Every finding on record at Camden Healthcare & Rehab Center

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure as needed (PRN) psychotropic medications for 2 of 5 (Resident #45 and #46) sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or document rationale for continued use of the medication. The findings include: 1. Review of the facility policy titled, Medication-Psychotropic, dated 10/30/2023, revealed .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record .PRN order for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration ( .14 days) .If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses which included Senile Degeneration of Brain, Dementia, Altered Mental Status, and Benign Neoplasm of Meninges [layers of membranes that protect the brain and spinal cord]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. Continue review revealed Resident #45 exhibited no behaviors during the assessment reference period. Further review revealed Resident #45 did not receive an antianxiety medication over the last 7 days. Review of Resident #45's Medication Administration Record (MAR) dated 2/1/2025-2/28/2025, revealed she received Lorazepam (psychotropic antianxiety medication given for anxiety) 0.5 milligram (mg) 1 tablet by mouth every 4 hours prn for anxiety one time on 2/20/2025. Review of Resident #45's MAR dated 3/1/2025-3/31/2025, revealed she did not receive the prn Lorazepam during the month. Review of Resident #45's MAR dated 4/1/2025-4/30/2025, revealed she did not receive the prn Lorazepam during the month. Review of Resident #45's current care plan dated 4/14/2025, revealed a focus for behaviors related to dementia as evidenced by the resident refused showers. Continued review revealed a focus for psychotropic/mood stabilizer medication as evidenced by antianxiety medications. Review of Resident #45's Order Review History Report with print date of 4/30/2025, revealed, .Lorazepam Oral Tablet 0.5 mg give 1 tablet by mouth every 4 hours as needed for anxiety for 180 days document behavior in progress note .Active .Order Date .01/07/2025 .Order End Date .07/06/2025 . Review of the Order Review History Report revealed Resident #45 had a continued order for a prn psychotropic medication for the past 114 days. 3. Review of the medical record revealed Resident #46 admitted to the facility on [DATE], with diagnoses which included Malignant Poorly Differentiated Neuroendocrine Tumors [A tumor that forms from cells that release hormones into the blood in response to a signal from the nervous system], Secondary Malignant Neoplasm of Unspecified Lung, Malignant Neoplasm of Uterus, and Repeated Falls. Review of the Quarterly MDS dated [DATE], revealed Resident #46 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #46 exhibited no behaviors during the assessment reference period. Further review revealed Resident #46 received an antianxiety medication over the last 7 days. Review of Resident #46's MAR dated 2/1/2025-2/28/2025, revealed she received Lorazepam 0.5 mg 1 tablet by mouth every 4 hours as needed for anxiety/agitation 18 times during the month. Review of Resident #46's current care plan with a revision date of 2/27/2025, revealed a focus for resident takes psychotropic/mood stabilizer medication as evidenced by the use of antianxiety medications. Review of Resident #46's MAR dated 3/1/2025-3/31/2025, revealed she received the prn Lorazepam 22 times during the month. Review of Resident #46's MAR dated 4/1/2025-4/30/2025, revealed she received the prn Lorazepam 21 times during the month. Review of Resident #46's Order Review History Report with a print date of 4/30/2025, revealed, .Ativan [Lorazepam] Oral Tablet 0.5 mg give 1 tablet by mouth every 4 hours as needed for anxiety/agitation for 180 days .Order Date .1/7/2025 .Order End Date .7/6/2025 . Review of the Order Review History Report revealed Resident #46 had a continued order for prn psychotropic medication for the past 114 days. During a telephone interview on 4/30/2025 at 11:45 AM, the Pharmacist was asked about the use of prn antianxiety medications after 14 days. The Pharmacist was asked if the regulation excluded residents on hospice care. The Pharmacist stated, .I know hospice is not excluded .prn can't exceed 14 days and if used longer the doctor should document duration and rationale . During an interview on 4/30/2025 at 2:30 PM, the Assistant Director of Nursing (ADON) was asked about Resident #45 and Resident #46's prn antianxiety medications being ordered longer than 14 days. The ADON stated, .both are hospice patients . During an interview on 4/30/25 at 3:26 PM, the Social Service Director (SSD) was asked about psychotropic medication given to Resident #45 and #46 prn in the past 14 days. The SSD stated, .hospice residents .this is one of their normal orders .it is on the care plan to monitor for side effects, also in the orders and on the MAR . The SSD was asked if she was aware a rationale has to be obtained from the physician if PRN psychotropic medications are given past 14 days. SSD stated, .I am not aware of that issue when it comes to the medications . During an interview on 4/30/2025 at 3:49 PM, the ADON stated, .I called him [referring to the Medical Director] today and he gave us a rationale for the use of the prn antianxiety meds . During an interview on 5/1/2025 at 4:04 PM, the Medical Director was asked if he was aware that psychotropic medications should have 14 days stop date and if used longer what should be completed. The MD stated, .yes, I understand 14 days stop date should be on them and if used longer I would document why they require it .and also make sure psychiatric evaluation was completed .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent potential accidents when safety interventions were not implemented during smoke breaks, when a resident was not re-evaluated after burn holes were found in his clothing, and when thorough assessments and follow up were not completed after falls for 4 of 15 (Resident #12, #24, #43, and #50) sampled residents reviewed for accident hazards. The findings include: 1. Review of the facility policy titled, Smoking Policy Smoking Campus-Residents, dated 5/31/2023, revealed .It is the policy of this facility to establish and maintain safe resident smoking practices .This policy is used to educate residents and representatives .Smoking items (cigarettes, lighters .) will be kept secured in a designated area with limited staff access .All residents that smoke will sign, or have their legal surrogate sign the facility's smoking policy upon admission . Review of the facility's policy titled, Falls-Clinical Protocol, with a revised date of 11/2/2023, revealed .As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task .Admission Evaluation Data Form, which includes the falls risk evaluation .the assessments and forms identified in this protocol are completed in the EHR [electronic health records] .Information obtained from this assessment includes, but is not limited to vital signs, orientation, diagnoses, cognitive and communication abilities, behavioral symptoms .all un-witnessed falls regardless of the resident's cognitive status should have neurochecks [a neurological assessment, often used to monitor a patient's neurological status] per MD [Medical Doctor] orders or protocol .The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .care plan and CNA [Certified Nursing Assistant] Kardex in the electronic Health Record should be updated as interventions change . 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Tobacco Use, Hemiplegia and Hemiparesis, and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #24 was cognitively intact. Resident #24 currently used tobacco. Review of Resident #24's Nursing Quarterly/Significant Change Evaluation dated 2/12/2025, revealed .Resident may smoke .Yes, without smoking aid(s) . Review of the Care Plan dated 2/27/2025, revealed, .Focus .Resident chooses to smoke .10/31/2023 .Goal .Resident will smoke safely .Interventions .Observe the resident's safety during smoking .10/31/2023 .Periodically complete safe smoking evaluation .10/31/2023 .Requires supervision while smoking .10/31/2023 . 3. Review of the medical record revealed Resident #50 admitted on [DATE], with diagnoses which included Mild Neurocognitive Disorder, Anxiety Disorder, and encounter for Surgical Aftercare following surgery on the Circulatory System. Review of Resident #50's comprehensive care plan dated 8/2/2024, revealed .Focus Resident chooses to smoke .Goal Resident will smoke safely at the designated area(s) at scheduled times .Inform resident or /family responsible regarding the center's smoking policy, designated smoking areas, and storage of smoking materials .Keep oxygen away from smoking materials. Ensure removal prior to resident smoking .Observe the resident's safety during smoking .Remind/assist resident to remove oxygen prior to going out to smoke as needed, if applicable . Resident #50's care plan dated 8/2/2024, did not address the need to wear an apron during the smoke break. Review of the Quarterly MDS dated [DATE], revealed Resident #50 had a BIMS score of 13, which indicated no cognitive impairment. Review of Resident #50's Nursing Quarterly/Significant Change Evaluation dated 4/23/2025, revealed .Resident may smoke .Yes, with smoking aid .Smoking aids needed .Smoking apron . Observation on 4/28/2025 at 9:40 AM, revealed Resident #24 and Resident #50 outside on the patio smoking with Certified Nursing Assistant (CNA) B supervising the smoke break. No residents were wearing a smoke apron. The residents were asked if anyone wears smoke aprons. Resident #50 stated, .we don't need aprons .we [have] been evaluated for that . Observation on the patio on 4/28/2025 at 4:04 PM, revealed Resident #24 and Resident #50 were outside on smoke break. Neither resident wore a smoke apron. During an interview on 4/29/2025 at 8:14 AM, the Laundry/Housekeeping supervisor was asked if she had ever observed any burn holes in resident clothing. The Laundry/Housekeeping Supervisor stated, I have seen burn holes in [Named Resident #24]'s pants. I mentioned it in the morning meeting. The Administrator and the Director of Nursing were present during the meeting . During an interview on 4/29/2025 at 8:32 AM, the Director of Nursing (DON) was asked to review Resident #50's smoking assessment. The DON stated, .it was completed on 4/23/2025 with the quarterly assessment and she should smoke with an apron . The DON was asked when staff take the residents out to smoke how would the staff know the resident needs to wear an apron. The DON stated, .it would be on the care plan .a list would be in the smoke box, too . The Assistant Director of Nursing (ADON) obtained the smoke box, opened it up, and pulled out the list of residents who smoke. The DON stated, .that is an old list those residents are no longer here . The smoke box did not reflect Resident #50 required an apron during smoke break. During an observation and interview outside in the smoking area on 4/29/2025 at 9:25 AM, Resident #24 stated, .I got some of my brother's clothes and he was a heavy smoker .I know they had burn holes in the pants, but I am not sure exactly when the burn holes happened to the pants . During an interview on 4/29/2025 at 10:28 AM, the DON stated, .I didn't see anything in our meeting notes about his [Named Resident #24] clothes having burn holes .if we had known he had burn holes in his clothing we would have immediately evaluated him for safe smoking . 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Schizophrenia, Coronary Artery Disease, Atrial Fibrillation, Hypothyroidism, Anemia, and Congestive Heart Failure. Review of the Nurses' Note dated 12/10/2024 at 5:56 PM, revealed Resident [#12] was lying in the floor on his right side between [named 2 room numbers]. No injury noted. No c/o [complaint of] pain or discomfort. [Named Sister] made aware by the nurse. Continuing to monitor . Review of the Fall Investigation dated 12/10/2024, revealed Resident #12 fell on [DATE]. The following vital signs were documented: a.Most Recent Temperature: 98.3 [Fahrenheit] .12/7/2024 at 6:10 [6:10 AM] . b.Most Recent Pulse: 74 .12/7/2024 at 6:10 . c.Most Recent Respiration: 20 .12/7/2024 at 6:10 . d.Most Recent O2 Sats [oxygen saturation]: 98% [percentage sign] .10/21/2024 at 13:15 [1:15 PM] . e.Most Recent Blood Pressure: 134/66 .12/7/2024 at 6:10 . The fall occurred on 12/10/2024 and the vital signs were from different dates. Review of the quarterly MDS dated [DATE], revealed Resident #12 had a BIMS score of 10, which indicated moderate cognitive impairment. No falls were documented. Review of the Nurses' Note dated 2/18/2025 at 2:33 PM, revealed Resident [#12] was in the dining room for breakfast this morning. He was standing there waiting for somebody to be out of his way when his legs got weak causing him to fall. No injury noted. No c/o of pain or discomfort. [Named Sister] aware. Continuing to monitor . Review of the Fall Investigation dated 2/18/2025, revealed Resident #12 fell on [DATE]. The following vital signs were documented: a.Most Recent Temperature: 96.6 .2/15/2025 at 13:59 [1:59 PM] . b.Most Recent Pulse: 78 .2/15/2025 at 13:59 . c.Most Recent Respirations: 16 .2/15/2025 at 13:59 . d.Most Recent 02 Sats: 98 .1/14/2025 at 09:08 [9:08 AM] . e.Most Recent Blood Pressure: 115/58 on 2/15/2025 at 13:59 . The fall occurred on 2/18/2025 and the vital signs were from different dates. Review of the Care Plan for Resident #12 dated 3/13/2025, revealed Resident is at risk for falls/injury related to behaviors: bladder incontinence, bowel incontinence, high risk for falls, history of falls .visual problems .Resident to start using wheelchair/remove rollator . Review of the Nurses' Note dated 4/17/2025 at 6:11 PM, revealed .This nurse heard other res [residents] asking for help in dining room, upon arrival res [Resident #12] was on floor in sitting position. Other res in dining room states that he [Resident #12] was trying to get up from WC [wheelchair] and WC was unlocked so it slid back and he end [ended] up on floor. Vitals WNL [within normal limits]. No new skin issues, No c/o pain . Review of the Fall Investigation dated 4/17/2025, revealed Resident #12 fell on [DATE]. The following vital signs were documented: a.Most recent Temperature: 97.9 .4/17/2025 at 18:12 [6:12 PM] . b.Most recent Pulse: 88 .4/17/2025 at 18:12 . c.Most recent Respiration: 20 .4/12/2025 at 6:11 [AM] . d.Most recent O2 Sat: 99 .3/19/2025 at 22:44 [10:44 PM] . e.Most recent Blood Pressure: 122/79 .4/17/2025 at 18:12 . The fall occurred on 4/17/2025 and the respirations and 02 Sats were from different dates. Observation in the resident's room on 4/28/2025 at 8:18 AM, revealed a fall mat beside the bed. Observation in the Dining Room on 4/29/2025 at 4:55 PM, revealed Resident #12 was sitting in a wheelchair waiting for the supper tray. 5. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphagia, Anxiety, Rheumatoid Arthritis, Tremor, and Bipolar Disorder. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 00 which indicated Resident #43 had severe cognitive impairment. Review of the Nurses' Note dated 4/14/2025, revealed, .Resident [#43] was walking back to her room from the dining room when her shoe got caught on the corner of [the] 500 Hall shower room causing her to fall. Resident stuck her hand out to brace herself causing the last 2 fingers on her right hand to have some deformities . Review of the Initial Fall Report for Resident #43 dated 4/14/2025, revealed blood pressure, pulse, respiration, and O2 sat were dated 2/28/2025. Review of the Situation, Background, Assessment, and Recommendation (SBAR) form for Resident #43 dated 4/14/2025, revealed the blood pressure, pulse, respiration, and 02 sat were dated 2/28/2025. Review of the [Named Hospital] Emergency Department (ED) documentation dated 4/14/2025, revealed .Visit Diagnoses .closed head injury, initial encounter .contusion [bruise] of left knee, initial encounter .Broken fingers, closed, initial encounter .Chief complaint .c/o [complaint/of] head and nose pain after falling, deformity noted to fingers of r [right] hand .Physical exam .R3,4,5th fingers [3rd, 4th, and 5th fingers of right hand] with ulnar angulation [describes where the distal (away from the body) fracture fragment is in relation to the proximal (situated nearer to the center of the body or the point of attachment) fragment] .XR [x-ray] HAND 3+ [plus] VIEWS RIGHT .CT [computerized tomography scan] HEAD/FACIAL BONES WO [without] CONTRAST .reason for exam fall hitting nose/face, eval [evaluation] for fx [fracture] .XR KNEE 1-2 VIEWS LEFT .reason for exam pain .immobilization: splint .splint type: finger .supplies used: aluminum splint .fracture management: I provided definitive fracture management . Resident #43 returned to the facility after ED visit. Review of the Medication Administration Record and Treatment Administration Record dated 4/1/2025 through 4/28/2025, revealed no documentation or orders to provide care to Resident #43's fractured fingers from 4/14/2025-4/28/2025. Observation on the 500 Hall on 4/28/2025 at 9:52 AM, revealed Resident #43 walked in the hallway with a wrap noted to the fingers of the right hand. Review of the Care Plan for Resident #43 dated 4/29/2025, revealed .Resident has an impaired musculoskeletal status related to arthritis, fractured fingers .cast care: keep clean and dry; do not immerse while bathing .Periodically observe for capillary refill of nail bed and temperature of skin around cast . Review of the Nurses' Note for Resident #43 dated 4/29/2025, revealed, .Resident returned from MD [Medical Doctor] appointment with hard cast in place to right hand. Verbal instructions given by [named Social Services Director] who accompanied resident to appt. Keep cast dry during shower, may use mole skin to pad as needed, and return on 5/16/25 for follow up . Observation in Resident #43's room on 4/29/2025 at 11:23 AM, revealed a blue hard cast to the right hand. During an interview on 4/30/2025 at 4:54 PM, the Director of Nursing (DON) was asked about taking vital signs after a fall. The DON stated, They should take vital signs after a fall .They took vital signs on 12/11/2024 the day after the fall .The vital signs on 2/10/2025 and 2/18/2025 were off . During an interview on 5/1/2025 at 11:32 AM, the ADON confirmed vital signs are part of the neuro assessment and should be completed with every unwitnessed fall, and with Fall Follow Up assessments for 72 hours. The ADON was asked if Resident #43 had been assessed for a head injury, left knee injury, or pain related to the (Named Hospital) Emergency documentation and x-rays related to the areas. The ADON stated that Resident #43 had no signs of injury to head, face, or left knee. The ADON was asked what was done for Resident #43's right hand broken fingers from the time the resident returned from the ED on 4/14/2025 until the cast was placed on 4/29/2025. The ADON stated that it was just buddy wrapped, until she got the cast on 4/29/2025. The ADON was asked if there were any orders related to the wrap or the fractured fingers of the right hand during that period. The ADON stated, I don't see any. The ADON was asked should there have been orders during that period to monitor the wrap, fingers, and circulation. The ADON stated, Yes. The DON was unable to provide documentation that vital signs were obtained at the appropriate time for the fall event, SBAR, fall follow ups, and ED transfer. During an interview on 5/1/2025 at 4:04 PM, the Medical Director was asked how often vital signs should be completed and should a set of vital signs be completed with a fall. The MD stated, .vital signs at least 2-3 times per day .I would expect vital signs to be obtained with a fall to watch for hypotension which could cause dizziness and a fall .find the root cause for the fall . The MD was asked if a resident had fractured fingers would he expect a skin check to be completed after the injury. The MD stated, .I would expect skin checks . The MD stated, I would expect the nurses to follow physician orders. 51365

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Interview (RAI) Manual review, medical record review, and interview, the facility failed to ensure MDS assessments were accurately coded for 1 of 16 (Resident #46) residents reviewed for MDS assessments. The findings include: 1. Review of the RAI Manual dated 10/2024, revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .Coding Instructions for J .Determine the number of falls that occurred since .prior assessment .Coding Instructions for J1900C, Major Injury .Code 1, one: if the resident had one major injurious fall since .prior assessment . 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses which included Malignant Poorly Differentiated Neuroendocrine Tumors (A tumor that forms from cells that release hormones into the blood in response to a signal from the nervous system), Secondary Malignant Neoplasm of Unspecified Lung, Malignant Neoplasm of Uterus, and Repeated Falls. Review of Resident #46's Progress Notes dated 12/29/2024, revealed .Heard someone yell help and upon entering resident's room observed [Resident #46] sitting on floor in front of her bed. Stated was standing at end of bed straitening [straightening] her blanket and her leg just twisted and she fell on her right leg. Complained of pain in right upper foot and right toes then she said right knee and that she thought something may be broken .On-call nurse notified and new order to send to .hospital ER [emergency room ] . Review of the Quarterly MDS dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #46 was independent with chair/bed-to-chair transfer and unable to walk 10 feet due to her medical condition and safety concerns. Further review revealed no falls were coded for Resident #46 in the last month, since the prior assessment, and no major injury coded since prior assessment. The MDS did not accurately reflect Resident #46's status for her fall with major injury noted 12/29/2024. During an observation and interview in the resident's room on 4/28/25 at 3:12 PM, Resident #46 was asked if she had experienced any falls while in the facility. Resident #46 stated, I fell in my room .I got dizzy standing up in front of my wheelchair and fell . Resident #46 then showed this surveyor a bruise noted to her left shoulder. Resident #46 stated, .I broke two of my toes .the staff just couldn't get to me in time . During an interview on 5/1/2025 at 4:25 PM, the MDS Coordinator was asked to review the quarterly MDS assessment dated [DATE] and asked was section J related to a fall in the last month and no major injury since prior assessment coded correctly. The MDS Coordinator stated, .should have been marked for bone fracture, yes .I missed that . During an interview on 5/1/2025 at 4:50 PM, the Assistant Director of Nursing (ADON) was asked about the Xray results for Resident #46's fall on 12/29/2024. The ADON stated, .x-ray results were obtained here at the facility .it showed Acute Fractures 3rd through 5th metatarsal necks [3rd, 4th, and 5th toe fractures] .

