Every finding on record at Lakeside Health Center

Based on record review and interview, the facility failed to implement a care plan for residents with a diagnosis of Post Traumatic Stress Disorder (PTSD) for 2 of 2 sampled residents (Resident #4 and #91).The findings included: A review of the facility's Behavioral Health Services policy, last reviewed on 09/02/25, documented the facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs, and includes individualized approaches to care. Under procedure it was documented to complete the nursing assessment and social services assessment upon admission/readmission, quarterly, and as needed with changing condition. Through this assessment the facility should identify residents to ensure an accurate diagnosis of a mental disorder or psychosocial adjustment difficulty, or PTSD was made by a qualified professional. Initiate behavior monitoring, behavior management care plan, and kardex as indicated by assessment findings, use of psychoactive medications, resident/responsible party conversations, and observations. The social worker is primarily responsible for initiation of the behavior management care plan. 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included PTSD. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment, was independent for activities of daily, and had a primary medical condition of PTSD. A review of Resident #4's care plan did not address the resident's diagnosis of PTSD, including the cause and triggers the resident may exhibit. An interview was conducted with the Social Service Director (SSD) on 12/17/25 at 12:00 PM. The SSD acknowledged the findings. 2) Record review revealed Resident #91 was admitted to the facility on [DATE]. Further review of the record revealed that Resident #91's diagnosis included in part, Chronic Obstructive Pulmonary Disease (COPD), Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). A review of Resident #91's care plan did not address the resident's diagnosis of PTSD, including the cause and triggers the resident may exhibit. An interview was conducted with the Social Service Director (SSD) on 12/17/25 at 3:40 PM. The SSD acknowledged the findgs.

Based on record review and interview, the facility failed to document a change in a resident's condition for 1 of 1 sampled resident reviewed for respiratory infection (Resident #74). The findings included: A review of the facility's policy titled, Changes in Resident's Condition or Status, last reviewed 08/29/25, documented in part: Documentation associated with identifying and communicating a change in a resident's status includes: date and time of procedure, acute change in status, behavioral changes, vital signs, oxygen saturation level, other assessment findings in the appropriate areas in the residence medical record, nursing interventions, and communication with healthcare team members.Record review revealed Resident #74 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required partial A moderate assistance with activities of daily living. A review of Resident #74's care plan revealed a care plans, dated 12/15/25, that documented the resident is on antibiotic therapy related to an Upper Respiratory Infection (URI).A review of Resident #74's physician orders revealed an order dated 12/12/25 for Amoxicillin, (an antibiotic), 500 milligrams by mouth every 12 hours for URI for 7 days.A review of Resident #74's progress notes dated 12/05/25-12/13/25 did not reveal any indications or symptoms of the resident having an URI. A review of residence #74's vital signs revealed no indication of the Resident having an infection.A review of Resident #74's progress notes revealed a progress note dated 12/14/25 that documented the resident was receiving Amoxicillin 500 milligrams by mouth every 12 hours for URI for 7 days and was tolerating well.An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 12:00 PM. The DON acknowledged the above and stated she would look into it. A follow up interview was conducted with the DON on 12/18/25 at 1:00 PM. The [NAME] stated that Resident #74 was seen by the Nurse Practitioner (NP) on 12/12/25 and provided documentation of such visit (not in resident's record). A review of the NP's progress note dated 12/12/25 at 9:30 AM documented: Patient (Resident #74) was seen today for ongoing issues with upper respiratory signs and symptoms. Staff reported increased nasal drainage and cough a few days ago and due to patient history of allergies he was started on Zyrtec (allergy medication). Today patient has ongoing worsening signs and symptoms and has some complaints of nasal congestion with the drainage along with not much improvement in cough. Patient has no fevers, has history of recurrent sinus infections. Plan: Amoxicillin 500 milligrams two times a day for 7 days, continue allergy medications, follow up any non- resolved signs and symptoms.

