Every finding on record at Vernon Green Nursing Home

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a facility staff member for 1 of 3 sampled residents (Resident #1). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 1/14/26. Findings include: Per record review, Resident #1 has diagnoses that include generalized anxiety disorder, major depressive disorder, and moderate dementia with other behavioral disturbance. Progress notes dated 2/22/2026 reflect that Resident #1 had been exhibiting aggressive behaviors of yelling and lashing out at staff. The Resident was sitting in their wheelchair in the nursing station yelling out and kicked the Registered Nurse (RN), grabbing her arm. Per interview with the Director of Nursing (DON) on 6/3/2026 at approximately 3:25 PM, on the evening of 2/22/2026 she received a call from the facility informing her of a staff to resident altercation. The DON stated that when she interviewed the unlicensed Nurse Assistant (NA), she reported that she had reacted to being kicked and spit on by the Resident by slapping him on the cheek because she had PTSD (post-traumatic stress disorder) from experiences in her past. The DON confirmed that the NA had hit the Resident and that the NA stated that she could have walked away. Per interview on 6/3/2026 at 4:46PM the Licensed Nursing Assistant (LNA) who witnessed the altercation stated that she and the NA were sitting at the nurses' station with Resident #1 because s/he was having aggressive behaviors. Another Resident approached and needed help, so the LNA went to help them. When the LNA returned to the nurses' station, Resident #1 and the NA were raising their voices, yelling at each other. Resident #1 tried to kick and spit at the NA. The NA had been sitting on the counter of the nurses' station, and she jumped down and grabbed the Resident's wheelchair and was trying to tip the Resident out of the wheelchair and was yelling at her/him. The LNA was attempting to keep the wheelchair from tipping. The NA slapped Resident #1 once in the face with little contact, so she slapped her/him again.Per interview on 6/4/2026 at 1:55 PM, the Registered Nurse (RN) on duty at the time of the 2/22/2026 incident, expalined that she had asked the NA to sit with the Resident at the nurses' station because the Resident was being a bit combative, but s/he doesn't hit hard. At the time, an LNA was also there, and the RN did not want to leave her alone with the Resident, so she asked the NA to stay with them. She then heard the NA say oh, you want to kick me? The RN said that she looked around the corner and saw the NA holding the Resident's hands and the wheelchair was leaned back with the LNA trying to prevent it from tipping over. The NA then slapped the Resident across the face, leaving a red mark. Per review of the facility summary of investigation submitted to the Licensing Agency by the Director of Nursing on 2/26/2026, the NA had stated that Resident #1 had been trying to hit her and kicked her 3 times in her bad leg. The NA stated that she did not remember if she kicked the Resident, but when s/he was trying to swing at her and spit at her she reacted without thinking and struck the Resident with an open hand on the cheek. The summary documentation confirmed that the conclusion of the incident investigation verified the incident allegation of staff to resident abuse. Based on corrective actions completed on 3/5/2026, prior to the onsite, this citation is designated as past non-compliance with a compliance date of 3/5/2026. The following actions were completed by the facility:The facility reported the incident to the Licensing Agency, police, and the Office of Professional Regulation.The unlicensed Nursing Assistant's employment was terminated.An assessment of all residents was completed to identify any injuries of unknown origin such as bruising or skin tears and changes in behaviors that may indicate abuse. Residents that were intervenable were interviewed regarding abuse and mistreatment. No other residents were identified. Staff were educated on staff to resident abuse and recognizing potential concerns in coworker behaviors.The results of the audits are reported and evaluated during the quality assurance, performance improvement quarterly meetings.

Based on interview and record review, the facility failed to follow up to ensure that 1 of 5 sampled staff members (unlicensed Nursing Assistant [NA] #1) who were hired as Licensed Nursing Assistants (LNAs) obtained actual licensure within 4 months of passing a training and competency evaluation program approved by the state. Findings include:Per record review, NA #1's employee file revealed that the unlicensed NA #1 was hired by the facility on [DATE]. An employee information sheet states that she had a job change on [DATE] to an LNA. NA #1 was granted a provisional nursing assistant license by the State Board of Nursing on [DATE] with an expiration date of [DATE]. There was no evidence in the employee file that the facility had followed up to ensure that the NA had obtained their official license when the provisional license had expired. The NA was employed by the facility to perform LNA duties from [DATE] through [DATE] without the required license. During an interview on [DATE] at approximately 3:25PM the Director of Nursing (DON) confirmed that NA #1 had not obtained her nursing assistant license that is required to perform duties of an LNA. The DON also confirmed that the facility had not followed up to ensure that the NA had done so. Based on corrective actions completed on [DATE], prior to the onsite, this citation is designated as past non-compliance with the compliance date of [DATE]. The following actions were completed by the facility:The facility reported the incident to the Licensing Agency, police, and the Office of Professional Regulation.The unlicensed Nursing Assistant's employment was terminated.An audit of all licensed staff was completed to ensure that there were no other staff working without a current license. The facility implemented continued auditing of licensed staff files with a spreadsheet of all staff with dates of license expiration.Staff were educated on staff to resident abuse and recognizing potential concerns in coworker behaviors.The results of the audits are reported and evaluated during the quality assurance, performance improvement quarterly meetings.

Based on interview and record review the facility failed to ensure there were competent nursing staff for one of five nurses and five of five Licensed Nursing Assistants in the sample. Findings include:1.Review of the State of [NAME]'s Title 26 : Professions and Occupations- Chapter 028 : Nursing Subchapter 004 : NURSING ASSISTANTS, A person shall not practice nursing or nursing-related functions as defined in section 1641 of this subchapter without being licensed by the Board.The State of [NAME] definitions include Nursing assistant means an individual who performs nursing or nursing-related functions under the supervision of a licensed nurse and Nursing or nursing-related functions means nursing-related activities as defined by rule, which include basic nursing and restorative duties for which a nursing assistant is prepared by education and supervised practice. Per the State of [NAME] statutes, in order for a Licensed Nursing Assistant to handle and administer medications to a nursing home resident, the Assistant must have completed a Board-approved medication administration education program and an examination as set forth by rules adopted by the Board; and (C) is endorsed by the Board and authorized to administer medication in a nursing home. The statutes further state a Medication nursing assistant means a licensed nursing assistant who is under the supervision of a nurse holding a currently valid endorsement authorizing the delegation to the nursing assistant of tasks of medication administration performed in a nursing home. [Title 26: Professions and Occupations, Chapter 028: Nursing, Subchapter 004: NURSING ASSISTANTS, (Cite as: 26 V.S.A. 1641) 1641. Definitions, 1644. Prohibitions; offenses.] Review of Prescribed Orders for Resident #5 include Lidocaine External Patch 4 % (Lidocaine patch is a topical anesthetic used to stop pain,) Apply to left and right hip topically at bedtime on 12 hours. off 12 hours. and remove per schedule. An interview was conducted with the Staff Nurse for Resident #5 on Jan. 13 at 9:11 AM. The Staff Nurse stated the LNAs [Licensed Nursing Assistants] take off the lidocaine patches. The Staff Nurse stated that no LNA had reported removing the lidocaine patches to her. Per observation on 1/13/26 at 9:14 AM the Staff Nurse then entered Resident #5's room to administer the resident their oral medications and did not check Resident #5 to remove the left and right Lidocaine patches before or after administering the medications and leaving the room. Per record review, review of the facility's Job description: Licensed Nurse Assistant reveals no mention of assisting with medication administration. Review of 5 sampled LNA's training and competencies revealed no training regarding medication administration or assisting with medication administration for any of the 5 LNAs. An interview was conducted with the facility's Administrator on 1/13/26 at 12:24 PM. The facility's Administrator reported there are no Licensed Nursing Assistants in the facility that are certified/trained to assist with medication administration, including removal of lidocaine patches. 2.Per review of employee training and competency files it was noted that a Registered Nurse who was hired on12/16/2025 had no proof that the facility had assessed her for skills competency. One of five Licensed Nursing Assistant's flies reviewed revealed no proof of competency assessment for 2024 and 2025. Per interview with the Director of Nursing on 1/14/2026 at 1:17 PM, S/He stated the RN is very new; and new staff are given a packet of competencies to go through with their preceptor and then they return them when they are done. The DON confirmed that the RN was working shifts and had not handed in her competencies yet. The DON also confirmed that the LNA did not have proof of competency for 2024 and 2025 competency packet and there was no evidence of training.

Based on observation and interview, the facility failed to ensure cleanliness of the kitchen, the food prep area, and the dish storage area. Contamination from biological, chemical and/or physical means can have an adverse effect on all residents. Findings include: Per observation, during the initial tour of the kitchen on 1/12/2026 at approximately 11:10 AM, there was a large metal box style vent above and to the right of a rack of clean plate covers. Vent grates were covered in dust and several pieces of a white flaky substance.Per interview with a member of the kitchen staff on 1/12/2026 at 11:12 AM, s/he confirmed that the dust and/or pieces of flaky substance from the vent could fall onto the clean dishes and result in contamination.Per observation, during a follow up tour of the kitchen on 1/14/2026 at 8:45 AM, some ductwork, which had three vents, was running along the width of the kitchen, passing over food preparation area and dish washing stations. The three vent registers were covered in dark substances and dust.Per interview with the kitchen manager on 1/14/2026 at 8:50 AM, s/he confirmed the dark substance and dust on the three vents had the potential to contaminate food preparation areas and the dishwashing stations. S/he did not know when the vents were last cleaned.Per interview, on 1/14/2026 at approximately 2:00 pm, the maintenance supervisor confirmed the kitchen vents needed to be cleaned.

