Every finding on record at Adviniacare Newton Wellesley

Based on observation and interview the facility failed to provide a homelike environment on two out of two dementia care certified nursing units.Findings include:On 12/30/25 and 12/31/25, the surveyors observed the first floor and second floor units to not have a homelike environment. The surveyors were unable to locate a single picture on the walls in the hallways and the resident rooms other than a few family photographs provided by family members in less than half of the resident rooms. The surveyors observed the walls in the residents' rooms and hallways to be painted without decoration. The surveyors also observed the first-floor unit hallways and dining rooms to have multiple areas that have been patched but not painted. During an interview on 12/31/25 at 10:15 A.M., the Administrator said that there are no purchase orders or formalized plans for making the units more homelike. The Administrator then said that she was aware that the units and resident rooms were sterile looking. The Administrator said that in the past the facility had tried to get a school art program to volunteer to paint murals on the walls but that it didn't work out. During an interview on 12/31/25 at 12:32 P.M., Family Member #1 said that it would be nice if the hallways and resident rooms on the second-floor unit had some sort of pictures. Family Member #1 then said that the facility wasn't really homelike. During an interview on 12/31/25 at 12:34 P.M., Family Member #2 said the hallways and rooms on the first-floor unit have nothing to look at, there is nothing on the walls. Family Member #2 said she would love to see more things and colors for the residents to look at to keep them stimulated.

Based on record review and interview the facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly.Findings include:Review of the QAPI (Quality Assurance Performance Improvement) sign in records failed to indicate that the Medical Director participated in one (7/31/25) out of the last four quarters. During an interview on 12/31/25 at 1:22 P.M., the Administrator said that the facility QAPI meets monthly but the medical director attends only quarterly per the regulation. The Administrator said that she had fired the previous medical director in July 2025. The Administrator said that she did not review the QAPI program with the new medical director who was hired 8/5/25. The Administrator said that the new medical director did not participate in QAPI until the October 2025 QAPI meeting. The Administrator said that for six months the medical director did not attend a QAPI meeting and no other physician attended to represent the medical director.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three Residents (#5, #9 and #82) out of a total sample of 21 residents. Specifically,1.For Resident #5, who has identified pressure ulcers, the facility failed implement Enhanced Barrier Precautions during high contact care. 2. For Resident #9, who has an identified pressure ulcer, the facility failed implement Enhanced Barrier Precautions during high contact care.3. For Resident #82, the facility failed to implement Enhanced Barrier Precautions during straight catheter (urinary catheter) procedures.Findings include:Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Resident #5 was admitted to the facility in May 2024 with diagnoses that included dementia, dysphagia, cognitive communication deficit, anxiety and pain. Review of Resident #5's most recent Minimum Data Set (MDS) assessment, dated 12/5/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated the Resident had one unhealed stage three pressure ulcer. Review of Resident #5's physician order, dated 12/1/25, indicated Enhanced barrier precautions. Review of Resident #5's physician order, dated 12/24/25, indicated Right buttock Stage 3 Pressure Ulcer: clean with NS (normal saline) or wound cleaner, pat dry, apply Calcium Alginate and cover with Silicone Foam border gauze. Review of Resident #5's physician order, dated 12/28/25, indicated Right medial Heel- Clean with wound cleanser, pat dry and cover with DPD (dry protective dressing) daily. On 12/30/25 at 8:19 A.M., the surveyor observed a Certified Nurse Aide (CNA) providing morning incontinence care to Resident #5 with only gloves on. The surveyor observed signage on the Resident's door that indicated they are on EBP and staff should apply PPE (personal protective equipment) including a gown and gloves during care. On 12/31/25 at 8:08 A.M., the surveyor observed a staff member apply socks to Resident #5 without gloves or any other PPE on. The staff member struggled to apply to socks due to the left heel dressing. The surveyor then observed Nurse #1 enter the room and applied gloves only. Nurse #1 was observed to remove the wrap from his/her left heel wound with only gloves on. During an interview on 12/31/2025 at 10:56 A.M., Nurse #1 said Resident #5 does have pressure ulcers and skin tears on his/her body. Nurse #1 said residents with wounds are on enhanced barrier precautions and all staff should wear PPE during care and wound dressing changes. Nurse #1 said she should have had on more than just gloves while touching his/her left heel dressing. During an interview on 12/31/2025 at 12:05 P.M., the Corporate Nurse said staff are expected to DON (apply) PPE while providing care to residents with wounds. During an interview on 12/31/25 at 12:52 P.M., the Director of Nurses, who also covers the role of Infection Preventionist, said that Enhanced Barrier Precautions are used to prevent transmission of organisms to a resident. She said Enhanced Barrier Precautions are used for residents who have wounds, intravenous lines or urinary catheters. She said that Resident #5 has multiple wounds and staff should be donning PPE while caring for him/her. 2. Resident #9 was admitted to the facility in November 2013 with diagnoses that included dementia, contracture of right knee and major depressive disorder. Review of Resident #9's most recent Minimum Data Set (MDS) assessment, dated 12/18/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated the Resident had one unhealed stage two pressure ulcer. Review of Resident #9's physician order, dated 12/24/25, indicated Right Buttock Pressure Ulcer stage 2 (open blister): Clean area with NS/ WC, pat dry, apply xeroform and cover with silicone border gauze. Further review of the orders failed to indicate an order for Enhanced Barrier Precautions (EBP). Review of Resident #9's weekly skin check, dated 12/23/25, indicated a right gluteal fold open area. On 12/30/25 at 8:22 A.M., the surveyor observed Resident #9 in bed. The door did not have signage to indicate the Resident should be on enhanced barrier precautions due to his/her wound. The surveyor also did not observe PPE in front of the room, in the room or in the hallway. On 12/31/25 at 8:10 A.M., the surveyor observed a Certified Nurse Aide (CNA) providing morning incontinence care to Resident #9 with only gloves on. The CNA said Resident #9 does have a wound on their buttocks but is not on any special precautions needing PPE. During an interview on 12/31/2025 at 10:50 A.M., Nurse #2 said Resident #9 has had a wound on his/her buttocks for some time and should be on EBP. Nurse #2 said when CNA's provide care, they should have PPE on including a gown to protect themselves and the Resident from any infections. During an interview on 12/31/2025 at 12:05 P.M., the Corporate Nurse said staff are expected to DON (apply) PPE while providing care to residents with wounds. During an interview on 12/31/25 at 12:52 P.M., the Director of Nurses, who also covers the role of Infection Preventionist, said that Enhanced Barrier Precautions are used to prevent transmission of organisms to a resident. She said Enhanced Barrier Precautions are used for residents who have wounds, intravenous lines or urinary catheters. She said that Resident #9 has a pressure ulcer and gets rashes often and staff should be donning PPE while caring for him/her. 3. Resident #82 was admitted to the facility in December 2025 with diagnoses that included retention of urine. Review of Resident #82's most recent Minimum Data Set (MDS) Assessment, dated 12/18/25, indicated a Brief Interview for Mental Status score of 7 out of 15, indicating severe cognitive impairment. The MDS further indicated that the Resident received intermittent (urinary) catheterization. Review of physician's orders indicated the following: -Straight catheterization every shift, dated 12/18/25. Further review of physician's orders failed to indicate orders for the use of Enhanced Barrier Precautions. Review of the active care plan dated 12/14/25 indicated the following: -Impaired urinary elimination due to neurogenic bladder with interventions that included intermittent catheterization every shift as ordered. During observations on 12/30/25 at 1:45 P.M., and 12/31/25 at 6:57 A.M., there were no signs on the Resident's door or outside of the Resident's room to indicate the need for Enhanced Barrier Precautions. During an interview on 12/31/25 at 6:49 A.M., Nurse #3 said that she had already performed the straight catheterization for her shift. She said that the Resident is not on any specific precautions. She said she uses universal precautions to perform the straight catheterization, including washing her hands and glove use, but does not utilize a gown for the procedure. During an interview on 12/31/25 at 12:05 P.M. Nurse #2 said that Resident #82 is not on any extra precautions besides universal precautions with hand washing and glove use when performing straight catheterization. She said she does not utilize a gown for the procedure. During an interview on 12/31/25 at 12:52 P.M., the Director of Nurses, who also covers the role of Infection Preventionist, said that Enhanced Barrier Precautions are used to prevent transmission of organisms to a resident. She said Enhanced Barrier Precautions are used for residents who have wounds, intravenous lines or urinary catheters. She said that Resident #82 was not on Enhanced Barrier Precautions during urinary catheter procedures because she did not think she needed to be.

Based on record review and interview, the facility failed to notify the physician of changes in Resident weights for 2 Residents (#6 and #1) out of a total of 21 sampled Residents.Specifically:1. For Resident #6 the facility failed to notify the physician of a significant weight loss.2. For Resident #1 the facility failed to notify the physician of a significant weight gain.Findings include:Review of the facility policy titled Weight Assessment and Interventions dated revised 5/2019 indicated that the licensed nurse should notify the dietician of identified weight change once reviewed. Further review indicated that dietician notification should be documented in the medical record. 1. Resident #6 was admitted to the facility in November 2025 with diagnoses including dementia, psychosis and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #6 is severely cognitively impaired scoring a 0 out of 15 on The Brief Interview for Mental Status exam. Further review indicated that Resident #6 is dependent for most activities of daily living. Review of the care plan dated 11/25/25 indicated the following focus: Potential for Malnutrition as evidenced by Nutritional Screening Tool at Risk of Malnutrition - Altered nutrition-related to dementia, and DM (diabetes) with indication for therapeutic diet.Date Initiated: 11/25/2025. Further review indicated the following interventions:Intervention: carb-modified meal planMonitoring/Criteria: Labs, Weight, meal consumption, Skin, BSDate Initiated: 11/25/2025 Establish appropriate short- and long-term eating goalsDate Initiated: 11/25/2025 Monitor eating environmentDate Initiated: 11/25/2025 Monitor weight closely for gain/lossDate Initiated: 11/25/2025 Review of the medical record on 12/30/25, indicated the following weights: 12/30/25; 135.9 Lbs. (pounds)12/23/2025; 135.8 Lbs., a significant weight loss of 5.83%12/16/2025; 136.5 Lbs., a significant weight loss of 5.34%12/9/2025; 137.8 Lbs.12/9/2025; 137.8 Lbs.11/25/2025; 142.4 Lbs.11/20/2025; 144.2 Lbs. Further review of the medical record indicated the only dietician progress note dated 11/25/25, indicated a weight of 142.5. No other dietician notes were in the medical record. Review of the progress notes dated 11/20/25 through 12/28/25 failed to indicate that the facility notified the physician or the dietician of the significant weight loss. Further review indicated that Resident #6 is at risk for weight loss related to dementia and to monitor weights and address need for additional nutrition support as needed. Review of the Nurse Practitioner progress note dated 12/9/25 indicated mild weight loss of no concern. Review of the Physician progress note dated 12/29/25 failed to indicate that he was made aware of the weight loss and the weight loss was not addressed. Review of the physician orders dated November and December 2025 failed to indicate the weight loss was addressed or any new medical interventions were initiated. During an interview on 12/31/2025 at 7:26 A.M., the Dietician said that she was not aware of the weight loss. She then said she reviews weights weekly but for some reason she did not see this one and if she had she would have put an intervention in place to prevent further weight loss. During an interview on 12/31/25 at 9:02 A.M., the Administrator said that it is her expectation that nursing would inform the physician and dietician of a significant weight loss and interventions to prevent further weight loss be put in place. She then said that nursing should be monitoring all residents who are on weekly weights and report any changes. 2. Resident #1 was admitted to the facility in January 2022 with diagnoses including dementia and depression. Review of the Minimum Data Set, dated [DATE] indicated Resident #1 is severely cognitively impaired and unable to complete the Brief Interview for Mental Status exam. Further review indicated that Resident #1 is dependent on staff for all activities of daily living. Review of the care plan failed to indicate need for notification of physician for significant weight gain. Review of the physician orders dated December 2025 indicated an order for weekly weights every day shift every Tuesday. Review of the medical record indicated weights as follows:12/30/25; 158.2 Lbs. (pounds) a significant weight gain of 9.18%12/23/25; 158.0 Lbs., 12/17/25; 157.2 Lbs., 12/15/25; 157.6 Lbs.12/10/25; 157.6 Lbs. a significant weight gain of 8.76%11/11/25; 144.9 Lbs. Review of the medical record indicated the last dietician note was dated 12/2/25 and indicated a weight of 144.9 obtained 11/11/25. Dietician requested updated weight. No further dietician notes were in the medical record. Review of the progress notes dated November and December 2025 failed to indicate that the physician or nurse practitioner had been notified of Resident #1's significant increase in weight. Review of the medical record indicated a physician note dated 12/20/25, failed to indicate review of Resident #1's weight. Review of the nurse practitioners note dated 12/5/25 failed to indicate a review of Resident #1's weight and referenced the 11/11/25 weight of 144.9 lbs. No further nurse practitioner notes are in the medical record. During an interview on 12/31/25 at 7:35 A.M., the Dietician said that Resident #1 should have had a note written but she was not concerned because there was no etiology for the weight gain. During an interview on 12/31/25 at 9:44 A.M., the Director of Nursing (DON) said that most residents are weighed monthly and if weekly weights are initiated it is because of a concern. The DON then said that weekly weights should be monitored weekly by the Dietician and nursing.

