Every finding on record at Apostolic Christian Home of Eureka

Based on Observation, Interview and Record Review, the facility failed to ensure opened refrigerated and frozen food items were labeled with expiration dates, cool down temperatures were monitored and recorded for food cooked and then stored in the refrigerator, and ensure all employees wore a hair restraint that covered all of their hair while in the kitchen and preparing food. This failure has the potential to affect all 90 residents residing in the facility. Findings include:The facility's Dietary Refrigerated Food Storage policy, dated 6/19/24, documents It is the policy of this facility to date and label food that has been opened and to discard food in a manner that promotes the health and safety of our residents. All food that has been opened needs to be labeled with the date that it was opened as well as the discard date, which would be 6 days from the date opened (with the exception of condiments, pickles, sauerkraut, cheese, salad dressing, mayonnaise). Example: A food item opened on 7-8 would have a discard date of 7-14. Any condiment, pickles, sauerkraut, cheese, salad dressing, syrup or mayonnaise may be saved for one month after opening.The facility's Dietary Cool Down Procedure policy, dated 6/19/24, documents The temperature of food should be taken as soon as it is brought to the main kitchen from meals and /or advance prep is completed. The temperature should be 135 degrees F (Fahrenheit). or above. Record temp and time on Cool Down Procedure Sheet. This is the start cool down temperature. Follow Quick Chill method. Place food in metal pans with no more than two-inch thickness. Label with name of food, date, time and temperature. Place in walk- in freezer. Take temperature and document in the first hour. Take temperature and document in the second hour to make sure the temperature reaches 70 degrees (Fahrenheit). If the temperature does not reach 70 degrees within two hours, the food needs to be disposed of or re-heated to 165 degrees, at which point the cool down process can be started again. If the food fails to reach 70 degrees the second time, it must be disposed of. Food needs to be temped every hour and documented. If the food does not reach 40 degrees in four additional hours, it needs to be heated to 165 degrees and the cool down process started again. If the food fails to reach 40 degrees by the end of the process the second time it must be disposed of.On 3/23/26 at 10:00 AM, V4 (Dietary Manager) walked through the kitchen for a tour. V4 had a buzzed haircut and did not wear a hair covering hairnet or hat. At this same time, V5 (Cook) and V7 (Assistant Dietary Manager) were both observed preparing food items and walking around the kitchen with a baseball style hat and both kitchen employees had long hair in a ponytail or partial ponytail protruding through the back of their hats. The long hair was loose and not restrained. V6 (Dietary Assistant/Cook) was also observed in the kitchen and was wearing a baseball style hat with approximately four inches of longer length hair sticking below his ballcap and unrestrained.On 3/23/2026 at 10:10 AM, the kitchen's reach-in cooler contained five plastic containers of previously cooked meats. These containers documented Turkey 3/19, Ham (sliced roast) 3/15, Fish Nuggets 3/20, Pork (sliced loin) 3/20, Braut Burgers 3/21. At this time V4 confirmed these meats have been cooked and stored in the fridge to use for pureed diet preparation. V4 confirmed that the dates on the containers are the dates they were placed in the cooler and stated They (kitchen staff) don't put expiration dates, just the date it was placed in the cooler. These meats are mostly used for purred diets, and we would just keep them for no longer that 7 days. The kitchen's most recent Cooling Food Temperature Log documents the last item to have been monitored for cooling down temperatures was taco meat on 12/2/25. At this same time V4 confirmed he does not have a cool down record for the meats stored in the reach-in cooler and stated I wasn't aware that we have to record cool downs. I don't think that's ever been asked for.On 3/23/26 at 10:15 AM, the kitchen's walk-in cooler contained a plastic jug of opened olives labeled 2/17, a metal bowl of strawberries labeled 3/21, a plastic jug of opened pickles labeled 2/21, a large bag of opened shredded cheddar cheese, a large bag of opened mozzarella cheese, and a large, opened bag of bacon bits all without any date. At this time V4 confirmed that all of these food items do not document an expiration date and that the shredded cheese and bacon bits do not contain a date at all. V4 stated Those items would last longer (condiments). With fruit it's about three days or if it looks bad (for expiration). I would expect the bags of cheese and bacon bits to be labeled when opened. With cheese for expirations, we would also just go by the look of it.On 3/23/26 at 10:20 AM, the facility's walk-in freezer contained an opened bag of chicken patties that was not dated. V4 confirmed that the bag should have been labeled with a date when opened.On 3/23/26 at 11:19 AM, V6 recorded steam table temperatures and prepared items for the noon meal service in the facility's lower-level satellite kitchen. V6 remained wearing a baseball style hat with approximately four inches of longer length hair sticking below his ballcap, unrestrained. At this time V6 stated the requirements for hair covering in the kitchen is Either a hat with hair tied up if it goes to the shoulders, or a hairnet.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/24/26 and signed by V1 (Administrator) documents 90 residents reside within the facility.

Based on interview and record review, the facility failed to provide a copy of the bed hold policy for a resident who transferred to the hospital for one of three residents (R4) reviewed for bed holds in the sample of 31. Findings include: The Facility Transfer Procedures Policy dated (revised) 10/25/2024, documents The charge nurse will notify the appropriate persons of pending transfer to the hospital, reason for transfer, hospital being transferred to, and obtain consent for transfer from the resident's legal representative. Copies of the following will be sent to the resident: Notice of Transfer and Bed Hold Policy form for Resident; Resident Representative; or Healthcare POA (Power of Attorney). R4's Time of Transfer, dated 8/30/24 at 5:03 PM, documents R4 was transferred to the local hospital with paramedics for evaluation, decline in condition, and medical necessity. R4's medical record does not document a bed hold policy was provided to R4 upon being transferred to the hospital on 8/30/24. On 11/27/24 at 2:00 PM, V9 (Nurse Consultant) confirmed R4 was sent to the hospital on 8/30/24. V9 stated I searched for proof of my nurse that day giving Notice of Transfer and Bed Hold policy, but she did not do it. The nurse working that day should have done it, it is something we missed and will be working on.

