Every finding on record at Care One at Peabody

Based on observation and interview the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles on three of three units. Specifically, 1. The facility failed to secure drugs and biologicals on three of three units when two treatment carts and one medication room were accessible to the surveyor unsupervised. 2. The facility failed to properly label and store medications in medication carts on two of three units. 3. The facility failed to secure medications in a resident room for one (Resident #90) of 28 sampled residents. Findings include: Review of facility policy titled Medication Labeling and Storage, dated as revised February 2023, indicated the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage -Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Medication Labeling -Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. -Antiseptics, disinfectants and germicides used in any aspect of the resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications. 1. On 3/25/25 at 7:52 A.M., the surveyor observed an unlocked and unattended treatment cart on the first-floor unit. The surveyor was able to gain access to the cart which contained treatment supplies as well medicated creams and ointments. The surveyor observed three staff walk by the unlocked treatment cart without addressing it. During an interview on 3/25/25 on 7:54 A.M., Nurse #1 said that the treatment cart should be locked when unattended. On 3/25/25 at 7:59 A.M., the surveyor observed an unlocked and unattended treatment cart on the second-floor unit. The surveyor was able to gain access to the treatment cart which contained treatment supplies as well as medicated creams and ointments. During an interview on 3/25/25 at 8:00 A.M., Nurse #3 said that the treatment cart should be locked when unattended, but it was not. On 3/25/25 at 10:43 A.M., Nurse #4 unlocked the medication room on the third floor to let the surveyor in the medication room. She left the surveyor alone in the medication room and walked away. During an interview on 3/25/25 at 10:45 A.M., The Infection Preventionist said that the nurse should not have left the surveyor unsupervised in the medication room. During an interview on 3/25/25 at 2:06 P.M., the Director of Nurses said that treatment carts should be locked when they are unattended, and nurses should not leave unauthorized people in the medication room alone. 2. On 3/25/25 at 9:03 A.M., the surveyor observed the following in the first floor A side medication cart: -Two unopened vials of Humalog insulin in the medication cart. -One unopened Lantus insulin pen. During an interview on 3/25/25 at 9:06 A.M., Nurse #2 said that unopened insulin should be stored in the fridge until it is opened and not in the medication cart. On 3/25/25 at 10:46 A.M., the surveyor observed the following on the third floor B side medication cart: -A bottle of liquid protein opened, and without an open date. The bottle reads 3-month shelf life from date opened. -Dried and sticky spills from a red liquid in one of the drawers of the medication cart where medications are stored. During an interview on 3/25/25 at 10:49 A.M., Nurse #4 said that the liquid protein should be labeled with an open date, but it was not, and that the medication cart was dirty and needed to be cleaned where leaks or spills from medication had happened. On 3/25/25 at 10:52 A.M., the surveyor made the following observations on the third floor A side medication cart: -Cleaning wipes stored in the same compartment as oral medications. -A Lupin inhaler with Tiotropium Bromide inhalation capsules stored in a bag, unlabeled without any resident identification on the bag or inhaler. During an interview on 3/25/25 at 10:58 A.M., Nurse #5 said that the inhaler should be labeled with a resident name to identify who it is for and that the cleaning wipes should not be stored with medications. During an interview on 3/25/25 at 11:05 A.M., the Infection Preventionist said that medication carts should be clean and cleaning products should not be stored with medications. She also said that medications with shortened expiration dates should be labeled when opened and medications should have a resident label on them. During an interview on 3/25/25 at 2:06 P.M., the Director of Nurses said unopened insulin should be stored in the fridge until it is opened. She further said that she would expect that medication carts are clean and without spills. The Director of Nurses also said that medications should be labeled with open dates if they have shortened expiration dates. Further she said that cleaning supplies should not be stored with medications. 15016 3. Resident #90 was admitted to the facility in June 2021, and has active diagnoses which include diabetes, malnutrition, depression and chronic obstructive pulmonary disorder. Review of Resident #90's Minimum Data Set assessment, dated 1/30/25, indicated that the Resident had intact cognition. Review of Resident #90's Self-Administration of Medications assessment, dated 2/5/25, indicated nursing staff were to pour the medications, and the Resident was allowed to self-administer them. During an interview and observation on 3/25/25 at 10:13 A.M., the surveyor observed approximately eight pills of different colors and shapes on the floor under Resident #90's bed. Resident #90, who was lying in bed, said an unidentified staff member accidentally knocked the pills off his/her meal tray onto the floor. Resident #90 said the staff person told him/her someone would return to the room to remove the pills, but no one did. Resident #90 said the pills may have been under the bed for a couple of days. During an interview on 3/27/25 at 1:00 P.M., the Director of Nurses (DON) said Resident #90 was assessed and determined to be able to self-administer medications. The DON said that all medications should be secured in the bedroom and not left on the floor.

Based on record review and interview, the facility failed to follow professional standards of practice for one Resident (#494) out of a total sample of 28 residents. Specifically, the facility failed to implement a physician's order to notify provider (physician, nurse practitioner) if Resident #494's daily weight indicated an increase of greater than two pounds. Findings include: Review of facility policy titled 'Weight Assessment and Intervention' dated March 2023, indicated the following but was not limited to: - Resident weights are monitored for undesirable or unintended weight loss or gain. Resident #494 was admitted to the facility in March 2025 with diagnoses including heart failure and chronic respiratory failure with hypoxia. Review of Resident #494's most recent Minimum Data Set (MDS) assessment, dated 3/19/25, indicated an entry tracking record and a comprehensive MDS had not been completed. Review of Resident #494's physician's orders, dated 3/19/25, indicated daily weights. Notify provider of weight of two pounds or more daily or five pounds in a week in the morning. Review of Resident #494's nursing progress note, dated 3/23/25, indicated notified weight to NP (Nurse Practitioner) Brown, no new order. Continue to monitor the weight. Review of Resident #494's physician notes failed to indicate that the physician was notified of a weight change from 3/24/25 to 3/26/25. Review of Resident #494's daily weights indicated the following: -3/22/25 284.6 pounds (lbs.) -3/23/25 290.0 lbs. (gain of 5.4 lbs). -3/24/25 294.8 lbs. (gain of 4.8 lbs). -3/25/25 295.0 lbs. (gain of 0.2 lbs). -3/26/25 296.0 lbs. (gain of 1.0 lbs) (total gain of 11.4 lbs. since 3/22/25). During an interview on 3/27/25 at 11:22 A.M., Unit Manager #1 said she was unaware the physician had not been notified of Resident #494's weight gain, the physician should have been notified, and that the notification should be documented in the nursing notes. During an interview on 3/27/25 at 1:08 P.M., the Director of Nursing said that physician's orders should be followed, and that Resident #494's weight gain should have been reported to the physician and documented in the nursing notes.

Based on observation, record review and interview, the facility failed to update the care plan for Activities of Daily Living (ADL) for one Resident (#75) out of a total sample of 28 residents. Findings include: Review of the Facility's Policy titled Care Plans Comprehensive Person-Centered, dated 4/25/22, indicated that assessments of the residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #75 was admitted to the facility in February 2025 with diagnoses including stroke and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated that Resident #75 was rarely/never understood and a staff assessment for Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment. The MDS further indicated Resident #75 required partial/moderate assistance with meals, was holding food in mouth or cheeks or residual food in mouth after meals and had a mechanically altered diet. On 3/25/25 at 8:37 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/26/25 at 8:12 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/26/25 at 12:20 P.M., the surveyor observed Resident #75 sitting up in wheelchair in his/her room eating lunch. Resident #75's lunch tray included a lip plate, but did not have built up utensils. Resident #75 said he/she used to have built up utensils but guessed they changed the rules. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/27/25 at 8:24 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There were no staff present in the room providing assistance and the Resident was not visible from the hallway. Review of Resident #75's physician's order, 2/26/25, indicated: built up utensils and lip plate at all meals. Review of Resident #75's physician's order, dated 3/13/25, indicated diet: soft and bite sized texture. Review of Resident #75's plan of care for ADL's, dated 2/21/25, indicated assist with eating as needed. Review of Resident #75's plan of care for diet, dated 3/3/25, indicated uses adaptive equipment: built up utensils, lip plate and 1:1 dependent. Review of Resident #75's Speech Language Pathologist's (SLP) treatment note, dated 3/18/25, indicated patient was noted to be provided with weighted utensils on this date. Patient has order for built up utensils in place. Occupational Therapy (OT) consulted and made aware. During an interview on 3/27/25 at 11:17 A.M., the SLP said that Resident #75 should be seated upright during meals and have his/her food cut up. Resident #75 does not need to be supervised for meals. He said that OT had initiated the built-up utensils but had reassessed the utensils to be too large for Resident #75 to manage so they were discontinued. Review of Resident #75's OT evaluation, dated 2/24/25, indicated Resident required partial/moderate assist for eating. Review of Resident #75's OT treatment note, dated 3/25/25, indicated Resident required set up for eating. Review of Resident #75's Documentation Survey Report (indicates level of assist Resident requires with care), indicated the following: Eating: 1:1 dependent, built-up utensils, lip plate. During an interview on 3/27/25 at 11:22 A.M., Unit Manger #1 and the surveyor reviewed Resident #75's Documentation Survey Report, physician's orders, and plan of care. She said Resident #75 only requires set up for meals and no longer requires built up utensils. She was unaware that the care plan, physician orders, and Documentation Survey Report did not reflect Resident #75's current level of care, but they should. During an interview on 3/27/25 at 1:06 P.M., the Director of Nursing said Resident's care plan should be updated to reflect level of care required for the Resident.

Based on record review and interviews, the facility failed to provide care and services consistent with professional standards including ongoing communication and collaboration with the dialysis facility for one Resident (#536), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of 28 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility and failed to implement a Dietitian's recommendation to give phosphate binders (a medication to absorb phosphate from the food you eat to help prevent high phosphorus levels) that was communicated in Resident #536's dialysis communication book. Findings Include: Review of the facility policy titled Hemodialysis Pre and Post Care revised March 2010, indicated the following but not limited to: - Document all communications in the hemodialysis communication progress note or dialysis center communication book. - Ensure ongoing communication with dialysis staff. Resident #536 was admitted to the facility in March 2025 with diagnoses including End stage renal disease, Dependence on renal dialysis. Review of Resident #536's most recent Minimum Data Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15, indicating moderate cognitive impairment. Further review of the MDS indicated the Resident received hemodialysis treatment. Review of Resident #536's Dialysis Communication Book document dated March 2025 indicated the following: - The Resident's phosphorous range goal was between 3.0 to 5.5 mg/dL (milligrams per deciliter) and that the Residents phosphorus level was 7.6 mg/dL, indicating his/her phosphorus levels were elevated. - Please be sure patient takes 3 Calcium Acetate with meals related to a high phosphorus. Review of the current physician's orders failed to indicate calcium acetate had been ordered for the Resident. Review of the Medication Administration Record (MAR) for March 2025 failed to indicate the Resident was receiving calcium acetate. Review of Resident #536's care plan date initiated 3/10/25: Renal insufficiency related to chronic renal failure; Coordinate dialysis care with the dialysis center. During an interview on 3/7/25 10:57 A.M., Unit Manager # 1 said it is the responsibility of the medication nurse to check the dialysis communication book in her absence when the resident returns to the facility from dialysis. Unit Manager #1 also stated it appeared that no one had checked the dialysis communication book as the Resident did not have an order for the calcium acetate. During an interview on 3/27/25 11:20 A.M., the Director of Nursing said it is the responsibility of the nurse or unit manager to check the dialysis communication book when the resident returns to the facility and they were responsible for updating the physician on any orders or recommendations from the dialysis center. During an interview on 3/28/25 8:00 A.M., the Dialysis Nurse said communication reports are given by the dietitian on the second week of the month, as monthly labs were drawn on the first of the month. The Dialysis Nurse also said Resident #536 had his/her labs drawn between 3/3/25 and 3/4/25 and would have received the communication report on the week of 12th-14th of March with a follow up communication to the facility by the dietitian. 52138

Based on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs. Findings include: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report, submitted by the facility for Fiscal Year (FY) Quarter 1 2024 (October 1, 2023 - December 31, 2023), was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the facility assessment indicated the following: - Based on the above information and programming goals, a staffing plan has been developed to meet the professional, technical and administrative needs of the center. The plan is informed by historical experience, and projected changes. The approach takes into consideration both the type of staff (licensure or other credential) and number provided. SEE ATTACHMENT 1 - Staffing by shift. -Attachment 1 indicated the total Direct Care PPD (Per Patient Day) was .87 and Nursing PPD was 3.91. The Administrator provided the surveyor with the expected daily PPD of the facility. The weekday expected PPD was 3.392 and the weekend expected PPD was 3.22. Review of the daily schedules from October to December 2023 indicated that 59 of 66 weekday shifts during this time frame were below the facility's expected staffing levels, with only 7 weekday shifts reaching a PPD of 3.392. Review of the daily schedules from October to December 2023 indicated that 19 of 27 weekend shifts during this time frame were below the facility's expected staffing levels, with only 8 weekend shifts reaching a PPD of 3.22. Review of the daily schedules from January to April 2024 indicated that 65 of 73 weekday shifts during this time frame were below the facility's expected staffing levels, with only 8 weekday shifts reaching a PPD of 3.392. Review of the daily schedules from January to April 2024 indicated that 12 of 28 weekend shifts during this time frame were below the facility's expected staffing levels, with only 16 weekend shifts reaching a PPD of 3.22. During an interview on 4/9/24 at 1:45 P.M., Certified Nurse Aide (CNA) #4 said she is unable to shower residents and is unable to change residents on time due to staffing levels at the facility. CNA #4 said it is hard to answer call lights when they are short staffed during the week and the weekend. During an interview on 4/9/24 at 1:46 P.M., CNA #7 said she is unable to shower residents at times and is unable to always check and change incontinent residents during both the week and weekend shifts due to staffing. During an interview on 4/9/24 at 7:48 A.M., Nurse #4 said she did not know the residents on her assignment because she does not usually work on this unit and has to float around to different assignments. During an interview on 4/10/24 at 7:57 A.M., the Administrator said staffing is always difficult, but she feels the building has made significant improvement in staffing levels over the past few months. The Administrator said the facility has been focusing on recruitment and has been able to hire a lot of new staff, which has helped their staffing levels. The Administrator said she feels the daily staffing PPD levels have been met. The Administrator said it is common in all buildings for staff to complain there is not enough staff in the building and that the facility staffs to the census.

Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure hairnets were worn in the food preparation area, food was labeled, and dented cans of food were not stored with usable cans. Findings include: Review of the facility's policy titled Food Preparation and Service, revised November 2022, indicated, but was not limited to, the following: - Food and nutrition service staff wear hair restraints (hair net, hat, beard restraint etc.) so that hair does not contact food. Review of the facility's policy titled Food Receiving and Storage, revised November 2022, indicated, but was not limited to, the following: - Policy Interpretation and Implementation: 5. When food is delivered to the facility it is inspected for safe transport and quality before being accepted. -Refrigerated/frozen storage: 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date.) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. -Foods and Snacks Kept on Nursing Units: 1. All food items to be kept at or below 41 degrees Fahrenheit are placed in the refrigerator located at the nurses' station and labeled with a use by date. 2. All foods belonging to residents are labeled with the resident's name, the item and the use by date. 4. Beverages are dated when opened and discarded after 72 hours unless otherwise indicated on the manufacturer's label. 5. Other opened containers are dated and sealed or covered during storage. Review of the facility's policy titled Refrigerators and Freezers, revised November 2022, indicated, but was not limited to, the following: - Policy Interpretation and Implementation: 7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. 8. Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy. 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates or to decipher codes on packaging. On 4/7/24 at 7:00 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: - One staff member was in the food preparation area without a hair restraint. - A significantly dented can of marinara on the can rack in the dry storage room. - A container labeled tuna salad, with a prepared-on date of 4/4 and use-by date of 4/6 in the walk-in refrigerator. - A container labeled egg salad, with a prepared-on date of 4/1 and use-by date of 4/5 in the walk-in refrigerator. - Six sandwiches on a plate, wrapped but undated in the walk-in refrigerator. - Two salads with lettuce, egg, tomato and deli meat wrapped but undated in the walk-in refrigerator. The lettuce showed signs of decomposition as evidence by browning. - Two containers of pureed texture food, undated and unlabeled in the walk-in refrigerator. - A container labeled pasta cooked with a prepared on date of 4/2 and a use by date of 4/5 in the walk-in refrigerator. - Two containers of juice, opened but unlabeled in a reach-in refrigerator. On 4/7/24 at 8:31 A.M. the surveyor made the following observations in the second floor unit kitchenette's refrigerator: - Three containers of juice opened, but undated. - A salad wrapped with a prepared-on date of 4/4 and use-by date of 4/6. - Two undated containers of resident food containing fish, carrots, beets and potatoes. On 4/7/24 at 8:45 A.M. the surveyor made the following observations in the third floor unit kitchenette's refrigerator: - Five containers of juice opened, but undated. - A container of resident food dated 3/28. - Two containers of a fortified nutritional shake open, but undated. Both containers were nearly empty. On 4/7/24 at 8:52 A.M. the surveyor made the following observations in the first floor unit kitchenette's refrigerator: - An unlabeled and undated mayonnaise-based sandwich on a plate with a plate cover. - Three juices opened but undated. During an interview on 4/8/24 at 7:14 A.M. the Food Service Director (FSD) said all food should be labeled when opened or prepared. The FSD said the use-by date is automatically generated by the label-printing system which has pre-programmed use-by dates depending on the food item. The FSD said he defers to the pre-programmed use-by dates as they are updated regularly, and all food items should be discarded after the use-by date. The FSD said the dietary department is responsible for regularly checking the kitchenette refrigerators and that all unlabeled foods, or food kept for over three days must be discarded. The FSD said all staff members in the food preparation area of the kitchen should be wearing hairnets at all times. The FSD also said cans should be inspected on delivery and that all dented cans, including the observed dented can of marinara, should be placed in his office to be discarded and should not be placed on the can rack as this poses a risk for botulism (a serious illness caused by a toxin produced by Clostridium botulinum bacteria that attacks the body's nerves and causes difficulty breathing, muscle paralysis, and even death).

Based on observation, interview and policy review, the facility failed to provide a dignified dining experience on the second and third floor units. Findings include: Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; avoiding the use of labels when referring to residents (e.g., feeders). Review of the facility policy titled Dignity, dated February 2021, indicated the following: - When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. The surveyor made the following observations on the third-floor unit: - On 4/7/24 at 8:20 A.M., while organizing the meal carts in the hallway, staff referred to a resident as a feeder with other residents sitting nearby in the hallway. - On 4/8/24 at 8:31 A.M. and 8:45 A.M., while organizing the meal carts in the hallway, staff were heard saying she's a feed with other residents sitting nearby in the hallway. - On 4/8/24 at 9:10 A.M., a staff member was observed standing over a resident sitting in his/her wheelchair feeding him/her oatmeal, not at eye level in the dining room. The surveyor made the following observation on the second-floor unit: - On 4/8/24 at 11:42 A.M., a staff member was heard saying she is a feeder in the hallway with other residents nearby. During an interview on 4/9/24 at 9:30 A.M., the Staff Development Coordinator, who was covering as the third-floor unit manager, said staff should be sitting at eye level when assisting residents with feeding. She continued to say staff should not be referring to residents as feeders or feeds. During an interview on 4/9/24 at 9:58 A.M., the Director of Nursing (DON) said staff should not be standing while feeding other residents or refer to residents as feeders or feeds.

Based on observations, record review, policy review and interviews, the facility failed to provide assistance for Activities of Daily Living (ADLs) for five Residents (#414, #100, #19, #95, and #61) out of a total sample of 28 residents. Specifically, 1.) For Residents #414, #100, and #19, the facility failed to provide showers, 2.) For Resident #95, the facility failed to provide supervision during meals, and 3.) For Resident #61, the facility failed to provide incontinence care. Findings include: 1.) Review of the facility policy titled Bath, Shower/Tub, dated 2001, indicated the following: - The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. - If a resident refused the shower/tub bath, the reason(s) why and the intervention taken. [sic] 1a.) Resident #414 was admitted to the facility in June 2023 with diagnoses including chronic respiratory failure, diabetes and pneumonia. Review of Resident #414's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (MDS) score of 5 out of a possible 15, which indicated he/she had severe cognitive impairment. During an interview on 4/7/24 at 8:35 A.M., Resident #414 was observed lying in bed. His/her hair looked greasy. Resident #414 said he/she has not been assisted with a shower and has all bathing completed at sponge bath level. Resident #414 said he/she would really like a full shower. Review of Resident #414's ADL care plan, last revised 6/30/23, indicated the following intervention: - Assist to bath/shower as needed. Further review of Resident #414's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: - In February, Resident #414 had only 2 out of 8 scheduled showers. - In March, Resident #414 had only 2 out of 8 scheduled showers. - In April, Resident #414 had not been provided with a shower in the first 9 days of the month. Review of Resident #414's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 said Resident #414 is able to take a shower and needs to be assisted because he/she fatigues easily. CNA #2 was unable to remember the last time Resident #414 was provided with a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said she was unaware Resident #414 had not had a shower. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses. 1b.) Resident #100 was admitted to the facility in April 2023 with diagnoses including depression, anxiety and schizophrenia. Review of Resident #100's most recent Minimum Data Set (MDS), dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #100 was dependent on staff for showering tasks. During an interview on 4/7/24 at 8:40 A.M., Resident #100 said he/she is not able to fit in the shower chair and has not been provided with his/her scheduled showers. Resident #100 said he/she would like a shower so he/she can feel most clean. Review of the nursing note, dated 3/12/24, indicated the following: - Resident on call light frequently for drinks, snacks. Nurse assisted CNA (Certified Nursing Assistant) w/ (with) inc (incontinence) care, resident difficulty w/rolling in bed, CNA washed resident, resident c/o (complained of), 'I want a deep cleaning wash between my legs,' nurse washed area a second time, attempt to satisfy resident needs, repositioned, resident placed a ziploc bag of hair products between (his/her) legs. Review of Resident #100's ADL care plan, last revised 4/21/23, indicated the following intervention: - Assist/dependent to bathe/shower as needed. Further review of Resident #100's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: -In February, Resident #100 was not provided with a shower. -In March, Resident #100 had only 2 out of 8 scheduled showers. -In April, Resident #100 had not been provided with a shower in the first 9 days of the month. Review of the shower schedule indicated Resident #100 is scheduled for showers on Fridays during the day shift and Mondays during the evening shift. During an interview on 4/9/24 at 10:46 A.M., Resident #100 said he/she did not get his/her scheduled shower last night (Monday). Review of Resident #100's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 the facility has a shower chair that Resident #100 can fit into, however it is on a different unit. CNA #2 said Resident #100 often refuses a shower, so they just provide a bed bath all the time and don't offer a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said Resident #100 was just transferred to this unit about a month ago and the report from the other unit was that the Resident did not like to take showers. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses. 1c.) Resident #19 was admitted to the facility in July 2023 with diagnoses including Alzheimer's Disease. Review of Resident #19's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) of 4 out of a possible 15, which indicated he/she had severe cognitive impairment. During an interview on 4/7/24 at 9:06 A.M., Resident #19's spouse translated for the Resident. Resident #19's spouse said Resident #19 is not given showers frequently and both the spouse and the Resident would like him/her to have a shower. Resident #19's spouse said the Resident is supposed to have a shower twice a week and that never happens. Review of Resident #19's ADL care plan, last revised 8/1/23, indicated the following intervention: - Assist to bath/shower as needed. Further review of Resident #19's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: - In February, Resident #19 had only 3 out of 8 scheduled showers. - In March, Resident #19 had only 3 out of 8 scheduled showers. - In April, Resident #19 had not been provided with a shower in the first 9 days of the month. Review of Resident #19's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 said Resident #19 used to take showers, but he/she jumped in the shower and now needs two staff members to assist in the shower for safety. CNA #2 could not remember the last time Resident #19 was provided with a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said Resident #19 is not aggressive and she is unsure why he/she has not been provided showers as scheduled. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled for to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses. 45984 2.) Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Facility staff will serve resident trays and will help residents who require assistance with eating. - The nursing staff will prepare residents for eating. Resident #95 was admitted to the facility in December 2021 with diagnoses including dysphagia (difficulty swallowing), unspecified psychosis and anxiety disorder. Review of Resident #95's most recent Minimum Data Set Assessment (MDS), dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires supervision/touching assist for eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 4/7/24 at 8:13 A.M., Resident #95 was lying in his/her bed with his/her breakfast tray in front of him/her. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. Resident #95 asked the surveyor for help finding his/her utensils so he/she could eat his/her breakfast. Resident #95 began eating his/her breakfast. At 8:29 A.M., 16 minutes after the Resident started eating, a staff member checked in on the Resident. - On 4/7/24 at 12:14 P.M., Resident #95 was lying in his/her bed with his/her lunch tray in front of him/her. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. - On 4/8/24 at 7:53 A.M., Resident #95 received his/her breakfast tray, a staff member set up his/her tray and left the room. At 7:56 A.M., Resident #95 was observed with food on his/her chest that spilled as the Resident was bringing the food to his/her mouth. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. Review of Resident #95's physician's order, dated 6/6/23, indicated the following: - Regular diet pureed texture, mildly thick consistency, for risk for malnutrition. Review of Resident #95's Kardex (a form indicating the level of assistance a resident requires) indicated the following: - Eating: supervised with meals, mildly thick liquids. Review of Resident #95's Activities of Daily Living (ADL) deficit care plan, dated 1/5/22, indicated the following: - Assist of (1-2 person) with ADL's. - Supervision with meals. Review of Resident #95's Diet care plan, dated 12/16/21, indicated the following interventions: - Diet Texture: Pureed. - Liquid consistency: Mildly Thick. Review of Resident #95's Nutrition Evaluation, dated 12/5/23, indicated the following: - Chewing/swallowing difficulty related to dysphagia as evidenced by modified diet, see Speech Language Pathologist notes. - Average ~50% intake with supervision/assistance. He/she reports some meal fatigue, especially at dinner time. Review of Resident #95's Nutrition Evaluation, dated 3/4/24, indicated the following: - Chewing/swallowing difficulty related to dysphagia as evidenced by modified diet, see Speech Language Pathologist notes. - Feeding assistance as needed/accepted. - Continues with supervision/assistance Review of the document titled Speech Therapy SLP Recert, Progress Report & Updated Therapy Plan, dated from 8/6/23 - 9/4/23, indicated the following: - Impairments: Decreased safety awareness, impulsivity, decreased bolus control, decreased mastication skills. - Justification for Continued Skilled Services: Skilled SLP interventions warranted for analysis of oral/pharyngeal function with PO (by mouth) trials and education and training of compensatory safe swallow strategies to minimize the risk of aspiration/choking and promote patient's overall safety during PO intake. -Long-Term Goal: Patient will tolerate least restrictive diet for reduced aspiration pna (pneumonia) risk and adequate nutrition/hydration 90% via caregiver cues/assist as needed. During an interview on 4/9/24 at 9:22 A.M., Certified Nursing Assistant (CNA) #5 said she knows her residents well and knows what level of care they all need. CNA #5 said Resident #95 needs supervision with meals, and he/she is on pureed foods for safety since his/her throat is very sensitive. During an interview on 4/9/24 at 9:28 A.M., Nurse #3 said Resident #95 needs supervision at all times when eating. Nurse #3 continued to say that staff looks at the Resident's Kardex to know what level of care they need. During an interview on 4/9/24 at 9:30 A.M., the Staff Development Coordinator (SDC), covering as the third-floor unit manager, said supervision with meals means we need to have our eyes on the residents while they are eating at all times. The SDC continued to say that Resident #95 needs to be supervised when he/she is eating. During an interview on 4/9/24 at 9:58 A.M., the Director of Nursing (DON) said Resident #95 needs to be supervised with meals. She continued to say that supervision means watching a resident while they eat. After the surveyor shared his observations of Resident #95, the DON said, it sounds like he/she needs it (referring to supervision). 45763 3.) Review of the facility policy titled Urinary Continence and Incontinence - Assessment and Management, revised August 2022, indicated, but was not limited to, the following: - The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. - Management of incontinence will follow relevant clinical guidelines. - As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. - As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. - A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. Resident #61 was admitted to the facility in May 2022 with a diagnosis of dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #61 scored a 4 of 15 on a Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated Resident #61 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #61's activities of daily living care plan indicated the following intervention: - Assist of two persons dependent with activities of daily living. Review of Resident #61's urinary incontinence care plan related to impaired mobility, decreased sensation unaware of need to void: -Adjust toileting times to meet patient needs. Review of Resident #61's bowel incontinence care plan related to disease process impaired mobility, medications: -Provide incontinence care as needed. Review of Resident #61's most recent bowel and bladder assessment, dated 1/31/24, indicated the Resident was not continent of bowel or bladder and that Resident #61 was unable to express urge sensation. Review of the Certified Nursing Assistant (CNA) Flowsheets indicated Resident #61 was dependent on staff for toileting and incontinent of bowel and bladder every day in March and April of 2024. During an interview on 4/8/24 at 1:40 P.M., CNA #8 said residents with incontinence should be checked for incontinence every two hours. CNA #8 said Resident #61 was incontinent of both bowel and bladder, and that he/she would not be able to verbalize when he/she needs to be toileted. During an interview on 4/8/24 at 1:46 P.M., Nurse #5 said residents with incontinence should not go more than three hours without being checked for incontinence and changed if needed. Nurse #5 said Resident #61 was incontinent of both bowel and bladder, and that he/she would not be able to verbalize when he/she needs to be toileted as he/she is alert to self only. On 4/8/24 at 8:53 A.M., the surveyor observed Resident #61 seated in the common area across from the nurses station on the second floor unit. The Resident was taken into the dining room at 10:28 A.M., where he/she remained until after lunch. During the five hour continuous observation from 8:53 A.M., until 1:58 P.M., Resident #61 was not checked for incontinence or changed until the surveyor brought the concern to the attention of facility staff. During an interview and observation on 4/8/24 at 2:00 P.M., a surveyor observed Resident #61 receiving incontinence care for the first time since 8:53 A.M. The Resident's briefs and pants were saturated from his/her buttocks up to his/her lower back; there was an odor of urine. CNA #8 said the brief was saturated with urine, and that there were streaks of stool. During an interview on 4/8/24 at 2:00 P.M., the Assistant Director of Nursing (ADON) said residents with incontinence should be checked around breakfast time and again around lunch time, the ADON said Resident #61 should not have gone five hours without being checked for incontinence. During an interview on 4/9/24 at 12:53 P.M., the Director of Nursing said residents with incontinence should be checked, and changed if needed, every two to three hours. During an interview on 4/9/24 at 1:30 P.M., Resident #61's spouse said the Resident was incontinent, and that he/she would expect staff to check and change the Resident during regular intervals even when he/she is visiting with family. Resident #61's spouse said the Resident would not be able to verbalize when he/she needs to be toileted. REF F725

