Every finding on record at Union House Nursing Home

Based on observation, interview, and record review, the facility failed to maintain a critical fall-prevention intervention for 1 of 3 sampled residents (Resident #1), who was at high risk due to severe cognitive impairment and repeated falls. Despite a care plan and motion detector alarm system, the device was unplugged and non-operational during the fatal fall. Leadership admitted that an active monitor could have prevented the incident, which resulted in death. Findings include:Per record review, Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 (a cognitive assessment score demonstrating level of impairment), indicating severe cognitive impairment; diagnoses include Alzheimer's disease, dementia, muscle weakness, cognitive communication deficit, anxiety, depression, and difficulty in walking.Per review of a facility incident report, dated [DATE], Resident #1 experienced a witnessed fall in the doorway of his/her room on [DATE] at approximately 8:00 AM, was assessed for injury, then transported to the emergency department.Per review of a physician readmission assessment note, dated [DATE], after diagnostic imaging in the ER, Resident #1 was found to have sustained a head injury with right-sided intracranial hematoma (blood clot under the skull), subarachnoid hemorrhage (bleeding between the brain and the membrane that covers it), and a fracture to vertebrae C1 and C2 (the first 2 vertebrae of the spine). Resident #1 was admitted to the hospital for further management and after discussing care goals with the decision maker, s/he was transferred back to the facility on [DATE] on comfort care due to his/her poor overall prognosis. Resident #1 continued on comfort care until his/her death on [DATE].Per Resident # 1's death certificate, dated [DATE], the manner of death listed as complications of blunt force trauma to head and neck sustained in a fall from standing.Per review of the care plan, Resident #1 was at risk for falls and had several fall-prevention interventions in place, including a motion detector alarm system that the facility implemented on [DATE]. Resident #1 had experienced 9 falls since the implementation of the monitoring system. Per interview with the Nursing Supervisor (NS) on [DATE] at 12:30 PM, she stated Resident #1 was at a high risk for falls. She confirmed that Resident #1's motion detection monitor was in place and functioning as a fall-prevention intervention until the morning of [DATE], when the alarm box was found unplugged from the wall. Per review of the incident investigation report, dated [DATE], a Licensed Nursing Assistant (LNA) was asked to check the monitor alarm box after Resident #1's fall because it had not alerted them to the fact that s/he was out of bed. The LNA found the alarm box unplugged and reported this to the nurse.Per additional investigation documentation, dated [DATE], staff reported responding to Resident #1's alarm 4-5 times during the night and early morning hours of [DATE] - [DATE].Per interview with a LNA on [DATE] at 10:00 AM, she stated that the monitor had alarmed maybe a couple of times on the morning of [DATE] before Resident #1 fell at 8:00 AM, but she was not sure of the times. She stated that responding to a motion detector alarm meant going into the resident's room and checking on them to make sure they were not at risk of falling.Per interview with a Registered Nurse (RN) on [DATE] at 2:25 PM, she stated that the dining/activities area was where the monitor system was plugged in and pointed at an outlet situated under a table where residents were sitting. She stated that one of the LNAs reported hearing the alarm that morning before Resident #1 fell at 8:00 AM.Per interview with the facility Administrator, the Administrator in Training (AIT), and the Regional Clinical Director (RCD) on [DATE] at 1:45 PM, they confirmed that the motion detection monitoring system was implemented as a fall prevention measure for Resident #1. They confirmed it was functioning correctly until the morning of [DATE] and that the alarm box was found unplugged and not working after Resident #1's fall. They confirmed staff had responded to the alarm during the night and early morning hours. The Administrator, AIT, and RCD confirmed it was possible that a functioning motion detection monitor could have prevented Resident #1's fall.