Based on observation, interview, and record review the facility failed to document and care plan targeted behaviors to warrant the use of an anti-psychotic medication, monitor for underlying conditions prior to increasing an anti-psychotic medication dose, and perform a comprehensive evaluation for the use of an anti-psychotic for one of one resident (R66) reviewed for anti-psychotic medication use with the diagnosis of Dementia in the sample of 31. Findings include: The facility's Psychotropic Medication Use and Behavior Monitoring policy dated 10/2021 documents, Psychotropic medication refers to drugs which are used for anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic purposes. It is the policy of the facility to keep each resident's medication regimen free from unnecessary drugs. Psychotropic medications will not be administered for the purpose of discipline or staff convenience and when not required to treat the resident's symptoms. Psychotropic drug therapy will be instituted at the lowest dose for the shortest duration of time to control the specific and documented behavioral problems as prescribed the physician. The resident's need for psychotropic medication will be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued. This monitoring shall include identification of the resident's behaviors that the psychotropic drug could conceivable address (target behaviors). Assessment of potential cause of the behaviors that, if addressed, could eliminate the behaviors without the use of psychotropic drugs (medical, environmental, family stresses, adjustment reactions, etc.) Discussion of non-medical behavior management strategies that have been implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment and the resident's response to these interventions. Behaviors for which psychotropic medications should not be used include crying out, yelling, screaming, fidgeting, insomnia, nervousness, not-cooperative, poor self-care, restlessness, simple pacing, unsociability, and wandering. R66's Physician's Orders dated 2-15-23 document R66's Risperidone (anti-psychotic medication) was increased from 0.25 mg (milligrams) daily at bedtime to 0.5 mg daily at bedtime for the diagnosis of Behavioral Disorders associated with Dementia. R66's Physician's Orders dated 2-15-23 through 9-19-23 document R66 has received Risperidone 0.5 mg one tablet at bedtime for the diagnosis of Behavioral Disorders associated with Dementia since 2-15-23. R66's Electronic Health Record does not include documentation of the facility assessing or monitoring R66 for underlying conditions prior to increasing R66's Risperidone on 2-15-23. R66's MDS (Minimum Data Set) Assessments dated 4-14-23 and 7-7-23 document R66 is severely cognitively impaired and has no behavioral symptoms that impact the resident or others, cause significant risk of injury to himself or others, or interfered with R66's cares. R66's Care Plan (Resident Care Guide) dated 7-13-23 does not include the targeted behaviors or non-pharmacological interventions to address targeted behaviors for the use of R66's Risperidone. On 09/19/23 from 9:35 AM to 10:15 AM R66 was sitting in the recliner eating breakfast. R66 had no behaviors during this time. On 09/20/23 at 10:45 AM, R66 was sitting in the recliner watching television in the dining area. R66 had no behaviors during this time. On 09/20/23 at 10:46 AM, V9 (CNA/Certified Nursing Assistant) stated, I have worked here three years and have always taken care of (R66). (R66) does not have any behaviors or aggressiveness. (R66) does not have behaviors with cares. (R66) just gets fidgety. On 09/20/23 at 10:50 AM, V10 (CNA) stated, I take care of (R66) regularly. (R66) just fidgets with cares. (R66) does not have any behaviors and does not refuse cares. 09/20/23 09:55 AM, V2 (Director of Nursing) stated, (R66) does not have an anti-psychotic medication evaluation in his medical record. (R66's) Risperidone was increased from 0.25 mg (milligrams) daily at bedtime to 0.5 mg daily at bedtime on 2-15-23 due to (R66) resisting cares with staff. We (the facility) did not evaluate (R66) for underlying conditions prior to increasing the Risperidone. (R66) is using Risperidone for the diagnoses of Dementia with behaviors. (R66's) care plan does not include the target behaviors that Risperidone is being used for.

Based on interview and record review, the facility failed to ensure resident call lights were responded to in a timely manner for 2 of 18 residents (R1 and R39) reviewed for call lights in a sample of 34. Findings include: The facility's Job Description for Certified Nursing Assistant (CNA), revised 10-1-07, documents Scope of Position: The purpose of the Certified Nursing Assistant (CNA) position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the resident's care plan and with the policies and procedures of this facility under the direction of the (a.)Lead CNA (b.)Unit Coordinator (c.)Charge Nurse (R.N./L.P.N.) (d.)Assistant Director of Nursing (e.)Director of Nursing or (f.)Administrator, to assure that the highest degree of quality of resident care is provided at all times .Job Responsibilities: 1. Provide personal care to residents in a manner conducive to their safety and comfort consistent with the facility clinical policies and procedures as well as state/federal guidelines and regulations. Including a minimum of the following: .i. Promptly respond to resident's call lights. 1. On 10-11-22 at 10:11 am, R39 stated that R39 has to wait a long time for staff to come when R39 puts the call light on. R39 stated I have waited an hour before. R39 stated R39 has had urinary accidents while waiting and I go through a lot of diapers. I'm getting used to it. It's been this way since I've been here. R39's current Care Plan documents R39 admitted to the facility on [DATE]. R39's Admission Minimum Data Set/MDS assessment, dated 8-8-22, documents R39 is cognitively intact, requires extensive assistance with transfers and toileting, is frequently incontinent of bladder, and consistently continent of bowel. On 10-12-22 at 12:34 pm, V9 (R39's family member) sat in R39's room and stated the following: Yesterday V9 was with (R39) when (R39) put the call light on to use the bathroom (for a bowel movement) at 25 minutes past the hour. V9 could not recall what time of day it was, but it was 10 minutes past the next hour (total of 45 minutes) before someone came. (R39) held it for that long but was passing gas. (R39) grumbled about it. 2. The Quarterly MDS (Minimum Data Set) assessment for R1, dated 9/23/22, documents R1 is cognitively intact and requires extensive assistance with transfers, toileting, and is occasionally incontinent of bladder and frequently incontinent of bowel. The Current Care Plan for R1 documents Provide prompt assistance to the toilet upon request to promote my continence. On 10/11/22 at 10:29 AM, R1 stated It takes them way too long to answer the call lights. I wait at least 20 minutes on a consistent basis. On 10/12/22 at 12:44 PM, upon entering hallway, noted R1's call light sounding and lit up over R1's door. On 10/12/22 at 12:54 PM, R1 propelled his wheel chair out into the hallway and waited for a staff member to come by. At this same time R1 alerted a staff member that was walking past him that he needed assist to the bathroom. Unable to determine when the call light was initiated however, total observed wait time was ten minutes. R1 stated he had been waiting for over 30 minutes for someone to come and no one came until he went and sat in the hallway. On 10/14/22 at 9:34 AM, V2 DON (Director of Nursing) stated the facility does not have a specific policy and procedure for resident call lights. On 10/14/22 at 1:50 PM, V2 stated, Obviously we want them (the staff) to answer call lights immediately if they can, if possible; but realistically, goals would be five to ten minutes.

Based on observation, interview, and record review, the facility failed to change gloves during toileting for two of three residents (R39 and R60) reviewed for incontinence care in a sample of 34. Findings include: The facility's policy Toileting Assistance, dated 5-2010, documents Procedure: TOILETING: Wash your hands and gather equipment .Put on disposable gloves if needed and additional PPE if indicated .Assist resident onto toilet or with appropriate receptacle .Once elimination has been completed, perform peri care .Remove your soiled gloves and wash your hands. Apply new clean gloves .Position resident comfortable with call light within reach .Throw gloves in soiled/urinated attends in the garbage bag provided in each resident's bathroom and dispose of immediately in the dirty utility room. Perform hand hygiene. The Facility's policy Infection Control Handwashing, undated, documents PURPOSE: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections .NOTES: Always follow Standard Precautions. Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated. Change gloves and discard after each resident contact. One (1) pair of gloves - one (1) resident. Change gloves when moving from a contaminated body site to a clean body site on the same resident. 1. On 10-11-22 at 9:52 am, V8 Certified Nursing Assistant/CNA assisted R39 with toileting. After R39 voided V8 wiped R39's front and back areas. With the same soiled gloves V8 pulled up a clean incontinence brief, R39's pants up and adjusted R39's shirt. V8 removed V8's gloves then without hand sanitizing V8 assisted R39 to a recliner then left the room for a straw. V8 retrieved a straw just down the hall, brought it back to the room opened it and placed it in R39's drink. V8 tied up the bathroom garbage and then hand sanitized and left the room. On 10-13-22 at 1:30 pm, V8 CNA stated that V8 should have changed V8's soiled gloves after cleaning R39 up. 2. On 10-12-22 at 9:25 am, V8 Certified Nursing Assistant/CNA and V4 Infection Control Preventionist/ICP assisted R60 to stand with the lift and transported R60 to the bathroom. With gloved hands V8 CNA removed R60's soiled brief then lowered R60 to the toilet. After R60 voided and with the same soiled gloves V8 CNA wiped R60's perineal area front to back. With the same soiled gloves V8 CNA put a clean incontinence brief on and handled the lift to transfer R60 back to bed. As V8 CNA assisted R60 into the bed, V8 touched R60's clothing and skin, pulled the linens up and adjusted the head of the bed with the bed control. V8 then used hand sanitizer on V8's gloves and assisted R60 to eat/drink a little. On 10-12-22 at 9:45 am, V8 CNA stated I should have changed my gloves after removing her brief and again after wiping her. There weren't any in the bathroom. Then I used hand sanitizer on my gloves thinking that may help.