Based on observation, record review and interviews, the facility failed to ensure a resident centered care plan was implemented for one Resident (#54) out of a total sample of 21 residents. Specifically, for Resident #54 who was assessed to be at risk for skin breakdown, the facility failed to implement his/her abductor wedge.Findings include:Resident #54 was admitted to the facility in November 2023 with diagnoses that included dementia, hemiplegia and hemiparesis, wrist drop and weakness. Review of Resident #54's most recent Minimum Data Set (MDS) assessment, dated 12/11/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS further indicated that the Resident was at risk for developing pressure ulcers. Review of Resident #54's physician's order, dated 10/6/25, indicated Blue Soft Abductor wedge to LLE (left lower extremity) every day and evening shift remove and re-apply as needed, check placement. Review of Resident #54's skin breakdown care plan, revised 10/6/25, indicated Blue Soft abductor wedge to bilateral knee while in wheelchair, remove in PM (P.M.) check placement/skin integrity every shift. On 12/30/25 at 8:24 A.M., 12:37 P.M. and 1:54 P.M., the Resident was observed in his/her wheelchair without an abductor wedge in place. The Residents' knees were observed to be touching each other. On 12/31/25 at 8:08 A.M., the Resident was observed in his/her wheelchair without an abductor wedge in place. Resident #54's room was observed, and the surveyor was unable to visualize the abductor wedge. The Residents' knees were observed to be touching each other. Review of the nursing progress notes failed to indicate the Resident refused the abductor wedge. During an interview and observation on 12/31/2025 at 10:50 A.M., Nurse #2 said Resident #54 should always have an abductor wedge in between his/her knees when he/she is out of bed because the Resident's knees touch. Nurse #2 said the Certified Nurse Aides (CNA's) normally put it on when they get the Resident out of bed but did not. During an interview on 12/31/25 at 12:58 P.M., the Director of Nursing said Resident #54 should have an abductor wedge in place when he/she is out of bed as it is an intervention to prevent skin breakdown due to his/her knees touching due to contractures in the Residents' legs.

Based on observations, record review and interview the facility failed to develop and implement a plan of care for one Resident (#72) with a contracture out of a total sample of 21 Residents. Specifically, the facility failed to develop and implement a nursing plan of care to manage a contracture as recommended by Occupational Therapy. Findings include:Review of facility policy titled Contracture Prevention, undated, indicated the following:-Residents with inactive extremities should have range of motion exercises done to those extremities as part of their daily care. Resident #72 was admitted to the facility in March 2022 with diagnoses that included contracture left shoulder, contracture left elbow, contracture left wrist and contracture of the left hand. Review of the most recent Minimum Data Set (MDS) Assessment, dated 11/6/25, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated the Resident had functional limitations in Range of Motion to the upper extremity on one side. During an observation on 12/30/25 at 8:09 A.M., the surveyor observed Resident #72 sitting in the dining room in a wheelchair. Resident #72's left hand was in a tight fist, and his/her arm is held tightly against their chest. During an observation on 12/30/25 at 1:44 P.M., the surveyor observed the Resident sitting in his/her wheelchair with his/her left hand in a fist held tightly against his/her chest. During an observation on 12/31/25 at 6:50 A.M., the surveyor observed the Resident in bed sleeping with his/her left hand in fist held tightly against his/her chest. Review of the Occupational Therapy (OT) note, dated 8/20/25, indicated the following:-Diagnoses: contracture, left hand-Will OT treat to address contracture impairment? No, Nursing is managing patient's contracture impairment. Review of physician's orders failed to indicate any orders pertaining to contracture management. Review of Resident #72's active plan of care failed to indicate a plan of care regarding contracture management. Review of Nursing progress notes failed to indicate that range of motion or any other contracture management had been provided or completed with the Resident. During an interview on 12/31/25 at 9:43 A.M., Certified Nurse Aide (CNA) #2 said that when assisting the Resident with activities of daily living (ADL) care they clean his/her left hand, but other than that there is no specific plan of care for the contracture. She said that there is no program to provide range of motion to the Resident's arm or hand. During an interview on 12/31/25 at 9:46 A.M., Nurse #2 said that she is assigned to Resident #72. She said that there is no specific plan of care for management of the Resident's contractures that is being followed. She said there are no physician's orders for ranging or management of the contracture. During an interview on 12/31/25 at 11:55 A.M., the Regional Occupational Therapist said that she had spoken with the treating therapist for Resident #72 and it was discussed that the Resident was not compliant with an orthotic device, but that nursing would continue to provide range of motion exercises to maintain the function of the left arm and hand. During an interview on 12/31/25 at 12:58 P.M., the Director of Nurses said that there should be a plan of care in place and being implemented and documented to prevent worsening of the contracture.

Based on record review and interview the facility failed to adequately maintain the nutrition and hydration status of one Resident (#6) out of a total sample of 21 residents. Specifically for Resident #6, the facility failed to ensure significant weight loss was assessed and continually monitored. Findings include:Review of the facility policy titled Weight Assessment and Interventions dated revised 5/2019 indicated that the licensed nurse should notify the dietician of identified weight change once reviewed. Further review indicated that dietician notification should be documented in the medical record. Resident #6 was admitted to the facility in November 2025 with diagnoses including dementia, psychosis and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #6 is severely cognitively impaired scoring a 0 out of 15 on The Brief Interview for Mental Status exam. Further review indicated that Resident #6 is dependent for most activities of daily living. Review of the medical record on 12/30/25, indicated the following weights:12/30/25; 135.9 Lbs. (pounds)12/23/2025; 135.8 Lbs., a significant weight loss of 5.83%12/16/2025; 136.5 Lbs., a significant weight loss of 5.34%12/9/2025; 137.8 Lbs.12/9/2025; 137.8 Lbs.11/25/2025; 142.4 Lbs.11/20/2025; 144.2 Lbs. Further review of the medical record indicated the only dietician progress note dated 11/25/25, indicated a weight of 142.5. No other dietician notes were in the medical record. Review of the progress notes dated 11/20/25 through 12/28/25 failed to indicate that the facility notified the physician or the dietician of the significant weight loss. Further review indicated that Resident #6 is at risk for weight loss related to dementia and to monitor weights and address need for additional nutrition support as needed. Review of the Nurse Practitioner progress note dated 12/9/25 indicated mild weight loss of no concern. Review of the Physician progress note dated 12/29/25 failed to indicate that he was made aware of the weight loss and the weight loss was not addressed. Review of the physician orders dated November and December 2025 failed to indicate the weight loss was addressed or any new medical interventions were initiated. Review of the care plan dated 11/25/25 indicated the following focus: Potential for Malnutrition as evidenced by Nutritional Screening Tool At Risk of Malnutrition - Altered nutrition-related to dementia, and DM with indication for therapeutic dietDate Initiated: 11/25/2025. Further review indicated the following interventions:Intervention: carb-modified meal planMonitoring/Criteria: Labs, Weight, meal consumption, Skin, BSDate Initiated: 11/25/2025 Establish appropriate short- and long-term eating goalsDate Initiated: 11/25/2025 Monitor eating environmentDate Initiated: 11/25/2025 Monitor weight closely for gain/lossDate Initiated: 11/25/2025 During an interview on 12/31/2025 at 7:26 A.M., the Dietician said that she was not aware of the weight loss. She then said she reviews weights weekly but for some reason she did not see this one. The Dietician said if she had known of the weight loss she would have put in an intervention to prevent further weight loss. During an interview on 12/31/25 at 9:02 A.M., the Administrator said that it is her expectation that nursing would inform the physician and dietician of a significant weight loss and interventions, to prevent further weight loss, be put in place. She then said that nursing should be monitoring all residents who are on weekly weights and report any changes.During an interview on 12/31/25 at 9:44 A.M., the Director of Nursing (DON) said that most residents are weighed monthly and if weekly weights are initiated it is because of a concern. The DON then said that weekly weights should be monitored weekly by the Dietician and nursing and interventions put in place if needed.

Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on one of two certified dementia units.Findings Include:Review of facility policy titled On Tray Dietary Policies and Procedures, undated, indicated the following:-Policy: food temperatures are maintained during serving times.-Purpose: To ensure residents receive safe food served at acceptable temperatures-Hot foods are served at 135 degrees or higher and cold foods/ beverages are served at 41 degrees or lower. During a continuous observation on 12/30/25 from 8:06 A.M. to 8:25 A.M., the surveyor observed meal pass in the first-floor dining room.Upon the surveyor's arrival in the dining room at 8:06 A.M., there were 20 residents in the dining room, and the food truck had already arrived in the dining room.At 8:14 A.M., residents in the dining room had not yet been served any food or drinks.At 8:17 A.M., the first resident was served a tray in the dining room.By 8:25 A.M., six residents in the dining room had been provided with a meal. Fourteen residents continued to sit at their tables waiting for food and fluids to be served to them. On 12/31/25 at 7:40 A.M., the surveyor observed the first food truck arrive to the dining room on the first floor. On 12/31/25 at 8:24 A.M., the surveyor observed 23 residents in the dining room. Five residents still had not received their breakfast trays. On 12/31/25 at 8:27 A.M., the surveyor requested one of the remaining resident trays in the food cart to check food temperatures. The following was recorded: -Pureed eggs at a temperature of 102 degrees.-Pureed bread at a temperature of 100 degrees.-Oatmeal at a temperature of 102 degrees.-Thickened milk at a temperature of 45 degrees. During an interview and observation on 12/31/25 at 8:32 A.M., the Food Service Director (FSD), who arrived in the dining room while the surveyor was checking the temperature of the meal, said that food should be served to the residents at a temperature of 130-140 degrees. He said that this tray was not warm enough to serve to a resident. During an interview on 12/31/25 at 8:36 A.M., Certified Nurse Aide (CNA) #2 said that there are a lot of residents who require assistance with meals on the first-floor unit. She said it takes a long time for staff to assist them all and the food often gets cold before it can be served to the residents. She said there are not enough staff to assist all of the residents timely with meals. During an interview on 12/31/25 at 1:00 P.M., the Director of Nurses said that meals should be served timely and at appropriate and safe temperatures for the residents.

