Every finding on record at Vermont Veterans' Home

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident #1 and Resident #2) remained free from misappropriation of property. Findings include: #1 Per record review, Resident #1 has diagnoses that include Parkinson's Disease, PTSD (post-traumatic stress disorder), dementia, schizoaffective disorder bipolar type, and psychotic delusions. Per an MDS (Minimum Data Set, a resident assessment tool) dated 10/2/25, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, indicating fully intact cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per review of the facility investigation, Resident #1 told the LCSW (Licensed Clinical Social Worker) that he had been giving LPN #1 money. S/he reported that LPN #1 asked for it for gas and cigarettes. LPN #1 did not repay the money. Per review of the police report, Resident #1 he had given LPN #1 money for gas and cigarettes when she didn't have money. S/he could not recall how much, but that it was approximately $30 on several different occasions. The police made contact with LPN #1 on 10/6/25 at 12:40 PM. LPN #1 stated that she accepted money from Resident #1, 4 to 5 times, in amounts ranging from $20 to $60 and stated that she knew she was not supposed to accept money from residents. LPN #1 has been charged with two counts of Financial Exploitation of an Older Adult. Per record review, Resident #1 has a care plan focus dated 6/5/26 which states, On 10/6/25, [Resident #1] disclosed that a staff member had asked for money from [her/him] and [s/he] gave money to this person. Immediate report made to APS, L&P and [NAME] PD concerning financial exploitation. This care plan focus goes on to say that Resident #1 has been referencing this situation more frequently as the staff person in question has a relative who recently came back to work there and states that LPN #1 still has not apologized to him. The facility follow-up investigation report to Survey & Certification states that [Resident #1] is depressed, anxious and sometimes angry in regard to LPN #1's actions. Per record review of the facility investigation follow-up report submitted to Survey & Certification, the facility verified misappropriation of funds from Resident #1 by LPN #1. Per interview with the Administrator on 6/9/26 at 11:40 AM, she confirmed that the facility had verified misappropriation of funds from Resident #1 by LPN #1. The Facility Employee Handbook policy on gratuities states that Employees are not to accept or solicit gratuities from Residents, their families, or friends. #2 Per record review, Resident #2 has an MDS (Minimum Data Set, a resident assessment tool) dated 9/10/25, which lists a BIMS (Brief Interview for Mental Status) score of 15, indicating fully intact cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per facility investigation, Resident #2 said s/he gave LPN #1 $150 approximately 6 weeks ago to purchase cigarettes and stated s/he was heartbroken over the situation. Per the police report, the investigating officer was approached by Resident #2 after he had interviewed Resident #1. Resident #2 stated s/he had given LPN #1 $110 in cash 6 weeks ago to purchase cigarettes for her/him and stated that LPN #1 had not made any attempt to pay her/him back or given her/him any cigarettes. LPN #1 confirmed that Resident #2 had given her $110 for cigarettes approximately 6 weeks prior and that she had not purchase her/him cigarettes or returned the money. Per record review of the facility investigation follow-up report submitted to Survey & Certification, the facility verified misappropriation of funds from Resident #2 by LPN #1. Per interview with the Administrator on 6/9/26 at 11:40 AM, she confirmed that the facility had verified misappropriation of funds from Resident #2 by LPN #1. The Facility Employee Handbook policy on gratuities states that Employees are not to accept or solicit gratuities from Residents, their families, or friends. Based on corrective actions completed prior to the onsite survey, this citation is designated as past non-compliance. The following actions were completed by the facility: Following an investigation, LPN #1 no longer works at the facility. The facility has obtained a no trespassing against LPN #1 to prevent her from coming on their grounds. Alert and oriented residents on the affected units were interviewed after the incident and there were no additional findings. The facility updated their resident trust policy and their policy on staff accepting gifts or gratuities. Facility staff have been educated on the new policies. Residents have been educated via resident council and individually about what to do if staff asked for money as well as information placed in their newsletter about what to do if asked about a gift. Resident trust accounts are monitored for large withdrawals and any outliers are investigated, and more specific documentation is required for resident purchases. The administrator audits this process. The facility's corrective actions were completed on 11/5/25.

Based on interview and record review, the facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and failed to maintain effective supervision that would reduce the likelihood of incident or injury for 1 of 2 residents in the applicable sample (Resident #93). As a result, Resident #93 suffered a facial burn that resulted in pain, redness, and loss of skin. This is a repeat deficiency for this facility, with the violation cited during the previous re-certification survey, dated 1/29/25. Findings include:Based on interview and record review, the facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and failed to maintain adequate supervision for 1 of 2 residents in the applicable sample (Resident #93). As a result, Resident #93 suffered a facial burn that resulted in pain, redness, and loss of skin. Findings include:Per a record review, Resident #93 was recently admitted to the facility's long term care unit from residential care due to increased care needs, with diagnoses that included nicotine dependence and respiratory failure.A smoking assessment completed on 2/11/26, noted Resident #93 as an unsupervised smoker who is allowed to keep their cigarettes with them but needs to request their lighter when they wish to smoke.Nursing progress notes dated 2/16/26, reflect that the resident had increasing agitation and confusion throughout the night requiring increased staff supervision and was receiving 4 liters of continuous oxygen via nasal canula. A nursing progress note written at 6:51 am states that at 6:20 am nursing staff observed black soot on the Resident's nose and burned oxygen tubing under their nose. When nursing staff asked the Resident what had happened s/he stated that another resident had lit his/her cigarette, and it had caught on fire. The note also states that Resident #93 sustained a burn to his/her face with a width of 0.67 centimeters, length of 1.53 centimeters and area of 0.58 centimeters, noted to be painful.Review of Resident #93's care plan revealed that the facility had failed to care plan his/her smoking status, including the hazard of Resident 93's oxygen, until 2/17/26, the day after the resident sustained a facial burn when his/her cigarette was lit while s/he was using oxygen.The facility policy titled Smoking Policy Nursing Home - Veterans & Members, revised 8/15/22, states that oxygen use is prohibited in smoking areas.Per interview with the DON (Director of Nursing) on 3/11/26 at 3:31 PM, she confirmed that Resident #93 went to the smoking room with his/her oxygen on and sustained a burn due to his/her cigarette being lit. She also confirmed that a sign prohibiting the use of oxygen in the smoking room was not placed on the smoking-room door until after Resident 93's burn injury was sustained.Ref. F655Based on corrective actions completed prior to the onsite, this citation is designated as past non-compliance. The following actions were completed by the facility:Resident #93 continued to have supervision with smoking and was reassessed per facility policy.The facility reassessed all residents who smoke to ensure assessments and care plans are up to date.The facility updated their smoking policy to clearly define the steps to be taken when the resident who is on oxygen is also a smoker.All independent smokers were re-educated that they are not to assist other smokers with lighting their cigarettes, as well as how to call for assistance from the smoking room and the location of the nearest fire alarm pull station.Staff were educated on the updates to the resident smoking policy.A security camera was installed in the smoking room to provide a recording that can be reviewed if future incidents take place.Signage was posted in the smoking-room regarding emergency procedures and the prohibition of oxygen in the smoking room.The administrator is auditing changes in conditions in smoking residents that might impact their smoking.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and failed to ensure freezers were maintained at the appropriate temperature. Findings include:Per observation of the kitchen freezer on 3/9/26 at 11:36 AM there was a pack of three sausages and a package of smart dogs opened in the freezer with no date or label. In the dry storage area, there was a 10-pack of instant grits with an expiration date of 11/25. There was a 13.7-ounce bag of cheese queso that had expired on 6/12/25. An interview was conducted with Kitchen Staff Member #1 on 3/9/26 at approximately 11:40 AM. The Kitchen Staff Member confirmed these items were expired. He confirmed that the package of sausages and smart dogs were opened and unlabeled.Per observation of the kitchen on 3/11/26 at 9:01 AM there was one package of open and undated hot dog buns and two packages of hamburger buns with no date or initial. The package of sausages and smart dogs were still in the freezer. An interview was conducted with Kitchen Staff Member #2 on 3/11/26 at approximately 9:05 AM. Kitchen Staff Member #2 confirmed that these items should have been thrown away stating, I'll throw those away.Per the facility's Dietary-Food Storage policy [last revised 7/23] it states, 12. All Refrigerators and freezers will meet national sanitation foundation standards and will follow recommended temperatures. A. Temperature for freezer and refrigerator units will be monitored on a regular basis and equipped with a Fahrenheit thermometer which can easily be read. B. Elevated temperatures will be immediately brought to the attention of the Dietary manager or designee and environmental services.Per review of the facility's freezer logs, on 2/8/26, the C wing freezer was recorded at 10 degrees F [Fahrenheit]. On 2/10/26, the North wing freezer temperature was recorded at 5 degrees F. On 2/11/26, the North wing freezer temperature was recorded at 5 degrees. On 2/12/26, the North wing freezer temperature was recorded at 5 degrees F.Per interview with the Food Service Coordinator on 3/11/26, at approximately 12:00 PM, the Food Service Coordinator confirmed that these temperatures for the freezer were elevated stating, We tell maintenance about this and put a work order in. The Food Service Coordinator confirmed that she did not submit the work orders for the freezers after these elevated temperatures were documented.

Based on observation and interview, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents who reside on one of three units of the facility. Findings include: Per observation on 3/9/26 at 1:53 PM in the bathing room on the 500 halls of the Cardinal memory care unit, the tub had chipped paint on both the seat and the tub itself. There were damaged tiles and debris in one of the two shower stalls. The toilet backrest had cracks in the padding and rust on the framing. On both the 500 and 600 halls of the Cardinal memory care unit, there were stained and damaged ceiling tiles, including outside of room [ROOM NUMBER]. The room number signs were missing outside of rooms [ROOM NUMBERS], with the room numbers instead written in with magic marker on the walls outside the room. These items were reviewed and confirmed per interview and tour with the Administrator, Director of Nursing, and Quality Assurance Nurse on 3/11/26 at 10:45 AM.

