Every finding on record at Cambridge Place

Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received her pain medication as ordered to help alleviate her pain. This deficient practice placed R1 at risk of pain and emotional distress from being in pain. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of acute fracture of the lumbar fifth vertebrae (broken lower back bone), dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS), dated 03/11/26, documented R1's Brief Interview for Mental Status (BIMS) interview of zero, which indicated severely impaired cognition. The MDS documented R1 received scheduled and as-needed pain medication for pain. The MDS documented R1 received opioid (a class of controlled drugs used to treat pain) pain medication daily during the lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/11/26, documented R1's cognition would be addressed in R1's care plan, instructed staff to communicate with R1 using short, simple sentences to allow R1 adequate time to understand and communicate her needs. R1's Care Plan, dated 02/20/26, directed staff to assess R1 for pain each shift and treat reported pain in a timely manner. The care plan directed staff to assess R1 for pain, restlessness, agitation, constipation, and other symptoms of discomfort, medicate as ordered and evaluate for effectiveness. R1's EMR documented an order from her primary care physician on 02/03/26 to apply a Lidocaine 5% patch to R1's lower back in the morning for back pain. R1's EMR documented an order received from her primary care physician on 02/06/26 to apply a fentanyl transdermal patch 25 micrograms (mcg) every 72 hours for moderate to severe pain. The February Order Summary Report, signed by R1's primary care physician on 02/25/26, documented R1 received a Lidocaine 5% pain patch and a fentanyl transdermal 25 mcg pain patch. The March Medication Administration Record (MAR) documented R1 had not received her Lidocaine 5% patch from 03/14/26 through 03/25/26 due to not being available. The March MAR, documented R1 had received a 25 mcg fentanyl transdermal patch on 03/23/26. On 03/25/26, R1's primary care physician discontinued the 25 mcg fentanyl transdermal patch and replaced it with a 12 mcg fentanyl transdermal patch. The previous 25 mcg fentanyl transdermal patch was not removed from R1's left shoulder, and a new 12 mcg fentanyl transdermal patch was not applied until 03/28/26. The March MAR, documented R1 had to be given a 5 milligram (mg) dose of oxycodone for pain rated at a five on 03/27/26. R1's clinical record lacked evidence staff notified R1's physician that the pain medications were not given to R1. On 04/13/26 at 12:30 PM, observation revealed R1 sat in her wheelchair at the assisted living lunch table with her husband. R1 could not carry on a conversation. R1 stared blankly when asked a question. On 03/04/24 at 12:15 PM, Licensed Nurse (LN) G stated she had known the old fentanyl patch was still on R1's left shoulder 03/27/26, but since they did not have the replacement patch, she chose to leave the old patch on. LN G stated she had not called to check on why the new fentanyl patch was not available. LN G stated she did not know anything about R1 not receiving the Lidocaine patch because the Certified Medication Aides (CMAs) administered them. On 03/04/24 at 01:00 PM, Administrative Nurse D acknowledged that R1 had not received her pain medications as ordered. Administrative Nurse stated there was a lack of communication on the new order for fentanyl between the primary care physician, the facility, and the pharmacy, and new processes were being put in place to ensure orders were not missed. Administrative Nurse D stated the Lidocaine patch had been missed for twelve days; the CMAs had not communicated with the charge nurse or pharmacy about not having the medication, but just charted the medication as unavailable. Administrative Nurse D stated all the nurses and CMAs had received education regarding ensuring medication orders were followed. The undated Pain Management Policy documented the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient staffing. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and delayed care.Findings Included:- A review of the facility's Payroll-Based Journal (PBJ - Staffing Data Report) from 04/01/22 through 03/31/25 indicated the facility triggered for Excessively Low-Weekend Staffing for Fiscal Year (FY) 2024 Quarter Four (07/01/24 - 09/30/24), FY 2025 Quarter One (10/01/24 - 12/31/24), and FY 2025 Quarter Two (01/01/25 - 03/31/25). On 08/25/25 at 10:21 AM, Certified Medication Aide (CMA) R stated that staff often would be busy completing care for the residents, and group activities may not always be completed on Saturdays and Sundays. CMA R stated the secured unit sometimes only had one or two staff members and often had difficulties providing supervision while performing care. (See citation F689)On 08/26/25 at 11:00 AM, the facility's Resident Council reported that the facility lacked consistent activities on the weekend due to the lack of staff present. The council reported that the activity director only worked weekdays. The council reported that direct care staff were already struggling to complete resident care, but would not have enough staff to cover weekend activity groups. The council reported long call-light wait times and delayed care on weekends due to low staffing, which were normal occurrences. On 08/25/25 at 11:24 AM, Activity Staff ZZ stated she only worked the weekdays, and direct care staff were expected to assist with scheduled activities on weekends. She also stated that the residents could complete self-guided activities from the activities cart if they chose to. On 08/25/25 at 12:30 PM, Administrative Nurse D stated she didn't feel the facility had issues with low weekend staffing. She stated the reports would often account for changes in both facility locations, and the reported times might be an error. The facility's Staffing, Sufficient and Competent Nursing policy, revised 04/2025, indicated the facility was to provide sufficient and competent staff to ensure the completion of care and services for all residents in accordance with resident care plans and the facility assessment.

The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.Findings included:- On 08/24/25 at 09:21 AM, observation in the kitchen revealed a three-door refrigerator had the following:An unlabeled, undated 1/2 full 10-pound (lb.) package of pepperoni.An unlabeled, undated plastic bag with five hard-boiled eggs.An unlabeled, undated pan with 17 square chocolate chip cookies.An unlabeled, undated plastic bag of sliced ham.An unlabeled, undated plastic bag of square yellow cheese.An unlabeled, undated plastic bag with sliced onions.An unlabeled, undated plastic bag with shredded yellow cheese.An unlabeled, undated bowl of turkey salad.An unlabeled, undated bowl of apple cobbler cake.An unlabeled, undated bowl of lime Jello with apples.An unlabeled, undated plastic bag of chicken strips.An unlabeled, undated plastic bag of creamed corn.A chest-type freezer had an untied blue plastic bag with diced chicken and an unlabeled, undated plastic bag of whole kernel corn. The freezer had approximately 3/4 inch of ice buildup all around the inside of the freezer.A two-door refrigerator had an unlabeled, undated plastic bag with six saltine crackers that had peanut butter in the middle.On 08/24/25 at 09:30 AM, Dietary Staff (DS) DD verified the above findings and stated staff had talked to the night cook about not labeling and dating food items. DS DD discarded the above items in the trash.On 08/25/25 at 11:00 AM, observation in the kitchen revealed the following:The wallpaper border, which ran behind the back of the oven and the three-sink area, had numerous places with peeling paper.A chest-type deep freeze that had approximately three-quarters-inch-thick ice buildup on the inside.A missing piece of linoleum, approximately two feet (ft) wide by two ft long by 3/4 inch (in) deep, located underneath the dishwasher where the clean dishes came out.A missing piece of linoleum, approximately one ft wide by one ft long by 3/4 in deep, located in the walking area when entering the dishwashing areaA wall had approximately four feet long by six inches wide, located by a two-door refrigerator, with numerous different-sized areas with bubbling, peeling paint.A missing piece of linoleum, approximately four feet long by 18 inches wide, located in front of the three-sink area.An undated flour and sugar bin with numerous, different-sized blackish-gray specks around the outside of it.On 08/25/25 at 11:45 AM, DS BB verified the above findings and stated she was going to defrost the chest-type freezer this week. DS BB stated staff should label and date food items before placing them in the refrigerator or freezer. DS BB stated the facility had talked about replacing the linoleum. DS BB stated the wallpaper border had been peeling for a while, and the peeling paint by the two-door refrigerator was caused by a water leak.The Kitchen Cleaning Schedule had tasks listed for staff to complete daily, weekly, and monthly. The facility's Cleaning and Sanitation of Dining and Food Service Areas Policy, revised 05/01/17, documented the director of food and nutrition services would determine all cleaning and sanitation tasks needed for the department.

The facility had a census of 72 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff used Styrofoam plates and bowls instead of regular dinnerware for meal service. This placed the residents of the facility at risk for impaired dignity.Findings included:- On 08/24/25 at 12:30 PM, observation during the lunch meal service revealed that staff provided Styrofoam plates for meatloaf, mashed potatoes, and carrots, and used Styrofoam bowls for the strawberry cake. On 08/25/25 at 08:45 AM, observation during the breakfast meal service revealed that staff provided Styrofoam plates for scrambled eggs, toast, and either sausage or bacon, and provided Styrofoam bowls for cereal.On 08/24/25 at 12:55 PM, Dietary Staff (DS) BB stated that the facility used the Styrofoam plates and bowls because the kitchen was short-staffed and did not have enough help to clean the dishes.On 08/26/25 at 10:30 AM, Administrative Nurse D verified that staff should not have used Styrofoam plates and bowls for daily meal service. Administrative Nurse D stated she verified with dietary staff that the reason they use them for the two meals was due to a lack of staff.The facility's Dining Room Standards policy, dated 2020, documented staff would ensure that an attractive, cheerful dining room was maintained with comfortable sound, lighting, furnishings, temperature, and adequate space. The policy documented that single-use disposable dining ware was not permitted except for emergencies.

