Cadia Rehabilitation Capitol

Based on interview and record review, it was determined that for two (R30 and R108) out of nine residents sampled for abuse, the facility failed to report an allegation of abuse to the state agency within two hours. Findings include:2. Review of R108's clinical record revealed:
10/26/25 - E7 (CNA) documented in a written statement, On October 25, 2025 .around 11:15 PM I went to check on all my patients. When I got to [R108] she stated that 'the CNA that had her torn her clothes and was rough with her .
10/26/25 11:08 AM - The facility submitted an allegation of staff to resident abuse incident involving R108 to the state agency, greater than two hours after R108's initial report to the facility.
1/23/26 10:19 AM - During an interview E7 (CNA) confirmed the aforementioned written statement and that R108's allegation of abuse was reported to a nurse on 10/25/25.
1/23/26 1:57 PM - During an interview E3 (ADON) confirmed the finding. E3 stated, I found out through reading notes and things that it happened on the 25th but no one made leadership aware.
1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).
The facility policy on abuse last updated 1/9/26 indicated, Allegations of abuse shall be reported to the appropriate state regulatory authority within two hours.
1. A review of R30's clinical record revealed:
1/6/19 – R30 was admitted to the facility.
10/25/25 7:15 PM – R30 reported E4 (CNA) was rough with care.
10/27/25 11:09 AM – The facility reported an allegation of abuse to the State agency.
1/22/25 11:07 AM – During an interview with E3 (DON), it was confirmed that the allegations of abuse must be reported within two hours.
1/22/25 12:00 PM – During an interview with E1 (NHA), it was confirmed that the alleged abuse was not reported within two hours.
The facility failed to report the allegation of abuse to the State Agency within the designated timeframe of two hours.
1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview and record review, it was determined that for one (R5) out of nine residents reviewed for medication administration, the facility failed to ensure that R5 received the correct dose of morphine sulfate for pain when R5 erroneously received 15 mL (milliliter) of the concentrated morphine sulfate oral solution instead of the physician prescribed dose of 0.25 mL on 12/7/25 at 10:58 AM. With this significant medication error, R5 was at risk of a severe, life-threatening respiratory depression or death. R5 was administered Naloxone 0.4 mg/mL intramuscularly two times to reverse R5's overdosage on 12/7/25 at 4:13 PM and 8:02 PM. An immediate Jeopardy (IJ) was identified starting 12/7/25. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non - compliance with an abatement date of 12/11/25. Findings include: A facility policy titled Medication Administration, dated 1/13/26, documented, It is the policy of this facility to ensure that all medications are administered safely, accurately, timely, and in accordance with physician's orders, federal and state regulations . Medication administration shall comply with the Rights of Medication Administration . Definitions . Medication Administration Rights: Right resident, right medication, right dose, right route, right time, right documentation, right reason, right response. Review of R5's clinical record revealed:8/16/19 - R5 was admitted to the facility with diagnoses including but not limited to dementia.9/25/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed that R5's cognition was moderately impaired with a BIMS score of 10 and was receiving opioids (a class of drugs used primarily to treat moderate - to - severe pain).11/21/25 - R5 had a physician's order for 0.25 mL = 5 mg (milligram) morphine sulfate (an opioid concentrate) oral solution every three hours as needed for pain.12/7/25 7:04 AM - R5 had a new physician's order for MS Contin (morphine sulfate) oral tablet extended release 15 mg by mouth two times a day for pain. 12/7/25 4:43 PM - A nurse progress note documented, At about 1530 (3:30 PM) during rounds on (unit), the outgoing nurse called me because 300 mg morphine sol (sic) was given to [R5]. [P1] (facility Medical Director) was called, family was made aware and Hospice was too (sic). [R5] monitor for any changes.12/7/25 7:11 PM - A nurse progress note documented, Late entry at 1520 (3:20 PM) order from [P1] for naloxone (medication used to reverse or reduce the effects of opioids). Naloxone was given at 1613 (4:13 PM). 12/7/25 7:44 PM - A nurse progress note documented, Naloxone HCL (hydrochloride) Injection Solution 0.4 MG/ML Inject 0.4 mg/ml intramuscularly STAT (at once/immediately) for overdose.12/7/25 8:02 PM - A nurse progress noted documented, gave 2nd dose of Naloxone 0.4 mg/ml per [P1].12/7/25 - A written statement by E30 (LPN) documented, On December 7, 2025 at about 0900 am (sic), I made a medication error during my morning medication pass. I administered 15 mL of morphine to a patient [R5] instead of the intended dose of 0.25 mL. The system displayed the ordered dose of morphine 15 mg, while the patient's bottle label stated 0.25 mL. I sought clarification from my supervisor, who confirmed that I should follow the dose listed in the patient's MAR (Medication Administration Record) in the system. Unfortunately, I incorrectly interpreted 15 mg as 15 mL. 12/7/25 - A written statement by E19 (3-11 shift RN Supervisor) documented, During my rounds on (unit) the off going (sic) nurse [E30] called me and she said 'I made a medication error on the narcotic' . I called [P1] and notified her of the error . 12/8/25 9:12 AM - A physician note by P1 documented, I was notified yesterday, 12/7/25 at 3:30 PM by nursing staff that pt (patient) was given 15 ml of liquid morphine by floor nurse at 930 AM 12/7/25. Liquid morphine has concentration of 20 mg/ml so pt was given 300 mg of morphine instead of 5 mg. I was told that the nurse made a mistake. I was told that pt's sleepy but vitals are stable. I requested 0.4 mg Narcan to be administered. I called back at 5 PM and was told that pt's heart rate is dropping, so I ordered another dose of Narcan 0.4 mg. I also advised staff to hold all PO meds until further orders. I called back at 9 PM, and I was told that pt is stable and is resting. I have emailed DON and Administrator today to set up a call to investigate this grave med error and so that we can do a root cause analysis.12/10/25 - A facility follow up report documented that approximately 9:00 AM E30 administered 15 mL of morphine sulfate concentrate to R5 after reading morphine 15 mg 1 tablet on the MAR. During the shift exchange (between 7-3 and 3-11) E30 recognized the error in administration of mL versus mg. The follow up report further documented, [R5] had order for Morphine Sulfate Solution 100 mg/5mL give 0.25 mL every 3 hours as needed. On 12/7 [R5] had new order for MS Contin oral tablet give 15 mg two times a day for pain which was pending delivery from the pharmacy . Upon identification of medication error, [R5] was assessed and monitored. [P1] was notified and order was given for Narcan (Naloxone), which was administered twice. [R5] was placed on alert charting and vital signs, respiratory status and mentation monitored. [P1] gave order to hold medications . 1/22/26 2:20 PM - In an interview, E12 (RN) stated that she was the supervisor on 12/7/25 during the 7-3 shift. E12 stated that on that morning she was doing her rounds and was walking to E30's unit on her way to see another resident. E12 stated she saw E30 who was passing meds. E30 stopped her to ask what to do when a resident's narcotic medication ran low, and whether to administer the last dose of the medication or to hold it. E12 stated that she told E30 to administer the medication as ordered by the physician and to call the doctor and pharmacy for refill. E12 further stated, I did not know what specific narcotic medication she was talking about. I thought it was just a general procedure question that she asked me as I walked past her on my way to another resident's room. At the end of our day shift, I was notified by the incoming nurse that [E30] gave the wrong dose of medication to [R5]. 1/22/26 3:34 PM - During an interview, E16 (LPN) stated that she worked on 12/7/25 and was the incoming and reliving nurse on the 3 - 11 shift. E16 stated that she saw E30 looking at the narcotic book and told her that R5 ran out of the concentrated morphine sulfate. E16 stated that she worked a double shift (7-3 and 3-11) the day before on the same unit with R5 on her assignment and was familiar with R5's morphine sulfate dosage order. E12 further stated, I know [R5] gets 0.25 mL morphine sulfate every three hours when needed for pain. I left my shift at 11:00 PM on 12/6/25, with [R5's] 17.25 mL remaining morphine sulfate concentrate in the bottle. [E30] informed me that she gave 15 mL morphine sulfate concentrate to [R5]. The facility failed to ensure that R5 was free from significant medication administration error when R5 received 15 ml of the concentrated morphine sulfate oral solution instead of the ordered dose of 0.25 ml on 12/7/25 at 10:58 AM. This resulted in a significant medication error for R5 who received 59 more doses of the morphine sulfate solution than the prescribed physician order.1/27/26 10:45 AM - An Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA). During this conference, E1 confirmed that there had been no other incidents of significant medication error after the 12/7/25 incident. 1/22/26 - E1 (NHA) presented to surveyor an acceptable documentation of corrective action plan that was fully abated on 12/11/25. The facility's corrective actions at the time of the incident included:1. Upon discovery of the medication error, R5 was immediately assessed, and physician was notified. New order for Narcan (Naloxone) obtained and administered out of an abundance of caution. R5's responsible party and Hospice were also notified. R5 was placed on alert charting to monitor vital signs and respiratory status. R5 remains in the facility and had no adverse outcomes related to the medication error.2. All residents with orders for liquid morphine have the potential to be affected by this deficient practice. An audit was completed on like residents receiving morphine and no other errors were identified. An audit of like residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified. 3. The facility conducted a root cause analysis, and it was determined that the assigned nurse failed to perform the five rights of medication administration when the nurse misinterpreted 15 mg as 15 ml. Education with licensed nurses was completed on five rights of medication administration. Education was completed on 12/11/25. Medication error was reviewed with medical director at an ad hoc QAPI meeting on 12/10/25. The facility was back in substantial compliance on 12/11/25.4. Director of Nursing will conduct audits of liquid morphine medication administration. The audits will be performed weekly or until 100% compliance is achieved for 3 consecutive weeks. Audits will continue monthly until 100% compliance is achieved for 3 consecutive months. Once 100% compliance is met, the deficient practice will be considered resolved. All audits will be reviewed by the Quality Assurance Performance Improvement Committee.No immediate action required related to past non-compliance. This was verified by review of facility documents and interview with facility staff and residents.1/27/25 5:45 PM - Findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 29 sample residents (Resident (R) 50 had an alternative call light device available when the call light system malfunctioned. The failure created the potential for the resident's care needs to be unmet.
