Every finding on record at Grundy Care Center

Based on interviews, schedule review and CMS (Centers for Medicare and Medicaid Services) document submission review, the facility failed to submit accurate licensed nurse coverage hours into the CMS system, resulting in the appearance of low weekend staffing and lack of 24 hour licensed coverage. The facility reported a census of 30 residents. Findings include:Review of the facility's licensed coverage submission for the 4th quarter of July 1, 2025 - September 30, 2025, listed the facility short of the 24 hours requirements:7/5/25 (Saturday); 12.97 hours7/6/25 (Sunday): 18.92 hours7/12/25 (Saturday): 18.31 hours7/13/25 (Sunday): 17.86 hours9/20/25 (Saturday): 17.48 hoursAn email sent by the Administrator on 1/6/26 at 12:24 PM, documented she looked at the facility's payroll system to see why the daily sheet hours didn't transfer over. On 1/6/26 at 1:25 PM, the Administrator reported they had something wrong with the system and they have reached out to corporate. She stated that on the above days, most of the days were covered by nurses who punch a timeclock and those hours should have automatically been pulled over but didn't. She stated the facility has to manually input hours worked by staff who do not punch a time clock. The Administrator reported getting frustrated as she knew they had the weekend and license coverage they needed but understood that the submission has to be accurate. An undated Payroll Based Journal policy directed the following:It is the policy of this facility to electronically submit timely to CMS (Centers for Medicare and Medicaid Services), complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Definitions: Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines:The facility will electronically submit timely to CMS complete and accurate direct care staffing information including the following:The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);Resident census data; andInformation on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).When reporting information about direct care staff, the facility will specify whether the individual is an employee of the facility or is engaged by the facility under contract or through an agency.The facility will submit direct care staffing information in the uniform format specified by CMS.The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.The facility shall submit information (specify frequency), and no later than the deadline specified for the specific quarter in which the data is to be reported.Reporting deadlines:Fiscal Quarter 1 (October 1 - December 31): February 14Fiscal Quarter 2 (January 1 - March 31): May 15Fiscal Quarter 3 (April 1 - June 30): August 14Fiscal Quarter 4 (July 1 - September 30): November 14The facility will ensure all staffing data entered in the Payroll-Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and/or tied back to a contract.The facility will utilize the current submission guidelines as described in the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual.Responsibilities for data submission:The Administrator, HR Director, and Director of Nursing are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports.The Business Office Manager is responsible for verifying the accuracy of census data and collaborating with MDS Coordinator for any needed corrections. Reports available through CASPER may be utilized to assist with verifying data.(Designated individual or vendor) is responsible for submitting data and obtaining validation reports.The Administrator is responsible for reviewing validation reports and ensuring that any needed corrections are made before the quarterly deadline.

Based on observations, interviews, and policy review, the facility failed to safely handle food while preparing a sandwich. The staff put on gloves then touched other items with their gloved hands prior to touching bread with the same gloved hands. The facility reported a census of 30 residents.Findings include:During an observation on 1/6/26 at 11:54 AM Staff A, Cook, wore gloves during the meal pass for multiple residents on the line. The next resident ordered a hamburger; Staff A touched the potholders on the line then put the hamburger on a plate from behind her in the microwave. With the same gloves, she reached into a bag of buns, pulled one out, and put it on the resident's tray. She then opened the bun on the tray. After finishing the burger, she took it out of the microwave, with the same gloves, picked up the burger, and placed it on the bun. She put the top bun on the burger and smashed it down. Finally, she removed her gloves and performed hand hygiene.In an interview on 1/7/26 at 9:43 AM with the Administrator and Staff B, Dietary Manager, Staff B explained Staff A could remove the bun with tongs or her gloves, but she should remove gloves and perform hand hygiene if she did so. She added she could use gloves or tongs to touch the patty but, again, if she used gloves, she must perform hand hygiene as she also touched the microwave and then the resident's food. They both acknowledged the issue with using gloved hands and touching food after touching other objects with the same gloved hands.An undated policy titled Food Safety Requirements directed the staff to adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects and that staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. It also indicated that additional strategies to prevent foodborne illness include but are not limited to preventing cross-contamination of foods.

Based on clinical record review, policy review, video footage review and staff interviews, the facility failed to prevent a resident deemed as high risk for elopement exit the building without supervision for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed she had a diagnosis of non-Alzheimer's dementia and a memory deficit following a cerebral infarction (stroke). The MDS further revealed a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The Care Plan revised 6/26/25 revealed Resident #1 had a risk for injury due to wandering and attempting to elope. The Interventions directed the staff to supervise the resident when she was outside the facility.The Incident Report (IR) dated 8/26/25 at 3:30 PM revealed Resident #1 was found walking in the hospital parking lot by an employee and walked back into the building without incident. The Progress Note dated 8/26/25 at 4:04 PM revealed Resident #1 was found outside the facility across the street in the hospital parking lot by a staff member at 3:33 PM. No door alarm had gone off at the facility prior to the resident being found outside the facility. The resident was assisted back to the facility safely. Review of facility policy titled, Elopement/Missing Resident, updated 2/6/23 revealed the purpose of the policy was to secure and maintain resident safety and defined elopement as an incident in which a resident who has impaired decision-making ability leaves the facility without the knowledge or supervision of staff. During an interview on 10/15/25 at 11:00 AM the Administrator revealed they believed Resident #1 exited out the back (east) door following a subcontractor after he entered the code to deactivate the alarm prior to exiting. The Administrator further revealed the facility did not have cameras however she had been in contact with security at the hospital and after he reviewed the footage, he reported it appeared Resident #1 walked out the back door following someone and then walked across the street to the hospital parking lot. During an interview on 10/15/25 at 1:35 PM, Staff A, Human Resources, revealed she had been pulling out of the parking lot on 8/26/25 after getting off work at 3:30 PM and as she looked to the right, she saw Resident #1 in the hospital parking lot across the street. Staff A reported she parked her car and approached Resident #1 who reported she had been looking for her roommate. Staff A reported she told Resident #1 that she knew the location of her roommate and Resident #1 walked back to the facility with her without incident. Staff A further revealed she could see how a visitor would not realize Resident #1 was a resident as she walks very well and looks like a visitor. During an interview on 10/16/25 at 8:40 AM the Administrator revealed all the doors except the door Resident #1 exited when she followed the subcontractor on 8/26/25 had signage alerting visitors to ensure residents didn't follow them out the door. The Administrator stated the door had the signage alerting visitors like the other exit doors but for some reason it had been removed.On 10/16/25 at 1:30 PM, met with the Director of Facility Operations at the local hospital and observed video footage which revealed Resident #1 first observed on the camera at 3:32:05 PM just prior to crossing the street to the hospital parking lot. Staff A had come in contact with the resident at 3:33:33 PM and began walking her back to the facility. The facility corrected the deficiency prior to the start of the survey on 8/27/25 by implementing the following: a. Resident #1 placed on 1:1 staff supervision immediately upon returning to the facility. Resident #1 continued on 1:1 supervision until transferred to another facility with a locked unit on 10/2/25. b. Physician and the responsible party were notified of findings. No new orders given.c. Head to toe assessment completed on resident. Assessment within normal limits for residentd. Sign placed on back door and checked for placement on all other doors to remind staff, visitors, or contractors to look behind them when exiting and not to let residents out the door unsupervised.e. Staff educated immediately regarding elopement on 08/26/25.f. Resident Council held 8/27/25 to educate residents on elopement and the importance of keeping all residents safe.g. Elopement reviewed at the Quality Assurance and Performance Improvement (QAPI) meeting.h. Resident #1's plan of care was reviewed to ensure interventions in place to prevent future elopements.i. Additional staff and alert and oriented resident interviews completed.j. Process started to find resident placement in a locked dementia unit due to the fact that Resident #1 won't wear a wander guard and removes the wander guard as soon as it is placed. The wander guard had actually caused the resident to have behaviors when she was wearing it and stated, I feel like a prisoner.k. Will continue elopement drills in the facility to ensure employee compliance.

Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to protect a resident from physical and mental abuse for 1 of 3 residents reviewed (Resident #1). Staff A, Certified Nurse Aide (CNA), accepted money, kissed, sent inappropriate pictures via text, and exchanged inappropriate touch with Resident #1. The inappropriate interactions continued until Staff A resigned from the facility. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/16/24 on 1/6/25 at 2:55 PM The facility staff removed the Immediate Jeopardy on 1/7/25 by implementing the following actions: a. Resident #1 saw psychiatry on 11/14/24 (prior to self-report), then again on 12/12/24, and is scheduled to see psychiatry again on 1/9/25. Resident #1 will receive on-going psychiatry services as indicated by the provider and as needed (PRN). b. 1/6/25: The facility interviewed all interviewable residents. The interviews determined no additional concerns. c. 1/6/25: The facility interviewed all staff, and concerns raised about Resident #1 isolating himself. The administrator interviewed Resident #1 about these concerns and addressed the concerns d. 1/6/25: The facility educated all staff. The facility provided and reviewed a copy of the abuse policy and procedure for reporting, trauma informed care, and education regarding psychosocial well-being of the residents. e. All newly hired staff and agency staff will complete annual training for trauma-informed care upon hire and be provided with the policy for abuse and abuse reporting. f. 1/6/25: Quality Assurance and Performance Improvement (QAPI review), with on-going audits that include interviews with residents and staff. The facility reported a census of 30 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed Resident #1 utilizing a manual wheelchair independently and requiring supervision/touching assistance to partial/moderate assistance for bathing, lower body dressing, and tub/shower transfers. Resident #1 had a colostomy (a surgical opening in the abdomen to assistance with the passage of stool) and an indwelling urinary catheter. The MDS included diagnoses of neurogenic bladder (trouble with urination), anxiety, bipolar disorder, depression, and post-traumatic stress disorder (PTSD), and paraplegia (inability to move part of the body). Resident #1 reported almost constant pain during the five-day lookback period. Pressure injuries noted on the MDS include one Stage 2 pressure injury and three Stage 4 pressure injuries. Resident #1 received antipsychotics, antidepressants and opioids during the lookback period. The Care Plan Focus initiated 9/17/24 indicated Resident #1 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. Resident #1 liked to be as independent as possible. The Interventions directed the following: a. Assist of 1 with transfers b. Provide a sponge bath daily and showers twice a week. c. Resident #1 self-transfers from his bed to his wheelchair. d. Assist with ADLs PRN. The Care Plan Focus revised 11/20/24 reflected Resident #1 had a mood problem, bipolar II disorder (mood disorder), depression, anxiety, and PTSD. The Interventions instructed the following: a. Resident #1 would receive psychiatric services with a mental health provider approximately every three to six months or as determined by provider b. Offer one on one (1:1) as often as Resident #1 will allow c. Frequent checks d. Administer medications as ordered e. Staff to monitor, record, and report to the primary care provider (PCP) PRN acute episodes of sadness, loss of pleasure, feelings of worthlessness or guilt, change in appetite/eating, change in sleep patterns, diminished ability to concentrate, or change in psychomotor skills f. Staff to monitor, record, and report to PCP PRN risk for harm to self or others. The Skin/Wound Note dated 9/5/24 at 9:00 PM labeled Late Entry indicated Resident #1 admitted to the facility from the hospital with medically complex conditions. He had diagnoses of paraplegia, neurogenic bladder, colostomy status, Stage 4 pressure injuries, chronic pain related to trauma, bipolar type 2, PTSD, sickle cell disease, anxiety, and depression. The assessment described Resident #1 as alert, oriented, pleasant, cooperative, and able to make his needs known. Resident #1 required a wheelchair but could perform transfers by himself with stand-by assistance from staff. The Health Status Note dated 9/6/24 at 5:25 PM reflected Resident #1 had a good appetite and fluid intake. The note described Resident #1 as pleasant and cooperative with staff. The Health Status Note dated 9/11/24 at 2:17 AM indicated Resident #1 appeared in a good mood. He talked, joked, and laughed with the nurse and other staff members. The Health Status Note dated 9/16/24 at 3:18 PM indicated Resident #1 saw the physician and he received new orders for duloxetine (antidepressant and nerve pain medication) 30 milligrams (mg) daily for chronic pain. The physician gave an order for referral for evaluation for suprapubic catheter. The Health Status Note dated 9/18/24 at 10:15 PM identified Resident #1 had increased pain. He said all of the pain came from taking a shower and that's what made it so much worse. The Order Note dated 9/19/24 at 4:40 PM reflected Resident #1 saw the pain clinic and received adjustments to his pain medications. The Health Status Note dated 9/22/24 at 10:56 AM indicated the staff noted Resident #1 staying in his room all shift. He appeared down and depressed. Recent medication changes interfered with sleep and pain caused his depression to worsen. Resident #1 declined a psychiatry visit. Resident #1 stated talking with staff helped. The staff encouraged therapeutic conversations with people he felt comfortable with and to use socialization as a pain distraction. The Health Status Note dated 9/22/24 at 3:59 PM identified Resident #1 left his room frequently. He had conversations and joked with staff, other residents, and visitors. The Health Status Note dated 9/25/24 at 10:12 PM reflected Resident #1 refused to shower. He said the CNA is too young and it made him uncomfortable. The Health Status Note dated 10/24/24 at 12:28 identified Resident #1 isolated himself in his room that shift and the day before. Resident #1 stated he felt embarrassed due to his colostomy bag smell. The nurse notified the Social Work (SW) and Director of Nursing (DON) of his decline in mood. The Health Status Note on 10/24/24 at 3:31 PM indicated Resident #1 isolated himself, didn't attend the activities he normally attended, and he didn't eat. The SW discussed increasing his depression medications as may not be at therapeutic level. Resident #1 agreed and they scheduled a psychiatry visit. The Progress Note CPT created by Staff J, Nurse Practitioner (NP), on 10/8/24 reflected he had an upcoming appointment with urology to discuss placement of a suprapubic catheter to replace the urinary catheter. The note reflected he participated in facility activities and is very social with other peers and staff at the facility. n. On 10/29/24 at 12:54 PM: Duloxetine increased to 60 mg daily related to increased depression, anxiety, and isolation. The Health Status Note dated 10/31/24 at 11:47 PM identified Resident #1 continued to have a withdrawn attitude and hardly coming out of his room to socialize that evening. Resident #1 continued to talk in a low slow voice. Staff encouraged resident to come out of room earlier but was not successful. The Health Status Note dated 11/1/24 at 12:39 PM indicated the facility received a fax with a new order for methadone (narcotic for pain) 5 mg twice a day for severe chronic pain due to trauma. The Health Status Note dated 11/2/24 at 10:47 PM reflected Resident #1 continued his new order of methadone (narcotic for pain) 10 mg twice a day for 15 days for pain management. Medication appeared effective as he came out that evening socializing, joking and laughing with staff and other residents. He also agreed to take a shower later due to not having his wound vac at that time. The Nursing Staff Information for 11/2/24 reflected Staff A worked 6:00 PM until 6:00 AM that evening. The Psychiatry Intake Form dated 11/14/24 described Resident #1 as having a depressed affect and withdrawn. They discussed increasing his duloxetine from 60 mg to 80 mg daily. The Health Status Note dated 11/16/24 at 11:27 PM identified Resident #1 in his room, tearful, and complaining of increased depression. The Health Status Note dated 11/17/24 at 11:55 PM reflected Resident #1 in a good mood that evening joking and laughing with staff. The Health Status Note dated 11/18/24 at 11:39 PM indicated Resident #1 appeared to be in good mood as he joked and laughed with staff. The Health Status Note dated 11/19/24 at 11:26 AM labeled as Late Entry written by Staff I, Assistant Director of Nursing (ADON), indicated she learned of alleged abuse between former employee and Resident #1. Head to toe assessment completed with no findings. Resident #1 declined emergency room visit for evaluation and declined facility staff to contact alternative or emergency contact. Staff I notified the administration staff, the police, and attempted to contact the physician. A document titled Iowa Incident Report [NAME] Center Police Dept revealed on 11/19/24 at 3:40 PM, the police responded to a report of dependent adult abuse. The report identified Resident #1 as the victim and Staff A as the offender. Resident #1 reported Staff A attempted to kiss him and he pushed away. Resident #1 also reported that Staff A wanted him to move in with her and she would take care of him. Resident #1 reported the conversations began in October through Facebook. Staff A revealed to the police that a kiss did occur and verified the conversations began on Facebook. The case was reported to the Department of Human Services (DHS) by the police and the Department of Inspections, Appeals and Licensing (DIAL) by the facility. A document titled Iowa Incident Report Supplemental dated 11/25/24 revealed that the Administrator notified the police with further information on the relationship between Resident #1 and Staff A. The Administrator learned through their investigation that the relationship was sexual and occurred during and after working hours. The DHS rejected the report and closed the case. The document titled Facility Investigative report dated 11/19/24 revealed: a. Staff I, Assistant Director of Nursing (ADON), notified management of alleged abuse after obtaining statements from Resident #1 and Staff A, CNA. b. Staff A terminated employment without notice on 11/18/24. c. A physical assessment was conducted on Resident #1. d. Police was notified of the incident. e. Staff and Resident interviews were conducted. A document titled Interview Statement of Witness dated 11/19/24 at 1:30 PM, labeled 1st statement, signed by Staff I indicated Resident #1 identified having conversations on the phone, text, Facebook messenger and in person. He stated she tried to kiss me and I pulled away or she would have, during a visit after work time. Resident #1 felt Staff A spent more time with him than other residents and other residents commented about how much time she spent in his room. A document titled Interview Statement of Witness dated 11/19/24 at 2:30 PM, Staff B, CNA, reported being aware of a relationship between Resident #1 and Staff A. This included a few hugs and that Staff A was in Resident #1's room a lot. Staff B was not aware of any other detail. A document titled Interview Statement of Witness dated 11/19/24 at 9:30 PM, labeled 2nd statement signed by Staff I, reflected Resident #1 identified October 16th, 2024, as the date he changed his profile on his phone, and Staff A sent a message that stated damn your hot. Resident #1 stated the conversations continued via telephone, text messages, and Facebook messenger. Staff A also started to come into the facility on her day off during the day and in the evenings. Resident #1 stated when Staff A came into his room during work hours, she always closed the door, and the conversations became sexual in nature. Resident #1 stated Staff A was going to leave her husband, file for divorce so they could be together in a trailer that she was going to purchase. She would take care of him, manage his wounds, so he didn't have to stay in the facility forever since he had nowhere to go. Resident #1 stated Staff A initiated the first contact, hugging, and kissing. She requested personal contact to her breasts and between her legs, and he complied. Resident #1 stated Staff A would get mad if he didn't follow her requests. Resident #1 stated Staff A requested having sex, but he stated he couldn't because of the catheter and the wound vac. Resident #1 stated Staff A would get mad when he didn't respond to the messages and would come to the facility to confront him asking, don't I want to be with her anymore? and is there someone else?. Resident #1 stated Staff A sent a text on 11/18/24 to his phone that stated she quit her job so they could be together and they didn't have to hide it (relationship) anymore. On 11/19/24 Staff A texted she (Staff A) talked to Staff I and only told her the bare minimum. She told her they never had any physical contact between them. Resident #1 stated Staff A sent him nude pictures of her on multiple occasions. Resident #1 stated Staff A continued to text I am broken hearted for you, I don't know if I want to live without you. Resident #1 stated he isolated in his room, felt guilty, felt like people were judging him, his depression got worse, and felt like he was taken advantage of. Staff A told him that her brothers acquired personal information about his past. When asked how that happened, Staff A stated she gave her brothers his personal information and they looked him up. A document titled Interview Statement of Witness dated 11/20/24 at 11:00 AM, indicated Staff C, Cook, didn't know about a relationship between Resident #1 and Staff A. During a call on 11/19/24 Staff A told Staff B, she and Resident #1 kissed and she was going to lose her license. When Staff C arrived to work the same day, Resident #1 told Staff C, Staff A told on herself and that he wanted to talk to them about it. Staff C did not engage in any further conversations. A document titled Interview Statement of Witness dated 11/20/24 at 1:09 PM, Staff F, Medical Records Clerk, detailed a phone conversation with Staff A where she reported she messed up big time. Upon further questioning, Staff A informed Staff F of an inappropriate relationship she had with Resident #1. Staff F ended the conversation at that time and immediately contacted Staff I. The Progress Note CPT created by Staff J dated 11/21/24 indicated: a. Resident #1 had concern of right lower eyelid pain, redness and swelling. b. Resident #1 to have surgery (11/22/24) to place a suprapubic (above the pubic area) catheter. He completed his 14 days of Macrobid (antibiotic) the day before as ordered by urology. c. Resident #1 continued to isolate himself in his room. The psychiatric provider increased duloxetine to 40 milligrams (mg) a week prior. On 12/30/24 at 12:20 PM, observed Resident #1 in his room with the door closed. As Resident #1 sat in his wheelchair with his urinary catheter bag laying on his lap, he smiled as he moved the wheelchair with one hand and spoke on the phone with the other hand. Resident #1 spoke in clear, quiet tones, and looked at the floor during the interview. Resident #1 appeared alert, oriented to person, place and time. Resident #1 left the facility with his sister for a social visit after the interview with the Department of Inspection, Appeals and Licensing (DIAL) surveyor. During an interview on 12/30/24 at 12:20 PM, Resident #1 stated he talked to his brother and he planned to move soon to live with his father, brother, and sister. Resident #1 stated the facility provided everything he needed, including supplies for his catheter and wound care. He added he didn't have any complaints about the facility. Resident #1 stated he met Staff A in September 2024 when he first admitted to the facility and she gave him a lot of care. Resident #1 stated Staff A worked both day and evening shifts. Resident #1 denied a relationship with Staff A and reported it wasn't really nothing. During an interview on 1/6/25 at 4:00 PM, Staff A stated she met Resident #1 when he came to live at the nursing facility where she worked as a CNA. Staff A stated she exchanged phone numbers with Resident #1, followed him on social media, would message him via text, and Facebook Messenger. Staff A stated it evolved into a relationship, neither did something the other didn't want. Staff A described the relationship as consensual and she shared texts with the facility management. Staff A stated Resident #1 texted her when she worked to bring him cookies from the snack cart, a hug, and a few kisses. Staff A acknowledged the relationship lasted 2 months, from September 2024 until she quit on 11/18/24. Staff A stated she felt she had to quit as she was not a person to hide stuff and she didn't want to get into trouble. Staff A stated she wanted a relationship beyond the facility, but that didn't work out and I wanted it to be over, so I quit and didn't give notice. Staff A stated on the evening, after she quit, she returned to the facility, went to Resident #1's room, and sat on his bed to talk. Staff A stated Staff H, Registered Nurse (RN) asked her why she quit and why she was there. Staff A stated she returned to the facility the next day to give a statement of why she quit. Staff A told Staff I, me and (Resident #1) had a thing going on and I could not work there no more. Staff A stated Staff I went to Resident #1's room to talk, returned, asked her to leave and not to return to the facility. Staff A stated she received the Dependent Adult Abuse training. Staff A acknowledged Resident #1 was a dependent adult living at the facility and lived there to receive care. Staff A acknowledged that she worked as a CNA at the facility that Resident #1 lived in, where they met after he admitted to the facility, and the inappropriate physical touch happened during her working shift. Staff A stated, It was just kissing that's all. Staff A stated, I messed up, will I lose my license? Staff A reported she spoke to the police. Staff A stated she hadn't returned to the facility and had no further contact with Resident #1. On 1/7/25 at 9:00 AM the Administrator stated Resident #1 received a text from Staff A on 1/6/25 at 5:20 PM that said the facility was going to take her license. The Administrator described Resident #1 as concerned. During an interview on 12/31/24 at 10:53 AM, Staff B, CNA reported Resident #1 was a jokester and Staff A became his Sugar Mama. Staff B took this as a joke since Resident #1 was outgoing and he made us laugh. Staff B stated Staff A was married and she thought Staff A and Resident #1 were friends. Staff A told Staff B she exchanged phone numbers with Resident #1 before Halloween. At the beginning of November, Resident #1 informed Staff B he exchanged phone numbers with Staff A. He wanted Staff A to pick-up something from the store and he gave Staff A money for it. Staff B stated she didn't notice too much going on until Staff A resigned on 11/18/24. The day after Staff A quit, she was observed going into Resident #1's room and sat on his bed. On 12/2/24, Staff B received a text message from Staff A stating she (Staff A) sent Resident #1 a Facebook message on Thursday (11/28/24) that read Baby I miss you. I still care about you and I hope you're doing good. Staff A noted Resident #1 never read or deleted it. During an interview on 12/31/24 at 1:20 PM, Staff C reported Staff A sent her the following text: Resident #1 and I had a thing so I quit. But now he won't talk to me and Staff I knows about it .I don't know what changed with him and he totally broke my heart .I'm just really heartbroken and he just seems to not to give a (f**k). During an interview on 12/31/24 at 2:37 PM, Staff G, CNA, stated Resident #1 and Staff A had a weird relationship, describing it as more intense than with other residents. Staff G stated when Staff A provided showers to Resident #1, it took an hour. Staff G stated when she provided showers to Resident #1, it took 10 minutes as he could do everything himself. Staff G reported Staff A spent more time with Resident #1 about a month before quitting. Staff G stated she noticed Resident #1's demeanor changed, self-isolating in his room, and appeared to be depressed. During an interview on 12/31/24 at 3:20 PM, Staff H, Registered Nurse (RN), reported shortly after Staff A resigned, Resident #1 talked a little about the situation. Staff H stated Resident #1 shared that one time during a shower, Staff A attempted/offered oral sex. Staff H stated her understanding of the conversation, this was not accepted. During an interview on 1/6/25 at 10:30 AM, Staff D, Activities Coordinator, recalled a conversation with Staff A on 11/19/24. Staff A told Staff D she wanted to talk to Resident #1. Staff D took this statement as Staff A wanted to get to know Resident #1, like a relationship. During an interview on 1/6/25 at 11:20 AM, Staff I stated Resident #1 lived at the facility since September 2024. Staff I stated at first Resident #1 kept to himself and didn't socialize a lot, but once he got to know the staff, Resident #1 came out of his room, joked, and laughed. Staff I stated at the end of October 2024, Resident #1 started isolating in his room, not laughing, or joking. Staff I stated the Social Worker set-up a psychiatry visit. Staff I stated after the relationship with Staff A became widely known, Resident #1 still isolated in his room. Staff I stated Resident #1 told her that he felt embarrassed, guilty, ashamed, and felt he taken advantage of. Staff I reported she first learned of their relationship when Staff F, Medical Records Clerk, alerted her on 11/19/24. Staff A returned to the facility that day and Staff I obtained a statement from her. Staff A stated she texted and talked to Resident #1 outside of work. Staff A added they had a few friendly hugs but nothing else. When asked why she wanted to quit, Staff A replied she wanted to quit before anyone found out. Staff I stated after they took Staff A's statement, she talked to Resident #1. Staff I stated Resident #1 acknowledged texting Staff A since October and friendly hugs. Resident #1 reported Staff A tried to kiss him but he pulled back. Staff I stated she conducted a second interview with Resident #1, with him more forthcoming. After obtaining staff and resident interviews throughout the day on 11/19/24, Staff I realized the situation had more going on. Staff I returned to visit with Resident #1 at approximately 10:30 PM. At this time, Resident #1 appeared sad and started crying. Resident #1 shared Staff A sent nude pictures of herself to him. Staff I received permission to see the pictures on his personal cell phone. He felt other residents didn't get the time they needed for care due to Staff A being in his room. Resident #1 reported they kissed multiple times. Staff A asked Resident #1 to touch her between her legs and he did. Staff A asked for sex, Resident #1 replied he couldn't because he had a catheter. Resident #1 reported to Staff I that Staff A had marital problems. Staff A told him she planned to buy a trailer in town so they could move-in together and she would take care of him. After the conversation concluded, Staff I notified the medical director and the rounding nurse practitioner. During an interview on 1/7/25 at 3:00 PM, the Administrator stated Quality Assurance expected the staff identify and report suspected abuse timely. A document titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 revealed: a. All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. b. This includes prohibiting nursing facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. c. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. d. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. e. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. f. The training will educate staff on: i. Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. ii. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and iii. Dementia management and resident abuse prevention.

Based on staff interview, resident interview, policy review, Facility Assessment and Payroll Based Journal (PBJ) review the facility failed to ensure appropriate staffing, lacked Registered Nursing (RN) coverage and lacked a Director of Nursing (DON) on four days. The facility reported as census of 26 residents. Findings include: 1. On 11/04/24 at 10:00 AM upon entrance to the facility , the Assistant Director of Nursing (ADON) relayed the Director of Nurses (DON) left last Wednesday 10/30/24 without notice and there was no DON covering as of yet. The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. On 11/04/24 at 11:14 AM Staff #7 relayed, they definitely needed more staff. The DON just up and quit and the Administrator quit, there are many temporary staff and definitely needed staff improvements. The Facility Assessment updated 8/5/24 documented the resources needed to provide competent support and care for resident population every day and during emergencies. It included a general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time is as follows, DON, RN full-time Days. The type of staff members, health care professionals, and medical practitioners needed to provide support and care for residents included Administrator and DON. 44972 2. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 (April 1- June 30) reported the facility lacked 8 hours of Registered Nurse (RN) coverage on the following dates: 4/20/24, 5/4/24, 5/5/24, 6/1/24, and 6/2/24. In an interview on 11/6/14 at 1:49 PM, the Interim Administrator stated they had their time cards through another company at the time of the reported dates on the PBJ Staffing Data Report and she would try to obtain the information from them. In an interview on 11/7/24 at 10:55 AM, the Interim Administrator stated the facility would not be able to get the information for RN coverage until 11/8/24 at the earliest. The facility failed to provide any information or verification of RN coverage for 4/20/24, 5/4/24, 5/5/24, 6/1/24 or 6/2/24. Review of the facility provided nursing schedules for the time period of 10/1/24 through 11/7/24, the facility reported the contracted Director of Nursing (DON) provided the RN coverage for 17 days in October, but on 9 of those days the DON was either not present in the facility or did not work 8 hours. The punch detail revealed the following: 10/6/24 - No RN coverage in house 10/7/24 - RN coverage for 7.5 hours 10/9/24 - RN coverage for 7.5 hours 10/10/24 - RN coverage for 6.5 hours 10/15/24 - RN coverage for 7.5 hours 10/19/24 - RN coverage for 5.5 hours 10/20/24 - RN coverage for 4.3 hours 10/28/24 - No RN coverage 10/29/24 - No RN coverage In an interview on 11/7/24 at 1:25 PM, the Interim Administrator stated it was the expectation the facility provides a minimum of 8 hours RN coverage daily. In a facility provided policy titled Departmental Supervision, Nursing, last revised 8/22 stated a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