Based on record review and interviews, the facility failed to maintain accurate medical records for four Residents (#100, #18, #41, and #61) out of a total sample of 28 residents. Specifically, 1.) For Resident #100, the facility failed to complete daily documentation for Activities of Daily Living (ADLs), 2.) For Resident #18, the facility failed to ensure nursing accurately documented the presence and function of an air mattress, 3.) For Resident #41, the facility failed to ensure a nurse accurately documented a wound dressing as not completed, instead of as completed, and 4.) For Resident #61, the facility failed to ensure a physician's plan of care for liquid protein for wound healing and malnutrition was documented accurately. 1.) Resident #100 was admitted to the facility in April 2023 with diagnoses including depression, anxiety and schizophrenia. Review of Resident #100's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #100 was dependent on staff for transfers. Review of the shower documentation section on the document titled, Documentation Survey Report, dated April 2024, indicated documentation was incomplete for 15 of the possible 27 nursing shifts. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC) said Certified Nursing Assistants (CNAs) document daily for ADLs. The SDC said CNAs should document every shift and there should be no holes(incomplete sections) in the documentation. During an interview on 4/9/24 at 12:19 A.M., the Director of Nursing (DON) said CNAs should be documenting a Resident's level of care/assistance needed during all shifts of care. The DON said CNA documentation has been identified as an issue in the building and the facility needs to develop a plan to ensure all documentation is completed throughout all shifts. 48990 2.) Resident #18 was admitted to the facility in June 2023 with diagnoses including diabetes and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the physician's order, dated 12/29/23, indicated: -Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of Resident #18's plan of care related to actual skin breakdown, last revised 2/28/24, indicated: -Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of TELS (an electronic system used to request maintenance services) work order, dated 3/26/24, indicated a request to replace air mattress was created on 3/26/24 at 1:59 P.M. This order has a status update of completed on 3/27/24 at 9:36 A.M. Review of Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/34, 3/31/24, 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, and 4/6/24, indicated the order to check for air mattress placement and function was documented as implemented. On 4/7/24 at 8:43 A.M. and 4/8/24 at 7:52 A.M., the surveyor observed Resident #18 in bed, not on an air mattress. Resident #18 said his/her air mattress was broken and had been removed a few weeks ago. Resident #18 said he/she was supposed to get a new air mattress, but it had not come yet. During an interview on 4/8/24 at 9:52 A.M., Unit Manager #2 said she put in a request in the TELS system to replace Resident #18's air mattress with another air mattress on 3/25/24. Unit Manager said it was replaced with a regular mattress and since Resident #18's wound had healed she decided not to request another air mattress. Unit Manager said she noticed there was still an order for it yesterday, when the survey began, so she discontinued the order without discussing with the physician. During an interview on 4/8/24 at 9:42 A.M., the Assistant Director of Nursing (ADON) said the order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. During an interview on 4/9/24 at 12:22 P.M., the Director of Nursing (DON) said the order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. 3.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #41 had an arterial/venous wound. Review of wound physician progress note, dated 3/20/24, indicated Resident #41 had an unhealed right ankle arterial ulcer. This note indicated Resident #41's had a physician's order to apply iodosorb (a gel that's applied to the skin to treat wet ulcers and wounds) and then apply gentac (a gentle silicone adhesive dressing) to his/her right ankle arterial ulcer. Review of Resident #41's physician's order, dated 3/15/24, indicated: -Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam (border foam), change daily, and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary.) On 4/7/24 at 9:18 A.M., 4/8/24 at 8:19 A.M., and 4/8/24 11:54 A.M., Resident #41 was observed with a wound on his/her right ankle that had yellowish/brown hardened scab-like wound bed that was approximately the size of a pea. There was no dressing on his/her right ankle. During an interview on 4/8/24 at 8:19 A.M., Resident #41 said nursing had not put a dressing on his/her right ankle wound since Friday (4/5/24) because there was nobody around to do it. Resident #41 said he/she asked for a dressing to be put on but the nurse did not because they were too busy. Review of Treatment Administration Record, dated 4/7/24 and 4/8/24, indicated the nurses had documented the physician's order for Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam, change daily, and PRN had been implemented. During an interview on 4/9/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said if dressing was not completed, it should not be documented as implemented. During an interview on 4/9/24 at 12:22 P.M., the Director of Nursing (DON) said if an order was was not implemented, it should not be documented as implemented. 4.) Resident #61 was admitted to the facility in May 2021 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident #61 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Review of dietitian note, dated 9/1/23, indicated Resident #61's order for liquid protein was discontinued. This note indicated collaboration with Resident #61's provider. Review of physician's orders history indicated the following order was discontinued by provider 9/1/23: -Active Liquid Protein **Sugar Free 16 GM (gram)/30ML (milliliter). Review of physician note, dated 2/21/24, indicated Resident #61 should continue with daily liquid protein supplements for malnutrition and a stage four pressure ulcer. During an interview on 4/10/24 at 9:20 A.M., Regional Nurse #1 said the physician documented this in error because Resident #61 had an order for liquid protein discontinued based on his/her clinical status on 9/1/23. During an interview on 4/10/24 at 9:45 A.M., the Director of Nursing (DON) said the physician documented the plan to continue liquid protein in error because the physician had discontinued the order.

Based on observations, record reviews and interviews, the facility failed to provide services that met professional standards of quality to three Residents (#61, #41 and #214) out of a total sample of 28 residents. Specifically, 1.) For Resident #61, the facility failed to transcribe and implement physician's orders for changes in a pressure wound treatment, 2.) For Resident #41, the facility failed to implement a physician's order to apply a dressing to an arterial wound, and 3.) For Resident #214, the facility failed to implement a physician's order to remove sutures. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1.) Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018), indicated, but was not limited to: -The nurse shall describe and document/report the following: current treatments. -The physician will order pertinent wound treatments, including dressings. Resident #61 was admitted to the facility in May 2021 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident #61 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated that Resident #61 had two pressure ulcers, including one stage four pressure ulcer. Review of Resident #61's active physician's order, dated 3/14/24, indicated: Wound Documentation: Right heel wash with Nacl (sodium chloride, which is a wound cleansing solution), pat dry, cover with Oil Emulsion f/b (followed by) Hydroconductive. cut to size f/b bordered foam & wrap with kerlix twice daily and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary). Review of the Wound Physician's progress note, dated 4/3/24, indicated Resident #61 right heel stage four pressure ulcer was worsening and indicated the following treatment recommendations: 1. Wound cleanser. 2. Apply Hydroconductive to base of the wound. 3. Secure with Rolled gauze, Zetuvit (type of wound dressing). 4. Change Twice a day, PRN for soiling, saturation, or accidental removal. Review of form titled Unavoidable Pressure Ulcer Physician Documentation, dated 1/10/24, indicated Resident #61 was determined by his/her physician that the development of this pressure ulcer was unavoidable for factors including Parkinson's, immobility, incontinence, palliative with PACE (Program of All-Inclusive Care for the Elderly) program, and comfort measures and care. On 4/8/24 at 1:12 P.M., the surveyor observed Nurse #5 and the Assistant Director of Nursing (ADON) change the dressing on Resident #61's right heel. Nurse #5 prepared to place an oil emulsion dressing on Resident #61's heel, but the ADON instructed Nurse #5 to administer a different dressing because the order had changed last week. Nurse #5 applied a hydroconductive dressing to the base of the wound and applied a Zetuvit dressing on the ADON's instruction. During an interview on 4/8/24 1:51 P.M., the ADON said Physician #1 approved the Wound Physician's treatment recommendation on 4/3/24 and the order should have been transcribed but was not. The ADON said because it was not transcribed so Resident #61 had continued to receive the incorrect wound dressing. The ADON said she knew the wrong dressing was received because during the dressing change there was an oil emulsion dressing removed and the incorrect order in the Treatment Administration Record (TAR) was signed off. The ADON said Resident #61 should not have had oil emulsion applied to his/her right heel wound from 4/3/34 to 4/8/24. Review of Resident #61's Treatment Administration Record (TAR), dated 4/3/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, and 4/8/24, indicated the following order was documented as implemented: -Wound Documentation: Right heel wash with Nacl, pat dry, cover with Oil Emulsion f/b (followed by) Hydroconductive. Cut to size f/b bordered foam & wrap with kerlix twice daily and PRN. On 4/9/24 at 11:07 A.M., the surveyor observed Unit Manager #2 and the ADON change the dressing on Resident #61's right heel in order to assess if the wound had worsened. During this dressing change, a black area was noted in the right heel wound bed. The ADON said this area was eschar. The ADON said eschar is worse than slough. The ADON said there is more pain documented in the TAR. The ADON said new treatment orders should be transcribed to try to prevent decline, prevent infection, and prevent pain, but deterioration of the wound was expected. Review of the Treatment Administration Record (TAR) order for Wound Documentation, dated 4/6/24, indicated Resident #61's wound had worsened and there was the presence of eschar in the wound bed. Review of Resident #61's medical record failed in indicate the presence of eschar in the wound prior to 4/6/24, three days after the physician ordered the wound treatment be changed. Review of the Treatment Administration Record (TAR), dated 4/5/24, 4/6/24, 4/7/24, and 4/8/24, indicated an increased frequency pain in the right heel wound, which previously was documented less frequently. During an interview on 4/9/24 at 11:41 A.M., Physician #1 said he approved the change to the treatment order because the wound had worsened. Physician #1 said it was a concern that the order was not followed. Physician #1 said Resident #61 is care and comfort, and the goal is not to heal, but to maintain skin integrity and prevent pain and odor. During an interview on 4/9/24 at 11:49 A.M., the Wound Physician said Resident #61's goal is to maintain skin integrity and would not be surprised if it deteriorated. Review of Resident #61's plan of care related to right heel stage three pressure ulcer, revised 4/9/24, indicated: - Goal: Will develop no new areas of skin breakdown. - Goal: Will heal without complication. - Administer treatments per physician orders. During an interview on 4/9/24 at 12:22 P.M., The Director of Nursing (DON) said wound orders from physicians should be transcribed and should be followed. 2.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #41 had an arterial/venous wound. Review of wound physician progress note, dated 3/20/24, indicated Resident #41 had an unhealed right ankle arterial ulcer. This note indicated Resident #41's had a physician's order to apply iodosorb (a gel that's applied to the skin to treat wet ulcers and wounds) and then apply gentac (a gentle silicone adhesive dressing) to his/her right ankle arterial ulcer. Review of Resident #41's physician's order, dated 3/15/24, indicated: -Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam (border foam), change daily, and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary.) On 4/7/24 at 9:18 A.M., 4/8/24 at 8:19 A.M., and 4/8/24 11:54 A.M., Resident #41 was observed with a wound on his/her right ankle that had yellowish/brown hardened scab-like wound bed that was approximately the size of a pea. There was no dressing on his/her right ankle. During an interview on 4/8/24 at 8:19 A.M., Resident #41 said the nurse had not put a dressing on his/her right ankle wound since Friday (4/5/24) because there is nobody around to do it. Resident #41 said he/she asked for a dressing to be put on, but the nurse did not because they were too busy. Resident #41 said he/she likes to have a dressing on it, because it hurts when things touch it without the dressing on. Review of Treatment Administration Record, dated 4/7/24 and 4/8/24, indicated the nurses had documented the physician's order for Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam, change daily, and PRN had been implemented. Review of the plan of care related to right ankle arterial wound, revised 4/2/24, indicated: -Administer treatment per physician's order. Review of the nursing progress notes, dated 3/10/24 to 4/9/24, failed to indicate resident refused wound treatments or care. During an interview on 4/9/24 at 7:48 A.M., Nurse #4 said a dressing should be on Resident #41's ankle wound and was put on yesterday (4/8/24). Nurse #4 said if a Resident has an order for a wound dressing, the dressing should be in place. During an interview on 4/9/24 at 9:22 A.M., Unit Manager #2 said Resident #41 does not refuse treatments or care. Unit Manager #2 said he/she had rejected care initially when admitted last year, but recently has not refused any dressings or care. During an interview on 4/9/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said if dressing is ordered it should be on. The ADON said if the dressing fell off, it should be replaced because there a PRN order. The ADON said she was not aware of Resident #41 refusing care or wound dressings, and if it were refused, the refusal should be documented. 43846 3.) Resident #214 was admitted to the facility in April 2024 with diagnoses that included fracture of left patella, asthma and insomnia. Review of Resident #214's Brief Interview for Mental Status (BIMS), dated 4/5/24, indicated he/she scored a 15 out of 15 on the BIMS indicating the Resident is cognitively intact. On 4/7/24 at 8:16 A.M., the surveyor observed Resident #214 in bed. Resident #214 said he/she recently fell and has stitches (sutures) in his/her nose that will be coming out today. On 4/8/24 at 7:35 A.M., the surveyor observed Resident #214 in his/her room, stitches were observed in the Residents' nose. Resident #214 said the nurse never came in to remove the stitches and said he/she would really like them out. During an interview and observation 4/8/24 at 11:30 A.M., the surveyor and Nurse #1 observed Resident #214's nose. Nurse #1 said the Resident still has stitches in his/her nose. Nurse #1 said the nurse from yesterday should have taken the Residents' stitches out as ordered and did not. Review of Resident #214's physician orders, dated 4/4/24, indicated Remove sutures from nose on 04/07 (4/7/24). Review of Resident #214's April 2024 Medication Administration Record (MAR), indicated on 4/7/24 on the 7:00 A.M. to 3:00 P.M. shift the order for Remove sutures from nose on 04/07 (4/7/24) every day shift was checked off as completed. During an interview on 4/8/24 at 11:33 A.M., Unit Manager #1 said if the order is signed off by the nurse, then the sutures should not be in the Residents' nose. Unit Manager #1 said she worked on 4/7/24 and the nurse assigned to Resident #214 never asked her for assistance to remove the sutures. During an interview on 4/8/24 at 11:35 A.M. the Director of Nursing (DON) said Resident #214's sutures should have been removed as ordered. The DON said if the order was signed off as completed then the sutures should not be in the Residents' nose. The DON said if the Resident refused then there should be a nursing progress note to indicate that and the physician should have been notified.

Based on observations, record review and interview, the facility failed to provide appropriate treatment and services related to hearing for two Residents (#91 and #41) out of a total of 28 sampled residents. Specifically, the facility failed to ensure Resident #91 and Resident #41 were ever seen by Audiology services or were provided assistive devices for hearing. Findings include: Review of the facility policy titled Physician Orders for Consultation, revised and dated 1/5/22, indicated the following: - Referrals and consultations will be ordered by the attending physician or designated practitioner. - Ensure that consultations for specialty care or ancillary services (including audiology services) are ordered by the attending physician to meet the medical or clinical care needs of each patient. - The interdisciplinary team (including the attending physician, nurses, therapists, and social workers) will identify the need for consultative services. - The attending physician or designated practitioner will order consultative services when necessary to meet individualized medical and clinical needs of the resident. - The center will assist residents with obtaining services as needed including making appointments and arranging transportation. 1.) Resident #91 was admitted to the facility in February 2022 with diagnoses including spondylosis (abnormal wear on the cartilage and bones of the neck) and type 2 diabetes mellitus. Review of Resident #91's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that the Resident has moderate cognitive impairment. Further review of the MDS indicated that Resident #91 requires total dependence on staff for activities of daily living. During an interview on 4/7/24 at 7:57 A.M., Resident #91 said he/she has a hard time hearing what the surveyor is saying and has not seen the ear doctor in a long time and would like it. The surveyor had to repeat multiple times as Resident #91 could not hear what the surveyor was saying. During an interview on 4/8/24 at 8:16 A.M., Resident #91 said it is hard not being able to hear other people and he/she wants to get his/her ears looked at. The surveyor had to repeat multiple times as Resident #91 could not hear what he was saying. As the surveyor was approaching the room, Resident #91's television could be heard from multiple rooms away. Review of a quarterly care conference progress note date 9/1/22 written by the social worker indicated the following: - A referral was also placed with the contracted Audiology service for hearing care. Review of Resident #91's medical record which includes care plans and physician's orders failed to indicate that any interventions or orders were ever implemented related to Audiology services or assistive devices for his/her hearing. During an interview on 4/8/24 at 11:05 A.M., the Unit Secretary said she just started this position in November and was trying to catch up with all the residents being seen by the contracted services offered which includes Audiology services. The surveyor and Unit Secretary reviewed the progress note and she said she was not sure why it was not addressed, and she would expect a referral to have been followed up since then as it was 19 months ago, and the Resident was admitted to the facility in February 2022. During an interview on 4/8/24 at 11:41 A.M., the Unit Secretary provided a consent form to be seen by Audiology services on 6/20/22. When asked why Resident #91 has not been seen she did not know. The Unit Secretary provided a new consent form for Audiology Services dated 3/30/24. Under the Audiology section, the following was checked off: Family/staff notices recent decreased patient responsiveness. Review of the history of visits from the contracted Audiology company the facility uses failed to indicate that Resident #91 was ever seen by Audiology. During an interview on 4/8/24 at 11:51 A.M., the Staff Development Coordinator (SDC), covering as the third-floor unit manager, said if a referral was made for Audiology services, then Resident #91 should have been seen. During an interview on 4/8/24 at 1:08 P.M., the Director of Nursing (DON) said she would expect the referral to be followed up on given it was in 2022. During an interview on 4/8/24 at 2:07 P.M., the Unit Secretary did not know why other services are not being offered if the contracted Audiology company has not been coming in consistently. During an interview on 4/8/24 at 12:36 P.M., the Unit Secretary said the facility started to doing audits In January 2024 and realized the contracted Audiology services have not been coming and she does not know how often they should be coming in. The Unit Secretary said Audiology was last in the facility in November 2023. During an interview on 4/9/24 at 12:56 P.M., the Director of Nursing said the facility needs to find other interventions for the hard of hearing residents since our consulting services are not coming in. She continued to say that the Rehabilitation department offered amplifiers for residents, but she did not know if Resident #91 was ever offered one. During an interview on 4/9/24 at 1:09 P.M., Resident #91 said someone came by today to offer him/her a headset to help him/her hear. Resident #91 continued to say this was the first time anyone has ever offered him/her this device. He/she continued to say he/she really wants to get his/her ears checked by the doctor and he/she feels like his/her hearing has gotten worse. 48990 2.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated that, without the use of hearing aids or other hearing appliance, Resident #41 has minimal difficulty hearing. Review of nursing progress note, dated 1/28/24 indicated: -Resident won't talk at times, may have a lot to do with his/her poor hearing. Review of the plan of care related to hearing loss, revised 4/2/24, indicated: -Resident had difficulty communicating related to hearing loss. -Refer to audiology evaluation as needed. Review of a form, titled Attending Physician Request for Services/Consultation, dated 8/23/23, indicated a request for an audiological consultation by the facility's contracted Audiologist servicer for the purpose of obtaining additional information necessary for the evaluation of the need for or appropriate type of medical or surgical treatment of a new hearing deficit or a related medical problem. Reason's for this consultation that were indicated on this form included: -Family/staff notices a decreased patient responsiveness. -New complaint of blocked ears. -Complains of newly decreased hearing. -New verbal communication difficulties such as need to have commands repeated, note turning when spoken to, difficulty understanding speech. On 4/7/24 at 9:18 A.M., the surveyor observed Resident #41 without hearing aids. Resident #41 said he/she cannot hear what the surveyor says, even with adjusted volume and repeated communication. Resident #41 said he/she wants hearing aids and was supposed to get hearing aids when he/she came here, but never did. On 4/9/24 8:21 A.M., the surveyor observed Staff Member #1 talking to Resident #41 about removing his/her meal tray. Staff Member #1 had to repeat questions several times, even with adjusted volume of speech. Staff Member #1 said Resident #41 is hard of hearing and requires repeating communication, adjusting volume, and showing items if he/she cannot hear. On 4/09/24 1:15 P.M., the surveyor attempted to ask Resident #41 questions about her ability to participate in activities and socialize, but Resident #41 was unable to hear the surveyors questions, even with adjusted volume and repeated speech. The surveyor wrote questions down in large print on a notebook, and Resident #41 was unable to see the written words. Resident #41 said he/she has poor vision. On 4/9/24 at 1:18 P.M., the surveyor asked Regional Nurse #1 to assist her with asking questions because Resident #41 could not hear the surveyor. Regional Nurse #1 communicated by directing speech directly and closely into Resident's left ear. Resident #41 said he/she used to use a hearing amplifier and it helped him/her hear better. Resident #41 said he/she would like to have a hearing amplifier again. Review of Resident #41's medical record including care plans and physician's orders failed to indicate that new interventions, audiology consultations, or hearing assistive devices were implemented after the request for audiology services for a hearing decline on 8/23/23. During an interview on 4/9/24 9:06 A.M., the Assistant Director of Nursing (ADON) said Resident #41 never had hearing aids or a hearing amplifier. The ADON said if a consent was signed and request was made for a Resident to be seen by the audiology, then the Resident should have been seen. During an interview on 4/8/24 at 12:36 P.M., the Unit Secretary said the facility started to doing audits in January 2024 and realized the contracted Audiology services have not been coming and she does not know how often they should be coming in. The Unit Secretary said audiology service consent and request for treatment was completed and signed on 8/23/23 for Resident #41, but the audiologist had never seen the Resident. The Unit Secretary said Audiology was last in the facility in November 2023. During an interview on 4/8/24 at 2:07 P.M., the Unit Secretary did not know why other services are not being offered if the contracted Audiology company has not been coming in consistently. During an interview on 4/9/24 at 12:56 P.M., the Director of Nursing (DON) said the facility needs to find other interventions for the hard of hearing residents since our consulting services are not coming in. During an interview on 4/09/24 at 2:01 P.M., the Director of Nursing said Resident #41 was given a hearing amplifier at some point when he/she was on the first floor, but that Resident #41 did not have one and nobody had been using one.