Findings include:
Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R50 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure with hypoxia, and interstitial pulmonary disease.
Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/03/24 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R50 was severely cognitively impaired.
Observation on 12/11/24 at 10:46 AM, R50 had no call light plugged into the wall unit, or a substitute call device available. R50 stated, I haven't had one, the other one broke. When asked how she would call staff for assistance, R50 stated, I don't have anything, just my voice.
During an interview on 12/11/24 at 11:10 AM, the Administrator, Director of Nurses (DON), and nurse consultants (NC1 and NC2) were notified of R50 not having a call bell device. R50 stated to the administrative staff, I guess I could try to yell. The DON looked for the doorbell device in the resident's room, however none was located.
During an interview on 12/11/24 at 11:59 AM, the Administrator identified that the call light system had failed in May 2024. All but two rooms returned to normal functioning. R50 resided in one of the two rooms that did not have a functioning call light system. The Administrator stated, Due to the wiring. [R50's] room could not be fixed. The DON stated, we gave them all a doorbell.
Observation of the two rooms identified not having a functioning electronic call light system, on 12/11/24 at 12:13 PM, revealed three of the four residents (R4, R12, and R14) had doorbell like devices which rang into the hall. R50 had no such device.
On 12/11/24 at 4:30 PM, the Administrator stated, The Certified Nurse Aides (CNAs) know to check on the residents. We will make sure they check for the bell too.
Interview on 12/12/24 at 8:47 AM, CNA3 stated, Yes, we check for the bell. I don't know what happened to it.

Based on record review, interview and policy review, the facility failed to complete a through investigation of an allegation of abuse for one of six residents (Resident (R) 11) reviewed for abuse and neglect out of a total sample of 29. This failed practice had the potential to affect resident safety at the facility.
Findings include:
Review of R11's electronic medical records (EMR) revealed the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24 found under the MDS with an admission date of 03/26/23 and a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated R11 was cognitively intact.
Interview on 12/10/24 at 8:43AM, R11 stated that he has never had any problems with staff at the facility. R11 also stated that no one has ever been rough with him during care, and no one has ever pulled on his testicles.
During an interview on 12/12/24 at 9:30AM, the Director of Nurses (DON) stated that R11 reported on 01/11/24 that while receiving care on 12/25/24, Certified Nurse Aide (CNA)9 was rough with him during care; forcefully pulling on his genitals. The DON stated that CNA9 was suspended pending an investigation. The DON stated that the investigation revealed that the facility could not substantiate R11's allegation due to lack of evidence. The DON stated that the facility interviewed a female resident and no other residents, whether there were any issues with CNA9 being rough during care. The DON was asked if the facility should have interviewed other male residents that CNA9 had provided care to on 12/25/24. The DON stated that other male residents should have been interviewed.
Review of the facility's investigative document revealed that the facility had only interviewed one female resident about how CNA9 had provided care. There was no documentation of interview with other residents especially male residents regarding the care CNA9 provided.
Review of the facility's policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime dated 01/03/24 indicated, .all alleged incidents involving abuse . shall be reported to the NHA [Nursing Home Administrator] or designee immediately. The NHA or designee shall investigate allegations . All persons identified as involved in or with knowledge of the occurrence will be interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure one of 29 residents (Resident (R) 39 reviewed had their call light accessible for use creating the potential for needs not to be met.
Findings include:
Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was initially admitted on [DATE] with diagnoses that included adjustment disorder with depressed mood, congestive heart disease, chronic kidney disease stage three, and gout.
Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/29/24 revealed R39 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R39 was moderately cognitively impaired.
On 12/09/24 at 12:44 PM, R39 was in bed and the call light was underneath his bed.
On 12/09/24 at 1:09 PM, R39 was observed in bed and the call light was underneath the bed. During an interview at the time of the observation. R39 said he did not know where the call light was.
During an observation on 12/11/24 at 8:35 AM, R39 was in bed and the call light was underneath his bed.
During an interview on 12/11/24 at 9:41 AM, Licensed Practical Nurse (LPN1) was asked was R39's call light. LPN1 located the call light under the bed and confirmed that R39 was able to use the call light if it was in reach of his right hand. LPN1 stated, He can't use his call light if it's under the bed, the staff know better than this.
During an interview on 12/11/24 at 10:39 AM, Certified Nurse Aide (CNA3) stated, Yes, I took care of [R39] this morning. I didn't realize the call light was under the bed.
Interview on 12/11/24 at 4:30 PM, R39 demonstrated how he was able to push the call bell with his right hand and stated, I can push it, just my left hand doesn't work.
Interview on 12/12/24 at 9:16 AM, the Director of Nurses (DON) confirmed that the CNAs were to ensure that each resident had their call light accessible to them during and after cares.
Interview on 12/12/24 at 4:00 PM, the Nurse Consultant (NC2) stated, We don't have a policy on call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure two (Residents (R) R71 and R37 ) of six residents reviewed for abuse, were free from resident-to resident abuse for two separate incidents. This had the potential to affect resident safety at the facility.
Findings include:
Review of the facility's abuse policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse .
1. Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's.
Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/09/24 indicated a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicating the resident was severely cognitively impaired. The assessment indicated the resident exhibits physical and verbal behavior toward others.
Review of the Care plan located in the EMR under the Care Plan tab indicated R52 had a tendency to be verbally and physically aggressive to others.
Review of the Progress Note located in the EMR under the Progress Note tab revealed that on 11/25/23, R71 was ambulating in the hallway and began urinating in the floor. R52 walked up to R71 and struck him in the back. The residents were immediately separated.
Review of R71's Face Sheet located in the EMR under the Profile tab in the EMR indicated the resident was admitted to the facility on [DATE] with diagnosis of alcohol abuse, schizophrenia, anxiety, and depression.
Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 09/05/24, indicated the resident had a BIMS score of four out of 15 indicating the resident was severely cognitively impaired.
Review of R71 Care Plan located in the EMR under the Care Plan tab indicated the resident with a behavior of being verbally aggressive.
Review of a facility incident reported 11/25/23 revealed R71 was ambulating in the hall outside of his room and started to urinate on the floor. The nurse attempted to redirect the resident to his room without success. R52 was ambulating in the hall and yelled at R71. R52 walked up to R 71 striking him in the back.
During an interview on 12/12/24 at 10:01 AM, Registered Nurse 2 (RN) stated that both residents can get agitated, but both can be redirected easily.
Interview on 12/12/24 at 12:59 PM, the Director of Nursing (DON) stated the incident was resident to resident abuse.
2. R63 was admitted to the facility on [DATE] with diagnosis of toxic encephalopathy, alcohol abuse, anxiety disorder, depression, and dementia.
Review of the quarterly MDS located under the MDS tab with an ARD of 10/25/24 indicated a BIMS score of nine out of 15 indicating the resident was moderately cognitively impaired. The assessment indicated the resident exhibits verbal behaviors directed at others.
Review of the resident's care plan located under Care Plan tab in the EMR revealed R63 was identified with behaviors of resisting care with use of his walker and wheelchair.
R37 was admitted to the facility on [DATE] with diagnosis of subarachnoid hemorrhage, dementia, depression, and traumatic brain injury.
Review of R37's Annual MDS located under the MDS tab in the EMR indicated a BIMS of four out of 15 indicating the resident was severely cognitively impaired.
Review of the resident's Care Plan located in the EMR under the Care Plan tab indicated the resident exhibited verbal behavior toward others.
Review of the facility's investigation of the incident revealed that on 05/07/24 at 17:00, R63 and R37 were reported to have gone for the same chair at dinner. R63 stated that R37 got smart with him, and he smacked her on the left side of the face. No redness, swelling or any other injury noted. R37 denied having said or done anything to R63.
During an interview on 12/12/24 at 08:59 AM, the DON stated that the incident with R63 slapping R37 was resident to resident abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure an incident of resident-to-resident abuse was reported to the State Agency (SA) within two hours of the incident as required for one residents (R)71) from six residents reviewed for abuse.
Findings include:
Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse .Guidelines .Reporting and Response .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours .
1 Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's.
Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/09/24 indicated a Brief Interview for Mental Status (BIMS) of 0 out of 15 indicating the resident was severely cognitively impaired.
Review of R71's EMR revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of alcohol abuse, schizophrenia, anxiety, and depression.
Review of the quarterly MDS located under the MDS tab with an ARD of 09/05/24 indicated a BIMS score of four out of 15 indicating the resident was severely cognitively impaired.
Review of the facility incident report dated 11/25/23 revealed R71 was ambulating in the hallway outside of his room and started to urinate on the floor. R52 yelled at R71 then walked up to him, striking him in the back.
During an interview on 12/12/24 at 12:59 PM, the Director of Nursing (DON) stated she became aware of the incident when she was reading notes from her home and called to find out what happened. The nurse that was on duty when the incident occurred failed to follow the reporting requirement to notify her of the incident. She stated that she reported the incident to the SA as soon as she was aware, but it should have been reported within two hours of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure one of 29 residents (Resident (R) 29 reviewed had a mattress that fit the bed frame. The failure created the potential for an injury if R29 's feet became tangled in the gap between the mattress and the footboard of the bed.