Based on observation and interviews the facility failed to ensure all drugs and biologicals were stored in locked compartments for 3 of 7 medication carts on two units. Findings include: Per observation on the [NAME] Unit on 3/9/26 at 2:01 PM a medication cart and a treatment cart were found unlocked, with no staff in the hallway. One resident observed ambulating near the medication cart.Per interview with the Registered Nurse (RN) assigned to the medication cart on 3/9/26 at 2:19 PM confirmed the medication and treatment cart were both unlocked. The medication cart contained medications, inhalers, topical patches, syringes, topical medications, Insulins, prescribed resident specific medications and narcotics in a separate locked compartment. The treatment cart contained wound cleansers, prescription topical creams/pastes, and prescription topical powders.Per interview with RN Unit Manager of the [NAME] Unit on 3/9/26 at 2:24 PM confirmed that medication carts left unattended in common areas with residents should be locked so that the contents within the cart are not accessible without the key.Per observation on the [NAME] Unit on 3/10/26 at 7:54 AM the medication cart was found unlocked.Per interview with RN Unit Manager of the [NAME] Unit on 3/10/26 at approximately 8:00 AM confirmed the medication cart was unlocked and it should not be.During observations on the North Village Unit on 3/12/26 at 7:45 AM, the medication cart was found unlocked, with no staff in the corridor and a resident sitting next to it. Per interview on 3/12/26 at 7:48 AM, the Licensed Practical Nurse assigned to the medication cart confirmed that the cart was not locked, as it should be, and that a resident was sitting next to the unlocked, unattended cart.Per review of the facility's policy titled, Medication Labeling and Storage it states, Compartments (including drawers cabinets rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and treys or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to develop a baseline care plan that addressed the smoking needs of 1 of 2 residents in the applicable sample (Resident #93). Findings include:Per a record review, Resident #93 was admitted to the facility on [DATE] with diagnoses that included nicotine dependence and respiratory failure.A smoking assessment dated [DATE] states that Resident #93 is capable of holding his/her own cigarette and smoking unsupervised. The assessment also states that his/her lighter would need to be secured by nursing and would be available as needed.A nursing progress note dated 2/12/26 states that Resident #93 went to smoke several times that day and had to be reminded repeatedly to wear O2 (oxygen). Another nursing progress note dated 2/13/26 states that the Resident went to smoke that day.Further review of nursing progress notes reveals that on 2/16/26 at 6:51 am Resident #93 approached the door of the North unit medication room with black soot on their nose and their oxygen tubing was burnt. The Resident stated that their cigarette had caught on fire from their oxygen. The progress note also states that the Resident had left the unit and went to the smoking room with their oxygen in place. Another Resident in the smoke room lit the cigarette. The other Resident stated that Resident #93 took 2 puffs of the cigarette and then it caught fire in his/her face. The fire went out by itself and Resident #93 left the smoking room. Resident #93 sustained a superficial burn to his/her face with a width of 0.67 centimeters, length of 1.53 centimeters and area of 0.58 centimeters, noted to be painful.A nursing progress note dated 2/16/26 at 7:55 pm states the skin was burned off the tip of Resident #93's nose after his/her smoking-room incident.Review of Resident #93's care plan that was in place while he/she was a resident of the residential care unit initiated 6/2/25 revealed that it did not address his/her smoking status, including the resident's use of oxygen, until 2/17/26, the day after the resident sustained a facial burn when his/her cigarette was lit while s/he was using oxygen.During an interview with the ADON (Assistant Director of Nursing) on 3/11/26 at 11:06 AM, the ADON confirmed that the care plan from the residential care unit would be considered the baseline care plan on admission to the long-term care facility. The ADON was unable to provide documented evidence that the Resident's baseline care plan addressed the smoking needs that were reflected in the Resident's smoking assessment until 2/17/26, the day after the incident.The facility policy titled Smoking Policy Nursing Home - Veteran & Members, states any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted in the care plan, and all personnel caring for the Veteran & Member shall be alerted to these issues. (Revision 8/15/22)

Based on observation, interview, and record review, the facility failed to ensure that infection control measures regarding hand hygiene were followed during medication administration for two (Resident #1 and Resident #89) of 9 residents sampled. Findings include:During observation of medication administration on 3/11/2026 at 11:50 AM, there were 9 missed opportunities for proper hand hygiene. An LPN (Licensed Practical Nurse) did not use hand sanitizer or soap and water as required before or after wearing gloves, when preparing and administering medications, or when using and cleaning a glucometer (a device used to collect blood for measurement of glucose). The LPN failed to cleanse hands before and after glove use to: Prepare an oral medication for Resident #1Administer an oral medication to Resident #1Prepare eye drops and glucose testing for Resident #89Instill eye drops for Resident #89Test Resident #89's blood glucose level with a glucometer Cleanse the glucometer and dispose of used testing suppliesPrepare an insulin injectionAdminister insulin by injection to Resident #89Upon completion of the injection Per interview on 3/11/2026 at 12:05 PM, the LPN confirmed that hand hygiene should be performed before and after putting on gloves, direct contact with residents, preparing or handling medication, and visiting a resident's room, as well as after handling contaminated equipment (e.g., glucometer). Facility policy titled Hand Hygiene Policy (no review date) states that gloves do not replace hand washing/hand hygiene and that a hand sanitizer containing at least 62% alcohol will be used before preparing or handling medications, before and after direct contact with residents, and after removal of gloves.

Based on observation, interview, and record review, the facility failed to ensure 4 out of 17 sampled residents (Resident #13, #17, #40, #52) received sufficient supervision to prevent resident to resident altercations, and failed to ensure the environment remains as free of accident hazards as is possible for 1 of 17 sampled residents (Resident # 1). Findings include: 1). A facility investigation report of a resident to resident altercation on 6/20/24 submitted to the State Agency stated staff heard veterans yelling in the porch area. When staff found the two residents [Resident #40] was holding [Resident #52's] right forearm. [Resident #52] stated, [S/he] hit me. Per the facility investigation, both residents were in the porch area without staff present when the altercation occurred. Per an Incident Note dated 6/13/24, [Resident #52] had red areas on the right lateral forehead and one red area on the left temple and mild redness on right lateral forearm. Per review of Resident #40's care plan dated 8/24/22 [Resident #40] mood can be labile going from happy go lucky to angry. During [his/her] angry outbursts [S/he] can have verbal aggression; yelling, screaming, and using abusive language with a history of resident to resident altercations. [S/He] can become physically aggressive and violent [toward staff and other residents]. Interventions per his/her care plan include anticipate and meet resident needs. Per review of Resident #52's care plan dated 2/14/23 [Resident #52] has a diagnosis of Alzheimer's disease and anxiety. Sometimes [his/her] reality can be disturbing, and [S/he] will be upset, anxious and use vulgar language . During these alternate realities [Resident #52] can become quite argumentative and agitated. During these times [S/he] may raise [his/her] fist, kick, hit or push [others], resident has history of resident altercations and per his/her care plan [Resident #52] is at risk to wander r/t dementia, disoriented to place, Impaired safety awareness. Per further review of his/her careplan, on 4/19/2023 [Resident #52] wandered into another Veteran's room which resulted in an altercation. The care plan includes the following intervention dated 10/30/23, When [Resident #52] becomes irritable and agitated and stands up, go with it! Use this as an opportunity to walk [him/her] away from the person or situation. Per the Facility assessment dated [DATE], the facility cares for residents with mental and behavioral health diagnosis that include complex mental health, medical conditions and medication- related issues causing psychiatric symptoms and behavior[s]. The facility's goal per report is to identify and implement interventions to help support individuals with these through the assessment of the [individual residents], early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions . There was no evidence provided by the facility that staff were providing supervision to Resident #40 or Resident #52 while on the porch on 6/14/24. Per interview on 1/29/25 at 2:00 PM with the Deputy Administrator and the Chief Executive Officer, both confirmed that Resident #40 and Resident #52 were on the porch together without supervision with a history of resident-to-resident altercations. 2). Per record review, Resident #17 has a care plan focus dated 5/11/23 that states [S/he] has repeatedly gone into other Veterans' rooms. [S/he] can be difficult to redirect from theses space[s]. Resident #17's care plan does not have any interventions in place to provide supervision or to address Resident #17's wandering or entering other residents' rooms. Per a progress note dated 6/13/2024, Resident #17 was self propelling down a hallway. Resident #13 was walking in the opposite direction, and when Resident #17 passed, Resident #13 turned and tapped him/her on the head. Resident #17 stopped propelling and raised his/her arm. An Incident Note dated 6/14/24 stated Resident #13 was at the end of the hall and was seen by a staff member standing behind the wheelchair of [Resident #17], pulling [his/ her] hair and hitting [him/her] on the top of the head. [Resident #13] stated that s/he is sick of [Resident#17] opening [his/her] door. Per facility investigation on 6/14/24 [Resident #13] was trying to stop [Resident #17] from going into his room. Per the facility investigation, the event occurred near the end of the hall outside of Resident #13 room. During an interview on 1/29/25 at 2:00 PM with the Deputy Administrator and the Chief Executive Officer, both confirmed that the above incidents occurred at the facility. 51586 3) Per observation and interview on 1/27/25 at 10:45 AM, Resident #1 had multiple scratches and abrasions in various states of healing on each of his/her knees. Resident #1 stated that when s/he transfers from their wheelchair using the grab bar mounted to their bathroom wall with a 1-person physical assist, they often scrape their knees on the toilet paper holder that is mounted to the wall next to the toilet. Resident #1 stated that they have asked several LNAs [licensed nursing assistants] to please get someone to move this toilet paper holder as it is hurting their knees on a regular basis. Resident #1 expressed feeling upset and disrespected stating that All I ever did was go fight in a war for them, I guess it is too much to ask [to have the toilet paper holder moved]. Facility policy VVH [[NAME] Veterans Home] Policy & Procedure Maintenance Repair Requisitions (effective date 5/11/22) states, It is the policy of this facility that maintenance repair requisitions will be generated by staff to provide notice and a record of repairs as necessary .Repair requests are to be entered into the MaintenanceCare system which can be accessed via VVH computer. Veterans/Members, Visitors, etc. are to notify staff members of their maintenance requests and staff will enter their requests into the MaintenanceCare system. In an interview on 1/28/25 at 4:10 PM, the Unit Manager confirmed that all staff have access to an online portal to enter maintenance requests and all staff are expected to do so if a resident asks them to. In an interview on 1/29/25 at 12:40 PM with the Director of Environmental Services, they confirmed that over the last 12 months no staff member has entered Resident #1's request to have their toilet paper holder moved. The Director of Environmental Services confirmed that all staff on the unit have access to the online portal for maintenence requests and should have entered this request into the system per facility policy.

Based on interview and record review, the facility failed to ensure that two residents [Res. #29 & #33 ] of 13 sampled residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Findings include: 1. Per review of Res.#29's medical record, the resident was admitted to the facility with diagnoses that include Post Traumatic Stress Disorder [PTSD]. Review of Physician Notes dated 12/27/24 record the resident is well known to myself and the staff here from past admissions. The Physician recorded when [Res.#29] gets irritable, [s/he] goes and hides because afraid [s/he] will blow up, at high risk of decompensation, very depressed, Military History: Army/ combat / communications - was all over Vietnam / still with flashbacks at times, startles easily - if have to awaken [h/her] - touch toes and call [h/her]. An interview was conducted with Social Services [SS] on 1/28/25 at 4:12 PM. SS stated that the facility utilizes a 'Behavioral Health Clinical Assessment' as an assessment tool to identify concerns related to the resident's condition and plan of care. Review of Res.#29's Behavioral Health Clinical assessment dated [DATE] records the Admission Reason/Presenting Problem as respite and recovery. Further review of the Behavioral Health Clinical Assessment for Res.#29 reveals no further information recorded. Blank areas in the assessment include: -Summary of Current Mental Health or Psychiatric Issues -History of trauma -Type of trauma experienced -Symptoms experienced -Triggers -Identified needs -Recommended services/plan of care Review of Res. #29's Care Plan revealed the resident as not identified as suffering from PTSD, and no interventions identified related to experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Per interview with Social Services [SS] on 1/28/25 at 4:12 PM, SS confirmed that Res. #29 was well known to the facility as diagnosed with PTSD. SS confirmed the resident was not care planned for h/her diagnosis of PTSD and was not assessed for trauma-related care and should have been. 48017 2. Per record review, Resident #61 was admitted to the facility with a diagnosis of PTSD, anxiety, and depression. A document that is titled Behavioral Health Clinical Assessment, dated 9/14/24 identifies that Resident # 61 has a history of trauma. The section Type of trauma experienced is not completed. The form does not contain any further information. Per review of Resident #61's record, no evidence was found that the resident was assessed for triggers that may re-traumatize the resident. No evidence was found in Resident 61's plan of care regarding the resident's triggers or how staff can provide care that avoids re-traumatizing the resident. Per an interview on 1/28/2025 at approximately 4:15 PM with Social Services and the Director of Social Services, the Licensed Social Worker indicated s/he was not aware of a trauma assessment format that the facility uses, and had not been assessing the residents for triggers related to their traumas as outlined in the facility policy. The Director of Social Services confirmed that Resident #61's trauma-specific triggers had not been identified , and Resident #61 should have had a trauma care plan.

