Every finding on record at Azria Health Olathe

The facility identified a census of 107 residents. The sample included 26 residents, with three reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure residents remained free from sexual abuse when cognitively impaired Resident (R) 16, a resident with a history of inappropriate touching, touched R75's genital area against R75's wishes. On 07/18/25, R16 touched a lady in a sexual way, and the facility sent R16 to the hospital for inappropriate behavior. R16 returned to the facility on [DATE], but the facility did not implement interventions to address R16's inappropriate touching. On 08/28/25, R16 exhibited sexual behaviors towards staff, but the facility did not address these behaviors with new interventions. On 08/29/25, R16 touched cognitively impaired R75, a resident unable to consent, in her genital area. R75 screamed at R16 to stop touching her. Staff separated R16 and R75 and placed R16 under one-to-one staff supervision until R16 transferred to an all-male unit in another facility. The facility's failure to identify and implement interventions in response to R16's inappropriate touching and behaviors to prevent sexual abuse placed R75 in immediate jeopardy. Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R16's 08/02/25 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS noted R16 with no upper or lower extremity impairments, and he used a wheelchair for mobility. The MDS noted R16 had physical, verbal, and other self-directed behaviors observed for one to three days. R16's Behavioral Care Area Assessment (CAA) triggered on 05/27/25. The CAA noted he had a history of physical and verbally aggressive behaviors. R16's Care Plan initiated 05/15/25 indicated he was admitted to the secured unit due to his medical diagnoses and risk for elopement. The plan noted staff monitored R16 frequently for safety (05/15/25). The plan noted he had cognitive impairment or impaired thought processes (05/15/25). The plan instructed staff to cue, orient, and supervise him as needed, engage the resident in simple activities, and keep his routine consistent (05/15/25). The plan noted he was dependent on staff for meeting his emotional, intellectual, physical, and social needs (06/20/25). The 09/02/25 care plan update indicated R16 had behaviors related to inappropriate touching. The plan instructed staff to anticipate his needs, offer tasks to divert his attention, and provide activities that accommodated his interests (09/02/25). The plan noted staff provided R16 with one-to-one supervision until his departure from the facility, and the facility provided abuse education (09/02/25). R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/16/25. The note indicated R16 was observed holding hands with another resident and using affectionate gestures towards other residents on the secured unit. The note indicated staff provided appropriate redirections to maintain personal boundaries in a respectful manner. The 07/17/25 Nurse's Note indicated R16 wheeled himself around the secured unit and was observed repeatedly touching other residents. The note revealed staff intervened promptly by redirecting him and provided verbal reminders regarding personal boundaries. The note revealed staff had to remove R16 from the immediate area and redirect to an activity table under staff supervision. The 07/18/25 Nurse's Note revealed R16 was observed touching a resident in a sexual way and staff provided several redirections. The note revealed R16 became aggressive upon redirection and wanted to hit the staff. The note revealed staff moved him back to his room and attempted to contact his resident representative. The 07/18/25 Nurse's Note revealed R16 was sent out to an acute medical facility for evaluation. The 07/28/25 acute medical facility summary indicated the facility reported concerns of worsening promiscuity and combativeness. The admission Progress Note completed on 07/28/25 revealed R16 returned to the facility at 04:00 PM following a hospital stay for treatment of inappropriate behaviors and gout. The Social Service Note completed on 08/28/25 revealed the facility notified R16's representative of R16's inappropriate touching. The note indicated he transferred to an all-male unit. The Behavior Note completed on 08/29/25 revealed staff witnessed R16's hands touching another resident's private area. The note documented both residents were immediately separated, and notification of the unit supervisor. The Facility Incident Report #3977 completed on 08/29/25 indicated staff observed R16 placing his hands between R75's (a severely cognitively impaired female resident) inner thighs. The report indicated R75 screamed out, Stop, don't touch me. The report indicated both residents were separated and assessed. The note revealed neither resident had memory recall of the incident, and the facility immediately placed R16 under one-to-one supervision. A Witness Statement completed by CNA UU on 08/29/25 documented she witnessed R16's hands in between R75's thighs in her private region. The statement indicated she immediately separated them and moved R16 to the men's table. The 09/04/25 Nurse's Note revealed R16 transferred out of the facility. On 09/09/25 at 11:20 AM, R75 reported she had no memory of the incident, but reported she did not like any males touching or providing care for her. On 09/09/25 at 02:30 PM, CNA WW stated R16 had ongoing sexual impulses on the unit. She stated staff were expected to supervise R75 and provide reminders related to appropriate behaviors. She stated he would continually attempt to hold female staff members' hands and then move toward their private areas.On 09/09/25 at 02:30 PM, CNA XX stated R16's sexual behaviors had been going on for a while. She stated staff had to watch him closely and provide constant redirection due to his mobility in his wheelchair. She stated staff would sit him with male peers to prevent him from grabbing at female residents.On 09/09/25 at 03:31 PM, Administrative Nurse D stated she did not see his behaviors as sexual. She stated she did not believe he went to the acute care facility on 07/18/25 for sexual behaviors, but rather due to his hand issues. She stated all staff had training to recognize and prevent abuse. She stated the facility transferred R16 to an all-male unit due to his increased behaviors. Administrative Nurse D stated the facility immediately placed R16 on one-to-one supervision until he transferred, and the facility provided abuse training to the staff.The facility's Abuse, Neglect, and Exploitation policy, revised 10/2023, documented that the resident has a right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated it was the responsibility of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse includes, but is not limited to, verbal or non-verbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy indicated that all staff were to be educated to identify, prevent, and intervene when potential abuse was identified. On 09/09/25 at 05:55 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R75 remained free from sexual abuse placed R75 in immediate jeopardy.The facility identified, implemented, and completed the following corrective actions related to the incident:1. The facility screened all residents on the secured unit on 09/01/25.2. The facility assessed both R16 and R75 for psychosocial trauma from the incident. 3. The facility will monitor and provide ongoing education through the Quality Assurance and Performance Improvement program (QAPI) team. 4. All staff were educated on Abuse, Neglect, and Exploitation on 08/30/25.5. R16 was immediately placed under one-to-one staff supervision on 08/29/25 until his transfer from the facility on 09/04/25. This deficient practice was deemed past non-compliance when the facility completed the corrective actions on 08/30/25, prior to the surveyor entering the facility. The deficient practice remained at a scope and severity of a G to represent actual harm determined by the visual agitation of the resident during the event, as well as using the reasonable person concept based on the fact that R75 was unable to verbalize or express the psychosocial impact of the abuse.

The facility identified a census of 107 residents. The sample included 26 residents, with five medication carts and three medication rooms. Based on observation, record review, and interviews, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily work shifts and maintain the staff count sheets for the controlled drugs. This placed residents at risk for misappropriation of medications and/or diversion of controlled substances. Findings included:- On 09/09/25 at 07:30 AM, a review of the September 2025 Narcotic Shift Count Sheet on the 200 hall from 09/01/25 to 09/09/25 (nine days) revealed a missing signature either for the on-coming nurse or the off-going nurse on the following dates: 09/01/25, 09/02/25, 09/03/25, 09/04/25, 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25. On 09/09/25 at 07:33 AM, Licensed Nurse (LN) K stated that each shift should count the narcotics at shift change with the oncoming nurse and the off-going nurse. LN K stated it was the expectation of the facility that reconciliation of the narcotics was expected when the shift started and ended. On 09/10/25 at 01:23 PM, Administrative Nurse D stated she expected the narcotics to be counted between the oncoming nurse and the off-going nurse. The facility's Controlled Substances policy, last revised April 2019, documented the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled medications were counted at the end of each shift. The nurse coming on duty and the nurse going off duty determined the count together. Any discrepancies in the controlled substance count were documented and reported to the director of nursing services.

The facility identified a census of 107 residents, with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk of food-borne illnesses and food safety concerns. Findings Included: - On 09/08/25 at 07:05 AM, a walkthrough of the facility's kitchen was completed. An inspection of the main kitchen area revealed:The floor was heavily dirty with old food debris and trash in the food prep and stove area. A soiled towel was on the floor next to the stove top ovens. Dessert saucers and plates were stored upwards in the dishware storage rack. An inspection of the dry food storage area revealed dirty floors and a soiled Band-Aid in the center of the dry food storage room floor. A dented 6.56-pound (lb.) can of fruit cocktail was on the canned storage rack. An inspection of the walk-in refrigerator revealed a metal tray of five packaged turkey cold cut meat underneath the walk-in refrigerator's air blower. The tray had liquid dripping on the turkey packages and pooling in the tray, dripping from a pipe coming from the air conditioner. On 09/11/25 at 12:01 PM, Dietary Staff BB stated that food was not to be placed underneath the air conditioner in the walk-in units. He stated the food was moved and thrown out. He stated that staff were expected to clean after every meal service.A review of the facility's Food Services and Nutrition policy, dated 10/2017, indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted that all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be labeled/dated and stored in a manner that is safe and maintains nutritional value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted that all kitchen and dining equipment be stored in a manner that prevents soiling or contamination of clean items.

The facility had a census of 107 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included:- Review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA MM, hired on 06/26/24, had not completed the required in-services in the past 12 months. CNA NN, hired on 09/29/24, had not completed the required in-services in the past 12 months. CNA OO, hired on 09/22/22, had not completed the required in-services in the past 12 months. CNA PP, hired on 11/22/23, had not completed the required in-services in the past 12 months. CNA QQ, hired on 10/25/23, had not completed the required in-services in the past 12 months. On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the facility did have monthly meetings. CNA O stated she could not remember the last time she had a dementia (a progressive mental disorder characterized by failing memory and confusion) in-service. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated the facility did provide monthly in-services. LN K stated he could not remember the last dementia care in-service. LN K stated we are provided abuse and neglect in-services often. On 09/10/25 at 01:23 PM, Administrative Nurse D stated the facility human resource department, and the administrative staff were responsible for ensuring the direct care staff received the required 12 hours of in-services. The facility's In-Service Training, All Staff policy, last revised 08/2022, documented all staff must participate in initial orientation and annual in-service training.

The facility identified a census of 107 residents. The sample included 26 residents. The facility had one oxygen storage room on the 100 hall and one oxygen storage room on the 200 hall. The facility had a total of six cognitively impaired, independently mobile residents who resided on either the 100 or the 200 hall. Based on observation, record review, and interview, the facility failed to ensure oxygen tanks were stored in a securely locked room. The facility failed to ensure that Resident (R) 28's nothing by mouth (NPO) physician's order was followed. This deficient practice placed residents at risk of possible avoidable injury.Findings included:- On 09/08/25 at 07:14 AM, during the initial tour of the facility, the oxygen storage room on 200 hall was unlocked with 21 unused full oxygen cylinders present. On 09/08/25 at 07:15 AM, the oxygen storage room on the 100 hallway was unsecured with 32 Oxygen E-tanks stored in the room. On 09/08/25 at 09:01 AM, a return to the 200-hall oxygen storage room continued to be unlocked. On 09/08/25 at 07:18 AM, Certified Nurse Aide (CNA) M stated the oxygen storage room should be locked, but the lock was broken. CNA M stated the door had been broken for the past two years. On 09/08/25 at 09:02 AM, Licensed Nurse (LN) G stated that the code for the oxygen storage room had been changed recently. LN G stated that the room should be locked all the time. On 09/10/25 at 01:22 PM, Administrative Nurse D stated that the oxygen storage rooms should always be locked unless a staff member is replacing a used tank with a new one. The facility lacked a policy regarding oxygen storage or accidents. - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein calorie malnutrition (a nutritional deficiency where the body doesn't get enough protein and calories (energy) from food), retention of urine, impulse disorder, legally blind, need for assistance with personal cares, and dysphagia (swallowing difficulty) oropharyngeal phase (the second phase of swallowing). The admission Minimum Data Set (MDS) for R28, dated 06/10/25, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented eating was not applicable and was dependent on staff for all activities of daily living (ADL). R28's Nutrition Status Care Area Assessment (CAA) dated 06/10/24 documented impaired nutritional status, internal tube placement, and nothing by mouth (NPO) status. Contributing factors include cerebral palsy, protein-calorie malnutrition, gastrostomy status, colostomy status, legal blindness, congenital malformation, and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R28's CAA documented staff would anticipate his needs, administer medications and enteral feedings per orders, and monitor for signs and symptoms of aspiration. The CAA documented that the registered dietician would do an evaluation for caloric intake/need and report to the healthcare practitioner as needed. R28's Care Plan dated 06/05/25 documented R28 required tube feeding related to malnutrition and chronic ileus (a condition where the normal movement of food and waste through the intestines has slowed or stopped) that recently resulted in small bowel obstruction that was surgically repaired. R28's plan of care documented he would maintain adequate nutrition and hydration status and maintain a stable weight. R28's plan of care documented staff should allow R28 to have thin water, five ml of Provale (special water) cup, on a pleasure feeding basis; staff were to limit one cup of water per day. The plan of care for R28 documented he was to have 100 percent staff supervision during intake, and his cup was to be stored with nursing or in the nourishment room when not in use. The plan of care documented staff were to monitor R28 for potential aspiration. R28's plan of care, revised on 06/12/25, documented R28 was NPO, receives all nutrition through his feeding tube, but it was ok to have ice chips as requested. R28's EMR under the Orders tab documented the following physician order: NPO diet, Not Applicable texture, NPO consistency, dated 06/12/25. On 09/08/25 at 11:30 AM, R28 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) outside of the day room. R28 had a cup of crushed ice in a Styrofoam cup with a spoon. There was no nursing staff to monitor R28 for aspiration. On 09/09/25 at 12:30 PM, R28 sat in his Broda chair in hallway 200. R28 had a cup of chunked ice with a spoon; there was no staff monitoring R28 for possible aspiration. On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated the nurse knows how often R28 could have ice chips. She stated the nurse monitored R28 when he received ice chips. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated R28 could have ice chips every hour if he wanted. He stated that the nurse gave him his ice chips, but he should be monitored while receiving the ice. LN K stated there should be an order stating R28 could have ice chips. On 09/10/25 at 01:22 PM, Administrative Nurse D stated staff monitored R28 while he ate his ice chips. She stated there should be an order for ice chips or some documentation stating he was safe to have ice chips. Administrative Nurse D stated that speech therapy had worked with R28. The facility did not provide an accident policy.

The facility identified a census of 107 residents. The facility had three medication rooms and five medication carts. Based on observation, record review, and interview, the facility failed to ensure the medication cart was kept locked and secured with cognitively impaired and independently mobile residents on the hall. This placed the residents at risk of accidental ingestion of medication and adverse reactions.Findings included:- On 09/08/25 at 07:14 AM, the nurse's medication cart on the 200 hall was left unlocked and unattended by staff. The medication cart contained two insulin pens and two vials of insulin.On 09/08/25 at 07:18 AM, Licensed Nurse (LN) H stated that she had stepped away from the cart briefly to assist another nurse, but the cart should always be locked when she was away from it. On 09/10/25 at 01:22 PM, Administrative Nurse D stated that the medication carts should not ever be left unlocked when staff are away from the cart. The facility's Security of Medication Cart policy, dated January 2023, documented that the medication cart shall be secured during medication passes. The nurse or certified medication aide must secure the medication cart during the medication pass to prevent unauthorized entry. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. When it's not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

The facility had a census of 107 residents. The sample included 26 residents, with four reviewed for accommodation of needs for assistive device. Based on observation, record review, and interview the facility failed to utilize foot pedals during wheelchair transports for Resident (R) 37, R43, R104, and R122. This placed the residents at risk for preventable accidents. Findings Included: - On 09/09/25 at 07:40 AM, R37 (a severely cognitively impaired resident on the secured unit) was wheeled from her room to the dining room table. R37's wheelchair lacked foot pedals, and her feet slid on the ground as she was pushed. On 09/09/25 at 07:50 AM, R43 (a severely cognitively impaired resident on the secured unit) was wheeled to the dining room area from her room. Her wheelchair lacked foot pedals, and her feet slid on the floor as she was pushed.On 09/09/25 at 08:42 AM, R104 (a severely cognitively impaired resident on the secured unit) was pushed from the hallway to the dining room table. R104's wheelchair lacked foot pedals. Her feet touched the floor as she was pushed to the table. On 09/09/25 at 08:15 AM, R122 wheeled to her room from the main dining hall by staff. R122's wheelchair lacked foot pedals, and her feet slid on the ground as she was pushed.On 09/10/25 at 12:22 PM, Certified Nurse's Aide (CNA) O stated foot pedals were to be used on all residents while being pushed in their wheelchairs. She stated that all the wheelchairs had foot pedals available to use. She stated that pushing residents in their wheelchairs without them could cause an injury or fall. On 09/10/25 at 12:34 PM, Administrative Nurse D stated that staff were expected to use foot pedals while pushing the resident's wheelchair. The facility was unable to provide a policy related to assistive devices or accidents as requested on 09/10/25.

The facility identified a census of 107 residents. The sample included 26 residents, with 26 residents reviewed for baseline care plans. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 121 to include her chronic pain. This deficient practice placed R121 at risk of impaired care related to uncommunicated care needs.Findings included:- R121's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Guillain-Barre syndrome (a disorder in which the body's immune system attacks the nerves), fractured toe, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The admission Minimum Data Set (MDS) was in progress. R121's Care Area Assessment (CAA) was in progress. R121's Baseline Care Plan dated 09/05/25 documented nursing staff would administer all medication as ordered by the physician. The care plan lacked direction for R121's chronic pain related to a fractured toe, Guillain-Barre syndrome, and fibromyalgia.Review of R121's EMR under the Evaluation tab revealed the Baseline Care Plan e-signed on 09/05/25 lacked documentation related to R121's chronic pain.On 09/10/2025 at 08:01 AM, R121 sat in her electric wheelchair at the dining room table. R121 stated she had to wait for her pain medication after she was admitted to the facility. R121 stated her chronic pain was horrible at times. On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the resident's information for their care and what assistance the resident required for care could be found on their care plan or the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated the baseline care plan was an under-defined assessment (UDA) in the EMR under the Evaluation tab. LN K stated the admission nurse would answer all the nursing questions on the assessment. LN K stated that for a resident with a diagnosis of chronic pain the information should be included in their baseline care plan.On 09/10/25 at 01:23 PM, Administrative Nurse D stated she expected the baseline care plan to be completed within 24 hours after the resident's admission. Administrative Nurse D stated that chronic pain should be addressed on the resident's baseline care plan with person-centered interventions.The facility's Baseline Care Plans policy, last revised 03/2022, documented the baseline plan of care was to meet the resident's immediate health and safety needs, and was developed for each resident within forty-eight (48) hours of admission. The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

The facility identified a census of 107 residents. The sample included 26 residents, with five reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Residents (R) 43 and R20. This deficient practice placed both residents at risk for impaired dignity and unmet care needs.Findings Included:- The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R43's Annual Minimum Data Set (MDS) completed 07/01/25 indicated a Brief interview for Mental Status (BIMS) score of zero (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required substantial to maximal assistance for her activities of daily living (ADL) and supervision during meals. The MDS noted no weight loss. R43's Cognitive Loss Care Area Assessment (CAA) triggered on 05/27/25, indicating she was at risk for a decline in her ADLs related to her memory loss, impaired decision making, and need for assistance. The CAA noted she was at risk for nutritional impairment due to her medical diagnoses and cognitive impairment. R43's Communication CAA triggered on 05/27/25, indicating she was at risk for impaired communication related to her hearing and communication deficits. The CAA noted that a care plan was implemented to minimize the risks associated with her impairments, and staff were to anticipate her needs. R43's Care Plan initiated 07/11/24 indicated she was dependent on staff for meeting her emotional, intellectual, physical, and social needs due to her cognitive impairments. The plan instructed staff to provide a consistent routine and use approaches to ensure her involvement in decision-making. The plan instructed staff to anticipate and meet her needs. On 09/09/25 at 07:50 AM, R43 was wheeled to the dining room area. Her wheelchair lacked foot pedals, and her feet slid on the floor as she was pushed. R43 told staff, I'm hungry, and staff moved her to the table. At 07:55 AM, staff started serving trays two at a time from the kitchen. At 08:00 AM, R43 again informed staff she was hungry as she sat at the table. At 08:10 AM, two other residents had their food at the table she sat at and they ate their food. At 08:15 AM, staff placed a plate of food in the empty seat next to her. At 08:20 AM, the majority of the room had already served their meals except R43. R43 again complained she was hungry and began looking at the meal ticket for the empty seat next to hers. At 08:30 AM, R43 finally received her meal and began eating. The majority of the room had completed their meals before R43 received her plate. On 09/09/25 at 08:45 AM, Administrative Staff B stated the kitchen had to serve the meals two at a time to ensure the food stayed hot. She stated the dishwasher had been down for a week, and the kitchen had to serve the meals on Styrofoam plates. On 09/10/25 at 11:20 AM, Dietary Staff BB stated the dishwasher had been broken for the last week and a half. He stated the facility was waiting for a part and had to use Styrofoam plates. He stated the meals were to be served on the units to ensure they come out at the same time for each resident to enjoy their meals together. On 09/10/25 at 12:32 PM, Certified Nurses Aide (CNA) O stated the residents were to be served their meals around the same time so they could enjoy their meals together. She stated residents should not wait more than five minutes to receive their meals during breakfast. She stated the residents should never be allowed to watch other residents eat while they wait. The facility's Resident Rights policy, revised 12/2018, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.- The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), major depressive disorder (major mood disorder), and need for assistance for personal cares. R20's Quarterly Minimum Data Set (MDS) completed 06/19/25 indicated a Brief interview for Mental Status (BIMS) score of 15 (intact cognition). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he had physical, verbal, and other self-directed behaviors observed for one to three days. The MDS noted he was independent for toileting, transfers, bathing, bed mobility, dressing, personal hygiene, and putting on footwear. The MDS noted no behaviors or rejection of care. R20's Functional Ability Care Area Assessment (CAA) was triggered on 09/11/25. The CAA noted he required assistance from staff related to medical diagnoses. The CAA noted that a care plan was implemented to minimize the risks related to his potential decline in activities of daily living. R20's Care Plan initiated 05/10/18 indicated he was at risk for falls, nutritional deficit, and ADL decline related to his medical diagnoses. The plan indicated he could complete bathing, toileting, transfers, dressing, bed mobility, and personal hygiene with minimal staff assistance. The plan noted he was at risk for a psycho-social decline related to his history of anxiety. The plan instructed staff to move R20 to a calmer environment when conflict arose and allow him to share his feelings. A Facility Incident Report #2381 completed on 08/27/25 reported that an incident occurred between Dietary Staff CC and R20. The report indicated on 08/27/25, Dietary Staff CC got into a verbally aggressive argument with R20 in the dining area during dinner meal service. The report indicated R20 asked Dietary Staff CC for some milk. The report indicated that Dietary Staff CC informed R20 that he could not have milk. The report indicated that Dietary Staff CC became verbally aggressive with R20 upon being asked why he could not have milk. The report indicated that Dietary Staff CC was removed from the facility and immediately suspended. A Witness Statement was completed by Certified Nurse Aide (CNA) XX on 08/27/25. The statement indicated CNA XX witnessed R20 in the dining room, upset that he could not get milk with his meal. CNA XX noted in the statement that she witnessed Dietary Staff CC throw his hands in the air and run at R20. CNA XX noted in her statement that Dietary Staff CC continued to yell at R20, and she stood in front of Dietary Staff CC and told him to return to the kitchen. The statement indicated that Dietary Staff CC returned to the kitchen after multiple staff members requested him to leave. A Witness Statement was completed by Certified Nurse Aide (CNA) YY on 08/27/25. The statement indicated she witnessed Dietary staff CC aggressively approach R20 during the altercation and get into R20's face. She stated CNA XX got in between the two and told Dietary Staff CC to leave the dining room. On 09/09/25 at 11:32 AM, R20 sat in his room. R20 reported he remembered the incident on 08/27/25. He stated he felt threatened that staff would assault him over a carton of milk. He stated the kitchen staff aggressively yelled at him and got in his face until another staff member intervened. He stated the other staff was able to get him milk without issue. He stated he never he issues with staff until that day. He stated he felt humiliated and dehumanized that staff would treat him in such a rude manner over milk. On 09/09/25 at 02:30 PM, CNA WW stated all staff received training related to abuse, dementia care, and communication at least every quarter. She stated the previous abuse training was held in July 2025. She stated that staff were to always talk to the residents in a respectful manner. She stated milk and condiments were always available to the residents. On 09/10/25 at 12:23 PM, Administrative Nurse D stated the facility holds abuse training annually and after any incidents occur. She stated staff were expected to treat all residents in a dignified manner and protect the residents from abuse. She stated staff were expected to accommodate the residents' needs and asked the department managers if items were not immediately available. The facility's Resident Rights policy, revised 12/2018, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.