Findings include:
Review of the admission Record located under the Profile tab in the electronic medical record revealed R29 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction, and disorders of bone density and structure.
Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R29 was cognitively intact.
On 12/10/24 at 11:56 AM, R29 was observed in bed with the head of the bed in an upright position. A large gap, which measured 11 inches from the mattress to the footboard was observed. The footboard was noted to be angled away from the mattress. R29 was asked if she ever slides down, toward the footboard, when in bed and stated, Yes, I have many times when I am put in the bed. When asked if her feet had ever become entangled in the gap, R29 said, Yes.
On 12/11/24 at 10:37 AM, R29 was observed in bed with the head of the bed in an upright position and a six inch gap was noted between the mattress and the footboard.
On 12/11/24 at 11:02 AM, the Administrator, Director of Nurses (DON), and Nurse Consultants (NC1 and NC2) observed the gap between the mattress and the footboard of R29's bed. The DON was asked to measure the gap which was noted to be six inches. R29 stated, My feet have gotten down in the hole before, when I move the bed up. The DON stated, Yes, six inches. We need a bolster.
The Administrator and DON were asked to provide a policy on ensuring resident's mattress fits bed frames. No policy was provided as of the exit, on 12/12/24 at 5:45 PM.

Based on observation, interview, and facility policy review, the facility failed to ensure that beard guards were worn during food production in accordance with professional standards for food service safety and failed to store food in accordance with professional standards for service safety with the potential to affect 109 of 109 residents who consumed food from the kitchen. This failure had the potential for physical contamination of the food in the facility.
Findings include:
1. Review of the facility's policy titled, Dress Code dated August 30, 2017, revealed sanitary food preparation staff must wear: hair net or a disposable hat while on duty. Any employee with facial hair must wear a beard guard.
During observation of the lunch meal preparation on 12/09/24 at 11:45 AM, two male Dietary Aide (DA)2 and DA 3 with beards did not have beard nets covering their beard at the food preparation station.
During observation of the dinner meal preparation on 12/09/24 at 4:45 PM, DA2 and DA3,with beards did not have beard nets covering their beard at the food preparation station.
During observation of the breakfast meal preparation on 12/10/24 at 8:10 AM, DA2 and DA3 with beards did not have beard nets covering their beard at the food preparation station.
During observation of the noon meal preparation on 12/10/24 at 11:30 AM, while accompanied by the Dietary Manager (DM), DA2 and DA3 with beards did not have beard nets covering their beard at the food preparation station.
During an interview on 12/10/2024 at 11:40 AM, the Food Service Director (FSD) stated that staff with beards must wear a beard net to cover their beard. I did not observe the two male kitchen staff members not wearing beard nets until I observed them today.
During an interview on 12/10/24 at 1:25 PM, the Dietary Aide (DA) 2 stated, Yes, I know that I must wear a beard guard when I'm in the kitchen. I just forgot.
During an interview on 12/10/24 at 1:30 PM, the Dietary Aide (DA) 3 stated, Yes, I know that I must wear a beard guard when I'm in the kitchen. I just forgot.
2. During the observation of the main refrigerator on 12/09/24 at 09:30 AM, while accompanied by the FSD the following food items were expired or had no current dates after being used:
Cardboard box with black substance on the right side of the outside of the cardboard box. Inside the cardboard were two 64 oz containers of potato salad that were split open. Outside the cardboard box was a dated 08/28/24.
One gallon size plastic container of Thousand Island salad dressing was dated 08/28/24.
Twenty peeled, hard-boiled eggs were wrapped individually in plastic wrap without a date.
One 64-ounce grape jelly glass jar with half a jar remaining contained no date.
Chicken salad in a 64-ounce metal container was half full and undated.
3. During the observation of the main freezer on 12/09/24 at 10:30 AM, while accompanied by the FSD the following food items that were expired or had no current dates after being used:
An open cardboard box revealed an open plastic bag of 32 frozen chicken cutlets with no date.
Open cardboard box revealed an open plastic bag of 40 frozen hamburger patties with no date.
During an interview on 12/09/2024 at 10:55 AM, the FSD stated that the weekend kitchen staff are supposed to check and throw out food items that are out of date.

Based on interview, record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents the facility failed to provide adequate supervision to prevent an accident. R1, a totally dependent resident was rolled out of bed when a staff person lost grip on R1 during care. R1 rolled from the bed and fell three (3) feet to the floor sustaining a laceration to the head and was emergently transported to the hospital, this resulted in harm to R1.
6/6/17 - R1 was admitted to the facility with diagnoses of but not limited to unspecified dementia (a brain disorder with memory loss), sarcoidosis (an inflammatory disease) and aphasia (neurological condition affecting language).
5/20/24 - An annual MDS documented R1 as totally dependent for self-care, bed mobility and was severely impaired cognition.
6/3/24 - R1's care plan included that the resident was at risk of falls and interventions included: anticipate and meet the resident's needs.
6/1/24 - 6/12/24 - A review of CNA documentation revealed R1 was totally dependent on staff for self-care and mobility.
6/12/24 10:23 PM - A progress note documented, R1 was emergently transferred to the hospital and admitted to Neuro ICU with hourly neuro checks from an acute subdural hemorrhage.
6/13/24 at 1:21 AM - A progress note by E5 (LPN) documented, 6/12/24 9:20 PM This nurse was notified by CNA that resident fell out of bed while giving her a bed bath. Noticed resident lying supine on the floor with blood smeared on the roommate's bed frame and the floor under the bed. Resident noted with moderate amount of blood at the back of head on the floor. Unable to move or assessed where laceration is located at the back of her head, due to the possibility of neck or head injury. Resident is fully conscious, vital signs and neuro check within normal level. No rotation or shortening noted. Skin remains intact. T97.9 P75 R20 B/P 134/52.
7/12/24 11:36 AM - During an interview with the E6 (CNA) it was revealed that R1 was totally dependent for care and that personal care hygiene (bath) was being provided to R1 when the accident occurred. E6 stated that E6 was cleaning R1 with right hand and holding R1 with left hand, when rolling R1 away from her, E6 lost grip on R1 and R1 rolled off the bed and onto the floor. E6 stated that it was an accident, R1 was responding, R1's eyes were open and E6 asked R1 if she was okay R1 responded yes, E6 went to get the nurse and returned to R1. E6 further revealed that R1 was bleeding when E6 returned to the room. E6 stayed with R1 and talked with R1 until the ambulance arrived. R1 remained conscious while at the facility.
7/12/24 approximately 2:30 PM - In an interview with E2 (DON) and E3 (CNO) it was revealed that the facility recognized the seriousness of the 6/12/24 accident. The state agency was provided with the facility investigation, root cause analysis, a facility wide sweep to identify other residents that might be affected by the deficient practice, education, who completed the education, a plan to address staff who were PRN or on leave and audits that were in place for monitoring. After reviewing documents, completing staff interviews and current observations, it was determined that the facility regained compliance on 6/14/24 and past non-compliance was recommended by the state agency.
7/16/24 3:00 PM - Findings were reviewed with E1, E2, E3 (CNO), E10 (COO), E11 (Corporate Nurse) and E12 (Corporate Nurse).
7/17/24 4:30 PM - An observation and visit with R1 revealed that she had returned to baseline and continues to be totally dependent.

Based on observation and document review, it was determined that the facility failed to ensure safe sanitary storage of food, maintain food preparation equipment and kitchen area in a sanitary condition, and maintain food temperature logs. Findings include:
10/30/23 9:53 AM - A build up of dried food residue was discovered around the cutting surface of the stationary can opener.
10/30/23 10:03 AM - The ice scoop was stored on top of the ice inside of the ice machine and a tomato based frozen entrée was discovered with a large portion of the foil lid peeled back exposing the frozen food to contamination from dirt and other debris.
10/30/23 10:15 AM - Significant amounts of dust and other debris were noted inside and suspended from the openings in the air vents located in the kitchen ceiling.
10/30/23 11:57 AM - During a review of the food temperature logs, forty-three (43) meals out of two hundred seventy-six (276) reviewed for temperatures had no temperatures recorded. Temperatures of cooked foods and cold ready to eat foods were not being consistently recorded prior to being served. Fish, meat, and poultry must be heated to an appropriate specific temperature depending on the type of food and the method used to prepare it. Vegetables must be heated to one hundred thirty-five (135) degrees Fahrenheit (F), and cold ready to eat foods must be held below forty-one (41) degrees (F) to maintain food safety.
10/30/23 12:16 PM - The temperature in the nourishment refrigerator on the Magnolia wing was noted to be 46 degrees Fahrenheit (F).
10/30/23 11:45 PM - Findings were confirmed with E8 (Director of Dining Services).
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on interview, record review and review of other facility documentation, it was determined that the facility failed to ensure, in accordance with professional standards and practices, that medical records for one (R66) out of twenty nine (29) of the investigative sampled residents were accurate. Findings include:
Review of R66's clinical record revealed:
2/8/21 - R66 was admitted to the facility with left-sided hemiplegia due to a stroke.
7/22/23 - The annual MDS assessment documented R66 was cognitively intact with an impairment on one side for the upper extremities and the lower extremities for her functional range of motion. The MDS also documented R66 required extensive assistance of one staff for dressing.
9/28/23 - An active Physician's order for R66 for a left modified resting hand splint.
