of a nurse's note dated 10/10/24 at 7:54 A.M. written by LPN #2 identified Resident #3 has increased behaviors was aggressive and hitting staff. LPN #2 identified while Resident #3 passed by her h/she was making gestures of cutting someone's throat. LPN #2 indicated she redirected Resident #3 and put Resident #3 in the psych book. Review of a nurse's note dated 10/10/24 at 9:35 P.M. written by LPN #7 identified Resident #3 continues with verbally abusing staff and residents. A review of APRN #2's (psych) note dated 10/10/24 at 2:00 P.M. identified she collaborated with LPN #3 who reported Resident #3 has been exhibiting recent aggressive behaviors, hitting staff, making gestures towards staff of cutting someone's throat as h/she passed by the nursing staff in the hallway on 10/10/24. APRN #2 identified Resident #3 endorses h/she has random anxiety with aggression and acknowledges that h/she has not been coping effectively. APRN #2 identified the plan for Resident #3 was to continue to monitor mood, anxiety, sleep, appetite, promote adaptive coping, and provide emotional support. The 5-day MDS dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of eleven (11) indicative of moderately impaired cognition with verbal behavioral symptoms directed towards others, and during the last 7 days was taking high-risk drugs which included antipsychotics and antidepressants. A review of APRN #2's (psych) note dated 10/14/24 at 1:30 P.M. identified RN #3 asked her to see Resident #3 related to recent anxiety and aggression with a concern as to whether Resident #3 is exhibiting psychosis. APRN #2 identified Resident #3 endorsed mild anxiety at the time of evaluation and acknowledged h/she has random agitation and aggression associated with anxiety. APRN #2 indicated Resident #3 agreed to let nursing staff know if h/she is experiencing random anxiety. A review of a nurse's note dated 10/15/24 at 10:13 P.M. written by LPN #4 identified Resident #3 continues with behaviors, Resident #3 is verbally aggressive towards staff and other residents. LPN #4 identified Resident #3 was not easily redirected. Review of a nurse's note dated 10/16/24 at 6:49 A.M. written by LPN #6 identified Resident #3 was self-propelling in h/her wheelchair with a very rapid on the unit. LPN #6 identified Resident #3 was sitting and staring at her using side-to-side hand gestures across h/her throat while pointing at her using threatening comments and foul language. LPN #6 indicated Resident #3 was talking to h/herself with a rapid voice and directing anger at staff. LPN #6 indicated Resident #3 turned up the volume on the television to the point it was waking neighboring residents. LPN# 6 identified when she requested that Resident #3 turn the volume down Resident #3 attempted to hit her. LPN #6 identified during the shift Resident #3 had numerous confrontations with staff and when attempts were made to educate Resident #3 h/she would curse. Review of a nurse's note dated 10/16/24 at 9:55 A.M. written by RN #1 identified Resident #3 had a verbal and physical altercation with another resident and was placed on one to one. RN #1 identified Resident #3 continued with agitation and aggression was sent to the emergency room . Interview and clinical record review with LPN #8 (MDS Coordinator) on 2/27/25 at 12:45 P.M. was unable to provide documentation to reflect that Resident #3 had a comprehensive care plan implemented with appropriate interventions to manage behaviors. The MDS Coordinator indicated for when a resident has behaviors there should be an intervention implemented to manage the behaviors. Additionally, the MDS Coordinator could not identify why Resident #3 did not have a comprehensive care plan implemented to address h/her behaviors. Interview and clinical record review with the Director of Nursing Services (DNS) on 2/27/25 at 2:30 P.M. identified her expectation when a resident has behaviors is that a comprehensive care plan is implemented with person centered interventions. The DNS was unable to provide documentation to reflect that Resident #3 had a comprehensive care plan implemented for behaviors. The DNS identified Resident #3 should have had a comprehensive care plan in place to identify and address Resident #3's behaviors. The DNS further identified the MDS Coordinator and nursing supervisors can update and oversee the care plans. The DNS was unable to explain why Resident #3 did not have a comprehensive care plan implemented. Review of facility comprehensive care plan policy dated 9/16/2018 identified it is the policy that the interdisciplinary team in conjunction with the resident develops a comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial, and functional needs and implemented for each resident and care plan interventions are chosen only after careful data gathering, proper sequencing of events, and careful consideration of the relationship between the resident's problem areas and their causes.

Based on clinical record review, review of facility policy and interviews for nine sampled residents (#26, #27, #32, #43, #50, #61, #64, #69, and #376) reviewed for care planning, the facility failed to ensure the interdisciplinary team (IDT) resident care plan meetings were held following comprehensive and quarterly assessments and failed to ensure comprehensive care plans were developed by the IDT team with resident/family/responsible party involvement. The findings include: 1. Resident #26 admitted in the facility on 7/3/24 with diagnoses that included pericardial effusion, hypertensive heart disease with heart failure, orthostatic hypotension, atrial fibrillation, and implantable cardiac defibrillator. The admission MDS assessment should have been completed by 7/17/24 and the comprehensive care plan developed by the interdisciplinary team should have been developed by 7/24/24. Review of Resident #26's clinical record failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 7/17/25 and 7/24/24. Interview on 8/26/24 at 11:00 AM with Resident #26 identified he/she had not seen the social worker since being admitted to the facility. Additionally, Resident #26 noted that he/she had not been invited or participated in a care plan meeting. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for completing and developing the resident care plans when a resident is admitted to the facility and an interdisciplinary care plan meeting is held to discuss resident goals of care. She further identified that the interdisciplinary care plan meeting and development of the comprehensive care plan should occur within 21 days of resident's admission in the facility. LPN #2 noted Resident #26 did not have a care plan meeting held because she just started in the position of MDS Coordinator, and they did not have a Social Worker to coordinate the care plan meetings. Interview with SW #1 (covering social worker) on 8/26/24 at 1:40 PM identified she was only in the building for one day and worked remotely if the facility had any concerns. Interview with the DNS on 8/27/24 at 10:30 AM identified that although, Resident #26 should have had an interdisciplinary care plan meeting held with the resident in attendance to discuss goals of care, no meeting had taken place, and the comprehensive care plan was not developed because they did not have an MDS Coordinator, and they did not have a full-time Social Worker to coordinate the meeting. The RAI user manual 3.0 identified that the comprehensive admission MDS needed to be completed on the 14th calendar day of the resident's admission (admitted + 13 calendar days), Care Area Assessment (CAA) also need to be completed on the 14th calendar day, and comprehensive care plan completion need to complete CAA completion date + 7 calendar days. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, and seborrheic dermatitis. The admission MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition. The care plan dated 5/10/24 failed to identify that Resident #27 and/or his/her representative participated in choosing treatment options or were given the opportunity to have input in the development of the plan of care. Interview with Resident #27's representative on 8/21/24 at 12:25 PM identified that he/she had not yet attended a resident care conference but one was scheduled for the following day and he/she planned on attending. Interview with the DNS on 8/22/24 at 2:58 PM identified that resident care conferences were not being completed routinely, due to multiple staff changes in the facility's social work and MDS positions. The DNS further identified that while the facility had corporate support and the support of a consultant company, not having the social work and MDS positions filled with permanent employees created a break down in scheduling and implementing the resident care conferences. The DNS indicated that the facility had hired an MDS coordinator and that she had been in the position for less than one month and over the past 2 weeks had started to schedule and complete resident care conferences; including Resident #27's care conference, which was completed earlier that afternoon. The DNS further indicated that she would have expected Resident #27 to have had an initial meeting, completed within 72 hours of admission, and then another conference around Day 14. The DNS identified that the meetings include participation from various members of the interdisciplinary team, as well as the resident and resident representative. The facility's Resident Participation-Assessment/Care Plans policy directs the resident, and his/her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The resident and his/her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy further directs that the resident/representative's right to participate in the development and implementation of his/her plan of care includes the right to: participate in the planning process, identify individuals to be included in the planning process, request meetings, request revisions, participate in establishing goals and expected outcomes of care plan, participate in the type, amount, frequency and duration of care, receive the services and/or items included in the care plan, refuse, request changes to and/or discontinue care or treatment offered or proposed, be informed in advance of the risks and benefits of the care or treatment proposed, have access to and review the care plan, and be informed of, review & sign the care plan after any significant changes are made. Resident assessments are begun on the first day of admission and completed no later than the 14th day after admission, and a comprehensive care plan is developed within seven days of completing the resident assessment. 3. Resident #32's diagnoses included Type 2 diabetes mellitus, anemia, and vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #32 had intact cognition, required maximal assistance with personal hygiene, transfers and utilized a wheelchair for mobility. Resident #32's care plan identified that it was last reviewed and revised on 4/28/24. Interview on 8/22/24 at 10:30 AM with Resident #32 identified that he/she had not been invited and or attended a care conference meeting since 2023. Review of the care conference sign in records identified the last interdisciplinary care plan conference meeting was held on 8/2/2023. Review of the clinical record identified the resident had an annual MDS assessment dated [DATE], and quarterly assessments dated 12/18/23 and 4/1/23 (care plan conferences should have been held after each of the stated quarterly assessments as well as the annual assessment in September but were not according to the documentation and the interviews). Interview with Social Worker #1 on 8/26/24 at 1:31 identified she worked one day per week from January to April of 2024. SW#1 further identified that on a daily basis, there should be social work contact with the residents and at a minimum there should be monthly notes and quarterly reviews and participation in the quarterly care conferences. Interview with the Administrator on 8/22/24 at 2:52 PM identified that he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker; however, he identified he had not had success in finding a qualified social worker to fill the position. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative would develop and implement a comprehensive, person-centered care plan for each resident. The policy further identified that the IDT must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. Review of the Resident Participation-Assessment/Care plans policy identified that the Social Service Director or designee was responsible for notifying the resident/representative and for maintaining records of such notices of the care conferences. 4. Resident #43's diagnoses included dementia, heart failure, depression, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #43 had severe cognitive impairment and required total assistance with dressing, toileting, hygiene, and transfers. Review of the clinical record and the care plan dated 3/9/24 on 8/27/24 identified that there had not been an interdisciplinary care conference (inclusive of the resident/responsible party) held to review and/or revise the comprehensive care plan. A care conference should have been held in July/2024. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for reviewing the quarterly care plans and scheduling the care plan conference meetings. She further identified that the care plan indicates the dates when it was last reviewed. In addition, she identified that care plan conferences are held at least every quarter where the care plans are all reviewed. Further, LPN #3 identified Resident #43's care plan was not reviewed because the facility did not have an MDS Coordinator. Interview with the DNS on 8/25/24 at 11:30 AM identified she was aware that the interdisciplinary care conference meetings were not being held every quarter and care plans were not being reviewed and/or revised because the MDS position had been vacant. The care plan policy identified that required assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 5. Resident #50's diagnoses included alcoholic cirrhosis of the liver, anxiety and respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #50 was cognitively intact, required set up for eating, required substantial assistance with bed mobility and utilized a manual wheelchair for mobility. review of Resident #50's care plan identified several revision dates throughout the document, the most recent reviewed and revised date was noted as 8/17/24. Interview on 8/21/24 at 10:46 AM with Resident #50 identified he/she had never been invited, attended and/or anyone discussed his/her plan of care with him/her. Interview on 8/22/24 at 12:11 PM with the Director of Nursing (DNS) identified that the position of Minimum Data Set Nurse had been filled for the past 3 weeks, the previous MDS nurse had taken a leave for about 4 months and in the interim, a consultant company was hired. She also identified that the facility was limited on having care plan meetings because the facility did not have a Social Worker employed in the building for a long time. Interview on 8/22/24 at 1:36 PM with LPN #3 identified Resident #50 had not had a care plan meeting held since being admitted to the facility (7/17/23). Review of the clinical record identified Resident #50 had an admission assessment dated [DATE], and quarterly assessments dated 10/23/23, 1/14/24 and 4/15/24. Interdisciplinary care conferences should have been held following each of these assessments (four in total) Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. 6. Resident #61's diagnoses included Type 2 diabetes mellitus, and right and left below knee amputations. The annual MDS assessment dated [DATE] identified Resident #61 was without cognitive impairments, utilized a wheelchair, utilized set up or clean up assistance for eating, was independent for oral hygiene, toileting hygiene, and shower and bathing as well as upper body dressing. Resident #61's care plan dated 6/2/24 identified resident is at risk of an alteration in psychosocial wellbeing related to possible temporary room change and loud noise due to construction in building with interventions that included: assist the resident to a quiet area if one is available, afford the resident the opportunity to ventilate feeling and concerns regarding room change, and social work intervention as indicated to assist with resolution of concerns related to the change. Interview with Resident #61 on 8/21/24 at 10:30 AM identified he/she had not been invited and/or attended a care conference meeting or had anyone discussed his/or care plan with him/her since last year. Resident #61 further identified that he/she was interested in being considered for the Money Follows the Person (MFP) program and discharge to the community. He/she further noted that there had not been a Social Worker in the building to speak to about the above in the past year. Review of the care conference sign in records identified the last interdisciplinary care plan conference meeting was held was on 8/16/23 (Resident #61 was noted to attend) Review of the clinical record identified the resident had a quarterly MDS assessments dated 11/3/23, 1/29/24 and 3/22/24 (care plan conferences should have been held after each of the stated quarterly assessments as well as the annual assessment in June). Review of the social service notes identified that there were no notes documented after 2/22/24. Interview with Social Worker #1 on 8/26/24 at 1:31 identified she worked one day per week from January to April of 2024. SW#1 further identified that on a daily basis, there should be social work contact with the residents and at a minimum there should be monthly notes and quarterly reviews and participation in the quarterly care conferences. Interview with the Administrator on 8/22/24 at 2:52 PM identified that he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker; however, he identified he had not had success in finding a qualified social worker to fill the position. The comprehensive care plan policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. 7. Resident #64's diagnoses included type 2 diabetes mellitus, obstructive and reflux uropathy, depression, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #64 had severe cognitive impairment and required extensive assistance with dressing, toileting, hygiene, and transfers. Review of the clinical record and the care plan dated 11/11/23 on 8/27/24 identified that there had not been an interdisciplinary care conference (inclusive of the resident/responsible party) held to review and/or revise the comprehensive care plan in March/2024 or July/2024 following the dates where MDS assessments were due to be completed. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for reviewing the quarterly care plans and scheduling the care plan conference meetings. She further identified that the care plan indicates the dates when it was last reviewed. In addition, she identified that care plan conferences are held at least every quarter where the care plans are all reviewed. Further, LPN #3 identified Resident #64's care plan was not reviewed because the facility did not have an MDS Coordinator. Interview with the DNS on 8/25/24 at 11:30 AM identified she was aware that the interdisciplinary care conference meetings were not being held every quarter and care plans were not being reviewed and/or revised because the MDS position had been vacant. The care plan policy identified that required assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 8. Resident #69 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, ischemic cardiomyopathy, and unspecified psychosis. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up or clean up assistance with eating, oral hygiene, moderate assistance with shower/bathing, personal hygiene and utilized moderate assistance with dressing. Review of the facility documentation on Resident's Care Conferences held for Resident #69 failed to identify that a Resident care conference was completed upon admission or thereafter. Interview with Resident #69 on 8/21/24 at 10:40 AM identified that he/she had not attended a care plan meeting since admission to the facility. Review of Resident #69's clinical record failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 6/25/24 and 7/9/24. Interview with Social Worker (SW #1) (who worked from January 11th, 2024, to May 1, 2024) on 8/26/24 at 1:31 PM identified that she started working in the facility in January of 2024 only one day per week for 8 hours until April of 2024. During this timeframe she would work on MFP, discharges, PASSR, Level of Consciousness (LOC) and some 72 hours initial assessments. She identified that she was not able to complete all the task as she was only in the building for one day, and worked at another facility, which was owned by the same company, where she would be contacted to work remotely on urgent concerns for this facility. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 identified that daily there should be social worker contact with the residents, minimum a monthly note and quarterly review for the resident care conference. Interview with the Administrator on 8/22/24 at 2:52 PM that he was aware of the concerns that the resident's had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first. 9. Resident #376 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, anxiety, depressive episodes, and extended spectrum eta lactamase (ESBL) resistance. The admission nursing assessment dated [DATE] identified Resident #376 was alert and oriented to person, place and time, required assistance with bed mobility, transfers, and dressing. The admission MDS assessment should have been completed by 7/26/24 and the comprehensive care plan developed by the interdisciplinary team should have been developed by 8/2/24. Review of Resident #376's clinical record on 8/26/24 failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 7/26/24 and 8/2/24 (making the comprehensive care plan 24 days late at that point in time). Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first. 47402 47457 47489 47900 48950

