Life Care Center Of Paradise Valley

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that a mechanical lift for resident transfer, was cleaned and disinfected according to professional standards. The deficient practice could result in the spread of infection and resident illness. Findings include: At the conclusion of a mechanical lift observation conducted on June 19, 2025 at 12:45 p.m., the Certified Nursing Assistant (CNA/Staff #20) rolled the mechanical lift to the end of the hallway. Cleaning and disinfection of the lift was not performed after resident use. A second mechanical lift transfer observation was conducted. The mechanical lift was not cleaned or disinfected prior to resident use at approximately 12:50 p.m. At the conclusion of the second mechanical lift observation, CNA/Staff#7 was observed rolling the mechanical lift with the sling to the end of the hall without cleaning or disinfecting the equipment. At approximately June 19, 2025 at 1:10 p.m., CNA # 20 was observed picking up the unwiped sling from the parked mechanical lift with bare hands and proceeded to walk down the hall with it open to air. An interview was conducted on June 19, 2025 at 1:13 p.m. with CNA # 7, who confirmed that the mechanical lift was not wiped down after its use. The CNA stated that it was important making sure resident equipment is cleaned properly after every use to decrease the chance of spreading infection. During an interview on June 19, 2025 at 1:20 p.m., with the Unit Manager (Staff # 54), she stated that after a resident lift is completed the lift should be cleaned and disinfected before storage and before use on another resident in order to decrease spread of illness, and to keep the machine clean and in working condition. An interview was conducted with the Director of Nursing (DON/Staff # 1) on June 19, 2025 at approximately 1:25 p.m., who stated that the facility expectation are to make sure resident equipment is cleaned and disinfected according to facility policy after resident use. The Mechanical Lift User Instruction Manual, instructs the user to clean the equipment before use. The manual further specifies that the lift is to be cleaned with ordinary soap and water and/or any hard surface disinfectant. The facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised August 22, 2022 revealed equipment will be cleaned and disinfected prior to storage. The facility's Transfer with a mechanical lift, long-term care policy, revised August 9, 2023, instructs the staff to clean and disinfect the mechanical lift accessory equipment after use according to the manufacturer's instructions to prevent the spread of infection.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that a mechanical lift for resident transfer, was cleaned and disinfected according to professional standards. Findings include: At the conclusion of a mechanical lift observation conducted on June 19, 2025 at 12:45 p.m., the Certified Nursing Assistant (CNA/Staff #20) rolled the mechanical lift to the end of the hallway. Cleaning and disinfection of the lift was not performed after resident use. A second mechanical lift transfer observation was conducted. The mechanical lift was not cleaned or disinfected prior to resident use at approximately 12:50 p.m. At the conclusion of the second mechanical lift observation, CNA/Staff#7 was observed rolling the mechanical lift with the sling to the end of the hall without cleaning or disinfecting the equipment. At approximately June 19, 2025 at 1:10 p.m., CNA # 20 was observed picking up the unwiped sling from the parked mechanical lift with bare hands and proceeded to walk down the hall with it open to air. An interview was conducted on June 19, 2025 at 1:13 p.m. with CNA # 7, who confirmed that the mechanical lift was not wiped down after its use. The CNA stated that it was important making sure resident equipment is cleaned properly after every use to decrease the chance of spreading infection. During an interview on June 19, 2025 at 1:20 p.m., with the Unit Manager (Staff # 54), she stated that after a resident lift is completed the lift should be cleaned and disinfected before storage and before use on another resident in order to decrease spread of illness, and to keep the machine clean and in working condition. An interview was conducted with the Director of Nursing (DON/Staff # 1) on June 19, 2025 at approximately 1:25 p.m., who stated that the facility expectation are to make sure resident equipment is cleaned and disinfected according to facility policy after resident use. The Mechanical Lift User Instruction Manual, instructs the user to clean the equipment before use. The manual further specifies that the lift is to be cleaned with ordinary soap and water and/or any hard surface disinfectant. The facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised August 22, 2022 revealed equipment will be cleaned and disinfected prior to storage. The facility's Transfer with a mechanical lift, long-term care policy, revised August 9, 2023, instructs the staff to clean and disinfect the mechanical lift accessory equipment after use according to the manufacturer's instructions to prevent the spread of infection.

Based on clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure one resident #77, was free from verbal and/or physical abuse from a family member.

Findings include:

Resident #77 was admitted to the facility on June 8, 2023 with diagnoses that included unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 2 (mild) and rheumatoid arthritis, unspecified.

A review of a quarterly Minimum Data Set (MDS) assessment dated May 11, 2024 revealed resident #77 BIMS (Brief Interview of Mental Status) score was 14 which indicated intact cognition.

The care plan revised on January 13, 2024 included resident #77 had limited mobility and pain from severe rheumatoid arthritis, contractures and deformity of the back, neck, bilateral hands, feet and ankles. The Care Plan revealed that resident required extensive assist by 1-2 staff for toileting and personal hygiene.

A review of resident's progress notes revealed an entry dated August 17, 2024 at 6:34 PM. The note revealed assigned Certified Nursing Assistant (CNA/Staff #202) reported that patients' family was yelling at her and left the building immediately after. Furthermore, progress notes revealed resident reporting to staff that the family member had slapped her.

An interview was conducted on August 26, 2024 at 3:11p.m. with the CNA (Staff #202). Staff #202 stated she was working in the unit where resident #77 resides and heard yelling and screaming. She stated it was coming from resident #77's room. She stated as she approached the room she observed that the door was opened and heard, "you're an OCD Bitch." I also heard resident #77 yelling "Help, Help!". Staff stated as she was entering the room, resident's #77 family member (Resident #77's sister) was exiting the room. She stated when she entered the resident's room, the resident had head down and was crying- and stated "she hit me, she hit me very hard on my mouth." Staff #202 stated she immediately told the assigned licensed practical nurse, (LPN/Staff#180). Staff #202 stated she went back to the resident's room and she was visibly shaking and asked to call her mother. She further stated she did not observe any redness or bruising. Staff #202 stated she has observed that the family member does not have patience with the resident and will often make faces and raise her voice when talking to the resident, but, stated she had not "heard them like this before." She stated the family member help with the residents laundry and brings her snacks and always appeared happy to see her family member and is excited for her visit.

An interview as conducted August 26, 2024 at 3:02p.m. with the LPN (Staff #180). He stated the family member visited 1-2 times per week and brought supplies. He stated Staff#202 had reported to him that she had heard arguing in resident #77's room and then had observed the family member leaving. He stated he went to check on the resident and was told by the resident, regarding her family member, "she beat me up and called me an OCD bitch and slapped me on the face." Staff #180 stated he completed an assessment and did not observe any bruising or redness. Staff #180 stated that he was aware of prior arguments between the resident and the family member that included elevated voices and yelling. He stated he did not report this to anyone or document the prior incidents, nor could he recall when the incidents happened. Staff #180 stated he has received abuse training and that there is now a picture of the family member at the front lobby desk and that family member is not allowed to enter or visit at this time.

An interview was conducted on August 26, 2024 at 3:37p.m. with resident #77 at 3:37p.m. the resident reported that family member "gets all riled up" and had become upset when the resident had stated she wanted to keep an empty tissue box that her family member wanted to toss away. The resident stated a disagreement ensued, and that family member "went ballistic". Resident #77 stated the family member hit her in the face with the tissue box, hitting her in the mouth. The resident stated the family member always gets mad at her and raises her voice at her. She stated that the family member complained about having to come to the facility to see her. She stated the family member cursed at her all the time calling her a "selfish bitch" "OCD bitch"- and other names. The resident stated she has told her nurse, staff#180 about the name calling and how her sister made her feel. The resident stated she became depressed following the incident and did not get up or go out.

An interview was conducted on August 26, 2024 at 4:17p.m. with Social Services Director (SSD/Staff#205). Staff # 205 stated the incident happened during the weekend and was informed to follow-up with the resident to address and discuss how to move forward with the situation. Staff #205 stated the family member is not allowed to interact with the resident at this time. Staff #205 stated the resident is stressed out due to the situation between her and her family member and concern was now going to provide the additional support. She stated that the follow-up visit was for socio-emotional assessment and did not discuss the relationship between the resident and the family member.

An interview was conducted on August 26, 2024 at 4:28 p.m. with Administrator (Staff#15) who stated her expectations are that staff report what they see or hear, stop it and report it to their supervisor on duty or if unavailable to any supervisor. Staff #15 stated verbal abuse are any derogatory remarks or mocking, mean statements directed toward a resident and the expectations are that staff would report any abuse and staff are not to decide what is reportable, that they are to report any incidents.

Review of the facility policy titled "Abuse-Prevention" states it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on record review and staff interview, the facility failed to participate in mandated drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.

Findings include:

Based on record review and staff interview on August 07, 2024, revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or based exercise or table top drills for the last year.

During the exit conference conducted on August 07, 2024, the management team acknowledged that they failed to participated in a full scale emergency exercise that was community based within the last year.

Based on record review and interview the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code one per shift per quarter to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.7.1.4* "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions." Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Section 19.7.1.7 "When drills are conducted between 9:00 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms."

Findings include:

Based on record review and interview on August 07, 2024, revealed that the facility failed to conduct fire drills during the first first and second quarter of 2024 for the second shift.

During the exit conference on August 07, 2024, the above findings were again acknowledged by the Administrator and Director of Maintenance.

Based on observations and staff interview, the facility failed to provide battery-operated emergency lighting to all EPS equipment locations. Failing to install, test, and document the battery backup emergency lighting units in case of an emergency or power outage could cause harm to the patients during a power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

NFPA 110: Standard for Emergency and Standby Power Systems, 2010 Edition - Chapter 7 Installation and Environmental Considerations 7.3 Lighting. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

Findings include:

Observations made while on tour on August 07, 2024, revealed the emergency lighting for the generator was not functioning. When asked when the last time the light had been tested the facility Maintenance Director stated that it has never been tested.

During the exit conference conducted on August 07, 2024, the deficiency was acknowledged by the management team.

Based on personnel file review, staff interviews, facility policy review and Center for Medicare and Medicaid Services (CMS) guideline, the facility failed to ensure that the occupational therapist (OT/staff #88) had a valid Cardiopulmonary Resuscitation (CPR) and first aid certifications.

Findings include:

Review of the personnel file for an occupational therapist (OT/staff #88) revealed a hire date of 02/28/2012. Continued review of the personnel file included that the CPR or First Aid certification had an expiration date of February 28, 2012.

During an interview conducted on July 18, 2024 at 11:00 a.m, a review of the personnel file of the OT was conducted with the Payroll Coordinator (staff #55) who stated that there was no evidence found of any valid CPR or First Aid certifications for the OT (staff #88). The payroll coordinator stated that she thought that CPR or First Aid certifications were only required for only nurses and nurse aids, and, not required for Physical Therapy (PT)/OT staff.

An interview was conducted on July 18, 2024 at 1:42 p.m. with the Director of Nursing (DON, Staff #12) who stated she was told by the Director of Rehabilitaion that CPR and First Aid were longer required of PT or OT staff.

Review of Centers for Medicare & Medicaid Services (CMS) guideline on Cardiopulmonary Resuscitation (CPR) in Nursing Homes dated October 18, 2013 included that staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment.

The facility policy titled, Specialized Rehabilitative Services, included that care provided by facility associates should be coordinated and consistent with the specialized rehabilitative services provided by qualified personnel.

The facility policy titled, Competent Staff, included that the facility will have staff with the appropriate competencies and skills needed to provide nursing and related services to assure resident safety and maintain the highest level of care.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident's (#3) choice regarding advance directives and orders were accurately reflected in the medical record.

Findings include:

Resident #3 was initially admitted to the facility on December 12, 2023 and was re-admitted on June 20, 2024 with diagnoses including acute kidney failure, pneumonitis, anxiety, and depression.

The advance directive statement form dated December 20, 2023 revealed the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest.

The care plan dated December 27, 2023 revealed the resident had an Advance Directives of CPR and was a full code. Goal was that the resident's advance directives will be honored. Interventions included that code status will be reviewed quarterly and as needed.

Review of the Minimum Data Set (MDS) assessment dated June 15, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.

The advance directive statement form signed by the resident and dated June 17, 2024 included that the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest.

In another advanced directive statement form signed by the resident and dated on June 20, 2024, it included that the resident did not want CPR in the event that he experiences cardiac arrest.

However, review of provider order recap revealed that the resident had a full code status.

Further, the care plan was not revised to reflect the resident's change in advance directives.

On July 17, 2024, the resident signed another advance directive statement form indicating that he wanted CPR in the event that he experiences cardiac arrest.

An interview was conducted on July 17, 2024 at 11:20 AM with a Licensed Practical Nurse (LPN / Staff #63) who reviewed the medical record and stated that Resident #3 was a Full Code. The LPN said that the resident signed a revised advanced directive choosing DNR on June 20, 2024. She stated that staff should base code status on the resident's most recent advance directive which was a DNR (Do Not Resuscitate). However, the LPN was no able to find any orders for a DNR or any paper versions of the resident advance directive. The LPN further stated that this situation could result in staff not following a residents' advance directive choice.

During an interview with the Director of Nursing (DON/ Staff #12) conducted on July 18, 2024 at 1:42 PM, the DON stated that resident #3 should have been a full code; and, the inconsistencies in the advance directives of the resident had corrected after the issue brought to their attention.

Review of a facility policy on Advance Directives and Advance Care Planning, included that residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, and immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor. The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect. The facility census was 89, and the resident sample was 18.

Findings include:

Resident #25 was admitted on August 08, 2014 with diagnoses that included, dementia, type 2 diabetes mellitus with hyperglycemia, hemiplegia/hemiparesis related to cerebral infarction.

The care plan, initiated on November 18, 2019 revealed the following areas of focus:
-Cognitive deficits related to diagnosis of dementia, and history of CVA
-Communication: may have barriers to communication related to expressive aphasia

Review the June 2024 Medication Administration Record (MAR) revealed change of condition monitoring for mental well-being from June 12, 2024 through June 15, 2024.