10/25/23 - R66's care plan documented the potential for contractures from decreased functional mobility. The interventions for the R66 included to use a left modified resting hand splint.
Observations made of R66 without left resting splint on for 10/30/23, 10/31/23, 11/1/23 and 11/2/23.
A review of the CNA documentation task records revealed the task for the left resting hand splint was being marked as Done for 10/30/23, 10/31/23, 11/1/23 and 11/2/23.
11/3/23 9:20 AM - During an interview, E13 (UM) confirmed the splint was being signed off as completed even though the splint was not placed on R66.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on document review, it was determined that the facility failed to have acceptable measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens. Findings include:
11/6/23 9:22 AM- Document review revealed that the facility did not have a comprehensive water management plan based on nationally accepted standards (e.g., ASHRAE, CDC, or EPA), including a flow diagram with narrative text depicting areas where Legionella and other opportunistic waterborne pathogens could grow and spread, facility specific measures to prevent the growth of opportunistic waterborne pathogens in the building's water system, methods the facility uses to monitor the prevention measures that are in place, and established steps to intervene when control limits are not met.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on record review and interview, it was determined that for one (E18) out of twelve staff being sampled for abuse training, the facility failed to ensure that E18 received the annual abuse training. Findings include:
11/2/23 1:54 PM - Surveyor requested that E1 (NHA) and E3 (CNO) complete the Annual Training/Vaccination Form.
11/3/23 untimed - Results received and reviewed by surveyor.
11/3/23 12:45 PM - In an interview, E3 stated that E18 (COTA) was a transfer from another facility. Her last training had occurred in August 2022 and, as such, is overdue for 2023.
11/3/23 approximately 3:00 PM - E3 provided updated abuse training documentation, which was completed by E18 on 11/3/23.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation and interview, it was determined that for one (R90) out of two residents reviewed for dignity, the facility failed to ensure care was provided in a way that promoted dignity and respect. Findings include:
7/1/22 - R90 was admitted to the facility with degenerative disease of the back.
11/1/23 11:04 AM - During an observation R90 was ambulating in the front hallway of the facility, by the lobby, with E25 (PTA) wearing a night shirt and no pants. R90's upper thighs and incontinence brief was visible to residents, staff and visitors.
11/1/23 11:06 AM - During an interview, E25 (PTA) confirmed that R90's night shirt was bunched up at the waist, and private parts of her body could be seen by others.
11/1/23 11:28 AM - During an interview, E14 (OT) confirmed that she was aware that residents should be appropriately dressed for therapy. E- stated that it would be undignified for a resident to ambulate in the hallway with an ill-fitting night shirt exposing their thighs and brief. E14 stated that she and would have noticed and ensured that the resident was appropriately covered.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on record review and interview, it was determined that for two (R98 and R417) out of twenty-nine residents reviewed for resident assessment, the facility failed to accurately complete MDS assessments to reflect resident status. Findings include:
1. Review of R98's clinical record revealed:
5/9/23 - R98 was readmitted to the facility with dementia.
5/10/23 1:00 AM - A provider progress note documented that R98 was, referred from home to Cadia for LTC (long term care) due to progressive dementia.
5/11/23 - R98's care plan included that R98 had impaired cognitive function or impaired thought process related to dementia.
5/17/23 - R98's admission MDS assessment did not include R98's diagnosis of dementia.
5/31/23 12:42 PM - A psychiatric progress note documented that R98 had a diagnosis of dementia with behavioral disturbances.
8/15/23 1:00 AM - A provider progress note documented a history of dementia.
8/17/23 - R98's quarterly MDS assessment did not include R98's diagnosis of dementia.
11/7/23 10:44 AM - During an interview, E26 (RNAC) confirmed that R98's admission and quarterly MDS assessments failed to include R98's MDS diagnosis of dementia.
2. Review of R417's clinical record revealed:
7/30/22 - R417 was admitted to the facility after a stroke affecting his left side.
8/5/22 - R417's MDS assessment documented that R417 did not have any pressure ulcers.
8/12/22 12:17 PM - A nursing progress note documented that R417 had 2 new open areas to his buttocks.
8/13/22 3:11 PM - A nursing progress note documented that R417 has a open stage 2 wound on outer left ankle.
8/17/22 - R417's discharge MDS assessment documented that R417 had one stage 2 pressure ulcer that was present on admission and one unstageable pressure ulcer present on admission. R417 did not have any pressure ulcers on admission. Review of R417's clinical record was not consistent with the MDS data.
11/7/23 1:30 PM - During an interview, E3 (CNO) confirmed the R417's 8/17/22 MDS assessment was inaccurate based on the the initial 8/5/22 admission assessment.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

4. Review of R74's clinical record revealed:
10/15/20 - R74's preadmission PASARR documented that R74 was exempt for a level II PASARR.
1/15/21 - R74 was admitted to the facility including, but not limited to a diagnosis of dementia.
8/21/22 - R74 had a new diagnosis of persistent mood (affective) disorder.
8/23/22 - R74 had a new diagnosis of post-traumatic stress disorder.
11/2/23 9:53 AM - During an interview, E7 (SW) confirmed that R74 only had one PASARR completed three months prior to his 1/15/21 admission, and had not been referred to [State PASARR contractor] for any further review with his new diagnoses. E7 stated that she would submit another level 1 PASARR to [State PASARR contractor] for further review with his new diagnoses.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.
3. Review of R38's clinical record revealed the following:
2/3/16 - R38 was admitted to the facility.
9/26/17 - A PASARR Level I Screen was completed, which stated, Individual does not require additional evaluation due to the following determination and needs can be met at a NF (nursing facility): The individual does have a documented serious mental illness . and the individual needs can be met in a NF without further evaluation .
10/30/23 2:20 PM - A review of R38's diagnoses in his clinical record revealed the following diagnoses were added on 12/1/22: adjustment disorder with depressed mood; major depressive disorder, recurrent, severe with psychotic symptoms; anxiety disorder, unspecified; delusional disorders; suicidal ideations; persistent mood (affective) disorder, unspecified.
11/1/23 1:58 PM - During an interview, E7 (SW) stated the State PASARR contractor will tell the facility that an updated PASARR Level II was not needed, but she would check. She provided a list of residents currently being considered for a PASARR Level II and R38's name was not included.
11/3/23 approximately 1:50 PM - E3 (CNO) provided a report dated 11/3/23 from the State PASARR contractor confirming that a PASARR Level II was needed for R38.
11/8/23 9:00 AM - During an interview, E3 and E2 (DON) confirmed additional mental health diagnoses had been added to R38's diagnoses, but no PASARR Level II was completed. They confirmed that E7 will coordinate the PASARR Level II evaluation for a representative to meet with R38 to conduct a face-to-face PASARR Level II evaluation.
11/8/23 2:42 PM - E3 advised the survey team that the PASARR team coming on 11/9/23 to evaluate the four residents who need a level II PASARR.
Based on interview and record review, it was determined that for four (R30, R38, R40 and R74) out of five residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include:
1. Review of R30's clinical record revealed:
3/7/18 - R30 was admitted to the facility.
3/6/18 - A review of R30's medical record revealed that R30 had a PASARR level I that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time.
9/17/18 - A review of R30's medical record revealed that R30 had a PASARR level I.5 that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time.
9/7/22 - A review of R30's medical record revealed that R30 has the following new diagnoses: major depressive disorder, delusional disorder, hallucinations, and adjustment disorder with depressed mood.
11/1/23 1:58 PM - An interview with E7 (social worker) confirmed that a PASARR level II was never requested for R30.
11/7/23 8:40 AM - An email correspondence with, S3 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1.5 (Notice Date 9/7/18) was not an accurate reflection of (R30) mental health status and new diagnoses.
2. Review of R40's clinical record revealed:
2/7/17 - R40 was admitted to the facility.
5/19/17 - A review of R40's medical record revealed that R40 had a PASARR level I that indicated R40 had a documented serious mental illness (bipolar, major depressive disorder, and anxiety) and demonstrated a full level II was not indicated at that time.
10/1/22 - A review of R40's medical record revealed that R40 had the following new diagnoses: adjustment disorder with depressed mood, dementia with agitation, delerium, and delusional disorder.
5/14/23 - A review of R40's MDS revealed anxiety, bipolar, depression, psychotic disorder, and non-alzheimer's dementia were documented.
11/1/23 1:58 PM - An interview with E7 (social worker) confirmed that a PASARR level II was never requested for R40 when new diagnoses were identified.
11/7/23 8:40 AM - An email correspondence with, S3 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1 (Notice Date 5/19/17) was not an accurate reflection of (R40) mental health status and new diagnoses.

3. Review of R89's clinical record revealed:
4/13/22 - R89 was admitted to the facility.
4/11/23 1:32 PM - R89's weight was documented as 172.8 pounds.
8/24/23 - R89's significant change MDS assessment documented a significant weight loss of 5% in one month or 10% loss in six months, and was not on MD (doctor) prescribed weight loss program.
10/12/23 11:56 AM - A quarterly nutrition assessment documented, Decline in overall meal intakes and unplanned weight loss noted this review period.
10/23/23 11:18 AM - R89's weight was documented as 158.2 pounds (an 8.45 % weight loss since 4/11/23).
11/02/23 2:18 PM - During an interview, E22 (RD) confirmed that although R89 had a significant weight loss, R89's nutrition care plan was not initiated until 10/30/23. E22 stated that it fell through the cracks.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference
2. Review of R514's clinical record revealed:
7/6/23 - R514 was admitted to the facility with a diagnosis of COPD.
Review of R514's physician orders revealed:
Respiratory inhaler for COPD.