Based on review of the resident council meeting minutes, review of facility documentation, review of facility policy and interviews, the facility failed to respond to concerns identified by the resident council regarding the need to speak with a Social Worker in the facility. The findings include: Review of the Resident Council meeting minutes dated 4/26/24, 5/31/24, 6/28/24, and 7/26/24 identified the expressed wish to speak with the Social Worker and although, there were designated resident council department response forms that were utilized to answer resident council requests, concerns and grievances, there were no resolutions identified to the residents' expressed aspirations and no indication that the social worker had attended any of the meetings to address the requests from the period of 4/26/24 through 7/26/24. The group interview held on 8/22/24 with nine members of resident council identified their on-going concern of wanting to speak with a social worker during their monthly resident council meetings and they further identified that it had been a while since they'd had a full-time social worker. Additionally, the Residents noted they were told that the facility was working on hiring someone for the position, but they still did not have a full-time social worker and their requests to see a social worker had not been obliged. Interview with the Director of Recreation on 8/22/24 at 2:15 PM identified that she is responsible for documenting the resident council minutes, completing the top portion of the Resident Council Department Response form and distributing the forms to the appropriate departmental heads. She identified that after the meeting concludes, the expectation is for the Resident Council Department Response form to be completed and returned to her within a week. The Director of Recreation further identified the concern of wanting a social worker was an ongoing concern of the residents that she has brought to the Administrator's attention, who has not addressed the concerns regarding the lack of a social worker at any of the resident council meetings. Interview with the Administrator on 8/22/24 at 2:52 PM identified the Director of Recreation provides him with the Resident Council Department Response forms after the resident council meetings and he returns the form within a week. The Administrator further identified that he is responsible for concerns related to the Social Worker. He noted that he made the Social Worker aware of the residents' requests to see the social worker, but he could not provide any information regarding the follow up with the resident council by the Social Worker or himself. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (employed from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day a week until April of 2024. During this timeframe she worked on money follows the person (MFP), discharges, PASRR (Preadmission Screening and Resident Review), Level of Consciousness (LOC) and some 72 hours initial assessments. She identified that she was not able to complete all the task as she was only in the building for one day and worked remotely if the facility had any concerns. Social Worker #1 identified when shown her timesheet for the time period of January 2024 through May 2024, that for most of those hours she was at another facility that was owned by the same company, when this facility would call with questions or concerns which she would address remotely. Interview with the Administrator on 8/26/24 at 2:54 PM identified that he could not recall if he had returned the Resident Council Department Response forms, as the issue of the Social Worker was an ongoing concern, and he was unable to recall if he notified the Social Worker at the time. Review of the Resident Council policy identified that a Resident Council Response form will be utilized to track issues and their resolution, and the facility department related to any issues would be responsible to address the item (s) of concern. The policy further identified that the Administrator would review minutes and any response from the departments within the facility and responses are presented at the next meeting, or sooner if indicated.

1. Based on observations, and interviews, the facility failed to provide a homelike, safe, and sanitary environment for two shower rooms on the central and middle unit and for the identified carpeted areas on the central unit. The findings include: Observation of the shower room area on 8/21/24 at 10:16 AM identified two of three shower rooms in the central shower area to have several items stored to include two rolling shower chairs stacked two high, six IV poles, a lounging shower chair, a utility cart, a cardboard box, and a black substance on the ceiling and a shower curtain with holes in it. The third shower room contained two rolling shower chairs. Observation on 8/21/24 at 10:25 AM of the south wing hallway identified several dark brown stains of unknown substance on the carpet. Interview with Resident #61 on 8/21/24 at 11:08 AM identified that she/he had an issue with the shower rooms being so cluttered and that it did not provide a homelike environment. The shower rooms had been like this for some time and was unsure if the two that were cluttered even functioned anymore, one had a leak at one point. Anytime someone had to go in the shower room they had to see all the clutter, and could not utilize the other shower areas, just one was able to be utilized. Also, the shower chairs that were utilized by the residents did not have a basin under them so when a resident is wheeled through the hallway in the shower chair they sometimes are incontinent of urine or feces and there are several stains on the carpet in the hallways due to this. Interview with NA#2 on 8/22/24 at 11:17 AM identified the one shower room was utilized a couple times each day, and that items had been stored in the shower for about two years. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the black substance on the ceiling in the shower room was mold or dirt and was unsure when the area was last cleaned. Interview with the Maintenance Director on 8/27/24 at 1:45 PM identified the shower rooms were being utilized for storage due to the lack of storage in the building. The shower leaks in the wall and will be part of the remodel project where the wall will be removed to make a bigger shower. The rug in the hallway needs to be replaced as well and was unsure what the substance on the rug was. Interview with the administrator on 8/28/24 at 10:45 AM identified that the items were now cleaned from the shower area and the area has been cleaned, but the items were stored there due to lack of storage. Environmental rounds were conducted however just with a hot list and not a formal documentation. This list would then be given to whomever it was designated on the list to fix it. The showers were not identified to be an issue because they were being utilized for storage. Interview with the Infection Preventionist on 8/28/24 at 12:56 PM identified she did complete environmental rounds however did not list the shower room stalls on the environmental rounds as an issue due to the fact they had been like that for approximately two years, and it wasn't something new that jumped out at her. Review of the Environmental Round Policy indicated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in a such a manner to acknowledge and respect resident rights to the extent possible. This includes providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. the facility failed to provide a homelike, safe, sanitary environment for three of three showers sampled. The findings include: Observation of the shower room area on 8/21/24 at 10:16 AM identified two of three shower rooms in the central shower area to have several items stored to include two rolling shower chairs stacked two high, six IV poles, a lounging shower chair, a utility cart, a carboard box, and a black substance on the ceiling and a shower curtain with holes in it. The third shower room contained two rolling shower chairs. Observation on 8/21/24 at 10:25 AM of the south wing hallway identified several dark brown stains of unknown substance on the carpet. Interview with Resident #61 on 8/21/24 at 11:08 AM identified that she/he had an issue with the shower rooms being so cluttered and that it did not provide a homelike environment. The shower rooms had been like this for some time and was unsure if the two that were cluttered even functioned anymore, one had a leak at one point. Anytime someone had to go in the shower room they had to see all the clutter, and could not utilize the other shower areas, just one was able to be utilized. Also, the shower chairs that were utilized by the residents did not have a basin under them so when a resident is wheeled through the hallway in the shower chair, they sometimes are incontinent of urine or feces and there are several stains on the carpet in the hallways due to this. Interview with NA#2 on 8/22/24 at 11:17 AM identified the one shower room was utilized a couple times each day, and that items had been stored in the shower for about two years. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the black substance on the ceiling in the shower room was mold or dirt and was unsure when the area was last cleaned. Interview with Maintenance Director on 8/27/24 at 1:45 PM identified the shower rooms were being utilized for storage due to the lack of storage in the building. The shower leaks in the wall and will be part of the remodel project where the wall will be removed to make a bigger shower. The rug in the hallway needs to be replaced as well and was unsure what the substance on the rug was. Interview with the Administrator on 8/28/24 at 10:45 AM identified that the items were now cleaned from the shower area and the area has been cleaned, but the items were stored there due to lack of storage. Environmental rounds were conducted however just with a hot list and not a formal documentation. This list would then be given to whomever it was designated on the list to fix it. The showers were not identified to be an issue because they were being utilized for storage. Interview with the Infection Preventionist on 8/28/24 at 12:56 PM identified she did complete environmental rounds however did not list the shower room stalls on the environmental rounds as an issue due to the fact they had been like that for approximately two years, and it wasn't something new that jumped out at her. Review of the Environmental Round Policy indicated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in a such a manner to acknowledge and respect resident rights to the extent possible. This includes providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 2. Observation on 8/21/24 at 9:53 AM of the Central unit shower room identified kit was filled with numerous items such as intravenous poles, rolling plastic cart (not for laundry), cardboard box, a bucket, a bedpan, and multiple ripped shower curtains. Observation on 8/22/24 at 11:15 AM of the Central unit shower room identified the following items: 4 intravenous poles, 1 unopened box sitting on the bottom of the intravenous pole, 1 rolling plastic cart that had a cardboard box on it, 1 bucket, and 1 bed pan. Observation on 8/22/24 at 9:03 AM of the Middle unit shower room identified it was untidy, and did not appear homelike. A rusty pipe was observed along the ceiling of the shower room, a dirty glove was on the floor, the ceiling light fixture cover was cracked and had a burnt-out light bulb, there was a ripped shower curtain that contained holes and was ripped along the top causing it to not be able to hang properly. In addition, there were also numerous areas of the shower room that appeared to be stained with rust and a brown substance. Interview with NA#2, on 8/22/24 at 11:17 AM identified that she utilized the both the Central and Middle shower rooms for residents. NA#2 identified that the Central shower room has had multiple items stored in it for over a month and that the facility was limited on storage. NA#2 identified that maintenance oversees maintaining the shower rooms, equipment and that the showers was not homelike. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the brown substance was mold and Housekeeper #1 was unsure of when the Middle shower room was cleaned last. Interview with Maintenance Director on 8/22/24 at 11:39 AM identified that the Central shower room had parts that were used for storage because the facility was limited on storage. Also identified was that the Middle shower room brown substance was dirt and dust, had a cracked light cover, and a ripped shower curtain. Interview with Administrator on 8/22/24 at 2:49 PM identified that he was aware of the rusty wire cover, burnt out light bulb, and broken cover on overhead light and that they will be fixing those items. The Administrator identified that the Middle shower room was not homelike.