Based on interview, record review and policy review, the facility failed to timely report to the State Agency allegations of resident-to-resident abuse for 4 of 6 sampled residents, Resident #1 and Resident #2 involved in an incident; and Resident #5 and Resident #6 involved in another incident. The findings included: Review of the Policy titled Abuse-Reporting and Response - No Crime Suspected, issued on 10/04/22 and reviewed on 06/17/24 documented, in part, . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance to State law through established procedures. 1. Record review revealed Resident #1 was admitted to the facility 01/02/25 with diagnoses including recurrent Major Depressive Disorder, Paranoid Schizophrenia, Anxiety Disorder, unspecified Intellectual Disabilities, Impulsiveness, and Emotional Lability. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented mood and behavior symptoms that occurred frequently. Record review revealed Resident #2 was admitted to the facility 07/22/22 with diagnosis including Moderate Vascular Dementia with Mood Disturbance, generalized Anxiety Disorder, unspecified Dementia with unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Resident #2 did not have a BIMS score, indicating the resident was unable to answer any of the interview questions. Review of the abuse incident that happened on 02/11/25 documented an incident that had occurred between Resident #1 (the perpetrator) and Resident #2 (the victim.) The incident was reported by the Social Services Director (SSD) as followed: Incident time: 11:00 AM . Staff became aware of the incident .11:10 AM . Allegations: Physical Abuse .Time reported to the Abuse Registry: 12:43 PM. This report was not submitted to the State Agency until 4:26 PM, approximately 5 and a 1/2 hours after the incident occurred. 2. Review of an incident that happened on 02/10/25 documented an incident had occurred between Resident #5 (the perpetrator) and Resident #6 (the victim.) The incident was reported by the SSD as followed: Incident time: 6:00 PM . Staff became aware of the incident .6:01 PM . Allegations: Physical Abuse .Time reported to the Abuse Registry: 10:39 AM on 02/11/25. This report was submitted to the Abuse Registry approximately 16 and a 1/2 hours later and to the State Agency at 11:49 AM on 02/11/25, approximately 18 hours after the incident occurred. During an interview on 02/27/25 at 1:45 PM, when asked what the timeframes were involved with abuse allegation reporting, the SSD stated it must be reported within two hours to Adult Protective Services. When asked if that was the only agency that needed to know of the incident, she stated, Just Adult Protective Services within 2 hours and the State agency right after, but I have not been instructed on a specific timeframe for the State Agency. She stated that there was no way she could submit a timely report without doing her own observations and interview, checking on both residents' safety and compiling a list of witnesses to the incident. The SSD explained if she had to report it within 2 hours to the State Agency, her report would not be detailed. During a side-by-side review of the regulation, the SSD agreed she should have completed the immediate report to the State Agency within 2 hours. During an interview on 02/27/25 at 3:22 PM, when asked why the abuse report between Resident #5 and Resident #6 was not submitted timely, the Director of Nursing (DON) stated that the reason that staff (the evening supervisor) was not working for the facility any longer. The DON stated the incident between Resident #5 and Resident #6 happened during the evening, and the evening supervisor did not report the incident to anyone. The DON stated she found out about the incident the next morning. When asked what the timeframes were for reporting abuse allegations, the DON stated it is within 2 hours for both Adult Protective Services and the State Agency. When asked why the SSD did not know the reporting time for the State Agency, the DON stated she should have known it was 2 hours.

Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse for 1 of 2 sampled residents (Resident #3) by a resident (Resident #2) with a history of physical abuse to staff and other residents. This is evident by the lack of supervision of Resident #2, contributing to re-offended physical abuse towards Resident #3. The findings included: Review of the closed record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Dementia, Adjustment Disorder with Anxiety, and Major Depressive Disorder. Further review revealed a comprehensive assessment dated [DATE] that documented the resident had severe cognitive impairment and required substantial/maximum assistance with activities of daily living. Resident #2 was transferred to the hospital on 09/05/24 for weight loss and functional decline per family request. Resident #2 was care planned for physically aggressive/combative behaviors with interventions included: administer medications as ordered, psych consult as indicated, and document observed behaviors and attempted interventions. Resident #3 was admitted to the facility on [DATE] with diagnoses which included Dementia. Record