11/1/23 10:52 AM - An interview with R514 confirmed the use of a respiratory inhaler.
11/1/23 11:11 AM - During an interview, E10 (LPN) confirmed that R514 was administered his respiratory inhaler every morning.
11/1/23 11:14 AM - During an interview, E11 (RN,UM) confirmed that R514 had a diagnosis of COPD and physician orders for respiratory interventions.
A record review lacked evidence of a person-centered care plan for R514's respiratory status that included interventions for COPD.
Based on interview and record review, it was determined that for three (3) (R40, R89, and R514) out of twenty nine residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plan for an identified need. Findings include:
1. Review of R40's clinical record revealed:
2/7/17 - R40 was admitted to the facility.
2/26/21 - A comprehensive care plan was initiated for R40's verbally aggressive behavior with the following interventions: allow 10-15 minutes to calm down then reapproach; explain all procedures; and identify triggers that cause outbursts.
10/1/22 - A review of R40's medical diagnoses revealed a diagnosis of dementia unspecified severity with agitation.
5/14/23 - A review of R40's MDS revealed that R40 had a diagnosis of non-alzheimers dementia.
11/1/23 10:25 AM - A review of R40's progress notes revealed R40 was receiving services from psychology related to dementia and bipolar disorder.
11/3/23 2:03 PM - An interview with E21(LPN) revealed that care and interventions are based on a care plan and if a resident does not have one to notify the unit manager to update.
11/3/23 2:12 PM - An interview with E13 (LPN UM) confirmed that R40 did not have a comprehensive person centered care plan related to dementia.

Based on interview and record review, it was determined that for four (R7, R20, R56, and R87) out of twenty-nine residents reviewed for care plans, the facility failed to ensure the care plan was revised to reflect current care needs. For R7 and R20, the facility failed to have the required members present for the IDT (interdisciplinary team) meeting. Findings include:
1. Review of R56's clinical record revealed the following:
11/22/21 - R56 was admitted to the facility.
A care plan for R56 was documented for having a potential/actual impairment impaired mobility with a goal of [R56] will have no complications r/t (related to) DTI (deep tissue injury of the second tow through the review date was initiated on 9/29/22 and revised on 10/21/22.
6/12/23 at 2:52 PM - A nurse's note revealed the following: Resident was noted to have an open area on left foot second toe. Measurement 1.50cm X 0.6cm. Area was measured, dressed and NP and unit manager was informed.
7/24/23 - Bilateral arterial duplex scans completed and revealed no doppler flow detected in left posterior tibialis artery and right dorsalis pedis artery.
8/1/23 - E17 (NP) note for wound assessment documented a wound to the right second toe on the right leg.
10/30/23 9:59 AM - During an interview, R56 stated he has a wound on my toe and it has to be amputated.
11/7/23 12:18 PM - Interview with E3 (CNO) at which time the care plan was reviewed with him. Although the care plan problem was revised on 10/13/23, it refers to a DTI (deep tissue injury) and not an arterial wound. It also did not address R56's current situation. E3 stated he will ensure that the care plan is updated.
The facility's policy on Care Planning revision date 1/12/2023 documented,A comprehensive care plan must be prepared by an interdisciplinary team, that includes .
- The attending physician;
- A nurse with responsibility for the resident;
- A nurse aide with responsibility for the resident;
- A member f the food and nutrition services staff;
- To the extent practicable, the participation of the resident and the resident's representative;
- Other appropriate staff as determined by the resident's needs or as requested by the resident.
3. Review of R7's clinical record revealed:
7/6/23 - R7 was admitted to the facility.
7/22/23 3:27 PM - A review of R7's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present.
11/2/23 2:08 PM - A review of R7's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present.
4. Review of R20's clinical record revealed:
6/12/23 - R20 was admitted to the facility.
6/22/23 10:53 AM - A review of R20's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present.
9/19/23 1:46 PM - A review of R20's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present.
11/7/23 11:18 AM - During an interview, E7 (SW) confirmed there was no physician or their designee in attendance at the meetings. E7 stated they never attend the meetings, I didn't think they had to. E7 also confirmed there wasn't a CNA in attendance at any of the meetings.
11/7/23 12:33 PM - During an interview, E3 (CNO) confirmed that neither the physician, designee or CNA attended or provided input at the meetings.
The facility lacked evidence that the post-admission care plan conference meetings included Physician input and CNA input with responsibility for the resident.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 and E4 (COO) during the exit conference.
2. Review of R87's clinical record revealed:
3/7/22 - R87 was admitted to the facility.
3/14/22 - A careplan for R87 was initiated for ADL self care performance deficit related to limited mobility.
12/8/22 - A physicians order was written for R87 to get out of bed for lunch daily.
11/2/23 9:17 AM - A review of R87's care plan revealed that current interventions did not include R87 to get out of bed for lunch daily.
11/7/23 10:42 AM - An interview with E15 (CNA) confirmed that the CNA task sheet and care plan did not include R87's intervention of getting out of bed daily for lunch.
The facility failed to update R87's careplan to reflect the current needs of R87.

Based on observation, interview and record review, it was determined that for one, (R7), out of three residents reviewed for (ADLs) for activities of daily living, the facility failed to ensure that residents who are unable to carry out ADLs received the necessary services to maintain good grooming. Findings include:
1. 4/3/23 - R7 was admitted to the facility following a stroke.
4/8/23 - An admission MDS documented R7 as needing one person extensive assistance with grooming.
10/30/23 approximately 10:00 AM - During an observation and subsequent interview, R7's fingernails were long and he was unshaven. R7 stated that he would like to have his finger nails trimmed and to be shaved.
11/2/23 1:06 PM - During an interview, at R7's bedside E12 (CNA) confirmed that finger nails on both hands were long and R7 would like them trimmed. E12 stated, I'll trim them, and I'll shave him. E12 also confirmed that grooming was part of providing care.
11/2/23 through 11/6/23 - Multiple observations of R7 revealed that his finger nails had not been trimmed and he was unshaven.
11/6/23 1:15 PM - During an observation R7's finger nails were not trimmed and he was still unshaven, a follow up interview R7 revealed he still wanted to have his finger nails trimmed and to be shaved.
11/6/23 1:23 PM - During an interview, E11 (RN, UM) confirmed that R7's nails had not been trimmed and still remained unshaven. E11 stated that he would, take care of it.
11/7/23 2:55 PM - Observation of R7 revealed his finger nails were trimmed but was still unshaven.
Despite shaving being a part of providing grooming to a resident, R7 was not shaved.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on interview and record review, it was determined that, for one (R87) out of one resident sampled for activities, the facility failed to ensure that R76 was provided their activity of interest. Findings include:
Review of R87's clinical record revealed:
3/7/22 - R87 was admitted to the facility.
3/11/22 - A review of R87's care plan revealed that R87 preferred to have little involvement with activities and chooses not to participate.
11/7/23 10:31 AM - An interview with R87 revealed that R87 wants to participate in bingo when available and wishes to get out of bed to attend this activity.
11/8/23 9:27 AM - A review of R87's activity task log dated 10/24/23 to 11/18/23, revealed R87 attended one bingo out of four bingo activities offered.
11/8/23 9:41 AM - An interview with E20 (Activities Director) confirmed that R87 attended one bingo activity out of four offered in the last sixteen days. E20 confirmed activities were offered but staff are not getting R87 out of bed to attend activities.
The facility failed to provide R87 with activity of choice.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation, interview and record review, it was determined that for two (R58 and R87) out of twenty-nine (29) residents reviewed for quality of care, the facility failed to follow physician orders. Findings include:
1. Review of R58's clinical record revealed:
8/8/22 - R58 was admitted to the facility with dementia.
9/15/23 12:29 AM - A nursing progress note documented, Resident [R58] in roommate's bed hitting him, trying to make him get out of his bed. Staff attempted to redirect resident to his bed, however, resident punched and kicked staff.
9/15/23 11:24 AM - A Physician order included: Resident (R58) placed on 1:1 (one to one) supervision.
11/1/23 3:35 PM - During an interview E3 (CNO) confirmed the facility lacked evidence of one-to-one supervision implemented following a resident-to-resident altercation.
2. Review of R87's clinical record revealed:
3/7/22 - R87 was admitted to the facility.
12/8/22 - A physician's order was written for R87 to get out of bed daily at lunch time.
5/31/23 - A quarterly MDS revealed that R87 is totally dependent for transfer with hoyer lift.
11/01/23 12:38 PM - An observation of R87 in bed during lunch.
11/02/23 12:22 PM - An observation of R87 in bed during lunch.
11/07/23 10:42 AM - An interview with E15 (CNA) revealed that the CNA flow sheet did not reflect the physician's order to get R87 out of bed for lunch daily and confirmed that the CNA's were not aware of this order.
11/07/23 10:52 AM - An interview with E16 (UM) confirmed that nurses will transcribe orders into the electronic records and update the CNA flow sheets to reflect new orders.
The facility lacked evidence of following a physician's order for R87 to get out of bed daily for lunch.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R66) of four residents reviewed for ROM/mobility, the facility failed to provide appropriate services, equipment, and assistance to maintain function/mobility. Findings include:
Review of R66's clinical record revealed:
2/8/21 - R66 was admitted to the facility with left sided hemiplegia due to a stroke.
7/22/23 - The annual MDS assessment documented R66 cognitively intact with an impairment on one side for the upper extremities and the lower extremities for her functional range of motion. The MDS also documented R66 required extensive assistance of one staff for dressing.
9/28/23 - An active Physician's order for R66 for a left modified resting hand splint.