Based on record review, staff interview, and policy review the facility failed to provide licensed nurse coverage 24 hours a day 7 days a week. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed the facility failed to provide licensed nurse coverage 24 hours per day on 5/7/24, 5/11/24, 5/13/24, 5/19/24, 6/15/24, 6/29/24, and 6/30/24. Findings include: In an interview on 11/6/14 at 1:49 PM, the Interim Administrator stated they had their time cards through another company at the time of the reported dates on the PBJ Staffing Data Report and she would try to obtain the information from them. In an interview on 11/7/24 at 10:55 AM, the Interim Administrator stated the facility would not be able to get the information for licensed nurse coverage until 11/8/24 at the earliest. On 11/7/24 at 10:56 AM, Staff C, Certified Medical Assistant (CMA)/Scheduler provided a list of licensed nurse coverage staff for the dates the facility was reportedly missing licensed coverage. Staff C reported per the facility records the coverage was provided by the following staff but they were waiting on verification of punch details for the facility staff. The list revealed the following: 5/7/24 - 6:30 AM - 6:45 PM Licensed Practical Nurse (LPN) (agency) and 4:15 PM - 6:15 AM Registered Nurse (RN) (agency) 5/11/24 - 6:00 AM - 6:30 PM RN (agency) and 6:00 PM - 6:00 AM RN (facility) 5/13/24 - 6:00 AM - 6:30 PM RN (facility), 6:00 PM - 10:00 PM RN (facility), and 10:00 PM - 6 AM LPN (facility) 5/19/24 - 6:00 AM - 6:00 PM LPN (facility), 6:00 PM - 6:15 AM LPN (agency) 6/15/24 - No information provided 6/29/24 - 6:00 AM - 6:15 PM RN (agency) and 5:34 PM - 6:00 AM RN (agency) 6/30/24 - 4:00 AM - 6:00 PM RN (agency) and 5:45 PM - 7:15 AM RN (agency) In an interview on 11/7/24 at 1:25 PM, the Interim Administrator stated it was the expectation the facility provides 24 hours licensed nurse coverage daily. The facility did provide time cards from the staffing agency to verify the shifts that agency nurses worked for the above dates. In a facility provided policy titled Departmental Supervision, Nursing, revised 8/22, stated a licensed nurse (registered nurse (RN)/licensed practical nurse (LPN)/licensed vocational nurse (LVN)) was to be on duty twenty-four hours per day, seven days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse was to be designated as a charge nurse on each shift.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure repositioning for 2 of 3 residents reviewed for positioning and skin care (Residents #4 & #20). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 4 out of 15 indicating severe cognition impairment. The MDS also documented the resident had Moisture Associated Skin Damage (MASD). The MDS coded the resident was dependent for assistance of two (2) or more for toileting, personal hygiene, dressing, and transfers. The Care Plan focus initiated 11/01/20 documented Resident #4 had an alteration in elimination related to decreased mobility and frequent episodes of incontinence and potential for impaired skin integrity. Interventions included to complete peri-care after any incontinent episodes. The Care Plan also documented Resident #4 had self-care deficits, required two assist for transfers, to reposition side to side when in bed and to keep pressure off buttocks as allowed. An observation on 11/06/24 at 08:45 AM, Resident #4 sat in their room in a recliner with a breakfast room tray. An observation on 11/06/24 at 11:24 AM Resident #4 remained in the recliner, stated they needed to go to the bathroom, nursing staff summoned. An observation on 11/6/24 at 11:35 AM, Certified Nursing Assistant (CNA) Staff A and CNA Staff B assisted the resident up from the chair with a lift, that revealed on the chair pad a brownish fluid, appearance of a brown wet stain on the white pad. Further observation on 11/06/24 at 11:40, following transfer of Resident #4 from the chair to the bed via lift, CNA, Staff A and CNA Staff B along with the Director of Nurses, interim (DON) present, proceeded and removed the residents pants after he laid down, liquid bowel movement observed outside of the brief on the side of both legs and residents upper back. Disposable brief removed, resident's skin was cleansed to remove the bowel movement. Resident #4 moaned, appeared uncomfortable, vocal moan each time he was cleansed with each wipe. Following cleanse, Resident #4 buttocks was severely excoriated, multiple areas of bleeding and dark redness. At 11:50 AM CNA Staff B voiced Resident #4 bleeds all the time. On 11/06/24 at 11:50 AM the Director of Nursing (interim) acknowledged Resident #4 excoriated buttocks, asked the CNA, Staff B, how long has resident bottom been like that. The DON applied additional coating of skin cream and relayed it was to soothe Resident #4's discomfort. CNA, Staff B responded, can only do what I can. In an interview on 11/06/24 at 11:51 AM CNA, Staff A and CNA, Staff B acknowledged Resident #4 had not been repositioned in the chair since he got out of bed to the recliner for breakfast. The DON asked at this time if the CNA's had asked if the resident wanted to lie down and Staff B replied could not get to that, indicated they were busy with other residents. CNA, Staff B relayed there was no reposition schedule, stated Resident #4 required a lift with two staff and stated we transfer when we can. In an interview on 11/06/24 at 12:08 PM the DON relayed it is the expectation that dependent residents be encouraged and repositioned every few hours along with routine skin assessments. In an interview on 11/06/24 at 12:19 PM the Assistant Director of Nursing (ADON) relayed the expectation was to reposition every two (2) hours, relayed they had completed a skin assessment on Wednesday and documented as healed. The ADON relayed Resident #4 had chronic skin breakdown and the expectation was resident to be moved by staff from the wheel chair, to bed and to the recliner. The ADON stated standard practice was for staff to reposition Resident #4 every two hours. Policy titled Repositioning, revised May 2013 documented repositioning for preventing skin breakdown, promoting circulation and providing pressure relief, critical for a resident who is dependent upon staff for repositioning. Residents who are in bed should be on at least every two-hour repositioning schedule. Residents who are in a chair should be on every hour repositioning schedule. 49698 2. Review of Resident #20's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment and diagnoses of Stroke, Aphasia (inability to understand and express language), Gastrostomy status (feeding tube), Tracheostomy status, and Persistent Vegetative state. Review of Resident #20's Care Plan dated 9/19/24 indicated the resident required tube feedings, had a tracheostomy, had a communication deficit with interventions including anticipating and meeting resident's needs. Resident #20 was at risk for skin impairment related to limited physical mobility, need for assistance with ADLs and incontinence with interventions to avoid scratching and keeping resident's hands and body parts from excessive moisture. Keep skin clean and dry. Monitor and document location, size, and treatment of skin injury. Resident #20 had a colostomy and was incontinent of bladder with interventions including use of disposable briefs, check Resident #20 at regular intervals and as required for incontinence. Wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Resident #20 had an ADL self care performance deficit requiring full assistance of two with all cares, transfers with a mechanical lift, and total dependence on staff for repositioning and turning. Observations on 11/05/24 revealed the following: At 9:02 AM, Resident #20 was observed sitting in a recliner, leaning to the right side with a chuck (absorbent pad) and mechanical lift sling under him. The sling was draped over bilateral shoulders. At 12:02 PM, Resident observed sitting in the same position in the recliner, asleep, tube feeding running. Incontinence chuck and mechanical lift sling under resident with sling draped over bilateral shoulders. At 3:06 PM, Resident #20 observed in the same position, leaning on the right side in the recliner, asleep, tube feeding running. At 3:24 PM, CNA's entered Resident #20's room with a mechanical lift, after completing care a CNA observed exiting with a visibly wet soiled chuck. Observations on 11/06/24 revealed the following: At 9:28 AM, Resident #20 was observed in a recliner with a blanket draped over his lap, mechanical lift sling under resident with left side strap up above shoulder and behind head and the right side strap draped behind his right shoulder. Resident #20 was leaning to the right side. At 11:19 AM Resident #20 observed in the recliner, leaning to the right side, blanket draped over his lap with mechanical lift sling under resident, left side up above left shoulder and behind his head, right strap continued to be draped behind his right shoulder. Resident #20 did not appear to have been moved since the previous observation. Review of Resident #20's Point of Care Report of documented incontinence cares and rolling/repositioning Resident #20, revealed incontinence cares and rolling/repositioning being completed three times a day, once each shift. Review of facility provided Repositioning Policy revision date May 2013 stated residents who are in bed should be on at least an every two hour repositioning schedule. Residents who are in a chair should be on an every hour repositioning schedule.

Based on observation, staff interviews, and policy review, the facility failed to ensure the medication and treatment cart remained locked in a resident care area when not under staff supervision. The facility reported a census of 26 residents. Findings include: During an observation 11/4/24 at 9:24 AM, the medication cart in the central hallway next to the nurses station was noted to be unlocked with no staff present. During an observation 11/4/24 at 10:38 AM, the treatment cart in the central hallway next to the nurses station was noted to be unlocked with no staff present. Further observations revealed the following: a. 10:38 AM Housekeeper cleaning the dining room floor across from the unlocked treatment cart. b. 10:39 AM a resident self propelled in a wheelchair past the unlocked treatment cart. c. 10:40 AM a staff member walked into the nurses station, another resident self propelled in a wheelchair past the unlocked treatment cart, and a staff member walked passed going down the west hall. d. 10:42 AM 2 staff members exited the nurses station and walked past the unlocked treatment cart. e. 10:44 AM a staff member walked past the unlocked treatment cart. f. 10:45 AM a staff member walking with a resident using a walker, walked past the unlocked treatment cart. g. 10:45 AM 2 staff members walked past the unlocked treatment cart. h. 10:46 AM, Staff D, RN, pulled supplies from the treatment cart, locked it and walked away. Observation on 11/4/24 at 10:56 AM, treatment cart noted to be unlocked and unattended again. Residents and staff continue to pass the unlocked treatment cart. At 11:06 AM Staff D, RN removed 6 individual containers (holding insulin pens) from the treatment cart and placed them on top of the medication cart. Staff D, locked the treatment cart and continued with the medication cart down the west hall. Staff D, entered a resident's room leaving 5 containers (holding insulin pens) unattended on top of the medication cart with staff and residents passing the medication cart. During an interview on 11/07/24 at 3:14 PM, the Facility Administrator, stated her expectations are medication and treatment carts remain locked when not in use or supervised and all medications are to be locked in medication or treatment carts when not being used or supervised. Review of facility provided Medication Labeling and Storage revision date February 2023, stated Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. The facility reported a census of 26 residents. Findings include: On 11/04/24 at 10:46 AM, Initial observation of the kitchen's refrigerators and freezers revealed opened items that were unsealed (open to air), and lacked labeling to identify product, open date, and use by date. During an interview 11/6/24 at 3:39 PM, Dietary Manager acknowledged these items should have been sealed, labeled, and dated when opened. During an interview on 11/7/24 at 3:26 PM the facility's Administrator, stated expectations that all opened and stored foods are to be labeled with identification of product, open date, and expiration date. Review of policy titled Food Receiving and Storage revised November 2022 indicated, all foods stored in the refrigerator or freezer are covered, labeled and dated.

Based on record review, observation, and staff interviews the facility failed to effectively and efficiently maintain the highest well-being of each resident. The facility failed to sustain their Plan of Correction (POC) dated 9/12/23, to ensure required members were present at the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 26 residents. Findings include: Review of the facility citations from their annual recertification survey dated 8/17/23, the facility failed to have the required members present for the quarterly QAPI meetings. The facility put a POC in place on 9/12/23 and failed to sustain it. The attendance sheets for the QAPI meetings held on 12/12/23, 4/18/24, 7/29/24, and 10/8/24 revealed the Director of Nursing (DON) was not in attendance. The attendance sheets for the QAPI meetings held on 12/12/23, 3/22/24, 4/18/24, and 7/29/24 revealed the Infection Preventionist (IP) was not in attendance. In an interview on 11/7/24 at 1:20 PM, the Interim Administrator stated it was the expectation the QAPI committee meet at least quarterly. It was expected that all department heads, the Medical Director and any other staff that wanted to join be present for the meetings. Going forward the meetings would be communicated via outlook calendar and the facility would follow the employee discipline process if the required employees were not in attendance.

Based on record review, staff interview, and policy review the facility failed to have the required members present at their Quality Assurance and Performance Improvement (QAPI) meetings. The facility did not have the Director of Nursing (DON) or the Infection Preventionist (IP) in attendance at all quarterly meetings. The facility reported a census of 26 residents. Findings include: Review of the attendance sheets for the QAPI meetings revealed the required members attended on 9/12/23. The attendance sheets for the QAPI meetings held on 12/12/23, 4/18/24, 7/29/24, and 10/8/24 revealed the DON was not in attendance. The attendance sheets for the QAPI meetings held on 12/12/23, 3/22/24, 4/18/24, and 7/29/24 revealed the IP was not in attendance. In an interview on 11/5/24 at 11:04 AM, the Interim Administrator stated she would look at the attendance sheets and see if she could figure out who the IP was for the listed meetings and if the DON was present but the DON was most likely not in attendance. In an interview on 11/7/24 at 1:20 PM, the Interim Administrator stated it was the expectation the QAPI committee meet at least quarterly. It was expected that all department heads, the Medical Director and any other staff that wanted to join be present for the meetings. Going forward the meetings would be communicated via outlook calendar and the facility would follow the employee discipline process if the required employees were not in attendance. Per a facility provided policy titled QAPI Meeting Management, last revised 8/19, the Risk Management/QAPI committee was to consist of no less than 5 members. Members were to be appointed by the Administrator and would include, but not limited to: Administrator, Director of Nursing, Infection Preventionist, Medical Director or Physician designee, and at least two additional facility staff.

Based on record review, facility provided document, staff interview, and policy review the facility failed to notify a Resident's Representative and the Long Term Care Ombudsman of discharge/transfer of residents as required for 2 of 4 residents reviewed who were discharged /transferred from the facility (Residents #3, #20). The facility reported a census of 26 residents. Findings include: 1. Review of the facility's Census Report, Resident #3 was transferred and hospitalized on [DATE] until he reentered the facility on 10/11/24. The clinical record lacked documentation of notification to Resident #3's Representative and the Long Term Care Ombudsman that Resident #3 had been discharged to the hospital as required by federal regulation. Facility provided document, Notice of Transfer Form to Long Term Care Ombudsman dated 9/27/24-10/27/24 failed to indicated Resident #3's hospital transfer. Review of Resident #3's clinical record documented on 10/7/24, Resident #3's Guardian had called the facility and had expressed concern of not being notified of Resident #3 being sent and admitted to the hospital on 10/5/24. 2. Review of facility's Census Report, Resident #20 was transferred and hospitalized on [DATE] until he reentered the facility on 8/17/24. The clinical record lacked documentation of notification to the Long Term Care Ombudsman that Resident #20 had been discharged to the hospital as required by federal regulation. Email communication with the facility's Administrator dated 11/7/24 at 11:07 AM stated August does not have a report (Notification to the Long Term Care Ombudsman) as there were no transfers or discharges. During an interview on 11/7/24 at 3:26 PM the facility's Administrator, acknowledged the facility's failure to notify the Ombudsman of transfer for Residents #3 and #20 and notification to Resident #3's Guardian. The Administrator stated her expectations of accurate notification of resident transfers to the Ombudsman and notification to resident's representative at the time of a resident's transfer.

Based on staff interview, clinical record review and policy, the facility failed to submit for an updated Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident reviewed with a new mental health diagnosis (Resident #7). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating intact cognition. The MDS further documented diagnoses of mood disorders, anxiety, depression, and psychotic disorder. The Care Plan for Resident #7 initiated 1/3/23 revealed the Resident #7 used psychotropic medications that included, antipsychotics, antidepressants, and anxiolytics related to delusional disorder. The PASRR dated 12/1/22 for Resident #7's nursing facility admission revealed diagnoses of anxiety disorder and depressive disorder. The Clinical Record for Resident #7 revealed an updated mental health diagnosis on 3/9/23 of delusional disorder. The clinical record further revealed an updated PASRR had not been submitted following the new diagnosis. In an interview on 11/05/24 at 12:29 PM the Assistant Director of Nurses (ADON) relayed they were familiar with PASRR requirements, must have it prior to nursing facility admit and another screening with changes including a new mental health diagnosis. The ADON acknowledged Resident #7 received a new mental health diagnosis of delusional disorder on 3/9/23 and there should have been a request for an updated PASRR evaluation. In an interview on 11/05/24 at 12:29 PM the Director of Nurses (DON) agreed a new PASRR should have been completed when Resident #7 was diagnosed with delusional disorder. Policy titled Behavioral Assessment, Intervention, and Monitoring, dated 2001 directed new onset or changes in behavior that indicate newly evident or possible serious mental disorder or related disorder should be referred for a Level II (two) PASRR evaluation.

Based on observation, record review, staff interview, and policy review the facility failed to follow professional standards regarding following facility policy, following physician's orders, and failing to notify physician for 2 of 12 residents reviewed (Residents #3 and #23). The facility reported a census of 26 residents. Findings include: 1. While interviewing a resident on 11/04/24 at 11:12 AM, an observation of a medication cup with pills sitting on the resident's bedside table, during conversation the resident picked up the medication cup and took the pills with water also sitting on her bedside table. The Resident's medications were delivered by the nurse, the nurse failed to provide supervision while the resident took the medications. During an interview on 11/07/24 at 3:14 PM, Facility Administrator stated the expectations are for Nurses and/or Certified Medication Aides to be present with residents until the medications have been administered and not leave the medications unattended. 2. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Resident #3 had diagnoses of Stroke, Diabetes Mellitus, and Benign Prostatic Hyperplasia. Review of Consultant Pharmacist Recommendation to Physician document dated 7/31/24 indicated Resident #3 was receiving two drugs with very similar therapeutic activity: Oxybutynin ER 15 mg daily for Overactive Bladder Oxybutynin ER 20 mg daily for Urinary Frequency The facility Physician noted to discontinue the Oxybutynin ER 20 mg dosage and signed on 9/16/24. Notation by a nurse dated 9/19/24 indicated this notation was documented in a Progress Note and the Medication Administration Record (MAR). Review of Resident #3's Progress Notes dated 9/19/24 at 11:23 AM stated, Per pharmacy recommendations discontinue Oxybutynin 20 mg as resident is receiving 2 drugs with very similar therapeutic activity. Reviewed by physician and signed order discontinued. Review of Resident #3 ' s MAR indicated in September: 1. Ditropan (Oxybutynin) XL 10 mg tablet, give 2 tablets by mouth one time a day for urinary frequency in the morning. Order Date 7/24/24, Discontinue date 10/10/24 was administered to Resident #3 every day in September. 2. Oxybutynin Chloride ER 15 mg tablet, give 1 tablet by mouth one time a day in the morning related to Benign Prostatic Hyperplasia. Order date 8/1/24, Discontinue date 10/10/24 was administered to Resident #3 every day in September. Review of Resident #3's MAR indicated in October: 1. Ditropan (Oxybutynin) XL 10 mg tablet, give 2 tablets by mouth one time a day for urinary frequency in the morning. Order Date 7/24/24, Discontinue date 10/10/24 was administered to Resident #3 on 10/1, 10/2, 10/3, 10/5 and discontinued on 10/10/24 2. Oxybutynin Chloride ER 15 mg tablet, give 1 tablet by mouth one time a day in the morning related to Benign Prostatic Hyperplasia. Order date 8/1/24, Discontinue date 10/10/24 was administered to Resident #3 on 10/1, 10/2, 10/3, 10/5 and discontinued on 10/10/24 During an interview on 11/07/24 at 3:14 PM, the Facility Administrator acknowledged the discontinued Oxybutynin order was not accurately processed. The Administrator stated expectations to accurately follow physician's orders and process in a timely manner. 46513 3. The Minimum Data Set (MDS) annual assessment, dated 8/23/24 for Resident #23 listed diagnoses that included diabetes mellitus, coronary artery disease, heart failure, and peripheral vascular disease. The Care Plan focus initiated 3/23/24 documented Resident #23 had Diabetes Mellitus. Interventions included, administer diabetes medication as ordered by doctor, monitor, document for side effects and effectiveness. Review of the October 2024 Medication Administration Record (MAR) for Resident #23 revealed on 10/13/24 at HS (hours of sleep), blood sugar was 461. The Medication Administration Record (MAR) October 2024 for Resident #23 revealed a physician order for Insulin and directed amounts of insulin to be administered based on sliding scale (blood glucose results) directed staff to notify the provider if Blood Glucose (BG) is greater than 400. The clinical record for Resident #23 lacked documentation of physician notification as directed for hyperglycemia (high blood glucose). On 11/06/24 at 11:07 AM the Administrator (interim) relayed they would expect the nurse to inform the physician as the order directed, in addition they relayed could not locate documentation of the provider notification. Facility policy provided titled Acute Change in Condition, Revised February 2022 documented the nurse will notify the residents attending physician or physician on call when there has been specific instruction to notify the physician of changes in the resident's condition.