review revealed a comprehensive assessment dated [DATE] that documented the resident had severe cognitive impairment and required partial/moderate assistance with activities of daily living. A review of Resident #2's progress notes revealed a note, dated 08/18/24 at 3:54 PM, that documented: Received report from resident (Resident #3) that a naked man came in her room and hit her with his fist. CNA (Certified Nurse Assistant) confirmed that this resident (Resident #2) was naked and removed from other resident's (Resident #3) room after hearing the resident call for help. Resident unable to give description. Resident assessed, no new injuries noted, family and NP (Nurse Practitioner) notified. A progress note dated 08/20/24 at 4:02 PM documented: This writer received report from CNA that she heard another resident (roommate of Resident #2) yell for help, upon entering the room she found this resident (Resident #2) over other resident (the roommate) with bed remote in hand, in the striking position, removed this resident (Resident #2) from resident's (roommate of Resident #2) room. A progress noted dated 08/22/24 at 2:57 PM documented: IDT (Interdisciplinary Team) Meeting: [Resident #2] discussed in meeting in regards to resident's behaviors. Psych was in to see resident, medication adjustment made. Team placed call to resident's family member to discuss resident's behaviors, team discussed with family member the need for one-on-one supervision. Family member stated he would discuss with family and let us know. Team stressed the importance of having a one on one. Family member stated he would be in today to discuss further. A progress note dated 08/23/24 at 11:13 AM documented: SSD (Social Services Director) and writer called resident's (Resident #2) family member to follow up about conversation in regarding to one on one. Family member stated that he is discussing with other family members. We offered private sitters. SSD to forward information on agencies. We reiterated the significance of the one-to-one companionship need for his safety and other. Provided information on the disease process. Family member voiced concerns in regard to other residents wandering into the resident's room, it was explained to Family member that it is common to have residents wander due to cognitive impairments, but the resident (Resident #2) is experiencing aggression and can be sexually inappropriate. Previous incidents have occurred in other resident's room where the resident (Resident #2) has wandered into. Family member verbalized understanding and stated that he would get back to us no later than Monday. A progress note dated 08/28/24 at 1:40 PM documented: Placed call to resident's (Resident #2) family member in regard to resident's behavior and incident that occurred with another resident (Resident #3). A review of Resident #3's progress notes revealed a noted dated 08/18/24 at 12:06 PM documented: This writer attempted to assist resident in eating and resident expressed that she did not want to eat much due to pain in her mouth. I was sleeping, and I heard some noises, I woke up and the man (Resident #2) didn't have no clothed on, and he started to hit me on my face. This writer asked resident to open her mouth to assess, bruising noted on the inside of the left side of bottom lips, skin assessment completed, no other visible injuries noted, vitals stable, PRN (as needed) pain medication administered, NP (Nurse Practitioner) notified, family notified. A progress notes for Resident #3 dated 08/28/24 at 1:51 PM documented: Received report that resident was on the floor in east hallway, resident observed on buttocks sitting against the wall. Resident Description: He (Resident #2) came in my room and started to take off his clothes. I told him to stop. Jehovah would not want you to do this. I got up and left the room. He followed me and pushed me down and I fell . Resident assessed and assisted to get up with the help of other staff member. Resident was assisted to recliner inside room, head to toe skin assessment completed, no injuries noted, resident complained of slight pain to left arm, PRN administered, ROM completed without difficulty, able to move all extremities, stop sign banner in place, NP and Daughter notified. An interview was conducted with the Social Services Director (SSD)/Abuse Coordinator on 09/09/24 at 2:30 PM. The SSD stated Resident #2 was declining cognitively. The resident had become much more aggressive and had more behaviors. The resident gets physical with staff and other residents. The facility had multiple conversations with family regarding the resident's decline. The facility provided 1:1 supervision as short term/couple of days. Resident #2's family had agreed to come in on a rotating basis. The family stopped showing up. They looked at low-cost companionship and provided the family with a list of agencies. An interview was conducted with the Director of Nursing (DON) on 09/09/24 at 3:00 PM. The DON acknowledged the lack of supervision of Resident #2 contributed to the physical abuse of Resident #3. The DON acknowledged it was the facility's responsibility to keep their residents free from abuse.