Based on interview and record review, the facility failed to provide routine dental services for 1 resident [Res. #26] of 3 residents sampled with identified dental issues. Findings include: Per review of Res. #26's medical record, the resident was admitted to the facility with diagnoses including dysphagia [a condition with difficulty in swallowing food or liquid]. Review of Res. #26's Nutrition Assessment conducted for admission to the facility dated 10/28/2024 assessed the resident as having some 'chewing' difficulty related to temporary dentures only with the resident edentulous [lacking teeth], Has temporary dentures. Needs permanent ones. Further record review reveals Res. #26 was seen by a dentist on 10/31/24. Dental Notes record The patient had teeth extracted in June or July and expected a new set [of dentures] to be made after healing. I will contact [Veterans Administration] and see what has been approved and whether I can take over here. An interview was conducted with Res. #26 on 1/27/25 at 3:00 PM. Res. #26 stated There is one thing I would like; to know when my next dentist appointment is. I was seen and told I need new dentures and I have not heard anything since. Review of Res. #26's Nutrition assessment dated [DATE] records the resident at nutritional risk with the resident reports some trouble chewing related to being edentulous with only temporary dentures. Saw dentist on 10/31/24. Needs permanent dentures per MD. Review of Res. #26's Care Plan confirms the resident is edentulous with only temporary dentures .Needs permanent dentures per MD. An interview was conducted with Res. #26's Unit Manager [UM] on 1/28/25 at 4:25 PM. The UM confirmed that Res.#26 was identified as needing dentures upon admission in October 2024. The UM stated that after the resident saw the dentist on 10/31/24 the facility's process is to reach out to the Veterans Administration per the dentist's instructions to see if services were in place. The UM confirmed this was not done and could not ensure that the resident's need for new dentures was being addressed.

Based on staff interviews and record review the facility failed to ensure that an allegation of staff to resident abuse was reported to the State Licensing Agency as required. Findings include: During an interview on 2/12/2024 at 2:30 PM Resident #1's significant other reported that she/he had placed a camera with no sound recording in Resident #1's room when visitation was being restricted due to COVID. The significant other stated that on 1/22/2022 while viewing the camera she/he witnessed a licensed nursing assistant (LNA) abuse her/his spouse. According to the significant other this allegation was not reported to the facility until 1/4/2023, on the same day an email was sent to the Deputy Administrator reporting the allegation. At this time the significant other was under the impression that the LNA was let go. On 12/5/2023 approximately one year after the initial allegation, while visiting Resident #1 she/he saw the LNA walk down the hall that Resident #1 resides in and realized that the LNA was allowed to return to work. Per the significant other she/he was very upset to see the LNA back and she/he sent another email to the Deputy Administrator asking how they could allow a known abuser to return to work. Per review of emails provided by the facility the Deputy Administrator, on 1/4/2023 Resident #1's significant other sent an email alleging that in the early evening of 1/22/2022 she/he witnessed a LNA holding the handles of Resident #1's wheelchair and proceeded to suddenly, rapidly, and abruptly, drop the wheelchair into a fully reclined position. This movement startled Resident #1 as evidenced by the resident shooting his/her hands out with palms up. The significant other alleged that the resident stated something like, Hey! Take it easy! and that the LNA stepped in front of the resident and in an angry pose, pointed his/her finger like S/he was scolding the resident. The facility did not report this incident to the licensing agency at the time. Approximately one year later on 12/5/23, after seeing the LNA in the hall, Resident #1's significant other sent another email to the Deputy Administrator asking how a known abuser of helpless defenseless residents could be allowed to return to work. Per interview on 2/13/24 at 10:45 AM with the Deputy Administrator, S/he stated that when Resident #1's significant other reported this concern, the LNA was put on leave, and an investigation was completed by the Human Resource Department (HR). The Deputy Administrator confirmed that the allegation had not been reported to the State Licensing Agency. During an interview on 2/13/24 at approximately 12:30 PM the facility Administrator confirmed that the 1/4/2023 or the 12/5/23 abuse allegations had not been reported to the State Licensing Agency. Per the Administrator the initial report made by Resident #1's significant other was considered a customer service or resident right issue, not an abuse allegation. The second allegation was not reported because it had been investigated by HR in the past and was found unsubstantiated.

Based on staff interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 3 of 6 residents in the sample (Resident #1, #3, and #4). Findings include: 1 . Per record review Resident #1 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease. Review of Resident #1's progress notes and care plan reveal that Resident #1 has exhibited aggression toward staff and other residents, such as yelling, slapping, throwing dishes, grabbing, and being combative with care. Review of Resident #2's record reveals that s/he was admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease and resides on the facility's licensed memory care unit. Resident #2's progress notes and care plan reveal that Resident #2 can be territorial with his/her perceived space and can exhibit aggression towards others. On 10/26/2023 at 8:30 PM Resident #1 was found by staff in Resident #2's room on the floor on top of Resident #2. Resident #2 sustained injuries from the incident and was sent to the hospital emergency department (ED) for evaluation and treatment. While in the ED Resident #2 required the administration of IM (intramuscular) Haldol (an antipsychotic medication) for agitation. Per a progress note written in Resident #1's record, on 10/26/23 at 8:30 PM Resident #1 was found in Resident #2's room, on top of Resident #2 swinging his/her hands and arms toward Resident #2. Resident #1 was separated from Resident #2 and was escorted to their room where s/he got in bed and went to sleep. Progress notes written in Resident #2's record on 10/26/23 and 10/27/23 reflect that Resident #2 was on the floor with Resident #1 on top of him/her on 10/26. Resident #1 was removed, and Resident #2 was assessed by charge registered nurse (RN). Resident #2 has multiple abrasions and open areas on body including shoulder, arms, back, and right leg. S/he was unable to clearly give an account of what happened. Resident #2 was sent to the hospital by rescue squad. An Incident Note written on 10/26/23 states Staff noted [Resident #2] was on the floor in [her/his] room while another veteran was swinging [her/his] hands and arms at [them]. Veterans were separated by staff and were assessed for pain and injury. Small scratches, some bleeding noted to right upper thigh, left shoulder, left back of arms and chest. Abrasions noted to right should blade and left tricep. Large skin tear noted to right elbow with moderate bleeding noted. Subcutaneous tissue/?? bone exposed . Areas cleansed and covered. Range of motion intact per norm of veteran. Denies pain. An Acute Visit Provider Note written on 10/27/2023 states that Resident #2 sustained multiple wounds, mostly superficial except for [his/her] right elbow which involved steri strips and bandage. Review of the facility incident file, a witness statement completed by a Licensed Practical Nurse (LPN) who responded to the incident states Resident #2 was in bedroom and seen on floor in bedroom cradled by another resident, while attempting to defend self. Resident is cornered on the floor, blood is dripping, nurse attempting to break up altercation. Resident has bruising, scratches, and deep laceration on elbow (right). and [Resident #1] in another resident's bedroom and seen cradling over another resident. [Resident #1] is punching other resident, while blood is on the floor from other resident. [Resident #1] is separated off top of other veteran, and [s/he] immediately goes in [her/his] room and falls back asleep. During a phone interview with the LPN on 12/5/23 at 2:15 PM when s/he responded to the incident s/he saw Resident #1 on-top of Resident #2 and they were pretty much duking it out, they were punching each other . and I had to get in and break them apart. [Resident #1] was crouched over [Resident #2] and both were making contact with each other. Prior to the incident Resident #1 had been on 15-minute checks. The LPN also stated that Resident #1 is typically more aggressive and volatile. S/he was placed on the Buddy 1 to 1 staff to resident after the incident. Per interview with the Director of Social Services at 1:30 PM it is likely that Resident #1 had entered Resident #2's bedroom through the adjoining bathroom and woke Resident #2. The Director of Social Services confirmed that the Resident-to-Resident altercation occurred however, due to cognitive issues and the inability for either Resident to recall the event it is undetermined by the facility who the initial aggressor was. 2. Per record review Resident #1 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease and resides on the licensed memory care unit. Review of Resident #1's progress notes and care plan reveal that Resident #1 has exhibited aggression toward staff and other residents, such as yelling, slapping, throwing dishes, grabbing, combativeness with care, and recent history of Resident-to-Resident physical abuse. Per record review Resident #4 was admitted to the facility with the diagnosis of Alzheimer's Disease and resides on the licensed memory care unit. On 11/27/23 at 2:45 PM Resident # 4 was the victim of Resident-to-Resident physical abuse when staff witnessed Resident #1 striking him/her twice with a plastic garbage pail. Per a nurses Incident Note written on 11/27/23, when the nurse and licensed nursing assistant (LNA) responded, they saw Resident #4 sitting on the floor against their dresser. The LNA had witnessed Resident #1 striking Resident #4 twice with a plastic garbage pail. Resident #4 had bruising to the area above her/his left elbow, some redness and a scratch to their left side of their back, and a small abrasion across the bridge of his/her nose. Resident #4 denied pain but said that it hurt when s/he was hit. Per interview with the Director of Social Services on 12/5/23 at 1:30 PM Resident #1 is unpredictable and it is difficult to pinpoint when s/he will become aggressive. The care team has huddles after each incident to review the possible cause of the escalation, and Resident #1 is now on staff 1-1 Buddy. 3. Per record review, on 11/25/23 Resident #1 was ambulating down the hall on the memory care unit. As s/he was walking by, Resident #3 punched her/him in the left side of her/his face. Per interview on 12/4/23 at 2:00 PM the LNA who witnessed the altercation confirmed that Resident #3 hit Resident #1. The LNA stated that when Resident #1 was struck s/he stepped back and leaned into the wall with a confused look on her/his face. Resident #1 did not engage in the altercation and the two residents were separated. During an interview on 12/5/23 at 1:30PM the Director of Social Services confirmed that Resident #3 had hit Resident #1 in the face, and that after review of the incident staff were unable to determine why Resident #3 had struck Resident #1. Although Resident #1 seemed to recall the incident for a brief time, there have been no other altercations between the two residents since.