Based on observations, policy review, interviews, and record review, the facility failed to ensure nursing provided treatment and services consistent with professional standards of practice to promote healing and prevent development of new pressure ulcers for two Residents (#18 and #71), out of 28 total sampled Residents. Specifically, 1a.) For Resident #18, the facility failed obtain a physician order to discontinue a dressing for a recently healed pressure ulcer. 1b.) For Resident #18, the facility failed to obtain a physician order to discontinue an air mattress ordered for skin integrity management. 2.) For Resident #71, the facility failed to ensure an air mattress was at the correct settings for a Resident with multiple pressure ulcers. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, indicated, but was not limited to: - The nurse shall describe and document/report the following: current treatments. - The physician will order pertinent wound treatments, including dressings. 1.) Resident #18 was admitted to the facility in June 2023 with diagnoses including diabetes and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the most recent Norton Plus Skin Risk Assessment, dated 3/4/24, indicated Resident #18 was at high risk for skin breakdown as evidenced by a score of 7. 1a.) On 4/7/24 at 8:43 A.M., the surveyor observed boxes of wound dressings on Resident #18's dresser. Resident #18 said he/she has a couple sores on his/her buttocks, and said staff does not use these dressings. Resident #18 said the sores are treated only with a cream. Review of Resident #18's physician's order, dated 3/8/24, indicated: Wound Documentation - Left Buttock- cleanse with wound cleanser apply Collagen cut to size and cover with b-foam (border foam), change daily and PRN. This wound treatment order failed to indicate an end date or instructions to discontinue when the wound is healed, and was indicated as discontinued by Physician #1 on 4/7/24. During an interview on 4/8/24 at 9:15 A.M., Certified Nurse Assistant (CNA) #7 said Resident #18 does not need a dressing for his/her buttocks, and only gets a cream put on it. CNA #7 said she regularly cares for Resident #18 and the last time she saw a dressing when doing incontinence care was at some point the previous week. On 4/8/24 at 9:24 A.M., the surveyor observed multiple small open wounds on Resident #18's left buttock/upper thigh with Nurse #7 and the Assistant Director of Nursing (ADON). The ADON said this appears to be moisture associated skin damage. **Review of Skin Observation Tool, dated 3/26/24, indicated: -Boder [sic] foam apply to left buttock to release pressure at the area. During an interview on 4/8/24 11:39 A.M., Unit Manager #2 said when she looked at Resident #18's left buttock yesterday there was not a dressing on it, so she discontinued it. Unit Manager #2 said she did not obtain an order from the physician because the wound was healed and she didn't need to. During a telephonic interview on 4/8/24 at 11:29 A.M, Physician #2 said Physician #1 had been on vacation since 4/5/23. Physician #2 was on call and said the facility did not call to obtain any orders to discontinue any dressings for Resident #18 since Physician #1 left for vacation 4/5/24. Physician #2 said she would expect an order to be obtained to discontinue a dressing order. During an interview on 4/8/24 at 1:01 P.M., the Director of Nursing (DON) said a physician's order is required to discontinue a dressing. 1b.) On surveyor 4/7/24 at 8:43 A.M. and 4/8/24 at 7:52 A.M., the surveyor observed Resident #18 in bed, not on an air mattress. Resident #18 said his/her air mattress was broken and had been removed a few weeks ago. Resident #18 said he/she was supposed to get a new air mattress, but said it had not come yet. Resident #18 said the regular mattress he/she is on is not comfortable and would like the air mattress when it comes in. Review of Resident #18's physician's order, dated 12/29/23, indicated: - Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of Resident #18's plan of care relating to risk for alteration in skin integrity, last revised 2/28/24, indicated: - Air mattress to bed Setting ALT 250 or per resident comfort. Check placement and function Q shift. Review of TELS (an electronic system used to request maintenance services) work order, dated 3/26/24, indicated a request to replace air mattress was created on 3/26/24 at 1:59 P.M This order has a status update of completed on 3/27/24 at 9:36 A.M. Review of Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/34, 3/31/24, 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, and 4/6/24, indicated the order to check for air mattress placement and function was documented as implemented. During an interview on 4/8/24 at 9:52 A.M., Unit Manager #2 said she put in a request in the TELS system to replace Resident #18's air mattress with another air mattress on 3/25/24. Unit Manager #2 said it was replaced with a regular mattress and since Resident #18's wound had healed she decided not to request another air mattress. Unit Manager #2 said she noticed there was still an order for it yesterday, and said she discontinued the order without discussing with the physician. During a telephonic interview on 4/8/24 at 11:29 A.M, Physician #2 said Physician #1 had been on vacation since 4/5/23. Physician #2 was on call and said the facility did not call to obtain any orders to discontinue an air mattress for Resident #18 since Physician #1 left for vacation 4/5/24. Physician #2 said she would expect an order to be obtained to discontinue an air mattress. During an interview on 4/8/24 at 9:42 A.M., the Assistant Director of Nursing (ADON) said Resident #18's order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. During an interview on 4/8/24 at 1:01 P.M., the Director of Nursing (DON) said a physician's order is required to discontinue physician's orders, including an order for air mattress placement and function. 43846 3.) Resident #72 was admitted to the facility in March 2024 with diagnoses that included chronic respiratory failure with hypoxia, dysphagia, and heart failure. Review of Resident #72's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident had a stage three and stage four pressure ulcer and is at risk for developing pressure ulcers. On 4/7/24 at 8:03 A.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/8/24 from 7:57 A.M. to 9:00 A.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/8/24 at 11:55 A.M. and 1:28 P.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/9/24 at 11:41 A.M. and 1:21 P.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. Review of Resident #72's actual skin breakdown, dated 3/15/24, indicated Specialty mattress on bed. LAL with 8 LED up from bottom. Review of Resident #72's physician orders, dated 3/28/24, indicated Air Mattress-LAL with 8 LED up from bottom. Check for placement and function every shift. Review of Resident #72's physician orders, dated 3/20/24, indicated Wound Documentation-R heel-Cleanse, pat dry, apply silver alginate (cut to size), cover with foam dressing and wrap in kerlix. Change daily and PRN (as needed). Review of Resident #72's [NAME], dated 4/6/24, indicated he/she scored 11 which indicated he/she was at moderate risk for skin breakdown. During an interview on 4/9/24 at 8:53 A.M., Nurse #2 said Resident #72's air mattress should be set to the 8th light from the bottom as ordered and said it is a wound management intervention. During an interview on 4/8/24 at 1:21 P.M., Unit Manager #1 said Resident #72's air mattress should be set to the 8th light from the bottom as ordered and said the Resident has multiple pressure ulcers. Unit Manager #1 said the air mattress is an intervention for Resident #72's wound management.

Based on record review, interview and policy review the facility failed to maintain acceptable parameters of nutrition status for two Residents (#69 and #29) out of a total sample of 28 residents. Specifically, 1.) For Resident #69, the facility failed to identify and put an intervention in place for a significant weight loss, and 2.) For Resident #29, the facility failed to identify and address a potential significant weight loss by not reweighing the Resident in a timely manner to confirm a significant weight loss. Findings include: Review of the facility policy titled Weight Assessment and Intervention, revised 6/15/22, indicated the following: - Weights obtained by the dialysis center, hospice, or other provider may be referred to in clinical documentation but should not be entered into the electronic medical record as the facility obtained weight. - A weight change of 5 lb (pounds) or more in a patient weighing more than 100 lbs. since the last weight assessment will be retaken for verification. If the weight is verified, nursing notifies the Dietitian. For non-significant weight changes either the dietitian or provider is notified upon consideration of the resident's overall clinical condition. - The Dietitian will respond timely to a verified significant weight change. - Weights are reviewed monthly to follow individual weight trends over time. Negative trends are evaluated to determine significant unplanned and undesired weight loss. - The threshold for significant unplanned and undesired weight loss is based on the following criteria (where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100): -a. 1 month - 5% weight loss is significant. -b. 6 months - 10% weight loss is significant. 1.) Resident #69 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS), dated [DATE], indicated the Resident was not able to complete the Brief interview for Mental Status (BIMS) and staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #69 required maximal assistance with bathing/showering. Resident #69 was not able to be interviewed secondary to his/her level of cognition. During an interview on 4/8/24 at 2:05 P.M., Resident #69's spouse said she was aware the Resident had not been eating well but had never been told by the facility staff if the Resident had lost weight. Resident #69's spouse said she would want an intervention to be put in place if the Resident had lost weight. Review of Resident #69's weights indicated the following: - On 2/20/23, the Resident weighed 201.5 lbs. (pounds) - On 2/22/24, the Resident weighed 201.4 lbs. - On 2/26/24, the Resident weighed 200.6 lbs. - The Resident was not weighed in the month of March secondary to being admitted to hospice services. - On 4/3/24 the Resident weighed 183.4 lbs., an 8.98% weight loss since 2/20/24. Review of Resident #69's hospice care plan, last revised on 4/3/24, indicated the following intervention: -Report skin breakdown, lack of analgesia effectiveness, unexpected weight loss or decline in appetite. Review of the nutritional assessment, dated 3/29/24, indicated Resident #69 was admitted to hospice services but the Dietitian would continue monitor and be available as needed. During an interview on 4/8/24 at 1:15 P.M., the Registered Dietitian (RD) said she works at the facility four days a week and checks the weight report frequently. The RD said the electronic Medical Record triggers all significant weight loss and will alert her in a report. The RD said all significant weight losses are treated with a new weight loss intervention which may include double portions of food, adding supplements, adding sweets (ice cream) or speaking with the physician to add an appetite stimulant. The RD said this process applies to all residents, even those that are on hospice services. The RD reviewed Resident #69's weights with the surveyor and said the Resident had a significant weight loss of over 7.5% in 3 months or less. The RD said she was unaware of Resident #69's significant weight loss as neither the nursing staff or electronic medical record alerted her to the loss. The RD said she would have still put in an intervention for Resident #69 even though he/she is receiving hospice services. During an interview on 4/8/24 at 1:27 P.M., the Staff Development Coordinator (SDC), who was working as Unit Manager, said all weights are taken as ordered. The SDC said nursing enters the weights and should notice if a significant weight change has occurred. The SDC said if a significant change in weight occurs, nursing needs to notify the Physician and Dietitian. The SDC said a weight loss intervention should be put in place right away. The SDC said that although Resident #69 is on hospice services, the nursing staff should have identified the Resident's significant weight loss and followed the process of referring him/her to the Dietitian for a weight loss intervention. During an interview on 4/9/24 at 8:53 A.M., the Director of Nursing (DON) said she was unsure why the Resident was not weighed since he/she was on hospice services. The DON said whether the weight was supposed to be taken or not, once taken, the nurses should have identified the weight loss and followed the facility procedure of notifying the Resident's family, the Dietitian and the physician and put an appropriate intervention in place. 45984 2.) Resident #29 was admitted to the facility in January 2021 with diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3 and vascular dementia. Review of Resident #29's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 9 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated Resident #29 requires assistance with all activities of daily living. Resident #29's medical record indicated that he/she receives services through the Program of All-Inclusive Care for the Elderly (PACE). Review of Resident #29's Weights and Vitals summary indicated the following: - 02/8/24: 204.5 lbs. - 03/1/24: 179.8 lbs. From 2/8/24 through 3/1/24, Resident #29 had a significant weight loss of 12.08%. Review of Resident #29's care plan for at risk for malnutrition, revised and dated 11/3/22, indicated the following interventions: - Nutrition related medication management. - Weights as ordered. Review of Resident #29's Quarterly Nutrition Follow-Up Evaluation completed by the Registered Dietitian (RD) dated 1/30/23 indicated the following: - Nutrition Problems and Interventions: Impaired nutrient utilization, at risk for malnutrition. - Nutrition interventions include: continued communication/collaboration with RD team. - Recommendations: RD will continue to monitor. Review of Resident #29's progress note, written by the RD on 3/21/24, indicated the following: - Reweigh requested. Value: 179.8 lbs. The Registered Dietitian requested a reweigh for Resident #29 twenty days after the Resident was documented having a significant weight loss. Within that time frame, Resident #29 was not assessed/evaluated for a significant weight loss and no interventions were implemented. During an interview on 4/8/24 at 8:54 A.M., the Staff Development Coordinator (SDC), covering as the third floor unit manager, said when residents are enrolled with PACE, a representative will come in and assess the resident and input a note into the resident's medical record so the facility can monitor the resident. The SDC continued to say the facility is in communication with the RD from PACE and they will communicate with the facility's RD for any recommendations if a significant weight change is identified or if interventions need to be implemented. During an interview on 4/8/24 at 11:30 A.M., Certified Nursing Assistant (CNA) #6 said CNAs weigh the residents and would either tell the nurses the resident's weight or document it on the resident's flow sheets in a binder. During an interview on 4/8/24 at 1:16 P.M., the Registered Dietitian (RD) said she works in the building four days each week. The RD said when a resident gets weighed it gets inputted in the medical record. She continued to say if a significant weight change is identified the medical record system will trigger it and alert her. The RD said when a significant weight change is identified a reweigh needs to be done as soon as possible. When asked about Resident #29's documented significant weight loss, she said a reweigh should have been implemented sooner than 20 days so the resident could be assessed and start interventions if needed. The RD continued to say she communicates with the PACE RDs who implement the primary interventions for Resident #29, and she would monitor their recommendations. She said without verifying Resident #29's documented significant weight loss the PACE RD's would not know to implement interventions. During an interview on 4/8/24 at 1:08 P.M., the Director of Nursing (DON) said she would expect a reweigh to happen in a timelier manner for Resident #29 to determine if the significant weight change was accurate which would lead the resident being assessed.

Based on record review, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two Residents (#49 and #69) out of a total sample of 28 Residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, dated 2/2/23, indicated psychotropic medications are not prescribed or given on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. 1. If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1.) Resident #49 was admitted to the facility in March 2014 with diagnoses that included dementia, dysphagia, and major depressive disorder. Review of Resident #49's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. Review of Resident #49's physician orders indicated the following: - Lorazepam (Ativan) (an anti-anxiety medication) oral tablet 0.5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for anxiety/agitation. The Lorazepam order failed to indicate an end date. During an interview on 4/9/24 at 8:22 A.M., Unit Manager #1 said if a resident has an as needed (PRN) Ativan order there needs to be a stop date with an re-evaluation by the doctor to continue the as needed order. 41456 2.) Resident #69 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS), dated [DATE], indicated the Resident was not able to complete the Brief interview for Mental Status (BIMS) and staff assessed him/her to have severe cognitive impairment. Review of Resident #69's physician orders indicated the following: - Ativan (an anti-anxiety medication) oral tablet 0.5 MG (milligrams). Give 0.5 mg by mouth every 4 hours as needed for anxiety/agitation. The Ativan order failed to indicate an end date. During an interview on 4/8/24 at 11:14 A.M., Nurse #6 said all as needed psychotropic medications need to be re-evaluated after one month. Nurse #6 said the process for psychotropic medication use is the same whether a resident is on hospice or not. During an interview on 4/8/24 at 11:17 A.M., the Staff Development Coordinator (SDC) who was covering as Unit Manager, said any psychotropic medications that are used on an as needed basis need to be re-evaluated after the first 14 days. The SDC said if the medication is continued after the first 14 days, there needs to be a clinical reason for its use and the order also needs to have an end date so the ordering physician will re-evaluate the need for the medication again. The SDC said she was unaware Resident #69's order for Ativan failed to have an end date/reassessment date.

Based on observations, policy review, record review and interviews, the facility failed to identify and provide interventions for a decrease in range of motion for one Resident (#5) out of a total sample of 28 residents. Findings include: Review of the policy titled Resident Mobility and Range of Motion, dated July 2017, indicated the following: - Residents will not experience an avoidable reduction in range of motion (ROM). - As part of the resident's comprehensive assessment, the nurse will identify the resident's: -c. limitations in movement or mobility - As part of the resident's comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: -e. contractures. - The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. - Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards or practice and be consistent with state laws and practice acts. Resident #5 was admitted to the facility in November 2020 with diagnoses including heart failure and stroke without residual deficits. Review of Resident #5's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she was cognitively intact. Section GG of the MDS indicated the Resident did not have an impairment in range of motion to any joint. During interviews on 4/7/24 at 11:31 A.M. and on 4/9/24 at 8:21 A.M., Resident #5 said he/she has trouble straightening his/her fingers on his/her right hand. Resident #5 said his/her right hand has been getting bad over the last couple of months and would like nursing to address this concern. Resident #5's second and fifth fingers were only able to actively open to approximately 75% of full range of motion and needed to be pushed open with his/her other hand to fully straighten. Resident #5's third and fourth fingers could only straighten to approximately 50% of full range of motion and, even with assistance, could not straighten further. Resident #5 said he/she has new and worse pain in his/her right hand, and it has affected his/her ability to complete tasks. Resident #5 said he/she can still do things for him/herself, but it has become increasingly harder, and he/she has had to adapt to doing things in a different way. At the time of the interview, Resident #5 was eating breakfast and said he/she had to hold the utensils more in his/her palm than with his/her fingers. Review of Resident #5's listed medical diagnoses failed to indicate a neurological or arthritic condition that would lead to an unavoidable decrease in range of motion. Review of the nursing summary, dated 10/22/23, failed to indicate Resident #5 had any decrease in range of motion, contractures, or rigidity. Review of Resident #5's care plans failed to indicate a care plan for impairment in range of motion or contractures. Review of the Occupational Therapy evaluation, dated 12/13/23, indicated Resident #5's range of motion was within functional limits. The evaluation failed to indicate pain in the right hand, a deficit of strength in the right hand, and indicated there was no contracture present. During an interview on 4/9/24 at 8:32 A.M., Nurse #4 said she has not worked with Resident #5 in a while, but when she last worked with him/her, the Resident was able to fully straighten his/her right-hand fingers. During an interview on 4/9/24 at 8:34 A.M., Certified Nursing Assistant (CNA) #4 said she is unaware of Resident #5's limited range of motion. During an interview on 4/09/24 at 8:38 A.M., CNA #3 said she often takes care of Resident #5. CNA #3 said Resident #5's right hand may be gradually closing more but it had never been perfectly straight. During interview on 4/09/24 at 9:22 A.M., the Occupational Therapist (OT) said she previously had worked with Resident #5 and remembered that the Resident's right finger joints would deviate to the side but could not remember if they were closed and unable to open. The surveyor described how she had observed Resident #5's hand and the OT said this sounded different from before and would go to see for herself. During a follow-up interview on 4/9/24 at 9:36 A.M., the OT said she just observed the Resident's right hand. The OT said the third and fourth fingers of the right hand were definitely stuck in a bent position and the Resident is unable to straighten them. The OT said Resident #5 definitely complained of more pain now and had less range of motion than when he/she was previously seen for therapy. The OT said Resident #5 is cognitively intact and would be accurate if reporting worsening range of motion and more pain. During an interview on 4/9/24 at 10:06 A.M., the Director of Nursing said she would expect nursing to make a referral to therapy if a change in range of motion were to occur. During an interview on 4/9/24 at 10:44 A.M., the Director of Rehabilitation (DOR) said the therapy department completes screenings of all residents in the building quarterly and annually. The DOR said changes in range of motion would be looked at during screens, but nursing also would send a referral to therapy if a resident experienced a change in range of motion. The DOR said Resident #5 had previously been on therapy after falling but does not remember the Resident ever needing an evaluation for a change in range of motion. The DOR said Resident #5 is vocal about his/her impairments and said if the Resident is complaining of pain or a decline in range of motion it is most likely accurate. During an interview on 4/9/24 at 11:23 A.M., Unit Manager #2 said she was unaware of Resident #5's change in range of motion.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error when his/her Admission Physician Order for Metoprolol, (medication used to treat high blood pressure) was not transcribed into his/her Medication Administration Record (MAR) and as a result, he/she was not administered the medication for several days. Findings Include: The Facility Policy titled Adverse Consequences and Medication Errors, dated as revised February 2023, indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with Physician's Orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. The Policy indicated that examples of medication errors included omission, when a drug is ordered but not administered. Resident #1 was admitted to the Facility in December 2023, diagnoses included muscle weakness, depression, acute kidney failure, atrial fibrillation (an irregular often rapid heart rate commonly causing poor blood flow), and hypertension (high blood pressure). Review of Resident #1's Hospital Discharge Summary, dated 12/07/23, indicated he/she was to be administered Metoprolol Succinate XL 50 mg, one tablet by mouth daily. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/26/23, indicated that on 12/19/23 it was discovered that Resident #1 had not received his/her Metoprolol Succinate 50 milligrams (mg) daily from 12/08/23 through 12/12/23, which had been prescribed upon admission. The Report indicated that the medication omission had been discovered after Resident #1 had been readmitted to the Facility after he/she had been transferred from the Facility to the Hospital Emergency Department for high blood pressure. Review of the Facility Medication Error Report, dated 12/19/23, indicated that when Resident #1 was admitted to the Facility, an order for his/her Metoprolol Succinate 50 mg by mouth daily had not been transcribed (onto his/her MAR) upon admission. Review of Resident #1's MAR, for the month of December 2023, indicated there was no order for Metoprolol and therefore he/she had not been administered the medication by nursing from 12/08/23 through 12/12/23. Review of the Situation, Background, Assessment, and Recommendation (SBAR) Form, dated 12/12/23, indicated Resident #1 experienced a change of condition and was hypertensive. The Form indicated that Resident #1's blood pressure was 198/99 and his/her heart rate was 123 (beats per minute) and indicated that 911 was called. During an interview on 02/12/24 at 1:52 P.M., Nurse #6 said when she admitted Resident #1 to the Facility, she had not transcribed Resident #1's Metoprolol onto his/her MAR by mistake and said it was an oversight. During an interview on 02/12/24 at 2:48 P.M., the Director of Nursing (DON) said nursing had not administered five doses of Resident #1's Metoprolol because it had not been transcribed onto his/her MAR from the Hospital Discharge Summary Orders upon admission. The DON said the medication error occurred because the transcription error was an oversight on Nurse #6's part. On 02/12/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 12/20/23, Unit Managers and/or their designee began audits on the next business day for residents newly admitted and/or readmitted to ensure a medication reconciliation has been completed and that Admission Orders are accurately transcribed. Audit sheets will be submitted to the DON. B) 12/21/23, the DON and Regional Clinical Nurse completed audits on all residents newly admitted and/or readmitted over past thirty days, which included reviewing the resident's admission orders and comparing them to the resident's MAR. C) 12/22/23, the DON and Facility Educator educated nursing staff about the procedure for order transcription during the resident admission process and about ensuring that orders transcribed into a resident's MAR are double checked by a second nurse. D) DON will continue with follow-up audits by reviewing five random resident Medical Records daily to ensure the resident's Admission and Physician's Orders were transcribed accurately. This will be completed for three weeks and then will be completed monthly for two months. E) 01/31/24, the DON presented the Facility's Plan of Correction and audits to the Quality Assurance Performance Improvement Committee and will continue to present the Plan of Correction for two more months. F) DON and/or Designee are responsible for overall compliance.

Based on record review and interview, the facility failed to provide behavioral health services to 2 Residents (#209 and #206), after verbalizing suicidal ideation, out of a total sample of 33 residents. Findings include: Review of the facility policy, titled Behavioral Assessment, Intervention, and Monitoring, dated February 2019, indicated the following: -The facility will provide and residents will receive the behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. 1. Resident #209 was admitted in 08/2021 with diagnoses including depression, schizzoaffective disorder, and obsessive compulsive disorder. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #209 scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicates intact cognition. Review of the Mood/PHQ-9 Assessment (A mental health assessment questionnaire), dated 8/12/2021, indicated that Resident #209 expressed feeling down, depressed, or hopeless for a duration of 12-14 days. The assessment also indicated that Resident #209 had felt bad about him/herself for a duration of 12-14 days. The total score of the assessment was a 12, indicating moderate depression. There was no indication in the clinical record that Resident #209 had been seen/evaluated by psych services after the assessment. Review of the progress note, dated 9/23/21, indicated that Resident #209 had a change in condition and was hearing voices, called 911 several times, and was sent to the hospital. Review of another progress note, dated 9/23/21, indicated the hospital had called the facility and said Resident #209 stated that if he/she came back to the facility, then he/she was going to kill him/herself. Review of the clinical record indicated that Resident #209 was readmitted to the facility in late October, 2021. Review of the record failed to indicate Resident #209 was evaluated by psych services and did not have a care plan developed after re-admission to the facility despite suicidal ideation. Review of the clinical record indicated that on 10/29/21, Resident #209 was found in his/her room attempting to kill him/herself with the metal piece of the call bed light. Resident #209 was sent out to the hospital on a section 12 at that time. During an interview on 1/30/23 at 8:41 A.M., Social Worker #1 said that the behavioral health services group is in the building 1-2 times per week. SW #1 said that if someone scores high on the PHQ-9 (A mental health assessment questionnaire) or expresses suicidal ideation, then the facility would have psych services come into the building right away. SW #1 said that if the resident is currently expressing suicidal ideation or has a history of suicidal ideation, then a care plan should be developed. SW #1 said that if a resident scores higher than a 10 on the PHQ-9, then social services will put them in the psych log book to be seen. If a resident refuses, then that should be documented in the clinical chart. Review of the record failed to indicate Resident #209 was offered or refused psychiatric services at the facility. Review of the record failed to indicate Resident #209 was ever seen by psychiatric services. 2. Resident #206 was admitted to the facility in 01/2023 with diagnoses including dementia. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #206 was unable to participate in the Brief Interview for Mental Status (BIMS). Review of the progress note, dated 10/23/23, indicated that Resident #206's family told the facility that Resident #206 had asked for his/her pills to kill him/herself due to being sick 3 days prior to admission. The progress note indicated that Resident #206 declined depressive thoughts or a plan. Review of the Behavioral Health Services Log indicated that, on 1/23/23, Social Worker #2 referred Resident #206 for behavioral health services. The log indicated that on 1/25/23, the behavioral health services provider reviewed the referral and wrote covid positive. will see for telehealth or when out of isolation. Review of the record on 1/31/23, 8 days after the initial referral, did not indicate that Resident #206 was ever evaluated or seen by psych services. During an interview on 1/31/23 at 11:50 A.M., Resident #206's family member said that no one had been in to speak with Resident #206 and that the representative would have liked if a therapist came to talk to Resident #206. The family member said that Resident #206 was feeling much better and was not actively expressing suicidal ideation, but said that no one had been in to see Resident #206. During an interview on 1/31/23 at 11:55 A.M., Social Worker #2 said that he spoke to Resident #206 and the family member and that this was a baseline for Resident #206. Social Worker #2 said that he let nursing know and put the Resident's name in the behavioral health services log, but was unsure of who followed up after that. When asked who monitors for follow up with Resident #206, Social Worker #2 said he was not sure. Social Worker #2 said he never followed up to make sure Resident #206 was seen by behavioral health. During an interview on 1/31/23 at 12:36 P.M., Social Worker #1 said that if a resident is admitted with a history of expressing suicidal ideation that behavioral health services would be in within a week to see the Resident. Social Worker #1 said that the facility will use telehealth if necessary to get the resident seen or if a resident has covid.