Based on policy review, observation, interview and record review the facility failed to report and investigate an injury of unknown origin (bruise), for 1 of 6 sampled residents reviewed for abuse (Resident #36). The facility also failed to ensure a thorough investigation as evidenced by documented inconsistencies for 1 of 6 sampled residents reviewed for abuse (Resident #10). The findings included: 1) Review of the policy titled abuse-identification of types dated 10/04/22 indicated it is the policy of this facility to identify abuse, neglect and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. Definition of abuse-is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment by an individual, including a caretaker, of goods or services that are residents from abuse. Necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This policy documented injuries of unknown source-an injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The procedure included: 1) the facility will apply the following definitions to identify abuse, neglect and exploitation. 2) the facility staff should report any suspected abuse, neglect, or exploitation noted based on the below definitions to the executive director or director of nursing. 3) based on the reports of suspected abuse, neglect, or exploitation noted based on the below definitions the facility will follow the abuse-investigation policy and the abuse-protection policy. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hrs. after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. 1). Record review revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including: anxiety disorder, bipolar disorder, and psychotic disorder. Review of the significant change minimum data set (MDS) assessment, reference date 04/12/24, recorded a brief interview for mental status (BIMS) score of 11, which indicated Resident #36 was cognitively moderately impaired. This MDS recorded the following moods: Feeling down, depressed, or hopeless. Feeling tired or having little energy. Feeling bad about self - or that failure or have let self or family down. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. Review of physician order dated 08/21/23 indicated weekly skin checks on Mondays. On 06/17/24 at 11:09 AM observed Resident #36 in her room, sitting up in wheelchair. An interview process was conducted with her. The surveyor asked her questions regarding abuse. She stated that on Memorial Day, a person in the facility named [ ] punched her right upper arm. The resident was noted with a bluish/purple bruise to the outside aspect of the right upper arm (deltoid area). Resident #36 claimed the bruise was much bigger. Subsequently, she started pointing to the bruised area, while stating, this whole area was bruised, touching her upper deltoid down to above the elbow area. Resident #36 also said that another person in the facility named [ ] slapped her in the face and her stomach and stepped on her big toe on purpose. She claimed she has been abused a lot in the facility. When inquired about reporting the abuse. She voiced that the facility was aware of the abuse because she had reported it to a staff member (unknown name). On 06/20/24 at 11:53 AM an interview was conducted with Staff B, a licensed practical nurse (LPN), regarding Resident #36. She revealed she works with Resident #36 a lot. When asked about the bruise to the resident right upper arm (deltoid area), she said she was not aware of the bruise, when asked about skin assessment, and inquired when was the last time her skin was checked? Staff B revealed her skin assessment should be done weekly. She said the last skin assessment was completed on 06/17/24. During that time a review of the skin assessment document was conducted. The record did not indicate any skin issue, it did not reflect the bruise on the resident's skin. On 06/20/24 at 12:03 PM an interview was held with the Social Service Director (SSD) regarding Resident #36. When inquired about the resident, the SSD voiced that Resident #36 is fun, she loves pop culture, she likes to watch the shows with the famous singers. When asked specifically about the resident's skin does the resident have any bruises? SSD revealed she was not aware of any bruise on the resident's skin. When mentioned that the resident had said a person named [ ] had punched her in the right upper arm (deltoid area). The SSD said that must be a famous person's name, as she gives people she encounters famous people names. When informed the resident also voiced [ ] had slapped her and hurt her big toe. The SSD stated, that name could be one of the famous people as well. The surveyor informed the SSD that the surveyor had observed a bruise to the resident right upper arm on 06/17/24 at 11:09 AM. The surveyor then advised the SSD to contact the director of nursing (DON), so that they could go and talk to the resident together. At 12:13 PM the SSD, DON, and the Regional Clinical Consultant accompanied the group to the Resident's room. The SSD asked Resident #36 about the bruise. The resident explained to the group that a person named [ ] punched her in the right upper arm on Memorial Day. During that time the DON proceeded to check the resident's right upper