Based on interview and record review the facility failed to ensure that four of four sampled residents (Res.#1, Res.#2, Res.#3, and Res.#4) were free from misappropriation of property related to medication. Findings include:Per record review of the facility's Identifying Exploitation, Theft, and Misappropriation of Resident Property policy [last revised April 2021] states, 4.Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include .f. drug diversion (taking the resident's medication) .Per review of an initial incident report from the facility to the state agency on 11/10/25, the facility investigated the allegation of drug diversion by LPN [Licensed Practical Nurse] #1 for Residents #1, #2, and #3 regarding discrepancies in controlled substance documentation and medication counts in addition to medication tampering. Per review of the facility's final 5 day summary submitted to the state agency on 11/17/25, it was discovered that LPN #1, who started working at the facility on 11/4/25, had diverted the following controlled substances, Oxycodone (20 tablets), Tramadol (1 tablet), and Lorazepam (1 tablet), from Residents #1, #2, #3, and #4 between 11/7/25 and 11/8/25. Errors were identified with medication counts matching the medication administration records and the controlled substance log. It was also determined that multiple medication cards were tampered with, revealing narcotic medications replaced with non-narcotic medications.Per record review of a document from the State of [NAME] Secretary of State Office of Professional Regulation (OPR) Board of Nursing in the facility incident file states, 54. After further investigation, [LPN #3 and RN#2] discovered that [Resident #3] Oxycodone cards had been tampered with by replacing the narcotic with non-narcotic medications, including Hydroxyzine [a medication used for anxiety], Prednisone [a steroid], Meclizine [a medication used to treat nausea and vomiting], and Metoprolol [a medication used to treat high blood pressure], which were all medications available from the medication cart. 55. [RN#2] later told OPR Investigator that Prednisone and Metoprolol were contraindicated with medications that some of the residents were prescribed and that, if medication tampering had not been discovered, it could have caused great harm to the residents.60. [RN#1] was able to determine by the different colors and sized of the tablets contained in [Resident #1]'s medication card that seven of the oxycodone tablets had been replaced with what appeared to be Spironolactone, which is a potassium sparing diuretic.62. In total the Nursing Home discovered that approximately twenty Oxycodone tablets were unaccounted for the after [LPN#1]'s shifts on November 7, and 8, 2025, either because they had been recorded by [LPN#1] as being dispensed without also recording their administration or because the tablets were discovered to be missing from the medicationAn interview was conducted with the DON [Director of Nursing] on 5/6/26 at 11:37 AM. The DON confirmed that the medications for Resident #1, Resident #2, Resident #3, and Resident #4 had been diverted by LPN #1. The DON confirmed this incident should not have occurred.

Per interview and record review, the facility failed to ensure one of four sampled employees received medication administration competency prior to administering medications. Findings include:Per record review of Licensed Practical Nurse (LPN) #1's training log, there was no documentation that LPN #1 received a medication administration competency prior to starting her position. She worked for four days starting on 11/4/25 to 11/8/25 with no medication administration competency. The employee was terminated on 11/8/25 for medication diversion of Oxycodone (a medication used for moderate to severe pain), Tramadol (a medication used to treat pain), and Lorazepam (a medication used to treat anxiety). See F602 for more information.Per email notification from the Director of Nursing on 5/7/26, she confirmed that the facility did not have documentation related to medication administration for LPN #1 in writing, I could not find her med pass competency .

Based on observations and interviews the facility failed to ensure that drugs and biologicals in the medication storage room were within their expiration date. Findings include: Per observation on 02/10/2026 at 2:23 PM, of the medication storage room the following expired medications were noted: 2 bottles of Naproxen Sodium 220mg 50 caps expired 7/20252 bottles of Caltrate Bone Health Advance 60 tablet expired 12/20252 bottles of Cranberry 450mg 100 tablet expired 12/20252 bottles of Vitamin E 180mg/400IU 100 soft gels expired 12/20253 bottles of Vitamin D 10mcg/400IU 100tabsexpired 5/20254 bottles of CoQ10 100mg 30 soft gels expired 5/20251 bottle of Biotene Dry Mouth Rinse 16oz expired 11/20252 boxes of Antidiarrheal 2mg 24 caps expired 7/20251 box of Antidiarrheal 2mg 12 caps expired 10/20254 boxes of Acid Reducer 10mg 90 tabs expired 6/20252 bottles of Bisacodyl 5mg 100 tabs expired 4/2025 1 bottle of stool softener 100mg 100tabs expired 7/2025 Per interview on 02/20/2026 at approximately 2:45 PM, the Unit Manager confirmed that the above medications were expired.

Based on record review and interview, the facility failed to ensure 1 of 6 Licensed Nursing Assistants (LNA) had completed the mandatory 12 hours of annual training, and 2 of 6 LNAs had completed dementia training.Findings include: Per review of employee Human Resources files for permanent and contracted staff, the facility had no evidence of the required 12 hours of annual training for LNA #4, hired on 9/8/20/23. LNA #3 with a date of hire of 12/3/1991 and LNA #5 with a date of hire of 4/16/2018 did not have evidence of dementia training. Per interview on 2/2/26 at approximately 3:30 PM, the RN Nursing Supervisor was unable to provide any evidence that LNA #4 had completed their required 12-hour annual training, and LNA #3 and LNA #5 had received the mandatory dementia training. The RN Nursing Supervisor confirmed that the employee files reviewed contained the only documentation the facility had for staff training.