The facility identified a census of 107 residents. The sample included 26 residents, with two sampled residents reviewed for hospitalization and one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 and their representative were provided, as soon as practicable, a written notification of transfer upon their transfer to the hospital. The facility failed to ensure a discharge summary, and a recapitulation of R120's stay was completed upon discharge from the facility. This placed R1 and R120 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), hypertension (HTN- elevated blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R1's Discharge Minimum Data Set (MDS) dated 11/15/24 documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS dated 11/15/24 documented a re-entry to the facility from an acute hospital. R1's Discharge MDS dated 12/07/24 documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS dated 12/09/24 documented a re-entry to the facility from an acute hospital. R1's Annual MDS dated 12/19/24 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required substantial assistance, being dependent on staff for her cares. The overall goal for R1 was to remain in the facility. No active discharge planning was occurring. R1's Discharge MDS dated 05/01/25 documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS dated 05/03/25 documented a re-entry to the facility from an acute hospital. R1's Functional Abilities Care Area Assessment (CAA) dated 12/30/25 documented she required assistance with her activities of daily living (ADL) and had impaired balance and impaired transition during transfers, and functional impairment in activity. Contributing factors included R1's generalized weakness and decreased safety awareness. R1's risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. R1's Care Plan, revised 06/09/25, directed staff that due to her daily care needs, R1 wished to remain in long-term care. The Care Plan directed staff to encourage her to express her concerns and feelings. The Care Plan directed staff that R1 would have all her spiritual needs met. On 09/09/25 at 09:15 AM, R1 lay in bed with her supplemental oxygen on; R1 voiced no complaints. On 09/10/25 at 01:22 PM, Administrative Nurse D stated that social services typically completed the bed hold and notification of transfers when a resident was sent to the hospital. Administrative Nurse D stated all of R1's bed holds, and notification of transfer should be in her scanned chart. The facility lacked a policy regarding written notification of transfer. - R120's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of traumatic brain injury (TBI- an injury to the brain caused by external forces), insomnia (inability to sleep), and hemiplegia (paralysis of one side of the body). The Entry Minimum Data Set (MDS) dated 07/09/25 documented R120 admitted to the facility. The admission MDS dated 07/14/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R120 was independent with bed mobility and toileting. The MDS documented R120 required partial to moderate staff assistance with dressing. R120's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 07/24/25, documented R120 required staff assistance with activities of daily living. R120's Care Plan, dated 07/16/25, documented he required staff supervision during bathing. The Nurses Note on 07/14/25 at 03:52 PM documented R120 discharged to home at 01:30 PM with his personal belongings. The facility was unable to provide a discharge summary, which included a recapitulation of his stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications. R120 was admitted on [DATE] and discharged home on [DATE]. On 09/09/25 at 01:45 PM, Administrative Staff A stated R120 was a respite care resident, and his discharge summary was overlooked at the time of discharge. The facility's Discharge Summary and Plan policy, revised 10/2022, documented that when a resident's discharge was anticipated, a discharge summary and post-discharge plan would be developed to assist the resident with discharge. The discharge summary included a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident.

The facility identified a census of 107 residents. The sample included 26 residents, with four residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 14's low air loss mattress was at the correct weight setting, and R48's offloading boots were applied to her heels to prevent pressure ulcers. This placed R14 and R48 at increased risk for developing pressure ulcers.Findings Included:- R14's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), hypertension (HTN- high blood pressure), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and pressure ulcer of left buttocks Stage 3 (full-thickness pressure injury extending through the skin into the tissue below).The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R14 had impairment on both sides of her upper body and both sides of her lower body. The MDS documented R14 was dependent on staff for toileting and bathing. The MDS documented R14 was dependent on the staff to roll right to left. The MDS documented R14 was at risk for pressure ulcers and had one stage 3 pressure ulcer. The MDS documented R14 had a pressure-reducing device in her chair and a pressure-reducing device on her bed. R14's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 07/26/25 documented impaired skin integrity, current pressure ulcers, diabetic foot ulcers, and surgical wounds. The CAA documented the contributing factors, which included osteomyelitis (local or generalized infection of the bone and bone marrow), surgery on the genitourinary system, DM, and paraplegia. R14's Care Plan dated 02/17/23 documented R14 was offered and accepted a low air loss mattress and a foam wedge for positioning; staff were to monitor to ensure proper functioning. R14's plan of care documented R14 was at risk for further alteration in skin integrity related to her medical diagnoses. The plan of care dated 07/17/25 documented R14 had a left lateral (position that was the side) foot, left posterior (back of the body) thigh, right posterior thigh wound, Stage 3 pressure ulcer, and right foot surgical wound. The plan of care for R14 documented staff was to do skin assessments with every care provided and report to the nurse any necessary findings. R14's plan of care lacked direction for staff to monitor her low-air-loss mattress.R14s EMR under the Orders tab revealed the following orders: Left posterior thigh: cleanse all open areas with hypochlorous acid (wound cleaner) or normal saline, pat dry. Apply skin prep (adhesive dressing) to peri-wound (skin surrounding the wound). Cut a collagen (protein-derived wound treatment used to promote wound healing) pad to fit the posterior and medial area and place it over the wound bed. Apply black foam to the base of a large wound and use a wound vacuum device (also known as a negative pressure wound therapy or NPWT), change every day shift on Tuesday, Thursday, and Saturday, dated 08/28/25.R14's EMR under the Weights and Vitals tab document:Weight 213.6 pounds on 09/03/25.R14's Braden Scale for Prediction Pressure Sore Risk dated 08/05/25 documented a score of 14, indicating a moderate risk for pressure ulcers.R14's Weekly Wound Assessment dated 09/02/25 documented R14 had a diabetic foot ulcer on the left foot. On 09/08/25 at 08:25 AM, R14 laid in her bed on her back. R14's low-air-loss mattress was set at 550 pounds. On 09/09/25 at 08:27 AM, R14 laid on her bed on her back. R14 was eating her breakfast. R14's low-air-loss mattress was set at 550 pounds.On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated that CNAs did not do anything with the low air loss mattresses. CNA O stated that she would ensure the bed was working, but did not know anything about the dials. She stated the mattresses were set up by the supply person, and she didn't think the dials needed to be touched after the setup. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K set the low air loss mattresses according to weight. He stated the mattress should be set close to the resident's weight. He stated that the medical supply set the beds up. He stated there was no place on the Treatment Administration Record (TAR) for the nurse to mark to ensure the bed was set at the correct weight. He stated he was unsure who was monitoring the residents' mattresses. On 09/10/24 at 01:22 PM, Administrative Nurse D stated all mattresses were rented. She stated that medical supplies and maintenance set the mattress up. She stated the mattresses were set by weight and should be close to the resident's weight. She stated she was unsure of who was monitoring the mattress daily. The facility's Prevention of Pressure Injuries policy dated 03/20 documented the purpose of the procedure was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Review the residents' care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors and use a standardized injury screening tool to determine and document risk factors. Inspect skin every seven days and document results.- R48's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin), dysfunction of the bladder, hypotension (low blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pressure ulcer of sacral (back and buttocks) region, and pressure ulcer of left buttocks Stage 3 (full-thickness pressure injury extending through the skin into the tissue below).The Quarterly Minimum Data Set (MDS) for R48 dated 06/12/25 recorded a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R48 had an impairment of both sides of his upper and lower body. The MDS documented R48 was dependent on staff assistance for all activities of daily living (ADL). The MDS documented R48 was at risk for pressure ulcers and had a pressure-reducing device in his wheelchair and on his bed. R48's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 12/12/24 documented R48 pressure ulcers CAA triggered secondary to R48 having an actual pressure ulcer. R48's contributing factors include ADL/functional/mobility impairment, history of pressure ulcers, actual pressure ulcers, and use of medications that can contribute to skin breakdown, incontinence, and pain. The CAA documented R48's risk factors include pain, the development of pressure ulcer condition, and fluid deficit risk. A licensed nurse assesses skin each week and puts proper interventions in place to prevent skin breakdown. Skin was also assessed by caregivers with each bath and each time R48 was dressed. The physician was to be notified of any abnormal findings, and treatment orders were to be obtained. The dietitian monitored food and fluid intake and implemented dietary interventions as necessary. R48's Care Plan dated 03/12/24 documented R48 was at risk for altered skin integrity related to ADL self-care deficit, immobility, impaired sensation, incontinence of bowel, and a history of skin alterations. R48's plan of care documented that nursing was to complete treatments as ordered by the provider, notify the provider of any abnormal changes or worsening in condition. The plan of care documented R48 was often non-compliant with skin and wound care. This often occurred when R48 was up in a wheelchair and did not want to get back in bed. The plan of care for R48 documented staff were to encourage and assist R48 to offload pressure between lunch and dinner for pressure reduction. R48's plan of care documented he had a low-air-loss mattress in place, and staff were to monitor for changes in skin integrity, assist with ADLs, and report to the charge nurse. The plan of care for R48 documented staff was to offload bilateral heels using multiple pillows or soft heel lift boots when in bed, as R48 would allow or tolerate. R48's Braden Scale for Prediction Pressure Sore Risk dated 09/04/2025 documented a score of 13, indicating a high risk for pressure ulcers. R48's physician orders under the Orders tab revealed the following orders: Weekly skin assessment every Saturday, day shift, dated 09/13/25.R48's Nursing Progress Notes lacked documentation R48 was offered his heels floated or refused to have his heels floated.On 09/08/25 at 08:10 AM, R48 laid on his bed, R48's heels lay directly on his mattress. On 09/08/25 at 09:11 AM, R48 laid on his bed, R48's heels lay directly on his mattress.On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated if a resident needed their heels floated, the nurse would let the CNAs know. She stated the nursing staff would help her float the residents' heels. She stated that floating of a resident's heels would be a nursing duty, but that would probably show up on her Kardex (a nursing tool that gives a brief overview of the care needs of each resident).On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated that if a resident was to have their heels offloaded, whether with boots or pillows, that order would show on the nursing Treatment Administration Record and the resident's care plan. He stated that any nursing staff member was able to float a resident's heels.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that floating of a resident's heels would show on the Treatment Administration Record (TAR) Kardex and the resident's care plan. She stated nurses would check to ensure the task was done.The facility's Prevention of Pressure Injuries policy dated 03/20 documented the purpose of the procedure was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Review the residents' care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors and use a standardized injury screening tool to determine and document risk factors. Inspect skin every seven days and document results.

The facility identified a census of 107 residents. The sample included 26 residents with one resident was reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 44 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R44 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included:- R44's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of contracture of the left elbow, contracture of the left hand, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Annual Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R44 had bilateral lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) and limited ROM on one upper extremity. The MDS documented R44 was dependent on staff's assistance for oral hygiene, transfers, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS documented R44 had not rejected care during the observation period. The MDS documented R44 had no nursing restorative program. The Quarterly MDS dated [DATE] documented a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R44 had bilateral lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) and limited ROM on one upper extremity. The MDS documented R44 was dependent on staff's assistance for oral hygiene, transfers, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS documented R44 had not rejected care during the observation period. The MDS documented R44 had no nursing restorative program.R44's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/22/25 documented she required assistance with activities of daily living.R44's Care Plan dated 08/23/22 documented nursing staff would administer her medication as ordered by the physician. The plan of care documented the nursing staff would notify the nurse of decreased ROM, redness, pressure areas, or increased pain. The plan of care dated 10/02/22 documented R44 refused the use of a left resting splint. The plan of care dated 10/08/24 documented the nursing staff would assist her to maintain proper body position in the bed and when she was in her wheelchair.Review of R44's EMR lacked documentation of a re-evaluation of her current left hand and left elbow contracture. The EMR also lacked documentation of alternative interventions or services provided to R44 to prevent worsening of her contractures. R44's EMR lacked documentation of refusals to wear the left-hand splint. On 09/09/25 at 08:13 AM, R44 laid on the bed with the head of her bed elevated. R44's left elbow was bent and lay against her abdomen with her left hand closed with no splint or device to prevent the worsening of her contractures. On 09/10/25 at 08:01 AM, R44 laid on the bed with her left arm bent at the elbow and her left hand was tightly closed.On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the therapy department would evaluate the residents and determine if the residents required any type of contracture care. CNA O stated the nursing staff would apply the splints if ordered by therapy. CNA O stated the nursing staff would chart the application and removal in the residents' EMR.On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated that the therapy evaluated the residents with contractures. LN K stated the nurse would apply the splint and monitor the application of the splint. LN K stated if a resident refused to wear their splint, the nurse would refer them back to the therapy department for re-evaluation. LN K stated the nurse would document the application of the splint or their refusal on the Treatment Administration Record (TAR).On 09/10/25 at 01:23 PM, Administrative Nurse D stated that some of the residents were on therapy maintenance programs. Administrative Nurse D stated the nurse would monitor the application and removal of the splints, and that would be documented on the TAR. Administrative Nurse D stated that if a resident were to refuse to wear their hand splint, that resident would be referred to the therapy department for another assessment.The facility was unable to provide a policy related to quality of care.

The facility identified a census of 107 residents. The sample included 26 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 24's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). The facility failed to ensure R24's care plan provided interventions to direct staff and implement care and services according to the professional standards of practice in order to meet the resident's dialysis care needs. This deficient practice placed R24 at risk for missed dialysis visits and complications related to dialysis.Findings included:- R24's EMR documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow), end-stage renal disease (ESRD- a terminal disease of the kidneys), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hemiplegia (paralysis of one side of the body).R24's admission Minimum Data Set (MDS) dated 08/20/25 documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated an intact cognition. R24 had functional limitation in range of motion with impairment in both upper and lower extremities. R24 used a walker and a wheelchair to assist with mobility. R24 required substantial assistance to total dependence on staff for his functional abilities. R24 required peritoneal dialysis (procedure performed to remove toxins, drugs, or other wastes in the blood normally excreted by the kidney).R24's Functional Abilities Care Area Assessment (CAA) dated 08/25/25 documented he needed assistance with his activities of daily living (ADL) and mobility. Contributing factors include osteomyelitis (local or generalized infection of the bone and bone marrow) of the lumbar vertebra, discitis (inflammation that develops between the intervertebral discs of the spine), ESRD, COPD, and hemiplegia. Staff anticipated his needs and administered his medications as prescribed. Staff assist with his ADLs per the care plan.R24's Care Plan, revised 09/04/25, directed staff that he received hemodialysis. R24's Care Plan directed staff to check and change his dressing daily at the access site in the left upper arm. The Care Plan directed staff not to draw blood or take blood pressure in the left arm. R24's Care Plan lacked staff direction on his dialysis days, the location of his dialysis clinic, the contact information of the dialysis clinic, and how information would be communicated between the facility and the dialysis clinic.R24's EMR lacked a physician's order for dialysis.On 09/08/25 at 01:49 PM, R24 laid in his bed resting.On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated that when a resident was admitted , the admitting nurse was responsible for entering orders in the EMR. LN K stated that the unit manager would review his order the next day to make sure everything was entered correctly. LN K stated R24's EMR should have his dialysis order entered. LN K stated R24's care plan should direct staff on which days he goes to dialysis, as well as any special care needed regarding care before and after his dialysis treatment.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that R24's order for his dialysis should have been entered into the EMR at the time of his admission on [DATE]. Administrative Nurse D stated that the unit manager should have caught that during her audit that the order was not in the EMR. Administrative Nurse D stated she expected R24's care plan to reflect which days and times he went to dialysis, as well as the dialysis clinic name, and other special instructions.The End-Stage Renal Disease, Care of a Resident policy, dated February 2022, documented that staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care would be managed, including: how the care plan would be developed and implemented; how information will be exchanged between the facilities; and responsibility for waste handling, sterilization, and disinfection of equipment; and the resident's comprehensive care plan would reflect the resident's needs related to ESRD/dialysis care.

The facility identified a census of 107 residents. The sample included 26 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to assess and identify trauma-based triggers related to R11's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R11. These deficient practices placed R11 at risk for decreased psychosocial well-being and ineffective treatment. Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of PTSD, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and hydronephrosis (a condition where urine backs up into the kidney, causing it to swell).R11's Annual Minimum Data Set (MDS) dated 03/20/25 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R11 required only supervision from staff for her cares. R11 had an active diagnosis of PTSD. R11's Psychotropic Drug Use Care Area Assessment (CAA) dated 03/02/25 documented the use of psychotropic meds to manage psychiatric illness/condition. A licensed nurse monitored for side effects every shift, and the physician/psychiatrist was to be notified of any abnormal findings. A pharmacist consultant would review medications monthly, and the physician would review medications with each visit. R11's CAAs lacked her PTDS being addressed.R11's Care Plan, revised on 08/05/25, directed staff that she had adjustment issues related to recent losses and changes. The Care Plan directed staff to allow R11 the opportunity to communicate her feelings. The Care Plan directed staff to encourage R11 to participate in conversations with staff and other residents daily. The Care Plan lacked staff direction on her PTSD triggers and interventions to prevent re-traumatization.On 09/10/25 at 11:15 AM, R11 sat in her wheelchair near the entrance of the building, visiting with a staff member.On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated he knew that some residents' care plans did address a PTSD diagnosis, but was not certain R11's care plan did. LN K stated staff should be made aware of past trauma and what might be triggers.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that social services did an initial evaluation on each resident at admission and then quarterly. Administrative Nurse D could not say if the evaluation addressed PTSD. Administrative Nurse D stated she would expect R11's care plan to address past traumas and have interventions to prevent re-traumatization.The Trauma-Informed and Culturally Competent Care policy, dated October 2023, documented the purpose was to guide staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma-informed care was an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. The policy documented the performance of universal screening of residents, which included a brief, non-specialized identification of possible exposure to traumatic events. Utilize screening tools and methods that were facility-approved, competently delivered, culturally relevant, and sensitive. Screening may include information such as trauma history, including type, severity, and duration; depression, trauma-related or dissociative symptoms; risk for safety (self or others); concerns with sleep or intrusive experiences; behavioral, interpersonal, or developmental concerns; historical mental health diagnosis; substance use; protective factors and resources available; and physical health concerns. Utilize initial screening to identify the need for further assessment and care. Assessment involved an in-depth process of evaluating the presence of symptoms, their relationship to trauma, and the identification of triggers. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Use assessment tools that are facility-approved and specific to the resident population. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety, and depression). Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms, and values.