Based on clinical record reviews and interviews for five sample residents (Resident #26, #35, #69, and #376) who required psychosocial support, the facility failed to ensure a Social Worker was available to meet resident needs. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included pericardial effusion, hypertensive heart disease with heart failure, orthostatic hypotension, atrial fibrillation, and implantable cardiac defibrillator. The RCP dated 7/4/24 identified Resident #26 was at risk for alteration in psychosocial well-being. Care plan interventions directed to encourage communication with visitation, monitor for psychosocial changes, observe and report any changes in mental status caused by situational stress, and provide opportunity to express feelings related to situational stressors. The admission MDS assessment dated [DATE] identified Resident #26 had intact cognition and required extensive assistance with toileting, hygiene, bed mobility, dressing, and transfers. Interview with Resident #26 on 8/26/24 at 11:00 AM identified he/she had not been seen by a social worker since his/her admission to the facility. Review of the clinical record failed to identify social service progress notes and /or social service assessments for the time period of 7/3/24 to 8/27/24. Interview with Social Worker #1 (covering social worker) on 8/26/24 at 1:40 PM identified that the Social Worker is responsible for evaluating residents upon admission to the facility and documenting in the progress notes. The Social Worker typically meets with the resident within 72 hours of admission to the facility and assesses needs such as the resident's community support, equipment that may be needed upon discharge, and any follow up necessary with the community physician. She further identified that the facility did not have a full-time social worker, and she only worked one day per week. Additionally, she confirmed that she had not seen Resident #26. 2. Resident #35's diagnoses included acute respiratory failure with hypoxia, other chronic osteomyelitis, morbid obesity and other cirrhosis of the liver. Review of the Social Service progress notes dated 1/31/2024, the last social service entry, indicated that an application for Money Follows the Person was submitted by Social Worker #1. The 5 day MDS dated [DATE] identified Resident #35 was cognitively intact, was dependent with toileting hygiene and transfers and required substantial/maximal assistance with lying to sitting or sitting to lying. Interview with Resident #35 on 8/21/2024 at 10:27 AM identified the resident was unhappy with care and follow up at the facility. Resident #35 identified he/she was waiting for updates on Money Follows the Person and was ready to be discharged from the facility over the previous year. The Care Plan dated 6/1/2024 identified Resident #35 was very independent and self-scheduled medical appointments and contact with family. Resident #35 was care planned for ADLs and identified the resident was admitted for short-term rehab and expected to be discharged to the community with interventions that social work will utilize community resources to ensure a safe discharge. Interview with the Administrator on 8/26/2024 at 1:22 PM identified the facility hasn't had a social worker and identified SW #1 had been in the facility, since May, 16 hours weekly. Interview with Social Worker #1 on 8/26/2024 at 1:30 PM identified she had been intermittent, on loan, in this facility off and on over the last year but does not have dedicated hours. She indicated she was helping with discharges, getting caught up on admissions and significant things. SW #1indicated that discharge planning starts at admission and should be reflected in the care plan and social worker documentation. Additionally, she indicated that any resident with Money Follows the Person (MFP) there is a monthly meeting and there should be a monthly note or update In the progress notes. Specifically with Resident #35 there should have been a follow up with the resident regarding status of the MFP program, and at least a quarterly note. SW#1 indicated that based on the absence of social worker notes, it would appear that Resident #35 had not been interacted with since January. 3. Resident #69 was admitted to the facility on [DATE] with diagnoses included cerebral infarction due to embolism, ischemic cardiomyopathy, and unspecified psychosis. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up or clean up assistance with eating, oral hygiene, moderate assistance with shower/bathing, personal hygiene and dressing. The 48-hour baseline care plan dated 6/19/24 identified Resident #69 required assist with activities of daily living and functional mobility with interventions that included assist of one for bathing, bed mobility, personal hygiene and transfers. Interview with Resident #69 on 8/21/24 at 10:40 AM identified that he/she never had a care plan meeting upon admission and never saw a social worker since he/she has been admitted to the facility but has wanted to speak with a social worker. Review of the Social Worker progress notes from 6/18/24 to 8/27/24 failed to identify Resident #69 was seen or evaluated by the facility's Social Worker since admission. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Interview with the Administrator on 8/22/24 at 2:52 PM identified he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (who worked from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day per week for 8 hours until April of 2024, when shown her timesheet for the time period of January 2024 through May 2024, Social Worker #1 identified that for most of those hours she was at another facility that was owned by the same company and would work remotely if this facility had any questions or concerns. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 further identified that there should be daily contact with the residents with a note written monthly in the resident's record at minimum. The Social Worker job description provided by the facility identified that the Social Worker provides direct clinical case work and group work services to residents and their families through supportive services, participate in resident assessment process and discharge planning, available to deal with psycho-social-emotional or with family-related problems of the residents as they arise during the resident's stay in the facility, and interviews resident/family to obtain biographies, psychological and social history. 4. Resident #376 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, anxiety, depressive episodes, and extended spectrum eta lactamase (ESBL) resistance. The admission nursing assessment dated [DATE] identified Resident #376 was alert and oriented to person, place and time, required assistance with bed mobility, transfers, and dressing. The RCP dated 7/14/24 identified Resident #376 was at risk for alteration in psychosocial well-being with interventions that included: encourage communication with visitation, monitor for psychosocial changes, observe and report any changes in mental status caused by a situational stress, and provide opportunity to express feelings related to situational stressor. Interview with the Resident #376 on 8/26/24 at 1:40 PM identified he/she requested to see a Social Worker when first he/she was first admitted to the facility and has to date not been seen by the Social Worker. Review of the clinical record failed to identify social service progress notes and /or social service assessments for the time period of 7/12/24 to 8/27/24. Interview with the Administrator on 8/22/24 at 2:52 PM that he was aware of the concerns that the resident's had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (who worked from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day per week for 8 hours until April of 2024, when shown her timesheet for the time period of January 2024 through May 2024, Social Worker #1 identified that for most of those hours she was at another facility that was owned by the same company and would work remotely if this facility had any questions or concerns. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 further identified that there should be daily contact with the residents with a note written monthly in the resident's record at minimum. On 8/28/24 (after surveyor inquiry) Resident #376 was seen by SW #1 who wrote a progress note that identified Resident #376 needed to return to the community and was requesting a referral for Money Follows the Person (MFP). The Social Worker job description provided by the facility identified that the Social Worker provides direct clinical case work and group work services to residents and their families through supportive services, participate in resident assessment process and discharge planning, available to deal with psycho-social-emotional or with family-related problems of the residents as they arise during the resident's stay in the facility, and interviews resident/family to obtain biographies, psychological and social history. 47402 47489 47900

Based on review of facility documentation, facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure that the facility's antibiotic surveillance tracking form was completed as directed and failed to ensure that the reports presented at the monthly and quarterly medical staff meetings contained the Antibiotic Stewardship review. The findings include: A review of the Antibiotic Stewardship program for the past two years with the DNS and the Infection Preventionist (RN#2) on 08/27/24 at 10:39 AM identified RN#2 had been the IP since the end of May, beginning of June 2024. The DNS indicated RN#2 had other duties that she is responsible for including weekly IP reports and is able to work remotely to complete these tasks. RN#2 indicated her practice for infection control included surveillance but was unable to show the tracking/surveillance when asked. RN#2 identified Antibiotic stewardship is tracked monthly and used McGeer's criteria to tract they labs are reviewed and checked off in the antibiotic stewardship book but the labs are not included in the book. RN#2 indicated that she reviewed the labs in the chart and marks on the stewardship book whether they are within range, however, was not able to produce the stewardship book. Interview with the DNS on 8/28/24 at 1:14 PM identified that Antibiotic stewardship is discussed at the Interdisciplinary Team meetings. However, she then identified that the meeting minutes do not document what exactly is discussed in the meetings and I am still attempting to locate the antibiotic stewardship paperwork. The DNS was able to provide antibiotic stewardship review from Trident care from 1/1/2022 to 12/31/2022 She had already given me the 10/23 through the 2/24 and identified that she was not able to locate anything that would identify they were reviewed or discussed. Review of the facility policy for antibiotic stewardship identified Antibiotic stewardship activities included regular review of antibiotic utilization patterns and sensitivity patterns at the committee meeting, including reports from the laboratory on sensitivity and resistance patterns over time (quarter, year, past years), and review of antibiotic utilization over time.

Based on observations, interviews, facility documentation, and policy for the facility Infection Prevention position, the facility failed to ensure the Infection Preventionist had appropriate time to complete IP duties at the facility. The findings included: The Facility Assessment 2023, signed on 1/31/2024, identified RN #2 as the team member holding the Infection Preventionist/Staff Development position. Additionally, the Infection Control section of the Facility Assessment identified the facility conducted an infection control risk assessment yearly, which evaluated and determined the risk or potential vulnerabilities within the resident population and the surrounding community. According to CT Public Act 22-58 identified that each nursing home with more than 60 residents shall employ a full-time Infection prevention and control specialist and that each infection prevention and control specialist worked on a rotating schedule that ensures the specialist covered each eight-hour shift at least once per month. Review of the facility Monthly schedules from May 16th, 2024 through September 4th, 2024 identified RN #2 was scheduled 7a-3p at least 5 days per week and was scheduled as the RN supervisor. Review of the daily schedules for this time period identified RN #2 was scheduled as the RN Supervisor almost daily. Interview with the DNS and RN #2 on 8/27/24 at 10:39 AM identified RN #2 had been the Infection preventionist since the beginning of June 2024. The DNS identified that RN #2 does not have designated hours for Infection Prevention. The DNS identified RN #2 is in the building as the RN Supervisor and is sometimes pulled to the floor to cover call-outs or short staffing. The DNS identified the RN supervisor position as a free float supervisor position, so RN #2 is able to get other work done if time allowed and RN #2 was able to work from home. Interview with the DNS on 8/28/2024 at 10:30 AM identified the previous IP/staff development person worked 32 hours as the IP and 8 hours at staff development. The previous position holder was not an RN supervisor. The DNS identified the corporate entities identified there was no Federal minimum for hours for an Infection Preventionist, and, now the position is a combined position of IP/staff development and RN supervisor. The DNS identified that RN #2 is scheduled predominantly as the RN Supervisor and completed other tasks as time allowed. Facility documentation reviewed 8/27/2024 at 1 PM identified RN #2 had completed the Nursing Home Infection Preventionist training 3/2/2024 and had the appropriate education for the Infection Prevention position.

Based on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #27) reviewed for advance directives, the facility failed to accurately document the resident's life support choices. The acute care Hospital discharge summary dated 5/2/24 identified Resident #27's code status (directs the medical team to administer or withhold life support systems in the event of a cardiac or respiratory arrest) was: full resuscitation (all resuscitative and aggressive curative treatments are provided). Resident #27 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, and pneumonia. The Advance Directive form dated 5/2/24 and signed by the Resident #27's Representative and the Physician on 5/3/24 identified Resident #27's options for medical care and treatment were do not resuscitate (DNR) and do not intubate (DNI). Review of physician's orders from 5/2/24 through 8/22/24 directed Resident #27's code status was full code (resuscitate and directed to ensure Resident #27 signs the Advance Directive form and place a copy in the chart. The admission MDS dated [DATE] identified Resident #27 had severely impaired cognition. Interview and clinical record review with RN #3 on 8/22/24 at 9:43 AM failed to identify that the advance directive form and the physician's order were congruent. RN #3 indicated that Resident #27 was a full code on admission, and that the face sheet had been updated to reflect Resident #27's DNR/DNI status, but the physician's order was not updated to reflect the change. RN #3 further indicated that it was the responsibility of the charge nurse or nursing supervisor to update the orders when the advance directive form was completed. Interview with the DNS on 8/22/24 at 2:48 PM identified that when a code status is changed, she expects the order to be updated in the resident's clinical record by the charge nurse or RN supervisor. The Advance Directives policy directs that resident preferences regarding end-of-life decisions and medical decisions are always respected. Nursing reviews the advanced directive options and completes the form, the form is filed in the medical chart, and a doctor's order is written into the electronic medical record. The policy further identified that advance directives can be changed at any time by the appropriate party and in all cases, the decision of the individual resident and/or designee will be respected within the state and federal guidelines. These wishes will be brought to the attention of staff on the advance directives form and in the electronic medical record.