Based on observation, interview and record review, the facility failed to protect a resident's right to a dignified existence by failing to provide access to the first floor of the building in a manner that provided safety and comfort for 1 applicable resident in the sample (Resident #1). Findings include:On 2/9/26 at 12:22 PM and 2/11/26 at 12:30 PM, Resident #1 was observed eating lunch in his/her room.During an interview with Resident #1, on 2/11/26 at 3:58 PM, s/he indicated that s/he recently went to the hospital, and the facility staff used a stair-chair to transport her/him down the stairs to the ambulance. S/He expressed a fear of being dropped on the stairs while being carried down the stairs in the stair-chair. Resident #1 indicated s/he enjoyed taking the elevator to the 1st floor to meet with social services. Over the past few weeks, s/he was unable to access the 1st floor because the elevator was out of service. Resident #1 reported missing the first-floor visits. S/he stated that fear of the chair prevented him/her from visiting the first floor; and s/he preferred to stay in his/her room. Per the care plan, revised 12/21/25, Resident #1 has a diagnosis of Schizophrenia and is exhibiting self-isolating behaviors. Per the care plan, reviewed on 12/29/25, Resident #1 is wheelchair-dependent for mobility, requires assistance from one person to transfer into the wheelchair, and resides on the second floor of a two-story structure.Per the interview on 12/11/26, at 1:25 PM, the Unit Manager stated that the facility was not honoring the rights of Resident #1 because they failed to provide an alternate way for him/her to access the first floor other than the stair-chair which caused Resident #1 to be fearful. She agreed that Resident #1 benefited from the ability to leave the second floor, as s/he rarely participated in activities outside of his/her room.

Based on interview and record review the facility failed to provide the Notice of Medicare Non-Coverage at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies were ending for 1 of 3 residents reviewed (Resident #32). Findings include: Per review of Resident # 32's BNP notice, it revealed the resident's services ended on 10/19/25 and the letter was dated 10/20/25 which did not provide the resident with the required 48-hours. Per interview on 2/11/26 at 1:44 PM, The MDS coordinator confirmed that Resident #32 was not notified that their services were ending on 10/19/25 until 10/20/25, which is less than the required 48-hour notification. Per interview on 2/12/26 at approximately 9:25 AM, the Social Services Director stated Resident #32 had been informed in September of 2025 that their benefits would end on 10/19/25 based on a letter the facility had received from the insurance company. Per interview on 2/12/26 at approximately 9:50 AM, the Social Services Director confirmed that neither Resident #32 nor their family were informed at least 48-hours prior to the services ending and she was aware that this was a federal requirement.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living [ADLs] without assistance receives the proper level of assistance for nail care for 1 of 2 sampled residents (Resident #10). Findings include:Per review of the facilities policy titled Fingernails/Toenails, Care of with a revision date of 2/18, it states that nail care is daily cleaning and regular trimming. It also identifies that personal protective equipment like gloves should be used as needed.Per observation and interview on 2/9/26 at 5:07 PM, Resident #10's fingernails were observed to be long on both hands. Resident #10 was asked if their fingernails were at their desired length and they stated that their fingernails were poking into their skin when they closed their fist and that they wanted their nails shorter. Resident #10 also stated that they were able to peel one of their long fingernails off.Per interview with a Registered Nurse (RN) on 2/11/26 at 3:46 PM, she stated that the Resident #10's fingernails had been cut. When asked to observe Resident #10's feet, the RN assisted Resident #10 with taking off his/her shoes. Resident #10 stated that his/her toe's hurt as the nurse checked his/her toenails. Resident #10's toenails were observed to be long and thick. The RN confirmed that the toenails needed to be trimmed and were thick.

Based on interview and record review the facility failed to provide culturally competent and trauma-informed care by failing to ensure a care plan identified triggers of past trauma and provided interventions for those triggers for 1 applicable resident in the sample (Resident #8). Findings include:Per review of the facility policy Trauma-informed Care and culturally Competent Care revised 8/22, it states: Resident Care Planning, 2). Identify and decrease exposure to triggers that may re-traumatize the resident. Per record review, Resident #8 has a diagnosis of post-traumatic stress disorder. His/her care plan with a review date of 01/08/26, lists several traumatic events. The care plan goal reveals that the resident will feel safe in her living environment and not exhibit any negative psychosocial impact related to experiencing trauma triggers. Per a document titled Primary Care PTSD Screen, dated 4/17/25, it shows that Resident #8's family provided information on traumas that had affected him/her. The resident was startled easily and was afraid of stairs due to past falls.The care plan does not identify triggers that may retraumatize the resident or interventions to mitigate them.Per interview with an LNA on 2/12/26 at 10:45 AM, she stated that she was not aware of Resident #8's triggers.Per interview with the Director of Nursing (DON) on 2/12/26 at 11:04 AM, she confirmed that the care plan did not include identification of triggers or interventions to prevent re-traumatization of Resident #8.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 4 residents in the sample, (Resident #1). Findings include:Per record review, Resident #2 has diagnoses that include schizophrenia, major depressive disorder, and anxiety disorder. Per review of Resident #2's care plan, s/he has a care plan focus that reads, Resident has potential for behavior [related to] schizophrenia, and major depressive disorder, and has [history] of aggression towards others, initiated on 8/12/15. Per an email dated 11/26/25 from the Director of Nursing (DON), Resident #2 was involved in a resident-to-resident altercation on 8/12/24, in which Resident #2 had hit his/her roommate. Per record review, a facility reported incident (FRI) was submitted to the State Agency on 8/1/25, with an allegation of physical abuse related to a resident-to-resident altercation that occurred on 8/1/25 between Resident #1 and Resident #2. The submission revealed that Resident #2 was observed sitting in the dining area when Resident #1 walked out of his/her room and walked by Resident #2. Resident #2 was calling Resident #1 names and struck Resident #1 in the chest multiple times.A 5-day investigation summary, submitted to the state on 8/7/25 includes a documented interview between the facility and Resident #2, where Resident #2 admitted to striking Resident #1. S/He admitted that s/he does not like Resident #1 because s/he walks around in his/her briefs. The 5-day investigation summary verified that physical abuse occurred to Resident #1.Per interview with the Director of Nursing (DON) on 11/25/25 at approximately 9:40 AM, she stated that this incident did occur as reported in the FRI submitted on 8/1/25.