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide appropriate behavioral monitoring for psychotropic medications for 1 of 5 (Resident #23) sampled residents reviewed for psychotropic medication use. The findings include: 1. Review of the facility policy titled, Gradual Dose Reduction of Psychotropic Drugs, dated 10/26/2023, revealed .Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .Gradual Dose Reduction (GDR) .is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued .Psychotropic Drugs .is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include .antipsychotics . Review of the facility policy titled, Behavior Management Program, dated 10/27/2023, revealed .Each resident's drug regimen must be free from unnecessary drugs .that residents who have not used a antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record .Residents on an antipsychotic, resident's exhibiting behaviors negatively affecting self or other residents or with new behaviors negatively affecting self or other residents will be reviewed by the Behavior Management team .The team will explore the root cause of behaviors/mood. The team will identify target behaviors and an individualized plan of care .Resident documentation of observed behaviors will be maintained and monitored using our electronic medical records .system .A description of the behavior or symptom observed and or reported behavior may include the following .Reason, Place, Intervention, and outcome . Review of the facility policy titled, Medication-Psychotropic, dated 10/30/2023, revealed Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record .For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician .target symptoms for monitoring shall be included in the documentation .Residents and/or representative shall be educated on the risks and benefits of psychotropic drug use-as well as alternative treatments/non-pharmacological interventions .Enduring conditions .The resident's symptoms .shall be clearly and specifically identified and documented . 2. Review of the medical record revealed Resident #23 admitted to the facility on [DATE], with diagnoses which included Hypertension, Atrial Flutter, Type 2 Diabetes Mellitus with Foot Ulcer, and Vascular Dementia with Severe Mood and Behavioral Disturbance. Review of Resident #23's CONSENT TO USE OF PSYCHOACTIVE MEDICATION THERAPY form, dated 12/15/2023, revealed .Specific Condition to be Treated (check all that apply) Dementia, Vascular with Behavioral Disturbance .If Dementia Related Psychiatric Diagnosis with Associated Behavioral Symptoms, Identify Harmful Behaviors . No behaviors were marked or described for Resident #23. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. Continued review revealed Resident #23 had no indicators of psychosis or behavior problems noted during the assessment period. Further review revealed Resident #23 received an antipsychotic and antianxiety daily for the assessment reference period. Review of the Medication Administration Record (MAR) dated 10/2024, revealed an order for Haloperidol (antipsychotic medication used to treat nervous, emotional, and mental conditions related to Schizophrenia and Bipolar Disorder) Tablet 1 milligram (mg) give 1 tablet by mouth at bedtime related to Vascular Dementia. Review of the MAR dated 2/2025, revealed an order for Haloperidol Tablet 1 mg give 1 tablet by mouth at bedtime related to Vascular Dementia. Review of the MAR dated 3/2025, revealed an order for Haloperidol Tablet 1 mg give 1 tablet by mouth at bedtime related to Vascular Dementia. Review of the MAR dated 4/2025, revealed an order for Haloperidol Tablet 1 mg give 1 tablet by mouth at bedtime related to Vascular Dementia. Review of the current care plan with a revision date of 4/8/2025, revealed, .Focus .Resident has behavior (s) as evidenced by: removing colostomy. Resident's sleep pattern is inconsistent. Resident may stay up all night and sleep all day. Is drowsy some days when this occurs .Goal .Resident will have no adverse effects related to behaviors .if resident becomes agitated and shows signs of escalation, re-approach later .Keep resident safe during episodes of behaviors .Observe and document episodes of inappropriate behaviors .Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations . Review of the Pharmacy recommendation dated 4/16/2025, revealed .This resident has been taking Haloperidol .since 10/24 [10/2024]. Please evaluate the current dose and consider a dose reduction . Further review revealed the Medical Doctor left a check mark for .Resident with good response, maintain the current dose . Review of Resident #23's current task documentation dated 4/2025, revealed her targeted behaviors were .staying up all night .Removing colostomy bag .sleeping all day . The task documentation revealed no behaviors related to Dementia for which staff needed to monitor listed on the form. Observation in the resident's room on 4/28/25 at 9:25 AM, revealed Resident #23 was asleep in a low bed with a fall mat to the right side of the bed. During a telephone interview on 4/30/2025 at 11:45 AM, the Pharmacist was asked if a gradual dose reduction (GDR) had been recommended for Resident #23. The Pharmacist stated, .GDR was suggested in April . The Pharmacist was asked if monitoring for staying up all night and sleeping all day would be appropriate behaviors to chart for the use of Haldol. The Pharmacist stated, .no, that would not be targeted behaviors for the use of Haldol .the coded diagnosis for the Haldol is Dementia Vascular with agitation .I would review the Psychiatric notes for behaviors, and I think she had intermittent delusions .there needs to be more specific behaviors . During an interview on 4/30/25 at 2:56 PM, the Social Service Director (SSD) was asked about behaviors with Resident #23 and the use of Haldol with a resident diagnosed with Dementia. The SSD stated, .I would make sure Dementia is care planned .I know in my area I would add it to the Kardex [documentation system used to quickly access patient information for daily nursing care] behaviors .she [Resident #23] was interviewed upon admission she was later diagnosed with Dementia .her son is here every evening, Monday through Friday, IDT [Interdisciplinary Team] discuss behavior issues in morning meetings .I pull dashboard reports where the Certified Nursing Assistants chart behaviors .Progress notes are also reviewed .she doesn't really participate in activities much anymore. Sleeping all day and staying up all night, I don't necessarily feel it is a behavior we wanted to monitor .she cycles, staying up all night . The SSD was asked why staying up all night was a concern for the facility or resident. The SSD stated, .it doesn't really concern me, it is just not her normal cycle . The SSD was asked if Resident #23 exhibited any disruptive behaviors or wandering at night. The SSD stated, .she sits in her chair and socializes with the staff usually . The SSD was asked what the rationale was or need for the use of the Haldol. SSD stated, .I think we have tried to take her off of it before and her anxiety would increase, it was the best way we could make her comfortable .at this time in her care I don't think behavior is a big concern at this time . During a telephone interview on 5/1/2025 at 10:39 AM, Family Member (FM) I stated, .At one point mom was trying to elope from the building and argumentative with the staff. They sent her to [a] psych unit .She doesn't have many behaviors now .she will mention going home at times but that is about it .I don't recall the facility ever going over Dementia care since she was admitted . My mom has been nervous all her life . During a telephone interview on 5/1/2025 at 4:04 PM, the Medical Doctor (MD) stated (Resident #23's) behaviors were restlessness, agitation, and hallucinations. The MD was asked would sleeping during the day and staying up at night be behaviors for the use of Haldol. The MD stated, .that is not behaviors . The MD was asked would you expect the nursing staff to be charting on her restlessness, agitation, and hallucinations. The MD stated, .yes .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident received adaptive devices as ordered by the physician for 1 of 3 (Resident #15 ) sampled residents reviewed for nutrition. The findings include: 1. Review of the facility policy titled, Use of Assistive Devices, revised 10/26/2023, revealed .The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity .Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities. They may help the individual .eat .Assistive devices include .eating utensils .The facility will provide assistive devices for residents who need them .The resident's assigned nurse will monitor for the consistent use of the device . 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Postural Kyphosis, Anxiety, and Tremor. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #15 was moderately cognitively impaired. Review of the Care Plan dated 2/27/2025, revealed .Resident [#15] has an impaired neurological status related to dementia, Parkinson's Disease .Administer medications and treatments as indicated by orders .Provide assistance with meals as needed . Review of the Physician's Orders dated 3/26/2025, revealed .Pt. [Patient/Resident #15] to have divider plate and 2 handled cup at meals to reduce food spillage at meals . During observation and interview in the resident's room on 4/28/2025 at 10:00 AM, Resident #15 exhibited tremors in both arms and hands. Resident #15 stated, .I spilled my drink and stopped eating because I was spilling things . Observation in the resident's room on 4/28/2025 at 12:02 PM, revealed a cup with no handles on Resident #15's tray. Resident #15 grabbed the cup with no handles with both hands and spilled the drink. Review of the Kardex (system for documenting and organizing patient information) Report dated 4/30/2025, revealed .Provide adaptive equipment: (2 handled cup .). Review of the Meal Card dated 4/30/2025, revealed .Two Handled Cup . Observation in the resident's room on 5/1/2025 at 8:02 AM, revealed the cups on Resident #15's breakfast tray had no handles. During an interview on 5/1/2025 at 8:05 AM, Certified Nursing Assistant (CNA) H confirmed that Resident #15 was supposed to have a two handled Cup. During interview on 5/1/2025 at 2:02 PM, the Assistant Director of Nursing (ADON) confirmed staff should follow the physician's orders. Observation in the resident's room on 5/1/2025 at 5:47 PM, revealed the cups on Resident #15's dinner tray had no handles. During an interview on 5/1/2025 at 5:49 PM, the ADON confirmed staff should provide adaptive equipment at mealtime if the physician had ordered it. During an interview on 5/1/2025 at 5:50 PM, the Dietary Manager (DM) confirmed the facility had enough Two Handled Cups to provide for their residents.