Based on record review and interview, the facility failed to 1. develop a care plan for 2 Residents (#209 and #206), after expressing suicidal ideation, 2) failed to implement physician orders for 1 Resident (#97) and 3) failed to develop a care plan for substance abuse for 1 Resident (#60) out of a total sample of 33 residents. Findings include: Review of the facility policy, titled Depression- Clinical Protocol, dated November 2018, indicated the following: -The physician and staff will review available information and inquire further to identify and document individuals who have a history of depression or another mood disorder, other psychiatric disorders, psychiatric treatment or hospitalization s, or suicide attempts. -The staff will provide pertinent individualized non-pharmacological interventions for the individual with depression; for example, addressing related psychological, spiritual, and family issues. 1a. Resident #209 was admitted in 08/2021 with diagnoses including depression, schizzoaffective disorder, and obsessive compulsive disorder. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #209 scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicates intact cognition. Review of the progress note, dated 9/23/21, indicated that Resident #209 had a change in condition and was hearing voices, called 911 several times, and was sent to the hospital. Review of another progress note, dated 9/23/21, indicated that the hospital had called the facility and said that Resident #209 stated that if he/she came back to the facility, then he/she was going to kill him/herself. Review of the clinical record indicated that Resident #209 was readmitted to the facility on [DATE]. Review of the clinical record did not indicate that Resident #209's care plan was updated or a care plan was created after the new onset of suicidal ideation. Review of the clinical record indicated that on 10/29/21, Resident #209 was found in his/her room attempting to kill him/herself with the metal piece of the call bed light. Review of the care plan indicated that, on 11/1/21, a care plan for suicidal risk related to depression was created, 6 days after Resident #209's re-admission back to the facility. During an interview on 1/30/23 at 8:41 A.M., Social Worker #1 said that when a resident expresses suicidal ideation, a care plan should be created and if someone was admitted with a history of suicidal ideation, then a care plan should be developed. 1b. Resident #206 was admitted to the facility in 01/2023 with diagnoses including dementia. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #206 was unable to participate in the Brief Interview for Mental Status (BIMS). Review of the progress note, dated 10/23/23, indicated that Resident #206's family told the facility that Resident #206 had asked for his/her pills to kill him/herself due to being sick 3 days prior to admission. The progress note indicated that Resident #206 declined depressive thoughts or a plan. Review of the care plan did not indicate that a care plan had been initiated for Resident #206 regarding suicidal ideation. During an interview on 1/31/23 at 11:55 A.M., Social Worker #2 said that he would expect a care plan to be initiated for anyone that expresses suicidal ideation. During an interview on 1/30/23 at 8:41 A.M., Social Worker #1 said that when a resident expresses suicidal ideation, a care plan should be created and if someone was admitted with a history of suicidal ideation, then a care plan should be developed. 41456 2. For Resident #94, the facility failed to follow a physician's order for ace wraps and skin checks. Resident #94 was admitted to the facility in July 2021 with diagnoses including muscle weakness, diabetes and stroke. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15 which indicates he/she is cognitively intact. On 1/29/23 at 12:37 P.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/30/23 at 8:10 A.M, Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/31/23 at 6:35 A.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. Review of Resident #94's physician orders indicated the following orders: *Apply ace wraps to RLE (right lower extremity) daily at 6am off at 6pm, every day and evening shift, initiated on 6/2/22. *Weekly skin check every Thursday, initiated on 1/5/23. Review of the Medication Administration Report for the month of January 2023 indicated skin checks had not been completed on 1/5/23 and 1/19/23. During an interview on 1/31/23 at 8:05 A.M., Nurse #9 said she was unaware Resident #94 had orders for ace wraps and did not know why they were not on. During an interview on 1/31/23 at 8:21 A.M., Unit Manager #2 was unaware that Resident #94 was not wearing the ordered ace wraps during the surveyor observations and was also unaware of the missed skin checks. 43846 3. Resident #60 was admitted in June 2022 with diagnoses that included major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood. Review of the facility's policy titled Care Planning, dated March 2022, indicated the interdisciplinary team is responsible for the development of the resident care plans. Review of Resident #60's Behavioral Health Note dated 7/1/22, indicated Substance Use / Addiction History: records indicate Polysubstance abuse Nicotine. Review of Resident #60's Behavioral Health Note dated 12/31/22, indicated Substance Use / Addiction History: records indicate Polysubstance abuse Nicotine. Review of Resident #60's Nursing Progress Note dated 1/23/23, indicated Patient (pt) was assessed in his/her room to be nonresponsive. Respiratory depression. VS 96.7-58-12-106/60, 80% on room air. Pt was nonverbal, unconscious. Applied 5 L o2 (liters of oxygen) on nonrebreather. Lung sounds were labored and shallow. Administered 4 mg naloxone (a medication used for a suspected overdose) intranasal at 11:05 and 11:20. Review of Resident #60's Nurse Practitioner Progress Note, dated 1/26/23, indicated Today pt (resident) seen at NSG (nursing) request in f/u on recent event of unresponsiveness w/ slow reaction to narcan x2, meds were not administered from the night before. Pt w/ recent visitors,? narc brought from outside. Pt was tx (transported) to the hospital where also had unresponsive episode responded to IV narcan. Review of Resident #60's Hospital Discharge Summary, dated 1/25/23, indicated Has prior history of substance use disorder as well as per facility history of pocketing prescription pain medication. Etiologies include medication overdose. Review of Resident #60's medical record failed to indicate that a history substance abuse care plan was developed. During an interview on 1/31/23 at 12:07 P.M., Unit Manager #1 said Resident #60 had a known history of substance abuse and said it hasn't been proven but staff have wondered if he has cheeked medication during his stay here. During an interview on 1/31/23 at 12:23 P.M., the Director of Nursing said she would expect a care plan to be developed with someone with a past history of substance abuse especially because Resident #60 went to the hospital for a suspected overdose.

Based on observation, record review and interview the facility failed to provide required Activity Daily Living (ADL) assistance to 3 Residents (#35, #50 and #91), out of a total 33 sampled residents. Findings Include: 1. Resident #35 was admitted to the facility in October 2020 and has diagnoses that include dementia and encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/22, indicated Resident #35 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #35 required extensive 1 person physical assistance with eating and bed mobility. During an observation on 1/29/23 at 8:31 A.M., Resident #35 was observed on the side of his/her bed, hunched over a tray table, feeding him/herself breakfast. No staff were present to supervise or assist the Resident. During a record review the following was indicated: * A Licensed Nursing Summary, dated 1/28/23, indicated Resident #35 requires continual supervision 1:8 ratio with meals. * An Activities of Daily Living (ADL) care plan: Supervision with eating 1:8 and assist of (1 person) with ADLs. * The current Kardex (resident specific instructions for staff on resident's care needs) indicated Resident #35 requires supervision of 1:8 with eating. * The Certified Nursing Assistant (CNA) task documentation indicated Resident #35 ate meals with continual supervision in the previous 14 days. * The most recent Nutrition Assessment, dated 1/19/23, indicated Resident #35 consumes meals with supervision. During an observation on 1/30/23 at 8:04 A.M., Resident #35 was observed laying in bed, alone in his/her room. A staff person placed a breakfast tray beside the bed, exited the room and continued passing trays to other residents. Staff failed to assist Resident #35 to a seated position or to provide supervision for the meal. During an observation 1/31/23 at 7:48 A.M., Resident #35 was observed laying in bed, alone in his/her room. Resident #35 was observed leaning on his/her side, attempting to reach the food on the tray. After multiple attempts Resident #35 picked up a piece of toast, then laid back down in bed and ate the food while laying flat. Staff failed to assist Resident #35 to a seated position or to provide supervision for the meal. During an observation on 2/01/23 at 8:10 A.M., Resident #35 was observed alone in his/her room, drinking a bowl of oatmeal. Moments later he/she began to cough profusely. During an observation and interview on 2/01/23 at 8:12 A.M., the surveyor and Nurse (#3) observed Resident #35 alone in his/her room, coughing as he/she drank oatmeal. Nurse #3 said supervision with meals meant that someone should be with Resident #35 the entire time he/she eats. During an interview with a CNA (#5) on 2/01/23 at 8:17 A.M., she said Resident #35 required assist with all his/her care and supervision with meals. CNA #5 said that she tried to supervise Resident #35 today but had to take care of the other residents on her assignment. During an interview with the Nurse Unit Manager (#2) on 2/01/23 at 8:20 A.M., he said that Resident #35's CNA had called out that day. He said that it was the expectation that Resident #35 be supervised throughout his entire meal and be assisted to a seated position to eat. During an interview with the Director of Nursing on 2/01/23 at 9:12 A.M., she said that it was her expectation that resident's that require assistance with bed mobility and supervision with meals receive the assistance. 43846 2. Resident #50 was admitted to the facility in October of 2018 with diagnoses that included Alzheimer's Disease, feeding difficulties and dysphagia. On 1/29/23 the surveyor observed the following: * From 8:47 A.M. to 9:09 A.M., the surveyor observed Resident #50 in bed staring at his/her breakfast tray, not initiating self feeding without supervision. * From 12:37 P.M. to 12:40 P.M., the surveyor observed Resident #50 in bed staring at his/her lunch tray, not initiating self feeding, without supervision. On 1/30/23 the surveyor observed the following: * From 8:27 A.M. to 8:39 A.M., the surveyor observed Resident #50 in bed staring at his/her breakfast tray and was crying, not initiating self feeding, without supervision. On 1/31/23 the surveyor observed the following: * From 12:13 P.M. to 12:25 P.M., the surveyor observed Resident #50 in a chair next to his/her bed alone with his/her lunch tray. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #50 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS also indicated for eating that Resident #50 needed a one person physical assist with limited assistance. Review of Resident #50's Certified Nurse Aide (CNA) Kardex, dated 1/30/23, indicated continual supervision (1:8) with eating may and need to be fed. Review of Resident #50's Activity of Daily Living (ADL) Care Plan, dated 7/13/21, indicated continual supervision (1:8) with eating and may need to be fed. Review of Resident #50's Nutrition Follow Up Note, dated 1/3/23, indicated chewing/swallowing difficulty, diet modified in texture weight loss. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's Kardex will tell us how to care for the resident. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA Kardex will tell what assistance level a resident needs and the care plan which filters into the Kardex and said they would expect supervision to be provided as the kardex or care plan reads. 3. Resident #91 was readmitted in January 2021 with diagnoses that included Dementia, dysphagia, and hypertension. On 1/29/23 the surveyor observed the following: * From 8:49 A.M. to 8:58 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. * At 12:45 P.M., Resident #91 was observed sitting on the edge of the bed eating his/her lunch alone without supervision. On 1/30/23 the surveyor observed the following: * From 8:12 A.M. to 8:33 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. On 1/31/23 the surveyor observed the following: * From 8:26 A.M. to 8:29 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. * From 12:23 P.M. to 12:28 P.M., Resident #91 was observed sitting on the edge of the bed eating his/her lunch alone without supervision. Review of Resident#91's most recent Minimum Data Set (MDS) dated [DATE], indicated for eating Resident #91 needed one person physical assist and supervision. The MDS also indicated Resident #91 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. Review of Resident #91's Certified Nurse Aide (CNA) Kardex dated 1/30/23 indicated continuous supervision of 1:8 for meals, needs encouragement. Review of Resident #91's Activity of Daily Living (ADL) Care Plan, dated 3/4/21, indicated continuous supervision of 1:8 for meals, needs encouragement. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's Kardex will tell us how to care for the resident and how much assistance they need for ADLs. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA Kardex will tell what assistance level a resident needs and the care plan which filters into the Kardex and said they would expect supervision to be provided as the kardex or care plan reads.

Based on observation, record review and interview the facility failed to ensure professional standards for 1. staff sleeping while on resident units, 2. obtaining weekly weights as ordered for one Resident (#46) and 3. setting a Resident's (#79) air mattress at the setting ordered by the physician, out of a total 33 sampled residents. 1. Review of the facility's Human Resources Policies and Procedures Manual, dated June 2007, indicated Inappropriate Workplace Behavior/ Inappropriate Professional Behavior- The Facility (Care One) expects all employees to serve as a positive reflection of the facility by being courteous and respectful to co-workers and residents at all times. Sleeping on the job. During an observation on 1/30/23 at 3:57 A.M., on the 2nd floor unit the surveyor observed a Certified Nursing Assistant (CNA) #4 slumped low in a chair, soundly sleeping. During an interview on 1/30/23 at 3:59 A.M., Nurse #6 said it was the expectation that staff not sleep on the resident units. During an observation on 1/30/23 at 4:00 A.M., CNA #4's alarm sounded loudly. Nurse #6 and the surveyor observed CNA #4 wake up, sit up and turn off the alarm on his telephone. During an interview with CNA #4 on 1/30/23 at 4:02 A.M., he acknowledged that he had been sleeping and said that he was exhausted because he had worked a double shift. During an observation on 1/30/23 at 3:59 A.M., the surveyor observed a Certified Nurses Aide (CNA #3) asleep in a chair with her head on a bedside table on the third floor. During an interview on 1/30/23 at 4:03 A.M., Nurse #1 said the expectation for the CNA is to stay awake all shift so they can provide care to the residents and said she does try to wake them if she notices they are asleep. Review of the facility's grievance log book indicated a grievance dated 7/28/22, with a concern staff seen sleeping at desk or end of hallways on 11pm -7 am shifts. During the Resident Group interview on 1/30/23 at 10:10 A.M., 2 of 5 residents participating in the meeting said that they had seen staff sleeping on the 11-7 shift and that it had been reported to Nurse Unit Manager #2. During an interview on 2/01/23 at 7:59 A.M., the Administrator and the Director of Nursing (DON) said that it is the expectation that staff stay awake their entire shift. The DON said if staff are tired they should clock out and tell the nurse on duty. 43846 2. Resident #46 was admitted to the facility in January of 2022 with diagnoses that included Dementia, unspecified protein-calorie malnutrition and type 2 diabetes . Review of the facility's policy titled, Weight Assessment and Intervention, dated June 2022, indicated residents are weighed upon admission and at intervals established by the interdisciplinary team such as: as ordered. Weights will be recorded in each resident's medical record. Review of Resident #46's Medical Record indicated the only weight taken in December 2022 was on 12/2/22 which was 137.6 pounds and in January 2023 was on 1/9/23 which was 132.5 pounds, no further weights have been taken since. Review of Resident #46's Nutrition Care Plan, dated 1/31/22, indicated weights as ordered. Review of Resident #46's January Physician Orders indicated Weekly Weights. Review of Resident #46's Nutrition Evaluation, dated 1/4/23, indicated weekly weights. Review of Resident #46's Certified Nurse Aide (CNA) Kardex, dated 1/30/23, indicated Weigh Weekly. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's Kardex will tell us how to care for the resident and how often they should be weighed. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA Kardex will tell what assistance level a resident needs and the care plan which filters into the CNA Kardex. During an interview on 1/31/23 at 12:10 P.M., the Dietitian said she would expect nursing to obtain the weekly weight as ordered. During an interview on 2/01/23 at 8:09 A.M., the Director of Nursing (DON) said if someone has an order for weekly weights she would expect the weight to obtained weekly. The DON also said she would expect that the nursing staff would read the Physician's order and not just look for an empty block on the MAR. 41456 3. Resident #79 was admitted to the facility in June 2021 with diagnoses including dementia. Review of Resident #79's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #79 requires extensive assistance from staff for bed mobility. On 1/29/23 at 11:09 A.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 320 lbs (pounds). On 1/30/23 at 2:00 P.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 320 lbs. On 1/31/23 at 6:41 A.M., and at 10:45 A.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 400 lbs. Review of Resident #79's weight log indicated her was last weighed on 12/1/22 and his/her weight was 133.4lbs. Review of Resident #79's physician orders indicated the following order initiated on 12/7/22: *Air mattress with setting of 4 lights down from the top. Check placement and function every shift Review of Resident #79s skin integrity care plan, last revised 1/27/23, indicated the following intervention: *Pressure relieving mattress on bed and cushion on wheel chair - air mattress with setting of 160 lbs. During an interview on 1/31/23 at 10:50 A.M., Nurse #8 said she was unaware of what setting Resident #79's air mattress should be set to. During an interview on 1/31/23 at 10:55 A.M., Unit Manager #1 said the air mattress should be set to the level that the physician order is written to. Unit Manager #1 said she was unaware that Resident #79 was on an air mattress that was set by weight, not level as the current physician order read. Unit Manager #1 said the air mattress should be set to the Resident's weight and that 300-400 pounds is too heavy of a weight for Resident #79. During an interview on 1/31/23 at approximately 11:00 A.M., the Assistant Director of Nursing (ADON) said Resident #79's type of air mattress must have changed once he/she was admitted to hospice and the physician order did not match the newer air mattress that the Resident is currently using. The ADON said the air mattress should be set to the Resident's weight.

Based on observation, record review and interview, the facility failed to identify and address bilateral hand contractures for 1 resident, (#87), out of a total of 27 sampled residents. Findings include: Resident #87 was admitted to the facility in June 2016 with [DIAGNOSES REDACTED]. Review of Resident #87's most recent Minimum Data Set Assessments ((MDS) dated [DATE] and 1/15/20, indicated that he/she was totally dependent on staff for activities of daily living and that Resident #87 had no upper extremity impairment. On 2/11/20 at 10:00 A.M., the surveyor observed Resident #87's bilateral hands. Both hands were closed into fists. During an interview with Family Member #1 on 2/11/20 at 10:03 A.M., she said that Resident #87's hands were not always contracted and had started to become contracted months ago. Family Member #1 said that Resident #87's hand contractures had gotten worse recently and the nursing department and rehab department had not assessed Resident #87's contractures. Family Member #1 said that they would be interested in having a rehab screen regarding Resident #87's contractures. Family Member #1 said that one of Resident #87's hands had become so contracted that he/she cannot open them without pain. Family Member #1 then opened Resident #87's left hand and Resident #87 yelled out in response. Review of Resident #87's care plans, care card, list of diagnoses, nursing and medical progress notes, and monthly nursing summaries failed to identify Resident #87's contracted hands or decreased range of motion (ROM). Review of Resident #87's most recent Rehab screen, dated 1/22/19, indicated that he/she did not have any range of motion impairment. Review of the hospice note dated 12/6/19, indicated that the hospice nurse recommended the use of rolled face cloths for Resident #87's left and right hand at all times (remove for washing). An additional hospice note dated 12/9/19, indicated that Resident #87 was utilizing rolled face cloths in both hands as he/she was beginning to ball them up. Review of Resident #87's Treatment Administration Records (TAR), dated December 2019 and January 2020, indicated that Resident #87 utilized a rolled face cloth in both hands daily, during all three shifts, from 12/6/19 through 1/6/20 and did not refuse their use. Resident 87's medical record indicated a physician's orders [REDACTED]. During an interview with CNA #4 on 2/11/20 at 11:17 A.M., she said that she has been Resident #87's primary CNA for a few months. CNA #4 said that Resident #87 used to be able to open his/her hands but she could not remember when his/her hands began to curl up. CNA #4 said that Resident #87 started using hand rolls a couple months ago. CNA #4 said that one of Resident #87's hands is so contracted, they cannot get a hand roll into his/her hand. During an interview on 2/11/20 at 12:51 P.M., Nurse #4 said that she is not usually assigned to Resident #87, but knows Resident #87 and Family Member #1 very well. Nurse #4 said she did not know that Resident #87's hands were contracted. Unit Manager #3 was interviewed on 2/11/20 at 12:59 P.M. and 1:15 P.M. Unit Manager #3 said that she was aware of Resident #87's right hand being contracted, and it had gotten worse. Unit Manager #3 said that because Resident #87 was on hospice, she did not make a referral to the rehab department to assess Resident #87's worsening contracture. Unit Manager #3 said that she was not aware that Resident #87's left hand was contracted. The Director of Rehab was interviewed on 2/11/20 at 12:09 P.M., and 1:07 P.M. The Director of Rehab said that she was not aware of any referrals for Resident #87 for rehab services. The Director Of Rehab said that she was not aware that Resident #87 had developed bilateral hand contractures and that rehab should have been notified to obtain a referral and assess Resident #87's condition. During an interview with the Director of Nursing on 2/11/20 at 1:23 P.M., she said that the facility does not have a policy on when to refer residents to rehab services. The Director of Nursing said that Resident #87 should have been assessed for a significant change in his/her status related to his/her hand contractures.