Based on interviews and record review the facility failed to create and implement a policy related to national background checks for their employees. The facility also did not complete national background checks for 19 of the 22 Licensed Nursing Assistants (LNAs) employed by the facility. Findings include: Record review of 5 LNA human resource files revealed there was no evidence of national background checks for 3 of the LNAs sampled. The facility provided an additional list of all LNAs employed at the facility and confirmed that only three of the 22 LNAs had evidence of national background checks. Per interview with the Clinical Lead Registered Nurse (RN) on 12/18/2024 at approximately 12:00 PM, s/he stated that the facility did not complete national background checks for their employed LNAs. Per record review, a memo from [Department of Aging and Independent Living] was sent out to nursing facilities on October 5, 2022, that states, 1. Prior to employing an individual and at least annually thereafter, a Facility must query the following entities regarding the prospective / current employee: .Agency providing a national criminal background check . To check whether the individual is barred from employment based on prior convictions in any state .2. Under [NAME] and federal laws and regulations, a Facility must decline to employ a prospective or current employee with: .Criminal convictions for the abuse/exploitation/neglect of a vulnerable adult or child in any state . In addition to the prohibitions mentioned above, [NAME] laws prohibit long-term care facilities from employing individuals with criminal convictions relating to bodily injury, theft or misuse of funds or property, and/or crimes inimical to the public welfare. Per review of the facility policy titled Abuse Prevention Program last revised 12/2016 states the following As part of the resident abuse prevention, the administration will . Conduct employee background checks .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of residents. The policy did not specify the requirement for national background checks. Per interview with the Clinical Lead RN on 12/18/2024 at 2:00 PM, s/he confirmed that s/he was not aware of the memo and that the abuse policy had not been updated to reflect requirement to complete at least one national background check for their employees. S/He also confirmed that the national background checks had not been done for the employees and they should have been.

Based on interview and record review, the facility failed to ensure Care Plan interventions were implemented for three residents [Resident #27, Resident #39, and Resident #294] of 21 sampled residents. Findings include: 1. Per review of the medical record for Res. #27, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to immobility, urinary incontinence, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 6/27/24 and have not been revised. A review of nursing documentation titled Assessments for Resident #27 showed skin checks done on 6/22/24, 7/23/24 and 8/27/24, only 3 times in 24 weeks. 2. Per review of the medical record for Res. #39, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to incontinence, immobility, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 7/31/24 and have not been revised. A review of nursing documentation titled Assessments for Resident #39 showed a skin check done on 7/16/24, only once in 19 weeks. 3. Per review of the medical record for Res. #294, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to incontinence, immobility, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 7/23/24 and have not been revised. A review of nursing documentation titled Assessments for Resident #294 showed skin checks done on 7/11/24 and 12/10/24, only twice in 20 weeks. During an interview on 12/17/24 at 12:38 PM with a Licensed Practical Nurse and the Director of Nursing, both staff members confirmed interventions of Weekly skin checks by a Licensed Nurse to prevent alterations in skin integrity were not implemented for Residents #27, #39, and #294 per their plans of care.

