Every finding on record at Twin Maples Healthcare, Inc

Based on clinical record review, facility policy and interviews, for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to ensure a complaint made by a resident regarding a staff member was referred to the designated grievance official, investigated, and documented with findings and resolution. The findings include:Resident #1's diagnoses included Traumatic Brain Injury (TBI), dementia with behavioral disturbances, conduct disorder, anxiety disorder and psychosis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), required substantial assistance with bed mobility and was dependent on staff for personal hygiene, toileting and transfers.The Resident Care Plan (RCP) dated 1/29/26 identified Resident #1 had impaired cognitive function/dementia or impaired thought processes due to a TBI/head injury, impaired decision making and made allegations and inappropriate comments towards staff members, yelled and swore at staff, had angry outbursts, raised his/her fist in anger towards others and had poor social boundaries. Interventions included providing the resident with necessary cues and stopping interactions/care and returning if agitated, providing a calm approach, anticipating and meeting needs, assisting the resident to develop more appropriate methods of coping and interacting, staff to provide a calm but firm approach with resident when having angry outbursts and redirecting the resident as needed.A Behavior Note written by the Director of Social Services dated 2/13/26 at 10:57 AM identified she was made aware that Resident #1 was heard making inappropriate comments towards a staff member that was assisting other residents and other residents were disturbed by the behavior. She identified she met with Resident #1, discussed the behavior and provided emotional support, reassurance and assistance with Resident #1's needs.Interview with Resident #1 on 2/19/26 at 11:22 AM identified NA #5 is mean to him/her and he/she does not want NA #5 near him/her. Resident #1 was unable to provide specific examples and could not recall the 2/13/26 incident but reported staff knows to keep NA #5 away from him.Interview with NA #5 on 2/19/26 at 12:17 PM identified up until 2/13/25, he was Resident #1's primary NA on the 7:00 AM to 3:00 PM shift. He reported on 2/13/25 the DON notified him Resident #1 made generalized allegations against him and he would no longer be assigned to Resident #1. NA #5 identified he was shocked, never had issues with Resident #1 and Resident #1 never complained directly to him about anything. NA #5 reported he was not asked by the DON or other administrative staff to write a statement related to the complaint.Interview with the Director of Social Services on 2/19/26 at 12:38 PM identified she was aware of the 2/13/26 incident and met with Resident #1 following the incident. She was not aware that Resident #1 made a complaint regarding NA #5 following her initial encounter. She identified a grievance should have been initiated and the complaint should have been investigated. She reported that if she were notified of Resident #1's complaint, she would have met with Resident #1 again and asked him/her questions regarding the complaint, provided emotional support to Resident #1 and followed up with him/her daily for three (3) days and as needed.Interview with the DON on 2/19/26 at 1:18 PM identified following the 2/13/26 incident, she met with Resident #1, who reported to her that he/she was upset because NA #5 was a chump but did not obtain any further details as to what that implied. The DON reported Resident #1 had a history of making allegations toward staff and there were no prior complaints regarding NA #5. She reported she spoke with NA #5 and determined the complaint was unsubstantiated. The DON reported she did not document Resident #1's complaint as a grievance, obtain statements, conduct an investigation, document why she determined the complaint was unsubstantiated, or notify the Director of Social Services for further follow up.Review of the Grievance policy (undated) directed, in part, that complaints shall be referred to the appropriate Department Head who will then investigate the complaint, document his/her findings, document the resolution to the problem and is responsible for addressing any issues or concerns. The Social Worker is designated as the grievance official and will be responsible for preparing a written investigative report, contacting the complainant with the problem resolution as necessary and the written report will be forwarded to the Administrator for review and filing.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 sampled residents (Resident #2), reviewed for falls, the facility failed to transfer the resident per the physician's order, rehabilitation screen, and nurse aide assignment card, which resulted in a fall with multiple fractures. The findings include:Resident #2's diagnoses included Erb's paralysis due to birth injury, hemiplegia affecting the right dominant side and paralytic gait.A review of the Interdisciplinary Therapy Screen conducted by Occupational Therapist (OT) #1 dated 6/23/25 identified Resident #2 was assessed for transfers and was an assist of 2 staff members for Stand, Pivot, Transfer (SPT). The Resident Care Plan dated 6/24/25 identified Resident #2 was at risk for falls related to decreased independent mobility. Interventions included Occupational Therapy to evaluate and treat as ordered or as needed and transfer with assistance of 1 staff to wheelchair. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required substantial/maximal assistance from staff with toileting hygiene, and was dependent on staff for all transfers. Additionally, the MDS identified Resident #2 had a functional limitation in range of motion impairment on one side. A review of the Fall Risk Evaluation dated 9/15/25 at 12:48 PM identified Resident # 2 had a score of 10 indicating a high risk for falls. The Accident/Incident Report dated 9/28/25 identified that on 9/28/25 at 10:15 AM Resident #2 was being assisted to the bathroom, when his/her foot got caught on the lip of the bathroom and he/she fell to the floor. The physician's orders in effect on 9/28/25 directed Resident #2 to be provided with SPT and assistance of 2 staff members. A nurse's progress note dated 9/28/25 at 10:37 AM identified Resident #2 sustained a fall at 10:15 AM while transferring to the bathroom, was witnessed, but LPN #1, but was unable to get to Resident #2 in time. A nurse's progress note dated 9/28/25 at 10:52 AM identified LPN #1 was with Resident #2 when his/her foot got caught on the lip of the bathroom floor and fell. A review of the Fall Risk Evaluation dated 9/28/25 at 10:41 AM post fall identified Resident # 2 had a score of 12 indicating a high risk for falls. The Fall Description Details dated 9/28/25 identified that on 9/28/25 at 10:15 AM Resident #2 had a witnessed fall to the floor while being transferred -assisted by staff per the care plan (Although the care plan identified Resident #2 was an assist of 1, a rehabilitation screen dated 6/23/25, physician's orders in effect on 9/28/25, and the Nurse Aide (NA) assignment card directed 2 staff for SPT). Additionally, Licensed Practical Nurse (LPN) #1 was assisting Resident #2 with a transfer when he/she got his/her foot caught on the lip of the bathroom floor and began to fall. LPN #1 was unable to lift him up/hold him up and Resident #2 twisted his/her leg in the process of falling. The care plan intervention was to remove the lip of the bathroom/resident room door. The Accident/Incident follow up statement dated 9/28/25 identified LPN #1 was assisting Resident #2 with a bathroom transfer on 9/28/25 at 10:15 AM when Resident #2's foot got caught on the lip of the bathroom causing his/her body to twist and he/she fell to the floor. Resident #2 was wearing rubber soled footwear at the time. The facility summary submission details sent to the State Agency dated 10/3/25 identified that prior to this incident Resident #2 required the assistance of 1 person with transferring, hygiene, toileting and toileting tasks, was non-ambulatory, alert and oriented with a Brief Interview of Mental Status score of 15 on 7/31/25. On 9/28/25 at 10:15 AM Resident #2 was transferring himself from the wheelchair to the toilet, with the nurse standing behind the wheelchair. The resident caught his/her foot on the lip to the door and sustained a fall to the floor. He/She was transferred to the hospital for evaluation, then was transferred to another hospital due to a right tibial shaft fracture, a right malleolus fracture, and a right humerus fracture. Review of the hospital Discharge summary dated [DATE] identified Resident #2, due to a mechanical fall, sustained a right proximal humerus (upper arm) fracture and right distal tibia (shin bone) and fibular (shin bone) shaft fractures. Resident #2 was taken to the operating room on 9/29/25 for an open repair internal fixation of the right tibial shaft fracture with placement of intramedullary nailing and right trimalleolar (3) ankle fracture with fixation of posterior malleolus. Interview with Resident #2 on 10/7/25 at 10:11 AM identified he/she was residing in a different room at the time of the fall. Resident #2 indicated that he/she activated the call light for assistance to the bathroom. LPN #1 came in to assist him/her with the transfer. Resident #2 was holding on to the grab bar in the bathroom while attempting to stand up and his/her foot got stuck on the lip which resulted in a fall. Additionally, Resident #2 identified that Licensed Practical Nurse (LPN) #1 was assisting him with the transfer, without the benefit of a gait belt, even though he/she keeps telling staff to use one. Resident #2 never indicated the transfer was urgent. Interview with LPN #1 on 10/7/25 at 10:37 AM identified that she does not usually transfer residents to the bathroom but on 9/28/25 she happened to be outside Resident #2's room doing her medication pass when the resident rang to go to the bathroom. LPN #1 stated she assisted Resident #2 by rolling his/her wheelchair to the bathroom, stood behind the wheelchair with one hand on the resident's hip, and as the resident stood and turned, he/she caught his/her foot on the bathroom floor lip, and fell. LPN #1 stated the facility policy required staff to refer to and follow physician's orders for transfers, but she was unable to identify what level of assistance Resident #2 required per the orders (2 staff) or if the facility policy required the use of a gait belt during transfers. Although LPN #1 was able to state the facility policy, she was unable to explain why she did not check Resident #2's physician's orders prior to assisting Resident #2 to the bathroom. Interview with Physical Therapist (PT) #1on 10/7/25 at 10:59 AM identified it was protocol for the Rehabilitation Department to perform screens/evaluations on residents and then give those recommendations to the nurses to be placed in the physician orders in the electronic health record. PT #1 identified she worked at the facility part time and worked off notes left for her by the Director of Rehabilitation, Occupational Therapist (OT) #1, which specified Resident #2's transfer status was an assist of 1 stand pivot. Additionally, PT #1 identified that an assist of 1 meant a staff member had to have their hand always place on the resident during the transfer. PT #1 stated that since the fall he/she was an assist of 2, which similarly meant 2 staff members had to have at least 1 hand on the resident during the transfer at all times. PT #1 identified that depending on the resident, gait belts were used for transfers and ambulation, with directions specified on the care plan or care assignment located in the resident room. Observation of Resident #2's room with PT #1 failed to identify a care assignment behind the door, or inside the closet. Further, PT#1 stated that in the 3 weeks that she had worked at the facility, she had never seen Resident #2's care assignment. Interview and record review with Registered Nurse (RN) Supervisor #1 on 10/7/25 at 11:03 AM identified staff were required to refer to the Nurse Assistant Assignment cards to obtain information as to how much assistance residents needed with ambulation and transfers. The facility policy directed the use of gait belts with all transfers and ambulation. A review of Resident #2's assignment sheet dated both 9/8/25 and 9/26/25 directed Resident #2 required the assistance of 2 staff for transfers and toileting. Additionally, RN #1 identified that at the time of the fall on 9/28/25 per the assignment sheet Resident #2 required an assist of 2 staff members for transfers, meaning 2 staff members should have been assisting Resident #2 when he/she fell. Interview with the Director of Nurses (DNS) on 10/7/25 at 11:11 AM identified the facility had no policy on transfers and ambulation, but the protocol was to follow the physician's orders and recommendations from the Rehabilitation Department. Additionally, she identified that gait belts should be used with transfers and ambulation but we're not good with that here. Although the physician's order, Rehabilitation Department screening, and the Nurse Assistant Assignment sheet identified Resident #2 required the assistance of 2 staff for transfers and toileting, the DNS stated that on 9/28/25, at the time of the fall, Resident #2 