Based on interview and record review the facility failed to ensure that staff treated each resident with respect and dignity for 1 of 26 sampled residents (Resident #18) by making remarks related to call bell usage. Findings include: Resident #18 was admitted to the facility in August 2023, and prior to admission Resident #18 had suffered a cerebral vascular accident (a blockage or rupture of an artery to the brain blocking the blood flow to the brain) resulting in right-sided hemiplegia (paralysis of the right arm and leg), and right-hand contracture (shortening and stiffening of the joints preventing normal movement). On October 23, 2023, when Resident #18 was asked if s/he felt they were treated with dignity and respect s/he stated Not when someone comes in and says you rang your bell twice in the same hour and the other guy did too. We're not going to spend the whole night coming down here. Resident #18 became visibly upset with a furrowed brow and raised tone as s/he described needing assistance due to their inability to walk and having one hand with very limited use which s/he demonstrated for the surveyor. Resident #18 could not recall what assistance they had rang the call bell for or if they had received the assistance. Resident #18 has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition and was able to identify the time of this interaction as the night before at approximately midnight. A review of Resident #18's care plan contained focus areas mentioning reliance on call bell use including: 1. Activities of daily living deficit for which interventions included- Encourage to use call bell for assist. Extensive assist for dressing, Set up assist for eating, Stand lift with 2 assist for toilet and transfer. [name removed] requires limited assistance by 1 staff to turn and reposition in bed as necessary. 2. [Name removed] is (at) risk for serious injury from falls related to hemiplegia, bladder and bowel incontinence, psychoactive drug use, impaired mobility. Be sure [name removed] call light is within reach and encourage him/her to use it for assistance as needed. [name removed] needs prompt response to all requests for assistance. On 10/24/23 at 1 p.m., the unit manager was interviewed regarding the allegation of the disrespectful response reported by Resident #18. To determine the identity of the staff working at the time of the alleged incident the nursing supervisor joined the discussion and provided a paper copy of the schedule in question. When the staff members were identified the surveyor asked if, based on the staff present at the time of the allegation they would be surprised by the report of this disrespectful interaction. Per both the unit manager and the supervisor it would not be surprising if any of the four staff on duty at the time had used a tone or made [NAME] statements. On 10/25/23 at approximately 2 p.m., the facility administrator provided a copy of the interview conducted by social services with Resident #18 earlier that day. Statements in this interview include- When asked about how he feels his nursing care is going, [name removed] stated that everyone is good and helpful. One person is impossible, I don't speak with her. [Name removed] then stated about 4 days ago at 6 a.m., s/he rang his/her bell to have his/her urine collection device emptied. [name removed] said s/he had to ring a few minutes later because s/he wanted a washcloth for his/her eye. S/he said that a staff member came back to his/her room and said, We have been in here for five calls in five minutes and something about getting out the door. [name removed] reports s/he told him/her to 'get the hell out of my room now.

Based on observation, interview, and record review the facility failed to ensure that a resident who was capable of self-administration of medications was able to store them safely and securely. Findings include: During an interview with Resident #50 on 10/23/23 at 3:12PM it was noted that there were several bottles of dietary and herbal supplements on their overbed table, dresser, shelf, and in a three-drawer plastic bin. These supplements included Chewable Vitamin C, Inflama-Rest (support for healthy inflammation response), RejuvenZyme (heart, joint, and immune support), Magnesium [NAME], Wellness Formula, Ashwagandha (rejuvenating tonifier), Tums, and Ultra-Cal Night, Daily essential Enzymes. Per record review Resident #50 has been assessed as capable for self-administration of these supplements. A physician's order states that the resident may self-administer [his/her] supplements based on [his/her] last self-administration assessment. Review of the facility policy titled Veteran/Member Supplement Use states, 5) The Veteran, Member, responsible party and VVH staff will follow the facility's self-administration of medication policy. The policy titled Medication Administration, Self Storage 1. Any Veteran/Member deemed able to self administer medications may choose to have his/her medications stored in the medication cart room on the unit or in their room. 2. If a Veteran/Member stores medication in his/her room the following must be implemented: A. The medications will remain in a locked container at all times i.e., a locked box. During an interview on 10/25/23 at 11:49 AM the administrator confirmed that the supplement policy does refer to the Medication Administration, Self-policy and that the supplements should be kept secure.

Based on interview and record review the facility failed to ensure that each resident has a person-centered comprehensive care plan developed and implemented to address the resident's medical needs for 1 of 26 residents sampled (Resident #18) regarding impaired cardiac output. Findings include: Resident #18 was admitted to the facility in August 2023, prior to admission Resident #18 had suffered a cerebral vascular accident (a blockage or rupture of an artery to the brain blocking the blood flow to the brain) resulting in right-sided hemiplegia (paralysis of the right arm and leg), and right-hand contracture (shortening and stiffening of the joints preventing normal movement). Additional diagnoses include permanent atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the heart) and unspecified bradycardia (an abnormally slow resting heart rate). Per record review on 8/31/23 Resident #18 was sent emergently to the hospital with symptomatic bradycardia and long pauses (abnormally long intervals between heartbeats), s/he was sent to [NAME] Medical Center to be evaluated for a pacemaker and per the provider note it is not completely {clear} why s/he did not receive a pacemaker in [NAME] Medical Center. The resident returned to the facility from [NAME] Medical Center on 9/7/23. On 10/10/23 Resident #15 became dyspneic (short of breath), and hypoxic (low oxygen level in the blood), and coughing. Resident #15 was again sent emergently to the local hospital and admitted with congestive heart failure and probable bacterial pneumonia. Resident #15 was admitted to the hospital and on 10/16/23 s/he had a pacemaker placed. A review of the care plan revealed that there was no area relating to the resident's cardiac status nor was there mention of the resident having a pacemaker. During an interview with the unit manager on 10/24/23 at 1:45 p.m. s/he confirmed the care plan did not but should contain reference to the pacemaker and of the the impaired cardiac status of the resident.

Based upon interview and record review the facility failed to ensure the plan of care for 1 resident [Res.#83] of 20 sampled residents with falls was reviewed and revised to prevent future falls and injury. Findings include: Review of Res. #83's medical record reveals the resident was admitted to the facility with diagnoses that included Degenerative Arthritis with severe chronic pain. Per review of Res. #83's Care Plan, the resident is identified as at risk for fall related injury related to deconditioning, symptoms of pain from arthritis, reports history of fall prior to admission along with sustained a witnessed fall with no injury, related to Poor Balance, Unsteady gait. Review of Res.#83's medical record reveals the resident suffered 4 falls between August and September 2023. Progress notes record: - 8/16/2023 Incident Note. Resident was calling for help, when LNA [Licensed Nurse's Aide] went to room, [Res.#83] was sitting on the floor in front of [their] recliner. [They] stated [they] slid off recliner . Neurological checks and vital signs initiated per fall protocol. - 8/19/23 Called to the unit by nursing staff to eval [Res.#83] who had rang [their] bell and was noted lying on the floor when staff entered. - 9/7/2023 [Res.#83] left the dining room (in electric wheelchair) after eating [their] breakfast. Was self-transferring and lost [their] balance. [Res.#83] was noted on the floor with a head wound. [Res.#83] was assisted (via Hoyer lift) off the floor to [their] recliner. Due to the head wound and feeling oozy [Res.#83] was transported to Southwestern [NAME] Medical Center. A re-admission update when Res.#83 returned to the Veteran's Home reveals [Res.#83] was sent from Southwestern [NAME] Medical Center [SVMC] to [NAME] Medical Center after a fall. [They] had a 12 hour stay in the local Emergency Department. [They were] sent to [NAME] Medical Center from SVMC where [they were] diagnosed with a subdural hemorrhage ., [A subdural hemorrhage is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull. Specifically, it is a bleed just under the dura, which is one of the protective layers of tissue that surrounds the brain]. (www.rwjbh.org/treatmentcare/neuroscience/neurology/conditions/subdural-hemorrhage) Further review of Progress Notes for Res.#83 reveals 2 days after the fall with injury on 9/7/23, the resident fell again. - 9/9/2023 Incident Note: Resident noted on the floor by rest room door. Pillow placed under resident's head. Per LNA resident was being assisted out of restroom, in which resident started sliding to the floor. LNA in turn assisted resident to floor landing resident on [their] buttocks. Did not hit head .Resident voiced pain of 7/10 pain to [their] buttock. Per review of the '[NAME] Veteran's Home Falls Program' [dated March 19, 2014], the policy states All Veteran/members experiencing a fall will receive appropriate care and investigation of the cause. Assess Veteran/member's condition immediately to determine extent of injury for both witnessed and unwitnessed falls. The Falls policy also includes the statement Update care plan with new interventions and communicate interventions to staff. After the fall on 9/9/23, Res.#83's Care Plan was revised with the interventions: - Continue interventions on the at-risk plan, dated 9/9/2023 [after the 4th documented fall] along with 'new' interventions listed as monitoring the resident for 72 hours and determining factors contributing to the fall, which according to the '[NAME] Veteran's Home Falls Program' are applied to all residents after all falls. Further review of Care Plan revisions related to fall risk and actual falls for Res.#83 include the interventions: Implemented bariatric non-skid socks: listed as a new revision and dated 9/9/2023 but repeating the intervention Ensure that [Res.#83] is wearing . h/her anti-skid socks dated 4/11/2023. Per record review, after assessing the resident as able to ambulate with rolling walker unsupervised and noting that the resident asks for help despite not needing it, after 3 falls, an intervention to prevent future falls was added as Remind [Res.#83] to call for assistance if walker/wheelchair is not in [h/her] reach before transferring dated 9/7/23, and then repeated as a new intervention and revision after another fall as Educated resident use of walker, dated 9/9/23. An interview and record review were conducted with Res. #83's Unit Manager on 10/25/23 at 9:50 AM. The Unit Manager confirmed that new interventions to prevent future falls were not added after a fall on 9/7/23 which resulted in a subdural hemorrhage. The resident suffered another fall on 9/9/23 shortly after returning to the facility, again with no new interventions added to prevent future falls. The Unit Manager also reported that if any interventions were attempted but not put in Res.#83's care plan, there was no process in place to communicate those changes to staff on a continuing basis. Additionally, the Unit Manager confirmed that Care Plan interventions dated as added after falls on 9/7/23 and 9/9/23 were not new interventions or revisions, but identical interventions attempted before that did not prevent future falls, and/or repeating the facility's Falls Policy which is in effect for all residents at all times.

Based on interview and record review the facility failed to ensure that one of three residents (Resident #1) in the applicable sample were treated with dignity and respect. Findings include: Per record review, Resident #1 has diagnoses that include major depressive disorder, personality change, frontal lobe and executive function deficit, cerebrovascular disease, dementia, and behavioral disturbances. Per record review, on 4/8/23 at approximately 8:40 AM a Licensed Nurse Assistant (LNA) was working as a buddy, sitting in a chair 1 door down from Resident #1's room. Per documented witness interview conducted by the Deputy Administrator, Resident #1 and the LNA were yelling like a husband and wife were fighting and [Resident #1] yelled 'get the fuck out of my room and fuck off' [the LNA] said as exiting the room 'right back at you I hope you choke on your food.' According to the facility investigation, 20-30 minutes after the incident the LNA who had overheard the verbal exchange saw the LNA involved re-enter the room and say to Resident #1 I'm so sorry [name omitted], do you forgive me? Per interview with the Licensed Nursing Home Administrator (LNHA) on 6/5/2023 at 12:25 PM there had been no concerns with the LNA's interactions with any Residents in the past, and the LNA had recently received education related to this specific Resident's behaviors. The LNHA confirmed there had been a verbal altercation between Resident #1 and the LNA who was in her/his room, and that the Resident had not been treated with dignity and respect.