Based on record review and interview, the facility failed to 1.) follow the water management plan for Legionella prevention and 2.) failed to implement the infection prevention and control program. Specifically, 2a.) The facility failed to implement enhanced barrier precautions for a Resident (#11) with a wound. 2b.) The facility failed to ensure Nurse #1 performed a dressing change according to acceptable standards of practice. Findings include: 1.) Review of the facility Water Management Program For Building Water Systems: Site Management Plan, dated May 1, 2018, indicated the following: - 2.4. Monitoring and Verification Plan: This section defines the site-specific monitoring and verification plan. - 2.4.1 Cold Water Services * Task: Legionella Culture Test. Sample at the source or nearest outlet. Method: Lab culture test. Frequency: Annually. During an interview on 12/12/24 at 9:30 A.M., the Maintenance Director said that he does not test the water in the facility for Legionella because he was told the town is responsible for monitoring the water in the facility. The Maintenance Director said the facility has not tested the water for Legionella since he has been here. The Maintenance Director said that he had been working in the facility since December 2023. Review of the town report provided to the surveyor indicated the town report monitors minerals of the water and other contaminants, but failed to indicate the monitoring of Legionella in the facility. 44095 2a.) Review of the facility policy, Enhanced Barrier Precautions, dated 4/1/24, indicated Enhanced Barrier Precautions (EBP) will be initiated for residents as applicable in accordance with CMS and/or state regulations and/or in accordance with CDC guidance to reduce the risks of transmission of Multiple Drug Resistant Organisms (MDROs). DEFINITIONS: Enhanced Barrier Precautions is applicable for residents with any of the following: -Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Review of Resident #11's physician's order, dated 11/26/24 and discontinued on 12/10/24, indicated: - To the open area on the mid spine area: wash with normal saline, apply bacitracin followed by dry protective dressing daily, every night shift. Review of Resident #11's physician's order, dated 12/10/24, indicated: -To the open area on the mid spine area: wash with normal saline, apply medihoney followed by dry protective dressing daily, every night shift. On 12/10/24 at 7:36 A.M., 12/11/24 at 7:13 A.M., and on 12/12/24 at 7:00 A.M., the was no signage or evidence that staff should utilize enhanced barrier precautions for Resident #11. On 12/11/24 at 7:16 A.M., the surveyor observed Nurse #1 perform a dressing treatment without the use of EBP. During an interview on 12/12/24 at 7:01 A.M., Nurse #1 said that Resident #11's treatment for his/her open wound is scheduled on the night shift and she routinely completes the treatment. Nurse #1 said Resident #11's wound does not require enhanced barrier precautions. Nurse #1 said that there would be a sign posted as to when enhanced barrier precautions is indicated. Nurse #1 said she would have to gown and glove to provide wound care. During an interview on 12/12/24 at 11:03 A.M., the Assistant Director of Nursing (Infection Control Nurse) said that nursing should utilize EH during wound care. 2b.) Review of the facility policy, Non-Sterile Dressing, dated as revised 1/23, indicated that designated staff member will use non-sterile dressing technique for all dressing changes unless otherwise indicated by physician or manufacturer guidelines. Clean aseptic should be used. In the event of multiple wounds, each wound is considered a separate treatment. PROCEDURE: 3. Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface. 4. Place trash bag at end of bed or within easy reach of working area. 5. Wash hands, apply gloves. 6. Prepare/open dressing items on table. If dressings need to be cut to size, use clean or sterile scissors. 8. Remove soiled dressing; place it in the trash bag. Note date on old bandage prior to removal. 9. Remove gloves, wash hands, apply new gloves. 11. Clean wound with normal saline or prescribed cleanser. 12. Pat the tissue surrounding the wound dry with a 4x4. 13. Remove gloves, wash hands, apply new gloves. 15. Apply prescribed topical agent to wound. 16. Apply wound dressing. Wound dressing should cover the entire wound. 19. Discard gloves and all used supplies in trash bag. Remove equipment. 20. Wash hands On 12/11/24 at 7:16 A.M., the surveyor observed Nurse #1 enter Resident #11's room. Nurse #1 placed dressing supplies onto an unclean nightstand. Nurse #1 applied gloves without performing hand hygiene. Nurse #1 then picked up oxygen tubing from the floor and she applied the oxygen tubing directly off the ground to the Resident's nares. Nurse #1 with the same gloves removes the old dressing from Resident #11's spine and places it directly on the night stand next to the new dressing supplies. Nurse #1 does not change her gloves that she removed the dirty dressing with. Nurse #1 then begins to clean the wound with premoistened gauze from the nightstand. Nurse #1 with the same gloves applied a dressing that she has already applied the medihoney to prior to entering the room. Nurse #1 then gathers up all the supplies and throws them in the trash in the bathroom. Nurse #1 removes her gloves and immediately begins to adjust her glasses without performing hand hygiene. During an interview on 12/12/24 at 11:06 A.M., the Assistant Director of Nursing said that nursing should change gloves during dressing changes and perform hand hygiene before and after glove removal. The ADON said that nursing should have changed the oxygen tubing.

Based on observations, interviews, and record reviews the facility failed to provide a dignified experience for two Residents (#57 and #11) and six non-sampled Residents, out of a total sample of 18. Specifically: 1.) For Resident #57 and six non-sampled Residents, the facility failed to ensure a dignified private space in their rooms when a Certified Nursing Assistant (CNA) was using his/her personal cell phone during care. 2.) For Resident #11, the facility failed to ensure his/her dignity was maintained when his/her privacy curtain was not closed during care exposing him/her to his/her roommate. Findings include: 1.) Review of the facility policy titled 'Quality of Life - Dignity', dated 10/22, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 8. Residents' private space and property shall be respected at all times. Review of the Facility Personnel Manual, dated as revised November 16, 2022, indicated that employees may not make or receive personal phone calls or text messages while on duty at the facility except for emergencies. This includes the use of cellular phones. Employees may only use cell phones while on break and in designated break areas. Please refer to the company cell phone policy for further details. Resident #57 was admitted to the facility in April 2024 with diagnoses including dementia and osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #57 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. On 12/11/24 between 6:57 A.M. and 7:03 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 in Resident #57's room talking on her personal cell phone on speaker in a foreign language. There were three roommates present in the bedroom. The surveyor continued make the observation and observed CNA #1 go from Resident #57's room through the adjoining bathroom into the adjacent Resident room where there were three Residents present. The surveyor entered the room and interrupted the CNA while she was chatting on her phone and making a Resident bed with a Resident next to her. During an interview on 12/11/24 at 7:03 A.M., CNA #1 said she should not use her phone while providing care. During an interview on 12/12/24 at 9:22 A.M., Nurse #2 said that no cell phones should be in use while providing care. During an interview on 12/9/24 at 5:11 P.M., the Ombudsman said that she receives calls from Resident's family that staff are frequently on their personal cell phones in Resident areas. During an interview on 12/12/24 at 11:00 A.M., the Director of Nursing said that no cell phones should be in use while providing care. 2.) Review of the facility policy titled 'Quality of Life - Dignity', dated as 10/22, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 12. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures and use of telemedicine when applicable. Resident #11 was admitted to the facility in February 2024 with diagnoses including dementia, anxiety, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #11 had a severe cognitive impairment. On 12/11/24 at 7:14 A.M., the surveyor observed Resident #57 calling out during care, Resident #57 was naked, and his/her breasts and groin area were exposed, there was no privacy curtain pulled to maintain his/her dignity and his/her roommate was in bed next to him/her. On 12/11/24 at 7:16 A.M., the surveyor observed Nurse #1 enter the room and perform a dressing change to Resident #57's spine and Nurse #1 does not close the privacy curtain continuing to expose Resident #11 to his/her roommate. During an interview on 12/12/24 at 11:02 A.M., the Director of Nursing said nursing should close the curtain during care.

Based on record review, and interviews, for one Resident (#33), out of 18 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, for Resident #33, the facility failed to ensure nursing implemented a physician's ordered parameter and administered scheduled lisinopril (a medication that lowers blood pressure) when a blood pressure was outside of the parameters range. Finding include: Review of the facility policy titled 'Medication Administration', dated as revised 10/22, indicated that medications shall be administered only upon the order of physicians who are members of the medical staff. 7. The following information must be check/verified for each resident prior to administering medications: b. Vital signs, if necessary related to parameters. Resident #33 was admitted to the facility in March 2024 with diagnoses including dementia and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/27/24, indicated that Resident #33 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of Resident #33's physician's order, dated 8/9/24, indicated: - Lisinopril Tablet 20 milligrams, give 1 tablet by mouth one time a day for hypertension *** Hold for systolic blood pressure (SBP) less than (<) 120 or heart rate (HR) < 60. Review of Resident #33's plan of care related to alteration in cardiovascular status related to hypertension, dated as revised 10/3/24, indicated: - Monitor VITAL SIGNS. Notify physician (MD) of significant abnormalities. Review of Resident #33's Medication Administration Record (MAR), dated October 2024, November 2024, and December 2024, indicated nursing administered Resident #33 his/her lisinopril even though his/her blood pressure was outside of the physician ordered parameters on the following dates: - 10/2/24 blood pressure 115/73, administered. - 10/6/24 blood pressure 116/60, administered. - 10/9/24 blood pressure 110/71, administered. - 10/12/24 blood pressure 101/66, administered. - 10/19/24 blood pressure 105/69, administered. - 10/20/24 blood pressure 105/69, administered. - 10/23/24 blood pressure 115/64, administered. - 10/25/24 blood pressure 103/63, administered. - 10/26/24 blood pressure 112/72, administered. - 10/27/24 blood pressure 112/72, administered. - 11/6/24 blood pressure 115/73, administered. - 11/11/24 blood pressure 107/74, administered. - 11/13/24 blood pressure 116/62, administered. - 11/24/24 blood pressure 114/68, administered. - 11/29/24 blood pressure 119/73, administered. - 12/2/24 blood pressure 119/77, administered. - 12/7/24 blood pressure 117/74, administered. - 12/8/24 blood pressure 112/69, administered. - 12/10/24 blood pressure 114/64, administered. During an interview on 12/12/24 at 9:18 A.M., Nurse #2 said that nursing should hold Resident #33's lisinopril for a systolic blood pressure less than 120. During an interview on 12/12/24 at 11:01 A.M., the Director of Nursing said that nursing should hold the lisinopril for a systolic blood pressure less than 120.

Based on observations, interviews, and record review, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet as a potential restraint for one Resident (#31) out of a total sample of 18 residents. Findings include: Review of the facility policy titled Restraint Use, revised 1/2023, indicated: - Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. - The use of restraint shall be based on a comprehensive resident assessment that includes a physical assessment to identify medical conditions that may be causing behavior changes in the resident. The assessment will also be performed to determine the safety and protective needs of the resident prior to the application of restraint. Resident #31 was admitted to the facility in October 2020 with diagnoses including Alzheimer's dementia and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated Resident #31 was rarely/never understood and had severe cognitive impairment as evidenced by a staff assessment of mental status. This MDS also indicated Resident #31 did not utilize any restraints. Review of Resident #31's medical record failed to indicate a restraint assessment had ever been completed to determine whether the pillows placed underneath a fitted sheet would be a potential restraint. Review of Resident #31's medical record failed to indicate a physician's order for the use of pillows underneath a fitted sheet. Review of Resident #31's care plan failed to indicate the use of pillows underneath a fitted sheet. On 12/11/24 at 6:52 A.M., the surveyor observed Resident #31 in bed with pillows underneath a fitted sheet bilaterally at hip/thigh level. The foot of the bed was elevated. Resident #31 was rolling in bed and attempting to repeatedly kick his/her legs over the side of the bed where there was a pillow underneath the fitted sheet. On 12/11/24 at 3:35 P.M., the surveyor observed Resident #31 in bed with pillows underneath a fitted sheet bilaterally at hip/thigh level. Resident #31 was awake and independently moving from lying to sitting multiple times. On 12/12/24 at 6:34 A.M., the surveyor observed Resident #31 in bed with pillows underneath a fitted sheet bilaterally at hip/thigh level. The foot of the bed was elevated. During an interview on 12/12/24 at 6:35 A.M., Certified Nurse Assistant (CNA) #3 observed Resident #31 in bed with the surveyor. CNA #3 said Resident #31 can roll without assistance and sit himself/herself up in bed. CNA #3 said the staff put pillows underneath the fitted sheet to stop him/her from moving. CNA #3 said they do this because they don't want him/her to try to roll out of bed or try to stand because he/she could fall. CNA #3 also said staff elevate the legs of his/her bed so he/she cannot sit up in bed for the same reason. During an interview on 12/12/24 at 6:45 A.M., Nurse #3 observed Resident #31 in bed with the surveyor. Nurse #3 said the pillows were underneath the fitted sheet because Resident #31 is unpredictable and rolls in bed, but cognitively it's not safe for him/her to try to get out of bed because he/she could fall. During an interview on 12/12/24 at 10:49 A.M., the Director of Nursing (DON) said if staff put interventions in place that could restrict a resident's ability to move in/out of bed then a restraint assessment should be completed to assess if the intervention is a restraint. The DON said a restraint assessment should have been completed to assess the use of pillows underneath a fitted sheet since it was a potential restraint.