arm, she and the SSD acknowledged the bruise. The SSD informed the surveyor that she had not started an investigation process for the resident as she was not made aware of the bruise, but she will start an investigation immediately. During that time, again, the surveyor informed the SSD the surveyor had seen the bruise on 06/17/24 at 11:09 AM and no skin issue was documented on the skin assessment document dated 6/17/24 at 12:30 PM. During a subsequent interview held with the SSD on 06/20/24 at approximately 12:46 PM, the SSD voiced had she been made aware of the bruise she would have initiated an investigation process. A subsequent observation and interview were conducted on 06/20/24 at approximately 1:15 PM, by another nurse surveyor with the Regional Clinical Consultant who was present. He asked Resident #36 if he could see the bruise on her right arm. Resident #36 lifted the short sleeve to her blouse and a blue/purple bruise, about 3 to 4 cm across was noted. When asked what happened to her arm, Resident #36 stated, I was punched by LD. When asked when she was punched, Resident #36 stated, on Memorial Day. The resident continued and stated she was slapped, followed by something about her toe. When asked if she reported the slap, Resident #36 stated she had told the receptionist. When asked if she was talking about the receptionist at the entrance or at the nurse's station, the resident pointed to the nurse's station, which was in the opposite direction to the lobby. When asked if she recalled the name of the person, she reported the slap to Resident #36 named Staff C, who was a certified nursing assistant who was suspended earlier in the day for an unrelated issue, as per the Regional Clinical Consultant. During the conversation the resident also mentioned [ ] (a famous person's name) and another staff or two. 50895 2) An interview conducted with Resident #10 on 06/18/24 at 11:05 AM revealed that she was hit in the nose by a male resident. Resident #10 stated I started bleeding. They called the MD, and the MD came and said I have a cut on my nose. He treated me and thank God, I see I don't have a scar there. Per record review, an assessment performed on 5/12/2024 showed that this resident understands and is understood. Her brief interview for mental status (BIMS) score is 13, which indicates that she is cognitively intact. During an interview on 06/19/24 2:58 PM, the director of social services (SSD) was asked if she remembered an incident that occurred to Resident #10 in the dining room. The SSD responded: she was walking around and the man in the wheelchair took his cup and he threw it at her face. I had to do an incident report. She had a bruise, a little scratch. Review of the report submitted to the State documented the allegation of physical abuse occurred on 4/29/24 at 2:01 PM. The allegation details listed a detailed description of any outcome to the resident, including any physical injuries and psychosocial outcome. It documented There were no physical injuries noted. The victim decided to go to her room after altercation and not participate in the Ice Scream [sig] Social even though it was recommended to have them sit very far from one another and closely monitored. This description was entered by SSD at 4:03 PM. In the report section on steps taken immediately in response to the incident, the SSD wrote on 4/30/24 at 8:58 AM: her BIMS are much higher than the alleged perpetrator. She is able to comprehend and has good recall. She proceeded with wanting to enjoy the ice scream social as she had originally intended. Continued observations were made during ice scream social . In the summary of the facility's interview with the following participants section, the SSD wrote on 5/1/24 that the interview with Resident #10 was also inconclusive, since she reacted passively to the altercation and due to her psychiatric dx, is incapable of providing real details. During an interview on 06/20/24 at 1:12 AM the SSD was asked how she knew that there were no physical injuries sustained to Resident #10 on 4/29/24 from being hit in the face. The SSD responded, at the immediate there was no visual indication that there was injury. When the social worker was told that Resident #10 said she was bleeding, the SSD responded, she was not bleeding. When SSD was asked: Were you there? SSD stated I was not present when it occurred. Someone ran to my office letting me know what had happened and I went over there. The SSD was made aware of discrepancies between the incident report that said no injury and the Resident's interview. SSD was also made aware of the discrepancies on the incident report that describe that the resident went to her room after the altercation and later describe that the resident proceeded to enjoy the ice cream social. When asked why there was this discrepancy the SSD said initially she went to her room and then she really wanted the ice cream, so she went back to the social. They were kept far apart. The SSD added that she told Resident #10 we will ensure you are not in danger and come on, let's go back to the social. A record review of a progress note written by the [NAME] Unit Manager, RN, on 4/29/2024 at 2:37 PM said that the resident sustained a laceration to the nose and first aid was provided. During an interview on 06/20/24 at 11:50 AM the [NAME] Unit Manager was asked what he remembers about the incident that occurred regarding resident #10 when she was in the dining room. The RN replied the activities director brought it me that she saw Resident #10 and the guy in the dining room and that he hit her with a coffee cup. I think she had a small cut, a laceration on the bridge of her nose.