The facility identified a census of 107 residents. The sample included 26 residents, with two reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related behavioral interventions for Resident (R) 16 to promote the resident's highest practicable level of well-being. This deficient practice placed R16 at risk for decreased quality of life, isolation, and impaired dignity.Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R16's Quarterly Minimum Data Set (MDS) completed 08/02/25 indicated a Brief interview for Mental Status (BIMS) score of three (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he had physical, verbal, and other self-directed behaviors observed for one to three days. The MDS noted he required substantial to maximal assistance from staff for toileting, transfers, bathing, bed mobility, dressing, personal hygiene, and putting on footwear. R16's Behavioral Care Area Assessment (CAA) triggered on 05/27/25. The CAA noted he had a history of physical and verbally aggressive behaviors. R16's Care Plan initiated 05/15/25 indicated he was admitted to a secured unit due to his medical diagnoses and risk for elopement. The plan noted he was monitored frequently for safety (05/15/25). The plan noted he required substantial assistance from staff for transfers, bathing, toileting, dressing, personal hygiene, and oral hygiene (05/15/25). The plan noted he had cognitive impairment or impaired thought processes (05/15/25). The plan instructed staff to cue, orient, and supervise him as needed (05/15/25). The plan instructed staff to engage in simple activities and kept his routine consistent (05/15/25). The plan noted he was dependent on staff for meeting his emotional, intellectual, physical, and social needs (06/20/25). On 09/02/25, R16's plan was updated, indicating he had behaviors related to inappropriate touching. The plan instructed staff to anticipate his needs, offer tasks to divert his attention, and provide activities that accommodated his interests (09/02/25). The plan noted he was placed on one-to-one supervision until his departure from the facility, and facility staff provided abuse education (09/02/25). The plan lacked interventions related to his inappropriate touching or boundary concerns prior to 09/02/25. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/16/25. The note indicated R16 was observed holding hands with another resident and using affectionate gestures towards other residents on the secured unit. The note indicated staff provided appropriate redirections to maintain personal boundaries in a respectful manner. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/17/25. The note indicated R16 wheeled himself around the secured unit. The note revealed R16 was observed repeatedly touching other residents. The note revealed that staff intervened promptly by redirecting him and provided verbal reminders regarding personal boundaries. The note revealed staff had to remove R16 from the immediate area and redirect to an activity table under staff supervision. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/18/25. The note revealed R16 was observed touching a resident in a sexual way and provided several redirections. The note revealed R16 became aggressive upon redirection and wanted to hit the staff. The note revealed that staff moved him back to his room and attempted to contact his resident representative. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/18/25. The note revealed R16 was sent out to an acute medical facility for evaluation. R16's EMR under Miscellaneous revealed an acute medical facility summary from 07/28/25. The summary indicated the facility report concerns of worsening promiscuity and combativeness. R16's EMR under Progress Notes revealed an admission Progress Note completed on 07/28/25. The note indicated he returned to the facility at 04:00 PM following a hospital stay for treatment of inappropriate behaviors and gout. R16's EMR under Progress Notes revealed a Social Service Note completed on 08/28/25. The note revealed R16's Resident representative was notified that R16 had been touching and being inappropriately with staff. The note indicated he was being transferred to an all-male unit. R16's EMR under Progress Notes revealed a Behavior Note completed on 08/29/25. The note revealed that staff witnessed R16's hands touching another resident's private area. The note revealed that both residents were immediately separated, and the unit supervisor was notified. A Facility Incident Report #3977 completed on 08/29/25 indicated R16 was observed by staff placing his hands between R75's (a severely cognitively impaired female resident) inner thighs. The report indicated R75 screamed out, Stop, don't touch me. The report indicated that both residents were separated and assessed. The note revealed neither resident had memory recall of the incident. The note revealed R16 was immediately placed under one-to-one supervision. A Witness Statement completed by CNA UU on 08/29/25 documented that she witnessed R16 putting R16's hands in between R75's thighs in her private region. The statement indicated she immediately separated them and moved R16 to the men's table. R16's EMR under Progress Notes revealed a Nurse's Note completed on 09/04/25. The note revealed R16 was transferred out of the facility. On 09/09/25 at 11:20 AM, R75 reported she had no memory of the incident, but reported she did not like any males touching or providing care for her. On 09/09/25 at 02:30 PM, CNA WW stated R16 had ongoing sexual impulses on the unit. She stated staff were expected to supervise R75 and provide reminders related to appropriate behaviors. She stated he would continually attempt to hold female staff members' hands and then move toward their private areas. She stated the facility provided dementia related training annually. She was not sure what specific interventions were in place for R16's behaviors. On 09/09/25 at 02:30 PM, CNA XX stated R16's sexual behaviors had been going on for a while. She stated staff would have to watch him closely and provide constant redirection due to his mobility in his wheelchair. She stated staff would sit him with male peers to prevent him from grabbing at female residents.On 09/09/25 at 03:31 PM, Administrative Nurse D stated she did not see his behaviors as sexual. She stated she did not believe he went to the acute care facility on 07/18/25 for sexual behaviors, but rather due to his hand issues. She stated all staff had training to recognize and prevent abuse. She stated the facility transferred R16 to an all-male unit due to his increased behaviors. Administrative Nurse D stated that the facility immediately placed R16 on one-to-one supervision until he transferred, and the facility provided abuse training to the staff.The facility was unable to provide a policy related to dementia or behavioral services as requested on 09/11/25.

The facility identified a census of 107 residents. The sample included 26 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's insulin (a hormone that lowers the level of glucose in the blood) was given before meals according to the physician-ordered parameters related to blood glucose monitoring. This deficient practice placed R25 at risk for hypoglycemia (less than normal amount of sugar in the blood), delayed treatment, and unnecessary medication complications. Findings included:- R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses hypertension (HTN high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), fracture of shaft of left tibia (the inner and typically larger of the two bones between the knee and the ankle), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), need for assistance with personal care, muscle weakness, cognitive ( relates to all the mental processes involved in knowing, thinking, learning, remembering, and understanding things), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R25 needed setup or cleanup for eating and oral hygiene. The MDS documented R25 was dependent on staff for toileting and needed substantial to maximal assistance for bathing. The MDS documented R25 had DM and received insulin during the look-back period.R25's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/09/25 documented R25's need for assistance with activities of daily living (ADL) and mobility. Contributing factors include displaced fracture with routine healing, quadriplegia, DM, HTN, anxiety, and depression. The CAA documented staff would anticipate R25's needs, administer medications as prescribed, prepare and serve his diet as ordered.R25's Care Plan dated 07/11/25 documented R25 had DM and he would have no complications related to diabetes through the review date. The plan of care for R25 documented staff would check his body for breaks in skin and treat promptly as ordered by the physician, and give diabetes medication as ordered. R25's care plan documented the dietician would discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in the daily nutritional plan, and compliance with nutritional regimen.R25's EMR under Orders revealed the following physicians' orders:Insulin Glargine Subcutaneous (beneath the skin) solution pen injector 100 units/milliliter (ml) (insulin Glargine- long-acting insulin), inject five units subcutaneously at bedtime for diabetes, dated 07/04/25.Humalog (fast-acting insulin) Mix 75/25 Kwik Pen Subcutaneous suspension pen injector (75-25) 100 unit/ml (insulin Lispro Protamine (intermediate-acting insulin) and Lispro (fast-acting insulin)), inject three units subcutaneously with meals for diabetes hold if blood sugar < (less than) 200 ml/dl, dated 07/04/25.Insulin Glargine subcutaneous solution pen-injector 100units/ml (insulin Glargine), inject ten units subcutaneously at bedtime for diabetes, dated 07/14/25.R25's EMR under the Treatment Administration Record (TAR) recorded the following blood glucose levels under 200 milligrams per deciliter (ml/dl). R25's TAR that lacked evidence, R25's insulin was held.08:00 AM Blood glucose readings:07/08/25 113 ml/dl07/11/25 165ml/dl07/12/25 123ml/dl07/13/25 140 ml/dl07/16/25 108 ml/dl07/17/25 123 ml/dl07/21/25 132 ml/dl07/22/25 150 ml/dl07/28/25 178 ml/dl07/30/25 160 ml/dl12:00 PM Blood glucose readings:07/16/25 170 ml/dl07/21/25 196 ml/dl07/22/25 137 ml/dl07/30/25 160 ml/dl05:00 PM Blood glucose readings:07/12/25 196 ml/dl07/16/25 113 ml/dl07/17/25 135 ml/dl07/22/25 120 ml/dl08:00 AM blood glucose readings:08/03/25 106 ml/dl05:00 PM blood glucose readings:08/29/25 125 ml/dl08/30/25 152 ml/dlR25 admitted to the facility on [DATE] and discharged to the hospital on [DATE].On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated it was the nurse's duty to ensure the nurse double checked the TAR before nurses would give insulin. He stated nurses waited until the resident had his meal tray or would give the insulin after the resident had eaten.On 09/10/25 at 01:22 PM, Administrative Nurse D stated the facility needed to do a better job at oversight of insulin given. She stated nurses should ensure they are giving the correct amount of insulin to a resident. She stated that if a resident should be given insulin with meals, the insulin should be given when the meal arrived, or while the resident was eating.The facility did not provide a policy for unnecessary medications.

The facility identified a census of 107 residents. The sample included 26 residents, with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Residents (R) 4 and R5. This placed the resident at risk for inadequate end-of-life care. Finding Included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), epilepsy (brain disorder characterized by repeated seizures), psychosis (any major mental disorder characterized by a gross impairment in reality perception), dementia (a progressive mental disorder characterized by failing memory and confusion), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), repeated falls, need with assistance with personal cares, muscle weakness, encounter for palliative care, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, dressing, and eating. The MDS documented R4 received hospice services. R4's The Functional Abilities Self-Care and Mobility Care Area Assessment (CAA), dated 08/12/25, documented R4's activities of daily living (ADL) function CAA triggered secondary to assistance required in ADLs, impaired balance, transitions during transfers, and functional impairment in activity. R4's contributing factors include generalized weakness and decreased safety awareness. R4's risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. The CAA documented R4's care plan would be initiated/reviewed to improve/maintain current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. R4's Care Plan dated 09/05/24 documented R4 was admitted to hospice due to a terminal diagnosis, cerebral atherosclerosis (a condition where fatty deposits build up in the arteries that supply blood to the brain). R4's plan of care documented comfort would be maintained, and staff would adjust the provision of ADLs to compensate for the resident's changing abilities. R4's plan of care documented that staff were to encourage participation to the extent the resident wished to participate and encourage the support system of family and friends. R4's plan of care documented to keep the environment quiet and calm, keep linens clean, dry, and wrinkle-free. R4's plan of care documented staff were to keep the lighting low and familiar objects nearby. The plan of care for R4 documented the hospice provider would review the resident's living will and ensure it was followed. The plan of care for R4 documented staff were to involve the family in the discussion. R4's plan of care documented Vitas hospice would provide durable medical equipment (DME), and staff would work cooperatively with hospice team to ensure R4's spiritual, emotional, intellectual, physical, and social needs were met. A review of the hospice-provided communication binder revealed R4 was admitted to hospice services on 09/05/24. On 09/09/25 at 08:35 AM, R4 sat in the dining area waiting for her breakfast, holding her doll. On 09/09/25 at 08:50 AM, R4 sat in the dining room with staff assisting her with breakfast. On 09/10/25 at 12:30 PM, Certified Nursing Aide (CNA) O stated she was unsure what hospice provided for the residents. She stated the hospice aides would let the staff know if the hospice provider left any supplies or gave a shower. CNA O stated she didn't think that what hospice provided, the CNAs could see. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated he was unsure what hospice provided. He stated he did not do the care plans; the MDS coordinator did the care plan. LN G stated he did not think what hospice provided would need to be on the facility's care plan. LN G stated that hospice aides and nurses were good at letting the facility know what equipment and supplies they brought to the resident. He stated if there was something specific the facility needed to know, they could look in the hospice binder specific to each resident. On 09/10/25 at 01:22 PM, Administrative Nurse D said she knew the hospice providers had detailed care plans and staff would know specific services by those. She stated she thought everything hospice provided should be on the care plan. The facility's Hospice Program policy, dated 07/17, documented hospice services were available to residents at the end of life. The facility had an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Upon admission and periodically during their stay, residents were informed of the availability of hospice services coordinated through the facility. - R5's Electronic Medical Record (EMR) documented diagnoses of malignant neoplasm (cancer- an abnormal growth of cells that can invade and spread to other parts of the body) of lung, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hemiplegia/paresis (weakness and paralysis on one side of the body). R5's admission Minimum Data Set (MDS) dated 08/25/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R5 required substantial/maximal assistance to being dependent on staff for his activities of daily living (ADL) care. R5 was on hospice care. R5's Functional Abilities Care Area Assessment (CAA) dated 08/27/25 documented his need for assistance with his ADLs and mobility due to his lung cancer, need for palliative care, and failure to thrive. R5's Care Plan initiated on 08/19/25 directed staff that he had a terminal prognosis and elected hospice care. The Care Plan directed staff to adjust provisions of his ADLs to compensate for his changing abilities. The Care Plan directed staff to encourage participation to the extent the resident wished to participate. The Care Plan directed staff to encourage the resident to express his feelings and listen with non-judgmental acceptance and compassion. The Care Plan directed staff to encourage a support system of family and friends. The Care Plan directed staff to keep the environment quiet and calm, keep linens clean, dry, and wrinkle-free, keep the lighting low, and keep familiar objects nearby. The Care Plan directed staff to observe R5 closely for signs of pain and administer pain medications as ordered and notify the physician immediately if there was breakthrough pain. The Care Plan directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. R5's Care Plan lacked staff direction on who the hospice provider was and the contact information. R5's Care Plan lacked staff direction on what hospice provided for the resident as far as supplies, durable medical equipment (DME), medications, and hospice staff information (who would visit and the frequency of the visits). On 09/09/25 at 01:15 PM, R5 lay resting on his low air loss mattress, the bed in low position, and the call light within reach. On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated that the nurses would usually tell staff when a resident was on hospice. CNA O stated that the hospice aide would come a couple of times a week, and the hospice nurse came to the facility weekly and would usually ask if a resident needed any supplies. CNA O stated that the items/equipment supplied had the hospice name on them. CNA O stated she was not certain if R5's care plan had all that information in it or not. On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated the hospice information was at the nurse's station and the hospice plan of care was in the resident's hospice books. LN K could not say for certain if R5's care plan had all the information about hospice in it as far as the contact information and what hospice supplied, but would expect that the care plan should have that information on it. On 09/10/25 at 01:22 PM, Administrative Nurse D stated they had been working on improving the resident care plans. Administrative Nurse D stated R5's care plan should document the hospice provider and contact information as well as what hospice provided and when hospice staff would visit. Administrative Nurse D stated she would ensure R5's care plan was revised to reflect that information. The Hospice Program policy, dated January 2024, documented coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The coordinated care plan would reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including palliative goals and objectives, palliative interventions, and medical treatment and diagnostic tests.

The facility identified a census of 102 residents. The sample included 22 residents with six residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure a dignified care environment for Resident (R)33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining when the facility used disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being. Findings Included: - The Facility Reported Incident 2181 documented that on 08/13/23, R33 assisted emergency medical services (EMS) by holding open a door so EMS could enter the facility. The report indicated Administrative Staff B approached R33 and told R33 to move out of the way. The report indicated R33 refused to move, and Administrative Staff B used profanity towards R33. On 01/17/24 at 08:05 AM an inspection of the main dining area revealed residents ate breakfast with Styrofoam plates/cups and disposable plastic silverware. At 08:05 AM Dietary Staff BB stated the facility had enough silverware for all three meal services, but staff did not return the silverware to the kitchen in time for the next service. On 01/17/24 at 08:30 AM an inspection of the [NAME] Hall dining service revealed residents ate breakfast with Styrofoam plates/cups and disposable plastic silverware. On 01/17/24 at 12:14 PM R75 (a severely cognitively impaired resident) rested in the dining area in her Broda chair (specialized wheelchair with the ability to tilt and recline). R75 sat at the table with her head and arms resting on the table. An unidentified staff member walked up to R75 and informed her it was lunchtime. R75 stated she preferred to rest with her head on the table. Staff then repositioned her upright in her wheelchair without notifying her or asking her if she wanted to sit up. R75 agreed to eat lunch. The unidentified staff member yelled out I'll feed her to another staff across the room. On 01/22/24 at 09:56 AM Licensed Nurse (LN) G administered R88's morning medications through her gastrotomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and completed a dressing change. LN G failed to close the door or pull the privacy curtain during the provided care with multiple people walking past the room within sight of the provided care. During the dressing change, Administrative Nurse D walked by R88's room, then stopped and closed the door. LN G stated she usually would close the door when she provided wound care but not while working with G-tubes. On 01/22/24 at 11:50 AM R89 (a severely cognitively impaired resident) sat at the dining table closest to the television and awaited her lunch. Certified Nurses Aid (CNA) NN brought R89's meal to her and prepped her for lunch. CNA NN provided assistive feeding for R89 while standing next to the resident. At 11:56 AM, LN J approached CNA NN and instructed her to sit down next to R89 while providing assisted feeding. CNA NN sat down and remained seated during the meal assist. On 01/22/24 at 11:58 AM R62 was assisted to the dining room by CNA LL. R62 sat at the table next to the window and CNA LL adjusted her seat. CNA LL completed hand hygiene and retrieved R62's meal and drink from the food cart. CNA LL stood next to R62 and began spoon-feeding her mechanically soft beef and mashed potatoes. At 12:01 PM CNA LL continued to provide assistive feeding to R62 without offering or alternating drinks with her solid food. At 12:09 PM CNA LL picked up R62's red beverage and offered it to her. R62 took a large drink and continued her meal while CNA LL stood next to her to assist. On 01/23/24 at 11:20 AM CNA M stated staff were expected to always be seated with the residents during assistive feedings. She stated it would be disrespectful to stand over someone else while trying to feed them. On 01/23/24 at 11:55 AM LN I stated staff should always communicate before repositioning residents and always sit with them while assisting them with meals. She stated staff should always ensure privacy while providing personal care assistance and dressing changes. On 01/23/24 at 12:50 PM Administrative Nurse D stated staff was expected to ensure the residents had privacy during care. He stated staff should always sit while providing assisted meals and be at eye level to ensure effective communication. He stated staff should always communicate with the residents before repositioning them and ask for their opinion or input. A review of the facility's Resident Rights policy revised 12/2016 indicated all residents had the right to be treated with dignity, respect, and kindness. The policy indicated the facility would provide care in a manner that communicates understanding and preferred choices related to each resident's needs, wants, and preferences. The facility failed to ensure a dignified care environment for R33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining related to using disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being.

The facility identified a census of 102 residents with six residents on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment. Findings Included- - On 01/22/23 at 10:15 AM Dietary Staff BB placed a tin of cooked beef and another of beef stock in the preparation area. The food processor machine had previously been used for food and had not been washed before puree use. Dietary Staff BB placed the contents of the cooked beef in the food processor and started to puree the meat. Dietary Staff BB then added beef stock to the processor without measuring to amount of liquid stock to be added. Dietary Staff then prepared a tin serving pan with non-stick spray and removed the textured mixer from the processor to the serving tray. An inspection of the mixer revealed a wet pudding-like consistency for the prepared meat. Dietary Staff BB did not review the pureed beef recipe throughout the preparation of the pureed meal. Dietary Staff BB explained the recipes were available for review and pointed to the recipe book on a table. On 01/23/23 at 11:23 PM Dietary Staff BB stated recipes must be followed by staff during meal preparation and staff were to review them during preparation. The facility's provided Food Preparation and Service 04/2019 indicated food will be prepared and maintained to ensure proper nutritional values are maintained and to meet the dietary requirements of each resident. The facility failed to follow a nutritionally approved recipe during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment.

The facility identified a census of 102 residents with 22 residents included in the sample. The facility identified two residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 81 and R 28. This failure placed the residents at risk for impaired decision-making. Findings included: - A review of R81's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 08/17/23 and ended on 08/21/23. R81 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. A review of R28's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 07/12/23 and ended on 09/01/23. R28 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. On 01/23/23 at 11:25 PM Social Services X stated that she was unaware the form CMS-10055 needed an estimated cost for continued services. The facility's Advance Beneficiary Notices policy, dated 04/2021, documented that the current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary and the contents of the form shall comply with related instructions and regulations regarding the use of the form. The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices. This failure placed the residents at risk for impaired decision-making.