The progress note dated June 12, 2024 through June 15, 2024, revealed no documentation of behavioral changes or signs of distress.

The facility 5-day investigation report dated June 18, 2024 revealed on June 12, 2024, resident #25 was in the 400-station day room reading near the window and another resident (#392) was seated in a wheelchair in front of the television. A staff member heard a visitor of resident #392 state "you mother f**ker, I'm going to throw you out the window"; and that, the visitor requested that staff come into the day room. The investigation included interviews with the staff who reported that the visitor yelled and cursed at resident #25; and that, the visitor was concerned the other resident's (#392) breasts were exposed and her pants were pulled down. The report indicated that Resident #25 was placed on change of condition monitoring for three days after the incident. Further, the report also included a type written interview with resident #25 conducted during the facility investigation on June 13, 2024. Resident #25 denied putting his hands on the other resident (#392); and stated that he was holding onto his reading material, and that he left the room when the yelling began.

Review of a quarterly Minimum Data Set (MDS) dated June 29, 2024, included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment also included that the resident had no behaviors identified.

An interview was conducted on July 16, 2024 at 10:42 AM, with the Director of Nursing (DON/Staff #12), who stated that staff reported that on June 12, 2024, a visitor was seen walking past the 400-unit nursing station, entered the day room, and immediately returned to the nursing station asking for a nurse. The DON stated that the visitor returned to the day room with the nurse and then yelled and cursed at resident #25. The DON stated that the resident (#392) the visitor was visiting had pants that did not fit well and would often fall down; and that, staff would cover the resident with a blanket, but the resident would remove it. The DON stated that the visitor was immediately removed from the day room and his behavior was discussed with management. The DON stated that the visitor later told the facility that he really did not think that resident #25 did anything to the resident (#392) he was visiting; but, but he was concerned that the resident was not covered appropriately. The DON further stated that there had been no other complaints/concerns regarding resident #25 being inappropriate with other residents.

An interview was conducted on July 17, 2024 at 11:12 AM with a Registered Nurse (RN/staff #13) who stated that on June 12, 2024 on the 400-unit, a visitor who seemed angry stated "I need someone in this room (referring to the day room at the station) now." The RN stated when she entered the day room, resident #25 was sitting a few feet away from the door reading, and resident (#392) was visiting was sitting in front of the TV with her blanket on the floor. The RN stated that the visitor pointed that the other resident (#392) nipples were exposed. The RN stated that she immediately pulled the other resident's (#392) shirt down and apologized to the visitor. The RN further stated that the visitor reported that resident #25 was touching the other resident (#392); and that, he would throw resident #25 out of the window. The RN stated she asked the visitor not to talk to the residents like that and the visitor told her to get out of his face. The RN stated that a CNA took resident #25 out of the room, and called the supervisor. The RN said that she assessed resident #25 after the incident; and that, she asked resident #25 if he had touched the other resident (#392). The RN said that resident #25 reported that he did not know what happened. The RN further stated that later in the day a CNA reported that resident #25 was very upset about the situation.

An interview was conducted on July 17, 2024 at 11:30 AM with a Licensed Practical Nurse (LPN/staff #75) who stated that a visitor of another resident (#392) entered the 400-unit day room, and less than a minute later went back to the nursing station and asked the nurse to get in the room immediately. The LPN stated that the visitor thought that resident #25 had moved the other resident's (#392) clothing. The LPN stated that when she and the RN (staff #12) entered the day room, resident #25 was on the other side of the room day room reading. The LPN stated that when the visitor saw the other resident (#392) exposed, the visitor thought that resident #25 had done it. The LPN stated that the other resident (#392) would play with her clothes and would pull her shirt up and her pants down; and, this was a normal behavior for the other resident (#392) that staff would keep her covered and faced toward the TV. The LPN also stated that resident #25 did not comprehend what was going on, and he was removed from the day room immediately. The LPN stated that the nurses were standing between resident #25 and the visitor. Further, the LPN stated that the next day resident #25 was kind of sad, but did not know why he was sad. The LPN stated that resident #25 did not have the capacity to comprehend but was aware of time/place. However, the LPN said that resident #25 had to be guided. The LPN stated that she had not observed this type of behavior from the visitor previously, and he had always been a "really nice guy."

In an interview with another LPN (staff #68) conducted on 07/17/2024 at 12:19 PM, the LPN stated that she was the acting nurse supervisor on June 12, 2024, and she spoke with an RN (staff #13) and the visitor regarding the incident that occurred that day. The LPN stated that the RN (staff #13) came to her office with the visitor and reported that the visitor had yelled at, threatened to punch and throw resident #25 out the window. The LPN stated that the visitor told her he was angry because the other resident's (#392) clothes were askew and resident #25 was next to her reading; and that, as soon as resident #25 saw him, resident #25 backed up. The LPN stated that she discussed the incident with the visitor and she thought that he became upset that the other resident (#392) was exposed, but educated the visitor that he cannot threaten patients or staff. The LPN stated that after the incident, the visitor was only allowed to visit with the other resident (#392) in the lobby and not in the unit. The LPN also stated that her previous interactions with the visitor had always been civil, and she would never have thought that he would do that sort of thing.

An interview with Social Services (Staff #50) was conducted on July 17, 2024 at 12:26 PM. Staff #50 stated that she met/interviewed resident #25 on June 12, 2024, after the incident; and, the resident told her that he d

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident's (#3) choice regarding advance directives and orders were accurately reflected in the medical record. The deficient practice could result in resident's choices noted being followed. The resident census was 89 and the sample was 18.

Findings include:

Resident #3 was initially admitted to the facility on December 12, 2023 and was re-admitted on June 20, 2024 with diagnoses including acute kidney failure, pneumonitis, anxiety, and depression.

The advance directive statement form dated December 20, 2023 revealed the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest.

The care plan dated December 27, 2023 revealed the resident had an Advance Directives of CPR and was a full code. Goal was that the resident's advance directives will be honored. Interventions included that code status will be reviewed quarterly and as needed.

Review of the Minimum Data Set (MDS) assessment dated June 15, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.

The advance directive statement form signed by the resident and dated June 17, 2024 included that the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest.

In another advanced directive statement form signed by the resident and dated on June 20, 2024, it included that the resident did not want CPR in the event that he experiences cardiac arrest.

However, review of provider order recap revealed that the resident had a full code status.

Further, the care plan was not revised to reflect the resident's change in advance directives.

On July 17, 2024, the resident signed another advance directive statement form indicating that he wanted CPR in the event that he experiences cardiac arrest.

An interview was conducted on July 17, 2024 at 11:20 AM with a Licensed Practical Nurse (LPN / Staff #63) who reviewed the medical record and stated that Resident #3 was a Full Code. The LPN said that the resident signed a revised advanced directive choosing DNR on June 20, 2024. She stated that staff should base code status on the resident's most recent advance directive which was a DNR (Do Not Resuscitate). However, the LPN was no able to find any orders for a DNR or any paper versions of the resident advance directive. The LPN further stated that this situation could result in staff not following a residents' advance directive choice.

During an interview with the Director of Nursing (DON/ Staff #12) conducted on July 18, 2024 at 1:42 PM, the DON stated that resident #3 should have been a full code; and, the inconsistencies in the advance directives of the resident had corrected after the issue brought to their attention.

Review of a facility policy on Advance Directives and Advance Care Planning, included that residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, and immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives.

Based on observation, staff interviews, and policy review, the facility failed to ensure one Registered Nurse's (RN/ Staff #98) was compliant with the fingerprint clearance.

Findings include:

Review of the personnel records revealed that Registered Nurse (RN/Staff #98) was hired on December 05, 2023 with a valid fingerprint clearance card, which was issued June 6, 2018. However, the fingerprint clearance card had an expiration date of June 6, 2024.

Further review of the personnel file revealed that the RN had an expired fingerprint clearance card since June 7, 2024.

Review of employee punch record revealed that the RN was working as a Registered Nurse at this facility during the period during which the fingerprint clearance card was expired. Staff #98 had recently worked shifts on June 04, 2024 and June 14, 2024.

An interview was conducted on July 18, 2024 at 11:00 a.m. with the Payroll Coordinator (Staff #55) who stated that there should be a current fingerprint clearance card for the RN (staff #98).

In a later interview with the Payroll Coordinator (staff #55) conducted on July 18, 2024 at 2:30 p.m., the payroll coordinator provided a copy of the completed application for a fingerprint clearance card for the RN and was dated June 18, 2024.

The facility policy titled, Competent Staff, included that the facility will have staff with the appropriate competencies and skills needed to provide nursing and related services to assure resident safety and maintain the highest level of care.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan intervention for monitoring medication side effects related to use of an antianxiety medication was implemented for one resident (#60). The deficient practice could result in the resident not receiving the care and services to meet their needs.

Findings include:

Resident #60 was admitted on December 26, 2023 with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status.

The active physician order summary included an order to monitor for side effects related to anti-anxiety medications.

The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness.

The physician order dated December 28, 2023 included to monitor behaviors of restlessness every shift for 14 days; and, to code whether behavior improved, worsened or unchanged.

The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication and to administer the medications as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated May 3, 2024, included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment.

A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024.

The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024.

Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024.

The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold.

An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that the side effect monitoring was not implemented by staff as care planned between June 13, 2024 and June 24, 2024. The DON stated the risk for not following the care planned interventions could result in lack of identifying side effects and effectiveness of the medication and could affect the overall care of the resident.

Review of the facility policy titled, Comprehensive Care Plans and Revisions, revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan and to ensure that the comprehensive care plans reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update and quarterly review assessments.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan was revised to include resident-specific nutritional goals for one resident (#76). The deficient practice could result the resident not being involved and not able to make decisions about their care and needs.

Findings include:

Resident #76 was admitted on May 02, 2024 with diagnoses of acute metabolic acidosis, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, anemia, dysphagia, and chronic kidney disease.

The weight on May 03, 2024 was 130 lbs. (pounds)

Review of the nutrition care plan initiated on May 03, 2024 revealed the resident had nutritional problems due her medical diagnoses of dysphagia, esophageal stenosis, and cerebrovascular accident; and, had nutritional risks due to suboptimal meal intakes related to decreased appetite, and potential for weight fluctuations/fluid deficit due to fluid shifts due to diuretic medication. Interventions included to report results to physician and follow up as indicated on any signs and symptoms of dysphagia, to provide and serve diet as ordered, monitor intake and record every meal, registered dietician to evaluate and make diet change recommendations as needed, and to weigh and monitor per orders. The goal was that the resident will have no signs and symptoms of aspiration.

The admission Minimum Data Set (MDS) assessment dated May 6, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment.

The skilled note dated May 6, 2024 included the resident was alert and oriented x 2-3 and was non-compliant with physician orders.

A Nutrition Admission Assessment progress note dated on May 6, 2024 revealed the resident was alert and oriented, had swallowing difficulties related to dysphagia, had a weight of 130 pounds; and, was consuming an average of 50% of meals. Per the documentation, interventions included medication pass supplement 4 ounces three times per day and to monitor weight and oral intakes.

The weight record on May 9, 2024 was 121.4 lbs.

The Nutrition/Dietary Note dated May 9, 2024 revealed that the weight was 121.4 lbs. and the resident had a weight loss of 8.6 lbs. in 1 week. The documentation included that the resident was refusing the medication pass supplement 6 times due to "terrible taste"; and that, the resident agreed to have supplemental cereal at breakfast and supplemental pudding at lunch and dinner.

The care plan was revised on May 9, 2024 to include an intervention to provide and serve supplements as ordered. The care plan did not include any resident-specific goals and desired outcomes related to her nutrition and weight loss.

The physician note dated May 10, 2024 included that the resident did not have the capacity to make her own decision.

The skilled nursing note dated May 13, 2024 included that the resident complaint of nausea and vomiting post breakfast and was administered with an antiemetic medication.

The skilled note dated May 20, 2024 included that the resident refused her breakfast, ate her lunch and was compliant with most of her medications.

The weight record on May 20, 2024 was 115.8 pounds, which was a 14.2 pound weight loss in 17 days.

The order administration note dated May 20, 2024 included that the resident was alert and oriented x 4 and refused SNP pudding (supplement).

A Nutrition/Dietary Note dated May 22, 2024 revealed the resident had a weight of 115.8 lbs.; and that, the resident had a 14.2% weight loss in 3 weeks. The documentation included that the resident consumed an average of 35% of meals; 55% average of the SNP pudding and 35% of the SNP cereals. Recommendations included to add the house shakes three times a day for additional 600 kcal (kilo calories/18 g (grams) protein; and to continue to monitor weights and oral intakes.

The care plan was revised on May 22, 2024 to include that the weekly weight loss continued and the supplements were increased. However, the care plan did not include resident's goals and desired outcomes related to her nutrition and weight loss.

The weight record on June 1, 2024 was 115 lbs.

The Nutrition/Dietary note dated June 12, 2024 revealed the resident was on palliative care, had a weight of 115 lbs. and had a significant unplanned weight loss of 15 lbs. in a month. Per the documentation, the resident had an inadequate intake consuming on the average 40% of her meals, had a decreased appetite and refused supplements. Plan included fortified food house shakes three times daily. Further the documentation included that there were no new recommendations at this time.

Despite documentation of resident refusal of supplements in the clinical record, the care plan was not revised to include interventions to address this issue; and, the care plan was not revised to include any new or revised resident-specific goals.

An interview was conducted on July 18, 2024 at 9:45 a.m. with the Registered Dietician (RD/staff #77), who stated that she was not following resident #76 for any weight loss; and that, a referral for an evaluation would have been appropriate for the resident due to her significant unplanned weight loss.

In an interview with the Director of Nursing (DON/staff #12) conducted on July 18, 2024 at 10:51 a.m., the DON stated that the facility monitors the effectiveness of interventions through IDT (interdisciplinary team) reviews; and, the care plan was discussed weekly in the IDT meeting or daily, and revised if needed. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence found in the clinical record that the care plan did not have any resident-specific goals related to the resident's continued weight loss since the resident's admission on May 3, 2024. The DON further stated that the care plan should have been revised to address the weight loss with resident-specific goals.