required the assistance of 1 staff for transfers. Interview and observation with Nurse Assistant (NA) #3 on 10/7/25 12:20 PM identified that he was the regular NA for Resident #2 when he/she occupied a previous room at the time of the fall. NA #3 indicated that Resident #2's transfer status at the time of the fall on 9/28/25, was an assist of 1 or 2 depending on who was helping Resident #2 with the transfer. Additionally, NA #3 identified he always assisted Resident #2 with another staff member, since the NA Assignment sheet directed this was the requirement. NA #3 identified Resident #2 did not tend to self-transfer to the bathroom independently and always used the call light for help, describing his/her call bell habits as on it non-stop. NA #3 additionally identified that gait belts were utilized in the facility, and available in the utility room. Observation of the utility room with NA #3 identified a single gait belt available, and NA #3 indicated he did not currently have a gait belt with him. Interview and clinical record review with the DNS on 10/7/25 at 1:09 PM identified the facility summary details submitted to the State Agency dated 10/3/25 indicated prior to the 9/28/25 fall Resident #2 required the assistance of 1 person with transferring, toileting, and toileting tasks. The physician's orders originally dated 6/23/25 and in effect on 9/28/25 (the date of Resident #2's fall) however, directed facility staff to provide the assistance of 2 staff members to stand and pivot. The DNS identified that she had obtained the assist of 1 information through talking to staff and observing them transfer Resident #2 with 1 staff member. Although the DNS stated during her interview on 10/7/25 at 11:11 AM Resident #2 required the assistance of 1 staff with transfers, she clarified that staff should have followed the physician's directive, per the physician's orders, requiring 2 staff members (not 1) to assist him/her with stand pivot transfers, and that this was Resident #2's status on the day he/she fell, 9/28/25, and sustained multiple fractures. Interview and clinical record review on 10/7/25 at 1:11 PM with the Director of Rehabilitation, Occupational Therapist (OT) #1 identified she completed the initial Interdisciplinary Therapy Screen assessment dated [DATE] indicating Resident #2 required 2 staff members to safely Stand/Pivot/Transfer, (SPT). OT #1 indicated that due to a denial by hospice, she had never treated Resident #2 prior to the 9/28/25 fall. Re-interview and clinical record review with OT #1 on 10/8/25 at 1:11 PM identified Resident #2 had previously had 2 falls, 1 on 7/9/25 and 1 on 8/15/25 with subsequent Rehabilitation Department Interdisciplinary Screens performed. Although the comment section (optional) on the form addressed the falls, Resident #2's transfer/ambulation status was not addressed. OT #1 identified that the lack of reference to the resident's transfer/ambulation status indicated that there were no changes from the original rehabilitation screen which indicated Resident #2 required the assistance of 2 staff for transferring. OT #1 did not explain why, PT #1 had been given notes from her indicating Resident #2 required the assistance of 1 staff member. OT #1 did not provide any further screens, evaluations, requests to change physician orders, or further documentation indicating Resident #2 was re-evaluated to be able to safely use 1 staff member to transfer. Despite the irregularities in staff interviews and facility documentation, the facility failed to utilize a gait belt or provide hands on assistance during a transfer that occurred on 9/28/25 resulting in Resident #2 sustaining multiple fractures. The Fall Prevention Policy dated 9/15/22 directed, in part, that the facility attempts to identify residents at risk for falling, evaluating the factors that place the residents at risk to fall and implement measures to prevent falls. A review of the Gait Belt Policy dated March 2025 directed, in part, that gait belts are to be used with all residents that require physical assistance with ambulation and transfer (assist of 1 and 2). A review of the Therapy Screenings Policy revised 7/18/25 directed, in part, that therapy screening(s) are utilized to identify an individual's risks and determine the potential need for rehabilitation or other services and to promote health and wellness. Additionally, the purpose is to gather information about an individual's physical/cognitive/functional performance using an accepted screening process and tool, for the purpose of identifying the individual's care needs and/or for facilitation of interprofessional team collaboration and care planning.Although requested, a Transfer/Ambulation Policy, Transfer Protocol, Activities of Daily Living, and Physician's Order Policy were not provided.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of wandering throughout the facility and self-ambulated with a walker, the facility failed to implement the Missing Person Policy when Resident #1 was not accounted for. The findings include:Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of wandering throughout the facility and self-ambulated with a walker, the facility failed to implement the Missing Person Policy when Resident #1 was not accounted for. The findings include: Resident #1's diagnoses included vascular dementia, hemiplegia, and insomnia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long-term memory recall deficits and was independent with ambulation with the use of a walker. The Resident Care Plan dated 7/23/25 identified Resident #1 wandered into other resident's rooms and was an elopement risk. Interventions directed use of a wander guard in the tennis ball placed on the walker because the resident removed the wander guard when placed on his/her body, to redirect the resident out of other's rooms, remind resident to use walker when ambulating. The Wander risk assessment dated [DATE] identified Resident #1 was not exit seeking. Resident #1 wandered on the unit and sometimes into other residents' rooms, continuously removed the wander guard which was inside the tennis ball off the walker, and the facility planned to trial Resident #1 without the wander guard and monitor behavior for exit seeking. The nurse's note dated 10/4/25 at 8:16 AM identified the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #2, was alerted around 5:15 AM that Resident #1 was not on the unit. The note indicated Resident #1 was last seen at 4:30 AM. The interior and perimeter of the building were searched. The Director of Nursing (DON) was notified at 6:00AM and the state police were called at 6:03 AM and Resident #1 was found at 6:40 AM. Resident #1 was transferred to the hospital for further evaluation and Resident #1 was discharged back to the facility with diagnoses of skin tear to the left hand, contusion of the left lower extremity and contusion to the right lower leg. Interview with the 11PM-7AM nurse aide, Nurse aide (NA) #2, on 10/7/25 at 12:05 PM and on 10/8/25 at 8:40 AM identified on 10/4/25 at approximately 5:00 AM another nurse aide, NA #1, approached her and reported she did not know where Resident #1 was. NA #2 explained she and NA #1 proceeded to check the bathrooms and notify the 11PM-7AM nursing supervisor, Registered Nurse (RN) #2, when they were unable to locate Resident #1. NA #2 identified RN #2 initiated the search protocol and after searching the entire inside of the building, she proceeded to go outside through the employee exit to search the grounds. NA #2 identified after she was unable to locate Resident #1, RN #2 contacted the police. Interview with the Director of Nursing (DON) on 10/7/25 at 1:30 PM and 10/8/25 at 9:20 AM identified Resident #1 was evaluated as an elopement risk initially. The DON indicated on 10/4/25, Resident #1 exited the building. The DON identified the search for Resident #1 was initiated at 5:15 AM on 10/4/25 and the police were not contacted until 6:03 AM, forty-five minutes later, which exceeded the directions in the facility Missing Person Policy which required notification to the police within ten (10) minutes of discovering a resident was missing. The DON stated she was not notified until 6:00 AM that Resident #1 was missing. Interview with RN #2 on 10/7/25 at 1:48 PM and on 10/8/25 at 8:47 AM identified she last saw Resident #1 at 4:30 AM on 10/4/25 seated in a chair next to another resident by the doors on the unit closest to the lobby and at 5:00 AM, NA #1 asked her if she had seen Resident #1. RN #2 explained a search was initiated of the interior and exterior of the building, the DON and administrator were notified at 6:00 AM and the police were notified at 6:03 AM. Interview with the Administrator on 10/8/25 at 9:30 AM and on 10/9/25 at 11:00 AM identified an elopement drill was done on 6/1/25 with facility staff and documentation identified RN #2 participated in the drill. Interview with Housekeeper #1 on 10/9/25 at 10:25 AM identified on 10/4/25 when he came to work at 5:30 AM, he was informed Resident #1 was missing and he immediately began to assist with the search and discovered Resident #1 at 6:40 AM. The facility Missing Person Policy identified when a resident was missing the police would be notified within ten (10) minutes.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who had difficulty swallowing, the facility failed to follow the physician's recommended therapeutic diet which resulted in the resident choking. The findings include: Resident #2's diagnoses included cerebral vascular accident and dysphasia (difficulty swallowing). The Speech Therapy Treatment Encounter note dated 2/25/25 identified Resident #2's diet was downgraded to a Level 5 minced and moist diet after Resident #2 was observed coughing on a Level 6 diet. The barium swallow results dated 3/10/25 identified diet recommendations for the International Dysphagia Diet Standardisation Initiative (IDDSI) Level 5, minced and moist, regular dry bread and mixed consistency not allowed, alternate solids and liquids, and supervised feeding. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some slight memory recall deficits, required staff assistance with activities of daily living, and supervision when eating. The Resident Care Plan revision dated 5/22/25 identified Resident #2 was at risk for a swallowing problem related to the cerebral vascular accident. Interventions directed a Level 5 minced and moist diet, to maintain an upright position, eat slowly, and chew each bite, monitor for signs and symptoms of aspiration, and supervision with eating. A physician's order dated 6/1/25 directed a regular Level 5 minced and moist texture diet, thin liquid consistency, no bread and mixed consistency, and may use straws. The nurse's progress note dated 6/14/25 at 1:35 PM identified the charge nurse notified the Nursing Supervisor that Resident #2 had choked on the food and required the implementation of the Heimlich maneuver. The charge nurse reported Resident #2 coughed up a piece of chicken tender. The note indicated that the Advanced Practice Registered Nurse was notified and directed for a STAT chest x-ray to be obtained. The nurse's note dated 6/14/25 at 6:18 PM identified the chest x-ray results indicted there was no pneumonia or congestive heart failure. Interview with the Dietary Director on 7/3/25 at 9:30 AM identified it was her responsibility to ensure kitchen staff are educated on therapeutic diet recommendations, and that meals are served as ordered. The Dietary Director stated Resident #2 was on a minced moist diet, and on 6/14/25, Resident #2 was served a minced chicken nugget, the sauce was on the side, and not applied directly on the meat as it should have been. The Dietary Director identified all kitchen staff, nurses, and aides have been re-educated to double-check the trays before serving. Interview with the dietary aide/evening cook on 7/3/25 at 11:47 AM identified she worked on 6/14/25, the day Resident choked, the meals were to be minced and moist and she could not explain why Resident #2's meal had not been prepared as ordered. Interview with the Director of Nursing (DON) on 7/3/25 at 2:00 PM identified the cook was responsible for ensuring all meals are prepared and served to the residents as ordered. Although attempted an interview with RN #1 was unsuccessful. Facility policy The Implementation of the IDDSI, dated 8/1/24, identified the purpose was to provide consistency and standardization of all diets under IDDSI guidelines to increase safety at mealtime. The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of May 21, 2025. Resident #2 was assessed and had no ill effects from the deficient practice. Any resident on a modified consistency diet has the potential to be affected by the same deficient practice. An audit of resident records identified seventeen (17) residents were prescribed a modified consistency diet. The dietary department has received re-training, the signage in the kitchen has been updated, and policies and procedures have been reviewed. Random audits will be conducted to evaluate the distribution of the modified diets, these audits were initiated on 6/23/25 and are ongoing. The results of the audits will be reported at the facility Quality Assurance/Performance Improvement Committee meeting beginning in July 2025. The Dietary Manager and Dietician have been designated the responsibility to monitor the plan of correction. Compliance date 7/3/25.

