Every finding on record at Crestwood Treatment Center

Based on observation, interview and record review, the facility failed to protect two of four sampled residents' (Resident 2 and 4) right to be free from physical abuse when:Resident 1 struck Resident 2 on the lip with closed fist in the television room.Resident 3 struck Resident 4 in the nasal area with closed hand in the television room.These failures resulted in Resident 2 sustaining skin tear to lower lip and Resident 4 abrasion on the bridge of nose. During a review of Resident 1's Annual Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 4/29/25, the MDS indicated Resident 1 was admitted to the facility on [DATE]. MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 09 meaning impaired cognition. MDS indicated Resident 1 had verbal behavior symptoms directed towards others e.g., threatening, screaming, and cursing at others. Resident 1 had slurred speech, with difficulty communicating but able if prompted. MDS indicated Resident 1 used manual wheelchair for mobility. MDS indicated Resident 1 was independent once seated in wheelchair and able to wheel at least 50 feet and make turns. MDS indicated Resident 1's diagnosis included traumatic brain injury and non-Alzheimer's' dementia (a progressive disease that destroys memory and other important mental functions).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (memory loss) and stroke. MDS indicated Resident 2's BIMS score was 09 meaning impaired cognition. MDS indicated Resident 2 used wheelchair for mobility. MDS indicated Resident 2 needed a helper with ability to wheel at least 50 feet and make two turns once seated in wheelchair. MDS indicated Resident 2 had clear speech, able to make self-understood and understand others.During a review of Resident 2's Progress Notes (PN), dated 4/11/26, PN indicated Resident 2 was stationed in his wheelchair in the television room when Resident 1 approached him and attempted to position his wheelchair close to Resident 2's wheelchair. Resident 1's wheelchair contacted Resident 2's wheelchair. Resident 2 made an unclear statement to staff when Resident 1 struck Resident 2 on the lip with closed fist and Resident 2 sustained minor skin tear on the lip.During a concurrent observation and interview on 5/22/26, at 9:50 a.m. with Resident 1, Resident 1 was seated up in his wheelchair in his room. Resident 1 stated he did not strike Resident 2 with his hands. Resident 1 stated he was not in the television room. Resident 1 backed up his wheelchair from his room to the hallway and rolled his wheelchair down the hallway.During a review of Resident 1's impaired cognition plan, revised 2/20/24, the care plan indicated Resident 1 had impaired thought processes related to history of traumatic brain injury. Care plan indicated Resident 1 rolled his wheelchair near other residents in a seemingly intentional manner and into tight spaces without attending to circumstances; this behavior and his teasing behavior could be triggering to other residents and placed residents at risk to become recipient of contact. Resident 1's care plan interventions included to provide supervision, proactively anticipate needs of resident in the event he attempted to redirect his peers.During an interview on 5/22/26, at 10:26 a.m. with Program Leader (PL 1), PL 1 stated she was on duty monitoring residents in the television room when Resident 1 came into the television room. PL 1 stated Resident 1 backed up his wheelchair into the television room without looking and bumped into Resident 2. PL 1 stated Resident 1 punched Resident 2 on the lips and tried to punch Resident 2 again. PL 1 stated she was aware Resident 1 would roll near other residents intentionally. PL 1 stated she was alone monitoring residents in two television rooms. PL 1 stated she tried to redirect Resident 1. PL 1 stated at least two program leaders should be in the television room to monitor residents.During a review of Resident 3's admission Record (AR), dated 5/22/26, AR indicated Resident was admitted to the facility on [DATE], with diagnoses that included schizophrenia and dementia.During a review of Resident 3's MDS dated [DATE], MDS indicated Resident 3's BIMS score was 11 meaning impaired cognition. MDS indicated Resident 3 had verbal behavior symptoms directed towards others e.g., threatening, screaming, and cursing at others and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or verbal/vocal symptoms like screaming and disruptive sounds). MDS indicated Resident 3 had clear speech, able to make self-understood and understand others. MDS indicated Resident 3 used manual wheelchair for mobility. MDS indicated Resident 3 was independent once seated in the wheelchair and able to wheel at least 50 feet and make turns.During a review of Resident 4's admission Record (AR), dated 5/22/26, AR indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health condition that causes extreme mood swings) and dementia.During a review of Resident 4's MDS, dated [DATE], MDS indicated Resident 4's BIMS score was 15 meaning intact cognition. MDS indicated Resident 4 had verbal behavior symptoms directed towards others e.g., threatening, screaming, and cursing at others and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or verbal/vocal symptoms like screaming and disruptive sounds). MDS indicated Resident 4 had clear speech, able to make self-understood and understand others.During a review of Resident 4's Progress Note (PN), dated 4/10/26, the PN indicated that while residents were waiting in the television room, Resident 3 approached Resident 4 as Resident 4 sat in the television room. Resident 3 asked Resident 4 to move his walker. Resident 4 could not hear due to Resident 4 wearing his headphone. As Resident 4 attempted to move his walker, Resident 3 became upset and struck Resident 4 with closed hands in the nasal area, knocking down his glasses. Resident 4 sustained an abrasion on the nasal bridge.During a concurrent observation and interview on 5/22/26, at 10:07 a.m. with Resident 4, Resident 4 was in his room standing with a walker. Resident 4 stated that he did not know why he was hit on the face by Resident 3. Resident 4 stated he had his headphone on his head and did not hear what Resident 3 was saying. Resident 4 said he was suddenly hit on the face. Resident 4 stated he sustained injury on his nose.During a review of Resident 4's mood problem care plan, initiated on 8/28/25, care plan indicated Resident 4 exhibited intrusive and verbally aggressive behaviors towards staff members, and Resident 4 initiated physically aggressive contact toward staff members during care. Care plan interventions included that staff members were encouraged to maintain a safe distance from Resident 4 if he was exhibiting loud verbal outbursts or verbal aggression to reduce potential for physically aggressive contact.During an interview on 5/22/26, at 10:40 a.m., with Program Leader (PL 2), PL 2 stated that Resident 3 bumped into Resident 4's walker. PL 2 stated Resident 3 pushed Resident 4's walker out of the way then punched Resident 4 in the face. PL 2 stated the incident happened in the television room. PL 2 said that he was the only staff present. PL 2 stated at least two program leaders should be in the television room to monitor residents.During an interview on 5/22/26, at 10:54 a.m., with Resident 3, Resident 3 stated he hit Resident 4 in the face. Resident 3 said Resident 4 did not listen to Resident 3. Resident 3 stated Resident 4 had headphone on his head and could not listen to him. During an interview on 5/22/26, at 10:22 a.m., with Director of Therapeutic Recreation (DTR), DTR stated a minimum of three to four staff should be in the television rooms to facilitate activities every shift to manage resident behaviors and environment. DTR stated staff monitor residents, anticipate residents' needs, help guide the residents into an appropriate place to sit, redirect, and provide reassurance.During an interview on 5/22/26, at 11:02 a.m., with Director of Nursing (DON) and Administrator (Admin), Admin stated facility increased the number of staff supervision to cover the activities in the television room.During a review of the facility's policy and procedure (P&P) titled, Elder and Dependent Abuse/Suspicion of a crime, dated 6/25/24, the P&P indicated, Facility believes every person served, or resident has the right to be free of physical abuse, neglect, financial abuse, abandonment, isolation, abduction, exploitation, or other treatment with resulting physical harm or pain or mental suffering.