Based on observation, interview, and record review, the facility failed to ensure dental services were provided for one of one residents reviewed for dental services in a sample of 36. This has the potential to affect all residents. Findings include: The facility's Residents' Rights, undated, documents Your facility must provide services to keep your physical and mental health at their highest practical levels. On 11/6/19 at 10:25 am, one of R15's upper front teeth was missing. On 11/6/19 at 10:29 am, R15 stated I need to see a dentist and haven't since I moved in here. I lost a crown right after I came in. My front tooth was mended and has since fallen out, and that was one of my strong ones. R15's Minimum Data Set/MDS, dated [DATE], documents R15 is cognitively intact. Section K of this same MDS does not indicate any dental issues such as broken natural teeth, and none of the above were present is selected. R15's face sheet documents that R15 was admitted on [DATE] and does not include an assigned dentist for R15. On 11/7/19 at 12:20 pm, V6 Social Service Director/SSD stated that he is unaware of R15 having a chipped tooth. V6 stated they no longer have a facility dentist since he retired earlier this year and they haven't had one come to the facility for close to two years. V6 confirmed (at this time) that R15 has not been seen by a dentist in the past two years. On 11/8/19 at 1:40 pm, V1 Administrator was unable to provide a facility dental contract and confirmed that they currently do not have a dentist available for the residents. The Resident Census and Conditions of Residents Centers for Medicare and Medicaid Services (CMS) form, dated 11/5/19, documents that 89 residents currently reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for one (R42) resident of two reviewed for medications in a sample of 36. Findings include: 1. The facility's Pharmacy-Storage of Medication, reviewed 2/2019, documents The bedside storage of medications is limited to sublingual or inhalation forms of emergency drugs. Self-administration and bedside storage of medication is permitted only upon written orders from the physician. Bedside medications must be properly labeled, and the resident must be instructed on their use. The use of bedside medications is documented in the resident's clinical record. R42's current Physician order [REDACTED]. R42's Physician Orders, doesn't include a Physician order [REDACTED]. On 11/5/19 at 10:47 am, V11 LPN (Licensed Practical Nurse) brought R42's morning medications into R42's room. R42 told V11 to just leave the medication on her dresser and she would take them. V11 placed R42's medication on her dresser, left R42's room and returned at 10:47 am with pain medication that R42 took immediately. V11 exited R42's room again leaving R42's medications on her dresser. V11 returned to R42's room at 11:32 am and asked R42 if she had taken her medications (which were still on the dresser). R42 told V11 not to worry about it, and V11 left R42's room without R42's medications. On 11/5/19 at 11:46 am, R42 exited her room, leaving all her medication in the cup on her dresser. On 11/5/19 at 11:53 am, V11 LPN stated R42 usually comes down to the nurses station and gets her medicine but I was running a little behind today. I don't usually leave her medicines. V11 stated there are a few residents who wander the hallways and will go remove R42's medication from her room. On 11/7/19 at 2:00 pm, V2 DON (Director of Nursing) confirmed V11 LPN should not have not left R42's medications in her room.