Based on interview and record review the facility failed to ensure care plans were revised timely for four residents (Residents #6, #14, #37, and #57) of 16 sampled residents. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23. Findings include:1.Per a record review, Resident #6 has diagnoses that include anemia, GERD (gastro esophageal reflux disease), non-pressure chronic ulcer of the left foot, and other malaise, all indications that present a risk for weight loss. Per a record review, Resident #6 weighed 123.6 pounds on 12/7/25. Resident #6's next recorded weight of 114.4 pounds was taken on 12/22/25. The weight loss of 9.2 pounds or 7.4% in a 15-day period between 12/7/25 and 12/22/25 is a significant weight loss, per MDS (Minimum Data Set) guidelines. According to CMS (Centers for Medicare & Medicaid Services) for long-term care residents, a significant weight loss is defined as a loss of 5% or more of body weight in the last 30 days or 10% or more of body weight in the last 180 days (6 months). Per a record review, Resident #6 has a care plan approach dated 10/30/24 which states, I am at risk for weight changes and altered fluid status D/T [due to] my variable meal intake r/t [related to] my physical limitations, as well as my cognitive/mood state. Resident #6 has a care plan approach dated 10/30/24, which states that she/he should be monitored for sudden weight loss. Per a record review, the facility dietician noted the weight loss in a progress note dated 12/29/25 at 3:15pm, WEIGHT WARNING: Value: 114.4 [pounds] Vital Date: 2025-12-22 11:01:00. -3.0% change from last weight [7.4%, 9.2] -7.5% change [8.5%, 10.6]. Resident #6's care plan was not updated to reflect any interventions for the weight loss. Per an interview with the DON (Director of Nursing) on 1/13/26 at 1 pm, the DON stated that there should have been a progress note from the dietitian during the month of 12/25 addressing Resident #6's significant weight loss. Per an interview with the dietician on 1/14/26 at 11:59 am, the dietician stated that she/he was aware of the weight loss incurred by Resident #6. The dietitian stated that in a discussion s/he had with Resident #6 about the current weight loss, the resident stated to the dietitian that s/he did not want an additional intervention and would like to wait and see if their weight increased. During the interview on 1/14/26 at 11:59 am, the dietitian stated, I should have written a note about that, shouldn't I. 2.Per a record review, Resident #37 has diagnoses that include unspecified dementia of unspecified severity with other behavioral disturbance, repeated falls, history of falling, weakness, and unsteadiness on feet. Per a record review, Resident #37 has a care plan problem dated 3/31/25 that states, I am at risk for falling R/T [ related to] my decreased safety awareness. Per a record review, Resident #37 sustained 8 documented falls between 9/29/25 and 12/27/25. Per a record review, Resident #37 sustained a fall on 9/29/25. A nursing progress note dated 9/29/25 at 8:31 pm states, Resident sitting on floor next to wc [wheelchair] in former single room across the hall from current trip [triple] occupancy room. Appears to have lowered [him/her-self] to the ground. Resident #37 sustained a fall on 10/17/25. A nursing progress note dated 10/17 pm at 5:47 pm states, Unwitnessed, found on floor in bathroom of old room across hallway from current room; Unwitnessed fall. Resident #37 sustained a fall on 11/8/25. A nursing progress note dated 11/8/25 at 11:52 pm states, Resident found on floor next to bed. Unwitnessed fall; holding head with goose egg/presumed hematoma to left of apex of head; I hit my head. I was trying to get into bed. I have a headache. Resident #37 sustained a fall on 11/22/25. Per a nursing progress note dated 11/22/25 at 11:30 pm, At 6:15p Lna [licensed nursing assistant] reported that [Resident #37] was on the floor on his head. Upon getting to hallway [s/he] was in front of [his/her] w/c on knees and forehead resting on [his/her] hat. Resident #37 sustained a fall on 12/7/25. Per a nursing progress note dated 12/7/25 at 4:35 pm, [Resident #37 fell forward out of w/c, redness to right knee. Denies pain. Witness and [s/he] did not hit [his/her] head. Staff assisted up to w/c and then [s/he] went to bed. Resident #37 sustained a fall on 12/26/25. Per a nursing progress note dated 12/26/25 at 2:53 am states, Resident seen sitting on the floor just outside of room - resident is naked with [his/her] brief to [his/her] thigh - resident assessed - incontinent of bowel and bladder - denies hitting head - just my pride very apologetic. Resident #37 sustained two falls on 12/27/25. A nursing progress note dated 12/27/25 at 1:01 pm states, Observed by staff walking out of another patients room when [s/he] lost [his/her] balance and fell. Patient did not hit [his/her] head, no injuries noted. A nursing progress note dated 12/27/25 at 8:38 pm states, PT attempting to get OOB [out of bed] at approx. [approximately] 2020 [8:20 pm] and rolled out of bed and onto floor before staff could assist. Did not hit head and no injuries noted. There were no new interventions documented in Resident 37's care plan subsequent to any of the above-mentioned falls. Per an interview with the DON (Director of Nursing) on 1/14/26 at 9:06 am, s/he confirmed that Resident #37's care plan should have been updated subsequent to each fall. 3.Per record review, Resident #14 has a Care Plan which identifies the resident as at risk for falls related to decreased cognition, poor safety awareness, requiring encouragement to sit or rest. The four interventions listed in Resident #14's Care Plan to prevent future falls are all dated 12/5/2025. Review of Progress Notes for Resident #14 dated 1/4/26 reveal at 9:20 AM the resident was Sleeping in chair, leaning forward and fell to the floor hitting their right frontal head on floor. The resident sustained a quarter sized bump on right lateral forehead - ice applied. Further review of Resident #14's Care Plan revealed no updates to prevent future falls for the resident. Further review of Progress Notes for Resident #14 reveals 2 days later the resident fell again. Progress Notes record on 1/6/26 At 4:30 this morning [Resident #14's] bed alarm could be heard. When staff went to check, [Resident #14] was sitting on the floor next to [h/her] bed. A quarter size abrasion is noted to the left side of [h/her] forehead. Further review of Resident #14's Care Plan again revealed no updates added to prevent future falls for the resident. An interview was conducted with the DON [Director of Nursing] on 1/14/26 at 9:06 AM. The DON confirmed Resident #14's care plan was not updated to prevent future falls after falls on 1/4/26 and 1/6/26. 4.Per review of Resident #57's medical record, they have a BIMS [Brief Interview of Mental Status] score of 99 as of 11/25/25 which indicates severe cognitive impairment. The resident was dependent on staff for ADLs [ Activities of Daily Living] and hygiene. Resident #57 had medical diagnoses of dementia, history of TIA [Transient Ischemic Attack] and cerebral infarction, and MDD [Major Depressive Disorder]. Per review of a progress note dated 11/16/25 at 5:54 AM it states, Called to [Resident]'s room, observed eyes closed skin warm and dry to touch, right side of [his/her] face drooping, nonresponsive, 107/88 99.8 92 18 o2 oxygen saturation] sat 95%. no mottling or edema, observed, [s/he] is moving around, picking [his/her] legs up, picking [his/her] nose. Per review of a progress note dated 11/16/25 it states, [Resident #57] noted with facial droop. Resident is nonverbal but nurse suspects resident might have had a stroke. POA [Power of Attorney] was notified, does not wish to have resident transferred to hospital. Request to have comfort measures in place. Per review of a physician progress note dated 11/26/25 at 6:30 PM (occurred on 11/17/25 this is LATE entry) it states, [Resident #57] was noted by staff yesterday to have left-sided facial droop and to be nonverbal. They had high suspicion of a cerebrovascular infarction at that time. They reach out to [his/her family representative] who is her DPOA and [s/he] did not want [him/her] transferred to the hospital at that time and preferred that [s/he] be started on comfort measures and to remain here at [facility]. Due to advanced dementia [Resident #57]'s quality of life had been declining over recent years and [his/her family representative] felt that any transfer to the hospital would be more traumatic than beneficial and would not have wanted any major interventions done if a condition was found. Per review of the facility's Care Planning-Interdisciplinary Team policy [last revised 11/28/23] it states, Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.3.The care plan is based on the resident's comprehensive assessment and is developed by a [sic] interdisciplinary team which includes, but is not necessarily limited to the following personnel: a. attending physician; registered Nurse who has a responsibility for the resident; c. Dietary Manager/Dietician d. Social Services Worker responsible for resident; e. Activity Director/Coordinator; f. Therapists (speech, occupational . recreational, etc.), as applicable; consultants (as appropriate); h. Director of Nursing (as applicable);i. Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. others as appropriate or necessary to meet the needs of the resident. Per review of Resident #57's care plan, there is no information regarding the resident being placed on comfort care. An interview was conducted with the DON [Director of Nursing] on 01/13/26 at 3:59 PM. The DON confirmed that care plan was not updated to reflect comfort care stating, I don't see it there.

Based on observation and interview the facility failed to ensure there was adequate mechanical ventilation on the memory care unit to prevent excessive buildup of mildew and urine odors. Findings include:During the initial tour of the licensed memory care unit (B-Wing) on 1/12/2026 at 11:28 AM a strong odor of mildew was noted on entrance to the unit. After walking by room [ROOM NUMBER] the mildew odor mixed with the smell of urine was present down the entire hall. The damp, mildew, urine smells remained throughout the length ogf the survey. During a walkthrough of B-Wing with the Director of Maintenance on 1/14/2026 at 10:16 AM he was asked about the dampness and musty smell in the air, he stated that some residents are incontinent and will try to go to the bathroom in all different places such as on the rug. The facility has carpet extractors that will clean the urine out of the rugs. When a resident is incontinent on the rug, staff try cleaning it right away and also try to get it done in the evening time when everyone isn't walking around. When questioned if the rugs have enough time to dry, he expressed that it is difficult to get them to dry in the wintertime as they cannot open windows or run the HVAC (heating, ventilation, and air conditioning) as frequently as in the summer because it makes it too cold for the residents. He confirmed that the dampness and the odors have been an ongoing issue. When asked if he keeps a log of how often he runs the ventilation system he stated that no he did not.