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to have evidence that all alleged violations were thoroughly investigated for 6 of 16 (Resident #6, #13, #20 #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to thoroughly investigate allegations resulted in Immediate Jeopardy (IJ) related to Residents #6, #13, #20, #24, #25 and #38 when on an unknown date Resident #38 gave Resident #6 an unwanted touch on her arms and legs, and on a separate occasion wheeled up behind Resident #6 in his wheelchair and grabbed her wheelchair, on 2 different occasions Resident #38 entered Resident #6's room unwanted and uninvited, and on one of those occasions wheeled directly up to Resident #6's bed. These actions by Resident #38 caused Resident #6 to be fearful and uncomfortable and resurfaced painful childhood memories of being sexually abused by her father. Incidents of sexual abuse occurred on an unknown date when Resident #38 cupped Resident #13's testicles, leaving the male resident feeling embarrassed and shameful, when Resident #38 made inappropriate comments to Resident #20's about her chest/breast area leaving Resident #20 agitated and angry, when Resident #38 gave Resident #24, a severely cognitively impaired resident an unwanted kiss on the lips, and when Resident #38 self-propelled his wheelchair into Resident #25's room and touched his knee and attempted to give him a kiss. The facility failed to thoroughly investigate allegations that Resident #38, a cognitively impaired resident who self-propels his wheelchair and had episodes of inappropriate sexual behaviors towards staff since admission to the facility on [DATE], and also had inappropriate touching and sexual behaviors towards other residents. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-610 on 4/17/2024 at 4:39 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of K, which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a Plan of Correction (PoC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Identifying correcting, and intervening in situations in which abuse, neglect .is more likely to occur .and assure that the staff assigned have knowledge of the individual resident's need and behavioral symptoms .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur .written procedures of investigation include .Identifying staff responsible for the investigation .Investigating different types of alleged violations .Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent and the cause .providing complete and thorough documentation of the investigation .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, stage agency, adult protective services and to all other required agencies .within specified timeframes . 2. Review of the (Named Hospital's) medical record notes revealed the following documentation of Resident #38's behaviors, prior to Resident #38 being admitted to the nursing home: On 1/22/2024, a Nursing Docs (documentation) note revealed, .pt [patient, Resident #38] is very 'handsy' with female staff. Pt [patient, Resident#38] likes to feel female staff . On 1/24/2024, a hospital Neurological note revealed, .Inappropriate shifting of attention . On 1/24/2024, a hospital Psychosocial note revealed, .[Patient Interaction w (with) Healthcare Team] Inappropriate interaction with healthcare team . On 1/25/2024 at 5:03 AM, a hospital Nursing Docs note revealed, .Making sexual remarks to staff . Review of the medical record revealed Resident #38 was admitted the facility on 1/25/2024, with the diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the Care Plan dated 1/25/2024 revealed .Resident has an ADL self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024. Placed resident on 30 minute checks throughout the night then changed to q [every] shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 .Revision on 2/14/2024 .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner] /PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] .Date Initiated 1/26/2024 .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident noted to have frequent episodes of inappropriate behaviors towards staff this night. On call and MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych (psychiatric) consent was obtained on 1/25/2024 . resident be started on Medroxyprogesterone .10 mg daily for sexually inappropriate behaviors .shared for [Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed Medical Director in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10mg daily for increased inappropriate sexual behaviors. Review of a [Named Mental Health Services facility] dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the admission MDS dated [DATE] revealed Resident # 38 was assessed with a BIMS score of 8, indicating the resident was moderately cognitively impaired, had behaviors directed toward others .(e.g.[example] abusing others sexually) .wandering behaviors .significantly intrude on the privacy or activity of others .incontinent of both bowel and bladder, and had active diagnoses of Non Alzheimer's Dementia, and vision problems. Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of a facility's SOC Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Psych Services .recommended Paxil 10 mg to see if it would help to decrease these behaviors . Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest . Review of the facility's Medication Review Report summary dated 4/8/2024 revealed, .medroxyprogesterone [hormone to decrease sexual desire] .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 .PARoxetine (antidepressant used to decrease sexual desire) .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . During an interview on 4/11/24 at 3:55 PM, LPN J was asked if Resident #38 ever displayed inappropriate sexual behavior. LPN J confirmed Resident displayed inappropriate sexual behavior when he was initially admitted on [DATE]. LPN J confirmed that it was reported to her by a staff member that Resident #38 grabbed Resident #6's chair and her arm while in the dining room. LPN J was asked did you report this to anyone. LPN J stated, No, I didn't think it was something to report .well now that I think about it .but I see alot of residents with dementia so that is why I did not report it . LPN J was asked should you have reported this to administration. LPN J stated, Yes, I guess I should have . LPN J was asked has he expressed any sexually inappropriate gestures. LPN J stated, Yes when he first got here but that is not uncommon with men with dementia so I did not think about it .I see it all the time but now I see that I should have .I just redirected him and told him it was not nice .he was just talking dirty but I am use [used] to that, is just what men with dementia do . LPN J was asked should he be wandering into other residents rooms. LPN J stated, He has dementia .I see it all the time with people with behaviors . During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed there should be a documented investigation for allegations of abuse. During an interview on 4/15/24 at 10:09 AM, Administrator was asked what is considered a reportable occurrence. The Administrator stated, Allegation of abuse .we usually have calls before we make final determination if actual harm involved .I will have to look at regulations on these we do not have many of these .I will check regulations and get in touch with corporate and legal, they are a little more familiar with that and with the kiss, is that actual harm should that be reported .we have a call this afternoon . The Administrator was asked should those be treated as allegation of abuse. The Administrator stated, No. The Administrator was asked what about the allegations for Resident #38. The Administrator stated, .I could not rule out he had diminished capacity and that would not be reportable and we have checked [BIMS] and rechecked and it is lower now . During an interview on 4/16/2024 at 7:15 PM, the Administrator confirmed there was not an investigation regarding Resident #38 making an inappropriate comment about Resident #20's chest/breast area. During an interview on 4/17/2024 at 9:00 AM, the Administrator entered the Conference room and handed this Surveyor a State Survey Reporting sheet. The Administrator was asked is the investigation. The Administrator stated, We reported it last night. The Administrator was asked should it have been reported before now. The Administrator stated, We did not feel that it was a reportable after our investigation. The Administrator was asked did you get witness statements. The Administrator stated, We are working on that . 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, .Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Observe for signs of mood changes or distress . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 was assessed with a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024, revealed .Pt [patient] examined via [by way] telehealth .regarding inappropriate touching via another resident .Pt does disclose past event to examine today .Pt has declined pharmacologic interventions in past; staff report pt open to such at this time .Zoloft [medication used for depression] .25 mg [milligram] Q [every] day anxiety . Review of the Care Plan revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Trauma Informed Care assessment completed .consented to antidepressant .4/9/2024 . Review of the Social Services Progress Notes dated 4/10/2024, revealed .spoke with resident .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of the Social Services Progress Notes dated 4/12/2024, revealed .spoke with resident on 4/11/24 [2024] .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when he came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a Certified Nursing Assistant (CNA) came and took him out of her room and that she had told the Social Service Director and the Activity Director. During an interview on 4/8/24 at 4:07 PM, the Social Service Director (SSD) was asked about what occurred with Resident #6 and Resident #38. The SSD confirmed Resident #38 entered Resident #6's room without her permission and was unsure of the date of occurrence. The SSD was asked has Resident #38 touched Resident#6 without her permission before. The SSD confirmed Resident #38 touched Resident #6's shoulder and that a few weeks later a nurse on the floor reported the incident to her (SSD). The SSD confirmed it was Licensed Practical Nurse (LPN) J who had reported it to her. The SSD confirmed she spoke with Resident #6 and the resident told her the same thing that she had told LPN J, that she was going down the hall and Resident #38 came up behind her touched her shoulder and that it frightened her, and that there had been a traumatic issue in her past and it caused her to think about those things. The SSD was asked what you did after she reported this to you and you spoke with Resident #6. The SSD confirmed that she and Resident #6 talked about it. The SSD confirmed that she reported it in the morning meeting but was unsure of the exact date, that she reported it in the meeting. The SSD was asked was the DON or the Administrator present in the meeting when it was discussed. The SSD stated, They were involved [when Resident #6's report was discussed in the morning meeting] . The SSD was asked what time of day did LPN J report this to you. The SSD confirmed that it was at the end of the day, and she was on her way out the door to go home, and she told the Administrator before she left the building. The SSD was asked what was put in place to ensure the safety of the resident. The SSD confirmed that a STOP sign was placed across the doorway to prevent entrance into Resident #6's room. The SSD confirmed that if there was an investigation she was not involved in the investigation. During an interview on 4/8/24 at 4:59 PM, the Activities Director (AD) was asked if you have a resident to report that another resident has made inappropriate gestures, comments, or touching what would you do. The Activities Director stated, We encourage them to come to me or [Named SSD] to talk about it, we had that to happen .we separate as much as we can .one gentleman that likes to reach out and hold the ladies hands and we try to do a lot of redirection . The AD was asked who that resident was. The AD stated, .[Named Resident #38], we try to do a lot of redirection . The Activities Director was asked has anyone said that he makes them feel uncomfortable. The Activities Director stated, [Named Resident #6], he wandered in her room looking for a bathroom .it was at night .she [Named Resident] told me the next day and we discussed it .and it was reported to [Named Administrator] and [Named DON]. The Activities Director was asked did Resident#6 say it made her feel uncomfortable or fearful. The Activities Director stated, .It definitely made her feel uncomfortable . The Activities Director confirmed that when residents come and speak with her, she goes the SSD. The Activities Director was asked did Resident #6 tell you she felt uncomfortable around him related to her childhood. The Activities Director stated, Yes .we had a long discussion .her dad was abusive to her and her first husband was abusive to her .her dad was sexual [sexually] abusive .her husband was mental and physical [mentally and physically] abusive .it brought up a bunch of stuff that she had worked hard to get past . The Activities Director was asked was the Administrator aware. The Activities Director confirmed the Administrator was not aware. The Activities Director confirmed the Administrator was the Abuse Coordinator. The Activities Director was asked should you have reported this to the Abuse Coordinator. The Activities Director stated, I am not sure this is new, this has never been this big of an issue, learning how to deal with this is a new process but I should have definitely taken it to [Named Administrator]. During an interview on 4/8/24 at 5:44 PM, the DON confirmed the Administrator is the Abuse Coordinator and if there are any reports of an allegation it should be reported to the Administrator. The DON was asked are you aware of any occurrences with Resident #6 and Resident #38 being in her room and making her feel uncomfortable. The DON confirmed she was not made aware of Resident #38 touching or entering Resident #6's room without permission. The DON was asked should those occurrences have been reported and investigated if they made the residents feel unsafe and uncomfortable. The DON stated, Yes . The DON was asked if there is an allegation made what should the facility do when it is reported to a staff member. The DON stated, They should report that to [Named Administrator], he is the Abuse Coordinator . The DON was asked what role you play in an allegation of abuse. The DON stated, I help with the investigation. The DON was asked did you assist with the investigation concerning Resident #6. The DON confirmed she had no part of the any investigation and there were no statements on the occurrence. The DON was asked should there have been. The DON stated, Yes. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses of Hypertension, Diabetes, Depression, Anxiety and Post Traumatic Stress Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 was assessed with a BIMS score of 12, indicating the resident was moderately cognitively impaired. Review of the Care Plan revised 2/6/2024, revealed the following interventions for Post Traumatic Stress Disorder. Provide a calm, safe environment when resident is emotional and frustrated, and allow time to voice feelings. Observation in the resident's room on 4/9/2024 at 10:11 AM, revealed Resident #13 alert and oriented. Resident was sitting on the side of his bed, facial expression sad and upset, folding/wringing hands together, voice trembling asking if he could talk about an incident that has been bothering him for several weeks. During an interview in the resident's room on 4/9/2024 at 10:15 AM, Resident #13 stated, .a few weeks ago while in the dining room a man touched me and grabbed my private parts [testicles] in his hand, after 5 or 6 seconds I took his wrist and sat it on the table, he didn't get mad and went back to his normal seat. It was quite disconcerting and embarrassing. I told [Named Resident #25] that day. He was sitting there when I told ADON [Assistant Director of Nursing] what had happened. She now tells me that I didn't tell her about the incident. I also told [CNA F] a nurse's aide that walks with me. This is all so embarrassing and not normal. No man should have to deal with that. I was shocked and surprised. I have been through 2 wars in my lifetime and now I have to live with this . Resident was asked if there was anything else he would like to share. Resident #13 stated, .this was not the first instance with this man. He has been bothering the women also. I am the resident council president, and I have addressed this before with the DON on the women's behalf and by witnessing it. She would only say that they have a plan for him . During an interview on 4/9/2024 at 10:59 AM, CNA G confirmed Resident #13 is alert and oriented. During an interview on 4/10/2024 at 11:12 AM, LPN K confirmed Resident #13 was alert to self, time and place. During an interview on 4/11/2024 at 4:31 PM, CNA F was asked when Resident #13 told her about another resident touching him inappropriately. CNA F stated, .he's acting upset today I'm trying to keep my distance from him .he said he told me about being touched on his privates by [Named Resident #38], but I told him I don't remember. During an interview on 4/16/2024 11:19 AM, the Assistant Director of Nursing (ADON) was asked when she was made aware of Resident #13's testicles being cupped by another resident. The ADON stated, I was made aware during our abuse questions and staff interviews. The ADON was asked when Resident #13 told her about him being touched inappropriately by Resident #38. The ADON stated, I do not remember that. The ADON was asked if the resident council president [Resident #13] had brought his concerns of [Named Resident #38] inappropriate behaviors toward other residents. The ADON stated I don't remember. The ADON was asked if she knows how to start a facility investigation regarding physical, sexual or verbal abuse. The ADON stated, I think I do, I haven't completed one on my own . During an interview on 4/16/2024 at 6:16 PM, the Director of Nursing (DON) was asked when she was made aware of Resident #13's testicles being cupped by another resident. The DON stated, I was doing interviews for staff and residents and [Named Resident #13] stated that he told me about this .I assured him that he had not told me . The DON was asked if Resident #13 shared his concerns with her of Resident #38's inappropriate behaviors with other residents. The DON stated, I don't remember. The DON was asked when an allegation of abuse should be reported. The DON stated, It should have been reported immediately. Review of the facility's abuse investigation dated 4/10/2024, (during the survey team's investigation) revealed the facility failed to identify and investigate an allegation of abuse for Resident #13. 5. Review of the medical record revealed Resident #20 was readmitted to the facility on [DATE], with diagnoses of Hemiplegia, Hypotension, Aphasia, Dysphagia, Hypertension, Diabetes, Epilepsy, Chronic Pain Syndrome, and Pseudobulbar Affect. Review of the quarterly MDS dated [DATE] revealed Resident #20 was assessed as being moderately cognitively impaired, limited Range of Motion on both the upper and lower extremities, dependent on staff for Activities of Daily Living skills, and incontinent of bowel and bladder. Review of the Care Plan dated 4/17/2024, revealed .Resident has impaired cognitive function .with aphasia .Resident has impaired communication .cognitive impairment .as evidence by aphasia .Request feedback .to ensure understanding . Review of a facility's SOC (Standard of Care) Behavior note dated 3/28/2024, revealed Behavior displayed .Anger and agitation at a male resident .She indicated to staff that male resident [Resident #38] had made a comment about her chest .She was removed from the dining table and moved to her normal one. SSD will monitor. Review of a facility's Social Services Progress Note dated 3/29/2024 revealed, SSD spoke with resident regarding incident that occurred in which another resident made a comment about her chest . During an interview on 4/16/2024 at 5:01 PM, the SSD was asked what occurred with Resident #20 and Resident #38. The SSD stated, .one of the CNAs documented on the dash board [electronic medical record] that the female [Resident #20] had been agitated during supper and that the male resident had said something about her chest . The SSD confirmed that the staff member that made the entry was CNA A and the male resident was Resident #38. The SSD confirmed that she reviews the dashboard every morning upon reporting to work at 8 AM and prior to the morning meeting at 9 AM and reports any needed information to the administrative staff during that meeting. The SSD confirmed that the incident was discussed during the morning meeting on 3/28/2024 and the incident occurred on the evening of 3/27/2024 during the supper meal. The SSD confirmed she called and spoke with the DON that morning when she discovered it on the dashboard and asked if she had reviewed the dashboard and saw what was written. The SSD confirmed that the DON said that she had seen it. The SSD confirmed that the information was discussed in the morning meeting that included all department heads, the DON and the Administrator. The SSD confirmed that nothing was reported, and no formal investigation was completed to her knowledge. During an interview on 4/16/24 at 5:26 PM, CNA A was asked what occurred between Resident #20 and Resident #38. CNA A stated, .I walked in the dining room, and I saw her [Resident #20] coming away from where he was sitting and she was agitation [agitated] and she started pointing and making [made motion toward chest/breast area]. CNA A confirmed that Resident #20 had very limited speech and usually make gestures or points to what she wants. CNA A confirmed when she came back she asked what had happened, and said Resident #20 used her hands and pointed to her breast area, and she asked if Resident #38 touched her and Resident #20 denied it by motioning her head left to right indicating no. CNA A then asked Resident #20 if Resident #38 said something, and she shook her head up and down, indicating yes. CNA A confirmed it was reported to Licensed Practical Nurse (LPN) J, the charge nurse, and also had put it in the dashboard. CNA A confirmed that during her training at the facility on the dashboard that all of the appropriate people, including the DON, Assistant Director of Nursing, Social Services and floor nurses could read and receive alerts that are put in on the dashboard. CNA A confirmed that no one asked her about what occurred or asked her to provide a written statement of the occurrence until today, 4/16/2024, about 30 minutes prior. CNA A was asked when you asked Resident #20 what occurred did she seem upset or frightened. CNA A confirmed that Resident #20 was really upset and angry and that she could not tell me what he said but she made hand gestures pointing to her chest/breast area. CNA A was asked when did the incident occur. CNA A confirmed it was on the 27th or 28th of March. 6. Review of the medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Diabetes, Vascular Dementia, Anxiety and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #24 was assessed with a BIMS score of 06, indicating severe cognitive impairment. Observations on 4/8/2024 at 10:30 AM, in resident's room revealed Resident #24 alert to self, and required extensive assistance of staff for activities of daily living (ADLs). During an interview on 4/11/2024 at 8:21AM, the Med Tech (Medication Technician) stated, [Named Resident #24] incident with [Named Resident #38] occurred in the dining room. I do not remember the date .[Named Resident #24] was in the door way, she has these crying episodes calling out for her son .I saw [Named Resident #38] come over to her and appeared to be talking .He was rubbing her back, then [Named Resident #38] turned her head and kissed her on the lips .He was in a wheelchair .when he kissed her .I did not complete a statement when it occurred until this week when the DON asked me to . During a phone call on 4/12/2024 at 1:30 PM, Resident #24's son, confirmed he was notified about his Mother's (Resident #24) incident of being kissed and touched, stating .I was there at the facility a month or so ago sitting with my Mother in the dining room. A man [Resident #38] in a wheelchair came rolling up beside her. She acted like she didn't want him near her. She pulled away and leaned away from him and whispered to me that he kissed her and touched her and that she didn't want him to do that again. I asked him to please go away that she doesn't want you near her .the DON called me this week about this incident of her being kissed and touched by a man who resides at the nursing home . During an interview on 4/16/2024 at 10:02 AM, the Administrator was asked when should staff report inappropriate touching and kissing of a severely cognitively impaired resident. The Administrator stated, .we usually have calls before we make a finalization to see if actual harm is involved .checking with my regulations and checking with corporate and legal, we wondered about the kiss and if that actually should have been reported we usually contact corporate and legal before making that finalization. During an interview on 4/16/2024 at 5:48 PM, the DON was asked when Resident #24's inappropriate touching and kissing was reported. The DON stated, .when I was doing staff interviews and a CNA told me that she had seen it happen a while ago .we were talking about reporting abuse timely, and she thought she told the nurse supervisor . The DON was asked when the CNA should have reported the alleged abuse of inappropriate touching and kissing. The DON stated, It should have been reported immediately . Review of the facility's abuse investigation dated 4/10/2024, (during the survey investigation) revealed the facility failed to identify, report, and thoroughly investigate an allegation of abuse for Resident #24 on the date the abuse occurred. The facility failed to notify Adult Protective Services (APS) on 4/10/2024. The facility did not complete an occurrence report, the facility did not know the exact date of the abuse allegation. 7. Review of the medical record revealed Resident #25 was admitted on [DATE], with diagnoses of Heart Failure, Stroke, Hemiplegia, Anxiety, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #25 was assessed with a BIMS score of 14, indicating th[TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to ensure all residents' right to be free from abuse for 6 of 16 (Resident #6, #13, #20, #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to ensure residents' right to be free from abuse resulted in Immediate Jeopardy (IJ) when on 1/25/2024, Resident #38, a cognitively impaired resident who self-propels in his wheelchair, began episodes of inappropriate sexual behaviors that continued after being started on Medroxyprogesterone (a hormone, that can be administered to males for sexually inappropriate behaviors) 10 milligrams (mg) daily, for inappropriate sexual behavior on 1/26/2024. On an unknown date, Resident #6, a vulnerable cognitively intact resident, was in the Dining Room when Resident #38 rubbed her arms and legs, when Resident #38 wheeled up behind Resident #6 and grabbed her wheelchair, and on two different occasions when Resident #38 entered Resident #6's room and rolled directly up to her bed after she had asked him to leave. These incidents brought up painful childhood memories of being sexually abused by a family member for Resident #6. Observation revealed Resident #6 was tearful and uncomfortable while talking about Resident #38's behaviors. On an unknown date, Resident #13, a vulnerable and moderately cognitively impaired resident reported, that while in the Dining Room, Resident #38 rolled up in his wheelchair and cupped Resident #13's testicles. Observation revealed Resident #13 was emotional, embarrassed, and shameful over Resident #38's behavior. On 3/27/2024, Resident #20, a vulnerable, aphasic (nonverbal) resident with moderate cognitive impairment, was observed in the Dining Room upset and pointing in the direction of Resident #38. Resident #20 confirmed through gestures to a staff member that Resident #38 said an inappropriate statement about her chest (breast) area. Interview revealed Resident #20 appeared distressed and upset by Resident #38's behaviors. On an unknown date, Resident #24, a vulnerable and severely cognitively impaired resident, was in the Dining Room when staff observed Resident #38 rub her back and then kissed her on the lips. An interview revealed Resident #24 appeared distressed by Resident #38's behaviors, but did not recall the date. On 4/14/2024, Resident #25, a cognitively intact resident reported that on an unknown date Resident #38, entered his room and touched his knee and attempted to give him a kiss while Resident #25 was lying in bed. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-600 on 4/15/2024 at 11:01 AM, and notified of an addendum for F-600 on 4/17/2024 at 4:39 PM in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of K which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a plan of correction (PoC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes as required by state and federal regulations .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury . Review of the facility's policy titled, Resident Rights revised on 1/1/2022, revealed Employees shall treat all residents with kindness, respect, and dignity .If any Staff member witnesses or becomes aware of any violation of this policy, they are required to immediately report it to their supervisor or the Administrator of the facility, and cooperate in any investigation that may be conducted . 2. Review of the (Named Hospital's) medical record notes revealed the following documentation of Resident #38's behaviors, prior to Resident #38 being admitted to the nursing home: On 1/22/2024, a Nursing Docs (documentation) note revealed, .pt [patient, Resident #38] is very 'handsy' with female staff. Pt [patient, Resident#38] likes to feel female staff . On 1/24/2024, a hospital Neurological note revealed, .Inappropriate shifting of attention . On 1/24/2024, a hospital Psychosocial note revealed, .[Patient Interaction w (with) Healthcare Team] Inappropriate interaction with healthcare team . On 1/25/2024 at 5:03 AM, a hospital Nursing Docs note revealed, .Making sexual remarks to staff . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with the diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the Care Plan dated 1/25/2024 revealed, .Resident has an ADL [activities of daily living] self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024. Placed resident on 30 minute checks throughout the night then changed to q [every] shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 .Revision on 2/14/2024 .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner]/PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] .Date Initiated 1/26/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident [Resident #38] noted to have frequent episodes of inappropriate behaviors towards staff this night. On call and MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych [psychiatric] consent was obtained on 1/25/2024 .from son .Referral submitted .SSD [Social Services Director] received call from [Named Psychiatric Services] NP [Nurse Practitioner] .recommends .resident be started on Medroxyprogesterone .10 mg daily for sexually inappropriate behaviors .shared for [Named Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed the Medical Director was in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10 mg daily for increased inappropriate sexual behaviors. Review of the practitioner's order dated 1/26/2024, revealed .medroxyprogesterone (hormone to decrease sexual desire) .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 . Review of a [Named Mental Health Services facility] dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #38 had behaviors directed toward others (abusing others sexually), wandering behaviors, significantly intrudes on the privacy or activity of others, was incontinent of both bowel and bladder, had active diagnosis of Non Alzheimer's Dementia, and vision problems. Review of a facility's Mood/Behavior Monitoring sheet for 1/25/2024 to 1/31/2024 revealed, .wandering .0 [symbol for zero indicating no behavior of that sort occurred] . There was no documentation on the Mood/Behavior Monitoring sheet listed for Resident #38's sexually inappropriate behaviors. Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of the facility's Medication Review Report summary revealed a practitioner's order dated 2/14/2024, for .PARoxetine [antidepressant used to decrease sexual desire] .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . The Paroxetine was added in addition to the Medroxyprogesterone. Review of a facility's SOC (Standard of Care) Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Yes .Psych Services evaluated him on 2/13/2024 and recommended Paxil 10 mg to see if it would help to decrease these behaviors .Resident has exhibited sexual behaviors with staff as well as wandering in another residents room to use her bathroom .SSD will continue to monitor and follow . Review of the facility's Mood/Behavior Monitoring sheet for February 2024 revealed, .wandering .0 .grabbing staff, trying to kiss on face/lips . Review of the medical record revealed the facility failed to document date and time for the inappropriate behavior of grabbing and attempting to kiss staff in February 2024 by Resident #38. Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest [breast]. History of behaviors: Yes .Intervention .Separated residents .Resident is accused of making an inappropriate comment about a female resident's chest .SSD will continue to monitor . There was no documentation the facility revised Resident #38's plan of care interventions for the continued sexual behaviors. Review of the facility's Medication Review Report summary dated 4/8/2024 revealed, .medroxyprogesterone (hormone to decrease sexual desire) .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 .PARoxetine (antidepressant used to decrease sexual desire) .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . Record review revealed there was no further documentation related to Resident #38's inappropriate sexual behaviors until the survey team began investigating on 4/8/2024. Review of the Care Plan for Resident #38 dated 4/9/2024 revealed: .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . Observations beginning on 4/9/2024 and during the survey revealed there was a staff member outside Resident #38's room or in the resident's room. During an interview on 4/8/24 at 4:07 PM, the Social Service Director (SSD) was asked what they would do if a resident spoke to them about an incident that made them upset or feel uncomfortable and if reported that a resident felt unsafe or was upset regarding another resident did something to them, what would the SSD do. The SSD confirmed that she would speak with the Administrator and the Director of Nursing (DON) and sometimes she will interview other residents in the affected area. The SSD was asked had Resident #38 been involved in any other occurrences in the facility. The SSD confirmed that when Resident #38 was initially admitted to the facility on [DATE], he was saying sexually inappropriate things to female staff members and that he touched them in inappropriate areas. The SSD was asked what was done about the inappropriate behavior. The SSD confirmed she was instructed by the Director of Nursing (DON) to speak with the resident's responsible party and obtain consent for a psychiatric evaluation. The SSD confirmed that as a result of the evaluation the resident was started on a hormone to decrease sexual arousal. The SSD was asked if the medication alleviated the behaviors. The SSD confirmed that it was almost 3 months later before Resident #38 had another episode of behaviors towards residents, but there were additional incidents with staff members that occurred. The SSD was asked what was done. The SSD confirmed that the facility kept him separate and continued to monitor his inappropriate sexual behaviors. The SSD confirmed one of the staff members was Certified Nursing Assistant (CNA) A. The SSD was asked about incidents with other residents. The SSD confirmed on one occasion a resident (Resident #44) returned to her room and found Resident #38 in her bed. The SSD was asked was his wandering behavior addressed. The SSD confirmed that it was documented and discussed in the morning meeting and he was care planned for wandering into other resident rooms and a STOP sign was placed at her (Resident #6) door but nothing was done to prevent it from occurring to other residents. The SSD confirmed that a psych service referral was made and lab work to rule out a urinary tract infection. The SSD was asked what the psych services recommendation was. The SSD confirmed that they recommended for him to be placed on Paroxetine (medication used for depression with a side effect of decrease sexual arousal) low dose to decrease his inappropriate sexual behaviors. The SSD confirmed that Resident #38 remains on the medication. The SSD was asked had any other residents reported any inappropriate behavior or wandering behavior by Resident #38. The SSD confirmed that Licensed Practical Nurse (LPN) J reported to her that Resident #6 reported that Resident #38 entered her room on an unknown night and woke her up and that on an unknown day he came up behind her and touched her on her shoulder and that it scared her. The SSD confirmed that Resident #6 confirmed that she has a past trauma of sexual abuse and it made her think about those past occurrences. The SSD was asked did you report the occurrences with Resident #38 towards Resident #6 that made her fearful and brought back memories of a traumatic past. The SSD confirmed it was discussed in the morning meeting which included the DON and the Administrator. The SSD was asked what time of day this was reported to you. The SSD confirmed that it was reported at the end of the day around 6:00 PM and that a STOP sign was placed across Resident #6's doorway. The SSD confirmed she did not report it immediately to the Administrator or the DON, that it wasn't reported until the next day in the morning meeting. The SSD confirmed that she was not asked to give a statement and that there was no documentation for the occurrence that Resident #6 reported to her. The SSD confirmed that she failed to speak to other residents to ensure nothing had occurred with them and that she should have. The SSD was asked if she (Resident 36) reported any other occurrences with Resident #38 that would have made her (Resident #6) feel fearful or upset. The SSD confirmed that she should have documented what Resident #6 said and reported immediately what she was told by Resident #6. The SSD was asked if there was anything further reported concerning Resident #38 and his inappropriate behaviors. The SSD confirmed that there was an education meeting held by her and the Activities Director with a few female residents for gossiping about Resident #38, and confirmed that the female residents were told that Resident #38 has dementia and they should redirect him if this happens to them again, and put on the call light for assistance. The SSD confirmed the additional female residents included Resident #8, #20, #31, and #44. The SSD was asked if she had asked any of the 5 female residents in the meeting if they felt fearful or uncomfortable around Resident #38. The SSD stated, No, but looking back, I should have . The SSD was asked if the facility is considered the resident's home, should the resident feel safe in their home. The SSD stated, Yes . The SSD confirmed that Resident #38 was found in Resident #25's bed over the 4/13/2024 weekend and that it has not been reported to the Administrator or the DON. The SSD confirmed that she read on the dashboard that Resident #25 was upset that Resident #38 came into his (Resident #25's) room and touched him and tried to kiss him. The SSD was asked if this should have been reported and discussed before now. The SSD confirmed it should have. The SSD was asked in looking back at residents reporting that Resident #38 was found in their rooms, in their beds, making them feel unsafe and fearful and making inappropriate sexual gestures and comments since Resident #38's admission, should the facility have put interventions in place to keep the residents safe and free from abuse. The SSD confirmed she should have been a more vocal advocate and it is the responsibility of all staff to ensure the safety of all residents. The SSD was asked are you the residents' advocate. The SSD stated, I'm supposed to be . The SSD was asked who is responsible for keeping the resident's safe. The SSD stated, We all are. The SSD was asked do you feel that you kept the residents safe. The SSD stated, No, ma'am . During an interview on 4/8/24 at 4:59 PM, the Activities Director was asked if any resident reported any inappropriate behavior from January to April 2024. The Activities Director confirmed that Resident #6 made her and the SSD aware of instances where Resident #38 made her feel uncomfortable. The Activities Director was asked when did the meeting with the female residents take place. The Activities Director confirmed it was after Resident #38 entered Resident #44's room. The Activities Director was asked who attended the meeting. The Activities Director confirmed the meeting included Resident #6, Resident #20, and Resident #31. The Activities Director was asked if this was reported to anyone. The Activities Director confirmed it had been reported to the DON and the Administrator. The Activities Director was asked did either one of the ladies say that he makes them feel fearful or unsafe. The Activities Director stated, [Resident #6], it definitely made her feel uncomfortable . The Activities Director was asked did you and the SSD speak with any other residents about how Resident #38 made them feel or if there was an occurrence with him wandering in their rooms. The Activities Director stated, .yeah, probably . The Activities Director was asked was Resident #38 exhibiting any inappropriate sexual behavior on admission. The Activities Director stated, Yes, from day 1 .Yes, inappropriate touching .the nursing staff before he got her [Resident#6] .they did tell me that . The Activities Director was asked did Resident #6 tell you she felt uncomfortable around him related to her childhood. The Activities Director stated, Yes .we had a long discussion .her dad was abusive to her and her first husband was abusive to her .her dad was sexual [sexually] abusive .her husband was mental and physical [mentally and physically] abusive .it brought up a bunch of stuff that she had worked hard to get past . The Activities Director was asked what you told her. The Activities Director confirmed she instructed her to keep the STOP sign up . The Activities Director was asked what the intervention was for Resident #38 for the prevention of inappropriate sexual behavior and sexual abuse. The Activities Director stated, .when we see him we try to use redirection with him .and 1:1 [one on one monitoring] .and encourage him to keep his hands down . The Activities Director was asked what the facility is doing to keep the residents safe. The Activities Director confirmed she has heard staff tell Resident #38 to keep his hands down and she has spoken with the DON about it. The Activities Director confirmed she has spoken with the Administrator and she stated, He was aware that we had a little meeting with the ladies. The Activities Director was asked do you feel like you should have reported it to him with him being the Abuse Coordinator. The Activities Director stated, This is new, it's never been this big .learning to deal with this has been a new process for me. The Activities Director confirmed that it had been reported to the DON and the Administrator and she should have definitely taken things to the Administrator, and she thought things were being taken care of when she reported them to the SSD. The Activities Director was asked should the ultimate goal for prevention of any kind of allegation of abuse is to keep the resident safe. The Activities Director stated, .basically you just keep an eye on him, turn on the TV [television] and talk about sports and he likes to come to activities and bingo and church . The Activities Director was asked should a resident feel safe and comfortable in their home. The Activities Director stated, Yes, absolutely .I am sorry . During an interview on 4/9/2024 at 8:52 AM, with Resident #38's Responsible Party (RP), confirmed that he is the RP of Resident #38, the RP was asked if the facility gives you a report of any occurrences or incidents that involve your Resident #38. The RP confirmed that the facility calls him with any changes or occurrences that involves his father. The RP was asked if he had been notified of any allegations that his father had been touching and saying sexually inappropriate things to residents and staff members. The RP confirmed that the facility called him a few months ago when he first got there and told me about some things he had said and did, the RP stated, I think they called it hypersexuality . and confirmed the facility had ordered Resident #38 some medication for the issue. The RP confirmed that his father had been a patient in the hospital prior to being admitted to the facility. The RP was asked did his father experience any of the behaviors while being a patient in the hospital. The RP stated, Yes . The RP confirmed that a meeting was held as part of the intake admission process and that department heads were in the meeting to include the Administrator. The RP confirmed that he is more than sure that the hospital also reported his father's behaviors to the facility. The RP was asked what the facility said they would do for the behaviors. The RP confirmed they said they would call the Medical Director and that they would prescribe medication for Resident#38's behaviors. The RP confirmed the facility called yesterday and told him of an incident that occurred a few months ago, that was just reported of his father's inappropriate behavior toward another resident that made her feel uncomfortable. During a telephone interview on 4/11/2024 at 12:24 PM, the Psychiatric Nurse Practitioner (Psych NP) was asked is Resident #38 is being seen by psych. The Psych NP confirmed that Resident #38 is being seen by psych services and has been on the case load since his admission (1/25/2024). The Psych NP confirmed Resident #38 was seen for impulsive dementia and for a neuro (neurological) cognitive screening. The Psych NP confirmed he was referred on 1/26/2024 for wandering behaviors and impulsiveness. The Psych NP confirmed that Resident #38 was having inappropriate sexual behaviors and was placed on medroxyprogesterone and about 2 weeks later he was placed on Paxil when he was seen in February. The Psych NP was asked if he was aware that Resident #38's behaviors toward staff and residents made a female resident feel fearful and uncomfortable. The Psych NP confirmed Resident #38's behaviors toward the female resident (Resident #6) who had a history of abuse, both sexual, verbal, and physical, definitely triggered some anxious feelings, and it did cause restless feelings. The Psych NP confirmed that if the resident showed those feelings (fear and being uncomfortable) and cried it would have released an emotional response. The Psych NP was asked would you expect staff and the facility to ensure Resident #6 felt safe, if Resident #38 triggered those feelings and emotional response. The Psych NP stated, Yes, I would . The Psych NP confirmed that it has been addressed in the past, her need for medication but the resident was reluctant but has been more receptive this time when it was addressed. The Psych NP was asked if it was because of this occurrence. The Psych NP stated, Yes. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, .Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Interventions . Observe for signs of mood changes or distress . Review of the Care Plan for Resident #6 dated 2/25/2024, and revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Interventions .Trauma Informed Care assessment completed .consented to antidepressant .04/09/2024 . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #6 was cognitively intact. Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024 revealed, .Pt [patient- Resident #6] examined via [by way] telehealth .regarding inappropriate touching via another resident .Pt does disclose past event to examine today .Pt has declined pharmacologic interventions in past; staff report pt open to such at this time .Zoloft .25 mg [milligram] Q [every] day anxiety . Review of the Physician Order for Resident #6 dated 4/9/2024 revealed, .Sertraline Tablet 25 MG [milligram] .Give 1 tablet by mouth one time a day related to ANXIETY DISORDER . Review of the April Medication Administration Record revealed, Resident #6 received Sertraline 25mg on 4/10/2024. Review of Social Services Progress Notes dated 4/10/2024 revealed, .spoke with resident .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of Social Services Progress Notes dated 4/12/2024 revealed, .spoke with resident on 4/11/24 .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident [Resident #38] . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when he came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a CNA came and took him out of her room and that she had told the Social Service Director and the Activity Director. During an observation and interview on 4/9/2024 at 8:09 AM, revealed Resident #6 lying in bed eating breakfast. Resident #6 stated, .the DON .[Named Social Worker] .[Named ADON] .came in this morning . Resident #6 was asked do you feel better. Resident #6 stated, Yes and no .offered counsel .[Named DON] told me she didn't know anything about anything .and that tells they [referring to the Social Service Director and the Activity Director] didn't tell anybody .I don't want to leave here .I'm happy this is my room .[Named DON] suggested counseling .I have not said a thing to him about it .[Named Psych NP] .I want to do something .I want to feel safe .don't want to look over my shoulder that someone is following me . Resident #6 was asked about the meeting that she had with the Social Service Director and the Activity Director. Resident #6 stated, It was more like a welcome home .[Named Resident #31] .she had been gone a long time .confirmed they talked about him [Resident #38] .[Named Social Service Director] brought up it was an education meeting .they wanted to educated me .how to deal with this man [Referring to Resident #38] .I've never been around anyone with dementia how to get away from him .I ended up telling the group my story .[Named Social Service Director] already knew it .I've kept everything to myself .I was embarrassed .my kids didn't know it .my childhood, what happened .so here I am in this group of ladies, start bawling like a baby everything come out .I can understand them not wanting to stir up trouble .but I don't want to stay in my room all [the] time .I like doing things . Resident #6 was asked do you feel safe and comfortable now. Resident #6 stated, .a little bit .it's going to be slow .I still have to look over my shoulder . During observation and interview on 4/11/2024 at 8:52 AM, revealed Resident #6 was lying in bed looking at her phone and stated, .took my first antidepressant this morning .I feel bad don't want to get anyone in trouble .me and [Named SSD] her had a good talk yesterday .I felt like when I left the party .she [Referring to the Social Service Director] didn't understand where I was coming from .like she just dismissed me .and wanted me to concentrate on him [Resident #38] and his feeling .but we talked yesterday and she kept apologizing and didn't mean to make me feel like I didn't count .I had [Named the Administrator] and [Named the DON] come see me yesterday and he told me .what everyone is telling me .that I did the right thing in telling what happened .that way they can get an eye on things and be more alert on what's going on and they want me here .I just don't want to look behind and see him [Referring to Resident #38] sneaking up behind me .I will be talking to [Named Psych NP] .I feel like someone is listen to me now and they want to help me .it didn't go any further .when I found out they [referring to the SSD and Activities Director(AD)] didn't tell .I thought they would [tell] [Named the DON] .[Named the Administrator] .first incident rubbing his hands on me .has come in my room twice .one was a couple of weeks ago .first time he walked in my room .I was surprised, never seen him [Resident #38] walking .my friend was here helping me set up my phone and I told him to get out this wasn't his room .next time I was in bed .he [Resident #38] rolled right up to my bed and I did same thing raised my voice and told him to leave but he didn't listen to me and rolled up to my bed .2 or 3 minutes he was leaving and [Staff E] took him out. During an interview on 4/08/2024 at 5:4[TRUNCATED]

Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to report allegations of abuse to the appropriate agencies for 7 of 16 (Residents #5, #6, #13, #20, #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to report incidents of abuse to the State Survey Agency and to other State Agencies (Adult Protective Services and Ombudsman) resulted in Immediate Jeopardy (IJ) when the facility failed to report allegations of verbal abuse for Resident #5, and failed to report allegations of sexual abuse for Resident #38 who was a cognitively impaired resident who self-propelled in his wheelchair and had frequent episodes of inappropriate sexual behaviors towards staff upon his admission to the facility on [DATE]. On an unknown date, it was documented Resident #38 touched Resident #6, (cognitively intact) on her arms and legs without consent and on another occasion wheeled up behind Resident #6 in his wheelchair and grabbed her wheelchair. On two (2) separate occasions Resident #38 entered Resident #6's room uninvited, and on one of those occasions wheeled directly up to Resident #6's bed. These actions by Resident #38 caused Resident #6 to be fearful and uncomfortable and resurfaced painful childhood memories of being sexually abused by her father. On another unknown date, Resident #38 grabbed and cupped Resident #13's testicles, leaving Resident #13 feeling embarrassed and shameful. Resident #38 made inappropriate comments to Resident #20 about her chest/breast area leaving Resident #20 agitated and angry. Resident #24, a severely cognitively impaired Resident was given an unwanted kiss on the lips by Resident #38; and Resident #38 self-propelled his wheelchair into Resident #25's room and touched his knee and attempted to give him a kiss. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-609 on 4/17/2024 at 4:39 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of K, which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a plan of correction (POC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, stage agency, adult protective services and to all other required agencies .within specified time frames as required by state and federal regulations .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury . Review of the facility's policy titled, Resident Rights, revised on 1/1/2022, revealed Employees shall treat all residents with kindness, respect, and dignity .If any Staff member witnesses or becomes aware of any violation of this policy, they are required to immediately report it to their supervisor or the Administrator of the facility, and cooperate in any investigation that may be conducted . 2. Review of the facility's undated Administrator Job Description revealed, .Administration .Responsible for the efficient and profitable operation of the facility, facility compliance with [Corporate name] policies and State and Federal rules and regulations, and providing the highest quality of care possible .Manages day to day operations of the facility .Directs and guides the activities of clinical, administrative, and service departments .Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement, and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee .Knowledge of Long Term Care and Medicaid and Medicare regulations and standards .Ability to communicate effectively with residents and their family members, and at all levels of the organization .Ability to react decisively and quickly in emergency situations . Review of the facility's undated Director of Nursing [DON] Job Description revealed, .Manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations and policies and procedures .Plans and facilitates meetings and committees to address resident care issues .Manages the Nursing Department with the goal of achieving and maintaining the highest quality of care possible .Develops and manages systems to assure clinical competencies .Participates in developing, implementing and evaluating programs that promote the recruitment, retention, development and continuing education of nursing staff members .Initiates studies to evaluate effectiveness of nursing services in relation to their objectives and costs .Investigate and resolve residents/family/employee concerns .Ensures that annual competency evaluation and performance reviews are completed in the appropriate time frame .Pro-actively addresses survey and/or standards of care issues .Plans and guides the professional development of nursing staff . Assures that all clinical protocols and nursing policies and procedures are followed .Assure Pharmacy, dietary, physician consults are followed in timely manner .Assumes complete responsibilities of the Center in absence of Administrator . Review of the undated Social Services (SS) job description revealed the SS was responsible to provide direct psychosocial intervention, perform resident assessments at admission, upon condition change and/or annually, create, review and update care plan and progress notes, assist resident's families in coping with skilled nursing placement, physical illness and disabilities of the resident, and the grieving process and to conduct in-service programs to educate staff regarding psychosocial issues and patient rights. 3. Review of the medical record revealed Resident #38 was admitted the facility from the hospital on 1/25/2024, with diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the hospital's transfer notes revealed during the hospitalization , Resident #38 experienced inappropriate sexual gestures towards hospital staff. Review of the Care Plan dated 1/25/2024 revealed, .[Resident #38] has an ADL [activities of daily living] self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident noted to have frequent episodes of inappropriate behaviors towards staff this night. On call MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych consent was obtained on 1/25/2024 .from son .Referral submitted .SSD received call from [Named Psychiatric Services] NP .recommends .resident be started on Medroxyprogesterone 10 mg daily for sexually inappropriate behaviors .shared for [Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed the Medical Director was in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10mg daily for increased inappropriate sexual behaviors. Review of the Psychiatric Services note for Resident #38 dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the revision to the care plan dated 1/26/2024 revealed, Placed resident on 30 minute checks throughout the night then changed to q (every) shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 . Review of the admission MDS dated [DATE], revealed Resident # 38 was assessed with a BIMS score of 8, indicating the resident was moderately cognitively impaired, and had behaviors directed toward others .(e.g.[example] abusing others sexually) .wandering behaviors .significantly intrude on the privacy or activity of others .incontinent of both bowel and bladder, and had active diagnoses of Non Alzheimer's Dementia, and vision problems . Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of the revision to the care plan dated 2/14/2024 revealed, .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner]/PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] . Review of a facility's SOC (Standard of Care) Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Yes .Psych Services evaluated him on 2/13/2024 and recommended Paxil 10 mg to see if it would help to decrease these behaviors .Resident has exhibited sexual behaviors with staff as well as wandering in another residents room to use her bathroom .SSD will continue to monitor and follow . Review of a facility's Mood/Behavior Monitoring sheet for 1/25/2024 to 1/31/2024 revealed, .wandering .0 [symbol for zero indicating no behavior of that sort occurred] . Review of the facility's Mood/Behavior Monitoring sheet for February 2024 revealed, .wandering .0 .grabbing staff, trying to kiss on face/lips . There was no documentation of the date and time for the inappropriate behavior of grabbing and attempting to kiss staff in February 2024 by Resident #38. Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest. History of behaviors: Yes .Intervention .Separated residents .Resident is accused of making an inappropriate comment about a female resident's chest .SSD will continue to monitor . Review of the facility investigations revealed the facility failed to report an allegation of abuse involving Resident #38 related to inappropriate sexual behaviors. Review of the revision to the care plan dated 4/9/2024 revealed, .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . During an interview on 4/11/24 at 3:55 PM, LPN J was asked if Resident #38 ever displayed inappropriate sexual behavior. LPN J stated that it was reported to her by a staff member that Resident #38 grabbed Resident #6's chair and Resident #6's arm while in the dining room. LPN J was asked did she report this to anyone. LPN J stated, No, I didn't think it was something to report .well now that I think about it .but I see a lot of residents with dementia so that is why I did not report it . LPN J was asked should she have reported this to administration. LPN J stated, Yes, I guess I should have . LPN J was asked if Resident #38 had expressed any sexually inappropriate gestures. LPN J stated, Yes when he first got here but that is not uncommon with men with dementia so I did not think about it .I see it all the time but now I see that I should have .I just redirected him and told him it was not nice .he was just talking dirty but I am use [used] to that, is just what men with dementia do . LPN J was asked did Resident #38 ever wander into residents' room. LPN J stated that Resident #38 would wander into other residents' room and that Resident #38 was removed and redirected when it was witnessed. LPN J was asked was Resident #38's wandering behavior reported to administration. LPN J confirmed she had not reported it to anyone. LPN J was asked should Resident #38 be wandering into other residents' rooms. LPN J stated,[Resident #38] has dementia .I see it all the time with people with behaviors . During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed that any allegation of abuse should be reported within 2 hours if injury and within 24 hours if no harm or injury. The Administrator was asked who allegations of abuse should be reported to. The Administrator stated, The State, if allegation of a crime then the local police .the ombudsman and other required agency .within 24 hours to state agency and APS [adult protective services] . The Administrator confirmed there should be a documented investigation. The Administrator confirmed that if any state agency including APS was notified of the allegation it should be documented and included in the investigation. During an interview on 4/15/24 at 10:09 AM, the Administrator was asked what was considered a reportable occurrence. The Administrator stated, Allegation of abuse .we usually have calls before we make final determination if actual harm involved .I will have to look at regulations on these we do not have many of these .I will check regulations and get in touch with corporate and legal, they are a little more familiar with that and with the kiss, is that actual harm should that be reported .we have a call this afternoon . The Administrator was asked should those be treated as allegation of abuse. The Administrator stated, No. The Administrator was asked what about the allegations for Resident #38. The Administrator stated, .I could not rule out he had diminished capacity and that would not be reportable . 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with the diagnoses of Multiple Sclerosis, Insomnia, Diabetes, Abnormal Gait and Mobility, and Muscle Weakness. Review of the Care Plan dated 2/9/2024 revealed, .ADL self-care deficit .Impaired communication related to making self-understood and understanding others .incontinent of bowel and bladder .impaired musculoskeletal status related to osteoarthritis, Cervical degenerative disc disease .impaired neurological status related to Multiple Sclerosis . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, required maximum assistance with Activities of Daily Living skills (ADLs) and required the use of a diuretic. Review of the facility's investigation dated 5/28/2023, revealed Resident #5 reported to staff that on 5/26/2023, that a staff member spoke to her in an inappropriate way and would not give her peri care after attempting to have a bowel movement. Resident #5 voiced complaints that the same staff member spoke to her in a rude manner. An investigation was launched which included witness statements, statement from the perpetrator and statement from Resident #5, an incident report, and a report to the State Survey Agency and to the Ombudsman. The facility's investigation revealed the facility failed to report the allegation of verbal abuse to Adult Protective Services (APS). During an interview on 4/10/2024 at 9:19 AM, Licensed Practical Nurse (LPN) I confirmed she was the nurse on duty and was in Resident #5's room administering medications when Resident #5 reported that CNA L had spoken to her in a rude manner and refused to give her incontinent care after attempting to have a bowel movement. LPN I confirmed that Resident #5 said that the incident made her feel uncomfortable and she was not agreeable with CNA L taking care of her and preferred for CNA L not to return to her room. LPN I confirmed that she notified the Administrator and the Registered Nurse (RN) on-call but was unsure of who the RN call was at the time. During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed that any allegation of abuse should be reported within two (2) hours if injury and within 24 hours if no harm or injury. The Administrator was asked who allegations of abuse should be reported to. The Administrator stated, The State, if allegation of crime, then the local police .the ombudsman and other required agency .within 24 hours to state agency and APS . The Administrator confirmed there should be a documented investigation. The Administrator confirmed that if any state agency including APS was notified of the allegation it should be documented and included in the investigation. The Administrator was asked if he reported to APS the allegation of verbal abuse for Resident #5. The Administrator stated, Oh, yes I always print that out .I do not see it in there .we were told by APS to not report anything to them unless it was major . The Administrator was asked should allegations of abuse be reported to the state agencies including APS according to the allotted time frames set forth of 24 hours if no injury and two (2) hours if injury. The Administrator stated, Yes . 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, . Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Observe for signs of mood changes or distress . Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 was assessed with a BIMS of 15 which indicated the Resident was cognitively intact. Review of the Care Plan revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Trauma Informed Care assessment completed .consented to antidepressant .4/9/2024 . Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024, revealed, .[Resident #6] examined via [by] telehealth .regarding inappropriate touching via another resident [Resident #38] .[Resident #6] does disclose past event to examiner today .[Resident #6] has declined pharmacologic interventions in past; staff report [Resident #6] open to such at this time .Zoloft [medication used for depression] .25 mg [milligram] Q [every] day anxiety . Review of the Physician Order dated 4/9/2024 revealed, .Sertraline [name brand used for Zoloft] Tablet 25 MG .Give 1 tablet by mouth one time a day related to ANXIETY DISORDER . Review of Social Services Progress Notes dated 4/10/2024 revealed, .spoke with resident [Resident #6] .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of Social Services Progress Notes dated 4/12/2024 revealed, .spoke with resident on 4/11/24 [2024] .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident [Resident #38] . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when Resident #38 came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a CNA came and took Resident #38 out of her room and that she had told the Social Service Director (SSD) and the Activity Director. During an interview 4/8/2024 at 4:07 PM, the Social Service Director (SSD) was asked what occurred with Resident #6 and Resident #38. The SSD confirmed Resident #38 entered Resident #6's room without her permission and was unsure of the date of occurrence. The SSD was asked if Resident #38 had touched Resident #6 before without her permission. The SSD confirmed Resident #38 had touched Resident #6's shoulder. The SSD stated she was informed of this incident by LPN J a few weeks after this occurred. The SSD stated she spoke with Resident #6 and the Resident had told her that she was going down the hall and Resident #38 came up behind her touched her shoulder and that it frightened her and that there had been a traumatic issue in her past and it caused her to think about those things. The SSD was asked after Resident #6 had reported this what did she do with the information. The SSD stated she reported the incident in the morning meeting but was unsure of the exact date that she reported it in the meeting. The SSD was asked if the DON or the Administrator were present in the meeting when it was reported. The SSD stated, They [DON and Administrator] were involved . The SSD was asked if there was an investigation into this allegation/incident. The SSD stated that if there was an investigation she was not involved in the investigation. During an interview on 4/8/2024 at 4:59 PM, the Activities Director was asked if a resident reported to you that another resident had made inappropriate gestures, comments, or touching what would you do. The Activities Director stated, We encourage them to come to me or [Named SSD] to talk about it, we had that to happen .we separate as much as we can .one gentleman that likes to reach out and hold the ladies hands and we try to do a lot of redirection .[Named Resident #38], we try to do a lot of redirection . The Activities Director was asked had any residents mentioned that Resident #38 makes them feel uncomfortable. The Activities Director stated, [Named Resident #6], and continued, [Resident #38] wandered in [Resident #6] room looking for a bathroom .it was at night . [Named Resident #6] told me the next day and we discussed it .and [the incident] was reported to [Named Administrator] and [Named DON]. The Activities Director was asked did she say it made her feel uncomfortable or fearful. The Activities Director stated, .It definitely made her feel uncomfortable . During an interview on 4/8/2024 at 5:44 PM, the DON confirmed the Administrator was the Abuse Coordinator and if there were any reports of an allegation of abuse it should be reported to the Administrator. The DON was asked if she was aware of any incidences with Resident #38 being uninvited in Resident #6's room and making Resident #6 feel uncomfortable. The DON stated she was not made aware of any of the occurrences surrounding Resident #6 and Resident #38 making her feel uncomfortable, being in her room or touching her without permission. The DON stated she was not informed about Resident #6 feeling unsafe. The DON was asked if she had been made aware that the SSD and the Activities Director had a meeting with five (5) female residents about how Resident #38 made them feel uncomfortable. The DON stated she was made aware of the meeting prior to this interview. The DON was asked should those incidences have been reported and investigated if they made the residents feel unsafe and uncomfortable. The DON stated, Yes . The DON was asked if there was an allegation of abuse made what should the facility do when it is reported to a staff member. The DON stated, They should report that to [Named Administrator], he is the Abuse Coordinator . The DON was asked what her role was when an allegation of abuse was made. The DON stated, I help with the investigation. The DON was asked did she assist with the investigation concerning Resident #6. The DON confirmed she had no part of the any investigation and there were no statements obtained for Resident #6's allegation/incident. The DON was asked should there have been an investigation and the DON stated, Yes. The DON was asked if resident behaviors are discussed in the morning meetings. The DON confirmed that behaviors are discussed during the morning clinical meeting where all administrative staff are in attendance including the Administrator. The DON was asked was Resident #38's behaviors discussed during those clinical meetings. The DON put her head down, gave a loud sigh, and did not answer the question. During an observation and interview on 4/9/2024 at 8:09 AM, revealed Resident #6 lying in bed eating breakfast. Resident #6 stated, .the DON, [Named SSD], [Named Assistant Director of Nursing (ADON)] .came in this morning . Resident #6 was asked if she felt better. Resident #6 stated, Yes and no .offered counseling .[Named DON] told me she didn't know anything about anything .and that tells they [referring to the SSD and the Activity Director] didn't tell anybody .I don't want to leave here .I'm happy this is my room .[Named DON] suggested counseling .I have not said a thing to him about it .[Named Psychiatric Nurse Practitioner (NP)] .I want to do something .I want to feel safe .don't want to look over my shoulder that someone is following me . Resident #6 was asked about the meeting that she had with the SSD and the Activity Director. Resident #6 stated, It was more like a welcome home .[Named SSD] brought up it was an education meeting .they wanted to educate me .how to deal with this man [Referring to Resident #38] .I've never been around anyone with dementia how to get away from him .I ended up telling the group my story .[Named SSD] already knew it .I've kept everything to myself .I was embarrassed .my kids didn't know it .my childhood what happened .so here I am in this group of ladies, start bawling like a baby everything come out .I can understand them not wanting to stir up trouble .but I don't want to stay in my room all [the] time .I like doing things . Resident #6 was asked if she felt safe and comfortable now. Resident #6 stated, .a little bit .it's going to be slow .I still have to look over my shoulder . During observation and interview on 4/11/2024 at 8:52 AM, revealed Resident #6 lying in bed looking at her phone and stated, .took my first antidepressant this morning .I feel bad don't want to get anyone in trouble .me and [Named SSD] had a good talk yesterday .she [Referring to the SSD] didn't understand where I was coming from .like she just dismissed me .but we talked yesterday and she kept apologizing and didn't mean to make me feel like I didn't count .I had [Named Administrator] and [Named DON] come see me yesterday and he [Administrator] told me .what everyone is telling me .that I did the right thing in telling what happened .that way they can get an eye on things and be more alert on what's going on and they want me here .I just don't want to look behind and see him [Referring to Resident #38] sneaking up behind me .I will be talking to [Named Psych NP] .I feel like someone is listening to me now and they want to help me . 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses of Hypertension, Diabetes, Depression, Anxiety and Post Traumatic Stress Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 was assessed with a BIMS score of 12, indicating the resident was moderately cognitively impaired. Review of the Care Plan revised 2/6/2024, revealed the following interventions for Post Traumatic Stress Disorder, Provide a calm, safe environment when resident is emotional and frustrated, and allow time to voice feelings. Observation in the resident's room on 4/9/2024 at 10:11 AM, revealed Resident #13 alert and oriented. Resident was sitting on the side of his bed, facial expression sad and upset, folding/wringing hands together, voice trembling asking if he could talk about an incident that has been bothering him for several weeks. Resident #13 stated, .a few weeks ago while in the dining room a man [Resident #38] touched me and grabbed my private parts in his hand, after 5 or 6 seconds I took his wrist and sat it on the table, he [Resident #38] didn't get mad and went back to his normal seat. It was quite disconcerting and embarrassing. I told [Named Resident #25] that day. He was sitting there when I told [named ADON] what had happened. She [ADON] now tells me that I didn't tell her about the incident. I also told [CNA F] a nurse's aide that walks with me. This is all so embarrassing and not normal. No man should have to deal with that. I was shocked and surprised. I have been through 2 wars in my lifetime and now I have to live with this . Resident #13 was asked if there was anything else he would like to share. Resident #13 stated, .this was not the first instance with this man [Resident #38]. He has been bothering the women [Resident #6] also. I am the resident council president, and I have addressed this before with the DON on the women's behalf and by witnessing it. [The DON] would only say that they have a plan for him [Resident #38] . Review of the facility's abuse investigation dated 4/10/2024, during the survey investigation, revealed the facility failed to identify and investigate an allegation of abuse for Resident #13 when abuse occurred. The facility failed to notify Adult Protective Services (APS) on 4/10/2024. The facility did not complete an occurrence report, the facility did not know the exact date of the abuse allegation. The facility failed to report an allegation of abuse for Resident #13 on the date the abuse occurred. During an interview on 4/11/2024 at 10:30 AM, the Psychiatric NP confirmed treating Resident #13 for Post Traumatic Stress Disorder (PTSD) related to being in 2 wars and he was cognitively intact. When asked if he had been notified of Resident #13's allegation of inappropriate touching by Resident #38, the Psychiatric NP stated, No one notified me of the incident. During an interview on 4/11/2024 at 4:31 PM, CNA F was asked if Resident #13 had told her about Resident #38 touching him inappropriately. CNA F stated, . [Resident #13] is acting upset today I'm trying to keep my distance from him .[Resident #13] said he told me about being touched on his privates by [Named Resident #38[TRUNCATED]