Based on interview, and record review the facility failed to prevent physical and verbal abuse for four residents, (R1, R2, R3 and R4), in the sample of five residents reviewed for abuse. Findings include: The facility's Abuse Prevention and Response policy, review date 1/2019, states the following: No resident of this facility will be mistreated, abused or neglected. This policy also documents, Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, and The potential exists for abuse, neglect or misappropriation of property to be inflicted by staff, volunteers, visitors, family members or other residents. Under IDENTIFICATION:, the policy states A training document titled Recognizing Elder Abuse outlines the types of abuse and provides a list of indicators of abuse/neglect. The list will be provided to all new hires at the new employee orientation and to all employees annually at the Staff Blitz to help the staff understand how to identify abusive situations. The facility's undated, Recognizing Elder Abuse policy states the following: Physical abuse may include but is to limited to hitting, kicking, pinching, choking, shoving, pushing, biting, slapping, punching, striking with an object, burning or cutting of a resident. This policy also documents, Verbal or Psychological (Mental) abuse may include but is not limited to the use of words, signs or gestures to intimidate, demean, curse, harass, cause emotional anguish or distress, ridicule, or threaten harm to the resident. R1's current person-centered care plan, dated 9/27/19 documents the following: My family describes me as being strong-willed and I have a quick temper. My wife and I had been sharing a room. I had some inappropriate behaviors where I lashed out at her verbally and physically. We had separate rooms for a time, but then forgot what happened and insisted on rooming together again. Continue to monitor our interactions and intervene as needed for safety. I am no longer aware of appropriate social boundaries due to my dementia and have also lashed out at other residents that get in my space. Monitor my whereabouts and assist in helping me maintain my personal space in an appropriate manner for the safety of myself and others. The facility's Alleged Resident to Resident Incident report, dated 5/28/19, includes a hand-written witness statement dated 5/28/19 by V16, RN (Registered Nurse), and states: 5/28/19 at approximately 1700 (5:00PM), Resident (R1) stated I'm going to leave while sitting at the dinner table with (R2), his wife. (R2) shoved (R1) in his left arm, stating, Just stay here, and (R1) then back-handed wife in the right chest, residents then started shouting. This hand-written witness statement is also signed by V13, Certified Nursing Assistant (CNA). Incident report includes the following documentation by V4, SSD (Social Services Director): Both (R1) and (R2) are residents on our memory care unit and are husband and wife but reside in separate rooms on the unit. We have already needed to have them reside in separate rooms and have even separated them at the dining table, but after a short separation, both request to be seated near one another again. Staff will continue to monitor their interactions and attempt to intervene if it appears either are getting frustrated with the other. R1's Behavior Documentation in the electronic Nurses Notes, dated 5/28/19 by V16, RN at 6:12 PM, documents the following: The resident (R1) is currently exhibiting behaviors. The behaviors are directed at others, wife: combative, swings hands/fists, backhanded at wife's right side of chest after she shoved him at the dinner table. On 10/24/19 at 1:50 PM, V16, RN stated that she heard a shout and (R2) said he (R1) hit her; (R2) shouted, He back-handed me. It did upset her that he did that. She seemed visibly shaken by it. An Alleged Resident to Resident Incident by V4, (Social Services Director, SSD) and dated 8/9/19 at 10:30 PM documents that R1and R4 are residents on our memory care unit and have been roommates on the unit for some time, CNAs (V17 and V20), witness R4 come out of his room and go directly to the Nurse (V7, LPN,) (Licensed Practical Nurse), where he reported that he had a situation, his roommate was swinging at him. (V7, LPN) asked R4 if his roommate hit him and (R4) replied, Well, yeah, he was swinging at me. According to (V7, LPN), R4 did appear to be scared and appeared to have tears in his eyes. R4 was asked where he was hit and he said he didn't know. As a precaution, and to help alleviate (R4's) being scared of being in the room, he was moved to another room for the evening, which will be a permanent room change. This incident report included a handwritten witness statement, dated 8/9/10, by V17, CNA stating the following:, (R4) was scared, he had tears in his eyes. I then had him lay down and I put the call light next to him and not even 5 minutes later, he pressed it, stating he was scared, and I told him .no one was going to come into that room. He felt better about that, but still pretty shaken up. R4's Nurses Note dated 8/9/19 by V7, LPN at 11:02 PM documents the following: RESIDENT STATEMENT AT THE TIME OF INCIDENT: I have a situation and I am scared. My roommate was swinging and hitting me. When asked where he was hit, resident stated, I don't know, but he was swinging and hitting. R1's Nurses Note, Behavior Documentation, dated 8/9/19 by V7, LPN at 10:30 PM documents the following: The resident (R1) is currently exhibiting behaviors; The behaviors are directed at others: another resident; PHYSICALLY ABUSIVE: hit, swinging at resident (R4) The facility's Alleged Resident to Resident Incident-Initial and Final Report by V4, SSD and dated 9/20/19 includes the following documentation: It was reported to Administrator (V1) by Nurse (V7), LPN, on the evening of (MONTH) 19, 2019 that there had been some sort of incident between resident (R1) and his spouse, (R2), who is also a resident, where (R2) was heard screaming from her room, which she shares with her husband, (R1). Both (R1) and (R2) are residents on our memory care unit and are husband and wife who currently reside in the same room together per their request. Both residents were in their room preparing for bed when staff heard screaming coming from the room. The Incident report states that R2 was sitting on her bed and R1 was standing beside her and yelling at her. (R2) was asked why she was screaming and she said that her hands and wrists hurt. (R2) was then asked why they were hurting and (R2) replied that (R1) had grabbed them. R2's Nurses Notes by V7, LPN and dated 9/19/19 at 10:10 PM, documents: R2 was heard screaming. R2 appeared very upset. When this Nurse asked the resident if she was okay, resident (R2) looked up at her husband and, stated she was fine and that nothing had happened. This Nurse discussed that something made her (R2) scream and asked her again what made her scream. Resident (R2) then complained that her wrists and hands hurt. This Nurse then asked (R2) why her wrists and hands hurt. Resident (R2) replied that her husband (R1) had grabbed her wrists. R1's Nurses Notes dated 9/19/19 at 9:47 PM by V7, LPN states the following: Heard it was reported by his wife (R2) that resident (R1) grabbed her wrists. Resident (R1) stated that he was just trying to shut her up and stop her from screaming. The facility's Alleged Resident to Resident Incident-Initial and Final Report dated 10/04/19 by V4 Social Service Director documents the following incident: On Thursday (MONTH) 3, 2019, it was reported that resident (R1) had made some rude comments to (R3) at the dinner table. It was reported by V9, CNA (Certified Nursing Assistant) she had heard (R1) saying to (R3), you are wacko, you and your ugly laugh. The incident report goes on to state: He was also observed to have slapped his hand on the table while saying this. Additionally, an Alleged Resident to Resident Incident - Initial and Final Report, dated 10/16/19, by V4, Social Service Director documents the following: It was reported to administrator (V1) on the evening of (MONTH) 15, 2019 that there had been some sort of incident between (R1) and his spouse (R2), who is also a resident, where (R2) was heard screaming from her room, which she shares with her husband, (R1). Both residents were in their room preparing for bed when staff heard (R2) scream in their room. Staff immediately went to the room and found (R2) lying on her bed and (R1) was standing beside her. The nurse (V7, LPN) asked if everything was ok and (R1) replied, No, everything is not ok, we were having a disagreement and I held her down. The nurse (V7) asked (R2) is she was ok, and initially (R2) said she was fine, but then said that (R1) had held her wrists. R1's Nurses Notes by V7, LPN and dated 10/15/19 at 10:22 PM document, under Behaviors: The Resident (R1) is currently exhibiting behaviors. The behavior is/are directed at others: Another resident. PHYSICALLY ABUSIVE: Resident (R1) verbalized he was holding his wife down. R1's Nurses documentation continues, under COMMENTS: is as follows: Resident's (R1's) wife heard screaming. Staff entered (R1's) room to find (R1) standing over his wife who was laying on the bed. This nurse asked if everything was okay. Resident (R1) turned calmly around and stated No, everything is not okay. We had a disagreement and I held her down. R2's electronic Nurses Notes by V7, LPN, dated 10/15/19 @ 10:05 PM document the following: Mental state at the time of the occurrence, oriented. RESIDENT STATEMENT AT TIME OF INCIDENT: At first resident (R2) state that she was fine. Resident (R2) then stated that her husband had grabbed her wrists, holding them down. On 10/24/19 at approximately 7:00 AM, V7, LPN stated the following: Regarding the incident of 8/9/19 with R4: (R1) was not rooming with his wife and was in another room with a male resident. That night, (R4) came out of his room like he had seen a ghost, he was shaking and scared and said that there was a situation and (R1) was swinging and hitting him. We put (R4) in different room. At some point during the night, (R4) put on his call light and said he was afraid (R1) was going to come down to his new room. V7 continued, stating, regarding the incident on 9/19/19: On 9/19/19 I was called to (R1's) room for a spousal conflict. We heard her (R2) screaming, like something bad is happening scream. She (R2) was sitting on the bed, he (R1) was next to her (R2). She (R2) said that he grabbed her wrists. He was getting mad because she was talking to me. Every time she (R2) would say something, he (R1) got madder. V7 stated that on 10/15/19, I heard (R2) screaming n her room again. I ran down the hall into (R2's) room. I asked (R2) what happened and she said he (R1) grabbed her wrists and held them down on the bed. V7 stated that, later that night R1 stated, while in the memory unit's living room, I think she (R2) is still mad at me because I held her down. On 10/22/19 at 8:42 am, V4 SSD (Social Service Director) stated he is the Abuse Prevention Coordinator and if there is an allegation of abuse he is notified by V1 Administrator. V4 stated he reported the Abuse Allegations involving R1 as the perpetrator, dated 5/28/19, 8/9/19, 9/19/19, 10/3/19, and 10/15/19 to the State Agency.