Based on record review and interview, the facility failed to ensure nursing staff followed physician orders for 3 of 7 sampled residents reviewed for medication use. Staff held insulin without an order and failed to provide an ordered hypertensive (blood pressure) medication as per ordered parameters for Resident #38. Staff failed to follow physician orders for blood pressure and heart rate parameters for Residents #26 and #53. The findings included: 1) Review of the record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses to include diabetes, hypertension (high blood pressure), and end-stage renal disease receiving dialysis services. Review of the current physician orders revealed the following: a) As of 10/21/23 staff were to provide 0.1 mg (milligrams) of clonidine every eight hours as needed for a systolic blood pressure greater than 160. b) As of 03/11/24 staff were to provide 5 units of Humalog insulin before meals and at bedtime. This order did not include any parameters to hold the medication. c) As of 05/09/24 staff were to provide 23 units of rezoglar insulin at bedtime. This order did not include any parameters to hold the medication. Review of the Medication Administration Records (MARs) for April, May, and June 2024 revealed staff were monitoring the resident's blood pressure twice daily. Further review of these MARs and corresponding progress notes, related to the insulin, revealed the following: c) On 05/02/24 at 2100 (9 PM) the 5 units of Humalog insulin were held. d) On 06/11/24 at 2100 the 5 units of Humalog insulin were held. e) On 06/11/24 at 2100 the 23 units of rezoglar insulin were held. f) On 06/12/24 at 0600 (6 AM) the 5 units of Humalog insulin were held. The corresponding progress notes all documented the Vitals outside of parameters of administration. These insulin orders lacked any parameters. The progress notes also lacked any evidence the physician was notified. Further review of these MARS and corresponding progress notes, revealed the following blood pressure readings with a systolic reading greater than 160: g) On 04/02/24 at 0900 (9 AM) the resident's blood pressure was 197/91. h) On 04/05/24 at 2000 (8 PM) the reading was 176/67. i) On 04/06/24 at 0900 the reading was 195/82. j) On 04/09/24 at 0900 the reading was 166/88. k) On 04/11/24 at 0900 the reading was 168/76. l) On 04/12/24 at 0900 the reading was 174/81. m) On 04/16/24 at 0900 the reading was 237/83. n) On 04/20/24 at 0900 the reading was 169/90. o) On 04/25/24 at 0900 the reading was 169/77. p) On 04/26/24 at 0900 the reading was 174/79. q) On 05/14/24 at 0600 the reading was 168/64. r) On 05/28/24 at 0600 the reading was 215/89. s) On 06/02/24 at 0900 the reading was 161/77. t) On 06/11/24 at 0800 the reading was 191/81. u) On 06/13/24 at 1700 the reading was 180/100. The record lacked any evidence nurses administered the ordered clonidine, as per the parameters to give the medication with a systolic reading greater than 160. During a side-by-side review of the record and interview on 06/19/24 at 2:51 PM, Staff A, Registered Nurse (RN), one of the nurses who care for Resident #38, agreed with the above findings and had no explanation as to why she had failed to provide the clonidine as per order, except that Resident #38 often refuses medications. The RN agreed the refusal should have been documented. During a side-by-side review of the record and interview on 06/20 24 in the morning, the Director of Nursing (DON) agreed with the findings. 33103 2) Review of Resident #26 Record review revealed Resident #26 was admitted to the facility on [DATE] with a diagnosis to include Hypertensive Chronic Kidney Disease, Anxiety Disorder, Atrial Fibrillation, Hyperlipidemia, Cardiac Pacemaker, Dementia, Cardiomyopathy, Type II Diabetes. A review of the Physicians Orders document Diltiazem HCl tablet 30 MG. Give 1 tablet by mouth two times a day (9:00 AM and 5:00 PM) for hypertension, to hold for SBP less than 130. start date 02/06/24. On the following dates the systolic blood pressure (SBP) was less than 130 and the nurse gave the resident the medication Diltiazem HCl tablet 30 MG. 06/01/24 9:00 AM: B/P 126/78 and 5:00 PM: B/P 120/67 06/02/24 9:00 AM: B/P 129/73 06/03/24 9:00 AM: B/P 125/66 06/08/24 9:00 AM: B/P 115/55 06/11/24 9:00 AM: B/P 128/80 and 5:00 PM: B/P 110/74 06/13/24 5:00 PM: B/P 119/60 06/14/24 9:00 AM: B/P 127/60 06/15/24 5:00 PM: B/P 127/81 06/17/24 9:00 AM: B/P 110/56 06/19/24 5:00 PM: B/P 116/65 05/01/24 9:00 AM: B/P 129/79 and 5:00 PM: B/P 116/67 05/05/24 9:00 AM: B/P 129/78 05/07/24 5:00 PM: B/P 122/78 05/09/24 9:00 AM: B/P 129/79 05/10/24 9:00 AM: B/P 128/69 and 5:00 PM: B/P 121/68 05/11/24 9:00 AM: B/P 101/74 05/12/24 5:00 PM: B/P 122/79 05/13/24 9:00 AM: B/P 124/68 and 5:00 PM: B/P 127/76 05/14/24 