Based on record review and interview it was determined that the facility failed to develop and implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings water systems. Review of the facility's Infection Control Program revealed there were no policies or educational curriculum in place to ensure the facility had a process in place that ensured an adequate water management program to prevent the growth of Legionella or other opportunistic waterborne pathogens. Interview on 11/2/22 at 2:40 PM with the Infection Control Nurse and the Director of Nurses confirmed that the facility's current Infection Control Program did not include measures to educate staff on the prevention of Legionella or a system to monitor the facility's water systems for potential opportunistic waterborne pathogens, to include Legionella.

Based upon observation, interview, and record review, the facility failed to ensure refrigerator temperatures on resident units were maintained to prevent the potential for food borne illness. Findings include: Per observation of the resident food/snack refrigerator in the 'Sports Bar' area of the facility's North unit, on 11/2/22 at 11:18 AM, the temperature sensor located on the outside of the refrigerator read 49.5 degrees F. [Fahrenheit]. A review was conducted of the written refrigerator temperature log for the Sports Bar refrigerator. The temperature log includes the notation Fridge temp 36-40 degrees F. If temperature is out of range, notify maintenance department right away, put out of order sign in the door, inspect and remove items if needed. Review of the temperature log from July 31, 2022, through the date of the survey 11/2/22 revealed the highest temperature recorded as 54.8 degrees F. on 8/15/22, with the temperature reaching over 50 degrees 6 times during the review period. Additionally, no recorded temperature was listed as 41 degrees or below on any date, and no temperatures were recorded in the written log for 24 days during the period reviewed. Per interview with the facility's Administrator [ADM] and the Maintenance Director on 11/2/22 at 12:20 PM, staff are assigned daily to record the resident refrigerator temperatures on all resident units. If the refrigerator's temperatures are out of range [per facility policy Fridge temp 36-40 degrees F.] the maintenance department is to be notified. Per interview with the Maintenance Director, there is no record that the maintenance department was notified on any date regarding the out of range temperatures during the greater than 3 month period reviewed for the 'Sports Bar' resident refrigerator. Review of the facility's Nursing Schedule reveals a section listing The following staff is responsible for checking unit refrigerator temps and documenting, with a staff member assigned to each resident unit. Per review of the resident food/snack refrigerator log for the American Way unit for October 2022, temperatures were not recorded as taken on 18 of 31 days. An interview was conducted with the American Way Unit Manager [UM] on 11/2/22 at 11:33 AM. The UM stated that resident refrigerator temperatures are to be recorded twice daily. The UM confirmed that temperatures were missing on 18 of 31 days, and that temperatures were not taken twice daily on any of the 31 days, despite the form having sections for 'AM' and 'PM' on each date. A review was conducted on 11/2/22 of the resident food/snack refrigerator log for the residents' Activities Room for October 2022. The review revealed that temperatures were not recorded as taken on 27 of 31 days. Further review on 11/2/22 revealed no November 2022 temperature log had been initiated.

Based on staff interview and record review the facility failed to revise the plan of care to include providing additional fluids for one resident (Resident #38) of 38 residents sampled. Findings include: On October 12, 2022 Resident #38 was sent to the emergency room for evaluation of decreased responsiveness. The resident was returned to the facility after receiving treatment including 1 liter of intravenous fluid. Based on concerns regarding hydration status the provider wrote an order on October 13, 2022, for nursing to sign off that Resident #38 received 1500 ml's (milliliters) of fluid on the first and second shifts. The medication administration record was reviewed from October 14-October 31, 2022 where it was noted of 34 opportunities to provide the resident the ordered 1500 ml this goal was met 11 times and missed 23 times. Resident #38's plan of care was reviewed and it was noted the care plan had not been revised to include the provision of additional fluids. On 11/1/22 the unit manager confirmed the plan of care should have been revised to provide this direction for the nursing staff but had not been.

Based on clinical record review, staff interview, observations, review of the Abuse Prevention Policy and review of behavior/intervention monthly flow records, the facility failed to prevent staff to resident physical abuse, resulting in Immediate Jeopardy when one Resident (#1) was struck in the face by a staff nurse and sustained bilateral nasal bone fractures. The Director of Nursing, Assistant Director of Nursing, Administrator and Assistant Administrator were notified on 09/13/12 at 4:15 P.M. that Immediate Jeopardy began on 09/11/12 at 7:05 P.M. when Licensed Practical Nurse (LPN) #5 struck Resident #1 in the face. Resident #1 was treated in the emergency roiagnom on [DATE] and sustained bilateral nasal bone fractures. Review of an Event Reporting Form submitted to the Division of Licensing and Protection by the Director of Nursing on September 13 revealed that LPN # 5 reported to a Nursing Supervisor that LPN # 5 struck Resident # 1 in the face on September 11, 2012. Review of a September 11, 2012 Physician Communication note signed by a facility RN reveals a notation that Resident # 1 was punched in the nose by staff. Review of the record for Resident #1 on 09/13/12, revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment ((MDS) dated [DATE], indicates Resident #1 has moderately impaired cognitive function with no short or long term memory problems. The mood severity score is seven and indicates Resident #1 reports daily hopelessness, is short tempered, and had one recent expression of the desire to inflict self harm. The MDS indicates care is rejected 4-6 of 7 days. Resident #1 requires limited assistance (non weight bearing) of one staff for bed mobility, transfer, locomotion off the unit, dressing, personal hygiene and bathing. Resident #1 is independent with eating, toileting, and locomotion on the unit. The plan of care for behavioral symptoms, dated 05/11/12, indicates Resident #1 has behavioral symptoms related to being verbally abusive to staff and other residents, and can be resistive to care being offered. On 08/28/12 an additional notation was made of suicidal ideation related to pain and on 09/12/12 a notation of physical abuse towards others. An undated notation indicates Resident #1 has ongoing behaviors such as throwing items at staff and foul language as evidenced by nurses notes on 04/10/12 and previous. The goal stated for Resident #1 indicates the resident should have improved or maintain acceptable behavior through next review. The interventions include 1) Assess, monitor and document unacceptable behaviors. Observe what may trigger these behaviors, document and notify the MD. 2) Intervene to ensure the safety of the Resident and others, encourage to ask for assistance and ring the call light. 3) Visual checks only at night - do not wake up - per Resident request. 4) Anticipate the needs of the resident before the resident becomes overly stressed. Approach calmly. 5) Provide 1:1 time for resident to express feelings and concerns. 6) Maximize strengths and positive behaviors. Offer meals in room with increased behaviors. 7) Administer medications as ordered. Observe for effectiveness and side effects. The Licensed Nurse Aid (LNA) assignment sheet updated 09/12/12 was reviewed and indicated Resident #1 required 1 assistance when in bed, was independent in the wheelchair, required 1 assistance with toileting and special instructions indicated the Resident took Ensure with meals. A physician's orders [REDACTED]. The corresponding progress note indicated the Resident had been refusing medication for greater than one week and requested all medication be stopped. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The reason was not documented. Review of the behavior/intervention monthly flow record for 08/2012 revealed that agitation /irritability as evidenced by verbal abuse was documented on day shift on 08/10/12 and positive results were noted from redirection and reapproach. On 08/29/12 no results were noted from redirection, 1:1, return to room, or position change when attempted. The record for 09/2012 revealed that agitation, as evidenced by verbal abuse, was displayed on 09/01/12, 09/02/12 and 09/03/12. Interventions included redirect, 1:1 and re approach and were effective only on 09/03/12. No behaviors were documented on 09/11/12. Review of the nurses notes for 09/2012 revealed no documented behaviors for 09/2012 and the documentation on 09/11/12 specifically, did not indicate behaviors. A care plan meeting note was made on 09/11/12 and was untimed. It indicated Resident #1 did not attend and the same plan of care was to continue. Review of Situation, Background, Assessment, Request (SBAR) form dated 09/11/12 revealed that on 09/11/12 at 7:10 P.M., Resident #1 was "punched in the nose by staff" LPN #5. The attached progress note indicated that the Registered Nurse supervisor was called to the American Way unit at 7:10 P.M. on 09/11/12, when Resident #1 reported being hit in the nose by staff. Staff reported Resident #1 had been agitated, calling them names and throwing things through out the evening. Resident #1 initially declined to go to the emergency room but later agreed. Resident #1 was transferred with police escort at 7:50 P.M. The emergency room Department Report indicated Resident #1 arrived with dried blood in the right nares and mild bilateral tenderness to palpation. CT scan revealed mildly displaced bilateral nasal bone fractures. The report indicates Resident #1 had a known history of deeply invasive squamous cell [MEDICAL CONDITION] of the right face. The nurses note dated 09/12/12 at 3:00 A.M., indicated Resident #1 returned to the facility on [DATE] at 2:30 A.M. with [DIAGNOSES REDACTED]. The documentation indicated Resident #1 asked on return "Is that man here?, the one who hit me?" The nurse documented reassurance and observation of slight swelling to the nose. Review of the facility investigation revealed that all staff on the unit documented statements and all staff indicated Resident #1 had been agitated through out the evening, beginning in the dining room at the evening meal, calling them vulgar names, cursing and throwing water bottles at them. No one witnessed the incident. Observation of Resident #1 on 09/13/12 at 11:05 A.M. revealed an abrasion, slight swelling and redness to the tip of the nose and dried blood visible in the nares. The nose deviates slightly to the left. During interview at this time, Resident #1 stated "of course it hurts". LPN #5 "hit me for no reason". Resident #1 stated that the nasal fracture is painful. Resident #1 refused further comment. Interview of the RN caring for Resident #1 on 09/13/12 at 11:50 A.M. revealed that Resident #1 "has never been very nice, but has had increased behaviors lately". When asked to elaborate the RN stated "since the antidepressant was discontinued. I think for refusal, but (Resident #1) always takes medications for me". The RN indicated that Resident #1 displayed verbally abusive behaviors but denied knowledge of any physical behaviors. Interview of the LNA who cared for Resident #1 on 09/11/12 revealed that on that date many different people were in and out of Resident #1's room. The LNA indicated that Resident #1 had daily verbal outbursts and they were worse on this date. The LNA indicated behaviors were typical and that the assignment sheet did not address Resident #1's behaviors. The LNA stated "we had nothing to go by" then. The LNA indicated that now there are "steps to follow" to manage the behaviors and try to keep them from getting that bad. Interview of the Social Worker for American Way unit and the Social Worker from unit D, where Resident #1 resided prior to a room change late in June, on 09/13/12 at 4:00 P.M., revealed that Resident #1 had always displayed verbal behaviors. They stated that after the move, the end of June, Resident #1's behaviors improved and recently started to return to previous patterns. They stated the Resident's pattern was to be distant until suddenly, rapidly escalating to an [MEDICAL CONDITION]. They indicated the Resident is difficult to support without overwhelming. During review of the plan of care at that time, both confirmed that there were no specific interventions listed to manage Resident #1's behaviors and stated that is why the Plan of Action in case of escalating behavior was developed on 09/12/12. They stated that staff were being in-serviced on the plan of action but that was ongoing, at shift change each day and all staff had not been in-serviced. Both reviewed the behavior/intervention flow records for 08/2012 and 09/2012 and verified that daily behaviors were reported by staff but not documented and reported they were unaware of increased behaviors until the 09/11/12 incident. They reported that Resident #1 scored a 13 of 13 on the geriatric depression scale on 09/13/12, indicating severe depression and 21 of 30 on the mini mental status exam completed on 09/13/12, indicating moderately impaired cognitive function. The Social Worker from unit D reported that Resident #1 had asked during interview, if the nurse was still there and Resident #1 indicated to the Social worker that s/he was afraid someone might try to kill him/her. Interview of the DNS and Administrator on 09/13/12 at 4:15 P.M. confirmed that daily behaviors were reported by staff during the investigation but were not consistently documented per the plan of care. The DNS stated we have identified that and are in the process addressing it. They confirmed that the LNA assignment sheet did not reflect current information about the behaviors of Resident #1 and did not reflect the updates made on 09/12/12 to provide 2 staff with care.