Review of the facility's policy titled, "Comprehensive Care Plans and Revisions", dated Aug 22, 2023, revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. According to the procedure section of this policy, the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include; additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions to address a time limited condition.

Based on review of clinical record review, resident/staff interviews the facility documentation and policy review, failed to ensure a discharge planning based on the assessed needs and goals was in place for one resident (#49). The deficient practice could result in the delay of the resident transfer/discharge to the facility of choice.

Findings include:

Resident #49 was admitted on December 21, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure.

The care plan dated December 21, 2023 included a discharge plan that the resident wished to return home.

The communication note dated May 23, 2024 included that the social services director (SSD/staff #50) had a conversation with the resident's family related to a request to transfer to an assisted living (AL). Per the documentation, the family wanted the transfer.

An email correspondence dated May 23, 2024 between the SSD (staff #50) and the Director of Marketing (DoM of the assisted living facility (ALF) the resident was going to) revealed that the planned discharged to the ALF was the choice of the resident and her family.

A late entry nurse practitioner (NP) progress note dated May 28, 2024 included that the resident had an advanced COPD, CRF with hypoxia, was O2 (oxygen) dependent at 2 LPM (liters per minute), and used a CPAP (continuous positive airway pressure) at night.

The follow-up email from the DoM on June 4 and 5, 2024 addressed to the SSD revealed another request for the physician to sign the documents necessary to discharge the resident to the ALF.

The follow-up psych evaluation note dated June 10, 2024 included that the resident was alert and oriented to person, place and time.

An email correspondence from the insurance case manager addressed to the SSD (staff #50) and dated June 20, 2024 revealed a request to have TB test completed timely as the resident was very anxious to be discharged.

The social service note dated June 21, 2024 included that the SSD followed up with the ALF regarding the resident's transfer to ALF on June 26, 2024.

An email correspondence from the DoM to the SSD dated June 21, 2024 revealed that the resident was scheduled for discharge on June 25, 2024.

The email from the DoM addressed to the SSD dated June 24, 2024 revealed a request from the resident's family for confirmation that transportation had been set up for June 25, 2024.

The SSD replied to this email on June 25, 2025 (the day of the planned discharge) that it was the role of the accepting facility to set up transportation and not the discharging facility.

An email from the DoM addressed to the SSD and dated June 25, 2024 included that per the resident's LTC (long term care) insurance that it should be the discharging facility that sets up transportation.

The SSD replied to this email on June 25, 2024 that the resident had a manual wheelchair, had several boxes of personal belongings, and needed home oxygen equipment.

However, there was no evidence found in the clinical record that the SSD sent the DME referral for the home oxygen equipment and supplies to the approved DME vendor.

Another email from the DoM addressed to the SSD and the LTC case manager and dated June 25, 2025 revealed that the DoM was inquiring whether the home oxygen and DME had been set up for discharge for resident #49.

A communication note dated June 25, 2024 included that the concerns with transfer of the resident to the ALF was discussed with the ALF.

The order administration note dated June 25, 2024 included that the portable oxygen tank was switched to an oxygen concentrator at bedtime.

An email correspondence from the ED (Executive Director of the ALF the resident was going to be transferred) addressed to the facility and dated June 25, 2024 revealed the ED informed the SSD and the DON that it was the role of the discharging facility to set up the DME orders through an approved DME provider for the discharging resident. It also included a request that the facility send the orders including any DME orders, and a discharge summary to assist in the setting-up of the DME referral for Resident #49 for discharge.

The ED of the facility (staff #140) replied to this email on June 25, 2025 that the facility does not set up DME orders and will not be arranging transport.

Review of the Quarterly Minimum Data Set (MDS) assessment dated June 26, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment.

A late entry mood note dated June 26, 2024 revealed that the resident was in the process of transferring to another facility per the resident and family request.

Despite the documentation that the resident will be transferred to the ALF on June 26, 2024, there was no evidence found in the clinical record that discharge plan was developed to assess and address the resident's discharge needs to include oxygen and DME (durable medical equipment) needs.

A fax cover sheet with transmission date of June 27, 2024 addressed to the DME provider from the social services revealed a hand written note that the resident was transferring to the ALF; and, to "drop off equipment" at the ALF and to confirm the delivery date and time. It also included a Respiratory and Durable Medical Equipment Referral form with a blank "RX date" and included that an oxygen test was done on June 26, 2024. However, this form was signed by the physician on February 6, 2024.

The care management note dated June 28, 2024 included that the SSD informed that the DME and transportation for resident #49 were not confirmed.

The communication note dated June 30, 2024 included that the resident family was requesting for an update on the resident's DME; and that, the SSD informed the family that a referral was sent and "follow-up emails" had been provided.

Despite the documentation that the DME were not confirmed, there was no evidence found in the clinical record that the DME referral was re-sent to the DME provider; or, that facility asked the DME provider for any clarification as to why the DME referral was not processed or confirmed until July 8, 2024.

A fax cover sheet with transmission date of July 8, 2024 addressed to the DME provider from the facility social services included a hand written note that the request was resident #49; and to follow up with the ALF staff. It also included a Respiratory and Durable Medical Equipment Referral form with a blank "RX date" and included that an oxygen test was done on July 8, 2024. However, this form was signed by the physician but did not have a date as to when it was signed.

In an email from the LTC case manager addressed to the SSD, DON, the ED of the ALF and the DoM dated July 08, 2024 included that an oxygen test had be completed and results had to be faxed to the approved DME provider; and, if DME provider receives the DME order and the requested oxygen test, it can be delivered on the same date. It also included that the LTC case manager requested that once the receiving facility confirmed the delivery of the DME, the SSD would schedule transportation for the following date of July 09, 2024.

An email correspondence from the DoM addressed to the SSD and dated July 11, 2024 included that the DoM was asking the facility to check the status of the DME equipment referral. Per the documentation, once the DME equipment was delivered, Resident #49 can move in to the ALF. However, the documentation included that the DME equipment had not been delivered to the ALF.

In an email from the ED of the ALF addressed to the facility and dated July 12, 2024, the ED of the ALF informed that after reserving the apartment reserved for r

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use. The deficient practice could result in scaling down of services, provided by the facility, that do not align with the highest practicability of care.

Findings include:

Resident #49 was admitted on December 21, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure.

The care-plan initiated on January 11, 2024 revealed that the resident had oxygen therapy related to COPD. Interventions included O2 (oxygen) via nasal cannula continuous per medical doctor orders.

A physician order dated July 18, 2024 revealed an order for oxygen at 2 liters per minute continuously via nasal cannula; may titrate to 4 liters to maintain 88% saturation.

An observation conducted on July 18, 2024 at 2:03 p.m. revealed Resident #49 was in the activity room playing bingo with nasal cannula on. The oxygen tank gauge displayed an empty oxygen tank.

An interview was conducted on July 18, 2024 with Certified Nursing Assistant (CNA/Staff # 42) who stated that in order to prevent the oxygen tank for Resident #49 from being empty was to monitor the gauge when it was nearing empty. However, the CNA stated that there were instances in the past where the oxygen tank had been empty and it happens.

In another observation conducted on July 18, 2024 at 2:03 p.m., the CNA (staff #42) told the resident that she needed a replacement for her oxygen tank.

An interview was conducted on July 18, 2024 with Director of Nursing (DON/Staff # 12) who stated that a resident with continuous oxygen orders and utilizing an empty oxygen would not meet the facility's expectations. The DON further stated that if there was an oxygen order for a resident, staff were expected to be checking the resident's oxygen throughout the shift.

Review of the facility's policy titled, "Administration of Medications" (reviewed August 2023) revealed, the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. It also included that staff must adhere to right of medication administration including: Right Time and Frequency, check the order for when it would be given and when was the last time it was given; Right Assessment, note the resident's history and any parameters around drug administration; Right Evaluation, ensure the medication is working the way it should, ensure medications are reviewed regularly, ongoing observations if required.

Based on personnel file review, staff interviews, facility policy review and Center for Medicare and Medicaid Services (CMS) guideline, the facility failed to ensure that the occupational therapist (OT/staff #88) had a valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. The deficient practice could result in staff not being knowledgeable of how to prvide emergency care to residents.

Findings include:

Review of the personnel file for an occupational therapist (OT/staff #88) revealed a hire date of 02/28/2012. Continued review of the personnel file included that the CPR or First Aid certification had an expiration date of February 28, 2012.

During an interview conducted on July 18, 2024 at 11:00 a.m, a review of the personnel file of the OT was conducted with the Payroll Coordinator (staff #55) who stated that there was no evidence found of any valid CPR or First Aid certifications for the OT (staff #88). The payroll coordinator stated that she thought that CPR or First Aid certifications were only required for only nurses and nurse aids, and, not required for Physical Therapy (PT)/OT staff.

An interview was conducted on July 18, 2024 at 1:42 p.m. with the Director of Nursing (DON, Staff #12) who stated she was told by the Director of Rehabilitaion that CPR and First Aid were longer required of PT or OT staff.

Review of Centers for Medicare & Medicaid Services (CMS) guideline on Cardiopulmonary Resuscitation (CPR) in Nursing Homes dated October 18, 2013 included that staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment.

The facility policy titled, Specialized Rehabilitative Services, included that care provided by facility associates should be coordinated and consistent with the specialized rehabilitative services provided by qualified personnel.

The facility policy titled, Competent Staff, included that the facility will have staff with the appropriate competencies and skills needed to provide nursing and related services to assure resident safety and maintain the highest level of care.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure there was adequate monitoring for side effects related to the use of a psychotropic medication for one resident (#60). The census was 89. The deficient practice could result in residents being at risk for unidentified adverse reactions related to the use of the medication.

Findings include:

Resident #60 was admitted on December 26, 2023 with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status.

The active physician order summary included an order to monitor for side effects related to anti-anxiety medications.

The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness.

The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication every shift and to administer the medications as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated May 3, 2024, included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment.

A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024.

The follow-up psych evaluation note dated June 17, 2024 included the resident continued to have intermittent episodes of yelling out along with severe restlessness and agitation. Per the documentation, Ativan helped with the symptoms; and that, the resident continued to receive Ativan at least once daily. Plan was to continue Ativan as needed for anxiety as evidenced by restlessness.

A follow-up psych evaluation note dated June 24, 2024 revealed that the resident continued to have intermittent episodes of restlessness and agitation along with episodes of yelling out. The documentation included that staff reported the resident responded well to Ativan when he exhibited these behaviors; and that, the record showed that the resident received Ativan at least twice daily for his symptoms of restlessness. The plan was to change Ativan to a scheduled medication twice daily.

The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024.

Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024.

The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold.

An interview was conducted on July 17, 2024 at 10:04 a.m. with a Licensed Practical Nurse (LPN/staff #112), who stated that the resident should be monitored for behaviors and side effects while taking Ativan, regardless of the medication being scheduled or given as needed. The LPN stated that behaviors and side effects monitoring should be documented in the MAR; and, whenever a psychoactive medication such as Ativan was ordered there should be an additional order to monitor for behaviors and side effects related to its use. During the interview, the LPN reviewed the clinical record and stated that there was an active order for Ativan which was administered to the resident. However, the LPN stated that there was no documentation of that the side effects related to the use of Ativan was monitored on June 13 through June 24, 2024. The LPN further stated that the risk could result in staff not being able to monitor the actual effects of the medication on the resident.

An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that there was no documentation of side effects monitoring completed during that time period; and that, this could result in staff not identifying the side effects should it happen and could affect the overall care of the resident.

Review of the facility policy titled, Psychotropic Medication Use, revealed that psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, and sedative-hypnotics that affect brain activities associated with mental processes and behavior. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medial or psychiatric causes of behavioral symptoms. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences.

Based on review of clinical record review, resident/staff interviews the facility documentation and policy review, failed to ensure a discharge planning based on the assessed needs and goals was in place for one resident (#49).

Findings include:

Resident #49 was admitted on December 21, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure.

The care plan dated December 21, 2023 included a discharge plan that the resident wished to return home.

The communication note dated May 23, 2024 included that the social services director (SSD/staff #50) had a conversation with the resident's family related to a request to transfer to an assisted living (AL). Per the documentation, the family wanted the transfer.

An email correspondence dated May 23, 2024 between the SSD (staff #50) and the Director of Marketing (DoM of the assisted living facility (ALF) the resident was going to) revealed that the planned discharged to the ALF was the choice of the resident and her family.

A late entry nurse practitioner (NP) progress note dated May 28, 2024 included that the resident had an advanced COPD, CRF with hypoxia, was O2 (oxygen) dependent at 2 LPM (liters per minute), and used a CPAP (continuous positive airway pressure) at night.

The follow-up email from the DoM on June 4 and 5, 2024 addressed to the SSD revealed another request for the physician to sign the documents necessary to discharge the resident to the ALF.

The follow-up psych evaluation note dated June 10, 2024 included that the resident was alert and oriented to person, place and time.

An email correspondence from the insurance case manager addressed to the SSD (staff #50) and dated June 20, 2024 revealed a request to have TB test completed timely as the resident was very anxious to be discharged.

The social service note dated June 21, 2024 included that the SSD followed up with the ALF regarding the resident's transfer to ALF on June 26, 2024.

An email correspondence from the DoM to the SSD dated June 21, 2024 revealed that the resident was scheduled for discharge on June 25, 2024.

The email from the DoM addressed to the SSD dated June 24, 2024 revealed a request from the resident's family for confirmation that transportation had been set up for June 25, 2024.

The SSD replied to this email on June 25, 2025 (the day of the planned discharge) that it was the role of the accepting facility to set up transportation and not the discharging facility.

An email from the DoM addressed to the SSD and dated June 25, 2024 included that per the resident's LTC (long term care) insurance that it should be the discharging facility that sets up transportation.

The SSD replied to this email on June 25, 2024 that the resident had a manual wheelchair, had several boxes of personal belongings, and needed home oxygen equipment.