10/25/23 - R66's care plan documented the potential for contractures from decreased functional mobility. The interventions for the R66 included to use a left modified resting hand splint.
10/30/23 1:52 PM - During an interview, R66 stated she did not have her splint on yet today and it usually gets put on in the morning and stays on for 7 to 8 hours. She stated she can take the split off herself but is not able to put it on herself. The splint was observed in her lower side table drawer.
Observations made of R66 without left resting splint on for 10/30/23, 10/31/23, 11/1/23 and 11/2/23.
11/3/23 9:16 AM - During an interview, E15 (CNA) stated that the day shift (7 am to 3 pm) puts the splint on and the evening shift (3 pm to 11 pm) will remove the splint.
11/3/23 9:20 AM - During an interview with R66 and E13 (UM), R66 stated, I have not had my splint on anytime this week. E13 confirmed R66 did not have her splint on and stated she will look into this.
11/3/23 10:45 AM - During an interview E14 (OT) stated the splint was used to keep R66's hand from getting in the clenched position.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on record review and interview, it was determined that for one (R58) out of six residents reviewed for unnecessary medications, the facility lacked evidence of a gradual dose reduction (GDR) and qualifying diagnosis for R58's physician prescribed antidepressant. Findings include:
A facility policy (effective 6/23, last revised 4/29/21 and reviewed on 1/20/23) documented, It is the policy of Cadia Healthcare that residents receive only those psychoactive medications, in the doses and the duration that is clinically necessary to treat the resident's condition.
1. Review of R58's clinical record revealed:
8/8/22 - R58 was admitted to the facility with dementia.
7/19/23 - A pharmacy recommendation to the Physician documented, This resident [R58] is receiving therapy with Trazadone 50 mg QHS (an antidepressant at bedtime) for insomnia since 11/11/22. Federal guidelines require periodic dose reduction trials in an attempt to minimize or discontinue medications that are unnecessary. Please consider a trial dose reduction. The Physician response was to decrease the medication.
7/26/23 - A Physician's order included to decrease R58's Trazadone to 25 mg at bedtime for insomnia.
11/02/23 12:34 PM During an interview E3 (CNO) confirmed R58 did not have a GDR attempt for his Trazadone from 11/11/22 to 7/17/23 as noted in the pharmacy review.
2. Review of R58's clinical record revealed:
11/11/22 - R58 had a Physician's order for Trazadone 50 mg at bedtime for insomnia.
9/27/23 11:45 PM - A psychiatric progress note documented, Chief Complaint: staff reports increased anxiety and agitation . consider increasing Trazadone if behavior persists. While the medication was ordered for insomnia, this note reflects that it is being used for anxiety, agitation and/or behaviors.
11/1/23 1:35 PM - During an interview, E24 (RN, UM) stated that R58 was receiving Trazadone for his behaviors and rarely has insomnia since his room was changed.
11/1/23 2:54 PM - During a phone interview E23 (PNP) confirmed R58's order identified insomnia as the diagnosis for R58's prescribed Trazadone. E23 stated, The diagnosis for the prescribed Trazadone should be anxiety and agitation with behavioral disturbance. You can use it for insomnia, but it is definitely for his agitation.
11/1/23 3:35 PM - During an interview, E1 (NHA), E2 (DON) and E3 (CNO) confirmed the discrepancies in diagnoses for R58's Trazadone.
The facility failed to identify the specific condition for R58's prescribed Trazadone.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on interview and record review, it was determined that for one (R56) out of one sampled resident for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include:
A facility policy titled, Dental Services Available to Residents last revised on 1/20/23 states, as follows: It is the policy of Cadia Healthcare to ensure that residents have access to contracted Dental Services . Dental Services are coordinated for each resident as needed and requested and include routine and emergent dental care.
Review of R56's clinical record revealed the following:
11/22/21 - R56 was admitted to the facility.
11/25/21 - The admission MDS assessment documented that R56 had no natural teeth or tooth fragment(s) (edentulous).
11/29/21 - A dental care plan was revised, as follows, [R56] has potential for oral health problems r/t being edentulous (without teeth), poor nutrition, poor oral hygiene Coordinate arrangements for dental care, transportation as needed/as ordered.
10/30/23 9:51 AM - During an interview, R56 stated he was without dentures. He stated that he had them at home, but they are now gone because his house and belongings were sold. He stated he has tried to make a dental appointment, but nothing happened.
11/1/23 untimed - Surveyor requested R56's dental reports.
11/1/23 at approximately 12:00 PM - E3 (CNO) advised that there were no dental reports for R56.
11/2/23 at approximately 9:13 AM - During an interview, E7 (SW) stated she contacts a dental contractor to schedule appointments based on recommendations from the provider. She does not assess the residents and relies on nursing/providers to tell her which residents need to be seen. E7 stated she is not aware of any dental complaints by this resident.
11/7/23 9:35 AM - During an interview, E3 confirmed that residents within the facility have not been offered an annual dental assessment. E3 stated he will make changes to ensure residents are offered a dental exam annually and that their responses are documented.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R34) out of three residents reviewed for food preferences, the facility failed to accommodate R34's food preferences or choices. Findings include:
Review of R34's clinical record revealed:
7/7/23 - R34 was admitted to the facility with stroke and multiple sclerosis.
10/12/23 - A quarterly MDS documented R34 had a BIMS score of 14/15, revealing an intact cognitive state.
10/30/23 10:47 AM - During an interview, R34 stated she did not have her menu brought up to make her food choices for this current week. She did not get her menu choices for 10/29/23 and she was served whatever option the kitchen had put on her tray for the day. She said she had spoke to E8 (Food Service Director) about it.
11/3/23 1:17 PM - During an interview, E8 confirmed the menus go from Sunday to Saturday. The menu for the next week is brought up to residents on Thursdays so the residents can make their choices. R34 needs assistance where a dietary aide will circle her choices for her at the bedside. E also confirmed if a menu gets missed then they will bring it the next day.
11/3/23 1:42 PM - During an interview with R34, E8 and E9 (dietary aide), E9 stated she completed the menu choices for R34 on 10/31/23. R34 denied having her menu choices taking by E9.
Observations for breakfast and lunch meals for R34 on 10/30/23, 10/31/23, 11/1/23 and 11/2/23 were meals the resident did not choose from a provided menu.
R34 did not have her food menu choices for 15 of 21 meals served for the menu week 10/29/23 to 11/4/23.
The facility lacked evidence of the resident receiving her menu choices for the meals provided from 10/29/23 to 11/2/23.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for four (R5, R39, R40 and R66) out of six sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include:
A facility policy and procedure titled, Dental Services Available to Residents, with last reviewed of 1/20/23, documented, Routine dental care includes, but is not limited to, initial evaluation of the resident's dental needs; consultation with the resident, family, responsible party, staff, guardian and dental consultant as needed.
A facility policy titled, Dental Services Available to Residents last revised on 1/20/23 documented, It is the policy of Cadia Healthcare to ensure that residents have access to contracted Dental Services . Dental Services are coordinated for each resident as needed and requested and include routine and emergent dental care.
1. Review of R5's clinical record revealed the following:
3/30/22 - R5 was admitted to the facility.
3/30/22 - The admission MDS assessment documented that R5 had obvious or likely cavity or broken natural teeth.
8/2/22 - A dental care plan was revised, as follows, [R5] has p/f (potential for) oral/dental health problems - [R5] has 2 teeth on the bottom/ broken/carious teeth noted Coordinate arrangements for dental care, transportation as needed/as ordered.
10/30/23 11:09 AM - In an interview, R5 stated she needs dentures.
10/31/23 3:07 PM - After surveyor requested R5's dental visit records, in an interview, E3 (CNO) confirmed there were no such records for this resident.
11/2/23 at approximately 9:13 AM - During an interview, E7 (SW) stated she contacts a dental contractor to schedule dental appointments based on recommendations from the provider. She does not assess the residents and relies on nursing/providers to tell her which residents need to be seen.
11/7/23 9:35 AM - During an interview, E3 confirmed that residents have not been offered an annual assessment. He stated he will make changes to ensure residents are offered a dental exam annually and that their responses are documented.
2. Review of R39's clinical record revealed the following:
12/14/17 - R39 was admitted to the facility.
12/20/17 - The admission MDS assessment documented that R39 had no natural teeth or tooth fragment(s) (edentulous).
9/23/20 - A dental care plan was initiated and revised, as follows, P/F (potential for) alteration in oral/dental status [R39] is edentulous and has upper and lower dentures. Coordinate arrangements for dental care, transportation as needed/as ordered.
3/16/21 - A Dental Exam and Treatment/Exam revealed the following, Visit for denture try on. Went in to try on patient's denture wax set up and patient stated he had found his dentures. F/S discontinue denture 'c__se' (writing not legible).
Review of R39's clinical record did not reveal any additional dental visits.
10/30/23 9:30 AM - In an interview, R39 stated that his dentures do not fit well. R39 stated he does not know if he can see dentist and that the last time that he saw one was eight years ago, prior to coming to the facility. R39 does not think anyone has asked if he wants to see a dentist.
11/2/23 at approximately 9:13 AM - During an interview, E7 (SW) stated she contacts the dental contractor to schedule dental appointments based on recommendations from the provider. She does not assess the residents and relies on nursing/providers to tell her which residents need to be seen.
11/7/23 9:35 AM - During an interview, E3 confirmed that residents have not been offered an annual dental assessment. He stated he will make changes to ensure residents are offered a dental exam annually and that their responses are documented.
3. Review of R40's clinical record revealed:
2/7/17 - R40 was admitted to the facility.