Based on observation, interview, and record review, the facility failed to follow proper food storage, sanitation, and food handling, when: 1. Kitchen pantry had two food items that were stored past their used-by dates; 2. Microwave was not cleaned routinely; 3. The lid of the ice machine was dirty; 4. Chopping boards had deep cuts and scratches. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 2/24/25, at 10:30 a.m., with Dietary Manager (DM), DM stated the kitchen pantry had food items that were stored past their used-by dates: - An unopened Sweet Pickle Relish gallon container with received date of 11/8/23 and used-by date of 11/8/24. - An unopened Thousand Island Salad Dressing gallon container with received date of 9/4/24 and used-by date of 12/4/24. DM stated the food items should have been thrown out as they were past the used-by dates. During an interview on 2/27/25, at 10:50 a.m., DM stated food items past the used-by dates may have salmonella and cause food contamination. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2017, the P&P indicated, Food and supplies will be stored properly and in a safe manner .All food products will be used per the times specified in the Dry Food Storage Guidelines, . During a review of the facility's Dry Goods Storage Guidelines, dated 2018, the guidelines indicated: Pickles, relish - storage length when unopened on shelf - one year Salad dressing, bottled - storage length when unopened on shelf - four months. 2. During a concurrent observation and interview on 2/24/25, at 10:30 a.m., with DM, DM stated the kitchen microwave interior (inside) had dried food build-up from food splashes. During an interview on 2/27/25, at 10:50 a.m., DM stated microwave had to be cleaned after every use due to danger of food contamination. During a review of the facility's P&P titled, Equipment and Supplies, dated 2018, the P&P indicated, Effective maintenance management does not just happen! It is brought about by a thorough understanding and implementation of the principles of sanitation, and a knowledge of the necessary tools required for each cleaning task . Sanitizers or Germicides . a sanitizer is recommended for sanitizing utensils or surfaces which have direct contact with food, but which cannot be sanitized by immersion in 180 degrees Fahrenheit (F) water for 30 seconds, such as refrigerators or tables. It is important to thoroughly rinse the utensils or surface prior to applying the sanitizing agent as sanitizers will be effective in the present of some detergents and food particles . 3. During a concurrent observation and interview on 2/24/25, at 10:30 a.m., with DM, there were multiple areas of black residue on the baffle (lid) of the ice machine. DM stated kitchen staff were to clean it monthly. DM also stated the ice machine had preventive maintenance done twice a year by an outside service. When the surveyor wiped the surface of the lid with a white paper towel, the surface felt rough, and some black residue came off onto the paper towel. During an interview on 2/25/25, at 3:35 p.m., with Maintenance Assistant (MA), MA stated residue and discoloration was due to wear and tear, however, after he cleaned an area of the lid, there was less residue. MA stated he had not been informed of the residue build-up until yesterday. During a review of the facility's P&P, dated 2018, titled Ice Machine Cleaning Procedures, the P&P indicated, Be sure special attention is paid to cleaning the door molding and the lid of the machine. 4. During a concurrent observation and interview on 2/24/25, at 10:30 a.m., with DM, there were five cutting boards (cream, white, green, red, off-white) that had faded colors, scratches, and deep cuts on the surfaces. DM stated there was a danger of bacteria and cross contamination since the cutting boards could not be adequately cleaned. According to the 2017 Federal Food Code, food contact surfaces are to be smooth, free from inclusions, pits, and similar imperfections and are to be smooth and clean to sight and touch. Also, according to the Food Code Annex, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.

Based on observation, interview, and record review, the facility failed to ensure the garbage dumpster bin located outside the facility grounds had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest-related diseases for 58 residents out of a facility census of 58. Findings: During an observation on 2/24/25, at 9:00 a.m., outside the facility, there was a garbage dumpster bin located on the parking lot at the right side of the facility. The garbage bin had two panels of black-colored lids. The garbage dumpster bin had excess garbage inside which created gaps as both lids could not be closed. The gap between the lid and the bin on the left side was at least twelve inches. The gap between the lid and the bin on right side was at least six inches. On the ground, to the left of the dumpster bin, were at least ten plastic bags of garbage. During a concurrent observation and interview on 2/24/25, at 10:00 a.m., with Maintenance Director (MD), MD stated the two black-colored lids of the garbage bin could not be closed because of overflowing garbage. Per MD, he had no concerns with gaps between the lid and bin. MD added he had no concerns with overflowing garbage as long as the surrounding areas on the ground were neat, clean, and had no scatter. During an interview on 2/27/25, at 10:50 a.m., with Dietary Manager (DM), DM stated the trash bin should not be overflowing. Per DM, lids should be closed for safety due to rodents potentially getting inside the dumpster bin and in the facility. During a review of the facility's policy and procedure (P&P) titled, Garbage and Trash, dated 2018, the P&P indicated, Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish.

Based on observation, interview, and record review, the facility failed to ensure three of 25 sampled residents (Resident 1, Resident 3, and Resident 12) received proper care in a manner to prevent the spread of infection during meal assistance. These failures to perform hand hygiene after each contact with Resident 1, Resident 3, and Resident 12, had the potential to result in transmission of pathogens (bacteria, virus, or other microorganisms capable of causing infection or disease) from one resident to the next and cause infection or disease. Findings: A review of Resident 12's admission Record, printed 2/27/25, indicated resident was admitted in 2007 with multiple diagnoses of dementia (memory loss; a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury, and hemiplegia (muscle weakness on one side of the body) affecting right dominant side. A review of Resident 12's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 11/20/24, indicated resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) during eating. The MDS further indicated Resident 12 had a swallowing disorder and was at risk for coughing or choking during meals or when swallowing medications. A review of Resident 12's Care Plan, dated 7/7/23, indicated resident had a nutritional challenge or a potential nutritional challenge related to cognitive and behavioral deficits .One intervention indicated, .may provide proactive feeding assistance as needed and as tolerated when exhibiting impulsivity (tendency to act without thinking) and poor safety awareness at meals . A review of Resident 12's Physician Order, dated 4/2/24, indicated resident had an order of pureed (to blend, chop, mash, or strain food until it has the soft consistency) diet, pureed texture, and honey-thick (slightly thicker like honey or milkshake) liquids consistency. A review of Resident 1's admission Record, printed 2/27/25, indicated resident was admitted in 2006 with multiple diagnoses of dementia, Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and gastro-esophageal reflux disease (when stomach contents move up to the esophagus). A review of Resident 1's MDS, dated [DATE], indicated resident required supervision or touching assistance during eating, but without a swallowing disorder. A review of Resident 1's Care Plan, dated 1/13/21, indicated resident had a nutritional challenge or a potential nutritional challenge related to cognitive and behavioral deficits .One intervention indicated, .Resident may demand assistance beyond need, may ask for staff to feed him, responds to gentle encouragement, guiding tactile initiation of movement, or assistance scooping then placing utensil in resident's hand. A review of Resident 1's Physician Order, dated 9/20/23, indicated resident had an order of mechanical soft diet, mechanical soft (foods that are soft and easy to chew) texture, and honey-thick liquids consistency. A review of Resident 3's admission Record, printed 2/27/25, indicated resident was admitted in 2003 with multiple diagnoses of dementia and traumatic brain injury. A review of Resident 3's MDS, dated [DATE], indicated resident required supervision or touching assistance during eating, but without a swallowing disorder. A review of Resident 3's Care Plan, dated 1/13/21, indicated resident had a nutritional challenge or a potential nutritional challenge related to cognitive and behavioral deficits .One intervention indicated, .Provide gentle cues as needed to increase alertness if noted to be sleepy at meals . A review of Resident 3's Physician Order, dated 2/11/21, indicated resident had an order of cut-up meat texture, regular consistency . During a lunch dining observation on 2/24/25, at 12:10 p.m., in the main dining room, Licensed Vocational Nurse 3 (LVN 3) was noted assisting one of the three residents seated around the table. LVN 3 was observed guiding Resident 12's right hand as the resident put food in his mouth. While Resident 12 continued to work on his lunch meal, LVN 3, without performing hand hygiene, turned to assist Resident 1 who was seated to the right of LVN 3. LVN 3 picked Resident 1's cup and moved it closer so that it was within Resident 1's reach. LVN 3 also assisted Resident 1 in scooping the food with his spoon. LVN 3 then turned back toward Resident 12 to continue assisting Resident 12. LVN 3 was noted switching from assisting Resident 12 to Resident 1 at least twice, then LVN 3 walked to a nearby table where Resident 3 was seated with another resident. LVN 3 touched Resident 3's bowl and moved it closer to Resident 3. LVN 3 was observed providing feeding assistance to Resident 12, Resident 1, and Resident 3 without performing hand hygiene in between switches. During an interview on 2/24/25, at 12:20 p.m., with the Director of Staff Development (DSD), DSD stated, during feeding assistance, staff should not move from one resident to the next without hand hygiene due to cross contamination, infection control, and the dynamics of each resident. During an interview on 2/24/25, at 12:30 p.m., LVN 3 stated she should have washed her hands in between feeding more than one resident. LVN 3 stated it was important to sanitize or wash hands in between feeding residents to prevent cross contamination. During an interview on 2/25/25, at 8:44 a.m., with the Director of Nursing (DON), DON stated one staff per resident is usually assigned to assist in feeding. DON further stated if a staff needed to feed more than one resident, the staff should wash hands in between residents to prevent infection and cross contamination. A review of the facility's policy and procedure (P&P) titled, Dining Program, dated 9/1/13, indicated, Each resident/client receives nourishing, palatable, attractive meals to meet their individual needs in an environment that provides a supporting setting with the services necessary to maintain and/or improve each resident/client's dining skills .Hygiene: Hand washing should be completed for staff prior to and after mealtime . A review of the facility's P&P titled, Infection Control Program, undated, indicated, The facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection .

Based on observation, interview, and record review, the facility failed to ensure open date/ use-by date was added to the insulin pen (a device which contains long-acting insulin used to help manage blood sugar levels in residents with high blood sugar levels) after it was removed from the refrigerator for administration to one of 16 sampled residents (Resident 35). This failure placed Resident 35 at risk for receiving the insulin beyond the use by date with the potential to result in unsafe and ineffective administration of the medication. Findings: During a record review of Resident 35's Order Summary Report (OSR), dated 02/2025, the OSR indicated, Resident 35 had an order to administer Basaglar KwikPen Subcutaneous Solution Pen Injector 100 unit/mL [milliliter, unit of measure] every morning) since 12/3/24. During a concurrent observation and interview on 2/24/25, at 10:16 a.m., with Licensed Vocational Nurse 1 (LVN 1) and Director of Nursing (DON), Resident 35's Basaglar KwikPen Insulin pen 100 unit/1 mL was stored inside Resident 35's medication tray in the Medication Room at Nursing Station 1. The pen had a green label stating Date Opened and Discard After adhered to it, however both areas were left blank. LVN 1 stated the pen had another label which indicated, Discard unused medication after 28 days. Staff had no way of knowing when to discard the insulin pen or if the pen was in use beyond 28 days, and the pen still had medication left in it, since there was no date opened listed on the pen.

Based on interview and record review, the facility failed to ensure 56 of 56 sampled residents received a Medication Regimen Review (MRR, a pharmacist review of resident's medications to ensure safe and appropriate medications were prescribed by physician) for two months. This failure placed the facility's 56 residents at risk of side effects from psychoactive medications (medications used in the treatment psychiatric disorders and require monitoring for side effects), insulin (medication to treat high blood sugar and require monitoring to maintain normal blood sugar) and anti-coagulation medications (medications that prevent blood clots and require monitoring for excessive bleeding). Findings: A review of the facility document titled, MDS Resident Matrix, dated 4/10/23, indicated the facility had 54 residents on psychoactive medications, six residents on insulin, and three residents on anti-coagulation medications. During a concurrent interview and record review, on 4/12/23, at 10:53 a.m., with the Director of Nursing (DON), the facility MRR binder was reviewed. The DON stated the February 2023 and March 2023 MRR were not in the binder, and the pharmacist (PH) had the two MRR's for February and March. The DON stated the PH was expected to complete a monthly MRR for all residents. During an interview on 4/12/23, at 11:43 a.m., with PH, PH stated he completed the MRR for February 2023, and March 2023, but was unable to provide completed copies of either the March 2023 MRR, or the February 2023 MRR. PH stated the facility had not received copies of the MRR for February 2023 and March 2023. PH stated monthly MRR were completed to ensure resident medications were reviewed and monitored to prevent unwanted side effects of medications. A review of facility policies and procedures indicated the facility did not have a policy or procedure for the pharmacist to follow to ensure residents received a monthly MRR.

Based on observation and record review, the facility infection prevention plan did not include a system or process to monitor for bacteria in the facility water system. The facility failed to develop or implement policies or procedures to ensure the facility water system was free of bacterial contamination including Legionella (the bacterium which flourishes in stagnant water and air conditioning and central heating systems and can cause disease). This failure had the potential to result in illness or death for residents exposed to contaminated water from ingestion or airborne exposure from ventilation systems. Findings: During an interview on 04/13/23, at 10:58 AM, with the Director of Nurses (DON) and Administrator (Admin), the Admin stated questions about facility water testing to rule out Legionella bacteria should be directed to the Maintenance Director (Main-D). During an interview and concurrent record review on 04/13/23, at 11:30 AM, with Main-D, the facility's maintenance records were reviewed. Main-D was unable to provide documentation of a facility water management plan to include a system, verification or validation process to ensure the facility remained free of Legionella in accordance with nationally accepted standards. Main-D stated the facility had no policies or procedures or any measure in place to ensure there was no Legionella in the water system.

Based on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Kitchen Pantry had multiple food items that were stored past its used-by dates. 2. Reach-in Refrigerator 1 had four trays of prepared jelly in cups that were not labeled and dated. 3. Walk-in Refrigerator had: - two boxes of iceberg lettuce that were discolored, wilted, and did not have received-by or used-by dates. - half a bag of breadsticks was hard, dry, and without a date or label. 4. Microwave was not cleaned routinely. 5. Chest freezer had ice build-up around the wall and freezer rim and did not have a thermometer or a temperature log monitoring system. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 4/10/23, at 10:30 a.m., with the Dietary Manager (DM), DM stated the kitchen pantry had food items that were stored past its used-by dates: - A half-full clear bin of sugar with received date 12/8/21 and used-by date 12/8/22. - Two clear bins of saltine crackers with received date 9/14/22 and used-by date 12/14/22. - A clear bin of graham crackers with received date 1/4/23 and used-by date 3/4/23. - A clear bin of hot cocoa mix (regular chocolate and diet chocolate) with received date 9/21/22 and used-by date 12/21/22. - A a clear bin of jam/jellies (jelly regular and diet) with received date 7/24/19 and used-by date 7/24/20. - A clear bin of corn flakes cereals with received date 1/6/23, used-by date 4/6/23. DM stated the food items should have been discarded once used-by dates had been reached. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, undated, the P&P indicated, Food and supplies will be stored properly and in a safe manner .All food products will be used per the times specified in the Dry Food Storage Guidelines, .The storage times in the guidelines are intended to be on the safe side . During a review of the facility's Dry Goods Storage Guidelines, dated 2018, the guidelines indicated: Sugar - storage length when opened on shelf - one year Saltine crackers - storage length when opened on shelf - one month Graham crackers - storage length when opened on shelf - one month Cocoa mixes - storage length when unopened on shelf - six months Jam/jellies - storage length when unopened on shelf - one year Corn flakes - storage length when opened on shelf - two months 2. During a concurrent observation and interview on 4/10/23, at 10:50 a.m., with DM, the Reach-in Refrigerator 1 had four trays of prepared jelly in cups that were not labeled and dated. DM stated the jelly in cups will be served for lunch on the same day of 4/10/23 but should have been labeled and dated when prepared by the dietary staff. During a review of the facility's P&P titled, Procedure for Refrigerated Storage, undated, the P&P indicated, .Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice .Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated . 3. During a concurrent observation and interview on 4/10/23, at 10:55 a.m., with DM, the Walk-in Refrigerator was observed with half a bag of breadsticks that was hard, dry, and without a date or label. In the same refrigerator were two boxes of iceberg lettuce, one box with five heads of lettuce and the other, a full unopened box. DM stated the two boxes of iceberg lettuce did not have received-by or used-by dates. DM also confirmed all the heads of iceberg lettuce in both boxes were discolored, wilted, soft, and wrinkled which can no longer be used or served. During a review of the facility's P&P titled, Storage of Food and Supplies, undated, the P&P indicated, .Bread will be delivered frequently and used in the order that it was delivered to assure freshness. Bread products not used within 5 days can be frozen. Some breads do last 5-7 days. Check manufacturer's recommendations. Do not store bread in the refrigerator . During a review of the facility's P&P titled, General Receiving of Delivery of Food and Supplies, undated, the P&P indicated, .Produce is to be fresh and free of any wilting or spoilage .Label all items with the delivery date or used-by date. 4. During a concurrent observation and interview on 4/10/23, at 11:15 a.m., DM stated the kitchen microwave interior (inside) and exterior (outside) walls had dried food particle build-up from spills and splashes. DM stated it should be cleaned routinely to avoid bacterial growth. During a follow-up observation on 4/11/23, at 11:06 a.m., the microwave was still observed uncleaned. During a review of the facility's P&P titled, Equipment and Supplies, dated 2018, the P&P indicated, Effective maintenance management does not just happen! It is brought about by a thorough understanding and implementation of the principles of sanitation, and a knowledge of the necessary tools required for each cleaning task .Sanitizers or Germicides .a sanitizer is recommended for sanitizing utensils or surfaces which have direct contact with food, but which cannot be sanitized by immersion in 180 degrees Fahrenheit (F) water for 30 seconds, such as refrigerators or tables. It is important to thoroughly rinse the utensils or surface prior to applying the sanitizing agent as sanitizers will be effective in the presence of some detergents and food particles . 5. During a concurrent observation and interview on 4/11/23, at 10:59 a.m., with Cook 2, in the Dish Room, the chest freezer was opened and observed. There were no thermometers inside or outside the appliance to monitor the freezer temperature, no posted or unposted Temperature Log or Cleaning Monitoring System, and there was ice build-up all around the inside freezer wall and rim. Cook 2 stated ice build-up was not good as air can get in and freezer will not function properly and may affect food shelf life. During a follow-up interview on 4/11/23, at 12:10 p.m., DM stated the freezer needed a thermometer and a temperature log to monitor the temperature. DM also stated the freezer had to be defrosted and cleaned regularly to prevent ice build-up. During a review of the facility's P&P titled, Procedure for Freezer Storage, undated, the P&P indicated, .Each freezer must have two thermometers that are easily visible. Freezer temperatures should be recorded twice. Temperatures are to be recorded upon opening and closing of kitchen by a designated employee, and logged in the Cold Storage Temperature Log .Freezer doors are to close tightly .