Based on review of facility documentation, facility policy and interviews, the facility failed to complete annual nurse aide performance evaluations. The findings include: Interview and review of facility documentation identified the facility employs a total of 25 nurse aides for all three shifts (7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift). Review of the personnel files of NA #1, NA #7, and NA #8 failed to reflect that annual performance evaluations had been completed. Interview with the DNS on 5/21/25 at 12:12 PM identified she has been employed by the facility for 7 years. The DNS indicated she has not completed nurse aide performance evaluations since she has been in the position. The DNS indicated annual nurse aide performance evaluations had not been completed in 2021, 2022, 2023, 2024, and 1/1/25 - 5/21/25. Interview with the Administrator on 5/21/25 at 12:20 PM identified he was not aware that the DNS had not completed nurse aide performance evaluations in 7 years. Review of the facility employee handbook identified performance improvement the facility will make efforts to periodically review the employee work performance. The performance improvement process will take place on an annual basis, or as needs dictate. The performance improvement process is a means for increasing the quality and value of the employee work performance.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #5 and 36) reviewed for accidents, for Resident #5 the facility failed to implement the comprehensive care plan for a resident with a history of repeated falls and for Resident #36 the facility failed to develop a comprehensive care plan related to the resident's behavior of flailing arms. The findings include: 1. Resident #5 had diagnoses that included schizophrenia and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with two wheeled rolling walker for transfers and ambulation. A facility reported event dated 4/7/25 identified at 11:15 AM Resident #5 was observed lying on the floor in his/her room on the left side. Resident #5 reported he/she was walking to use the bathroom, lost balance and fell. Resident #5 denied hitting his/her head and there were no injuries noted on assessment. The physician and resident representative were notified. An accident follow up statement dated 4/7/25 identified NA #1 was assigned to Resident #5, who was last seen at 10:00 AM when the resident was provided toileting assistance. NA #1 was later notified by a co-worker Resident #5 was observed on the floor in h/her room. An interview with the DNS on 5/22/25 at 7:59 AM identified the root cause of the fall resulting from NA #1 leaving Resident #5 in h/her room unattended according to the care plan. An interview with NA #1 on 5/22/25 at 12:26 PM identified he was the assigned nurse aide during the 7:00 AM to 3:00 PM shift on 4/7/25. Resident #5 had eaten in the dining room earlier in the day and could not recall if he or another aide had brought the resident back to his/her room. NA #1 later observed Resident #5 sitting alone in his/her room and provided toileting assistance. Afterward, NA #1 left Resident #5 sitting on his/her bed and was informed a short time later the resident was observed on the floor. NA #1 indicated he was unaware Resident #5 was not to be left unattended in his/her room during the day and routinely left Resident #5 unattended in his/her room during the day. NA #1 further identified following the incident, he was instructed by the DNS to keep a close eye on Resident #5. A review of the facility policy for fall prevention directed the facility to identify residents at risk for falling, evaluate the factors that places the resident at risk and implement measures to prevent falls. 2. Review of the hospital discharge documentation dated 4/21/23 through 4/29/23 identified Resident #36 was brought into the hospital by the resident representative for multiple falls. The resident representative indicated Resident #36 had 1 unwitnessed fall on 4/20/23 and another unwitnessed fall on 4/21/23 at the assisted living facility. Resident #36 was diagnosed with several fractures including a left wrist carpal bone fracture, left distal radial fracture, left ulnar fracture, left wrist/hand fractures. Resident #36 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, fracture of left wrist carpal bone, fracture of left pubis, and repeated falls. The care plan dated 10/13/24 identified Resident #36 had an activity of daily living (ADL) self-care performance deficit related to dementia and was totally dependent on caregiver. Interventions included to transfer with a mechanical lift to a customized wheelchair with assist of two. The quarterly MDS dated [DATE] identified Resident #36 had severely impaired cognition and was dependent on staff for transfers with two persons physical assist. A physician's order dated 1/1/25 directed to transfer out of bed via mechanical lift to customized wheelchair with pelvic positioning belt, head rest and leg rests with assist of two. The nurse's note dated 1/14/25 at 11:03 AM identified Resident #36 was noted to have a pink rash area on left forearm and was scratching the area. House lotion applied with good effect. The nurse's note failed to reflect documentation of a thorough assessment to the left forearm. The reportable event form dated 1/15/25 identified at approximately 9:45 AM Resident #36 was noted to have a slightly red left wrist area (injury of unknown origin). An x-ray of the left arm was ordered which identified a distal ulna fracture with mild displacement, and mild soft tissue swelling. The APRN was notified of the x-ray results with order for an orthopedic consultation. Investigation initiated. Resident #36 was unable to verbalize what happened, had no falls or unusual incidents in the last week. The care plan dated 1/15/25 identified Resident #36 presents with swollen, red left forearm, and a left ulna fracture. Intervention included orthopedic consultation, medication for pain as needed, and padding applied to side rails on bed. Review of a statement written by NA #6 dated 1/15/25 identified she was assigned to Resident #36 on 1/13/25 on the 3:00 PM - 11:00 PM shift and 1/14/25 on the 3:00 PM - 11:00 PM shift. NA #6 indicated on 1/14/25 on the 3:00 PM - 11:00 PM shift she reported to RN #2 that Resident #36 was scratching his/her arm, and when clothing was being removed, he/she yelled. NA #6 indicated RN #2 indicated she had taken care of it this morning and someone had already reported it. NA #6 indicated she and NA #9 continued to provide care. The APRN progress note dated 1/16/25 at 7:49 AM identified Resident #36 was found to have a swollen area on the left forearm distally. Resident #36 has a history of a left wrist fracture that was radial in nature. X-ray was done and a distal left ulnar fracture was found. Recommendations included orthopedic consultation, non-weight bearing to left arm, therapy as needed, and Tylenol for pain as needed. Review of the orthopedic consultation form dated 1/17/25 identified Resident #36 has a diagnoses of left ulna shaft fracture. Recommendations include short arm EXO brace on at all times, follow up in 4 weeks, repeat x-ray, and non-weight bearing to left upper extremity. The nurse's note dated 1/17/25 at 1:40 PM identified Resident #36 had an orthopedic appointment this morning and returned with an EXO brace on left wrist. The resident has a follow-up appointment on 2/3/25. Review of a statement written by NA #1 dated 1/17/25 identified he worked on 1/13/25 on the 7:00 AM - 3:00 PM shift and 1/15/25 on the 7:00 AM - 3:00 PM shift. NA #1 indicated Resident #36 had no behavioral issues, and no pain during his shift on 1/13/25. NA #1 indicated on 1/15/25 he was informed by a co-worker that Resident #36 wrist was discolored and slightly swollen. Review of a statement written by RN #2 dated 1/17/25 identified she worked on 1/13/25 on the 7:00 AM - 3:00 PM shift and 1/14/25 on the 7:00 AM - 3:00 PM shift, and the 3:00 PM - 11:00 PM shift. RN #2 indicated she was not aware of anything that occurred with Resident #36 that may have led to this injury. RN #2 indicated there was some small pink area on the left wrist which appeared to look like irritation. RN #2 indicated lotion was applied to the area, no swelling was noted. The summary report dated 1/17/25 at 3:04 PM identified Resident #36 is confused, non-ambulatory, transfers with a mechanical lift and assist of 2 persons. All staff were questioned. No unusual events occurred. The resident is fidgety when in bed. The resident had a medication change on 1/10/25 when the Escitalopram (used to treat depression and anxiety disorder) was decreased from 15mg to 10mg daily. Side rail pads were added to the side rails, a body pillow was added to the left side of the bed to prevent the resident from rolling out of bed. As a result of this investigation, there was no clear understanding of how this injury occurred. Interview with Person #1 on 5/21/25 at 9:47 AM identified Resident #36's left arm/wrist was slightly swollen on 1/14/25. Person #1 indicated he/she did not tell the staff of the swelling. Interview with NA #1 on 5/21/25 at 10:13 AM identified he was assigned to Resident #36 on 1/15/25 on the 7:00 AM - 3:00 PM shift. NA #1 indicated after morning care he was dressing Resident #36 and when he guided his/her left hand to put it through the shirt Resident #36 was saying ouch, ouch. NA #1 indicated the left arm was not swollen at that time. NA #1 indicated he told the nurse that Resident #36 had pain in the left arm. NA #1 indicated he does not remember who the nurse was. NA #1 indicated Resident #36 has a habit of grabbing your hands during care or anything near and swinging (flailing) his/her arms. NA #1 indicated now the side rails are padded and a pillow is placed by the side rails. Interview with RN #4 on 5/21/25 at 10:45 AM identified she does not remember the incident because it was so long ago and indicated to read her statement. RN #4 indicated Resident #36 used to be fidgety and would flail his/her arms. Interview with LPN #1 on 5/21/25 at 11:06 AM identified she worked on 1/13/25, 1/14/25, and 1/15/25 from 8:00 AM - 5:30 PM. LPN #1 indicated she remembered NA #1 brought Resident #36 to the dining room for breakfast. LPN #1 indicated