8/14/23 - A quarterly MDS revealed R40 had no missing or broken teeth.
10/30/23 10:25 AM - An interview with R40 revealed that dental services have not been received since admission. R40 stated that an outside dentist provided dental care prior to admission to the facility.
11/01/23 9:21 AM - A review of the clinical record revealed no evidence of R40 receiving dental services. R40 had routine oral evaluations quarterly by staff.
11/01/23 9:35 AM - An observation of R40 revealed that R40 has no natural upper teeth and broken or missing lower teeth. R40 denies pain but would like to receive services to obtain dentures.
11/01/23 12:03 PM - An interview with E3 (CNO) confirmed R40 did not have routine visits with a dentist or physicians orders to receive dental services.
4. Review of R66's clinical record revealed:
2/8/21 - R66 was admitted to the facility with left sided hemiplegia.
7/22/23 - The annual MDS assessment documented that R66 did not have any broken or chipped teeth.
10/30/23 - During an interview, R66 stated that they have partial dentures and asked a nurse to see a dentist over one year ago. She stated she hasn't seen a dentist yet.
There was lack of evidence of any routine dental consultation since admission on [DATE].
11/3/23 11:27 AM - During an interview with E7 (SW), stated there are no routine dental services provided to residents every 12 months.
11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 and E4 (COO) during the exit conference.

Based on observation, record review and interview, it was determined that for one (R50) out of three sampled residents reviewed for pressure ulcers, the facility failed to initiate a treatment to a pressure ulcer behind R50's right ear. Findings include:
Review of R50's clinical record revealed:
2/7/22 - R50 was admitted to the facility with a broken back.
3/14/22 - R50's Braden scale was 14 indicating moderate risk for the development of pressure ulcers.
3/22/22 11:04 AM - During an observation and interview, R50 complained of pain behind her right ear from her oxygen tubing. R50 pulled her ear back and a small open pressure area was observed behind her right ear.
3/22/22 11:10 AM - E7 (LPN) was informed of the resident complaint of pain behind her right ear and that there was pressure from the oxygen tubing. E7 stated that she would take care of it and was observed at the treatment cart getting gauze to pad the oxygen tubing.
3/24/22 - A Physician's order included: Cleanse opened area behind right ear with normal saline, pat dry, apply antibiotic ointment to opened area and leave opened to air once daily for 7 days. Monitor for signs and symptoms of worsening condition and notify MD/NP.
3/24/22 10:10 PM - A Nurses note documented, Small opening noted behind patient's right ear. Area cleanse (sic) with normal saline, pat dry, bacitracin ointment applied.
3/25/22 11:49 AM - R50 was observed in bed with gauze on her oxygen tubing behind both of her ears.
3/25/22 12:40 PM - A Dietician note documented, Skin trauma noted behind ear related to oxygen tubing.
3/25/22 1:26 PM - During an interview, E10 (UM) confirmed that the area to the right ear was observed there on 3/22/22 and the nurse who assessed it did not obtain an order for a treatment until 3/24/22. E10 added that the CNA's had spoken to her about the issue and reported that the resident has been tugging on the oxygen tubing and making it tight and rub.
Although the facility was aware of the condition of R50's right ear on 3/22/22, the facility failed to obtain a treatment order until two days later on 3/24/22.
3/29/22 1:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on observations and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include:
The following were observed during the kitchen tour on 3/22/22 from approximately 9:20 AM to 10:30 AM:
- The Facility failed to ensure the hand washing station closest to the dining room was adequately accessible by not removing the clutter (trash can and dish rack);
- The Facility was using moisture trapping material (paper) as padding for the food storage rack in the walk-in refrigerator.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for two (R55 and R95) out of five residents reviewed for immunizations, the facility failed to provide evidence that influenza immunizations were offered or declined for the current influenza season. Additionally, the facility failed to provide evidence that Pneumococcal immunizations were offered or declined for R95. Findings include:
The facility policy on influenza, last updated January 4, 2022, indicated, Influenza immunization is offered to all residents annually.
The facility policy on Pneumococcal immunizations, last updated January 4, 2022, indicated, It is the policy of the facility to follow CDC guidelines in offering pneumococcal immunizations to residents.
1. Review of R55's clinical record revealed:
9/15/20 - R55 was admitted to the facility.
Review of R55's electronic medical record (EMR) lacked evidence that R55 was offered or declined the influenza immunization for the current flu season. R55's last declination for influenza vaccine was dated 11/2/20.
2. Review of R95's clinical record revealed:
7/28/17 - R95 was admitted to the facility.
Review of R95's EMR lacked evidence that R95 was offered or declined the influenza immunization for the current flu season. R95's last declination for the influenza vaccine was dated 12/3/20.
Review of R95's EMR lacked evidence that R95 was offered or declined the Pneumococcal immunization.
During an interview on 3/28/22 at 1:17 PM, E3 (CNO) confirmed the facility was unable to provide evidence of the offering or declination of the above immunizations for R55 and R95.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for two (R85 and R199) out of five residents reviewed for COVID-19 immunizations, the facility failed to provide evidence that the COVID-19 vaccines were offered or declined. Findings include:
The facility policy on COVID-19 vaccination, last updated January 27, 2022 indicated COVID-19 vaccinations will be offered to all residents.
1. Review of R85's clinical record revealed:
3/7/22 - R85 was admitted to the facility.
Review of R85's electronic medical record (EMR) lacked evidence that R85 was offered or declined any COVID-19 vaccinations.
2. Review of R199's clinical record revealed:
3/10/22 - R199 was admitted to the facility.
Review of R199's EMR lacked evidence that R199 was offered or declined any COVID-19 vaccines.
During an interview on 3/28/22 at 1:17 PM, E3 (CNO) confirmed the facility was unable to provide evidence of offering COVID-19 vaccines to R85 and R199.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on observation and interview, it was determined that for one (R47) out of thirty eight sampled residents, the facility failed to provide dignity for a resident with a urinary catheter. Findings include:
3/22/22 10:00 AM - A random observation from the doorway of R47's room revealed R47 had an uncovered catheter bag hanging on the bed.
3/23/22 12:08 PM - During an interview, E8 (CNA) revealed catheter bags usually have a cover and E8 was not sure why R47 didn't have a catheter cover. E8 stated that the Nurse or someone from the supply department usually gets the cover for the catheter bag.
3/23/22 1:23 PM - During an interview, E4 (Unit Manager) confirmed that all catheter drainage bags should be covered with a privacy bag for resident privacy.
3/25/22 2:50 PM - R47's catheter bag was observed on the side of her bed and it had a privacy cover on it.
These findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review, interview and review of other facility documentation, it was determined that the facility failed to ensure that one (R51) out of four sampled residents for abuse was free from sexual abuse. Findings include:
The facility policy on abuse, updated January 3, 2022, indicated It is the policy of the facility to protect residents and prevent occurrences of abuse.
1/25/21 - A quarterly MDS assessment documented R154 as cognitively intact with no documented behaviors.
2/15/21 - An annual MDS assessment documented R51 as severely cognitively impaired, with memory problems and communication that was rarely or never understood by others and that R51 rarely or never understands others. R51 had multiple diagnoses including aphasia (difficulty speaking) and dementia.
3/20/21 9:12 PM - E12 (RN) documented the following behavior note, R154 seen 3 times grabbing another resident's hand and following that resident and preventing that resident from walking. Verbally spoke with resident to let R154 know this behavior is not acceptable. Resident verbalized understanding. Gave resident a snack and redirected. Resident currently sitting in chair near nurses station.
3/22/21 1:55 PM - A Physician progress note written by E14 (NP) documented, R154 seen today for medical review .has presented some behavioral disturbances including grabbing another resident. There was no evidence in the clinical record of a change in orders for R154 related to the documented behaviors.
3/23/21 10:02 PM - A Nurses note documented, R154 continues to follow residents as they walk on the unit. Patient redirected for which R154 verbalized understanding but behavior continues.
3/24/21 9:12 PM - E11 (RN) documented in a Nurses note, [E14 (NP)] notified of new behaviors, [E15 (NP)] was notified and Telehealth visit attempted but [R154] refused to discuss behaviors with NP, stating there was nothing to discuss. [E15] gave new order for psychotropic to be increased . [R154] closely monitored during shift.
3/24/21 10:23 PM - A Nurses note documented, [R154] monitored for untoward behaviors toward residents and change in medication.
3/25/21 11:29 AM - A Physician progress note documented, Late entry note [R154] visit for behavioral disturbances. Due to behavioral disturbances including attempts to elope patient was transferred into a locked unit last month. [R154] continues to present with behavioral disturbances including increased observation and 'stalking' of female dementia patient who wanders around the unit, including blocking [R51's] path and touching R51's clothing. Redirection by staff unsuccessful to the point that resident required one-on-one supervision yesterday. Review of the clinical record lacked evidence of one on one assignment of staff to R154.
3/25/21 7:38 PM - A Nurse Practitioner note documented,Psychiatric consult, evaluated R154 Long term care/memory care unit per staff request secondary to psychotropic medication use and recent behavioral escalations including grabbing at other residents and following female residents closely around unit; history of elopement attempts when resided off memory care unit.
4/1/21 4:20 PM - A Nurses note documented, [R154] reported observed following female resident seen placing hand under residents shirt. Residents separated and redirected. Resident placed on every 15 minute checks. Psychiatric and medical doctor to review medications.
4/1/21 4:37 PM - A Nurses note documented, Reported by nursing staff [R51] wandering building followed by a male resident which was seen placing his hand under her blouse residents separated and redirected to common area for closer monitoring.