Based on interview and record review, the facility failed to ensure that two residents [#39 & #11] of 21 sampled residents remained as free of accident hazards as possible regarding adequate supervision, implementing interventions to reduce hazards and risks, and assessing interventions for effectiveness. Findings include: 1.) Per record review, Res. #39 was admitted to the facility with diagnoses that include Alzheimer's disease, anxiety disorder, and muscle weakness. A Quarterly Fall Risk assessment dated [DATE] identified the resident as a High Risk for falls, determining the resident was disoriented, had a history of recent falls, with poor vision, poor safety judgement and attempted to get out bed and chairs unsafely. Review of Res.#39's Care Plan identifies the resident as is at risk for falls due to unsteady gait when tired, Alzheimer's disease, and history of falls. Record review reveals Resident #39 had sustained 4 falls in the past 2 months, including 2 falls on back-to-back days on 11/23 & 11/24/24. Further review revealed Res.#39 suffered a 5th fall on 12/5/24. Review of Progress Notes record the resident was Combative at care, screaming, hitting, and pinching. This evening, [staff] was standing near the nurses' station, [Res.#39] was observed watching a Christmas movie and suddenly standing up from the wheelchair in a jumpy way and landing on [h/her] palms and knees on the floor before staff were able to intervene. Resident was combative during assessment, screaming and trying to grab onto [staff]. In the days following the fall, Progress Notes [dated 12/7/24] record Res.#39 continues to be combative with care, as well as with redirection, with interventions such as Reapproach/reassurance assessed as ineffective. Per review of the facility's Fall and Fall Risk, Managing policy, under the policy's Resident-Centered Approaches to Managing Falls and Fall Risk section is If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Additionally, under Monitoring Subsequent Falls and Fall Risk is If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. [Policy version 1.2 (H5MAPL0313) revised 2018]. Per interview with the Director of Nursing [DON] on 12/17/24 at 12:38 PM, the DON confirmed the facility's policy is to review a resident's Care Plan after each fall and add additional interventions to prevent future falls. Per record review and confirmed during the DON interview, there were no new interventions added to Res. #39's Care Plan after the fall on 12/5/24 to prevent the resident from falling again. 2.) Per record review, Res.#11 was admitted to the facility with diagnoses that include: dementia, schizophrenia, anxiety, depression, and psychosis, as well as difficulty in walking, muscle weakness, muscle wasting, and unsteadiness on [h/her] feet. Review of Res.#11's Care Plan identifies the resident as at risk for falls due to: poor safety awareness due to Schizoaffective Disorder, Anxiety, Depression, and Psychosis, poor posture when ambulating, and using furniture to walk. Record review reveals Resident #11 had sustained 3 falls in the past 4 months, including a fall with bruising to their forehead. Further review revealed Res.#39 suffered a 4th fall on 12/5/24. Review of Progress Notes record the resident was found sitting on [h/her] buttocks in [h/her] room, in between bathroom door and [h/her] wheelchair in front of [h/her]. Per interview with the Director of Nursing [DON] on 12/17/24 at 12:38 PM, the DON confirmed the facility's policy is to review a resident's Care Plan after each fall and add additional interventions to prevent future falls. Per record review and confirmed during the DON interview, there were no new interventions added to Res. #11's Care Plan after the fall on 12/5/24 to prevent the resident from falling again.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 21 sampled residents (Resident #20). Findings include: Per observation on 12/17/24 at 1:37 PM Resident #20 unwrapped a gauze dressing covering a wound on their hand. The dressing was visibly soiled with blood. Resident #20 unwrapped the gauze until it was dangling from their hand and touching the floor of the dining area/TV room. At this point a staff Licensed Nursing Assistant [LNA] who was not wearing gloves began to redress the wound with the same gauze. Moments later a staff Registered Nurse [RN] came over to assist. The RN providing care to the resident was also not wearing gloves. Once Resident #20's hand was fully wrapped the staff RN secured the gauze with the original tape which had been stuck to the arm of Resident #20's chair. In an interview with the facility's Director of Nursing [DON] on 12/18/24 at 1:36 PM the DON confirmed that the soiled dressings that had been in contact with the floor should not have been reused to dress the wounds on Resident #20.

Based on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility by locking all doors to the facility 24 hours a day, seven days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This can potentially affect all residents of the facility and all visitors, including family, legal representatives, and advocates. During an observation on 5/15/24 at 9:20 AM, this surveyor encountered a barrier to entry. The front door to the facility was locked. The only way to gain access was to press a doorbell, which alerted the staff. A staff member then had to come and physically open the door. The staff member explained that to exit the facility, a staff member would have to access a keypad on the side of the door and enter a code to open the door . Per observation on 5/15/24 at 9:40 AM, another entrance to the facility is located on a wing that houses resident rooms and egresses out to a porch. This door is locked with a keypad panel on the side and requires a code to open it. Per interview on 5/15/24 at 10:00 AM, the Director of Nursing (DON) stated that only employees can have the codes to open the outside doors; residents may not have access to this code. Per interview on 5/15/2024 at approximately 10:15 AM, the Administrator and the DON stated that the doors are always locked and have been since they can remember. Per the Administrator, the facility has alert and independent residents in their population. The Administrator could not locate a policy or procedure for the doors being locked or operating a completely locked facility. The DON stated that only employees know the code. When asked if there is a process for assessing residents and ensuring those without safety risks can exit the building independently, the DON stated, We had an issue recently; therefore, residents may not have the code. The DON confirmed that residents cannot exit the building anytime without staff assistance. Per interview, on 5/15/2024 at approximately 12:30 PM, Resident # 1 has resided at the facility since 2014 S/he states that s/he frequently uses the porch outside the locked entrance on the side of the facility. S/he often leaves the facility for outside interests. In the past, s/he was allowed to have the code to the locked doors to exit the facility independently. Recently, the combination was changed, and s/he was told that only the staff would be allowed to have the code. It's not as easy to come and go; I have to call the staff to let me out and then ring the bell to be let back in. Per interview on 5/15/24 at approximately 12:40, Resident #2 has resided at the facility for the past two years, s/he states s/he enjoys the chairs outside and frequently exits the building to sit in them. S/he states a staff member must access the code on the door to open the door and let him/her out. S/he must ring a bell outside the door and wait for a staff member to open it. S/he does not have access to the door code. I have had to ask the staff for assistance to go out since I have been here. Per an interview at approximately 2:00 PM, the DON confirmed that only the staff were given the code to open the exterior doors; s/he confirmed that s/he could not locate a policy or procedure addressing the locked facility.