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for two of two sampled residents (Resident 52 and Resident 44) when Licensed Vocational Nurse 1 (LVN 1) did not complete the 72-hour Neurological Check (a simple assessment tool used to check a person's level of consciousness [LOC], pupil reaction, speech, hand grasp, movement, and vital signs) on 4/11/23. This failure had the potential to result in inaccurate assessments of Resident 52 and Resident 44 and delay in the provision of resident care needs. Findings: A review of Resident 52's Admission Record, dated 4/11/23, indicated Resident 52 was admitted in May 2023, with diagnoses of dementia (memory loss) and Schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). A review of Resident 52's Change of Condition Notes, dated 4/9/23, indicated Resident 52 was a recipient of physical aggression and obtained an abrasion (scrape) on middle of forehead and swelling around the left eye. Recommendations include medical charting times (x) 72 hours, Neuro Check x 72 hours, and Weekly Skin Assessment initiated. A review of Resident 44's Admission Record, dated 4/11/23, indicated Resident 44 was admitted in November 2018, with diagnoses of dementia, Schizophrenia, and traumatic brain injury. A review of Resident 44's Change of Condition Notes, dated 4/9/23, indicated Resident 44 had an episode of initiating physical aggressive behavior towards peer and in return he was struck on the right side of face without injury. Recommendations include medical charting x 72 hours, Neuro Check x 72 hours, and Weekly Skin Assessment initiated. During a concurrent interview and record review on 4/12/23, at 12:35 p.m., with the Director of Nursing (DON), Resident 52 and Resident 44's Neurological Flow Sheets were reviewed. DON stated neuro checks for both residents should be done every 15 minutes for first hour, every hour for the next 4 hours, and every shift for a total of 72 hours. DON stated LVN 1 did not complete flow sheets for both residents during day shift on 4/11/23. DON stated, She was supposed to continue the neuro check but it was missed. During an interview on 4/12/23, at 2:08 p.m., with LVN 1, LVN 1 confirmed she worked the morning shift of 4/11/23. LVN 1 stated she assessed Resident 52 and Resident 44 but forgot to document on their Neurological Flow Sheets nor in the Nurses Progress Notes. LVN 1 further stated, because it was not documented on 4/11/23, LVN 1 had no proof that neuro checks were performed as needed for both residents. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessments (Neuro Checks), dated 9/1/13, the P&P indicated, Neuro-checks are performed by a licensed nurse per physician's order, or upon changes in condition when neurological deficits are suspected or anticipated, including, but not limited to .Suspected head injury, i.e. sudden change in LOC, or signs/symptoms of head injury (i.e .bleeding .altercation, or other event) .Collect neurological signs data as follows (unless otherwise ordered per physician) and record on Neurological Evaluation Flow Sheet: a. every 15 minutes for the first hour. b. Every hour for the next (four) 4 hours. c. Every shift for a total of 72 hours .

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage when the following were noted: 1. Two dietary staff did not have their hair fully covered; 2. In refrigerator #2, a tray of raw eggs were placed on top of prepared snacks, and a container labeled menudo had an use-by-date of [DATE]; and, 3. There were two packages of mousse mix and one packet of whipped topping with expiration dates of ,[DATE] in the dried storage area of the kitchen. These deficient practices had the potential to cause food-borne illnesses to residents receiving their meals in the kitchen of facility. Findings: During a kitchen observation with the Food Service Director (FSD) and concurrent interviews on [DATE] at 8:18 a.m., the Dietary Aide (DA 1) was observed with braided hair hanging down her back with her hair net covering only the top of her head. The DA 1 stated her braids were just done yesterday and that she could not figure out how to cover her braids/hair with a hairnet. DA 1 then stated, It still hurts to gather my hair up together. By observation on [DATE] at 8:20 a.m., in Refrigerator #2, a tray of raw eggs was placed on top of prepared sandwiches and pudding. Additionally, a container labeled, menudo, dated [DATE] with an use by date of [DATE]. The FSD stated that the eggs should not be placed on top of prepared foods. During an observation and concurrent interview with the FSD while in the dry storage room area on [DATE] at 8:30 a.m., there were two packages of mousse mix and one packet of whipped topping with expiration date of ,[DATE]. The FSD stated, These are expired., and then proceeded to remove the packets. The FSD stated there was no designated staff to check the storage room and that, Whoever is on duty should do it. During a follow-up kitchen observation on [DATE] at 10:43 a.m., a second Dietary Aide (DA 2) had her hair partially covered with her bangs and hair exposed down her back. The DA 2 then stated, Yes, this is how I cover it. A review of the facility policy and procedure titled, Dress Code, dated for (YEAR), indicated female staff should wear a, Hair net or hat which completely covers the hair. Review of the facility policy and procedure titled, Food Preparation, dated (YEAR), indicated that the facility would, Use refrigerated leftovers within 72 hours.

Based on observation, interview and record review, for one of three sampled residents (Resident 59), the facility failed to ensure Resident 59 received treatment and services when Resident 59's eyes developed thick, purulent, sticky yellow drainage without assessment and initiation of treatment. This failure resulted in the delay of treatment and had the potential to result in complications. Findings: Review of Resident 59's Admission Record on 6/10/19 indicated Resident 59 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation on 6/10/19 at 12:54 p.m., Resident 59's eyes had thick, purulent, sticky, yellow drainage. Additionally, by continued observation, both of Resident 59's eyes had a brown, dried, crusty substance around them. During an interview on 6/10/19 at 12:54 p.m., Certified Nursing Assistant (CNA 1) stated she assisted Resident 59 in the bathroom the morning of 6/10/19, however had not noticed Resident 59's eyes. CNA 1 then checked Resident 59's eyes, confirmed that both eyes had drainage, then stated, I will let the nurse know right now. In a concurrent interview and record review with Registered Nurse (RN 1) and the Director of Nursing (DON) on 6/10/19 at 1 p.m., RN 1 stated Resident 59's eye drainage was normal. RN 1 then stated that Resident 59 refused to have his eyes cleaned at times. RN 1 acknowledged she had not noticed Resident 59's eyes on 6/10/19. The DON stated Resident 59 had a chronic eye condition which was treated with an antibiotic (MONTH) 2019, however was unable to show that the facility had assessed or developed a plan of care for Resident 59's purulent eye drainage. The DON then stated, We will call the doctor now. Review of an undated facility policy and procedure titled, Change of Patient Status, indicated that all residents who have a significant change in condition, medical or behavioral, will be assessed by the licensed nurse and the findings will be reported to the medical or behavioral doctor, psychiatrist and conservator.