Based on clinical record review and interview, the facility failed to implement the plan of care for management of one resident's behaviors. This affected one (Resident #1) resident in the applicable sample. Findings include: Review of an Event Reporting Form submitted to the Division of Licensing and Protection by the Director of Nursing on September 13 revealed that LPN # 5 reported to a Nursing Supervisor that LPN # 5 struck Resident # 1 in the face on September 11, 2012. Review of a September 11, 2012 Physician Communication note signed by a facility RN reveals a notation that Resident # 1 was punched in the nose by staff. Review of the record for Resident #1 on 09/13/12, revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment ((MDS) dated [DATE], indicates Resident #1 has moderately impaired cognitive function with no short or long term memory problems. The mood severity score is seven and indicates Resident #1 reports daily hopelessness, is short tempered, and had one recent expression of the desire to inflict self harm. The MDS indicates care is rejected 4-6 of 7 days. Resident #1 requires limited assistance (non weight bearing) of one staff for bed mobility, transfer, locomotion off the unit, dressing, personal hygiene and bathing. Resident #1 is independent with eating, toileting, and locomotion on the unit. The plan of care for behavioral symptoms, dated 05/11/12, indicates Resident #1 has behavioral symptoms related to being verbally abusive to staff and other residents, and can be resistive to care being offered. On 08/28/12 an additional notation was made of suicidal ideation related to pain and on 09/12/12 a notation of physical abuse towards others. An undated notation indicates Resident #1 has ongoing behaviors such as throwing items at staff and foul language as evidenced by nurses notes on 04/10/12 and previous. The goal stated for Resident #1 indicates the resident should have improved or maintain acceptable behavior through next review. The interventions include 1) Assess, monitor and document unacceptable behaviors. Observe what may trigger these behaviors, document and notify the MD. 2) Intervene to ensure the safety of the Resident and others, encourage to ask for assistance and ring the call light. 3) Visual checks only at night - do not wake up - per Resident request. 4) Anticipate the needs of the resident before the resident becomes overly stressed. Approach calmly. 5) Provide 1:1 time for resident to express feelings and concerns. 6) Maximize strengths and positive behaviors. Offer meals in room with increased behaviors. 7) Administer medications as ordered. Observe for effectiveness and side effects. Review of the behavior/intervention monthly flow record for 08/2012 revealed that agitation /irritability as evidenced by verbal abuse was documented on day shift on 08/10/12 and positive results were noted from redirection and reapproach. On 08/29/12 no results were noted from redirection, 1:1, return to room, or position change when attempted. The record for 09/2012 revealed that agitation, as evidenced by verbal abuse, was displayed on 09/01/12, 09/02/12 and 09/03/12. Intervention included redirect, 1:1 and re approach and were effective only on 09/03/12. No behaviors were documented on 09/11/12. Review of the nurses notes for 09/2012 revealed no documented behaviors for 09/2012 and the documentation on 09/11/12 specifically, did not indicate behaviors. A care plan meeting note was made on 09/11/12 and was untimed. It indicated Resident #1 did not attend and the same plan of care was to continue. No documentation was located to indicate that staff attempted to remove Resident #1 from the dining room on the evening of 09/11/12. Review of Situation, Background, Assessment, Request (SBAR) form dated 09/11/12 revealed that on 09/11/12 at 7:10 P.M., Resident #1 was "punched in the nose by staff" LPN #5. The attached progress note indicated that the Registered Nurse supervisor was called to the American Way unit at 7:10 P.M. on 09/11/12, when Resident #1 reported being hit in the nose by staff. Staff reported Resident #1 had been agitated, calling them names and throwing things throughout the evening. Interview of the LNA who cared for Resident #1 on 09/11/12 revealed that on that date many different people were in and out of Resident #1's room. The LNA indicated that Resident #1 had daily verbal outbursts and they were worse on this date. The LNA confirmed that Resident #1 was displaying severe verbal outbursts and cursing in the dining room on 09/11/12 at the evening meal. The LNA indicated that the Resident was not removed from the dining room during the outbursts. Interview of the Social Worker for American Way unit and the Social Worker from unit D, where Resident #1 resided prior to a room change late in June, on 09/13/12 at 4:00 P.M., revealed that Resident #1 had always displayed verbal behaviors. Both reviewed the behavior/intervention flow records for 08/2012 and 09/2012 and verified that daily behaviors were reported by staff but not documented per the plan of care and reported they were unaware of increased behaviors until the 09/11/12 incident. Interview of the DNS and Administrator on 09/13/12 at 4:15 P.M. confirmed that staff reported daily behaviors but did not document the behaviors per the plan of care. The DNS stated "we have identified that and are in the process addressing it".

Based on observation, interview, and record review, the facility failed to promote care that maintains dignity related to repeated episodes of incontinence for one resident (Resident #1) of the sample group. Findings include: 1. Per record review Resident #1, whose [DIAGNOSES REDACTED]. Per interview on 5/29/12 at 1:35 P.M. with the Veteran Care Assistant (VCA), on 4/26/12 the nurse on Resident #1's unit told the VCA that h/she would be accompanying Resident #1 on transport to the Hospital. During the transport Resident #1 needed to urinate but was unable to hold the urinal. The VCA stated h/he had to hold the urinal while Res. #1 voided. The VCA stated h/she was never trained to assist with this. Later at the Hospital, Res. #1 again had to void. The VCA stated they had to go into a Men's Room where there were other people present and again assisted Res. #1 with voiding. The VCA stated Res. #1 told h/her "this is not right". Per record review, Resident #1's Care Plan, marked reviewed on 3/9/12 - Res. #1 'has a self care deficit...frequently incontinent of urine...Approaches: Incontinent care as needed and toileted as (Res. #1) requests. (Res. #1) wears an incontinent product for dignity'. Per record review of the Bladder Incontinence Evaluation 12/8/11 'daily incontinence episodes'...Functional status: 'extensive assist'...Contributing factors: '[MEDICAL CONDITION], depression, dementia, obesity, paranoid [MEDICAL CONDITIONS] joint disease, tremors, [MEDICAL CONDITION]'. Medication regimen: 'diuretics, sedative/hypnotics, narcotics, antipsychotics, antidepressants'. Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review Occupational Therapy (OT) Progress Report 3/21/12 indicates Res. #1 needs extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per record review on 5/30/12 of written statements in the facility's investigation of the incident, reported on 5/3/12, the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), the Clinical Care Coordinator of Resident #1's unit (CCC), and the unit's Registered Nurse (RN) were aware that the VCA was to accompany Resident #1 on the transport. Per record review on 5/30/12: Vermont Veteran's Home Job Description-Veteran Care Assistant (VCA): 'A Veteran Care Assistant may not do any patient care.' Per record review of the Administrator's (ADM) interview of the VCA during the facility investigation: on 4/26/12, prior to the transport "there was no conversation about what (the VCA) should do if (Res. #1) needed to go to the bathroom". Per interview with Resident #1 on 5/30/12 at 2:23 P.M. the resident described h/her feelings during the 4/26/12 incident as "undignified". Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM confirmed that the resident was knowingly sent with a staff member who, per facility policy, could not assist with toileting or incontinence care, and was assisted with both by the female VCA in a Men's Room with other people present. The ADM stated that a VCA had accompanied Resident #1 on other transports and there had never been any issues. 2. Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1 had an appointment in Troy, NY on 5/14/12. The resident was set up to be transported alone in h/her wheelchair. The Supervisor stated h/she spoke with the DNS who said the unit's nurse did not have to go with the resident. The Supervisor reported this to the ADM and stated to h/her that the ADM had said after the incident on 4/26/12 Resident #1 would never leave the facility again without a nurse. The Supervisor reported Resident #1 was sent alone to the appointment on 5/14/12. Per record review of Nursing Notes dated 5/14/12 "Vet left for (MD) appointment in Troy, NY. Vet toileted and brief in place prior to leaving. Urinal with veteran". An additional Nursing Note dated 5/14/12 states "(MD)'s office called. Vet incontinent of urine there. Office asked why no LNA (Licensed Nursing Assistant) or extra brief sent with (h/her)". Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review, an Occupational Therapy (OT) Progress Report dated 3/21/12, Res. #1 required extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per interview with Resident #1 on 5/30/12 at 2:23 P.M. h/she was transported alone to the appointment. The resident reported h/she was in a brief and given a urinal but was incontinent of urine on h/her clothes and in the transport van, and again in the doctor's office. Resident #1 stated h/she was in the wet brief for approximately 3 ? hours and the brief was not changed until h/she returned to the facility. The resident stated "the [MEDICAL CONDITION] skin" and the incident was "demeaning". Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1's sister had met the resident at the doctor's office. Afterwards, the sister had spoken to the ADM and was very upset that she had to take care of (Res. #1)'s urinating on the floor in the doctor's office. Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM also confirmed that the resident, after being incontinent on the previous trip, was sent without any assistance on 5/14/12 and was again incontinent and had to wait until h/her return to the facility before receiving help.