Based on observation, clinical record review, review of facility policy, and interviews for one of five sampled residents (Resident #59) observed for medication administration, the facility failed to ensure that an extended-release medication was not crushed and that a physician's order was in place to administer crushed medications to a resident. The findings include: Resident #59's diagnoses included Alzheimer's disease, dysphagia, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #59 had severe cognitive impairment, required set up assistance for meals, had no swallowing difficulties and was on a therapeutic diet. The physician's order dated 5/7/24 directed regular diet, regular texture, thin liquids, magic cup every day with Boost (nutritional supplement), aspiration precautions, upright for all meals, set up for all meals, assist of one as needed for initiation. The orders further directed; Metoprolol Succinate tablet extended release 24 hr., 25mg, 1 tab by mouth once a day, Depakote Sprinkles delayed release capsule 125 mg by mouth once a day, Buspirone tablet 12.5 mg by mouth twice a day, Cranberry capsule once in the morning. The Care Plan dated 5/17/24 identified Resident #59 had dysphagia and was an aspiration risk with interventions that included: alternate liquids with solids, small sips and bites, monitor for signs and symptoms (s/s) of coughing and aspiration during meals, observe for s/s of respiratory infection from silent aspiration: cough, fever, wheeze, dyspnea, malaise, provide dietary consistency per physician's orders, provide supervision and assistance per therapy recommendations. Observation on 8/27/24 at 7:42 AM of medication administration identified LPN #7 prepared the following medications for Resident #59: 1 tablet of Buspirone 10mg, 1 tablet of Buspirone 5 mg, 1 capsule of Divalproex 125 mg delayed release,1 tablet of Irbesartan 300 mg, 1 tablet of Metoprolol Succinate 25mg extended release, and 1 Cranberry capsule 425 mg. LPN #7 placed the Buspirone, the Irbesartan, and the Metoprolol Succinate into a plastic envelope and crushed the medication, she then mixed the crushed medications into chocolate pudding and then opened the Divalproex and Cranberry capsules and sprinkled the contents onto the chocolate pudding mixture. She mixed all of the medications into the chocolate pudding and went into the resident room to administer the medications to Resident #59. Once LPN #7 approached the resident, this surveyor interrupted and asked to speak with LPN #7 in the corridor. Interview with LPN #7 identified Resident #59 did not have a physician's order to crush medications and noted that extended-release medications should not be crushed. She further noted that administering the medications mixed with pudding was a better way to administer the medications to Resident #59 because the resident chewed the medications. LPN #7 further identified that she did not know if this behavior had been reported to the physician. Observation of the medication administration following the interview and following LPN #7 pouring the same medications into a medication cup and administering them to the residents with water, identified the resident chewed the medications prior to swallowing them. Interview with the RN Supervisor on 8/27/24 at 8:10 AM identified there is usually an order for medications to be crushed. The RN supervisor identified that aspiration precautions could indicate there are swallowing problems but there should still be an order for crushed medications, if that is how they are to be administered. Interview with the DNS on 8/27/24 at 9:05 AM identified medications should be administered whole unless there is an order for the medications to be crushed or the capsules opened. The aspiration precautions in the care plan do not indicate the medications should be crushed. Interview with Pharmacist #3 on 8/29/24 at 1:39 PM identified that there should be a physician's order if medications are to be crushed for administration. Pharmacist #3 identified that extended-release medications should not be crushed because they lose the extended-release properties and act faster than intended. The Metoprolol Succinate could cause decreased blood pressure. Pharmacist #3 further identified that Depakote Sprinkles can be opened and sprinkled but should be swallowed in the pudding and not chewed or crushed because it could change the timed effect and could affect the resident negatively. The Medication Administration policy identified a provider order is required before administration of any medication and should include the five rights: right person, right medication, right route, right dose, right time. Right route gives further direction to check the provider's order and ensure that the medication can be safely administered to the resident via this route.

Based on clinical record review, review of facility policy, and interviews for one of three sampled residents (Resident #26) reviewed for discharge planning, the facility failed to develop a discharge plan in a timely manner. The findings include: Resident #26 was admitted in the facility on 7/3/24 with diagnoses that included pericardial effusion, hypertensive heart disease with heart failure, orthostatic hypotension, atrial fibrillation, and implantable cardiac defibrillator. The initial care plan dated 7/4/24 identified the focused area of discharge planning with and intervention to evaluate short-term or long-term stay placement and social service evaluation. The admission MDS assessment dated [DATE] identified Resident #26 was without cognitive deficits, and required extensive assistance for toileting, hygiene, bed mobility, dressing, and transfers. The assessment further identified the resident received occupational and physical therapy and had a discharge plan in place. Review of social service progress notes from 7/3/24 to 8/27/24 failed to identify Resident #26 discharge plan was discussed with the resident. Interview on 8/26/24 at 11:00 AM with Resident #26 identified he/she had not had any interaction with a Social Worker since being admitted to the facility. Resident #26 further identified he/she had not participated in the care plan process and/or the discharge planning process. He/she further noted his/her goal was to return to the community but did not know at that point when this would occur or what was needed for this to occur. Interview with SW#1 (covering social worker) on 8/26/24 at 1:40 PM identified that the social worker is responsible for timely discharge planning, and it should start when a resident is admitted to the facility. She also identified that members of the interdisciplinary team should meet with the resident within 72 hours to discuss the resident's discharge plan. SW #1 further noted that the social worker ascertains the resident's living arrangements, equipment needed, resident support in the community and his/her primary care physician in the community to plan for effective discharge. The discharge planning is documented in the social service progress notes. Additionally, she identified that no discharge planning had been addressed for Resident #26 either in the social work progress notes or the comprehensive care plan. Interview with the DNS on 8/28/24 at 12:30 PM identified that discharge planning would start upon admission of the resident in the facility. The discharge planning would be documented in the progress notes and/or the coordination of discharge planning would be reflected in the care plan, and it would be updated as needed. She identified that Resident #26 did not have a discharge plan timely because the facility did not have a full-time social worker.

Based on clinical record review, review of facility documents, review of facility policy, and interviews for one sampled resident (Resident #69) reviewed for activities. The facility failed to provide weekend recreation activities. The findings include: Resident #69's diagnoses include cerebral infarction due to embolism, ischemic cardiomyopathy, and adjustment disorder with depressed mood. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up assistance with eating, and utilized moderate assistance with dressing. It further identified the resident did not have behaviors and it was somewhat important for him/her to read books, listen to music, have access to the news, have access to his/her favorite activities and to be able to experience fresh air. The care plan dated 7/8/24 identified Resident #69 preferred in room activities, with an interventions to offer transport to programs. Interview with Resident #69 on 8/21/24 at 10:35 AM identified he/she did not like that there were no activities offered through recreation on the weekends. Resident #69 further noted that although he/she sometimes prefers in room activities, he/she also prefers to attend group activities and would like the option of having weekend activities available. The resident further noted that there is no recreation staff working on the weekend and it is boring because he/she does not receive visitors. Review of the activities calendar for the month of August identified that the only activities noted for Saturday and Sunday were family visits. Interview with the Director of Activities on 8/27/24 at 2:15 PM identified there was no recreation programming on the weekend due to budgetary constraints. She noted that prior to the COVID pandemic there were two recreation staff members; one scheduled for twenty-four hours a week and one scheduled for eight hours a week, in addition to herself who worked forty hours a week. Further, she identified that post pandemic, she works 40 hours but is in charge of maintaining the website, going out to the community to promote the facility, is in charge of petty cash for the residents, and resident funds. Additionally, there is one other recreation staff member who works twenty hours a week (M-F 10 AM-2 PM). She noted that the estimated time per week she spends on recreation activities with the residents is about twenty hours per week and no extra hours are permitted per management. The Director of Activities further identified that she has spoken to the Administrator and the owner of the facility regarding the need for more hours/staff, and was told it was not in the budget. She added that she feels the residents get bored and restless on the weekends and feel that if they had more activities there may be fewer behavioral episodes. The Activity Programs policy directed activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. Individualized and group activities are provided that: Reflect the schedules, choices and rights of the residents.

Based on observations, review of the clinical record, review of facility policy and review of facility documentation for two of four sampled residents (Resident #1 and #27) reviewed for skin conditions, the facility failed to implement the neurologist's orders for over 3 months and failed to ensure a compression glove ordered for dependent edema and comfort was applied and removed, per the physician's orders. The findings include: 1. Resident #1's diagnoses included chronic obstructive pulmonary disease, Type 2 diabetes mellitus, dementia, and skin-picking disorder. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, required set up assistance with eating, oral and personal hygiene, and upper and lower body dressing. The assessment further identified the resident was independent mobility but required supervision or touching assistance with shower transfers. Review of the clinical record identified a neurology consultant's physician's order dated 7/11/2024 that directed Primidone (a barbiturate medication that is used to treat partial and generalized seizures and essential tremors. It's common side effects include sleepiness, poor coordination, nausea, and loss of appetite. Severe side effects may include suicide and psychosis) was to be discontinued and the resident was to start Sinemet 10-100mg three times daily with meals for persistent tremor, due to the resident being poorly responsive to primidone. Review of the Medication Administration Record (MAR) for July 2024 identified two orders. The first was Primidone tablet 50 mg with directions to administer 1/2 tab to equal 25 mg as part of 75 mgs every night for tremors. This medication was administered every day in July with the exception of July 18th, where there was no indication of administered or not administered. The second order identified an order for Primidone tablet 50 mg with directions to administer 1 tablet by mouth every night for tremors as part of 75 mg dose at bedtime. The MAR identified this medication had been administered July 1 through July 10, 2024, and was marked not administered for the rest of the month. Physician's orders dated 8/1/24-8/27/2024 identified resident was prescribed Primidone tablet 50mg 1/2 tab at bedtime with instructions to take 25 mgs = 1/2 tab as part of 75 mg QHS for tremors. Review of the MAR for August 2024 identified an order for Primidone tablet 50 mg with directions to administer 1/2 tablet to equal 25mg at bedtime as part of 75 mg at bedtime for tremors. There were no additional orders for Primidone. There were not orders for Sinemet. Review of the neurology consultation progress note dated 8/8/2024 indicated Resident #1 was seen in July (2024) and Primidone was discontinued due to lack of therapeutic benefit, but Primidone had not been discontinued at that time. Recommendations were to trial Sinemet 10-100mg three times daily with meals for persistent tremor, poorly responsive to Primidone and Cogentin, and to discontinue Primidone at that time. Review of the Resident visit list dated 8/8/2024 indicated Resident #1 was seen as a follow-up to a visit on 7/11/2024 with recommendation to add Sinemet 10-100mg three times a day. Interview and record review with PA #1, neurology consultant, on 08/26/24 at 9:58 AM indicated when recommendations are made for a resident, PA #1 gives a list of the recommendations to the nursing supervisor to either make the changes when approved by the provider or write a note if it is something that won't be implemented. PA #1 indicated she made the recommendation on the resident visit list and gave it to the nursing supervisor. PA#1 identified she had been working at the facility for three years and that had been the practice. PA#1 further indicated the medication she wanted to discontinue wasn't at a high enough dose to be toxic or have negative side effects, but it was not providing a benefit to the resident and another medication might. Interview with RN#2 on 8/22/24 at 11:57 AM indicated the RN supervisor on shift is responsible for inputting the consultant recommendations. Additionally, RN #2 identified that the RN supervisors are able to be pulled to the floor to work and RN#2 also held other positions, Infection Control and Staff Development and that being pulled in several directions made it difficult to complete all tasks. In the event that something is not completed by one supervisor, it is passed on to the next shift. Interview and chart review with the DNS on 8/22/24 at 1:41 PM identified the supervisors on duty make sure the consultant or MD recommendations were reviewed or put in place. Review of the neurology visit for 7/11/24 with the DNS and it was indicated that the nursing supervisor should have changed the orders as directed at that time. Review of the facility policy for MD consults/Appointments identified the purpose of the policy was to ensure residents receive timely and coordinated care. Additionally, the policy identified follow-up included to review any instructions or recommendations provided and implement any necessary care plan changes or follow-up needed. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, and seborrheic dermatitis. The admission MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition, was dependent for lower body dressing and required moderate assistance with upper body dressing. The care plan dated 6/11/24 identified Resident #27 had cellulitis to the right upper extremity and was on antibiotic therapy with an intervention to observe and report signs of localized infection (localized pain, redness, swelling, tenderness, loss of function, and heat at the infected area). A physician's order dated 6/18/24 directed to apply a compression wrap to the right upper extremity during the day and remove nightly. A care plan intervention dated 7/4/24 directed to apply a compression glove to the right-hand during AM care, remove after 8 hours, hand wash the glove and allow to drip dry. Review of the Medication Administration Records (MAR) and the Treatment Administration Records (TAR) from 6/18/24 through 8/22/24 failed to identify documentation that the compression glove and/or wrap was applied during AM care, removed after 8 hours, hand washed and drip dried, and/or that the resident's skin was assessed for signs and symptoms of localized infection. Interview with Resident #27's representative on 8/21/24 at 12:25 PM identified Resident #27 had occasionally complained that his/her right hand hurt and that sometimes the skin felt dry and itchy due to wearing the compression wrap. Observation on 8/22/24 at 1:50 PM identified the skin to Resident #27's right upper arm was intact, skin color was normal, sporadic dry patchy areas observed with no noted swelling. Interview and clinical record review with APRN #1 on 8/22/24 at 2:09 PM identified that in June Resident #27 was treated for cellulitis to the right upper extremity. APRN #1 further identified that she ordered a compression sleeve for dependent edema and comfort, which was to be applied in the morning and removed nightly. Interview and clinical record review with the DNS on 8/22/24 at 2:47 PM identified that the order to apply a compression wrap to the right upper extremity during the day and remove nightly was not entered into the system correctly so the task did not populate to the MAR or the TAR, therefore the nurses were not prompted to sign off the task; the clinical record failed to reflect daily documentation that the compression sleeve was applied during AM care and removed at night. The DNS indicated that there were 2 progress notes documenting the presence of the compression sleeve, but she would expect daily documentation to be in the clinical record upon applying and removing the sleeve. The DNS further indicated that, in addition to the weekly skin assessments, ordered by the physician, she would expect the area under the compression sleeve to be assessed every shift and documented on the MAR or TAR. The facility's Skin and Wound Management policy directs the following information should be recorded in the resident's medical record utilizing facility forms: the type of assessment conducted, the date/time and type of skin care provided, the name and title of the individual who conducted the assessment, any change in the resident's condition, the condition of the skin, how the resident tolerated the procedure and/or ability to participate in the procedure, any problems or complaints related to the procedure, and observations of anything unusual exhibited by the resident. 47489