Based on staff interview, resident interview, clinical record review, observations, and policy review the facility failed to provide appropriate interventions to minimize or prevent complications of infections for 1 of 2 residents reviewed for urinary conditions (Residents #10). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) for Resident #10 dated 8/7/24 relayed Resident #10's BIMS score of 10 out of 15 that indicated moderate cognitive impairment. Diagnoses included diabetes, anxiety, depression, lung disease, and renal insufficiency. The Care Plan focus initiated 10/1/24 for Resident #10 documented, had an indwelling catheter related to diagnoses of obstructive uropathy and urinary retention. Interventions included to monitor, record, and report to the provider signs and symptoms of urinary tract infection An Emergency Department Report dated 10/3/24 documented Resident #10 urinalysis report findings included bacteria and included a diagnoses of a urinary tract infection associated with indwelling urethral catheter. A new prescription for Cephalexin (antibiotic) one 500 milligram capsule two times a day for ten days was prescribed. During an observation on 11/04/24 at 12:35 PM Resident #10 walked down the hall with Staff A, Certified Nursing Assistant (CNA). Staff A held on to the resident's gait belt secured around the resident's waist. The catheter tubing dragged on the floor as the resident walked. In an interview on 11/04/24 at 12:36 PM, Staff A, CNA acknowledged the catheter tubing dragged on the floor and stated last week he had a shorter tube so did not realize the tubing dragged. In an interview on 11/05/24 at 01:38 PM, Resident #10 revealed the catheter was put in on 9/20/24 due to the bladder not emptying as it should. Resident #10 reported he had developed a urinary tract infection (UTI) shortly after and required antibiotics to clear up the infection. In an interview on 11/7/24 at 10:04 AM with The Director of Nursing (DON) and the Assistant Director of Nursing (ADON), both relayed and agreed for infection control purposes and to avoid a possibility of a fall, Resident #10 should not have walked as the catheter tubing dragged on the floor. A policy titled Catheter Care, Urinary dated 2009 documented to prevent catheter associated urinary tract infections to be sure the catheter tubing and drainage bag are kept off the floor.

Based on record review, document review, interviews, and policy review, the facility failed to provide the Bed Hold policy for 1 of 2 residents reviewed (Resident #3). On 10/5/24 Resident #3 was admitted to the hospital, a Bed Hold policy was not discussed/given to Resident #3 or their representative. The facility reported a census of 26 Residents. Findings include: Review of the facility's Census Report, Resident #3 was transferred and hospitalized on [DATE] until he reentered the facility on 10/11/24 Review of clinical record lacked documentation of notification and discussed/given Bed Hold policy provided to Resident #3 or their representative. On 10/7/24 Resident #3's clinical record documented, Resident #3's Guardian had called the facility and had expressed concern of not being notified of Resident #3 being sent and admitted to the hospital on 10/5/24. Review of Resident #3's clinical record, a Bed Hold document with a scanned date of 10/22/24, revealed an undated Bed Hold document signed by Resident #3's representative. During an interview on 11/7/24 at 3:26 PM the facility's Administrator, acknowledged the facility's failure to notify Resident #3's Representative of the hospital transfer and Bed Hold policy. The Administrator stated her expectations of accurate notification of resident transfers to resident's representative at the time of Resident #3's transfer and Bed Hold provided within 24 hours as stated in facility's Bed Hold policy. Facility provided Bed-Holds and Returns Policy revised October 2022, stated: All residents/representatives are provided written information regarding the facility and state Bed-Hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s or therapeutic leave). Resident, regardless of payer source, are provided written notice about these policies at least twice: Notice 1: well in advance of any transfer (e.g., in the admission packet); and Notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observations, interviews, and record review, the facility failed to accurately document pressure ulcers for 1 of 3 residents reviewed (Resident #1). During the record review of Resident #1's record, the assessments revealed inconsistent documentation related to their wound on their right buttock. As the wound declined, the facility failed to update the stages of the pressure ulcer with worsening changes. The facility reported a census of 27 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI (Resident Assessment Instrument) Manual. Stage 1 Pressure Injury: Non blanchable erythema of intact skin Intact skin with a localized area of non blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full thickness skin loss Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full thickness skin and tissue loss Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Other staging considerations include: o Deep Tissue Pressure Injury (DTPI): Persistent non blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], reflected they had no pressure ulcers during the assessment lookback period. The History And Physical dated 8/5/24 documented Resident #1 saw the wound clinic for a furuncle (also known as a boil, is a painful, pus filled bump on the skin that results from a bacterial infection of the hair follicle). The Weekly Skin Assessment - V5 dated 7/24/24 reflected Resident #1 had an abscess to his right buttock that measured 1.8-centimeter (cm) length by (x) 0.6 cm width x 0 depth, no stage. The Weekly Skin Assessment - V5 dated 7/30/24 indicated Resident #1 had an abscess to his right buttock that measured 2.1 cm length x 0.6 cm width x 0 depth, no stage. The Weekly Skin Assessment - V5 dated 8/6/24 indicated Resident #1 had a abscess to his right buttock that measured 2.4 cm length x 1.8 cm width x 0 depth, stage I. In addition, he had a skin tear to his buttock that measured 1.7 cm length x 0.4 cm width x 0.1 cm depth, stage II. The buttock had thin, watery, clear drainage. The Weekly Skin Assessment - V5 dated 8/13/24 indicated Resident #1 had an abscess to his right buttock that measured 3.8 cm length x 3.5 cm width x 0 depth, stage I. In addition, he had a skin tear to his buttock that measured 1 cm length x 0.4 cm width x 0.1 cm depth, stage II. The right buttock had thin, watery, pale, red/pink drainage. The Weekly Skin Assessment - V5 dated 8/20/24 indicated Resident #1 had three abscesses to his right buttock. a. Type: Redness - Abscess that measured 10.5 cm length x 18 cm width x 0 depth, Not Applicable (N/A) stage. b. Type: Blackened - Abscess that measured 6.8 cm length x 7.7 cm width x 0 depth, N/A stage. c. Type: Abscess that measured 1.1 cm length x 1.1 cm length x 0.1 cm, stage II. i. The 2 abscesses on the right buttock had a scant amount of purulent drainage (a thick, milky consistency, with a green or yellow appearance indicating an infection) with hardness noted to the surrounding skin/wound edges. During an interview on 8/26/24 at 2:25 PM Staff A, Registered Nurse, reported it is different each week who did the skin assessments, as it is the nurses on the floor who complete them each week. When asked if they had any training on skin assessments she reported the facility didn't have special training. She reported each nurse may measure and document things differently. She reported Resident #1 had a boil that turned into an open pressure area. During an interview on 8/26/24 at 3:07 PM, the Advanced Registered Nurse Practitioner (ARNP) reported it changed very quickly. She voiced she didn't like the inconsistency in documentation for the wounds because it made it hard to determine what it looked like until she saw it on rounds. She saw Resident #1 the day the facility sent him to the hospital. That is why they ordered labs and did the creatinine level, he was sent out. He had black necrotic tissue over a pressure area. During an interview on 8/26/24 at 3:25 PM the Nurse Consultant reported the facility had inconsistency in their skin assessments. She reported that she didn't know why they staged Resident #1's skin tear if it wasn't a pressure ulcer. She added the facility didn't have consistent staging with each assessment. The Skin Care and Wound Management policy dated June 2015 defined a pressure ulcer as a localized injury to skin and/ or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Monitor for consistent implementation of interventions and effectiveness of the interventions

Based on observations, document review, menu review, and staff interview the facility failed to follow the planned menu for residents on all diet types. The facility identified a census of 28 residents. Findings include: Observation of lunch meal service on 7/30/24 from 11:15 AM through 12:20 PM revealed the unsigned dietary menu intended for Tuesday 7/30/24 lunch listed: cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo bars, and milk. The meal observed to the residents included: Ham salad sandwich, French fries, beets, a cookie and milk. Review of the unsigned Week 1, Regular NAS (no added salt) Tuesday menu for the facility dated for the week that started on Sunday 7/28/24 directed: cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo, and milk. Interview on 7/30/24 at 3:30 PM the Dietary Manager said she didn't know the Dietitian didn't sign the current menu and couldn't locate a signed menu. The Dietary Manager added they made some last-minute changes to the menu and didn't have the Dietitian approve. In addition, she didn't know the Dietitian had to approve the change prior to implementation. Interview on 7/30/4 at 3:30 PM the Corporate Dietitian stated she usually signed the approved menus and if the menu didn't have a signature, then she must have missed it. The Dietitian further stated she expected the facility staff to follow the menu and if they had changes she would review, approve and sign off before they served the meal. She responded no one told her about the changes to that day's menu. Interview on 7/30/24 at 11:15 AM Staff A, Cook, reported they couldn't always to follow the menu, so, sometimes they had to improvise. She said they had to improvise that day because the facility didn't have the items on the menu, so they had to improvise with what the facility had available.

Based on observation and staff interview, the facility failed to protect food from contamination during meal service. The facility reported a census of 28 residents. Findings include: During lunch service observation on 7/30/24 at 11:22 AM, Staff A, Cook, served ham salad sandwiches, French fries, beets and cookies. Under constant observation Staff A repeatedly touched the ham salad sandwiches with a gloved hand to steady the sandwich while cutting. The continued observation revealed Staff A touched a variety of surfaces with gloved hands including, but not limited to: the outside of the hamburger bun bag, the surface of the counter, the scoop handle, tong handle, serving lids, and her cheek. She repeatedly handled the ready to eat ham salad sandwiches and French fries with the contaminated gloves. The staff directly served the ham salad sandwiches and French fries to the residents. During an interview on 7/30/24 at 3:30 PM, the Dietary Supervisor stated she noticed Staff A repeatedly touch the ready to eat food with contaminated gloves during the meal service. The Dietary Supervisor stated she expected the staff to handle food to prevent food borne illness and not to touch ready to eat food with bare hands or contaminated gloves. The Food Code version 1/18/23 directed that food employees must not touch ready to eat food with their bare hands and must use suitable utensils such as deli tissue, spatulas, tongs, single use gloves or dispensing equipment. The Food Code further required food employees to clean their hands immediately before engaging in food preparation, including before donning gloves for working with food, and as often as necessary to remove soil and contamination in order to prevent cross contamination when changing tasks.

Based on observation, document review and staff interview, the facility failed to ensure licensed nurse coverage 24 hours a day. On 6/15/24 the night nurse clocked out at 6:45 AM and the day nurse clocked in at 8:41 AM The facility did not have a licensed nurse on duty, in house during that time frame. The facility staff contacted the Director of Nursing (DON) and the Administrator who failed to act to immediately to provide licensed coverage. The facility identified 15 diabetic residents, 8 of whom are insulin dependent with one resident (Resident #7) who had a blood glucose reading of 65, during the time the facility didn't have no licensed nurse coverage. In addition, the facility had one resident (Resident #2) had a tracheostomy that required suctioning three times a day (TID) and as needed. The facility identified a census of 28 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] reflected they sometimes could make themselves understood and sometimes understood others. The MDS identified Resident #2 had severely impaired cognitive skills for decision making. Resident #2 required total assistance with rolling side to side and transfers. The MDS included diagnoses of stroke, aphasia (inability to speak), and a tracheostomy. Resident #2's June 2024 Treatment Administration Record (TAR) included the following orders: a. Suction free of mucus and crusting at least 3 times a day with application of sterile saline suctioning as needed. b. Use humidified air to the tracheostomy as much as possible. c. Keep the area around the stoma area free of crusting and debris with gentle cleansing with half strength hydrogen peroxide solution every hour as needed. d. Provide trach cares, including removing and cleaning of the inner cannula. On 7/31/24 at 12:15 PM Staff B, Registered Nurse (RN), demonstrated the emergency tracheostomy supplies and suction equipment located in Resident #2's bedside stand. Resident #2 required total assistance of 2 staff for repositioning and couldn't respond to verbal instructions. Staff B reported only a licensed nurse could provide suctioning and care of the tracheostomy and if the tracheostomy became dislodged or pulled out, the resident would need immediate intervention and transfer to the hospital. 2. Resident #7's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognitive skills for decision making. The MDS listed Resident #7 as independent with sit to stand and chair to bed transfer. The MDS included diagnoses of stroke, intellectual disability, and diabetes mellitus. The Care Plan Focus revised 2/20/24 indicated Resident #7 had diabetes mellitus type 2. The Interventions directed staff the following: a. Provide diabetic medication as ordered. b. Monitor and document for side effects and effectiveness. c. Monitor, document, report to provider signs and symptoms of hypoglycemia (low blood sugar less than 80) and hyperglycemia (elevated blood sugar greater than 150). Resident #7's June 2024 TAR included an order for Fiasp FlexTouch 100 unit/ml (insulin) pen injector, inject as per sliding scale three times a day dated as ordered 3/6/24. The TAR included the following blood sugar readings in the AM (morning) and insulin units injected: 6/14/24 Blood sugar 533 required 15 units of insulin, 6/15/24 65 required no insulin. During an interview on 7/30/24 at 2:28 PM, Staff C, Licensed Practical Nurse (LPN), stated on 6/15/24 she called and reported to the DON she would be late. Staff C responded when she arrived at the facility the other nurse had already left. The facility didn't have a nurse at the facility during that time. She reported being very surprised that the nurse left, leaving the facility without a licensed nurse. She expected the facility have a licensed nurse on duty at all times. In an interview on 7/31/24 at 11:25 AM Staff D, Certified Medication Aide (CMA), said on 6/15/24 Staff E, Agency Registered Nurse (RN), informed her about Staff C being on her way and then she left, leaving the facility without a nurse. Staff D recalled that Staff E left at approximately 6:45 AM and Staff C didn't arrive for a couple of hours. Staff D stated she got the residents' blood sugars because it was in her scope of practice, however, she wouldn't be in her scope of practice to administer insulin or assess a resident with a low blood sugar. Staff D recalled having concern with Resident #7's low blood sugar reading as his blood sugar varies a lot from day to day. She recalled that he didn't show symptoms when really low or really high blood sugars. Staff D added she would have referred the blood sugar reading of 65 to the nurse to assess and direct interventions or monitoring. Staff D reflected being nervous about a fall, Resident #2's tracheostomy, and the diabetic residents. She added if Resident #2's tracheostomy came out she couldn't reinsert it, because not within her scope of practice. Staff D stated the expectation is to have a nurse present in the facility at all times. During an interview on 7/31/24 at 11:45 AM Staff F, CMA, stated she worked the day shift on 6/15/24. She saw Staff E leave the facility and get in a car in the parking lot at 6:45 AM. Staff D informed her they didn't have a nurse in the facility. She took Resident #7's blood sugar and if she had a nurse in the building, she would have notified them of a reading of 65. Then she would give orange juice or whatever the nurse directed her to do. Staff F stated she called the Director of Nursing (DON), however, she didn't answer the phone or respond to the multiple text messages sent. In an interview on 7/31/24 at 11:53 AM Staff G, Housekeeper, stated on 6/15/24 when she arrived to work around 8:00 AM, she learned the night nurse left and the day nurse hadn't arrived yet. So, she notified the Administrator that the facility still didn't have a nurse. Staff G provided a screenshot of the text she sent to the Administrator at 8:25 AM that included: the nurse left at 6:45 AM and so it's been almost two hours without a nurse in the building. At 8:32 AM the Administrator responded: Yes, we already spoke with her. She understood, the facility should always be a nurse on duty 24/7. In an interview on 8/1/24 at 10:53 AM Staff E stated on 6/15/23 she worked a 12-hour shift. At 6:15 AM she called Staff C who told her she overslept and was on her way. Staff E stated Staff C told her to just go ahead and go because she would be in soon. Staff E added she called the DON who also instructed to go ahead and go because Staff C would be in soon, and she, would also be at the facility soon. Staff E responded the expectation is to have a licensed nurse at the facility at all times. During an interview on 7/31/4 at 8:10 AM the Interim Administrator provided documentation that Staff C arrived at the facility on Saturday 6/15/24 at 8:41 AM and the night nurse, Staff E clocked out at 6:45 AM. The review of the staffing sheet documented the facility didn't have a nurse on duty during that time. The Interim Administrator stated she didn't know the facility didn't have a nurse on 6/15/24. She added she would have expected the Agency Nurse to stay and the DON come in when she became aware the facility didn't have licensed nurse coverage. She expected the facility have a licensed nurse in the facility at all times. The Interim Administrator responded the facility didn't have a formal policy regarding nursing staffing, as the facility would follow regulations. Further interview on 8/1/24 at 12:57 PM the Interim Administrator reported the facility did not have a medication administration policy nor a policy on tracheostomy care, but expected a licensed nurse would administer insulin and perform tracheostomy care and suctioning. Review of the staffing agency invoice revealed Staff E clocked out at 6:45 AM on 6/15/24. Review of an Employee Timesheet for Staff C revealed on 6/15/24 Staff C clocked in at 8:41 AM. A facility document titled Nursing Staffing Information revealed on 6/14/24 listed Staff E as the nurse on duty from 6:00 PM until 6:00 AM on 6/15/24. The form listed Staff C as scheduled for the 6:00 AM to 6:00 PM shift on 6/15/24. The form didn't have other nurses on the schedule. The facility provided a typed document that identified 15 residents with a diagnosis of diabetes, with 8 insulin dependent.