Based on observation, interview and record review the facility is not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. (Resident #1) Findings include: 1. Per record review Resident #1, whose [DIAGNOSES REDACTED]. Per interview on 5/29/12 at 1:35 P.M. with the Veteran Care Assistant (VCA), on 4/26/12 the nurse on Resident #1's unit told the VCA that h/she would be accompanying Resident #1 on transport to the Hospital. During the transport Resident #1 needed to urinate but was unable to hold the urinal. The VCA stated h/he had to hold the urinal while Res. #1 voided. The VCA stated h/she was never trained to assist with this. Later at the Hospital, Res. #1 again had to void. The VCA stated they had to go into a Men's Room where there were other people present and again assisted Res. #1 with voiding. The VCA stated Res. #1 told h/her "this is not right". Per record review, Resident #1's Care Plan, marked reviewed on 3/9/12 - Res. #1 'has a self care deficit...frequently incontinent of urine...Approaches: Incontinent care as needed and toileted as (Res. #1) requests. (Res. #1) wears an incontinent product for dignity'. Per record review of the Bladder Incontinence Evaluation 12/8/11 'daily incontinence episodes'...Functional status: 'extensive assist'...Contributing factors: '[MEDICAL CONDITION], depression, dementia, obesity, paranoid delusions, [MEDICAL CONDITION] joint disease, tremors, [MEDICAL CONDITION]'. Medication regimen: 'diuretics, sedative/hypnotics, narcotics, antipsychotics, antidepressants'. Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review Occupational Therapy (OT) Progress Report 3/21/12 indicates Res. #1 needs extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per record review on 5/30/12 of written statements in the facility's investigation of the incident, reported on 5/3/12, the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), the Clinical Care Coordinator of Resident #1's unit (CCC), and the unit's Registered Nurse (RN) were aware that the VCA was to accompany Resident #1 on the transport. Per record review on 5/30/12: Vermont Veteran's Home Job Description-Veteran Care Assistant (VCA): 'A Veteran Care Assistant may not do any patient care.' Per record review of the Administrator's (ADM) interview of the VCA during the facility investigation: on 4/26/12, prior to the transport "there was no conversation about what (the VCA) should do if (Res. #1) needed to go to the bathroom". Per interview with Resident #1 on 5/30/12 at 2:23 P.M. the resident described h/her feelings during the 4/26/12 incident as "undignified". Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM confirmed that the resident was knowingly sent with a staff member who, per facility policy, could not assist with toileting or incontinence care, and was assisted with both by the female VCA in a Men's Room with other people present. The ADM stated that a VCA had accompanied Resident #1 on other transports and there had never been any issues. 2. Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1 had an appointment in Troy, NY on 5/14/12. The resident was set up to be transported alone in h/her wheelchair. The Supervisor stated h/she spoke with the DNS who said the unit's nurse did not have to go with the resident. The Supervisor reported this to the ADM and stated to h/her that the ADM had said after the incident on 4/26/12 Resident #1 would never leave the facility again without a nurse. The Supervisor reported Resident #1 was sent alone to the appointment on 5/14/12. Per record review of Nursing Notes dated 5/14/12 "Vet left for (MD) appointment in Troy, NY. Vet toileted and brief in place prior to leaving. Urinal with veteran". An additional Nursing Note dated 5/14/12 states "(MD)'s office called. Vet incontinent of urine there. Office asked why no LNA (Licensed Nursing Assistant) or extra brief sent with (h/her)". Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review, an Occupational Therapy (OT) Progress Report dated 3/21/12, Res. #1 required extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per interview with Resident #1 on 5/30/12 at 2:23 P.M. h/she was transported alone to the appointment. The resident reported h/she was in a brief and given a urinal but was incontinent of urine on h/her clothes and in the transport van, and again in the doctor's office. Resident #1 stated h/she was in the wet brief for approximately 3 ? hours and the brief was not changed until h/she returned to the facility. The resident stated "the [MEDICAL CONDITION] skin" and the incident was "demeaning". Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1's sister had met the resident at the doctor's office. Afterwards, the sister had spoken to the ADM and was very upset that she had to take care of (Res. #1)'s urinating on the floor in the doctor's office. Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM also confirmed that the resident, after being incontinent on the previous trip, was sent without any assistance on 5/14/12 and was again incontinent and had to wait until h/her return to the facility before receiving help. 3. Per record review Resident #1, whose [DIAGNOSES REDACTED]. Per interview on 5/29/12 at 1:35 P.M. with the Veteran Care Assistant (VCA), on 4/26/12 the nurse on Resident #1's unit told the VCA that h/she would be accompanying Resident #1 on transport to the Hospital. Per record review of facility Policy 'Administering Medications' the policy includes "only persons licensed or permitted by this State to prepare, administer, and document the administration of medications may do so". Per record review, Vermont Veteran's Home Job Description-Veteran Care Assistant (VCA): The VCA assists Veterans/Members by performing duties that do not require a license to perform. During the interview on 5/31/12 the ADM and DNS stated that because of Resident #1's Parkinson tremors, the VCA accompanying him was instructed by the Clinical Care Coordinator "only to hold (h/her) hand to steady it" while Resident #1 took the medications. The ADM and DNS stated that the VCA "had taken it upon herself" to administer the medication. Per observation on 5/30/12 at 11:00 A.M. Resident #1 received his oral medications on a spoon in applesauce, administered by a staff LPN. The resident did not assist in the administration. Per interview with Resident #1 on 5/30/12 at 2:23 P.M. when asked how the resident receives h/her medications, the resident stated "they put a spoon in my mouth". Per interview on 5/31/12 at 2:30 P.M. the ADM and DNS confirmed that instructing the VCA to assist Resident #1 in getting the medication into h/her mouth was equivalent to the VCA administering the medication, and that the VCA was not licensed to administer medications. Per record review of the facility's investigation of the incident, reported on 5/3/12, written statements by staff RN, Assistant Director of Nursing Services (ADNS),and the Clinical Care Coordinator of Resident #1's unit "discussed the nurse could prepare his medication and the VCA could hand (Res.#1) a spoon". The statement continues "(Res. #1) would retrieve the medication from the med cup and medicate (h/her self)". Per record review of facility policy: 'Self Administration of Medications', nursing is to use the form "Assessment for Self-Administration of Medications Ability", the Care Plan Team is to review the completed form, the resident is to be evaluated for safety and compliance, and a note is to put on the MAR 'Resident self-medicating.' Per interview with Resident #1 on 5/30/12 at 1:30 P.M. stated s/he had asked Nursing previously if s/he could self-administer medications and "they said 'no'". Per interview with the ADM, the DNS, the AADM and ADNS on 5/31/12 at 2:30 P.M. confirmed Resident #1 was never assessed for self- administration of medications, and there was no documentation on the MAR indicated [REDACTED]. Per record review on 6/4/12 'Vermont State Board of Nursing-The Role of the Nurse in Delegating Nursing Interventions Position Statement-Delegation: Transferring to a competent individual the authority to perform selected nursing tasks in a selected situation. Background: The RN and LPN delegate tasks based on the needs and condition of the patient, potential for harm, stability of the patients condition, complexity of the task, predictability of the outcomes, and the abilities of the staff to whom the task is delegated.' (1) 4. Per record review Resident #1, whose [DIAGNOSES REDACTED]. as ordered by provider'. Per record review of Resident #1's Medication Administration Record [REDACTED].M.: [MEDICATION NAME] (anti-anxiety medication), [MEDICATION NAME] (cardiac medication), [MEDICATION NAME] (anti-psychotic medication), [MEDICATION NAME] (an anticonvulsant and mood stabilizer), [MEDICATION NAME] (a laxative), Calcium Antacid, Potassium, Vitamin D, a stool softener, along with [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) which is scheduled to be given at 1:30 P.M., 4:00 P.M., and 6:30 P.M. Per record review of Nursing Notes for 4/26/12, Resident #1 was transported to a doctor's appointment at the Albany Veterans Affairs Hospital. Resident #1 missed h/her scheduled appointment, was seen later by the doctor, and did not return to the facility until 5:45 P.M. Because of the extended length of the trip, The facility obtained an order for [REDACTED]., to be administered by the Hospital. Per record review of the Medication Administration Record [REDACTED].M. was signed as given by 'AVA' (Albany Veterans Hospital). Per record review Nursing Notes 4/26/12 5:50 P.M. "Veteran did not receive [MEDICATION NAME] at AVA ER per order of (Nurse Practioner)." Per record review of physician's orders [REDACTED].M. an order was obtained to administer the 6:30 P.M. dose of [MEDICATION NAME] at the present time. Per interview with the facility's DNS and ADM on 5/31/12 at 2:30 P.M. the DNS confirmed that the 4:00 P.M. [MEDICATION NAME] dose signed as given was not, and the nurse who signed out the medications "should have written a note" but did not. The DNS and ADM confirmed that a total of 9 medications due to be given to Resident #1 at 4:00 P.M. were not, that an order should have been obtained to administer the missed medications, and that there was no documentation any attempt had been made. The ADM confirmed this was against facility policy and that the Care Plan for Resident #1 called for "administer medications as ordered" and they were not.

Based on observation, interview and record review the facility is not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. (Resident #1) Findings include: 1. Per record review, the facility submitted a Plan Of Correction (POC) for regulatory violations with the approved compliance date of 6/27/12. Included in the Systemic Changes in the POC for all of the regulatory violations is "Education to all nurses...regarding obtaining and documenting medications while resident is out on pass." Per record review of the facility's policy for Medication Administration - Out on Pass, dated 6/21/12, there is no reference or statement regarding how nurses are to document medications given while the resident is out on pass. Per interview on 7/17/12 at 3:30 P.M., the Director of Nursing (DON) stated the facility's protocol is for the nurse administering the medications to take the resident's MAR (Medication Administration Record) with them while out on pass and initial when the resident had received their medications, or to make a copy of the MAR and initial on that, then transcribe the information to the original MAR after returning to the facility. The DON confirmed there are no written instructions in the facility's policy regarding documenting medications while the resident is out on pass, and confirmed there had been no education given to nurses on how to do so. Per interview with 3 of the facility's nursing staff and a unit Clinical Care Coordinator (CCC) on 7/17/12 at 1:10 P.M., staff confirmed they had received no education regarding documenting medications while a resident is out on pass, and had no knowledge of the facility's procedure on how to do so. 2. Per record review, Resident #1 was scheduled to be transported to the Albany Veteran Affairs Hospital (AVA) on 7/5/12 for a doctor's appointment. Per record review of Nursing Notes for Resident #1 on 7/5/12, marked '12:15 - 1630' (4:30 P.M.), "Veteran went to AVA during these hours with this [MEDICATION NAME] 600 mg (milligrams) given PO (by mouth) for pain". The Nursing Note at 4:30 P.M. records "[MEDICATION NAME] 5 mg PO given PRN (as needed) per request". The next Nursing Note at 5:00 P.M. lists "SPV (Supervisor), DON (Director of Nursing) and Administrator aware of above as well as CCC (Clinical Care Coordinator)." Per record review on 7/17/12 there are no initials on Resident #1's Medication Administration Record (MAR) recording [MEDICATION NAME] having been given while out on pass or [MEDICATION NAME] 5 mg having been given on 7/5/12. Per interview on 7/17/12 at 3:30 P.M. the DON confirmed the nurse's administration of both the [MEDICATION NAME] and the [MEDICATION NAME] should have been initialed on the MAR per facility protocol but were not. 3. Per record review, [MEDICATION NAME]/[MEDICATION NAME] (a drug used to treat [MEDICAL CONDITION]) is initialed on Resident #1's MAR as being given to the resident while out on pass at 1:30 P.M. on 7/5/12. The DON confirmed the nurse had documented in h/her notes the medications h/she had given to Resident #1, but did not document [MEDICATION NAME]/[MEDICATION NAME] .The DON agreed that since the nurse was out of the facility at 1:30 P.M., it would not be possible for h/her to obtain and administer that medication to Resident #1, and that the charting was done in error. 4. Per record review, the facility's Plan Of Correction (POC) for regulatory violations includes "review of 100% of records where resident required medications while on transport to assure appropriate personnel and documentation in place". Per record review of the facility's Out on Medical Pass with Medications Audit dated 7/2 - 7/8/12, the audit of documentation of Resident #1's transport on 7/5/12 reports "follow up needed- none", indicating that there was no follow up needed after the audit. Per interview on 7/17/12 at 3:30 P.M., the DON confirmed that the audit was inaccurate, that the errors in medication documentation for Resident #1 should have appeared on the audit, and that the audit would have to be redone. 5. Per record review, Resident #2, whose [DIAGNOSES REDACTED]. Resident #2 returned from SVMC to the facility at 7:45 P.M. During the time Resident #2 was gone from the facility, 4 medications; [MEDICATION NAME] (a narcotic pain reliever), [MEDICATION NAME] (used to treat muscle spasms), [MEDICATION NAME] (an anti-anxiety drug), and [MEDICATION NAME] Sodium (a stool softener) scheduled for 4:00 P.M., were not administered because the resident was unavailable until 7:45 P.M. Per record review Nurse's Medication Notes on 7/8/12 "1600 (4:00 P.M.) all meds held. Vet out to ED". Per interview with the DON at 3:31 P.M. on 7/17/12, it is h/her expectation that Resident #2's nurse would contact the physician, after the resident had returned, regarding what to do about the missed doses of medications. The DON confirmed there was no documentation that Resident #2's physician had been contacted regarding the missed medications, and indicated that the medications were significant and necessary for Resident #2's well being.