The facility identified a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation.Findings Included:- A review of the facility's Activity Calendars for June 2025, July 2025, and August 2025 was completed. A review of the calendars indicated the residents only had access to an activity cart on Saturdays for self-led activities. The calendars noted that the residents were only provided a televised church service on Sundays. No other activities were listed for weekends for the residents.On 08/26/25 at 11:00 AM, the facility's Resident Council reported that the facility lacked consistent activities on the weekend due to the lack of staff present. The council reported that the activity director only worked weekdays. The council reported that direct care staff were already struggling to complete care and did not have enough staff to cover weekend activity groups. The council reported long call-light wait times and delayed care on weekends. On 08/25/25 at 10:21 AM, Certified Medication Aide (CMA) R stated that staff often would be busy completing care for the resident, and group activities may not always be completed on Saturdays and Sundays.On 08/25/25 at 11:24 AM, Activity Staff ZZ stated she only worked the weekdays, and direct care staff were expected to provide the scheduled activities on weekends. She also stated the residents could complete self-guided activities from the activities cart if they chose to. On 08/25/25 at 02:05 PM, Activities Staff ZZ provided a movie and popcorn group to the resident in the main dining room area. The facility's Activities policy (undated) indicated the facility would provide activities that meet the residents' needs and interests to support their physical, mental, and psychosocial well-being.

The facility identified a census of 77 residents. The sample included 18 residents, with 13 reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of nine cognitively impaired, independently mobile residents. The facility additionally failed to provide adequate supervision and ensure Resident (R) 44's fall prevention interventions were followed, resulting in multiple non-injury falls. This placed the affected residents at risk for preventable accidents.Findings Included: - On 08/24/25 at 09:00 AM, an initial walkthrough of the facility was completed. An inspection of the main nurse's station area revealed a storage closet propped open by a cloth sling rope. An inspection of the storage closet revealed ten containers of purple disinfectant wipes on a shelf in the room. The containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.An inspection of the kitchenette across from the main dining hall revealed a purple disinfectant wipe container in an unlocked cabinet above the sink. The container contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.On 08/24/25 at 09:00 AM, Certified Medication Aide (CMA) R stated that cleaning chemicals were to be stored in a locked closet or drawer. On 08/26/25 at 11:30 AM, Administrative Nurse D stated that staff were expected to ensure chemical products were locked up after use. The facility's Chemical Storage policy, revised 01/2020, indicated the facility would ensure an environment free from potentially hazardous materials, chemicals, and equipment.- R44's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, unsteadiness on feet, and a history of falls. R44's Significant Change Minimum Data Set (MDS) completed 08/04/25 revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted she required assistance from staff for toileting, bathing, personal hygiene, dressing, and transfers. The MDS noted she required partial to moderate assistance from staff while walking. The MDS noted she was at risk for falls and had a history of falls since the last assessment.R44's Falls Care Area Assessment (CAA) completed 08/18/25 indicated she was at risk for a decline in her activities of daily living (ADL) related to her decreased mobility, fatigue, and cognitive impairment. The CAA noted she had a history of falls. The CAA noted that a care plan was implemented to minimize the risks related to her fall history.R44's Care Plan initiated 10/17/20 indicated she was at risk of falls and altered ADLs related to her medical diagnoses. The plan noted she required non-skid footwear (10/17/20). The plan instructed staff to ensure her call light remained within reach (10/17/20). The plan instructed staff to provide appropriate lighting and ensure her room was free from clutter (10/17/20). The plan noted she was dependent on staff assistance for walking, toileting, transfers, bed mobility, personal hygiene, dressing, and bathing (11/15/23). The plan noted she had an unwitnessed fall and instructed staff to place a brightly colored bow on her front wheeled walker (01/30/24). The plan noted R44 had a non-injury fall on the enclosed patio of the secured unit on 09/04/24. The plan noted R44 had a non-injury fall while not wearing the appropriate non-skid footwear on 10/16/24. The plan noted that staff were re-educated on 03/12/25 to use a gait belt after a fall occurred during staff assistance. The plan noted she had a fall on 03/09/25 while wearing regular non-skid black socks. The plan noted that staff were to sign off under R44's medication administration report on each shift to ensure she had non-skid footwear. The plan noted she had a non-injury fall on 03/21/25 while not wearing non-skid socks. The plan noted that a sign was placed above her bed to remind staff to provide her with the appropriate socks. The plan noted R44 had an unwitnessed non-injury fall in front of the nurse's station on 06/03/25. The plan noted that staff were re-educated that R44 required supervision and/or touch assistance while ambulating. R44's EMR under Progress Notes revealed a Communication with Providers note completed on 09/03/24. The note indicated staff were alerted by the secured unit's patio door alarm and found R44 outside on the patio floor of the enclosed patio. The note revealed R44 was assessed by nursing and brought back inside. On 08/26/25 at 07:41 AM, R44 slept in her bed. Her bed was in the lowest position with a fall mat on the floor next to her bed. R44's front-wheeled walker was positioned next to her recliner. R44's walker did not have a bright-colored ribbon tied to it. An inspection of her room revealed the non-skid sock signage was placed above her room's dresser behind a flowerpot. On 08/26/25 at 09:00 AM, Certified Medication Aide (CMA) R stated R44 used both her walker and wheelchair due to her decline in abilities and being placed on hospice care (end-of-life comfort care). She stated R44 was a fall risk due to her weakness and cognitive impairment. She stated staff were expected to ensure her fall interventions were followed and in place. CMA R stated the unit sometimes only had one or two staff members and often had difficulties providing supervision while performing care. On 08/26/25 at 12:24 PM, Administrative Nurse D stated all staff had access to review the care plan and ensure the interventions were in place. She stated new interventions would be discussed by the interdisciplinary team, and staff would be informed by the nurse. The facility's Accidents and Supervision policy (undated) indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility had a census of 44 residents. Based on observation, interview, and record review, the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk of receiving ineffective medication. Findings included:- On 08/18/25 at 08:20 AM, observation in the facility's East medication room revealed the following expired stock medications:One bottle of Docusate sodium (laxative medication) 500 micrograms (mcg), 100 tablets, with an expiration date of 11/27/24.One bottle of ASA (medication to reduce pain, fever, inflammation, and blood thinner) 325 milligrams (mg), 200 tablets, with an expiration date of 01/23/25. One bottle of Vitamin B12 (a vitamin the body uses to make and support healthy nerve cells) 500 mcg, 100 tablets, with an expiration date of 03/07/25. One bottle of Ibuprofen (anti-inflammatory medication) 200 mg, 100 tablets, with an expiration date of 06/05/25. On 08/18/25 at 08:25 AM, Licensed Nurse (LN) G verified that the expired drugs should have been disposed of. On 08/20/25 at 12:20 PM, Administrative Nurse D verified that the night shift should check the medication cart for expired medications. Each nurse administering the medications should check for expired medications and dispose of them if they have expired. The facility's Medication Storage in the Facility policy, dated 01/01/20, documented all medications in the premises would be stored in the medication carts or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitization, temperature, light, ventilation, moisture control, segregation, and security. The policy stated the medication rooms were routinely inspected by the facility designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications were destroyed in accordance with the facility's Destruction of Unused Drugs Policy.

The facility had a census of 77 residents. The sample included 18 residents, with five residents reviewed for immunizations, Resident (R) 3, R16, R34, R35, and R49, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination, or a physician documented contraindication for the pneumococcal vaccination, including the PVC20 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.Findings included:- Review of R3, R16, R34, R35, and R49 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine, including the PVC20.Review of R3's electronic health record revealed the resident was admitted to the facility on [DATE]. R3 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R16's electronic health record revealed the resident was admitted to the facility on [DATE]. R16 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R34's electronic health record revealed the resident was admitted to the facility on [DATE]. R34 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R35's electronic health record revealed the resident was admitted to the facility on [DATE]. R35 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission. Review of R49's electronic health record revealed the resident was admitted to the facility on [DATE]. R49 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.On 08/25/25 at 12:10 PM, Administrative Nurse D stated the resident's immunization status was assessed upon admission, and the website would be accessed through the Center for Medicaid and Medicare Services (CMS) to determine what immunizations the resident has received and when they received the vaccination. After they determine who would be eligible for the vaccinations, they would send an order over to the physician to be signed, and they would administer the vaccination at the facility. Administrative Nurse D verified the facility would provide the consent forms with the information regarding the vaccine to the resident and/or Durable Power of Attorney (DPOA) to sign. Administrative Nurse D verified that the director of Nursing was on medical leave and did not have a system in place to identify who needed what pneumonia vaccine. The facility's Pneumococcal Vaccine policy dated 01/31/22 documented the facility would offer the residents immunization against pneumococcal diseases in accordance with current CDC guidelines and recommendations. Each resident would be assessed for pneumococcal immunizations upon admission, and each resident would be offered a pneumococcal immunization unless medical contraindicated or the resident has already been immunized. Following assessment for any medically contraindicated conditions, the immunization may be administered in accordance with physician approval standing orders. The resident receiving the immunization, or the resident representative, would be provided with a copy of the CDC's current vaccine information statement relative to the vaccine. The resident and/or representative retains the right to refuse the immunization, and a consent form shall be signed prior to the administration of the vaccine and filed in the resident's medical record. The type of pneumococcal vaccine (PVC15, PVC20, or PPSV23/PPSV) offered would depend on the residents' age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations.

