Every finding on record at Chelsey Park Health And Rehabilitation

Based on record review, staff interviews, and review of the facility's policy titled Abuse Prohibition, the facility failed to protect two of three sampled residents' (R) (R2 and R3) rights to be free from abuse. Specifically, the facility failed to protect R3 from physical abuse by a staff member and failed to protect R2 from sexual abuse by another resident (R1). Findings include: Review of the facility's policy titled Abuse Prohibition, reviewed 12/27/2025, revealed under Policy: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. The policy further defined Physical abuse as including hitting, slapping, pinching, and kicking and controlling behavior through corporal punishment. Sexual abuse included sexual harassment, sexual coercion, or sexual assault.1. Review of the Facility's Incident Report, dated 05/03/2026, revealed that the facility reported an allegation that Food Service Aide AA hit R3 and was placed on suspension pending investigation. Review of the facility-provided Associate Status Change Form revealed that Certified Nurse Aide (CNA) AA was placed on suspension on 05/03/2026. The Reason for Separation section documented Abuse/Resident Rights. Review of the facility-provided Separation Notice revealed that CNA AA was terminated on 05/05/2026. The Reason for Separation section documented Company violation: physical abuse of a resident. Review of the facility's investigation revealed that, immediately following the incident, a full-body assessment was completed for R3 with no findings. The Medical Director, Responsible Party, and the local Sheriff Department were notified, an officer responded, and the resident could recall the event. Review of the facility-provided statement, dated 05/05/2026, revealed that on 05/03/2026, CNA FF witnessed CNA AA slap R3 when R3 began eating from a meal tray. CNA FF stated that the action appeared reflexive rather than malicious and that Food Service Aide AA immediately apologized. Review of the electronic health record (EHR) for R3 revealed diagnoses included Parkinson's disease, severe vascular dementia with behavioral disturbances; unspecified dementia with agitation, senile degeneration of the brain, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment for R3, dated 06/29/2026, revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E (Behaviors) documented no physical or verbal behaviors and rejection of care. Review of the care plan for R3 revealed interventions addressing dementia with cognitive impairment, communication deficits related to hearing impairment, limited mobility, self-care deficits, choking/aspiration risk, and behavioral management. The care plan included interventions to assist with activities of daily living and to maintain the resident's safety while addressing cognitive, behavioral, and physical needs.Review of the Initial COC [Change of Condition]_Report to MD [Medical Doctor], dated 05/03/2026, revealed the Assessment section documented A potential for an injury of the arm after being swatted at. No injuries noted.2. Review of the Facility's Incident Report, dated 06/09/2026, revealed that the facility reported an allegation that R1 touched R2 without permission. The residents were separated, and an investigation was pending.Review of the Event-Initial Encounter Note dated 06/09/2026 revealed CNAs witnessed another resident kiss and touch R2 on the leg. The Administrator, Director of Nursing (DON), Social Services, and the Hospice MD were notified. There were no injuries, and R2 was severely cognitively impaired. Review of the facility's investigation revealed that, immediately following the incident, the residents were separated, and full-body assessments were completed for R1 and R2 with no findings. The local police department was notified, an officer responded, and neither resident could recall the event. A) Review of the EHR for R1 revealed diagnoses included senile degeneration of the brain, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, unspecified anxiety disorder, unspecified depression, and encounter for palliative care.Review of the annual MDS assessment for R1, dated 06/12/2026, revealed a BIMS score of 7, indicating severe cognitive impairment. Section E (Behaviors) documented physical and verbal behaviors directed toward others and rejection of care.Review of the care plan for R1, last reviewed 06/14/2026, revealed behaviors that included wandering, sexually inappropriate comments and touching toward female staff, attempts to advance toward female staff, staring at female residents in their rooms, and entering the entrance areas of female residents' rooms. Interventions included assessing for possible clinical causes of behavioral changes, identifying circumstances and triggers, redirecting R1 and reminding him that the behavior was inappropriate, providing frequent checks, using preferred activities and other methods of distraction, maintaining