However, there was no evidence found in the clinical record that the SSD sent the DME referral for the home oxygen equipment and supplies to the approved DME vendor.

Another email from the DoM addressed to the SSD and the LTC case manager and dated June 25, 2025 revealed that the DoM was inquiring whether the home oxygen and DME had been set up for discharge for resident #49.

A communication note dated June 25, 2024 included that the concerns with transfer of the resident to the ALF was discussed with the ALF.

The order administration note dated June 25, 2024 included that the portable oxygen tank was switched to an oxygen concentrator at bedtime.

An email correspondence from the ED (Executive Director of the ALF the resident was going to be transferred) addressed to the facility and dated June 25, 2024 revealed the ED informed the SSD and the DON that it was the role of the discharging facility to set up the DME orders through an approved DME provider for the discharging resident. It also included a request that the facility send the orders including any DME orders, and a discharge summary to assist in the setting-up of the DME referral for Resident #49 for discharge.

The ED of the facility (staff #140) replied to this email on June 25, 2025 that the facility does not set up DME orders and will not be arranging transport.

Review of the Quarterly Minimum Data Set (MDS) assessment dated June 26, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment.

A late entry mood note dated June 26, 2024 revealed that the resident was in the process of transferring to another facility per the resident and family request.

Despite the documentation that the resident will be transferred to the ALF on June 26, 2024, there was no evidence found in the clinical record that discharge plan was developed to assess and address the resident's discharge needs to include oxygen and DME (durable medical equipment) needs.

A fax cover sheet with transmission date of June 27, 2024 addressed to the DME provider from the social services revealed a hand written note that the resident was transferring to the ALF; and, to "drop off equipment" at the ALF and to confirm the delivery date and time. It also included a Respiratory and Durable Medical Equipment Referral form with a blank "RX date" and included that an oxygen test was done on June 26, 2024. However, this form was signed by the physician on February 6, 2024.

The care management note dated June 28, 2024 included that the SSD informed that the DME and transportation for resident #49 were not confirmed.

The communication note dated June 30, 2024 included that the resident family was requesting for an update on the resident's DME; and that, the SSD informed the family that a referral was sent and "follow-up emails" had been provided.

Despite the documentation that the DME were not confirmed, there was no evidence found in the clinical record that the DME referral was re-sent to the DME provider; or, that facility asked the DME provider for any clarification as to why the DME referral was not processed or confirmed until July 8, 2024.

A fax cover sheet with transmission date of July 8, 2024 addressed to the DME provider from the facility social services included a hand written note that the request was resident #49; and to follow up with the ALF staff. It also included a Respiratory and Durable Medical Equipment Referral form with a blank "RX date" and included that an oxygen test was done on July 8, 2024. However, this form was signed by the physician but did not have a date as to when it was signed.

In an email from the LTC case manager addressed to the SSD, DON, the ED of the ALF and the DoM dated July 08, 2024 included that an oxygen test had be completed and results had to be faxed to the approved DME provider; and, if DME provider receives the DME order and the requested oxygen test, it can be delivered on the same date. It also included that the LTC case manager requested that once the receiving facility confirmed the delivery of the DME, the SSD would schedule transportation for the following date of July 09, 2024.

An email correspondence from the DoM addressed to the SSD and dated July 11, 2024 included that the DoM was asking the facility to check the status of the DME equipment referral. Per the documentation, once the DME equipment was delivered, Resident #49 can move in to the ALF. However, the documentation included that the DME equipment had not been delivered to the ALF.

In an email from the ED of the ALF addressed to the facility and dated July 12, 2024, the ED of the ALF informed that after reserving the apartment reserved for resident #49 for over a month, the ALF had to released it from being held for Resident #49. Additionally, The ED

Based on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor.

Findings include:

Resident #25 was admitted on August 08, 2014 with diagnoses that included, dementia, type 2 diabetes mellitus with hyperglycemia, hemiplegia/hemiparesis related to cerebral infarction.

The care plan, initiated on November 18, 2019 revealed the following areas of focus:
-Cognitive deficits related to diagnosis of dementia, and history of CVA
-Communication: may have barriers to communication related to expressive aphasia

Review the June 2024 Medication Administration Record (MAR) revealed change of condition monitoring for mental well-being from June 12, 2024 through June 15, 2024.

The progress note dated June 12, 2024 through June 15, 2024, revealed no documentation of behavioral changes or signs of distress.

The facility 5-day investigation report dated June 18, 2024 revealed on June 12, 2024, resident #25 was in the 400-station day room reading near the window and another resident (#392) was seated in a wheelchair in front of the television. A staff member heard a visitor of resident #392 state "you mother f**ker, I'm going to throw you out the window"; and that, the visitor requested that staff come into the day room. The investigation included interviews with the staff who reported that the visitor yelled and cursed at resident #25; and that, the visitor was concerned the other resident's (#392) breasts were exposed and her pants were pulled down. The report indicated that Resident #25 was placed on change of condition monitoring for three days after the incident. Further, the report also included a type written interview with resident #25 conducted during the facility investigation on June 13, 2024. Resident #25 denied putting his hands on the other resident (#392); and stated that he was holding onto his reading material, and that he left the room when the yelling began.

Review of a quarterly Minimum Data Set (MDS) dated June 29, 2024, included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment also included that the resident had no behaviors identified.

An interview was conducted on July 16, 2024 at 10:42 AM, with the Director of Nursing (DON/Staff #12), who stated that staff reported that on June 12, 2024, a visitor was seen walking past the 400-unit nursing station, entered the day room, and immediately returned to the nursing station asking for a nurse. The DON stated that the visitor returned to the day room with the nurse and then yelled and cursed at resident #25. The DON stated that the resident (#392) the visitor was visiting had pants that did not fit well and would often fall down; and that, staff would cover the resident with a blanket, but the resident would remove it. The DON stated that the visitor was immediately removed from the day room and his behavior was discussed with management. The DON stated that the visitor later told the facility that he really did not think that resident #25 did anything to the resident (#392) he was visiting; but, but he was concerned that the resident was not covered appropriately. The DON further stated that there had been no other complaints/concerns regarding resident #25 being inappropriate with other residents.

An interview was conducted on July 17, 2024 at 11:12 AM with a Registered Nurse (RN/staff #13) who stated that on June 12, 2024 on the 400-unit, a visitor who seemed angry stated "I need someone in this room (referring to the day room at the station) now." The RN stated when she entered the day room, resident #25 was sitting a few feet away from the door reading, and resident (#392) was visiting was sitting in front of the TV with her blanket on the floor. The RN stated that the visitor pointed that the other resident (#392) nipples were exposed. The RN stated that she immediately pulled the other resident's (#392) shirt down and apologized to the visitor. The RN further stated that the visitor reported that resident #25 was touching the other resident (#392); and that, he would throw resident #25 out of the window. The RN stated she asked the visitor not to talk to the residents like that and the visitor told her to get out of his face. The RN stated that a CNA took resident #25 out of the room, and called the supervisor. The RN said that she assessed resident #25 after the incident; and that, she asked resident #25 if he had touched the other resident (#392). The RN said that resident #25 reported that he did not know what happened. The RN further stated that later in the day a CNA reported that resident #25 was very upset about the situation.

An interview was conducted on July 17, 2024 at 11:30 AM with a Licensed Practical Nurse (LPN/staff #75) who stated that a visitor of another resident (#392) entered the 400-unit day room, and less than a minute later went back to the nursing station and asked the nurse to get in the room immediately. The LPN stated that the visitor thought that resident #25 had moved the other resident's (#392) clothing. The LPN stated that when she and the RN (staff #12) entered the day room, resident #25 was on the other side of the room day room reading. The LPN stated that when the visitor saw the other resident (#392) exposed, the visitor thought that resident #25 had done it. The LPN stated that the other resident (#392) would play with her clothes and would pull her shirt up and her pants down; and, this was a normal behavior for the other resident (#392) that staff would keep her covered and faced toward the TV. The LPN also stated that resident #25 did not comprehend what was going on, and he was removed from the day room immediately. The LPN stated that the nurses were standing between resident #25 and the visitor. Further, the LPN stated that the next day resident #25 was kind of sad, but did not know why he was sad. The LPN stated that resident #25 did not have the capacity to comprehend but was aware of time/place. However, the LPN said that resident #25 had to be guided. The LPN stated that she had not observed this type of behavior from the visitor previously, and he had always been a "really nice guy."

In an interview with another LPN (staff #68) conducted on 07/17/2024 at 12:19 PM, the LPN stated that she was the acting nurse supervisor on June 12, 2024, and she spoke with an RN (staff #13) and the visitor regarding the incident that occurred that day. The LPN stated that the RN (staff #13) came to her office with the visitor and reported that the visitor had yelled at, threatened to punch and throw resident #25 out the window. The LPN stated that the visitor told her he was angry because the other resident's (#392) clothes were askew and resident #25 was next to her reading; and that, as soon as resident #25 saw him, resident #25 backed up. The LPN stated that she discussed the incident with the visitor and she thought that he became upset that the other resident (#392) was exposed, but educated the visitor that he cannot threaten patients or staff. The LPN stated that after the incident, the visitor was only allowed to visit with the other resident (#392) in the lobby and not in the unit. The LPN also stated that her previous interactions with the visitor had always been civil, and she would never have thought that he would do that sort of thing.

An interview with Social Services (Staff #50) was conducted on July 17, 2024 at 12:26 PM. Staff #50 stated that she met/interviewed resident #25 on June 12, 2024, after the incident; and, the resident told her that he did not feel safe, and that being yelled at felt like "s**t." Staff #50 stated that she could not find her documentation in the medical record, but it was included

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure there was adequate monitoring for side effects related to the use of a psychotropic medication for one resident (#60).

Findings include:

Resident #60 was admitted on December 26, 2023 with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status.

The active physician order summary included an order to monitor for side effects related to anti-anxiety medications.

The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness.

The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication every shift and to administer the medications as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated May 3, 2024, included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment.

A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024.

The follow-up psych evaluation note dated June 17, 2024 included the resident continued to have intermittent episodes of yelling out along with severe restlessness and agitation. Per the documentation, Ativan helped with the symptoms; and that, the resident continued to receive Ativan at least once daily. Plan was to continue Ativan as needed for anxiety as evidenced by restlessness.

A follow-up psych evaluation note dated June 24, 2024 revealed that the resident continued to have intermittent episodes of restlessness and agitation along with episodes of yelling out. The documentation included that staff reported the resident responded well to Ativan when he exhibited these behaviors; and that, the record showed that the resident received Ativan at least twice daily for his symptoms of restlessness. The plan was to change Ativan to a scheduled medication twice daily.

The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024.

Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024.

The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold.

An interview was conducted on July 17, 2024 at 10:04 a.m. with a Licensed Practical Nurse (LPN/staff #112), who stated that the resident should be monitored for behaviors and side effects while taking Ativan, regardless of the medication being scheduled or given as needed. The LPN stated that behaviors and side effects monitoring should be documented in the MAR; and, whenever a psychoactive medication such as Ativan was ordered there should be an additional order to monitor for behaviors and side effects related to its use. During the interview, the LPN reviewed the clinical record and stated that there was an active order for Ativan which was administered to the resident. However, the LPN stated that there was no documentation of that the side effects related to the use of Ativan was monitored on June 13 through June 24, 2024. The LPN further stated that the risk could result in staff not being able to monitor the actual effects of the medication on the resident.

An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that there was no documentation of side effects monitoring completed during that time period; and that, this could result in staff not identifying the side effects should it happen and could affect the overall care of the resident.

Review of the facility policy titled, Psychotropic Medication Use, revealed that psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, and sedative-hypnotics that affect brain activities associated with mental processes and behavior. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medial or psychiatric causes of behavioral symptoms. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan intervention for monitoring medication side effects related to use of an antianxiety medication was implemented for one resident (#60).

Findings include:

Resident #60 was admitted on December 26, 2023 with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status.

The active physician order summary included an order to monitor for side effects related to anti-anxiety medications.

The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness.

The physician order dated December 28, 2023 included to monitor behaviors of restlessness every shift for 14 days; and, to code whether behavior improved, worsened or unchanged.

The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication and to administer the medications as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated May 3, 2024, included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment.

A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024.

The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024.

Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024.

The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold.

An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that the side effect monitoring was not implemented by staff as care planned between June 13, 2024 and June 24, 2024. The DON stated the risk for not following the care planned interventions could result in lack of identifying side effects and effectiveness of the medication and could affect the overall care of the resident.

Review of the facility policy titled, Comprehensive Care Plans and Revisions, revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan and to ensure that the comprehensive care plans reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update and quarterly review assessments.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan was revised to include resident-specific nutritional goals for one resident (#76).

Findings include:

Resident #76 was admitted on May 02, 2024 with diagnoses of acute metabolic acidosis, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, anemia, dysphagia, and chronic kidney disease.

The weight on May 03, 2024 was 130 lbs. (pounds)

Review of the nutrition care plan initiated on May 03, 2024 revealed the resident had nutritional problems due her medical diagnoses of dysphagia, esophageal stenosis, and cerebrovascular accident; and, had nutritional risks due to suboptimal meal intakes related to decreased appetite, and potential for weight fluctuations/fluid deficit due to fluid shifts due to diuretic medication. Interventions included to report results to physician and follow up as indicated on any signs and symptoms of dysphagia, to provide and serve diet as ordered, monitor intake and record every meal, registered dietician to evaluate and make diet change recommendations as needed, and to weigh and monitor per orders. The goal was that the resident will have no signs and symptoms of aspiration.

The admission Minimum Data Set (MDS) assessment dated May 6, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment.

The skilled note dated May 6, 2024 included the resident was alert and oriented x 2-3 and was non-compliant with physician orders.

A Nutrition Admission Assessment progress note dated on May 6, 2024 revealed the resident was alert and oriented, had swallowing difficulties related to dysphagia, had a weight of 130 pounds; and, was consuming an average of 50% of meals. Per the documentation, interventions included medication pass supplement 4 ounces three times per day and to monitor weight and oral intakes.