Based on records reviewed, interviews, and observations for four of seven sampled residents (Resident #2, #3, #4, and #5), the facility failed to ensure that allegations of abuse were immediately and thoroughly investigation and failed to implement interventions to prevent and protect residents from subsequent incidents of abuse when from approximately 08/12/18 to 09/21/18 there were at least nine alleged incidents of Resident #1 abusing four other Residents of the opposite sex and one incident when the Director of Nurses allegedly subjected Resident #1 to abuse and Resident #3 to a situation where the potential for a repeated act of abuse could occur. Findings include: The Facility's Protection of Residents during Abuse Investigations Policy, dated (MONTH) (YEAR), indicated that the accused resident's representative and Attending Physician will be informed of the alleged abuse incident, and there may be restrictions on the accused resident's ability to visit other resident rooms. The Facility's Abuse Investigation and Reporting Policy and Procedure, dated (MONTH) (YEAR), indicated the Administrator assigns the investigation to an appropriate individual, keeps the resident's representative informed of the status of the investigation, and ensures that any further potential abuse is prevented. The Investigator ensures witness statements obtained are signed and dated. The Policy and Procedure indicated all alleged violations involving abuse will be reported by the Facility Administrator, or his/her designee, to the State licensing/certification agency. The Policy and Procedure indicated an alleged violation of abuse will be reported immediately, but no later than two hours. The Facility's Accidents and Incidents - Investigating and Reporting Policy Statement, dated 10/2017, indicated incidents involving residents on our premises shall be reported to the Administrator. The Nurse Supervisor shall promptly initiate and document investigation of the incident, complete the Report of Incident/Accident Form and forward to the Director of Nurse within 24 hours of the incident or accident. The Director of Nurses shall ensure that the Administrator also receive a copy of the Report of Incident/Accident Form. The Form will also be reviewed by the Safety Committee. 1. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 07/25/18, indicated he/she had severe cognitive impairment, ambulated with supervision, no wandering behavior was exhibited, and no behavioral symptoms were exhibited, such as a physical behavioral symptom of sexually abusing others. Review of Resident #1's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability to consent to a sexual relationship. The Record also indicated that Resident #1's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves) in (YEAR), due to his/her [DIAGNOSES REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 08/09/18, indicated he/she had severe cognitive impairment, experienced delusions, displayed physical and verbal behavioral symptoms towards others, was totally dependent for care, and required one person assist with dressing and ambulation. Review of Resident #3's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that on 08/12/18 she witnessed Resident #1 approach Resident #3, and grab Resident #3 by the waist. Nurse #7 said Resident #1 and Resident #3 were both fully dressed. Nurse #7 said while Resident #1 held Resident #3's waist, Resident #1 made a sexual movement of repeatedly thrusting his/her genitals up against Resident #3's buttocks. Nurse #7 said she immediately separated Resident #1 and Resident #3. Nurse #7 said she was not assigned to Resident #1 and reported the incident to Nurse #9 to document and report the incident. A Witness Statement, dated 10/01/18, written by Nurse #9, indicated the Director of Nurses (DON) requested that he (Nurse #9) alter his Progress Note, written on 08/12/18. The Witness Statement indicated Nurse #9 discussed the incident involving Resident #1 with the DON and they concluded the word hugging more accurately reflected the incident, as opposed to the original word, grabbing, used to describe the incident. Surveyor #1 interviewed Nurse #9 at 1:00 P.M. on 11/16/18. Nurse #9 said that on 08/12/18 he saw Resident #1 approached a resident of the opposite sex (unable to recall identity at the time of investigation) from the side and place his/her right arm across the Resident's back and around his/her shoulder. Nurse #9 said that he documented in his Progress Note that Resident #1 was observed grabbing a resident. Nurse #9 said that after discussion with the Director of Nurses (DON) about the incident, they concluded the word hugging, not grabbing, best described the situation and Nurse #9 said he altered his Progress Note, as instructed by the DON. Surveyor #2 interviewed Nurse #9 at 11:22 A.M. on 11/20/18. Nurse #9 said he was not witness to and could not recall receiving any information related to Resident #1 thrusting his/her genitals against Resident #3's buttocks on 8/12/18, from Nurse #7. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Review of the Facility's Internal Investigation, dated as initiated on 09/26/18, 45 days after the alleged incident was reported, indicated there was no documentation to support that the Facility staff immediately reported the incident or allegation from 08/12/18 regarding Resident #1 and Resident #3 to the Administrator, that a complete and thorough investigation was immediately conducted including interviews with staff and any other potential witnesses , that steps were taken to prevent or protect residents from potential subsequent abuse, and that the incident was reported to Resident #1's and Resident #3's Health Care Agents, Physicians or DPH. This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 2. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 08/01/18, indicated he/she had severe cognitive impairment, was rarely or never understood or understood others, wandered daily, was totally dependent for dressing, and ambulated with supervision. Review of Resident #2's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Occupational Therapist (OT) #1's Witness Statement, dated 09/26/18, indicated that she saw Resident #1 lying in his/her bed with Resident #2 lying beside him/her, she called for assistance Nurse #7 responded and assisted with getting Resident #2 off the bed. Surveyor #2 interviewed Occupational Therapist (OT) #1 at 12:50 P.M. on 11/09/18. OT #1 said that prior to early (MONTH) (YEAR) (exact date unknown), she saw Resident #2 lying with Resident #1, in Resident #1's bed. OT #1 said she immediately shouted out to staff for help after observing the two Residents (#1 and #2) in bed together. OT #1 said as she attempted to remove Resident #2 from the bed, Nurse #7 entered the room to assist her. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that (exact date unknown), sometime after 08/12/18, OT #1 told her that Resident #1 and Resident #2 were both sitting on the edge of Resident #1's bed. Nurse #7 said she immediately went into Resident #1's room with OT #1. Nurse #7 said she saw Resident #1 with his/her hands on Resident #2 hips at the waistband as Resident #2 was trying to get up. Nurse #7 said she did not know whether Resident #1 was trying to remove Resident #2's pants or trying to pull Resident #2 on top of him/her. Nurse #7 said Resident #1 and Resident #2 were immediately separated. Nurse #7 said OT #1 told her that after they separated the residents, she noticed that Resident #1 had an erect penis. Based on interviews conducted with Nurse #7 and OT #1, regarding the incident that occurred between Resident #1 and Resident #2, both Nurse #7 and OT #1 indicated that the incident occurred in (MONTH) of (YEAR). Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Review of the Facility's Internal Investigation, dated as initiated on 09/26/18, indicated there was no documentation to support that the facility staff immediately reported the incident or allegation from (MONTH) (YEAR) regarding Resident #1 and Resident #2 to the Administrator or DPH, that a complete and thorough investigation was immediately conducted including interviews with staff or any other potential witnesses , that steps were taken to prevent or protect residents from potential subsequent abuse . This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said that on 08/16/18, she walked into the hallway and saw that Resident #1 had Resident #2 pinned up against the wall and was thrusting the his/her genitals against Resident #2's buttocks. The Director of Activities said she immediately separated Resident #1 and Resident #2. The Director of Activities said she reported the incident to Nurse #7 and the Unit Manager. The Director of Activities said the Unit Manager told her not to document a Witness Statement because Resident #1 and Resident #2 were separated, and nothing happened. The Activities Director said she told the Unit Manager that despite her request, she still wanted to document a Statement about the incident. The Activities Director said she wrote a Statement on the day the incident occurred (08/16/18), made a copy for herself, and left the original copy on the Unit Manager's desk. The Director of Activities Witness Statement, dated 08/16/18, indicated she saw Resident #1 and Resident #2 together at the end of the hallway on the resident care unit. The Director of Activities indicated Resident #1 had Resident #2 pinned up against the wall and was forcibly and repeatedly thrusting his/her hips against Resident #2's buttocks. The Director of Activities indicated she redirected Resident #1 and Resident #2. The Director of Activities indicated the incident was immediately reported to Nurse #7 and the Unit Manager. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she could not recall how she became aware of the incident on 8/16/18, of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she could not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager denied receiving any reports of sexually abusive behavior involving Resident #1 before 09/21/18. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Review of the Facility's Internal Investigation, dated as initiated on 09/26/18, indicated there was no documentation to support that the facility staff immediately reported the incident or allegation from 08/16/18 regarding Resident #1 and Resident #2 to the Administrator or DPH, that a complete and thorough investigation was immediately conducted including interviews with staff or any potential witnesses and that interventions were implemented to prevent and protect residents from potential subsequent abuse., This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 4. Review of Activities Aide #1's Witness Statement, dated 09/25/18, indicated she saw Resident #1 holding Resident #2 firmly by the hips and quickly thrusting his/her genitals up against Resident #2's body. The Statement indicated that on 8/17/18 she and Nurse #7 separated Resident #1 and Resident #2 and notified the Unit Manger. Surveyor #1 interviewed Activities Aide #1 at 11:30 A.M. on 11/05/18. Activities Aide #1 said that on 08/17/18 she saw Resident #1 approach Resident #2 in the dining room. Activities Aide #1 said Resident #1 held Resident #2 by the hips and thrusted his/her genitals against Resident #2's buttocks. Activities Aide #1 said she felt she had witnessed an incident of sexual assault. Activities Aide #1 said Nurse #7 assisted her with separating Resident #1 and Resident #2. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she did not recall how she became aware of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she did not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not received any reports of sexually abusive behavior involving Resident #1 before 09/21/18. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Review of the Facility's Internal Investigation, dated as initiated on 09/26/18, indicated there was no documentation to support that the Facility immediately reported the alleged incident from 08/17/18 regarding Resident #1 and Resident #2 to the Administrator or DPH, that a complete and thorough investigation was immediately conducted including interviews with staff and any potential witnesses and that interventions implemented to prevent and protect residents from potential subsequent abuse. This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 5. Resident #5's [DIAGNOSES REDACTED]. Resident #5's Annual MDS assessment, dated 10/03/18, indicated he/she had severe cognitive impairment, required a two person extensive assist with bed mobility, required a one person assist with dressing and required a one person extensive assist with ambulation. Review of Resident #5's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #5's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). CNA #4's Witness Statement, dated 09/26/18, indicated she saw Resident #1 in bed with Resident #5, at approximately 9:00 P.M. or 9:30 P.M. sometime in (MONTH) (YEAR). CNA #4's Witness Statement indicated she heard Resident #5 yelling get off of me so she went to Resident #5's room and saw Resident #1 lying on top of Resident #5. The Statement indicated Resident #5 had on a brief and a hospital gown, CNA #4 called for help, CNA's and Nurses responded, removed Resident #1 from Resident #5's bed and redirected Resident #1 out of Resident #5's bedroom. Surveyor #1 interviewed Certified Nurse Aide (CNA) #4 at 3:55 P.M. on 11/05/18. CNA #4 said that approximately 9:30 P.M., in late (MONTH) or early (MONTH) (exact date unknown), she heard Resident #5 calling for help. CNA #4 said upon entering Resident #5's bedroom, she saw Resident #1 on top of Resident #5 in bed. CNA #4 said she called out for help because she was unable to remove Resident #1 off of Resident #5. CNA #4 said Resident #5's hospital gown was lifted up and part of one of his/her breast was exposed. CNA #4 said CNA #6 and Nurse #5 arrived to assist. CNA #4 said Resident #1 held onto the bed's side rail and kicked at CNA #6 and Nurse #5 as they attempted to remove Resident #1 from the bed. CNA #4 said Nurse #2 was notified of the incident upon his return to the Unit from a work break. CNA #4 said she observed the following evening that Resident #1 on a one to one supervision. Surveyor #3 interviewed Nurse #5 at 11:05 A.M. on 11/07/18. Nurse #5 said she was informed by a CNA (unable to recall identity at the time of investigation), that Resident #1 was in Resident #5's bed. Nurse #5 denied assisting another staff member with removing Resident #1 from another resident's bedroom. Surveyor #1 interviewed CNA #6 at 2:15 P.M. on 11/06/18. CNA #6 denied assisting any staff members to remove Resident #1 from another resident's bedroom. CNA #6 said she had not witnessed Resident #1 in a resident's bedroom or in in another residents bed. Surveyor #1 interviewed Nurse #2 at 12:30 P.M. on 11/06/18. Nurse #2 said he had not received any report of Resident #1 being in bed with Resident #5. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Although CNA #4's Witness Statement indicated she found Resident #1 in bed with Resident #5's and that she required the assistance of at least two other staff members to physically remove Resident #1 from the bed, there was no documentation to support that the Facility staff immediately reported the alleged incident from (MONTH) (exact date unknown) regarding Resident #1 and Resident #5 to the Administrator or DPH, that a complete and thorough investigation was immediately conducted including interviews with staff and any potential witnesses and that interventions were implemented to prevent and protect residents from potential subsequent abuse. This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 6. Activities Aide #2's Witness Statement, dated 09/25/18, indicated she told the DON that Resident #1 grabbed Resident #3 by the genitals. Activities Aide #2's Statement indicated that the DON went into the dining room, proceeded to stand next to Resident #1 pushing her breasts towards Resident #1 and stated words to the effect of, she did not believe Resident #1 had made any sexually abusive gestures towards other residents. The Statement indicated the DON said words to the effect, that because Resident #1 was not paying attention to her and Resident #3 was not attractive, therefore, why would Resident #1 grab Resident #3's genitals. Surveyor #2 interviewed Activities Aide #2 at 1:30 P.M. on 11/07/18. Activities Aide #2 said that on 09/07/18, while conducting an activity with Activity Aide #1, she observed Resident #3 stand up from the dining room table, where he/she was seated with Resident #1, and began to walk away. Activities Aide #2 said she saw Resident #1 reach out from a seated position and grabbed Resident #3's genital area with his/her hand. Activities Aide #2 said she told Resident #1 to let go, which startled Resident #1, and his/her grip on Resident #3 genital area was released. Activities Aide #2 said she immediately approached the DON, who was at the nursing station and informed her of the incident. Surveyor #1 interviewed Activities Aide #1 at 11:30 AM on 11/05/18. Activities Aide #1 said she asked the DON if she wanted Resident #3 brought back to the table to see if Resident #1 would attempt to grab Resident #3 again and the DON replied, yes. Activities Aide #1 said Activities Aide #2 brought Resident #3 back to the table and seated him/her next to Resident #1 per the DON's direction. Activities Aide #1 said it felt wrong to be doing what they were doing, returning Resident #3 to the table with Resident #1. Activities Aide #1 said she, the DON, and Activities Aide #2, stood away from the table to observe Resident #1's response to Resident #3, and observed Resident #1 then pull Resident #3's chair closer to him/her. Activities Aide #1 said Activities Aide #2 immediately separated Resident #1 and Resident #3. Activities Aide #2 said the DON asked that Resident #3 be brought back to the table with Resident #1. Activities Aide #2 said the DON stood by Resident #1, stuck her breasts forward toward Resident #1 and said it was hard to believe Resident #1 was not paying attention to her (DON). Activities Aide #2 said the DON said Resident #3 had physical features which resembled his/her opposite gender , and because of that, it was odd that Resident #1 paid attention to Resident #3. Activities Aide #2 said the DON's comment was loud enough to be heard by Resident #3, who was seated at the table. Activities Aide #2 said she, the DON and Activities Aide #1 then moved away from the table to observe how Resident #1 would behave with Resident #3. Activities Aide #2 said that after approximately 20 seconds, Resident #1 reached his/her hand forward toward Resident #3 and the DON then immediately separated Resident #1 and Resident #3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said she was sitting with a resident in the activities/dining room on 09/07/18 and witnessed the DON puffing out her chest/made her chest more pronounced to see if Resident #1 would reach out to grab her chest, or words to that effect. The Director of Activities said the DON placed her hands on her hips and said Resident #1 was not doing anything (in response to her gesture). The Director of Activities said she witnessed one of the Activities Aides sit Resident #3 at a table with Resident #1 and then observed as Resident #1 reached over and pulled Resident #3's chair closer to him/her, which is when the DON intervened. The Director of Nurses Witness Statement, dated 11/02/18, indicated she stood next to Resident #1 on 09/07/18, in an attempt to assess the nature of his/her behavior and actions. The DON's statement indicated she denied presenting any part of her body toward Resident #1. The DON's Statement indicated Activities Aide #1 suggested having a resident of the opposite sex sit near Resident #1 to observe any inappropriate sexual behavior. The Statement indicated three staff members were present at the time and at no point was either resident at risk. Surveyor #2 interviewed the Director of Nurses at 2:10 P.M. on 11/07/18. The DON said Activities Aide #2 reported to her that Resident #1 reached for another resident's genitals. The DON said it was difficult for her to believe a sexually abusive incident had occurred because she thought Resident #1 only had behaviors of hugging residents. The DON said she questioned if Resident #1 was unable to keep his/her hands to himself/herself and said she proceeded to the dining room where Resident #1 was seated. The DON said she wanted to determine if Resident #1's alleged inappropriate sexual behaviors were instinctive or impulsive. The DON said if Resident #1 reached for a person of the opposite sex, then new interventions needed to be implemented. The DON said she attempted to assess Resident #1, with Activities staff present. The DON said she stood near Resident #1 with her shoulders back and chest forward. The DON said Resident #1 had not responded to her gesture. The DON said Activities Aide #1 told her Resident #1 would not act sexually abusive in the presence of staff members. The DON said she decided to assess Resident #1's response to Resident #3 (a member of the opposite sex). The DON said Resident #3 was assisted back to the table and seated near Resident #1. The DON said Resident #1 was observed, by her and the Activities staff from approximately 15 feet away, to reach his/her hand toward Resident #3. The DON said Resident #1 stopped reaching for Resident #3 when staff intervened and Resident #3 was removed from the table by staff. The Surveyor #2 interviewed Family Member #1 at 1:55 P.M. on 11/06/18. Family Member #1 said that, while in the dining room one day, she heard the DON say words to the effect of I'm going to flaunt myself in front of Resident #1 to see if he/she does anything. Family Member #1 said she observed the DON stand approximately 4 feet away from Resident #1 who was seated at a table. Family Member #1 said she observed the DON tug at the shirt on her shoulders and looking sexy, or words to that effect, stuck her breasts forward while swaying her shoulders back and forth in front of Resident #1. Family Member #1 said she heard the DON say words to the effect of, Resident #1 was not responding to her gesture. Family Member #1 said the DON was trying to see if Resident #1 would touch her (DON). Family Member #1 said she heard the DON say she had never seen Resident #1 touch another person and then heard the Activities Aide #1 tell her to wait 5 minutes. Family Member #1 said Activities Aide #1 asked Resident #3 to come sit next to Resident #1. Family Member #1 said she heard the DON say Resident #1 was not going to do anything, or words to that effect. Family Member #1 said she saw Resident #1 move his/her chair closer to Resident #3 and heard the DON say, repeatedly, that she could not believe what she was seeing and could not believe what Resident #1 was doing (referring to his/her reaching for Resident #3). Family Member #1 said she heard Activities Aide #1 say the DON and Unit Manager had been told of incidents by Resident #1 and no one had responded to the reports. Although Activity Aide #1 and Activity Aide #2 reported to the Director of Nurses that Resident #1 grabbed Resident #3's genitals and the Director of Nurses observed Resident #1 attempt to grab Resident #3 again, there was no documentation to support that the Director of Nurses initiated an investigation into the allegation of Resident #1's inappropriate sexual behaviors, that the DON informed the Administrator, implemented interventions to protect other residents from potential abuse or reported the alleged sexual assault to DPH as required. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Although Activity Aide #1 and Activity Aide #2 reported to the Director of Nurses that Resident #1 grabbed Resident #3's genitals and the Director of Nurses observed Resident #1 attempt to grab Resident #3 again, there was no documentation to support that the Director of Nurses immediately initiated a complete and thorough investigation, including interviews with staff and other potential witnesses and that interventions were implemented to prevent and protect residents from potential subsequent abuse. This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 7. Activities Aide #1's Witness Statement, dated 09/10/18, indicated Resident #1 held Resident #2 firmly on the hips, and was pulling Resident #2 to the bed while he/she spoke loudly pulling back. The Statement indicated after Resident #2 was separated from Resident #1, he/she buried his/her face into Nurse #7's shoulder and cried. The Statement indicated that there was a written notation by the DON that she had received the Statement on 09/11/18. Surveyor #2 interviewed Activities Aide #1 at 9:50 A.M. on 11/06/18. Activities Aide #1 said at 1:15 P.M. on 09/10/18, she heard a loud sound coming from Resident #1's bedroom so she went into Resident #1's room to see what it was. Activities Aide #1 said Resident #1 and Resident #2 were standing and facing each other, alongside Resident #1's bed. Activities Aide #1 said Resident #1 held Resident #2's hips while Resident #2 was arching away from him/her. Activities Aide #1 said Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she thought Resident #1's actions were sexually intended. Activities Aide #1 said she yelled let Resident #2 go, repeated the statement and said she told Resident #1 that Resident #2 does not want to be here. Activities Aide #1 said as she led Resident #2 out of the bedroom, he/she cried, and said Resident #2 embraced Nurse #7, and buried his/her head into Nurse #7's shoulder and cried. Activities Aide #1 said she reported to Nurse #7 that Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she immediately wrote a Witness Statement and gave it to Nurse #7 and the Activities Director. Activities Aide #1 said she was not interviewed by the DON regarding this incident. Nurse #7 said on 09/10/18, at approximately 1:15 P.M., Activities Aide #1 called out for help. Nurse #7 said she approached Resident #1's bedroom. Nurse #7 said Resident #1 was sitting on the bed and was attempting to pull Resident #2 on top of him/her. Nurse #7 said Resident #2 was trying to get away from Resident #1. Nurse #7 said she reported Resident #1's behaviors to the Unit Manager, who responded words to the effect, staff intervened and therefore, nothing happened. Nurse #7 said Activity Aide #1 wrote a Statement about the incident despite the Unit Managers direction not to, and said the DON has a copy of the Activity Aide #1's Statement. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not received any reports of sexually abusive behavior involving Resident #1 before 09/21/18. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said staff had not informed her of Resident #1 exhibiting sexually abusive behaviors towards other residents, prior to 09/21/18. Although Activity Aide #1 and Nurse #7 reported to the Unit Manger that Resident #1 attempted to pull Resident #2 into bed with him/her and that Resident #2 was upset by the incident, there was no documentation to support that the allegation was immediately reported to the Administrator or DPH, no documentation to support the Facility immediately initiated a complete and thorough investigation, including interviews with staff and other potential witnesses, and that interventions were implemented to prevent and protect residents from potential subsequent abuse, the Unit Manager informed the Administrator, implemented interventions to protect and prevent other residents from potential abuse and report to DPH as required. This was not consistent with the Facility's Protection of Residents during Abuse Investigations Policy and The Facility's Abuse Investigation and Reporting Policy and Procedure 8. Resident #4's [DIAGNOSES REDACTED]. Resident #4's MDS assessment, dated 09/12/18, indicated he/she had severe cognitive impairment, wandering behavior, was totally dependent w

Based on records reviewed and interviews, for five of seven sampled residents (Resident #1, #2, #3, #4, and #5), the facility failed to ensure that reports of sexual abuse by Resident #1 toward four Residents, and reports of abuse by the Director of Nurses toward Resident #1 and Resident #3, were immediately reported to the Department of Public Health (DPH) in accordance with regulatory requirements and facility's policies and procedures. Findings include: The Facility's Abuse Investigation and Reporting Policy and Procedure, dated (MONTH) (YEAR), indicated all alleged violations involving abuse will be reported by the Facility Administrator, or his/her designee, to the State licensing/certification agency. The Policy and Procedure indicated an alleged violation of abuse will be reported immediately, but no later than two hours. The Facility's Abuse Prevention Program Policy and Procedure, dated 04/05/18, indicated the facility will report any allegations of abuse within timeframes required by the federal requirements. 1. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 07/25/18, indicated he/she had severe cognitive impairment, ambulated with supervision, no wandering behavior was exhibited, and no behavioral symptoms were exhibited, such as a physical behavioral symptom of sexually abusing others. Review of Resident #1's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability to consent to a sexual relationship. The Record also indicated that Resident #1's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves) in (YEAR), due to his/her [DIAGNOSES REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 08/09/18, indicated he/she had severe cognitive impairment, experienced delusions, displayed physical and verbal behavioral symptoms towards others, was totally dependent for care, and required one person assist with dressing and ambulation Review of Resident #3's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). A Nurse Progress Note, dated 08/12/18, indicated Nurse #9 originally documented that Resident #1 was observed grabbing residents of the opposite sex to his/her body, three times during this shift. A Witness Statement, dated 10/01/18, written by Nurse #9, indicated the Director of Nurses (DON) requested that he (Nurse #9) alter his Progress Note, written on 08/12/18. The Witness Statement indicated Nurse #9 discussed the incident involving Resident #1 with the DON and they concluded the word hugging more accurately reflected the incident, as opposed to the original word, grabbing, used to describe the incident. Surveyor #1 interviewed Nurse #9 at 1:00 P.M. on 11/16/18. Nurse #9 said that on 08/12/18 he saw Resident #1 approached a resident of the opposite sex (unable to recall identity at the time of investigation) from the side and place his/her right arm across the Resident's back and around his/her shoulder. Nurse #9 said that he documented in his Progress Note that Resident #1 was observed grabbing a resident. Nurse #9 said that after discussion with the Director of Nurses (DON) about the incident, they concluded the word hugging, not grabbing, best described the situation and Nurse #9 said he altered his Progress Note, as instructed by the DON. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that on 08/12/18 she witnessed Resident #1 approach Resident #3, and grab Resident #3 by the waist. Nurse #7 said Resident #1 and Resident #3 were both fully dressed. Nurse #7 said while Resident #1 held Resident #3's waist, Resident #1 made a sexual movement of thrusting his/her genitals repeatedly up against Resident #3's buttocks . Nurse #7 said she immediately separated Resident #1 and Resident #3. Nurse #7 said she was not assigned to Resident #1 and reported the incident to Nurse #9 to document and report the incident. Review of the Facility's Internal Investigation, dated 09/26/18, 45 days after the alleged incident occurred, indicated there was no documentation to support that the Facility immediately reported the incident to the Administrator and to the DPH within two hours, in accordance with Facility policy. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not submit a report of the alleged sexual assault of Resident #3 to DPH until 09/26/18, 45 days after the alleged incident occurred. 2. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 08/01/18, indicated he/she had severe cognitive impairment, was rarely or never understood or understood others, wandered daily, was totally dependent for dressing, and ambulated with supervision. Review of Resident #2's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Surveyor #2 interviewed Occupational Therapist (OT) #1 at 12:50 P.M. on 11/09/18. OT #1 said that prior to early (MONTH) (YEAR) (exact date unknown), she saw Resident #2 lying with Resident #1, in Resident #1's bed. OT #1 said the front of Resident #1's body was up against the back of Resident #2's body. OT #1 said she immediately shouted out to staff for help after observing the two Residents (#1 and #2) in bed together. OT #1 said as she attempted to remove Resident #2 from the bed, Nurse #7 entered the room to assist her. OT #1 said she could not recall when she was asked to document the incident. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that (exact date unknown), sometime after 08/12/18, OT #1 told her that Resident #1 and Resident #2 were both sitting on the edge of Resident #1's bed. Nurse #7 said she immediately went into Resident #1's room with OT #1. Nurse #7 said she saw Resident #1 with his/her hands on Resident #2 hips at the waistband as Resident #2 was trying to get up. Nurse #7 said she did not know whether Resident #1 was trying to remove Resident #2's pants or trying to pull Resident #2 on top of him/her. Nurse #7 said Resident #1 and Resident #2 were immediately separated. Nurse #7 said OT #1 told her that after they separated the residents, she noticed that Resident #1 had an erect penis. Based on interviews conducted with Nurse #7 and OT #1, regarding the incident that occurred between Resident #1 and Resident #2, both Nurse #7 and OT #1 indicated that the incident occurred in (MONTH) of (YEAR). Review of the Facility's Internal Investigation, dated 09/26/18, indicated there was no documentation to support that the Facility immediately reported the incident to the Administrator and to the DPH within two hours, in accordance with Facility policy. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not submit a report of the alleged sexual assault to DPH until 09/26/18. 3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said that on 08/16/18, she walked into the hallway and saw that Resident #1 had Resident #2 pinned up against the wall and was thrusting the his/her genitals against Resident #2's buttocks. The Director of Activities said she separated Resident #1 and Resident #2 immediately. The Director of Activities said she reported the incident to Nurse #7 and the Unit Manager. The Director of Activities said the Unit Manager told her not to document a Witness Statement because Resident #1 and Resident #2 were separated, and nothing happened. The Activities Director said she told the Unit Manager that despite her request, she still wanted to document a Witness Statement about the incident. The Activities Director said she wrote a Witness Statement on the day the incident occurred (08/16/18), made a copy for herself, and left the original copy on the Unit Manager's desk. The Director of Activities Witness Statement, dated 08/16/18, indicated she saw Resident #1 and Resident #2 together at the end of the hallway on the resident care unit. The Director of Activities indicated Resident #1 had Resident #2 pinned up against the wall and was forcibly and repeatedly thrusting his/her hips against Resident #2's buttocks. The Director of Activities indicated she redirected Resident #1 and Resident #2. The Director of Activities indicated the incident was immediately reported to Nurse #7 and the Unit Manager. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she could not recall how she became aware of the incident on 8/16/18, of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she could not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not received any reports of sexually abusive behavior involving Resident #1 before 09/21/18. There was no documentation to support that the Facility immediately reported the incident to the Administrator or the DPH in accordance with Facility policy. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility never reported this alleged 8/16/18 incident of sexual assault of Resident #2 by Resident #1 to DPH. 4. Review of Activities Aide #1's Witness Statement, dated 09/25/18, indicated she saw Resident #1 holding Resident #2 firmly by the hips and quickly thrusting his/her genitals up against Resident #2's body. The Statement indicated that on 08/17/18 she and Nurse #7 separated Resident #1 and Resident #2 and notified the Unit Manger. Surveyor #1 interviewed Activities Aide #1 at 11:30 A.M. on 11/05/18. Activities Aide #1 said that on 08/17/18 she saw Resident #1 approach Resident #2 in the dining room. Activities Aide #1 said Resident #1 held Resident #2 by the hips and thrusted his/her genitals against Resident #2's buttocks. Activities Aide #1 said she felt she had witnessed an incident of sexual assault. Activities Aide #1 said Nurse #7 assisted her with separating Resident #1 and Resident #2. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she did not recall how she became aware of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she did not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not received any reports of sexually abusive behavior involving Resident #1 before 09/21/18. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not report this 08/17/18 alleged incident of sexual assault of Resident #2 by Resident #1 to DPH. 5. Resident #5's [DIAGNOSES REDACTED]. Resident #5's Annual MDS assessment, dated 10/03/18, indicated he/she had severe cognitive impairment, required a two person extensive assist with bed mobility, required a one person assist with dressing and required a one person extensive assist with ambulation. Review of Resident #5's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #5's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). CNA #4's Witness Statement, dated 09/26/18, indicated she saw Resident #1 in bed with Resident #5, at approximately 9:00 P.M. or 9:30 P.M. sometime in (MONTH) (YEAR). CNA #4's Witness Statement indicated she heard Resident #5 yelling get off of me, she went to Resident #5's room and saw Resident #1 lying on top of Resident # 5. The Statement indicated Resident #5 had on a brief and a hospital gown, CNA #4 called for help, CNA's and Nurses responded, removed Resident #1 from Resident #5's bed and redirected Resident #1 out of Resident #5's bedroom. Surveyor #1 interviewed CNA #4 at 3:55 P.M. on 11/05/18. CNA #4 said that approximately 9:30 P.M., in late (MONTH) or early (MONTH) (exact date unknown), she heard Resident #5 calling for help. CNA #4 said upon entering Resident #5's bedroom, she saw Resident #1 on top of Resident #5 in bed. CNA #4 said she called out for help because she was unable to remove Resident #1 off of Resident #5. CNA #4 said Resident #5's hospital gown was lifted up and part of one of his/her breast was exposed. CNA #4 said CNA #6 and Nurse #5 arrived to assist. CNA #4 said Resident #1 held onto the bed's side rail and kicked at CNA #6 and Nurse #5 as they attempted to remove Resident #1 from the bed. CNA #4 said Nurse #2 was notified of the incident upon his return to the Unit from a work break. Surveyor #3 interviewed Nurse #5 at 11:05 A.M. on 11/07/18. Nurse #5 said she was informed by a CNA (unable to recall identity at the time of investigation), that Resident #1 was in Resident #5's bed. Nurse #5 denied assisting another staff member with removing Resident #1 from another resident's bedroom. Surveyor #1 interviewed CNA #6 at 2:15 P.M. on 11/06/18. CNA #6 denied assisting any staff members to remove Resident #1 from another resident's bedroom. CNA #6 said she had not witnessed Resident #1 in a resident's bedroom or in another residents bed. Surveyor #1 interviewed Nurse #2 at 12:30 P.M. on 11/06/18. Nurse #2 said he had not received any report of Resident #1 being in bed with Resident #5. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not report this alleged incident of sexual assault of Resident #5 by Resident #1 to DPH. 6. Activities Aide #2's Witness Statement, dated 09/25/18, indicated she told the DON that Resident #1 grabbed Resident #3 by the genitals. Activities Aide #2's Statement indicated that the DON went into the dining room, proceeded to stand next to Resident #1 pushing her breasts towards Resident #1 and stated words to the effect of, she did not believe Resident #1 had made any sexually abusive gestures towards other residents. The Statement indicated the DON said words to the effect of, that because Resident #1 was not paying attention to her and Resident #3 was not attractive, why would Resident #1 grab Resident #3's genitals. Surveyor #2 interviewed Activities Aide #2 at 1:30 P.M. on 11/07/18. Activities Aide #2 said that on 09/07/18, while conducting an activity with Activity Aide #1, she observed Resident #3 stand up from the dining room table, where he/she was seated with Resident #1, and began to walk away. Activities Aide #2 said she saw Resident #1 reach out from a seated position and grabbed Resident #3's genital area with his/her hand. Activities Aide #2 said she told Resident #1 to let go, which startled Resident #1, and his/her grip on Resident #3 genital area was released. Activities Aide #2 said she immediately approached the DON, who was at the nursing station and informed her of the incident. Activities Aide #2 said the DON asked that Resident #3 be brought back to the table with Resident #1. Activities Aide #2 said the DON stood by Resident #1, stuck her breasts forward toward Resident #1 and said, words to the effect of, it was hard to believe Resident #1 was not paying attention to her (DON). Activities Aide #2 said the DON said Resident #3 had physical features which resembled his/her opposite gender , and because of that, it was odd that Resident #1 paid attention to Resident #3. Activities Aide #2 said the DON's comment was loud enough to be heard by Resident #3, who was seated at the table. Activities Aide #2 said she, the DON and Activities Aide #1 then moved away from the table to observe how Resident #1 would behave with Resident #3. Activities Aide #2 said that after approximately 20 seconds, Resident #1 reached his/her hand forward toward Resident #3 and the DON then immediately separated Resident #1 and Resident #3. Surveyor #2 interviewed the Director of Nurses at 2:10 P.M. on 11/07/18. The DON said Activities Aide #2 reported to her on 9/7/18 that Resident #1 reached for another resident's genitals. The DON said it was difficult for her to believe a sexually inappropriate incident had occurred because she thought Resident #1 only had behaviors of hugging residents. The DON said she questioned if Resident #1 was unable to keep his/her hands to himself/herself and said she proceeded to the dining room where Resident #1 was seated. The DON said she wanted to determine for herself if Resident #1 exhibited inappropriate sexual behaviors. The DON said if Resident #1 reached for a person of the opposite sex, then new interventions needed to be implemented. The DON said she attempted to assess Resident #1's behaviors, with Activities staff present. The DON said she stood near Resident #1 with her shoulders back and chest forward. The DON said Resident #1 had not responded to her gesture. The DON said Activities Aide #1 told her Resident #1 would not act sexually inappropriate in the presence of staff members. The DON said she decided to assess Resident #1's response to Resident #3 (a member of the opposite sex). The DON said Resident #3 was assisted back to the table and seated near Resident #1. The DON said Resident #1 was observed, by her and the Activities staff from approximately 15 feet away, to reach his/her hand toward Resident #3. The DON said Resident #1 stopped reaching for Resident #3 when staff intervened and Resident #3 was removed from the table by staff. Review of the Facility's Internal Investigation, dated 11/02/18, indicated there was no documentation to support that the Facility immediately reported the incidents to the Administrator and to the DPH within two hours, in accordance with Facility policy. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not submit a report of the alleged sexual assault of Resident #3 by Resident #1; alleged abuse of Resident #1 by the DON and alleged incident of Resident #3 being subjected by staff to the potential for further abuse by Resident #1 to DPH until 11/02/18, 7. Activities Aide #1's Witness Statement, dated 09/10/18, indicated Resident #1 held Resident #2 firmly on the hips, and was pulling Resident #2 to the bed while Resident #2 spoke loudly pulling back. The Statement indicated after Resident #2 was separated from Resident #1, he/she buried his/her face into Nurse #7's shoulder and cried. The Statement indicated that there was a written notation by the DON that she had received the Statement on 09/11/18. Surveyor #2 interviewed Activities Aide #1 at 9:50 A.M. on 11/06/18. Activities Aide #1 said that at 1:15 P.M. on 09/10/18, she heard a loud sound coming from Resident #1's bedroom so she went into Resident #1's room to see what it was. Activities Aide #1 said Resident #1 and Resident #2 were standing and facing each other, alongside Resident #1's bed. Activities Aide #1 said Resident #1 held Resident #2's hips while Resident #2 was arching away from him/her. Activities Aide #1 said Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she thought Resident #1's actions were sexually intended. Activities Aide #1 said she yelled let Resident #2 go, repeated the statement and said she told Resident #1 that Resident #2 did not want to be there. Activities Aide #1 said as she led Resident #2 out of the bedroom, Resident #2 cried, embraced Nurse #7, and buried his/her head into Nurse #7's shoulder and cried. Activities Aide #1 said she reported to Nurse #7 that Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she immediately wrote a Witness Statement and gave it to Nurse #7 and the Activities Director. Activities Aide #1 said she was not interviewed by the DON regarding this incident. Nurse #7 said on 09/10/18, at approximately 1:15 P.M., Activities Aide #1 called out for help. Nurse #7 said she approached Resident #1's bedroom. Nurse #7 said Resident #1 was sitting on the bed and was attempting to pull Resident #2 on top of him/her. Nurse #7 said Resident #2 was trying to get away from Resident #1. Nurse #7 said she reported Resident #1's behaviors to the Unit Manager, who responded words to the effect, staff intervened and therefore, nothing happened. Nurse #7 said Activity Aide #1 wrote a Statement about the incident despite the Unit Managers direction not to, and said the DON had a copy of the Activities Aide #1's Statement. There was no documentation to support that the Facility immediately reported the incident to the Administrator or informed the Administrator following the DON's awareness of the allegation on 09/11/18. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not report the alleged incident of sexual assault of Resident #2 by Resident #1 until 9/26/18, 15 days after the alleged incident occurred. 8. Resident #4's [DIAGNOSES REDACTED]. Resident #4's MDS assessment, dated 09/12/18, indicated he/she had severe cognitive impairment, wandering behavior, was totally dependent with one person physical assist for dressing, and ambulated with supervision. Review of Resident #4's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #4's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Surveyor #2 interviewed Family Member #1 at 3:20 P.M. on 11/06/18. Family Member #1 said on 09/14/18, while in the dining room, visiting her family member she observed Resident #4 stand by Resident #1, who was seated at the dining room table. Family Member #1 said Resident #1, while seated, extended his/her hand and rubbed Resident #4's back and buttocks. Family Member #1 said Resident #1's hand lingered on Resident #4's buttocks. Family Member #1 said she called Activities Aide #1 who removed Resident #4 from the room. Family Member #1 said she had not reported the incident to any other staff. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 3:45 P.M. on 11/20/18. Nurse #7 said in (MONTH) (YEAR) (exact date unknown) around 3:00 P.M., she saw Resident #4 standing next to Resident #1 who was seated in the dining room around the change of shift. Nurse #7 said she saw Resident #1 rub Resident #4's buttocks and thighs in an up and down motion. Nurse #7 said she may have reported the incident to a nurse during a change of shift report. There was no documentation to support that the Facility immediately notified the Administrator and the DPH within two hours, in accordance with Facility policy. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not report the alleged incident of sexual assault of Resident #4 by Resident #1 until 09/26/18, 12 days after the alleged incident was reported by Family Member #1.