Based on observations, interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136 and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touching Resident #136 and Resident #187. All 3 of these residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 psychosocial harm. These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 32. On 8/10/23 at 3:18 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/10/23 and decreased the scope to a D, after the facility staff completed the following: a. Education to all staff on resident to resident altercations and actions to take. b. Resident #18's room change to a room closer to the nurses' station. c. A door alarm placed on Resident #18's door and 1:1 staff supervision of Resident #18 when Resident #18 was out of his room. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #136 included non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented that Resident #136 scored an 8 out of 15, which indicated Resident #136 had moderately impaired cognition. Resident #136 required extensive assist of 1 for transfers, ambulation, and dressing. A Progress Note for Resident #136 dated 6/25/22 at 1:54 PM, documented the following: Notified at this time by staff that resident had been touched by another resident in her genital area over her clothing. Assessed resident to ensure no injury was done to her person, no injuries observed, resident denies pain or discomfort. Resident alert and oriented to self only per usual, very smiley and pleasant at this time. Resident's family notified of incident and precautions taken to prevent future incidents, stated thank you for letting us know. Notified physician via phone, no new orders given. A 5 day Investigation Summary provided by the facility documented that the Certified Nurse Aide (CNA) reported to the nurse that Resident #18 had his hands in between Resident #136's legs on the outside of her pants and brief rubbing in circular motions. It documented the date of the incident was 6/25/2022 at 3 PM. The reported event was resident to resident inappropriate touching. The description of the incident was Resident #136 was fully dressed when sitting in her wheelchair in the dining room. Staff observed Resident #18 entering the dining room. Minutes later CNA entered the dining room and observed Resident #18 with his hands in between Resident #136's legs rubbing in a circular motion on the outside of her pants and brief. CNA asked Resident #18 to stop, and he was escorted back to his room. Resident #18 had no reaction to any of this interaction and remained her normal pleasant self. The immediate response to the incident was Separation of residents, Resident #136 was assessed, and no injuries/harm observed. 2. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #17 included Post Traumatic Stress Disorder (PTSD). It documented that this resident admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) documented that Resident #17's BIMS score was 7, which indicated Resident 17's cognition was severely impaired. Resident required extensive assist of 2 for transfers, bed mobility, and locomotion. A Minimum Data Set (MDS) dated [DATE], documented that this resident's BIMS score had increase to 15 out of 15 which indicated intact cognition. On 5/18/2023 at 5:24 AM, a progress note from Resident #18's chart documented the following: Resident #18 was sitting in the doorway of room [ROOM NUMBER] (Resident #17's room). When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When the CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. There was no documentation of this incident in Resident #17's progress notes. There was no report turned in of this incident. On 8/10/23 at 8:44 AM, Resident #17, when asked about a resident watching her from the doorway in the middle of the night, stated 'you mean (Resident #18's name)?, Oh yes.' Resident #17 stated she told him not to come into her room. She said she was scared at the time. She stated she was really sick at the time and just wanted him to go away. She stated he hasn't done that since. Resident #17 said she's much better now and she thinks he knows better. She said if a resident would try to fondle her, she would tell them to stop and to get away from her. 3. A MDS dated [DATE], documented that Resident #20's diagnoses included Alzheimer's disease. It documented that this resident admitted to the facility on [DATE]. A BIMS documented a score of 9 out of 15, which indicated Resident #20's cognition was moderately impaired. This resident required supervision for transfers and ambulation. A MDS dated [DATE], documented that this Resident's BIMS score had decreased to 3 out of 15, which indicated severely impaired cognition. This resident required an extensive assist of 1 for transfers, ambulation, and locomotion. A Progress Note for Resident #20 documented the following: Staff witnessed in the Dining room prior to supper a male resident (Resident #18) kiss resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed male resident on watch for 1 on 1 with staff, call placed to make Administrator, Director of Nursing (DON), provider, and brother aware. A 5 day Investigation Summary provided by the facility documented the date of the incident was 6/24/23 and the reported event was a resident to resident personal interaction. The description of the incident was that Resident #20 and Resident #18 were observed giving a kiss while sitting in their individual wheelchairs in the front dining room by a CNA. The CNA separated residents immediately. The CNA observed both residents within 2 minutes prior to observing the kiss, sitting next to each other talking. Resident #20 was the one that approached Resident #18 in the dining room. The facility investigative findings were that the residents do not recall kissing each other. The kiss occurred in the front dining room while residents were sitting in their wheelchairs. Staff did not report any other inappropriate touching and residents with a BIMS higher than 12 stated Resident #18 had not touched them inappropriately. Staff reported that neither male or female resident appeared or expressed upset after the kiss on the lips. The corrective action/actions to be taken were close observation with Resident #18 when outside his room around females. 4. A MDS dated [DATE], documented that Resident #187's diagnoses included Alzheimer's. It documented that this resident admitted to the facility on [DATE]. The facility showed no score for the BIMS for this resident. This MDS documented that Resident #187 had hallucinations and delusions. This resident required assistance of 1 for transfers and ambulation. A Progress Note for Resident #187 dated 5/7/23 at 8:01 PM, documented that Resident observed being touched by another Resident (Resident #18). When this writer approached Resident, stated that this other Resident is her husband then also her son. Tried to have Resident walk up to lobby but was followed. Resident is extremely agitated at this point. States she is going home and that her husband/son is going with her. A 5 day summary was not done for this incident. A Progress Note for Resident #187 dated 7/4/23 at 12:35 AM, documented: a CNA was yelling down the hall for a nurse. When nurse got to room, she found Resident #18 in Resident #187's room and the CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident #18 was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident #18 was removed from Resident #187's room. Nurse did assessment on Resident #187, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified - (administrator is reporting incident). A 5 day Investigation Summary provided by the facility, documented that the date of the incident was 7/3/23 and the event was reported as Sexual Abuse. The description of the incident was staff reported they heard a resident calling out down the hallway. Staff moved down hallway looking in each room. Resident that was hollering out was okay. Staff did find male resident (Resident #18) in Resident #187's room. Staff reported that Resident #18 (male) had his hands on female residents' breast (Resident #187) and genitals. Staff reported having eyes on residents within 10 minutes prior to the incident. Staff removed male from the room. Both female (BIMS 0) and male (BIMS of 5) were upset that the other was separated. Resident #187 stated the person that was touching her was a husband/brother, and Resident #18 felt like she was his girlfriend. Both residents stated nothing was wrong. The Facility Investigative Findings were that CNA's observed Resident #18 and Resident #187 in their own bedrooms when walking the hallway. 10 minutes later CNA was responding to a resident calling out down that same hallway. As CNA was passing Resident #187's room she noticed Resident #18 was in Resident #187's room next to her bed. Resident #18 had his hands inside Resident #187's clothing touching a breast and genitals. Resident #18 was removed from the room. Both residents were upset that they were interrupted. Resident #18 returned to his room. Resident #187 was placed in a new room down a different hallway. Skin assessment completed, showing no new bruises or scratches. Both residents calm and in own rooms rest of the night. The Corrective Actions /Actions to be taken were Resident #187 was moved to another wing of the building that was opposite of Resident #18. Residents with a BIMs greater than 12 were interviewed. They all reported that they feel safe. Each resident stated they have not seen inappropriate touching between others or had anyone touch them inappropriately. Staff were interviewed and asked if they have witnessed any inappropriate touching that was not reported. Staff stated they have not witnessed anything that was not reported already. Resident #187 was on hospice, and it was noted in multiple progress notes that she would continue to encourage relations with him due to her believing he was her husband. Resident #187 has since passed away and Resident #18 has not made any inappropriate moves towards any other female resident. 5. A MDS dated [DATE], documented that Resident #18's diagnoses included dehydration and alcohol dependence in remission. It documented that this resident admitted to the facility on [DATE]. This Resident had a BIMS of 9 out of 15, which indicated moderately impaired cognition. This resident required supervision for transfers and was independent with ambulation. A MDS dated [DATE], documented that this resident's BIMS remained at a 9 out of 15. It documented that this resident did not ambulate during the assessment period. It documented that this resident was independent for locomotion in his room and adjacent hallway to his room and required supervision for locomotion to dining room and other areas in the facility. This assessment documented that this resident had a diagnosis of mood disorder. A MDS dated [DATE], documented that this resident's BIMS score was 5 out of 15, which indicated severely impaired cognition. The following entries were documented in Resident #18's progress notes: -On 6/25/22 at 3:01 PM: Staff found resident touching another resident's (female) groin area over her clothes. Staff had to intervene and asked resident to go to room. Resident complied. -On 6/25/22 at 3:19 PM: Staff notified the nurse. The staff notified this nurse that they found resident in dining room with a female resident, whom was confused, and noted his hand on her groin/perineal area outside of her pants and making a rubbing motion. Staff told resident we will have none of that. Resident removed via wheelchair from dining area and asked to go to room, he complied. He stated I was touching her leg. Resident removed from situation. Other resident assessed, no injuries/harm observed. Notified DON (Director of Nursing), notified family. Thirty minute checks initiated. Resident not allowed to be in dining room unsupervised if female residents present. -On 6/30/22 at 12:59 PM, Staff informed the nurse that resident had moved his dinner to a different table in the dining room, this table was only ladies. Due to recent incidents resident is to be away from any female residents. Resident was asked by staff to move back to his table and he refused. The Director of Nursing (DON) was asked to step in due to resident not cooperating. When DON asked resident to move tables, he stated that he didn't want to, and when he was informed that he could not sit at this particular table the resident stated he was done and left the dining area. -On 7/2/22 at 2:08 PM, Staff reported resident respectful with staff and residents. Asked to distance himself from female resident at mealtime and did so quickly and kindly. -On 7/24/22 at 3:48 PM, Resident told multiple times today to keep hands to himself and not touch the female residents. Resident (was) finally asked to either keep hands to himself or go to his room. Resident began to get angry and resident told staff to mind their own business or call the cops as he was allowed to touch whoever he wanted and staff didn't need to be concerned with what he was doing. -On 8/4/22 at 2:01 PM, Resident was seen by the Advanced Registered Nurse Practitioner (ARNP), today and received a new diagnosis of mood disorder and hypersexuality. Also received a new order to start taking Paroxetine (an anti-depressant) 10 mg PO daily x 7 days then increase to 20 mg PO daily. Resident is aware and pharmacy has been notified. -On 12/4/22 at 8:28 AM, Resident was yelling and cussing at staff related to another resident screaming in her room. Resident was educated and still unsuccessful and was upset. Offered resident to sleep for the night in a room on another hall and this made resident happy. -On 1/7/23 at 7:34 AM, Resident came out to dining area last night when he heard a resident yelling, he started yelling at the staff to do their jobs. Nurse tried to explain to resident that the resident yelling had just been checked on and he was still mad telling the nurse to do her job. He then went down the hall and looked into other residents' room and came back to nurses' station and was yelling at the nurse again. Nurse told Resident that he needs to go to his room to calm down. Resident stayed in his room the rest of the night -On 1/17/23 at 2:49 AM, Certified Nurse Aide (CNA) informed nurse that he found resident in a female resident's room. CNA told resident that he was not allowed to be in her room, and he got mad and said that he was in her room because no one takes care of her. Female resident was sleeping at the time and this nurse had just checked on her 10 minutes before this incident happened. CNA also informed nurse at 10:00 PM that the resident got in an argument with roommate. Roommate told CNA that resident tried to unplug his TV because he was watching something resident didn't like. CNA told resident that he can't be doing that. Resident was mad and went to dining area to get coffee and snack. Nurse went in room at 10:30 PM to check on them and they were watching TV together. -On 1/19/23 at 4:50 AM, Resident was sitting in his wheelchair in front of door to room [ROOM NUMBER]. Resident informed that he does not need to be sitting in front of that door and resident asked to return to his room. Resident states she is yelling for help and you all aren't doing anything for her. Resident informed that other resident is fine and that her yelling is not his concern. Resident again asked to return to his room, resident states that's where I was going. Resident also told staff you aren't going to tell me what to do and then proceeded to sit in his wheelchair in the hallway. Resident asked by both nurse and CNA to return to his room, resident loudly stated if you would shut the hell up maybe I would. Resident asked to lower his voice as other residents are sleeping and was again asked to return to his room. Resident did finally return to his room. -On 2/5/23 at 2:06 PM, At approximately 1:30 PM, It was brought to the nurse's attention by another resident that resident was reaching out to touch a nonverbal resident yesterday, but did not actually touch the resident. This nurse educated resident that he cannot touch other residents without consent. Resident stated I know, I keep my hands right where they belong and that is to myself. DON aware. -On 2/9/23 at 5:58 PM, Resident was in dining area and was constantly messing with a female resident after staff asked him several times to please leave her alone so she could sleep. Staff decided to move female resident to her room to allow her more privacy and quiet space to try and sleep. Female resident was very anxious and kept yelling, the CNAs and nurse were doing checks between helping other residents get to bed and giving medications. Resident kept going past her door and would yell at the staff to check on her and help her. He said we weren't doing our jobs. Nurse tried to explain to resident that the resident was fine and that she was just checked on, he said the nurse was lying and was yelling even louder. Male CNA got up to go into female resident's room and resident tried to hit him when he was walking by. Resident was told that it is not ok to hit people and was sent back to his room. He has been in his room the rest of the night. -On 3/24/23 at 4:59 AM, Resident kept coming down the hall to tell the CNAs to do their job when he heard a resident say hello. The resident that was saying Hello had just woken up and CNAs had been in her room several times to sit with her. The resident fell back to sleep and Resident #18 came back down the hall yelling at CNAs and when they tried to tell him that she was sleeping he got mad and called CNA a bitch and was yelling and woke up the sleeping resident. Nurse told him that he needs to go to his room if he was going to be yelling at staff and be disruptive to other residents. After a few minutes he went back to his room. -On 5/7/23 at 7:53 PM, Resident caught touching another Resident in the hallway. When asked to stop touching other Resident states, I do not have to. She likes me. Tried to explain to Resident that this other Resident was confused and thought he was her brother or her husband. Resident laughs at this and tries approaching Resident again. When this writer tried to remove the other Resident from the area, he started following. Asked this Resident to go his room and he stated he didn't have to. At this time he tried grabbing the other Resident's walker and put his foot in front of her walker to stop her from walking. This writer tried to move his wheelchair and Resident threw his coffee at this writer and started running wheelchair into this writer's leg. His roommate came into the hallway and asked Resident to stop. At this distraction, walked other Resident up to front lobby. Resident followed up and is up in front lobby as well at this time. Observing interaction. -On 5/7/23 at 8:57 PM, Nurse spoke with on-call ARNP (Advanced Registered Nurse Practitioner), regarding resident touching a female resident, throwing coffee on staff, running his wheelchair into staff, grabbing another resident's walker and putting himself in front of resident's walker. Received phone order for Lorazepam 0.5 mg PO PRN (as needed)1 time only dose for restlessness or anxiety for 24 hours only. ARNP also suggested staff contact another provider on 5/8/23 to update on resident's behaviors. -On 5/8/23 at 6:38 AM, Resident has been on 1:1 supervision (staff were to be supervising him at all times) since 2145 last evening. Resident came out of room x 3 during the night, 2 times he sat at end of west hallway looking out the window, and 1 time he came down to dining room. Before going to bed last night resident was redirected away from another resident multiple times, as this resident followed other resident down hallway, into lobby, into dining room, and was encouraging other resident to sit with him at a dining room table. When other resident would refer to this resident as her husband/son, this resident did not state he was not those people. When resident was redirected away from other resident, this resident stated call the cops and see what they have to say about it. Resident was asking the resident (Resident #187) what room she was in as wanted this resident to come to her room. Resident has not been in room [ROOM NUMBER] and they were monitoring his location. -On 5/11/23 at 1:29 AM, CNA just informed this nurse that resident was sitting in the doorway of a female resident's room. Female resident was sleeping at this time. CNA asked if he needed anything, resident said no. CNA then asked what he was doing sitting in her doorway, he replied that he was just sitting here, watching her. CNA told him he needed to move, he cannot just sit in a resident's doorway watching her. Resident was easily redirected and went back to his room. The other resident remains asleep. -On 5/12/23 at 6:41 PM, Resident noted to be sitting in his wheelchair in dining room behind female resident with his right hand on left shoulder and attempting to snap her cloth bib. This resident made aware that he cannot be touching another resident at any time. This resident states I'm not touching her, this resident informed this nurse can see him touching the other resident's shoulder and trying to snap the bib. This resident stopped touching other resident's shoulder and trying to snap cloth bib, this nurse then snapped resident's cloth bib. -On 5/18/23 at 5:24 AM, Resident was sitting in the doorway of room [ROOM NUMBER]. When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. -On 5/19/23 at 3:01 AM, Resident came down the hall when another resident was yelling. Nurse and CNA have been in and out of this resident's room several times for the past few hours because of the yelling. Resident #18 came down the hall and was telling the CNA and nurse to get up and do their job. When nurse tried to comfort Resident #18 said, You shut up I am not talking to you. The nurse said, I understand you are not talking to me, but you are talking to the CNA and being very disrespectful. The nurse explained to Resident #18 that they were taking care of the other resident and he needs to either go back to his room or go to the dining area. He cannot sit in the hall by her door. He got very mad and was yelling at this nurse. Nurse went into the other resident's room and shut the door. After about ten minutes Resident #18 went back to his room. -On 5/19/23 at 8:49 AM, A CNA told the Activity Director that Resident #18 was yelling at another resident that she needs to move out of his spot. The activity director went out to the dining room to deescalate the situation and separate the two residents away from each other. -On 5/20/23 at 5:04 AM, Around 2400 (midnight) last night this resident was noted to be following female resident (Resident #187) as resident as stating for this resident to come down to her room and go to sleep, Resident #187 thought this resident (Resident #18) was her son and he needed to go to sleep. When this resident and Resident #187 were in lobby and staff was trying to walk Resident #187 down to her room, this resident (#18) stopped his wheelchair in front of Resident #187 so she could not walk forward. This resident was asked multiple times by staff to please go down to his room or back to the dining room so staff could get resident down to her room. This resident proceeded to follow staff and Resident #187 down the hallway, this resident would stop in his wheelchair every time resident #187 and staff stopped in the hallway. When staff and Resident #187 were stopped outside of room [ROOM NUMBER], this resident ran his wheelchair into CNA and then hit the CNA on the back. This resident was informed that he cannot run into staff with his wheelchair nor can he hit staff, and resident was again asked to go to his room or back to the dining room. Resident refused to go to his room or back to dining room. Resident continued to follow staff and Resident #187 down the hallway. Resident did go into his room around 12:30 AM after sitting in the doorway of his room watching staff and Resident #187. -On 6/5/23 at 10:00 AM, Resident was trying to take a female resident into the back room with him. The resident from room [ROOM NUMBER] was in a wheelchair at church and he was trying to pull her away. Several staff members tried to redirect resident and he began yelling at staff, kicking at staff and making fists at staff members. Removed the female resident from the dining room and eventually she was brought back and sat with a staff member to enjoy the service and this resident sat alone at a table without further incident. -On 6/5/23 at 10:29 AM, As soon as the facility's staff member left the church service, this resident approached the female resident from room [ROOM NUMBER] and tried pulling her in her wheelchair away from the table with him. The resident from room [ROOM NUMBER]'s wife asked resident to please leave resident from room [ROOM NUMBER] alone and he began yelling at the visitor and hit her on her arm 3 times. The visitor has no injuries and filled out a statement of this event. -On 6/5/23 at 10:28 AM, About ten minutes after this progress note was made, Resident attempted to get to other Resident again. Called providers, and notified them of this situation. Notified DON and administrator. Resident's Vital Signs (VS) assessed and stable. No signs or symptoms of infection noted. Denies N/V/D/C (nausea/vomiting/diarrhea/constipation). Denies back pain, suprapubic pain (above pelvis), dysuria (difficulty urinating), or polyuria (frequent urination). Has not had any recent medication changes and was treated for a UTI (Urinary Tract Infection) last month. No recent falls or injuries noted. Will continue to monitor for further behaviors. -On 6/8/23 at 8:50 AM, Resident was sitting in west hallway in front of room [ROOM NUMBER]. Nurse entered room [ROOM NUMBER] and asked resident if she is ok and needing anything. When nurse exited room [ROOM NUMBER] this resident stuck his leg out in front of nurse causing nurse to stumble. When this resident informed that behavior was inappropriate, this resident laughed. This resident then went down to his room. -On 6/20/23 at 9:34 AM, resident was yelling at CNA about helping another resident that was sitting in the dayroom. This writer asked him to back off and let it go that someone would take care of it and he need not concern himself. He proceeded to tell staff that he was going to continue to interfere because no one was doing their job. Staff removed resident #20 and asked Resident #18 to go back to the table and let it alone. -On 6/20/23 at 10:35 AM, Received an order to start Carbamepine (anti convulsant also used for bipolar) 50 mg at HS (hour of sleep) for impulsive behavior and aggression, with follow up in 1 month. Orders updated. Communications updated. -On 6/24/23 at 6:05 PM, Staff witnessed in the dining room prior to supper resident kissing a female resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed resident on watch for 1 on 1 with staff. Call placed to make administrator, DON, and provider service aware. Left message for brother to return call. -On 6/24/23 at 9:00 AM, Late entry, Dietary aide and Social Worker reported to this nurse when she was walking the halls passing bedtime snacks, resident #187 was looking for [NAME], and when dietary aide and resident #187 were going by this resident's (#18) room, dietary aide heard this resident say [NAME]'s in here to resident #187. -On 6/26/23 at 12:52 PM, No other behaviors noted so far besides verbal aggression when Resident told he has to be with a staff member if he's out of his room. Gets upset and states to this writer, stop following me around, I can be out here -On 7/04/23 at 12:35 AM, CNA was yelling down the hall for nurse. When nurse got to room, she found Resident #18 in Resident #187's room and CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident was removed from room. Nurse did assessment on female resident, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified- (administrator is reporting incident) In an observation on 8/9/23 at 12:30 PM, Resident #18 was sitting in the dining room at a table with other men. Staff were present in dining room. On 8/9/23 at 3:05 PM, the Administrator acknowledged that there have been a lot of incidents with Resident #18 and female residents. When asked what the facility has done to prevent incidents, she stated they had involved providers and tried to stay vigilant. A Timeline of Interventions the facility put in place was provided by the Administrator and documented the following: -March 2023 Moved to a men's only table -Change of medications-multiple different types of medications -Psych consultation with monthly visits 4/26/23 -Observation when out of room -Redirected if going near females -1:1 during main behaviors 6/24-6/25 went to ER, 1:1 with Female Resident #20 -Police officer conversation regarding aggressive behavior on 6/5/23. -Sent out to ER for behavior observation -Behavior occurred, labs and tests. UTI found. 1:1 continued until antibiotic was complete due to assumed cause of initial behavior. Resident #187 was also encouraging and okay with touches. She didn't understand why touches couldn't happen. 5/7 one on one started. 5/11 antibiotic UTI start. 5/16 end of antibiotic. No behavior since 5/7. 1:1 ended 5/12. -6/24 1:1 with Resident #20 and eyes on Resident #18 when out of room. Behavior,ER on ,d+[DATE]. No changes or orders and psych consult set up for 7/6 plus medication increase. 7/4 behavior med changes. No other focus on females at this time. An observation on 8/10/23 at 8:16 AM, revealed Resident #18 was sitting at a dining table with 3 other male residents. He wheeled himself into the smaller dining room and grabbed a box of tissues. He then wheeled back into the main dining room and went to Resident #20. Resident #18 handed Resident #20 a tissue, leaning close into her space. No staff were present in dining room. Resident was aware that a surveyor was in the room and looked at the surveyor several times when he handed Resident #20 the tissue. He then patted Resident #20's back then backed away from her and went back to the men's table. On 8/10/23 at 8:30 AM, A Certified Medication Aide (CMA) brought the medication cart in to the dining room. No other staff were in the dining room until the CMA came in with the medication cart. On 8/10/23, 2 Immediate Jeopardies (IJs) were given to th