The weight record on May 9, 2024 was 121.4 lbs.

The Nutrition/Dietary Note dated May 9, 2024 revealed that the weight was 121.4 lbs. and the resident had a weight loss of 8.6 lbs. in 1 week. The documentation included that the resident was refusing the medication pass supplement 6 times due to "terrible taste"; and that, the resident agreed to have supplemental cereal at breakfast and supplemental pudding at lunch and dinner.

The care plan was revised on May 9, 2024 to include an intervention to provide and serve supplements as ordered. The care plan did not include any resident-specific goals and desired outcomes related to her nutrition and weight loss.

The physician note dated May 10, 2024 included that the resident did not have the capacity to make her own decision.

The skilled nursing note dated May 13, 2024 included that the resident complaint of nausea and vomiting post breakfast and was administered with an antiemetic medication.

The skilled note dated May 20, 2024 included that the resident refused her breakfast, ate her lunch and was compliant with most of her medications.

The weight record on May 20, 2024 was 115.8 pounds, which was a 14.2 pound weight loss in 17 days.

The order administration note dated May 20, 2024 included that the resident was alert and oriented x 4 and refused SNP pudding (supplement).

A Nutrition/Dietary Note dated May 22, 2024 revealed the resident had a weight of 115.8 lbs.; and that, the resident had a 14.2% weight loss in 3 weeks. The documentation included that the resident consumed an average of 35% of meals; 55% average of the SNP pudding and 35% of the SNP cereals. Recommendations included to add the house shakes three times a day for additional 600 kcal (kilo calories/18 g (grams) protein; and to continue to monitor weights and oral intakes.

The care plan was revised on May 22, 2024 to include that the weekly weight loss continued and the supplements were increased. However, the care plan did not include resident's goals and desired outcomes related to her nutrition and weight loss.

The weight record on June 1, 2024 was 115 lbs.

The Nutrition/Dietary note dated June 12, 2024 revealed the resident was on palliative care, had a weight of 115 lbs. and had a significant unplanned weight loss of 15 lbs. in a month. Per the documentation, the resident had an inadequate intake consuming on the average 40% of her meals, had a decreased appetite and refused supplements. Plan included fortified food house shakes three times daily. Further the documentation included that there were no new recommendations at this time.

Despite documentation of resident refusal of supplements in the clinical record, the care plan was not revised to include interventions to address this issue; and, the care plan was not revised to include any new or revised resident-specific goals.

An interview was conducted on July 18, 2024 at 9:45 a.m. with the Registered Dietician (RD/staff #77), who stated that she was not following resident #76 for any weight loss; and that, a referral for an evaluation would have been appropriate for the resident due to her significant unplanned weight loss.

In an interview with the Director of Nursing (DON/staff #12) conducted on July 18, 2024 at 10:51 a.m., the DON stated that the facility monitors the effectiveness of interventions through IDT (interdisciplinary team) reviews; and, the care plan was discussed weekly in the IDT meeting or daily, and revised if needed. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence found in the clinical record that the care plan did not have any resident-specific goals related to the resident's continued weight loss since the resident's admission on May 3, 2024. The DON further stated that the care plan should have been revised to address the weight loss with resident-specific goals.

Review of the facility's policy titled, "Comprehensive Care Plans and Revisions", dated Aug 22, 2023, revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. According to the procedure section of this policy, the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include; additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions to address a time limited condition.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use.

Findings include:

Resident #49 was admitted on December 21, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure.

The care-plan initiated on January 11, 2024 revealed that the resident had oxygen therapy related to COPD. Interventions included O2 (oxygen) via nasal cannula continuous per medical doctor orders.

A physician order dated July 18, 2024 revealed an order for oxygen at 2 liters per minute continuously via nasal cannula; may titrate to 4 liters to maintain 88% saturation.

An observation conducted on July 18, 2024 at 2:03 p.m. revealed Resident #49 was in the activity room playing bingo with nasal cannula on. The oxygen tank gauge displayed an empty oxygen tank.

An interview was conducted on July 18, 2024 with Certified Nursing Assistant (CNA/Staff # 42) who stated that in order to prevent the oxygen tank for Resident #49 from being empty was to monitor the gauge when it was nearing empty. However, the CNA stated that there were instances in the past where the oxygen tank had been empty and it happens.

In another observation conducted on July 18, 2024 at 2:03 p.m., the CNA (staff #42) told the resident that she needed a replacement for her oxygen tank.

An interview was conducted on July 18, 2024 with Director of Nursing (DON/Staff # 12) who stated that a resident with continuous oxygen orders and utilizing an empty oxygen would not meet the facility's expectations. The DON further stated that if there was an oxygen order for a resident, staff were expected to be checking the resident's oxygen throughout the shift.

Review of the facility's policy titled, "Administration of Medications" (reviewed August 2023) revealed, the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. It also included that staff must adhere to right of medication administration including: Right Time and Frequency, check the order for when it would be given and when was the last time it was given; Right Assessment, note the resident's history and any parameters around drug administration; Right Evaluation, ensure the medication is working the way it should, ensure medications are reviewed regularly, ongoing observations if required.

Based on clinical record reviews, facility and hospital documentation, staff interviews and policy review, the facility failed to ensure that two residents (#17, 10) was free from verbal abuse.

Findings include:

-Resident #10 was admitted on 6/9/2023 with diagnoses of Major Depressive Disorder, Adjustment Disorder with disturbance of conduct.

Review of a care plan initiated 12/19/2023 included that this resident displays comments towards other residents and visitors at times as noted aggressive like behaviors. This care plan included 2 incidents: Family visiting and resident verbalized "you need to control your kids" and stated fat people are ugly, continued comments related to residents' appearances and body size. 12/19/2023 interaction with another resident and 3/27/24 confrontational language. This care plan included an intervention of observe interaction around others and intervene if noted concerns.

However, an abusive incident was noted on 3/27/2024.

A progress note dated 3/27/2024 included that at approximately 1530, nurse observed resident #17 shouting at resident #10 in T-Hall walk way area near the nurse's station. Nurse stood between the 2 residents to prevent any incidents from occurring. The note stated resident #17 was redirected to the nurse station, and calmed down and resident #10 was assisted by wheelchair to the other end of the hall.

Another progress note dated 03/27/2024 included that Social Services (SS) and the Assistant Director of Nursing spoke with resident#10 regarding a verbal exchange that took place between her and resident #17. The note stated that resident#10 stated she did not like the way another resident was dressed and stated that "Her fat was hanging out. It was disgusting." Resident #10 stated this upset resident #17. Resident #10 then called resident #17 "fatso" and resident #17 began yelling. The note further stated SS asked what resident #17 yelled at her and she said she was unable to hear exactly what was said. SS asked resident if she felt safe, she stated yes. SS reminded resident#10 that language can be hurtful and encouraged her to refrain from saying things to others that may be perceived as such. The note stated resident#10 verbalized understanding.


-Resident #17 was admitted on July 22, 2022 with diagnoses of schizoaffective disorder, bipolar disorder current episode manic severe with psychotic features and attention-deficit hyperactivity disorder.

Review of a care plan initiated 5/19/2023, resident #17 has a behavior problem yelling, verbal aggression, throws items, plays in feces & accusatory related to delusions/psychosis and included that the resident has expressed thoughts of self-harm and thoughts of harming others. This care plan included an 3/27/2024 verbal aggression, and thoughts of harming self. This care plan included interventions of intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and to remove from situation and take to alternate location as needed.

Review of a quarterly Minimum Data Set (MDS) assessment dated 1/4/2024 included that this resident experienced delusion, and had verbal behavioral symptoms directed at others and had other behavioral symptoms not directed at others.

A progress note dated 3/27/2024 included that at approximately 1530, the nurse observed resident #10 shouting at resident #17 in T-Hall walk way area near the nurse's station. This note includes the nurse stood between the 2 residents to prevent any incidents from occurring. This note included that the resident was redirected to the nurse station, and calmed down and that the other resident #17 was assisted by wheelchair to the other end of the hall.

Another progress note dated 3/27/2024 included that at approximately 1533, a nurse transported resident to the office and the writer asked the resident what they could help her with and she stated "I'm going to kick her ass". This note included that when the writer asked resident who she was referring to and she named a resident #10. This note included that the writer asked her what transpired and she stated "she called my friend fat and I don't appreciate that. (another resident) is not fat and I'm not going to let her talk about my friend like that", then the writer asked her did she mean what she had just said and this resident repeated again "I'm going to kick her ass". This note included that the writer asked this resident if she have a plan on how she was going to accomplish that and she stated "yes I'm going to strangle her in her sleep" and then the writer asked the resident "did she want to harm herself as well?" and she stated "yes" and that she did not have a plan. This note included that a medical doctor was consulted and that the doctor said to send the resident out to the hospital for a psychiatric evaluation and that the residents were kept separated until that happened.

An interview was conducted on 06/14/2024 at 1:31 P.M. with resident #10 who said that resident #17 is a very disturbed person and that she would go around half naked. This resident said she should cover herself. This resident said that resident #17 came after her multiple times, that she swung at her and called her bitch but they were in wheelchairs passing and she could not hit me. She said that the staff knew and that they restrained her from going after me.

An interview was conducted on 6/14/2024 at 1:07 P.M. with a Certified Nursing Assistant (CNA/staff #32) who said that resident #17 was kind of aggressive but denied witnessing incidents between residents. She said that abuse could be verbal and that it should be reported to the nurse right away.

An interview was conducted on 6/14/24 at 12:46 P.M. with a Licensed Practical Nurse (LPN/staff #55) who said that abuse can be sexual, financial, neglect, seclusion, physical, verbal or mental. She said that if a resident is cussing or threatening another resident it's verbal abuse. She said that if she encountered that situation, that she would make sure that the two residents are never together. This nurse said that she would change floors or change destinations, have social services involved, and care plan that. She said that she would have to make the change occur so it would no longer happen.

An interview was conducted on 6/14/24 at 1:45 P.M. with the Director of Nursing (DON/staff #27) who said that if a resident to resident occurs that immediately staff separate them and report right away to management. This DON included that resident #17 was here when she came back in august, and that she had quite a few behaviors, diagnoses, manipulative when they had to set boundaries. This DON said that they had to speak to her about activities, and that she would make statements to other residents, she was very involved in psych services and that they had to monitor her behavior because some days she was manic, some days not. This DON said that resident #17 would get the idea that someone did not like her and she would take things upon herself to resolve it. She said that her understanding of what happened in that instance, that resident #17 said that resident #10 had made a comment about her appearance. This DON stated that resident #10 was also verbally abusive and that incidents were going to happen but that they would take steps to prevent them.

A policy reviewed 7/18/2023 revealed that it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record reviews, facility and hospital documentation, staff interviews and policy review, the facility failed to ensure that two residents (#17, 10) was free from verbal abuse.

Findings include:

-Resident #10 was admitted on 6/9/2023 with diagnoses of Major Depressive Disorder, Adjustment Disorder with disturbance of conduct.

Review of a care plan initiated 12/19/2023 included that this resident displays comments towards other residents and visitors at times as noted aggressive like behaviors. This care plan included 2 incidents: Family visiting and resident verbalized "you need to control your kids" and stated fat people are ugly, continued comments related to residents' appearances and body size. 12/19/2023 interaction with another resident and 3/27/24 confrontational language. This care plan included an intervention of observe interaction around others and intervene if noted concerns.

However, an abusive incident was noted on 3/27/2024.

A progress note dated 3/27/2024 included that at approximately 1530, nurse observed resident #17 shouting at resident #10 in T-Hall walk way area near the nurse's station. Nurse stood between the 2 residents to prevent any incidents from occurring. The note stated resident #17 was redirected to the nurse station, and calmed down and resident #10 was assisted by wheelchair to the other end of the hall.

Another progress note dated 03/27/2024 included that Social Services (SS) and the Assistant Director of Nursing spoke with resident#10 regarding a verbal exchange that took place between her and resident #17. The note stated that resident#10 stated she did not like the way another resident was dressed and stated that "Her fat was hanging out. It was disgusting." Resident #10 stated this upset resident #17. Resident #10 then called resident #17 "fatso" and resident #17 began yelling. The note further stated SS asked what resident #17 yelled at her and she said she was unable to hear exactly what was said. SS asked resident if she felt safe, she stated yes. SS reminded resident#10 that language can be hurtful and encouraged her to refrain from saying things to others that may be perceived as such. The note stated resident#10 verbalized understanding.


-Resident #17 was admitted on July 22, 2022 with diagnoses of schizoaffective disorder, bipolar disorder current episode manic severe with psychotic features and attention-deficit hyperactivity disorder.

Review of a care plan initiated 5/19/2023, resident #17 has a behavior problem yelling, verbal aggression, throws items, plays in feces & accusatory related to delusions/psychosis and included that the resident has expressed thoughts of self-harm and thoughts of harming others. This care plan included an 3/27/2024 verbal aggression, and thoughts of harming self. This care plan included interventions of intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and to remove from situation and take to alternate location as needed.

Review of a quarterly Minimum Data Set (MDS) assessment dated 1/4/2024 included that this resident experienced delusion, and had verbal behavioral symptoms directed at others and had other behavioral symptoms not directed at others.

A progress note dated 3/27/2024 included that at approximately 1530, the nurse observed resident #10 shouting at resident #17 in T-Hall walk way area near the nurse's station. This note includes the nurse stood between the 2 residents to prevent any incidents from occurring. This note included that the resident was redirected to the nurse station, and calmed down and that the other resident #17 was assisted by wheelchair to the other end of the hall.