Based on interview and record review the facility failed to implement it's Abuse policy by ensuring a perpetrator of physical abuse (R1) was immediately evaluated by the attending physician, for five of five abuse allegations reviewed (5/28/19, 8/9/19, 9/19/19, 10/3/19 and 10/15/19). FINDINGS INCLUDE: The facility's policy, Abuse Prevention and Response, dated (reviewed 1/19) documents, When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated by the attending physician to determine the most suitable therapy and placement of the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. Referral to the social work consultant, local Ombudsman or other appropriate personnel to assist in the evaluation or referral may be considered. The facility report, Alleged Resident to Resident Incident Initial and Final Report, dated 5/28/19 documents, It was reported to (V1/Administrator) that there had been an incident between (R1) and (R2) where R1 shoved (R2) on the left arm and (R1) pushed (R2) away (R1 back handed R2 in the chest) while trying to leave the dinner table. This same report concludes with, Findings: staff will continue to monitor their (R1 and R2)'s interactions and attempt to intervene if it appears either are getting frustrated with each other. The POA (Power of Attorney) was notified and this report will also be sent to their physician for information purposes. The facility report, Alleged Resident to Resident Incident Initial and Final Report, dated 8/9/19 documents, At approximately 10:00 P.M. on 8/9/19 that R4 reported R1 had hit him. At the time of reporting, R4 appeared scared and had tears in his eyes. This same report concludes with,Findings: R4 was moved to another room. Both POAs were notified of this incident and this report will also be sent to their physicians for informational purposes. The facility report, Alleged Resident to Resident Incident Initial and Final Report, dated 9/19/19 documents, On the evening of 9/19/19 there was an incident between R1 and R2. Staff heard screaming coming from their room and found R2 sitting on the bed and R1 standing beside R2, yelling at R2. R2 complained that R2's hands and wrists hurt and stated that R1 had grabbed R2's wrists and hurt R2. This same report concludes with, Findings: The staff closely closely monitored their room from the hallway throughout the night. The POA for both residents was notified and the nurse also notified the physician by fax of this incident. The facility report, Alleged Resident to Resident Incident Initial and Final Report, dated 10/4/19 documents, On 10/3/19 it was reported that R1 made rude comments to R3 at the dinner table. R1 was overheard calling R3 names and aggressively hit the table near R3 while name calling. This same report concludes with, Findings: Both residents and their spouses reside on our memory care unit and have been sitting together at the dinner table since R3 and R3's spouse came into the facility. It is unclear why R1 was reacting this way to R3, except it is not unusual for R1 to become upset over people talking and laughing. POAs for both residents were notified and this report has been faxed to the physician to make him aware of the interaction. The facility report, Alleged Resident to Resident Incident Initial and Final Report, dated 10/16/19 documents, It was reported on the evening of 10/15/19 there had been an incident between R1 and R2. Both residents were in their room preparing for bed when staff heard R2 scream. Staff found R2 laying on R2's bed and R1 was standing over R2. R1 stated they were having a disagreement and that (R1) had held R2 down. R2 stated R1 had held her wrists. This same report concludes with, Findings: It is unknown what precipitated this event. It was R2's screams that alerted staff that something had taken place. The POA for both residents was notified and the report will be faxed to their physician for notification purposes. On 10/29/19 at 9:28 [NAME]M., V2/Director of Nurses verified that R1 was the perpetrator for the incidents on 5/28/19, 8/9/19, 9/19/19, 10/3/19 and 10/15/19. V2 also verified that at the time of the incidents R1 was not seen by his physician or sent out of the facility to be evaluated by a physician. On 10/29/19 at 11:55 [NAME]M., V19/Physician stated, I was notified a day or two after the incidents involving R1, by fax. I did not come in to evaluate or examine R1 immediately after the incidents occurred.

Based on interview and record review the facility failed to complete a thorough investigation for five abuse allegations reviewed for three of three residents (R2, R3, and R4) reviewed for abuse. Findings include: The facility's Abuse Prevention and Response) policy, reviewed 1/19, documents The Abuse Prevention Coordinator will interview the reporter, the allegedly involved resident, the allegedly involved employee/family/friend/other (if known), and all potential witnesses to the event. In the absence of witnesses, able residents may be interviewed regarding their experience of care provided by the allegedly involved employee. Each interviewed employee shall also record in writing exactly what they know about the incident on an Abuse/Neglect Interview Form supplied by the Social Services Department. Each resident interview will be recorded by the interviewer on audio tape or in writing. On 10/23/19 at 1:10 P.M., V2 DON (Director of Nursing) stated she is not involved in the formal abuse investigations and that V4 SSD (Social Service Director) completes the abuse investigations and she gets a copy of the report after it is completed and reviews it. On 10/24/19 at 4:40 P.M., V4 SSD (Social Service Director) stated he is the Abuse Prevention Coordinator for the facility and is responsible for all of the abuse investigations and after he completes the investigation the resident Care Plan is updated if needed. The Alleged Resident to Resident Incident reports, dated 5/28/19, 8/9/19, 9/19/19, 10/3/19, and 10/15/19, completed by V4 SSD (Social Service Director) do not include interviews with all potential witnesses to these events.

Based on observation, interview, and record review, the facility failed to administer a medication using aseptic technique for one (R54) of five residents observed for infection control during medication administration. R54 was not on the sample. Findings include: Facility policy Pharmacy-Medication Administration Med Pass Times, reviewed 10/2015, documents Medication Administration: All medications will be given following the accepted professional standards and principals. Aseptic technique shall be used by the the staff during drug administration. R54's current physician orders [REDACTED]. On 10/04/18 at 8:26 AM, V4 RN (Registered Nurse) was preparing R54's [MEDICATION NAME] for administration and V4 dropped R54's [MEDICATION NAME] 1mg tablet on the medication cart, V4 picked up R54's [MEDICATION NAME] with V4's bare right hand, and put it in R54's medication cup. Then, V4 administered R54's [MEDICATION NAME] tablet to R54. On 10/04/18 at 8:50 AM, V4 RN confirmed V4 picked up R54's [MEDICATION NAME] with bare hands.

Based on observation, interview, and record review, the facility staff failed to wear a hairnet during food preparation and failed to remove dirt/dust/debris that was on the side/top of a refrigerator and on the over-head light fixtures. This failure has the potential to affect all 84 residents residing in the facility. Findings include: Facility Policy, entitled Hairnet Usage, dated 11/2015, documents, Each Dining Service team member will wear a hairnet in the following venues: e. While in the kitchen during meal service or when foods are being prepped. Facility Policy, entitled Refrigerator Policy, dated 10/2000, documents, Housekeeping staff are responsible for keeping the refrigerators cleaned and defrosted. On 12/11/2017, at 6:15 a.m., during the initial tour, of the Main kitchen, V3/Head Cook was preparing food, in an uncovered food processor, without wearing a hairnet. The stand-up refrigerator, in close proximity to the food processor, had dirt/debris on the top and side. On 12/11/2017, at 6:20 a.m., V3 confirmed a hairnet, or hat, will be worn while preparing food. V3 also confirmed the refrigerator had dirt/debris hanging on the side and covering the top surfaces. On 12/11/2017, at 6:30 a.m., during the initial tour, of the Downstairs kitchen, dirt/dust/debris was hanging down on the overhead light fixtures positioned above food preparation areas. On 12/11/2017, at 6:35 a.m., V4/Dietaryn AIde confirmed the dirt/dust/debris, in the light fixtures, and stated, I will call maintenance. On 12/11/2017, at 6:40 a.m., during the initial tour, of the upstairs kitchen, dirt/dust/debris was hanging down on the overhead light fixtures positioned above food preparation areas. On 12/11/2017, at 6:45 a.m., V5/Cook confirmed the dirt/dust/debris on the light fixtures. The Centers for Medicare Services Form 672, entitled Resident Census and Conditions of Residents, dated 12/12/2017, documents a total of 84 residents reside in the facility.

Based on record review and interview, the facility failed to ensure a Practitioner Order for Life-Sustaining Treatment (POLST) Form was signed by a physician. This failure has the potential to affect one resident (R288) of 18 residents reviewed for advanced directives, in a total sample of 22. Findings include: On 12/12/2017, R288's POLST Form, signed by R288's legal representative, documents R288's advanced directive is that of Do Not attempt Resuscitation (DNR). R288's POLST does not contain the required signature of an Authorized Practitioner (medical doctor). On 12/12/2017, at 3:10 p.m., V2/Director of Nursing and V6/Social Services Director confirmed R288's POLST Form did not have the required authorized practitioner's signature, thus making R288's POLST Form invalid.