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one dependent Resident (#57) out of a total sample of 18 residents. Specifically, for Resident #57, the facility failed to remove unwanted chin hair. Findings include: Review of the facility policy titled 'Activities of Daily Living (ADL) Support', dated as revised 10/22, indicated that Residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Resident #57 was admitted to the facility in April 2024 with diagnoses including dementia and osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #57 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS indicated Resident #57 required substantial/maximum assistance with personal hygiene including shaving. This MDS indicated Resident #57 did not reject care. On 12/10/24 at 7:48 A.M., and 12/10/24 at 8:30 A.M., the surveyor observed Resident #57 with white chin hairs measuring approximately one centimeter. On 12/11/24 at 7:04 A.M., and 12/11/24 at 8:26 A.M., the surveyor observed Resident #57 with approximately 40 white chin hairs measuring approximately one centimeter in length. Resident #57 said he/she would like someone to shave his/her beard. On 12/12/24 at 6:54 A.M., the surveyor observed Certified Nurse Assistant (CNA) #1 bring Resident #57 into the bathroom for morning care. On 12/12/24 at 8:30 A.M., the surveyor observed Resident #57 with chin hair. Review of Resident #57's plan of care related to activities of daily living, dated 4/3/24, indicated: - personal hygiene, maximum assist. During an interview on 12/12/24 at 9:14 A.M., CNA #1 said that facial hair removal should be completed during care. On 12/12/24 at 9:16 A.M., the surveyor and Nurse #2 went into Resident #57's room. Resident #57 said to Nurse #2 will you shave my beard? Resident #57 had over 40 one-centimeter-long chin hairs. Nurse #2 said that CNAs should shave facial hair during care and that Resident #57 does not refuse care. During an interview on 12/12/24 at 10:58 A.M. the Director of Nursing said that Resident #57's facial hair should be removed during care.

Based on record review and interview, the facility failed to develop a trauma informed care plan for one Resident (#59) with a diagnosis of post traumatic stress disorder (PTSD) out of a total sample of 18 residents. Findings include: Resident #59 was admitted in February 2023 with diagnoses including post traumatic stress disorder. Review of the Minimum Data Set, dated dated [DATE], indicated Resident #59 was unable to participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the care plans for Resident #59 failed to indicate a trauma informed plan was developed. During an interview on 12/12/24 at 9:39 A.M., the Social Worker said that she is covering the building right now, but if there was a diagnosis of PTSD then she would have expected an individual care plan to be developed.

Based on record review, interview, and observation for one Resident (#11), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to document Resident #11's wound on a weekly skin check. Findings include: Review of the facility policy, Risk and Skin Assessments, dated as revised 1/23, indicated prevention of pressure ulcers requires early identification and the implementation of prevention strategies. 5. Weekly skin checks should be done by a licensed nurse weekly and as needed. a. When completing skin checks licensed nurses should identify and current skin concerns as well as any new concerns. Resident #11 was admitted to the facility in February 2024 with diagnoses including dementia, hypertension, depression, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #11 had a severe cognitive impairment and did not have a pressure ulcer. On 12/11/24 at 7:16 A.M., the surveyor observed Nurse #1 perform a dressing change to Resident #57's spine. Review of Resident #11's physician's order, dated 11/14/24, indicated: - Skin integrity check reminder-complete NSG: Weekly Skin Check Evaluation, every night shift every Friday for prophylaxis. You MUST document skin check in the NSG: Weekly Skin Check Evaluation. Review of Resident #11's physician's order, dated 11/26/24 and discontinued on 12/10/24, indicated: - To the open area on the mid spine area: wash with normal saline, apply bacitracin followed by dry protective dressing daily, every night shift. Review of Resident #11's physician's order, dated 12/10/24, indicated: - To the open area on the mid spine area: wash with normal saline, apply medihoney followed by dry protective dressing daily, every night shift. Review of Resident #11's hospice note, dated 11/24/24, indicated visited with ADON, saw new open area on lumbar spine, continue bacitracin and pillow propping. No other changes to plan of care. Review of Resident #11's nursing note, dated as a late entry 11/26/24, indicated: - The red area on the spine opened up slightly. Review of Resident #11's WEEKLY SKIN CHECK assessments, indicated the following: - SKIN PROBLEMS (OTHER THAN TO FEET), dated 11/30/24 not complete - SKIN INTACT- NO CONCERNS, dated 12/7/24 During an interview on 12/12/24 at 7:59 A.M., Nurse #1 said she completed the skin check on 12/7/24. Nurse #1 said she did not document the open area because the wound was already documented. During an interview on 12/12/24 at 11:08 A.M., the Director of Nursing said skin checks should be accurately documented in the medical record.

Based on observations, record review and interview, the facility failed to 1.) ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units and 2.) failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals. Findings included: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. During an interview on 12/18/23 at 9:02 A.M., the Director of Nursing said that the facility does not accept clinically complex residents and all residents must have a diagnosis of dementia to be admitted . 1. The facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units Review of the facility assessment, dated as reviewed 1/16/23, indicated the following during a typical month: An average daily resident census of 93 with a facility capacity for 110 residents. Further review indicated that the daily number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 27 full time equivalents (FTE's); 1.02 hours per resident per shift on the 7 A.M.- 3 P.M. and 3 P.M.-11 P.M. shifts and .407 hours per resident per shift on the 11 P.M.-7 A.M. shift. Further review failed to indicate if staffing levels change based on the acuity level of the residents and failed to indicate what the current acuity level of the residents is. Review of the staffing schedules dated 11/25/23, through 12/12/23, indicated the facility failed to ensure staffing levels for CNA's were maintained at the level their facility assessment indicated was needed to safely and adequately meet each resident's personal and cognitive care needs. Further review indicated the following: - On 7 A.M.-3 P.M. 11 out of the 18 shifts did not meet the required number of hours. - On 3 P.M.-11 P.M. 17 out of the 18 shifts did not meet the required number of hours. - On 11 P.M.-7 A.M. 14 out of the 18 shifts did not meet the required number of hours. 2. The facility failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals. a.) Resident #54 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and Alzheimer's. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/23, indicated that Resident #54 scored 0 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated that Resident #54 requires verbal cues or touching assistance with eating. Review of the care plan, dated as revised 10/17/23, indicated that Resident #54 requires assistance/ potential to restore function to maximum self-sufficiency for eating related to: cognitive deficits related to dementia, easily distracted. On 12/15/23 at 12:25 P.M., the surveyor observed Resident #54 in her/his room, sitting in a chair eating her/his meal. The surveyor also observed that no staff member was in the room assisting the Resident. b.) Resident #64 was admitted to the facility in November 2022 with diagnoses including dysphagia, dementia and hallucinations. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #64 scored 2 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Further review indicated that Resident #64 requires verbal cues or touching assistance with eating. Review of the care plan, dated as revised 11/11/22, indicated that Resident #64 requires limited assistance from staff to eat. On 12/15/23, at 12:25 P.M., the surveyor observed Resident #64 in her/his room, sitting in a chair eating her/his meal. The surveyor also observed that no staff member was in the room. During an interview on 12/13/23, at 2:18 P.M., CNA #9 said that continual supervision means that someone has to watch the resident at all times. CNA #9 then said that it is everyone's responsibility, but there is not enough staff because almost everyone requires cues and supervision and there is just not enough staff. CNA #9 then said that we leave some of the heavier care residents in bed when we don't have enough staff, we can't do it all. CNA #9 said that there are not enough activities for the residents which makes it much harder to care for everyone because the residents wander around and it's not safe. During an interview on 12/13/23 at 2:31 P.M., CNA #8 said it is really difficult to supervise everyone in the dining room because we are so short staffed. She continued to say that especially on the weekends we are very short staffed, sometimes there are only two CNA's on the second floor, we have to leave dependent residents in bed because we don't have the staff to feed everyone so they have to eat late. Ever since the new company took the building over it seems like they are not hiring. During a follow-up interview on 12/19/23 at 10:49 A.M., CNA #8 said there are not enough staff in the building and the residents are suffering from it. CNA #8 said we cannot provide as many showers to the residents as we should be. She continued to say that residents are always waiting to be fed because they need to wait for us to finish assisting other residents with meals, dependent residents are unable to be fed at the same time. During an interview on 12/13/23 at 2:15 P.M., Nurse #6 said we are short staffed, so it is hard to always supervise residents during meal time. During an interview on 12/14/23 at 6:59 A.M. Nurse #2 said that staffing is short on the weekends. He said they typically run on the evening shift with 3 or 4 CNAs and need at least 5. Nurse #2 said when staffing is bad they leave non ambulatory residents in bed for meals. He said nurses are taken away from their medication pass and nursing duties to assist with feeding. 41105 During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that the facility does not have enough staff to supervise the dining rooms. She said that this is a dementia facility, and we need more staffing than a traditional nursing facility. Nurse Supervisor #1 said weekends are particularly low staffing and that I tell the staff if there aren't enough staff on, then feed resident's 50%, then move onto the next person because at least they got something in them. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyors inquired, based on what had been observed thus far in the survey process, if the staff to resident ratio was sufficient given the volume of resident-to-resident altercations and lack of required supervision at meals. The NHA said that he was not sure, and the DON said that they often are not able to meet the safe level they have determined through their facility assessment. During a follow-up interview on 12/15/23 at 1:15 P.M., the surveyors again addressed concerns regarding staffing as it relates to resident safety, supervision and assistance with meals with the DON and NHA. They said that part of the problem was that the facility's ownership had not paid one of their staffing agencies and that the agency therefore wouldn't send staff to the facility. The NHA said that ownership was cutting the agency a check that day and that the agency would assist to staff the facility adequately that coming weekend. On Monday 12/18/23, review of the weekend staffing indicated that despite reassurance from the NHA that the staffing would be sufficient over the weekend, it still remained considerably less than directed by the facility assessment. The facility assessment indicates staffing for CNA's each day, based on the census should be 85.68 hours on the 7-3 and 3-11 shift: * On Saturday 12/16/23, there were 72 hours of CNAs on the 7-3 shift and 64 hours on the 3-11 shift. * On Sunday 12/17/23, there were 80 hours of CNAs on the 7-3 shift and 72 hours on the 3-11 shift. SEE F600, F607, F689, F699 45984 44095

Based on interview and record review, including review of the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was sufficiently staffed per the Facility Assessment; 2. ensuring quality of care related to abuse was maintained for one Resident (#62); and 3. ensuring quality of care related to safety & hazards in the facility was maintained for two Residents (#30 and 35) out of a total sample of 29 residents. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, 06/01/23, indicated that the Governing Body included, but was not limited to, the Administrator, Director of Nursing (DON), Assistant Director of Nursing, the Chief Operating Officer and the Medical Director. 1. During an interview on 12/12/23 at 9:37 A.M., with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the DON said that the facility had not had most key staff positions in place since she started in February of 2023. The DON said that this included lack of a staff educator or Infection Preventionist nurse until this past month. On day 2 of the survey the Staff Educator/Infection Preventionist nurse quit. During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. During an interview on 12/13/23 at 12:21 P.M., the Staff Development Coordinator (SDC) said that she was unable to locate any documentation that the staff had received any dementia training for the year 2023. During an interview on 12/13/23 at 2:31 P.M., Certified Nursing Assistant (CNA) #8 she said that ever since the new company took over last year (December 2023) we don't have any support and it feels like they are not hiring anyone. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor (#1) she said that the facility does not have enough staff to supervise the dining rooms. She said that this is a dementia facility and we need more staffing than a traditional nursing facility. Nurse Supervisor #1 said weekends are particularly low staffing and that I tell the staff if there aren't enough staff on, then feed resident's 50% then move onto the next person because at least they got something in them. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyors inquired, based on what had been observed thus far in the survey process, if the staff to resident ratio was sufficient given the volume of resident to resident altercations and lack of required supervision at meals. The NHA said that he was not sure and the DON said that they often are not able to meet the safe level they have determined through their facility assessment. During an interview on 12/14/23 at 11:45 A.M., with the Director of Nursing (DON) she said Corporate was not assisting her with getting support for the vacant positions, they just say there are no applications coming in. The DON said that she had only seen the Corporate Nurse once since she started in February 2023 and that she cannot get her DON duties done because there's no help. During a follow-up interview on 12/15/23 at 1:15 P.M., the surveyors again addressed concerns regarding staffing as it relates to resident safety, supervision and assistance with meals with the DON and NHA. They said that part of the problem was that the facility's ownership had not paid one of their staffing agencies and that the agency therefore wouldn't send staff to the facility. The NHA said that ownership was cutting the agency a check that day and that the agency would assist to staff the facility adequately that coming weekend. During the Recertification survey, newly hired employees and their education records were requested. A total of 20 new employees, including the Director of Nurses and Nursing Home Administrator, had been identified as being hired since January of 2023. The facility was unable to provide documentation that 10 of the 20 new hires had the required dementia training. During an interview on 12/18/23, at 9:20 A.M., the Human Resource Director (HR) said that no annual reviews have been completed since the change of ownership on 12/15/22, and she was not able to locate any annual reviews for the eight employee records the surveyor requested. The HR Director also said that she could locate only one of the 8 yearly staff competencies requested and that it was completed the day before on 12/17/23. Review of the staffing schedules dated 11/25/23, through 12/12/23, indicated the facility failed to ensure staffing levels for CNA's were maintained at the level their facility assessment indicated was needed to safely and adequately meet each resident's personal and cognitive care needs. Further review indicated the following: 1. 7 A.M.-3 P.M. 11 out of the 18 shifts did not meet the required number of hours. 2, 3 P.M.-11 P.M. 17 out of the 18 shifts did not meet the required number of hours. 3. 11 P.M.-7 A.M. 14 out of the 18 shifts did not meet the required number of hours. 2. Resident #62 was admitted to the facility in March 2023 and has diagnoses that include dementia, anxiety and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/07/23, indicated that Resident #62 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #62 had behavior of wandering in 4 to 6 of the last 7 days of the assessment period. During survey Resident #62 was involved in the following resident to resident altercations in the 1 [NAME] Unit dining room: * On 12/12/23 at 8:31 A.M., Resident #44 punched Resident #62 in the arm. The surveyor witnessed the incident and immediately notified facility staff. * On 12/13/23 at 1:01 P.M., Resident #16 open handed slapped #62 on the hand. The surveyor and a facility staff member witnessed the incident. * On 12/18/23 at 12:18 P.M., Resident #16 open handed slapped #62 on the shoulder. The surveyor witnessed the incident and immediately notified facility staff. The facility neglected to investigate each incident timely, resulting in continued episodes of abuse to Resident #62. 3. For Resident #30, with a diagnosis of dysphagia (difficulty chewing and swallowing), the staff failed to provide continual supervision during breakfast in the 1 [NAME] Unit dining room on 12/12/23, and Resident #30 ate pieces of his/her paper meal ticket. Following the staff becoming aware of this behavior, and the facility stating that all paper would be removed from Resident #30's tray at meals, Resident #30 continued to be served paper products for three additional meals and the continual supervision was not provided at that time. For Resident #35, during lunch in the 1 [NAME] Unit dining room on 12/13/23, the staff failed to provide the required assistance with meals and Resident #35 ate part of a napkin and continued to accidentally push a napkin into his/her mouth and chew on it while attempting to self feed him/herself food. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that the facility does not have enough staff to supervise the dining rooms. During an interview on 12/13/23 at 2:15 P.M., Nurse (#6) said we are short staffed, so it is hard to always supervise residents during mealtime. During an interview on 12/13/23 at 2:31 P.M., Certified Nursing Assistant (CNA) #8 said it is really difficult to supervise everyone in the dining room because we are so short staffed. See F725, F600, F689