Based on records reviewed, observations and interviews, for five of seven sampled residents (Resident #1, #2, #3, #4, and #5). The facility failed to ensure staff implemented and followed policies and procedures related to abuse: failed to ensure allegations of abuse were immediately reported to the Administrator and investigated to prevent residents from further potential sexual abuse, and failed to ensure the Department of Public Health (DPH) was notified no later than 2 hours after the alleged incidents occurred. Findings include: The Facility's Protection of Residents During Abuse Investigations Policy, dated (MONTH) (YEAR), indicated the accused resident's representative and Physician will be informed of the alleged abuse incident, and there may be restrictions on the accused resident's ability to visit other resident rooms. The Facility's Abuse Investigation and Reporting Policy and Procedure, dated (MONTH) (YEAR), indicated the Administrator assigns the investigation to an appropriate individual, keeps the resident's representative informed of the status of the investigation, and ensures that any further potential abuse is prevented. The Investigator ensures witness statements obtained are signed and dated. The Policy and Procedure indicated all alleged violations involving abuse will be reported by the Facility Administrator, or his/her designee, to the State licensing/certification agency. The Policy and Procedure indicated an alleged violation of abuse will be reported immediately, but no later than two hours. The Facility's Accidents and Incidents - Investigating and Reporting Policy Statement, dated 10/2017, indicated incidents involving residents on our premises shall be reported to the Administrator. The Nurse Supervisor shall promptly initiate and document investigation of the incident, complete the Report of Incident/Accident Form and forward to the Director of Nurse within 24 hours of the incident or accident. The Director of Nurses shall ensure that the Administrator also receive a copy of the Report of Incident/Accident Form. The Form will also be reviewed by the Safety Committee. The Facility's Abuse Prevention Program Policy and Procedure, dated 04/05/18, indicated residents have the right to be free from physical and sexual abuse; identify and assess all possible incidents of abuse; and investigate and report any allegations of abuse within timeframes required by the federal requirements. 1. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 07/25/18, indicated he/she had severe cognitive impairment, ambulated with supervision, no wandering behavior was exhibited, and no behavioral symptoms were exhibited, such as a physical behavioral symptom of sexually abusing others. The Record indicated that Resident #1's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves) in (YEAR), due to his/her [DIAGNOSES REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 08/09/18, indicated he/she had severe cognitive impairment, experienced delusions, displayed physical and verbal behavioral symptoms towards others, was totally dependent for care, and required one person assist with dressing and ambulation. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). A Witness Statement, dated 10/01/18, written by Nurse #9, indicated the Director of Nurses (DON) requested that he (Nurse #9) alter his Progress Note, written on 08/12/18. The Witness Statement indicated Nurse #9 discussed the incident involving Resident #1 with the DON and they concluded the word hugging more accurately reflected the incident, as opposed to the original word, grabbing, used to describe the incident. A Nurse Progress Note, dated 08/12/18, indicated Nurse #9 originally documented that Resident #1 was observed grabbing residents of the opposite sex to his/her body, three times during this shift. Surveyor #1 interviewed Nurse #9 at 1:00 P.M. on 11/16/18. Nurse #9 said that on 08/12/18 he saw Resident #1 approach a resident of the opposite sex (unable to recall identity at the time of investigation) from the side and place his/her right arm across the Resident's back and around his/her shoulder. Nurse #9 said that he documented in his Progress Note that Resident #1 was observed grabbing a resident. Nurse #9 said that after discussion with the Director of Nurses (DON) about the incident, they concluded the word hugging, not grabbing, best described the situation and Nurse #9 said he altered his Progress Note, as instructed by the DON. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that on 08/12/18 she witnessed Resident #1 approach Resident #3, and grab Resident #3 by the waist. Nurse #7 said Resident #1 and Resident #3 were both fully dressed. Nurse #7 said while Resident #1 held Resident #3's waist, Resident #1 made a sexual movement of thrusting his/her genitals repeatedly up against Resident #3's buttocks. Nurse #7 said she immediately separated Resident #1 and Resident #3. Nurse #7 said she was not assigned to Resident #1 and reported the incident to Nurse #9 to document and report the incident. Surveyor #2 interviewed Nurse #9 at 11:22 A.M. on 11/20/18. Nurse #9 said he was not a witnessed to and could not recall receiving any information related to Resident #1 thrusting his/her genitals against Resident #3's buttocks on 08/12/18, from Nurse #7. The Facility's Internal Investigation, dated as initiated on 09/26/18, indicated there was no documentation to indicate that the facility staff immediately reported the incidents or allegation from 08/12/18 regarding Resident #1 and Resident #3 to the Administrator, that an investigation was conducted, that steps were taken to prevent or protect other residents from further potential abuse, and that it was reported to the DPH as required. A Social Service Progress Note, dated 09/27/18, 46 days later, indicated Resident #3's Representative was updated regarding the recent events on Resident #3's Unit. Review of the Incident Report Form, indicating Resident #1 grabbed Resident #3 by the waist/hips and began thrusting his/her body against Resident #3's body was not submitted via HCFRS by the Facility, until 4:23 P.M. on 09/26/18, 45 days after the incident occurred. 2. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 08/01/18, indicated he/she had severe cognitive impairment, was rarely or never understood or understood others, wandered daily, was totally dependent for dressing, and ambulated with supervision. Review of Resident #2's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care decisions for themselves). Occupational Therapist (OT) #1's Witness Statement, dated 09/26/18, indicated that she saw Resident #1 lying in his/her bed with Resident #2 lying beside him/her . OT #1 indicated Resident #1 had his/her hands on Resident #2's hips as they were in a spooning position. OT #1 indicated she called for assistance, Nurse #7 responded and assisted with getting Resident #2 off the bed. Surveyor #2 interviewed Occupational Therapist (OT) #1 at 12:50 P.M. on 11/09/18. OT #1 said that on an unknown date prior to early (MONTH) (YEAR) (exact date unknown), she saw Resident #2 lying with Resident #1, in Resident #1's bed. OT #1 said the front of Resident #1's body was up against the back of Resident #2's body and both of them were dressed. OT #1 said she did not observe Resident #1 or Resident #2 touching each other. OT #1 said she immediately shouted out and, as she was removing Resident #2 from the bed, Nurse #7 entered to assist her. OT #1 said she did not recall when she was asked to document the incident. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that (exact date not recalled), sometime after 08/12/18, OT #1 told her that Resident #1 and Resident #2 were both sitting on the edge of Resident #1's bed. Nurse #7 said she immediately went into Resident #1's room with OT #1. Nurse #7 said she saw Resident #1 with his/her hands on Resident #2's hips at the waistband as Resident #2 was trying to get up. Nurse #7 said she did not know whether Resident #1 was trying to remove Resident #2's pants or trying to pull Resident #2 on top of him/her. Nurse #7 said Resident #1 and Resident #2 were immediately separated. Nurse #7 said OT #1 told her that after they separated the residents, she noticed that Resident #1 had an erect penis. Based on interviews conducted with Nurse #7 and OT #1, regarding the incident that occurred between Resident #1 and Resident #2, both Nurse #7 and OT #1 indicated that the incident occurred in (MONTH) of (YEAR). Review of the Facility's internal investigation indicated there was no documentation to support that the facility staff immediately reported the alleged incident to the Administrator, that an investigation was conducted, that steps were taken to prevent or protect other residents from potential abuse. The Facility did not initiate an investigation until 09/26/18, at which point the Facility also reported the incident to the DPH. 3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said that on 08/16/18, she walked into the hallway and saw that Resident #1 had Resident #2 pinned up against the wall and was thrusting his/her genitals against Resident #2's buttocks. The Director of Activities said she separated Resident #1 and Resident #2 immediately. The Director of Activities said she reported the incident to Nurse #7 and the Unit Manager. The Director of Activities said the Unit Manager told her not to document a Witness Statement because Resident #1 and Resident #2 were separated by staff, and nothing happened. The Activities Director said she told the Unit Manager that despite her request, she still wanted to document a witness statement about the incident. The Activities Director said she wrote a witness statement on the day the incident occurred (08/16/18), made a copy for herself, and left the original copy on the Unit Manager's desk. The Director of Activities Witness Statement, dated 8/16/18, indicated she saw Resident #1 and Resident #2 together at the end of the hallway on the resident care unit. The Director of Activities indicated Resident #1 had Resident #2 pinned up against the wall and was forcibly and repeatedly thrusting his/her hips against Resident #2's buttocks. The Director of Activities indicated she redirected the Resident #1 and Resident #2. The Director of Activities indicated the incident was immediately reported to Nurse #7 and the Unit Manager. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she could not recall how she became aware of the incident on 08/16/18 of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she did not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not received any reports of sexually abusive behavior involving Resident #1 before 9/21/18. Although the Director of Activities reported the alleged incident of sexual abuse of Resident #2 by Resident #1 to Nurse #7 and the Unit Manager, there was no documentation to support that the Facility staff followed the Facility's abuse policy for reporting, starting an investigation and protecting other residents. 4. Review of Activities Aide #1's Witness Statement, dated 09/25/18, indicated she saw Resident #1 holding Resident #2 firmly by the hips and quickly thrusting his/her genitals up against Resident #2's body. The Statement indicated that on 08/17/18 she and Nurse #7 separated Resident #1 and Resident #2 and notified the Unit Manger. Surveyor #1 interviewed Activities Aide #1 at 11:30 A.M. on 11/05/18. Activities Aide #1 said that on 08/17/18 she saw Resident #1 approach Resident #2 in the dining room. Activities Aide #1 said Resident #1 held Resident #2 by the hips and thrusted his/her genitals against Resident #2's buttocks. Activities Aide #1 said she felt she had witnessed an incident of sexual assault. Activities Aide #1 said Nurse #7 assisted her with separating Resident #1 and Resident #2. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she did not recall how she became aware of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she did not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she did not receive any reports of sexually abusive behavior involving Resident #1 before 09/21/18. Although Activities Aide #1 reporting an alleged incident of sexual abuse of Resident #2 by Resident #1 to Nurse #7 and the Unit Manager, there was no documentation to support that the Facility staff followed the Facility's abuse policy for reporting, starting an investigation and protecting other residents. 5. Resident #5's [DIAGNOSES REDACTED]. Resident #5's Annual MDS assessment, dated 10/03/18, indicated he/she had severe cognitive impairment, required a two person extensive assist with bed mobility, required a one person assist with dressing and required a one person extensive assist with ambulation. Review of Resident #5's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability to consent to a sexual relationship. The Record also indicated that Resident #5's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). CNA #4's Written Statement, dated 09/26/18, indicated she saw Resident #1 in bed with Resident #5, at approximately 9:00 P.M. or 9:30 P.M. sometime in (MONTH) (YEAR). CNA #4's Written Statement indicated she heard Resident #5 yelling get off of me so she went to Resident #5's room and saw Resident #1 lying on top of Resident #5. The Statement indicated Resident #5 had on a brief and a hospital gown, CNA #4 called for help, CNA's and Nurses responded, removed Resident #1 from Resident #5's bed and redirected Resident #1 out of Resident #5's bedroom. Surveyor #1 interviewed CNA #4 at 3:55 P.M. on 11/05/18. CNA #4 said that at approximately 9:30 P.M., in late (MONTH) or early (MONTH) (exact date unknown), she heard Resident #5 calling for help. CNA #4 said upon entering Resident #5's bedroom, she saw Resident #1 on top of Resident #5 in bed. CNA #4 said she called out for help because she was unable to remove Resident #1 off of Resident #5. CNA #4 said Resident #5's hospital gown was lifted up and part of his/her breast was exposed. CNA #4 said CNA #6 and Nurse #5 arrived to assist. CNA #4 said Resident #1 held onto the bed's side rail and kicked at CNA #6 and Nurse #5 as they removed Resident #1 from the bed. CNA #4 said Nurse #2 was notified of the incident upon his return to the Unit from a work break. Surveyor #3 interviewed Nurse #5 at 11:05 A.M. on 11/07/18. Nurse #5 said she was informed by a CNA (unable to recall identity at the time of investigation), that Resident #1 was in Resident #5's bed. Nurse #5 denied assisting another staff member with removing Resident #1 from another resident's bedroom. Surveyor #1 interviewed CNA #6 at 2:15 P.M. on 11/06/18. CNA #6 denied assisting any staff members to remove Resident #1 from another resident's bedroom. CNA #6 said she had not witnessed Resident #1 in a resident's bedroom or in bed with a resident. Surveyor #1 interviewed Nurse #2 at 12:30 P.M. on 11/06/18. Nurse #2 said he had not received any report of Resident #1 being in bed with Resident #5. A Social Service Progress Note, dated 09/27/18, 46 days later, indicated Resident #5's Representative was updated regarding the recent events on Resident #5's Unit. Although CNA #4's Witness Statement, indicating that she found Resident #1 in bed with Resident #5's and that she required required the assistance of at least two other staff members to physically remove Resident #1 from the bed, there was no documentation to support that the Facility staff followed the Facility's abuse policy for reporting, starting an investigation and protecting other residents. 6. Activities Aide #2's Witness Statement, dated 09/25/18, indicated she told the DON that Resident #1 grabbed Resident #3's genitals. Activities Aide #2's Statement indicated that the DON went into the dining room, proceeded to stand next to Resident #1, pushing her breasts towards Resident #1 and stated she did not believe Resident #1 had made any sexually abusive gestures towards other residents. The Statement indicated the DON said Resident #1 was not paying attention to her and Resident #3 was not attractive, therefore, why would Resident #1 grab Resident #3's genitals. Surveyor #2 interviewed Activities Aide #2 at 1:30 P.M. on 11/07/18. Activities Aide #2 said that on 09/07/18, while conducting an activity with Activity Aide #1, she observed Resident #3 stand up from the dining room table, where he/she was seated with Resident #1, and began to walk away. Activities Aide #2 said she saw Resident #1 reach out from a seated position and grabbed Resident #3's genital area with his/her hand. Activities Aide #2 said she told Resident #1 to let go, which startled Resident #1, and his/her grip on Resident #3's genital area was released. Activities Aide #2 said she immediately approached the DON, who was at the nursing station and informed her of the incident. Activities Aide #2 said the DON asked that Resident #3 be brought back to the table with Resident #1. Activities Aide #2 said the DON stood by Resident #1, stuck her breasts forward toward Resident #1 and said, words to the effect of, it was hard to believe Resident #1 was not paying attention to her (DON). Activities Aide #2 said the DON said, words to the effect of, Resident #3 had physical features which resembled his/her opposite gender , and because of that, it was odd that Resident #1 paid attention to Resident #3. Activities Aide #2 said the DON's comment was loud enough to be heard by Resident #3, who was seated at the table. Activities Aide #2 said she, the DON and Activities Aide #1 then moved away from the table to observe how Resident #1 would behave with Resident #3. Activities Aide #2 said that after approximately 20 seconds, Resident #1 reached his/her hand forward toward Resident #3 and the DON then immediately separated Resident #1 and Resident #3. Surveyor #1 interviewed Activities Aide #1 at 11:30 AM on 11/05/18. Activities Aide #1 said she asked the DON if she wanted Resident #3 brought back to the table to see if Resident #1 would attempt to grab Resident #3 again and the DON replied, yes. Activities Aide #1 said Activities Aide #2 brought Resident #3 back to the table and seated him/her next to Resident #1 per the DON's direction. Activities Aide #1 said it felt wrong to be doing what they were doing, returning Resident #3 to the table with Resident #1. Activities Aide #1 said she, the DON, and Activities Aide #2, stood away from the table to observe Resident #1's response to Resident #3, and observed Resident #1 then pull Resident #3's chair closer to him/her. Activities Aide #1 said Activities Aide #2 immediately separated Resident #1 and Resident #3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said she was sitting with a resident in the activities/dining room on 09/07/18 and witnessed the DON puffing out her chest, made her chest more pronounced to see if Resident #1 would reach out to grab her chest, or words to that effect. The Director of Activities said the DON placed her hands on her hips and said Resident #1 was not doing anything (in response to her gesture). The Director of Activities said she witnessed one of the Activities Aides sit Resident #3 at a table with Resident #1 and then observed as Resident #1 reached over and pulled Resident #3's chair closer to him/her, which is when the DON intervened. The Director of Nurses Witness Statement, dated 11/02/18, indicated she stood next to Resident #1 on 9/7/18, in an attempt to assess the nature of his/her behavior and actions. The DON's statement indicated she denied presenting any part of her body toward Resident #1. The DON's Statement indicated Activities Aide #1 suggested having a resident of the opposite sex sit near Resident #1 to observe any inappropriate sexual behavior. The Statement indicated three staff members were present at the time and at no point was either resident at risk. Surveyor #2 interviewed the Director of Nurses at 2:10 P.M. on 11/07/18. The DON said Activities Aide #2 reported to her on 09/07/18 that Resident #1 reached for another resident's genitals. The DON said it was difficult for her to believe a sexually abusive incident had occurred because she thought Resident #1 only had behaviors of hugging residents. The DON said she questioned if Resident #1 was unable to keep his/her hands to himself/herself and said she proceeded to the dining room where Resident #1 was seated. The DON said she wanted to determine for herself if Resident #1 exhibited inappropriate sexual behaviors. The DON said if Resident #1 reached for a person of the opposite sex, then new interventions needed to be implemented. The DON said she attempted to assess Resident #1's behaviors, with Activities staff present. The DON said she stood near Resident #1 with her shoulders back and chest forward. The DON said Resident #1 had not responded to her gesture. The DON said Activities Aide #1 told her Resident #1 would not act sexually abusive in the presence of staff members. The DON said she decided to assess Resident #1's response to Resident #3 (a member of the opposite sex). The DON said Resident #3 was assisted back to the table and seated near Resident #1. The DON said Resident #1 was observed, by her and the Activities staff from approximately 15 feet away, to reach his/her hand toward Resident #3. The DON said Resident #1 stopped reaching for Resident #3 when staff intervened and Resident #3 was removed from the table by staff. The Surveyor #2 interviewed Family Member #1 at 1:55 P.M. on 11/06/18. Family Member #1 said that, while in the dining room one day, she heard the DON say words to the effect of I'm going to flaunt myself in front of Resident #1 to see if he/she does anything. Family Member #1 said she observed the DON stand approximately 4 feet away from Resident #1 who was seated at a table. Family Member #1 said she observed the DON tug at the shirt on her shoulders and looking sexy, or words to that effect, stuck her breasts forward while swaying her shoulders back and forth in front of Resident #1. Family Member #1 said she heard the DON say words to the effect of, Resident #1 was not responding to her gesture. Family Member #1 said the DON was trying to see if Resident #1 would touch her (DON). Family Member #1 said she heard the DON say she had never seen Resident #1 touch another person and then heard the Activities Aide #1 tell her to wait 5 minutes. Family Member #1 said Activities Aide #1 asked Resident #3 to come sit next to Resident #1. Family Member #1 said she heard the DON say Resident #1 was not going to do anything, or words to that effect. Family Member #1 said she saw Resident #1 move his/her chair closer to Resident #3 and heard the DON say, repeatedly, that she could not believe what she was seeing and could not believe what Resident #1 was doing (referring to his/her reaching for Resident #3). Family Member #1 said she heard Activities Aide #1 say the DON and Unit Manager had been told of incidents by Resident #1 and no one had responded to the reports. Although Activities Aide #1 and Activities Aide #2 reported to the DON that Resident #1 grabbed Resident #3's genitals and the DON observed Resident #1 attempt to grab Resident #3 again, there was no documentation to support that the Director of Nurses followed facility policy to initiate an investigation into the allegation of Resident #1's inappropriate sexual behaviors, that the DON informed the Administrator, implemented interventions to protect other residents from potential abuse or reported the alleged sexual assault to the DPH as required. 7. Activities Aide #1's Witness Statement, dated 09/10/18, indicated Resident #1 held Resident #2 firmly on the hips, and was pulling Resident #2 to the bed while Resident #2 spoke loudly pulling back. The Witness Statement indicated after Resident #2 was separated from Resident #1, he/she buried his/her face into Nurse #7's shoulder and cried. The Witness Statement indicated that there was a written notation by the DON that she had received the Statement on 09/11/18. Surveyor #2 interviewed Activities Aide #1 at 9:50 A.M. on 11/06/18. Activities Aide #1 said at 1:15 P.M. on 09/10/18, she heard a loud sound coming from Resident #1's bedroom so she went into Resident #1's room to see what it was. Activities Aide #1 said Resident #1 and Resident #2 were standing and facing each other, alongside Resident #1's bed. Activities Aide #1 said Resident #1 held Resident #2's hips while Resident #2 was arching away from him/her. Activities Aide #1 said Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she thought Resident #1's actions were sexually intended. Activities Aide #1 said she yelled to Resident #1 to let go of Resident #2, repeated the statement and said Resident #2 does not want to be here. Activities Aide #1 said that as she led Resident #2 out of the bedroom, he/she cried, and then Resident #2 embraced Nurse #7, and buried his/her head into Nurse #7's shoulder and cried. Activities Aide #1 said she reported to Nurse #7 that Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she immediately wrote a witness statement and gave it to Nurse #7 and the Activities Director. Activities Aide #1 said she was not interviewed by the DON regarding this incident. Nurse #7 said on 09/10/18, at approximately 1:15 P.M., Activities Aide #1 called out for help. Nurse #7 said she approached Resident #1's bedroom. Nurse #7 said Resident #1 was sitting on the bed and was attempting to pull Resident #2 on top of him/her. Nurse #7 said Resident #2 was trying to get away from Resident #1. Nurse #7 said she reported Resident #1's behaviors to the Unit Manager, who responded with words to the effect of, staff intervened and therefore, nothing happened. Nurse #7 said Activities Aide #1 wrote a Statement about the incident despite the Unit Manager's direction not to, and said the DON has a copy of the Activities Aide #1's Statement. Although Activities Aide #1 and Nurse #7 reported to the Unit Manager that Resident #1 attempted to pull Resident #2 into bed with him/her, that Resident #2 was upset by the incident, there was no documentation to support that the Unit Manager followed facility policy to initiate an investigation into the allegation of Resident #1's inappropriate sexual behaviors, that the Unit Manager informed the Administrator, implemented interventions to protect other residents from potential abuse or reported the alleged sexual assault to the DPH as required, until 09/26/18. 8. Resident #4's [DIAGNOSES REDACTED]. Resident #4's MDS assessment, dated 09/12/18, indicated he/she had severe cognitive impairment, wandering behavior, was totally dependent with one person physical assist for dressing, and ambulated with supervision. Review of Resident #4's clinical record indicated that there was no documentation of an assessment or evaluation of his/her ability to consent to a sexual relationship. The Record also indicated that Resident #4's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Surveyor #2 interviewed Family Member #1 at 3:20 P.M. on 11/06/18. Family Member #1 said on 09/14/18, while in the dining room, visiting her family member she observed Resident #4 standing by Resident #1, who was seated at the dining room table. Family Member #1 said, Resident #1 was sitting and extended his/her hand, and rubbed Resident #4's back and buttocks. Family Member #1 said Resident #1's hand lingered on Resident #4's buttocks. Family Member #1 said she called Activities Aide #1 who removed Resident #4 from the room. Family Member #1 said she had not reported the incident to any other staff. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 3:45 P.M. on 11/20/18. Nurse #7 said in (MONTH) (YEAR) (exact date unknown) around 3:00 P.M. she saw Resident #4 standing next to Resident #1 who was seated in the dining room around the change of shift. Nurse #7 said she saw Resident #1 rub Resident #4's buttocks and thighs in an up and down motion. Nurse #7 said Resident #4 did not have a response to Resident #1 touching him/her. Nurse #7 said she may have reported the incident to a nurse during a change of shift report. Although Family Member #1 reported to Activity Aide #1 that Resident #1 was inappropriately touching Resident #4, and Nurse #7 also observed the same incident, there was no documentation to support that the Facility followed policy to initiate an investigation into the allegations of Resident #1's sexually abusive behaviors, that Facility staff, including Nurse #7 and Activity Aide #1 informed the Administrator, implemented interventions to protect other residents from potential abuse or reported the alleged sexual assault to the DPH as required, until 09/26/18. 9. Nurse #4's Witness Statement, dated 09/21/18 and 09/25/18, indicated that she witnessed Resident #1 being sexually abusive on 9/21/18. Nurse #4 indicated Resident #1 stood behind Resident #2, wrapped his/her arms around Resident #2's waist, and touched Resident #2's genitals with his/her hand, while moving his/her genitals against Resident #2's buttocks. Surveyor #1 interviewed Nurse #4 at 5:20 P.M. on 11/01/18. Nurse #4 said she was in the hallway with Nurse Practitioner #3 on 09/21/18. Nurse #4 said she saw Resident #1 hug Resident #2 from behind. Nurse #4 said she rushed toward Resident #1 and Resident #2 to intervene. Nurse #4 said Resident #1 placed his/her right hand on Resident #2's genitals while his/her left hand was on Resident #2's hip. Nurse #4 said she separated Resident #1 and Resident #2. Nurse #4 said she reported the incident to the Unit Manager. Nurse Practitioner #3's Witness Statement, date 09/21/18, indicated she witnessed Resident #1 hugging Resident #2 behind and Resident #1 moved his/her hands over Resident #2's leg and abdomen while he/she was fully dressed. Surveyor #2 interviewed Nurse Practitioner #3 at 12:10 P.M. on 11/06/18. Nurse Practitioner #3 saw Resident #1 in the hallway and hugging Resident #2 from behind, with his/her hands on the outside of Resident #2's legs/thigh. Nurse Practitioner #3 said Nurse #4 went down the hallway to separate Resident #1 and Resident #2. Nurse Practitioner #3 said she discussed the incident with the DON who stated she was aware Resident #1 had sexually abusive behaviors. The Nurse Progress Note, dated 09