a calm approach, and reinforcing positive behaviors.Review of the physician's orders for R1 revealed an order dated 06/09/2026 for Climara 0.025 mg (milligram)/24 hour transdermal patch, one patch weekly every Wednesday, and an order dated 06/10/2026 for Depakote 250 mg, one tablet, delayed release by mouth two times a day. B) Review of the EHR for R2 revealed diagnoses included vascular dementia, hemiplegia, hemiparesis following a cerebrovascular accident (CVA), major depressive disorder, recurrent, severe with psychotic symptoms, major depressive disorder, and anxiety disorder.Review of the quarterly MDS assessment for R2, dated 06/04/2026, revealed a BIMS of 5, indicating severe cognitive impairment. Review of the care plan for R2 revealed the resident had cognitive impairment, behaviors, anxiety, major depressive disorder, psychotropic drug use, and hospice services. The behavior care plan identified anxiety, crying, delusions, hallucinations, and inappropriate vocalizations. Interventions included administering medications as ordered for specific target behaviors, analyzing triggers and de-escalating factors, assessing behavior patterns, communicating face to face using simple statements, checking for unmet needs, distracting with preferred activities or music, maintaining a calm manner, involving the resident in activities of choice, and conducting behavior assessments as needed. Review of the skin assessment for R2, dated 06/09/2026, revealed normal skin color; thin, fragile skin; and no rashes, redness, bruising, discoloration, tears, or swelling.In an interview on 08/06/2026 at 10:30 AM, the Social Services Director (SSD) stated that the facility substantiated both abuse allegations because both incidents were witnessed. In the first incident, Food Service Aide AA acknowledged making physical contact with R3, which was also witnessed by another staff member. In the second incident, a staff member witnessed nonconsensual physical contact between R1 and R2. She further stated that none of the residents involved could recall the incidents due to cognitive impairment. In an interview on 08/06/2026 at 3:30 PM, the Administrator stated that it was her first day serving as the facility's Administrator. Based on her review of the facility's records, she confirmed that the facility substantiated both abuse allegations because each incident was directly observed by other staff. She stated that the facility addressed the incidents during a Quality Assurance and Performance Improvement (QAPI) meeting in June 2026, including discussions related to neglect, abuse, and staff education. The facility implemented the following corrective actions after becoming aware of the allegation on 05/03/2026:1. On 05/03/2026, the facility submitted an incident report to the State Survey Agency (SSA) and reported to the State CNA Registry.2. On 05/03/2026, CNA AA was suspended pending investigation.3. On 05/03/2026, the facility notified local law enforcement. 4. On 05/05/2026, CNA AA was terminated from employment. 5. On 05/03/2026, a skin assessment was completed for R3, and no injuries were identified. 6. On 05/05/2026, X-Rays of R3's left and right humerus and left and right forearm were conducted, and no fractures or dislocations were identified.7. On 05/04/2026, the facility completed full head-to-toe skin assessments for residents with a BIMS score of 10 or below. No findings indicative of abuse, neglect, or unexplained injury were identified.8. On 05/04/2026, the facility conducted structured abuse screening interviews for interviewable residents with BIMS scores of 11 or above. No findings indicative of abuse, neglect, or unexplained injury were identified.9. From 05/04/2026 through 05/07/2026, staff interviews were conducted and determined no staff had witnessed abuse and no residents had reported abuse to staff. 10. From 05/04/2026 through 05/12/2026, the facility provided abuse prevention education to all staff.The facility implemented the following corrective actions after becoming aware of the allegation on 06/09/2026:1. On 06/09/2026, the facility submitted an incident report to the State Survey Agency (SSA).2. On 06/09/2026, the facility notified local law enforcement. 3. On 06/09/2026, a skin assessment was completed for R2, and no injuries were identified. 5. From 06/09/2026 through 06/22/2026, R1 was on documented continuous one-to-one monitoring. 5. On 06/12/2026, the facility completed full head-to-toe skin assessments for residents with a BIMS score of 10 or below. No findings indicative of abuse, neglect, or unexplained injury were identified.6. On 06/12/2026, the facility conducted structured abuse screening interviews for interviewable residents with BIMS scores of 11 or above. No findings indicative of abuse, neglect, or unexplained injury were identified.7. From 06/09/2026 through 06/17/2026, the facility provided education, including dementia care and redirecting residents, to all staff.