4/1/21- Every 15 minute checks were initiated at 5:15 PM and lasted through 4/22/21.
4/1/21 - The facility reported an allegation of resident to resident abuse described as [R154] seen placing hand under [R51's] blouse, resident separated both redirected. [R154] placed on every 15 minute checks psych to evaluate resident.
4/1/21 - R154's care plan for inappropriate behaviors was updated to include inappropriate touching of other residents. An intervention for every 15 minute checks was implemented with the update.
4/1/21 6:24 PM - A Nurse Practitioner note documented, Psychiatric consult, evaluated [R154] Long Term Care/memory care unit secondary to psychotropic medication adjustment last week no further behavioral escalations until later this afternoon staff called to report [R154] was witnessed reaching under a female residents shirt after closely following female resident around unit/prior to this incident.
4/2/21 3:32 PM - E14 (NP) wrote a Physician progress note that documented, Late entry note [R154] visit for behavioral disturbances due to behavioral disturbances including attempts to elope [R154] was transferred into a locked unit in February. R154 continued to present with behavioral disturbances including increased observation and 'stalking' of female dementia patient who wanders around the unit, including blocking [R51's] path and touching her clothing. Redirection by staff was unsuccessful to the point that resident required one-on-one supervision. Psychiatric NP increased medications on 3/24/21 (see progress note dated 3/25/2021). On 4/1/2021 R154 began again to follow the same resident and placed his hand underneath her shirt. He was then again put on one-on-one supervision. Psychiatric follow-up done the same day with new recommendations to decrease psychotropic medications dose and start patient on a new medication. [R154] seen today in his room, resting in bed, awake and alert, calm, with poverty of speech, does not wish to discuss incident but endorses that he would rather be accommodated outside of locked unit and preferably be reintegrated into community with lower level of care .Awaiting recommendations for therapeutic communication and nonpharmacological nursing interventions. Recommend scheduling care conference with patient and POA to discuss options of accommodation in different area of facility and/or community reintegration.
4/6/21 - A Psych note documented, Staff report [R154] touched a female resident inappropriately. Assess mental status and recommend interventions .Pt is still in bed and not dressed at mid morning. Pt denies this incident of inappropriate touching. [R154] acknowledges the rules about touching other residents. Patient reports no desire to get out of bed. Patient will benefit from the offer of structured activities to encourage appropriate behavior .Low motivation. Denial of responsibility.
3/25/22 3:48 PM - The above findings were reviewed with E2 (DON).
During an interview on 3/25/22 at 3:53 PM, E12 (RN) confirmed that [R51] was the resident referenced in the 3/20/21 behavior note. E12 further stated, R51 was non-verbal, I remember seeing [R154] grab [R51's] hand and caress the hand. I let [R154] know that wasn't appropriate . [R51] was a repetitive walker and [R154] would block [R51's] path.
During an interview on 3/25/22 at 4:13 PM, E11(RN) stated, [R154] was high functioning and fairly young. [R154] kept following R51, they make loops and [R154] would watch [R51] . I think we increased surveillance, my desk was moved because there was blind spots and once [R154] stood in front of [R51] to block her path.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for two (R68 and R77) out of four residents sampled for hospitalization, the facility failed to notify the ombudsman of the transfer to the hospital. Findings include:
The following residents were transferred to the hospital for emergent medical needs and the ombudsman was not notiifed:
1. 2/11/22 - R68 was transferred emergently to the hospital and was admitted .
3/25/22 - A review of R68's records lacked evidence that the Ombudsman was notified of R68's transfer to the hospital.
2. 2/3/22 - R77 was transferred emergently to the hospital and was admitted .
3/25/22 - A review of R77's records lacked evidence that the Ombudsman was notified of R77's transfer to the hospital.
3/28/22 9:41 AM - During an interview E3, (Regional DON) confirmed that the Ombudsman was not notified of the transfer of R68 and R77 to the hospital.
3/29/22 1:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for three (R47, R68, and R77) out of four sampled residents reviewed for hospitalization, the facility failed to provide the bed-hold notice upon transfer to the hospital. Findings include:
According to the facility policy Bed Holds (revised 11/2/18), the facility must provide two notices, one on admission and then on transfer to emergency treatment at the hospital. It should accompany the resident to the hospital and the admission Director should call the resident representative to notify them of the policy, and they will document conversation and mail them to the representative for review.
1. 3/7/22 - R47 was transferred emergently to the hospital and was admitted .
2. 2/11/22 - R68 was transferred emergently to the hospital and was admitted .
3. 2/3/22 - R77 was transferred emergently to the hospital and was admitted .
3/25/22 - During record review there was no evidence found that a copy of the facility bed hold policy was provided by the facility to R47, R68, or R77's representatives when they were transferred to the hospital and admitted .
3/28/22 9:41 - During an interview, E3 (Regional DON) confirmed that R47, R68, and R77's representatives were not notified of the facilities bed hold policy when they were transferred to and admitted to the hospital.
3/29/22 1:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for one (R96) out of two sampled residents reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to have a PASARR on admission from the State authority. Findings include:
The facility policy on PASARR, last updated January 3, 2022, indicated, Prior to admission a Level 1 Preadmission Screening and Resident Review PASRR, is conducted to identify individuals who have or may have mental disorders, intellectual disability's, (sic) or a related condition .
Review of R96's clinical record revealed:
2/20/21- A PASARR level I screening was completed for R96's admission to an out of state nursing facility.
3/19/21- An admission MDS assessment documented R96 as being cognitively impaired with various diagnoses including dementia, anxiety, depression, and schizophrenia and was taking antipsychotic medication. R96 was assessed as having verbal behavioral symptoms directed towards others such as threatening others, screaming at others, and cursing at others for 1-3 days during the assessment.
3/23/22 9:11 AM - Review of R96's clinical record revealed a lack of evidence that the facility received a PASARR review from the State of Delaware authority for R96 prior to admission.
3/24/22 11:57 AM- An email contact with the State PASARR unit confirmed that there was no evidence of a completed PASARR screening for R96.
During an interview on 3/23/22 at 11:16 AM with E6 (SW), the absence of a PASARR from a State of Delaware authority was reviewed.
During an interview on 3/24/22 at 1:30 PM, E3 (CNO) confirmed the above findings.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on observation, interview and record review, it was determined for one (R86) out of five dependent residents reviewed for Activities of Daily Living (ADL's), the facility failed to assist R86 with shaving and transferring out of bed. Findings include:
Review of R86's clinical record revealed:
3/12/22 - A quarterly MDS assessment documented R86 as being cognitively intact and requiring extensive assistance of one staff member for shaving/hygiene. R86 had one to two transfers during the assessment that were not steady.
R86's care plan for ADL's, last updated 3/16/22, indicated R86 had an ADL self-care performance deficit related to decreased mobility and history of a stroke. Interventions for R86's care plan were for staff to assist R86 with daily hygiene, toileting, dressing, grooming, and oral care as needed.
During an interview on 3/22/22 at 10:23 AM, R86 stated, They don't shave me, they don't like to get me up in the wheelchair. I only get up when therapy helps me, its been about a month. The resident was observed unshaven and up in the wheelchair at that time.
3/25/22 10:02 AM - R86 was observed in the bed unshaven. When asked if he was offered a shave or to get out of bed to the wheelchair, R86 stated No, they don't do that.
During an interview on 3/25/22 at 2:16 PM, E4 (RN) and Unit Manager on R86's unit stated, To my knowledge, R86 refuses to get up. I am not aware that R86 refuses shaving. Review of R86's clinical record lacked evidence of refusals for shaving or getting out of bed.
A thirty day review from 2/27/22 - 3/27/22 of R86's record of transfers revealed R86 was assisted out of bed to the wheelchair eleven out of thirty days. There were no documented refusals of R86 getting out of bed to the wheelchair.
A thirty day review from 2/27/22 - 3/27/22 of R86's hygiene indicated R86 received hygiene completion, however, observation of R86 did not support the documentation. There were no documented refusals of R86 receiving a shave.
3/28/22 2:57 PM - R86 was observed in bed unshaven and stated, I don't want to get up today, but they still did not help shave me.
Findings were reviewed during the exit conference on 3/29/22 at 1:00 PM with E1 (NHA), E2 (DON) and E3 (Regional CNO).

Based on record review and interview, it was determined that for one (R151) out of six sampled residents reviewed for unnecessary medications, the facility failed to have an adequate indication for use of a psychotropic mediation. Additionally, the facility failed to monitor for behaviors and side effects associated with the medication use, including an assessment of abnormal movements (AIM's). Findings include:
Review of R151's clinical record review revealed:
6/16/21 - R151 was admitted to the facility.
6/16/21 - A physicians order included: Quetiapine Furmarate (an antipsychotic medication) for depression and anxiety when the medication was indicated for major depressive disorder and bipolar disease and not for anxiety.
6/16/21 - A physicians order included: Doxepin (an antidepressant medication) for depression.
6/17/21 - A physicians order included: Temazepam (a hypnotic medication) was to be given in the morning every other day for anxiety. The indication for the medication is for sleep, not anxiety.
Doxepin, Quetiapine and Temazepam require monitoring for behaviors and medication side effects.
Quetiapine requires that a baseline AIM's test must be conducted. The clinical record lacked evidence that the AIMS assessment was completed.
3/28/22 10:16 AM - During an interview, E3 (CNO) confirmed that R151's clinical record lacked evidence of monitoring for behaviors or medication side effects related to receiving psychotropic medications. E3 also confirmed that R151's clinical record lacked evidence of a baseline AIMS assessment being completed.
3/29/22 1:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (Regional CNO).