The facility identified a census of 99 residents. The sample included 23 residents; five residents were reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Eighteen residents resided on the memory care unit. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 248 when the facility failed to identify and implement resident-centered interventions to address violent/aggressive behaviors, wandering, and negative resident-to-resident altercations which included physical aggression. The facility further failed to assess, identify, record, and respond to R248's specific behaviors, triggers, and past/present interests and activities in order to promote an environment which supported R248's individualized care needs. As a result of these failures, R248, who was allowed to roam freely on the memory care unit, was involved in multiple resident-to-resident altercations which created an unsafe living environment and resulted in intimidation, acute care evaluations, hospital transfers for R248 and the other memory care residents and serious resident injury on [DATE]. This deficient practice placed all 18 residents who resided on the memory care unit in Immediate Jeopardy. Findings included: - R248 admitted to facility on [DATE], transferred to memory care unit on [DATE], transferred to hospital [DATE], readmitted to facility [DATE], transferred to hospital [DATE], readmitted to facility [DATE], transferred to hospital [DATE], readmitted to hospital [DATE], and transferred to hospital [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented R248 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R248 had physical and verbal symptoms directed towards others that occurred one to three days during the lookback period, rejection of care that occurred one to three days during the lookback period, and wandering that occurred daily. R248 was independent with one staff with bed mobility, walking, and locomotion; supervision with one staff with transfers; extensive physical assistance with two staff for dressing; limited physical assistance with one staff for toileting and personal hygiene; and independent with setup help only with eating. The interview for daily and activity preferences was not conducted. R248 received antipsychotic (class of medications used to treat [CONDITION(S)] and other mental emotional conditions) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications six days, and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications seven days in the seven-day lookback period. The [CONDITION(S)] [sudden severe confusion, disorientation and restlessness] Care Area Assessment (CAA) dated [DATE], documented inattention and disorganized thinking were baseline for R248. The Cognitive Loss/Dementia CAA dated [DATE], documented R248 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Behavioral Symptoms CAA dated [DATE], documented R248 had regular behaviors; staff referred to the care plan. The Care Plan dated [DATE], documented R248 resided on a secured unit due to his impulsivity and high risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff) and recorded R248 was encouraged to participate in all activities, frequently monitored for safety, and supervised/accompanied by staff when not on secured unit. The Cognitive Impairment/Dementia Care Plan dated [DATE], directed R248 had impaired cognitive function/dementia related to [CONDITION(S)] and directed staff administered medications as ordered, asked yes/no questions to determine R248's needs, and assisted R248 with decision making. It further directed staff monitored/documented/reported to medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The General Behavior Symptoms Care Plan dated [DATE]and revised [DATE], directed R248 displayed behavioral symptoms such as refusing/resisting care, voiding in inappropriate areas, impulsivity, wandering, and physical aggression towards staff and residents. The Care Plan documented interventions, initiated [DATE], that directed staff gave psychoactive medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) as ordered and recorded behavioral symptoms/side effects, intervened when inappropriate behavior was observed, and used interventions that addressed the abilities and needs reflected in the specific symptom or symptoms. The Care Plan documented an intervention, initiated [DATE], that staff offered redirection such as restroom, snack, coffee, going outside, and activities when R248 was seen wandering in other residents' rooms The Physically Aggressive Behavior Care Plan initiated [DATE], documented R248 demonstrated physical aggression towards others and on [DATE] R248 had a physical altercation and was placed on one-to-one supervision until transported to the hospital for psychiatric evaluation. The Care Plan directed if R248 became physically abusive, staff attempted to calm R248 by explaining that ladies and gentlemen do not behave like this. We do not touch other people. If talking to R248 was unsuccessful in stopping the behavior, staff tried walking with R248 to a quiet area, away from other individuals. Staff intervened by speaking calmly and professionally in a soft tone of voice and avoided raising own voice which tended to make R248 more upset. R248 often believed that others were in his home and he needed to remove them from his house, staff reassured him that they were where they need to be, and he was safe. R248's clinical record lacked an individualized Care Plan for activities. The Documentation Survey Report for February 2022 to [DATE] revealed the following behaviors for R248: [DATE] day rejection of care; [DATE] day wandering; [DATE] wandering; [DATE] day rejection of care, wandering, pushing, yelling/screaming, kicking/hitting, abusive language, and threatening behavior; [DATE] day sexually inappropriate and rejection of care; [DATE] day wandering; [DATE] day threatening behavior; [DATE] day wandering; [DATE] day wandering; [DATE] day wandering; [DATE] day rejection of care, kicking/hitting, and threatening behavior; [DATE] night wandering; [DATE] day rejection of care and threatening behavior; [DATE] day wandering; [DATE] day yelling/screaming, wandering, and threatening behavior; [DATE] day rejection of care, wandering, abusive language, and threatening behavior; and [DATE] day wandering. The Notes tab of R248's EMR revealed the following: A Behavior Note on [DATE] at 08:01 AM documented R248 displayed behaviors through out the night, he refused to be redirected. A Certified Nurse Aide (CNA) attempted to get him to bed, he kicked the CNA, was difficult through the night, did not allow staff to provide cares, and yelled, swung his fists, and attempted to kick CNAs during cares. A Behavior Note on [DATE] at 08:18 AM documented R248 continued to have behaviors was noncompliant with instructions and cares. He became quite aggressive, swinging, and yelling at staff, redirection was helpful at times. A Behavior Note on [DATE] at 07:44 AM documented R248 displayed many behaviors on last two night shifts on [DATE] and [DATE]. He attempted to hit the nurse when asked for permission to take vital signs, he urinated on the couch in the day room, shredded his incontinence (lack of voluntary control over urination or defecation) products in the day room and hallway, and wandered into other residents' rooms and disturbed them. He was difficult to redirect due to the language barrier and his dementia. A Behavior Note on [DATE] at 07:31 AM documented R248 was observed using the artificial tree in the day room as a bathroom. CNA attempted to redirect and R248 hit the CNA quite hard. R248 urinated in cups that were sitting in the day room and was quite difficult with staff. Other residents were in the day room and made comments related to R248's behaviors. A Behavior Note on [DATE] at 07:50 AM documented R248 continued to have negative reactions when staff attempted to redirect him. R248 refused to get up from the couch, swung at staff. He wandered into other residents' rooms, redirection was difficult, and he would push or swing at staff. R248 urinated in any trash can he came across and two staff were needed to get him to bed due to his aggression. A Behavior Note on [DATE] at 07:25 AM documented R248 wandered into other residents' rooms during the night and upset and woke some of the women. Three staff attempted to provide cares, R248 was unhappy and tried to swing at staff. A General Progress Note on [DATE] at 05:20 PM documented CNA observed R248 standing in female occupied room. The two residents in the room explained to CNA that they were extremely frightened by R248 being in their room. R248 was redirected to bathroom then to living room due to not being able to stay in room without constant supervision. A Communication with Family Note on [DATE] at 12:04 PM documented staff discussed with R248's family member the possibility of R248 moving back to the memory care unit and explained that the behaviors R248 exhibited made secured unit appropriate for him. His family member agreed that it was for his and others' safety to move him. An Interdisciplinary Team (IDT) Note on [DATE] at 09:35 AM documented R248 had been adjusting well to memory care and his behaviors and combativeness had diminished. R248 was pleasantly confused, wandering at times, and was easily redirected. He was found in other residents' rooms and chairs at times but when notified he was not in his room, he easily moved to his own bed. He participated in activities periodically as he chose. A General Progress Note on [DATE] at 06:05 AM documented R248 went into other resident's room and when asked to be assisted to his room, he got upset and became combative with staff. He spoke Spanish and when caregivers spoke to him in English, he got upset. A Behavior Note on [DATE] at 03:53 PM documented R248 walked up to another resident and attempted to use other resident's cane. The other resident told R248 it was not his cane. The nurse observed R248 lift his hand in a fist at the other resident, the nurse removed R248 and gave him his own cane. No physical contact was made, no further behaviors noted. A General Progress Note on [DATE] at 06:38 PM documented CNA reported to the nurse about an incident involving R248 and R48. R248 smacked R48 on his head. R48 was seated quietly on the recliner in the common room when it happened. Residents were separated to ensure safety and skin assessment performed on both residents, no physical bruising or injury noted. A General Progress Note on [DATE] at 01:20 PM documented R61 stated R248 hit her with the cane on her lip, no witness to the incident. Staff assessment revealed a small skin tear on the left side of R61's lip. R248 was sent to hospital for psychiatric evaluation. A General Progress Note on [DATE] at 04:55 PM documented R61 was seated in the dining room making rude hand gestures towards R248. R61 got up and walked towards R248, staff walked towards her and asked what she needed, she indicated she needed the bathroom. Staff indicated for R61 to follow them and positioned themself between R61 and R248 but R61 was able to pass the nurse and made contact with the back of R248's head with an open palm. Staff separated the two residents and with help from the nurse, R61 was removed from the situation and escorted to her room while nurse stayed with R248. An Alert Note dated [DATE] T 03:30 PM recorded R248 wanted wants to use the cane that another resident used. The unidentified staff gave the cane back to the other resident. R248 became very aggressive and believed the cane belonged to him. The note recorded the cane was with R248 for the sake of peace. The note documented the other resident surrendered his cane to R248 because he did not want to fight for it. A General Progress Note on [DATE] at 04:40 PM documented the nurse was doing rounds on the unit when they heard a resident hollering. Nurse looked up hallway and R248 was standing outside R61's room. The nurse and the aide, who communicated in Spanish, were able to get R248 to come away from the room and to the dining room. The aide told him that dinner was ready. A Behavior Note on [DATE] at 11:55 PM documented another resident alleged R248 hit him. R248 was observed resting on his bed. A General Progress Note on [DATE] at 10:02 AM documented while passing medications, a resident reported that R248 had hit him in the chest while in his own room. Staff checked on R248 and he was resting in his bed, R258 was frequently checked on throughout the shift. An IDT Progress Note on [DATE] at 03:48 PM documented R248 required redirection twice as he entered other residents' rooms believing them to belong to him. Staff intervened and attempted to show him his own room. R248 was telling female residents to get out of his house, though he was in their room. Staff escorted him to the patio to spend some time in the fresh air and sunshine which was helpful to his mood. A General Progress Note on [DATE] at 03:09 PM documented R248 was observed swinging at another resident without provocation, no contact was made. R248 threated to punch the CNA who tried to give him a shower, CNA claimed that R248 raised his fist while refusing to take a shower. One-on-one care initiated for the safety of R248 and others around him. An IDT Progress Note on [DATE] at 06:09 PM documented R248 was denied financially by two psychiatric hospitals. For that reason, R248 was sent to hospital for psychiatric evaluation and treatment through the emergency room (ER). Continued one-to-one care at that time. An IDT Progress Note on [DATE] at 03:56 PM documented R248 had increased behaviors over last 48 hours. He attempted to interrupt the maintenance personnel during their painting project with the fixed belief that he was meant to oversee that job. Staff attempted to show R248 his room in efforts to redirect him. R248 was determined that a female resident's room was his own. Nurse had reported that R248 refused his medication and was confrontational and agitated when interacting with the nurse. A General Progress Note on [DATE] at 08:00 PM documented at approximately 06:45 PM, the nurse heard screaming in the unit from the management office. Upon entering the unit, she observed R249 standing in the hallway surrounded by multiple staff members, screaming that she had been assaulted. Per staff report, once they heard the screaming multiple staff members went into the hallway and approached R249 to ask what had occurred. R249 pointed toward R248 and accused him of hitting her in the back of her neck, no staff had witnessed R248 hitting R249 and he was not within arms reach of her when the staff came into the hallway. R249 was admitted to unit one and a half hours prior to the alleged incident and was upset, attempted to leave, and was very difficult to redirect upon admission. R249 stated that R248 came up behind her and hit her in the back of the neck and pointed to the bottom of her neck, directly between her shoulder blades. R248 unable to describe what had happened. New order to send R249 out to the ER for psychiatric evaluation due to unmanageable behaviors and potential danger to other residents. R249 was placed on one-on-one until transportation arrived and R248 was placed on one-on-one until R249 was transported. An IDT Progress Note on [DATE] at 03:44 PM documented R248 required redirection from staff throughout most of the shift. He believed other neighbors were intruders in his home and wanted them to be removed. R248 was provided reassurance and redirection, monitored and closely supported during that time. An Incident Note on [DATE] at 08:00 AM documented R248 sat at the dining room table while breakfast was served. Licensed Nurse (LN) H received reported from off-going nurse then began passing morning medications in the dining room. She noted R248 got up from his chair in the dining room at approximately 08:00 AM and proceeded down the hallway. Nurse continued passing medications in the dining room, a short time later she heard someone yelling stop and her name. She went down the hall to investigate. CNA M yelled she was in R32's room. As LN H approached R32's room, R248 came out of R32's doorway. CNA M stated that R32 and R248 were fighting. R248 was immediately placed on one-on-one with CNA M and LN H assessed R32. R32 laid in his bed with numerous injuries. A Medical Professional Progress Note in R32's EMR dated [DATE] at 12:45 PM documented a follow up on R32's condition following an assault on [DATE]. The note documented R32 returned to the facility from the hospital R32 was found to have a concussion (brain injury caused by a blow to the head or a violent shaking of the head and body) and a left orbital fracture (a break in one of the bones surrounding the eyeball). The note recorded R32 laid in his bed with his blanket over head and answered yes and no questions. The note further recorded R32 stated he remembered the incident that occurred the previous day. On [DATE] at 09:57 AM, Social Services X stated she was responsible for the activity care plan and every resident had an activity care plan. She stated the activity care plan was individualized to each resident with what they like or what the family tells her the resident likes. On [DATE] at 01:59 PM, CNA M stated on [DATE], she was tending to another resident across the hall from R32's room. She walked out of the bathroom to get a pair of pants and looked across the hall to R32's room. She observed R32 holding a chair up, pining R248 against the wall. R32's face was already bleeding. CNA M had heard R248 had other altercations with other residents, but she had not witnessed any herself. She stated if R248 had behaviors, she tried to redirect him and get him to do anything else, he was not combative or violent with her but would draw back a fist sometimes since he used to be a boxer. CNA M stated staff tried to get R248 to participate I activities and played cards and interacted with the group. She stated any interventions after altercations were found in his care plan. On [DATE] at 02:19 PM, LN H stated R248 had been suspected before of hitting other residents but there were no witnesses so unable to be proven. She stated typically, R248 did not have a lot of behaviors. R248 understood English but Spanish was his primary language so one of the Spanish speaking aides talked to him to see what was going on with him. LN H stated she did not feel like the staff had been able to keep residents safe from R248's behaviors, especially when he used his cane as he thought it was a weapon of sorts. She stated she did not see any changes from his previous psychiatric visits. R248 had incidents of violence and threatening people, he did not participate in activities but mostly sat and watched television (TV). LN H did not know if the care plan was updated after each altercation/incident. On [DATE] at 03:20 PM, Administrative Nurse F stated on [DATE], staff came to get her and told her something had happened on the unit. Upon entering the unit, CNA M was standing in R248's doorway and R248 was sitting in his recliner. LN H told Administrative Nurse F the details of what happened. R32 had a scratch on the left side of his face and his eye was starting to swell so she got him an ice pack. R32 and R248 were kept separated until R248 was transported to the hospital for psychiatric evaluation. R248 liked to watch TV, staff provided him with snacks, did one-on-one talks with him about his boxing, and took him outside to the patio sometimes. Administrative Nurse F stated R248 was easily redirected and felt like staff were able to redirect him well enough to keep residents safe. On [DATE] at 03:48 PM, Administrative Nurse D stated on [DATE], the CNA was assisting a resident across R32's room. R32 was yelling and holding a chair up trying to block R248 with the chair. CNA went up to the residents and removed the chair then called for help. R32 was already bloodied , the nurse tended to R32's injuries. CNA escorted R248 back to his room. R32 could not say what happened and R248 denied doing anything. The police, management, and the doctor were called, order for R248 to go out for psychiatric evaluation. Administrative Nurse D stated R32 was sent to ER for evaluation of his injuries. He stated the facility did not plan to accept R248 back at this time as it was not safe for the other residents on the memory care unit. Administrative Nurse D stated new interventions were put into place after each incident and updated on the care plan. On [DATE] at 04:19 PM, Administrative Nurse D stated R248 was generally a mild person when he was around other residents. The intervention on his care plan for staff to talk to him was more for redirection, not education and R248 was receptive to the staff on the memory care unit. The plan for behaviors was to increase monitoring when residents needed redirection. R248 was a touchy person, he would go up to other residents and touch them gently on the shoulder. Administrative Nurse D stated he felt like the staff kept the residents safe on the unit. He stated if there was information to back up allegations then the facility would put something in place to prevent the likelihood of another incident, the biggest intervention was redirection and he felt there was enough staff to redirect and assist residents. On [DATE] at 03:03 PM, CNA N stated she received dementia training and received in-services each month. She did not normally work on the memory care unit and had not received special dementia training. CNA N stated all dementia interventions were the same for all residents and she had received training on behaviors. On [DATE] at 03:08 PM, Social Services X stated dementia care plan basics were populated and staff could go in and add specific things for some residents. If a resident had behaviors, those interventions were on the behavior focus care plan. Social Services X stated during clinical meeting, the team discussed behaviors, determined root cause, and put new interventions in place for behaviors. R248 used to join activities, he liked going outside, liked to be alone, sat in his recliner in his room, and watched Spanish channels on TV. She stated CNAs accessed behavior interventions through EMR which included interventions if a resident was escalating. On [DATE] at 03:47 PM, LN G stated she received dementia training during in-services and was taught how to communicate with dementia residents. She stated she would look on the resident's care plan for specific interventions for dementia or behaviors and the social worker developed the individualized care plan for activities, dementia, and behaviors. She stated different interventions work on different residents so interventions on the care plan were usually specific to each resident. LN G stated R248 was difficult to redirect, snacks were not very helpful. She stated she had to use the interpreter and even then, most of what R248 said was jumbled and make sense some of the time. On [DATE] at 04:19 PM, Administrative Nurse D stated dementia training was received initially in orientation then in monthly in-services. If someone had not worked the memory care unit before, they received additional training. He stated interventions were set up in the EMR for CNAs regarding dementia and were individualized for each resident. Administrative Nurse D stated the care plans had general interventions for all residents, if a behavior was recurring then staff added specific interventions for that behavior. He stated the care plan was revised after any incident. The facility's Programming for Residents with Cognitive Impairments and Other Special Needs policy, revised [DATE], directed activity programs were provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility offered meaningful programs for residents with cognitive impairments that us reality and sensory awareness techniques. The facility's Activity Programs policy, revised [DATE], directed activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. Activity programs were designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are encouraged, but not required, to participate in scheduled activities. The facility did not provide a policy on dementia care upon request. The facility failed to provide dementia care and services for R248 to address violent/aggressive behaviors, wandering, and negative resident-to-resident altercations which included physical aggression. The facility further failed to assess, identify, record, and respond to R248's specific behaviors, triggers, and past/present interests and activities in order to promote an environment which supported R248's individualized care needs. As a result of these failures, R248, who was allowed to roam freely on the memory care unit, was involved in multiple resident-to-resident altercations which created an unsafe living environment and resulted in resident injury, intimidation, acute care evaluations, and recurrent hospital transfers for R248 and other memory care residents. This deficient practice placed all 18 residents who resided on the memory care unit in Immediate Jeopardy. The facility completed the following corrections by [DATE]: R248 discharged to an acute care facility. All resident to resident altercations on the memory care unit were reviewed to ensure appropriate interventions added to residents' plan of care. All applicable interventions related to resident behaviors and dementia behavioral symptoms were linked to the Kardex. A root cause analysis was completed for all resident to resident behaviors on the memory care unit. The facility staff reviewed memory care residents for activity assessments and evaluations. The facility policy Admission Criteria for Memory Care Program was updated. Inservice and education was provided to staff on resident management process, root cause analysis for behavioral symptoms and dementia training. The deficiency was cited as past noncompliance.

The facility reported a census of 113 residents. The sample included three residents at risk for falls. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received adequate care and supervision to prevent a fall. On 10/07/21 at approximately 11:00 AM, while being supervised and assisted by a facility staff member, R1 fell from a wheelchair onto the pavement in a parking lot, at an offsite location (drug store) when the facility staff member diverted her attention from R1's safety to her cell phone. R1 sustained skin tears, abrasions, and a laceration (cut) which required evaluation and treatment which included sutures (stitches) at a local hospital before returning to the facility. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of: [CONDITION(S)] of vertebra (bones that form the spine), lumbar region (an inflammation in the lower back) of bone or bone marrow, usually due to infection), [CONDITION(S)] (paralysis of the legs and lower body, typically caused by spinal injury or disease), and a need for assistance with personal care. The Five Day Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status score of 13 which indicated R1's cognition was intact. The MDS documented R1 required extensive to total assistance of one to two staff members with most activities of daily living (ADLs). The assessment recorded R1 had functional limitations in range of motion to his lower extremities and ambulated by use of a wheelchair with one-person extensive assistance. The 08/26/21 ADL Care Area Assessment (CAA) recorded staff and therapy were available and provided services to ensure R1's daily needs were met and reported and documented any changes. The 08/26/21 Falls CAA recorded R1 was at risk for falls due to decreased mobility, weakness, and lumbar pain. The CAA directed staff to work with R1 on strengthening and balance. The facility's Fall Risk assessment dated [DATE] documented a score of 10 or greater placed a resident at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. R1's Care Plan for ADLs initiated on 08/24/21 and revised on 09/24/21 directed staff to consult physical therapy per order, ensure R1's call light was available, and evaluate R1's ability to perform ADLs. The Care Plan lacked documentation to address the R1's level of assistance needed, how the resident transferred, ambulated, and/or R1's ability to complete any ADLs on his own. R1's Care Plan for falls initiated 08/24/21 directed staff to evaluate R1's fall risk on admission and as needed. If a fall occurred, alert the provider and initiate frequent neurological checks and a bleeding evaluation per facility protocol. The 10/07/21 revised Care Plan documented R1's fall with injury, transportation staff's re-education, a review of job descriptions, and safety techniques. On 10/08/21 R1's Care Plan noted a wheelchair maintenance evaluation and directed staff to determine R1's ability to transfer. The Facility Investigation documented on 10/07/21 at about 11:00 AM revealed staff transported R1 by a contracted medical transport company to a local drug store/pharmacy for a vaccine. Designated Facility Transporter (DFT) M accompanied R1. While exiting the store, DFT M was in the process of calling transportation, when R1's wheelchair rolled and went over resulting in R1 falling out of the chair and onto the pavement. In a Witness Statement DFT M documented R1 and DFT M were going out of the store. DFT M was on the phone with the facility to give to the facility the address of DFT M and R1's location. DFT M put the left side wheelchair brake on and then turned to look at the building address. When DFT M turned around, she heard R1 saying wait, wait and observed R1 on the concrete parking lot. When R1 fell , he was face down, and DFT M went to R1 and asked him if he was alright, then called 911. In a Witness Statement Medical Company Driver (MCD) N documented he was in the parking lot and saw DFT M come out of the store. SFT M was on her cell phone. DFT M looked up at the building and as she did so, MCD N witnessed R1 roll off the sidewalk in his wheelchair and then fall out of the wheelchair. When MCD N picked up the wheelchair, the brakes worked. MCD N then secured R1 in the transportation van before leaving the premises. The Nurse Progress Notes dated 10/7/2021 at 7:06 PM recorded at 11:30 AM transport staff reported the resident was sent to the hospital following a fall. MCD N stated that R1 fell out of the wheelchair onto the pavement after leaving a vaccine appointment at a local drug store. R1 had several superficial injuries noted, including a laceration to the face above R1's right eyebrow with three sutures in place. The 3rd, 4th, and 5th toes on R1's left foot had open areas which were bleeding and R1's right great toe was also bleeding. R1 had bloody abrasions to the left and right elbow, left forearm, and two lacerations to his left knee. R1 denied pain, and staff notified R1's family and physician. Staff cleansed all open areas and applied treatments. Staff started neurological checks when R1 returned to the facility at approximately 5:30 PM. Observation on 10/12/21 at 10:59 AM revealed R1 laid in bed with bilateral arm bruising, an adhesive pad dressing on bilateral elbows, and a cut to his right forehead/eyebrow. Both feet were wrapped in gauze. Interviewed on 10/12/21 at 10:59 AM R1 confirmed the skin tears and a mashed left foot were a result of a fall. R1 pointed to his right temple and stated, I also received three stitches. R1 stated while being assisted out of the local drug store by the facility driver, R1's wheelchair went over the curb and he fell face first to the ground. R1 could not confirm whether staff locked his wheelchair brakes. R1 stated, that is where the story becomes convoluted, [DFT M] was behind me, so I cannot tell you, all I know is that my wheelchair went over the curb. We were not facing the ramp to go toward the van. Interviewed on 10/12/21 at 12:34 PM R1 felt the accident could have been prevented. R1 stated the facility transporter should not have been transporting R1 while distracted. R1 added, I don't know what was going on behind me, all I know is we were not lined up with the ramp, you know how at [local drug stores] they have the ramp by the stores' corner entrance? Well, we were lined up with the curb and I yelled, Stop! Stop! and then I was on the ground. Interviewed on 10/12/21 at 12:00 PM Administrative Staff A stated after they reported the incident, they suspended DFT M at 12:30 PM on 10/7/21 pending the investigation. DFT M received instruction and reeducation on appropriate times to use a phone and resident safety. On 10/12/21 at 03:30 PM DFT M was unavailable for interview. The facility's Driver-Job Description updated 2/21/21 documented in keeping with the organization's goal of improving the lives of residents they serve, the driver plays a critical role in providing transportation for residents to and from the facility in accordance with current federal, state and local standards governing the facility, to ensure that the highest degree of quality care is maintained at all times. The undated Training Outline Checklist for Resident Transport Drivers for loading and unloading documented to make sure wheelchair brakes worked and were safe. The facility's Cell Phones policy revised 01/20/21 documented personal cell phones and electronic devices were only permitted in patient care areas for authorized business purposes. This same policy also recorded personal cell phones should not be carried or worn during working hours. The facility failed to provide adequate supervision and appropriate interventions to prevent an accident with injury, when during wheelchair transport, a distracted staff member allowed R1's unsecured wheelchair to drift over a curb. As a result, R1 fell from the wheelchair sustained skin tears, abrasions, a laceration and a need for emergency treatment . The facility investigated and implemented corrective action which included training and check list competency for involved staff which was completed on 10/07/21 therefore the deficient practice was cited as past noncompliance.