5:00 PM: B/P 119/68 05/15/24 9:00 AM: B/P 121/64 05/16/24 5:00 PM: B/P 129/73 05/17/24 9:00 AM: B/P 123/65 05/20/24 5:00 PM: B/P 128/76 05/25/24 9:00 AM: B/P 121/67 05/26/24 5:00 PM: B/P 128/71 05/27/24 9:00 AM: B/P 124/62 05/30/24 5:00 PM: B/P 128/71 05/31/24 9:00 AM: B/P 107/57 04/02/24 5:00 PM: B/P 126/77 04/04/24 9:00 AM: B/P 112/67 and 5:00 PM: B/P 113/76 04/05/24 9:00 AM: B/P 117/76 and 5:00 PM: B/P 117/76 04/06/24 9:00 AM: B/P 122/67 and 5:00 PM: B/P 118/61 04/10/24 9:00 AM: B/P 116/85 and 5:00 PM: B/P 121/59 04/11/24 5:00 PM: B/P 128/73 04/12/24 9:00 AM: B/P 129/78 and 5:00 PM: B/P 113/54 04/13/24 5:00 PM: B/P 126/84 04/14/24 9:00 AM: B/P 124/84 04/15/24 5:00 PM: B/P 117/65 04/16/24 9:00 AM: B/P 117/65 and 5:00 PM: B/P 126/85 04/17/24 9:00 AM: B/P 118/67 and 5:00 PM: B/P 126/85 04/19/24 5:00 PM: B/P 121/67 04/21/24 9:00 AM: B/P 124/79 04/22/24 9:00 AM: B/P 125/89 04/26/24 5:00 PM: B/P 120/61 3) A review of Resident #53's record revealed Resident #53 was admitted to the facility on [DATE] with a diagnosis to include Hypertension, Dementia, Alzheimer's Disease, Chronic Kidney Disease. A review of the Physician Orders revealed Resident #53 was on Amlodipine Besylate Tab 5 MG. hold if SBP (Systolic Blood Pressure) is less than 110 or Heart Rate is less than 60. The start date is 07/04/22. Review of the MARS (Medication Administration Record) for April 2024, May 2024, and June 2024 documented the Amlodipine Besylate Tab 5 MG 1 tablet twice daily with an order to hold if systolic blood pressure (SBP) is less than 110 or Heart rate is less than 60 start date 07/04/22. The following dates show the medication was given outside parameters to hold. 04/07/24 5:00 PM: B/P 98/74 04/16/24 18:13: Heart rate 58 04/17/24 5:00 PM: Heart rate 54 05/11/24 9:00 AM: B/P 105/54 and Heart rate 58 05/16/24 9:00 AM: Heart rate 56 05/27/24 9:00 AM: Heart rate 56 06/15/24 9:00 AM: Heart rate 56 05/18/24 9:00 AM: Heart rate 55 During an interview on 06/20/24 at 9:36 AM with the DON (Director of Nursing), she was asked to review the MARS for April 2024, May 2024 and June 2024 for Resident #26 and Resident #53. She reviewed the MARS for these residents and acknowledged the medications were given when it specifically documented to hold the medication. She stated I did in-service after pharmacist mentioned it on another resident. I did the Inservice on 04/29/24. During an interview on 06/20/24 at 10:02 AM with RN Unit Manager, he was asked to review the physician orders vs the MARS for April 2024, May 2024 and June 2024. He acknowledged that the nurses did not hold the medication as per physician order. During an interview on 06/20/24 at 10:20 AM, with Staff G, LPN (Licensed Practical Nurse) she was asked to review Resident #26 and Resident #53 orders and MAR for these residents. She was asked to look at the resident's B/P vs the medication order on the days she worked and gave the medication. She didn't understand what the concern was and was asked if she should have held the medications for when the systolic B/P was below 130 for Resident #26. She did not have an answer and why she gave it.

Based on observation, interview, record review, and policy review, the facility failed to ensure that pain management was provided for 1 of 1 sampled residents observed in pain (Resident #74). The findings included: Review of the Therapy Related Care Plan: Pain Management 2021 that is used as a guide for the facility (per Regional Clinical Consultant) instructs staff to complete a thorough pain assessment, to assess for verbal and nonverbal signs of pain, to implement interventions for pain, and to notify prescriber when pain control is not maintained. On 06/17/24 at 12:36 PM, observation revealed Resident #74 sat in the dining room and made loud verbal whines. No one approached the resident in a timely manner to follow-up on his needs. Later that afternoon at 2:30 PM, Resident #74 was heard groaning while he sat in the wheelchair in his room close to the bed next to the door. At the same time, Staff E, Certified Nursing Assistant (CNA), was observed in his room as she fed the resident in the bed near the window. This CNA did not stop feeding that resident to attend to # 74's needs. No other staff came into this resident's room to check up on Resident #74 in a timely manner. On 06/20/24 at 12:22 PM, an interview was conducted with Staff E, the CNA assigned to Resident #74 during the 7:00 AM-3:30 PM shift on Monday, 06/17/24. This CNA was asked how she knows when Resident #74 is in pain. She responded: With him you know. He usually hits his leg or cries out when he's in pain. So, we bring him to the nurse. When asked if you are busy with another resident what do you do if he is calling out? The CNA answered you get the nurse. She usually gives him pain medicine. When asked if the resident appears more comfortable after he receives pain medication, she answered yes. When asked do you remember how he was feeling on Monday, the CNA responded, I don't remember anything about Monday. A record review of Resident #74's comprehensive care plan, illustrates that the facility was aware that Resident #74 was at risk for generalized pain/discomfort. Interventions listed in the care plan for pain updated 05/31/24 