Based on review of the Board of Examiners of Nursing Home Administrators (BENHA) Form, policy review, job description review, and interview, the facility's Administration failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents were free from verbal, physical, and sexual abuse. Administration failed to provide oversight that established and implemented policies and procedures to ensure facility staff thoroughly investigated allegations of abuse. Administration failed to provide oversight that established and implemented policies and procedures to ensure allegations of abuse were reported timely. The findings include: 1. Review of the BENHA form revealed the current Administrator's date of hire was 7/31/2003. 2. Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 1/10/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law .The facility will implement policies and procedures to prevent and prohibit all types of abuse .by establishing policies and protocols for preventing sexual abuse .Identifying, correcting, and intervening in situations in which abuse .is more likely to occur with the deployment of trained and qualified .staff on each shift .to meet the needs of residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms .Providing residents, representatives, and staff information on how to whom they may report concerns, incidents, and grievances without fear of retribution .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse during and after the investigation .Responding immediately to protect the alleged victim and integrity of the investigation .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes as required by state and federal regulations .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .The Administrator will follow up with government agencies .to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . Review of the facility's Administrator Job Description undated, revealed .Administration .Responsible for the efficient and profitable operation of the facility, facility compliance with Northpoint policies and State and Federal rules and regulations, and providing the highest quality of care possible .Manages day to day operations of the facility .Directs and guides the activities of clinical, administrative, and service departments .Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement, and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee .Knowledge of Long Term Care and Medicaid and Medicare regulations and standards .Ability to communicate effectively with residents and their family members, and at all levels of the organization .Ability to react decisively and quickly in emergency situations . Review of the facility's undated Director of Nursing [DON] Job Description, revealed .Manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations and policies and procedures .Plans and facilitates meetings and committees to address resident care issues .Manages the Nursing Department with the goal of achieving and maintaining the highest quality of care possible .Develops and manages systems to assure clinical competencies .Participates in developing, implementing and evaluating programs that promote the recruitment, retention, development and continuing education of nursing staff members .Initiates studies to evaluate effectiveness of nursing services in relation to their objectives and costs .Investigate and resolve residents/family/employee concerns .Ensures that annual competency evaluation and performance reviews are completed in the appropriate time frame .Pro-actively addresses survey and/or standards of care issues .Plans and guides the professional development of nursing staff .Assures that all clinical protocols and nursing policies and procedures are followed .Assure Pharmacy, dietary, physician consults are followed in timely manner .Assumes complete responsibilities of the Center in absence of Administrator . Review of the facility's undated Assistant Director of Nursing [ADON] Job Description, revealed .Assists the Director of Nursing [DON] with administration duties as designated and the supervision of nursing staff not to exceed scope of practice .Acts as liaison between nursing units, admission and the DON .Plans and facilitates meeting and committees to address resident care issues .Monitors and evaluates nursing staff and makes recommendations for training or work modification to the DON .Performs personnel management functions such as establishing personnel qualification requirements, drafting procedure manuals, in-service programs, and installing record and reporting systems .Monitor noise level and satisfaction of residents with care/or dissatisfaction .Monitor and audit charts weekly for Episodic; Medicare documentation; all assessments; nursing summaries, MAR's [Medication Administration Record]; treatment; flow sheets; residents profile for CNA's [Certified Nursing Assistant] .Pro-actively addresses survey and/or standards of care issues .Follow up on residents/family/employee concerns in a timely manner .Represents the DON at meetings, in the community, and assumes responsibility for nursing operations in the DON's absence . Review of the facility's undated Social Worker Job Description, revealed .Provides psychosocial support to residents and their families .Provides direct psychosocial intervention .Performs resident assessments at admission, upon condition change and/or annually .Creates, reviews, and updates care plan and progress notes .Coordinates resident visits with outside services, dental, optical, etc .Attends and documents resident counsel meetings .Assists resident's families in coping with skilled nursing placement, physical illness and disabilities of the resident, and the grieving process .Works with the patient, family and other team members to plan discharge .Conducts in-service programs to educate staff regarding psychosocial issues and patient rights .Supervises and guides Social Services Assistants . 3. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure allegations of abuse were identified, reported, and thoroughly investigated. On an unknown date, Resident #6, a vulnerable cognitively intact resident, was in the Dining Room when Resident #38 rubbed her arms and legs, when Resident #38 wheeled up behind Resident #6 and grabbed her wheelchair, and on two different occasions when Resident #38 entered Resident #6's room and rolled directly up to her bed after she had asked him to leave. These incidents brought up painful childhood memories of being sexually abused by a family member for Resident #6. Observation revealed Resident #6 was tearful and uncomfortable while talking about Resident #38's behaviors. On an unknown date, Resident #13, a vulnerable and moderately cognitively impaired resident reported, that while in the Dining Room, Resident #38 rolled up in his wheelchair and cupped Resident #13's testicles. Observation revealed Resident #13 was emotional, embarrassed, and shameful over Resident #38's behavior. On 3/27/2024, Resident #20, a vulnerable, aphasic (nonverbal) resident with moderate cognitive impairment, was observed in the Dining Room upset and pointing in the direction of Resident #38. Resident #20 confirmed through gestures to a staff member that Resident #38 said an inappropriate statement about her chest/breast area. Interview revealed Resident #20 appeared distressed and upset by Resident #38's behaviors. On an unknown date, Resident #24, a vulnerable and severely cognitively impaired resident, was observed in the Dining Room when Resident #38 rubbed her back and then kissed her on the lips. An interview revealed Resident #24 appeared distressed by Resident #38's behaviors, but did not recall the date. On 4/14/2024, Resident #25, a cognitively intact resident reported that on an unknown date Resident #38, entered his room and touched his knee and attempted to give him a kiss while lying in bed. During an interview on 4/16/2024 11:19 AM, the ADON was asked when she was made aware of Resident #13's testicles had been cupped by another resident. The ADON stated, I was made aware during our abuse questions and staff interviews. The ADON was asked when Resident #13 told her about him being touched inappropriately by Resident #38. The ADON stated, I do not remember that. The ADON was asked if the resident council president [Resident #13] had brought his concerns of [Named Resident #38] inappropriate behaviors toward other residents. The ADON stated I don't remember. The ADON was asked if she knows how to start a facility investigation regarding physical, sexual or verbal abuse. The ADON stated, I think I do, I haven't completed one on my own . During an interview on 4/16/2024 at 5:01 PM, the SSD [Social Services Director] was asked what occurred on 3/28/2024 with Resident #20 and a male resident. The SSD stated, .one of the CNAs (certified nursing assistants) documented on the dash board (electronic medical record) that the female (Resident #20) had been agitated during supper and that the male resident had said something about her chest The SSD confirmed that the staff member that made the entry was CNA A and the male resident was Resident #38. The SSD confirmed that she reviews the dashboard every morning upon reporting to work at 8 AM and prior to the morning meeting at 9 AM and reports any needed information to the administrative staff during that meeting. The SSD confirmed that the incident was discussed during the morning meeting on 3/28/2024 and the incident occurred on the evening of 3/27/2024 during the supper meal. The SSD confirmed she called and spoke with the DON that morning when she discovered it on the dashboard and asked if she had reviewed the dashboard and saw what was written. The SSD confirmed that the DON said that she had seen it. The SSD confirmed that the information was discussed in the morning meeting that included all department heads, the DON and the Administrator. The SSD confirmed that it was determined that Resident #38 would be closely monitored for any future behaviors. The SSD confirmed that nothing was reported, and no formal investigation was completed to her knowledge. The SSD was asked did you document any conversations that you may have had with Resident #20. The SSD confirmed that a late entry was completed on 4/16/2024 when it was discovered by the Surveyor. During an interview on 4/16/2024 at 5:49 PM, the Director of Nursing (DON) confirmed that she had access to the resident's dashboard alerts and recalls discussing residents during morning meetings with the Administrator being present at those meetings. The DON confirmed that the Administrator failed to request investigations or witness statements pertaining to resident allegations or concerns during those morning meetings. The DON confirmed that the Social Services Director manages the Behavior Management Program and reports facility behaviors to the Administrator and the DON. The DON was asked who is responsible for completing the investigation on allegations. The DON stated, He [referring to the Administrator] over sees it. The DON confirmed on multiple accounts that the administration was informed of allegations of abuse and failed to investigate and report. During an interview on 4/17/2024 at 2:48 PM, the Administrator was asked what he thought the root cause analysis was for the failure to report and investigate allegations of abuse. The Administrator stated .we felt like the issue of his [referring to Resident #38] dementia affected the employees thought of the Resident #38 not knowing better .doesn't realize that the touching was unwanted . The Administrator confirmed that the facility does not have anything in place other than re-education on policies and procedures to prevent things slipping through the cracks. The Administrator confirmed that he is the one ultimately responsible and was asked if the Administration was ineffective. The Administrator confirmed his knowledge of a facility breakdown that needs to be corrected. Refer to F-600, F-609, and F-610

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment when 4 of 7 (Resident #14, #16, #25, and #41) sampled residents reviewed for smoking were observed using an existing lit cigarette to light another cigarette, and when 3 of 3 (Resident #18, #24, and #53) sampled residents reviewed for fall investigations did not have witness statements, and when 2 of 49 (Resident #13's room and #30's room) resident rooms observed during random observations had unsecured and unattended razors. The findings include: 1.Review of the facility's policy titled Smoking Policy Smoking Campus-Residents, revised 1/1/2022, revealed .It is the policy of this facility to establish and maintain safe resident smoking practices .Residents with smoking privileges shall not be permitted to retain any types of smoking articles to include cigarettes, tobacco .either on his or her person or within his/her living or sleeping area, at any time . Review of the facility's policy titled, Falls - Clinical Protocol, revised 11/2/2023 revealed, .For an individual who has fallen, staff should attempt to define possible causes within 24 hours of fall .Once a fall occurs it is important to gather as much information as possible .Observe for evident trauma .Observe to determine what the resident was attempting to do if possible .Observe for environmental hazards If the resident is able, what does he/she state happened .Staff present and responders, what do they see/hear .An accident/incident report will be completed and forwarded to the DON as part of the facility's internal Quality Assessment and Assurance Program .Review staff and witness statements (to include last time resident seen, provided care, and what type of care) .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. Review of the facility's policy titled, Sharps Disposal, revised on 10/30/2023 revealed, .Contaminated sharps will discard them immediately or as soon as feasible into the designated containers .Contaminated sharps will be discarded into containers that are closable, puncture resistant, leakproof .labeled .Impermeable . Review of the facility's policy titled Contaminated Materials revised on 12/13/2023 revealed, .Materials contaminated with blood or body fluids shall be discard appropriately if the item is a disposable single use item .All resident use items .are considered contaminated once used on the resident .Sharps disposal will be processed through the facility's vendor for hazardous waste . 2. Review of the medical record revealed Resident #14 was admitted [DATE] to the facility with the diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, Anxiety, Depression, Polyneuropathy, and Osteoarthritis. Review of the Care Plan revised 7/26/2023 revealed, .Resident is a smoker .resident will smoke safely at the designated area(s) at scheduled times through the next review .Observe the resident's safety during smoking . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14 was assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and assessed for tobacco use. Resident required the use of 1 person assist to perform Activities of Daily Living (ADLs), and use of a wheelchair for mobility. Observation in the courtyard on 4/10/2024 at 9:42 AM, revealed Resident #14 lit a cigarette with her existing lit cigarette before putting the existing cigarette in the ashtray. 3. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with the diagnoses of Schizoaffective Disorder, Cerebrovascular Accident, Dementia, Hemiplegia, Peripheral Vascular Disease, Anxiety, Depression, and Schizophrenia. Review of the Care Plan revised 10/31/2023, revealed .Resident chooses to smoke. Resident will smoke safely at the designated area(s) at scheduled times through the next review .Observe the resident's safety during smoking. Periodically complete safe smoking evaluation. Requires supervision while smoking . Review of the quarterly MDS dated [DATE], revealed Resident #16 was assessed with a BIMS score of 15 which indicated resident was cognitively intact. Resident required 1 person assist to perform ADLs and the use of a wheelchair for mobility. Observation in the courtyard on 4/9/2024 at 9:43 AM, revealed Resident #16 lit a cigarette with his existing lit cigarette before putting the existing cigarette in the ashtray. 4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with the diagnoses of Stroke, Heart Failure, Hypertension, Peripheral Vascular Disease, Hemiplegia, Anxiety, Depression, and Polyneuropathy. Review of the Care Plan revised 10/31/2023, revealed .Resident chooses to smoke. Resident will smoke safely at the designated area(s) at scheduled times through the next review .Observe the resident's safety during smoking. Periodically complete safe smoking evaluation. Requires supervision while smoking. Review of the quarterly MDS 1/5/2024, revealed Resident #25 was assessed with a BIMS score of 14 which indicated resident was cognitively intact. Resident required 1 person assistance when performing ADLs and use of a wheelchair for mobility. Resident assessed for tobacco. Observations in the courtyard on 4/9/2024 at 9:44 AM and 4/10/2024 at 9:43AM, revealed Resident #25 lit a cigarette with his existing lit cigarette before putting the existing cigarette in the ashtray. 5. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with the diagnoses of Stroke, Hypertension, Hemiplegia, Anxiety, and Depression. Review of the Care Plan revised 10/31/2023, revealed .Resident choose to smoke. Resident will follow and verbalize understanding regarding the facility rules for designated smoking areas and smoking material through next review .Observe the resident's safety during smoking. Periodically complete safe smoking evaluation. Notify nurse immediately if resident has violated the smoking policy. Observe clothing for signs of cigarette burns . Review of the quarterly MDS dated [DATE], revealed Resident #41 was assessed with a BIMS score of 13, which indicated cognitively intact without behaviors. Resident required extensive 1 person assistance with ADLS and required the use of a wheelchair for mobility. Review of the Safe Smoking Eval [Evaluation] dated 3/15/2024, revealed .Cognitive Patterns .Short-term memory within normal limits .No .Long-term memory within normal limits .No .Decision-making skills are reasonable and consistent .No .Observations .Resident is able to light cigarette safely .No . Observation in the courtyard on 4/10/2024 at 9:41 AM, revealed Resident #41 lit a cigarette with his existing lit cigarette before putting the existing cigarette in the ashtray. The facility failed to establish and maintain safe resident smoking practices for Residents #14, #16, #25, and #41. During an interview on 4/10/2024 at 4:50 PM, The Administrator was asked should residents be allowed to light cigarettes from an existing lit cigarette. The Administrator stated, No, that is a good way to drop some fire . 6. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Retention of Urine, Hypertension, Altered Mental Status, Chronic Kidney Disease, and Dementia. Review of the Care Plan dated 2/21/24, revealed .Resident is at risk for falls/injury related to generalized weakness, high risk of falls, impaired cognition with decreased safety awareness, needs assistance with ADLs . Review of the admission MDS dated [DATE], revealed Resident #18 was assessed for a BIMS score of 8, which indicated moderately cognitive impairment. Requires maximum assistance with ADLs and the use of a wheelchair for mobility. Resident assessed for indwelling catheter, frequently incontinent of bowel, tobacco use, and falls. Review of the Unwitnessed Falls Incident Report dated 3/15/2024, revealed .resident was found in his room on the floor outside of the bathroom door. He had pulled his catheter out bulb inflated and was bleeding profusely from his penis. Blood on him and the floor. No other injury noted at the time. a new cath [catheter] tube has been reinserted with a new bsb [bedside bag]. I got to the bathroom and shut the door on my tube and it pulled out .INTERVENTION: residents bed was lowered to floor .family member and physician notified. Review of the medical record revealed the facility failed to obtain witness statements for the fall that occurred on 3/15/2024, for Resident #18. 7. Review of the medical record revealed that Resident #24 was admitted on [DATE], with the diagnoses of Diabetes, Vascular Dementia, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #24 was assessed for a BIMS score of 6, which indicated severely cognitively impaired with behaviors of wandering. Resident was assessed for falls, and urinary incontinence. Resident required maximum assistance with performing ADLs, and the use of wheelchair for mobility. Review of the Care Plan dated 4/5/2024 revealed .Resident at risk for falls/injury related to .bladder incontinence .decreased strength and endurance .impaired cognition .needs assistance with ADLs .wandering . Review of the medical record revealed that Resident #24 sustained falls on 12/15/2023, 2/8/2024, 2/10/2024, 2/22/2024, and 3/16/2024. Review of the facility's fall investigations for Resident #24's falls that occurred on 12/15/2023, 2/8/2024, 2/10/2024, 2/22/2024, and 3/16/2024 revealed the facility failed to obtain witness statements and interviews. 8. Review of the medical record review revealed Resident #53 was admitted to the facility on [DATE], with diagnoses of Aphasia, Schizophrenia, Hypertension, Post-Traumatic Stress Disorder, Gastrostomy, and Pressure Ulcer Sacral Region. Review of the Care Plan dated 12/28/2023 revealed .Resident is at risk for falls/injury related to Cerebral Accident (CVA), generalized weakness, high risk for falls, history of falls, impaired cognition with decreased safety awareness . Review of the medical record revealed that Resident #53 sustained falls on 12/29/2023, 1/4/2024, and 1/26/2024. Review of the facility's fall investigations for the falls that occurred on 12/29/2023, 1/4/ 2024, and 1/26/2024, revealed the facility failed to obtain witness statements and interviews. The facility failed to obtain witness statements for falls of Residents #18, #24, and #53. During an interview on 4/11/2024 at 3:18 PM, the DON was asked if staff are to assess resident, complete an incident report, notify family and doctor, transcribe new orders, complete new interventions for staff and witness statements. The DON stated, Yes, if the fall is witnessed. If the fall is not witnessed, the nurse makes the note of the observation. The DON was asked, should the report include the person that actually found the resident. The DON stated, Yes. The DON was asked, would that be a witness statement. The DON stated, That would be yes. The DON was asked, staff should have the person write a statement and what they observed. The DON responded, Yes. The DON was asked, does your policy include witness statements. The DON stated, Yes. The DON was asked, Do you have any witness statements. The DON stated, No. 9. Review of the medical record revealed Resident #13 was admitted [DATE], with diagnoses of Hypertension, Diabetes, Depression, Anxiety, and Post Traumatic Stress Disorder. Review of the quarterly MDS dated [DATE], revealed Resident #13 was assessed for a BIMS score of 12, which indicated moderately cognitively impaired. Resident required stand by assistance of staff to perform ADLs. Observations in the resident's room on 4/8/2024 at 11:53 AM and 1:40 PM, revealed an exposed sharp razor standing upright out of a pocket of the door holder on the back of Resident #13's bathroom door. 10. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with the diagnoses of Fractures, Obstructive Uropathy, Diabetes, Arthritis, and Paraphimosis. Review of the Care Plan dated 8/16/2023, revealed .Resident is at risk for abnormal bleeding or hemorrhage related to anticoagulant therapy .Report to Nurse any signs or symptoms of bleeding, excessive bleeding when shaving . Review of the quarterly MDS dated [DATE], revealed that Resident #30 was assessed for a BIMS score of 5, which indicated severely cognitively impaired without behaviors. Resident requires 2-person assistance with ADLs. Observations in the resident's bathroom on 4/8/2024 at 9:21 AM, 10:41 AM, and 1:43 PM, revealed an exposed, unsecured, and unattended razor in a Styrofoam cup on the resident's bathroom vanity. The facility failed to discard sharps/razors immediately into the designated containers. During an interview on 4/9/2024 at 3:45 PM, The DON was asked should an unsecured and unattended razor be exposed and visible in a resident's room. The DON stated, No, razors should not be left out and exposed in residents' rooms.