Based on observation, interview and record review the facility failed to ensure appropriate infection prevention and control related to disinfecting a shared electric shaver that is used for multiple residents. Findings include:Per observations in the B-Wing shared shower room on 1/14/2026 at 9:16 AM an electric razor was noted on the shelf by the bathtub; this electric shaver did not have a resident name on it. At the time of the observation, the Registered Nurse confirmed that the shaver was used for multiple residents when they needed a shave. During an interview with 2 Licensed Nursing Assistants (LNAs) on 1/14/2026 at approximately 11:30 AM when asked who the electric shaver belonged to, they stated that it is used for residents who need a quick shave after their bath. The LNAs were asked about the cleaning method used between residents and they stated that they use an alcohol pad to clean it. Per review of the facility Infection Control Policy issued 3/16/2020 states that equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents . Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact properly sterilize equipment before use on another patient). Per interview on 1/14/2026 at 1:17 PM with the Director of Nursing, she had not been aware that staff were using this specific shaver, nor had she been aware that they were using the shaver for multiple residents. The Director of Nursing confirmed that the use of an alcohol pad was not an appropriate or effective way to clean the shaver between use.

Based on observation and interview the facility failed to ensure the facility was free from medication errors greater than 5% with 2 errors in 32 opportunities [6.25%]. Findings include: Review of the facility's Medication Administration/Medication Errors Policy and Procedure [Document ID: VACH-PP-1-6-623, Reissued 11/29/23] reveals Medications shall be administered in a safe and timely manner and as prescribed, in accordance with good nursing principles and practices .1). Review of Prescribed Orders for Resident #5 include Lidocaine External Patch 4 % (Lidocaine patch is a topical anesthetic used to stop pain,) Apply to left and right hip topically at bedtime- on 12 hours, off 12 hours and remove per schedule.Review of the Medication Administration Record [MAR] for Resident #5 for Jan. 12, 2026, reveals licensed nursing staff initialed as completed the application of Lidocaine patches to the left and right hip of Resident #5 at 8:00 PM on Jan. 12, 2026.Per interview with the Staff Nurse for Resident #5 on Jan. 13 at 9:11 AM, the Staff Nurse stated I have no concern signing off [on removing the Lidocaine patches] before I check [to see if the two patches are present.] The Staff Nurse stated that no LNA had reported removing the lidocaine patches to her. The Staff Nurse then marked the electronic MAR order for the removal of the two lidocaine patches as completed at 7:59 AM on Jan. 13, 2026. Per observation on 1/13/26 at 9:14 AM the Staff Nurse then entered Resident #5's room to administer the resident their oral medications and did not check Resident #5 to remove the left and right Lidocaine patches before or after administering the medications and leaving the room.2). Review of Physician Orders for Resident #44 include Lidocaine External Patch 4 % Apply to midback topically at bedtime for pain. Further orders include Remove Lidocaine patch every AM (mid back).Review of the Medication Administration Record [MAR] for Resident #44 for Jan. 12, 2026, reveals licensed nursing staff initialed as completed the application of Lidocaine patches to the mid back of Resident #44 at 8:00 PM on Jan. 12, 2026.Per observation on 1/13/26 at 9:24 AM the Staff Nurse then entered Resident #44's room to administer the resident their oral medications. During the medication administration, the Staff Nurse attempted to remove the lidocaine patch but was unable to locate it. The Staff Nurse was then observed initialing Resident #44's MAR as having completed the order to remove the lidocaine patch, without actually confirming the patch was ever present. An interview was conducted with the facility's Director of Nursing [DON] on 1/13/26 at 1:30 PM. The DON confirmed that neither order for Resident #5 or Resident #44's lidocaine patches were completed as ordered. The DON further confirmed the Staff RN was in error when documenting on the MAR that the removal of the patches were completed as ordered.

Based on interview and record review the facility failed to ensure interventions were implemented after a significant weight loss for one of two sampled residents (Res #6).This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 10/30/24. Findings include:Per a record review, Resident #6 has diagnoses that include anemia, GERD (gastro esophageal reflux disease), non-pressure chronic ulcer of the left foot, and other malaise, all indications that present a risk for weight loss.Per a record review, Resident #6 weighed 123.6 pounds on 12/7/25. Resident #6's next recorded weight of 114.4 pounds. was taken on 12/22/25. The weight loss of 9.2 pounds. or 7.4% in a 15-day period between 12/7/25 and 12/22/25 is a significant weight loss, per MDS (Minimum Data Set) guidelines. According to CMS (Centers for Medicare & Medicaid Services) for long-term care residents, a significant weight loss is defined as a loss of 5% or more of body weight in the last 30 days or 10% or more of body weight in the last 180 days (6 months).Per a record review, Resident #6 has a care plan approach dated 10/30/24 which states, I am at risk for weight changes and altered fluid status D/T my variable meal intake r/t my physical limitations, as well as my cognitive/mood state. Resident #6 has a care plan approach dated 10/30/24, which states that s/he should be monitored for sudden weight loss. Resident #6 has a care plan approach dated 10/30/24 that states Weigh me per my physician's orders and chart. Report any significant weight changes to my MD/Family.Per a record review, the facility dietician noted the weight loss in a progress note dated 12/29/25 at 3:15pm, WEIGHT WARNING: Value: 114.4 [pounds] Vital Date: 2025-12-22 11:01:00. -3.0% change from last weight [7.4%, 9.2] -7.5% change [8.5%, 10.6]. Resident #6's care plan was not updated to reflect any interventions for the weight loss. Resident's #6's record does not reflect notification of the MD or family with regard to the significant weight loss.Per an interview with the DON (Director of Nursing) on 1/13/26 at 1pm, the DON stated that there should have been a progress note from the dietitian during the month of 12/25 addressing Resident #6's significant weight loss.Per an interview with the dietician on 1/14/26 at 11:59am, the dietician stated that s/he was aware of the weight loss incurred by Resident #6. In a discussion with Resident #6 about the current weight loss, the resident stated to the dietitian that s/he did not want an additional intervention and would like to wait and see if their weight increased. During the interview on 1/14/26 at 11:59am, the dietitian stated, I should have written a note about that, shouldn't I.

Based on interview and record review the facility failed to ensure residents were free from accidents and hazards for two of 11 sampled residents (Residents #14 and #37). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23. Findings include: 1.Per record review, Resident #14 has a Care Plan which identifies the resident as at risk for falls related to decreased cognition, poor safety awareness, requiring encouragement to sit or rest. The four interventions listed in Resident #14's Care Plan to prevent future falls are all dated 12/5/2025. Review of Progress Notes for Resident #14 dated 1/4/26 reveal at 9:20 AM the resident was Sleeping in chair, leaning forward and fell to the floor hitting their right frontal head on floor. The resident sustained a quarter sized bump on right lateral forehead - ice applied. Further review of Resident #14's Care Plan revealed no new intervention added to prevent future falls for the resident. Further review of Progress Notes for Resident #14 reveals 2 days later the resident fell again. Progress Notes record on 1/6/26 At 4:30 this morning [Resident #14's] bed alarm could be heard. When staff went to check, [Resident #14] was sitting on the floor next to [h/her] bed. A quarter size abrasion is noted to the left side of [h/her] forehead. Further review of Resident #14's Care Plan again revealed no new intervention added to prevent future falls for the resident. An interview was conducted with the DON [Director of Nursing] on 1/14/26 at 9:06 AM. The DON confirmed there were no new interventions implemented to prevent future falls for Resident #14 after falls on 1/4/26 and 1/6/26. 2.Per a record review, Resident #37 has diagnoses that include unspecified dementia of unspecified severity with other behavioral disturbance, repeated falls, history of falling, weakness, and unsteadiness on feet. Per a record review, Resident #37 has a care plan problem dated 3/31/25 that states, I am at risk for falling R/T my decreased safety awareness. Per a record review, Resident #37 sustained 8 documented falls between 9/29/25 and 12/27/25. Per a record review, Resident #37 sustained a fall on 9/29/25. A nursing progress note dated 9/29/25 at 8:31 pm states, resident sitting on floor next to wc [wheelchair] in former single room across the hall from current trip [triple] occupancy room. Appears to have lowered [him/her-self] to the ground. Resident #37 sustained a fall on 10/17/25. A nursing progress note dated 10/17 pm at 5:47 pm states, unwitnessed, found on floor in bathroom of old room across hallway from current room; Unwitnessed fall. Resident #37 sustained a fall on 11/8/25. A nursing progress note dated 11/8/25 at 11:52 pm states, Resident found on floor next to bed. Unwitnessed fall; holding head with goose egg/presumed hematoma to left of apex of head; I hit my head. I was trying to get into bed. I have a headache. Resident #37 sustained a fall on 11/22/25. Per a nursing progress note dated 11/22/25 at 11:30 pm, At 6:15p Lna [licensed nursing assistant] reported that [Resident #37] was on the floor on his head. Upon getting to hallway [s/he] was in front of [his/her] w/c on knees and forehead resting on [his/her] hat. Resident #37 sustained a fall on 12/7/25. Per a nursing progress note dated 12/7/25 at 4:35 pm, [Resident #37 fell forward out of w/c, redness to right knee. Denies pain. Witness and [s/he] did not hit [his/her] head. Staff assisted up to w/c and then [s/he] went to bed. Resident #37 sustained a fall on 12/26/25. Per a nursing progress note dated 12/26/25 at 2:53 am states, resident seen sitting on the floor just outside of room - resident is naked with [his/her] brief to [his/her] thigh - resident assessed - incontinent of bowel and bladder - denies hitting head - just my pride very apologetic. Resident #37 sustained two falls on 12/27/25. A nursing progress note dated 12/27/25 at 1:01 pm states, Observed by staff walking out of another patients room when [he/she] lost [his/her] balance and fell. Patient did not hit [his/her] head, no injuries noted. A nursing progress note dated 12/27/25 at 8:38 pm states, PT attempting to get OOB at approx [approximately] 2020 [8:20 pm] and rolled out of bed and onto floor before staff could assist. Did not hit head and no injuries noted. Per a record review, there were no documented interventions implemented in Resident #37's care plan subsequent to any of the above listed falls. Per an interview with the DON (Director of Nursing) on 1/14/26 at 9:06 am, s/he confirmed that there should have been new interventions attempted after each fall.