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #5) reviewed for accidents, the facility failed to provide appropriate supervision and follow the facility policy for residents at risk for elopement. The finding include: Resident #5's [DIAGNOSES REDACTED]. Review of the clinical record identified Resident #5 had a Conservator of Person and Estate. The Hospital Emergency Department History dated 6/17/2020 identified Resident #5 presented to the ED via EMS from a skilled nursing facility after an involvement in an altercation with another resident.The report also noted Resident # 5 does not like when people touch him/her, refused hands-on physical evaluation and vital signs and noted clearance from psychiatry. Resident #5 also had multiple questions regarding the facility including whether he/she would be allowed outside and verbalized it sounds like a prison. The facility pre-admission screen identified Resident #5 was to be admitted on [DATE] and would require a wanderguard. The admission assessment dated [DATE] identified R #5 ambulated independently, was oriented to person and place, and refused to be touched or looked at. The facility Elopement Risk assessment dated [DATE] identified R #5 was ambulatory and had dementia; score of seven (7) which represented a low risk for elopement( low risk 0 - 8). The Resident Care Plan (RCP) dated 6/24/2020 identified a potential to elope/wander due to dementia, past TBI, staff attempted to apply wanderguard R #5 but he/she did not want to be touched. Close observation initiated. Interventions directed to orient to facility and redirect t away from exit doorways. The nurse's note dated 6/24/2020 at 10:18 PM identified R #5 arrived at approximately 2:50 PM to the facility and was shown to his/her room. The resident was oriented to the building, was walking around inside the building numerous times. Staff attempted to place wanderguard four (4) times and R #5 told staff not to touch him/her. Staff observed R #5 enter his/her room and close the door at 6:15 PM. The nurse's note dated 6/24/2020 at 10:38 PM also identified R #5 refused wanderguard and name bracelet on his/her person. The RN went to room to see R #5, the door was closed and TV on but R #5 was not in the room. DR.(NAME)was announced, and search begun at approximately 7:05 PM. DNS, Administrator and 911 called and reported R #5 missing. Conservator and sister notified. The nurse's notes 6/24/20 noted the police reported R #5 was found at approximately 8:45 PM ( 2 and half hour later ) and was sent to hospital for and evaluation. The facility Incident Report dated 6/24/2020 at 7:00 PM identified R #5 was last seen by staff at 6:15 PM, staff were unable to locate R #5 at 7:00 P.M, Dr.(NAME)search was conducted with no results and the police were called. The police notified the facility at approximately 8:30 PM that R #5 had been at a liquor store and R #5 left before police arrived. At approximately 9:30 PM a Nurse Aide (NA) found R #5 in the Burger(NAME)parking lot, police responded at approximately 9:41 PM, and at 9:45 PM was transported to the hospital. Observations and Mapquest review identified Burger(NAME)parking lot was located 0.4 miles from the facility and would require R #5 to cross three (3) streets, including East Main Street a heavily traveled street . A review of the acute care ED History and Physical Exam report dated 6/24/2020 at 11:16 P.M. identified R #5 was AWOL from nursing home, found intoxicated at Burger(NAME)parking lot and brought to ER for an evaluation, [DIAGNOSES REDACTED].#5 was uncooperative with care requiring four-point restraints and chemical sedation. The report further detailed Resident #5 was verbally abusive, derogatory toward female staff and staff was directed to continue four-point restraints. ER laboratory report dated 6/25/2020 identified blood [MEDICATION NAME] specimen collected at 1:00 A.M. was 211 (normal 0 to 3 mg/dL). Interview, clinical record review and facility documentation review with Licensed Practical Nurse ( LPN #1) on 7/1/2020 at 10:47 A.M. identified R #5 required the wanderguard to monitor his/her attempts to elope due to R #5 was ambulatory, had dementia and unknown prior history regarding elopement. LPN #1 verbalized that she, NA #1 and NA #2 last saw R #5 at 6:15 PM. Interview, clinical record review and facility documentation review with Registered Nurse (RN#2) on 7/1/2020 at 11:06 AM identified she saw R #5 numerous times on 6/24/2020 walking around the building. RN #2 indicated she was given a wanderguard bracelet to apply on R #5 upon admission because someone said he was a risk, R #5 had dementia and we did not know his/her prior history. RN# 2 further indicated R #5 was last seen by staff about 6:15 PM, and she noted R #5 was missing on 6/24/2020 about 7:00 P.M. RN #2 also indicated during interview it was identified that R #5 was observed by NA #1 in the Burger(NAME)parking lot after she left work (6/24/2020 punch detail identified NA #1 punched out at 9:25 PM). NA #1 was unavailable for interview during survey. Interview, clinical record review and facility documentation review with the Administrator, Director of Nursing( DON) and Assistant Director of Nursing( ADON) on 7/1/2020 at 11:51 AM identified R #5 was last seen by staff at 6:15 PM, identified as missing about 7:00 PM. Police reported R #5 had gone to a liquor store, purchased two (2) small bottles and one (1) larger bottle, and at approximately 9:30 PM, R #5 was located by staff in the Burger(NAME)parking lot (missing from 6:15 PM to 9:30 PM, 3 ¼ hours). Resident #5 was transferred to the hospital at approximately 9:45 PM. Facility Summary Report dated 6/28/2020 identified R #5 was admitted to the hospital psychiatric unit and will not be returning to the facility. The facility was unable to provide a policy for monitoring residents whereabouts who are newly admitted and refused to wear a wanderguard.Interview with the Administrator and DON identified the facility expectation was that the resident should not be able to exit the facility without staff knowledge. a. Interview, clinical record review and facility documentation review with RN #2 on 7/1/2020 at 11:06 AM identified RN #2 did not have a resident photograph to provide to staff and/or the police when searching for R #5, and she provided a physical description of R #5. Interview, clinical record review and facility documentation review with the Administrator, DON and ADON on 7/1/2020 at 11:51 AM identified R #5 was identified to wear a wanderguard due to dementia, ambulated independently and unknow prior history. Resident photos are usually taken upon admission and residents who are at risk for elopement have photos at the nurse's stations and the receptionist. Interview identified R #5 should have had a photo taken upon admission and placed at the nurse's stations and the receptionist desk. Review of facility Resident Elopement Program Policy, Risk Assessment Elopement Decision Tree, directed in part, a photograph is placed in the elopement books with copies of the photo. Review of facility Elopement Risk Scale Policy directed in part, to keep copies of the resident's photograph in the medical record, one on the unit in the elopement risk book and copies at the front reception desk. Review of facility Missing Person Process Policy directed in part, the highest ranking onsite staff member assigns a search sector to each team member and provides photographs to the Search Team.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews, for one of three sampled residents (Resident #1) reviewed for a change in condition, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) in accordance with the resident's advance directives and activate Emergency Medical Services when the resident was noted to be without a pulse and respirations which resulted in a finding of Immediate Jeopardy. During the onsite visit on [DATE], Immediate Jeopardy was verified as abated when the facility implemented an immediate action plan to mitigate further risk to all residents. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advance Directives dated [DATE] signed by Resident #1 and the attending physician, identified Resident #1's choice was a full code/resuscitate and hospitalize. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a full code and to perform CPR. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had advanced directive of full code with interventions that the Resident's advanced directives would be honored. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicative of no cognitive impairments, had no prognosis that may result in a life expectancy of less than six (6) months, and required oxygen therapy. The nurse's note dated [DATE] at 5:30 AM identified Resident #1 was observed in bed with blue lips and fingers and was not responding. The note indicated the spouse was notified, was told about the emergency, and the spouse requested to wait for him/her to get there. The note identified the crash cart was obtained, CPR was initiated, the spouse arrived moments later, and requested the staff to stop. The spouse then called family and explained that Resident #1 had passed away. The progress note written by the Advanced Practice Registered Nurse (APRN) #1 dated [DATE] at 11:00 AM identified Resident #1 was lying in bed with no signs of life, the apical pulse was absent via auscultation for one (1) minute, no respirations were obtained and Resident #1 was pronounced at 11:00 AM. A review of the clinical record, facility documentation, and interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #3, on [DATE] at 11:47 AM identified she was the charge nurse on another unit on [DATE]. LPN #3 indicated at about 5:00 AM, the Nursing Supervisor, an agency Registered Nurse (RN) #2 and two (2) nurse aides from another unit came and told her that Resident #1 had passed away. LPN #3 stated she went to the unit with the staff, checked Resident #1's code status and noted that Resident #1 was a full code. LPN #3 identified she told RN #2 that they should start CPR and call 911, RN #2 told her no, that they were not going to do CPR and they were not going to call 911. LPN #3 stated that RN #2 told her a LPN works under the RN's license, that she was Resident #1's nurse, the supervisor, and it was her license and her decision. LPN #3 identified RN #2 told her that no one was going to perform CPR or call 911. LPN #3 stated she directed staff to call 911 and she was going to initiate CPR but RN #2 told all the staff that 911 was not going to be called, and no CPR was going to be provided by any staff. LPN #3 stated the crash cart was not brought to Resident #1's room, staff did not call 911, and CPR was not initiated. LPN #3 stated that CPR should have been provided and 911 should have been called. A review of the clinical record, facility documentation, and interviews with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on [DATE] at 12:39 PM identified that Resident #1 was alert and oriented, responsible for him/herself, was not married, and Resident #1's choice for advanced directives was a full code. The DON stated that on [DATE] she was notified that Resident #1 had passed away. The DON stated although RN #2 wrote a nurse's note that identified she obtained the crash cart, called 911, and initiated CPR, when staff found Resident #1, the facility investigation identified that staff did not provide CPR and did not call 911. The DON identified staff should have obtained the crash cart, called 911, and initiated CPR in accordance with the resident's wishes and facility policy. A review of the clinical record, facility documentation, and interview with the 11PM-7AM Nursing Supervisor, RN #2, on [DATE] at 7:57 AM she identified she was an agency nurse who worked at the facility prior to [DATE]. RN #2 identified she was aware Resident #1 was a full code. RN #2 stated she found Resident #1 unresponsive at about 5:30 AM on [DATE], was unable to obtain a pulse, pulse oximetry level, and blood pressure, and Resident #1's lips, hands and under the arms were blue. RN #2 indicated she left Resident #1 positioned in the bed and went to talk to NA #7, who told her that Resident #1 was last seen when toileted about 1:00 AM. RN #2 stated she then walked to LPN #3's unit and told LPN #3 that Resident #1 was unresponsive and not breathing and LPN #3 directed her to call Resident #1's husband, which she did. RN #2 stated that when the husband arrived (lived approximately five (5) minutes away) she showed the husband what CPR would entail if they were to do it, and stated the husband told her not to do CPR. RN #2 stated that although she had brought the crash cart to the nurse's station, she never brought it into Resident #1's room, and staff did not initiate CPR. RN #2 stated she did not initiate CPR because Resident #1 was unresponsive, had color changes, and R #1's eyes would not stay closed which she believed indicated rigor mortis. RN #2 further stated that she was aware that if a resident is a Full Code staff should get the crash cart, start CPR and call 911. A review of the clinical record, facility documentation, and interview with attending Physician #1 on [DATE] at 11:26 PM identified Resident #1 was a full code. Physician #1 stated that rigor mortis takes six (6) to twelve (12) hours to set in. Physician #1 identified that even if Resident #1 was found stiff and blue, 911 should have been called and CPR should have been provided in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record, facility documentation, and interview with NA #7 on [DATE] at 2:08 PM identified when Resident #1 was found unresponsive at approximately 5 AM on [DATE], LPN #3 told RN #2 several times that Resident #1 was a full code and that CPR needed to be initiated and 911 needed to be called, but RN #2 said that they were not going to do CPR and they were not going to call 911. NA #7 identified the crash cart was not brought into the room, no one provided CPR, and 911 was not called. Review of Advance Directives Policy, dated ,d+[DATE], directed in part, that the plan of care for each resident will be consistent with his/her documented treatment preferences/advance directives. Review of the CPR Policy, dated ,d+[DATE], directed in part, that personnel must provide basic life support, including CPR, to a resident who requires such emergency care prior to the arrival of emergency medical personnel, consistent with the resident's Advance Directives. The Policy directed staff to activate Emergency Medical Services (EMS). The Policy further directed to continue CPR until one of the following occurs: 1. The resident presents with effective, spontaneous circulation; 2. Care is transferred to EMS; 3. The rescuer is not able to continue due to exhausted; 4. Reliable and valid criteria indicates irreversible death. The facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) in accordance with the Resident #1's advance directives and failed to activate Emergency Medical Services when Resident #1 was noted to be without a pulse and respirations. As a result, Immediate Jeopardy was identified. On [DATE], the facility submitted an Allegation Letter for the Removal of Immediate Jeopardy which identified licensed staff were educated on the CPR policy, a CPR certification class was held, the facility has not employed agency Registered Nurses since [DATE], and contracted agency nurses will be educated on the CPR policy and the need to follow the resident's code status. The facility performed mock codes on all shifts, completed on [DATE]. Audit results were discussed in quality assurance meetings. Review of the documentation on [DATE] identified that only half of the licensed staff were educated. Subsequent to surveyor inquiry, the facility initiated education for the remainder of the licensed staff. Based on the submission of this action plan, Immediate Jeopardy for F678 was abated as of [DATE].