Based on policy review, medical record review, observations, and interview, the facility failed to maintain or enhance resident's dignity for 3 of 19 (Resident, #31, #37, and #104) sampled residents when staff members required residents to say please and thank you before granting the residents' request and for 5 of 19 (Resident #6, #8, #20, #31, and #44) sampled residents that were referred to as [NAME]. The findings include: 1. The facility's policy titled, Resident Rights revised on 1/1/2022 revealed, Employees shall treat all residents with kindness, respect, and dignity .If any Staff member witnesses or becomes aware of any violation of this policy, they are required to immediately report it to their supervisor or the Administrator of the facility, and cooperate in any investigation that may be conducted . 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses of Atherosclerotic Heart Disease, Anxiety, Depression and Hypothyroidism. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #31 was cognitively intact. During an interview on 4/10/2024 at 8:38 AM, Resident #31 confirmed that after her shower Certified Nursing Assistant (CNA) D helped her get dressed and stated, [Named CNA D] said I had pretty blouse and she said aren't you going to say thank you .I ignored her .she brought me back into my room . Resident #31 was asked how that made you feel. Resident #31 stated, Disrespected .I know how it's supposed to be . Resident #31 was asked what part made you feel disrespected. Resident #31 stated, The part where she asked me aren't you going to say thank you . During a telephone interview on 4/11/2024 at 1:01 PM, CNA D was asked did you tell Resident #31 she had a pretty blouse. CNA D stated, Yes. CNA D was asked did you asked her if she was going to tell you thank you after telling her she had a pretty blouse. CNA D stated, .I sure did . CNA D was asked are you supposed to ask a resident to say thank you after you give them a compliment or when completing a task for them. CNA D stated, No, ma'am . CNA D was asked do you feel that was treating her with respect and dignity by asking them to say thank you when you complete a task for them. CNA D stated, No, Ma'am . 3. Review of the medical record reviewed Resident #37 was admitted to the facility on [DATE], with diagnoses of Benign Prostatic Hyperplasia, Depression, Right Above the Knee Amputation, and Left Above the Knee Amputation. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated he was cognitively intact. Observation in Resident #37's room during dining on 4/8/2024 at 11:49 AM, revealed CNA B delivered Resident #37 a meal tray and placed it on the overbed table. Resident #37 raised the head of his bed to eat lunch and asked CNA B to remove the pillow from behind his back, CNA B stated, What do you say, Resident #37 stated, Please. CNA B then removed the pillow behind his back and exited the room. During an interview on 4/16/2024 at 8:15 AM, CNA B was asked is the facility the resident's home. CNA B stated, Yes. CNA B was asked should you treat residents with respect and dignity. CNA B stated, I know what this is about . CNA B was asked should a resident be told or made to say please or thank you before granting the resident's request. CNA B stated, .No . CNA B was asked, Resident #37 asked you to remove a pillow from behind his back in order to eat his meal and your reply was what do you say, and he said Please. CNA B confirmed that was not treating a resident with respect and dignity. 4. Review of the medical record revealed Resident #104 was admitted to the facility on [DATE], with diagnoses of Anxiety, Asthma, Benign Prostatic Hyperplasia, and Depression. Review of the admission MDS dated [DATE], revealed a BIMS score of 12 which indicated Resident #104 was moderately cognitively impaired. Review of the Care Plan dated 3/30/2024 revealed, .Resident has impaired communication related to .hard of hearing . Observation on 4/16/2024 at 8:03 AM, revealed CNA B delivered a meal tray to Resident #104's room, his television (tv) was on, CNA B turned the television volume completely down. Resident #104 stated, Why did you cut my tv down .I can't hear. CNA B stated, Because I can't hear . CNA B failed to ask Resident #104 for permission to turn his television volume down. During an interview on 4/16/2024 at 8:44 AM, the Director of Nursing (DON) confirmed the facility is considered the residents' home and residents should be treated with respect and dignity. The DON was asked should staff ask residents to say Please or Thank You before granting a resident's request. The DON stated .No . The DON was asked if a resident requests a staff member to complete a task for them like remove a pillow, what should the staff member do? The DON stated, The CNA came and told me that she was asked questions about that .she should do what they asked . The DON was asked should staff turn down a resident's television without asking for permission. The DON stated, You should asked first . The DON was asked if a staff member comments on residents' clothes for example to tell them you have on a pretty blouse should the staff ask the resident what should you say. The DON stated, She should not have said that . The DON confirmed this was not treating residents with respect and dignity. During an interview on 4/17/2024 at 2:31 PM, the Administrator confirmed the facility is the resident's home and they should be treated with respect and dignity and should not be asked to say, Thank You or Please. The Administrator was asked should a staff member turn down a resident television without asking for permission first. The Administrator stated, Not without asking . 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 was assessed with a BIMS score of 15, which indicated she was cognitively intact. 6. Review of the medical record revealed Resident #8 was readmitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Hypertension, Diabetes, Dementia, and Memory Deficit. Review of the quarterly MDS dated [DATE], revealed Resident #8 was assessed with short- and long-term memory loss. 7. Review of the medical record revealed Resident #20 was readmitted to the facility on [DATE], with diagnoses of Hemiplegia, Hypotension, Aphasia, Dysphagia, Hypertension, Diabetes, Epilepsy, Chronic Pain Syndrome, and Pseudobulbar Affect. Review of the quarterly MDS dated [DATE], revealed Resident #20 was assessed as being moderately cognitively impaired. 8. Review of the medical record revealed Resident #31 was readmitted to the facility on [DATE], with diagnoses of Acute Respiratory Failure, Atherosclerotic Heart Disease, Diabetes, Hearing Loss, and Legal Blindness. Review of the 5 day admission MDS dated [DATE], revealed Resident #31 was assessed with short-and -long term memory loss and being moderately cognitively impaired. 9. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Atherosclerotic Heart Disease, Pulmonary Hypertension, Diabetes, Hypertension Heart Disease, Cognitive Communication Deficit, and Anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 was assessed with a BIMs of 13, indicating the resident was cognitively intact. During an interview 4/8/24 at 4:07 PM, Social Service Director (SSD) was asked about the meeting held with female residents. The SSD stated, There was a group of residents that we were having issues with the ladies [Named Resident #44, Named Resident #6] gossiping about the resident [Named Resident #38] .I did an education with 5 ladies about dementia and how to redirect if this happened to them or happened to them again and call for help . The SSD was asked who were the other 3 female residents that attended the meeting. The SSD stated, [Named Resident #31, Named Resident #20, Named Resident #8] and [Named Activities Director] . During an interview on 4/8/24 at 4:58 PM, the Activities Director was asked what has been done to intervene with Resident #38 and his inappropriate behavior towards residents and staff. The Activities Director stated, .we put a plan together . The Activities Director was asked what the plan was. The Activities Director stated, .we got several of the ladies together for a [NAME] party . The Activities Director was asked who attended the party. The Activities Director stated, [Named Resident #6, Named Resident #31, Named Resident #20 and Named Resident #44] . During an interview on 4/9/24 at 8:33 AM, Resident #44 confirmed that she and a few ladies had went to another female resident's room to welcome her back because she had been in the hospital for a while. Resident #44 was asked who was in attendance. Resident #44 confirmed that the SSD entered the room and shut the door and talked about another male resident (Resident #38). Resident #44 was asked who the male resident was. Resident #44 pointed out the door and stated .the man in that room across the hall [pointing to Resident #38's room] . Resident #44 was asked what the SSD said about the resident. Resident #44 stated, .talked .somewhat about him that he had dementia and he does not know what he is doing and some of his actions may not be forthcoming . Resident #44 was asked who the ladies in attendance were. Resident #44 stated, [Named Resident #31] came from the hospital .and we had punch and cookies .and it was [Named Resident #6] she was there . The facility staff failed to ensure residents were addressed with respect and dignity when they were referred to as [NAME].

Based on policy review, medical record review, observation, and interview, the facility failed to ensure oxygen supplies were changed and dated for 2 of 3 sampled residents (Resident #11 and #22) reviewed for respiratory services. The findings include: Review of the facility's policy titled Oxygen Administration, dated 6/2/2021, revealed Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Change humidifier [water bottle used for the administration of oxygen] bottle when empty .every 72 hours . review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Review History Report, dated 10/2/2021-11/2/2021, revealed .Oxygen: RUN @ [at] 2 L[Liters]/[per] MIN [minute] VIA [by] .N/C [nasal cannula [plastic tubing used to administer oxygen through the nostrils] .PRN [as needed] .every shift for shortness of breath . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #11's room on 11/1/2021 at 9:22 AM, revealed a running oxygen concentrator with an undated nasal cannula hanging on the control knob of the concentrator and an empty water [humidifier] bottle dated 10/19/2021. Observation in the resident's room on 11/1/2021 at 3:25 PM and on 11/2/2021 at 10:30 AM, revealed Resident #11 was receiving oxygen at 2L/min via an undated nasal cannula. Review of the medical record, revealed Resident #22 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [2]L/MIN VIA N/C PRN . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .every night shift every Sun for Tubing change . Observation in the resident's room on 11/1/2021 at 9:45 AM, 10:45 AM, and 3:02 PM, revealed Resident #22 was lying in bed receiving oxygen at 2L/MIN BNC, the tubing was dated 10/14/2021 and an oxygen tubing storage bag was tied around the handrail of the bed and was dated 10/14/2021. Observation in the resident's room on 11/2/2021 at 8:25 AM and 4:00 PM, revealed Resident #22 was lying in bed receiving at oxygen at 2L/MIN BNC, the oxygen tubing was dated 10/14/2021 and the oxygen tubing storage bag tied on the handrail of the bed was dated 10/14/2021. During an interview on 11/3/2021 at 1:33 PM, the Director of Nursing (DON) confirmed that oxygen tubing should be dated and changed weekly by nursing the staff. The DON was asked should an empty humidifier bottle dated 10/19/2021 be in use on 11/1/201. The DON stated, No.

Based on medical record review, review of a facility investigation, and interview, the facility failed to ensure accidents were reported and investigated for 1 of 3 sampled residents (Resident #93) reviewed for falls. The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 10/30/2020, revealed .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Review of the medical record, revealed Resident #93 was admitted on [DATE], with diagnoses of Alzheimer's Disease, [CONDITION(S)], [CONDITION(S)] Disorder, Presence of Right Artificial Hip Joint, Anxiety, Depression, and [CONDITION(S)] Disorder. Review of the admission Minimum Data Set, dated dated dated [DATE], revealed Resident #93 had a Brief Interview for Mental Status score of 10, indicating cognitive impairment, and required assistance of staff with mobility and transfers. Review of a Nurses' Note dated 8/18/2021 at 1:57 PM, revealed .called to pts [patient's] room per floor maintance [maintenance] pt found very diaphoretic wet to touch, color gray 02 [oxygen] SAT [Saturation] @ [at] 89% [percent] on 2L [Liters] HR [Heart Rate] 136 TEMP [Temperature] 96.6 BP [Blood Pressure] 80/50 family notified EMS [Emergency Medical Services] called attempted to call ER [emergency room ] with no success pt confused. Review of a Nurses' Note dated 8/21/2021 at 5:04 PM, revealed .told wife .that x-ray ordered for left hip . Review of a Pertinent Charting Note dated 8/21/2021 at 8:26 PM, revealed .transferred to hospital r/t [related to] fracture . Review of a Nurses' Note dated 8/22/2021 at 12:37 AM, revealed .Arrived from ER to facility r/t L [Left] hip fracture/ demineralization of hip. Family declined surgery r/t advanced dementia- pain treated at ER, sent back with new orders . Review of a Radiology Consultation Report dated 8/21/2021 at 6:10 PM, revealed .There is a left subcapital fracture with moderate displacement .The bones appear diffusely demineralized .Acute left hip fracture . Review of a facility investigation beginning 8/21/2021, revealed an unnamed report showing .When CNA [Certified Nursing Assistant] .went to get the resident out of bed, he stated, his hip hurt from when he fell a few nights ago . Review of a Quality Assessment & [and] Assurance Investigation Report, dated 8/21/2021, revealed .Fracture .(L) [Left] subcapital fx [fracture] with moderate displacement .Time of last transfer 8/20/21 [2021] How accomplished pivot transfer A [assistance] x [of] 2 [staff members] . Review of a Quality Assessment & [and] Assurance Investigation Report, dated 8/23/2021, revealed .Injury of unknown origin .While interviewing staff - determined that on 8/18/21 [2021] Resident was seen with legs off of bed [and] was assisted back onto the bed. According to housekeeping res [resident] was on his knees on the floor. Resident was lying with his hip on the edge of the bed upon CNA arrival. Resident did not report a fall when CNAs pulled him up in the bed .Stated he fell [at] home 5 nights ago .Determined that resident did have a fall on 8/18/21 [2021] on (L) hip .to edge of bed. CNAs found resident on the edge of the bed with his feet on the floor [and] were unaware that resident had fallen . Review of a verbal Statement Of Witness, dated 8/23/2021, written by the Director of Nursing (DON) and signed by Housekeeper #1, revealed .Date and time of incident: 8/18/21 [2021] .I heard [named Resident #93] yelling in his room. When I went into his room he was laying on the edge of his bed with his knees on the floor .I saw [Named CNA #2] and told her about [Named Resident #93] . During an interview on 11/2/2021 at 11:10 AM, Housekeeper #1 reviewed and confirmed the verbal statement from 8/23/2021. Housekeeper #1 was asked where Resident #93 was when she entered the room. Housekeeper #1 stated His knees were on the floor, arms were on the bed, stomach was touching the bed. He looked like he was trying to climb back in bed . Review of a verbal Statement Of Witness, dated 8/23/2021, written by the DON and signed by CNA #1, revealed .Date and time of incident: 8/18/21 [2021] [and] 8/21/2021 .I helped [Named CNA #2] straighten [Named Resident #93] up in the bed. He was laying on the edge of his bed on his hip with his legs out on the floor .[Named Licensed Practical Nurse [LPN] #1] came in [and] assessed him and sent him to the ER .On Saturday 8/21 [2021] I went to help [Named Resident #93] get up .when he yelled out loudly . During an interview on 11/2/2021 at 11:27 AM, CNA #1 read and confirmed her statement from 8/23/2021 and was asked what position Resident #93 was in when she assisted him up in the bed on 8/18/2021. CNA #1 stated .rolled over on his stomach and his legs were sprawled out . CNA #1 was asked if she noticed any injuries following the incident. CNA #1 stated, His knees might have had a little red where they were touching the floor . Review of a verbal Statement Of Witness, dated 8/23/2021, written by the Director of Nursing and signed by CNA #2, revealed .[Named Housekeeper #1] .came to get me .saying she needed help with [Named Resident #93] .he was laying on the edge of his bed with his feet [and] legs hanging off the bed and his hip on the edge of the mattress. During an interview on 11/2/2021 at 2:20 PM, CNA #2 was asked what position Resident #93 was in when she assisted him up in the bed on 8/18/2021. CNA #2 stated, He was lying on his Left side. From approximately here up (touched her Left hip) was on the bed, from there down was on the floor . CNA #2 confirmed LPN #1 was in the room and assessed Resident #93 prior to him being repositioned. During an interview on 11/3/2021 at 10:44 AM, LPN #1 confirmed there was no event note for the fall dated 8/18/2021 and she was not notified that Resident #3's knees were on the floor when he was found on 8/18/2021. LPN #1 was asked if she should have been notified. LPN #1 stated Yes. During an interview on 11/3/2021 at 1:08 PM, the DON confirmed Resident #93's fall on 8/18/2021 was not reported. The DON was asked if staff had been educated on reporting falls. The DON confirmed that she educated Housekeeper #1 verbally, but no other staff had been inserviced regarding reporting falls. The facility was unable to provide documentation of any education provided to staff related to reporting falls or incidents.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 1 (Registered Nurse (RN) #1) nurses failed to perform hand hygiene after the removal of gloves during a dressing change. The findings include: 1. The facility's Wound Care policy documented, .4 .remove dressing .and discard into appropriate receptacle .Wash and dry your hands thoroughly .Put on gloves . 2. Observations in Resident #7's room on 8/14/19 at 1:20 PM, revealed RN #1 removed a foam dressing and Calcium Alginate from the wound, placed the soiled dressings inside of the gloves, and placed the gloves in a red bag. RN #1 donned new gloves and failed to wash her hands after removal of the soiled gloves. RN #1 continued with the dressing change. 3. Interview with the Director of Nursing (DON) on 8/14/19 at 4:06 PM, in the Dining Room, the DON was asked should hand hygiene be performed after the removal of soiled gloves during a dressing change. The DON stated, Yes, you should wash your hands before putting on gloves during wound care.

Based on policy review, observation, and interview, 2 of 19 (Certified Nursing Assistant (CNA) #1 and Speech Therapist #1) staff members failed to serve food under sanitary conditions to prevent the potential spread of infection during dining observations. The findings include: 1. The facility's Handwashing/Hand Hygiene policy revised 2007 documented, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 2. Observations in the Main Dining Room on 8/12/19 at 12:10 PM, revealed Speech Therapist #1 picked up a resident's bread with her bare hands to apply mustard to the resident's sandwich. Observations in the Main Dining Room on 8/13/19 at 5:43 PM, revealed CNA #1 removed the dinner tray from the dining cart, sat the cup of tea on the table, rubbed her nose with her bare hand, did not perform hand hygiene, and continued to set up the resident's meal tray. 3. Interview with CNA #1 on 8/13/19 at 5:43 PM, in the Main Dining Room, CNA #1 was asked should she have rubbed her nose during the resident's meal tray setup. CNA #1 stated, .I'm guilty . Interview with the Director of Nursing (DON) on 8/13/19 at 5:49 PM, in the DON's Office, the DON was asked should staff members touch the resident's food with their bare hands. The DON stated, No. The DON was asked should staff members rub their nose and continue with the resident's meal tray setup. The DON stated, No.

Based on observation and interview, the facility failed to ensure the environment was free of accident hazards when unsecured tools and screws were observed in 1 of 60 (room [ROOM NUMBER]) resident rooms. The findings include: Observations in room [ROOM NUMBER] on 8/12/19 at 9:46 AM, 12:15 PM, 3:00 PM, and 4:33 PM, and on 8/13/19 at 8:11 AM, 10:00 AM, 1:30 PM, 3:00 PM and 5:13 PM, revealed 1 electric drill with a drill bit attached, 3 pair of needle nose pliers, 1 pair vice grips, 6 loose drill bits, and 18 screws in an opened wooden box. Interview with the Assistant Director of Nursing (ADON) on 8/13/19 at 5:15 PM, in the ADON Office, the ADON was asked if unattended and unsecured tools and screws should be left in a resident's room. The ADON stated, .they really should not be . Interview with the Administrator on 8/13/19 at 5:37 PM, in the Conference Room, the Administrator was asked if he was aware that there were unsecured tools in Resident #26's room. The Administrator stated, .yes, we (staff) all knew .

Based on policy review, medical record review, observation, and interview, the facility failed to monitor the use of physical restraints for 1 of 1 (Resident #6) sampled residents reviewed for physical restraint use. The findings include: 1. The facility's Use of Restraints policy revised 2/15/11 documented, .Full documentation .to the use of the physical restraint, the type of the physical restraint used, the length of the effectiveness restraint time, and the individual applying such measures shall be entered in the resident's medical record . 2. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 8/12/19 documented, .BREAKAWAY LAP BUDDY to W/C (wheelchair) R/T (related to) Leaning Forward .A safety device that is restraining the resident will be released every 2 hours . Review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Record [REDACTED]. Observations at the 500/600 Nurses Station on 8/12/19 at 12:25 PM, revealed Resident #6 was seated in a wheelchair with a lap buddy restraint across his lower torso. Observations in the 500 Hall on 8/13/19 at 4:11 PM, revealed Resident #6 seated in a wheelchair with a lap buddy restraint across his lower torso and was being propelled by a visitor. Interview with the Minimum Data Set (MDS) Coordinator on 8/14/19 at 3:00 PM, in the Conference Room, the MDS Coordinator confirmed checking and releasing the lap buddy restraint was not documented.