The facility identified a census of 80 residents and reported 17 residents resided in Abbey Lane (the secure locked unit) . The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure one of three residents, Resident (R) 1, provide a secured, safe environment to prevent elopement. R1, who resided on the secure locked unit, opened and completely removed the window pane and crawled through the window. R1 exited the facility on 7/18/19 between approximately 5:00 PM and 5:30 PM . R1 walked approximately 100 yards (300 feet) to a nonsecure, unsupervised location and was found by facility staff standing next to the parking lot approximately 15minutes later. Staff found R1 in an urban metropolitan area with 4 lanes of traffic, and significant hazards, such as changing elevations and cross streets. The temperature was approximately 93 degrees Fahrenheit (F) per wunderground.com. R1 wore lounge pants, a short-sleeved t-shirt, a lightweight long-sleeved shirt, socks, and shoes. The secure locked unit was noted to have the same unsecured windows in each of the 17 residents' room which could be removed and allow for exit from the facility through the window. This deficient practice placed R1 and all the residents in the secure unit in immediate jeopardy at the level of a K. The immediate jeopardy was removed on 7/19/19. Findings included: - R1's (MONTH) 2019 electronic medical record (EMR) under the [DIAGNOSES REDACTED]. The 14-day Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 6 which indicated severely impaired cognition. The resident exhibited wandering behaviors 1 to 3 days during the 7-day look back period and was at risk of getting to a potentially dangerous place. He walked with supervision and set up help. The Care Area Assessment (CAA) dated 7/16/19 for cognition documented the resident had impaired decision-making, poor logic, and poor ability to understand cause and effect of actions. The CAA dated 7/16/19 for behavioral symptoms documented the resident wandered throughout the unit unaware of whereabouts or safety concerns due to confusion. R1's Elopement Risk assessment dated [DATE] documented a high risk for elopement. The care plan, lacked an elopement risk care plan with safety interventions prior to 7/18/19. Review of the progress notes (late entry) dated 7/18/19 at 5:45 PM documented R1 was not in the common area of Abbey Lane. Staff looked for him but could not find him on the unit. Staff then requested all available staff to initiate and participate in a search. Staff located R1 on the side of the building, in the grass. With assistance of staff, R1 returned to Abbey Lane at approximately 5:40 PM. Resident did not appear flushed, sweaty , or in any distress. The charge nurse assessed him and found no immediate injuries. The resident returned to the unit with staff. The nurse completed a skin assessment and bruising was noted on left hand and finger, a laceration on the left finger, and an abrasion on the chest area and left knee. The resident denied falling, hitting his head, or being in pain. Staff notified R1's primary physician's nurse practitioner, who ordered immediate blood work and urine analysis. Staff contacted R1's Durable Power of Attorney (DPOA). Staff also notified the Director of Nursing and Administrator immediately. Resident had been placed on one on one with a staff member and neurological checks had been initiated per facility protocol . Licensed Nurse (LN) G's signed, notarized (07/23/19 at 1:30 PM), witness statement documented Certified Nurse Aid (CNA) M notified LN G she was unable to find the resident. LN G told CNA M to look room to room and paged all extra help to the secure unit. CNA M noted the window was out in one of the rooms. The administrator and other staff were looking outside for R1. R1 was found with Administrative Staff A at the side of the building. Staff then assisted R1 back to the secured unit where he was given liquids . Per CNA M's notarized (07/23/19 at 2:10 PM), witness statement documented, CNA M was getting residents up and assisting them into the dining room. CNA M saw R1 walking around at the end of the hallway. She finished getting an unidentified resident up and then headed into the dining room. She was passing out trays when she noted the R1 and another unidentified resident were not present in the dining room. CNA M informed her coworker she was going to gather all staff and look for R1 room to room. R1 was not found in any of the rooms. Staff checked the clean laundry room and the window was hanging open. CNA M went to the hall, started yelling for help, and reported to LN G. She went running around the building. When she made it around the building, she observed R1 in the parking lot. CNA M helped R1 back into the facility at or around 5:30 PM. Per CNA N's notarized (07/23/19 at 2:55 PM) witness statement documented: CNA N was assisting in passing out trays to residents. She realized R1 was missing and started looking room to room. LN G was informed. CNA M found the window open. The outside area was searched, R1 was found, and returned to the unit. Per Certified Medication Aide (CMA) R's notarized (07/23/19 at 3:23 PM) witness statement documented CMA R was passing medications. CNA M loudly called for help and reported a resident out of the facility. When CMA R searched the facility, he saw the window opened and the resident was not there. All staff immediately ran out of the compound and after 10 to 20 minutes R1 was found. On 7/23/19 at 8:53 AM Administrative Nurse D stated the room that R1 exited out of the window was unoccupied and not used for residents. Administrative Nurse D stated that it could not be anticipated that R1 went out the window. Administrative Nurse D verified the only difference between the room R1 exited from and the other resident rooms was the room R1 used to exit the facility was used for the storage of linen. In an interview on 7/23/19 at 4:15 PM Administrative Staff A reported that after learning of R1 exiting through a window, she and the maintenance director immediately began securing the windows. Administrative Staff A stated maintenance placed safety screws in the window frame to prevent the residents from being able to fully open the windows or tilt the window pane for removal. The facility's policy and procedures for The Wandering, Unsafe Resident revised (MONTH) 2007 documented that if a resident was unsafe or was a risk for elopement the care plan would have interventions to try to maintain safety. The facility failed to provide a secured, safe environment to prevent an elopement when R1 exited the facility without staff knowledge through an unsecured window. This occurred on 7/18/2019 between approximately 5:00 PM and 5:30 PM. The secure locked unit was noted to have the same unsecured windows in each of the 17 residents' room which could be removed and allow for exit from the facility through the window. This deficient practice placed R1 and all the residents in the secure unit in immediate jeopardy. The facility was provided written notification of the immediate jeopardy on 7/23/19 at 02:30 PM. The deficient practice was cited as past non-compliance as the immediate jeopardy was removed when the facility completed the following corrective actions on 7/19/19 : R1 was re-directed back in to facility without difficulty and placed on 1:1 supervision. The room R1 used to exit was changed to a pad (locked) entry. The window was repaired and the window frame repaired and secured. All windows were checked for security by administrator or designee. Windows were noted to have a security screw in place. Maintenance identified how resident was able to disassemble/break the window. Additional protection has been added to all windows.

The facility reported a census of 70 residents. The sample included 3 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect all residents from abuse including residents #1 and #3 from verbal and physical abuse when direct care staff O spoke inappropriately to resident #1 on 1/05/17 and physically abused resident #1 on 1/09/17, and from direct care staff T when he/she verbally and physically abused resident #3 on 12/05/16. Direct care staff P and staff Y witnessed the abuse and failed to immediately report the incidents to administrative staff. Furthermore, direct care staff O continued to work, providing care until 1/11/17 and direct care staff T continued to work, providing care from 12/05/17 through 1/19/17. The facility failed to thoroughly investigate all alleged violations. This deficient practice placed all residents of the facility in Immediate Jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 0, which indicated severely impaired cognition. The Care Area Assessment (CAA) dated 1/16/17 for Cognitive Loss and Dementia documented the resident had severe cognitive impairment, disorganized thinking, and rambling conversation. The CAA dated 1/16/17 for Behavioral Symptoms documented the resident could become agitated and would become aggressive toward residents and staff. The Admission Care Plan dated 1/04/17 documented the resident had severe cognitive impairment and directed staff to approach him/her in a calm manner. On 1/18/17 at 10:30 A.M., the resident ambulated independently in the hallway of the secured unit. The resident appeared calm, had a flat affect (a severe reduction in emotional expressiveness), and continued to pace the unit. Review of the facility investigation dated 1/11/17 documented staff Y witnessed direct care staff O shove resident #1 into a wall on 1/09/17. Direct care staff P stated he/she had concerns about how direct care staff O talked to and treated the residents. The facility concluded that due to the nature of the allegations of abuse, direct care staff O was terminated. The facility investigation lacked documentation of interviews and notarized witness statements from licensed nursing staff on duty on 1/05/17 and 1/09/17. Review of the notarized witness statement dated 1/12/17 by direct care staff P documented on 1/05/17, staff assigned direct care staff O to monitor the door of the secured unit. Resident #1 was pacing the unit and direct care staff O stated he/she was testing him/her. Direct care staff P observed direct care staff O remove his/her glasses, charge the resident, talk in a very rude, mean voice, and state, Come on, hit me, I dare you. Direct care staff P stated these actions were verbal and emotional abuse. On 1/18/17 at 3:18 P.M., direct care staff P stated on 1/05/17, he/she observed the resident pacing the unit and walk toward the door. Staff assigned direct care staff O to monitor the door. The resident was pacing and walking toward him/her. Direct care staff P stated direct care staff O stood up, removed his/her glasses, moved toward the resident and stated, I dare you to hit me. Direct care staff P stated he/she was unsure how to handle the situation because direct care staff O played it off like he/she was joking but it made him/her uncomfortable. Direct care staff P stated he/she reported the incident to licensed nursing staff G who told him/her that he/she would report the incident to administrative nursing staff E. Direct care staff P stated he/she had received a written warning about not immediately reporting the incident. The interview of direct care staff P conflicts with his/her statement originally provided to the facility Director of Nursing (DON) and his/her notarized witness statement obtained by the facility. On 1/18/17 at 4:25 P.M., administrative nursing staff E stated licensed nursing staff G did not inform him/her of the incident that occurred on 1/05/17 between direct care staff O and resident #1. Administrative nursing staff E stated he/she learned of this incident when the facility began their investigation of the allegations from 1/09/17. He/she expected staff to immediately report all concerns of abuse. On 1/18/17 at 4:50 P.M., licensed nursing staff G stated he/she did not witness abuse between direct care staff O and resident #1 on 1/05/17 and he/she was not informed by direct care staff P that an incident had occurred. Licensed nursing staff G stated as a mandated reporter, he/she would have immediately reported this allegation to administrative staff A. On 1/18/17 at 6:00 P.M., administrative staff A stated he/she had not been informed on 1/05/17 of the abuse between direct care staff O and resident #1. On 1/18/17 at 7:43 P.M., direct care staff P stated he/she did not report the incident on 1/05/17 in a timely manner, but did report it eventually. On 1/18/17 at 2:20 P.M., staff Y stated on 1/09/17, staff assigned him/her to monitor the exit door and alarm of the secured unit. The resident was at the end of the hallway with direct care staff R and the resident held his/her hand up in a non-threatening manner toward staff. Direct care staff O ran down the hall, got in the resident's face, and physically pushed the resident into the wall so hard that he/she had to brace him/herself with his/her hands against the wall. The resident appeared frightened but did not say or do anything in return. Staff Y stated licensed nursing staff F did not witness the incident but was present on the unit. Staff Y stated he/she did not immediately report the incident because he/she feared direct care staff O would retaliate. On 1/18/17 at 5:15 P.M., direct care staff R stated he/she worked on 1/09/17. Resident #1 paced the halls, required redirection from entering other resident rooms, and had swung his/her arm at direct care staff R. Direct care staff O came down the hallway in an aggressive manner and pushed the resident across the hall. The resident appeared angry he/she had been pushed. Direct care staff R stated licensed nursing staff F witnessed the incident and told him/her that he/she would report it to the higher ups. On 1/18/17 at 5:03 P.M., licensed nursing staff F stated he/she worked on 1/09/17 but did not observe direct care staff O push resident #1 nor did staff report this incident to him/her. A progress note dated 1/09/17 by licensed nursing staff F documented the resident required frequent redirection when trying to flip over chairs and threatening to swing at staff. Review of the clinical record from 1/05/17 through 1/11/17 lacked documentation of any incidents of staff with the resident. Review of direct care O's timesheet documented he/she worked in the facility on 1/05/17, 1/06/17, 1/09/17, and entered the facility on 1/11/17 for an interview with administrative staff A and administrative nursing staff D. On 1/18/17 at 5:30 P.M., direct care staff O was not available for interview. On 1/18/17 at 11:05 A.M., administrative nursing staff D stated he/she expected staff to immediately report abuse to administrative staff A or him/herself and it was extremely alarming the staff had not immediately reported these incidents. Administrative nursing staff D stated the staff failed to follow the facility policy regarding reporting abuse. On 1/18/17 at 12:00 P.M., administrative staff A stated he/she expected staff to immediately report abuse. Review of the facility provided Abuse & Neglect Policy & Procedure dated 12/06/16 documented the facility would provide professional care and services in an environment free from any type of abuse. The policy defined abuse as the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. The facility failed to immediately report, thoroughly investigate verbal and physical abuse from direct staff O for this cognitively impaired resident, and failed to protect the resident's of the facility from direct care staff O when staff O continued to work after the incidents of verbal and physical abuse. This deficient practice placed all residents of the facility in immediate jeopardy. - The physician order [REDACTED].#3 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He/she required extensive assist of two staff for transfers and had a history of [REDACTED]. The Quarterly MDS dated [DATE] documented a BIMS score of 15, and required extensive assist of two staff for transfers. The Care Area Assessment (CAA) dated 4/21/16 for Activities of Daily Living documented the resident was very weak with impaired balance, strength, and endurance due to [MEDICAL CONDITION] right-sided weakness and required extensive assist of two staff for transfers. The Care Plan dated 5/03/16 documented the resident was at risk for falls and required extensive assistance with mobility. On 12/11/16, a revision to the Care Plan documented the resident was on a daily aspirin (a medication used to treat pain, fever, headache, inflammation, and reduce the risk of [MEDICAL CONDITION]) regimen and he/she was at risk for bruising or bleeding. Four large, blackened, dark purple bruises were found on the resident's body related to staff transfer of the resident and directed staff to ensure they transferred the resident in a gentle manner with the use of a gait belt and to use two staff for transfers. On 12/12/16, a revision to the Care Plan documented staff lowered the resident to the shower room floor because the resident's legs were unable to support his/her weight. On 12/18/16, a revision to the Care Plan documented the resident had bruising to his/her left flank (the side of a person's body between the ribs and the hip), left lower outside thigh, and approximately four inches under both axilla (a person's armpit). The bruises were very dark purple in color and large. The care plan directed staff to utilize a gait belt at all times for transfers. A progress note dated 12/11/16 at 2:00 P.M. documented staff notified the nurse of bruising on the resident's back and left lower extremity. A bruise on the left lower extremity measured 15.0 centimeters (cm) x 4.0 cm and was dark purple and yellow in color. Two dark purple bruises on the left lower back measured 4.0 cm x 12.5 cm, and another dark purple bruise on the left lower back measured 2.0 cm x 6.0 cm. A bruise under the left arm measured 4.5 cm x 7.5 cm and was dark purple in color. A bruise under the right arm measured 3.5 cm x 6.0 cm and was dark purple in color. Staff received a physician order [REDACTED]. Review of the facility investigation dated 12/12/16 documented the resident stated on 12/05/16 while in the shower room, staff repeatedly told him/her to stand up and stated, you just don't want to, and repeatedly made him/her stand up after he/she fell . Two staff placed their arms under his/her arms and pulled him/her into a chair. The resident stated he/she was crying and hurt. The facility investigation concluded the resident's bruising was consistent with his/her contact with the floor and the staff's attempts to put him/her into the chair. The facility provided education to staff on safe transfers and the use of a gait belt for all transfers. The facility investigation lacked documentation of interviews and notarized witness statements from licensed nursing staff on duty on 12/05/17. Review of the clinical record from 12/05/16 through 1/19/17 lacked documentation the resident had fallen in the shower or was lowered to the ground on 12/05/16 and lacked documentation of any incidents of staff with the resident. Review of the un-notarized witness statement dated 12/11/16 by direct care staff S documented he/she provided care to the resident on 12/11/16 and noticed two large bruises on his/her left leg and back. The resident told direct care staff S a nurse had pushed him/her to sit down in the chair and he/she missed the chair and fell on his/her back. Review of the notarized witness statement dated 12/11/16 by administrative staff B documented he/she interviewed the resident on 12/11/16. The resident stated he/she was told to get up and stand up by staff but he/she told them he/she could not. A staff of the same gender picked the resident up and let him/her loose and he/she fell to the ground. The staff of the same gender and a staff of the opposite picked the resident back up and he/she fell to the ground again. The resident repeatedly stated, help me, help me! and stated he/she was in pain. The resident stated a staff of the opposite gender with gray hair had given him/her a shower and badgered, yelled at him/her to be cooperative, and was rough. A social services progress note dated 12/11/16 at 3:15 P.M. by administrative staff B documented a certified nursing aid (CNA) student notified him/her of the resident having bruising from an unknown source. The social worker notified the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator. The social worker's progress note lacked documentation in the clinical record of the interview he/she obtained from the resident regarding the staff that had badgered, yelled at him/her to be cooperative, and was rough in the shower. On 1/19/17 at 3:24 P.M., administrative staff B stated he/she was informed on 12/11/16 by direct care staff S the resident had large, dark bruises on his/her leg and back, was in pain, and had stated a nurse had pushed him/her in the shower. Administrative staff B stated he/she and administrative staff A had interviewed all the staff that worked on 12/11/16 but none of them had any knowledge of an incident on 12/05/16. Review of the facility investigation lacked documentation of the interviews administrative staff A and B conducted on 12/11/16. On 1/19/17 at 3:48 P.M., administrative staff B stated after resident #3 told him/her in interview that staff had badgered, yelled at, and given a rough shower, he/she had not followed up or interviewed other residents regarding those allegations. Review of the notarized witness statement dated 12/12/16 by direct care staff T documented he/she gave the resident a shower on 12/05/16. The resident stated his/her legs were hurting and he/she couldn't stand. Direct care staff T attempted to stand the resident by him/herself and could not so he/she obtained assistance from the first person he/she found to help. When the resident stood up, his/her legs buckled and staff lowered him/her to the floor. Review of direct care staff T's timesheet documented he/she continued to work after the incident on 12/05/16 through 1/19/17. On 1/18/17 at 3:20 P.M., the resident lay in bed with a left quarter side rail up and his/her call light within reach. On 1/18/17 at 3:20 P.M., resident #3 stated someone had hurt him/her in the shower. A staff member tried to make him/her stand up and he/she fell . The resident stated the staff member continued to work at the facility. On 1/19/17 at 12:40 P.M., administrative nursing staff D stated direct care staff T did not report that the resident had fallen or that staff lowered the resident to the ground on 12/05/16 until the investigation began on 12/11/16. Administrative nursing staff D stated direct care staff T was not suspended during the investigation because the resident had initially identified the alleged perpetrator as a staff of the same gender but it was possible the resident mistook direct care staff T as the opposite gender. The facility concluded the bruising pattern and was consistent with direct care staff T's statement of an improper transfer. On 1/19/17 at 1:27 P.M., administrative staff A stated he/she received a phone call on 12/11/16 from direct care staff S who reported bruising and stated a nurse had pushed the resident in the shower. Administrative staff A stated the facility investigation determined the cause of the bruising was from improper transfer and lack of use of a gait belt and not abuse. He/she stated direct care staff T was not suspended during the investigation. Administrative staff A stated he/she did not document any staff interviews obtained on 12/11/16. On 1/19/17 at 11:12 A.M., direct care staff T, the staff that gave resident #3 a shower on 12/05/16, was not available for interview. On 1/19/17 at 3:01 P.M., licensed nursing staff H, the nurse on duty on 12/05/16, was not available for interview. Review of the facility provided Abuse & Neglect Policy & Procedure dated 12/06/16 documented the facility would provide professional care and services in an environment free from any type of abuse. The policy defined abuse as the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. The facility failed to immediately report and thoroughly investigate verbal and physical abuse from direct staff T for resident #3, and failed to protect the residents in the facility from abuse. This deficient practice placed all resident of the facility in Immediate Jeopardy. The facility abated the Immediate Jeopardy on 1/21/17 at 11:59 P.M. by initiating the following: the facility removed direct care staff O from the facility on 1/11/17 and terminated direct care staff O on 1/12/17. All of the facility staff were in-serviced regarding the notification of abuse, neglect, and exploitation of facility residents by the administrator. Staff provided every facility associate and resident access to the administrator's contact information and that of the director of nursing. Corporate ownership would establish a 1-800 number to be used for anonymous abuse, neglect, and exploitation reporting and the immediate initiation of investigations. This number would be monitored at all times by an answering service that would immediately report to the facility owners. When allegations occurred, all staff would be re-in-serviced on abuse reporting by the administrator or designee. The deficient practice remained at a scope and severity of F.