Based on interview and record review the facility failed to ensure PASARR screenings were completed for two of five sampled residents (Residents #5 and #48). Findings include: Per review of the medical records for Resident # 5 and Resident # 48, the records did not contain a PASARR (a Preadmission Screening and Resident Review). This is a federal requirement ensuring people with serious mental illness or intellectual/developmental disabilities are not wrongly placed in Medicaid-certified nursing facilities, instead directing them to the most appropriate, least restrictive setting with needed specialized services. A level 1 screening is conducted to identify conditions that require specialized services.Per interview with the Director of Social Services at 11:16 AM on 1/14/2026, she confirmed that all residents should have a Level 1 PASARR screening completed before they are admitted to the facility. She also stated that for a new admission to the facility, from the community, she will conduct the PASARR interview which starts with a Level 1 interview. She confirmed that PASARR documents are not in Resident #5 and Resident #109s' charts.

Based on interview and record review the facility failed to ensure discharge notices were sent to the Long-Term Care Ombudsman for one of two sampled residents (Resident #58). Findings include:Per review of Resident #58's medical record, Resident #58 has a BIMS [Brief Interview of Mental Status] score of 15 as of 12/29/25, indicating they did not have any cognitive impairment. Resident #58 has medical diagnoses of non-ST elevated myocardial infarction (a heart attack that partially obstructs the coronary artery) and unspecified dementia. Resident #58 was independent with ADLs [Activities of Daily Living] and hygiene.Per review of a social services progress note dated 12/17/25 at 12:46 PM states, .[Resident #58] who will be returning home on Saturday, 12-20-25 with services. [S/he] also has a friend who will help [him/her] and a place called [facility] that assists [him/her] with transportation needs. Both [Resident #58 and family representative] are aware that they should schedule a follow-up appointment with [his/her] PCP [primary care provider]. An administration note on 12/20/25 at 5:52 PM states, PT [Patient] discharged . Per review of the facility's Documentation of Transfers and Discharges policy [last revised 12/23/16] states, 1.All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. There is no mention of sending any transfer or discharge notices to the Long-Term Care ombudsman.An interview was conducted with social services on 1/13/26 at 1:42 PM. Social services confirmed she did not inform the ombudsman of the resident's discharge, stating, I didn't know I had to do that.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for one of three sampled residents (Res #54). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23. Findings include:Per review of the facility's Resident Abuse, Neglect, Exploitation, and Misappropriation of resident property policy [last revised 9/23/24] it states, Policy: It is the established priority of [facility] to provide its residents with a living environment free from any instance of abuse, neglect, exploitation and misappropriation of resident property.To that end, a policy has been established to deter the prospect of resident [abuse, neglect, exploitation and misappropriation] that governs staff screening and training, preventative and protective measure, and procedures for identification, investigation and reporting [abuse, neglect, exploitation, misappropriation].[Facility] will maintain a living and work environment that minimizes the likelihood of resident [abuse, neglect, exploitation, misappropriation].Per record review, Resident #54 has a BIMS [Brief Interview of Mental Status] score of 1 as of 1/8/26 indicating the resident is cognitively impaired. Resident #54 has medical diagnoses of dementia, Alzheimer's Disease, and depression. The resident is dependent on staff for ADLs [Activities of Daily Living] and hygiene.Per review of the facility's internal investigation it states, Two staff members [LNA [Licensed Nursing Assistant]#3 and LNA#4], LNAs reported that night shift LNA staff received in report that [Resident #54] had required 2 showers due to bowel movements and became aggressive with the second shower and the [LNA#1][ had sprayed [him/her] in the face with cold water. [LNA #2] had assisted [LNA #1] with the shower as [Resident #54] became aggressive. Both staff were laughing about the incident. The incident occurred on 11/13/25 during the evening shift.Per review of a witness statement from LNA#3 it states, [LNA#3] when she arrived at work [LNA#1] and [LNA#2] were behind the desk laughing about something. [LNA#1] was giving her report and said that [Resident #54] ad two blowouts and needed two showers. During the second shower [Resident #54] was agitated and pulling on the hose and pipes and [LNA#1] said she was so frustrated she just sprayed [Resident #54] with freezing water. [LNA#2] had to help because [Resident #54] was trying to rip the hose out of [LNA#1]'s hands and started pulling on the pipes. Both [LNA#12 and LNA#2] were laughing about this. [Resident #54] wanted to apologize to someone, [s/he] did not know who.Per review of the follow-up investigation it states, The allegation was reported to APS [Adult Protective Services], the [NAME] Board of Nursing and the [NAME] County Sheriff's Department. As of this date there are no outcomes [Resident #54] was assessed by the DON [Director of Nursing] and the social services director at different times throughout the day. [S/he has no recollection of the incident and his mood and behavior is at baseline .4. Corrective Action(s) Taken: [Resident #54] was assessed and has no recollection of the incident. [His/Her] mood and behavior are at baseline. Behavior is being monitored by staff and emotional support provided to both [Resident #54] and [his/her] [family representative]. [LNA#1] was suspended immediately pending investigation, and subsequently terminated from employment. [LNA#2] was suspended immediately pending investigation, and subsequently terminated from employment. MD [Medical Director] has been notified. Education regarding abuse and neglect is being done with staff. Social services and behavioral services will remain involved for ongoing support and management.3. Conclusion There is enough evidence to support that this allegation is substantiated.Per review of an addendum to final the report dated 11/19/25 it states, [Resident #54] was noted to have 5 bruises on [his/her] left forearm in healing stages. These are likely related to staff's attempt to prevent [him/her] from grabbing the water hose in the shower by holding onto [his/her] arm during the previously reported incident. [Resident #54] has no pain and is in good spirits at this time. [S/he] does not recall how the bruising occurred. Appropriate notifications have been made, will monitor bruising.On 1/13/26 at 1:30 PM an interview was conducted with the DON. She confirmed the abuse occurred, stating, Yes, I substantiated it. She confirmed that the abuse should not have occurred.

Based on observation interview and record review the facility failed to ensure professional standards were maintained regarding delegation of nursing duties for one of four sampled residents (Resident #5). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23.Findings include: Review of Prescribed Orders for Resident #5 include Lidocaine External Patch 4 % (Lidocaine patch is a topical anesthetic used to stop pain,) Apply to left and right hip topically at bedtime on 12 hours. off 12 hours. and remove per schedule.Review of the Medication Administration Record [MAR] for Resident #5 for Jan. 12, 2026, reveals licensed nursing staff initialing as completed the application of Lidocaine patches to the left and right hip of Resident #5 at 8:00 PM on Jan. 12, 2026.An interview was conducted with the Staff Nurse for Resident #5 on Jan. 13 at 9:11 AM. The Staff Nurse stated the LNAs [Licensed Nursing Assistants] take off the lidocaine patches. I have no concern signing off [on the MAR regarding removing the Lidocaine patches] before I check [to see if LNAs removed the two patches.] The Staff Nurse stated that no LNA had reported removing the lidocaine patches to h/her. The Staff Nurse then marked the electronic MAR order for the removal of the two lidocaine patches as completed at 7:59 AM on Jan. 13, 2026. Per observation on 1/13/26 at 9:14 AM the Staff Nurse then entered Resident #5's room to administer the resident their oral medications and did not check Resident #5 to remove the left and right Lidocaine patches before or after administering the medications and leaving the room. Per review of the National Guidelines for Nursing Delegation [ Effective Date: 04/01/2019 Written by: American Nurses Association - National Council State Boards of Nursing -Jointly Adopted by: ANA Board of Directors / NCSBN Board of Directors],delegation rights include:The activity falls within the delegate's job description or is included as part of the established written policies and procedures of the nursing practice setting.The licensed nurse along with the employer and the delegate is responsible for ensuring that the delegate possesses the appropriate skills and knowledge to perform the activity.The licensed nurse is responsible for monitoring the delegated activity, following up with the delegate at the completion of the activity,The licensed nurse should ensure appropriate documentation of the activity is completed. Per record review, review of the facility's Job description: Licensed Nurse Assistant reveals no mention of assisting with medication administration.Review of 5 sampled LNA's training and competencies revealed no training regarding medication administration or assisting with medication administration for any of the 5 LNAs. An interview was conducted with the facility's Administrator on 1/13/26 at 12:24 PM. The facility's Administrator reported there are no Licensed Nursing Assistants in the facility that are certified/trained to assist with medication administration, including removal of lidocaine patches. Review of the [NAME] State Board of Nursing LNA [Licensed Nursing Assistant] Scope of Practice Statement includes An LNA may not perform activities which exceed the scope defined by the level of licensure. This means that LNAs may not perform, even if directed to do so, an activity not appropriate to their level of licensure or otherwise prohibited by law.[References/Citations: 26 V.S.A. S 1592. Definitions: Administrative Rules 2.8 (c) [NAME] Board of Nursing Position Statement: The Role of the Nurse in Delegating Nursing Interventions-Date of Initial acceptance: January 2011, Revised (Date) _ January 12, 2015, July 9, 2018].An interview was conducted with the facility's Director of Nursing [DON] on 1/13/26 at 1:30 PM. The DON confirmed that there are no Licensed Nursing Assistants in the facility that are certified/trained to assist with medication administration. The DON further confirmed it is out of the scope of practice for the Staff Nurse to delegate a task to staff member unqualified and lacking the certification to perform the task, and out of the scope of practice for an LNA who is not certified as required to perform the delegated task. The DON confirmed that participating in medication administration, as in removal of a prescribed medication patch, was both out of an LNA's scope of practice and the LNA's job description. The DON further confirmed thatthe facility's Medication Administration/Medication Errors Policy and Procedure [Document ID: VACH-PP-1-6-623, Reissued 11/29/23] includes Medications shall be administered in a safe and timely manner and as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. The DON confirmed that the Staff Nurse delegating the medication patch removal to an LNA and then signing off on the Medication Administration Record that a Physician's Order was completed without verification was a violation of facility policy and not according to accepted professional standards.