Another progress note dated 3/27/2024 included that at approximately 1533, a nurse transported resident to the office and the writer asked the resident what they could help her with and she stated "I'm going to kick her ass". This note included that when the writer asked resident who she was referring to and she named a resident #10. This note included that the writer asked her what transpired and she stated "she called my friend fat and I don't appreciate that. (another resident) is not fat and I'm not going to let her talk about my friend like that", then the writer asked her did she mean what she had just said and this resident repeated again "I'm going to kick her ass". This note included that the writer asked this resident if she have a plan on how she was going to accomplish that and she stated "yes I'm going to strangle her in her sleep" and then the writer asked the resident "did she want to harm herself as well?" and she stated "yes" and that she did not have a plan. This note included that a medical doctor was consulted and that the doctor said to send the resident out to the hospital for a psychiatric evaluation and that the residents were kept separated until that happened.

An interview was conducted on 06/14/2024 at 1:31 P.M. with resident #10 who said that resident #17 is a very disturbed person and that she would go around half naked. This resident said she should cover herself. This resident said that resident #17 came after her multiple times, that she swung at her and called her bitch but they were in wheelchairs passing and she could not hit me. She said that the staff knew and that they restrained her from going after me.

An interview was conducted on 6/14/2024 at 1:07 P.M. with a Certified Nursing Assistant (CNA/staff #32) who said that resident #17 was kind of aggressive but denied witnessing incidents between residents. She said that abuse could be verbal and that it should be reported to the nurse right away.

An interview was conducted on 6/14/24 at 12:46 P.M. with a Licensed Practical Nurse (LPN/staff #55) who said that abuse can be sexual, financial, neglect, seclusion, physical, verbal or mental. She said that if a resident is cussing or threatening another resident it's verbal abuse. She said that if she encountered that situation, that she would make sure that the two residents are never together. This nurse said that she would change floors or change destinations, have social services involved, and care plan that. She said that she would have to make the change occur so it would no longer happen.

An interview was conducted on 6/14/24 at 1:45 P.M. with the Director of Nursing (DON/staff #27) who said that if a resident to resident occurs that immediately staff separate them and report right away to management. This DON included that resident #17 was here when she came back in august, and that she had quite a few behaviors, diagnoses, manipulative when they had to set boundaries. This DON said that they had to speak to her about activities, and that she would make statements to other residents, she was very involved in psych services and that they had to monitor her behavior because some days she was manic, some days not. This DON said that resident #17 would get the idea that someone did not like her and she would take things upon herself to resolve it. She said that her understanding of what happened in that instance, that resident #17 said that resident #10 had made a comment about her appearance. This DON stated that resident #10 was also verbally abusive and that incidents were going to happen but that they would take steps to prevent them.

A policy reviewed 7/18/2023 revealed that it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (# 8) was free from verbal abuse. The deficient practice may result in psychosocial harm as a result of un-averting or intervening communication that may lead to verbal abuse.

Findings include:

Resident #8 was admitted to the facility on April 07, 2022 with diagnoses of acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, and recurrent severe major depressive disorder with psychotic symptoms.

The Annual MDS (minimum data set) assessment dated July 13, 2023 revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact.

A review of medical record documentation revealed that on August 17, 2023 at 10:30 a.m. Resident #8 reported to the facility's administrator that she had felt threatened a day prior by a night shift staff. Resident # 8 disclosed the interaction which made her feel threated involved Certified Nursing Assistant (CNA/Staff # 30). Resident # 8 admitted she should not have played a part of, nonetheless antagonized Staff # 30 by saying her name in a 'sing-songy voice'. Staff # 30 responded by telling Resident # 8 please don't talk to me. Resident # 8 then replied to Staff # 30 that they were both adults and had to move on adding that Staff # 30 should be careful because she was a resident. Staff # 30 then replied, "no you need to watch yourself".

During the facility's investigation of the incident on August 21, 2023 at 03:30 PM, review of documentation revealed that during an interview conducted by Administrator (ED/Staff # 1) and Director of Nursing (DON/Staff # 6), Staff # 30 stated she had felt antagonized by Resident # 8 for a few months, however had intensified in the recent weeks. Staff # 30 stated that in response to Resident # 8 telling her to watch herself, she responded with, "you need to watch yourself because you make me feel uncomfortable." Investigation revealed that Staff # 30 was terminated and reminded that even if she feels threatened, she is a healthcare professional and cannot engage in threatening behavior. Moreover, investigation revealed she should have removed herself from the situation immediately and called either Staff # 1 or Staff # 6. Staff # 30 was reported to the board of nursing as a result of the facility's investigation.

The care plan was updated on August 23, 2023 and revealed the resident had a behavior problem and that, the resident tend to antagonize staff at times. The interventions and tasks that were implemented included:
-If reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.
-Observe for behaviors antagonizing; document behavior and attempted interventions.
-Observe for behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations.

An interview was conducted with Director of Nursing (Staff # 6) on May 16, 2024 who confirmed that staff are terminated if found guilty of verbal abuse if the allegation were found accurate. Staff # 6 confirmed that Staff # 30 was terminated in lieu of verbally abusing Resident # 8. Staff # 6 stated that any type of abuse including verbal abuse does not meet the facility's expectations. Furthermore, Staff # 6 stated that the response by Staff # 30 which made Resident # 8 feel threatened did not meet facility's expectations.

Review of the facility's Policy titled, "Abuse, Neglect, and Exploitation" (reviewed July 18, 2023) revealed, it is the policy of this facility to identify abuse; this includes but is not limited to identifying and understanding the different types of abuse and possible indicators; the resident has the right to be free from abuse; the facility must not use verbal; mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (# 8) was free from verbal abuse.

Findings include:

Resident #8 was admitted to the facility on April 07, 2022 with diagnoses of acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, and recurrent severe major depressive disorder with psychotic symptoms.

The Annual MDS (minimum data set) assessment dated July 13, 2023 revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact.

A review of medical record documentation revealed that on August 17, 2023 at 10:30 a.m. Resident #8 reported to the facility's administrator that she had felt threatened a day prior by a night shift staff. Resident # 8 disclosed the interaction which made her feel threated involved Certified Nursing Assistant (CNA/Staff # 30). Resident # 8 admitted she should not have played a part of, nonetheless antagonized Staff # 30 by saying her name in a 'sing-songy voice'. Staff # 30 responded by telling Resident # 8 please don't talk to me. Resident # 8 then replied to Staff # 30 that they were both adults and had to move on adding that Staff # 30 should be careful because she was a resident. Staff # 30 then replied, "no you need to watch yourself".

During the facility's investigation of the incident on August 21, 2023 at 03:30 PM, review of documentation revealed that during an interview conducted by Administrator (ED/Staff # 1) and Director of Nursing (DON/Staff # 6), Staff # 30 stated she had felt antagonized by Resident # 8 for a few months, however had intensified in the recent weeks. Staff # 30 stated that in response to Resident # 8 telling her to watch herself, she responded with, "you need to watch yourself because you make me feel uncomfortable." Investigation revealed that Staff # 30 was terminated and reminded that even if she feels threatened, she is a healthcare professional and cannot engage in threatening behavior. Moreover, investigation revealed she should have removed herself from the situation immediately and called either Staff # 1 or Staff # 6. Staff # 30 was reported to the board of nursing as a result of the facility's investigation.

The care plan was updated on August 23, 2023 and revealed the resident had a behavior problem and that, the resident tend to antagonize staff at times. The interventions and tasks that were implemented included:
-If reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.
-Observe for behaviors antagonizing; document behavior and attempted interventions.
-Observe for behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations.

An interview was conducted with Director of Nursing (Staff # 6) on May 16, 2024 who confirmed that staff are terminated if found guilty of verbal abuse if the allegation were found accurate. Staff # 6 confirmed that Staff # 30 was terminated in lieu of verbally abusing Resident # 8. Staff # 6 stated that any type of abuse including verbal abuse does not meet the facility's expectations. Furthermore, Staff # 6 stated that the response by Staff # 30 which made Resident # 8 feel threatened did not meet facility's expectations.

Review of the facility's Policy titled, "Abuse, Neglect, and Exploitation" (reviewed July 18, 2023) revealed, it is the policy of this facility to identify abuse; this includes but is not limited to identifying and understanding the different types of abuse and possible indicators; the resident has the right to be free from abuse; the facility must not use verbal; mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#369) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family when the resident had a change of condition. This failure has the potential for confusion between resident's family and the facility.

Findings:

Resident (#369) was admitted to the facility on October 1, 2018 with diagnosis that included, cardiac arrhythmia, unspecified; Parkinson's disease; bradycardia, unspecified; unspecified dementia with behavioral disturbance; anorexia; major depressive disorder, single episode unspecified.

Review of the quarterly Minimum Data Set (MDS) dated December 9, 2020 revealed a Brief Interview for Mental Status (BIMS) record revealed resident score was 03, indicating severe cognitive impairment. Further review of the MDS revealed resident was dependent or required extensive assist with activities of daily living.

Review of the physician's orders revealed orders for COVID-19 Nasopharyngeal Swab Test one time only for potential COVID exposure for 3 Days. Resident was diagnosed with COVID on July 2, 2020.

A review of the Care Plan dated September 2, 2020 revealed the following, resident (#369) has a behavior problem psychosis related to diagnoses of dementia, anxiety, bipolar disorder, has impaired cognitive ability/impaired thought processes related to) Dementia.

There was no evidence in the facility documentation and clinical record that the family or responsible party was notified of a change in the resident's condition.

On February 14, 2024 at 12:05 PM, an interview was conducted with Social Services Director Staff (#87) and Social Services Assistant Staff (#110). Staff #87 stated during COVID nursing was responsible for notifying families if a resident contracted COVID and it would be as soon as possible. She stated the physician makes the decision to have a conversation with the family if a resident's decision-making capabilities are compromised due to their cognitive status and will also utilize the Ombudsman. She further stated It was oversight on the facility's end that the spouse was not notified of the residents change of condition.

An interview was conducted with the Director of Nursing (DON/Staff #94) on February 15, 2024 at 2:08PM. She stated nursing is responsible for notifying families for change of condition and the expected timeframe for notification is dependent on the change of condition, but that it is completed within their shift if the nurse is initiating the change of condition. She stated evaluations for decision making abilities are based on the residents BIM score and will, if needed get the physician involved and the Psych provider. She further added if it is documented that the resident is confused, alert to self only they would not be considered as able to make informed decisions for self. The facility would also look at the history of the patient and type of family dynamics with responsible party.

Review of the facility policy titled Changes in Residents Condition or Status states this facility will notify the resident, his, her primary care provider, and resident's/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#520) was free from abuse of another. The deficient practice could result in other residents being abused.

Findings include:

1.) Resident #520 (alleged victim) was admitted on October 3, 2022 with diagnoses that included Alzheimer's disease, and dementia.

Review of the quarterly Minimum Data Set (MDS) assessment dated December 28, 2022 revealed that a Brief Interview for Mental Status (BIMS) was not conducted, however the resident was assessed as being severely cognitively impaired. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms, or wandering during the assessment period.

A cognition care plan initiated on October 4, 2022 revealed that the resident has impaired cognitive ability and impaired thought process related to Alzheimer's disease and dementia. Interventions included to allow extra time for resident to respond to question and instructions.

A communication care plan initiated on October 18, 2022 indicated that the resident has difficulty communicating his needs since he only spoke Spanish. Interventions included to observe for physical/non-verbal indicators of discomfort or distress, and follow-up as needed.

A progress note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) found resident #525 (roommate/alleged perpetrator) hitting resident #520 multiple times. Resident #520 was found in his bed curled up. The note indicated that resident #520 stated that "I go him by him, I got him by him." The note also documented that resident #520 verbalized pain to his back, head, and right shoulder. Resident #520 was given pain medication. A skin assessment was completed and no visual injuries were noted at the time. The note indicated that the roommate/alleged perpetrator (resident #525) was removed from the room to ensure the residents' safety.

2.) Resident #525 (alleged perpetrator) was admitted to the facility on August 8, 2014 with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder.

Review of the cognition care plan initiated on November 18, 2019 revealed that the resident has cognitive deficits related to dementia and cerebral vascular accident (CVA). Interventions included to administer medications as ordered, allow time for resident to respond to questions and instructions.

A communication care plan initiated on November 18, 2019 indicated that the resident may have barriers to communication related to expressive aphasia secondary to CVA. Interventions included to anticipate and meet needs, allow adequate time to respond, repeat as necessary, do not rush, and request clarification to ensure understanding.

Review of the quarterly MDS assessment dated January 5, 2023 revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering.

A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said "I fucking him up because he pissed on the floor again." The note indicated that skin assessments were completed on both residents. Resident was removed from the room.

Review of the clinical record reveals no documentation of the resident having physical altercations with staff or other residents. There were two entries for verbal altercations, one on June 6, 2021 with his roomate, a room change was made and the other was on November 15, 2022 with a staff member.

A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up.

Review of the Event Report completed on February 10, 2023 indicated that nurse was notified by a CNA that resident #525 punched his roommate, resident #520 multiple times on the body. The report indicated that no injuries were observed at the time of the incident. The immediate action taken was the resident was removed from the room and placed in the dayroom and skin assessments were completed.

Review of the facility investigation report submitted February 15, 2023 indicated that a resident to resident altercation between residents #520 and #525 occurred on February 10, 2023 at approximately 5:10 AM. The report noted that a CNA saw resident #525 punching his roommate on the body multiple times. According to the report, resident #520 had urinated on the floor on February 9, 2023 which upset his roommate, resident #525 and resulted in the incident.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #25) on February 25, 2024 at 12:58 PM. Staff #25 stated that incidents/allegations of abuse are reported immediately. The CNA said that they make sure the resident(s) are safe, then it is reported to the charge nurse and ED (Executive Director). Staff #25 stated that in instances of resident to resident altercation, the staff separates the residents from each other and then talk to them. She noted that incidents are investigated. The investigation entails interview of staff working that day or was working with the residents, and any witnesses.

In an interview with a Licensed Practical Nurse (LPN/staff #22) conducted on February 25, 2024 at 1:17 PM, Staff #22 stated that in incidents or allegations of abuse, staff makes sure that the resident(s) are safe. Then the administrator is notified immediately. In cases of resident to resident altercation, residents are separated then the administrator is notified. Staff #22 indicated that she was familiar with both residents #520 and #525. She said that she heard there was an incident between them but was not sure of the details since it did not occur during her shift. Staff #22 said that given that one of them is confused and the other was a wanderer, they were not a good fit to be roommates.