Based on observation, interview, and records review, the facility failed to ensure storage of food under sanitary conditions when: 1. Multiple food items were unlabeled and undated. 2. Multiple cans of beverages were stored on the floor. 3. Employee's personal food was stored in the kitchen refrigerator. These failures had the potential to result in food borne illnesses. Findings: 1. During an observation and concurrent interview with Dietary Aide (DA) 1 on 6/19/17, at 7:15 a.m., the following unlabeled and undated food items were in the walk-in refrigerator: a. eight ham and cheese half-sandwiches, b. two whole cheese sandwiches, c. three whole ham and cheese sandwiches, d. and six glasses of pudding. The DA1 stated each of the above food items were unlabeled and undated. The DA1 further stated I don't know when it was prepared. During an interview with the Dietary Supervisor (DS) on 6/19/17, at 8:00 a.m., the DS stated It is our standard of practice to label and date when food is prepared. Review of the facility's undated policy and procedure titled Food Preparation indicated .Policy: Leftover food will be stored and served in a safe manner. Procedure: leftover foods are those that have been prepared for a meal and not served. 1. Storage of leftovers. b. Label and date 2. During an observation with the DS on 6/19/17, at 8 a.m., there were three loose cans of soda and two opened boxes of soda on the floor underneath the storage racks in the walk-in refrigerator. During an interview with the DS on 6/19/17, at 8 a.m., the DS stated The sodas should be placed six inches above the floor, that's why there's a rack. Review of the facility's undated policy and procedure titled Storage of Food and Supplies indicated all food and food containers were to be stored six inches off the floor and on a clean surface in a manner that protects food from contamination. 3. During an observation and concurrent interview with the DA 2 on 6/19/17, at 6:30 a.m., there was an undated and unlabeled paper plate of fried rice and stir fried beef and vegetables in the kitchen refrigerator. The DA 2 stated the paper plate of food belonged to her. The DA 2 further stated employee food should be stored in the employee lounge refrigerator. A review of the facility's policy and procedure titled Food Brought by Employees From Outside the Facility, dated 2/10, indicated .Employees bringing food from outside the facility may not keep their food in the refrigerator used to store food for the residents. They may bring food which can be kept in the employee lounge

Based on interview and record review, the facility failed to assess and monitor the pacemaker function of one, Resident 3, of 15 sampled residents. (pacemaker: a small device placed in the chest to help control abnormal heart rhythms with low-energy electrical pulses) For Resident 3 there was assessment in his medical record regarding the type of pacemaker, date of insertion, rate, name of the cardiologist (heart specialist), or date that it was last examined by the cardiologist. This failure had the potential for the pacemaker to malfunction without staff knowledge. Findings: Review of the admission record dated 3/27/13, on 6/11/15 showed that Resident 3 was re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The admission record was the only mention of Resident 3's pacemaker in his entire clinical record. There were no evaluations by physicians for it, and no monitoring done by staff from admission on 3/27/15 until 6/11/15. In a joint staff interview on 6/11/15 at 9:00 a.m., Registered Nurse 1, ( RN 1), stated, I am not aware or can not recall that he (Resident 3) has a pacemaker. RN 1 was unable to provide any information regarding the type of pacemaker, date of insertion, rate, name of cardiologist, and date last examined by the cardiologist. The RN 1 stated, I can check his admission assessment. The Director of Nursing, (DON), confirmed that Resident 3 had no information at all in his medical record regarding his pacemaker. During an interview and concurrent record review on 6/11/15 at 9:05 a.m., the Resident Admission Assessment Form, dated 03/27/13, showed Resident 3 had a pacemaker in his left upper chest. The Appointment Coordinator (AC) stated, Resident 3 was not seen by a cardiologist for 3 years (2013, 2014 and 2015) because I am the one who does the appointment, and I don't remember making a follow up appointment after the cardiologist canceled his appointment on 09/24/13. In a second interview on 6/11/15 at 9:50 a.m., RN 1 stated, I called the conservator and she was not aware of when the pacemaker was inserted. We called his cardiologist and he will see him next Friday, 6/19/15. Review of the facility ' s policy and procedure titled Pacemaker, revised 09/01/13, showed the following: 1. Periodic pacemaker checks for functioning will be conducted per resident ' s physician or cardiologist orders. 2. Include an entry for pacemaker on the resident's care plan. 3. Enter on the resident's care plan the type of pacemaker and date of insertion, rate, when the battery may be due for replacement, and pacemaker check lab phone number, if applicable. 4. Record vital signs every month or more often depending on possible cardiac medications used, or per physician order, include rate and rhythm of apical pulse. 5. Report any unaccustomed sensations associated with the pacemaker to the physician as well as any vital sign parameters as ordered by the physician. 6. Advise resident to report signs/symptoms of dizziness, shortness of breath, chest pain or weakness. Report these symptoms to the resident's physician. 7. Observe resident for pain, swelling, or discoloration at pacemaker site. 8. Do not use any electrical appliances (e.g., electric razors) that come in contact with the resident's skin. Advise the resident to avoid microwave ovens, that may cause electrical malfunction. 9. Obtain plastic card or information sheet that comes with the pacemaker, as applicable, and affix to the inside of the resident's clinical record cover or care plan section of the chart.

Based on observation, interview, and record review, the facility failed to ensure medications were stored at a safe temperature and that narcotic boxes were locked. (narcotics: medications that can relieve pain, bring about sleep, or alter one's consciousness) 1. In the Central Supply Room located on Station 1, there were multiple bottles of temperature-sensitive over- the-counter medications and there was no thermometer or tracking log in place. This failure had the potential for medications to lose their stability and strength, and to become less effective. 2. Narcotic boxes at two separate nursing stations were observed to be unlocked. This failure had the potential for medication to be lost or stolen. Findings: 1. In an observation and concurrent staff interview on 6/10/15 at 3:15 p.m., the Director of Staff Development (DSD) stated, We keep our over the counter medications in this room with no thermometer. We were not aware that we need to place a thermometer in the central supply room. The DSD confirmed that there were multiple bottles of over the counter medications that included Senokot, Multivitamins, Aspirin, Hyperfiber, Prostat, Omeprazole, Docusate Sodium, Metamucil, Bacitracin and Hydrocortisone ointment. (over the counter: medication that can be purchased without a prescription from a doctor). Review of the medication labels showed instructions that medications were to be stored at a controlled room temperature between 59 degrees Fahrenheit (F) and 86 degrees. The Director of Nursing (DON), confirmed that there was no thermometer or tracking log in place. In a follow up observation on 6/11/15 at 10:35 a.m., the Appointment Coordinator (AC) confirmed there was no thermometer or tracking log in place. Record review of the facility's policy and procedure titled, Medication Storage and Disposal, dated 10/12, showed drugs requiring storage at room temperature are to be stored at a temperature no less than 15 degrees Celsius (59 degrees F) or more than 30 degrees Celsius (86 degrees F). Drugs requiring refrigeration are to be stored at a temperature not less than 2 degrees Celsius (36 degrees F). Medication requiring storage in a cool place may be stored in a refrigerator unless otherwise specified. A thermometer is kept in the refrigerator containing medications to help assure proper temperature. 2. In an observation and concurrent interview on 6/10/15 at 11:15 a.m., the DON confirmed that the Station 1 medication room narcotic box was unlocked. The DON stated, This should be locked at all times. In an observation and concurrent interview on 6/10/15 at 11:45 a.m., the DON confirmed that the station 2 medication room narcotic box was unlocked. The Licensed Vocational Nurse (LVN) 2 stated, I was called to help someone. I forgot to lock my narcotic box. In an interview on 6/11/15 at 8:25 a.m., Registered Nurse (RN) 2 stated, I take the narcotic from the box, sign the Narcotic Control manual, put the medication back and lock the box. RN 2 confirmed that there were controlled drugs in the unlocked box that included Ambien, Clonazepam, Ativan and Norco. Review of the facility's policy and procedure titled, Medication Pass, Medication Administration Essentials, under Controlled Drugs, revised 09/01/13, showed that controlled drugs shall be doubled locked in the medication cart or medication room.