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #19) reviewed for falls, the facility failed to provide appropriate assistance to prevent a fall with injury. The findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care card dated 3/11/19 identified Resident #19 required supervision with ambulation and modified assistance with toileting. A fall assessment dated [DATE] identified Resident #19 was at moderate risk for falling. The quarterly MDS ((MDS) dated [DATE] identified Resident #19 had moderately impaired cognition, was independent with bed mobility, transfers, and walking in room. The MDS also identified Resident #19 was independent with set up help only for toilet use, was frequently incontinent of bladder, and required supervision with locomotion. The care plan dated 8/15/19 identified Resident #19 was at high risk for falls related to deconditioning, gait, limited physical mobility, fatigue and balance problems. Interventions included to anticipate and meet the resident's needs, ensure the call light is within the reach, prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders, follow the facility fall protocol, do not leave the resident alone in the bathroom, every 1 hour rounds asking the '4 P's' (potty, pain, positioning and personal items) and supervision with ambulation and toileting. The Advanced Practice Registered Nurse progress note dated 8/21/19 at 7:43 PM identified Resident #19 had multiple falls in the past and remained at a high risk for falls. Additionally, continue to remind the resident to call for help when getting up. A nursing progress note dated 8/26/19 at 6:03 AM identified that a urine sample was obtained per order for a urinalysis with a culture. A physician's orders [REDACTED]. A nursing progress note dated 9/1/19 at 1:32 PM identified that Resident #19 complained of blood in his/her urine, the APRN was updated, and a urine sample was collected for a urine culture. A nursing progress note dated 9/2/19 at 11:43 AM identified Resident #19's urine culture results were still pending. A Reportable Event form dated 9/3/19 at 10:30 AM identified Resident #19 was observed to fall backwards, and hit the back of his/her head on the floor. A nursing progress note dated 9/3/19 at 11:39 AM identified when Resident #19 was coming out of the bathroom, he/she slipped in urine and fell backward hitting the back of his/her head and sustained a laceration. Subsequently, Resident #19 was transported to the emergency room for an evaluation. A hospital encounter note dated 9/3/19 identified Resident #19 had a fall and was found to have a nondisplaced skull fracture and a right frontal subarachnoid hemorrhage upon CT scan. Wound care was performed. A hospital encounter note dated 9/4/19 identified Resident #19 exhibited decreased functional mobility secondary to pain, decreased strength, decreased balance and decreased activity tolerance. Nurse's notes dated 9/7/19 at 6:01 PM identified Resident #19 was readmitted to the facility from the hospital with a cut to the back of the head. A facility APRN note dated 9/9/19 identified hospital discharge instructions were to continue to monitor the resident and provide supportive care. Interview with LPN #1 on 9/18/19 at 10:47 AM identified that on 9/3/19, Resident #19 was adamant about obtaining a urine sample. LPN #1 identified although Resident #19 did not have a physician's orders [REDACTED].#1 provided Resident #19 with a urine specimen container. LPN #1 identified he/she did not assist and/or offer assistance to Resident #19 to the bathroom to obtain the urine sample because Resident #19 did this all the time. Interview with the facility contracted Hospice Registered Nurse (Person #1) on 9/18/19 at 10:15 AM identified he/she was walking by Resident #19's room and observed the resident, who was alone, coming out of his/her bathroom with a urine specimen container in his/her hand, which contained bloody urine. As Resident #19 went to close the bathroom door he/she fell backwards and hit his/her head on the bathroom floor. Person #1 provided the facility with a written statement which was included in the Reportable Event dated 9/3/19. Interview with the DNS on 9/18/19 at 11:36 AM identified that if a resident's care plan identified that he/she is at risk for falls, and required supervision to the bathroom, that according to the facility fall prevention program the resident should not be left alone in the bathroom. The DNS further indicated he/she would expect staff to follow the fall prevention program. Review of the falls management policy identified the facility implements interventions to minimize and or/eliminate contributing factors for falls on residents at risk. LPN #1 did not accompany Resident #19 and/or offer assistance to Resident #19 to the bathroom on 9/3/19 which was not consistent with the physician's orders [REDACTED].#19 with assistance of 1 with the use of a walker for mobility, ambulation, bathing, and dressing, resulting in Resident #19 obtaining a urine sample by him/herself in the bathroom, self ambulating out of the bathroom, falling backwards, hitting his/her head resulting in a nondisplaced skull fracture and a subarachnoid hemorrhage.

Based on clinical record review, review of facility documentation review, and interview for one of two residents (Resident #117) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #117's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified Resident #117 with modified independence in cognitive skills, with the absence of behavior symptoms, and required extensive assistance for bed mobility, limited assistance for transfers and supervision for ambulation, and daily use of anti-depressant and antipsychotic medications. A care plan dated 4/11/18 identified Resident #117 with impaired cognitive skills with interventions that included to cue, re-orient and supervise as needed, communicate with resident/family regarding capabilities and needs, and provide consistent caregivers. Resident #64's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #64's with intact cognitive skills, was independent for transfers and ambulation in room, required supervision for locomotion in the hallways, and daily use of anti-depressant medication. RN #1 notes dated 4/3/18 identified Resident #117 reported he/she was inappropriately touched by another resident (Resident #64). Interview on 7/18/18 at 3:00pm with the RN #1 and review of facility documentation dated 4/3/18 identified that Resident #117 in the presence of the Caseworker reported on 4/3/18 that Resident #64 entered his/her room and then proceeded to touch his/her breast and kiss him/her on the mouth. Resident #117 indicated that he/she then turned his/her head and the kiss landed on his/her cheek. RN #1 further indicated that Resident #117 further reported Resident #64 bared his/her breasts during this incident. RN #1 indicated that the incident was then reported to the DNS for directions. Further review of facility documentation indicated that the police and physician were then notified. Further interview and review of facility documentation with the Social Worker on 7/18/18 at 2:30pm identified that when she was made aware of the incident, emotional support was provided with instructions to Resident #117 to alert staff if the other resident comes into the room again and after notification of the DNS a retractable stop sign was placed on Resident #117's doorway and a tab alarm with instruction for use was also provided. A behavioral health progress notes dated 4/4/18 identified Resident #117 history of sexual abuse was intensified after the incident with feelings of self blame, shame, guilt, and anxiety with reported increased hallucinations, nightmares and difficulty sleeping with recommendations to explore relaxation techniques and referral to the psychiatrist for medication review. Review of the medication administration kardex for Resident #117 for the period of (MONTH) 20, (YEAR) through (MONTH) 4, (YEAR) (prior to the initiation of routine [MEDICATION NAME] orders) indicated that [MEDICATION NAME] 0.5 mg was administered only five times during this period. Physician's orders for Resident #117 dated 4/4/18 directed to discontinue current order for [MEDICATION NAME] 0.5mg at hour of sleep (hs) as needed and initiate [MEDICATION NAME] 1mg at hs and 0.5mg in the morning. APRN psych notes dated 4/10/18 identified that Resident #117 was responding to current treatment and to continue behavioral/non-pharmacological interventions, continue psychotherapy and no dose reductions on medications due to risk of causing instability and exacerbating underlying medical and psychiatric disorder. Review and interview with the DNS on 7/18/18 at 9:20am indicated that Resident #64 was affectionate but had no prior history of this nature. Further review of the facility policy on abuse and neglect indicated that residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultant, volunteers.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one resident of two sampled residents reviewed for accidents (Resident # 75) , the facility failed to ensure the resident was free from accidents, and/or the facility failed to ensure interventions were initiated when a fall risk was identified. The findings include: Resident # 75 ' s [DIAGNOSES REDACTED].# 75 had severely impaired cognitive skills for daily decision making, required total assistance of two for personal hygiene, and extensive assistance of two for transfers. The Resident Care Plan (RCP) dated 5/02/17 identified a fall risk and impaired safety awareness. Interventions directed to provide verbal cues for safety and sequencing when needed, and P.T. evaluation PRN. A physician's order [REDACTED]. Review of the clinical record identified on 6/22/17 nursing requested rehabilitation to screen R # 75 for seating due to leaning forward, falling asleep, hanging over the side, and questioned if R # 75 would benefit from a tilt chair to be able to recline. Rehab's response on 6/30/17 indicated that the vendor was contacted to set up an appointment for evaluation for a tilt-in-space wheelchair. Additional rehab note dated 7/10/17 identified a wheelchair company was called to evaluate R # 75 for a tilt-in-space wheelchair and rehab recommended nursing staff to place R # 75 in bed for rest breaks. A nurse ' s note dated 7/10/17, 3-11 shift that recorded R # 75 returned from the hospital at 4:30 PM wearing a cervical collar, and had five sutures on forehead. Review of facility documentation Accident and Incident report (A & I) dated 7/10/17 at 11:05 AM identified R # 75 was observed face down on the floor with bleeding from his/her nose and a laceration to the forehead. R # 75 was in his/her wheelchair prior to the fall. Staff applied a pressure dressing to the laceration, and transferred R # 75 to the emergency department (ED). The A & I included a statement from RN # 5 which reported R # 75 was noted to have poor wheelchair positioning multiple times, lean forward and required repositioning by staff. Review of ED visit dated 7/10/17 identified R # 75 required seven sutures to close a forehead laceration and had a nondisplaced fracture of the posterior aspect of the right superior facet of C1 which courses inferiorly into the right transverse process of C1. Interview and review of facility documentation with O.T. # 1 on 8/02/17 at 10:08 AM identified therapy received several requests from nursing to evaluate R # 75 due to leaning in his/her wheelchair. O.T. # 1 indicated that nursing requested a therapy screen on 6/22/17 due to leaning. O.T. # 1 indicated that a screen was completed on 6/30/17 and the wheelchair vendor saw R # 75 on 7/05/17. However R # 75 did not qualify for payment of a custom wheelchair, and the facility did not have an adaptive wheelchair available for use. Rehab recommended that nursing staff transfer R # 75 back to bed if he/she was tired. O.T. # 1 further indicated rehab received a second rehab screen request from nursing on 7/10/17 due to leaning, falling asleep, and hanging over the side, with rehab ' s response to direct nursing to put resident back to bed if falling asleep. O.T. # 1 indicated that R # 75 was given a tilt-in-space wheelchair on 7/17/17. Interview and record review with RN # 5 on 8/2/17 at 10:26 AM identified he/she was aware R # 75 would lean forward in his/her wheelchair at times, and indicated that nursing tried to put a bedside table in front of R # 75 to give him/her something to do and requested a rehab screen for positioning. Interview and record review with the DON on 8/2/17 at 11:22 AM identified he/she was aware R # 75 was leaning in the wheelchair before the fall occurred on 7/10/17. The DON further indicated that although nursing requested a rehab to screen R # 75 for a tilt-in-space wheelchair when leaning was identified and no tilt-in-space wheelchair was available, nursing staff did not implement new interventions to prevent a fall. DON indicated that additional interventions should have been implemented to prevent a fall when R # 75 was noted to be leaning in his/her wheelchair. Review of facility's Fall Management Policy directed in part, the facility will identify residents at risk for falls, and will implement interventions to minimize and/or eliminate contributing factors for falls on residents at risk.