Resident #36's left forearm looked swollen and she immediately notified RN #1 who assessed the resident. LPN #1 indicated she did not get report from the 11:00 - 7:00 AM nurse that Resident #36's left arm was swollen. LPN #1 indicated Resident #36 used to flail his/her arms constantly but not anymore. LPN #1 indicated she did not document in the resident record when Resident #36 flailed his/her arms. Interview with the DNS on 5/21/25 at 12:38 PM identified she was not aware of Resident #36 flailing his/her arms. The DNS indicated if she was aware of the behavior she would have initiated a care plan and put interventions in place. The DNS indicated the nursing staff had not informed her of the behavior of flailing. Interview with MD #1 on 5/22/25 at 9:16 AM identified he was aware of the incident on 1/15/25 with Resident #36's left distal ulna fracture. MD #1 indicated the ulna bone is located on the pinkie side of the forearm. MD #1 indicated a distal ulna fracture comes from a direct blow or from a fall landing on the forearm or landing on an outstretched arm. MD #1 indicated the resident had to hit the forearm somewhere to obtain the fracture. MD #1 indicated he was not aware of Resident #36 flailing his/her arms. MD #1 indicated there is a possibility flailing of the arms can indeed cause a fracture of the forearm. MD #1 indicated there are risk factors with distal ulna fracture such as osteoporosis, post-menopausal women, and history of falls. Interview with RN #1 on 5/22/25 at 8:20 AM identified the DNS is responsible for initiating care plans and updating care plans. RN #1 indicated the licensed nurses do not initiate or update care plans. RN #1 indicated there will be new processes put into place. Review of the care plan dated 10/13/24, which was in effect on 1/15/25 when the resident began exhibiting pain in the left wrist, failed to reflect documentation or interventions to address the resident's behavior of flailing his/her arms. Review of the nurse's notes dated 1/1/25 - 1/31/25 failed to reflect documentation of Resident #36's behavior of flailing of arms. Although attempted, an interview with RN #2, APRN #2, NA #8 was not obtained. Although requested, a facility care plan policy was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #5) reviewed for accidents, the facility failed to revise the care plan following a fall for a resident with a history of repeated falls. The findings include: Resident #5 had diagnoses that included schizophrenia, bipolar disorder and overactive bladder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with two wheeled rolling walker for transfers and ambulation. A facility reported event dated 4/7/25 identified at 11:15 AM Resident #5 was observed lying on the floor in his/her room on the left side. Resident #5 reported he/she was walking to use the bathroom, lost balance and fell. Resident #5 denied hitting his/her head and there were no injuries noted on assessment. The physician and resident representative were notified. An accident follow up statement dated 4/7/25 identified NA #1 was assigned to Resident #5, who was last seen at 10:00 AM when the resident was provided toileting assistance. NA #1 was later notified by a co-worker Resident #5 was observed on the floor in h/her room. A review of the post-accident report and care plan failed to identify the care plan had been revised after the 4/7/25 fall to prevent future falls. An interview with the DNS on 5/22/25 at 7:59 AM identified the root cause of the fall was identified as NA #1 leaving Resident #5 in his/her room unattended. The DNS further identified the care plan had not been updated as the interdisciplinary team ran out of interventions to put in place to prevent future falls. A review of the facility policy for fall prevention directed the facility to identify residents at risk for falling, evaluate the factors that places the resident at risk and implement measures to prevent falls.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #41) reviewed for quality of care, the facility failed to ensure staff maintained current CPR (cardiopulmonary resuscitation) certification. The findings include: Resident #41 had diagnoses that included Parkinson's disease, and hypertension. The quarterly MDS dated [DATE] identified Resident #41 had moderate cognitive impairment required two person assist with bed mobility, transfers and toileting. The care plan dated [DATE] identified Resident #41 had advance directives specifying full code status meaning all life saving measures were to be implemented in the event of a medical emergency. Physician's order dated [DATE] directed full code status. A late entry nurse's note dated [DATE] at 9:00 PM identified between 8:00 PM and 8:30 PM, Resident #41 vomited a large amount twice and had a large bowel movement. A nurse's note dated [DATE] at 9:53 PM identified RN #4 was notified by the medication nurse, that Resident #41 was not breathing and the pulse was not palpable on assessment. Resident #41's status was verified full code and CPR was initiated. EMS was called at approximately 8:50 PM. Resident #41 was pronounced at 9:21 PM by the ED Physician. An interview with RN #4 on [DATE] at 9:12 AM identified Resident #41 had a vomiting episode and loose bowel movement earlier in the evening and later the resident had an explosive bowel movement. RN #4 went to assess the resident who was somewhat responsive but did not look well. RN #4 went to get the emergency cart. Upon return, Resident #41 was unresponsive with no pulse. RN #4 indicated she began chest compressions until the emergency medical response team arrived and took over. RN #4 identified she was unable to provide documentation of current CPR certification. An interview with the DNS on [DATE] at 12:45 PM identified she was responsible for maintaining CPR certifications for staff but had not maintained one for RN #4 as an oversight. Subsequent to surveyor inquiry, RN #4 obtained an updated CPR certificate. A review of the facility policy for CPR directs that CPR will be performed by a CPR certified licensed nurse. Although requested, a copy of RN #4's previous CPR certification was not provided. Attempts to interview NA #7 were unsuccessful.

Based on review of facility documentation, the facility assessment, and interview, the facility failed to ensure intravenous (IV) therapy certifications and competencies were completed for 6 of 11 licensed nursing staff. The findings include: Review of the IV Therapy Certifications and Infusion Medications Administration Competencies binder failed to identify the following: RN #7 (hired on 5/2/15) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #4 (hired on 4/24/18) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #5 (hired on 11/29/21) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #2 (hired on 5/27/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/8/23. RN #6 (hired on 7/6/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/12/23. LPN #4 (hired on 2/21/25) was certified in IV therapy or had completed an Infusion Medications Administration Competency. Interview and review of facility documentation with the DNS on 5/21/25 at 9:42 AM identified that she was responsible for overseeing the IV therapy program, as well as the nursing staff's education and competencies for IV therapy, and that there were 6 licensed nurses with no IV therapy certification or annual competency on file. The DNS indicated that their IV therapy certifications were old and therefore the facility did not have a copy on file. The DNS identified that IV therapy was not part of the nursing orientation, and while there was no documentation of a competency and/or annual competency being completed, she observed and validated each of the nurses administering IV medication or fluids. The DNS further indicated that it was not often that the facility had residents requiring IV therapy, but the 6 nurses had administered IV medications or fluids, on residents. The DNS identified that currently there were no residents in the facility receiving IV therapy, and she planned to have IV competencies completed for all licensed and unlicensed nursing staff, in June. The DNS further identified that while she did not have a policy that speaks to IV therapy certifications and competencies, the facility's practice was to have nursing staff complete an annual IV therapy competency. The Facility Assessment 2025 Synopsis directs all staff to receive the following education and testing of competency: specialized care-catheterization, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, IV-line care, tube feedings, wound care/dressings, and dialysis care. The Facility Assessment further directs the following will be conducted on licensed nursing staff annually: medication administration-injectable, oral, subcutaneous, topical, and intravenous. Although requested, a facility education for IV therapy policy was not provided.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to discard Insulin 28 days after it was opened according to professional standards. The findings include: Observation on [DATE] at 10:43 AM of a medication cart with LPN #1 identified the following. A vial of Novolog Insulin 100 units/ml 10 ml approximately ¾ full with an open date of [DATE], and a sticker that the Insulin was good for 28 days once opened. A vial of Lantus Insulin approximately ¼ full with an open date of [DATE], and a sticker indicating to discard 28 days after opening. Two vials of Aspart Insulin 100 units/ml 10 ml approximately 1/3 full with an open date of [DATE], and a sticker that indicated discard 28 days after opening. A vial of Lantus Insulin 100 units/per ml approximately ¼ full with an open date of [DATE] and a sticker that indicated discard 28 days after opening. Interview with LPN #1 on [DATE] at 10:48 AM indicated that she was the full-time charge nurse and administered medications, including Insulin to residents on both units. LPN #1 indicated that she administered the Insulin with a [DATE] and [DATE] open date yesterday and today. LPN #1 indicated that the Insulin once opened was only good for 28 days and then discarded. LPN #1 indicated that she did not check the dates on the Insulin vials prior to using them. LPN #1 indicated that she would discard the 4 vials and replace them. Interview with RN #2 on [DATE] at 10:52 AM indicated the charge nurse was responsible to date the Insulin vials when opened and discard them after 28 days. RN #2 indicated that there was new Insulin available. Interview with the DNS on [DATE] at 8:51 AM indicated that when the charge nurse opens a new vial of Insulin she is responsible to date it. The DNS indicated the nurses should be looking at the expiration date prior to each use and discard expired Insulin. Review of the vials and ampules of injectable medication policy identified expiration dates for unopened vials expire based on manufacturers expiration date. Opening a vial triggers a shortened expiration date. Although requested, the facility failed to provide a policy on the length of time Insulin can be used after being opened.