During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, the DON stated that the expectation is that allegations of abuse is reported timely within guidelines and that staff know who to report it to, and what to report. Staff #94 said that the reporting process is initiated when staff reports it to their supervisor. In instances of resident to resident altercation the expectation is that they are separated and the incident reported immediately. Abuse investigations should have information from the individual who reported, interview of everyone directly involved or had the potential to be involved, interview of staff and residents, and review of documentation, care plan, and notification of parties involved.

Review of the facility policy titled "Abuse-Protection of Residents" issued October 4, 2022 stated that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy noted that if the accused abuser is another resident, the residents must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents.

The facility policy titled "Abuse-Prevention" issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, asses

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that two resident's (#525, #535) care plans were updated and revised as needed.

Findings include:

1.) Regarding resident #525

Resident #525 was admitted to the facility on August 8, 2014 with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder.

Review of the quarterly MDS assessment dated January 5, 2023 revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering.

A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said "I fucking him up because he pissed on the floor again." The note indicated that skin assessments were completed on both residents. Resident was removed from the room.

Review of the clinical record did not reveal any documentation of physical aggression against staff or residents. There was documentation of a verbal altercation between the resident and his then roomater on June 6, 2020 resulting in a change of rooms and a second verbal altercation with a staff member on November 18, 2022 about moving his wheel chair from a doorway which was blocking access.

A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up.

However, review of the care plan post incident revealed that the careplan was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were put in place to mitigate further resident to resident incidents.

2.) Regarding resident #535

Resident # 535 was admitted to the facility on July 22, 2022 with diagnoses that included schizoaffective disorder, and bipolar disorder, with current episode manic severe with psychotic features.

Review of the quarterly Minimum Data Set (MDS) assessment dated April 11, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident had exhibited verbal behavior symptoms directed towards others which occurred 1-3 days during the assessment period.

A nursing note dated May 16, 2023 for resident #530, documented that resident #530 stated that her roommate, (resident #535) had threatened to kill her. Resident ##530 denied making any threats to harm her roomate.

A nursing note for resident #535 documented that resident #530 stated that resident #535 told her "I want to smother you with a pillow, and save a knife from the dinner tray and stab you." The note indicated that resident #535 was interviewed and denied threatening her roommate.

A nurse practitioner (NP) note dated May 24, 2023 indicated that resident #535's chief complaint was that she wanted her own room. Note indicated that resident was moved due to behaviors that resulted in conflict. The note stated that per staff, resident manipulates and make false accusations when she does not get her way.

Review of the care plan for residnet #535 revealed that it was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were in place to mitigate potential resident to resident incidents.

During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, she stated that her expectation is that following a resident to resident altercation, resident should be put on change on condition to monitor for psychosocial needs, discuss interventions such as move rooms and ensure that staff are aware of how to intervene and provide psych services. Staff #94 said that there should be an update of interventions on the care plan following a resident to resident altercation.

The facility policy titled "Comprehensive Care Plans and Revisions" issued March 2, 2022 stated that the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occurs, the facility should review and update the plan of care to reflect the changes to care delivery to include additional interventions on existing problems.

Review of facility policy titled "Abuse-Prevention" issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, assess, care plan for appropriate interventions, and monitor resident with needs and behaviors which might lead to conflict.

Based on clinical record review, staff interviews and review of facility policy and procedure, the facility failed to ensure that one resident (#333) was provided with floor mat for fall prevention and implementation of the care plan. The deficient practice could result in preventable accidents such as falls.

Findings include:

Resident #333 was admitted with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease with late onset hypothyroidism, unspecified, muscle weakness (generalized), difficulty in walking, not elsewhere classified, unspecified lack of delirium due to known physiological condition coordination, cognitive communication deficit, repeated falls, pain in left knee

A quarterly Minimum Data Set (MDS) assessment dated November 22, 2023, included a Brief interview for Mental Status (BIMS) score of 03 indicating the resident was cognitively impaired the assessment also included that the resident required substantial/max 1 person assist for transfers.

A care plan included the resident had an Activities of Daily Living (ADL) self-care performance deficit; and that, the resident had a risk for falls due to Alzheimer's Disease and had sustained multiple falls. The Care Plan with a date of 01/03/2024 states a floor mat x1 to extend bed perimeter when in bed.

An incident note dated January 8, 2024 included that IDT met and discussed event 1/3/24, resident was found on floor in dayroom, nurse performed assessment, small skin tear noted to Right Lower Extremity, able to move extremities on her own, neurological checks started, within normal limit's, resident has advanced dementia/Alzheimer's disease and delirium, unable to articulate desired activity, resident had shortly before event been in bed, appears resident crawled from bed to dayroom, floor mat x 1 placed next to bed to extend bed perimeter when in bed.

Review of the Fall Risk Assessment dated January 6, 2024 revealed resident had falls on 11/27/23, 12/4/23, 12/6/23, 12/19/23, 12/24/23, 01/03/24, 01/06/24

An observation was made on February 15, 2024 of resident #333 room, no visible floor mat was present.

An interview was conducted on February 15, 2024, at 12:04 PM with a Certified Nursing Assistant (CNA/staff #79) who stated that she is informed by her nursing supervisor before every shift of residents who are considered a high risk for falls. She stated some of the preventative measures used for fall prevention are non-slip wear, additional supervision, lower beds and floor mats. She further stated most residents who are fall risks have a band on their arms indicating so. CNA Staff # 79 stated she receives report every morning and gives report every afternoon, but has not received any information that resident #333 is supposed to use a floor mat and has never used one on her.

An interview was conducted on February 15, 2024, at 12:11 PM with a Licensed Practical Nurse (staff #88) who was assigned to the resident for that day. He stated nursing in general is responsible for implementing preventative measures for residents with fall risks and those measures usually involve low beds and floor mats. He further stated the CNA's are informed of the residents with fall risks and what measures are in place and that there is also a meeting at the beginning of day shift of any changes or a resident risk for falls. He stated this information is also found on the Kardex. LPN/Staff #88 stated resident #333 is considered a fall risk and has preventative measures in place by having a low bed and a mat on the floor when resident is in bed. An observation was made by the LPN who noted there was no mat in the resident's room, stating she should have one and he would get one for her.

An observation was made of LPN/Staff #88 on February 15, 2024, at 12:38 PM carrying a mat in the hallway. He stated it was for resident #333 and was taking it to her room

Review of the facility policy titled Fall Management, revised 04/07/2022 and reviewed 09/22/2023 states the facility will assess the resident upon admission / readmission, quarterly, with change in condition, and with any fall event for any falls and will identify appropriate interventions to minimize the risk of injury related to falls.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions, signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility.

Findings include:

Resident #408 was admitted on December 11, 2023 with diagnoses of surgical aftercare following surgery on the skin, sepsis (unspecified organism), and encounter for attention to gastrostomy. The most recent Admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact.

Review of medical records for Resident #408 revealed the presence of a feeding tube, wound, and a catheter. However, during an observation of care for Resident #408 February 13, 2024 at 10:05 AM, in Room 430 revealed no transmission-based precaution Centers for Disease Control (CDC) Prevention signage or personal protective equipment (PPE) outside or near the room entrance.

An interview was conducted on February 13, 2024 at 11:10 AM with Assistant Director of Nursing/Infection Preventionist (ADON/IP/Staff # 43), who stated that the facility does not use enhanced barrier precautions in the facility, and therefore no enhanced barrier precautions signage is outside any room. Staff # 43 stated it was a decision made by everyone because sometimes it is confusing for the staff. Staff # 43 stated the isolation precaution signage that the facility utilizes are only droplet and airborne. Staff # 43 stated the risks of not using appropriate PPE, or displaying transmission-based precaution signage recommended by the CDC, including for enhanced barrier precautions when it is initiated, may result in widespread infection for resident and staff.

An interview was conducted on February 13, 2024 at 11:22 AM with the Director of Nursing (DON/Staff # 94), who confirmed that enhanced barrier signage was not used in the facility. Staff # 94 stated that the facility follows CDC recommendations in regards to infection control as well as their facility policy, however due to verbiage regarding enhanced barrier by CDC it is up to the discretion of the facility whether to be implemented as well as recommendations made by advisors. Staff # 94 stated the risks of transmission-based precaution signage not being followed is possibly carrying infections to other residents.

On February 14, 2024 at 8:30 AM a list of resident names with G-tube, J-Tube, wounds, colostomy, nephrostomy, catheters, multi-drug-resistant organisms (MDRO) was requested which revealed the following number of residents in the facility within each category: G Tubes/J Tubes: 5 residents; Wounds: 8 residents; Colostomy, Nephrostomy, Catheter: 11 residents; MDRO: 2 residents.

On February 14, 2024 at 9:00-9:30 AM an observation of entire facility consisting of the 1st and 2nd floor hallway rooms revealed no PPE or enhanced barrier signage present at any resident room with G Tubes/J Tubes, Wounds, Colostomy, Nephrostomy, Catheter, or MDRO.

An interview was conducted on February 15, 2024 at 11:45 AM with the Executive Administrator (EA/Staff # 450), who confirmed that the entire management team have access to facility policies. Staff # 450 stated she expects policies to be followed and it would not meet facility expectations if staff did not follow enhanced barrier precaution facility policy.

The facility's policy and procedure document titled, "Transmission-based Precautions and Isolation Procedures" (revised September 15, 2023), revealed:

-450 Standard and transmission-based precautions to be followed to prevent spread of infections.

-450 Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following:

-360 Wounds or indwelling medical devices, regardless of MDRO colonization status
-360
-360 Infection or colonization with an MDRO
-360
-360 Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:
-360
-360 Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
-360
-360 Wound care: any skin opening requiring a dressing

When a resident is placed on transmission-based precautions, the staff should implement the following:

-360 Place type precaution signage to be initiated on the outside of the resident room in a conspicuous place such as door or on the wall next to the doorway identifying the CDC category or categories of transmission-based precautions (e.g. contact, droplet, airborne, or enhanced), instructions for use of PPE, and/or instructions to see the nurse before entering.

-360 Make PPE readily available near the entrance to the resident's room.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#520) was free from abuse of another. The deficient practice could result in other residents being abused.

Findings include:

1.) Resident #520 (alleged victim) was admitted on October 3, 2022 with diagnoses that included Alzheimer's disease, and dementia.

Review of the quarterly Minimum Data Set (MDS) assessment dated December 28, 2022 revealed that a Brief Interview for Mental Status (BIMS) was not conducted, however the resident was assessed as being severely cognitively impaired. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms, or wandering during the assessment period.

A cognition care plan initiated on October 4, 2022 revealed that the resident has impaired cognitive ability and impaired thought process related to Alzheimer's disease and dementia. Interventions included to allow extra time for resident to respond to question and instructions.

A communication care plan initiated on October 18, 2022 indicated that the resident has difficulty communicating his needs since he only spoke Spanish. Interventions included to observe for physical/non-verbal indicators of discomfort or distress, and follow-up as needed.

A progress note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) found resident #525 (roommate/alleged perpetrator) hitting resident #520 multiple times. Resident #520 was found in his bed curled up. The note indicated that resident #520 stated that "I go him by him, I got him by him." The note also documented that resident #520 verbalized pain to his back, head, and right shoulder. Resident #520 was given pain medication. A skin assessment was completed and no visual injuries were noted at the time. The note indicated that the roommate/alleged perpetrator (resident #525) was removed from the room to ensure the residents' safety.

2.) Resident #525 (alleged perpetrator) was admitted to the facility on August 8, 2014 with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder.

Review of the cognition care plan initiated on November 18, 2019 revealed that the resident has cognitive deficits related to dementia and cerebral vascular accident (CVA). Interventions included to administer medications as ordered, allow time for resident to respond to questions and instructions.

A communication care plan initiated on November 18, 2019 indicated that the resident may have barriers to communication related to expressive aphasia secondary to CVA. Interventions included to anticipate and meet needs, allow adequate time to respond, repeat as necessary, do not rush, and request clarification to ensure understanding.

Review of the quarterly MDS assessment dated January 5, 2023 revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering.

A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said "I fucking him up because he pissed on the floor again." The note indicated that skin assessments were completed on both residents. Resident was removed from the room.

Review of the clinical record reveals no documentation of the resident having physical altercations with staff or other residents. There were two entries for verbal altercations, one on June 6, 2021 with his roomate, a room change was made and the other was on November 15, 2022 with a staff member.

A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up.

Review of the Event Report completed on February 10, 2023 indicated that nurse was notified by a CNA that resident #525 punched his roommate, resident #520 multiple times on the body. The report indicated that no injuries were observed at the time of the incident. The immediate action taken was the resident was removed from the room and placed in the dayroom and skin assessments were completed.

Review of the facility investigation report submitted February 15, 2023 indicated that a resident to resident altercation between residents #520 and #525 occurred on February 10, 2023 at approximately 5:10 AM. The report noted that a CNA saw resident #525 punching his roommate on the body multiple times. According to the report, resident #520 had urinated on the floor on February 9, 2023 which upset his roommate, resident #525 and resulted in the incident.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #25) on February 25, 2024 at 12:58 PM. Staff #25 stated that incidents/allegations of abuse are reported immediately. The CNA said that they make sure the resident(s) are safe, then it is reported to the charge nurse and ED (Executive Director). Staff #25 stated that in instances of resident to resident altercation, the staff separates the residents from each other and then talk to them. She noted that incidents are investigated. The investigation entails interview of staff working that day or was working with the residents, and any witnesses.

In an interview with a Licensed Practical Nurse (LPN/staff #22) conducted on February 25, 2024 at 1:17 PM, Staff #22 stated that in incidents or allegations of abuse, staff makes sure that the resident(s) are safe. Then the administrator is notified immediately. In cases of resident to resident altercation, residents are separated then the administrator is notified. Staff #22 indicated that she was familiar with both residents #520 and #525. She said that she heard there was an incident between them but was not sure of the details since it did not occur during her shift. Staff #22 said that given that one of them is confused and the other was a wanderer, they were not a good fit to be roommates.