The Facility had a census of 77 residents. The sample included 18 residents, with one reviewed for the environment. Based on observation and interview, the facility failed to provide accommodation of needs for one sampled resident, Resident (R) 66, who had a call light on her wall that was unreachable from her bed. This deficient practice placed R66 at risk for preventable accidents and injuries.Findings included:- On 08/24/25 at 10:30 AM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall. The call light was unreachable by R66 when she was in bed.On 08/24/25 at 03:00 PM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall and was unreachable to R66 when she was in bed. On 08/25/25 at 03:08 PM, Certified Nurse's Aide (CNA) MM stated the resident liked to propel herself up and down the halls in her wheelchair and sit in the hall and dining room area. On 08/24/25 at 02:00 PM, Licensed Nurse (LN) I stated the resident was mobile in her wheelchair and had recently had a total knee replacement and was getting therapy, but could not safely ambulate independently. LN I stated every resident should have an accessible call light.On 08/24/25 at 03:15 PM, Administrative Nurse E stated R66 had moved from a room down the hall about one month ago. Administrative Nurse E had not known R66 did not have a call light bedside her bed. Administrative Nurse E verified that the resident should have a permanent call light to access from their bed, and R66 did not have access to one. On 08/26/25 at 10:30 AM, Administrative Nurse D verified that a resident's call light should be accessible to the resident in bed and should not be across the room from the bed.The facility's Call lights: Accessibility and Timely Response policy, dated 09/09/20, documented the facility would ensure it was adequately equipped with a call light at each resident's bedside and bathing area to allow residents to call for assistance, and the call lights would directly relay to a staff member or centralized location to ensure appropriate response. Staff would be educated on the proper use of the resident call light system, including how the system works, and ensure residents' access to the call light. The policy documented with each staff interaction in the resident's room or bathroom, the staff would ensure the call light was within reach of the resident and secured.

The facility had a census of 77 residents. Based on record review and interview, the facility failed to provide Resident (R) 9, R11, and R12, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055. This placed the resident at risk of uninformed decisions about their skilled services. Findings included:- The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services, the cost listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) I want to receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. This placed the residents at risk of uninformed decisions about their skilled services.Review of R9, R11, and R12's Part A Medicare discharge papers revealed the facility had not provided the residents with the Medicare ABN form 10055, disclosing the cost of continuing skilled services. On 08/26/25 at 12:15 PM, Administrative Staff A verified that the facility lacked documentation that the ABN form 10055 was provided to the discharged residents. The facility's Advanced Beneficiary Notices policy, dated 11/01/19, stated the facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides an item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary, or custodial care. The facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS- I 0055. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within two days of the last anticipated

The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one sampled resident, Resident (R) 47, which included interventions for antihypertensive (a class of medication used to treat high blood pressure) medications. This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.Findings included:- The Electronic Medical Record (EMR) for R47 had diagnoses of pulmonary hypertension (high blood pressure in the arteries of the lungs), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS) dated [DATE], documented R47 had moderately impaired cognition. R47 required partial assistance with oral hygiene, toileting hygiene, upper body dressing, personal hygiene, mobility, transfers, and ambulation. The MDS documented R47 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication used to promote the formation and excretion of urine) medications daily.R47's Care Plan dated 06/24/25, initiated on 03/10/23, documented R47 received medications that had black box warnings (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The care plan further directed staff to administer medications as ordered, refer to the eMAR (electronic medication administration record), as medications that have a BBW were designated by a black box that would show the full warning. The care plan lacked further direction to staff regarding interventions related to antihypertension medications. The care plan further failed to provide direction to staff for R47's Metoprolol (an antihypertensive) medication.The Physician's Order, dated 12/06/24, directed staff to administer Metoprolol ER (extended release), 25 milligrams (mg), by mouth, in the morning, for atrial fibrillation and hypertension. Hold the medication if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 millimeters of mercury (mmHg), or the heart rate (the number of times your heart beats in a minute) was less than 60 bpm (beats per minute).R47's Medication Administration Record (MAR) for July 2025 documented the following days R47 received the metoprolol when the heart rate was under the ordered parameters:07/18/25 - 58 bpm07/28/25 - 57 bpm07/31/25 - 57 bpmR47's MAR for August 2025 documented the following days R47 received the metoprolol when the heart rate was under the ordered parameters:08/05/25 - 59 bpm08/07/25 - 58 bpm08/08/25 - 58 bpm08/20/25 - 59 bpmOn 08/25/25 at 08:00 AM, R47 sat in her wheelchair in the dining room waiting for breakfast. On 08/26/25 at 09:10 AM, Certified Medication Aide (CMA) R stated R47 had two different hypertension medications, and each had different physician parameters. CMA R further stated that she did not usually worry about the heart rate; she focused on whether her blood pressure was out of parameters.On 08/26/25 at 09:18 AM, Licensed Nurse (LN) G stated that staff were to follow the physician's orders and hold the medication if the vital signs are out of the parameters. LN G further stated that the care plan should reflect that the hypertension medication R47 was prescribed could have side effects, and what staff should monitor for. LN G stated she would look at the care plan and update it with interventions for the hypertension medication. LN G stated she would provide education to the staff regarding the physician-ordered parameters.On 08/26/25 at 09:30 AM, Administrative Nurse F stated the medication should follow physician orders and notify the nurse if her heart rate was out of the physician-ordered parameters. Administrative Nurse F further stated that the care plan should reflect that the hypertension medication R47 was prescribed could have side effects, and what staff should monitor for.The facility's Comprehensive Care Plan Revisions Upon Status Change policy, dated 01/02/20, documented the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change. The care plan would be updated with the new or modified interventions and modified as needed by the MDS Coordinator or other designated staff members. The Unit Manager or other designated staff member would communicate care plan interventions to all staff involved in the resident's care.