Based on interview and record review, the facility failed to ensure a timely report of an incident of suspected resident-to-resident abuse for 2 of 2 residents (Resident#1 and Resident #2). Findings include: Review of a nursing progress note from 1/8/24 revealed that Resident #1 had approached Resident #5 and started to pull on Resident #5's wheelchair, when s/he told Resident #1 to stop, Resident #1 became angry and slapped Resident #5 on the right arm. A review of the facility's internal investigation file related to this incident on 1/8/24 revealed confirmation from Adult Protective Services (APS) that a report for this incident had been made to that agency however, there was no documentation or confirmation to support that a report had also been made to the State Agency (SA) which is a requirement. An interview on 2/20/24 with the Director of Nursing (DON) revealed that s/he believed s/he had reported the incident to APS and to the SA via an email sent through the facility fax machine. However, when this surveyor reviewed the ASPEN Complaint Tracking System (ACTS) on 2/20/24 during a previous facility-report complaint investigation, the report was not found, indicating that the suspected abuse report related to the incident on 1/8/24 had not been submitted to the SA. On 2/20/24 it was noted that the email address in the initial report was incorrect and therefore the report failed to reach the SA. The DON confirmed that the email address was incorrect on 2/20/24 and further indicated that s/he would send the report to the SA immediately. During the Facility Report Incident (FRI) investigation on 2/28/24, the DON confirmed the report was submitted 44 days late.

Based on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 3 sampled residents. (Resident #2) Findings include: Resident #1 has resided at this facility since 5/19/22, with diagnoses that include Alzheimer's, severe vascular dementia, and an agitation-induced psychotic disorder. Resident #2 has resided at the facility since 9/19/23 with diagnoses that include end-stage lewy body dementia and parkinsonism. Per record review, a witnessed resident to resident incident occurred between Resident #1 and Resident #2 on 12/9/23 at 5:47 AM. Resident #2 was standing in the doorway of his/her room, Resident #1 walked up to Resident #2 without speaking and hit her/his legs with her/his cane. Resident #2 attempted to move Resident #1 out of his way by grabbing his shirt; both residents fell to the ground. The investigative summary indicates Resident #2 could recall the incident and stated [Res. #1] whacked me three times on both legs [he/she] starts trouble with everyone. A review of statements by two witnesses dated 12/9/23 at 5:47 AM reveals that Resident #2 was standing in the doorway of their room when Resident #1 walked by and hit Resident #2 on his/her legs with his/her cane. Both witnesses attempted to intervene and re-direct but were unsuccessful, and the altercation continued, with both residents falling to the floor. A review of Resident #1's care plan indicates the following interventions initiated on 5/23/22 and reviewed on 12/5/23: utilize staff for one-on-one time if the resident is not easily directable, encourage residents to use his/her cane appropriately and not use it to hit others. Another intervention initiated on 11/9/23 and reviewed on 12/5/23 states, When resident is walking the halls, she/he will be closely monitored to ensure the safety of all residents and allow staff to intervene if s/he swings her/his cane. A progress note dated 12/13/2023 states that the resident is pacing the halls, swearing at staff, and taking food from another resident's plate; when a redirect was attempted, [s/he] hit staff with a fist and then a cane. Another note dated 12/28/23 reveals resident wandering into several resident rooms, shouting at other residents. Refusing to leave other resident's rooms when staff tried to re-direct, pulled glasses off a female resident's face. Hit a nurse with her/his cane who was attempting to re-direct. An interview was conducted with another resident on Res.#2's unit, Resident #3, on 1/2/24 at approximately 1:00 p.m. Res. #3 stated that s/he does not leave her/his room often as Resident # 1 will enter the room, rifle through her/his belongings, and often become aggressive, banging the cane on the floor and threatening to hit her/him. S/he feels safer in the room than in a common area. Per interview on 01/02/24 at 3:30 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing, they confirmed that Resident #1 struck and pushed Resident #2 and struck out at the staff when they tried to intervene or redirect his/her behaviors. The DON confirmed that the facility was not keeping the residents free from physical abuse.