Based on observations, interviews and record reviews the facility failed to implement their Abuse policy for 7 Residents (#62, #44, #16, #28, #11, #5 and #13) out of a total sample of 29 residents. Specifically 1. For Resident #62, the facility failed to implement the abuse policy following three incidents of Resident #62 being struck by peers in the 1 [NAME] Unit dining room on 12/12/23, 12/13/23 and 12/18/23. 2. For Resident #44, the facility failed to implement the abuse policy when he/she struck a peer in the 1 [NAME] Unit dining room on 12/12/23. 3. For Resident #16 the facility failed to implement the abuse policy after he/she struck a peer, on 12/13/23 and 12/18/23, in the I [NAME] Unit dining room. 4. For Resident #28, the facility failed to implement a timely investigation when he/she reported to staff that a man had come into his/her room the previous night and spit on him/her. 5. For Resident #11 the facility failed to implement a timely investigation into a bruise of unknown origin. 6. For Resident #5 the facility failed to implement their abuse policy and procedure when multiple staff members observed new bruising to Resident #5's face. 7. For Resident #13 the facility failed to ensure nursing implemented the facility abuse policy and reported an injury of unknown source, as required. Findings include: Review of the facility policy, titled Abuse, dated 10/23/22, indicated the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. -Investigation 1. All alleged violations involving abuse, neglect, exploitation, and/or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. 2. The facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved. 3. The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process upon receipt of the allegation. 4. An injury will be classified as an injury of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury or location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 5. Facility will initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation. -Reporting 1. Staff should notify the Shift Supervisor/Charge Nurse/Manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information. And investigation MUST be directed by the Administrator or designee immediately. 4. Notify the local law enforcement and appropriate State Agency(s) immediately (no late than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. 8. Report results of investigation to the proper authorities as required by state law. Review of the facility policy, titled Investigations, revised 10/2022, indicated the facility has designed and implemented processes to enable it to come to a resolution, after thoroughly investigating grievances, accidents, incidents, losses, thefts, allegations or other means in order to determine appropriate actions that can be taken to correct the situation and prevent further reoccurrences. -Procedure 1. Notify the Supervising Nurse or Charge Nurse as soon as a complaint is received, or an incident is reported. a. If the complaint is a verbal report of an accident or incident the incident/accident report shall be written by the person receiving the complaint with time and date of complaint. d. The Director of Nursing (DON) or Administrator must notify the state within 2 hours of an incident that is alleged or determined to be abuse, neglect, mistreatment or exploitation, as per your state guidelines. i. NOTE: Employees and licensed professionals are required by law to report any witnessed abuse, mistreatment or neglect to facility leadership. 3. The supervising nurse or nurse in charge, begins the investigation immediately. 4. The supervising nurse completes the Resident Incident Report. 5. The supervising nurse ensures the implementation of immediate intervention as indicated. i. If the incident involves an allegation of abuse, neglect, or mistreatment against an employee, the registered nurse (RN) supervisor or designee interviews the employee, gets a written statement an (sic) immediately suspends employee prior to investigation. The employee is removed from duty for the protection of residents during investigation. -Conducting the Investigation 1. The RN Supervisor or designee starts the investigation immediately. i) The investigator must remain objective. 3. The investigator conducts interviews in the following order: i) The resident(s) involved. Obtain a statement (if possible) about what occurred from the resident and complete appropriate nursing assessments (i.e. pain, skin integrity). ii) Locate and arrange interviews with the people involved in, or may have witnessed, the incident (i.e. the person who found the resident/patient or to whom the incident was first reported, people who were near the incident scene, the staff member responsible for the care of the resident or patient, the nurse responsible for the unit). This may involve going back 24 hours and interviewing staff on previous shifts (or greater than 24 hours if alleged incident occurred earlier). 11. Interview all potential witnesses. Request only information about what they actually observed. i) Employees ii) Roommates iii) Family member(s) 12. Document a brief, concise, objective description, in the medical record of what was actually observed. Do not speculate; record only factual information noted at the scene. 1. For Resident #62 the facility neglected to keep him/her safe and Resident #62 was struck three times by 2 peers, in the unit dining room, on 3 different days during the Survey and failed to immediately implement an abuse investigation following 2 of the 3 incidents. The facility policy titled Abuse, dated as revised 10/23/22, indicates the following: -Neglect is the failure to provide good or services to avoid physical harm, mental anguish or mental illness. -Under the policy's section titled Protection the policy indicates the following: 1. The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in process. 3. Provide for the immediate safety of the resident/patient upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Which may include but not limited to: a. Move resident/patient to another room or unit b. Provide 1:1 monitoring as appropriate Resident #62 was admitted to the facility in March 2023 and has diagnoses that include dementia, anxiety and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/07/23, indicated that Resident #62 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #62 had behavior or wandering in 4 to 6 of the last 7 days of the assessment period. Review of the most recent Licensed Nursing Summary, dated 11/26/23, indicated that Resident #62 had behavior of intrusive wandering for 30 of the last 30 days. Review of the behavior care plan, most recently updated 6/19/23, failed to indicate interventions to keep Resident #62 safe by addressing intrusive behavior in the unit dining room. On 12/12/23 at 8:31 A.M., the surveyor observed Resident #62 seated in the 1 [NAME] Unit dining room. Resident #62 was seated beside Resident #44 and multiple times Resident #44 told Resident #62 to go away and to shut up. Staff were across the room, out of eye sight of the two Residents. Resident #44 punched Resident #62 in the right upper arm and said get out of here. At 8:33 A.M., the surveyor notified Nurse #4 what had been observed. Nurse #4 said they don't sit together and, walked across the room to redirect Resident #62, while at the same time saying to Resident #44 you shouldn't punch him/her. Resident #62 was easily redirected away from Resident #44. During an interview on 12/13/23 at 12:14 P.M., with Nurse #4 she said that she notified Nurse Supervisor #1 of the incident on 12/12/23 and that the incident should have been investigated, statements obtained from staff, and skin check done of Resident #62. In this case she said she is not sure that any of that happened. Nurse #4 said that she did not conduct a skin check of Resident #62 and had not asked any staff for witness statements. On 12/13/23 at 12:58 P.M., Resident #62 stood directly beside Resident #16 at a table in the 1 [NAME] Unit dining room for several minutes. At 1:01 P.M., Resident #16 open handed slapped Resident #62. A staff person was near to Resident #62, observed the incident and immediately instructed Resident #62 to walk with her. Resident #62 complied and was easily redirected away. During an interview on 12/13/23 at 2:25 P.M., Certified Nursing Assistant (CNA) #3 said that he was not aware that Resident #62 had been struck by a peer at lunch that day. CNA #3 said that the nurse should have let me know. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that she was notified on 12/12/23 that Resident #62 had been struck by a peer but hasn't had a chance to look into it yet, nor could she state a plan to protect Resident #62 from further abuse. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyor discussed concerns that had been identified and observations that had been made during the survey process regarding the handling of resident to resident altercations and the implementation of the facility's abuse policy. The DON said that she was aware that Resident #62 had been struck twice by peers, on 2 days of survey, in the 1 [NAME] Unit dining room but had not yet a chance to look into it. Nor could she state a plan to protect Resident #62 from further abuse and said that behavior of striking others is expected on a dementia unit. During a follow-up interview on 12/15/23 at 11:51 A.M., with the DON she said that she has not yet spoken with staff, obtained statements regarding what occurred or was observed in the dining room on 12/12/23 or 12/13/23. The DON could not state a plan to protect Resident #62 from further abuse. On 12/18/23 at 10:50 A.M., the surveyor observed Resident #16 strike Resident #62 with an open hand in the 1 [NAME] Unit dining room. The Activity Assistant #1 was the only staff person in the room and did not observe the incident. The surveyor immediately notified her of what had occurred. During an interview on 12/18/23 at 12:35 P.M., the DON she said staff is unable to stop Resident #62 from getting into others personal space, adding that Resident #62 does this all the time. The DON was unable to state a plan to protect Resident #62 from further abuse. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 2. Resident #44 was admitted to the facility in March 2022 and had diagnoses that included vascular dementia with agitation and obsessive compulsive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/23/23, indicated that Resident #44 scored a 2 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that for the 1-3 of the previous 7 days Resident #44 had episodes of Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). Review of the most recent Licensed Monthly Summary, dated 11/26/23, indicated Resident #44 had no behaviors of being verbally abusive or physically abusive toward others in the month of November 2023. Review of the behavior care plan for Resident #44 indicated it was last updated on 10/13/22. The care plan focus area indicated Resident #44 exhibits nonverbal signs of communication when annoyed or space invaded . Review of the care plan interventions, last updated on 02/08/23, failed to indicate any interventions for when Resident #44 began to exhibit annoyance toward others. On 12/12/23 at 8:31 A.M., the surveyor observed Resident #62 seated in the 1 [NAME] Unit dining room. Resident #62 was seated beside Resident #44 and multiple times Resident #44 told Resident #62 to go away and to shut up. Staff were across the room, out of eye sight of the two Residents. Resident #44 punched Resident #62 in the right upper arm and said get out of here. The surveyor immediately notified the Nurse #4. At 8:33 A.M., the surveyor notified Nurse #4 what had been observed. Nurse #4 said they don't sit together and, walked across the room to redirect Resident #62 while at the same time saying to Resident #44 you shouldn't punch him/her Review of the clinical progress notes indicated a note dated 12/12/23 at 21:05 P.M., and written by Nurse #4: Reported to this writer that Res hit another Res while they were sitting in the dining room. This writer redirected Res with good effect and separated the Residents to different dining rooms. Safety Maintained. During an interview on 12/13/23 at 12:14 P.M., Nurse #4 said that Resident #44 is not nice to residents sitting nearby to him/her. Nurse #4 said that Resident #44 is regularly verbally abusive, but accepts redirection, and she said that that Resident #44 had never struck anyone before. Nurse #4 said that she notified Nurse Supervisor #1 of the incident on 12/12/23 and that the incident should have been investigated and statements obtained from staff. In this case she said she is not sure that any of that happened. During an interview on 12/13/23 at 3:13 P.M., the Nurse Supervisor #1 said that she was notified on 12/12/23 that Resident #44 had struck a peer but hasn't had a chance to look into it yet. Nurse Supervisor #1 said that Resident #44 hits other residents all the time, especially when someone is in his/her personal space. She added everybody has been slapped by Resident #44. During an interview on 12/15/23 at 11:51 A.M., the DON said that she had not yet spoken with staff and obtained statements regarding what occurred or was observed in the dining room on 12/12/23. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 3. Resident #16 was admitted to the facility in January 2021 and had diagnoses that included Alzheimer's disease and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/02/23, indicated that Resident #16 scored an 8 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Review of the current behavior care plan indicated that Resident #16 exhibits nonverbal signs of communication when annoyed or space invaded. An intervention on the care plan included Intervene as necessary. Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed On 12/12/23 at 8:58 A.M., the surveyor observed Resident #16 throw a cup at a peer. The surveyor immediately informed the Nurse #4 who went over to Resident #16 and took his/her tray away and said you cannot throw cups at people. Nurse #4 failed to implement the plan of care and Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed. On 12/12/23 at 9:00 A.M., Nurse #4 gave Resident #16 a cup of juice, said do not throw it at anyone, and walked away On 12/13/23 at 1:01 P.M., Resident #16 open hand slapped Resident #62, who had been standing beside his/her chair in the 1 [NAME] Unit dining room for approximately 3 minutes. The staff redirected the peer that had been slapped, however, they failed to implement the plan of care and Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed. During an interview on 12/13/23 at 2:25 P.M., CNA #3 said that he was not aware that Resident #16 had thrown a cup at a peer the day prior or that he/she had struck Resident #62 at lunch that day. CNA #3 said that the nurse should have let me know. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that she was notified at lunch about Resident #16 striking Resident #62 but hasn't had a chance to look into it yet. During an interview on 12/15/23 at 11:52 A.M., with the DON she said that she has not yet spoken with staff and obtained statements regarding what occurred in either incident of Resident #16 aggressing at peers on 12/12/23 or 12/13/23. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 4. Resident #28 was admitted to the facility in July 2023 and had diagnoses that include severe dementia with anxiety and insomnia. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/19/23, indicated Resident #28 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #28 had hallucinations, delusions or behaviors. Review of the most recent Licensed Monthly Summary, dated 10/25/23, indicated Resident #28 had no behaviors. Review of the most recent Psychiatric Evaluation, dated 11/10/23, indicated the following Assessment/Plan: * Dementia with behaviors-behaviors have been stable since admission, adjusting to facility, is calm and cooperative, accepts meds, participates in activities, stable appetite, and sleeping well. Has not exhibited any new or worsening signs of psychosis, mania, delusions, A/VH, or voiced any suicidal, self injurious, other injurious ideas, intentions, plans or action at this time. * Insomnia-well managed on Trazadone at bedtime, no signs of worsening insomnia or NOC restlessness. During an interview on 12/12/23 at 8:08 A.M., Resident #28 told the surveyor I had a terrible night last night, a man came in my room, I was in bed, and he sat at the end of my bed and wouldn't leave. Resident #28 said that finally they removed the man but that he/she let them know that he spit at me, and that they wiped Resident #28 down and got the spit off of him/her. On 12/12/23 at 8:36 A.M., the surveyor overheard Resident #28 tell Nurse (#4) that the guy came to my room last night and spit on me. Nurse #4 told Resident #28 that she would keep an eye on it and make sure he doesn't come back. On 12/12/23 at 9:13 A.M., the surveyor overheard Resident #28 tell the Activity Staff #1 about the man that came in his/her room the previous night and spit on him/her. The Activity Assistant #1 told Resident #28 we will make sure it doesn't happen again and walked away. During an interview on 12/13/23 at 12:18 P.M., with Nurse #4 she acknowledged that the previous morning Resident #28 had told her that a man came in his/her room and spit on him/her. Nurse #4 said to the surveyor that was a delusion and that Resident #28 has a history of abuse and having a man break into his/her home. Nurse #4 said that this is the first time Resident #28 said that someone spit on him/her, but that she attributes it to the abuse history and that when Resident #28 makes allegations she will redirect him/her like she did yesterday. During an interview on 12/13/23 at 3:06 P.M., with Nurse Supervisor #1 she said that she had not been made aware of Resident #28's allegation, so no investigation had been started. Nurse Supervisor #1 added that if it was not witnessed we cannot 100% believe that happened. During an interview on 12/13/23 at 3:58 P.M., with the DON and NHA the surveyor discussed concerns that had been identified and observations that had been made during the survey process regarding the implementation of the facility's abuse policy. The DON said that Resident #28's allegations of abuse should be looked into. During an interview on 12/19/23 at 11:27 A.M., with the DON and the NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 5. Resident #11 was admitted to the facility in September 2022 and had diagnoses that include dementia with agitation. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/14/23, indicated Resident #11 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #11 was totally dependent on staff for care. On 12/12/23 at 12:13 P.M., the surveyor observed a fading purple and yellow, quarter sized bruise on the left side of Resident #11's forehead. Resident #11 said that he/she did not know how he/she sustained the bruise. During an interview on 12/15/23 at 11:01 A.M., with Resident #11's Certified Nursing Assistant (CNA) #3 he said that he noticed that Resident #11 had a bruise on his/her forehead on Wednesday, 12/13/23. CNA #3 said that he did not tell Nurse (#4) because he figured she was aware. The surveyor and CNA #3 observed the bruise on Resident #11's head together and he asked Resident #11 how he/she got the bruise. Resident #11 said he/she didn't know. During an interview on 12/15/23 at 11:07 A.M., with Resident #11's Nurse #4 she said she observed the bruise for the first time the afternoon prior when observing Resident #11 with another surveyor and has no idea how Resident #11 got it. Nurse #4 could not explain why she had not noticed the bruise sooner as she had been Resident #11's nurse on 12/12/23 and 12/13/23. Nurse #4 said that she had not yet notified Nurse Supervisor #1 or the Director of Nursing about the bruise, and had not initiated an investigation into this bruise of unknown origin. She said that a full skin assessment should have been done when the bruise had been identified but she had not done one yet. During an interview on 12/15/23 at 11:18 A.M., Nurse Supervisor #1 said that staff should have reported the bruise to her immediately and began an investigation, including starting an incident report, getting statements from staff, and a full skin check. She said that she would then have notified the Director of Nursing because a bruise of unknown origin should be reported. During an interview on 12/15/23 at 11:53 A.M., the Director of Nursing said that she does not recall if she was aware that Resident #11 had a bruise of unknown origin and that she had not started an investigation. During a interview on 12/19/23 at 11:27 A.M., with the DON and Nursing Home Administrator (NHA), the NHA said I would say that there is a problem with reporting and abuse in the facility. 44095 6) For Resident #5, the facility failed to implement their abuse policy and procedure to investigate and report a bruise when multiple staff members observed bruising to Resident #5's face. Resident #5 was admitted to the facility in July 2022 with diagnoses including dementia, diabetes and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #5 had a Brief Interview of Mental Status (BIMS) score of 7 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #5 wanders and required supervision with walking. Review of the skin check, dated 12/8/23, indicated: -No skin issues. On 12/12/23 at 7:59 A.M., Resident #5 was observed in bed with purple discoloration to his/her right side of face. On 12/13/23 at 6:41 A.M., and 12/14/23 at 6:51 A.M., Resident #5 was in his/her bed and was observed with a purple discoloration to his/her right side of face. Review of the nursing progress note, dated 12/15/23, indicated: -Noted bruise on the bottom right chin. During an interview on 12/14/23 at 6:58 A.M., Nurse #2 said that Resident #5 sustained a bruise to his/her chin when he/she got into an altercation with Resident #13 on 12/11/23. During an interview on 12/15/23 at 11:00 A.M., Nurse #1 said that Resident #5 had a bruise on the bottom of his/her right chin. Nurse #1 said today (12/15/23) was the first time she saw the bruise. During an interview on 12/15/23 at 1:37 P.M., CNA #6 said that she found Resident #5 with a bruise on his/her face on 12/12/23 around 2:00 P.M., CNA #6 said that she did not witness Resident #6 hit his/her face, but CNA #6 said Nurse #1 was aware of the new bruising. During an interview on 12/15/23 at 11:02 A.M., the Activities Assistant said that she saw the bruise on Resident #5's right chin on 12/12/23. The Activities Assistant said that she did not report the bruise. During an interview on 12/15/23 at 11:04 A.M., CNA #5 said he saw the bruise on 12/12/23. CNA #5 said he did not report the bruise. During an interview on 12/15/23 at 11:03 A.M., CNA #3 said he saw the bruise on 12/14/23. CNA #3 said he did not report the bruise. During an interview on 12/15/23 at 11:07 A.M., CNA #2 said Resident #5 got the bruise from a resident-to-resident altercation, but he did not know the date. During an interview on 12/15/23 at 11:10 A.M., Nurse Supervisor #1 said she was not aware of Resident #5's bruise on his/her right side of the face until 12/15/23. Nurse Supervisor #1 said new bruises should be reported to management and investigated. During an interview on 12/15/23 at 8:51 A.M., the Nursing Home Administrator said that bruising of unknown origin needs to be reported within 2 hours. 7) For Resident #13, the facility failed to ensure nursing implemented the facility abuse policy and reported an injury of unknown source to the Department of Public Health, as required. Resident #13 was admitted to the facility in April 2023 with diagnoses including dementia with severe psychotic disturbance, bipolar disorder and major depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #13 had a Brief Interview of Mental Status (BIMS) score of 99 out of a possible 15 which indicated he/she was rarely understood. The MDS indicated Resident #13 experienced hallucinations and delusions. Resident #13 experienced wandering 4 to 6 days a week and physical and verbal behaviors 1 to 3 days a week. The MDS indicated Resident #13 was dependent on staff for bathing, toileting and personal hygiene. The MDS indicated Resident #13 required supervision or touching assistance with ambulation. On 12/12/23 at 7:58 A.M., Resident #13 was observed sitting on the edge of his/her bed. There was a purple discoloration under his/her right eye. Resident #13 was unable to say what happened to him/her. Review of the incident note, dated 12/11/23, indicated Resident #13 appeared agitated during meals throwing food on the walls and at staff CNA (Certified Nurse Assistant) during breakfast. The incident note indicated a CNA and this LPN (Licensed Practical Nurse) encouraged and redirected Resident #13 with no success. The note indicated Resident #13 then ambulated with assistance with a CNA to his/her room to rest. Staff observed Resident #13 hitting the walls and tables with his/her hands and fists. The note indicated Resident #13 threw sheets and a bed spread on the floor. The note indicated staff redirected Resident #13 to the dining room to participate in activities. The note indicated Resident #13's aggressive behavior continued and he/she was resistive to ADL care. The note indicated the nurse then observed that Resident #13 had a discoloration on his/her right cheek. Review of the facility incident report dated 12/11/23 at 14:00, indicated: Nursing Description: Resident seen with discoloration on the right cheek. Resident Description: Resident unable to give a description. Review of the plan of care related to bruise, dated 12/11/23, indicated: - Resident has a new bruise to the right cheek. From unknown source. Review of the written witness statements, dated 12/11/23, indicated CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7, did not witness how Resident #13 obtained a bruise. Review of the incident report notes, dated 12/14/23, indicated: - Follow up assessment done by Director of Nursing bluish discoloration on left cheek below eye [injury is below right eye]. - Bruise on left cheek may have been self inflicted. During an interview on 12/12/23 at 8:50 A.M., Nurse #1 said she was assigned to Resident #13 on 12/11/23. Nurse #1 said she did not witness Resident #13 hit him/herself in the face and did not witness Resident #13 obtain the bruise under his/her right eye. Nurse #1 said the injury was of unknown source. During an interview on 12/15/23 at 1:37 P.M., CNA #6 said she found Resident #13 with a bruise on his/her face. CNA #6 said that she did not witness Resident #13 hit his/her face and did not know how the bruise happened. During an interview on 12/14/23 at 2:28 P.M., Nurse Supervisor #1 said she was made aware of Resident #13's bruising when she read the incident report on 12/12/23 in the morning during report (approximately 19 hours after the injury was discovered by Nurse #1 and CNA #6). Nurse Supervisor #1 said Resident #13's bruise was an injury of unknown source. During an interview on 12/15/23 at 9:27 A.M., the Director of Nursing said she was made aware of the bruise on 12/12/23. The DON said the bruising was of unknown origin. During an interview on 12/15/23 at 8:51 A.M., the Nursing Home Administrator said bruising of unknown source needs to be reported to the Department of Public Health within 2 hours.