Based on observation, interview, and record review, the skilled nursing facility failed to maintain an accurate and complete clinical record for one, Resident 7, of 15 sampled residents. Resident 7 experienced [MEDICAL CONDITION] activity that was not completely documented in the nursing notes. Licensed nursing staff failed to document what the [MEDICAL CONDITION] looked like, how long it lasted, or what triggered it, (or may have led to), the [MEDICAL CONDITION]. This failure resulted in the potential for licensed staff to be unable to accurately track the progression of the [MEDICAL CONDITION]. ([MEDICAL CONDITION]: changes in the brain's electrical activity that causes involuntary body movements) Findings: The skilled nursing facility admitted Resident 7 on 8/20/14 with a [DIAGNOSES REDACTED]. In an observation and concurrent interview on 6/9/15 at 2:50 p.m., Resident 7 was observed to have [MEDICAL CONDITION] activity with rapid facial and eye twitching. The facility Social Worker, (SW), stated Resident 7 was having, pseudo [MEDICAL CONDITION], and the [MEDICAL CONDITION] were, Not medically based. He, (Resident 7), has pictures in his head. We have increased supervision of him. Record review on 6/15/15 at 9:47 a.m., of the facility's policy and procedure titled, Nursing Progress Notes, showed the, Licensed nurses are responsible for completion of the weekly progress summary, which addresses the specific progress or regression of the residents based on the care plan listed. In a concurrent interview, and record review on 6/11/15 at 10:30 a.m., the Director of Nursing, (DON), was asked about the nursing notes for Resident 7. The nursing notes showed the following: 6/11/15: Noted with episodes of Pseudo [MEDICAL CONDITION] in the shift (no detailed description of the [MEDICAL CONDITION]) 6/10/15: Resident noted with episodes of pseudo [MEDICAL CONDITION] (no description) 6/10/15: Had episodes of intermittent pseudo [MEDICAL CONDITION] (no description) 6/10/15: Had episodes of intermittent pseudo [MEDICAL CONDITION] this shift (no description) 6/9/15: Resident is currently having intermittent pseudo [MEDICAL CONDITION] (no description) The DON was asked to describe what a pseudo [MEDICAL CONDITION] was. The DON stated that it meant Resident 7 was, Intact. It happens frequently. The DON was then asked to show this surveyor a detailed description of what specifically was going on with Resident 7 when he had a pseudo [MEDICAL CONDITION]. The DON was observed looking through the computerized notes. The DON stated, Maybe the description is in the initial nursing notes. The DON was unable to locate a detailed description of the pseudo [MEDICAL CONDITION]. The Don was asked if the nursing notes were the only place where there would be a description of the pseudo [MEDICAL CONDITION]. The DON stated, Yes. The DON was then asked how, based on a review of the nursing notes, would the reader be able to assess if the [MEDICAL CONDITION] activity had changed. The DON stated, You are right. The nursing notes are not descriptive. If they were more descriptive, we could see if it is getting worse.

Based on observation, interview and record review, the facility failed to ensure that a change of medication order was reflected on the medication bubble pack (a card consisting of a plastic cover with pouches for individual medication doses). This failure had the potential for staff to administer an incorrect dose of medication. Findings: During the Medication Administration Observation with LVN (Licensed Vocational Nurse) 1 on 4/28/14 at 11:30 a.m., a discrepancy was observed between the number of doses of Bethanechol (stimulates the bladder to empty itself of urine), to be given from the MAR (Medication Administration Record), and the number of doses to be given on the medication bubble pack for 1 of 28 medication opportunities. When the surveyor questioned, LVN 1 stated when there was a change in a drug order, like how many doses to be given, and the nurses would continue to use the current bubble pack of the medication, "we put a "Change of Order" sticker on the bubble pack to ensure all licensed nurses were aware of the change." LVN 1 agreed there was no observed, "Change of Order" sticker on the bubble pack for the Bethanechol. He stated that he would put one on. Record review on 4/28/14 showed the medication was originally ordered for Resident 1 on 10/1/12, and read: Bethanechol Chloride - Give 50 mg (milligram) by mouth four times a day for bladder retention. The order was changed to three times a day following a hospital stay on 10/9/12. The order on the MAR then read: Give 50 mg by mouth three times a day for bladder retention but the bubble pack still read 50 mg by mouth four times a day for bladder retention. When asked about the discrepancy, LVN 1 stated that he had not noticed the discrepancy and was sure he had given the correct number of doses per day because the order was correct in the MAR and he always followed that. During an interview with the ADON (Assistant Director of Nursing) on 4/29/14 at 11:45 a.m., he indicated that when there was a change in an order, a "Change of Order" sticker should be placed on the bubble pack to ensure that the licensed staff were aware of the change. He also stated that it is routine to inform the pharmacy about changes such as this. During an interview and record review on 4/29/14 at 11:45 a.m., MDS (Minimum Data Set) LVN, agreed that the order had been changed from four times a day to three times a day on 10/13/12 following a four day stay in an acute hospital, but the pharmacy had not been notified to regarding the decrease in the numbers of times given per day.

Based on interview and record review, the facility failed to provide adequate staff training for 2 of 8 staff for disaster preparedness. This failure had the potential to threaten the safety and well-being of all of the residents. Findings: 1. During an interview on 4/29/14 at 6:35 a.m., when asked what water could be used in an emergency situation, CNA (Certified Nurse Assistant) 1 stated the bottled water but he did not know where the bottled water was stored. CNA 1 was able to identify the locations for the emergency water and gas shut offs but acknowledged that he did not know how to turn them off. The DSD (Director of Staff Development) provided material that was used to train the staff for emergency preparedness. Review of the facility's document titled, "Disaster Plan: Source of Water" on 4/30/14, showed in the event that the water is shut off, water would be secured from the following sources: 1. Hot water heaters 2. Toilet tanks 3. Melted ice cubes from the ice machines 4. Bottled water in the basement During an interview, on 4/27/14 at 4:41 p.m., Program leader (PL) 4 was unable to state where the emergency water and gas shut off were located. PL 4 stated that she was not sure and had never been shown. During an interview and concurrent record review on 4/30/14 at 3:05 p.m., the Director of Staff Development (DSD) stated emergency preparedness training was required for all staff. The DSD stated that the disaster drill was done every six months and fire drill was done every three months. The DSD reviewed the emergency preparedness training records and confirmed there was no documentation/in-service sheet to show that PL 4 had completed emergency preparedness training.