Based on records reviewed, observations and interviews, for five of seven sampled residents (Resident #1, #2, #3, #4, and Resident #5), the facility failed to prevent, protect and ensure Residents were free from abuse; failed to immediately and thoroughly investigate and report allegations of abuse to protect residents from subsequent incidents of abuse and failed to ensure staff did not subject residents to possible repeated acts of abuse. It was determined that from approximately 08/12/18 to 09/21/18 there were at least nine alleged incidents of Resident #1 abusing four other Residents of the opposite sex and one incident when the Director of Nurses allegedly subjected Resident #1 to abuse and Resident #3 to a situation where the potential for a repeated act of abuse could occur. Summary of Incidents: -On 08/12/18, Resident #1 was observed to approach Resident #3 from behind, grabbed him/her by the waist, and made sexual movements of thrusting his/her genitals repeatedly up against Resident #3's buttocks. -Approximately a couple of days after the alleged incident on 08/12/18, Resident #1 was observed in bed with Resident #2. Resident #1 had his/her hands on Resident #2's hips, around the area of the waist band of his/her pants, and Resident #2 was observed trying to get out of the bed. -On 08/16/18, Resident #1 was observed standing behind Resident #2, who was pinned up against a wall, as Resident #1 thrusted his/her genitals against Resident #2's buttocks area. -On 08/17/18, Resident #1 was again observed standing behind Resident #2, holding his/her hips and Resident #1 was thrusting his/her genitals against Resident #2's buttocks area. -Approximately late (MONTH) or early (MONTH) (exact date unknown), Resident #1 was observed by a Certified Nurse Aide (CNA), on top of Resident #5, in Resident #5's bed, with Resident #5's hospital gown, pulled up and exposing part of his/her breast. Resident #5 was heard yelling for help and as staff attempted to remove Resident #1 off of Resident #5, Resident #1 held onto the bed's side rail and kicked at staff. -On 09/07/18, during an activity in the dining room, Resident #1 was observed by Activity Aide #2 grabbing Resident #3's genitals with his/her hand. Although staff reported the incident to the Director of Nurses, she did not take immediate action to protect Resident #3, investigate and report. -On 09/07/18, Director of Nurses was observed, standing within an arm's reach of Resident #1, directing her breasts towards Resident #1, while saying, words to the effect of, she did not believe Resident #1 had been exhibiting sexually abusive behaviors, as reported by staff. The Director of Nurses also said loud enough to be heard by Resident #3, words to the effect of, Resident #3 resembled his/her opposite gender, was not attractive, and therefore she could not understand why Resident #1 would attempt to touch Resident #3 in a sexualized manner. -On 09/07/18, the Director of Nurses received after receiving an allegation of a sexual assault of Resident #1 grabbing Resident #3's genitals with his/her hand, the Director of Nurses instructed staff to get Resident #3 and return him/her back to the same table with Resident #1. The Director of Nurses left Resident #3 alone at the table with Resident #1 as she and other staff walked away, out of Resident #1 and Resident #3's vision, to observe if Resident #1 would attempt to sexually assault Resident #3 again. -On 09/10/18, Resident #2 was heard speaking loudly. Resident #1 and Resident #2 were observed standing and facing each other in Resident #1's room. Resident #1 had a hold of Resident #2's hips while trying to pull him/her onto the bed. Resident #2 was observed arching away from Resident #1 and attempting to get away from him/her and cried when staff intervened. - On approximately 09/14/18 Resident #1 was observed, in a seated position, extended his/her hand and rubbed Resident #4's back and buttocks. -On 09/21/18, Resident #1 was observed standing behind Resident #2 with his/her arms wrapped around Resident #2's waist. Resident #1's hand was touching Resident #2's genitals while thrusting his/her genitals against Resident #2's buttocks. Findings include: The Facility's Abuse Prevention Program Policy and Procedure, dated 04/05/18, indicated residents have the right to be free from physical and sexual abuse. 1. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 07/25/18, indicated he/she had severe cognitive impairment, ambulated with supervision, no wandering behavior was exhibited, and no behavioral symptoms were exhibited, such as a physical behavioral symptom of sexually abusing others. Resident #1's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity to consent to a sexual relationship. The clinical record indicated that Resident #1's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves) in (YEAR) due to his/her [DIAGNOSES REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 08/09/18, indicated he/she had severe cognitive impairment, experienced delusions, displayed physical and verbal behavioral symptoms towards others, was totally dependent, and required one person assist with dressing and ambulation Review of Resident #3's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #3's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). A Nurse Progress Note, dated 08/12/18, indicated Nurse #9 originally documented that Resident #1 was observed grabbing residents of the opposite sex to his/her body, three times during this shift. A Witness Statement, dated 10/01/18, written by Nurse #9, indicated the Director of Nurses (DON) requested that he (Nurse #9) alter his Progress Note, written on 08/12/18. The Witness Statement indicated Nurse #9 discussed the incident involving Resident #1 with the DON and they concluded the word hugging more accurately reflected the incident, as opposed to the original word, grabbing, used to describe the incident. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that on 08/12/18 she witnessed Resident #1 approach Resident #3, and grab Resident #3 by the waist. Nurse #7 said Resident #1 and Resident #3 were both fully dressed. Nurse #7 said while Resident #1 held Resident #3's waist, Resident #1 made a sexual movement of repeatedly thrusting his/her genitals up against Resident #3's buttocks. Nurse #7 said she immediately separated Resident #1 and Resident #3. Nurse #7 said she was not assigned to Resident #1 and reported the incident to Nurse #9 to document and report the incident. Surveyor #1 interviewed Nurse #9 at 1:00 P.M. on 11/16/18. Nurse #9 said that on 08/12/18 he saw Resident #1 approached a resident of the opposite sex from the side and place his/her right arm across the Resident's back and around his/her shoulder. Nurse #9 said he documented in his Progress Note that Resident #1 was observed grabbing a resident. Nurse #9 said that after discussion with the Director of Nurses (DON) about the incident, they concluded the word hugging, not grabbing, best described the situation and Nurse #9 said he altered his Progress Note, as instructed by the DON. Surveyor #2 interviewed Nurse #9 at 11:22 A.M. on 11/20/18. Nurse #9 said he did not witness and did not recall receiving any information related to Resident #1 thrusting his/her genitals against Resident #3's buttocks on 8/12/18 or at anytime. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #3 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 2. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 08/01/18, indicated he/she had severe cognitive impairment, was rarely or never understood or understood others, wandered daily, was totally dependent for dressing, and ambulated with supervision. Resident #2's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity to consent to a sexual relationship. The clinical record also indicated that Resident #2's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Occupational Therapist (OT) #1's Witness Statement, dated 09/26/18, indicated that she saw Resident #1 lying in his/her bed with Resident #2 lying beside him/her. OT #1's Statement indicated Resident #1 had his/her hands on Resident #2's hips as they were in a spooning position. OT #1's Statement indicated she called for assistance; Nurse #7 responded and assisted with getting Resident #2 off the bed. Surveyor #2 interviewed Occupational Therapist (OT) #1 at 12:50 P.M. on 11/09/18. OT #1 said that prior to early (MONTH) (YEAR) (exact date unknown), she saw Resident #2 lying with Resident #1, in Resident #1's bed. OT #1 said the front of Resident #1's body was up against the back of Resident #2's body and both of them were dressed. OT #1 said she had not observed Resident #1 or Resident #2 touching each other. OT #1 said she immediately shouted out to staff for help. OT #1 said as she attempted to remove Resident #2 from the bed, Nurse #7 entered the room to assist her. OT #1 said she could not recall when she was asked to document the incident. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 9:15 A.M. on 11/20/18. Nurse #7 said that (exact date unknown), sometime after 08/12/18, OT #1 told her that Resident #1 and Resident #2 were both sitting on the edge of Resident #1's bed. Nurse #7 said she immediately went into Resident #1's room with OT #1. Nurse #7 said she saw Resident #1 with his/her hands on Resident #2 hips at the waistband as Resident #2 was trying to get up from the bed. Nurse #7 said she did not know whether Resident #1 was trying to remove Resident #2's pants or trying to pull Resident #2 on top of him/her. Nurse #7 said Resident #1 and Resident #2 were immediately separated. Nurse #7 said OT #1 told her that after they separated the residents, she noticed that Resident #1 had an erect penis. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #2 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 3. The Director of Activities Witness Statement, dated 08/16/18, indicated she saw Resident #1 and Resident #2 together at the end of the hallway on the resident care unit. The Director of Activities indicated Resident #1 had Resident #2 pinned up against the wall and was forcibly and repeatedly thrusting his/her hips against Resident #2's buttocks. The Director of Activities indicated she redirected the Resident #1 and Resident #2. The Director of Activities indicated the incident was immediately reported to Nurse #7 and the Unit Manager. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said that on 08/16/18, she walked into the hallway and saw that Resident #1 had Resident #2 pinned up against the wall and was thrusting his/her genitals against Resident #2's buttocks. The Director of Activities said she immediately separated Resident #1 and Resident #2 and immediately reported the incident to Nurse #7 and the Unit Manager. The Director of Activities said the Unit Manager told her not to document a Witness Statement because Resident #1 and Resident #2 were separated by staff and therefore, nothing happened. The Activities Director said she told the Unit Manager that despite her request, she still wanted to document a Witness Statement about the incident. The Activities Director said she wrote a Statement on the day the incident occurred (08/16/18), made a copy for herself, and left the original copy on the Unit Manager's desk. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she could not recall how she became aware of the incident of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she could not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not receive any reports of sexually abusive behaviors involving Resident #1 before 09/21/18. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #2 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 4. Review of Activities Aide #1's Witness Statement, dated 09/25/18, indicated (date not provided on the Witness Statement) she saw Resident #1 holding Resident #2 firmly by the hips and quickly thrusting his/her genitals up against Resident #2's body. Activities Aide #7's Statement indicated she and Nurse #7 separated Resident #1 and Resident #2 and notified the Unit Manger. Surveyor #1 interviewed Activities Aide #1 at 11:30 A.M. on 11/05/18. Activities Aide #1 said that on 08/17/18 she saw Resident #1 approach Resident #2 in the dining room. Activities Aide #1 said Resident #1 held Resident #2 by the hips and thrusted his/her genitals against Resident #2's buttocks. Activities Aide #1 said she felt she had witnessed an incident of sexual assault. Activities Aide #1 said Nurse #7 assisted her with separating Resident #1 and Resident #2. Surveyor #2 interviewed Nurse #7 at 11:10 A.M. on 11/20/18. Nurse #7 said she did not recall how she became aware of Resident #1 thrusting his/her genitals against Resident #2's buttocks. Nurse #7 said she did not recall if she reported the incident. Surveyor #1 interviewed the Unit Manager at 8:36 A.M. on 11/01/18. The Unit Manager said she had not receive any reports of sexually abusive behaviors involving Resident #1 before 9/21/18. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #2 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 5. Resident #5's [DIAGNOSES REDACTED]. Resident #5's Annual MDS assessment, dated 10/03/18, indicated he/she had severe cognitive impairment, required a two person extensive assist with bed mobility, required a one person assist with dressing and required a one person extensive assist with ambulation. Review of Resident #5's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #5's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). CNA #4's Witness Statement, dated 09/26/18, indicated, sometime in (MONTH) (YEAR) (exact date not completed on the Witness Statement), at approximately 9:00 P.M. or 9:30 P.M. she observed Resident #1 in bed with Resident #5, in Resident #5's bed. CNA #4's Witness Statement indicated she heard Resident #5 yelling get off of me so she went to Resident #5's room and saw Resident #1 lying on top of Resident #5. The Statement indicated Resident #5 had on a brief and a hospital gown, CNA #4 called for help, CNA's and Nurses responded, removed Resident #1 from Resident #5's bed and redirected Resident #1 out of Resident #5's bedroom. Surveyor #1 interviewed CNA #4 at 3:55 P.M. on 11/05/18. CNA #4 said that at 9:30 P.M. one evening in late (MONTH) or early September, she heard Resident #5 calling for help. CNA #4 said upon entering Resident #5's bedroom, she saw Resident #1 on top of Resident #5 in bed, without the blankets covering the Residents. CNA #4 said Resident #5 typically slept covered with blankets. CNA #4 said she called out for help because she was unable to remove Resident #1 off of Resident #5. CNA #4 said Resident #5's hospital gown was lifted up and part of his/her breast was exposed. CNA #4 said CNA #6 and Nurse #5 arrived to assist. CNA #4 said Resident #1 held onto the bed's side rail and kicked at CNA #6 and Nurse #5 as they removed Resident #1 from the bed. CNA #4 said Nurse #2 was notified of the incident upon his return to the Unit from a work break. CNA #4 said the following evening, she observed that Resident #1 was placed on a one to one supervision. Surveyor #3 interviewed Nurse #5 at 11:05 A.M. on 11/07/18. Nurse #5 said she was informed by a CNA on 11/05/18, that Resident #1 was in Resident #5's bed. Nurse #5 denied assisting another staff member with removing Resident #1 from another residents bedroom. Surveyor #1 interviewed CNA #6 at 2:15 P.M. on 11/06/18. CNA #6 denied assisting any staff members to remove Resident #1 from another resident's bedroom. CNA #6 said she had not witnessed Resident #1 in a resident's bedroom or in another resident's bed. Surveyor #1 interviewed Nurse #2 at 12:30 P.M. on 11/06/18. Nurse #2 said he had not received any report of Resident #1 in bed with Resident #5. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #5 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 6. Activities Aide #2's Witness Statement, dated 09/25/18, indicated she told the DON that Resident #1 grabbed Resident #3's genitals. Activities Aide #2's Statement indicated that the DON went into the dining room, proceeded to stand next to Resident #1, pushing her breasts towards Resident #1 and stated she did not believe Resident #1 had made any sexually abusive gestures towards other residents. The Statement indicated the DON said Resident #1 was not paying attention to her and Resident #3 was not attractive, therefore, why would Resident #1 grab Resident #3's genitals. Surveyor #2 interviewed Activities Aide #2 at 1:30 P.M. on 11/07/18. Activities Aide #2 said that on 09/07/18, while conducting an activity with Activity Aide #1, she observed Resident #3 stand up from the dining room table, where he/she was seated with Resident #1, and began to walk away. Activities Aide #2 said she saw Resident #1 reach out from a seated position and grabbed Resident #3's genital area with his/her hand. Activities Aide #2 said she told Resident #1 to let go, which startled Resident #1, and his/her grip on Resident #3's genital area was released. Activities Aide #2 said she immediately approached the DON, who was at the nursing station and informed her of the incident. Activities Aide #2 said the DON asked that Resident #3 be brought back to the table with Resident #1. Activities Aide #2 said the DON stood by Resident #1, stuck her breasts forward toward Resident #1 and said, words to the effect of, it was hard to believe Resident #1 was not paying attention to her (DON). Activities Aide #2 said the DON said, words to the effect of, Resident #3 had physical features which resembled his/her opposite gender , and because of that, it was odd that Resident #1 paid attention to Resident #3. Activities Aide #2 said the DON's comment was loud enough to be heard by Resident #3, who was seated at the table. Activities Aide #2 said she, the DON and Activities Aide #1 then moved away from the table to observe how Resident #1 would behave with Resident #3. Activities Aide #2 said that after approximately 20 seconds, Resident #1 reached his/her hand forward toward Resident #3 and the DON then immediately separated Resident #1 and Resident #3. Surveyor #1 interviewed Activities Aide #1 at 11:30 AM on 11/05/18. Activities Aide #1 said she asked the DON if she wanted Resident #3 brought back to the table to see if Resident #1 would attempt to grab Resident #3 again and the DON replied, yes. Activities Aide #1 said Activities Aide #2 brought Resident #3 back to the table and seated him/her next to Resident #1 per the DON's direction. Activities Aide #1 said it felt wrong to be doing what they were doing, returning Resident #3 to the table with Resident #1. Activities Aide #1 said she, the DON, and Activities Aide #2, stood away from the table to observe Resident #1's response to Resident #3, and observed Resident #1 then pull Resident #3's chair closer to him/her. Activities Aide #1 said Activities Aide #2 immediately separated Resident #1 and Resident #3. Surveyor #1 interviewed the Director of Activities at 3:23 P.M. on 11/08/18. The Director of Activities said she was sitting with a resident in the activities/dining room on 09/07/18 and witnessed the DON puffing out her chest, made her chest more pronounced to see if Resident #1 would reach out to grab her chest, or words to that effect. The Director of Activities said the DON placed her hands on her hips and said Resident #1 was not doing anything (in response to her gesture). The Director of Activities said she witnessed one of the Activities Aides sit Resident #3 at a table with Resident #1 and then observed as Resident #1 reached over and pulled Resident #3's chair closer to him/her, which is when the DON intervened. The Director of Nurses Witness Statement, dated 11/02/18, indicated she stood next to Resident #1 on 9/7/18, in an attempt to assess the nature of his/her behavior and actions. The DON's statement indicated she denied presenting any part of her body toward Resident #1. The DON's Statement indicated Activities Aide #1 suggested having a resident of the opposite sex sit near Resident #1 to observe any inappropriate sexual behavior. The Statement indicated three staff members were present at the time and at no point was either resident at risk. Surveyor #2 interviewed the Director of Nurses at 2:10 P.M. on 11/07/18. The DON said Activities Aide #2 reported to her on 09/07/18 that Resident #1 reached for another resident's genitals. The DON said it was difficult for her to believe a sexually abusive incident had occurred because she thought Resident #1 only had behaviors of hugging residents. The DON said she questioned if Resident #1 was unable to keep his/her hands to himself/herself and said she proceeded to the dining room where Resident #1 was seated. The DON said she wanted to determine for herself if Resident #1 exhibited inappropriate sexual behaviors. The DON said if Resident #1 reached for a person of the opposite sex, then new interventions needed to be implemented. The DON said she attempted to assess Resident #1's behaviors, with Activities staff present. The DON said she stood near Resident #1 with her shoulders back and chest forward. The DON said Resident #1 had not responded to her gesture. The DON said Activities Aide #1 told her Resident #1 would not act sexually abusive in the presence of staff members. The DON said she decided to assess Resident #1's response to Resident #3 (a member of the opposite sex). The DON said Resident #3 was assisted back to the table and seated near Resident #1. The DON said Resident #1 was observed, by her and the Activities staff from approximately 15 feet away, to reach his/her hand toward Resident #3. The DON said Resident #1 stopped reaching for Resident #3 when staff intervened and Resident #3 was removed from the table by staff. The Surveyor #2 interviewed Family Member #1 at 1:55 P.M. on 11/06/18. Family Member #1 said that, while in the dining room one day, she heard the DON say words to the effect of I'm going to flaunt myself in front of Resident #1 to see if he/she does anything. Family Member #1 said she observed the DON stand approximately 4 feet away from Resident #1 who was seated at a table. Family Member #1 said she observed the DON tug at the shirt on her shoulders and looking sexy, or words to that effect, stuck her breasts forward while swaying her shoulders back and forth in front of Resident #1. Family Member #1 said she heard the DON say words to the effect of, Resident #1 was not responding to her gesture. Family Member #1 said the DON was trying to see if Resident #1 would touch her (DON). Family Member #1 said she heard the DON say she had never seen Resident #1 touch another person and then heard the Activities Aide #1 tell her to wait 5 minutes. Family Member #1 said Activities Aide #1 asked Resident #3 to come sit next to Resident #1. Family Member #1 said she heard the DON say Resident #1 was not going to do anything, or words to that effect. Family Member #1 said she saw Resident #1 move his/her chair closer to Resident #3 and heard the DON say, repeatedly, that she could not believe what she was seeing and could not believe what Resident #1 was doing (referring to his/her reaching for Resident #3). Family Member #1 said she heard Activities Aide #1 say the DON and Unit Manager had been told of incidents by Resident #1 and no one had responded to the reports. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #3 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said she was unaware of the allegations against the DON until the Department of Public Health contacted her on 11/02/18 to discuss the alleged incident involving the DON and Resident #1, which occurred on 09/07/18. The Administrator said she asked the DON to write a statement on 11/02/18, suspended her and began an investigation. 7. Activities Aide #1's Witness Statement, dated 09/10/18, indicated Resident #1 held Resident #2 firmly on the hips, and was pulling Resident #2 to the bed while Resident #2 spoke loudly pulling back. The Statement indicated after Resident #2 was separated from Resident #1, he/she buried his/her face into Nurse #7's shoulder and cried. The Statement indicated that there was a written notation by the DON that she had received the Statement on 09/11/18. Surveyor #2 interviewed Activities Aide #1 at 9:50 A.M. on 11/06/18. Activities Aide #1 said that at 1:15 P.M. on 09/10/18, she heard a loud sound coming from Resident #1's bedroom so she went into Resident #1's room to see what it was. Activities Aide #1 said Resident #1 and Resident #2 were standing and facing each other, alongside Resident #1's bed. Activities Aide #1 said Resident #1 held Resident #2's hips while Resident #2 was arching away from him/her. Activities Aide #1 said Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she thought Resident #1's actions were sexually intended. Activities Aide #1 said she yelled let Resident #2 go, repeated the statement and said she told Resident #1 that Resident #2 did not want to be there. Activities Aide #1 said as she led Resident #2 out of the bedroom, Resident #2 cried, embraced Nurse #7, and buried his/her head into Nurse #7's shoulder and cried. Activities Aide #1 said she reported to Nurse #7 that Resident #1 was trying to pull Resident #2 onto the bed. Activities Aide #1 said she immediately wrote a Witness Statement and gave it to Nurse #7 and the Activities Director. Activities Aide #1 said she was not interviewed by the DON regarding this incident. Nurse #7 said on 09/10/18, at approximately 1:15 P.M., Activities Aide #1 called out for help. Nurse #7 said she approached Resident #1's bedroom. Nurse #7 said Resident #1 was sitting on the bed and was attempting to pull Resident #2 on top of him/her. Nurse #7 said Resident #2 was trying to get away from Resident #1. Nurse #7 said she reported Resident #1's behaviors to the Unit Manager, who responded words to the effect, staff intervened and therefore, nothing happened. Nurse #7 said Activity Aide #1 wrote a Statement about the incident despite the Unit Managers direction not to, and said the DON has a copy of the Activity Aide #1's Statement. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #2 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 8. Resident #4's [DIAGNOSES REDACTED]. Resident #4's MDS assessment, dated 09/12/18, indicated he/she had severe cognitive impairment, wandering behavior, was totally dependent with one person physical assist for dressing, and ambulated with supervision. Review of Resident #4's clinical record indicated that there was no documentation of an assessment or evaluation of his/her cognitive capacity related to his/her ability consent to a sexual relationship. The Record also indicated that Resident #4's Health Care Agent had been invoked (indicating the person is no longer able to make health care related decisions for themselves). Surveyor #2 interviewed Family Member #1 at 3:20 P.M. on 11/06/18. Family Member #1 said that, on approximately 09/14/18, she saw Resident #4 stand by Resident #1 who was seated at the dining room table. Family Member #1 said she saw Resident #1, from a seated position, extended his/her hand and rubbed Resident #4's back and buttocks. Family Member #1 said Resident #1's hand lingered on Resident #4's buttocks. Family Member #1 said Resident #4 did not react to Resident #1's touch. Family Member #1 said she called Activities Aide #1 who removed Resident #4 from the room. Family Member #1 said she had not reported the incident to any other staff. Surveyor #1 interviewed Nurse #7 at 2:30 P.M. on 11/09/18 and at 3:45 P.M. on 11/20/18. Nurse #7 said that, on an unknown date in (MONTH) (YEAR) around 3:00 P.M., she saw Resident #4 standing next to Resident #1, who was seated in the dining room around the change of shift. Nurse #7 said she saw Resident #1 rub Resident #4's buttocks and thighs in an up and down motion. Nurse #7 said Resident #4 did not respond to the act. Nurse #7 said she may have reported the incident to a nurse during a change of shift report. There was no documentation to indicate the Facility conducted an immediate investigation, implemented appropriate interventions to protect Resident #4 from further abuse and did not immediately report the incident to the Department of Public Health (DPH). 9. Nurse #4's Witness Statements, dated 09/21/18 and 09/25/18, indicated she witnessed Resident #1 being sexually abusive on 09/21/18. Nurse #4's Statements indicated she observed that Resident #1 stood behind Resident #2, wrapped his/her arms around Resident #2's waist, and touched Resident #2's genitals with his/her hand, while moving his/her genitals against Resident #2's buttocks. Surveyor #1 interviewed Nurse #4 at 5:20 P.M. on 11/01/18. Nurse #4 said she was in the hallway with Nurse Practitioner #3 on 09/21/18. Nurse #4 said she saw Resident #1 hug Resident #2 from behind. Nurse #4 said she rushed toward Resident #1 and Resident #2 to intervene. Nurse #4 said saw Resident #1 had placed his/her right hand on Resident #2's genitals while his/her left hand was on Resident #2's hip. Nurse #4 said she separated Resident #1 and Resident #2. Nurse #4 said she reported the incident to the Unit Manager. Nurse Practitioner #3's Witness Statement, dated 0