Based on record review and interview, the facility failed to implement 14 day stop dates on prescribed as needed (PRN) psychotropic medications for 3 out of 5 residents in the sample (Resident's #24, #205 and #45). Findings include 1. Per record review, Resident #24 was admitted with a diagnosis of Alzheimer dementia and had the following medication orders written by the facility Provider on 10/7/2024: Quetiapine tablet; 25 mg; amt: 1 tab; oral .Twice A Day - PRN There was no documented evidence in the orders of a stop date for the antipsychotic medication as required or rationale by the Provider to extend the medications. 2. Per record review, Resident #205 was admitted on [DATE] with a diagnosis of lewy body dementia. S/He had the following PRN medication orders written by the facility Provider on 10/22/2024: Trazodone tablet; 50 mg: 1/2 tablet PRN three times a day without a stop date and Risperidone 0.25 mg, 1 tablet as needed without evidence of a stop date. Per interview with the Director of Nursing [DON] on 10/30/2024 at 10:20 AM. The DON stated and confirmed that PRN medications for Resident #24 and #205 did not have a stop date and should have. Per facility policy titled (PRN Psychotropic Medications) reviewed on 7/11/2024 PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, the following must be met i. The attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication and ii. The rationale for extending the PRN order for more than 14 days is documented in the resident ' S medical record. The duration of the PRN order must also be documented. 5. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 50431 3. Per record review, Resident #45 was admitted to the facility on [DATE] with diagnoses of bipolar disorder (a mental illness causing extreme mood swings) and vascular dementia (chronic cognitive impairment due to decreased blood flow to the brain). Per further record review Resident #45 had the following medication order: Lorazepam (a medication used to treat anxiety) 0.5 milligram (mg) tablet: Take one tablet by mouth once daily as needed. The medication order was placed on 9/19/24 with a stop date of 12/15/24. There is no Medical Provider documentation to support a prescribed as needed order beyond 14 days for Resident #45. Per interview with Registered Nurse #1 on 10/29/24 at 3:43 PM it was confirmed that Resident #45's order for Lorazepam had been extended past 14 days with no physician rationale.

Based on interviews and record review the facility failed to provide adequate supervision to maintain safety for one (1) resident (Resident #15) out 2 sampled residents. Findings include: Per record review Resident #15 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (an irregular heartbeat), depression, hypertension (high blood pressure), and dementia. Resident #15's care plan states I am at risk for falling R/T [related to] my decreased activity tolerance, as well as my decreased safety awareness. This was last edited on 9/5/24. Per record review, on 9/28/24 at approximately 7:54 PM Resident #15 had an unwitnessed fall in his/her room. Resident #15 was transported to the hospital by EMS [Emergency Medical Services]. Per record review of physician documentation, Resident #15 was admitted to the hospital for Left Hip fracture with small extraperitoneal pelvic hemorrhage (a left broken hip with some internal bleeding). S/he had surgery to fix his/her broken hip. Per the facility's Falls Risk Assessment and Care Planning policy, 5. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls . 6. The staff, with the support of the Attending Physician and therapy department, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. 7. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. Per record review of the facility's internal report, there is no documentation of an evaluation and analysis of hazards and risks in Resident #15's environment that could have caused the unwitnessed fall. There is no implementation of individualized, resident-centered interventions to reduce Resident #15's risks for falls related to possible hazards in the environment.

Based on observation, interview and record review the facility failed to meet professional standards related to a Licenced Nursing Assistant (LNA) acting outside his/her scope of practice by administrating medications to one resident in the sample (Resident # 205). Findings include Per observation at approimately 2:00 PM on 10/28/2024 the LNA was observed administrating medications to Resident #205 while at the nurse's station. Per Interview with a Licensed Nurse on 10/28/2024 at approximately 2:05 PM s/he stated that s/he or the other Nurse were unable to administer the medication to the Resident. S/He stated that they delegated the task to the LNA because s/he had a good rapport with Resident #205. Per Interview with the LNA on 10/28/2024 at 3:40 PM s/he confirmed that s/he gave Resident #205 his/her medications crushed in ice cream. The LNA stated that this was not the first time s/he has been delegated by nurses to give medications. The LNA stated that s/he has not been trained by the facility to give medications. According to the [NAME] State Board of Nursing and the LNA scope of practice An LNA may not perform activities which exceed the scope of practice defined by their level of licensure. This means that the LNA may not perform, even if directed to do so, an activity not appropriate to their level of licensure or otherwise prohibited by law. Examples of activities not within the LNA scope of practice include: nursing assessments, nursing judgments, and development of the plan of care. Durnig interview on 10/30/2024 at approximately 4:00 PM the Director of Nursing confirmed that administrating medications to residents is not in a LNA's scope of practice, and that the LNA should not do so.

Based on observation, interview, and record review the facility failed to implement care planned interventions for 2 of 29 Residents in the sample (Resident # 30) related to positioning, and (Resident #25) related to pressure ulcer prevention, pain control, and nutritional risks. Findings include: 1. Per recd review Resident #25 has advanced dementia. S/he developed an in house acquired stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister) pressure ulcer on her/his left heel and has experienced a significant weight loss of 11.84% over 3 months. A Nurses Progress note dated 9/10/2024 12:12 PM reads a fluid-filled blister was noted at outer edge of left heel found this AM during therapy session; resident c/o discomfort when blister was pushed on; the skin over the blister is dry/calloused; the right heel is slight pink . A Care Plan Problem with a start date of 2/19/2022 stated that Resident #25 has the potential for skin breakdown related to incontinence and decreased mobility, as well as a decline in ability to participate in ADL (Activities of Daily Living) care. A listed approach to care with a start date of 10/17/2024 reads Provide me with pressure relief boots on in r/c [reclining chair]. Another approach with a start date of 2/19/2022 is Assist me with frequent position changes. Per observation on 10/28/2024 at 3:00 PM Resident #25 was observed lying in a reclining chair. There were no pressure relief boots on her/his feet. During an interview on 10/28/24 at approximately 4:15 PM a Licensed Nurse Assistant (LNA) who is familiar with Resident #25 confirmed that the Resident should have pressure relief boots on when up in the reclining chair, and that s/he did not have them on. The LNA retrieved the boots from the Resident's room and applied them to the Resident's feet. During observations on 10/29/2024 at 12:40 PM Resident #25 was seen asleep in a reclining chair leaning to the right with a pillow on the arm of the chair under the right side of her/his head. There were no pressure relief boots on her/his feet. This Surveyor observed the Resident lying in the recliner from 12:40 PM - 4:10 PM without being assisted with repositioning. At 4:10 PM s/he was still lying in a recliner leaning to the right with her/his head on a pillow on the arm of the chair. S/he had not been repositioned and there were no pressure relief boots on her feet per care plan. Per interview with a LNA on 10/29/2024 at 4:20 PM Residents are usually toileted and repositioned about every two hours. The LNA confirmed that Resident #25 did not have pressure relief boots on her/his feet and that s/he should. The LNA retrieved the boots and applied them to Resident #25's feet. Further review of Resident 25's record revealed a Dieticians Progress Note dated 9/11/2024 that states Recommend increase in supplement to TID [three times per day] to provide 750 cal/27 gm pro., and Centrum silver QD [every day] to support wound healing and deter weight loss. See care plan. A Care Plan Problem for Nutritional Status last edited on 10/23/24 states I have a [history] of weight loss along with behavioral changes, and I am at risk for additional weight loss. I have increased pro/cal/vit [protein/calories/vitamin] needs for wound healing (Stage] II area 9/10/24). I can no longer feed myself due to decline in cognition. Care Plan interventions last edited on 9/11/24 state Provide me with my nutritional supplement as ordered. Increase to TID recommended 9/11/24 to support wound healing. Provide vitamins as ordered to support wound healing-centrum silver recommended. A Dietician Progress Notes dated 10/28/2024 reveals that Resident #25 had not started centrum tab or had any increase in her/his dietary supplement; this [was] recommended by dietician to support wound healing; sent fax to Doctor [name omitted] r/t [related to] this;. Review of Resident #25's October 2024 Medication Administration Record (MAR) revealed that the increase in dietary supplement and the administration of the Centrum Silver did not start until 10/29/2024. During an interview on 10/30/2024 at 3:33 PM the Director of Nursing confirmed that the the recommendations made by the dietician on 9/11/2024 had not been implemented until 10/29/2024. 50336 2. Per observation on 10/28/2024, at 05:19 PM Resident #30 was sitting at the dining table in a reclining chair. S/he was leaned over the left side of the chair with his/her face at eye level with the edge of the table. Resident #30 was not repositioned from his/her side prior to being given his/her meal. At 5:30 PM on 10/28/2024 the License Nursing Assistant (LNA) brought resident's tray to the table and without repositioning Resident #30, s/he handed the resident a half a sandwich. Resident #30 remained in the leaned over to the left side of the chair and was not repositioned prior to his/her meal. Resident #30 remained on his/her left side at eye level with the table while s/he attempted to eat the sandwich. Per record review Resident #30 was admitted to the facility with a diagnosis of Vascular Dementia, dysphasia and reflux disease. His/her care plan included .due to my medical diagnosis of dysphasia, I am an aspiration risk . Approach starting 3/14/2023 I need to be seated upright in the chair at 90 degrees for all intake . I need to be seated upright for 45-60 minutes after every meal to decrease my chance of reflux. Per further record review Speech, Language and Pathology note dated 6/8/2024 in section titled Impact on burden of care / daily living without interventions implemented, [Resident #30] is at risk for aspiration and general discomfort during intake due to severity of [his/her] cough [and] clearing [his/her] airway . Per interview on 10/28/2024 at 5:45 PM with the LNA staff confirmed that Resident #30 should have been repositioned and sat up prior to meal, and that s/he requires observation and assistance with all meals.