Based on observation, interview, and record review the facility failed to perform hand hygiene during incontinence care for one resident (R69) of five residents reviewed for incontinence in the sample of 22. Findings include: On 12/11/17, at 6:58 AM, V7 and V8, Certified Nurse Assistant/CNAs, transferred Resident #69 using a sit to stand to the toilet. V7 removed Resident 69's soiled brief. With the same soiled gloves and after Resident #69 urinated, V7 cleansed Resident #69's perineum, then touched the curtain, handles of the sit to stand, Resident 69's shirt and bare hand. On 12/11/17, at 12:50 PM, V7/CNA stated I should have changed my gloves more often. The facility's policy Infection Control - Hand Hygiene, revised 09/2017, documents All personnel will use the hand-hygiene techniques, as set forth in the following procedure: After working on a contaminated body site and then moving to a clean body site on the same resident, as well as After toileting. This policy continues by stating Change gloves when moving from a contaminated body site to a clean body site on the same resident.

Based on record review and interview, the facility failed to ensure staff immediately reported the exploitation of a cognitively impaired resident (R1) on social media and failed to investigate known unauthorized photographs taken by E4 (Certified Nursing Assistant) of a cognitively impaired resident (R4), for two of four residents (R1 and R4) reviewed for abuse, in a sample of four. This failure has the potential to affect all 89 residents living in the facility. Findings include: The facility Abuse Prevention and Response (3/06/17) policy documents, No resident of this facility will be mistreated, abused or neglected. Every employee who suspects that abuse/neglect has occurred must report it immediately. The facility will ensure that all alleged violations involving mistreatment, abuse, neglect, or misappropriation of resident property will be thoroughly investigated and reported to the appropriate agencies and officials in accordance with state law through established procedures. The Abuse Prevention and Response policy documents, Mistreatment: is defined as inappropriate treatment or exploitation of a resident and It is also the policy of this facility that all staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident through the use of any type of equipment (e.g., cameras, smart phones, and other electronic devices), to take, keep, or distribute photographs and recordings on social media. Further, only designated staff is permitted to take resident photos or videos. Under Investigation, the Abuse Prevention and Response policy documents, The Abuse Prevention Coordinator will interview the reporter, the allegedly involved resident, the allegedly involved employee/family/friend/other (if known), and all potential witnesses to the event. An Alleged Incident Final Report, dated 3/07/17, documents that E1 (Administrator) was notified on 3/03/17 that E4 (Certified Nursing Assistant) had taken a video of herself while on duty, with a resident visible in the background, and posted the video to social medial. The Alleged Incident Final Report documents that E6 (Certified Nursing Assistant) reported to E2 (Assistant Administrator) and E3 (Director of Nursing), on 3/03/17, that she saw a video posted by E4 on a social media website the evening of 3/01/17. According to E6's statement documented in the Incident Report, in the video you could see a resident in the background that appeared to be on a toilet, but you could not see the resident's face or tell who the resident was. E6 gave a statement, documented in the Incident Report, that right after the video popped up on her feed, she did show it to two other staff members (E7 - Certified Nursing Assistant and E8 - Certified Nursing Assistant) and the following day told three other staff members (E5, E9 and E10 all Certified Nursing Assistants) about the video. The Incident Report documents E6 reported that (E4) could be heard on the video saying .'her butthole hurts too' followed by, 'it's a good thing she can't hear.' Documentation in the Incident Report indicates E5, E6, E7, E8, E9 and E10 all admitted to knowledge of the video E4 posted to social media on 3/01/17; however, did not report the incident to the Administrator. According to a statement by E5 in the Incident Report, (E5) did not see the video, as it had been removed when (E6) talked to her about it at lunch on (3/02/17) (E6) understood enough of what happened that it upset her. (E6) is the one that mentioned it to her Mother that evening (3/02/17) and E6's Mother spoke with the Administrator about this incident on 3/03/17. The 3/07/17 Incident Report further documents that on 3/06/17, (E4) was asked if she had ever taken any videos or pictures of residents and posted them on social media. (E4) acknowledged that she had recently and that it involved (R1). She does not believe (R1) was aware of what she was doing. When asked about what prompted this, she indicated she was toileting (R1) and had gotten a snap chat from a friend .who told her she was having problems going to the bathroom .She started to reply to her while (R1) was on the toilet. When asked if she made any comments about (R1), she did not recall saying anything. She was told about what had been reported and said she might have said that. We had her explain how she did the video and she said that the resident was in the background and that you could not see her face as she was blocking the resident's face from being seen with her body. The Alleged Resident Incident Final Report indicates that during the course of the facility's investigation into that incident, E13 (Abuse Prevention Coordinator) reviewed all of the photographs on E4's phone. The Incident Report documents E13 found two additional pictures of a declined resident (R4) lying on her side in bed. Anyone that did not know this resident would not have known who the resident was as she had her arm in a position that was covering her face. (E4) explained that she was caring for this resident one night and that she felt the nurse needed to see something, but was busy, so she took the pictures to show the nurse and had forgotten they were even still on her phone. The Incident Report further documents that upon training staff regarding Abuse and Exploitation, it was determined that E12 (Certified Nursing Assistant) also had knowledge of E4's video taken of R1 on 3/01/17. According to E12's documented statement, E12 was working with E4 the night of 3/01/17 and E4 told E12 about the video with R1 on the toilet and that it had been uploaded and already removed from social media. On 3/21/17 at 10:40 a.m., E13 stated that it was determined through his investigation that a total of seven staff members (E5, E6, E7, E8, E9, E10 and E12), who work throughout the entire facility, had knowledge of the video recorded by E4 on 3/01/17, but failed to report the incident to anyone at the facility. E13 stated that R4 was identified as the resident in the two additional photographs found on E4's smart phone. E13 stated that he immediately deleted the two photographs of R4, as E4 was not authorized to take those photographs. E13 stated that E4 could not recall the date the photographs were taken or the nurse that she showed those photographs to. E13 stated that he did not investigate the incident of R4 being photographed any further, as E13 had deleted the photographs before determining a date stamp. E13 stated that he believed the photographs were taken for medical use, so a separate investigation was not conducted and R4's family/legal representative was not notified of the incident. E13 stated that R1 and R4 are both cognitively impaired and would not be able to consent to photographs/video being taken. The Facility Data Sheet, dated 3/20/17 and signed by E1 (Administrator) documents a total of 89 residents currently live in the facility.