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #15 and 78) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. The findings include: 1. Resident #15 was admitted to the facility in December 2024 with diagnoses that included dementia with mood disturbances, hyperlipidemia, and spiral fracture of arm. The care plan dated 12/17/24 identified Resident #15 had impaired cognition due to dementia. Interventions included cues, supervise, and reorient resident as needed. The admission MDS dated [DATE] identified Resident #15 had moderately impaired cognition and exhibited no hallucinations or delusions. Resident #15 did not show any physical or verbal behaviors directed towards others and had not rejected care. Resident #15 was receiving antipsychotic, antidepressant, and diuretic medications. A physician's order dated 1/31/25 directed to administer Seroquel (antipsychotic medication) 25 mg in the morning and 50 mg at bedtime for vascular dementia with moderate mood disturbances. Review of the progress notes dated 1/1/25 to 2/28/25 failed to reflect Resident #15 was seen by the pharmacist for a monthly medication review. A physician's order dated 3/20/25 directed to administer Seroquel 25 mg once in the afternoon for vascular dementia with moderate mood disturbances. The Pharmacracy Monthly Medication Review dated 3/24/25 identified Resident #15 had a recent fall. A review of medications indicates Resident #15 is receiving the following which may be causative or contributing to the falls. If no change is indicated, please note that the medication is necessary and potential risk versus therapeutic benefit of current Seroquel therapy in the next progress note. Additionally, consider monitoring orthostatic blood pressures each shift for 3 days and report systolic changes greater than 20 mm/Hg or diastolic changes greater than 10 mm/Hg to the provider. The Pharmacy Monthly Medication Review dated 5/8/25 (46 days later) identified the psychiatric APRN indicated she would reevaluate the Seroquel for a possible gradual dose reeducation. Resident #15 has poor safety awareness, does not ask for assistance and there are no reports that Resident #15 was drowsy or sedated. Interview with the DNS on 5/21/25 at 10:58 AM indicated pharmacy recommendations should be responded to by the physician or APRN within 2 weeks of receiving the recommendation. Further, after clinical record review, the DNS indicated there was no documentation that Resident #15 was seen by the pharmacy for a medication regimen review in February 2025. The DNS indicated she was responsible for implementing the physician's order for orthostatic blood pressures as per the pharmacy recommendation dated 3/24/25, however, it was not done. The DNS indicated that the psychiatric APRN did not receive the 3/24/25 pharmacy recommendation until 5/8/25, 6 weeks later, because she did not put the pharmacy recommendation in APRN communication book. Interview with the psychiatric APRN (APRN #1) on 5/21/25 at 11:15 AM identified she was responsible to respond to the pharmacy recommendations when she receives them in her communication book from the DNS. APRN #1 indicated that she did not receive the pharmacy recommendation from 3/24/25 until 5/8/25. APRN #1 indicated that when the pharmacist comes into the facility and makes recommendations she will reply to the recommendation on her next visit, and she is in the facility once every other week. APRN #1 indicated that her expectation was that the pharmacy recommendations would be completed within 2 weeks of the pharmacist visit. The interview MD #1 on 5/21/25 at 11:30 AM indicated that the pharmacy recommendations are addressed by the facility APRN for all medical concerns and by the psychiatric APRN for psychiatric medications. MD #1 indicated the DNS was responsible for getting the pharmacy reports and placing them into the white book for medical APRN who comes into the facility once a week. MD #1 indicated that his expectation was they would get done right away but he thinks they have a month to get them completed. MD #1 indicated that his expectation is it would be done in the week but no later than a month. Interview with Pharmacist #1 on 5/21/25 at 11:35 AM indicated that the providers have to complete the recommendations within a month. Although requested, a facility policy for pharmacy recommendations and pharmacy month reviews were not provided. 2. Resident #78 had diagnoses that included anxiety disorder and dementia. The quarterly MDS dated [DATE] identified Resident #78 was severely cognitively impaired and required two person assist with bed mobility and transfers. The care plan dated 11/3/24 identified Resident #78 required psychotropic medications related to depression and anxiety. Interventions included administering medications as ordered and arrange for psychiatric consultation as indicated. Physician's order dated 11/23/24 directed to administer Ativan 0.5mg every six hours as needed for anxiety with no stop date. Pharmacy recommendations dated 3/24/25 identified Resident #78 was receiving as needed psychotropic medication which was required to be re-evaluated after 14 days. Recommendations included noting the medical justification of the continued use of as needed Ativan and specifying the number of days the as needed order was to continue. An interview with the DNS on 5/20/25 at 8:37 AM and 5/21/25 at 10:27 AM identified she was responsible for addressing all pharmacy recommendations. All recommendations were to be provided to medical or psychiatry with the expectation of a documented response. The DNS indicated that while hospice had been involved with Resident #78's care on a routine basis, she had not discussed the recommendations with them as an oversight. The DNS further indicated she did not maintain any record keeping of pharmacy recommendations after the pharmacy mailed them to the facility. The interview with MD #1 on 5/21/25 at 11:30 AM indicated that the pharmacy recommendations are to be addressed by the facility APRN's (medical or psychiatry). MD #1 indicated the DNS was responsible to place the pharmacy reports into the white book for the medical APRN who comes into the facility once a week. MD #1 indicated that his expectation is it would be done in the week but no later than a month. An interview with APRN #1 on 5/22/25 at 10:54 AM identified she had previously provided psychiatric services to Resident #78 prior to receiving hospice care and that no requests had been made to re-evaluate the use of as needed Ativan until surveyor inquiry. APRN #1 indicated she would normally prescribe an initial as needed dose of Ativan for 14 days followed by a re-evaluation, but that hospice would need to review the recommendations before its initiation. A review of the facility policy for psychotropic medication directed that the facility will administer medications, including PRN psychotropic medications according to state and federal guidelines and according to pharmacy policies.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for eight (8) of ten (10) sampled residents (Resident #2, #3, #4, #5, #6, #7, #8, and #10) who were reviewed for the completion of a current Minimum Date Set assessment, the facility failed to ensure the assessments were completed within the fourteen (14) day timeframe requirement. The findings include: Resident #2 had a quarterly Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #3 had an annual Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #4 had a quarterly Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #5 had an annual Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #6 had an annual Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #7 had an annual Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #8 had an admission Minimum Data Set, dated dated dated [DATE] with the status of in process. Resident #10 had an annual Minimum Data Set, dated dated dated [DATE] with the status of in process. Interview with the Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) #2, on 11/12/24 at 12:14 PM identified she was the person responsible for ensuring the MDS assessments are completed within the guidelines set forth in the Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11 dated October 2023. RN #2 identified the facility does not have a specific policy regarding the MDS assessment completion but follows the guidance in the user's manual of completion within fourteen (14) days after the initiation of the assessment. RN #2 identified the assessments should have been completed. Interview with the Director of Nursing (DON) on 11/12/24 at 1:06 PM identified the facility does not have a policy on timely completion of the MDS, but they follow the guidance in the Long-Term Care Facility RAI 3.0 User's Manual. The DON identified the MDS Coordinator, RN #2 was responsible to ensure the MDS assessments were completed according to the User Manual. The DON identified the MDS assessments for Residents #2, #3, #4, #5, #6, #7, #8 and #10 were overdue. The DON identified RN #2 works on a part-time basis and just got behind. Review of the Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11 dated October 2023 directed, in part, the admission assessment, the MDS completion date must be no later than thirteen (13) days after the entry date. Additionally, the Manual identified for the other comprehensive MDS assessments, the Care Area Assessment (CAA) Completion Date must be no later than 14 days from the Assessment Reference Date (ARD).

Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required staff assistance with daily living skills and was reviewed for an allegation of mistreatment, a staff member failed to immediately report the allegation of mistreatment by another staff member while providing care to Resident #2 therefore the alleged perpetrator worked for three (3) days. The findings include: Resident #2's diagnoses included vascular dementia, hallucinations, blindness left eye and glaucoma right eye, depression, and incontinence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made poor decisions regarding tasks of daily life, experienced hallucinations, exhibited behaviors not directed towards others, and required maximum assistance for hygiene, dressing, and bathing. The Resident Care Plan dated 6/27/24 identified Resident #2 had a cognitive impairment, was hard of hearing, had periods of insomnia, had a self-care deficit, and exhibited behaviors such as making racially inappropriate comments, yelling out and swearing. Interventions directed medications as ordered, assistance of one (1) with bathing, announce self when providing care due to blindness, assist resident with coping skills, explain process step by step, when agitated offer use of bathroom, and psychiatric evaluation as needed. A physician's order dated 7/2/24 directed to administer (a sedative medication) Trazadone 50 milligrams (mg) take half (1/2) tablet every twenty-four (24) hours as needed for insomnia for fourteen (14) days. The nurse's note dated 7/16/24 at 1:34 PM identified a call was placed to Resident #2's family member informing him/her it was reported by staff Resident #2 may have been roughly handled by a staff member on Saturday evening 7/13/24. A complete body check was done, and no areas of concern were noted. The note indicated other statements of giving Resident #2 an inappropriate over the counter medication was also being investigated. The nurse's note dated 7/17/24 at 5:48 AM identified Resident #2 was calling out on and off in the early part of the shift and slept for approximately three (3) to four (4) hours in the chair. Interview with a 3-11PM nurse aide, Nurse Aide (NA) #1, on 8/13/24 at 11:45 AM she identified on 7/13/24 another nurse aide, NA #2, made a comment to her stating I guess I am going to sleep tonight because I am going to give Resident #2 liquid Melatonin (a hormonal supplement that plays a role in sleep). NA #1 indicated when NA #2 was assisting Resident #2 with a shower although Resident #2 was yelling stop she did not see NA #2 act rough towards Resident #2. NA #1 stated she did not report her concerns right away, she called the 3-11PM charge nurse at home the next day to report her concerns. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, identified NA #1 did not report any concerns to her until Sunday evening 7/14/24, after she had left the facility. LPN #1 stated she did not report the allegation, because she was not sure what she was supposed to do. LPN #1 identified on 7/15/24 she realized NA #2 was scheduled to work from 7-11PM so she reported NA #1's allegation to the Nursing Supervisor and NA #2 was removed from the facility pending an investigation. Interview with NA #2 on 8/13/24 at 12:25 PM identified he did assist Resident #2 with a shower on 7/13/24 and Resident #2 was yelling in the shower which was a typical behavior for him/her. NA #2 denied being rough during care and making a comment about giving Resident #2 Melatonin.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents (Resident #1) who were reviewed for pressure ulcers, the facility failed to ensure complete and accurate documentation for a resident with a scheduled skin inspection who subsequently developed a pressure ulcer. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 10/9/23 identified Resident #1 had a potential for impairment to skin integrity related to decreased mobility, incontinence (bowel) and muscle spasms of the lower extremities with interventions that directed to apply an alternating pressure mattress and return to bed after lunch daily to limit time seated in wheelchair and off load pressure to buttocks. A physician's order dated 11/1/23 directed a weekly skin assessment on Friday's during the 3:00 PM - 11:00 PM shift. Review of skin assessments from 10/4/ through 10/27/23 the clinical record failed to include a documented weekly skin assessment for 10/27/23. A nurse's note dated 11/1/23 at 11:37 PM identified Resident #1 had developed an open area to the coccyx (tail bone), which appeared necrotic, measuring 3 cm x 5 cm. A second macerated (breakdown in skin tissue) was also noted that measured 3 cm x 3 cm. The dressing was clean, dry, and intact. The Advance Practice Registered Nurse (APRN) and wound team to follow up for further evaluation. A subsequent Skin Only Evaluation dated 11/2/23 identified Resident #1 had developed an unstageable pressure ulcer at the coccygeal region that measured 2 cm x 3 cm with an unknown depth. A second moisture associated skin damage was also identified on the left buttock. A Wound Consultation dated 11/2/243 identified unstageable necrosis to the sacrum measuring 2.3 cm x 3 cm x 0.2 cm depth. A plan was in place for debridement. Orders were placed for calcium alginate, Santyl and a dry protective dressing every other day, An interview with Registered Nurse, RN #1 on 2/2/24 at 1:41 PM identified she was the assigned nurse on 10/27/23 during the 3:00 PM to 11:00 PM shift and would have been responsible for the Weekly skin inspection for Resident #1 during that time. RN #1 stated she did complete the weekly skin assessment on 10/27/23 and identified no skin integrity issues. RN #1 indicated she may not have completed the documented assessment. An interview with the Director of Nursing (DNS) on 2/2/24 at 2:44 PM identified she would expect -nursing staff to complete skin assessments on a weekly basis. Although requested, a policy complete and accurate documentation was not provided.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of two (2) residents,(Resident #1), who were reviewed for pressure ulcers, the facility failed to ensure appropriate infection control practices were followed for a resident receiving a wound treatment. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 11/5/23 identified Resident #1 had an unstageable pressure ulcer related to decreased mobility. Interventions directed to assess, record, monitor wound status and stage of healing weekly and provide treatment(s) as ordered. A physician's order dated 1/31/24 directed to irrigate the wound of the coccyx with normal saline. Moisten 4x4 gauze with normal saline, loosely pack wound and cover with a dressing twice daily and as needed. An observation during Resident #1's wound treatment on 2/2/24 at 10:10 AM identified Registered Nurse #2 cleansed the wound with a saturated piece of gauze and then begin to pack the wound with a second piece of gauze moistened with saline without the benefit of doffing her gloves, performing hand hygiene, and donning a clean pair of gloves. The task was interrupted and subsequently performed observing appropriate infection control practices. An interview with RN #2 on 2/2/24 at 10:10 AM identified that she would normally change gloves and perform hand hygiene between tasks but was nervous and therefore did not perform the task. An interview with the Director of Nursing, DNS on 2/2/24 at 2:44 PM identified she would expect nursing staff to change gloves and perform had hygiene between dirty and clean tasks. Although requested, a policy for hand hygiene during wound care was not provided.

Based on observations during the kitchen tour, review of facility policy and interviews, the facility failed to ensure items were appropriately labeled and dated when opened and failed to discard expired foods prior to the expiration date. The findings include: Observations during a tour of the kitchen on [DATE] at 9:55 AM identified the following: Refrigerator #1 (white) A. Use by date of sour cream was [DATE]. B. Feta shredded cheese lacked both an opened and expiration date. C. American shredded cheese lacking an opened date. D. Mozzarella shredded cheese lacking both an opened and expiration date. E. Parmesan cheese that expired on [DATE]. Refrigerator #2 (double door stainless steel) Barbeque sauce that was transferred from the original container to a plastic container on [DATE] but lacked an expiration date. Interview with the Food Service Supervisor (FSS) on [DATE] at 10:14 AM, identified all food should have a date when opened and an expiration date. The FSS indicated that foods are generally good for 7 days once opened. Additionally, the FSS identified all cooks were responsible for ensuring opened dates were written on containers, he was responsible to check the refrigerators to ensure food items were not expired and were dated when opened, and that he must have missed the undated and expired items. Subsequent to surveyor inquiry, the undated and expired food items were discarded. Review of the undated Food Safety Requirements policy directed, in part, to follow the national standards of food storage in a safe manner in long term care facilities. By doing so, critical control points are identified during the food preparation process, to prevent, reduce or eliminate foodborne hazards in the nursing facility.

Based on clinical record review, review of facility policy, review of facility documentation and interviews for one of three sampled residents (Resident #16) who experienced severe pain and inability to bear weight (change in condition) and required hospitalization , the facility failed to ensure that the APRN/physician was consistently updated when the resident's symptoms of pain persisted, inability to bear weight and the ordered ultrasound was not administered. The findings include: Resident #16's diagnoses included dementia, anxiety, hypertension, benign prostatic hyperplasia, and abnormalities with gait. The resident care plan dated 3/12/23 identified Resident #16 had an ADL (activities of daily living) self-care performance deficit related to dementia with interventions that included: assistance of one person with dressing and personal hygiene/showering. A fall risk assessment dated [DATE] identified Resident #16 was at high risk for falls. The quarterly MDS assessment dated [DATE] identified Resident #16 had moderately impaired cognition, no behavioral symptoms, required supervision with bed mobility, transfers, ambulation, and eating, required limited assistance with dressing, toilet use and personal hygiene. The assessment further noted that Resident #16's balance when moving from a seated position to a standing position and when moving on and off the toilet was unsteady but he/she was able to stabilize with assistance, no identified functional range of motion deficits, utilized a can or crutch for mobility, and experienced one fall without injury in the past three months. Monthly physician's orders for the month of May/2023 directed Resident #16 was to ambulate independently with a cane. The nurse's note dated 6/11/23 at 7:50 AM identified Resident #16 reported severe pain to right leg/upper thigh and would not let this writer touch his/her leg. Tylenol was given with good effect. The right lower extremity was noted to be swollen and appeared larger than the left lower extremity and no bruises were observed. The note further identified that the on-call APRN (#2) was notified and gave an order for Tylenol 975 mg (milligrams) every eight hours and obtain right lower extremity ultrasound to rule out deep vein thrombosis. The nurse's note dated 6/11/23 at 1:51 PM identified Resident #16 continued to have right lower extremity pain with a pain score of ten out of ten (10/10 representing the highest level of pain/ severe pain). The further identified that the ultrasound had not been completed, and Resident #16 was up in the wheelchair in the afternoon and was unable to bear weight on the right lower extremity and required the assistance of two staff to transfer the resident into the wheelchair. It further noted that Resident #16 had non pitting edema and the resident noted that his/her right heel and knee were the most painful. The nurse's note dated 6/11/23 at 9:16 PM identified Resident #16 continued to complain of right lower extremity pain with no warmth or redness noted on assessment. The note identified that a call was placed to the company responsible for administering the ultrasound to ascertain the time they would be arriving to perform the ultrasound. According to the nurse's note the company identified that they would be in that night. The nurse's note dated 6/12/23 at 2:54 PM identified Resident #16 was noted to have right leg shortening and external rotation in the morning. The APRN was notified at 9:00 AM and ordered the resident be sent to the hospital emergency department for further evaluation. In addition, the note identified that in the afternoon they were notified that Resident #16 was admitted to the hospital for a right intertrochanteric femur fracture. The hospital discharge summary dated 6/14/23 identified that facility provided history that Resident #16 was well until 6/10/23 at 11:00 PM. In the early morning of 6/11/23 Resident #16 complained of hip pain and stayed in bed because of inability to ambulate independently as before. The note further identified that Resident #16 presented to the emergency department with right hip pain and externally rotated right leg. X-ray imaging of the right hip identified a displaced intertrochanteric femur fracture with fracture extending through the greater and lesser trochanter. Interview with RN #2 on 6/21/23 at 1:09 PM identified that at approximately 1:30 AM on 6/11/23 a NA notified her that Resident #16 was complaining of pain. She noted that she went and assessed the resident and identified that Resident #16 was in pain, guarding the area and did not want her to touch him/her. She noted that she administered Tylenol to the resident and afterward the resident fell asleep. RN #2 further noted that she continued to check on Resident #16 throughout the shift and noted that he/she appeared to be asleep. She identified that she called the APRN around 7:00 AM to provide an update that Resident #16 had pain to the right leg, was guarding the upper thigh towards the groin and there was swelling. Additionally, she noted that Resident #16 stayed in bed all night, and the APRN ordered Tylenol 975 MG and an ultrasound. Interview on 6/21/23 at 1:29 PM with APRN #2 identified that on 6/11/23 RN #2 called her to provide an update on Resident #16 and she inquired if there were any other injuries or bruising and RN #2 identified that there were none. APRN #2 identified that since there was no suspicion that the resident had fallen, she ordered an ultrasound. APRN #2 further identified that she was on call for Saturday (6/10/23) and Sunday (6/11/23). She conveyed that she did not receive any follow up phone calls from the facility regarding Resident #16. She also noted that if she had been notified that the ultrasound was not administered and that Resident #16 had experienced a change in condition (as identified by nursing, where Resident #16 was reporting increased pain/discomfort, unable to bear weight to affected limb and required an assistance of at least two persons to move from one surface to the other), she would have changed Resident #16's pain medication, ordered an immediate X-ray of the affected area and directed that the resident be sent out to hospital for further evaluation. Interview on 6/22/23 at 8:45 AM with RN #3 identified Resident #16 had a history of arthritis so she assumed that might have been the problem and noted Resident #16 usually got out of bed and walked to the dining room daily for lunch. RN #3 identified that when Resident #16 was unable to get out of bed on 6/11/23 the nursing staff including herself had to help him/her. RN #3 further identified that Resident #16 was assisted by three persons (on 6/11/23) using the stand pivot technique to assist Resident #16 get out of bed to the wheelchair because he/she could not bear weight on the right lower limb and was in pain. In addition, RN #3 identified that two staff helped him/her to stand and pivot while the third person placed the wheelchair behind the resident. RN #3 further noted that she expected the ultrasound company to show up within 24 hours. She also identified that based on her judgement there was nothing else that could have been done because Resident #16 received assistance to complete activities as needed and the Tylenol was being administered as ordered. RN #3 identified that she left work at 3:00 PM. Interview on 6/22/23 at 11:45 AM with the DNS identified that the clinical record failed to reflect documentation that APRN #2 was updated regarding Resident #16's persistent pain and inability to bear weight and the ultrasound company not completing the ultrasound. She identified that it was expected that nursing staff would call the APRN/ physician and provide update regarding the status of Resident #16. She further identified that the staff moved Resident #16 because they assumed that the resident's arthritis was causing his/her pain and discomfort. A review of the facility's Resident Change of Condition (COC) policy identified that a resident change of condition is defined as any clinically significant deviation from a resident's baseline (normal self) status. The change may be physical, behavioral, functional, or cognitive. The purpose of identifying a COC is to appropriately treat and if necessary, notify the physician or designee, responsible party and transfer the resident to the hospital in a timely manner. The policy further identified that when a COC is noted, the RN will complete an assessment and notify physician or designee.