Based upon interview and record review, the facility failed to ensure one resident [Res. #35] of 21 sampled residents remained free from physical abuse. Findings include: Per record review of Progress Notes for Res. #35 dated 7/22/24 Other resident was in [h/her] room when [Res.#35] tried to enter the room. [Res.#35] asked the person to leave [h/her] room and they got agitated and would not let [h/her] in [h/her] own room. They took [Res.35's] glasses off and threw them across the room, poured a soda on [h/her] head and then was moving [h/her] wheelchair from side to side until [s/he] ultimately fell out of the wheelchair. [Res.#35] did call for help and staff arrived as soon as heard [h/her]. Per review of the facility's investigation of the incident, the investigation concluded the allegation was verified by evidence collected during the investigation and was witnessed by staff. Per review of corrective actions taken by the facility after the incident, the residents were immediately separated after the incident and assessed for injuries. Close supervision was provided. Care plans for both residents were updated. Family, physician, and authorities were notified, the incident was reported to the State Agency and investigated in the appropriate time frame. The perpetrator was psychologically evaluated and medications were adjusted. Res. #35 was moved off the perpetrator's unit, and Social Services and Behavioral Health Services were involved in care and treatment for both residents post incident. Review of Res.#35's medical record reveals no negative physical or psychological outcomes from the incident. The facility conducted a Behavior Analysis Report regarding the perpetrator's behaviors before and after the incident. Behaviors that were monitored included grabbing others, hitting others, pushing others, cursing at others, screaming at others, threatening others, and rejection of care. The facility monitored the number of behaviors, when they occurred, the intervention[s] provided, and whether the interventions were effective. Per review of the Behavior Analysis Report, interventions implemented to halt the behavior during the incident on 7/21/24 and new interventions implemented to prevent future incidents were documented and noted effective. Per interview with staff Licensed Practical Nurse [LPN] on 10/30/24 at 8:34 AM, the LPN confirmed the perpetrator's past behaviors and improvement post incident. The facility completed corrective actions after identifying this deficient practice, prior to the survey entrance; therefore, this deficiency is considered past noncompliance.

Based on observations, staff interviews and record reviews, the facility failed to revise the comprehensive care plan for two of twenty nine Residents in the sample (Resident #9 and Resident #15) as the Residents' plans of care changed related to Activities of Daily Living (ADLs) and Nutritional Status for Resident #9, and a fall with major injury at the facility for Resident #15. Findings include: 1. Per Observation on 10/28/24 and 10/29/2024, Staff were seen assisting Resident #9 with eating a meal. This surveyor observed the need for total assistance. Per record review, Resident #9's current Care Plan Problem category Nutritional Status states I have a history of weight loss. I continue to be at risk for weight loss and altered fluid status due to my variable meal intake at times, related to my cognitive/ mood state, as well as possible medication side effects. This Problem category has an Approach dated 12/04/2023 that states I am dependent on you to assist me with my meal to help me have sufficient intake. I will occasionally feed myself a drink. There is another Approach, dated 04/29/2021 that states Set my meal up for me to encourage my independent eating Resident #9's current Care Plan Problem category ADLs Functional Status/ Rehabilitation Potential states I have a self care deficit secondary to my physical limitations, as well as a decline in my functional strength and endurance with poor activity tolerance. This Problem category has an Approach dated 09/26/2022 that states Cue me for mouth and hair care and assist me as needed and as I will allow. There is another Approach that states Provide setup for my ADL care at my bedside or in my bathroom, which ever I may prefer. Encourage and cue me as needed to wash what I can and provide me with assistance as needed. Per interview on 10/30/2024, at 3:37 pm with Licensed Nursing Assistant (LNA) Resident #9 will open his/her mouth to be fed and to allow us to brush his/her teeth, but otherwise is dependent on staff for all ADLs. Per interview 10/30/24, at 3:45 pm, MDS Coordinator confirmed that the current Care Plan is incorrect/ contradictory and has not been revised. 50431 2. Per the facility's Falls Risk Assessment and Care Planning policy, 5. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls . 6. The staff, with the support of the Attending Physician and therapy department, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .The care plan will be reviewed and revised by the charge nurse or designee after each fall and additional nursing staff will be notified through shift reports and communication logs. Per record review, on 9/28/24 at approximately 7:54 PM Resident #15 had an unwitnessed fall in his/her room. Resident #15 was transported to the hospital by EMS [Emergency Medical Services]. Per record review of physician documentation, Resident #15 was admitted to the hospital for Left Hip fracture with small extraperitoneal pelvic hemorrhage (a left broken hip with some internal bleeding). S/he had surgery to fix his/her broken hip. Per record review of Resident #15's care plan states I am at risk for falling R/T my decreased activity tolerance, as well as my decreased safety awareness. This was last edited on 9/5/24. There are no new revisions in this section of the care plan after Resident #15's fall and hospitalization . Per interview with the DON [Director of Nursing] on 10/30/24 at 10:06 AM it was confirmed that Resident #15's care plan was not revised after his/her fall with major injury.

Based on observation, staff interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water and bathing water temperatures. The facility failed to have an adequate water temperature monitoring process in place that resulted in critically high water temperatures in resident rooms and in a shower/tub room. These failures resulted a likely risk of serious burns to residents and created an immediate jeopardy situation. Findings include: Per observation on 11/27/23 at 11:45 AM, the water from the resident handwashing faucet in room [ROOM NUMBER] was too hot to use when this surveyor went to wash their hands following resident interview. The faucets are located outside of the resident bathrooms in the main part of the resident rooms. The water temperature was taken at this faucet with a digital thermometer, which read exactly 120 degrees Fahrenheit at its hottest. The water temperature was then taken in additional resident rooms and in shower/tub rooms used for resident bathing. At 11:50 AM, the faucet water in resident room [ROOM NUMBER] read 124.1 degrees Fahrenheit at its hottest. At 11:52 AM, the faucet water in resident room [ROOM NUMBER] read 126.0 degrees Fahrenheit at its hottest. At approximately 12:00 PM, the B wing bathtub faucet water read 123.9 degrees Fahrenheit at its hottest. Per interview on 11/27/23 at 12:15 PM, the facility's Maintenance Director stated that the boiler with the mixer valve for hot water is set at 115 degrees Fahrenheit and is located under the main dining room in the basement. Rooms closer to the boiler are likely to be hotter, as the water takes less time to travel from the boiler to the faucets the closer they are to the boiler. The Maintenance Director stated that they check and record water temperatures every day at approximately 7:30 AM, when water usage is at its highest in the facility due to morning care. They confirmed that water temperatures are not taken in resident rooms, also due to morning care, and that water temperatures are taken from somewhere in the common areas or main lobby. When asked if they were ever aware of water temperatures being hot before, they confirmed that they had been made aware of it in the past, but that when the temperature of the boiler was turned down, the staff and residents would complain that there is not enough hot water at high usage times. For this reason, they set the boiler temperature back at 115 degrees Fahrenheit. When asked, the Maintenance Director confirmed that residents wash their hands and receive showers/baths at all times of the day. The Maintenance Director then confirmed that the facility's policy regarding water temperatures states that any water temperature above 120 degrees Fahrenheit is too hot and unacceptable. After the interview at approximately 12:30 PM, this surveyor and the Maintenance Director measured the temperature of the water in room [ROOM NUMBER] with our respective thermometers. This surveyor's thermometer read 122.1 degrees Fahrenheit, and the Maintenance Director's thermometer read 121.9 degrees Fahrenheit. The Maintenance Director confirmed that this is too hot for the water that residents have access to. Per review of the facility policy titled Water Temperature Precautions - Anti Scald, the policy states, water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit . Review of the facility's water temperature monitoring log for November 2023 shows that no temperatures exceeded 120 degrees Fahrenheit, but that water temperatures were recorded at 119.3 on the 7th, 119.6 on the 15th, 119.1 on the 23rd, and 119.2 on the 24th at times of high water use in the facility. Serious burns are likely within minutes of skin exposure to water around 120 degrees Fahrenheit or greater. Resident rooms #109 and #111 are on the long-term care unit and rooms #210 and the B wing tub room are located on the memory care unit where the facility's most cognitively impaired and vulnerable residents are located. Resident room faucets are easily accessible to anyone entering a resident room. The facility confirmed their water temperature monitoring process does not include a way to ensure measuring temperatures in resident rooms or at varying times of day. The facility also confirmed that they had been alerted to hot water concerns in the past but took no lasting action to address the issue. For these reasons, there was an immediate risk of harm to residents that was likely to result in serious burns.