During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, the DON stated that the expectation is that allegations of abuse is reported timely within guidelines and that staff know who to report it to, and what to report. Staff #94 said that the reporting process is initiated when staff reports it to their supervisor. In instances of resident to resident altercation the expectation is that they are separated and the incident reported immediately. Abuse investigations should have information from the individual who reported, interview of everyone directly involved or had the potential to be involved, interview of staff and residents, and review of documentation, care plan, and notification of parties involved.

Review of the facility policy titled "Abuse-Protection of Residents" issued October 4, 2022 stated that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy noted that if the accused abuser is another resident, the residents must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents.

The facility policy titled "Abuse-Prevention" issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, asses

Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#369) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family when the resident had a change of condition. This failure has the potential for confusion between resident's family and the facility.

Findings:

Resident (#369) was admitted to the facility on October 1, 2018 with diagnosis that included, cardiac arrhythmia, unspecified; Parkinson's disease; bradycardia, unspecified; unspecified dementia with behavioral disturbance; anorexia; major depressive disorder, single episode unspecified.

Review of the quarterly Minimum Data Set (MDS) dated December 9, 2020 revealed a Brief Interview for Mental Status (BIMS) record revealed resident score was 03, indicating severe cognitive impairment. Further review of the MDS revealed resident was dependent or required extensive assist with activities of daily living.

Review of the physician's orders revealed orders for COVID-19 Nasopharyngeal Swab Test one time only for potential COVID exposure for 3 Days. Resident was diagnosed with COVID on July 2, 2020.

A review of the Care Plan dated September 2, 2020 revealed the following, resident (#369) has a behavior problem psychosis related to diagnoses of dementia, anxiety, bipolar disorder, has impaired cognitive ability/impaired thought processes related to) Dementia.

There was no evidence in the facility documentation and clinical record that the family or responsible party was notified of a change in the resident's condition.

On February 14, 2024 at 12:05 PM, an interview was conducted with Social Services Director Staff (#87) and Social Services Assistant Staff (#110). Staff #87 stated during COVID nursing was responsible for notifying families if a resident contracted COVID and it would be as soon as possible. She stated the physician makes the decision to have a conversation with the family if a resident's decision-making capabilities are compromised due to their cognitive status and will also utilize the Ombudsman. She further stated It was oversight on the facility's end that the spouse was not notified of the residents change of condition.

An interview was conducted with the Director of Nursing (DON/Staff #94) on February 15, 2024 at 2:08PM. She stated nursing is responsible for notifying families for change of condition and the expected timeframe for notification is dependent on the change of condition, but that it is completed within their shift if the nurse is initiating the change of condition. She stated evaluations for decision making abilities are based on the residents BIM score and will, if needed get the physician involved and the Psych provider. She further added if it is documented that the resident is confused, alert to self only they would not be considered as able to make informed decisions for self. The facility would also look at the history of the patient and type of family dynamics with responsible party.

Review of the facility policy titled Changes in Residents Condition or Status states this facility will notify the resident, his, her primary care provider, and resident's/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that two resident's (#525, #535) care plans were updated and revised as needed.

Findings include:

1.) Regarding resident #525

Resident #525 was admitted to the facility on August 8, 2014 with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder.

Review of the quarterly MDS assessment dated January 5, 2023 revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering.

A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said "I fucking him up because he pissed on the floor again." The note indicated that skin assessments were completed on both residents. Resident was removed from the room.

Review of the clinical record did not reveal any documentation of physical aggression against staff or residents. There was documentation of a verbal altercation between the resident and his then roomater on June 6, 2020 resulting in a change of rooms and a second verbal altercation with a staff member on November 18, 2022 about moving his wheel chair from a doorway which was blocking access.

A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up.

However, review of the care plan post incident revealed that the careplan was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were put in place to mitigate further resident to resident incidents.

2.) Regarding resident #535

Resident # 535 was admitted to the facility on July 22, 2022 with diagnoses that included schizoaffective disorder, and bipolar disorder, with current episode manic severe with psychotic features.

Review of the quarterly Minimum Data Set (MDS) assessment dated April 11, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident had exhibited verbal behavior symptoms directed towards others which occurred 1-3 days during the assessment period.

A nursing note dated May 16, 2023 for resident #530, documented that resident #530 stated that her roommate, (resident #535) had threatened to kill her. Resident ##530 denied making any threats to harm her roomate.

A nursing note for resident #535 documented that resident #530 stated that resident #535 told her "I want to smother you with a pillow, and save a knife from the dinner tray and stab you." The note indicated that resident #535 was interviewed and denied threatening her roommate.

A nurse practitioner (NP) note dated May 24, 2023 indicated that resident #535's chief complaint was that she wanted her own room. Note indicated that resident was moved due to behaviors that resulted in conflict. The note stated that per staff, resident manipulates and make false accusations when she does not get her way.

Review of the care plan for residnet #535 revealed that it was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were in place to mitigate potential resident to resident incidents.

During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, she stated that her expectation is that following a resident to resident altercation, resident should be put on change on condition to monitor for psychosocial needs, discuss interventions such as move rooms and ensure that staff are aware of how to intervene and provide psych services. Staff #94 said that there should be an update of interventions on the care plan following a resident to resident altercation.

The facility policy titled "Comprehensive Care Plans and Revisions" issued March 2, 2022 stated that the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occurs, the facility should review and update the plan of care to reflect the changes to care delivery to include additional interventions on existing problems.

Review of facility policy titled "Abuse-Prevention" issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, assess, care plan for appropriate interventions, and monitor resident with needs and behaviors which might lead to conflict.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions, signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility.

Findings include:

Resident # 408 was admitted on December 11, 2023 with diagnoses of surgical aftercare following surgery on the skin, sepsis (unspecified organism), and encounter for attention to gastrostomy. The most recent Admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact.

Review of medical records for Resident # 408 revealed the presence of a feeding tube, wound, and catheter. However, during an observation of care for Resident # 408 February 13, 2024 at 10:05 AM, Room 430 revealed no transmission-based precaution Centers for Disease Control (CDC) Prevention signage or personal protective equipment (PPE) outside or near the room entrance.

An interview was conducted on February 13, 2024 at 11:10 AM with Assistant Director of Nursing/Infection Preventionist (aDON/IP/Staff # 43), who stated that the facility does not use enhanced barrier precautions in the facility, and therefore no enhanced barrier precautions signage is outside any room. Staff # 43 stated it was a decision made by everyone because sometimes it is confusing for the staff. Staff # 43 stated the isolation precaution signage that the facility utilizes are only droplet and airborne. Staff # 43 stated the risks of not using appropriate PPE, or displaying transmission-based precaution signage recommended by the CDC, including for enhanced barrier precautions when it is initiated, may result in widespread infection for resident and staff.

An interview was conducted on February 13, 2024 at 11:22 AM with the Director of Nursing (DON/Staff # 94), who confirmed that enhanced barrier signage was not used in the facility. Staff # 94 stated that the facility follows CDC recommendations in regards to infection control as well as their facility policy, however due to verbiage regarding enhanced barrier by CDC it is up to the discretion of the facility whether to be implemented as well as recommendations made by advisors. Staff # 94 stated the risks of transmission-based precaution signage not being followed is possibly carrying out infections to other residents.

On February 14, 2024 at 8:30 AM a list of resident names with G-tube, J-Tube, wounds, colostomy, nephrostomy, catheters, multi-drug-resistant organisms (MDRO) was requested which revealed the following number of residents in the facility within each category: G Tubes/J Tubes: 5 residents; Wounds: 8 residents; Colostomy, Nephrostomy, Catheter: 11 residents; MDRO: 2 residents.

On February 14, 2024 at 9:00-9:30 AM an observation of entire facility consisting of 1st and 2nd floor hallway rooms revealed no PPE or enhanced barrier signage present at any resident room with G Tubes/J Tubes, Wounds, Colostomy, Nephrostomy, Catheter, or MDRO.

An interview was conducted on February 15, 2024 at 11:45 AM with the Executive Administrator (EA/Staff # 450), who confirmed that the entire management team have access to facility policies. Staff # 450 stated she expects policies to be followed and it would not meet facility expectations if staff did not follow enhanced barrier precaution facility policy.

The facility's policy and procedure document titled, "Transmission-based Precautions and Isolation Procedures" (revised September 15, 2023), revealed:

-Standard and transmission-based precautions to be followed to prevent spread of infections.
-Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is
anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities
for transfer of MDROs to staff hands and clothing.

Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of
the following:

-Wounds or indwelling medical devices, regardless of MDRO colonization status
-Infection or colonization with an MDRO
-Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:
-Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
-Wound care: any skin opening requiring a dressing
-When a resident is placed on transmission-based precautions, the staff should implement the following:
-Place type precaution signage to be initiated on the outside of the resident room in a conspicuous place such as door or
on the wall next to the doorway identifying the CDC category or categories of transmission-based precautions (e.g.
contact, droplet, airborne, or enhanced), instructions for use of PPE, and/or instructions to see the nurse before entering.
-Make PPE readily available near the entrance to the resident's room.

Based on staff interviews and review of facility documentation, policy, and procedures, and the State Agency (SA) complaint tracking system, the facility failed to ensure that medical record for one resident (#1) was retained as required by State law.

Findings include:

Review of the SA complaint tracking system revealed that a complaint was submitted by resident #1 on September 30, 2018 at 5:50 p.m.

The facility letter dated January 18, 2024 and signed by the administrator revealed that the facility was using an offsite storage for medical records. It also included that according to State law, any records older than 6 years are then destroyed; and that, the oldest facility documentation retained off-site would be from 2019.

On January 18, 2024, at 12:00pm, an interview was conducted with the administrator (staff #120) who stated the facility transitioned to Electronic Medical Records in 2019; and that, the facility did not store any of the records onsite before the transition.

The facility policy on Document Management revised on March 31, 2023 included that each facility will provide its own records management in accordance with the company record retention schedule. The policy also included that the facility is responsible for monitoring retention of documents maintained by the facility. An inventory review of all retained records should be conducted to identify records due for destruction.

Based on staff interviews and review of facility documentation, policy, and procedures, the state regulation on record retention, and the State Agency (SA) complaint tracking system, the facility failed to ensure that medical record for one resident (#1) was retained as required by State law. The deficient pratice could result in pertinent clinical information not accessible.

Findings include:

Review of the SA complaint tracking system revealed that a complaint was submitted by resident #1 on September 30, 2018 at 5:50 p.m.

The federal regulation stated that medical records must be retained for the period of time required by State law.

The State law in section 36-401 on record retention stated that patient records must be retained for six years after the date of the patient's discharge.

The facility letter dated January 18, 2024 and signed by the administrator revealed that the facility was using an offsite storage for medical records. It also included that according to State law, any records older than 6 years are then destroyed; and that, the oldest facility documentation retained off-site would be from 2019.

Based on the facility letter, the records for resident #1 had been destroyed before the 6 year time frame.

On January 18, 2024, at 12:00 p.m., an interview was conducted with the administrator (staff #120) who stated the facility transitioned to Electronic Medical Records in 2019; and that, the facility did not store any of the records onsite before the transition.

The facility policy on Document Management revised on March 31, 2023 included that each facility will provide its own records management in accordance with the company record retention schedule. The policy also included that the facility is responsible for monitoring retention of documents maintained by the facility. An inventory review of all retained records should be conducted to identify records due for destruction.

Based on observation, record review, and staff interview, the facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and/or staff.

Findings include:

Based on observation, record review, and staff interview on January 23, 2024 revealed the facility Emergency Plan (EP) was not updated with the most current information. The EP book at nurse station 2 had vendor information for the facility fire sprinkler and fire alarm systems which was a company no longer being used.

During the exit conference on January 23, 2024 the above finding was again acknowledged by the management team.

Based on observation the facility failed to maintain two special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on January 23, 2024, revealed the following;

1) the Station 1 Courtyard delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 20 lbf
2) the Station 2 Stairway south wing delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 27 lbf

During the exit conference on January 23, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to keep two out of three commercial laundry room dryers clean from excessive lint accumulation. Failing to insure proper cleaning of the entire inside of the dryer from lint buildup could cause a fire and cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 10 Section 10.4. "Clothes Dryers Section 10.4.5.3 Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

Findings include:

Observations made while on tour on January 23, 2024, revealed two of the three clothes dryers in the laundry room had an excessive amount of lint below the lint screens. The lint accumulation observed was approximately one to two inches thick.

During the exit conference on January 23, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to prevent two (2) ABC type fire extinguishers from being blocked and readily accessible in the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings include:

During a facility tour conducted on January 23, 2024 revealed the following;

1) a portable ABC fire extinguisher located in the kitchen of the facility was being blocked by an unattended tray cart in kitchen dishwashing area
2) a portable ABC fire extinguisher located in the Station 4 Eastside corridor outside room 423, was being blocked by an unattended motorized wheelchair

During the exit conference on January 23, 2024 the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on January 23, 2024, revealed the following;

1) the first floor elevator fire doors failed to latch secure. Both sets of doors were missing a pin which secured the door to the upper frame
2) Station 2 hallway south wing 60 minute rated door for a food storage room, failed to latch secure when tested three of three times. The door and a 1/2 gap on the upper and lower handle side of the door. The door would not stop the travel of heat and smoke
3) room 221 failed to latch secure when tested three of three times


During the exit conference conducted on January 23, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to fill several penetrations of the smoke barriers in the facility. Failing seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and/or staff in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made while on tour on January 23, 2024, revealed the following;

1) Station 2 north wing dayroom had two penetrations in the firewall above the ceiling tiles
2) Second floor oxygen room had two penetrations approximately 2 inch in diameter in the firewall above the ceiling tiles
3) Second floor Activities room had two penetrations 2 inch in diameter in the firewall above the ceiling tiles

During the exit conference on January 23, 2024, the above findings were again acknowledged by the management team.