Based on record review and interview the facility failed to operationalize their Abuse Prevention and Response Policy when E4 (Certified Nursing Assistant) exploited a resident (R1) while toileting on social media, multiple staff members failed to report the exploitation of a resident (R1) on social media, and failed to investigate photographs known to be taken without a resident's (R4) consent. These failures have the potential to affect all 89 residents living in the facility. Findings include: The facility Abuse Prevention and Response (3/06/17) policy documents, No resident of this facility will be mistreated, abused or neglected. Every employee who suspects that abuse/neglect has occurred must report it immediately. The facility will ensure that all alleged violations involving mistreatment, abuse, neglect, or misappropriation of resident property will be thoroughly investigated and reported to the appropriate agencies and officials in accordance with state law through established procedures. The Abuse Prevention and Response policy documents, Mistreatment: is defined as inappropriate treatment or exploitation of a resident and It is also the policy of this facility that all staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident through the use of any type of equipment (e.g., cameras, smart phones, and other electronic devices), to take, keep, or distribute photographs and recordings on social media. Further, only designated staff is permitted to take resident photos or videos. Under Investigation, the Abuse Prevention and Response policy documents, The Abuse Prevention Coordinator will interview the reporter, the allegedly involved resident, the allegedly involved employee/family/friend/other (if known), and all potential witnesses to the event. An Alleged Incident Final Report, dated 3/07/17, documents that E1 (Administrator) was notified by on 3/03/17 that E4 (Certified Nursing Assistant) had taken a video of herself while on duty, with a resident visible in the background, and posted the video to social medial. The Alleged Incident Final Report documents that E6 (Certified Nursing Assistant) reported to E2 (Assistant Administrator) and E3 (Director of Nursing), on 3/03/17, that she saw a video posted by E4 on a social media website the evening of 3/01/17. According to E6's statement documented in the Incident Report, in the video you could see a resident in the background that appeared to be on a toilet, but you could not see the resident's face or tell who the resident was. E6 gave a statement, documented in the Incident Report, that she showed the video to two other staff members (E7 - Certified Nursing Assistant and E8 - Certified Nursing Assistant) and the following day told three other staff members (E5, E9 and E10 all Certified Nursing Assistants) about the video. The Incident Report documents E6 reported that (E4) could be heard on the video saying .'her butthole hurts too' followed by, 'it's a good thing she can't hear.' The Incident Report further documents it was determined that E12 (Certified Nursing Assistant) also had knowledge of E4's video taken of R1 on 3/01/17. According to E12's documented statement, E12 was working with E4 the night of 3/01/17 and E4 told E12 about the video with R1 on the toilet and that it had been uploaded and already removed from social media. Documentation in the Incident Report indicates E5, E6, E7, E8, E9, E10 and E12 all admitted to knowledge of the video E4 posted to social media on 3/01/17; however, the staff did not report the incident to the Administrator. The 3/07/17 Incident Report documents that on 3/06/17, E4 admitted she had recently taken a video with R1 sitting on the toilet in the background and that video was posted to social media. The Incident Report indicates that during the course of the facility's investigation into that incident, E13 (Abuse Prevention Coordinator) reviewed all of the photographs on E4's phone. The Incident Report documents E13 found two additional pictures of a declined resident (R4) lying on her side in bed .(E4) explained that she was caring for this resident one night and that she felt the nurse needed to see something, but was busy, so she took the pictures to show the nurse and had forgotten they were even still on her phone. On 3/21/17 at 10:40 a.m., E13 stated that it was determined through his investigation that a total of seven staff members (E5, E6, E7, E8, E9, E10 and E12), who work throughout the entire facility, had knowledge of the video recorded by E4 on 3/01/17, but failed to report the incident to anyone at the facility. E13 stated that R4 freely admitted to video recording herself with R1 in the background sitting on the toilet and posting it to social media. E13 stated that R4 was identified as the resident in the two additional photographs found on E4's smart phone. E13 stated that he immediately deleted the two photographs of R4, as E4 was not authorized to take those photographs. E13 stated that E4 could not recall the date the photographs were taken or the nurse that she showed those photographs to. E13 stated that he did not investigate the incident of R4 being photographed any further, as E13 had deleted the photographs before determine a date stamp. E13 stated that he believed the photographs were taken for medical use, so a separate investigation was not completed and R4's family/legal representative was not notified of the incident. E13 stated that R1 and R4 are both cognitively impaired and would not be able to consent to photographs/video being taken. The Facility Data Sheet, dated 3/20/17 and signed by E1 (Administrator) documents a total of 89 residents currently live in the facility.

Based on record review and interview, the facility failed to ensure the resident's family was notified when unauthorized photographs of the resident were found on a staff member's cellular phone, for one of four residents (R4) reviewed for abuse, in a sample of four. Findings include: The facility Abuse Prevention and Response (3/06/17) policy documents, under Definitions (Abuse), that It is also the policy of this facility that all staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident through the use of any type of equipment (e.g., cameras, smart phones, and other electronic devices), to take, keep, or distribute photographs and recordings on social media. Further, only designated staff is permitted to take resident photos or videos. The Abuse Prevention and Response policy further documents The Abuse Prevention Coordinator will notify the resident representative immediately upon being notified of the alleged case. The facility policy, titled Employee Conduct (no date), documents Confidentiality: As an employee .you have an obligation to hold all resident information in strictest confidence .Any pictures or video which include residents or staff that are taken during working hours and in working areas must only be taken with the facility's equipment and may not be taken without the express approval of the Administrator or Business Manager. Under no circumstances may cell phones or similar electronic devices be used by employees to take pictures or videos of residents or visitors without each individual's express written approval. An Alleged Resident Incident Final Report, dated 3/07/17, documents E4 (Certified Nursing Assistant) had allegedly taken a video of herself while on duty, with a resident in the background sitting on the toilet, and posted the video to a social medial website. The Alleged Resident Incident Final Report documents that during the course of the facility's investigation into that incident, E13 (Abuse Prevention Coordinator) reviewed all of the photographs on E4's phone. The Alleged Resident Incident Final Report also documents that E13 found two additional pictures of a declined resident (R4) lying on her side in bed. Anyone that did not know this resident would not have known who the resident was as she had her arm in a position that was covering her face. (E4) explained that she was caring for this resident one night and that she felt the nurse needed to see something, but was busy, so she took the pictures to show the nurse and had forgotten they were even still on her phone. On 3/21/17 at 10:40 a.m., E13 stated R4 was identified as the resident in the two additional photographs found on E4's smart phone. E13 stated he immediately deleted the two photographs of R4, as E4 was not authorized to take those photographs of R4 as stated in the facility's Abuse Prevention Policy and Employee Conduct Policy. E13 stated R4 would not be cognitively able to consent to photographs. E13 stated he believed the photographs were taken for medical use and R4's family/legal representative was not notified of the incident.