Based on review of the clinical record, facility documentation and staff interview for four of six sampled residents (Residents #16, 27, 52, and 103) reviewed for allegations of mistreatment, the facility failed to ensure staff immediately reported allegations of abuse that resulted in the finding of substandard quality of care. The findings include: 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified intact cognition; required extensive assistance with all ADL's and was occasionally incontinent of bowel and bladder. The care plan dated 3/31/15 identified a self-care deficit and exhibited verbally inappropriate language toward staff and other residents. Interventions included to provide a warm and reassuring environment and to remove the resident from situations that appear to trigger aggressive or inappropriate verbalizations. Interview with NA#7 on 12/3/15 at 4:30PM identified that prior to 4/8/15; he/she observed NA#2 swear at Resident #16 and used foul language including cursing that occurred on multiple occasions. A sworn statement dated 12/3/15 provided by NA#7 identified NA#2 was witnessed to swear at Resident #16. NA #7 did not report the incidents to administration because NA#7 felt intimidated and was afraid of retaliation. 2. Resident #27 ' s [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified short and long term memory deficits, severely impaired cognition, extensive assistance for all ADL's, always incontinent of urine and occasionally incontinent of bowel. The care plan dated 2/5/15 identified the resident utilized psychoactive medications with a goal that he/she would not show signs or symptoms of anxiety. Interventions included monitoring mood and document signs and symptoms of anxiety, providing emotional reassurance and redirect, providing psychiatric interventions and maintaining a consistent routine. The accident/incident report dated 4/9/15 identified a staff member reported NA#2 made an inappropriate comment to Resident #27.The investigation identified Resident #27 was calling out for his/her mother and NA#2 responded in an aggressive inappropriate manner she's dead. Interview with NA#5 on 12/3/15 at 11:00AM identified on 4/8/15, after dinner, Resident #27 was repetitiously calling out for his/her mother. NA#5 observed NA#2 bend down and whisper into the residents ' ear, she's dead. NA#5 identified he/she felt the incident was abusive and wrong, however, did not report the incident to the nurse. A sworn statement written by NA#5 dated 12/3/15 identified Resident #27 was calling out for his/her mother. NA#5 documented that he/she observed NA#2 go close to the resident's ear and whisper, she's dead in a mean very cold nasty tone. The facility investigation concluded the allegation of abuse was substantiated. 3. Resident #52's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified short and long term memory deficits, severely impaired cognition, required total care for all ADL's and was totally incontinent of bowel and bladder. The care plan dated 3/10/15 identified a self-care deficit with interventions that staff would provide all care. The physician orders [REDACTED]. a. The accident/incident report dated 4/9/15 at 1:00PM identified NA#2 was witnessed by NA #1 hit Resident #52's lower abdomen with an open hand. The investigation identified a statement from NA#1 dated 4/10/15, that identified on 4/8/15 between 4:00PM - 5:00PM NA#1 and NA#2 entered Resident #52's room to conduct incontinent rounds. Resident #52's covers were pulled back and the resident was noted to have his hand around his penis. NA#1 observed NA#2 take the residents hand off his penis, slap his hand, and say stop touching your penis, however NA#2 chose words that included cursing along with the use of a foul word to refer to his penis. Interview and review of the statement with NA#1 on 12/2/15 at 12:50PM identified he/she did see NA#2 slap the resident ' s hand and use vulgar language when addressing the resident on 4/8/15. NA#1 identified he/she did not report the incident until the following day. A sworn statement provided by NA#1 dated 12/3/15 identified he/she witnessed NA#2 slap the resident ' s hand away from his penis and further identified NA#2 told the resident to stop touching his penis, using a foul word to refer to his penis on 4/8/15. b.) A written statement dated 4/10/15 by NA#5 identified during incontinent care for Resident #52 he/she observed NA#2 stretch the residents penis and push it down in place with the brief and slam his/her hand down on the residents stomach while scolding the resident. Interview with NA#5 on 12/3/15 at 11:00AM identified the incident happened on 4/8/15 between 6:00PM - 7:00PM during incontinent care. NA#5 identified the resident is very feisty with his hands during incontinent care and NA#2 was observed to abruptly reposition his penis and quickly snap the residents abdomen in a scolding manner. Further interview with NA#5 identified that this was not the first time he/she had seen NA#2 care for the resident in this manner and indicated that it bothered him/her and is not a usual part of incontinent care. NA#5 identified he/she did not report the incident until 4/9/15 because he/she was very upset and afraid of repercussions. A sworn statement written by NA#5 dated 12/3/15 documented that he/she observed NA#2 grab Resident #52's penis, shove it between his legs and underneath him and slap his stomach to keep the residents hand from the periarea. NA#5 documented that he/she was overcome and afraid with what he/she saw, knew it was not right and reported it the next day. NA#5 documented that he/she froze when he/she observed what NA#2 did to Resident #52 and was afraid and intimidated of him/her. 4. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].The initial care plan dated 2/13/15 identified the resident had a self-care deficit with interventions that included providing assistance with ADL's and OT evaluation as indicated.The admission MDS dated [DATE] identified short and long term memory deficits, severely impaired cognition, required extensive assistance with all ADL's, utilized an indwelling catheter and was occasionally incontinent of bowel. Review of NA#4 ' s a statement, dated 4/9/15 documented that he/she witnessed NA#2 twist Resident #103's arm. Interview with the DNS and the Administrator on 12/3/15 at 1:30PM identified no additional information was obtained regarding this allegation of abuse during the investigation. Interview with NA#4 on 12/3/15 at 3:30PM identified that he/she did witness NA#2 twist Resident #103 ' s arm one time during care although a specific date could not be obtained. Additionally, NA#4 indicated that he/she did feel it was abusive but did not report the incident because he/she intervened and never saw it happen again. Interview with RN#1 on 12/2/15 at 10:20AM identified that he/she was the Nursing Supervisor on 4/8/15 during the 3:00PM-11:00PM shift when the incident with Resident #27 and 52 occurred. RN#1 indicated that he/she was not made aware by any of the NA's on duty that night of the incidents. Review of a sworn statement written by RN#1, the 3:00PM-11:00PM Nursing Supervisor, documented that he/she was the supervisor on 4/8/15 and was not aware of any allegations of abuse or mistreatment of [REDACTED]. Interview with the DNS on 12/3/15 at 10:20AM identified that this allegation of the residents arm being twisted by NA#2 came out as part of the facility investigation into the abuse of Residents #27 and 52. The DNS could not provide any additional information such as a date or time this incident occured. An accident/incident report was not provided. The facility provided a skin check dated 4/9/15 which indicated there was no brusing or redness on the residents arms. Review of the abuse prohibition policy identified that allegations of abuse will be reported promptly and thoroughly investigated. Any employee who has reasonable cause to believe a resident has been abused, mistreated or neglected shall immediately report alleged incidents to their supervisors, DNS or Administrator. If an employee is the alleged abuser, he/she will be removed from the care of the resident and suspended pending outcome of the investigation. Any employee who fails to report an incident of abuse immediately to the nursing supervisor will receive disciplinary action. Interview with the DNS and Administrator on 12/3/15 at 1:30PM identified that no formal questions were asked of staff regarding how long the abuse they witnessed had been occurring. Staff who failed to report abuse immediately were not disciplined because they wanted staff to feel free to come forward and report any and all allegations of abuse. The DNS and Administrator indicated that subsequent to the incident of abuse on 4/8/15 all staff were reeducated on the abuse policy and fear of retaliation, however, no surveillance and/or audits were completed to ensure that staff were compliant with the facility abuse policy. Multiple attempts to contact NA#2 were unsuccessful. NA #1, NA #4, NA #5, and NA #7 who identified knowledge of potential abusive incidents conducted by NA #2 towards three residents failed to report the incidents immediately per the facility policy resulting in the finding of substandard quality of care.

Based on review of the clinical records, facility documentation and staff interviews for three of six sampled residents (Residents # 16, 27, and 52) reviewed for allegations of mistreatment, the facility failed to ensure the residents were free from physical and verbal abuse. The findings include: 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].The quarterly MDS assessment dated [DATE] identified intact cognition, extensive assistance for all ADL's and occasionally incontinent of bowel and bladder.The care plan dated 3/31/15 identified a self-care deficit and exhibited verbally inappropriate language toward staff and other residents. Interventions included to provide a warm and reassuring environment and to remove the resident from situations that appear to trigger aggressive or inappropriate verbalizations. Interview with NA#7 on 12/3/15 at 4:30PM identified that prior to 4/8/15; he/she observed NA#2 swear at Resident #16, used foul language including cursing that occurred on multiple occasions. A sworn statement dated 12/3/15 provided by NA#7 identified NA#2 was witnessed to swear at Resident #16. NA#7 did not report the incidents to administration because NA#7 felt intimidated and was afraid of retaliation. The accident/incident report dated 12/3/15 identified NA #7 reported that NA#2 was overheard swearing at Resident #16. NA #7 was unable to identify any specific time frame and/or dates the incidents occurred. The investigation identified the incident was not reported because NA#7 did not feel he/she had a strong support system in the facility. Interview with the DNS on 12/3/15 at 5:00PM identified he/she was unaware of the allegation of verbal abuse of Resident #16 by NA#2 and would initiate an investigation. 2. Resident #27 ' s [DIAGNOSES REDACTED].The quarterly MDS assessment dated [DATE] identified short and long term memory deficits, severely impaired cognition, extensive assistance for all ADL's, always incontinent of urine and occasionally incontinent of bowel. The care plan dated 2/5/15 identified the resident utilized psychoactive medications with a goal that he/she would not show signs or symptoms of anxiety. Interventions included to monitor mood and document signs and symptoms of anxiety, provide emotional reassurance and redirect, provide psychiatric interventions and maintain a consistent routine.The accident/incident report dated 4/9/15 identified a staff member reported NA #2 made an inappropriate comment to Resident #27. The investigation identified Resident #27 was calling out for his/her mother and NA #2 responded in an aggressive inappropriate manner sayingshe's dead.Interview with NA#5 on 12/3/15 at 11:00AM identified that on 4/8/15, after dinner, Resident #27 was repetitiously calling out for his/her mother. NA#5 observed NA#2 bend down and whisper into the residents ' ear and say she's dead. NA#5 identified he/she felt the incident was abusive and wrong, however, did not report the incident to the nurse. A sworn statement written by NA#5 dated 12/3/15 identified Resident #27 was calling out for his/her mother. NA#5 documented he/she observed NA#2 go close to the resident's ear and whisper, she's dead, in a mean, very cold, nasty tone. The facility investigation concluded the allegation of abuse was substantiated. 3. Resident #52's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified short and long term memory deficits, severely impaired cognition, required total assistance for activities of daily living and was totally incontinent of bowel and bladder. The care plan dated 3/10/15 identifed a self-care deficit with interventions that staff would provide all care. The physician orders [REDACTED]. a. The accident/incident report dated 4/9/15 at 1:00 PM identified NA #2 was witnessed by NA #1 hit Resident #52's lower abdomen with an open hand. The investigation identified a statement from NA#1 dated 4/10/15 that identified on 4/8/15 between 4:00PM - 5:00PM NA#1 and NA#2 entered Resident #52's room to conduct incontinent rounds. Resident #52's covers were pulled back and the resident was noted to have his hand around his penis. NA#1 observed NA#2 take the resident's hand off his penis, slap his hand, and told the resident stop touching your penis, however chose words that included cursing along with the use of a foul word to refer to his penis. Interview and review of the statement with NA#1 on 12/2/15 at 12:50PM identified he/she did see NA#2 slap the resident ' s hand and use vulgar language when addressing the resident on 4/8/15. A sworn statement provided by NA#1 dated 12/3/15 identified he/she witnessed NA#2 slap the resident ' s hand away from his penis and further identified NA#2 told the resident to stop touching his penis, using a foul word to refer to his penis on 4/8/15. b. A written statement dated 4/10/15 by NA#5 identified during incontinent care for Resident #52 he/she observed NA#2 stretch the residents penis and push it down in place with the brief and slam his/her hand down on residents stomach while scolding the resident. Interview with NA#5 on 12/3/15 at 11:00AM identified the incident happened on 4/8/15 between 6:00PM - 7:00PM during incontinent care. NA#5 identified the resident is very feisty with his hands during incontinent care and NA#2 was observed to abruptly reposition his penis and quickly snap the residents abdomen in a scolding manner. Further interview with NA#5 identified that this was not the first time he/she had observed NA#2 care for the resident in this manner and indicated that it bothered him/her and is not a usual part of incontinent care. A sworn statement written by NA#5 dated 12/3/15 documented he/she observed NA#2 grab Resident #52's penis, shove it between his legs and underneath him and slap his stomach to keep the residents hand from the periarea. Review of the abuse prohibition policy identified that allegations of abuse will be reported promptly and thoroughly investigated. Any employee who has reasonable cause to believe a resident has been abused, mistreated or neglected shall immediately report alleged incidents to their supervisors, DNS or Administrator. If an employee is the alleged abuser, he/she will be removed from the care of the resident and suspended pending outcome of the investigation. Any employee who fails to report an incident of abuse immediately to the nursing supervisor will receive disciplinary action. Interview with the DNS and Administrator on 12/3/15 at 1:30PM identified the allegations of abuse were substantiated for Residents #27 and 52. Multiple attempts to contact NA#2 were unsuccessful.