The facility reported a census of 70 residents. The sample included 3 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal and physical abuse from direct care staff O when he/she verbally abused resident #1 on 1/05/17 and physically abused resident #1 on 1/09/17, and from direct care staff T when he/she verbally and physically abused resident #3 on 12/05/16. This deficient practice placed residents #1 and #3 in Immediate Jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 0, which indicated severely impaired cognition. The Care Area Assessment (CAA) dated 1/16/17 for Cognitive Loss and Dementia documented the resident had severe cognitive impairment, disorganized thinking, and rambling conversation. The CAA dated 1/16/17 for Behavioral Symptoms documented the resident could become agitated and would become aggressive toward residents and staff. The Admission Care Plan dated 1/04/17 documented the resident had severe cognitive impairment and directed staff to approach him/her in a calm manner. On 1/18/17 at 10:30 A.M., the resident ambulated independently in the hallway of the secured unit. The resident appeared calm, had a flat affect (a severe reduction in emotional expressiveness), and continued to pace the unit. Review of the facility investigation dated 1/11/17 documented staff Y witnessed direct care staff O shove resident #1 into a wall on 1/09/17. Direct care staff P stated he/she had concerns about how direct care staff O talked to and treated the residents. The facility concluded that due to the nature of the allegations of abuse, direct care staff O was terminated. Review of the notarized witness statement dated 1/12/17 by direct care staff P documented on 1/05/17, staff assigned direct care staff O to monitor the door of the secured unit. Resident #1 was pacing the unit and direct care staff O stated he/she was testing him/her. Direct care staff P observed direct care staff O remove his/her glasses, charge the resident, talk in a very rude, mean voice, and state, Come on, hit me, I dare you. Direct care staff P stated these actions were verbal and emotional abuse. Review of the direct care O's timesheet documented he/she worked in the facility on 1/05/17, 1/06/17, 1/09/17, and entered the facility on 1/11/17 for an interview with administrative staff A and administrative nursing staff D. A progress note dated 1/09/17 by licensed nursing staff F documented the resident required frequent redirection when trying to flip over chairs and threatening to swing at staff. Review of the clinical record from 1/05/17 through 1/11/17 lacked documentation of any incidents of staff with the resident. On 1/18/17 at 11:05 A.M., administrative nursing staff D stated he/she expected staff to immediately report abuse to administrative staff A or him/herself and it was extremely alarming the staff had not immediately reported these incidents. Administrative nursing staff D stated the staff failed to follow the facility policy regarding reporting abuse. On 1/18/17 at 12:00 P.M., administrative staff A stated he/she expected staff to immediately report abuse. On 1/18/17 at 2:20 P.M., staff Y stated on 1/09/17, staff assigned him/her to monitor the exit door and alarm of the secured unit. The resident was at the end of the hallway with direct care staff R and the resident held his/her hand up in a non-threatening manner toward staff. Direct care staff O ran down the hall, got in the resident's face, and physically pushed the resident into the wall so hard that he/she had to brace him/herself with his/her hands against the wall. The resident appeared frightened but did not say or do anything in return. On 1/18/17 at 3:18 P.M., direct care staff P stated on 1/05/17, he/she observed the resident pacing the unit and walk toward the door. Staff assigned direct care staff O to monitor the door. The resident was pacing and walking toward him/her. Direct care staff P stated direct care staff O stood up, removed his/her glasses, moved toward the resident and stated, I dare you to hit me. Direct care staff P stated he/she was unsure how to handle the situation because direct care staff O played it off like he/she was joking but it made him/her uncomfortable. On 1/18/17 at 5:15 P.M., direct care staff R stated he/she worked on 1/09/17. Resident #1 paced the halls, required redirection from entering other resident rooms, and had swung his/her arm at direct care staff R. Direct care staff O came down the hallway in an aggressive manner and pushed the resident across the hall. The resident appeared angry he/she had been pushed. Review of the facility provided Abuse & Neglect Policy & Procedure dated 12/06/16 documented the facility would provide professional care and services in an environment free from any type of abuse. The policy defined abuse as the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. The facility failed to provide an environment free from verbal and physical abuse from direct staff O on 1/5/17 and 1/9/17 for this cognitively impaired resident. This deficient practice placed resident #1 in immediate jeopardy. - The physician order [REDACTED].#3 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He/she required extensive assist of two staff for transfers and had a history of [REDACTED]. The Quarterly MDS dated [DATE] documented a BIMS score of 15, and he/she required extensive assist of two staff for transfers. The Care Area Assessment (CAA) dated 4/21/16 for Activities of Daily Living documented the resident was very weak with impaired balance, strength, and endurance due to [MEDICAL CONDITION] right-sided weakness and required extensive assist of two staff for transfers. The Care Plan dated 5/03/16 documented the resident was at risk for falls and required extensive assistance with mobility. On 12/11/16, a revision to the Care Plan documented the resident was on a daily aspirin (a medication used to treat pain, fever, headache, inflammation, and reduce the risk of [MEDICAL CONDITION]) regimen and he/she was at risk for bruising or bleeding. Four large, blackened, dark purple bruises were found on the resident's body related to staff transfer of the resident and directed staff to ensure they transferred the resident in a gentle manner with the use of a gait belt and to use two staff for transfers. On 12/12/16, a revision to the Care Plan documented staff lowered the resident to the shower room floor because the resident's legs were unable to support his/her weight. On 12/18/16, a revision to the Care Plan documented the resident had bruising to his/her left flank (the side of a person's body between the ribs and the hip), left lower outside thigh, and approximately four inches under both axilla (a person's armpit). The bruises were very dark purple in color and large. The care plan directed staff to utilize a gait belt at all times for transfers. A progress note dated 12/11/16 at 2:00 P.M. documented staff notified the nurse of bruising on the resident's back and left lower extremity. A bruise on the left lower extremity measured 15.0 centimeters (cm) x 4.0 cm and was dark purple and yellow in color. Two dark purple bruises on the left lower back measured 4.0 cm x 12.5 cm, and another dark purple bruise on the left lower back measured 2.0 cm x 6.0 cm. A bruise under the left arm measured 4.5 cm x 7.5 cm and was dark purple in color. A bruise under the right arm measured 3.5 cm x 6.0 cm and was dark purple in color. Staff received a physician order [REDACTED]. Review of the facility investigation dated 12/12/16 documented the resident stated on 12/05/16 while in the shower room, staff repeatedly told him/her to stand up and stated, you just don't want to, and repeatedly made him/her stand up after he/she fell . Two staff placed their arms under his/her arms and pulled him/her into a chair. The resident stated he/she was crying and hurt. The facility investigation concluded the resident's bruising was consistent with his/her contact with the floor and the staff's attempts to put him/her into the chair. The facility provided education to staff on safe transfers and the use of a gait belt for all transfers. Review of the notarized witness statement dated 12/11/16 by administrative staff B documented he/she interviewed the resident on 12/11/16. The resident stated he/she was told to get up and stand up by staff but he/she told them he/she could not. A staff of the same gender picked the resident up and let him/her loose and he/she fell to the ground. The staff of the same gender and a staff of the opposite picked the resident back up and he/she fell to the ground again. The resident repeatedly stated, help me, help me! and stated he/she was in pain. The resident stated a staff of the opposite gender with gray hair had given him/her a shower and badgered, yelled at him/her to be cooperative, and was rough. A social services progress note dated 12/11/16 at 3:15 P.M. by administrative staff B documented a certified nursing aid (CNA) student notified him/her of the resident having bruising from an unknown source. The social worker notified the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator. The social worker's progress note lacked documentation in the clinical record of the interview he/she obtained from the resident regarding the incident with staff that had badgered, yelled at him/her to be cooperative, and was rough in the shower. Review of the un-notarized witness statement dated 12/11/16 by direct care staff S documented he/she provided care to the resident on 12/11/16 and noticed two large bruises on his/her left leg and back. The resident told direct care staff S a nurse had pushed him/her to sit down in the chair and he/she missed the chair and fell on his/her back. Review of the notarized witness statement dated 12/12/16 by direct care staff T documented he/she gave the resident a shower on 12/05/16. The resident stated his/her legs hurt and he/she could not stand. Direct care staff T attempted to stand the resident by him/herself and could not, so he/she obtained assistance from the first person he/she found to help. When the resident stood up, his/her legs buckled, and staff lowered him/her to the floor. Review of the clinical record from 12/05/16 through 1/19/17 lacked documentation the resident had fallen in the shower or that staff lowered him/her to the ground on 12/05/16 and lacked documentation of any incidents of staff with the resident. Review of direct care staff T's timesheet documented he/she continued to work after the incident on 12/05/16 through 1/19/17. On 1/18/17 at 3:20 P.M., the resident lay in bed with a left quarter side rail up and his/her call light within reach. On 1/18/17 at 3:20 P.M., resident #3 stated someone hurt him/her in the shower. A staff member tried to make him/her stand up and he/she fell . The resident stated the staff member continued to work at the facility. On 1/19/17 at 12:40 P.M., administrative nursing staff D stated direct care staff T did not report that the resident had fallen or that staff lowered the resident to the ground on 12/05/16 until the investigation began on 12/11/16. Administrative nursing staff D stated direct care staff T was not suspended during the investigation because the resident had initially identified the alleged perpetrator as a staff of the same gender but it was possible the resident mistook direct care staff T as the opposite gender. The facility concluded the bruising pattern was consistent with direct care staff T's statement of an improper transfer. On 1/19/17 at 1:27 P.M., administrative staff A stated he/she received a phone call on 12/11/16 from direct care staff S who reported bruising and stated a nurse had pushed the resident in the shower. Administrative staff A stated the facility investigation determined the cause of the bruising was from improper transfer and lack of use of a gait belt and not abuse. He/she stated direct care staff T was not suspended during the investigation. Review of the facility provided Abuse & Neglect Policy & Procedure dated 12/06/16 documented the facility would provide professional care and services in an environment free from any type of abuse. The policy defined abuse as the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. The facility failed to provide an environment free from verbal and physical abuse from direct staff T for resident #3. This deficient practice placed resident #3 in Immediate Jeopardy. The facility abated the Immediate Jeopardy on 1/21/17 at 11:59 P.M. by initiating the following: the facility removed direct care staff O from the facility on 1/11/17 and terminated direct care staff O on 1/12/17. All of the facility staff were in-serviced regarding the notification of abuse, neglect, and exploitation of facility residents by the administrator. Staff provided every facility associate and resident access to the administrator's contact information and that of the director of nursing. Corporate ownership would establish a 1-800 number to be used for anonymous abuse, neglect, and exploitation reporting and the immediate initiation of investigations. This number would be monitored at all times by an answering service that would immediately report to the facility owners. When allegations occurred, all staff would be re-in-serviced on abuse reporting by the administrator or designee. The deficient practice remained at a scope and severity of G.

The facility identified a census of 74 residents. The facility identified 21 residents with side rails. The sample included 9 residents, with 8 sampled for accidents regarding side rails. Based on observation, record review and interview, the facility failed to ensure side rails used in the facility did not exceed the recommended measurements of the space between the side rail and the mattress of 2 ,[DATE] set by the Food and Drug Administration (FDA), failed to ensure staff thoroughly assessed residents ability to safely use side rails, failed to adequately care plan for use of side rails in a timely manner for 8 of 8 residents (#1, #3, #4, #5, #6, #7, #8, #9) sampled for accidents related to side rails. This failure resulted in side rail entrapment for one of the seven residents sampled for side rails. Staff found resident #1 with his/her head/neck entrapped between the side rail and the mattress, with his/her legs/knees on the floor, and the resident died . This deficient practice placed resident #1, along with residents #3, #4, #5, #6, #7, #8 and #9 in immediate jeopardy. Findings included: - Resident #1's signed physician's orders [REDACTED]. The resident's 14 day Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition, and the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident required extensive assist of two plus staff with bed mobility, and transfers; extensive assist of one person for locomotion on and off the unit. The resident was not steady and only able to stabilize with human assistance with moving from a seated to a standing position, moving on and off the toilet and surface to surface transfers; was not steady but able to stabilize without human assistance with walking and turning around and facing the opposite direction while walking. The resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. The resident had one no injury and one major injury fall since admission or prior assessment, and restraints were not used. The resident's Care Area Assessments completed with the [DATE] MDS did not address side rail use. The care plan last reviewed on [DATE] failed to address side rail use for this resident. The facility self-reported the incident to the state complaint hotline on [DATE] at 2:26 PM. The facility indicated at that time that the resident ha bruising noted on the right side of his/her neck that measured about 1 ,[DATE] x 1 inch. The facility's investigation of the incident recorded there were 4 staff present during the resident's death, and also recorded the resident had a 1 ,[DATE] x 1 inch bruise to the left side of his/her neck. After requests on ,[DATE], ,[DATE] and [DATE], for contact information for the 4 staff present during the incident, administrative staff A provided telephone numbers for 3 of the staff at 12:38 PM on [DATE]. After notifying administrative staff A that there were 4 names listed on the investigation, he/she provided a phone number for the 4th staff member present at 2:27 PM. Nurses notes dated [DATE] at 5:45 AM recorded the Certified Nurses Aide (CNA) notified the nurse that he/she found the resident on the floor. The nurses notes documented that upon entering the resident's room, the nurse found the resident on his/her knees with his/her head on the edge of the mattress with his/her face towards the rail. The resident was unresponsive with skin cool to touch but his/her hands were warm. The note documented he/she noted a pulse on assessment. The nurse called the CNA for assistance to get him/her off the floor and lay him/her on the bed. The nurse started and continued CPR (a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) until the ambulance arrived. The accident/incident report form dated [DATE] at 5:45 AM recorded the resident fell from bed, was found on the floor and was disoriented. Staff was unable to take vital signs as the resident was unresponsive. Nurses note dated [DATE] at 6:30 AM recorded the ambulance crew declared that the resident had passed. A witness statement dated [DATE] by licensed nursing staff E documented the resident was on the floor, on his/her knees with his/her head on the edge of the bed with his/her face towards the rail. The resident was unresponsive skin cool/cold to touch with pale skin. We repositioned the resident in his/her bed and started CPR chest compressions and another nurse notified 911. A witness statement obtained by direct care staff N on [DATE] at approximately 3:15 PM recorded at approximately 5:30 AM on [DATE], the nurse asked staff N to help him/her transfer a resident. Direct care staff N documented when he/she walked in the room, the resident's body was hanging off his/her bed to the floor, with only the head kept up in the side rail. Staff N, another CNA and the nurse carefully pulled the resident back onto the bed. The nurse started CPR. Direct care staff N drew a diagram of how the resident and bed were when he/she entered the room. The drawing showed the resident's head facing down and turned outward between the mattress and side rail, with his/her back facing up and the rest of his/her body on the floor. A witness statement by direct care staff O, dated [DATE] recorded he/she found the resident between the bed rail and the mattress and his/her knees were on the floor. A witness statement obtained on [DATE] by licensed nursing staff F stated a CNA came to get this nurse to come look at a resident on unit 2. This nurse saw the resident's lower body on the floor and his/her left side of head touching the mattress and the right side of his/her head touching the {side rail} bar. The resident was face down. The other nurse started CPR and licensed nursing staff F called 911. Observation of the resident's room at approximately 10:00 AM and again at 1:12 PM revealed a standard mattress in place and no side rails attached to the bed. During an interview on [DATE] at 12:23 PM, licensed nursing staff D stated if residents had side rails, they were on the care plan. Nurses do the side rail assessment to make sure they are appropriate. The assessments were completed at least annually. During an interview on [DATE] at 12:48 PM, administrative nursing staff B stated it was unclear from the documentation how the resident was found. Staff B had the staff come in and show them what the resident's position was and we asked them to demonstrate how they found him/her. The resident was in a low bed with a mat on the floor, and was on his/her knees and his/her head was slightly turned toward the wall. The resident had one arm thru the enabler rail and had the other arm stretched out on top of the bed according to 2 witnesses. The nursing staff B explained that the left side of the resident's head and face were on the mattress and the right side was against the side rail. The type of side rail this resident had allowed to be a ¼ rail or raised up for an enabler (side) rail. His/her rail was in the up position at the time of the incident. At this time, observation of the bed in the resident's room revealed a low bed with no side rail on the bed and a standard mattress. Administrative nursing staff B stated that he/she expected side rails to be care planned, and acknowledged that when he/she reviewed the resident's care plan, the side rail was not addressed. Charge nurses complete the side rail assessment on admission and quarterly. When staff found the resident, there was some discrepancy about if he/she was breathing or not. There was some disagreement between the two nurses. Reading the care plan doesn't describe the resident that was here when administrative nursing staff B was here, as he/she had declined, and the MDS coordinator is responsible for updating the care plan. During an interview on [DATE] at 1:12 PM, maintenance staff V stated his/her assistant took the resident's side rail off after the incident. Maintenance staff V stated when a resident discharges, staff tried to take side rails off the bed if they had them so there wasn't inappropriate use if another resident moves into that room and gets that bed. Maintenance staff V stated he/she could not state for sure if this was the same mattress that was on the bed when the resident was here. Maintenance staff V continued that there were 2 types of side rails used in the building. The type that resident #1 had, ,[DATE] rail that could be flipped up to a transfer bar, and another type that was an assistant rail and there were only 2 of these rails left in the building. During an interview on [DATE] at 5:28 AM, licensed nursing staff F stated he/she was working the night of the side rail incident. The resident's body was on the floor almost sitting. The right side of his/her face was against the side rail and left side against the mattress. The resident was facing down and he/she was not breathing. Licensed nursing staff F stated the charge nurse on that unit started CPR, while he/she called 911. The resident was cool but not cold at that point, and his/her feet and fingertips were blue. During an interview on [DATE] at 2:32 PM, direct care staff N stated he/she was not assigned to the resident the night the incident happened. Staff asked staff N to come into the resident's room. Direct care staff N stated when he/she saw the resident, he/she was a purplish white color. It was very traumatizing. The resident's head was in the rail a little sideways, and kind of twisted. The resident's bed was in the lowest position possible and his/her body was hanging off the bed. All three staff (nurse and two CNAs) helped put him/her in bed. The nurse said he/she felt a pulse and he/she started CPR. The other nurse {called over from another unit} called the ambulance then came back into the room. The resident's legs were on the floor, and he/she was on his/her knees. His/her head was in the side rail sideways and down but it was seriously in the rail and his/her neck was down. The nurse moved the resident's head out of the rail. It was kind of lodged in it, stuck between the rail and the mattress with his/her forehead on the rail. One cheek was against the mattress and one against the rail. The side rail was secure and the mattress was not deflated. Direct care staff N was not sure if the resident was on an air mattress or not. Direct care staff N stated he/she wrote a statement for the facility regarding this incident. However, the information provided by the facility lacked this staff member's witness statement. During an interview on [DATE] at 1:24 PM, licensed nursing staff E stated the resident needed 2 person assist with bed mobility and transfers. Licensed nursing staff E continued that a CNA notified him/her to go to the resident's room. The resident's head was on the bed and his/her knees were on the floor. The back of the resident's head was still on the mattress and facing the rail. His/her bedding was on the floor next to the bed. 2 CNAs and licensed nursing staff E had to physically move the resident. Licensed nursing staff E stated he/she did not think the resident could have moved his/her head on his/her own from the position he/she was in. The resident's arm was stuck inside the rail. I think his/her arm thru the rail and supported his/her head. Licensed nursing staff E stated 70% of his/her head was on the bed, and 30% was not. During an interview on [DATE] at approximately 5:00 PM, maintenance staff V (after surveyor Y questioned about another type of bed rail noted in a resident's room) stated he/she didn't even think about those types of rails when surveyor Y asked previously. Maintannce staff V stated they were ¼ rail rental for bariatric beds and they had 2 in the building. Maintenance staff V then confirmed that there were 3 types of side rails in the building rather than 2 as previously stated. During an interview on [DATE] at approximately 5:30 PM, administrative nursing staff B stated nurses completed the side rail assessments by checking the boxes and it acts as a guide. They answered the questions and if needed, they consult with therapy or family then contact the physician for an order to use a side rail. Administrative nursing staff B confirmed the side rail assessments lacked a key regarding how staff were to determine if side rails should be used or not. During an interview on [DATE] at approximately 1:30 PM, administrative staff A reported there were only 3 staff present at the time of the incident. (This contradicted the facility's investigation and interviews regarding staff present). According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. Although requested, the facility did not provide a policy specific to side rails. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. This failure resulted in the resident becoming entrapped in the side rail, and the resident died . - Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with short and long term memory impairment, an inability to recall current season, location of room, staff names and faces or that he/she was in a nursing home, and had severely impaired decision making skills. The resident required total assist with transfers, locomotion off unit, extensive assist of two plus staff for bed mobility, extensive assist of one person with locomotion on unit, and supervision with eating. The MDS recorded [DIAGNOSES REDACTED]. The MDS recorded the resident did not use any restraints. The Care Area Assessments (CAAs) dated [DATE] recorded the resident was nonsensical in conversation at times, and other time he/she just did not respond verbally. The CAAs failed to address the use of side rails. The care plan last revised on [DATE] recorded the resident had impaired cognition related to short and long term memory impairment and a BIMS score of 3, poor safety awareness, and history of traumatic brain injury. The care plan failed to address the use of side rails. On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was not physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #4's Physicians Order Sheet for November, 2016 recorded a [DIAGNOSES REDACTED]. The [DATE] quarterly Minimum Data Set (MDS) recorded a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS recorded the resident required extensive assistance of 2 plus staff for bed mobility and transfers, and did not have restraints. The Care Area Assessments failed to address the resident's side rail use. The side rail evaluation dated [DATE] recommended the resident use bilateral quarter rails to assist with transfers and repositioning. The [DATE] physician's orders [REDACTED].¼ side rails to assist with repositioning and transfers. Review the record lacked an order and/or assessment for side rail use until [DATE] (2 days after the incident with resident #1). The care plan dated [DATE] directed staff to assist with all ADLs, and failed to address the residents use of side rails. On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was not physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #5's signed [DATE] physician's orders [REDACTED]. The [DATE] quarterly Minimum Data Set (MDS) recorded the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS recorded the resident required extensive assist of two plus staff for bed mobility and transfers, and did not have restraints. The Care Area Assessments did not address side rail use. The side rail assessment dated [DATE] recommended the resident use bilateral quarter rails to assist with repositioning. The physician's orders [REDACTED]. Review the record lacked an order and/or assessment for side rail use until [DATE] (1 day after the incident with resident #1). The care plan dated [DATE] recorded the resident required a 2 person mechanical lift for transfers. The care plan did not address the resident's use of side rails. On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was not physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #6's [DATE] admission Minimum Data Set (MDS) recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded the resident required extensive assist of one person for bed mobility and transfers, and the resident did not have any restraints. The Care Area Assessments failed to address the resident's side rail use. The physician's orders [REDACTED]. The side rail evaluation dated [DATE] recorded the resident requested left ¼ rail for positioning and transfer assistance. Review the record lacked an order and/or assessment for side rail use until [DATE] (1 day after the incident with resident #1). The care plan dated [DATE] recorded the resident had ¼ side rail on his/her bed. On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #7's [DATE] admission Minimum Data Set (MDS) recorded the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The resident required limited assist of two plus staff for bed mobility and supervision of two plus persons for transfers. The resident did not use any restraints. The fall CAA dated [DATE] recorded the resident required extensive assist with transfers. The care plan dated [DATE] lacked documentation of side rails. On [DATE], the physician's orders [REDACTED].¼ rails for assistance and transfers. Review the record lacked an order and/or assessment for side rail use until [DATE] (1 day after the incident with resident #1). On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 3 inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #8's signed physician's orders [REDACTED]. The Care Area Assessments failed to address side rails. The side rail evaluation dated [DATE] recorded the resident requested left ¼ side rails to assist with positioning and transfers. The care plan dated [DATE] recorded the resident required 2 person assist for transfers and failed to address the use of side rails. The [DATE] physician's orders [REDACTED].¼ side rail for transfer and positioning assistance. Review the record lacked an order and/or assessment for side rail use until [DATE] (1 day after the incident with resident #1). On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated the resident was not physically capable to reposition him/herself using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. - Resident #9's physician's orders [REDACTED]. The side rail assessment dated [DATE] recommended the resident use right ¼ rail for transfer and repositioning assistance. The quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, and the resident was independent with bed mobility and transfers, and did not use restraints. The Care Area Assessments (CAAs) failed to address the resident's side rail use. The care plan dated [DATE] recorded the resident used bed rails during transfers. The care plan did not indicate what type or size of bed rail or if on one side of the bed or both. The physician's orders [REDACTED].¼ rail for transfers and repositioning assistance. Review the record lacked an order and/or assessment for side rail use until [DATE] (1 day after the incident with resident #1). On [DATE] at approximately 7:00 AM, observation revealed the space between the mattress and the side rail on the resident's bed measured 2 ½ inches. During an interview on [DATE] at 7:31 AM, direct care staff P stated it varied if the resident was not physically capable to reposition him/herself or not using the side rail. Although requested, the facility did not provide a policy specific to side rails. According to the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] revealed the FDA recommended a dimension be less than 2 ,[DATE] for neck diameter for spacing between the side rail and the mattress to reduce the risk of neck entrapment and 4 ,[DATE] for head entrapment. Factors that may increase the gap size included: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. This may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. The facility failed to thoroughly assess and ensure the resident had safe and appropriate side rails. This deficient practice placed the 8 residents identified with side rails exceeding the recommended measurements in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when the facility ensured the gaps between the side rails and the mattresses on resident beds were within FDA guidelines. All residents identified as needing side rails as quality of life and activities for daily living assistance devices would have physician or therapy orders prior to utilizing side rails, and said use would be care planned accordingly upon implementation. Facility maintenance director personally measured the gaps between any bed mounted rails and mattresses to ensure that they were within the FDA guidelines and record at least weekly. This deficient practice remained at the scope and severity of a G.