Based on record review and interview the facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for 1 of 8 sampled residents (Resident #5). Findings include: Resident #5 was admitted to the facility in May 2023 with diagnoses including heart failure, chronic kidney disease stage 3, major depressive disorder, and chronic obstructive pulmonary disease (a lung disease). A review of the Minimum Data Set (MDS ; an assessment tool used to gather information relevant to care plan development among other uses) dated 7/23/23 reveals in Section B regarding hearing/speech and vision, vision is assessed as highly impaired-object identification in question, but eyes appear to follow objects. Resident #5 has a current Brief Interview for Mental Status (BIMS) score of 13 (this score reflects cognitive function and ranges from 1-15 with lower scores indicating a higher level of impairment). A record review reveals the following physician documentation dated 10/3/23 . Resident has had 4 falls since last seen. [His/her] falls are mostly unwitnessed and occur in [his/her ] room with the oxygen off! [He/she] is commonly found sitting on [his/her] buttocks. Has had some scrapes from the falls but no significant injuries. Records indicate the falls referenced in the physician's note occurred on 8/20/23, 9/7/23, 9/9/23, 9/10/23. A progress note dated 10/4/23, the day following the physician's visit, reveals that Resident #5 was observed face down in lying position by the closet door with [his/her] walker beside [him/her]. The resident was assessed and stated that [he/she] hit [his/her] head and [his/her] left arm and shoulder and that it was hurting really bad. Resident was noted to have a skin tear to left elbow. Resident #5 was sent emergently to the local emergency department where he/she spent several hours and was found to have a distal radius and ulnar styloid fracture of the left forearm (a break of both bones in the forearm) requiring splinting. Resident #5's care plan was reviewed and noted to contain the nursing diagnosis Fall risk related to unsteady gait, chronic obstructive pulmonary disease, peripheral vascular disease [limited blood flow to extremities], hearing impaired, glaucoma, wears [bilateral ] hearing aids. This care plan entry was created 4/20/23 with a review date of 5/19/23. Beneath the entry is an additional notation stating [Resident #5]'s family reports that [he/she] is legally blind and has an unsteady gait. The Interventions included and intended to be a response to the risk of falls, include three that are written notices intended to be read and understood, which, based on the MDS visual assessment as well as the family report of legal blindness are unrealistic and proved to be ineffective: 1. Place a sign on walker to remind me to call for assistance before I ambulate by myself. 2. Put stop sign on oxygen tank to help deter turning oxygen settings. 3. Visual aide in room to remind [patient] to call for assistance before ambulating. There was no evidence that the Resident's ability to read the signs was assessed. There is also an intervention of every 15-minute safety checks to ensure {resident name} is safe and ask if he/she is needing anything. On 10/10/23 at approximately 3:45 PM the Licensed Practical Nurse (LPN) MDS coordinator provided a fall assessment for Resident #5 with a completion date of 5/4/23 and a next due date of 8/2/23, this assessment had a total score of 10 labeled HIGH. The LPN confirmed no other fall assessments had been done. The facility policy entitled Falls and Fall Risk, Managing with a revision date of March 2018 was reviewed. There is no reference to the fall risk assessment or how to use the scores determined by the assessment. On 10/11/23 at approximately 10:30 AM the Director of Nursing (DON) was interviewed regarding Resident #5 and their care plan interventions related to falls. The DON stated he/she had updated the care plan following the most recent fall by adding visual aide in room to remind pt to call for assistance before ambulating, and will refer to PT [physical therapy] for evaluation related to frequent falls and generalized weakness [status post] recent illness. The DON was not certain if a therapy evaluation had been completed and the care plan did not reflect any new interventions from a physical therapy screen or assessment. The DON also stated he/she was unaware that Resident #5 had impaired vision and had missed noticing that on the care plan, and did not know if Resident #5 was on 15-minute checks. Following this conversation , the surveyor and DON went to the medication nurse to request the 15-minute check sheet to verify the 15-minute checks were being completed per the care plan. The nurse advised there were no residents on 15-minute checks. The DON was able to locate check sheets that had been done every 30 minutes (although the care plan called for 15-minute checks) between 9/10/23-9/28/23 and appeared to have been discontinued without any explanation prior to the 10/4/23 fall with injury resulting.