The facility had a census of 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to consistently monitor Resident (R) 70's physician-ordered fluid restriction. This placed the resident at risk of complications related to fluid overload.Findings included:- The Electronic Medical Record (EMR) for R70 documented diagnoses of chronic kidney disease, stage 4 (a progressive, long term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), peripheral autonomic neuropathy (a disorder of the peripheral nerves that control automatic bodily functions), edema (swelling, resulting from an excessive accumulation of fluid in the body tissues), and hypo osmolality (when there is an abnormally low concentration of solutes in the blood, often caused by too much water in the body).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R70 had intact cognition. R70 required partial staff assistance with toileting hygiene, personal hygiene, mobility, transfers, and required set-up assistance with eating. The MDS further documented R70 had no functional impairment and was occasionally incontinent of bladder. The MDS documented R70 received diuretic (a medication to promote the formation and excretion of urine) medication daily.The Annual MDS, dated 07/29/25, documented R70 had severely impaired cognition. R70 required partial staff assistance for toileting hygiene, personal hygiene, dressing, mobility, and transfers. R70 had no functional impairment, independent with eating, and received diuretic medication daily.R70's Care Plan dated 08/13/25, initiated on 11/13/23, documented R70 was on a 1800 cc (cubic centimeters) per 24 hours fluid restriction and directed staff to follow physician orders. The care plan further directed staff to document fluid intake every shift and monitor for signs and symptoms of dehydration (when the body loses more fluids than it takes in, resulting in a lack of water and electrolytes), report abnormal findings to the physician, and monitor for weight gain or loss. The update, dated 08/14/24, documented R70 would refuse the fluid restriction at times and was aware of the impact it could have on R70's health.The Physician's Order, dated 04/16/25, directed a fluid restriction of 1800 cc per day and directed staff to provide 360 milliliters (ml) of fluids at breakfast, 240 ml of fluids at lunch and supper, and 320 ml of free fluids per shift. Nursing would provide 960 ml (320 ml per shift). The order further directed staff to administer free fluids of 320 ml at night, and for the nurses to include it in their documentation. This order was discontinued on 08/05/25The Physician's Order, dated 08/05/25, directed a fluid restriction of 1800 cc per day and directed staff to provide 360 milliliters (ml) of fluids at breakfast, 240 ml of fluids at lunch and supper, and 320 ml of free fluids per shift. Nursing would provide 960 ml (320 ml per shift). The order further directed staff to administer free fluids of 320 ml at night, and for the nurses to include it in their documentation. The staff were directed to notify the physician of non-compliance with the restriction and update the care plan.The Treatment Administration Record (TAR) for June 2025 lacked documentation of staff-monitored R4's fluid restriction on the following days:06/07/25 - day shift06/07/25 - evening shift06/12/25 - evening shift06/14/25 - evening shift06/20/25 - evening shift06/25/25 - evening shift06/26/25 - evening shiftThe Treatment Administration Record (TAR) for July 2025 lacked documentation of staff-monitored R4's fluid restriction on the following days:07/06/25 - evening shift07/11/25 - day shift07/17/25 - day shift07/29/25 - day shiftThe Treatment Administration Record (TAR) for August 2025 lacked documentation of staff-monitored R4's fluid restriction on the following days:08/07/25 - day shift08/09/25 - evening shift08/13/25 - evening shiftOn 08/25/25 at 11:45 AM, R70 had a pitcher with 450 ml of water on her bedside table. At 02:45 PM, the water pitcher had 300 ml of water in it.On 08/26/25 at 10:40 AM, Certified Nurse Aide (CNA) N stated she was unsure of the amount of fluid R70 was supposed to get on her shift, so she asked the kitchen before she provided R70 with any fluids at meals.On 08/26/25 at 09:18 AM, Licensed Nurse (LN) G stated that nursing staff worked with the kitchen on the fluid intake, and staff were to document per shift what the total intake of fluids was for that timeframe.On 08/26/25 at 09:40 AM, Administrative Nurse F stated she expected staff to follow the physician's orders for the fluid restriction and make sure the shift intake was properly documented in the medical record.The facility's Fluid Restriction policy, dated 2022, documented the fluid restriction would be followed in accordance with the physician's orders. The nurse would obtain and verify the physician's orders for the fluid restriction. An order written would include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department. The intake would be recorded on the medication record or other format as per facility protocol. The fluid restriction distribution would take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. Water would not be provided at the bedside unless calculated into the daily total fluid restriction.

The facility had a census of 77 residents. The sample included 18 residents, with two reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 4, who received dialysis treatment. This placed the resident at risk for complications and health decline.Findings included:- R4's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (ESRD- a terminal disease of the kidneys), 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 hemiplegia (paralysis of one side of the body).R4's admission Minimum Data Set (MDS), dated [DATE], recorded R4 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment. The MDS recorded R4 required partial to moderate assistance for toilet hygiene, personal hygiene, and to shower/bathe self. The MDS further recorded R4 received dialysis treatment.R4's Dialysis Care Plan, dated 08/0/25, documented R4 received dialysis three times a week on Mondays, Wednesdays, and Fridays. The care plan documented a fluid restriction of two liters and to follow the physician's order, and staff would use enhanced barrier precautions for dialysis. The Physician Order, dated 07/25/25, documented R4 would receive dialysis treatment three times a week on Monday, Wednesday, and Friday. The Physician Order, dated 07/25/25, documented R4 received a renal diet, regular texture, regular consistency, and lacked an order for a fluid restriction. The Standing Order faxed to the physician, dated 07/25/25, documented the facility's standing orders and questioned the physician if he wanted the resident to be on a fluid restriction due to her dialysis status. The physician responded on 07/30/25, R4 should be on a 2000 milliliter (ml) fluid restriction, and the nurse noted the order. On 08/25/25 at 09:00 AM, observation revealed R4 sat in a wheelchair in the dining room. R4 had scrambled eggs, oatmeal, and one cup of water. Continued observation revealed R4 was dressed in street clothes and nicely groomed. On 08/25/25 at 10:30 AM, Administrative Nurse D verified R4 received dialysis three times a week on Monday, Wednesday, and Friday. Administrative Nurse D verified the resident was admitted to the facility on [DATE], and the physician did not have a fluid restriction. Administrative Nurse D verified a fax from the facility to the physician asking if the resident was to be on a fluid restriction, and the fax documented Yes, 2000 ml, signed on 07/30/25. The facility's Fluid Restriction policy, dated 2021, documented it was the policy of the facility to ensure that fluid restriction would be followed in accordance with the physician's orders. The fluid restriction may be due to an underlying medical condition that may cause fluid buildup, such as congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid) or end-stage renal disease, in addition to an electrolyte (minerals that help keep the body's fluid levels in balance, necessary to help the muscles, heart, and other organs work properly) imbalance disorder. Fluid restriction amounts could vary according to the resident's condition and the physician's judgment. The nurse would obtain the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutritional department and the nursing department, and would be recorded on the medical record or other format as per facility protocol.

The facility had a census of 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician's ordered parameters for one resident, Resident (R) 47. This placed R47 at risk of low blood pressure and pulse side effects, and at risk of receiving unnecessary medication.Findings included:- The Electronic Medical Record (EMR) for R47 had diagnoses of pulmonary hypertension (high blood pressure in the arteries of the lungs), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R47 had moderately impaired cognition. R47 required partial assistance with oral hygiene, toileting hygiene, upper body dressing, personal hygiene, mobility, transfers, and ambulation. The MDS documented R47 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication used to promote the formation and excretion of urine) medications daily.R47's Care Plan dated 06/24/25, initiated on 03/10/23, documented R47 received medications that had black box warnings (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The care plan further directed staff to administer medications as ordered, refer to the eMAR (electronic medication administration record), as medications that have a BBW were designated by a black box that would show the full warning. The care plan lacked further direction to staff regarding interventions related to antihypertension (a class of medication used to treat high blood pressure) medications. The care plan further failed to provide direction to staff for R47's Metoprolol (an antihypertensive) medication.The Physician's Order, dated 12/06/24, directed staff to administer Metoprolol ER (extended release), 25 milligrams (mg), by mouth, in the morning, for atrial fibrillation and hypertension. Hold the medication if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 millimeters of mercury (mmHg), or heart rate (the number of times your heart beats in a minute) was less than 60 bpm (beats per minute).R47's Medication Administration Record (MAR) for July 2025 documented the following days R47 received Metoprolol when the heart rate was under the ordered parameters:07/18/25 - 58 bpm07/28/25 - 57 bpm07/31/25 - 57 bpm R47's MAR for August 2025 documented the following days R47 received the Metoprolol when the heart rate was under the ordered parameters:08/05/25 - 59 bpm08/07/25 - 58 bpm08/08/25 - 58 bpm08/20/25 - 59 bpm On 08/25/25 at 08:00 AM, R47 sat in her wheelchair in the dining room waiting for breakfast. On 08/26/25 at 09:10 AM, Certified Medication Aide (CMA) R stated R47 had two different hypertension medications, and each had different physician parameters. CMA R further stated that she did not usually worry about the heart rate; she focused on whether R47's blood pressure was out of parameters. On 08/26/25 at 09:18 AM, Licensed Nurse (LN) G stated that staff are to follow the physician's orders and held the medication if the vital signs are out of the parameters. LN G further stated that the care plan should reflect that the hypertension medication R47 was prescribed could have side effects, and what staff should monitor for. LN G stated she would look at the care plan and update it with interventions for the hypertension medication. LN G stated she would provide education to the staff regarding the physician-ordered parameters. On 08/26/25 at 09:30 AM, Administrative Nurse F stated the medication should follow physician orders and notify the nurse if her heart rate was out of the physician-ordered parameters. Administrative Nurse F further stated that the care plan should reflect that the hypertension medication R47 was prescribed could have side effects, and what the staff should monitor for. The facility's Medication Administration policy, dated 08/19/20, documented medications were administered by licensed nurses or other staff who are designated to do so in this state. Medications were administered as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff were to obtain and record vital signs, when applicable or per physicians' orders, and hold medication for those vital signs outside of the physician's prescribed parameters.