Based on observation, review of the clinical record, review of facility policy, and interviews for three of four sampled residents (Residents #2, #13, and #35) with bathrooms in their rooms, the facility failed to ensure that the water temperatures in the resident bathrooms were maintained within the required range of 105.0 to 120.0 degrees Fahrenheit. The findings include: 1. Resident #2's diagnoses included schizoaffective disorder, bipolar disorder, dementia, adjustment disorder, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #2 was cognitively intact and required limited assistance for bed mobility, dressing, transfers, ambulation, toilet use and personal hygiene. The resident care plan (RCP) dated 6/5/23 identified a self-care deficit due to psychiatric symptoms with interventions that included: set up assistance for bathing and showering, remind and encourage resident to take showers at times and provide frequent checks for incontinence. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #2's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #2's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit. 2. Resident #13's diagnoses include gait abnormalities, Parkinson's disease, normal pressure hydrocephalus and dementia. The quarterly MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairments, required extensive assistance for bed mobility, dressing, toileting and hygiene, was totally dependent for transfers and required supervision with eating. The RCP dated 5/27/23 identified a self-care deficit with interventions that included assistance with bathing, bed mobility, dressing, eating, personal hygiene, and transfers. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #13's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #13's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit. 3. Resident #35's diagnoses included heart failure, type 2 diabetes, osteoarthritis, and history of falls. The quarterly MDS assessment dated [DATE] identified Resident #35 had moderately impaired cognition, required limited assistance for bed mobility, transfers, and ambulation, required extensive assistance for hygiene, toileting, and dressing. The RCP dated 5/18/23 identified a self-care deficit with interventions that included: assist with bathing, showers, bed mobility, dressing, eating set up, hygiene, and toileting. Observation of water temperatures in Resident #35's bathroom on 6/20/23 at 12:30 PM registered a temperature of 128.6 F. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #35's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #35's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit.

Based on review of the facility assessment and interview for the intravenous therapy program, the facility failed to identify that licensed and nurse aide staff had demonstrated competency or were educated related to intravenous therapy use. The findings include: Review of the Facility Assessment document dated 9/1/22 identified that the facility would provide intravenous medications and that education and testing of competency for intravenous line care would be provided. Interview with the DNS on 6/22/23 at 1:21 PM failed to identify documentation that licensed nursing or nursing assist facility staff had received education or competencies for intravenous line managment as indicated on the facility assessment and per the facility policy. Review of the Qualifications for Nurse Providing Infusion Therapy policy dated 8/2018 directed documented successful completion of infusion therapy education, documented completion of clinical competencies, and documented annual infusion education which could consist of in-servicing, formal infution therapy educationn programs and or clinical competencies. Additional education and competency in central line care must be demonstrated.

Based on interview, review of facility narcotic records, clinical record review, and facility policy for 3 of 11 sampled residents (Resident #1, #6 and #16) who were reviewed for controlled substance records (narcotics), the facility failed to accurately reconcile controlled medication or identify the potential for diversion for controlled medications. The findings include: 1. Resident #1's diagnoses included cervical disc disorder, type 1 diabetes, and morbid obesity. 2. Resident #6's diagnoses included bipolar disorder and schizophrenia. 3. Resident #16's diagnoses included anxiety disorder, and unspecified dementia mild with anxiety. During a review of the controlled substance disposition records (narcotic sign out forms), irregularities for the correct number of medications administered to Resident #6 failed to match the physician's order at the top of the form. Further, for Resident #1 and Resident #16 the controlled substance disposition records identified that the medication had been distributed twice at the same time to Resident #1 and Resident #16, double the amount of medication prescribed. Interview and review of the Controlled Drug Disposition records with the Director of Nursing Services (DNS) for Resident #1, #6, and #16 indicated that the irregularities were not picked up during the reconciliation process. The DNS identified that the process of reviewing for drug irregularities, that medications were not given correctly or not investigated for possible diversion, was her responsibility, and that moving forward she would be paying closer attention. Review of the Medication Storage in the Facility/Controlled Substance Storage policy dated February 2019, identified that the Consultant Pharmacist or designee routinely monitors controlled substance storage, and records such as individual controlled substance accountability sheets during routine medication storage inspections.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #9) reviewed for resident to resident altercations, the facility failed to ensure the resident was protected from repeated abuse by Resident #1, which resulted in an injury. The findings include: Resident #9 had [DIAGNOSES REDACTED]. Resident #9's quarterly MDS dated [DATE] identified the resident had short and long term memory problems, severely impaired cognition, no exhibited mood or behaviors and no history of falls. Resident #9's corresponding care plan identified the resident walked with a rolling walker. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified Resident #1 had moderately impaired cognition, no mood or behavioral issues, and required supervision with transfers and ambulation. Resident #1's care plan dated 9/6/17 identified the resident had dementia, depression and [MEDICAL CONDITION]. Interventions included to allow Resident #1 to verbalize feelings and concerns and validate accordingly, meet with the resident periodically to monitor psychosocial well-being, encourage family visits, involve resident in plan of care, courage resident to communicate more with staff and peers. A psychiatric consultation dated 11/2/17 identified Resident #1 had major neurocognitive disorder due to multiple etiologies with behavioral disturbances. Recommendations included a Gradual Dose Reduction (GDR) of [MEDICATION NAME] 1mg nightly as follows: [MEDICATION NAME] 0.75mg nightly for 7 days. [MEDICATION NAME] 0.5mg nightly for 7 days. [MEDICATION NAME] 0.25mg nightly for 7 days then discontinue. Other recommendations included to monitor mood, behavior, appetite and sleep, ongoing evaluation of risks/benefits/side effects, and use (as needed) medications for behaviors and document effectiveness. Review of Resident #1's clinical record and care plan failed to reflect the psychiatrist recommendations dated 11/2/17 were implemented in the resident's plan of care. a. A nurse's note (Resident #1) dated 11/27/17 identified that at 2:45 PM, Resident #1 was in the main dining room. Resident #1 was witnessed to approach Resident #9 and shove him/her forcefully to the ground. Resident #1 was removed from the common area, placed on 1:1 observation and the psychiatric APRN was notified. A psychiatric consultation dated 11/27/17 identified Resident #1 pushed another resident to the floor. The note identified, that according to staff, Resident #1 had exhibited an increase in behaviors toward staff, and increased difficulty being redirected. GDR unsuccessful. Recommendations included to restart the [MEDICATION NAME], monitor mood, behavior, appetite and sleep, and ongoing evaluation of risks/benefits/side effects. Although the psychiatric evaluation dated 11/27/17 indicated Resident #1 had exhibited an increase in behaviors toward staff, and increased difficulty being redirected, according to staff, review of the clinical record and care plan failed to reflect the identified behaviors (increase in behaviors toward staff, and increased difficulty being redirected) and/or that (as needed medication) had been administered, and/or that the psychiatrist recommendations regarding documentation of ongoing monitoring according to the recommendations had been implemented. b. A nurse's note (Resident #1) dated 11/28/17 at 7:00 PM identified visitors witnessed Resident #1, unprovoked, push Resident #9 to the floor. Resident #9 began yelling that he/she (Resident #1) pushed me. The residents were separated, and the APRN was updated. The APRN directed Resident #1 be sent to the hospital for a psychiatric evaluation due to increased physical aggression. Review of readmission physician's orders [REDACTED]. A psychiatric consultation dated 12/5/17 identified Resident #1 was readmitted after a hospitalization related to aggressive behaviors. There are signs of anxiety. Recommendations included to continue current medications, monitor mood, behavior, appetite and sleep, and ongoing evaluation of risks/benefits/side effects. Resident #1 has an underlying medical or psychiatric disorder. A nurse's note (Resident #1) dated 12/30/17 at 10:40 AM identified Resident #1 pushed Resident #30, appeared irritable, and was reminded to keep hands to self. Resident #1 received [MEDICATION NAME] 25 mg, and the residents were immediately separated. A nurse's note (Resident #1) dated 12/30/17 at 4:15 PM identified the psychiatrist ordered Resident #1 to be sent to the hospital for a psychiatric evaluation to determine no harm status. A psychiatric consultation dated 1/11/18 identified staff asked psychiatry to see Resident #1 for increased confusion and signs/symptoms of anxiety. Upon evaluation, Resident #1 exhibited signs of anxiety. Recommendations included to start [MEDICATION NAME] 25mg every 4 hours as needed for anxiety, monitor mood, behavior, appetite and sleep, ongoing evaluation of risks/benefits/side effects. Use (as needed) medications for behaviors and document effectiveness. Although a psychiatric consultation dated 1/11/18 identified staff asked psychiatry to see Resident #1 for increased confusion and signs/symptoms of anxiety, the clinical record failed to reflect the identified behaviors and/or that (as needed medication) had been administered, and/or the psychiatrist recommendations regarding documentation of ongoing monitoring