Based on observation, interviews, record and policy reviewed for one Resident (#13) out of a total sample of 29 residents, the facility failed to ensure residents with a history of trauma received trauma informed care in accordance with professional standards. Specifically, the facility failed to implement Resident #13's trauma-informed plan of care which indicated he/she should have female care givers for personal care. Findings included: Review of the facility policy titled, Trauma Informed Care, revised 10/22/22, indicated to ensure residents, who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Care Planning: 1. The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions. 3. Care plans should have interventions that minimize or eliminate the effect of known triggers. a. If triggers are unknown/unreported facility should multiple [sic] ways to identify resident triggers. 4. Trigger-specific interventions should identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Resident #13 was admitted to the facility in April 2023 with diagnoses including dementia with severe psychotic disturbance, bipolar disorder and major depression. Review of the Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #13 was unable to complete the Brief Interview of Mental Status (BIMS) exam and was assessed by staff to have severely impaired cognition. Resident #13 experienced hallucinations and delusions. Resident #13 experienced wandering 4 to 6 days and physical and verbal behaviors 1 to 3 days. The MDS also indicated Resident #13 was dependent on staff for bathing, toileting and personal hygiene. The MDS indicated Resident #13 required supervision or touching assistance with ambulation. Review of the physician's order, dated 4/7/23, indicated: -Activate Heath Care Proxy Review of the plan of care related to related to care, dated 4/17/23, indicated: Focus: -History of being a victim of a traumatic event related to sexual assault when he/she was in his/her early 20's. Son reports no known triggers but he/she should have female staff providing all personal care. Intervention: -Female staff for all personal care Review of the 7:00 A.M. to 3:00 P.M. First Floor Assignment, dated 12/13/23, indicated five of five Certified Nurse Assistants (CNA) assigned to work were male. Review of the Documentation Survey Report v2 (Activities of Daily Living flow sheets), dated November 2023 and December 2023, indicated Resident #13 had a male caregiver for bathing and toileting hygiene on the following days: 11/2/23 3:00 P.M. to 11:00 P.M., 11/3/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/4/23 3:00 P.M. to 11:00 P.M., 11/6/23 7:00 A.M. to 3:00 P.M., 11/7/23 3:00 P.M. to 11:00 P.M., 11/8/23 7:00 A.M. to 3:00 P.M., 11/9/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/12/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/13/23 7:00 A.M. to 3:00 P.M., 11/14/23 7:00 A.M. to 3:00 P.M., 11/17/23 3:00 P.M. to 11:00 P.M., 11/18/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/19/23 7:00 A.M. to 3:00 P.M., 11/20/23 7:00 A.M. to 3:00 P.M., 11/23/23 3:00 P.M. to 11:00 P.M., 11/24/23 3:00 P.M. to 11:00 P.M., 11/25/23 3:00 P.M. to 11:00 P.M., 11/26/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/27/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/28/23 3:00 P.M. to 11:00 P.M., 11/29/23 7:00 A.M. to 3:00 P.M., 11/30/23 3:00 P.M. to 11:00 P.M., 12/1/23 3:00 P.M. to 11:00 P.M., 12/2/23 3:00 P.M. to 11:00 P.M., 12/3/23 3:00 P.M. to 11:00 P.M., 12/4/23 7:00 A.M. to 3:00 P.M, and 3:00 P.M. to 11:00 P.M., 12/5/23 3:00 P.M. to 11:00 P.M., 12/6/23 3:00 P.M. to 11:00 P.M., 12/7/23 7:00 A.M. to 3:00 P.M, 12/8/23 7:00 A.M. to 3:00 P.M, 12/10/23 7:00 A.M. to 3:00 P.M, 12/12/23 7:00 A.M. to 3:00 P.M, and 3:00 P.M. to 11:00 P.M., Review of the incident note, dated 12/11/23 at 16:41, indicated Resident #13 appeared agitated during meals throwing food on the walls and at staff CNA during breakfast, Staff CNA and this LPN encouraged and redirected with no success. Resident then ambulated with assistance with staff CNA to his/her room to rest. Resident seen hitting the walls and tables with his/her hands and fists. Resident throwing sheets and bed spread on the floor. Resident then redirected to the dining room to participate in activities. Aggressive behavior continued and was resistive to ADL care. Resident then seen by this Nurse with discoloration on the right cheek. Review of the behavior note, dated 12/12/23 at 8:43, indicated Resident #13 is alert, responsive with confusion at baseline. Denies pain or discomfort. Resident continues with extreme behaviors, getting up in the middle of the night going to other residents room, sitting on their beds, waking them up. Staff continue to provide frequent rounds, assist resident to use the bathroom and redirect resident back to his/her room with fair effect. Review of the incident note, dated 12/12/23 at 13:59, indicated Resident #13 ambulated by staff CNA to the dining room for breakfast. Resident began hitting his/her hand on the table and displaying aggressive behavior. Staff then redirected resident back into his/her room to administer 1:1 feed with good effect. Review of the psychiatric consult note, dated 12/14/23, indicated, asked to see Resident #13 with history of bipolar disorder, dementia with behaviors, depression, and delirium due to worsening aggression, agitation, combativeness, and other behaviors. Has had multiple med adjustments as result of labile behaviors. Review of the order note, dated 12/14/23, indicated new psych recommendation to increase Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) twice daily to Seroquel oral tablet 37.5 mg twice daily. On 12/13/23 at 8:15 A.M., Certified Nurse Assistant (CNA) #1, a male, was observed bringing Resident #13 into the bathroom. Two minutes later, CNA #1 and Resident #13 left the bathroom. CNA #1 said that Resident #13 requires toileting before meals and is resistive to care. During an interview on 12/13/23 at 8:00 A.M., Nurse #3 said Resident #13 has lots of behaviors and he/she shakes and can be combative and resist care. Nurse #3 said that Resident #13 will make fists like he/she is going to hit someone and recently required an increase in his/her antipsychotic medication for behavior management. Nurse #3 said that Resident #3 can have both male and female care givers. During an interview on 12/13/23 at 8:19 A.M., CNA #3 said there were only males assigned to work on the 7:00 A.M. to 3:00 P.M. shift on 12/13/23. CNA #3 said there are no residents who require female only care givers. During an interview on 12/14/23 at 6:58 A.M., Nurse #2 said there are no residents who require female care givers only on the first floor unit. During an interview on 12/14/23 at 2:29 P.M., Nurse Supervisor #1 said she is not aware of any residents on the first floor who require female care givers only. During an interview on 12/15/23 at 9:35 A.M., the Director of Nursing (DON) and Administrator said that Resident #13's trauma informed care plan should be followed. The Administrator continued to say that he was not sure if this was still an active problem and wasn't sure if female caregivers was still Resident #13's preference. During an interview on 12/15/23 at 11:55 A.M., Resident #13's activated Health Care Agent said that Resident #13 was a sexual assault victim. Additionally, the Health Care Agent said Resident #13 was sexually assaulted in his/her previous nursing home by a male. The Health Care Agent said that Resident #13 should only have female caregivers and the Health Care Agent is concerned that Resident #13 would strike a male if he got too close. During an interview on 12/15/23 at 12:27 P.M., the Social Worker reviewed Resident #13's care plan with the surveyor and said that Resident #13 should only have female CNAs. Using the reasonable person concept, an individual with a known history of sexual assault by a male, and who is unable to articulate or verbalize his/her concerns and trauma, would experience emotional distress when being cared for by men.