Based on records reviewed, observations and interviews, for one of seven sampled residents (Resident #1), the facility failed to ensure Resident #1's Plan of Care was individualized to accurately document his/her sexually abusive behaviors. The Plan of Care lacked consistent and clear information regarding Resident #1's actual behaviors which placed other residents at risk; lacked clear interventions for staff in managing Resident #'1's behaviors; and lacked strategies regarding supervision and monitoring. Findings include: Resident #1's [DIAGNOSES REDACTED]. Resident #1's clinical record indicated there was no documentation of an assessment or evaluation of his/her cognitive capacity to consent to a sexual relationship. The clinical record also indicated that Resident #1's Health Care Proxy had been invoked (indicating the person is no longer able to make health care related decisions for themselves) in (YEAR) due to his/her [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 07/25/18, indicated he/she had severe cognitive impairment, ambulated with supervision, no wandering behavior was exhibited, and no behavioral symptoms were exhibited, such as a physical behavioral symptom of sexually abusing others. Resident #1's Care Plan, initiated 11/07/17, indicated the Focus area as he/she being at risk for behavioral symptoms related to dementia with wandering. The Care Plan's Focus area indicated at times Resident #1 wandered to other residents rooms and slept on empty beds or next to residents in bed. The Care Plan's Goal, initiated 11/07/17, indicated the Facility will reduce the risk of behavioral symptoms. The Care Plan's Interventions/Tasks, initiated 08/13/18, included one to one supervision due to wandering and a history of attempting to hug staff/peers. There was no indication on the Care Plan whether or not the Intervention/Tasks of one to one supervision was discontinued. There was no documentation on the Care Plan to indicate that Resident #1 displayed sexually inappropriate behaviors which put others at risk of sexual abuse. It was determined that from approximately 08/12/18 to 09/21/18 there were at least nine alleged incidents of Resident #1 sexually abusing four other Residents of the opposite sex. There were no updates on Resident #1's Plan of Care Focus (problem) area prior to 09/24/18 to indicate the following incidents were known during the development of his/her goal and interventions: -On 8/12/18, Resident #1 made sexual movements of repeatedly thrusting his/her genitals against Resident #3's buttocks. -A couple of days later, Resident #1 was observed in bed with Resident #2, Resident #1 had his/her hands on Resident #2's hips by the waist band. -On 08/16/18, Resident #1 thrusted his/her genitals against Resident #2's buttocks while Resident #2 was up against a wall. -On 08/17/18, Resident #1 was again observed standing behind Resident #2, holding his/her hips and he/she was thrusting his/her genitals against Resident #2's buttocks. -In late (MONTH) or early (MONTH) (exact date at the time of investigation), Resident #1 was on top of Resident #5 in Resident #5's bed, and Resident #5's hospital gown was up exposing part of his/her breasts. Resident #1 resisted being removed by holding onto the bed's side rail and kicking staff. -On 09/07/18, during an activity in the dining room, Resident #1 grabbed Resident #3's genitals with his/her hand. -On 09/10/18, Resident #1 held Resident #2's hips, and tried to pull Resident #2 onto the bed. - On approximately 09/14/18 Resident #1 from a seated position extended his/her hand and rubbed Resident #4's back and buttocks. - On an unknown date in (MONTH) (YEAR) Resident #1 rubbed Resident #4's buttocks and thighs. -On 9/21/18, Resident #1 with his/her arms wrapped around Resident #2's waist from behind, touched Resident #2's genitals while thrusting his/her genitals against Resident #2's buttocks. Surveyor #2 interviewed the Director of Nurses at 2:10 P.M. on 11/07/18. The DON said Activities Aide #2 reported to her on 09/07/18 that Resident #1 reached for another resident's genitals. The DON said it was difficult for her to believe a sexually abusive incident had occurred because she thought Resident #1 only had behaviors of hugging residents. Surveyor #1 interviewed the Administrator at 10:35 A.M. on 11/09/18. The Administrator said the DON reported the incident to her which occurred on 09/21/18 that Resident #1 grabbed Resident #2's hips and genitals. The Administrator said it was not until the investigation began on 09/21/18 that staff provided Witness Statements revealing that Resident #1 had displayed sexualized behaviors prior to 09/21/18. The Administrator said no one had informed her of Resident #1's sexualized behaviors prior to 09/21/18. The Resident #1's Care Plan, initiated 09/24/18, indicated the Focus area as alleged inappropriate behavior consisting of hugging/touch, wandering in others rooms, laying in others beds related to [DIAGNOSES REDACTED].#1 will carry out sexual behavior with self only in privacy of own room and will not initiate physical contact of a sexual nature with residents or staff. The Care Plan's Interventions/Tasks, initiated 09/21/18, indicated to increase supervision, and monitor whereabouts (one to one as of 09/21/18 and distant supervision as of 10/25/18). Although the Care Plan (initiated on 09/24/18) indicated there was inappropriate behavior such as hugging and touch, the Focused problem area did not include specific information such as increased [MEDICAL CONDITION], aggression, disinhibited behaviors and allegations of abusive actions towards other residents in public areas and in bedrooms. Resident #1's Annual MDS assessment, dated 10/17/18, indicated he/she continued to display severe cognitive impairment, no wandering behavior, and no physical behavioral symptoms directed toward others, such as grabbing, and sexually abusing others. Resident #1's Annual MDS indicated there was a behavioral symptom displayed not directed at others, which did not interfere with social interactions or participation in activities. Resident #1's MDS indicated his/her current behavioral status in comparison with the prior assessment remained unchanged with regard to behaviors and other symptoms.

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain his/her highest practicable level of physical, mental and psychological well-being to alleviate escalating behaviors for 1 resident (#7) in a total sample of 24 residents which resulted in the resident receiving the administration of [MEDICATION NAME] (antipsychotic medication) 5 MG Intramuscular (IM). Findings include: Resident #7 was admitted to the facility 4/16 from a hospital psychiatric unit with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set assessment (MDS), dated [DATE], indicated the Brief Interview for Mental Status (BIMS) (a cognitive assessment) score was 9 out of a possible 15 (indicating moderate cognitive impairment). The MDS indicated that the resident had verbal behavioral symptoms not directed towards others. The resident requires assistance with all activities of daily living, ambulates with a walker, is usually understood and usually understands others. The Health Care Proxy is activated. Review of the quarterly MDS assessment, dated 7/27/16, indicated a BIMS score of 8 (indicating a decline in cognitive ability since his/her last MDS assessment). Review of the Resident Care Plan, last revised on 7/12/16, indicated that the resident is at risk for mood and behavior symptoms related to dementia with behaviors. Resident has history of the use of foul language, slamming his/her walker, yelling out and hallucinations. Interventions for these behaviors included the following: * Administer medications per physician order. * Attempt [MEDICAL CONDITION] drug reduction per physician orders. * Encourage the resident to engage in his/her plan of care to the fullest extent. * Participate in activities of interest. * Monitor behaviors to assist in determining causes such as place, time or situation. * Monitor for signs and symptoms of depression including weepiness, agitation, restlessness, decreased motivation, changes in sleep pattern, changes in appetite and isolation. * Notify the physician if moods or behaviors interfere with daily functioning. * Observe for escalation in behaviors, intervene as needed to ensure the safety of Resident #7 and others. * Observe for mental status or behavioral changes when a new medication is started or with dose changes. * Psychiatric referral as needed, reinforce positive behaviors and use consistent approaches when giving care. * Use consistent approaches when giving care. Resident #7 has an activated Health Care Proxy (HCP). The Care Plan indicated that the HCP will be informed of any changes in condition and to notify the physician if mood and behaviors interfere with daily functioning. The Care Plan also indicated that Resident #7 has difficulty communicating related to difficulty with word finding and understanding all information being delivered. Interventions include, anticipate and meet needs, communicate using yes or no questions and responses when able, encourage out of room activities, gain individual's attention before beginning to converse, involve in activities that do not depend on an ability to communicate like parties, crafts or movies. Mirror the resident's facial expressions and body language to communicate understanding of the emotion being expressed. Monitor for nonverbal means of communication. When talking to the resident, use gestures and simple sentences while maintaining eye contact. Review of a Psychiatric Nurse Practitioner (NP#1) assessment, dated 5/9/16, indicated a mood disorder evidenced by anger and resentment. Interventions include introducing yourself on approach, explain the reason for the visit and Resident #7 may benefit from Caucasian staff assisting with care, and educating African American staff to the resident culture resentment. Review of the clinical record indicated that on 7/30/16, Resident #7 was transferred from the short term rehab unit to a long term care floor. There was no evidence within the clincal record to indicate that the staff on the long term floor were aware of how to manage the resident's behaviors per the mood and behavior plan of care. Review of Nurses Notes, indicated within 48 hours after transfer from one nursing unit to another, the resident began exhibiting behaviors which included the following: *8/2/16 7:00 A.M.-3:00 P.M.- Resident #7 had multiple episodes of agitation. Yelling out derogatory names and abusing staff for 3 hours. He/she was angry because he/she had not received nail care at 10:00 A.M. Activities attempted redirection with nail care. [MEDICATION NAME] 12.5 MG by mouth was given without affect. * 8/2/16 3:00 P.M.- 11:00 P.M.shift -Resident #7 continued to be very agitated, physically and verbally abusing staff with inappropriate name calling. Repeatedly hitting staff members and refusing medication. The Resident said they want to kill me and you are trying to dope me up. HCP visited and was informed of behaviors. There was no evidence that the behavioral interventions specified in the resident's care plan were attempted. *8/3/16 11:00- 7:00 A.M. shift- At approximately 1:00 A.M., Resident #7 was ambulating with a rolling walker independently. The resident was aggressively agitated and intrusive, going into other resident rooms. Resident #7 was throwing books, attempting to knock over a computer, continued with racial remarks and refused care. The nursing supervisor was made aware of these occurrences. The MD was not notified of the continued change in condition at this time. There was no evidence that the behavioral interventions specified in the resident's care plan were attempted. At approximately 3:00 A.M., Resident #7 was again intrusive to other resident rooms sayingwe are getting bombed, people are going to kill us. The resident continued to become more aggressive and the physician was called. The on call Nurse Practitioner (NP#2) returned the call and was informed of the current situation with Resident #7. NP#2 ordered [MEDICATION NAME] 5 MG IM (intra muscular) one time for severe agitation. The [MEDICATION NAME] was given into the left buttocks by Nurse #2 with the assistance of the Nursing Supervisor and a certified nursing assistant (CNA). The Director of Nursing (DNS) was not notified. The HCP was not notified. There was no evidence that the behavioral interventions specified in the resident's care plan were attempted prior to the administration of the IM antipsychotic medication. During a telephone interview on 9/21/16 at 10:25 A.M., Nurse #2 (the nurse on duty 8/3/16 11:00 P.M.-7:00 A.M. shift) said she had received report from the 8/2/16 3:00 P.M.-11:00 P.M. shift that Resident #7 had been yelling and entering other resident rooms all shift. Nurse #2 said these same behaviors had continued during her shift. The resident was frequently redirected with some limited positive affects. The resident would go to his /her room and rest for approximately 20-30 minutes then arise and start yelling again. The more tired the resident became, the more agitated he/she became. Nurse #2 said she called call the physician and NP #2 returned the call. NP #2 gave Nurse #2 an order to administer [MEDICATION NAME] 5 mg IM, one time only. Nurse #2 said that she administered the [MEDICATION NAME] 5 mg IM to Resident #7 at the nurses station with the assistance of the CNA and the Nursing Supervisor on duty. Nurse #2 also said that providing 1:1 intervention would be difficult due to limited resources on the 11:00 P.M.-7:00 A.M. shift and a Section 12 (involuntary transfer to an acute care facility to manage residents with behaviors that put themselves or others at risk for harm) would be impossible at that time of night. She continued to say that the resources on 11:00-7:00 P.M. are limited. During interview on 9/21/16 at 11:05 A.M., the Medical Director said that Resident #7 has always been cooperative with him. The Medical Director was somewhat surprised by the [MEDICATION NAME] injection, saying it is aggressive. [MEDICATION NAME] is a drug of choice in these situations due to the absence of respiratory distress as a side effect. He said a Section 12 is not a difficult task to accomplish and transitioning to a new floor and room change may have contributed to the increase in behaviors. During interview on 9/22/16 at 2:00 P.M., the DNS said that the facility has no policy or procedure for administering antipsychotic injections in an emergent situation. [MEDICATION NAME] injection has never been given since she has been working here. Resident #7 was transferred to a different floor and a different room but had adjusted within 48 hours. The DNS said that the health care proxy was not notified of the resident's change in condition nor gave consent for the antipsychotic injection. During interview on 9/22/16 at 2:30 P.M., the resident's activated health care proxy, said that she witnessed the above described behaviors at the facility, left for dinner, then returned to the facility to try to calm her parent. She also told the Surveyor some of the paranoid ideation her parent was displaying with an emphasis on how her parent was escalating as time went on.

Based on staff interview and record review, the facility failed to notify the activated health care proxy (HCP) for a medication change and failed to notify the physician timely in regard to a resident's change of condition for 1 resident (#7) from a total sample of 24 residents. Findings include: 1. For Resident #7, the facility failed to notify the resident's physician timely in regard to a change in condition. Review of a nurses note, dated 8/2/16, indicated that Resident #7 had multiple episodes of agitation on the 7-3 shift. In addition, the note indicated that the resident was yelling out derogatory names and abusing staff for 3 hours. The note indicated that nursing gave the resident [MEDICATION NAME] 12.5 milligrams (mg) by mouth at 11:00 A.M. without effect. The physician was not notified of the resident's change in condition Review of a nurses note , dated 8/2/16 3:00 P.M.- 11:00 P.M. shift,, indicated that Resident #7 continued to be very agitated on 3-11. The note indicated that the resident was verbally abusing staff by calling staff inappropriate names. The resident's daughter visited and was informed by nursing of the behaviors and medication refusals. Nursing notes describe the resident stating they want to kill me and you are trying to dope me up. The physician was not notified of the resident's change in condition. During interview on 9/22/16 at 2:30 P.M., the resident's activated health care proxy said that she witnessed the above described behaviors at the facility , left for dinner, then returned to the facility to try to calm her mother. She also told the Surveyor some of the paranoid ideation her mother was displaying with an emphasis on how her mother was escalating as time went on. The physician was not notified until 8/3/16 at 3:00 A.M., for a change in condition in regard to the resident's behavioral status, which began on 8/2/16 at 10:00 A.M. Please refer to F309.

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was transferred in accordance with the Facility's Transfer Safety and Guidelines by not following the Care Card and using a gait belt to prevent injury. On 3/18/13, Certified Nursing Assistant (CNA) #1 transferred Resident #1 from the bed to the wheelchair without assistance, the use of a gait belt and the proper technique. During the transfer, Resident #1's right leg got caught under the wheel of the wheelchair and sustained an 11 centimeter (cm) laceration to the right lateral calf requiring 24 sutures. Findings include: Resident #1's quarterly Minimum Data Set assessment, dated 3/14/13, indicated he/she was unsteady and required extensive assistance from two staff for physical assistance with transfers. Resident #1's Care Card, dated 3/5/13, indicated he/she required extensive assistance from two staff for assistance with transfers. The Nurse's Note, dated 3/18/13 at 11:00 A.M., indicated a CNA requested the nurse go to Resident #1's bedroom. The Nurse's Note indicated Resident #1 was observed sitting in the wheelchair with blood on his/her right leg. The Nurse's Note indicated Resident #1 said his/her leg got caught on the wheelchair during a transfer from the bed to the wheelchair. The Emergency Department Physician report, dated 3/18/13, indicated Resident #1 sustained an 11 cm laceration to the right lateral (side) calf which was closed with 24 staples. The Surveyor interviewed the Staff Development Coordinator (SDC) at 8:05 A.M. on 6/14/13. The SDC said she provided training for staff at orientation and annually on the Facility's guideline for Using a Gait Belt and the Facility's Policy and Procedure titled Transfer Safety and Guidelines. The Transfer Safety and Guidelines (not dated) included the following: always begin by checking the CNA Care Card to know how many caregivers are required for the transfer; and apply the gait belt for the transfer. The Using a Gait Belt guideline (not dated) included the following: a gait belt is a safety device used around a person's waist to allow the caregiver to grab onto it and keep the person steady or to prevent them from falling. On 7/30/12, CNA #1 signed the Gait Belt Acknowledgement form indicating she was provided a gait belt, received training on the technique for using a gait belt, and was required to use the gait belt on all assisted transfers. The Surveyor interviewed Resident #1 at 11:40 A.M. on 4/4/13 and at 9:00 A.M. on 6/14/13. Resident #1 presented with intermittent confusion during the interviews. Resident #1 said the injury occurred to his/her leg during a transfer with one CNA (CNA #1) from the bed to the wheelchair. Resident #1 said during the transfer his/her hands were around CNA #1's neck and CNA #1's hands were around his/her waist. Resident #1 said he/she did not recall a gait belt being used during the transfer with CNA #1. Resident #1 said his/her right leg got caught on the wheelchair. The Surveyor interviewed CNA #1 at 12:25 P.M. on 4/4/13. CNA #1 said she knew Care Cards communicated to CNAs what care was required for each resident. CNA #1 said residents' Care Cards were accessible at the nursing station. CNA #1 said she had been assigned to care for Resident #1 approximately 6 times. CNA #1 said approximately 4 months ago, she saw a CNA conduct a one person transfer for Resident #1. CNA #1 said approximately 3 months ago, she assisted in conducting a two person transfer for Resident #1. CNA #1 said she did not review the Care Card for clarification. CNA #1 said she never reviewed Resident #1's Care Card in the past or before transferring Resident #1 without assistance at approximately 10:30 A.M. on 3/18/13. CNA #1 said a nurse never told her on 3/18/13, to conduct a one person transfer for Resident #1. CNA #1 said she did not seek assistance and decided to conduct the transfer alone. CNA #1 said she locked the wheelchair and placed it alongside the bed. CNA #1 said she sat Resident #1 up at the edge of the bed. CNA #1 said she transferred Resident #1 by placing her hands around Resident #1's waist, and held onto Resident #1's incontinent brief, while Resident #1 placed his/her arms around CNA #1's neck. CNA #1 said she knew Resident #1 did not have a lot of control over the right leg. CNA #1 said when she sat Resident #1 down into the wheelchair, Resident #1's right leg was positioned behind the front small wheel of the wheelchair. CNA #1 said she immediately noticed Resident #1's leg was cut. The SDC said the gait belt should be used for safe transfers on all residents. The SDC said a CNA should not hold onto a resident's incontinent brief instead of a gait belt during a transfer. The SDC said pulling the incontinent brief could cause a skin tear to the resident legs. The SDC said pulling the incontinent brief could cause it to come apart and the resident may fall. The SDC said she instructs CNAs, at orientation and annually, to use a gait belt and not to put a resident's hands around a CNA's neck. The SDC said if a resident was not steady on their feet, the CNA could come down on top of the resident. The Surveyor interviewed the Rehabilitation Director at 11:55 A.M. on 6/14/13. The Surveyor interviewed the Director of Nursing (DON) at 10:50 A.M. on 6/14/13. The Rehabilitation Director and the DON said resident's hands should not be around a CNA's neck while conducting a transfer. The DON said a resident could grab a CNA's name badge or become combative and squeeze a CNA's neck. The Rehabilitation Director and the DON said gait belts should be used for all one person and two person transfers.

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 Resident (#1) in a total sample of 23 residents. Findings include: 1. The facility failed to provide the necessary care and services for the prevention and treatment of [REDACTED]. Resident #1 was identified during the entrance tour on 1/10/12, at 10:00 A.M., as having a open area on the left foot. The area was described as a bunion, Stage IV which was a vascular wound. The Resident was described as having pain as a result of the vascular ulcer. Review of the medical record on 1/12/12, at 9:30 A.M., revealed that the physician had ordered [MEDICATION NAME] (a narcotic used to treat pain) 5 milligrams three times daily on 12/2/11. Resident #1 also had a physician's orders [REDACTED]. In addition, there were physician's orders [REDACTED]. A care plan was developed on 12/16/11 for Alteration in Comfort related to [MEDICAL CONDITION] and left foot ischemic ulcer. Interventions included: * assess pain on a scale of 1-10 and document. * pre-medicate before treatment i.e. PT/OT (physical therapy/occupational therapy), dressing changes etc. * monitor for verbal/non verbal cues regarding pain level. Report any changes to charge nurse/MD. A Significant Change Minimum Data Set, dated dated [DATE], documents the Resident as having a venous/arterial ulcer. The Resident is documented as having scheduled pain medication and exhibiting facial grimacing as evidence of pain. A treatment observation was conducted on 1/12/12 at 10:40 A.M. The left foot was observed to have an open area with exposed bone measuring 4 centimeters by 3.5 centimeters. As Treatment Nurse #1 began to wash the bunion area, Resident #1 was observed to pull the left foot upward and stated "no, no, stop." Treatment Nurse #1 asked the Resident if he/she was in pain. Resident #1 was observed grimacing. Treatment Nurse #1 stated that Resident #1 had been medicated with Tylenol and then proceeded to, again, wash the wound with a 4 x 4 piece of gauze which had been moistened with normal saline. Again, as Treatment Nurse #1 touched the open area, the Resident stated "no, no, stop" and pulled the left leg and foot upward towards his/her body and away from the Treatment Nurse's touch. Unit Manager #3, who was present during the treatment did not intervene or stop the treatment. This surveyor directed Treatment Nurse #1 to stop the treatment due to the Resident's pain. Unit Manager #3 was asked by this surveyor why he/she had not stopped the treatment when the Resident first indicated that he/she was in pain (when the open area was first touched). Unit Manager #3 stated "the Resident had received Tylenol." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 2:00 P.M. and 10:00 P.M. The scheduled Tylenol 650 milligrams was scheduled for 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Neither the PRN [MEDICATION NAME] or the PRN Tylenol had been signed off as being given before the treatment observation. The above observations were shared with the Clinical Services Supervisor on 1/12/11 at 11:00 A.M. The Clinical Services Supervisor stated that he/she would investigate whether any PRN medications had been given prior to the treatment. The Clinical Services Supervisor, after speaking with Treatment Nurse #1, stated that Resident #1 had not been given any PRN medication prior to the treatment being done. The Clinical Services Supervisor stated that Resident #1 had only received the schedule Tylenol at 9:00 A.M. (1 hour and 40 minutes before the treatment.) The Clinical Services Supervisor stated that the treatment should have been stopped when the Resident had first indicated/verbalized pain during the treatment.

Based on record review, observation and staff interview, the facility failed to implement the plan of care for 1 Resident (#1), in a total sample of 23 residents. The findings include: The facility failed to implement the plan of care for Resident #1 in regards to pre-medicating before a treatment. Resident #1 was identified during the entrance tour on 1/10/12, at 10:00 A.M., as having a open area on the left foot. The area was described as a bunion, Stage IV which was a vascular wound. The Resident was described as having pain as a result of the vascular ulcer. Review of the medical record on 1/12/12, at 9:30 A.M., revealed that the physician had ordered [MEDICATION NAME] (a narcotic used to treat pain) 5 milligrams three times daily on 12/2/11. Resident #1 also had a physician's orders [REDACTED]. In addition, there were physician's orders [REDACTED]. A care plan was developed on 12/16/11 for Alteration in Comfort related to [MEDICAL CONDITION] and left foot ischemic ulcer. Interventions included: * assess pain on a scale of 1-10 and document. * pre-medicate before treatment i.e. PT/OT (physical therapy/occupational therapy), dressing changes etc. * monitor for verbal/non verbal cues regarding pain level. Report any changes to charge nurse/MD. A Significant Change Minimum Data Set, dated dated [DATE], documents the Resident as having a venous/arterial ulcer. The Resident is documented as having scheduled pain medication and exhibiting facial grimacing as evidence of pain. A treatment observation was conducted on 1/12/12 at 10:40 A.M. The left foot was observed to have an open area with exposed bone measuring 4 centimeters by 3.5 centimeters. As Treatment Nurse #1 began to wash the bunion area, Resident #1 was observed to pull the left foot upward and stated "no, no, stop." Treatment Nurse #1 asked the Resident if he/she was in pain. Resident #1 was observed grimacing. Treatement Nurse #1 stated that Resident #1 had been medicated with Tylenol and then proceeded to, again, wash the wound with a 4 x 4 piece of gauze which had been moistened with normal saline. Again, as Treatment Nurse #1 touched the open area, the Resident stated "no, no, stop" and pulled the left leg and foot upward towards his/her body and away from the Treatment Nurse's touch. Unit Manager #3, who was present during the treatment did not intervene or stop the treatment. This surveyor directed Treatment Nurse #1 to stop the treatment due to the Resident's pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 2:00 P.M. and 10:00 P.M. The scheduled Tylenol 650 milligrams was scheduled for 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Neither the PRN [MEDICATION NAME] or the PRN Tylenol had been signed off as being given before the treatment observation. The above observations were shared with the Clinical Services Supervisor on 1/12/11 at 11:00 A.M. The Clinical Services Supervisor stated that he/she would investigate whether any PRN medications had been given prior to the treatment and not signed off on the medication administraton record. The Clinical Services Supervisor, after speaking with Treatment Nurse #1, stated that Resident #1 had not been given any PRN medication prior to the treatment being done. The Clinical Services Supervisor stated that Resident #1 had only received the schedule Tylenol at 9:00 A.M. (1 hour and 40 minutes before the treatment.) The Clinical Services Supervisor stated that the scheduled Tylenol had not been given close enough in time to the treatment to be considered a pre-medication. Please see F309.

Based on record review and interviews, the Facility failed to ensure, for one of ten sampled residents (Resident #1), that Resident #1's advance directives, were carried out. On [DATE], Resident #1, was found by Facility staff, unresponsive and without pulse. CPR (cardiopulmonary resuscitation) was initiated, Resident #1 was transported, by ambulance, to the Hospital, and placed on a ventilator, contrary to Resident #1's wishes physician's orders [REDACTED]. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Nurse #1 was interviewed on [DATE] at 1:00 PM. Nurse #1 said Resident #1 was readmitted to the Facility, from the Hospital, on [DATE] during the evening shift. Nurse #1 said that several nurses assisted with the admission, and some of Resident #1's clinical record remained from the previous admission. Nurse #1 said Resident #1 was readmitted to the Facility with comfort measures only, do not hospitalize, and do not intubate. Nurse #1 said that the Physician verified the admission orders [REDACTED]. The nurse's note, dated [DATE], indicated that at approximately 9:25 AM, Resident #1 was noted to be unresponsive, the clinical record indicated that Resident #1 was to be resuscitated, and CPR was initiated for Resident #1. The Nursing Supervisor was interviewed on [DATE] at 1:30 PM. The Nursing Supervisor said at approximately 9:30 AM on [DATE], Resident #1 was found unresponsive, and the Nursing Supervisor assisted staff in determining Resident #1's code status. The Nursing Supervisor said that under the advanced directive section of Resident #1's clinical record, there was a notation that Resident #1 was a full code. The Nursing Supervisor said CPR was initiated for Resident #1, and 911 was called for transport to the Hospital. Nurse #3 was interviewed on [DATE] at 1:45 PM. Nurse #3 said that on [DATE], Nurse #3 was notified at approximately 9:25 AM, that Resident #1 was non-responsive, Resident #1 had no advanced directives in the chart, and CPR was initiated by Nurse #3 and another staff member. The Nursing Supervisor said that when Resident #1's family member was notified of the incident, Resident #1's family Member indicated that Resident #1 did not want CPR, or intubation, and a paper had been signed for a DNR status. The Nursing Supervisor said that when Resident #1's clinical record was reviewed again, the physician's orders [REDACTED]. The Nursing Supervisor said that the advanced directive, indicated that Resident #1 was a DNR (do not resuscitate), was mixed in with other admission papers. The advanced directive "COMFORT CARE/DO NOT RESUSCITATE ("DNR") ORDER VERIFICATION" form had been signed, on [DATE], by both Resident #1's Health Care Agent and Resident #1's Physician. The nurse's note, dated [DATE], indicated that Resident #1 was intubated at the Hospital and had a pulse. Family Member #1 was interviewed on [DATE] at 10:00 AM and said Resident #1 suffered for almost 24 hours on a ventilator with tubes, and family members had to have the breathing tube discontinued because Resident #1's wishes were not to be resuscitated.