according to the recommendations had been implemented A reportable event form dated 1/28/18 at 6:00 PM identified Resident #1 was behind Resident #19 walking to the dining area. Resident #19 stopped suddenly, and Resident #1 pushed and slapped Resident #19 on his/her back. The nurse's note (Resident #1) dated 1/28/18 at 4:20 PM identified the psychiatrist was notified and ordered Resident #1 to be placed on 1:1 observation until a psychiatric evaluation could be completed. Additionally, the psychiatrist ordered Resident #1 to receive [MEDICATION NAME] 25mg as needed (already a signed physician's orders [REDACTED]. A reportable event form dated 2/16/18 at 3:45 PM identified Resident #30 yelled, and Resident #1 was witnessed pinching Resident #30 on the arm. Resident #30 sustained a skin tear. A physician's orders [REDACTED]. c. A nurse's note (Resident #1) dated 3/10/18 at 7:15 PM identified that Resident #1 was witnessed to stand from his/her chair, approach Resident #9, and push him/her into the door frame causing an injury. The incident was unprovoked and unanticipated. Resident #1 was placed on 1:1 observation, and an order obtained to send Resident #1 to the hospital for a psychiatric evaluation. The reportable event form dated 3/10/18 identified Resident #9 sustained a 2.5cm laceration to his/her occipital head. A pressure dressing was applied, and Resident #9 was transferred to the hospital. The facility investigation dated 3/15/18 identified that suddenly and without provocation, Resident #1 pushed Resident #9, who hit his/her head on a door frame. Resident #9 was transported via ambulance to the hospital and received staples to the laceration on his/her head. Subsequently, Resident #1 was sent to the hospital for a psychiatric evaluation. Interview and review of facility documentation with the Administrator and DNS on 8/9/18 at 10:30 AM identified that although Resident #1 had some medication changes, was hospitalized and treated for [REDACTED].#9) no new behavioral interventions were documented/attempted and/or repeat interventions were used in the care plan for 3 of 6 incidents. The DNS identified that Resident #1 was unpredictable and that there were no further interventions the facility could implement to prevent the Resident #1 from altercations with other residents. During review of the care plan, it was noted that interventions were undated, out of sequence, and repeated. Additionally, the DNS identified that on 3 occasions, he/she had incorrectly dated the care plan and could not explain why an intervention dated 9/2017 was listed ¾ of the way down a page for a care plan that began on 4/8/18. The Administrator identified that the care plans needed to be re-written, should be in sequential order, and interventions dated. Review of the facility care plan policy identified that when an interim care plan is needed, the appropriate personnel will write new information in the chart, leave a note for the RCP Coordinator who will monitor the care plans, assign on individual to be responsible to update care plan with interim problem/needs and interventions and care plan will be audited to ensure compliance. The facility failed to protect Resident #9 from Resident #1, who between 11/27/17 and 3/10/18 willfully (According to CFR F600 §483.12 Freedom from Abuse, Neglect, and Exploitation, the word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm) assaulted Resident #9 three times, Resident #19 once, and Resident #30 twice. Additionally, the facility failed to provide ongoing evaluation of the effectiveness of Resident #1's behavioral interventions and/or revisions to the plan of care to assure the safety of other residents. This failure resulted in the assault on Resident #9 on 3/10/18 at 7:15 PM when Resident #1, unprovoked, pushed Resident #9 into a door frame causing a laceration to Resident #9's head which required hospital level care and staples to close the wound.

Based on clinical record reviews, review of facility policies, review of facility documentation, observations and interviews, the facility failed to timely identify a respiratory outbreak and initiate appropriate infection control (IC) education and measures to prevent the spread of a respiratory infection resulting in a finding of immediate jeopardy. The finding includes: Facility documentation identified that the facility's licensed capacity was 44 beds and the census on [DATE] was 43 residents. Resident #6 was admitted to the facility on [DATE]. Nursing narratives dated [DATE] identified that the resident presented with a congested cough, MD #1 was notified on [DATE] and cough medicine was ordered. Review of the clinical record identified that Resident #6 exhibited respiratory symptoms periodically through [DATE]. Review of the facility IC log on [DATE] identified that Resident #7 developed a cough on [DATE]. By [DATE], Residents #1, #2, #4 and #11 were observed as having a cough and/or congested cough, and by on [DATE] Residents #8, #12, #13 and #14 were observed as having a cough and/or congested cough for a total of 10 residents with respiratory symptoms. Although greater than 10% of the resident population exhibited a similar respiratory symptom (cough) between [DATE] and [DATE], the facility failed to identify this as an outbreak and failed to implement infection prevention measures. The IC log review and/or resident record reviews on [DATE] indicated that 4 additional residents (Residents #3, #9, #15, #16) developed coughs between [DATE] and [DATE] for a total of 14 residents who had respiratory symptoms. The facility failed to implement IC measures to prevent the development and transmission of infection for 9 days after the number of residents exhibiting similar symptom (s) was greater than 10% of the population. The IC log and clinical record reviews also noted that on [DATE], [DATE] and [DATE], Resident #8, #9 and #7 were diagnosed with [REDACTED]. The IC log and clinical record reviews also noted that in addition to the initial respiratory symptoms, Residents #1, #2, #3 and #4 developed pneumonia due to underlying comorbidities and subsequently expired in the hospital or in the facility on [DATE], [DATE] and [DATE]. The facility event report dated [DATE] identified that the facility had an "apparent outbreak of viral illness with atypical presentation." The report indicated that staff were in-serviced at that time and additional cleaning of common areas would be done by housekeeping staff. Review of the in-servicing document identified that residents in the facility were exhibiting cold symptoms including runny nose, congested or dry cough, lethargy and confusion. Staff were instructed to maintain good infection control habits, make sure that residents washed hands after clearing their nose, and keep residents out of the dining room and recreation activities. Observations on [DATE] at 8:15 AM noted many residents eating breakfast in the dining room including Residents #5 and #6. Resident #6 was seated at a table with 2 other residents, and was observed frequently wiping nasal and eye secretions with his/her hands and touching the table and other items without hand washing/cleaning or staff intervention. Resident #5 was seated in a wheelchair with a tray table next to other residents and was observed to have a frequent congested cough and did not cover his/her mouth when coughing. Observation of Resident #6 on [DATE] at 10:30 AM identified that Resident #6 was seated in the common hallway used by other residents and staff, had a frequent congested cough, and multiple used tissues were on the resident's tray table and 1 tissue was on the floor. Subsequent to surveyor inquiry, the resident was provided a bag for tissue disposal. Observation on [DATE] at 1:05 PM noted that while providing care to Resident #5, a NA was in close proximity to the resident's face, without the benefit of a mask, and Resident #5 had a forceful congested cough directed towards the NA's face. Interview with Registered Nurse (RN) #1 on [DATE] at 8:25 AM indicated that it was difficult to keep residents in their rooms, the residents in the dining room were asymptomatic (contrary to surveyor observation), and the only two symptomatic residents, Residents #10 and #14 ate in their rooms. RN #1 identified that while providing care to Resident #6 who was experiencing respiratory symptoms, the resident sneezed toward RN#1's face and RN #1 subsequently experienced respiratory symptoms which required treatment. Review of the facility line list for the respiratory outbreak and interview with the Director of Nursing (DON) on [DATE] at 9:02 AM identified the following: 1. A total of twenty residents were identified with symptoms and included in the outbreak line list as of [DATE]. 2. the respiratory illness within the facility was not identified or reported as an outbreak until [DATE] ( 9 days after greater than 10% of the resident population exhibited similar respiratory symptom (s)). 3. Staff were in-serviced on [DATE] to keep symptomatic residents out of the dining room (allowed in halls). However, the DON could not provide a list of staff who received the in-service to reflect that all staff had been in- serviced. 4. Staff utilized gloves, frequently washed hands (but were not instructed to use gowns and masks). Interview with the IC Nurse (RN #2) on [DATE] at 10:20 AM noted that staff were to utilize contact precautions throughout the entire building and three staff (RN #1, a NA and RN #2) had experienced respiratory symptoms during the outbreak. Interview with MD #1 (Medical Director) on [DATE] at 2:50 PM indicated that he/she believed that the facility had "a problem" when eight or so residents experienced symptoms of a respiratory illness within a couple of days ([DATE] to [DATE]) and MD #1 believed that staff had instituted appropriate measures to include "universal" precautions, and keeping symptomatic residents in their rooms. MD #1 identified that he/she did not feel mask use by staff was necessary. The facility policy dated 2000 for outbreak investigation identified that when a commonality of symptoms is evident among residents or staff with common person, place, time or event, staff should suspect an Outbreak. The facility IC policies recommended standard precautions for adult respiratory infectious disease and included the use of appropriate hand hygiene and appropriate use of gloves, gowns and eye protection. The policy did not direct staff to utilize gowns or a mask. According to the Center for Disease Control Guidelines for Isolation, [DATE], standard precautions combine universal precautions and body substance isolation to include a group of infection prevention practices that apply to all patients for the use of gloves, gown, mask, and eye protection or face shield, depending on the anticipated exposure. On [DATE] the Department of Public Health requested an immediate action plan to address staff education, isolating symptomatic residents and staff use of personal protective equipment (PPE). Staff inservicing began on [DATE] and is ongoing.