The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 13. The facility staff failed to don (put on) gloves when emptying R13's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The facility staff also failed to wear gloves when picking up an uncovered urinary catheter bag from the floor. This deficient practice placed the residents at risk for possible exposure to infection.Findings included:- On 08/24/25 at 09:30 AM, observation revealed no EBP signage outside R13's door, but personal protective equipment (PPE) was on the inside of R13's room door. On 08/24/25 at 02:50 PM, observation revealed R13's room door opened partway; he stood by a recliner with his uncovered urinary catheter bag and tubing on the floor in front of a recliner. Certified Nurse Aide (CNA) P entered the room without donning gloves or a gown and assisted R13 with sitting in a recliner. CNA P left the room with the catheter bag and tubing still on the floor.On 08/24/25 at 03:38 PM, observation revealed R13 sat in a recliner in his room with the door open, and his urinary catheter bag and tubing were on the floor. Licensed Nurse (LN) J entered the room, with an ungloved hand, picked up the catheter bag, placed it on a walker beside the recliner, and left the room. LN J stated she should have placed gloves on before picking up R13's urinary catheter bag.On 08/25/25 at 01:45 PM, observation revealed R13 sat in a recliner in his room with the door open. CNA O entered the room, without a gown, applied gloves, and asked R13 if she could empty his urinary catheter bag, and he replied, Ok. CNA O retrieved a graduated cylinder from R13's bathroom, set it on the floor underneath the uncovered bag on a walker, unhooked the port from the bag, used an alcohol wipe on the port, opened the port, and drained yellow urine into the graduated cylinder. CNA O closed the port, used an alcohol wipe on the port, and placed it back into the holder on the urinary catheter bag. CNA O took the graduated cylinder into the bathroom, poured the urine into the toilet, set the graduated cylinder on top of the toilet, then removed and discarded the gloves and left R13's room.On 08/25/25 at 01:50 PM, when asked how staff could tell if a resident was on EBP, CNA O pointed to the green triangle in the upper corner of R13's entrance door frame and stated there was a green triangle in the corner of the entrance door. When asked if she should have placed a gown on before emptying R13's urinary catheter bag, she stated yes, but had forgotten.On 08/26/25 at 09:00 AM, Administrative Nurse F stated that staff are made aware of a resident being on EBP when they have a green triangle in the corner of the entrance door frame. EBP supplies are hung on the inside of the entrance door. Administrative Nurse F stated that staff could look at tasks on the computer, and the information is available in the care plan. Administrative Nurse F stated staff should keep a resident's urinary catheter bag and tubing off the floor, but if found uncovered on the floor, they should place gloves on to pick it up off the floor.The facility's Catheter Care Policy, revised 10/01/19, documented it was the policy of this facility to provide catheter care to all residents who have an indwelling catheter in an effort to reduce bladder and kidney infections.The facility's Enhanced Barrier Precautions policy, revised 06/11/25, documented it was the policy of this facility to implement EBP precautions for the prevention of transmission of multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics). Implementation of EBP would be performed with high-contact care activities. The policy documented high-contact resident care as follows: dressing, bathing, and transferring. Providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use with central lines (a long, thin tube inserted into a large vein in the neck, chest, or groin that reaches a major vein near the heart) urinary catheters, feeding tubes (tube for introducing high-calorie fluids into the stomach), tracheostomy(opening through the neck into the trachea through which an indwelling tube may be inserted), ventilator tube (a medical device that connects a person's windpipe to a ventilator machine, delivering air, oxygen, and medications directly into their lungs to help them breathe when they cannot do so effectively on their own), hemodialysis catheters (a procedure where impurities or wastes are removed from the blood), Peripherally Inserted Central Catheter (PICC) line (a long, thin tube inserted into a vein in the upper arm that is guided to a large central vein near the heart), midline (a long, thin, flexible tube inserted into a peripheral (outside, surface, or surrounding area of an organ, other structure, or field of vision) vein in the arm, typically for administering medications or fluids) catheters, and wound care: any skin opening requiring a dressing.

The facility had a census of 79 residents. The sample included two kitchens and 18 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 79 residents who resided in the facility and received their meals from the kitchen. Findings included: - On 12/06/23, review of the noon meal consisted of roast beef, buttered noodles, seasoned squash, dinner roll, and assorted deserts. On 12/06 /23 at 10:56 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/29/23 at 04:25 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had completed the course, failed the test and had to wait six months to repeat the class. On 12/6/23 at 12:30 PM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. On 12/07/23 at 12/05/23 at 8:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 12/07/23 at 09:10 AM, Dietary Staff BB verified she worked at the facility for [AGE] years and was not a certified Dietary Manager. Dietary Staff BB stated they do not have any pureed or mechanical soft diet. On 12/11/23 at 2:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The Facility's Director of Food and Nutrition Services dated 2021 documented the director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, cost management, and meeting nutritional need of the residents served. The director of food and nutrition services would be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that does not have a full-time dietician (registered dietician nutritionist or RDN) or clinically qualified nutritional professional must designate a person to serve as director of food and nutrition services. The director of food and nutrition services would be a certified dietary manager (CDM) or is a certified food service manager or has similar national certification for food service management and safety from an national certifying body or has an associate's or higher degree in food service management or in hospitality, if the course study includes food services or restraint management from an accredited intuition of higher learning and states that have established standards for food service managers or dietary managers, must meet state requirements for food service managers or dietary managers. The director of food and nutrition services would carry out his/her daily activities according to the job description, work schedule, and list of duties. The facility failed to employ a full time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 79 residents and two kitchens in the facility, placing the residents at risk for inadequate nutrition.

The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for all the residents who received their meals from the facility's two kitchens. This placed all residents at risk for food borne illness. Findings included: - On 12/05/23 at 08:27AM observation in the first of two kitchens revealed the following: The walk-in refrigerator had a cracked eggshell, an approximately one-half inch(in) by three in. wide piece of plastic wrap on the floor, and numerous different size pieces of paper underneath the bottom shelf. The white chest freezer had approximately one-quarter in. of ice around all the inside and had numerous different sized, dried brown, liquid stains on the bottom. The counter ice machine located at the entrance to the kitchen had numerous different size brown specks of food particle in and around the tray. On 12/06/23 at 10:22 AM, observation revealed in the kitchen the following: The wall behind the ovens located below the oven hood had, approximately six in by eight ft long, had numerous different size dried brown stains. Underneath the three-sink area a five-gallon bucket of concentrated pot and pan detergent had numerous different size food particles with brown dried substance. The pipes, approximately five feet long, located underneath the three-sink area had numerous different size blackish substance on them. The floor ice machine vents located in the dishwashing area had, approximately 12 in by 18 in, gray fuzzy substance throughout them. The four-square ceiling vents, approximately 18 inches in diameter, had gray fuzzy substance around them which flared out approximately 12 in in each corner. The outside of the two oven doors and bottom foot plates had numerous different size brown dried liquid substance and the handles, and the outside had white powdery substance. The two-shelf cart located by the oven had numerous different sized white powdery substance and white dried liquid. The walk-in refrigerator had a cracked egg with the top piece missing, which showed the yellow yoke and clear liquid placed in the pasteurized egg cartons with other eggs. The two fluorescent lights located above the prep table where the spices were had burnt out bulbs. The three fluorescent light frames, located next to the oven hood, had gray fuzzy particles all around them and the third one, located closest to the dishwashing area, had burnt out light bulbs. The counter toaster located next to stove top had numerous different size crumbs and gray greasy substance on the top and sides of it and the tray the toaster sat in had the same. The exchange air vent, approximately three feet (ft) by two ft, located by the dietary manager's office, had gray fuzzy particles throughout. The perimeter of the kitchen floor, approximately four inches wide and the mopboard had numerous different size blackish substance. The metal sharp knife container, fastened to the two-door white lower cabinet located on the wall across from the steam table, had numerous different size brownish black substance. The white bottom cabinet doors located on the wall across from the steam table, had numerous different size dried pink and brown liquid. Four (one gallon) plastic containers full of water, located underneath the steam table had grayish black substance all around the outside of each one. The wall underneath the dishwasher area approximately six ft long by three ft high had numerous different size blackish substance. The shelf and the legs which held up the dishwasher counter, where the dirty dishes were placed were rusted and the bottom shelf, had a hole in the middle approximately eight in long by four in. wide. The Daily Cleaning Duty Sheet, listed task for the morning and evening staff to complete daily. On 12/06/23 at 11:59 AM, Dietary Manager (DM) BB verified all the issues in the kitchen and stated the kitchen staff had a cleaning schedule, but it did not always get done. 27168 - On 12/05/23 at 09:00 AM, during initial tour, observation in the second of two facility kitchens revealed the following: One 16-inch oscillating table fan located on the cabinet top blowing air on the food preparation table. The metal fan mesh cover had gray fuzzy substance covering the metal and the three fan blades. Two 4-foot by 3 -foot ceiling mounted heater and air conditioning units, located on each side of the range hood and blowing air directly across the food preparation area. The air vent grills were rusted and covered with a brown greasy/sticky substance and gray fuzzy substance. On 12/06/23 at 12:30 PM, Dietary Staff (DS) CC verified the dirty fan, and the overhead heater/air units with dirty register/vents. The facility's General Sanitation of the Kitchen policy, dated 2021, documented the food and nutrition staff would maintain the sanitization of the kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitization tasks for the kitchen would be outlined in a written cleaning schedule and tasks would be assigned the responsibility of specific positions. The employee would train on how to perform the cleaning task and employees would initial and date tasks when completed. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 79 residents residing in the facility, who received meals from the facility kitchens.