Because of the facility's failure to have a system in place to assure that vulnerable residents were not victims of sexual abuse, Immediate Jeopardy was called on 9/25/13 at 12:10 p.m., with the facility's Administrator. On 09/25/13 at 1:45 p.m., the administrator presented a plan of correction action to the surveyor. The plan of correction consisted of the following elements: (1) All employee files will be reviewed for incidents that required counseling regarding protecting residents from abuse. (2) Determine whether the employee has previously been the subject of an employment-related investiation and, if so, whether a prior investigation relates to the employee's current conduct. (3) Follow-up with progressive disciplinary action as appropriate. (4) Social Worker to interview residents to confirm they feel safe and have no issues regarding the employee. (5) Determine if an allegation of an employee's offense requires closer supervision of the employee. (6) Provide additional, relevant in-service training to employee. (7) Schedule monthly follow-up meetings with the employee for a period of at least three months following an incident. (8) Administrator to report findings at Quarterly Q/A meetings and continue at six month intervals or resolved. On 9/25/13 at 2:40 p.m., the surveyor met with the administrator,and informed that the Immediate Jeopardy was abated. Based on resident, staff and police interviews and record review, for three (1, 2, 3) of three sampled residents, the facility failed to keep residents free from sexual abuse. A housekeeper (Hsk) engaged in sexual acts with Resident 1. Facility staff saw Resident 2 sit on the lap of the Hsk while both the resident and Hsk were in the day room. Resident 3 had reported to the administrator of being touched on his buttock area and kissed on the shoulder by the Hsk. The failure to monitor the activities and whereabouts of the Hsk resulted in inappropriate interactions between the Hsk and three residents (Resident 1, 2, 3) who were dependent adults. Findings: On 8/23/13, review of a police department investigation report, dated 8/21/13, showed that the facility reported an allegation of abuse, made by Resident 1, to the local police department (PD) on 8/21/13. The PD responded on 8/21/13 to investigate the allegation. As a result of the initial investigation by the local PD, on 8/22/13, a Detective (Det) from the PD's Sexual Assault Division conducted an investigation. The Det interviewed the facility Medical Director (MD) who confirmed Resident 1 had the ability to report the truth and could be trusted to do so during an investigation. The Det interviewed Resident 1 who selected the Hsk from a photo lineup provided by the Det. Resident 1 recounted sexual activity with the facility's Hsk. Further review of the PD report showed that when asked as to the cognitive ability of Resident 1, MD stated that Resident 1, "does not understand interpersonal or social relationships and the impact or consequences of his interactions in such relationships." Further review of the PD report showed that Hsk had been investigated by PD for sexual activity with a developmentally disabled man in 1994. Review of the clinical record for Resident 1, on 8/23/13, showed that the facility admitted Resident 1 on 8/8/11. The facility's assessment of Resident 1's condition (MDS, minimal data set- a documentation tool used to record the assessment of a resident's abilities and needs), dated 8/15/13, showed that Resident 1 was able to make himself understood and understand others and he had no memory problems. However, as a result of diagnoses, that included a [MEDICAL CONDITION], Resident 1 was at risk because of poor decision making and lack of safety awareness; he required a supervised living environment. On 8/23/13, review of the facility's investigation file for an allegation of abuse showed a letter from the facility's occupational therapist (OT) to the facility's administrator (Admin), dated 8/21/13, at 8:45 a.m. The letter recorded: "(Resident 1) mentioned to this writer (OT), 'he even touched my thing.' Asked what thing, he pointed to his private part. Asked if happened today, he said, 'no, but it happened several times. ' ... Asked why he did not report to me or other staff before, he said he did not want him (Hsk) losing job." During an interview on 8/23/13, at 8:50 a.m., the OT stated, "On Wednesday (8/21/13), at 8:45 a.m., (Resident 1) told me that he and (Hsk) had touched each other inappropriately...touched each other's private parts for several months but did not report it. He didn't want to feel bad about making (Hsk) be fired." Continued review of the investigation file showed a letter from the clinical director (CD) to the Admin, dated, 8/21/13 at 10:11 a.m. The letter recorded: "During a...walk with (Resident 1) asked if he could speak with me...(Resident 1) reported to me being touched inappropriately by (Hsk). He reported that for 6-8 months he has...touched and been touched by (Hsk) in his room with his curtain closed. Resident 1 stated, 'No pants were dropped.' I asked what body area had been touched and he responded, 'Mid area.' I asked him to point and he pointed to his groin area. (Resident 1) stated that 8-10 days ago fearing, 'getting in trouble,' he had told (Hsk) it must stop...I asked if this was seen by another person including a roommate and (Resident 1) said no the curtain was always drawn and no one saw it take place." In an interview with Resident 1 on 8/23/13, at 11 a.m., with the social service director (SSD) present per Resident 1's request, Resident 1 said, "We (Hsk) have been friends for a long time. For several months he started this thing about grabbing each other's crotch when we passed by each other...just for fun. I did it too. It was just for fun, like a game. He wanted to do more, but I never did drop my pants. He wanted me to give him oral sex and reach down my pants, but I didn't let him and I didn't reach down his either. When one of us came up behind the other we would bump the other one's butt like anal sex, but didn't actually do it. Two or three weeks ago I told him I didn't want to do it anymore and he got mad and wouldn't talk to me anymore. Then I wanted to know when I was getting my clothes from the laundry and he wouldn't tell me, so I had a blow-up in the hall. That's when I reported what he was doing to me sexually. I don't want him to lose his job, because I touched him too." The employee file for the Hsk was reviewed on 8/23/13. A document titled, "Notice of verbal counseling, " dated 5/10/04, showed that the Hsk was witnessed by facility staff allowing a male resident (Resident 2) to sit on his lap. According to the counseling document, Hsk had been counseled that such behaviors by the Hsk would not be tolerated. There were no documents found to indicate that the facility implemented any type of monitoring of the Hsk while on duty in the facility. Also in the employee's file, there was a progress note (author unknown) dated 3/2/06 at 11:50 p.m., that recorded that Resident 3 alleged the Hsk had touched his genitals.... and that it was happening since the resident had been readmitted to the facility in 2005. Continued review of the employee ' s file showed an untitled document (author unknown) A dated, 3/6/06, at 11:15 a.m. This document was titled, "Interview with (Resident 3)." According to this document Resident 3 stated he (Hsk) " ...grabbed my butt." Review of the employee's file did not show that the facility established a plan of action to monitor the Hsk and his activities while at work in the facility as a result of this allegation. During a phone interview with the Det., on 9/6/13 at 10:20 a.m., he stated the Hsk had been arrested and was currently in jail awaiting trial. The district attorney (DA) was charging the Hsk for 17 counts of "lewd and lascivious" (vulgar and showing sexual desire) behavior with a dependent adult. Review of the facility's policy and procedure titled, Elder and Dependent Adult Abuse, dated 2/12/13, showed that facility staff were to prevent abuse. "First and foremost, every ...resident has the right to be free of physical abuse ...or other treatment with resulting physical harm ..." The policy and procedure instructed facility staff to conduct a thorough investigation and there was to be a system of monitoring to ensure that confirmed abuse did not reoccur.

Based on staff interviews and record review, for six (C, D,E, F, G and H) of eight employees, the faciltiy failed to have policies and procedures to prohibit abuse. The facility did not screen non-licensed or non- certified staff, prior to employment, for a history of abuse of residents and did not monitor staff who had been alleged to abuse a resident. Lack of policies and procedures to ensure that residents were only cared for by persons with no history of abuse put residents at risk for abuse. Findings: 1. In interview with the facility's Administrator, on 9/25/13 at 10:20 a.m., she stated that the facility did not have a policy and procedure for pre-hire screening of employees other than licensed and certified staff. The Administrator stated that the facility did not have a plan for monitoring of employees who are investigated for an allegation of abuse if the allegation was not substantiated. If the facility substantiated an allegation, the employee would be terminated and no longer a problem. Upon request, for a policy and procedure regarding background screening of new employees, the Administrator provided a copy of the facility's policy and procedure, last revised on 11/5/05. According to this policy and procedure, licensed and certified staff were to maintain a current license or certification. If there was discovery of a criminal conviction, the facility would take, "appropriate disciplinary action." 2. On 9/25/13 at 1 p.m., during interview and concurrent review of employee files,for employees C, D, E, F, G and H, the facility's Staff Developer (SD) stated that the facility did not conduct background screening for new employees who were not licensed staff. According to SD the facility relied upon the State licensing boards for backgroud screening. None of these six employees, who were not licensed or certified, had documented evidence of a background screening before employment.