Based on observation, documentation review, policy review, and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for 1. All residents on four of four units, 2. Specifically for one Resident (#78) the facility failed to include the Resident in a preferred activity taking place on the unit, and 3. Failed to ensure adequate activity staff were scheduled to provide activities on 4 out of 4 units. Findings include: Review of the facility policy titled Dementia, dated as revised January 2023, Section: Dedicated Recreation Program; indicated that the facility provides residents with diagnoses of dementia with person-centered activities designed to provide familiar routines and create social outlets. The policy further indicated that for those with mild dementia who can follow simple directions, participating in group situations is recommended. Structure is key to having the same kinds of activities repeated daily and provides a routine that is comforting. The facility policy failed to indicate what types of activities are provided for residents with moderately and severely impaired cognition. During an interview on 12/18/23, at 9:02 A.M., the Director of Nursing said that all residents have to have a diagnosis of dementia of some kind to be admitted to the facility. Review of the activity calendar dated 12/12/23, indicated the following: 2:00 P.M. Ice Cream Social 3:00 P.M. Balloon Volleyball 3:30 P.M. Shake and Bake 4:00 P.M. Jeopardy 1. On 12/12/23, at 2:35 P.M., the surveyor observed eight residents in the 1 [NAME] dining room without an activity taking place. The surveyor observed one resident take a box of gloves, tear open the box and put a pair of gloves on his/her hands. The surveyor then observed Activity Assistant #1 remove a plastic box containing a small flash light, a pair of maracas, two small containers of play dough, a few playing cards and a picture of a farm. The surveyor observed Activity Assistant #1 give one resident three playing cards (an ace, a 2 and a 3) and tell the resident to match the playing cards. Activity Assistant #1 then put the plastic box on the counter without distributing any of the other items. She then escorted several other residents into the room and assisted them to sit down. On 12/12/23, at 3:25 P.M., the surveyor observed 20 residents in the 1 [NAME] dining room. The residents were seated at tables of four. One resident was interacting with Activity Assistant #1 using a balloon, one resident was coloring and 18 residents were without an activity. The surveyor then observed Activity Assistant #1 try to toss the balloon to two other residents. Activity Assistant #1 then put the balloon down and redirected several residents who were wandering and exhibiting intrusive behaviors. During an interview on 12/12/23, at 3:30 P.M., Activity Assistant #1 said that she goes from resident to resident with the balloon. She also said that while she is doing balloon toss with one resident the other residents are not participating in an activity. She also said that she has a cake in the oven and has to pay attention to it as well, and that is why she did not move everyone into a circle. Activity Assistant #1 then said that she spends a lot of time redirecting residents and there is no staff to help her with activities. She also said she thinks the facility is short-staffed for activities and she cannot provide activities to all the residents. On 12/12/23, at 3:35 P.M., the surveyor observed several residents on 2 East wandering in the hallway going in and out of other resident rooms. The surveyor also observed five residents in their rooms without an activity. The surveyor did not observe staff members encouraging residents to participate in an activity. On 12/12/23, at 3:38 P.M., the surveyor observed 12 residents in the 2 [NAME] dining room. The residents were seated at tables of four. eight of the ten residents were not involved in an activity, two residents were watching television, and two residents were coloring. During an interview on 12/12/23, at 3:40 P.M., Activity Assistant #2 said that it is past 3:30 P.M., so I put coloring books out right now because it is time for the residents to calm down. We're just keeping them calm and getting them ready for dinner. When asked about the 4:00 P.M. activity, Activities Assistant #2 did not know what was scheduled on the calendar. She then looked at the calendar and said she would put Jeopardy on the television for the residents to watch. The surveyor asked Activities Assistant #2 what activity option was available for residents who were unable to participate in an intellectually demanding program, like Jeopardy, On 12/12/23 at 3:46 P.M., Activities Assistant #2 went into the activity room and placed sensory items in front of three of the residents. On 12/12/23, at 4:10 P.M., the surveyor observed 13 residents in the 2 [NAME] dining room. One resident was watching the scheduled activity Jeopardy on the television, one resident had a sensory mat on the table in front of them, one resident was coloring and 10 residents were not involved in an activity. On 12/12/23, at 4:17 P.M., the surveyor observed 20 residents in the 1 [NAME] dining room. The surveyor observed 4 residents watching television, one resident looking at coloring pages and 15 residents were not involved in an activity. On 12/18/23, at 10:30 A.M. the surveyor observed Activity Assistant #1 in the 1 [NAME] dining room attempting to run an exercise program. Activity Assistant #1 was the only one in the dining room with 30 residents. Several residents were up and wandering. Activity Assistant #1 spent a total of 15 seconds instructing the residents in the exercise program, and the rest of the time she spent redirecting the wandering residents to sit. The surveyor then observed the Activity Assistant at 10:44 A.M., put an exercise video on the television. The surveyor observed that only three residents out of 30 were following the directions on the exercise video. On 12/18/23, at 10:57 A.M., Certified Nurse's Aide (CNA) #1 said that there were only three residents in the room that could participate in the activity. CNA #1 also said that the rest of the residents in the room could not participate because they didn't understand and could not follow simple directions because of their dementia. CNA #1 said the activity was not appropriate for all but three of the residents. 2. Resident #78 was admitted to the facility in August 2023 with diagnoses including Alzheimer's dementia and psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #78 was unable to complete the Brief Interview for Mental Status exam. Further review indicated Resident #78 was severely cognitively impaired. Review of the facility document titled Activities Quarterly, dated 11/30/23, indicated that Resident #78 enjoys arts and crafts, music, pets, and current events. Review of the activity calendar dated December 2023 indicated that the scheduled activity at 11:00 A.M. was holiday crafts. On 12/15/23, at 11:12 A.M., the surveyor observed Resident #78 in the 2 East dining room with six other residents and Certified Nurse's Aide (CNA) #10. Music was playing but no other activity was taking place. The surveyor observed Resident #78 and the six other residents sitting at separate tables and not interacting with each other or with CNA #10. During an interview on 12/15/23, at 11:13 A.M., CNA #10 said he thinks someone from the activity department will be in soon to help with the activity but he's not sure when. On 12/15/23, at 11:24 A.M., the surveyor observed Resident #78 and eight other residents in the 2 East dining room sitting at separate tables and not interacting with each other. The surveyor also observed two staff members in the room talking to each other and not interacting with the residents. On 12/15/23, at 11:26 A.M., the Activity Director entered the room and read current events to the residents for five minutes and then left the room. 3. Review of the activity staff schedule for the month of December 2023 indicated that on 12 of 31 days only one activity staff member was scheduled for the day to cover the four units. During an interview on 12/12/23, at 3:40 P.M., Activity Assistant #2 said there is not always enough activity staff to cover all the units.