Based on resident representative and staff interviews and record review, the facility failed to create and implement an individualized person-centered plan to render trauma-informed care to a resident with a personal history of trauma, related to witnessing a relative drown, for 1 of 20 residents sampled (Resident #30). Findings include: Record review reveals that Resident #30 was admitted in April 2021 with diagnoses including Alzheimer's disease, muscle weakness, and major depressive disorder. On 10/9/23 at approximately 12:20 PM, Resident #30's Representative noted that at times Resident #30 does not appear to have been bathed and at other times they receive reports that Resident #30 has assaultive behaviors that occur during bathing. Resident #30's Representative detailed a past traumatic event during which Resident #30 was witness to a family member drowning and has had a terror of water ever since. Per the Representative, this traumatic event was discussed with the Social Services Director during a care planning meeting. During a review of the care plan for Resident #30 an entry for activities of daily living is noted to include the requirement of 1-2 staff for bathing assistance however there is no mention of triggers related to water-induced trauma, strategies, approaches, or staff response to resultant behaviors. A review of the bathing record for Resident #30 between 9/1-10/9/23 reveals during the 6 week period Resident #30 received 3 tub baths. Per interview on 10/9/23 at 10:37 AM, the Social Services Director confirmed that s/he was made aware of Resident #30's history of trauma during an 8/31/23 a care planning meeting but was unsure of how that could be incorporated into the care plan. On 10/10/23 at 11:30 AM the Director of Nursing confirmed that resident-centered individualized information related to trauma-informed care was not in the care plan. On 10/10/23 at 1:30 PM a Licensed Nursing Assistant (LNA) described the bathing process for Resident #30 as horrible and stated that when they lower the resident into the water [s/he] screams and hits, [s/he] screams like you're killing [him/her], and I don't know if it's the water or what it is but we have to do it we can't have [him/her] stinking. Resident #30 was interviewed by the surveyor on 10/10/23 at approximately noon, Resident #30 demonstrated cognitive impairment and appeared unable to comprehend questions therefore was unable to describe any potential psycho-social outcomes related to his/her bathing experience. However, employing the reasonable person concept which allows determination of the severity of the psycho-social outcome or potential outcome the deficiency may have on a reasonable person in the resident's position it is clear that if one had a terror of water as Resident #30 has the experience of being lowered into the water despite screaming like one is being killed represents psychosocial harm.

Based upon interview and record review, the facility failed to ensure it used the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week for 52 days from April 1st, 2023, to Oct. 1st, 2023. Findings include: A review was conducted of the facility's staffing schedules from April 1st, 2023, to Oct. 1st, 2023 regarding nursing care provided to the facility's residents. Review of the staffing schedule for April 2023 revealed 10 days with no RN scheduled [4/3, 4/6, 4/10, 4/14, 4/17, 4/20, 4/24, 4/25, 4/26, 4/27]. May 2023 included 6 days with no RN coverage [5/8, 5/21, 5/22, 5/27, 5/28, 5/29], June 2023 included 3 days [6/10, 6/11, 6/28] and July 2023, 7 days [7/4, 7/5, 7/6, 7/15, 7/16, 7/20, 7/29]. August 2023 documented 15 days without RN coverage, including 5 consecutive days [8/1, 8/5, 8/8, 8/10 thru 8/14, 8/17, 8/18, 8/22, 8/26, 8/27, 8/30, 8/31] and September thru October 1st, 2023, included 11 days with no RN scheduled [9/2, 9/3, 9/8, 9/9, 9/10, 9/12, 9/14, 9/22, 9/23, 9/24, 10/1]. An interview was conducted with the facility's Administrator [ADM] and Director of Nursing [DON] on 10/11/23 at 11:27 AM. The ADM and DON both confirmed that the facility had no Registered Nurse scheduled or present in the building for a minimum of 8 hours daily as required by regulation on the 52 dates listed above.

Based on staff interview and record review, the facility failed to ensure 1 applicable resident ( Resident # 1) was free from physical abuse. Findings include: On 1/3/23, Resident # 1 initiated a physical altercation with Resident # 2, causing physical harm. Residents # 1 and 2 are roommates. Previously, on 9/10/22, an altercation occured between Residents # 1 and 2. A 9/10/22 nurses note stated that Resident # 1 had hit, punched and kicked Resident # 2. The Residents continued to live in the same room until 1/3/23. On 1/3/23, Resident # 1 was found by staff standing over Resident # 2's bed after staff heard screaming from the room. A nurses note dated 1/3/23 stated that Resident # 2 appeared to have a scratch on the left side of his face, above his lip that was bleeding and there was also red markings on the resident's neck. Resident #2 stated that Resident # 1 was hitting him in the face . On 1/4/23, Resident # 2 decided to press charges on Resident # 1 regarding the altercation that took place on 01/03/2023. Resident # 1 was issued a citation for simple assault by [NAME] State Police on that date. The above was confirmed by the Director of Clinical Services on 1/10/23 at 11:27 AM.