Based on observation and interview, the facility failed to ensure that meal assistance was provided in a manner to preserve the dignity of Residents that required feeding assistance. Staff were observed to be standing over Residents in the B unit dining room while assisting Residents with the evening meal on two days. This affected 10 of 13 Residents requiring significant assistance with their meal in the B unit dining room. Findings include: 1. Per staff interview and observation of meal service on 03/26/12, from 4:45 P.M. to 6:00 P.M., a table at the back of the room was noted to have four Residents positioned in large, reclining, wheeled chairs. All four required extensive feeding assistance from staff. The meal trays arrived on the unit and were delivered to the back table at 5:30 P.M. The charge nurse assisted to set the trays up for each Resident and encouraged them to attempt to feed themselves. Three did not. One Resident was able to sip soup from a mug, but did not attempt to use the utensils to eat from the plate. The charge nurse then began to assist the Residents to eat by feeding them. The charge nurse was observed to offer several bites to one Resident, then proceeded to the next Resident, in a clockwise rotation, providing several bites to each Resident before moving to the next. The charge nurse continued to feed the four Residents in this manner for approximately 15 minutes, until a second staff member arrived and sat down to assist two Residents. The nurse then continued to feed two of the Residents while standing over them. There were 24 residents observed in the dining room, and 13 required significant feeding assistance. Six staff members were present and assisting Residents at four tables. They were frequently observed to stop feeding Residents to assist other Residents in the dining room with various requests. At one point, two staff members left the dining room to assist a Resident, leaving four staff members in the dining room. During interview on 3/26/12 at 5:50 P.M., the nurse indicated that the staffing level observed in the dining room was the typical staffing pattern. Interview of the B unit Clinical Care Coordinator (CCC) on 3/26/12 at 6:00 P.M., revealed that staff were expected to sit when feeding Residents "when there are enough seats". Interview of the Administrator and the Assistant Administrator on 3/26/12 at 6:10 P.M. revealed that staff should be seated when feeding Residents. They revealed that one exception was care planned for a Resident seated at the back table, with a tall chair and positioning that made it difficult from a seated position. They revealed that all other Residents should be fed by staff that were seated. 2. Per staff interview and observation of the B unit dining area on 3/27/12 at 5:15 P.M., three staff members were observed to be standing and feeding Residents at three different tables. A table of three in the front, center of the dining room was being assisted by one standing staff member. A table of four in the back of the room was being assisted by one seated staff member and one standing staff member. The table of three, located in the center row, just in front of the table of four, was attended by one standing staff member. Two of them were frequently called away to meet requests of other Residents in the dining room. This observation was verified at that time by the CCC, who instructed the staff members to be seated when feeding Residents.

Surveyor:Dougherty, Terrance 5/31/12 Follow-up Based on observation, interview, and record review, the facility failed to promote care that maintains dignity related to repeated episodes of incontinence for one resident (Resident #1) of the sample group. Findings include: 1. Per record review Resident #1, whose [DIAGNOSES REDACTED]. Per interview on 5/29/12 at 1:35 P.M. with the Veteran Care Assistant (VCA), on 4/26/12 the nurse on Resident #1's unit told the VCA that h/she would be accompanying Resident #1 on transport to the Hospital. During the transport Resident #1 needed to urinate but was unable to hold the urinal. The VCA stated h/he had to hold the urinal while Res. #1 voided. The VCA stated h/she was never trained to assist with this. Later at the Hospital, Res. #1 again had to void. The VCA stated they had to go into a Men's Room where there were other people present and again assisted Res. #1 with voiding. The VCA stated Res. #1 told h/her "this is not right". Per record review, Resident #1's Care Plan, marked reviewed on 3/9/12 - Res. #1 'has a self care deficit...frequently incontinent of urine...Approaches: Incontinent care as needed and toileted as (Res. #1) requests. (Res. #1) wears an incontinent product for dignity'. Per record review of the Bladder Incontinence Evaluation 12/8/11 'daily incontinence episodes'...Functional status: 'extensive assist'...Contributing factors: '[MEDICAL CONDITION], depression, dementia, obesity, paranoid [MEDICAL CONDITIONS] joint disease, tremors, [MEDICAL CONDITION]'. Medication regimen: 'diuretics, sedative/hypnotics, narcotics, antipsychotics, antidepressants'. Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review Occupational Therapy (OT) Progress Report 3/21/12 indicates Res. #1 needs extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per record review on 5/30/12 of written statements in the facility's investigation of the incident, reported on 5/3/12, the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), the Clinical Care Coordinator of Resident #1's unit (CCC), and the unit's Registered Nurse (RN) were aware that the VCA was to accompany Resident #1 on the transport. Per record review on 5/30/12: Vermont Veteran's Home Job Description-Veteran Care Assistant (VCA): 'A Veteran Care Assistant may not do any patient care.' Per record review of the Administrator's (ADM) interview of the VCA during the facility investigation: on 4/26/12, prior to the transport "there was no conversation about what (the VCA) should do if (Res. #1) needed to go to the bathroom". Per interview with Resident #1 on 5/30/12 at 2:23 P.M. the resident described h/her feelings during the 4/26/12 incident as "undignified". Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM confirmed that the resident was knowingly sent with a staff member who, per facility policy, could not assist with toileting or incontinence care, and was assisted with both by the female VCA in a Men's Room with other people present. The ADM stated that a VCA had accompanied Resident #1 on other transports and there had never been any issues. 2. Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1 had an appointment in Troy, NY on 5/14/12. The resident was set up to be transported alone in h/her wheelchair. The Supervisor stated h/she spoke with the DNS who said the unit's nurse did not have to go with the resident. The Supervisor reported this to the ADM and stated to h/her that the ADM had said after the incident on 4/26/12 Resident #1 would never leave the facility again without a nurse. The Supervisor reported Resident #1 was sent alone to the appointment on 5/14/12. Per record review of Nursing Notes dated 5/14/12 "Vet left for (MD) appointment in Troy, NY. Vet toileted and brief in place prior to leaving. Urinal with veteran". An additional Nursing Note dated 5/14/12 states "(MD)'s office called. Vet incontinent of urine there. Office asked why no LNA (Licensed Nursing Assistant) or extra brief sent with (h/her)". Per interview with staff RN #2 on 5/30/12 at 11:11 A.M. Resident #1 "is total care. (H/she) will call when (h/she) needs to void but (h/she) needs assistance". Per record review, an Occupational Therapy (OT) Progress Report dated 3/21/12, Res. #1 required extensive assist with toileting. OT Progress notes dated 4/3/12 state 'current status (urinal): spills 4 out of 5 attempts'. Per interview with Resident #1 on 5/30/12 at 2:23 P.M. h/she was transported alone to the appointment. The resident reported h/she was in a brief and given a urinal but was incontinent of urine on h/her clothes and in the transport van, and again in the doctor's office. Resident #1 stated h/she was in the wet brief for approximately 3 ? hours and the brief was not changed until h/she returned to the facility. The resident stated "the [MEDICAL CONDITION] skin" and the incident was "demeaning". Per interview with a Staff Supervisor on 5/30/12 at 11:57 A.M. Resident #1's sister had met the resident at the doctor's office. Afterwards, the sister had spoken to the ADM and was very upset that she had to take care of (Res. #1)'s urinating on the floor in the doctor's office. Per interview with the facility's ADM on 5/31/12 at 2:30 P.M. the ADM confirmed Res. #1 had a history of [REDACTED]. The ADM also confirmed that the resident, after being incontinent on the previous trip, was sent without any assistance on 5/14/12 and was again incontinent and had to wait until h/her return to the facility before receiving help.

Based on resident and staff interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 applicable resident. (Resident #1) Findings include: 1. Per resident and staff interview, and record review, the facility failed to provide adequate supervision and assistance to Resident #1 during his/her participation in a regular activity of interest. Per resident interview on 10/19/10 at 1:22 PM, the resident describes his/her fall from a wheelchair, which occurred on 9/24/10 at approximately 4 PM, resulting in an injury requiring surgery and hospitalization . The resident, who is confined to a wheelchair, reports that s/he regularly participated in caring for plants in the hallway and in the Plant Room/Sun Room on the unit where the resident resides. As part of the care for these plants, s/he would fill and then hold a 2 liter bucket of water on his/her lap while sitting in the wheelchair and would then move to areas where the plants were located in order to water the plants. Review of the facility's 9/24/10 accident investigation reports, including the Director of Nursing (DNS) investigation report and statements written by staff present at the time of the fall, confirm that at the time of the fall on 9/24/10, Resident #1 was holding a bucket of water on his/her lap while in a wheelchair, stood up, spilled a large amount of water on the floor and fell . Record review also indicates that Resident #1 has several risk factors for falls. On 10/19/10 at 3:15 PM the resident showed this surveyor the 2 liter bucket used on the day of the fall. When filled to the level the resident carried on the day of the fall the bucket weighs 14 pounds as verified on the unit scale on 10/19/10. Per interview with the unit Clinical Care Coordinator (CCC) and a unit Registered Nurse (RN) on 10/19/10 at 1:47 PM they both confirmed that Resident #1 would sometimes use a shower chair with wheels to move the filled bucket of water to the plants, or staff would carry the water for the resident, or the resident would hold the bucket of water on his/her lap. The CCC also confirmed at this time that there is nothing on the Resident's Care Plan that specifically states s/he should only use a shower chair or the assistance of staff to move the water bucket to the plants. The Activities Care Plan dated 7/3/09 for Resident #1 only states: "Assist in obtaining items needed to pursue interests." There are no specific interventions listed on the care plan to say how staff should be assisting the resident in his/her pursuit of interest. Interviews on 10/19/10 at 2:07 PM with two Licensed Nursing Assistants (LNAs) who work on the unit with Resident #1 confirm that Resident #1 would usually hold the bucket of water on his/her lap while watering plants in the hallway and Plant Room. The above was confirmed by the DNS on 10/19/10 at 3:20 PM.