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 25 residents in the sample (Resident # 19), and the facility failed to protect the resident's right to be free from neglect for 1 of 25 residents in the sample (Resident #33). Findings include: 1. Per record review, Resident #19 has diagnoses that include major depressive disorder, advanced dementia with behavioral disturbances, and delusional disorders. Resident # 19's Activities of Daily Living (ADL)/Rehab Potential care plan reflects that s/he requires extensive to total staff assistance with ADLs. Review of Resident #19's Behavioral Symptoms care plan reveals that s/he wanders about the unit in her/his wheelchair. An MDS (Minimum Data Set, an assessment tool used for implementing standardized assessment and for facilitating care management in Long Term Care) dated 9/22/23 states that Resident #19 was unable to participate in the BIMS (Brief Interview for Mental Status) assessment due to severe cognitive impairment. Per Reveiw of the facility internal investigation a witness statement written by a licensed nursing assistant (LNA)dated 8/12/23 states I came out of [another resident's room] and saw (Resident #19) chair in [Resident #53's room], so I went to remove [him/her]. As I came around the corner I saw (Resident #53) holding (Resident #19) by the wrist, as (Resident #53) mastersterbated in close proximity to (Resident #19) face. Resident #19 appered to be covered in urine from the chest down. Resident #53's pant legs were soaked as well. (Resident #19) was removed from the room and (Resident #53) was put back to bed. A nurse progress note written on 8/13/23 at 8:38 PM reveals that the day after the incident Resident #19 was monitored and redirected all shift attempting to go into other residents' rooms several times. Wandering excessively all shift, very unsettled Had to be kept in [NAME] room for supper due to excessive wandering, attempted several unsafe risings during the shift from his/her wheelchair, continued to redirect and occupy resident all shift. Very resistant and combative during HS [hour of sleep] care. Per resident care plan dated 9/21/23 Resident #19 I may look to go home, and may wander about the unit in my wheelchair looking for away out, and I may be difficult to redirect at times. Without meaning to, I may wander into other's personal spaces I may be resistive or combative with care. I may become combative/aggressive with attempts at redirection or repositioning in my wheelchair. Further record review reveals that Resident #19's care plan last updated on 9/21/23 does not reflect that s/he is vulnerable to, at risk for, or an actual victim of abuse after the 8/12/23 incident. The care plan also has no interventions in place to protect Resident #19 from further incidents of abuse. Per review of Resident #53's medical record, s/he has a diagnosis of Alzheimer's disease and had been exhibiting a recent increase in sexual behaviors toward staff and other residents. An MDS quarterly assessment dated [DATE] reflects that Resident #53 has a BIMS score of 3 indicating severe cognitive impairment. S/he ambulated independently with a walker. Per a Nursing Progress Note dated 8/7/2023 a new physician order was recieved on 7/31/23 to increase daily Aricept to 10 mg. The Progress Note states that Residnet #3 had some copies of clinic notes in chart that came from The Memory Clinic. The notes state that 7/15/19 Aricept 10 mg seemed to precipitate an increase in agitation in patient. The Physician was notified of the notes from the Memory Clinic and nursing will continue to document every shift to monitor x 21 days. Nurses progress notes written between 8/8/23 and 8/13/23, both prior to and after the incident reflect that Resident #53 had required redirection by staff due to sexual comments and requests made to staff and other residents, fondling her/his own genitals, touching staff's buttocks and crotch areas, and attempting to kiss staff and another resident. A nurses progress note written on 8/12/23 at 2:22 PM states Since 7/31/23 [Resident #53] has had a documented increase in sexual libido and acting on urges in inappropriate places . The progress note also reflected that Resident #53's bed alarm should be re-positioned to the end of the bed to ensure that s/he cannot turn it off, alerting staff to his/her movement within his/her room. A nurses progress note written on 8/13/23 states during the night Resident #53 wandered into another resident's room bed alarm was in place resident was able to turn it off alarm. Resident #53's care plan initiated on 8/10/23 identifies a problem of I may be sexually inappropriate towards staff and other residents. There were no documented interventions implemented to protect other residents until 8/12/23 after the incident that involved Resident #19. There is also no evidence in the record that the Physician was notified of the increase in behaviors until 8/12/23 after the incident that involved Resident #19. During an interview on 11/27/23 at 2:30 PM a Licensed Practical Nurse (LPN) confirmed that Resident #19 is always in eyesight during his/her shift but does wander in his/her wheelchair and will attempt to go into other resident rooms. During an interview on 11/30/23 at 12:37 PM the Social Services Director confirmed that she/he was aware of the resident-to-resident abuse incident between residents #19 and #53. She/he also confirmed there is no care plan in place that addresses the fact that Resident #19 is at risk for or is an actual victim of abuse. 48017 2. Per record review, Resident #33 has resided at the facility since 10/17/2022 with diagnoses that include Depression, muscle weakness, and a BIMS of 12 (A cognitive screening measure that evaluates memory and orientation, indicating moderately impaired cognition). Per interview on 11/27/2023, at 2:10 PM, Resident #33 expressed feeling humiliated about being incontinent of urine and feces, and is told to go in her/his underwear, and they will clean her/him up. Per the resident, there was a urinal and a bedpan provided, but they are no longer available to her/him. Resident #33 explains that although it is difficult to transfer using the Hoyer lift (a mechanical lift used to move residents from one point to another), which requires additional staff, staff do not come back in time when s/he needs assistance, and s/he ends up soiling her/his clothes. Resident #33 says, I know I am a lot of work, and I feel bad if I ask for help; I'm a veteran and fought for my country; this feels bad. Per record review: A care plan problem reviewed on 9/7/2023 reads, s/he may experience episodes of incontinence . I require your assistance using the bathroom, secondary to my cognitive and physical limitations. Another progress note, dated 09/14/23, S/he may experience episodes of incontinence .S/he requires assistance using the bathroom and may choose to keep a urinal at the bedside. A progress note dated 9/22/23 I need to have a BM (bowel movement). It's stinging my butt, [incontinent of large BM and urine]. Another care plan intervention implemented on 10/17/2022: Offer me the bedpan or bedside commode with my routine comfort checks during the night . I prefer to use the urinal at night, but I may spill it and need staff assistance to empty it. Another intervention dated 10/17/2022 offer and assist me with using the bathroom pre and post-mealtime and at HS (before bed) and on request . Remind me to ask you for assistance whenever I need the bathroom. The facility is failing to implement Resident # 33's interventions as identified in her/his care plan, by not offering the bed pan and urinal, resulting in the resident waiting for extended periods of time and urinating in her/his clothes resulting in embarrassment and humiliation. Although there was no evidence that this practice caused physical harm to the Resident, the fact that Resident #33 expressed feelings of embarrassment and humiliation reflects psychological harm. Per interview on 11/28/2023 at 2:49 PM, Licensed Nursing Assistant (LNA) #1 stated Resident #33 must be moved to the bed using the Hoyer lift and then offered the bedpan. S/he says,A bedpan is kept in the bathroom for that purpose. S/he was unable to produce a bedpan when asked. Per interview on 11/28/2023 at 2:53 PM with LNA #2, s/he explained they may try to provide toileting or the bedpan to Resident # 33, but it's hard, s/he is a Hoyer lift, and we need a second person, so s/he wears an incontinence brief, it makes it easier . We don't have the staff to manage the residents who need the Hoyer to move them . Usually, s/he is incontinent anyway by the time we return, so we just put him/her on the bed and change her/him. On 11/29/2023 at 1:28 PM two LNAs were observed checking Resident #33 incontinence brief. S/he was incontinent of urine and was not offered to use the bedpan or urinal. Per interview with the LNA after the observation, at approximately 1:45 PM, the LNA stated, Resident #33 was already incontinent, so they provided incontinent care and did not offer the urinal. An interview with Resident #33 on 11/29/2023 at approximately 1:55 PM revealed that s/he had not been offered the bedpan, toilet, or urinal since s/he was given morning care at approximately 6:55 AM. On 11/28/2023 at approximately 3:25 PM, the Director of Nursing confirmed that staff was not providing the necessary care and assistance to Resident #33 by not implementing his/her care plan and not offering him/her the use of the bedpan, urinal, or bathroom.

Based on observations, interviews, and record reviews the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #3) received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. As a result, Resident #3 developed two stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcers after admission to the facility. Findings include: Per record review Resident #3 was admitted to the facility on [DATE] with diagnoses that include heart failure, atrial fibrillation (an irregular, often rapid heart rate), and peripheral vascular disease (circulation disorder). An Admission Nursing Assessment completed on 9/12/23 reflects that Resident #3 had a red rash on areas of their upper body, scabs on their right and left elbows and knees, and a small mark on their left side buttock fold. There were no pressure wounds identified on the admission assessment. A 48 Hour Post Admission Interdisciplinary Care Plan dated 9/14/23 reflected that the resident required Routine skin care, had no special treatments, and no pressure ulcers. A care plan focus started on 9/14/23 states that Resident #3 has the potential for skin breakdown related to incontinence and decreased mobility. Interventions implemented on 9/14/23 include check my skin thoroughly with my ADL care, incontinence care, and with my weekly shower. Report any [signs or symptoms] of breakdown to the nurse in charge and my [physician]. There are no preventative interventions in place to protect against the increased risk of development of pressure ulcers related to impaired circulation. Review of Resident #3's admission MDS (Minimum Data Set, an assessment tool used for implementing standardized assessment and for facilitating care management in Long Term Care) dated 9/21/23 the facility had determined that Resident #3 was at increased risk for developing pressure ulcers. It also revealed that Resident #3 did not have pressure ulcers but was at risk for pressure injury and should s/he experience impaired skin integrity, s/he may experience delayed wound healing not only due to hypothyroidism, but also altered perfusion related to atrial fibrillation and congestive heart failure. Progress notes reveal that Resident #3 developed injuries that progressed to bilateral heel stage two pressure ulcers. A progress note dated 11/23/2023 states During hs [hour of sleep] care [Licensed Nursing Assistant] noted heel leaking. When [Licensed Practical Nurse] took a look, it appears to be an old wound. It has a scab on it. The area around is very dry and cracking. It was cleaned with wound cleanser and mepilex applied. Notified [physician] via fax. There is no evidence in the record that reflects the date the pressure ulcers were developed. A Physicians Progress Note dated 11/24/23 reflects that nursing had sent the Physician a fax about potential areas of concern on [bilateral] heels . Left heel has open pressure wound that was draining moderate amount of serous material and sticking to [her/his] sock - area cleaned and mepilex applied. Right heel has mild amount of serous drainage from heel and area cleaned and mepilex [foam dressing] applied there as well. The progress note further states pressure ulcer of right heel stage 2. Area cleaned and mepilex applied. Elevate legs when able. Avoid pressure on heels. Pressure ulcer of left heel stage 2. Area cleaned and mepilex applied. Elevate legs when able. Avoid pressure on heels. There is no documentation of measurements in the record to establish the size of the pressure ulcers. Further record review revealed that there was no evidence of wound assessment of the bilateral heel pressure ulcers. There were no interventions implemented in the care plan that reflect preventive measures for heel pressure ulcers. In addition, the care plan was not revised to reflect the pressure ulcers when they developed, including interventions for pressure ulcer treatments, daily wound monitoring, weekly wound assessments related to the actual ulcers, or the Physicians recommendations to elevate legs when able and avoid pressure on heels. There was no evidence that weekly skin checks were performed as per the care plan. Per interview on 11/30/23 at 12:08 PM the MDS Coordinator confirmed that the care plan did not address the bilateral heel stage two pressure areas and interventions specific to the risk of developing pressure ulcers to the lower extremities related to impaired circulation. During an interview on 11/29/23 at approximately 1:00 PM the Director of Nursing confirmed that s/he had recently identified that wounds were not being assessed per policy.