Based on observations, interviews and record review, the facility failed to provide adequate supervision for all residents resulting in exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136, and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touched Residents #136 & #187. These residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 fear. The facility was aware of these and other incidents but failed to put interventions into place that would prevent Resident #18 from further exploiting female residents. These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 32. On 8/10/23 at 3:18 PM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/10/23 and decreased the scope to a D, after the facility staff completed the following: a. Education to all staff on resident to resident altercations and actions to take. b. Resident #18's room change to a room closer to the nurses' station. c. A door alarm placed on Resident #18's door and 1:1 staff supervision of Resident #18 when Resident #18 was out of his room. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #136 included non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented that Resident #136 scored an 8 out of 15, which indicated Resident #136 had moderately impaired cognition. Resident #136 required extensive assist of 1 for transfers, ambulation and dressing. A Progress Note for Resident #136 dated 6/25/22 at 1:54 PM, documented the following: Notified at this time by staff that resident had been touched by another resident in her genital area over her clothing. Assessed resident to ensure no injury was done to her person, no injuries observed, resident denies pain or discomfort. Resident alert and oriented to self only per usual, very smiley and pleasant at this time. Resident's family notified of incident and precautions taken to prevent future incidents, stated thank you for letting us know. Notified physician via phone, no new orders given. 2. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #17 included Post Traumatic Stress Disorder (PTSD). It documented that this resident admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) documented that Resident #17's BIMS score was 7, which indicated Resident 17's cognition was severely impaired. Resident required extensive assist of 2 for transfers, bed mobility, and locomotion. A Minimum Data Set (MDS) dated [DATE], documented that this resident's BIMS score had increase to 15 out of 15 which indicated intact cognition. On 5/18/2023 at 5:24 AM, a Progress Note from Resident #18's chart documented the following: Resident #18 was sitting in the doorway of room [ROOM NUMBER] (Resident #17's room). When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. There was no documentation of this incident in Resident #17's progress notes. On 8/10/23 at 8:44 AM, Resident #17, when asked about a resident watching her from the doorway in the middle of the night, stated 'you mean (Resident #18's name)?, Oh yes.' Resident #17 stated she told him not to come into her room. She said she was scared at the time. She stated she was really sick at the time and just wanted him to go away. She stated he hasn't done that since. Resident #17 said she's much better now and she thinks he knows better. She said if a resident would try to fondle her, she would tell them to stop and to get away from her. 3. A MDS dated [DATE], documented that Resident #20's diagnoses included Alzheimer's disease. It documented that this resident admitted to the facility on [DATE]. A BIMS documented a score of 9 out of 15, which indicated Resident #20's cognition was moderately impaired. This resident required supervision for transfers and ambulation. A MDS dated [DATE], documented that this Resident's BIMS score had decreased to 3 out of 15, which indicated severely impaired cognition. This resident required an extensive assist of 1 for transfers, ambulation and locomotion. A Progress Note for Resident #20 documented the following: Staff witnessed in the Dining room prior to supper a male resident (Resident #18) kiss resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed male resident on watch for 1 on 1 with staff. call placed to make admin., DON, provider and brother aware. 4. A MDS dated [DATE], documented that Resident #187's diagnoses included Alzheimer's. It documented that this resident admitted to the facility on [DATE]. The facility showed no score for the BIMS for this resident. This MDS documented that Resident #187 had hallucinations and delusions. This resident required assistance of 1 for transfers and ambulation. A Progress Note for Resident #187 dated 5/7/23 at 8:01 PM, documented that Resident observed being touched by another Resident (Resident #18). When this writer approached Resident, stated that this other Resident is her husband then also her son. Tried to have Resident walk up to lobby but was followed. Resident is extremely agitated at this point. States she is going home and that her husband/son is going with her. A Progress Note for Resident #187 dated 7/4/23 at 12:35 AM, documented: a CNA was yelling down the hall for a nurse. When the nurse got to the room, she found Resident #18 in Resident #187's room and the CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident #18 was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident #18 was removed from Resident #187's room. Nurse did assessment on Resident #187, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified - (administrator is reporting incident) 5. A MDS dated [DATE], documented that Resident #18's diagnoses included dehydration and alcohol dependence in remission. It documented that this resident admitted to the facility on [DATE]. This Resident had a BIMS of 9 out of 15, which indicated moderately impaired cognition. This resident required supervision for transfers and was independent with ambulation. A MDS dated [DATE], documented that this resident's BIMS remained at a 9 out of 15. It documented that this resident did not ambulate during the assessment period. It documented that this resident was independent for locomotion in his room and adjacent hallway to his room and required supervision for locomotion to dining room and other areas in the facility. This assessment documented that this resident had a diagnosis of mood disorder. A MDS dated [DATE], documented that this resident's BIMS score was 5 out of 15, which indicated severely impaired cognition. The following entries were documented in Resident #18's progress notes: -On 6/25/22 t 3:01 PM: Staff found resident touching another resident's (female) groin area over her clothes. Staff had to intervene and asked resident to go to room. Resident complied. -On 6/25/22 at 3:19 PM: Staff notified the nurse. The staff notified this nurse that they found resident in dining room with a female resident, whom was confused, and noted his hand on her groin/perineal area outside of her pants and making a rubbing motion. Staff told resident we will have none of that. Resident removed via wheelchair from dining area and asked to go to room, he complied. He stated I was touching her leg. Resident removed from situation. Other resident assessed, no injuries/harm observed. Notified DON (Director of Nursing), notified family. Thirty minute checks initiated. Resident not allowed to be in dining room unsupervised if female residents present. -On 6/30/22 at 12:59 PM, Staff informed the nurse that resident had moved his dinner to a different table in the dining room, this table was only ladies. Due to recent incidents resident is to be away from any female residents. Resident was asked by staff to move back to his table and he refused. The Director of Nursing (DON) was asked to step in due to resident not cooperating. When DON asked resident to move tables, he stated that he didn't want to, and when he was informed that he could not sit at this particular table. The resident stated he was done and left the dining area. -On 7/2/22 at 2:08 PM, Staff reported resident respectful with staff and residents. Asked to distance himself from female resident at mealtime and did so quickly and kindly. -On 7/24/22 at 3:48 PM, Resident told multiple times today to keep hands to himself and not touch the female residents. Resident (was) finally asked to either keep hands to himself or go to his room. Resident began to get angry and resident told staff to mind their own business or call the cops as he was allowed to touch whoever he wanted and staff didn't need to be concerned with what he was doing. -On 8/4/22 at 2:01 PM, Resident was seen by the Advanced Registered Nurse Practitioner (ARNP), today and received a new diagnosis of mood disorder and hypersexuality. Also received a new order to start taking Paroxetine (an anti-depressant) 10 mg PO daily x 7 days then increase to 20 mg PO daily. Resident is aware and pharmacy has been notified. -On 11/12/22 at 12:00 PM, The resident was witnessed laughing and making fun of another resident and then yelling at other resident to shut up. When redirected resident became angry with writer and told writer to shut the hell up and go away. Resident encouraged to go to his room if he could not be appropriate in the common area with other residents and if other residents were irritating him. Res continues to yell at writer and become angry. Writer walked away and resident continued with his dinner without any further behaviors towards other residents. -On 12/4/22 at 8:28 AM, Resident was yelling and cussing at staff related to another resident screaming in her room. Resident was educated and still unsuccessful and was upset. Offered resident to sleep for the night in a room on another hall and this made resident happy. -On 1/7/23 at 7:34 AM, Resident came out to dining area last night when he heard a resident yelling, he started yelling at the staff to do their jobs. Nurse tried to explain to resident that the resident yelling had just been checked on and he was still mad telling the nurse to do her job. He then went down the hall and looked into other residents' room and came back to nurses' station and was yelling at the nurse again. Nurse told Resident #18 that he needed to go to his room to calm down. Resident stayed in his room the rest of the night -On 1/17/23 at 2:49 AM, Certified Nurse Aide (CNA) informed nurse that he found resident in a female resident's room. CNA told resident that he was not allowed to be in her room, and he got mad and said that he was in her room because no one takes care of her. Female resident was sleeping at the time and this nurse had just checked on her 10 minutes before this incident happened. CNA also informed nurse at 10:00 PM that the resident got in an argument with roommate. Roommate told CNA that resident tried to unplug his TV because he was watching something resident didn't like. CNA told resident that he can't be doing that. Resident was mad and went to dining area to get coffee and a snack. Nurse went in room at 10:30 PM to check on them and they were watching TV together. -On 1/19/23 at 4:50 AM, Resident was sitting in his wheelchair in front of door to room [ROOM NUMBER]. Resident informed that he does not need to be sitting in front of that door and resident asked to return to his room. Resident states she is yelling for help and you all aren't doing anything for her. Resident informed that other resident is fine and that her yelling is not his concern. Resident again asked to return to his room, resident states that's where I was going. Resident also told staff you aren't going to tell me what to do and then proceeded to sit in his wheelchair in the hallway. Resident asked by both nurse and CNA to return to his room, resident loudly stated if you would shut the hell up maybe I would. Resident asked to lower his voice as other residents are sleeping and was again asked to return to his room. Resident did finally return to his room. -On 2/5/23 at 2:06 PM, At approximately 1:30 PM, It was brought to the nurse's attention by another resident that resident was reaching out to touch a nonverbal resident yesterday, but did not actually touch the resident. This nurse educated resident that he can not touch other residents without consent. Resident stated I know, I keep my hands right where they belong and that is to myself. DON aware. -On 2/9/23 at 5:58 PM, Resident was in dining area and was constantly messing with a female resident after staff asked him several times to please leave her alone so she could sleep. Staff decided to move female resident to her room to allow her more privacy and quiet space to try and sleep. Female resident was very anxious and kept yelling, the CNAs and nurse were doing checks between helping other residents get to bed and giving medications. Resident kept going past her door and would yell at the staff to check on her and help her. He said we weren't doing our jobs. Nurse tried to explain to resident that the resident was fine and that she was just checked on, he said the nurse was lying and was yelling even louder. Male CNA got up to go into female resident's room and resident tried to hit him when he was walking by. Resident was told that it is not ok to hit people and was sent back to his room. He has been in his room the rest of the night. -On 3/24/23 at 4:59 AM, Resident kept coming down the hall to tell the CNAs to do their job when he heard a resident say hello. The resident that was saying Hello had just woken up and CNAs had been in her room several times to sit with her. The resident fell back to sleep and Resident #18 came back down the hall yelling at CNAs and when they tried to tell him that she was sleeping he got mad and called CNA a bitch and was yelling and woke up the sleeping resident. Nurse told him that he needs to go to his room if he was going to be yelling at staff and be disruptive to other residents. After a few minutes he went back to his room. -On 5/7/23 at 7:53 PM, Resident caught touching another Resident in the hallway. When asked to stop touching other Resident states, I do not have to. She likes me. Tried to explain to Resident that this other Resident was confused and thought he was her brother or her husband. Resident laughs at this and tries approaching Resident again. When this writer tried to remove the other Resident from the area, he started following. Asked this Resident to go his room and he stated he didn't have to. At this time he tried grabbing the other Resident's walker and put his foot in front of her walker to stop her from walking. This writer tried to move his wheelchair and Resident threw his coffee at this writer and started running wheelchair into this writer's leg. His roommate came into the hallway and asked Resident to stop. At this distraction, walked other Resident up to front lobby. Resident followed up and is up in front lobby as well at this time. Observing interaction. -On 5/7/23 at 8:57 PM, Nurse spoke with on-call ARNP, regarding resident touching a female resident, throwing coffee on staff, running his wheelchair into staff, grabbing another resident's walker and putting himself in front of resident's walker. Received phone order for Lorazepam 0.5 mg PO PRN (as needed)1 time only dose for restlessness or anxiety for 24 hours only. ARNP also suggested staff contact