The facility identified a census of 74 residents. The sample included 9 residents. Based on observation, record review and interview, the facility failed to protect the 6 residents the opposite gender as resident #2 from sexual abuse, when resident #2 displayed at least six instances of sexual behaviors, and the facility failed to implement any interventions to address these repeated behaviors that occurred for at least eight months. This deficient practice placed the 6 opposite gender residents in immediate jeopardy. Findings included: - Resident #2's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and did not have physical behavioral symptoms directed toward others. The resident required supervision with transfers, walking in room or corridor and locomotion on unit. The resident did not use a mobility device. The MDS recorded the resident had [DIAGNOSES REDACTED]. The Care Area Assessments (CAAs) dated 3/1/16 recorded the resident had a [DIAGNOSES REDACTED]. The CAAs failed to address the resident's delusions or resident to resident incidents. The care plan, last updated 9/1/16, directed staff to obtain a psychiatry evaluation as needed. An intervention dated 3/17/16 documented the resident became affectionate (kissing) with another (opposite gender) resident. The care plan lacked identification of the resident, and lacked any interventions directing staff how to intervene if the resident displayed these behaviors, and how to protect the other residents in the facility. Nurses notes dated 2/8/16 at 1:50 PM recorded the resident had been kissing, holding hands and going into another resident's room. Per the other resident's family' s request, the nurse documented he/she spoke with both residents and observed them while they were visiting. However, resident #2 continued to hold the other resident's hands, kiss him/her and wait outside of his/her room. Resident #2 told this nurse today {opposite gender name} asked me to change {him/her} after lunch. Resident #2 believed (opposite gender name) was the other resident's family member, but was not. The other resident was married. However, resident #2 stated that is not what they tell me. The nurse recorded he/she would continue to supervise when the residents were visiting and reminded them not to hold hands etc. Nurses notes dated 2/10/16 at 3:30 PM recorded staff had reminded resident #2 many times a day to leave a specific resident alone. Staff found resident #2 this afternoon in this opposite gender resident's room while he/she was resting in bed, bent over kissing him/her asking him/her if he/she was ready to go home. After speaking to resident #2 and removing him/her from this opposite gender's room, he/she stated that the resident was no longer married and they were moving in together. The nurse documented that he/she explained the contrary gently and would continue to observe the two residents of them while visiting. Nurses notes dated 5/12/16 at 10:45 AM recorded the resident continued to have delusions that one of the residents was his/her spouse. Resident #2 kissed and held the opposite gender resident's hand. The nurses note recorded staff would continue with the resident's plan of care. Nurses notes dated 10/9/16 at 2:50 PM recorded resident #2 snuck into an opposite gender resident's room and laid down in bed while the other resident was napping. Staff redirected resident #2 and he/she stated, This is my {spouse}, I'm only laying to watch {him/her}. Staff escorted resident #2 back to his/her room would continue to observe the residents. The next nurses note after 10/9/16 was on 11/2/16 regarding the resident's back pain. There was no further documentation regarding the resident's sexual behaviors. Social Service notes dated 10/13/16 at 10:25 AM recorded the social service staff received notification that this resident was found in another resident's room by the other resident's family member and that resident #2 had his/her top off and upper body exposed. This resident was in the bed and once when the family member walked in, resident #2 jumped up and put his/her shirt on and exited the room. The family member does not want this resident in his/her family member's room. It was stated to the family member that residents on this unit wander, but staff would pay extra attention. This resident often mistakes the other resident as his/her spouse and says We're going on a trip. Resident #2 had these delusions often, and staff would continue to observe. This incident recorded on 10/13/16 in the social service notes was not documented in the resident's nurses notes, and there was no follow up monitoring or documentation in the record about this incident. There was also no documentation to show the social service staff notified nursing, administration, or any other staff of the incident. Observations on 11/7/16 revealed the following: At 2:57 PM, the resident stood up from the table and self-ambulated to his/her room using a walker. Observation revealed resident #2's room was next door to resident #3's room. At 6:02 PM, residents #2 and #3 sat side by side at the dining room table. At 6:10 PM, residents #2 and #3 sat side by side at the dining room table, the nurse was off the unit getting coffee from the kitchen, which left one CNA as the only staff on the unit. The CNA sat with his/her back to the two residents. At 6:14 PM, the nurse returned to the unit with coffee. During an interview on 11/7/16 2:18 PM, social service staff W stated resident #2 thought he/she was married to resident #3 and wanted to sit by him/her and held his/her hand. There was one incident where resident #2 was in resident #3's room and his/her shirt was off. Resident #3's family showed up and were not happy. Staff was doing a better job of keeping an eye on him/her now. This was the only incident staff W was aware of with him/her. Resident #2 kissed resident #3 in the past and it upset the family, and they just kind of came to terms with it. Resident #3 was severely cognitively impaired, and resident #2 had some cognitive impairment maybe not severely. During an interview on 11/7/16 at 3:15 PM, licensed nursing staff D stated /she had only worked on the unit for 3 days but had noticed increased confusion with the resident as he/she said that he/she and resident #3 were getting married. Staff D had not heard resident #3 talk. The two residents sit at the same dining room table together. Licensed nursing staff D stated there was nothing in particular that staff watch for or monitor with these two residents. During an interview on 11/7/16 at 3:38 PM, direct care staff R stated that resident #2 ambulated independently, and did not have any behaviors that he/she was aware of. Direct care staff R continued that there wasn't anything specific that staff watched for with him/her. Resident #2 liked resident #3, and staff had to watch him/her. Direct care staff R continued that staff checked on all residents every 30 minutes. During an interview on 11/7/16 at 5:11 PM, Administrative nursing staff B and C both stated that they were not aware of any incidents between the two residents, but they would look into it. Administrative nursing staff C continued that he/she did not know of any incidents, but knows the two residents do like to sit together at meals. During an interview on 11/7/16 at 5:16 PM, administrative nursing staff A stated he/she did not know of any concerns regarding these two residents. During an interview on 11/7/16 at 5:55 PM, administrative nursing staff B reported that after looking, there were no investigations or incidents related to the two residents. Upon surveyor Y's request on 11/7/16 at 6:08 PM for an immediate plan to keep the residents safe until the full investigation could be completed, administrative nursing staff A stated he/she would place resident #2 on 1:1's (the resident would be continuously observed by a staff member assigned specifically to them) until the investigation was complete. During an interview on 11/8/16 at 5:28 AM, licensed nursing staff F stated he/she had observed resident #2 touch resident #3's hands and had observed resident #2 kiss resident #3 on the forehead. Licensed nursing staff F continued that sometimes at night he/she had seen resident #2 try to sneak into resident #3's room and he/she redirected him/her. At times, resident #2 thought resident #3 was his/her spouse. Licensed nursing staff F stated resident #3 was not able to carry on a conversation. Licensed nursing staff F continued that there were 17 residents on the unit with one nurse and one CNA. Licensed nursing staff F stated that staff knew what care the residents need by reviewing the care plans. Licensed nursing staff F confirmed that resident #2's care plan does not address the interaction with resident #3. Licensed nursing staff F continued that for ANE training, he/she received a pamphlet during orientation to read. Licensed nursing staff F stated if there was an abuse situation, staff should remove residents from the area, make sure residents were safe and contact their supervisor or the state agency. Licensed nursing staff F stated if he/she observed kissing, or inappropriate touching, he/she would report this to his/her supervisor and/or state agency. During an interview on 11/8/16 at 5:34 AM, direct care staff R stated he/she received ANE training upon hire and education meetings. Direct care staff R stated he/she would report resident to resident incidents to the nurse immediately. Direct care staff R stated that resident #2 thought resident #3 was his/her spouse and tried to go into his/her room. During an interview on 11/8/16 at 6:23 AM licensed nursing staff G stated he/she received ANE training in orientation. If he/she had a concern, he/she would report the concern to the ADON (assistant director of nursing), DON (Director of Nursing)or administrator. Licensed nursing staff G stated he/she would stop situation if he/she observed residents holding hands kissing, going into one another's room, and let one of the three management staff know that the resident(s) need to be watched more closely. On 11/10/16 at 4:05 PM, social service staff W stated residents #2 and #3 were not able to make decisions on their own and had short and long term memory loss. Resident #3 was not able to verbally communicate. Resident #3's family member brought the concern to staff. A nurse told staff W about it. Administrative nursing staff B talked to resident #3's family today who does not want them separated. The resident's family member did voice the concern in October. During an interview on 11/10/16 at 5:00 PM, administrative nursing staff B stated he/she spoke to resident #3's family member yesterday, then the family member came in today and we finished that conversation. The resident's family member told staff W that the documentation that administrative nursing staff B observed was incorrect. The resident's family member stated another family member never walked in and saw anyone with their top off, and that it did not happen. Social service staff W stated he/she was told to document it by the nurse. The only thing that resident #3's family member asked was that if staff find resident #2 in resident #3's room to separate them. Administrative nursing staff B continued that resident #2 had been very sad because he/she felt that he/she was being punished and does not understand what was going on. The psychologist saw both residents today, and said that resident #2 was alert and oriented but was delusional. Administrative staff B stated that he/she does not trust the documentation that was there regarding the incident. During an interview on 11/16/16 at 9:30 A.M., licensed nursing staff I stated he/she was told in report to watch resident #2 closely due to sexual behaviors and to not allow him/her into other residents rooms. Licensed nursing staff I stated the resident had asked several times this morning if he/she could go into resident #3's room and take off his/her clothes and sleep in his/her bed. During an interview on 11/14/16 at 2:21 PM, family member U stated that when he/she visited resident #3 in October, he/she walked in the resident's room and resident #2 was in his/her bed with him/her. Resident #2 was cuddled up next to resident #3 and resident #2 had his/her leg propped up over resident #3's body and resident #2's hand was on resident #3's belly, kind of massaging it. Family member U continued that it just wasn't appropriate for resident #2 to be in bed with resident #3. During an interview on 11/15/16 at 8:15 AM, family member T stated a family member found resident #3 in resident #3's room when he/she visited. Resident #2 being in resident #3's room is about the only thing he/she discouraged and asked staff to gently remove resident #2 from resident #3's room. Family member T stated he/she was ok with the two residents to sit together and hold hands. Family member T stated he/she had not told staff not to allow this or to try to separate then, the only thing he/she requested was that resident #2 not be in resident #3's room. During an interview on 11/30/16 at 4:30 PM, family member T stated They would like for resident #2 to stay out of resident #3's room if possible, and we understand there will be times resident #3 may get in bed with resident #3. All we ask staff to do is remove resident #2 when it occurs. The facility's resident abuse policy last revised on 6/1/15 recorded any employee who witnessed or had knowledge of an act of abuse or an allegation of abuse to a resident, was obligated to report such information immediately to their supervisor. If the immediate supervisor was not available, the employee was to notify the designated nursing supervisor on duty at the time of the event. The supervisor was obligated to immediately report to the Executive Director who was the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services was the designated abuse coordinator. All reported events (which included abusive behaviors) would be investigated by the Director of Clinical Services. Patterns or trends would be identified that might constitute abuse. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted in the absence of the Executive Director, the Director of Clinical Services would serve as Abuse Coordinator. Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the allegation. The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. The Abuse Coordinator of the company will refer any or all incidents and reports of resident abuse to the appropriate state agencies. The policy failed to direct staff what to do specifically for resident to resident incidents. The facility failed to protect opposite gender residents in the facility from resident #2 who displayed multiple sexual behaviors toward another resident. -Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with short and long term memory impairment, an inability to recall current season, location of room, staff names and faces or that he/she was in a nursing home, and had severely impaired decision making skills. The resident required total assist with transfers, locomotion off unit, extensive assist of two plus staff for bed mobility, dressing and personal hygiene, extensive assist of one person with locomotion on unit, and supervision with eating. The MDS recorded [DIAGNOSES REDACTED]. The Care Area Assessments (CAAs) dated 11/17/15 recorded the resident was nonsensical in conversation at times, and other time he/she just did not respond verbally. The CAAs failed to address any resident to resident incidents. The care plan last revised on 8/30/16 recorded the resident had impaired cognition related to short and long term memory impairment and a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition, poor safety awareness, and history of [MEDICAL CONDITION]. Review of the resident's nurses notes from 3/29/16 thru 11/7/16 lacked any documentation regarding incidents between resident #2 and #3. The social service note dated 10/14/16 at 10:30 AM documented this writer received notification of an incident that occurred previously. This resident was in bed and another resident was in bed with him/her with his/her shirt off. When the resident's family member walked in, the other resident jumped up, put his/her shirt on, and left the room. The resident's family member requested that the other resident not go in his/her family member's room. The nurse on duty stated that the residents wander but staff will pay extra attention on the situation to help avoid another occurrence. Staff will continue to observe. This was the only social service note regarding resident to resident incidents between these two residents, although there were multiple documented incidents recorded in resident #3's medical record for resident #2. There was no follow up documentation regarding the incident, or the resident's response to the incidents. The social service note lacked documentation that the social service staff reported the incident to his/her supervisor or followed the facility's ANE (Abuse, Neglect and Exploitation) policy. During an interview on 11/7/16 at 2:18 PM, social service staff W stated resident #2 thought he/she was married to resident #3 and wanted to sit by him/her and hold his/her hand. There was one incident where resident #2 was in resident #3's room and his/her shirt was off. Resident #3's family showed up and were not happy. Staff was doing a better job of keeping an eye on him/her now. This was the only incident staff W was aware of with him/her. Resident #2 had kissed resident #3 in the past and it upset the family, and they just kind of came to terms with it. Resident #3 was severely cognitively impaired, and resident #2 had some cognitive impairment maybe not severely. The facility's resident abuse policy last revised on 6/1/15 recorded any employee who witnessed or had knowledge of an act of abuse or an allegation of abuse to a resident, was obligated to report such information immediately to their supervisor. If the immediate supervisor was not available, the employee was to notify the designated nursing supervisor on duty at the time of the event. The supervisor was obligated to immediately report to the Executive Director who was the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services was the designated abuse coordinator. All reported events (which included abusive behaviors) would be investigated by the Director of Clinical Services. Patterns or trends would be identified that might constitute abuse. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted in the absence of the Executive Director, the Director of Clinical Services would serve as Abuse Coordinator. Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the allegation. The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. The Abuse Coordinator of the company will refer any or all incidents and reports of resident abuse to the appropriate state agencies. The policy failed to direct staff what to do specifically for resident to resident incidents. The facility failed to protect this resident, as well as the other five residents of the opposite gender, from resident #2 when he/she displayed repeated resident to resident sexual behaviors toward resident #3 and the facility failed to determine/document if this was consensual. This deficient practice placed the opposite gender residents in immediate jeopardy. The facility abated the immediate jeopardy on 11/21/16 when the facility in-serviced all staff on the reporting of resident to resident abuse, neglect and exploitation, particularly of a potentially inappropriate sexual nature. The facility in-service the social worker on the proper identification, investigation and document of all potential resident to resident abuse allegations. The DON or designee would audit 100% of the facility charts interdisciplinary notes to determine if there were other incidents not investigated and/or reported appropriately. The administrator would report all incidents of resident to resident potentially harmful interaction within 24 hours, and the facility would initiate investigation protocols per state and federal guidelines at that time. The facility revised the existing abuse/neglect/exploitation policy to ensure that resident to resident sexual conflict investigation and reporting are reflected. The facility staffed the special care unit with at least three licensed or certified caregivers per shift per day. Residents involved in physical or sexual conflict would be kept on 1:1 observation until they could be sent out for evaluation and treatment if necessary. Staff installed a sensor on the doorway to resident #3's room to alert staff of anyone entering the room. This deficient practice remained at the scope and severity of an H.