Based on medical record review, observation, and interview the facility failed to provide care and services to maintain a urinary catheter when staff failed to keep the catheter leg bag off the floor for 1 of 2 (Resident #30) sampled residents reviewed for urinary catheters. The findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented the presence of an external urinary catheter. The physician's orders [REDACTED].Change condom catheter leg bag monthly and prn (as needed) for contamination . Observations in Resident #30's room on 9/16/18 at 9:40 AM, 12:05 PM, and 12:16 PM, revealed Resident #30's catheter leg bag lying on the floor in the resident's bathroom with the tubing exposed and lying on the floor. Interview with the Director of Nursing (DON) on 9/18/18 at 9:25 AM in the conference room, the DON was asked if a catheter leg bag should be lying on the floor in the resident's bathroom. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by failure to ensure appropriate cleansing and disinfecting of blood spills in 2 of 60 (Resident #64 and #95) resident bathrooms and 1 of 60 (Resident #80) resident rooms; by failure to ensure appropriate labeling and storage of a toothbrush in 1 of 60 (shared bathroom of Resident #12 and #72) resident bathrooms; and when 1 of 4 (Licensed Practical Nurse (LPN) #2) nurses failed to perform hand hygiene during medication administration. The findings included: 1. The facility's Cleaning Spills or Splashes of Blood or Body Fluids policy documented, .The purpose of this procedure is to minimize the danger of environmental contamination and the possible spread of bloodborne infections, including AIDS (Acquired Immunodeficiency Syndrome) (HIV (Human Immunodeficiency Virus)) and Hepatitis B (HBV) viruses, to employees and residents while cleaning up spills of blood or body fluid splashes .Report spills of blood or body fluids to the Infection Control Coordinator (or designee) or supervisor . A. Observations in Resident #64's bathroom on 9/25/17 at 9:25 AM, and 9/2717 at 8:25 AM, revealed a reddish-brown substance on the bathroom wall. Interview with Occupational Therapist (OT) #1 in Resident #64's bathroom on 9/27/17 at 8:26 AM, OT #1 was asked if she could identify the reddish-brown substance on the bathroom wall. OT #1 stated, It looks like blood. OT #1 confirmed the stain was not acceptable. Interview with the Director of Nursing (DON) on 9/27/17 at 8:27 AM, in Resident #64's bathroom, the DON was asked whether the reddish-brown substance on the wall was blood. The DON confirmed the substance looked like blood. The DON was asked whether it was acceptable to have blood stains on the bathroom wall. The DON stated, No. B. Observations in Resident #95's bathroom on 9/25/17 at 9:30 AM, 10:38 AM, and 11:56 AM, revealed a dirty bath basin heavily contaminated with red droplets and splatters, and a pool of red liquid in the bottom of the basin. Interview with Certified Nursing Assistant (CNA) #1 on 9/25/2017 at 11:56 AM, in Resident #95's bathroom, CNA #1 was asked what the red substance in the wash basin was. CNA #1 stated, I'm not quite for sure, but it does need to be cleaned . Interview with the DON on 9/27/17 at 8:27 AM, in Resident #64's bathroom, the DON was asked what she expected staff to do with bath basins contaminated with blood. The DON stated, .dispose of it. The DON was asked whether it was acceptable for a bath basin contaminated with blood to be stored in a resident's bathroom on the sink. The DON stated, No. C. Observations in Resident #80's room on 9/25/17 at 11:18 AM and 3:11 PM, 9/26/17 at 8:38 AM, and 9/27/17 at 8:30 AM, revealed a reddish-brown substance on the bedside chair. Interview with the Housekeeping Supervisor on 9/27/17 at 8:33 AM, in Resident #80's room, the Housekeeping Supervisor was asked if she could identify the reddish-brown substance on the chair. The Housekeeping Supervisor stated, It could be blood . The Housekeeping Supervisor was asked what she expected staff to do if they suspected a blood spill. The Housekeeping Supervisor stated, Clean it up as soon as they see it. It just got missed. 2. Observations in the shared bathroom for Resident #12 and Resident #72 on 9/25/17 at 10:36 AM and 3:35 PM, revealed an unlabeled and uncovered toothbrush in an emesis basin on the bathroom sink. Observations in the shared bathroom for Resident #12 and Resident #72 on 9/26/17 at 10:25 AM and 2:59 PM, revealed an unlabeled and uncovered toothbrush in a bath basin on top of the commode. Interview with CNA #2 on 9/26/117 at 3:00 PM, in the shared bathroom of Resident #12 and Resident #72, CNA #2 was asked whether the toothbrush was stored appropriately. CNA #2 stated, .it should be put up. It shouldn't be lying there like that . CNA #2 confirmed the toothbrush was not labeled. 3. The facility's Handwashing/Hand Hygiene policy documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .After removing gloves .The use of gloves does not replace handwashing/hand hygiene . Observations in the 500 hallway and Resident #18's room on 9/25/2017 at 4:27 PM, revealed LPN #2 donned gloves, cleaned a glucometer with bleach wipes, removed the gloves, prepared Resident #18's medication, gathered the medications and supplies, entered Resident #18's room, placed the supplies on a barrier on the overbed table, washed her hands, donned a glove on the left hand, administered Resident #18's medication with a spoon and gave her water, removed the glove from the left hand, and without performing hand hygiene, donned gloves on both hands, and performed a blood glucose check. Interview with the DON on 9/27/2017 at 11:27 AM, at the 100/400 hall nurses station, the DON was asked whether staff should perform hand hygiene when gloves were removed. The DON stated, Yes. The DON was asked whether staff should perform hand hygiene between glove changes during medication administration or blood glucose checks. The DON stated, Yes.

Based on policy review, medical record review, and interview, the facility failed to ensure residents were monitored for side effects of psychoactive medications for 3 of 5 (Resident #17, 51, and 63) sampled residents reviewed for unnecessary medication use. The findings included: 1. The Behavior Assessment and Monitoring policy documented, .The nursing staff .will monitor for side effects and complications related to psychoactive medications . 2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] (a psychoactive medication) 0.25 MG (milligrams) TABLET .GIVE 1 TABLET ORALLY THREE TIMES DAILY .[MEDICATION NAME] (a psychoactive medication) 150 MG TABLET .GIVE ½ TAB (TABLET) ORALLY AT BEDTIME .DEPRESSION .[MEDICATION NAME] (a psychoactive medication) .150 MG CAP (CAPSULE) .1 CAPSULE BY MOUTH DAILY .DEPRESSION . Medical record review revealed Resident #17 received [MEDICAL CONDITION] medications as ordered, but the facility failed to monitor for [MEDICAL CONDITION] medication side effects between August 1, 2017 and September 7, 2017. Interview with the Director of Nursing (DON) on 9/27/17 at 7:50 AM, in the DON office, the DON was asked to provide documentation for monitoring for side effects of [MEDICAL CONDITION] medications for Resident #17. The DON confirmed there was no documentation of [MEDICAL CONDITION] medication side effect monitoring from August 1 to September 7. 3. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] .(a psychoactive medication) 10 MG TABLET Give 1 tablet orally one time a day related to DYSTHYMIC DISORDER (a form of depression) . A physician's orders [REDACTED].[MEDICATION NAME] (a psychoactive medication) 10 MG TABLET Give one tablet orally at bedtime related to [MEDICAL CONDITION] . A physician's orders [REDACTED].[MEDICATION NAME] 5 MG TABLET Give 1.5 MG tablet orally two times a day related to [MEDICAL CONDITION] . Review of the Medication Administration Record [REDACTED]. Review of the Medication Record (MAR) for August, and September 2017 revealed the psychoactive medication side effect monitoring was not documented between August 1 and September 7, 2017. Interview with the DON on 9/26/17 at 3:43 PM, in the conference room, the DON was asked to provide documentation of [MEDICAL CONDITION] medication side effect monitoring for Resident #51. The DON confirmed there was no documentation that [MEDICAL CONDITION] medication side effects were monitored for Resident #51 from August 1 thru September 7, 2017, and confirmed that was a problem. 4. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] .(a psychoactive medication) 5 MG TABLET Give 1 tablet orally two times a day related to GENERALIZED ANXIETY DISORDER . A physician's orders [REDACTED].[MEDICATION NAME] (a psychoactive medication) 50 MG TABLET Give 1 tablet orally at bedtime related to MAJOR [MEDICAL CONDITION] . A physician's orders [REDACTED].[MEDICATION NAME] .(a psychoactive medication) 10 MG TABLET Give 3 tablet orally one time a day related to GENERALIZED ANXIETY DISORDER .MAJOR [MEDICAL CONDITION] . A physician's orders [REDACTED].[MEDICATION NAME] TABLET (a psychoactive medication) Give 7.5 mg orally three times a day for behaviors related to [MEDICAL CONDITION] Disorder . Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Records (MARs) for August and September, 2017 revealed that psychoactive medication side effect monitoring was not documented between August 1, 2017 and September 7, 2017. Interview with the DON on 9/26/17 at 4:53 PM, in the DON office, the DON confirmed that the side effects were not being monitored for Resident #63 between August 1 and September 7, 2017.

Based on policy review, medical record review, observation, and interview, it was determined the facility failed to ensure that 2 of 2 (Residents #76 and 96) residents who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed behaviors of cursing, spitting, kicking, slapping or hitting. The failure of the facility to provide the necessary services to address the behaviors resulted in actual harm for Resident #76 who was observed repeatedly screaming and hitting at staff and other residents. The findings included: 1. Review of the facility's "Problematic Behavior Management - Clinical Protocol" policy documented, "...1. As part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition... problematic behavior. The staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition... The physician will help verify that previously identified [DIAGNOSES REDACTED]. The staff will attempt as appropriate to identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The physician will help identify and authorize appropriate, targeted... and symptomatic treatments. a. If a psychiatric consultant is called to help manage behavioral issues, the Attending Physician will retain an active role by reviewing the consultant's recommendations, addressing medical issues that affect mood, cognition, and function; monitoring for complications related to treatment, and evaluating subsequent progress... 1. a... The physician will help review the progress of individuals with impaired cognition and behavior until stable..." Review of the facility's "The Quality Initiative, Caring for People with Dementia and Problem Behaviors..." policy documented, "...3. Does the behavior pose risks to the resident or others, or is the resident severely distressed? If yes, non-drug approaches fail, and medical work-up does not reveal another cause, consider drug therapy targeted at behaviors... Dementia Antipsychotic Prescribing Guide General Guidelines... 4. Justify use of an antipsychotic. The treatment target symptom must present a danger to the person or others, or cause the patient to experience one of the following: inconsolable or persistent distress, a significant decline in function, substantial difficulty receiving needed care... Appropriate antipsychotic treatment targets: Aggressive behavior (especially physical)... Severe distress as described above in #4 General Guidelines..." 2. Medical record review for Resident #76 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum (MDS) data set [DATE] documented, "...Staff Assessment for Mental Status... C1000. Cognitive Skills for Daily Decision Making... 3. Severely impaired - never/rarely made decisions... E0100. Potential Indicators of [MEDICAL CONDITION] B. [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality)... E0200. Behavioral Symptom - Presence & (and) Frequency... A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)... 2. Behavior of this type occurred 4 to 6 days, but less than daily... B. Verbal behavioral symptoms directed toward others (...threatening others, screaming at others, cursing at others)...1 . Behavior of this type occurred 1 to 3 days... E0800. Rejection of Care - Presence & Frequency... 1. Behavior of this type occurred 1 to 3 days..." Review of the care plan dated 12/17/12 documented, "...Problem... Non-compliance... Refuses meds (medications) @ (at) x's (times) & care... Notify MD (medical doctor) as needed... Problem... Cognitive Loss / Dementia... Alteration in cognitive function related to impaired memory... Approach... observe for changes in condition that may affect cognition (acute process). Notify MD PRN (as needed)... Problem... Behavioral Symptoms... Inappropriate social behavior related to agitation/aggression... frequently yells "mama" and "help me" /profanities... Problem... [MEDICAL CONDITION] Drug Use... Approach... Assess any behavioral changes... psych (psychiatric) services as needed..." The care plan was not revised to address the behaviors of cursing, spitting, kicking, slapping or hitting. Review of the nurse's notes documented the following: a. "12/26 (2012)... Combative c (with) staff during care..." b. "12-27-12... Pt (patient) yelling @ ppl (people) in hallway. Pt combative during care - slapping, kicking..." c. "12-28-12... Pt combative with care - slapping, kicking. Pt yells out @ x's..." d. "1/21/13...Pt irritated & (and) yelling in dining room & hit another resident... Pt unconsolable & continues to yell for "mama"..." e. "1-22-13... spit meds & slapped... 1/23/13... Pt screaming and cussing @ everyone. Very aggitated (agitated)..." f. "1-24-13... Pt constantly yells & curses @ pts, family, staff, & visitors... Pt yelling & cussing, had to be removed from dining room d/t (due to) upsetting other pt's in DR (dining room)..." g. "1/25/13... Pt. grabbing @ other pts. when they would go by & cussing @ them. Grabbed one pt's sleeve & twisted sleeve, had to separate..." Review of the "Behavior / Intervention Monthly Flow Record" for October, November, and December 2012 and for January 2013 documented daily behaviors of slapping and yelling out. Review of the "[MEDICAL CONDITION] MED (medication) MGT (management) PROGRESS NOTE" dated 11/29/12 completed by an Advanced Practice Registered Nurse - Board Certified clinician documented, "...Patient Status: Moderately Unstable... Staff notes pt. becomes combative during care. Hitting, pinching, biting, kicking staff. Yells at people down the hallway. Attempted to hit other pts. Refuses meds at times... Assessment Summary and Rationale for Recommendation(s) ...in the dining room she was screaming out her needs and became more confused calling out for her Mother... pt was screaming and cursing in hallway... pt is having hallucinations and [MEDICAL CONDITION] that are disturbing to her and make her paranoid to staff... pt continues to become physically aggressive with staff in her [MEDICAL CONDITION]. I suggest adding [MEDICATION NAME] 25mg (milligrams) at 1200 to prevent her afternoon worsening [MEDICAL CONDITION] Distressed Behaviors... No environmental, medication, or medical causes per record, Behavior interventions ineffective, Interventions Attempted: redirection, changes in environment, snacks..." The facility was unable to provide psychiatric notes after the 11/29/12 visit. Observations on the 400 hall on 1/28/13 at 5:00 PM, revealed Resident #76 seated in a wheelchair, screaming and repeatedly yelling "mama." Observations on the 400 hall on 1/29/13 at 9:35 AM, revealed Resident #76 seated in a wheelchair, screaming and cursing. Observations on the 400 hall on 1/29/13 at 4:30 PM, revealed Resident #76 seated in a wheelchair, yelled at and attempted to hit another resident in a wheelchair. Observations on the 400 hall on 1/30/12 at 2:00 PM, revealed Resident #76 seated in a wheelchair, repeatedly screaming "mama" and cursing. During an interview in Resident #85's room on 1/29/13 at 11:00 AM, Resident #85 was asked if this facility was a comfortable place in which to live. Resident #85 stated, "There is noise in the hall and dining room, residents screaming and cussing..." Resident #85 was asked if he had any concerns or problems with any other resident. Resident #85 stated, "Yes, (named Resident #76) yells and cusses..." During an interview on the 100 hall on 1/29/13 at 4:40 PM, Resident #58 stated, "Something is going to have to be done about her (Resident #76)... what is she yelling about? I going to have to call the police..." During an interview in the conference room on 1/30/13 at 10:00 AM, Resident #76's family stated, "We visit every day, and the nurses call us when they need us... they (nurses) called us yesterday, and we came out here to stay with her... She does have someone who comes every month... a psychiatrist and checks her... they have changed her medications... she was on the [MEDICATION NAME] now on [MEDICATION NAME] they have told us that may not be working so good for her any more..." During an interview on the 100 hall on 1/30/13 at 11:00 AM, Certified Nursing Assistant (CNA) #8 stated, "She (Resident #76) was up all night so we are letting her sleep..." During an interview in the conference room on 1/30/13 at 2:15 PM, Nurse #11 stated, "...when she (Resident #76) hollers I usually give her a snack, she hollers when she wants to take a nap, a snack, and is worse with a UTI (Urinary Tract Infection)..." During an interview on the 400 hall on 1/30/13 at 3:50 PM, Nurse #16 stated, "...we do one on one with her (Resident #76) as much as possible. We do call her son to help if necessary... she is okay at times and then at times she cannot be redirected, much worse since the UTI..." During an interview on the 100 hall on 1/31/13 at 9:00 AM, Nurse #2 stated, "...we do one on one with her when she gets upset, that is all we can do, she does not tolerate groups, she is not as bad when she doesn't have a UTI... she hits, slaps... I feel we are failing her, I think she is miserable..." During an interview in the conference room on 1/31/13 at 1:00 PM, Resident #76's physician stated, "She (Resident #76) does good for awhile then reverts back... I am in a quandary. I don't want to put her down (sedate) but also know she needs something, I am about ready to send her back to the unit... it is my understanding that the psychiatric services they had here quit and they are in the process of getting another one... not sure if they have been in here yet, but yes she could use psychiatric services..." During an interview in the conference room on 1/31/13 at 1:30 PM, the Activity Director stated, "...I do one on one with (named Resident #76)... she does not do groups..." During an interview in the conference room on 1/31/13 at 1:45 PM, the Social Worker stated, "...I do one on one with her... get her off away from groups... try to calm her, talk to her, redirect her. Our MDS (Minimum Data Set) nurse does the care plan but I do assist with behaviors. Would have to get with the nurse to discuss her current goal. I think she would benefit being in a facility with a behavior unit. We did have (named) psychiatric services coming, but I understand they have left and (named Administrator) is getting someone else..." During an interview in the conference room on 1/31/13 at 2:45 PM, the Director of Nursing stated, "We do one on one with her (Resident #76), talk with her, snacks, coffee, and call family if needed. She has days that she is worse... was being seen by (named psychiatric) service, they have left us... on weekends and at night the staff do the same thing... one on one with her. Our behavior management is documented on our behavior flow sheets... interventions should be included on the care plan... the Activity Directory and Social Worker also work with her one on one..." During an interview in the conference room on 2/1/13 at 8:00 AM, Resident #76's son stated, "She (Resident #76) needs something that can not be provided by this facility... I'm concerned that her outbursts are disturbing to other residents and families and that she can not be happy..." During an interview in the conference room on 2/1/13 at 1:20 PM, the Administrator stated, "...11/29/12 is last time (named psychiatric service) was in our building..." The Administrator confirmed no psychiatric visits were made to see Resident #76 in December 2012 or January 2013. During an interview in the conference room on 2/1/13 at 4:30 PM, the Regional Clinical Coordinator stated, "We started using the new initiatives on 11/14/12, (Resident #76) has a [DIAGNOSES REDACTED]. We are trying to manage behaviors with non drug use. The root cause was used, we looked at what acute process was going on when the behaviors increased, we notified the physician and did urinalysis, chest X-ray, and laboratory tests. Injectable medication was used instead of by mouth due to her history of spitting out drugs. The root cause this week was a UTI. The [MEDICATION NAME] was discontinued and [MEDICATION NAME] was increased in mid-November. I reviewed the behavior monitoring sheets for the past 4 months and behaviors improved after the [MEDICATION NAME] was discontinued. In mid- December there was an increase of behaviors with a urinalysis showing mixed flora, the physician wanted no treatment except to continue the maintenance Bactrim... we think the root cause of those behaviors was a full moon. In mid-January there was another behavior increase, she came back with an E Coli (Eschericia Coli) UTI and was ordered IM (intramuscular) [MEDICATION NAME]. We have reviewed the last 4 months of Behavior Monitoring Sheets. Her behaviors we are monitoring are slapping and yelling which indicates anxiety. In October she did 85 slaps and 84 yells. November 1 through 15, 64 slaps and 61 yells... we discontinued [MEDICATION NAME] on 11/15/12 and from 11/16 through 11/30/12 behaviors decreased to 29 slaps and 47 yells. In December she had 130 slaps and 151 yells. I can't help but think that was also lunar. In January she had 130 slaps and 170 yells more the last half of the month, She does exhibit behaviors... " The failure of the facility to provide the necessary services to address the behaviors resulted in actual harm to Resident #76 who was observed repeatedly screaming and hitting at staff and other residents. 3. Medical record review for Resident #96 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 12/20/12 documented, "...Problem... psych (psychiatric) drug use... r/t (related to) finger painting stool / washes hands in toilet..." Review of the "(Psychiatric services name) HEALTH SERVICES - [MEDICAL CONDITION] MED (medication) MGT (management) PROGRESS NOTE" dated 11/8/12 documented, "...Distressed Behaviors... Aggressive - Verbal... Behavior interventions not indicated in patient record..." The 11/8/12 date was the last visit documented for Resident #96 by psychiatric services. Review of the nurse's notes documented the following: a. 11/16/12 - "...has frequent episodes of using the trash can and floor and other places for a bathroom..." b. 12/16/12 - "...Pt (patient) playing with BM (bowel movement) this evening, upset when staff attempted to help..." c. 12/19/12 - "...Res. (resident) approached by the CN (charge nurse) to pull up clothing but before I could speak res. started cursing clawed CN's arm and kicked me in the stomach..." d. 1/4/13 - "...combative with staff, frequently throws briefs in floor of closet..." Observations in Resident #96's room on 1/28/13 at 3:00 PM, revealed Resident #96 lying down on her bed, turned toward the window and would not answer questions by the surveyor. During an interview in the conference room on 1/31/13 at 2:45 PM, the DON stated, "(Resident #96) will tell you to "leave me alone, I am just fine." The staff that work with her, especially the staff that work with her daily... they know her preferences. She... likes to watch the television, likes to be alone..." There was no psychiatric / behavior management documented since 11/8/12 to address her behaviors.