another provider on 5/8/23 to update on resident's behaviors. -On 5/8/23 at 6:38 AM, Resident has been on 1:1 supervision since 2145 last evening. Resident came out of room x 3 during the night, 2 times he sat at end of west hallway looking out the window, and 1 time he came down to dining room. Before going to bed last night resident was redirected away from another resident multiple times, as this resident followed other resident down hallway, into lobby, into dining room, and was encouraging other resident to sit with him at a dining room table. When other resident would refer to this resident as her husband/son, this resident did not state he was not those people. When resident was redirected away from other resident, this resident stated call the cops and see what they have to say about it. Resident was asking the resident (Resident #187) what room she was in as she wanted this resident to come to her room. Resident has not been in room [ROOM NUMBER] and they were monitoring his location. -On 5/11/23 at 1:29 AM, CNA just informed this nurse that resident was sitting in the doorway of a female resident's room. Female resident was sleeping at this time. CNA asked if he needed anything, resident said no. CNA then asked what he was doing sitting in her doorway, he replied that he was just sitting here, watching her. CNA told him he needed to move, he cannot just sit in a resident's doorway watching her. Resident was easily redirected and went back to his room. The other resident remains asleep. -On 5/12/23 at 6:41 PM, Resident noted to be sitting in his wheelchair in dining room behind female resident with his right hand on left shoulder and attempting to snap cloth bib. This resident made aware that he cannot be touching another resident at any time. This resident states I'm not touching her, this resident informed this nurse can see him touching the other resident's shoulder and trying to snap the bib. This resident stopped touching other resident's shoulder and trying to snap cloth bib, this nurse then snapped resident's cloth bib. -On 5/17/23 at 12:25 AM, at 11:20 PM on 5/16/23 CNA found this resident in his wheelchair in room [ROOM NUMBER] near resident's nightstand, was asleep and other resident in room [ROOM NUMBER], couldn't see this resident as privacy curtain was pulled. CNA removed this resident from room [ROOM NUMBER] and asked this resident what he was doing, this resident stated just hanging out. CNA educated this resident that he is not allowed to be in other resident's rooms. Both CNAs then went back into room [ROOM NUMBER] and saw that residents' wallet was opened and money was scattered on the nightstand. -On 5/17/23 at 3:41, At 3:00 AM this resident came up to 2 CNAs to tell them room [ROOM NUMBER] call light was on and that resident wanted help. CNA went down to room [ROOM NUMBER] and answered call light, stated that he accidentally bumped his light and didn't need anything. Resident was informed about this resident being in room last night and that this resident had potentially went thru resident wallet. Resident stated he knew exactly how much was in and counted in front of CNA, $139 was counted and resident stated that was the correct amount. Resident stated he told this resident (Resident #18) to leave his room when call light was on and this resident was asking him what he needed. Resident states when he told this resident to leave this resident said no. -On 5/18/23 at 5:24 AM, Resident was sitting in the doorway of room [ROOM NUMBER]. When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. -On 5/19/23 at 3:01 AM, Resident came down the hall when another resident was yelling. Nurse and CNA have been in and out of this resident's room several times for the past few hours because of the yelling. Resident #18 came down the hall and was telling the CNA and nurse to get up and do their job. When nurse tried to comfort Resident #18 said, You shut up I am not talking to you. The nurse said, I understand you are not talking to me, but you are talking to the CNA and being very disrespectful. The nurse explained to Resident #18 that they were taking care of the other resident and he needs to either go back to his room or go to the dining area. He cannot sit in in the hall by her door. He got very mad and was yelling at this nurse. Nurse went into the other resident's room and shut the door. After about ten minutes Resident #18 went back to his room. -On 5/19/23 at 8:49 AM, A CNA told the Activity Director that Resident #18 was yelling at another resident that she needs to move out of his spot. The Activity Director went out to the dining room to deescalate the situation and separate the two residents away from each other. -On 5/20/23 at 5:04 AM, Around 2400 (midnight) last night this resident was noted to be following female resident (Resident #187) as resident was stating for this resident to come down to her room and go to sleep, Resident #187 thought this Resident #18 was her son and he needed to go to sleep. When this resident and Resident #187 were in lobby and staff was trying to walk Resident #187 down to her room, this resident (#18) stopped his wheelchair in front of Resident #187 so she could not walk forward. This resident was asked multiple times by staff to please go down to his room or back to the dining room so staff could get resident down to her room. This resident proceeded to follow staff and Resident #187 down the hallway, this resident would stop in his wheelchair every time Resident #187 and staff stopped in the hallway. When staff and Resident #187 were stopped outside of room [ROOM NUMBER], this resident ran his wheelchair into CNA and then hit the CNA on the back. This resident was informed that he cannot run into staff with his wheelchair nor can he hit staff, and resident was again asked to go to his room or back to the dining room. Resident refused to go to his room or back to dining room. Resident continued to follow staff and Resident #187 down the hallway. Resident did go into his room around 12:30 AM after sitting in the doorway of his room watching staff and Resident #187. -On 6/5/23 at 10:00 AM, Resident was trying to take a female resident into the back room with him. The resident from room [ROOM NUMBER] was in a wheelchair at church and he was trying to pull her away. Several staff members tried to redirect resident and he began yelling at staff, kicking at staff and making fists at staff members. Removed the female resident from the dining room and eventually she was brought back and sat with a staff member to enjoy the service and this resident sat alone at a table without further incident. -On 6/5/23 at 10:29 AM, As soon as the facility's staff member left the church service, this resident approached the female resident from room [ROOM NUMBER] and tried pulling her in her wheelchair away from the table with him. The resident from room [ROOM NUMBER]'s wife asked resident to please leave resident from room [ROOM NUMBER] alone and he began yelling at the visitor and hit her on her arm 3 times. The visitor has no injuries and filled out a statement of this event. -On 6/5/23 at 10:28 AM, About ten minutes after this progress note was made, Resident attempted to get to other Resident again. Called providers, and notified them of this situation. Notified DON and administrator. Resident's Vital Signs (VS) assessed and stable. No signs or symptoms of infection noted. Denies N/V/D/C (nausea/vomiting/diarrhea/constipation). Denies back pain, suprapubic pain (above pelvis), dysuria (difficulty urinating), or polyuria (frequent urination). Has not had any recent medication changes and was treated for a UTI (Urinary Tract Infection) last month. No recent falls or injuries noted. Will continue to monitor for further behaviors. -On 6/8/23 at 8:50 AM, Resident was sitting in west hallway in front of room [ROOM NUMBER]. Nurse entered room [ROOM NUMBER] and asked resident if she is ok and needing anything. When nurse exited room [ROOM NUMBER] this resident stuck his leg out in front of nurse causing nurse to stumble. When this resident informed that behavior was inappropriate, this resident laughed. This resident then went down to his room. -On 6/20/23 at 9:34 AM, resident was yelling at CNA about helping another resident that was sitting in the dayroom. This writer asked him to back off and let it go that someone would take care of it and he need not concern himself. He proceeded to tell staff that he was going to continue to interfere because no one was doing their job. Staff removed Resident #20 and asked Resident #18 to go back to the table and let it alone. -On 6/20/23 at 10:35 AM, Received an order to start Carbamepine (anti convulsant also used for bipolar) 50 mg at HS (hour of sleep) for impulsive behavior and aggression, with follow up in 1 month. Orders updated. Communications updated. -On 6/24/23 at 6:05 PM, Staff witnessed in the dining room prior to supper resident kissing a female resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed resident on watch for 1 on 1 with staff. call placed to make administrator, DON, and provider service aware. Left message for brother to return call. -On 6/24/23 at 9:00 AM, Late entry, Dietary aide and Social Worker reported to this nurse when she was walking the halls passing bedtime snacks, Resident #187 was looking for [NAME], and when dietary aide and Resident #187 were going by this resident's (#18) room, dietary aide heard this resident say [NAME]'s in here to Resident #187. -On 6/26/23 at 12:52 PM, No other behaviors noted so far besides verbal aggression when Resident told he has to be with a staff member if he's out of his room. Gets upset and states to this writer, stop following me around, I can be out here -On 7/04/23 at 12:35 AM, CNA was yelling down the hall for nurse. When nurse got to room, she found Resident #18 in Resident #187's room and CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident was removed from room. Nurse did assessment on female resident, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified - (administrator is reporting incident) In an observation on 8/9/23 at 12:30 PM, Resident #18 was sitting in the dining room at table with other men. Staff were present in dining room. On 8/9/23 at 3:05 PM, the Administrator acknowledged that there have been a lot of incidents with Resident #18 and female residents. When asked what the facility has done to prevent incidents, she stated they had involved providers and tried to stay vigilant. A Timeline of Interventions the facility put in place was provided by the Administrator and documented the following: -March 2023 Moved to a men's only table -Change of medications-multiple different types of medications -Psych consultation with monthly visits 4/26/23 -Observation when out of room -Redirected if going near females -1:1 during main behaviors 6/24-6/25 went to ER, 1:1 with Female Resident #20 -Police officer conversation regarding aggressive behavior on 6/5/23. -Sent out to ER for behavior observation -Behavior occurred, labs and tests. UTI found. 1:1 continued until antibiotic was complete due assumed cause of initial behavior. Resident #187 was also encouraging and okay with touches. She didn't understand why touches couldn't happen. 5/7 one on one started. 5/11 antibiotic UTI start. 5/16 end of antibiotic. No behavior since 5/7. 1:1 ended 5/12. -6/24 1:1 with Resident #20 and eyes on Resident #18 when out of room. Behavior,ER on ,d+[DATE]. No changes or orders and psych consult set up for 7/6 plus medication increase. 7/4 behavior med changes. No other focus on females at this time. An observation on 8/10/23 at 8:16 AM, revealed Resident #18 was sitting at a dining table with 3 other male residents. He wheeled himself into the smaller dining room and grabbed a box of tissues. He then wheeled back into the main dining room and went to Resident #20. Resident #18 handed Resident #20 a tissue, leaning close into her space. No staff were present in the dining room. Resident was aware that a surveyor was in the room and looked at the surveyor several times when he handed Resident #20 the tissue. He then patted Resident #20's back then backed away from her and went back to the men's table. On 8/10/23 at 8:30 AM, A Certified Medication Aide (CMA) brought the medication cart in to the dining room. No other staff were in the dining room until the CMA came in with the medication cart. On 8/10/23, 2 Immediate Jeopardies (IJs) were given to the facility related to sexual exploitation and inadequate supervision. On 8/10/23 at 4:00 PM, Staff N, Clinical Regional Nurse and the Administrator stated the abatement plan for the 2 IJs included all staff education with agency staff being educated when they worked, they were looking at discharging this resident to another facility. They had contacted 3 facilities with 1 of the facilities having an all-male unit. Staff N stated they moved this resident closer to the nurses' station and a door alarm was placed on his door. When asked how staff would keep track of him after he left the room, she stated they would put a 1:1 on him when he was out of the room and they had contacted the psych ARNP to evaluate the need for this. On 8/14/23 at 12:23 PM, Resident #18 was sitting at the male table in the dining room. His door alarm sounded when housekeeping came out of it. Staff started toward the door and then saw the housekeeper. Staff present in dining room. On 8/14/23 at 4:35 PM, Resident #18's brother and emergency contact stated he was aware of his brother's inappropriate behavior with females. He stated the facility lets him know when his brother does things like that. Resident #18's brother stated that all the facility needs to do is tell his brother not to do those things, and his brother will stop doing them. Resident #18's brother stated the last time he visited his brother, he told his brother to not do those things anymore and Resident #18 stated he would stop. On 8/14/23 at 9:00 AM, Staff A, Registered Nurse (RN), stated that this resident's behaviors vary from day to day. Staff A stated that Resident #18 not only can be inappropriate with some of the ladies, he also has fits of anger. She stated Resident #18 and another resident did yell at each other but then shook hands right after and have been fine ever since. Staff A stated Resident #18 preys on the ladies that he knows can't tell on him or don't understand what he is doing. He also preys on the ones that really can't move themselves. She said Resident #18 was sneaky and that other residents watch out for him too. She said that one time Resident #18 was putting a blanket on Resident #20 and another resident wheeled by and told staff to watch Resident #18's hands, implying that this resident would try to touch Resident #20. Staff A stated that having a 1:1 on him was hard. She said they are responding when his door alarm goes off. She added they have the rest of the residents to take care of and it is difficult to get the workload done. She said because he is mobile, they have to stay with him because he is sneaky. She said he knows what he is doing and he stays aware of his surroundings. This RN said that he is one that would wait for staff to clear the room, and then he would