Based on records reviewed and interviews, for four of five sampled residents (Resident #2, #3, #4, and #5), who were cognitively impaired and had not been evaluated for capacity to consent, the Facility failed to ensure that residents were free from unwanted sexual contact. -On 08/02/19, Resident #3 and Resident #2 were sitting on a couch together and kissing while Resident #3 had his/her arm around Resident #2's shoulders. -On 08/04/19, Resident #1 kissed Resident #4 and in an affectionate way, touched his/her shoulder, neck, and ear while they were in the hallway and in the dining room. Resident #1 became agitated and yelled when Nurse #2 attempted to re-direct him/her way from Resident #4. -On 08/09/19, Resident #1, Resident #2 and Resident #5 were sitting on a sofa together in the dining room. Certified Nurse Aide (CNA) #8 witnessed Resident #1 and Resident #5 kissing each other. CNA #8 assisted Resident #5 away from Resident #1, but left Resident #1 and Resident #2 sitting on the couch together. After CNA #8 and Resident #5 left the dining room, Resident #1 leaned over toward Resident #2 and kissed him/her on the lips, hugged him/her and held his/her hand. Findings include: The Facility's Policy, titled Abuse Policy, dated (MONTH) 2019, indicated that residents had the right to be free from abuse and that the Facility encouraged an environment that recognized the special qualities of their residents and provided them with a safe environment. The Policy indicated staff members were required to immediately notify the administrative staff or nursing supervisor and protect the resident(s) from alleged abuse, suspend the accused employee, and begin the investigation by completing interviews and documenting an incident report for the alleged abuse. 1. Resident #2 was admitted to the Facility in (MONTH) (YEAR). Resident #2's Documentation of Resident Incapacity, dated 11/03/18, indicated that his/her physician determined he/she was unable to make his/her own health care decisions due to [MEDICAL CONDITION]. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 07/19/19, indicated that he/she had severe cognitive impairment and was sometimes able to make his/her needs known by responding to simple and direct communication. Resident #3 was admitted to the Facility in (MONTH) 2019. Resident #3's Documentation of Resident Incapacity, dated 02/15/19, indicated his/her physician determined he/she was unable to make his/her own health care decisions due to [MEDICAL CONDITION]. Resident #3's Quarterly MDS Assessment, dated 05/16/19, indicated that he/she had severe cognitive impairment and was usually able to make his/her needs known if prompted or given time. The Facility's Investigation, dated 08/02/19, indicated Resident #3's Family Member walked into the dining room and witnessed Resident #3 and Resident #2 sitting on a couch together and kissing while Resident #3 had his/her arm around Resident #2's shoulder. The Investigation indicated Resident #3's Family Member became upset and removed Resident #3 away from Resident #2. The Investigation indicated staff reviewed the security camera footage to substantiate the allegations. The Investigation indicated Resident #3 was moved to another unit in response to the incident. Activities Aide #1's Written Statement, dated 08/02/19, indicated that on 08/02/19, she witnessed Resident #3's arm around Resident #2's shoulders while they were sitting on the couch together in the dining room. The Statement indicated that she saw Resident #3 being affectionate towards Resident #2 and described the residents as being happy and safe. The Surveyor interviewed Activities Aide #1 at 1:17 P.M. on 08/22/19. Activities Aide #1 said she saw Resident #3 being affectionate toward Resident #2 prior to Resident #3's Family Member walking into the dining room. Activities Aide #1 said she was unclear about what sort of affection was allowed between residents. Activities Aide #1 said she did not separate the two Residents or report the incident to anyone. The Surveyor interviewed Activities Aide #2 at 1:41 P.M. on 08/22/19. Activities Aide #2 said that prior to Resident #3's Family Member walking into the dining room, she saw Resident #2 put his/her head on Resident #3's shoulder while the two residents were holding hands and sitting on a couch together. Activities Aide #2 said she tried to separate the residents but neither of them wanted to move, so she left the residents on the couch together because they appeared safe. Activities Aide #2 said she did not report the incident to anyone. Review of Resident #2 and Resident #3's clinical record indicated there was no documentation to support that staff reported the incident per Facility policy and there was no documentation to support that the facility had Resident #2 and Resident #3 assessed by psychiatric services after the alleged incident occurred. 2. Resident #1 was admitted to the Facility in (MONTH) 2019. Resident #1's Admission MDS Assessment, dated 07/09/19, indicated he/she was usually able to make his/her needs known if prompted or given time. Resident #1's Documentation of Resident Incapacity, dated 07/13/19, indicated that his/her physician determined he/she was unable to make his/her own health care decisions due to [MEDICAL CONDITION]. Resident #4 was admitted to the Facility in (MONTH) (YEAR). Resident #4's Documentation of Resident Incapacity, dated 12/14/17, indicated his/her physician indicated he/she was unable to make his/her own health care decisions due to [MEDICAL CONDITION]. Resident #4's Annual MDS Assessment, dated 08/02/19, indicated that he/she had severe cognitive impairment and was sometimes able to make his/her needs known by responding to simple and direct communication. A Nurse Progress Note, dated 08/04/19, indicated that Resident #1 was seen hugging and kissing another resident. The Note indicated that Resident #1 was re-directed with poor effect. The Note indicated the Nurse Supervisor was notified of the incident. The Facility Investigation, dated 08/05/19, indicated that on 08/04/19, Nurse #2 observed Resident #1 kissing Resident #4 in the dining room and in the hallway. The Investigation indicated Resident #1 became agitated and yelled when Nurse #2 attempted to re-direct him/her way from Resident #4. The Investigation indicated that upon review of the security camera footage, Resident #1 was observed leaning towards Resident #4, who was sitting on his/her seated walker, and in an affectionate way, touch Resident #4's shoulder, neck, and ear while they were in the hallway. The Investigation indicated Resident #4 was moved to another unit in response to the incident. The Surveyor interviewed Nurse #2 at 9:13 [NAME]M. on 08/29/19. Nurse #2 said that at approximately 1:00 P.M. on 08/04/19, she saw Resident #1 walk over to Resident #4, who was sitting at a dining room table, and sit down next to him/her. Nurse #2 said Resident #1 started kissing and hugging Resident #4. Nurse #2 said she tried to redirect Resident #1 but he/she became agitated, stood up, and began yelling at her for approximately 30 seconds. Nurse #2 said she walked away from Resident #1 and then he/she (Resident #1) sat back down next to Resident #4. Nurse #2 said she reported the incident to the Nurse Supervisor, who said she would call the Director of Nursing. Nurse #2 said she did not separate the residents, but said she began passing medications to the residents on her assignment. Nurse #2 said that at approximately 2:30 P.M. she saw Resident #1 pushing Resident #4 (who was seated on his/her rolling walker) down the hallway, and said she asked Resident #1 to stop. Nurse #2 said Resident #1 became agitated and began screaming at her again. Nurse #2 said that at the end of her shift (approximately 3:00 P.M.), she followed back up with the Nurse Supervisor, who said she was unable to reach the Director of Nursing (DON). The Surveyor interviewed the Nurse Supervisor at 12:30 P.M. on 08/22/19. The Nurse Supervisor said that at approximately 2:00 P.M. on 08/04/19, Nurse #2 came onto her unit and said that she thought love was in the air on her unit. The Nurse Supervisor said she asked Nurse #2 what she meant and Nurse #2 said it was because another resident may have licked Resident #4's face. The Nurse Supervisor said she asked Nurse #2 if any residents had kissed, and said that an incident report needed to be completed, or the DON needed to be notified. The Nurse Supervisor said when she spoke with Nurse #2, Nurse #2 had not indicated to her that any reportable incidents had occurred and said she did not hear from Nurse #2 for the remainder of the shift. A Nurse Progress Note, dated 08/06/19, indicated Resident #1 continued with behaviors of flirting with others and was redirected with fair effect. 3. Resident #5 was admitted to the Facility in (MONTH) (YEAR). Resident #5's Documentation of Resident Incapacity, dated 06/25/18, indicated that his/her physician determined he/she was unable to make his/her own health care decisions due to [MEDICAL CONDITION]. Resident #5's Annual MDS Assessment, dated 06/07/19, indicated that he/she had severe cognitive impairment and was sometimes able to make his/her needs known by responding to simple and direct communication. The Facility's Investigation, dated 08/09/19, indicated that at approximately 7:10 [NAME]M., Resident #1, Resident #2 and Resident #5 were sitting on a sofa together in the dining room. The Investigation indicated Certified Nurse Aide (CNA) #8 witnessed Resident #1 and Resident #5 kissing each other. The Investigation indicated that upon review of the security camera footage, Resident #1 was observed to also have his/her hand on the back of Resident #5's neck. The Investigation indicated CNA #8 assisted Resident #5 out of the dining room, away from Resident #1, but left Resident #1 and Resident #2 seated on the couch together. The Investigation indicated that upon review of the security camera footage, after CNA #8 and Resident #5 left the dining room, Resident #1 leaned over toward Resident #2 and kiss him/her on the lips while holding Resident #2's hand and hugging him/her. The Surveyor interviewed CNA #8 at 9:15 [NAME]M. on 08/29/19. CNA #8 said she saw Resident #1 and Resident #5 sitting on the couch together. CNA #8 said she saw Resident #1 lean over toward Resident #5 and kiss him/her. CNA #8 said she told Resident #1 to stop. CNA #8 said she moved Resident #5 away from Resident #1 by having Resident #5 walk with her to report the incident to the Nurse Manager. CNA #8 said she had not noticed Resident #2 was also on the couch with Resident #1. A Nurse Progress Note, dated 08/18/19, indicated Resident #1 had attempted to lean forward towards the face of another resident in a manner that appeared that he/she was trying to kiss the other resident, but was redirected by staff without incident. A Nurse Progress Note, dated 08/19/19, indicated that at approximately 6:30 [NAME]M. Resident # 2 and Resident #1 were walking together and when a nurse attempted to intervene, Resident #1 said in a firm voice, Resident #2 is coming with me. The Note indicated Resident #2 wanted to go with Resident #1, but was redirected and continued walking in the hallway. The Surveyor interviewed the Psychiatrist at 9:43 [NAME]M. on 08/29/19. The Psychiatrist said the Facility evaluates resident capacity to consent to a sexual relationship on an individual basis. The Psychiatrist said he has not evaluated any residents at the Facility for the capacity to consent to a sexual relationship. The Surveyor interviewed the Medical Director at 11:51 P.M. on 09/03/19. The Medical Director said that the Facility had not completed an evaluation for the capacity to consent to a sexual relationship for any of the residents at the Facility. The Medical Director said the first step to begin that process would be to make a referral to the Facility's Psychiatrist.