Based on observations, staff interview and review of facility policy titled Laundry Services, the facility failed to maintain infection control during the transport of clean linens and resident's clothing. The facility census was 49. Findings include: Review of facility policy titled Laundry Services reviewed 12/30/2022 revealed the intent of the policy is to protect associates who handle and process the laundry while facilitating an adequate supply of linens. The policy does not document information related to covering the cart when transporting clean linen or resident's clothing. Observation on 3/11/2023 at 9:19 a.m. revealed the clean linen cart was rolled off the elevator and down the 300 hall with one side uncovered. Observation on 3/11/2023 at 9:27 a.m. and 10:11 a.m. revealed the clean linen cart was rolled off the elevator and down the 200 hall with one side uncovered. Observation on 3/12/2023 at 8:21 a.m. revealed the laundry cart with resident's clean clothing was uncovered and being rolled down the 300 hall from room [ROOM NUMBER] and stopping in front of room [ROOM NUMBER]. Interview on 3/12/2023 at 10:48 a.m. with the Laundry Supervisor DD revealed they are transporting the cart to the halls to restock the linen closet on the units. The carts should always be covered until they start unloading. They should only uncover once they arrive to restock the closet. Interview with the interim Director of Nurses (DON) on 3/12/2023 at 3:25 p.m. revealed she expects staff to keep the clean linen covered at all times while moving through the facility.

Based on observation, interviews, record review, and review of the policy titled Skilled Nursing Services Restorative, the facility failed to provide treatment and care to address the positioning needs in accordance with professional standards of practice for one of 31 sampled residents (R) (R#8) related to contracture management. Findings included: A review of the policy titled Skilled Nursing Services Restorative dated 2020 with last review date of 12/30/22 revealed the following: to establish a communication system between nursing and skilled therapy to assure continuity of care between disciplines. This center promotes nursing interventions that assist the patient in his/her ability to adapt and adjust to living as independently and as safely as possible. On 3/10/23 at 11:14 a.m. R#8 was observed in her room lying in bed. She was observed with left hand and arm contracture and right-hand contracture. The resident did not have on any splints during this observation. There was a rolled pair of socks in the residents left hand. She stated that she is not able to use her left hand at all so she puts the sock in it but can still somewhat use her right hand. She stated that there may be splints in the drawer, but she hasn't used them for a long time. She does not know why. On 3/11/23 at 9:39 a.m. R#8 was observed in her room lying in bed. The resident did not have on any splints during this observation. Again, there was the same rolled pair of socks in the residents left hand. She stated that it's been such a long time since they applied the splints or provided exercises for her with her contractures, but she would be receptive to having the staff work with her with exercises and splints. She stated that they use to, but she doesn't know why they stopped. She stated that she did not have any pain in her hands at this time. A review of the clinical record revealed that the resident was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis (MS), Osteoarthritis, Polyneuropathy Disease, Age Related Osteoporosis, Contracture of Left Hand, and Functional Quadriplegia. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#8 has a Brief Interview for Mental Status (BIMS) score 15, indicating that the resident is cognitively intact. The assessment further revealed that the resident has diagnosis of MS and has impairments on both sides with limited range of motion in upper and lower extremities. A review of the Care Plan (onset date of 6/6/18) revealed R#8 has limited mobility; is dependent for her care needs; needs assistance with functional ADL's (Activities of Daily Living) as evidenced by unsteady gait; needs assistance moving from sitting to lying in bed; needs assistance with toileting transfers; needs assistance moving from sitting to standing (from chair, w/c, or side of bed); needs assistance moving from lying to sitting position on the side of the bed; needs assistance with transfers from bed to chair (or wheelchair); decreased ROM (Range of Motion) contracture(s) and to refer to therapy as indicated. A review of the restorative plan dated 10/27/2017 revealed that the goals for R#8 were that the resident would maintain / improve current level of function and reduce risk for further limitations to her extremities. The intervention was all extremities (upper and lower) gentle stretching and PROM (Passive Range of Motion) for 10 reps / 3 sets. There was a review of the therapy tab for any notes within the last two years and there was nothing related to R#8 contracture management. During an interview with the Director of Nursing (DON) on 3/11/23 at 11:59 a.m., she stated that they do not have designated Certified Nursing Assistants (CNA's) for the restorative program. She stated that the CNA's caring for the residents are responsible for providing services when giving care. She stated that she does not know how it is documented and she does not recall seeing any splinting. She does know that they assist with ambulation and eating. she has a list of residents that get assistance with eating transferring walking dressing however R#8 was not on that list. She stated that if there is an abnormality with residents with contractures, the nursing will report. She has only been in the building as the Interim DON since February 2023, and she has not had anyone identified with new contractures. She