Based on staff interview and record review the facility failed to provide adequate supervision for 1 of 4 residents who were at risk for falls in the applicable sample (Resident #39). Findings include: Per record review Resident #39's care plan reflects that s/he is at risk for falls. On 12/20/2021 after s/he experienced a fall, a care plan intervention was added that states ensure the resident is in line of sight of staff when out of room. S/he has since experienced falls on the following dates; 01/03/2022, 2/24/2022, 2/26/22, 2/28/22, 6/30/22, 7/3/22, 7/21/22, 7/29/22, 8/3/2022, 8/15/22 10:40 am, and 1:00 PM. The fall on 8/15/2022 resulted in a hip fracture. Review of the care plan reflects that the resident is at risk for falls. On 12/20/2021 after a fall, a care plan intervention was added to ensure the resident is in line of sight of staff when out of room. However, after 10 additional falls the resident continued to ambulate throughout the unit independently and without being in the line of sight at all times. The care plan had not updated to reflect a need for increased supervision or additional assistance prior to the last fall on 8/15/2022 that resulted in a fractured hip. A progress note written on 8/8/2022 at 2:45 PM states [Name omitted] is ambulating on the unit today with [her/his] rolling walker. [S/he] is leaning to the right while ambulating. [Her/his] walker is drifting to the right as well, and [s/he] is often bumping into objects. On 8/15/2022 at 10:40 am the resident was found by a [Licensed Nurse Assistant] (LNA) in [her/his] bathroom on the floor. [S/he] was laying on [her/his] right side, holding [her/his] walker which was also laying on it's side. The walker was facing backwards. [S/he] complained of a sore hip from being on the floor. She was able to move all extremities. [S/he] denied hitting [her/his] head. When [s/he] was stood up with 3 assist, [s/he] went pale, became clammy and passed out. [S/he] did not fall at that time. This writer held [her/him] up by placing [her/him] on a knee. [S/he] came to moments later . On 8/15/2022 at 1:00 PM, [Name omitted} attempted to stand from [her/his] wheelchair. [S/he] fell , hitting [her/his] head on the floor. [S/he] landed again on [her/his] right side. [S/he] reports increasing discomfort in [her/his] right hip. [Her/his] right leg appears to be a half inch shorter than the left. [S/he] has a skin tear to the right external elbow, and complaints of a headache . [Name omitted} will remain one-on-one with staff. During an interview with the MDS Coordinator on 11/16/2022 at 11:20 AM s/he stated that s/he and the Assistant Director of Nursing are responsible for updating the care plan as needed. When asked how s/he knew when the care plan needed to be updated s/he stated that the ADNS will tell her/him or s/he gets information from staff on the unit. The MDS Coordinator also confirmed that the resident's care plan did not reflect a need for assistance or increased supervision from being in line of sight when out of room.

Based on staff interview and record review, the facility failed to protect 1 applicable resident in the targeted sample from physical abuse as a result of actions by another resident. (Residents #1 & 2) Findings include: Per record review and confirmed by staff interview, Resident #1 caused serious injury to Resident #2 on 9/3/10 during an unprovoked attack. Staff failed to provide 1:1 supervision (per the care plan) for this resident who had a history of [REDACTED]. Per staff interview at 12:30 PM on 9/9/10, the incident occurred on 9/3/10 at 5 PM when Resident #1 grabbed Resident #2's shirt from behind and pulled the resident to the left and down, causing the resident to fall against the wall, hitting the left side of the head with force, and then fall to the floor. Subsequently, Resident #2 was transferred to the hospital and admitted for treatment. The description of the resident to resident incident was provided during interview with the evening shift LPN Charge Nurse on 9/9/10 commencing at 12:30 PM. During interview with the Director of Nursing Services (DNS), the Evening Charge Nurse and the RN in charge of monitoring resident incidents at 12:30 PM, all were aware of the pattern of intrusive, at times assaultive and potentially dangerous behaviors exhibited by Resident #1 since admission. Per review during the morning of 9/9/10, the resident's care plan stated "physically aggressive towards staff and other residents...episodes of biting staff, may became aggressive without cause, @ times without warning"...monitor interactions with other residents...attempt to redirect if safety issues should arise.., 1:1 with staff...consult with (psych nurse) PRN. Per review of the record, Resident #1 had a history of [REDACTED]. During interviews with the DNS, the day shift Charge Nurse and evening Charge Nurse during the afternoon on 9/9/10, all confirmed that although the resident had these known unpredictable behaviors, he/she was not consistently supervised. Refer also to F323

Based on staff interview and record review, the facility failed to provide adequate supervision for 1 applicable resident who had a history of [REDACTED]. (Residents #1, 2, 3, 4, 5, 6 & 7). Findings include: Per record review and confirmed by staff interview, Resident #1 caused serious injury to Resident #2 on 9/3/10 during an unprovoked attack. Staff failed to provide 1:1 supervision (per the care plan) for this resident who had a history of [REDACTED]. Per staff interview at 12:30 PM on 9/9/10, the incident occurred on 9/3/10 at 5 PM when Resident #1 grabbed Resident #2's shirt from behind and pulled the resident to the left and down, causing the resident to fall against the wall, hitting the left side of the head with force, and then fall to the floor. Subsequently, Resident #2 was transferred to the hospital and admitted for treatment. The description of the resident to resident incident was provided during interview with the evening shift LPN Charge Nurse on 9/9/10 commencing at 12:30 PM. During interview with the Director of Nursing Services (DNS), the Evening Charge Nurse, and the RN in charge of monitoring resident incidents at 12:30 PM, all were aware of the pattern of intrusive, at times assaultive, and potentially dangerous behaviors exhibited by Resident #1 since admission. Per review during the morning of 9/9/10, the resident's care plan stated "physically aggressive towards staff and other residents...episodes of biting staff, may became aggressive without cause, @ times without warning"...monitor interactions with other residents...attempt to redirect if safety issues should arise.., 1:1 with staff...consult with (psych nurse) PRN. During interviews with the DNS, the day shift Charge Nurse, and evening Charge Nurse during the afternoon on 9/9/10, all confirmed that although the resident had these known unpredictable behaviors, he/she was not consistently supervised on 1:1. Per review of the record, Resident #1 had potentially dangerous interactions with at least 5 other residents (#3, 4, 5, 6 & 7) during the time period from 8/3/10 until 9/8/10. The incidents with other residents included the following: 1. Per progress note dated 9/2/10, Resident #1 "put the bedside commode on top of (Resident #3) and tried to pull her/him out of bed. (Resident #3) got upset and started yelling for help" 2. Per progress note dated 8/15/10 at 9 PM, "call light sounding. Found (Resident #8) with head and right shoulder off bed, cord of call light wrapped around mid arm, 2nd resident (#1) pulling cord and trying to pull (Resident #8), who was yelling 'help' out of bed." The "cord was disconnected from wall". 3. Per progress notes dated 8/1/10, "Angry resident (#1) grabbed (Resident #4's) R arm...then hit her/him"...(Resident #4) "asked staff to 'help me' ". 4. Per progress note dated 8/1/10, "Grabbed on L arm by angry resident (#1) who tried to stop (Resident #5)...not able to stop her/him...tried to shove her/him to the floor". 5. Per progress note dated 8/1/10 at 9:30 AM, "A..(Resident #6) approached by angry resident (#1) and was hit on the upper L arm, then 10 minutes later X 2 on the wrist by the same resident". A second Immediate Jeopardy situation was noted to be present regarding a resident's use of electric bed controls on an occupied bed on the Special Care Unit with no subsequent action taken after the incident to ensure the safety of residents on the unit. Per review of a progress note in Resident #1's record, dated 9/7/10 at 11:30 PM, "Upon entering (room) Nurse found (Resident #1)...had bed controls of roommate and had the HOB (head of bed) ^ (up) and was pushing buttons still". Roommate was lying in bed on left side. "Remote removed out of (Resident #1)'s sight". Per interview with the DNS regarding the use of electric beds on the unit, she was not sure if the beds were lockable or whether there was a method to inactivate the controls. There had not been any action taken since the incident of 9/7/10 with the roommate's bed controls operated by Resident #1 to assure that no further incidents could occur. Per interview with the Administrator after discovery of the incident, he had not been aware of the incident and the potential risk to these residents. Although there had been some medication changes made to Resident #1's medication regime since admission on 7/25/10, s/he had been seen by the psychiatric nurse practitioner only twice (7/28/10 and 8/25/10). The nurse practitioner stated in her note of 7/28/10 that she would be glad to re-evaluate her/him weekly. The DNS confirmed that the nurse practitioner was in the facility weekly, although there was no evidence that she was asked to see the resident again. During August 2010, there were multiple progress notes describing Resident #1's attempts to hit, shove, pull and bite staff and other residents. The resident regularly intruded on other resident's privacy during care by opening bathroom doors during care multiple times per the documentation. Although nursing staff stated during interview on 9/9/10 that "they usually know where s/he is", the documentation in the record describes staff answering calls for help and responding to loud sounds, indicating a lack of supervision on multiple days. There was a care plan conference on 8/26/10 and there was no evidence that the physician was consulted and/or participated in discussions regarding the resident's continued unmanageable assaultive and intrusive behaviors. This was confirmed with the DNS and the Evening Charge Nurse the same afternoon (9/9/10).