The facility had a census of 79 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 1 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (5) dates. Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 12/06/23 at 08:30AM, observation revealed a registered nurse on duty in the facility. On 12/07/23 at 01:00PM, Administrative Staff (AS) A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Reporting Payroll Based Data Journal policy, dated 12/01/2019, states complete, and accurate direct care staffing information is to be reported electronically and, in the uniform, specified by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 79 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide infection control measures for residents' oxygen tubing when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections. Findings included: - Upon request, the facility was unable to provide evidence the facility assessed risks and implemented a surveillance plan to identify and prevent Legionella (prevent Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other opportunistic waterborne pathogens. On 12/05/23 at 08:45 AM, observation in R32's room revealed her uncovered oxygen tubing coiled up on the oxygen canister with the nasal canula touching the back of the tubing. On 12/05/23 at 10:48 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/06/23 at 07:37 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/07/23 at 07:38 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/07/23 at 12:55 PM, observation in R32's room revealed her uncovered oxygen tubing coiled up on the oxygen canister with the nasal canula touching the back of the tubing. On 12/07/23 at 01:01 PM, Administrative Nurse D verified the above finding at 12:55 PM and stated she was just in there and had not noticed it being uncovered. Administrative Nurse D stated staff should place R32's oxygen tubing and nasal canula in the bag on the front of the oxygen canister, with the breathing treatment mask. Administrative Nurse D started to place the oxygen tubing into the bag. When asked by the surveyor, Administrative Nurse D stated she probably should get a new one and placed the tubing into the trash can. On 12/11/23 at 10:00 AM, Administrative Nurse D stated nasal cannulas should be bagged when not in use. On 12/11/23 at 10:59 AM, Administrative Staff A stated the facility had nothing in place prior to now to prevent Legionella or other water borne illnesses in the water system. The Infection Prevention and Control policy, dated 08/15/22, stated a water management program had been established and control measures and testing protocols were in place to address potential hazards associated with the facility's water system. The maintenance Director would serve as the leader of the water management program. The policy stated the facility would conduct an annual review of the infection control program including policies and procedures. The facility's Oxygen Concentrator policy, dated 10/01/20, stated oxygen was administered under the orders of the physician. The policy stated staff would keep delivery devices covered in plastic bag when not in use. The facility failed to provide infection control measures for residents' oxygen nasal cannulas when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections.

The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the residents of one of two buildings who received their meals from that kitchen at risk for foodborne illness. Findings included: - On 12/05/23 at 8:27AM, observation in the kitchen revealed the walk-in freezer door had ice buildup on the frame of the door and would not stay closed. On 12/06/23 at 11:59 AM, Dietary Staff (DS) BB verified the walk-in freezer door had ice buildup on it for about six months, she had notified maintenance, but nothing got done. On 12/6/23 at 12:30PM, Administrative Staff A stated she was aware of the problem with the walk-in freezer door not closing due to ice buildup. The facility's Preventative Maintenance Program Policy, revised 10/25/19, documented the maintenance director was responsible for developing and maintain a schedule of maintenance services to ensure that the buildings, grounds, and equipment were maintained in a safe and operable manner. The facility failed to ensure and maintain one of two kitchens walk-in freezer was in safe operating condition, when the freezer door would build up with ice and would not completely shut. This placed the residents who received their meals from the facility kitchen at risk for foodborne illness.