confirmed that she completed the form on 3/10/23, indicating there were 21 residents with contracture and four were admitted with contracture. She again confirmed that there is no splinting being done in the facility that she is aware of. If therapy makes the recommendation, then they will get splinting, but she cannot say as to why there is currently no splinting being done. She has not done anything with the contractures like assessments or measurements. She stated that therapy may do measurement, but she has not delt with any contracture management since she has been at the facility. She confirmed that R#8 was not on the list for restorative and that she was not aware that R#8 had contracture. During an interview with the Therapy Director Physical Therapist on 3/11/23 at 12:22 p.m., she stated that residents with contractures should have an annual assessment/screening. There is a referral process that nursing use to refer residents to therapy if they notice contractures. She does not do any contracture management such as measurements. They only ask about pain, function, skin care, and positioning during the assessment. During an interview with the DON on 3/11/23 at 3:04 p.m. she stated that there is no way of knowing why they discharged R#8 from the restorative program. She was asked to provide any documentation as to the reason for discharge. During an interview with the DON on 3/11/23 at 3:55 p.m., she provided documents that stated R#8 was discharged from restorative program in 2018. She further stated that the last time R#8 was receiving restorative services, it was for only one hand. She isn't sure if both hands were contracted at that time. During an interview with the Therapy Director on 3/12/23 at 9:10 a.m., she stated that they have no written process or policy related to contracture management and that R#8 was admitted with left hand contracture. In 2018, her right hand started contracting. They were doing splinting as tolerated with the restorative program. She has not been on restorative case load since 2018. She stated that the resident would tolerate the splint sometimes. She stated that the resident does receive care from the aides, but she is not and has not been on any official restorative program since 2018. She was asked again to provide any documentation related to contracture assessments. During an interview with the Therapy Director on 3/12/23 at 10:32 a.m., she confirmed that there was no documentation that R#8 had any annual assessments or contracture management since 2018.

Based on record review, staff interview, and review of the facility policy titled Automatic Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two residents (R) (R#26, R#198) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#26 and R#198. Findings are: A review of the facility policy, Automatic Stop Orders, dated 2019, revealed PRN order for psychotropic medications would require the prescriber to specify a duration over 14 days with a clinical rationale. Per the policy, psychotropic orders would require a set duration time and could not be renewed for longer than 14 days without a direct evaluation of the patient by the prescriber. A review of the medical record revealed R#26 was admitted to the facility on [DATE] with a past medical history of Arthritis/OA, glaucoma (blind left eye), significant hearing deficit (able to hear minimal and left ear), TIA, aphasia, dementia, and frequent falls. A review of the Physician's orders dated 2/6/2023 revealed the Physician ordered lorazepam 0.5 mg by mouth every four hours as needed for anxiety. The order had a start date of 2/6/2023, but the order had no stop date. A medical record review revealed the facility's Psychoactive Medication Consent Form, dated 2/10/2023. The form indicated family gave consent to administer 0.5 milligrams of lorazepam for six months, by mouth, for anxiety. A facility nurse also signed the document. During an interview with the Interim Director of Nursing (DON) on 3/11/2023 at 11:05 a.m., she acknowledged R#26's as needed (PRN) order for lorazepam had no end date. She explained that the 12/31/9998 end date documented in the Physician's orders reflected no end date for the medication. The DON stated she was not aware an end date for psychotropic drugs was required for hospice patients. 38988 2. Review of the clinical record for R#198 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's disease, stage 4 pressure ulcer of sacral region, diabetes, anxiety disorder, major depressive disorder, peripheral vascular disease, and hypertension. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, indicating moderate cognitive impairment. Review of Summary Report dated 5/1/2022 through 8/13/2022 for R#198, revealed an order dated 5/5/22 for lorazepam (a medication used to treat anxiety) one (1) milligram (mg) every six hours as needed (PRN) agitation. There is no evidence of a 14 day stop date or a rationale from the physician for the extension past 14 days. Review of the Medication Administration Records (MARs) for May 2022, revealed as needed lorazepam was administered 16 times; 32 times in June 2022; 32 times in July 2022, and nine times in August 2022. Interview on 3/12/2023 at 2:43 p.m. with Licensed Practical Nurse (LPN) AA sated that she tries to use diversional tactics for residents who have behaviors, before administering psychotropic medications. She stated that if a resident's as needed psychotropic medication is discontinued, she will notify physician for re-order. She stated that she thought that when the psychotropic medications were entered into the electronic medical record, that the system automatically applied a stop date for the medications that are ordered on an as needed basis. She confirmed that she administered R#198 as needed lorazepam when he was a resident at the facility but stated she did not notice that the order did not have a stop date.