Based on record review and interview, the facility failed to ensure the resident's right to be free from exploitation on social media, for one of four residents (R1) reviewed for abuse, in a sample of four. Findings include: The facility Abuse Prevention and Response (3/06/17) policy documents, No resident of this facility will be mistreated, abused or neglected. The Abuse Prevention and Response policy documents, Mistreatment: is defined as inappropriate treatment or exploitation of a resident and It is also the policy of this facility that all staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident through the use of any type of equipment (e.g., cameras, smart phones, and other electronic devices), to take, keep, or distribute photographs and recordings on social media. Further, only designated staff is permitted to take resident photos or videos. An Alleged Incident Final Report, dated 3/07/17, documents that E1 (Administrator) was notified by on 3/03/17 that E4 (Certified Nursing Assistant) had taken a video of herself while on duty, with a resident visible in the background, and posted the video to social medial. The Alleged Incident Final Report documents that E6 (Certified Nursing Assistant) reported to E2 (Assistant Administrator) and E3 (Director of Nursing), on 3/03/17, that she saw a video posted by E4 on a social media website the evening of 3/01/17. According to E6's statement documented in the Incident Report, in the video you could see a resident in the background that appeared to be on a toilet, but you could not see the resident's face or tell who the resident was. The 3/07/17 Incident Report documents E6 reported that (E4) could be heard on the video saying .'her butthole hurts too' followed by, 'it's a good thing she can't hear.' The 3/07/17 Incident Report further documents that on 3/06/17, (E4) was asked if she had ever taken any videos or pictures of residents and posted them on social media. She acknowledged that she had recently and that it involved (R1). She does not believe (R1) was aware of what she was doing. When asked about what prompted this, she indicated she was toileting (R1) and had gotten a snap chat from a friend .who told her she was having problems going to the bathroom .She started to reply to her while (R1) was on the toilet. When asked if she made any comments about (R1) , she did not recall saying anything. She was told about what had been reported and said she might have said that. We had her explain how she did the video and she said that the resident was in the background and that you could not see her face as she was blocking the resident's face from being seen with her body. On 3/21/17 at 10:40 a.m., E13 (Abuse Prevention Coordinator) stated all facility staff had received training regarding the exploitation of residents on social media, as that verbiage had been incorporated into their Abuse Prevention Policy for some time. E13 indicated staff are given written instructions on Employee Conduct at the time they are hired and it is advised that any pictures or videos taken of residents is prohibited as part of their Abuse Prevention Program. E13 stated E4 freely admitted to video recording herself with R1 in the background sitting on the toilet and posting it to social media. E13 stated E4 was alerted by other staff that the video was on social media and removed the video from her social media feed. A Employee Handbook Acknowledgment Form, signed by E4 on 8/01/16, documents Any pictures or video which include residents or staff that are taken during working hours and in working areas must only be taken with the facility's equipment and may not be taken without the express approval of the Administrator or Business Manager. Under no circumstances may cell phones or similar electronic devices be used by employees to take pictures or videos of residents or visitors without each individual's express written approval. No pictures or videos of residents or visitors may be posted on the Internet without the express written approval of individuals appearing in the picture or video.

Based on record review and interview, the facility failed to ensure a resident's privacy for two of four (R1 and R4) resident's reviewed for abuse, in a sample of four. Findings include: The facility policy, titled Employee Conduct (no date), documents Confidentiality: As an employee .you have an obligation to hold all resident information in strictest confidence .Any pictures or video which include residents or staff that are taken during working hours and in working areas must only be taken with the facility's equipment and may not be taken without the express approval of the Administrator or Business Manager. Under no circumstances may cell phones or similar electronic devices be used by employees to take pictures or videos of residents or visitors without each individual's express written approval. No pictures or videos of residents or visitors may be posted on the Internet without the express written approval of individuals appearing in the picture or video. An Alleged Resident Incident Final Report, dated 3/07/17, documents E4 (Certified Nursing Assistant) acknowledged she had taken a video of herself on duty while R1 was in the background sitting on the toilet, and posted the video to a social medial website. According to the Alleged Resident Incident Final Report, E4 stated that R1's face was not visible in the video, as she was blocking (R1's) face with her body. The Alleged Resident Incident Final Report indicates that during the course of the facility's investigation into that incident, E13 (Abuse Prevention Coordinator) reviewed all of the photographs on E4's phone. The Alleged Resident Incident Final Report documents R13 found two additional pictures of a declined resident (R4) lying on her side in bed. Anyone that did not know this resident would not have known who the resident was as she had her arm in a position that was covering her face. (E4) explained that she was caring for this resident one night and that she felt the nurse needed to see something, but was busy, so she took the pictures to show the nurse and had forgotten they were even still on her phone. On 3/21/17 at 10:40 a.m., E13 stated R1 and R4 would not have the cognitive ability to consent to have their photograph taken. E13 concluded that E4 was not authorized to photograph residents in any capacity and R4 was asked to resign for violation of facility policies regarding resident privacy and confidentiality.

Based on observation, interview, and record review the facility failed to discontinue a walking boot with the development of a pressure ulcer per the physician's orders [REDACTED]. The initial failure resulted in R12 ' s wound progressing from redness to a Stage III pressure ulcer. 1. The facility's Skin Care Protocol and Prevention of Pressure Ulcers policy, dated 3/2008, documents, Certified Nursing Assistants are to inspect skin on each shift during Activities of Daily Living and do total body assessment weekly, during the tub bath. Any impairments should be reported to the charge nurse immediately. R12's physician's orders [REDACTED]. R12's Nurse's notes, dated 9/21/16 to 10/7/16, last document on 9/21/16 that the walking boot was removed to inspect R12's skin and no pressure ulcers were observed. R12's Physician's Telephone Orders, dated 10/18/16, documents that on 10/7/16, R12 received an order to treat the top of the left second toe by applying skin prep around the outer open area, cut to fit hydrogel dressing sheet to fit wound bed daily and leave the brace off at this time. Then, on 10/18/16 a new order was obtained to change the treatment to apply skin prep around the open area, apply barrier cream over the skin prep, cut to fit hydrogel gauze to fit wound bed, cover with foam, and wrap with gauze daily. R12's Skin Problems/Condition, dated 10/11/16, documents on this date that a Stage three pressure ulcer was discovered to R12's left second toe that measures 0.5 cm (centimeters) x 0.8 cm x 0.2 cm. R12's Skin Problems/Condition (most recent wound documentation), dated 10/25/16, documents that R12's pressure ulcer to R12's left second toe is now unstageable measuring 0.5 cm x 0.7 cm x undetermined depth due to wound bed covered with slough (white tissue). On 11/1/16 at 10:40 a.m., R12 had a round open area to R12's left second toe that measured 0.7 cm (centimeters) x 1 cm. The wound bed had yellowish white tissue present in the wound bed. On 11/3/16 at 10:15 a.m., E7 (Registered Nurse) stated, We were removing the immobilizer boot every shift and inspecting (R12's) skin. Not long after the boot was put on the tops of her toes became reddened on the joints .The toes were always reddened not sure if they were blancheable. I don't know if I documented any of that. Once I saw that it worsened and opened is when I notified the doctor to get a treatment order. On 11/3/16 at 11:35 a.m., Z1 (R12's Physician) stated that he would not have expected this pressure ulcer to have developed, and that the facility should have found the pressure ulcer before it became a Stage three. 2. The facility's Infection Control Handwashing policy, dated 8/2016, documents, All personnel will use the hand-hygiene techniques, as set forth in the following procedures .After working on a contaminated body site and then moving to a clean body site on the same resident; After coming in contact with bodily fluids, dressing, mucous membranes, etc., and hands are not visibly soiled Change gloves when moving from a contaminated body site to a clean body site on the same resident. On 11/1/16 at 10:40 a.m., E7 (Registered Nurse) removed a dressing from R12's left foot, exposing a round open area to the top of R12's left second toe. E7 removed E7's gloves and washed E7's hands. E7 applied a new set of gloves and cleansed E7's wound with wound cleanser. After cleansing the wound, E7 applied skin prep around the wound followed by barrier cream. Then, E7 put hydrogel gauze in the wound bed, covered the wound with foam, and wrapped it with gauze. After cleansing E7's wound and before performing the ordered treatment, E7 did not remove E7's soiled gloves and perform hand hygiene. On 11/1/16 at 11:00 a.m., E7 verified that E7 did not remove E7's gloves after cleansing R12's wound, wash hands, or apply a new pair of gloves before applying the ordered treatment.