The facility had a census of 83 residents. The sample included 6 residents, of which 3 were reviewed for neglect. Based on observation, interview, and record review the facility failed to implement timely interventions to alert staff to monitor for [MEDICAL CONDITION] for 1 of 3 sampled residents. Resident #1 had a [DIAGNOSES REDACTED]. Findings included: - Resident #1's (POS) Physician order [REDACTED]. The Medicare-14-day (MDS) Minimum Data Set assessment, dated 10/18/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderately impaired cognition, and a mood severity score of 6, indicating mild depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The MDS recorded the resident expressed feeling tired or having little energy, poor appetite or overeating 12-14 days, feeling bad about himself/herself and thoughts that he/she would be better off dead, never or 1 day, with no behaviors. The MDS recorded the resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene, and staff supervision with setup help only for eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had functional limitation in (ROM) Range of Motion on one side of lower extremities, and used a walker and wheelchair for mobility. The MDS recorded the resident had an indwelling urinary catheter, was occasionally incontinent of bowel, received scheduled pain medication, had no pain, and had one fall with injury. The MDS recorded the resident received insulin, antidepressant, and anticoagulant medications, (ST) Speech Therapy 175 minutes, 5 days, (OT) Occupational Therapy 147, 4 days, and (PT) Physical Therapy 196 minutes, 5 days. The 10/11/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the facility readmitted the resident following a hospital stay for the [DIAGNOSES REDACTED]. months or years), and weakness. The CAA recorded the resident required staff assistance in completing his/her ADL functions, and received skilled PT/OT services with goals to return to an independent level of function. The 11/23/18 care plan, recorded the resident had a [DIAGNOSES REDACTED]. The care plan directed staff to administer medications as ordered, monitor and document for side effects and effectiveness. The care plan recorded the resident received [MEDICATION NAME] and [MEDICATION NAME] (antidepressant medications) for depression, assist the resident in developing or provide the resident with a program of activities that was meaningful and of interest, and encourage and provide opportunities for exercise, and physical activity. The care plan recorded the resident needed time to talk, social worker visited as needed, and directed staff to encourage the resident to express his/her feelings, and visit with him/her in passing. The care plan further directed staff to discuss with the resident and family any concerns, fears, issues regarding health or other subjects (PRN) as needed, monitor, document, and report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, and impaired judgment or safety awareness. The 11/6/18 at 1:06 PM, (SSD) Social Services Director note, communication with physician, documented the resident felt very depressed since his/her recent illness. Today when completing his/her mood assessment he/she stated, I wish I could kill myself. I have nothing to live for. The note documented staff further discussed this and the resident stated he/she had no plan of action to harm himself/herself. The note documented the resident had no history of self-harm and no means to self-harm, he/she felt hopeless about his/her situation but still had the goal to get stronger and return home to his/her prior routine. The note documented he/she agreed that he/she would inform staff and his/her family member immediately if having thoughts of harming self, he/she also agreed to meet with a mental health provider through Meditelehealth (services including office visits and consultations that are provided using an interactive 2-way telecommunications system (with real-time audio and video) by a doctor or certain other health care provider who is not at your location), and was encouraged to attend activities for socialization. The note recorded staff continued to check on the resident daily and would update the physician if the resident's mood worsened. The note documented the resident received medications [MEDICATION NAME] delayed release 30 (mg) milligrams, every morning and [MEDICATION NAME] 100 mg every morning for depression. The note documented staff requested the following recommendations faxed to the physician: 1) orders for Meditelecare to evaluate and treat for psychiatric and psychological health, and 2) questioned any medication changes. The 11/6/18 at 3:24 PM, nurse's note documented the physician's response to the fax staff sent was, ok for Meditelecare. The note documented staff notified the resident's family member, and a copy of the order was left for the (LSW) Licensed Social Worker. A message was left for the LSW as the resident's family member wanted to know when the session was as he/she wanted to come to see it. The 11/13/18 Physical Therapy note recorded the resident demonstrated improved mobility distance before he/she became fatigued and/or short of air. The note recorded the resident seemed less depressed, but 50 minutes of PT was very fatiguing for him/her today. The 11/14/18 Occupational Therapy note recorded the resident continued to struggle with strength, activity tolerance, and ADLs, it was becoming more likely the resident may not be a candidate to return home if he/she did not show improvements in these areas soon. The 11/20/18 Physical Therapy note recorded the resident demonstrated improved distance and safety in walking short distances so will let him/her be independent in his/her room. The note recorded the resident still fatigued fairly quickly and did not have a lot of desire to make his/her goal of returning home. The 11/26/18 Mental Health note documented the resident reported to staff he/she wished he/she was dead, and said the same thing to the therapist during the session this afternoon, but said his/her mood was ok, although he/she had nothing to look forward to and his/her legs were weak. The resident stated he/she would not hurt himself/herself, but he/she would rather be dead, and indicated he/she wanted to get out of the nursing home. The 11/28/18 4:47 AM nurse's note documented at approximately 3:25 AM, staff was called to room [ROOM NUMBER] (ASAP) as soon as possible, upon arriving to the room, the resident was observed hanging from his/her bathroom door with a white rope tied around the inside and outside handle of the bathroom door, as well as around his/her neck. The note documented there was no slack in the rope, the resident had no pulse, and his/her skin was cold to touch. The note documented the nurse ran back up to nurse's station to retrieve a pair of scissors, which were given to the (CNA) Certified Nurse Aide to cut the resident loose, while the nurse called 911 (at 3:27 AM) On 11/28/18 at 9:08 AM, Nurse G stated he/she last observed the resident around 10:00 PM. Nurse G stated the resident was just upgraded to be independent in his/her room on 11/27/18, and he/she reminded the resident to call for help if he/she needed anything even though he/she was independent, it was better to be safe than sorry. Nurse G stated staff last observed the resident around 1:00 AM, he/she was in bed, one of the aides saw the resident with his/her eyes open, then one saw him/her with his/her eyes closed, they assumed the resident was sleeping. Nurse G stated today, at approximately 3:25 AM, CNA staff called him/her on the pager to the resident's room, and upon entering found the resident was cold to the touch, and had no pulse. Nurse G stated he/she ran up to the nurse's station to get a pair of scissors and gave them to Nurse Aide M, and Nurse Aide N cut the resident loose while Nurse G called 911 and looked up the resident's code status. Nurse G stated when he/she walked into the resident's room, the resident was hanging with a white rope around his/her neck from the bathroom door, the rope was wrapped around the outside of the door handle and then around to the inside of the door handle so it wouldn't slip off. Nurse G stated the resident was, for the most part, lying on the floor but his/her mid back and head were up against the door frame, and there was blood coming out of his/her nose and mouth. Nurse G stated you could tell the idea of hanging was a well thought out plan, not a spur of the moment idea. On 11/28/18 at 2:16 PM, Administrative Staff A stated after the resident made the comments about wanting to kill himself/herself on 11/6/18, staff faxed the doctor to see if he/she wanted to make a medication change and to see about having the resident seen by Meditelecare. Administrative Staff A stated the doctor was agreeable to Meditelecare, made no medication changes, and told staff to monitor the resident's mood. Administrative Staff stated he/she talked to both the resident and his/her family member. The resident's family member stated he/she was aware of the resident's mood, and stated the resident had been feeling depressed for a long time, after he/she moved to town, over a year ago. Administrative Nurse A stated he/she decided to continue to monitor the resident, Meditelecare was faxed for the referral and an appointment was scheduled for 11/26/18. Administrative Nurse A stated prior to 11/6/18 the resident had not made any comments about killing himself/herself, but there are notes in his/her 9/26/18 history and physical about him/her being depressed. Administrative Staff A stated staff monitored the resident by having the CNAs visit with him/her daily to see how he/she was feeling, but had not initiated the behavior monitoring to watch the resident for any signs or symptoms of hurting himself/herself until 11/23/18. Administrative Staff A stated he/she did not start the behavior monitoring, but stated it should have been started after the resident's first comment on 11/6/18. On 11/28/18 at 3:34 PM, Medication Aide O stated he/she was not aware of the comment the resident made on 11/6/18 that he/she wanted to kill himself/herself. Medication Aide O further stated he/she was not aware that the CNAs were supposed to monitor the resident, that the resident's physician told staff to monitor him/her, or that behavior monitoring was started on 11/23/18. On 11/28/18 at 3:44 PM, Nurse Aide P stated staff monitored the resident's behavior, the same way they did for all the residents, watching for yelling, crying, etc. but not for suicidal behaviors. Nurse Aide P stated he/she observed the resident at 9:15 PM and again at 10:30 PM, the resident was resting in his/her bed, and the last time he/she asked Nurse Aide P to leave the resident's walker close to his/her bed because he/she was cleared to walk independently in his/her room that day. On 11/28/18 at 5:05 PM, Administrative Staff A stated staff were made aware of the behavior monitoring because it showed up in the CNAs computer charting and it documented what the behavior was and what interventions to try. Administrative Staff A stated staff were already monitoring the resident for behaviors like they do for all the residents, crying, yelling, etc. Administrative Staff A stated the new behavior to monitor showed up as a new focus for a specific behavior, but he/she did not actually tell the CNAs there was a new behavior to watch for, and it was not brought up in report. Administrative Staff A stated he/she should have told the CNAs there was a new behavior. The appointment with Meditelecare took longer because the facility had to get pre-authorization for the resident to be seen. Administrative Staff A stated he/she sent the referral on 11/12/18, and the resident wanted to talk to his/her family member about the appointment before he/she agreed too. Administrative Staff A stated between 11/12/18 - 11/26/18, Meditelecare was in the process of setting things up, the resident saw the mental health physician on 11/26/18, and was scheduled to start Psychiatry sessions on 11/29/18. On 11/28/18 at 9:03 PM, Police Officer GG stated he/she was called at 3:27 AM and told that there was a hanging at the nursing facility. Officer GG stated he/she arrived around 3:37-3:40 AM and met Nurse Aide M at the facility door, when Officer GG got back to the resident's room, the resident was on the floor. Officer GG stated staff informed him/her that Nurse Aide M had checked on the resident at 1:30 AM and at 3:20 AM, he/she turned around and saw the resident attached to the bathroom door by the rope. On 11/29/18 at 9:08 AM, Administrative Nurse G stated he/she was not aware the resident stated he/she wanted to kill himself/herself, but thought it was just that he/she wanted to harm himself/herself. Administrative Nurse G stated the statement should have been communicated, the CNAs should have been told the resident had a new behavior and what it was, so they knew what behavior to watch for. On 11/29/18 at 11:03 AM, Nurse Aide M stated he/she started rounds around 1:00 AM, checked on the resident, and he/she was sleeping in his/her bed. Nurse Aide M stated he/she and Nurse Aide N began passing water, between 1:00 AM and 1:30 AM, he/she went into Resident #1's room to change his/her water, did not see the resident in his/her bed, turned around toward the door, and thought the resident had just fallen at first, so Nurse Aide M hollered for help. Nurse Aide M stated he/she started walking out of the resident's room to get help when he/she realized there was a rope wrapped around the resident's neck and around the door handle. Nurse Aide M stated staff monitored the resident for behaviors, but he/she did not remember being told it was to make sure the resident was not harming himself/herself. The facility's (MONTH) (YEAR) Behavior Monitoring policy documented the facility will assess the condition of those residents with behavioral problems. The facility will use a behavior monitoring tool which identifies the specific behavior or behaviors for which each behavior - treating drug was prescribed. Monitoring of the specific target behaviors will be daily, each shift. The facility failed to implement interventions to appropriately monitor Resident #1 for self harming behaviors, as directed by a physician, and failed to communicate the residents comments regarding wanting to kill himself/herself in a timely manner to staff. This deficient practice resulted in the resident taking his/her own life, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 11/29/18 at 7:45 PM, when the facility completed a reassessment of any resident that expressed suicidal ideation, exhibited suicidal behaviors, or whose medication or medications caused an increased risk for suicidal thoughts and behaviors. The resident was further assessed to ascertain if they had or were developing a plan for self-harm, and the physician was notified to seek medical direction. If the physician ordered Meditelecare to evaluate and treat the resident, the facility contacted such services within 24 hours, found out how soon the evaluation would take place, and reported this information back to the primary physician as well as a new assessment of the resident's condition. The current codes status of all residents was reviewed, and the facility checked the face sheet on the very front of each resident electronic health record to ensure such code status was available for staff reference. All facility staff was immediately trained for suicide prevention, immediate reporting of suicidal thoughts or behaviors, behavior monitoring procedures, and location of resident's code status. Licensed nurses and the social worker will report to the Administrator or Assistant Administrator, whenever any resident has expressed suicidal thoughts or behaviors. Each week a list of residents that are being monitored for the development of suicidal ideation or behaviors will be presented to the Administrator by the DON and the Social worker at Cambridge Place and to the Assistant Administrator by the SSD and the MDS Coordinator at the Blue Valley Senior Living building. The deficient practice remains at a scope and severity of a G.