Based on record review, facility policy review, interviews with physician, staff and family, the facility failed to implement cardiopulmonary resuscitation (CPR) for one (1) of nine (9) residents with an advanced directive for CPR. Record review established the facility staff failed to perform CPR when Resident #5' s advance directive indicated he/she wanted CPR. Record review and interviews revealed no facility staff initiated CPR when Resident #5 ceased breathing, without pulse or blood pressure and the resident died . The resident's physician present at bedside told the facility staff to not perform CPR denying the resident his/her right for self-determination. The findings constitute an immediate jeopardy to a residents health and safety. The facility identified a census of 34 residents. Findings include: The facility's policy for CPR (Basic Life Support Manual External Cardiac Massage and Mouth-To-Mouth Ventilation revised [DATE], documented the purpose as follows: To provide basic life support (manual external cardiac massage and mouth-to-mouth ventilation) in the event a cardiopulmonary arrest based on clinical criteria and resident preferences. The procedure documented the following: 1. CPR would have been initiated on all residents UNLESS: a. A valid physician's orders [REDACTED]. b. Obvious signs of death had been present: Dependent lividity: blotchy, black and blue, or reddish discoloration of the skin: that began in the parts of the body closest to the floor within minutes of death and progresses over the rest of the body; Rigor mortis: a postmortem contraction of muscles without relaxation; that caused a rigidity found first and the neck and jaw; Algo mortis: the steady lowering of body temperature after death, i.e., skin temperature had been cold. If CPR had not been initiated due to one of the above reasons, there must be detailed documentation in the resident's medical record supporting evidence of the resident's condition when found. According to a Minimum Data Set (MDS) assessment form dated [DATE], the resident had been a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment indicated the resident with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, with the ability to make self-understood and understand others, with fluctuating inattention and disorganized thinking, required supervision of staff with all activities of daily living (ADL'S) and with frequent pain. According to a Physicians Progress Notes form dated [DATE], the resident had [DIAGNOSES REDACTED]. An Extended Mini-Mental Assessment form dated [DATE], documented the resident received a score of 20 out of 20 which indicated no cognitive impairment. According to a Care Plan (not dated), the resident had been a FULL CODE. A facility form with the revised date of ,[DATE], titled DNR/CPR Instruction and Physician order [REDACTED]. The form indicated if DNR instructions had been the expressed wishes of the resident/responsible party, then a physician's orders [REDACTED]. According to Resident #5's DNR/CPR Instruction and Physician order [REDACTED]. The facilities Progress Notes documented the following information as dated: a. On [DATE] at 11:30 p.m. - Resident very anxious and nervous. Writer and CNA in resident's room. Resident talking clearly with staff and assisted him/her back to bed. Resident pushing slacks that he/she had been wearing up from his/her ankles to above kneecaps. Resident taking his/her long hair and repeatedly pushed it back behind his/her ear. Resident siting on the edge of the bed and we were going to assist the resident to his/her legs back into bed but the resident said no don't touch my leg! Offered resident 2 as needed (PRN) [MEDICATION NAME] but resident refused. Checked residents pulse oximetry readying and it was 84 on room air so started PRN oxygen (O2) at 2 liters per nasal cannula (n/c). Resident no lying in bed on back with head of bed up. Resident not as anxious and resting quietly on the bed. Call light in reach. Staff left the room. b. On [DATE] at 4:30 a.m. - Resident resting very quietly on his/her bed. Resident had O2 on per nasal cannula. Called family member and condition update given. c. On [DATE] at 6:30 a.m. - Resident lying in bed with rattling evident. Greenish-brown foamy sputum running out of mouth. No facial grimacing/moaning. Resident did not squeeze hand when asked to do so/did not open eyes/mumbled when asked question. Temperature 98.7, pulse 88, respirations 32, blood pressure ,[DATE], oxygen level at 60 % on 5 liters of oxygen. Family member asked that physician be called and questioned if we could send to hospital. The Oncologist had been phoned and spoke with daughter then this nurse. The Oncologist suggested Hospice to daughter to help with grief issues. The Oncologist planned to make referral when she arrived at the office. The family member left to get spouse. d. On [DATE] at 8:15 a.m. - at 7:30 a.m. this writer (went) to resident's room. Resident restless and trying to climb out of bed. Resident with increased secretions in the back of throat. Call to Medical Physician with condition. At 7:35 a.m. received new orders for [MEDICATION NAME] as well as [MEDICATION NAME] 20 milligrams (mg) sublingual now and then every 2 hours PRN (as need) which had been given. Updated family member, family on the way to facility. Advised family member of change in breathing and restlessness with medications given to help with comfort. Resident incontinent of bowel as well as a small amount of a brown emesis during cleaning resident up. After repositioning and cleaning resident up as well as medication this writer sat with resident. At 7:50 a.m. resident with a few breaths approximately 1 minute apart. At 8 a.m. resident with last breath noted and no pulse noted. The Physician at side and reported not to do CPR. The family advised and on way to facility. The family member met at door at approximately 8:05 a.m. with 1:1 given. Text messages dated [DATE], documented the following information send between the DON and Staff A: DON at 6:57 a.m., can you check on Resident #5 and (his/her family member) if you have not already. How bad is it? Staff A at 6:58 a.m., Yep as soon as I get there. DON at 7:03 a.m., Never mind. Physician said hospice now. Staff A at 7:04 a.m., Oh wow .Ok I can see him/her as soon as I get there .Still Full Code. Does family member know? DON at 7:05 a.m., Family is there. Bad Night. Yesterday was transition. It was not Meds. Staff A at 7:06 a.m., leaving house now. DON at 7:07 a.m., 60% on 5 l O2 ( liters of Oxygen) Staff A at 7:07 a.m., Full Code. DON at 7:08 a.m., Just paperwork now. It's not a crisis. Staff A, (time unknown), OK. The text messages continue between the DON and Staff A, and at 7:59 a.m. Staff A responds: Resident #5 is gone. DON responds at 8:19 a.m., oh my god! At 8:22 a.m., the DON asked about Resident #5's family member. At 8:25 a.m., Staff A responds: Here now . Only me and physician when passed. According to a written statement dated [DATE] at 2:46 p.m., the ADON documented when she reported to work on [DATE] at approximately 7:30 a.m. Staff D, RN reported to her the resident's family member had been upset because the resident had been a Full Code and the facility had not sent him/her to the hospital. Staff D called the Oncologist who spoke with the family member and explained the resident had been dying and sending him/her to the hospital would not prolong his/her life. According to Staff D, after the family member talked with the Oncologist, the family member was accepting it was Resident #5's time to go. The ADON then initiated her morning duties when she observed Staff A, RN on the computer and her cell phone when she asked Staff D what Staff A had been doing at which time she had been informed Staff A had been dealing with the resident's condition change. After assisting other residents, the ADON entered the resident's room. With Staff A present, she reminded her Resident #5 is Full Code (CPR) and the ADON stated they should do CPR, and this was ethically and morally wrong. Staff G, CNA also present stated this was illegal. The ADON stated the resident's family member wanted him/her sent out earlier that morning. The ADON observed the resident as grabbing at the air and very frigidly when she left the room. The ADON assumed her other duties and when she observed the Medical Physician walked into the building and asked where the resident's room had been located. At approximately 8:15 a.m. the Physician approached the ADON and informed her Resident #5 was gone. The ADON asked the physician why Resident #5 had not been sent to the hospital since he/she was a Full Code (CPR). According to the ADON the physician stated it would be inhumane to pound on Resident #5's chest as he/she was dying. The physician left the building and the ADON reported her concerns to the provisional Administrator. At approximately 9 a.m. the ADON went into the daily stand up meeting at which time it had been mentioned the resident passed away at 8 a.m. The Director of Nursing (DON) stated she had been told the resident passed away at 8:03 a.m. at which time Staff A stated the resident took one more breath. During an interview on [DATE] at 1:30 p.m. Staff A, (social service) stated she spoke to the DON the morning of the resident's death and questioned if the resident had still been a CPR. The staff member confirmed she and Staff G, CNA provided cares for the resident and she sat with the resident to keep him/her calm and so the resident had not been by himself/herself. The staff member confirmed when the Medical Physician arrived the resident had still been alive but started breathing differently and then stopped breathing at which time she reminded the Physician the resident had been a Full Code and he directed the staff member to not perform CPR. The staff member indicated the resident passed away at 8 a.m. Staff A confirmed at no time did the resident's family member indicate and/or say he/she did not want CPR performed on his/her family member or that he/she did not want him/her sent to the hospital. During an interview [DATE] at 11:05 a.m., the resident's family member confirmed the resident's CPR status never changed anywhere along the line. The family member confirmed he/she never gave anyone the permission not to perform CPR at which time she began to cry and stated her parent wanted CPR. The family member also confirmed Staff A asked her about the resident's CPR status prior to the condition change at which time she told her the resident had been a Full Code/CPR. The family member stated at approximately 4:30 a.m. she received a telephone call from Staff F, Licensed Practical Nurse (LPN) who informed her, her parent had declined. At that time the family member asked whether they should send the resident to the hospital and the staff member said that was not what would happen because the resident [MEDICAL CONDITION]. The family member came to the facility and observed her family member and talked with Staff D, RN and asked her about hospitalization . At this time the staff member said no the facility would not send the resident to the hospital. The family member said (so) you are just going to let him/her die and the staff member said no and called the oncologist physician who spoke with the family member on the telephone. The oncologist told the family member that a transport to the hospital would not have been beneficial to the resident. After a time the family member left the facility to speak with her spouse. The family member stated when she returned at 8:03 a.m. Staff A met her at the door and informed her that her loved one had passed away. In a follow up interview with the family member on [DATE] (no time), she stated she talked on the phone with the oncologist because she wanted her parent transferred to the hospital. The family member had been asked if the oncologist discussed what support care means and responded the oncologist stated she would call Hospice when she got to her office so she could talk to someone. The family member stated she had been looking into Hospice but was not ready for that. The family member was asked if the oncologist told her that supportive care would not include CPR and stated No, they did not talk about CPR. The family member stated her parent always wanted CPR. The family member stated no one ever told her that her parent would not receive CPR. A typed statement dated [DATE] from the resident's Nurse Practitioner via the Oncologist documented the following information: The resident was consulted by our office on [DATE]. The Oncologist and I were both involved in his/her care on that visit. He/she had been evaluated by us for widespread [MEDICAL CONDITION] and was clearly not in a curable condition. We were in the process of making a referral to Hospice at the time of his/her death, and under the circumstances, any attempt at CPR would have been futile. The Oncologist personally discussed the situation with the patient's daughter at 6;30 a.m. the day of his/her death and his/her family member expressed to the Oncologist that he/she only wanted supportive care for his/her family member. The patient died before we could implement any of these changes in the medical record. During an interview [DATE] at 9:58 a.m., a Nurse Practitioner who worked with the Oncologist who cared for the resident confirmed during the resident's appointment with the Physician they discussed Hospice and palliative care with a plan to provide [MEDICAL CONDITION] treatments for palliation and comfort measures but not a cure. The discussion had not been specific to CPR at that time rather palliation only. During an interview [DATE] at 9:06 a.m., Staff F (Licensed Practical Nurse, LPN) confirmed she spoke with the resident's family member around 4:30 a.m. and gave him/her a status report. At which time the family member questioned if the resident should have been transported to the hospital. Staff F stated she then called the Director of Nursing (DON), updated her related to the resident's condition and had been told the facility would not send the resident to the hospital because he/she had been full [MEDICAL CONDITION]. The staff member then returned call to the family member and informed him/her what the DON had told her. During an interview [DATE] at 12:42 p.m., Staff D, Registered Nurse (RN) confirmed she called the Oncologist the morning of the resident's death who in turn had spoken with the resident's family member. She also spoke with the physician and confirmed they never talked about hospitalization and that she had been aware the resident had been a CPR. During an interview [DATE] at 11:24 a.m., the resident's Medical Physician stated he arrived at 7:45 a.m., and Resident #5 was still alive. The physician stated he gave the verbal orders to not perform CPR to Staff A while standing at the resident's bedside and observing him/her take his/her last breath. The physician stated there was no way CPR could have been administered to Resident #5 as he would have crushed/broken twenty-four ribs and he was not going there. The physician reported the family was back and forth on DNR/Hospice and if he would have sent the resident to the hospital, the hospital physician would have laughed at him. The physician reported he told Staff A he would take the blame if something went wrong. During an interview [DATE] at 10:01 a.m., the resident's Medical Physician confirmed he had not discussed his decision/directive not to perform CPR on the resident while at bedside with the resident's daughter. The physician reported sometimes when a person gets to that stage, a humane decision needs to be made and that's what he did. A Record of Death form signed by a Physician [DATE], documented the resident passed away on [DATE] at 8 a.m. The resident's physician sent the facility a letter dated [DATE] which included the following information: Resident #5 had [MEDICAL CONDITION] and co-morbidity. The resident was being evaluated for [MEDICAL CONDITION] therapy. On the morning of [DATE], the resident entered the dying process as it is known in hospice terms. The oncologist doctor had already talked with the resident's family member and stated the resident's death was imminent and hospice services should be included. At that time he had been told the resident's family member wanted Hospice services. The resident's dying process progressed rapidly and hospice would not have had time to respond and put things in place. The physician stated he's the director for a Hospice service and knows how much paperwork is involved getting a resident entered into hospice program. He documented he was present at Resident #5's bedside when he/she ceased breathing and had no pulse or blood pressure. The physician documented it was his decision that no CPR be given in this process. During an interview [DATE] at 11:30 a.m., the Assistant Director of Nursing (ADON) identified 8 resident's currently in the facility who requested CPR. The facility abated the IJ on [DATE] when they notified the resident's physician of their new updated Policy for CPR & requested the physician sign and date acknowledgement of their CPR policy explaining when CPR should be performed. The policy included the following information: CPR (BASIC LIFE SUPPORT*) (NUR-1317) MANUAL EXTERNAL CARDIC MASSAGE AND MOUTH-TO-MOUTH VENTILATION * AMERICAN HEART ASSOCIATION PURPOSE: To provide basic life support (manual external cardiac massage and mouth-to-mouth ventilation) in the event a cardiopulmonary arrest based on clinical criteria and resident preferences. The facility does not have the equipment or personnel to perform advanced life support, including but not limited to, defibrillation, drug therapy, intubation. ELEMENTS: ¿Ï Ambu bag ¿Ï Face mask with 1 way valve PROCEDURE: CPR will be initiated on all residents UNLESS: 1. A code status validation form is completed and signed by the resident or their designee and the physician stating that no CPR should be performed. OR 2. Obvious signs of death are present: Dependent livido: blotchy, black and blue, or reddish discoloration of the skin; this begins in the parts of the body closest to the floor within minutes of death and progresses over the rest of the body; Rigor mortis: a postmortem contraction of the muscles without relaxation; this causes a rigidity found first in the neck and jaw; Decapitation: separation of the head from the body; Transection: a cross section; division by cutting [MEDICATION NAME]; Decomposition: act of decomposing; disintegration, decay. OR 3. Initiating CPR could cause injury or peril to the rescuer. If CPR is not initiated due to one of the above reasons, there must be detailed documentation in the resident ' s medical record supporting evidence of the resident ' s condition when found. On [DATE], the facility also educated nurses (LPNs and RNs) of their CPR policy. Additional training on the facility policy was provided to all employees. These actions lower the immediate jeopardy from a K severity to an E with the need for ongoing monitoring of nursing staff following residents advanced directives.