Based on review of the social worker's job description, policy review, medical record review, observation, and interview, it was determined the facility failed to ensure that 1 of 2 (Resident #76) sampled residents who displayed behaviors of anger, yelling, and hitting were provided medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The failure of the facility to provide medically related social services to address behaviors resulted in actual harm to Resident #76 who was observed repeatedly screaming and hitting at staff and other residents. The findings included: Review of the job description "Social Worker" documented, "Summary: Provides psychosocial support to residents and their families... Essential Functions: Provides direct psychosocial intervention..." Review of the facility's "Problematic Behavior Management - Clinical Protocol" policy documented, "...As part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition... problematic behavior. The staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition... The physician will help verify that previously identified [DIAGNOSES REDACTED]. The staff will attempt as appropriate to identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The physician will help identify and authorize appropriate, targeted... and symptomatic treatments. a. If a psychiatric consultant is called to help manage behavioral issues, the Attending Physician will retain an active role by reviewing the consultant's recommendations..." Medical record review for Resident #76 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented, "...Staff Assessment for Mental Status... C1000. Cognitive Skills for Daily Decision Making... 3. Severely impaired - never/rarely made decisions... E0100. Potential Indicators of Psychosis... B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality)... E0200. Behavioral Symptom - Presence & (and) Frequency... A. Physical behavioral symptoms directed toward others (...hitting, kicking, pushing, scratching, grabbing, abusing others sexually)... 2. Behavior of this type occurred 4 to 6 days, but less than daily... B. Verbal behavioral symptoms directed toward others (...threatening others, screaming at others, cursing at others)... 1. Behavior of this type occurred 1 to 3 days... E0800. Rejection of Care - Presence & Frequency... 1. Behavior of this type occurred 1 to 3 days..." Review of the care plan dated 12/17/12 documented, "...Problem... Non-compliance... Refuses meds (medications) @ (at) x's (times) & care... Notify MD (medical doctor) as needed... Problem... Cognitive Loss / Dementia... Alteration in cognitive function related to impaired memory... Approach... observe for changes in condition that may affect cognition (acute process). Notify MD PRN (as needed)... Problem... Behavioral Symptoms... Inappropriate social behavior related to agitation/aggression... frequently yells "mama" and "help me" /profanities... Problem... Psychotropic Drug Use... Approach... Assess any behavioral changes... psych (psychiatric) services as needed..." The care plan was not revised to address the behaviors of cursing, spitting, kicking, slapping or hitting. Review of the nurse's notes documented the following: a. "12/26 (2012) Combative c (with) staff during care..." b. "12-27-12... Pt (patient) yelling @ ppl (people) in hallway. Pt combative during care - slapping, kicking..." c. "12-28-12... Pt combative with care - slapping, kicking. Pt yells out @ x's..." d. "1/21/13... Pt irritated & yelling in dining room & hit another resident... Pt unconsolable & continues to yell for "mama"..." e. "1-22-13... spit meds & slapped..." f. "1/23/13... Pt screaming and cussing @ everyone. Very aggitated (agitated)..." g. "1-24-13... Pt constantly yells & curses @ pts, family, staff, & visitors... Pt yelling & cussing, had to be removed from dining room d/t (due to) upsetting other pt's in DR (dining room)..." h. "1/25/13... Pt. grabbing @ other pts. when they would go by & cussing @ them. Grabbed one pt's sleeve & twisted sleeve, had to separate..." Review of the "Behavior/Intervention Monthly Flow Record" for October, November, and December 2012 and for January 2013 documented daily behaviors of slapping and yelling out. Review of the "PSYCHOTROPIC MED (medication) MGT (management) PROGRESS NOTE" dated 11/29/12 completed by an Advanced Practice Registered Nurse - Board Certified clinician documented, "...Patient Status: Moderately Unstable... Staff notes pt. becomes combative during care. Hitting, pinching, biting, kicking staff. Yells at people down the hallway. Attempted to hit other pts. Refuses meds at times... Assessment Summary and Rationale for Recommendation(s)... in the dining room she was screaming out her needs and became more confused calling out for her Mother... pt was screaming and cursing in hallway... pt is having hallucinations and delusions that are disturbing to her and make her paranoid to staff... pt continues to become physically aggressive with staff in her psychosis. I suggest adding seroquel 25mg (milligrams) at 1200 to prevent her afternoon worsening psychosis... Distressed Behaviors... No environmental, medication, or medical causes per record, Behavior interventions ineffective, Interventions Attempted: redirection, changes in environment, snacks..." There were no other psychiatric notes in the medical record after the 11/29/12 visit. Observations on the 400 hall on 1/28/13 at 5:00 PM, revealed Resident #76 seated in a wheelchair, screaming and repeatedly yelling "mama." Observations on the 400 hall on 1/29/13 at 9:35 AM, revealed Resident #76 seated in a wheelchair, screaming and cursing. Observations on the 400 hall on 1/29/13 at 4:30 PM, revealed Resident #76 seated in a wheelchair, yelled at and attempted to hit another resident in a wheelchair. Observations on the 400 hall on 1/30/12 at 2:00 PM, revealed Resident #76 seated in a wheelchair, repeatedly screaming "mama" and cursing. During an interview in Resident #85's room on 1/29/13 at 11:00 AM, Resident #85 was asked if this facility was a comfortable place in which to live. Resident #85 stated, "...there is noise in the hall and dining room, residents screaming and cussing..." Resident #85 was asked if he had any concerns or problems with any other residents. Resident #85 stated, "Yes, (named Resident #76) yells and cusses..." During an interview on the 100 hall on 1/29/13 at 4:40 PM, Resident #58 stated, "...something is going to have to be done about her (Resident #76)... what is she yelling about? I going to have to call the police..." During an interview in the conference room on 1/30/13 at 10:00 AM, Resident #76's family stated, "We visit every day, and the nurses call us when they need us... they (nurses) called us yesterday, and we came out here to stay with her... She does have someone who comes every month... a psychiatrist and checks her... they have changed her medications... she was on the Aricept... now on Seroquel... they have told us that may not be working so good for her any more..." During an interview on the 100 hall on 1/30/13 at 11:00 AM, Certified Nursing Assistant (CNA) #8 stated, "She (Resident #76) was up all night so we are letting her sleep..." During an interview in the conference room on 1/30/13 at 2:15 PM, Nurse #11 stated, "When she hollers I usually give her a snack, she hollers when she wants to take a nap, a snack, and is worse with a UTI (Urinary Tract Infection)..." During an interview on the 400 hall on 1/30/13 at 3:50 PM, Nurse #16 stated, "We do one on one with her (Resident #76) as much as possible, we do call her son to help if necessary... she is okay at times and then at times she cannot be redirected, much worse since the UTI..." During an interview on the 100 hall on 1/31/13 at 9:00 AM, Nurse #2 stated, "We do one on one with her when she gets upset, that is all we can do, she does not tolerate groups, she is not as bad when she doesn't have a UTI... she hits, slaps... I feel we are failing her, I think she is miserable..." During an interview in the conference room on 1/31/13 at 1:00 PM, Resident #76's physician stated, "...She does good for awhile then reverts back... I am in a quandary. I don't want to put her down (sedated) but also know she needs something. I am about ready to send her back to the unit... it is my understanding that the psychiatric services they had here quit and they are in the process of getting another one... not sure if they have been in here yet, but yes she could use psychiatric services..." During an interview in the conference room on 1/31/13 at 1:30 PM, the Activity Director stated, "...I do one on one with (named Resident #76)... she does not do groups..." During an interview in the conference room on 1/31/13 at 1:45 PM, the Social Worker stated, "...I do one on one with her... get her off away from groups... try to calm her, talk to her, redirect her. Our MDS nurse does the care plan but I do assist with behaviors. Would have to get with the nurse to discuss her current goal. I think she would benefit being in a facility with a behavior unit. We did have (named Psychiatric service) psychiatric services coming, but I understand they have left and (named Administrator) is getting someone else..." During an interview in the conference room on 1/31/13 at 2:45 PM, the Director of Nursing stated, "We do one on one with her (Resident #76), talk with her, snacks, coffee, and call family if needed. She has days that she is worse... was being seen by (named psychiatric) service, they have left us... on weekends and at night the staff do the same thing... one on one with her. Our behavior management is documented on our behavior flow sheets... interventions should be included on the care plan... the Activity Directory and Social Worker also work with her one on one..." During an interview in the conference room on 2/1/13 at 8:00 AM, Resident #76's son stated, "She (Resident #76) needs something that can not be provided by this facility... I'm concerned that her outbursts are disturbing to other residents and families and that she can not be happy..." During an interview in the conference room on 2/1/13 at 1:20 PM, the Administrator stated, "11/29/12 is last time (named psychiatric service) was in our building..." The Administrator confirmed no psychiatric visits were made to see Resident #76 in December 2012 or January 2013. During an interview in the conference room on 2/1/13 at 4:30 PM, the Regional Clinical Coordinator stated, "We started using the new initiatives on 11/14/12, (Resident #76) has a [DIAGNOSES REDACTED]. We are trying to manage behaviors with non drug use. The root cause was used, we looked at what acute process was going on when the behaviors increased, we notified the physician and did urinalysis, chest X-ray, and laboratory tests. Injectable medication was used instead of by mouth due to her history of spitting out drugs. The root cause this week was a UTI. The Xanax was discontinued and Seroquel was increased in mid-November. I reviewed the behavior monitoring sheets for the past 4 months and behaviors improved after the Xanax was discontinued. In mid- December there was an increase of behaviors with a urinalysis showing mixed flora, the physician wanted no treatment except to continue the maintenance Bactrim... we think the root cause of those behaviors was a full moon. In mid- January there was another behavior increase, she came back with an E Coli (Escherichia Coli) UTI and was ordered IM (intramuscular) Invanz. We have reviewed the last 4 months of Behavior Monitoring Sheets. Her behaviors we are monitoring are slapping and yelling which indicates anxiety. In October (2012) she did 85 slaps and 84 yells. November 1 through 15 (2012), 64 slaps and 61 yells... we discontinued Xanax on 11/15/12 and from 11/16 through 11/30/12 behaviors decreased to 29 slaps and 47 yells. In December (2012) she had 130 slaps and 151 yells. I can't help but think that was also lunar. In January (2013) she had 130 slaps and 170 yells more the last half of the month... she does exhibit behaviors... " The failure of the facility to provide medically related social services to address behaviors resulted in actual harm to Resident #76 who was observed repeatedly screaming and hitting at staff and other residents.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow a care plan for psychological services and interventions for fall prevention for 2 of 41 (Residents #76 and 79) sampled residents included in the stage 2 review. The failure of the facility to follow the care plan for providing psychiatric services to address behaviors resulted in actual harm to Resident #76 who was observed repeatedly screaming and hitting at staff and other residents. The findings included: 1. Review of the facility's "Problematic Behavior Management - Clinical Protocol" policy documented, "...As part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition... problematic behavior. The staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition... The physician will help verify that previously identified [DIAGNOSES REDACTED]. The staff will attempt as appropriate to identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The physician will help identify and authorize appropriate, targeted... and symptomatic treatments. a. If a psychiatric consultant is called to help manage behavioral issues, the Attending Physician will retain an active role by reviewing the consultant's recommendations..." 2. Medical record review for Resident #76 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented, "...Staff Assessment for Mental Status... C1000. Cognitive Skills for Daily Decision Making... 3. Severely impaired - never/rarely made decisions... E0100. Potential Indicators of [MEDICAL CONDITION] B. [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality)... E0200. Behavioral Symptom - Presence & (and) Frequency... A. Physical behavioral symptoms directed toward others (...hitting, kicking, pushing, scratching, grabbing, abusing others sexually)... 2. Behavior of this type occurred 4 to 6 days, but less than daily... B. Verbal behavioral symptoms directed toward others (...threatening others, screaming at others, cursing at others)... 1. Behavior of this type occurred 1 to 3 days... E0800. Rejection of Care - Presence & Frequency... 1. Behavior of this type occurred 1 to 3 days..." Review of the care plan dated 12/17/12 documented, "...Problem... Non-compliance... Refuses meds (medications) @ (at) x's (times) & care... Notify MD (medical doctor) as needed... Problem... Cognitive Loss / Dementia... Alteration in cognitive function related to impaired memory... Approach... observe for changes in condition that may affect cognition (acute process). Notify MD PRN (as needed)... Problem... Behavioral Symptoms... Inappropriate social behavior related to agitation/aggression... frequently yells "mama" and "help me" /profanities... Problem... [MEDICAL CONDITION] Drug Use... Approach... Assess any behavioral changes... psych (psychiatric) services as needed..." The facility was unable to provide documentation of psychiatric services after 11/29/12 to address Resident #76's increase in behaviors. Review of the nurse's notes documented the following: a. "12/26 (2012)... Combative c (with) staff during care..." b. "12-27-12... Pt (patient) yelling @ ppl (people) in hallway. Pt combative during care - slapping, kicking..." c. "12-28-12... Pt combative with care - slapping, kicking. Pt yells out @ x's..." d. "1/21/13... Pt irritated & yelling in dining room & hit another resident... Pt unconsolable & continues to yell for "mama"..." e. "1-22-13... spit meds & slapped..." f. "1/23/13... Pt screaming and cussing @ everyone. Very aggitated (agitated)..." g. "1-24-13... Pt constantly yells & curses @ pts, family, staff, & visitors... Pt yelling & cussing, had to be removed from dining room d/t (due to) upsetting other pt's in DR (dining room)..." h. "1/25/13... Pt. grabbing @ other pts. when they would go by & cussing @ them. Grabbed one pt's sleeve & twisted sleeve, had to separate..." Review of the "Behavior / Intervention Monthly Flow Record" for October, November, and December 2012 and for January 2013 documented daily behaviors of slapping and yelling out. Review of the "[MEDICAL CONDITION] MED (medication) MGT (management) PROGRESS NOTE" dated 11/29/12 completed by an Advanced Practice Registered Nurse - Board Certified clinician documented, "...Patient Status: Moderately Unstable...Staff notes pt. becomes combative during care. Hitting, pinching, biting, kicking staff. Yells at people down the hallway. Attempted to hit other pts. Refuses meds at times... Assessment Summary and Rationale for Recommendation(s) ...in the dining room she was screaming out her needs and became more confused calling out for her Mother... pt was screaming and cursing in hallway... pt is having hallucinations and [MEDICAL CONDITION] that are disturbing to her and make her paranoid to staff... pt continues to become physically aggressive with staff in her [MEDICAL CONDITION]. I suggest adding [MEDICATION NAME] 25mg (milligrams) at 1200 to prevent her afternoon worsening [MEDICAL CONDITION] Distressed Behaviors... No environmental, medication, or medical causes per record, Behavior interventions ineffective, Interventions Attempted: redirection, changes in environment, snacks..." There were no other psychiatric notes in the medical record after the 11/29/12 visit. Observations on the 400 hall on 1/28/13 at 5:00 PM, revealed Resident #76 seated in a wheelchair, screaming and repeatedly yelling "mama." Observations on the 400 hall on 1/29/13 at 9:35 AM, revealed Resident #76 seated in a wheelchair, screaming and cursing. Observations on the 400 hall on 1/29/13 at 4:30 PM, revealed Resident #76 seated in a wheelchair, yelled at and attempted to hit another resident in a wheelchair. Observations on the 400 hall on 1/30/12 at 2:00 PM, revealed Resident #76 seated in a wheelchair, repeatedly screaming "mama" and cursing. During an interview in Resident #85's room on 1/29/13 at 11:00 AM, Resident #85 was asked if this facility was a comfortable place in which to live. Resident #85 stated, "There is noise in the hall and dining room, residents screaming and cussing..." Resident #85 was asked if he had any concerns or problems with any other residents. Resident #85 stated, "Yes, (named Resident #76) yells and cusses..." During an interview on the 100 hall on 1/29/13 at 4:40 PM, Resident #58 stated, "Something is going to have to be done about her (Resident #76)... what is she yelling about? I going to have to call the police..." During an interview in the conference room on 1/30/13 at 10:00 AM, Resident #76's family stated, "We visit every day, and the nurses call us when they need us... they (nurses) called us yesterday, and we came out here to stay with her... She does have someone who comes every month... a psychiatrist and checks her.. .they have changed her medications... she was on the [MEDICATION NAME] now on [MEDICATION NAME] they have told us that may not be working so good for her any more..." During an interview on the 100 hall on 1/30/13 at 11:00 AM, Certified Nursing Assistant (CNA) #8 stated, "She (Resident #76) was up all night so we are letting her sleep..." During an interview in the conference room on 1/30/13 at 2:15 PM, Nurse #11 stated, "When she hollers I usually give her a snack, she hollers when she wants to take a nap, a snack, and is worse with a UTI (Urinary Tract Infection)..." During an interview on the 400 hall on 1/30/13 at 3:50 PM, Nurse #16 stated, "We do one on one with her (Resident #76) as much as possible, we do call her son to help if necessary... she is okay at times and then at times she cannot be redirected, much worse since the UTI..." During an interview on the 100 hall on 1/31/13 at 9:00 AM, Nurse #2 stated, "We do one on one with her when she gets upset, that is all we can do, she does not tolerate groups, she is not as bad when she doesn't have a UTI... she hits, slaps... I feel we are failing her, I think she is miserable..." During an interview in the conference room on 1/31/13 at 1:00 PM, Resident #76's physician stated, "She does good for awhile then reverts back... I am in a quandary. I don't want to put her down (sedate) but also know she needs something. I am about ready to send her back to the unit... it is my understanding that the psychiatric services they had here quit and they are in the process of getting another one... not sure if they have been in here yet, but yes she could use psychiatric services..." During an interview in the conference room on 1/31/13 at 1:30 PM, the Activity Director stated, "I do one on one with (named Resident #76)... she does not do groups..." During an interview in the conference room on 1/31/13 at 1:45 PM, the Social Worker stated, "I do one on one with her (Resident #76)... get her off away from groups... try to calm her, talk to her, redirect her. Our MDS nurse does the care plan but I do assist with behaviors. Would have to get with the nurse to discuss her current goal. I think she would benefit being in a facility with a behavior unit. We did have (named Psychiatric service) psychiatric services coming, but I understand they have left and (named Administrator) is getting someone else..." During an interview in the conference room on 1/31/13 at 2:45 PM, the DON stated, "We do one on one with her (Resident #76), talk with her, snacks, coffee, and call family if needed. She has days that she is worse... was being seen by (named psychiatric) service, they have left us... on weekends and at night the staff do the same thing..one on one with her. Our behavior management is documented on our behavior flow sheets... interventions should be included on the care plan... the Activity Directory and Social Worker also work with her one on one..." During an interview in the conference room on 2/1/13 at 8:00 AM, Resident #76's son stated, "She (Resident #76) needs something that can not be provided by this facility... I'm concerned that her outbursts are disturbing to other residents and families and that she can not be happy..." During an interview in the conference room on 2/1/13 at 1:20 PM, the Administrator stated, "11/29/12 is last time (named psychiatric service) was in our building..." The Administrator confirmed no psychiatric visits were made to see Resident #76 in December 2012 or January 2013. During an interview in the conference room on 2/1/13 at 4:30 PM, the Regional Clinical Coordinator stated, "We started using the new initiatives on 11/14/12, (Resident #76) has a [DIAGNOSES REDACTED]. We are trying to manage behaviors with non drug use. The root cause was used, we looked at what acute process was going on when the behaviors increased, we notified the physician and did urinalysis, chest X-ray, and laboratory tests. Injectable medication (IM) was used instead of by mouth due to her history of spitting out drugs. The root cause this week was a UTI. The [MEDICATION NAME] was discontinued and [MEDICATION NAME] was increased in mid-November. I reviewed the behavior monitoring sheets for the past 4 months and behaviors improved after the [MEDICATION NAME] was discontinued. In mid- December there was an increase of behaviors with a urinalysis showing mixed flora, the physician wanted no treatment except to continue the maintenance Bactrim... we think the root cause of those behaviors was a full moon. In mid- January there was another behavior increase, she came back with an E Coli (Eschericia Coli) UTI and was ordered IM (intramuscular) [MEDICATION NAME]. We have reviewed the last 4 months of Behavior Monitoring Sheets. Her behaviors we are monitoring are slapping and yelling which indicates anxiety. In October she did 85 slaps and 84 yells. November 1 through (-) 15, 64 slaps and 61 yells... we discontinued [MEDICATION NAME] on 11/15/12 and from 11/16-11/30/12 behaviors decreased to 29 slaps and 47 yells. In December she had 130 slaps and 151 yells. I can't help but think that was also lunar. In January she had 130 slaps and 170 yells more the last half of the month, She does exhibit behaviors... " The failure of the facility to follow the care plan for providing psychiatric services to address behaviors resulted in actual harm to Resident #76 who was observed repeatedly screaming and hitting at staff and other residents. 3. Medical record review for Resident #79 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 8/16/12 documented, "...Problem... Falls... Resident at risk for falls... Approach... Non-skid mat by bed... Non Skid Mat in front of Recliner..." Review of the nurse's notes dated 12/10/12 documented, "...found resident on floor in front of recliner..." Review of the nurse's notes dated 12/19/12 documented, "...found by housekeeping... sitting (up) in floor..." Observations in Resident #79's room on 1/29/13 at 1:33 PM, revealed Resident #79 seated in the recliner in her room. There was no non-skid mat in front of the recliner or the bed. Observations in Resident #79's room on 1/31/13 at 10:41 AM, there was no non-skid mat in front of the recliner. During an interview in the conference room on 1/31/13 at 3:14 PM, the DON stated, the "Fall intervention was non-skid mat by recliner... and non-skid mat by bed..." During an interview at the 100/300 nurses' station on 2/1/13 at 2:45 PM, Nurse #13 was asked where the non-skid mats were documented. Nurse # 13 stated, "...Certified Nursing Assistants documented on their daily rounding sheets and give to the nurses..." The Daily Rounds Sheets for December (2012) and January (2013) had no documentation of non-skid mats recorded.