The facility identified a census of 74 residents. The sample included 9 residents. Based on observation, record review and interview, the facility failed to provide an environment free from resident to resident sexual abuse for 1 of 3 residents sampled for abuse. Cognitively impaired resident #2 sexually abused cognitively impaired resident #3 between the dates of 2/8/16 until 11/7/16. Resident #2 kissed, layed in bed with and held hands with resident #3, who was not cognitively aware to consent to sexual advances, on at least 5 documented occasions. This sexual abuse placed resident #3 in immediate jeopardy. Findings included: - Resident #2's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and did not have physical behavioral symptoms directed toward others. The resident required supervision with transfers, walking in room or corridor and locomotion on unit. The resident did not use a mobility device. The MDS recorded the resident had [DIAGNOSES REDACTED]. The Care Area Assessments (CAAs) dated 3/1/16 recorded the resident had a [DIAGNOSES REDACTED]. The CAAs failed to address the resident's delusions or resident to resident incidents. The care plan, last updated 9/1/16, directed staff to obtain a psychiatry evaluation as needed. An intervention dated 3/17/16 documented the resident became affectionate (kissing) with another (opposite gender) resident. The care plan lacked identification of the resident, and lacked any interventions directing staff how to intervene if the resident displayed these behaviors, and how to protect the other residents in the facility. Nurses notes dated 2/8/16 at 1:50 PM recorded the resident had been kissing, holding hands and going into another resident's room. Per the other resident's family's request, the nurse documented he/she spoke with both residents and observed them while they were visiting. However, resident #2 continued to hold the other resident's hands, kiss him/her and wait outside of his/her room. Resident #2 told this nurse today {opposite gender name} asked me to change {him/her} after lunch. Resident #2 believed (opposite gender name) was the other resident's family member, but was not. The other resident was married. However, resident #2 stated that is not what they tell me. The nurse recorded he/she would continue to supervise when the residents were visiting and reminded them not to hold hands etc. Nurses notes dated 2/10/16 at 3:30 PM recorded staff had reminded resident #2 many times a day to leave a specific resident alone. Staff found resident #2 this afternoon in this opposite gender resident's room while he/she was resting in bed, bent over kissing him/her asking him/her if he/she was ready to go home. After speaking to resident #2 and removing him/her from this opposite gender's room, he/she stated that the resident was no longer married and they were moving in together. The nurse documented that he/she explained the contrary gently and would continue to observe the two residents of them while visiting. Nurses notes dated 5/12/16 at 10:45 AM recorded the resident continued to have delusions that one of the residents was his/her spouse. Resident #2 kissed and held the opposite gender resident's hand. The nurses note recorded staff would continue with the resident's plan of care. Nurses notes dated 10/9/16 at 2:50 PM recorded resident #2 snuck into an opposite gender resident's room and laid down in bed while the other resident was napping. Staff redirected resident #2 and he/she stated, This is my {spouse}, I'm only laying to watch {him/her}. Staff escorted resident #2 back to his/her room would continue to observe the residents. The next nurses note after 10/9/16 was on 11/2/16 regarding the resident's back pain. There was no further documentation regarding the resident's sexual behaviors. Social Service notes dated 10/13/16 at 10:25 AM recorded the social service staff received notification that this resident was found in another resident's room by the other resident's family member and that resident #2 had his/her top off and upper body exposed. This resident was in the bed and once when the family member walked in, resident #2 jumped up and put his/her shirt on and exited the room. The family member does not want this resident in his/her family member's room. It was stated to the family member that residents on this unit wander, but staff would pay extra attention. This resident often mistakes the other resident as his/her spouse and says We're going on a trip. Resident #2 had these delusions often, and staff would continue to observe. This incident recorded on 10/13/16 in the social service notes was not documented in the resident's nurses notes, and there was no follow up monitoring or documentation in the record about this incident. There was also no documentation to show the social service staff notified nursing, administration, or any other staff of the incident. Observations on 11/7/16 revealed the following: At 2:57 PM, the resident stood up from the table and self-ambulated to his/her room using a walker. Observation revealed resident #2's room was next door to resident #3's room. At 6:02 PM, residents #2 and #3 sat side by side at the dining room table. At 6:10 PM, residents #2 and #3 sat side by side at the dining room table, the nurse was off the unit getting coffee from the kitchen, which left one CNA as the only staff on the unit. The CNA sat with his/her back to the two residents. At 6:14 PM, the nurse returned to the unit with coffee. During an interview on 11/7/16 2:18 PM, social service staff W stated resident #2 thought he/she was married to resident #3 and wanted to sit by him/her and held his/her hand. There was one incident where resident #2 was in resident #3's room and his/her shirt was off. Resident #3's family showed up and were not happy. Staff was doing a better job of keeping an eye on him/her now. This was the only incident staff W was aware of with him/her. Resident #2 kissed resident #3 in the past and it upset the family, and they just kind of came to terms with it. Resident #3 was severely cognitively impaired, and resident #2 had some cognitive impairment maybe not severely. During an interview on 11/7/16 at 3:15 PM, licensed nursing staff D stated /she had only worked on the unit for 3 days but had noticed increased confusion with the resident as he/she said that he/she and resident #3 were getting married. Staff D had not heard resident #3 talk. The two residents sit at the same dining room table together. Licensed nursing staff D stated there was nothing in particular that staff watch for or monitor with these two residents. During an interview on 11/7/16 at 3:38 PM, direct care staff R stated that resident #2 ambulated independently, and did not have any behaviors that he/she was aware of. Direct care staff R continued that there wasn't anything specific that staff watched for with him/her. Resident #2 liked resident #3, and staff had to watch him/her. Direct care staff R continued that staff checked on all residents every 30 minutes. During an interview on 11/7/16 at 5:11 PM, Administrative nursing staff B and C both stated that they were not aware of any incidents between the two residents, but they would look into it. Administrative nursing staff C continued that he/she did not know of any incidents, but knows the two residents do like to sit together at meals. During an interview on 11/7/16 at 5:16 PM, administrative nursing staff A stated he/she did not know of any concerns regarding these two residents. During an interview on 11/7/16 at 5:55 PM, administrative nursing staff B reported that after looking, there were no investigations or incidents related to the two residents. Upon surveyor Y's request on 11/7/16 at 6:08 PM for an immediate plan to keep the residents safe until the full investigation could be completed, administrative nursing staff A stated he/she would place resident #2 on 1:1's (the resident would be continuously observed by a staff member assigned specifically to them) until the investigation was complete. During an interview on 11/8/16 at 5:28 AM, licensed nursing staff F stated he/she had observed resident #2 touch resident #3's hands and had observed resident #2 kiss resident #3 on the forehead. Licensed nursing staff F continued that sometimes at night he/she had seen resident #2 try to sneak into resident #3's room and he/she redirected him/her. At times, resident #2 thought resident #3 was his/her spouse. Licensed nursing staff F stated resident #3 was not able to carry on a conversation. Licensed nursing staff F continued that there were 17 residents on the unit with one nurse and one CNA. Licensed nursing staff F stated that staff knew what care the residents need by reviewing the care plans. Licensed nursing staff F confirmed that resident #2's care plan does not address the interaction with resident #3. Licensed nursing staff F continued that for ANE training, he/she received a pamphlet during orientation to read. Licensed nursing staff F stated if there was an abuse situation, staff should remove residents from the area, make sure residents were safe and contact their supervisor or the state agency. Licensed nursing staff F stated if he/she observed kissing, or inappropriate touching, he/she would report this to his/her supervisor and/or state agency. During an interview on 11/8/16 at 5:34 AM, direct care staff R stated he/she received ANE training upon hire and education meetings. Direct care staff R stated he/she would report resident to resident incidents to the nurse immediately. Direct care staff R stated that resident #2 thought resident #3 was his/her spouse and tried to go into his/her room. During an interview on 11/8/16 at 6:23 AM licensed nursing staff G stated he/she received ANE training in orientation. If he/she had a concern, he/she would report the concern to the ADON (assistant director of nursing), DON (Director of Nursing)or administrator. Licensed nursing staff G stated he/she would stop situation if he/she observed residents holding hands kissing, going into one another's room, and let one of the three management staff know that the resident(s) need to be watched more closely. On 11/10/16 at 4:05 PM, social service staff W stated residents #2 and #3 were not able to make decisions on their own and had short and long term memory loss. Resident #3 was not able to verbally communicate. Resident #3's family member brought the concern to staff. A nurse told staff W about it. Administrative nursing staff B talked to resident #3's family today who does not want them separated. The resident's family member did voice the concern in October. During an interview on 11/10/16 at 5:00 PM, administrative nursing staff B stated he/she spoke to resident #3's family member yesterday, then the family member came in today and we finished that conversation. The resident's family member told staff W that the documentation that administrative nursing staff B observed was incorrect. The resident's family member stated another family member never walked in and saw anyone with their top off, and that it did not happen. Social service staff W stated he/she was told to document it by the nurse. The only thing that resident #3's family member asked was that if staff find resident #2 in resident #3's room to separate them. Administrative nursing staff B continued that resident #2 had been very sad because he/she felt that he/she was being punished and does not understand what was going on. The psychologist saw both residents today, and said that resident #2 was alert and oriented but was delusional. Administrative staff B stated that he/she does not trust the documentation that was there regarding the incident. During an interview on 11/16/16 at 9:30 A.M., licensed nursing staff I stated he/she was told in report to watch resident #2 closely due to sexual behaviors and to not allow him/her into other residents rooms. Licensed nursing staff I stated the resident had asked several times this morning if he/she could go into resident #3's room and take off his/her clothes and sleep in his/her bed. The facility's resident abuse policy last revised on 6/1/15 recorded any employee who witnessed or had knowledge of an act of abuse or an allegation of abuse to a resident, was obligated to report such information immediately to their supervisor. If the immediate supervisor was not available, the employee was to notify the designated nursing supervisor on duty at the time of the event. The supervisor was obligated to immediately report to the Executive Director who was the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services was the designated abuse coordinator. All reported events (which included abusive behaviors) would be investigated by the Director of Clinical Services. Patterns or trends would be identified that might constitute abuse. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted in the absence of the Executive Director, the Director of Clinical Services would serve as Abuse Coordinator. Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the allegation. The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. The Abuse Coordinator of the company will refer any or all incidents and reports of resident abuse to the appropriate state agencies. The policy failed to direct staff what to do specifically for resident to resident incidents. The facility failed to ensure an environment free from abuse for resident #3 from resident #2 who displayed multiple sexual behaviors toward another resident when facility failed to determine/document the sexual behaviors were consensual. -Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with short and long term memory impairment, an inability to recall current season, location of room, staff names and faces or that he/she was in a nursing home, and had severely impaired decision making skills. The resident required total assist with transfers, locomotion off unit, extensive assist of two plus staff for bed mobility, dressing and personal hygiene, extensive assist of one person with locomotion on unit, and supervision with eating. The MDS recorded [DIAGNOSES REDACTED]. The Care Area Assessments (CAAs) dated 11/17/15 recorded the resident was nonsensical in conversation at times, and other time he/she just did not respond verbally. The CAAs failed to address any resident to resident incidents. The care plan last revised on 8/30/16 recorded the resident had impaired cognition related to short and long term memory impairment and a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition, poor safety awareness, and history of [MEDICAL CONDITION]. Review of the resident's nurses notes from 3/29/16 thru 11/7/16 lacked any documentation regarding incidents between resident #2 and #3. The social service note dated 10/14/16 at 10:30 AM documented this writer received notification of an incident that occurred previously. This resident was in bed and another resident was in bed with him/her with his/her shirt off. When the resident's family member walked in, the other resident jumped up, put his/her shirt on, and left the room. The resident's family member requested that the other resident not go in his/her family member's room. The nurse on duty stated that the residents wander but staff will pay extra attention on the situation to help avoid another occurrence. Staff will continue to observe. This was the only social service note regarding resident to resident incidents between these two residents, although there were multiple documented incidents recorded in the resident #3's medical record for resident #2. There was no follow up documentation regarding the incident, or the resident's response to the incidents. The social service note lacked documentation that the social service staff reported the incident to his/her supervisor or followed the facility's ANE (Abuse, Neglect and Exploitation) policy. During an interview on 11/7/16 at 2:18 PM, social service staff W stated resident #2 thought he/she was married to resident #3 and wanted to sit by him/her and hold his/her hand. There was one incident where resident #2 was in resident #3's room and his/her shirt was off. Resident #3's family showed up and were not happy. Staff was doing a better job of keeping an eye on him/her now. This was the only incident staff W was aware of with him/her. Resident #2 had kissed resident #3 in the past and it upset the family, and they just kind of came to terms with it. Resident #3 was severely cognitively impaired, and resident #2 had some cognitive impairment maybe not severely. During an interview on 11/14/16 at 2:21 PM, family member U stated that when he/she visited resident #3 in October, he/she walked in the resident's room and resident #2 was in his/her bed with him/her. Resident #2 was cuddled up next to resident #3 and resident #2 had his/her leg propped up over resident #3's body and resident #2's hand was on resident #3's belly, kind of massaging it. Family member U continued that it just wasn't appropriate for resident #2 to be in bed with resident #3. During an interview on 11/15/16 at 8:15 AM, family member T stated a family member found resident #3 in resident #3's room when he/she visited. Resident #2 being in resident #3's room is about the only thing he/she discouraged and asked staff to gently remove resident #2 from resident #3's room. Family member T stated he/she was ok with the two residents to sit together and hold hands. Family member T stated he/she had not told staff not to allow this or to try to separate then, the only thing he/she requested was that resident #2 not be in resident #3's room. During an interview on 11/30/16 at 4:30 PM, family member T stated They would like for resident #2 to stay out of resident #3's room if possible, and we understand there will be times resident #3 may get in bed with resident #3. All we ask staff to do is remove resident #2 when it occurs. The facility's resident abuse policy last revised on 6/1/15 recorded any employee who witnessed or had knowledge of an act of abuse or an allegation of abuse to a resident, was obligated to report such information immediately to their supervisor. If the immediate supervisor was not available, the employee was to notify the designated nursing supervisor on duty at the time of the event. The supervisor was obligated to immediately report to the Executive Director who was the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services was the designated abuse coordinator. All reported events (which included abusive behaviors) would be investigated by the Director of Clinical Services. Patterns or trends would be identified that might constitute abuse. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted in the absence of the Executive Director, the Director of Clinical Services would serve as Abuse Coordinator. Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the allegation. The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. The Abuse Coordinator of the company will refer any or all incidents and reports of resident abuse to the appropriate state agencies. The policy failed to direct staff what to do specifically for resident to resident incidents. The facility failed to provide an environment free from abuse from resident #2 when he/she displayed repeated resident to resident sexual behaviors. This deficient practice placed this cognitively impaired, dependent resident in immediate jeopardy. The facility abated the immediate jeopardy on 11/21/16 when the facility in-serviced all staff on the reporting of resident to resident abuse, neglect and exploitation, particularly of a potentially inappropriate sexual nature. The facility in-service the social worker on the proper identification, investigation and document of all potential resident to resident abuse allegations. The DON or designee would audit 100% of the facility charts interdisciplinary notes to determine if there were other incidents not investigated and/or reported appropriately. The administrator would report all incidents of resident to resident potentially harmful interaction within 24 hours, and the facility would initiate investigation protocols per state and federal guidelines at that time. The facility revised the existing abuse/neglect/exploitation policy to ensure that resident to resident sexual conflict investigation and reporting are reflected. The facility staffed the special care unit with at least three licensed or certified caregivers per shift per day. Residents involved in physical or sexual conflict would be kept on 1:1 observation until they could be sent out for evaluation and treatment if necessary. Staff installed a sensor on the doorway to resident #3's room to alert staff of anyone entering the room. This deficient practice remained at the scope and severity of G.

The facility identified a census of 74 residents. The sample included 9 residents. Based on observation, record review and interview, the facility failed provide adequate psychosocial needs for 1 of 9 sampled residents. (#2 regarding psychosocial needs after separation from another resident) Findings included: -Resident #2's quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and did not have physical behavioral symptoms directed toward others. The resident required supervision with transfers, walking in room or corridor and locomotion on unit. The resident did not use a mobility device. The MDS recorded the resident had [DIAGNOSES REDACTED]. The Care Area Assessments (CAAs) dated 3/1/16 recorded the resident had a [DIAGNOSES REDACTED]. The CAAs failed to address the resident's delusions or resident to resident incidents. The care plan, last updated 9/1/16, directed staff to obtain a psychiatry evaluation as needed. An intervention dated 3/17/16 documented the resident became affectionate (kissing) with another (opposite gender) resident. The care plan lacked identification of the resident, and lacked any interventions directing staff how to intervene if the resident displayed these behaviors, and how to protect the other residents in the facility. Nurses notes dated 2/8/16 at 1:50 PM recorded the resident had been kissing, holding hands and going into another resident's room. Per the other resident's family's request, the nurse documented he/she spoke with both residents and observed them while they were visiting. However, resident #2 continued to hold the other resident's hands, kiss him/her and wait outside of his/her room. Resident #2 told this nurse today {opposite gender name} asked me to change {him/her} after lunch. Resident #2 believed (opposite gender name) was the other resident's family member, but was not. The other resident was married. However, resident #2 stated that is not what they tell me. The nurse recorded he/she would continue to supervise when the residents were visiting and reminded them not to hold hands etc. Nurses notes dated 2/10/16 at 3:30 PM recorded staff had reminded resident #2 many times a day to leave a specific resident alone. Staff found resident #2 this afternoon in this opposite gender resident's room while he/she was resting in bed, bent over kissing him/her asking him/her if he/she was ready to go home. After speaking to resident #2 and removing him/her from this opposite gender's room, he/she stated that the resident was no longer married and they were moving in together. The nurse documented that he/she explained the contrary gently and would continue to observe the two residents of them while visiting. Nurses notes dated 5/12/16 at 10:45 AM recorded the resident continued to have delusions that one of the residents was his/her spouse. Resident #2 kissed and held the opposite gender resident's hand. The nurses note recorded staff would continue with the resident's plan of care. Nurses notes dated 10/9/16 at 2:50 PM recorded resident #2 snuck into an opposite gender resident's room and laid down in bed while the other resident was napping. Staff redirected resident #2 and he/she stated, This is my {spouse}, I'm only laying to watch {him/her}. Staff escorted resident #2 back to his/her room would continue to observe the residents. The next nurses note after 10/9/16 was on 11/2/16 regarding the resident's back pain. There was no further documentation regarding the resident's sexual behaviors. Social Service notes dated 10/13/16 at 10:25 AM recorded the social service staff received notification that this resident was found in another resident's room by the other resident's family member and that resident #2 had his/her top off and upper body exposed. This resident was in the bed and once when the family member walked in, resident #2 jumped up and put his/her shirt on and exited the room. The family member does not want this resident in his/her family member's room. It was stated to the family member that residents on this unit wander, but staff would pay extra attention. This resident often mistakes the other resident as his/her spouse and says We're going on a trip. Resident #2 had these delusions often, and staff would continue to observe. This incident recorded on 10/13/16 in the social service notes was not documented in the resident's nurses notes, and there was no follow up monitoring or documentation in the record about this incident. Observations on 11/7/16 revealed the following: At 2:57 PM, the resident stood up from the table and self-ambulated to his/her room using a walker. At 6:02 PM, residents #2 and #3 sat side by side at the dining room table. At 6:10 PM, residents #2 and #3 sat side by side at the dining room table, the nurse was off the unit getting coffee from the kitchen, which left one CNA as the only staff on the unit. The CNA sat with his/her back to the two residents. At 6:14 PM, the nurse returned to the unit with coffee. During an interview on 11/7/16 2:18 PM, social service staff W stated resident #2 thought he/she was married to resident #3 and wanted to sit by him/her and held his/her hand. There was one incident where resident #2 was in resident #3's room and his/her shirt was off. Resident #3's family showed up and were not happy. Staff was doing a better job of keeping an eye on him/her now. This was the only incident staff W was aware of with him/her. Resident #2 kissed resident #3 in the past and it upset the family, and they just kind of came to terms with it. Resident #3 was severely cognitively impaired, and resident #2 had some cognitive impairment maybe not severely. During an interview on 11/7/16 at 3:15 PM, licensed nursing staff D stated /she had only worked on the unit for 3 days but had noticed increased confusion with the resident as he/she said that he/she and resident #3 were getting married. Staff D had not heard resident #3 talk. The two residents sit at the same dining room table together. Licensed nursing staff D stated there was nothing in particular that staff watch for or monitor with these two residents. During an interview on 11/7/16 at 3:38 PM, direct care staff R stated that resident #2 ambulated independently, and did not have any behaviors that he/she was aware of. Direct care staff R continued that there wasn't anything specific that staff watched for with him/her. Resident #2 liked resident #3, and staff had to watch him/her. Direct care staff R continued that staff checked on all residents every 30 minutes. During an interview on 11/7/16 at 5:11 PM, Administrative nursing staff B and C both stated that they were not aware of any incidents between the two residents, but they would look into it. Administrative nursing staff C continued that he/she did not know of any incidents, but knows the two residents do like to sit together at meals. During an interview on 11/7/16 at 5:16 PM, administrative nursing staff A stated he/she did not know of any concerns regarding these two residents. During an interview on 11/7/16 at 5:55 PM, administrative nursing staff B reported that after looking, there were no investigations or incidents related to the two residents. Upon surveyor Y's request on 11/7/16 at 6:08 PM for an immediate plan to keep the residents safe until the full investigation could be completed, administrative nursing staff A stated he/she would place resident #2 on 1:1's (the resident would be continuously observed by a staff member assigned specifically to them) until the investigation was complete. During an interview on 11/8/16 at 5:28 AM, licensed nursing staff F stated he/she had observed resident #2 touch resident #3's hands and had observed resident #2 kiss resident #3 on the forehead. Licensed nursing staff F continued that sometimes at night he/she had seen resident #2 try to sneak into resident #3's room and he/she redirected him/her. At times, resident #2 thought resident #3 was his/her spouse. Licensed nursing staff F stated resident #3 was not able to carry on a conversation. Licensed nursing staff F stated that staff knew what care the residents need by reviewing the care plans. Licensed nursing staff F confirmed that resident #2's care plan does not address the interaction with resident #3. During an interview on 11/8/16 at 5:34 AM, direct care staff R stated that resident #2 thought resident #3 was his/her spouse and tried to go into his/her room. On 11/10/16 at 4:05 PM, social service staff W stated residents #2 and #3 were not able to make decisions on their own and had short and long term memory loss. Resident #3 was not able to verbally communicate. Resident #3's family member brought the concern to staff. A nurse told staff W about it. Administrative nursing staff B talked to resident #3's family today who does not want them separated. The resident's family member did voice the concern in October. During an interview on 11/10/16 at 5:00 PM, administrative nursing staff B stated he/she spoke to resident #3's family member yesterday, then the family member came in today and we finished that conversation. The resident's family member told staff W that the documentation that administrative nursing staff B observed was incorrect. The resident's family member stated another family member never walked in and saw anyone with their top off, and that it did not happen. Social service staff W stated he/she was told to document it by the nurse. The only thing that resident #3's family member asked was that if staff find resident #2 in resident #3's room to separate them. Administrative nursing staff B continued that resident #2 had been very sad because he/she felt that he/she was being punished and does not understand what was going on. The psychologist saw both residents today, and said that resident #2 was alert and oriented but was delusional. Administrative staff B stated that he/she does not trust the documentation that was there regarding the incident. After surveyor Y notified the facility of the concern regarding residents #2 and #3, staff documented the following nurses notes: 11/10/16 at 1:30 PM, the resident asked this nurse why he/she was being punished and this nurse assured the resident that he/she was not being punished and that this was only temporary. The resident did not understand why he/she could not be around the opposite gender resident that he/she had formed a bond with. The nurse re-assured the resident. 11/10/16 at 3:00 PM the resident was seen by the psychologist, and received orders to increase [MEDICATION NAME] (antipsychotic). 11/14/16 at 11:30 AM, the resident spoke with the nurse and questioned why he/she was being punished and also wanted to know what he/she did wrong. The nurse assured the resident that everything was going to be ok. The resident just sits on the couch or sleeps and has little interaction with any other residents now. Staff documented they would continue to observe the resident. The medical record lacked any additional social service visits or psychosocial interventions for this resident following the above changes. The facility provided policy entitled Behavior Monitoring dated 12/12/14 recorded residents who exhibited behaviors would have a Behavior Symptom Monitoring Flow Record completed. Documentation of behavior and interventions for those behaviors including non-pharmacological interventions would be completed with each behavior. Residents with active behaviors that place the resident at risk to interfere with care, or compromise the quality of care or quality of life would be reviewed by the interdisciplinary team on a regularly scheduled time. The interdisciplinary team would review behaviors, causative factors/triggers and/or root cause to determine individualized interventions to minimize or eliminate the targeted behaviors, and residents' plan of care would be updated. The facility provided policy entitled Behavior/Incident/Accident Analysis dated 11/30/14 recorded behaviors, incidents, and accidents occurring on the Alzheimer's unit should be analyzed at the time of the occurrence in order to initiate prevention and management strategies and to prevent reoccurrence. The facility failed to meet the psychosocial needs of this resident who experienced delusions, separation from another resident, and displayed a change in activity and interaction.