The facility reported a census of 64 residents. The sample included 2 residents reviewed for abuse. Based on observation, interview, and record review the facility failed to provide an environment free of sexual abuse from 1 resident (#1) of the sampled residents when this resident inappropriately touched an unsampled (opposite gender) resident on 5/7/16 and inappropriately touched (opposite gender) resident #2 on 7/14/16. This deficient practice placed the (opposite gender) residents of this facility in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED].(progressive mental deterioration characterized by confusion and memory failure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) and personality disorder (a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving). The Admission Minimum Data Set ((MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 7 (less than 8 indicated severely impaired cognition). He/she experienced wandering and behaviors which intruded on the privacy of other residents. He/she required extensive assistance with locomotion on the unit. (Resident #1 was observed on 7/19/16 at 3:35 PM to propel himself/herself in the hall.) The Care Area Assessments (CAAs) dated 4/25/16 documented the resident had difficulty communicating and comprehending information, and adjusting to his/her new environment. He/she also displayed sexually inappropriate behaviors of undressing in public, which interfered with the privacy of others. The care plan dated 5/4/16 revealed the resident often wheeled himself/herself in the hallways. Staff explained to the resident why certain behaviors were inappropriate and unacceptable, and intervened to protect the rights and safety of others. The care plan directed staff in these situations to remove the resident from the situation and take the resident to another location. The care plan lacked interventions and measures to provide safety for (opposite gender) residents after the incidents on 5/7/16 or on 7/14/16. The nurse's noted dated 5/7/16 at 11:32 AM revealed resident #1 patted an unsampled (opposite gender) resident's buttocks, and the unsampled (opposite gender) resident became upset. Staff asked the resident to keep his/her hands to himself/herself. Review of the clinical record lacked documentation of interventions implemented to protect the (opposite gender) residents from resident #1's unwanted sexual behaviors. The record also lacked evidence staff notified the administrative staff, physician, completed investigation of the incident, or reported it to the State Survey Agency as required. The nurse's note dated 7/14/16 at 11:34 PM revealed resident #1 had sexual behaviors. (Opposite gender) resident #2 complained resident #1 put his/her hand up his/her shirt and down his/her pants. The clinical record lacked evidence of interventions implemented to protect the (opposite gender) residents from resident #1's unwanted sexual behaviors. The record also lacked evidence staff immediately notified the administrator as required. The clinical record for (opposite gender) resident #2 documented staff assisted the resident to his/her room and offered reassurance after the incident on 7/14/16. On 7/19/16 at 3:35 PM, resident #1 independently propelled himself/herself out of his/her room and in the hall. Direct care staff P spoke to the resident as he/she came down the hall. On 7/19/16 at 9:25 AM, resident #1 stated he/she did not have problems with the other residents. On 7/19/16 at 1:33 PM, administrative staff A stated he/she was unaware of the incident on 5/7/16 with this resident. On 7/19/16 at 1:52 PM licensed nursing staff H stated if he/she witnessed a resident to resident incident, he/she would separate the residents, assess them for injuries, and report it to the Director of Nursing. On 7/19/16 at 2:02 PM, direct care staff O stated he/she and other staff had found resident #1 in (opposite gender) residents' rooms. On 7/19/16 at 2:30 PM, administrative nursing staff D confirmed he/she documented the incident with this resident on 5/7/16. Administrative nursing staff D stated he/she did not report the incident on 5/7/16 to administrative staff or the State survey agency, because there was no injury to either resident. On 7/19/16 at 3:44 PM, direct care staff O stated if he/she witnessed a resident to resident incident, he/she would separate the residents and report it to the nurse. On 7/19/16 at 3:55 PM, resident #2 stated he/she felt disgusted after the incident on 7/14/16. On 7/20/16 at 4:15 PM, administrative staff A stated he/she was notified of the 7/14/16 incident the next day, on 7/15/16 at 9:00 AM. The facility's policy Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, reviewed 7/16, documented sexual abuse was defined as touching a resident in an intimate or suggestive manner. Staff were required to intervene, identify and correct situations where any type of abuse may occur. All reports of abuse were reported immediately to the administrator and Director of Nursing. The policy lacked the component regarding protection of the resident's during an investigation. The facility failed to provide an environment free of sexual abuse from this resident, admitted with a known history of sexually inappropriate behaviors, after two incidents of sexually inappropriate touching of opposite gender residents on 5/7/16 and 7/14/16, which placed the (opposite gender) residents of this facility in immediate jeopardy. The facility abated the immediate jeopardy on 7/22/16 at 11:00 PM by initiating the following: Provided one on one staff observation of resident #1 24 hours every day, the social service designee interviewed all (opposite gender) residents for concerns of sexual abuse, all staff in-serviced about policy and procedure for Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, re-evaluated the effectiveness of the training after 10 days, new employee orientation about policy and procedure for Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, with a re-evaluation in 10 days, and daily review of every resident's nurses notes by the Director of Nursing. The deficiency remained at a scope and severity of an E.

The facility reported a census of 64 residents. The sample included 2 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately report to the administrator, investigate, and report to the State survey agency an incident of sexual abuse which occurred on 5/7/16 between resident #1 and an unsampled (opposite gender) resident. The facility also failed to immediately report to the administrator an incident of sexual abuse which occurred on 7/14/16 between resident #1 and (opposite gender) resident #2. The facilities failure to protect the (opposite gender) residents from unwanted sexually inappropriate touching by resident #1 placed the (opposite gender) residents of this facility in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED].(progressive mental deterioration characterized by confusion and memory failure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) and personality disorder (a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving). The Admission Minimum Data Set ((MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 7 (less than 8 indicated severely impaired cognition). He/she experienced wandering and behaviors which intruded on the privacy of other residents. He/she required extensive assistance with locomotion on the unit. (Resident #1 was observed on 7/19/16 at 3:35 PM to propel himself/herself in the hall.) The Care Area Assessments (CAAs) dated 4/25/16 documented the resident had difficulty communicating and comprehending information, and adjusting to his/her new environment. He/she also displayed sexually inappropriate behaviors of undressing in public, which interfered with the privacy of others. The care plan dated 5/4/16 revealed the resident often wheeled himself/herself in the hallways. Staff explained to the resident why certain behaviors were inappropriate and unacceptable, and intervened to protect the rights and safety of others. The care plan directed staff in these situations to remove the resident from the situation and take the resident to another location. The care plan lacked interventions and measures to provide safety for (opposite gender) residents after the incidents on 5/7/16 or on 7/14/16. The nurse's noted dated 5/7/16 at 11:32 AM revealed resident #1 patted an unsampled (opposite gender) resident's buttocks, and the unsampled (opposite gender) resident became upset. Staff asked the resident to keep his/her hands to himself/herself. Review of the clinical record lacked documentation of interventions implemented to protect the (opposite gender) residents from resident #1's unwanted sexual behaviors. The record also lacked evidence staff notified the administrative staff, physician, completed investigation of the incident, or reported it to the State Survey Agency as required. The nurse's note dated 7/14/16 at 11:34 PM revealed resident #1 had sexual behaviors. (Opposite gender) resident #2 complained resident #1 put his/her hand up his/her shirt and down his/her pants. The clinical record lacked evidence of interventions implemented to protect the (opposite gender) residents from resident #1's unwanted sexual behaviors. The record also lacked evidence staff immediately notified the administrator as required. The clinical record for (opposite gender) resident #2 documented staff assisted the resident to his/her room and offered reassurance after the incident on 7/14/16. On 7/19/16 at 3:35 PM, resident #1 independently propelled himself/herself out of his/her room and in the hall. Direct care staff P spoke to the resident as he/she came down the hall. On 7/19/16 at 9:25 AM, resident #1 stated he/she did not have problems with the other residents. On 7/19/16 at 1:33 PM, administrative staff A stated he/she was unaware of the incident on 5/7/16 with this resident. On 7/19/16 at 1:52 PM licensed nursing staff H stated if he/she witnessed a resident to resident incident, he/she would separate the residents, assess them for injuries, and report it to the Director of Nursing. On 7/19/16 at 2:02 PM, direct care staff O stated he/she and other staff had found resident #1 in (opposite gender) residents' rooms. On 7/19/16 at 2:30 PM, administrative nursing staff D confirmed he/she documented the incident with this resident on 5/7/16. Administrative nursing staff D stated he/she did not report the incident on 5/7/16 to administrative staff or the State survey agency, because there was no injury to either resident. On 7/19/16 at 3:44 PM, direct care staff O stated if he/she witnessed a resident to resident incident, he/she would separate the residents and report it to the nurse. On 7/19/16 at 3:55 PM, resident #2 stated he/she felt disgusted after the incident on 7/14/16. On 7/20/16 at 4:15 PM, administrative staff A stated he/she was notified of the 7/14/16 incident the next day, on 7/15/16 at 9:00 AM. The facility's policy Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, reviewed 7/16, documented sexual abuse was defined as touching a resident in an intimate or suggestive manner. Staff were required to intervene, identify and correct situations where any type of abuse may occur. All reports of abuse were reported immediately to the administrator and Director of Nursing. The policy lacked the component regarding protection of the resident's during an investigation. The facility failed to immediately report to the administrator, investigate, and report to the State survey agency an incident of sexual abuse which occurred on 5/7/16 between resident #1 and an unsampled (opposite gender) resident. The facility also failed to immediately report to administrative staff an incident of sexual abuse which occurred on 7/14/16 between resident #1 and (opposite gender) resident #2. The facilities failure to protect the (opposite gender) residents from unwanted sexually inappropriate touching by resident #1 placed the (opposite gender) residents of this facility in immediate jeopardy. The facility abated the immediate jeopardy on 7/22/16 at 11:00 PM by initiating the following: Provided one on one staff observation of resident #1 24 hours every day, the social service designee interviewed all (opposite gender) residents for concerns of sexual abuse, all staff in-serviced about policy and procedure for Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, re-evaluated the effectiveness of the training after 10 days, new employee orientation about policy and procedure for Abuse, Neglect, Exploitation, and/or Reasonable Suspicion that a Crime has occurred, with a re-evaluation in 10 days, and daily review of every resident's nurses notes by the Director of Nursing. The deficiency remained at a scope and severity of an E.