Based on clinical record reviews, review of facility policies, review of facility investigations and staff interviews for 2 of 6 sampled residents dependent on staff for transfers (R # 4, 67), the facility failed to ensure the resident was transferred appropriately to prevent injuries, and/or for the only sampled resident that smoked (R#48), the facility failed to provide appropriate supervision and/or assessment when the resident was noted to be non-compliant with the no smoking policy, and/or the facility failed to maintain hot water at safe temperatures. The findings include; 1. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified severe cognitive impairment, and total dependence on staff for ADL's including transfers. The resident care plan dated 1/24/12 identified a self-care deficit secondary to weakness and MS. Interventions included providing max assistance with ADL ' s, and transferring with assist of 2 via a mechanical lift. Nurse's notes dated 4/12/12 at 3:30 pm identified that the RN Supervisor went to assess R#4. R#4 was noted with a bluish purple discoloration to the right upper inner arm. The area was noted to be slightly warm. R #4 complained of pain to the area when assessed. Additionally, the nurse's notes identified the area was first observed when the nurse aides were hooking the resident up to the mechanical lift. The family and physician were made aware and x-rays were obtained, revealing an impacted humeral head fracture. A facility investigation dated 4/12/12 at 3:30 pm identified that a bruise on the right upper arm was found with the cause unknown. The investigation identified that while staff were hooking the resident up to the mechanical lift, the resident complained of pain and the bruise was noted on the right upper arm. Also noted was that it was difficult to remove the lift pad from under the resident and that that process could have been how the fracture occurred. Interview with NA # 1 on 4/9/13 at 11am identified that they were getting the resident ready to transfer from the wheelchair to the bed when a bruise was noted to the right upper arm. NA #1 stated that R # 4 is not a resident who moves on his/her own and that is could be difficult to place the lift pad behind the resident. NA#1 stated that he/she had reported this to the nursing staff. Interview with NA #2 on 4/9/13 at 11:05am noted that when they were transferring the resident from the wheelchair to the bed, the bruise was noted to the right upper arm. NA#2 also noted that they had reported to nursing that it was difficult to place the lift pad under the resident, but until the fracture occurred, nothing had been done. Interview with RN Supervisor #1 on 4/9/13 at 10:45 am noted that R # 4 was unable to move on his/her own. Review of the clinical record with the MDS coordinator on 4/9/13 at 2:25pm noted that although the care plan identified the resident had contractures to the upper arms and not to lift the resident under the arms, the care plan failed to identify safe handling of the resident in bed and/or safe ways to use the lift pad for transfers. 2. Resident #67 ' s [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident was severely impaired for decision-making skills, and required extensive assistance from staff for bed mobility and transfers. The resident plan of cared dated 3/20/13 identified a self - care deficit. Interventions included transferring the resident with an assist of two (staff). Physician monthly orders for April 2013 directed two person assistance with transfers. Facility documentation and nurse's notes dated 4/5/13 at 9:05 A.M. identified that while receiving assistance with a transfer, NA #4 and NA #5 noted that the resident slid out from the bed when the aides were in the process of transferring the resident. Following the fall, the resident was observed laying on his/her back with scant amounts of blood noted to occipital region (back of the head) and a hematoma. On 4/11/13 at 1:25 P.M. an interview with NA #5 indicated that he/she was called to the resident's room to assist NA #4 with transferring the resident from the bed to a wheelchair. The aide further stated that he/she "never touched the resident", but watched NA#4 stand the resident up from the bed and sat him/her back down on the mattress with his/her legs at the bedside when the resident's body turned and he/she slid off the mattress. The aide further indicated that it was apparent that the resident struck his/her head when they noticed that there was blood on the floor. On 4/11/13 at 1:35 P.M. and 2:45 P.M. interviews with NA #4 indicated that the resident was already dressed. He/She sat the resident up from a lying position, brought the resident's legs "around" preparing him/her for a stand and pivot transfer when the resident "just slid off the bed" before he/she had a chance to apply a gait belt which was lying at the foot of the bed. On 4/12/13 at 9:35 A.M. interviews and review of the clinical record with the MDS Coordinator (LPN #1) in the presence of the DON indicated that although the resident was an assist of two with transfers, she felt that it was appropriate for NA #4 to independently maneuver the resident from a lying, to a standing and then a sitting position without the benefit of any assistance. 3. Resident #48's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that the resident was a current smoker who smoked one pack per day. The smoking assessment dated [DATE] identified that the resident was informed of the facility no smoking policy and was "ok" with it. The resident was offered a nicotine patch which he/she declined due to making skin irritated/itching. The MDS dated [DATE] and 12/24/13 identified that the resident was without cognitive impairment, displayed verbally inappropriate behavior, rejected care and required supervision with ADL's. The care plan dated 11/26/12 identified verbally aggressive and inappropriate language towards staff. Three separate care plans identified that the resident was non-compliant with the non-smoking policy; one dated 1/16/13, one dated 1/8/13 and the other with no date. Interventions included "periodic room checks", body audits and/or room searches after LOA, document and report to MD as needed, and follow by psych services. The care plans failed to document how the resident was non-compliant with the smoking policy. On 12/21/12, the resident signed the facility "no smoking" policy that noted that if suspected to have smoking materials or fire sources, the facility reserved the right to institute a room search and remove any items. The signed policy further noted that offenders to the smoking policy present a high risk situation and that the facility reserved the right to continue interventions up to and including discharge planning if needed. Nursing notes from admission on 11/21/12 through 1/16/13 identified ongoing non-compliance with dialysis attendance, medications, fluid restriction, finger stick blood sugar testing, and/or following a diabetic diet. The notes also documented repeated incidents of verbally abusive behavior directed at staff. On 1/16/13, nursing notes identified that the resident refused to go to a medical appointment that morning and was found smoking in the courtyard area of the facility. The resident agreed to a room search and cigarettes were locked in the supervisor's office. A memo/note by the administrator dated 1/16/13 in the social service section of the record, noted that the resident was found smoking outside in the courtyard and when the administrator reminded the resident of the no smoking policy that the resident signed, the resident denied being aware and claimed he/she was told that it was ok to smoke. The resident also refused to allow a search of the chair and clothing at that time, but did later surrender a pack of cigarettes and matches to the supervisor. The note further identified that a pack of cigarettes had been found in the resident's room in December. The resident was informed that that regular room searches would be performed and that he/she would be searched upon returning to the facility from LOA's or appointments outside the facility. The resident was offered smoking cessation assistance which was declined. Review of the clinical record and interview with the Administrator on 4/12/13 at 8 AM and RN#2 at 9:30 AM failed to provide documentation that the resident had been being searched upon returning from dialysis treatments and/or consistently upon returning from LOA/appointments. Further review failed to provide documentation that the care plan reflected the resident's specific non-compliance and risks related to smoking and/or specific interventions related to supervision to ensure the safety of the facility and other residents. The record also lacked documentation that the physician and/or psychiatric professional assessing the resident regularly was informed of the resident's non-compliance with the smoking policy and/or had conducted an assessment of the resident's risk to the facility/others. 4. On 4/10/13 at 11 AM, the water temperature in the visitor's bathroom was noted to be 170.4 degrees. Resident rooms were immediately assessed and noted as follows: Room 12 - 148 degrees Room 17 - 146.8 degrees Room 42 - 152.9 degrees Room 46 - 129.2 degrees Shower room - 127.2 degrees On 4/10/13 at 11:45 am, the Administrator and Maintenance Director were informed of the surveyors identified water temperatures. Immediate action was initiated with Maintenance shutting off the water heater. According to Administrator, a new water heater had been placed 2 weeks prior. The Maintenance Director stated that last week a couple of nurse aides said the water felt hot. He noted that he " checked the temperatures and they were fine". The Administrator noted that the thermometer used was sticking and that they had since obtained a new digital one to more closely monitor the temperatures.

Based on clinical record reviews, observations, staff interviews, and review of policies for one of three sampled residents (Resident #91) who required supervision while ambulating, the facility failed to provide care and/or supervision to prevent an accident and/or one of two sampled residents (Resident #25) who smoked, the facility failed to provide the necessary supervision while the resident was smoking. The findings include: 1. Resident #91 had a [DIAGNOSES REDACTED]. The resident was identified as restless, wandered, and required limited assistance when walking in the hallway. A physician's orders [REDACTED]. Despite the physician's orders [REDACTED].#91 ambulated ad-lib, and the Nurse Aide care instructions dated November 2010 identified that Resident #91 ambulated with distant supervision. In addition, Resident #91's care plan dated 6/29/10 identified a potential for increased restlessness secondary to upgrades of the facility, and for staff to redirect the resident away from unsafe areas. According to a physical therapy note dated 11/17/10 and an interview with NA #1 on 1/24/11 at 2 PM, Resident #91 was known to use handrails at times while walking in the hallway. A nursing progress note dated 11/17/10 at 7:45 AM identified that Resident #91 was found on the floor in the hallway on his/her right side, and had complained of pain in the right knee and right upper leg. Resident #91 was transported to an acute care hospital and diagnosed with [REDACTED]. According to facility documentation, Resident #91 had been walking in an area of the hallway where handrails had been removed from the walls as part of the renovations. The resident was not redirected away from this area, and subsequently sustained a fall resulting in a displaced fracture. Interview with NA #1 on 1/24/11 at 2 PM identified that he/she was assigned to Resident #91 on 11/17/10 and after assisting with morning care, Resident #91 was walking in the hallway (unsupervised), while NA #1 stayed in the resident's bedroom. NA #1 identified that he/she heard a noise, went to the hallway, and observed Resident #91 on the floor. 2. Resident #25's [DIAGNOSES REDACTED].#25 had moderate cognitive impairment with decision making, required cues and was independent with activities of daily living. The smoking assessment dated [DATE] identified that the resident required a smoking apron and close supervision and assistance while smoking. The resident care plan dated 8/16/10 and revised 10/16/10 identified that the resident smoked. Interventions directed staff to supervise during smoking and to utilize a smoking apron. Observations on 1/20/11 at 7:15 PM identified Resident #25 seated outside in the smoking area with a smoking apron on smoking a cigarette. The Nurse Aide (NA) #3 who was assigned to monitor smoking was noted to be standing near her car which was three feet and eight inches away from the smoking area. Interview with NA #3 on 1/20/11 at 7:50 PM identified that although she could see Resident #25, she was aware the resident required supervision and knew that she should have stayed close while the resident was smoking. Interview with the Director of Nurses on 1/20/11 at 8:00 PM identified that the facility practice was while smoking for the nurse aides to stay with the residents.