Based on observation, interview and documentation review, the facility failed to assess four of 60 sampled residents' (Resident 6, 8, 10 and 11) pain accurately in response to complaints of pain and failed to follow their pain management protocol. For Resident 6, pain medication dosage and frequently did not alleviate the resident's complaint of pain. For Resident 8, who sustained a fall injury, which resulted in a [MEDICAL CONDITION], for which the pain assessment failed to identify. For Resident 10, there was the potential that the lack of pain assessment to identify the cause of the pain would result in a continuation of Resident 10's pain. For Resident 11, there was the potential the facility would not be able to provide adequate pain relief for his deteriorating medical condition. These failures had the potential for a delay in pain relief and a delay in treatment for [REDACTED]. Findings: 1. Review of the clinical record showed the facility admitted Resident 6 on 9/26/12 with multiple diagnoses. The MDS (an resident assessment tool) dated 12/27/12, indicated Resident 6 had occasional, moderate pain. Review of physician's orders [REDACTED]." Review of Medication Administration Record (MAR) showed that: In October 2012, Resident 6 received Tylenol 650 mg., 12 times in the morning and 14 times in the afternoon for generalized moderate pain. No specific pain site was identified. In November 2012, the resident's pain medication increased. Resident 6 received Tylenol 650 mg 27 times in the morning, and 24 times in the afternoon for generalized moderate pain. No specific pain site was identified. By December 2012, Resident 6's received Tylenol 30 times in the morning and 28 times in the afternoon for generalized pain.No specific pain site was identified. Review of nursing documentation failed to indicated Patient 6 had been re-assessed for the cause of the pain which had resulted in an increase in the amount of Tylenol administered for pain relief. In addition, no documentation showed the physician had been notified of the increased amount of Tylenol being administered to Resident 6, nor had there been an Interdisciplinary Team (IDT) meeting about the pain management. No documentation showed that the licensed nurses assessed Resident 6 for the reason why the pain medication was increased. Resident 6's nursing care plan dated 9/26/12 titled "Alteration in comfort/pain related to [MEDICAL CONDITION]'s disease (Chorea)", failed to indicate a revision to address the increased amount of Tylenol administered and an intervention other than medication for pain relief. ([MEDICAL CONDITION]' Chorea: An inherited disease of the central nervous system which is evidenced by progressive dementia and irratic involuntary movements.) During an interview with the MDS coordinator on 1/30/13 at 11:05 a.m., he stated that he noticed that when he was a charge nurse, Resident 6 had a habit for asking for Tylenol all the time. Review of the nursing care failed to address the possibility fo an intervention for Resident 6's frequent request for pain medication. During an interview with the assistant director of nursing (ADON) on 1/30/13 at 1:23 p.m., he stated that every time the licensed nurses asked Resident 6 about pain, she always asked for Tylenol, sometimes, twice a day. The ADON stated that Resident 6's pain was discussed in the care conference but no documentation was recorded. On 1/31/13 at 9:15 a.m., Resident 6 told the surveyor that she asked for Tylenol because she had her pain in her legs and right elbow as a result of her freqent falls. No documentation indicated a history of frequent falls. 2. Review of the clinical documentation, showed the facility readmitted Resident 8 on 3/18/09 with multiple [DIAGNOSES REDACTED]. Review of Resident 8's Cumulative Progress Notes dated 12/26/12 at 11:25 a.m., documentation showed during a shower, staff noted a bruise on Resident 8's left shoulder. When the charge nurse asked Resident 8 what caused the bruise, Resident 8 stated, "I don't know." Nursing notes indicated the bruise measured 7 cm (centimeter) by 2 cm and Resident 8 had "no complaint of pain or discomfort" at that time. Cumulative Progress Notes dated 12/26/12 at 11:25 a.m. to 12/28/12 at 6 a.m., indicated documentation by all three shift nursing shifts which documented that Resident 8 had "no pain or discomfort." The Medication Administration Record (MAR) dated 12/1/12 to 12/31/12 indicated Resident 8 received Tylenol 650 mg (milligram) by mouth for a complaint of "generalized moderate pain" on 12/26/12 at 17:35 p.m., 12/27/12 at 18:30 p.m. and 12/28/12 at 9 a.m. On 12/28/12 at 10 a.m., the DSD (Director of Staff Development), documented Resident 8 stated he got the bruise on his shoulder when he fell three days ago. Resident 8 stated "he got up from bed to use bathroom...He lost his balance and hit left shoulder against the chair." Resident 8 complained of pain of his left shoulder with limited range of motion." At 10:45 am, on 12/28/13, Resident 8's attending physician was notified of Resident 8's fall and complaint of shoulder pain and ordered an x-ray. The X-ray revealed "a [MEDICAL CONDITION] clavicle with no displacement of the left shoulder." During an interview with the director of nursing (DON) on 1/28/13 at 4 p.m., she stated that nurses did "shift charting for Resident 8's shoulder pain." Nurses documentation mentioned no pain or discomfort, which meant no pain or discomfort on the left shoulder and that Tylenol is given for generalized pain is protocol." Further review of the "Initial Pain Assessment Tool" dated 12/26/12, showed the following documented assessment: 2. Intensity Present: 2 (Moderate pain) Worst pain gets: 3 (Horrible or excruciating pain) 3. Quality: (Use patient's own words, ...) "Hurt" 5. Manner of expression pain: Facial expression, verbalizing. 6. What relieves the pain? Pain medication. 7. What causes or increases the pain? During movement. During an interview with the Nursing Supervisor 2 on 1/29/13 at 2:08 p.m., she stated when she used the Initial Pain Assessment Tool to assess Resident 8, on 12/26/12, Resident 8 expressed he had moderate pain. During an interview with the director of staff development (DSD) who investigated the incident on 1/29/13 at 1:45 p.m., she stated the charge nurse told the day shift nurse that Resident 8 had a fall three days ago. When the DSD asked Resident 8 if he had pain on 12/28/12, the resident complained of left shoulder pain and she noted Resident 8 had limited range of motion. During an interview with licensed vocational nurse (LVN) 3 on 1/29/13 at 3:40 p.m., she stated that "in my mind, because of the bruise" on his left shoulder, "I did not ask him to do a full range of motion" to assess his pain. During an interview with occupational therapy (OT) on 1/29/13 at 4:15 p.m., she stated, "Resident 8 was not reliable" and that Resident 8 would usually call out for "help" if he fell . No one interviewed recalled hearing Resident 8 call out for help. Review of Occupational Therapy Note dated 12/31/12 indicated, "By history, resident was not a reliable reporter. Resident usually yells and loudly calling "help" for any minor irritant or when needing attention, but no fall or complaint of pain was reported by him before the investigation." The facility policy and procedure titled "Pain Management" undated, Procedure: Pain Assessment Elements, indicated: 1. Site/location and the resident to the exact location of the pain or whether it relates to other areas." 2. Intensity-ask the resident to rate the pain on a number scale 0 - no pain 1 - mild pain 2 - moderate pain 3 - severe or excruciating 3. Quality - listen to the resident describe the pain in his or her own words, when the pain began, how long the pain lasts. Determine if the pain is constant of intermittent. 3. The medical records showed that Resident 10 had multiple diagnoses, used a wheelchair, had a contracture (shortened of the tendons/muscles resulting in a deformity of the affected part) of his right hand and wore a hand splint. The medical administration record (MAR) showed that Resident 1 requested Tylenol almost every day during the months of December 2012 and January 2013. During an interview with Staff 1 on 1/30/13 at 9:39 a.m., he stated when residents repeatedly ask for Tylenol that there should be a care plan that addressed the use of Tylenol. At the time of the interview Staff 1 was unable to find a pain management care plan for Resident 10. During an interview with Staff 1 on 1/30/13 at 1:40 p.m. he indicated that it was facility standard protocol to treat generalized pain. However this was not reflected in protocol titled, "Pain Management". The Pain Management protocol included procedures to assess the site and location of pain and intensity, and assess residents who are noncommunicative for pain. The pain assessment scale was 0-no pain, 1-mild pain, 2-moderate pain and 3-severe or excruciating pain. The Medication Administration Record (MAR) showed that the documented reason for Resident 10's requests for Tylenol were for "generalized pain" with no identification of the location of the pain Resident 0 was experiencing. During an interview with the Program Director and Staff 2 on 1/31/13 at 2:35 p.m., Staff 2 stated that the reason for pain medication and the results after the pain medication was administered was recorded on the MAR and sometimes on the nursing notes. 4. On 1/30/13 the medical records for Resident 11 showed that Resident 11 had [DIAGNOSES REDACTED]. During the the initial tour on 1/28/13 at 10:00 a.m., the social worker stated that Resident 11's neurological condition was genetic and that a facility physician was researching it. The MDS (resident assessment tool) dated 1/10/13 showed that Resident 11 had occasional pain with moderate intensity over the past five days. Resident 11 had physician's orders [REDACTED]. For each administration of Tylenol the staff recorded that Resident 11's pain level was 2/3 (moderate) and the result of each administration was 0/3 (no pain). The MAR for the month of 12/2012 showed that Tylenol was administered on a frequent basis. During an interview with a State Agency Pharmacist consultant on 2/10/13 at 10:00 a.m., the pharmacist stated involuntary muscle movements could cause pain and that the facility needed to describe how it was specifically determined that Resident 11 was experiencing moderate pain. During an interview with the Program Director and Staff 2 on 1/31/13 at 2:35 p.m., Staff 2 said that it was not unusual that residents would not be able to describe their pain. However the facility "Pain Management" policy indicated that the staff needed to observe the resident, not behaviors and expressions to determine pain.