Based on observation, staff interviews, and policy review titled Medication Storage in the Care Center, the facility failed to ensure the medication cart and treatment cart on the second floor were locked and secured, when not in use. The facility census was 49 residents. Findings include: Review of the facility policy titled Medication Storage in the Care Center copyright 2023, revealed the intent is to ensure medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The guideline indicated medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 3/11/2023 at 7:47 a.m. revealed on the second floor, the medication cart directly across from the nurse's station was noted to be unlocked. The treatment cart, along the wall to the left of the nurse's station, was also noted to be unlocked. There was no nursing staff near the nurse's station at the time of this observation. There were two residents sitting in the small dining room, adjacent to the nurse's station. Surveyor observed both carts for approximately four minutes before staff member exited elevator and walked up to the medication cart. Interview on 3/11/2023 at 7: 53 a.m. with Licensed Practical Nurse (LPN) AA, stated she was not aware that the medication cart was unlocked. She stated she had to switch out the computers for medication pass because it was dead, and she must have forgotten to lock the medication cart when she left the floor. She stated that she had not used the treatment cart since she started her shift today and stated the night shift nurse must have left it unlocked. Interview on 3/12/2023 at 12:00 p.m. with Interim Director of Nursing (DON), stated it is her expectation that all medication and treatment carts be locked at all times, when not in the use by the nursing staff.

Based on observation and staff interviews the facility failed to have an up to date staffing information posted on 6/13/ 2021, 6/14/2021, 6/15/2021, and 6/16/2021. In addition, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months. Findings include: An observation on 6/13/2021 at 1:15 p.m. upon enterance the facility the staffing information was not posted in a prominent place readily accessible to residents and visitors. An observation of staffing posting on 6/13/2021 at 6:30 p.m. staffing information posted at the receptionist desk with a date of 6/13/2021, census 42, Licensed staff, and unlicensed staff listed. No Registered Nurse (RN) hours documented on the posting. An observation on 6/14/2021 at 8:45 a.m. staffing information was not posted. An observation on 6/15/2021 at 8:30 a.m. staffing information was not posted. An observation on 6/16/2021 at 9:00 a.m. staffing information was not posted. An interview was conducted on 6/16/2021 at 9:15 a.m. with the Assistant Director of Nursing (ADON) revealed that it is her responsibility to post the daily staffing information. The ADON stated she did not post the staffing information for the past three days although she cannot explain why she did not post the staffing. She further revealed that she does not keep the staffing data for the required 18 months. An interview was conducted on 6/16/2021 at 9:20 a.m. with the Director of Nursing (DON) revealed that she posted the staffing information on Sunday 6/13/2021 upon her arrival to the facility. The DON revealed that there was a RN in the facility but she failed to add the RN hours to the staffing information on 6/13/2021. An interview with the Administrator on 6/16/2021 at 10:45 a.m. revealed that the facility has not maintained the posted daily nurse staffing data for a minimum of 18 months.