included to observe and report to the nurse any signs or symptoms of non-verbal pain including vocalizations, moans, and yelling out. Interventions listed also included to anticipate the resident's need for pain relief and to respond immediately to any complaint of pain. In addition, it is noted in the record review that Resident #74 used an indwelling catheter secondary to a urinary tract disorder. There were orders related to the catheter which included to record this resident's pain level. A record review of the Progress Notes for Resident #74 showed that there were no progress notes written on 06/17/24. In addition, a review of the medication administration showed that there was no medication for pain given on 06/17/24. A record review showed that Resident #74 had a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. The resident also has anxiety disorder, and unspecified mood disorder. On 06/19/24 at 10:20 AM Staff D, LPN (Licensed Practical Nurse) was told that on Monday, Resident # 74 was heard making loud whining noises. The LPN was asked what she thought the loud vocalizations meant. The LPN answered: He can speak clearly when he feels like it. I know sometimes he screams. He used to be on ibuprofen. If I hear him now I give him Tylenol. He doesn't do it often, but sometimes. When the LPN was asked to clarify what she interprets this scream to mean? LPN answered pain. When asked does he understand when you ask him if he's in pain the LPN answered, he can shake his head but most of the time he doesn't answer. On 06/20/24 at 12:05 PM Staff F, LPN, was asked how she knows if Resident #74 is in pain she responded: He has pain on his left leg and if you see him hitting his leg that means he's in pain. Sometimes you will see him scream in pain. Staff F was asked what she does when he's in pain and she responded I give him Tylenol. And I tell them not to let him sit in the chair too long because then he will get in pain. On 06/20/24 at 12:44 PM, during a second interview with Staff F, LPN, was told that Resident #74 was heard crying out twice on Monday. The LPN was asked if anyone reported to her on Monday that the resident was in pain. Staff F answered, I gave him pain meds on Monday. Staff F was told that there was no documentation in the medication administration records that shows that medication was given for pain. The LPN responded I gave him medicine. It's everyday. If it's not in the morning, it's in the afternoon. Let me show you. The LPN opened up documentation from 06/19/24 that revealed that Resident #74 received medication for pain. Staff F did not work on 06/19/24. The LPN was asked again if she remembers anyone reporting that Resident #74 was in pain on Monday. Staff F stated No. I don't remember if he got medication on Monday. He was in the front all day. When asked to clarify what in the front meant the LPN stated that in the front means in the dining room or patio where residents eat and participate in activities.

Based on record review and interview, the facility failed to ensure consultant pharmacy services for 4 of 7 sampled residents reviewed for medication use. The consultant pharmacist failed to identify a psychotropic medication used PRN (as needed) that was ordered greater than 14 days and had no documented end date or specified duration for Resident #22. The consultant pharmacist failed to identify that nurses were holding insulin without an order and not providing an ordered hypertensive (blood pressure) medication as per ordered parameters for Resident #38, and staff were not following physician orders for blood pressure and heart rate parameters for Resident #26 and #52. The findings included: 1) Review of the record revealed Resident #22 was admitted to the facility on [DATE], with an admission to Hospice services as of 10/05/23. Admitting diagnoses included anxiety disorder. Review of the current order dated 02/29/24 documented the use of 0.5 milligrams of lorazepam (an anti-anxiety medication that is also a psychotropic medication), every four hours as needed for anxiety. Further review of this order lacked any end date or duration for use of the medication. During a phone interview on 06/20/24 at 11:07 AM, when asked about the PRN lorazepam use greater than 14 days, the consultant pharmacist stated there should be a re-evaluation for use to continue the medication more than 14 days, and agreed the medication should have a specific duration of time. 2) Review of the record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses to include diabetes, hypertension (high blood pressure), and end-stage renal disease receiving dialysis services. Review of the current physician orders revealed the following: a) As of 10/21/23 staff were to provide 0.1 mg (milligrams) of clonidine every eight hours as needed for a systolic blood pressure greater than 160. b) As of 03/11/24 staff were to provide 5 units of Humalog insulin before meals and at bedtime. This order did not include any hold parameters. c) As of 05/09/24 staff were to provide 23 units of rezoglar insulin at bedtime. This order did not include any hold parameters. Review of the Medication Administration Records (MARs) for April, May, and June 2024 revealed staff were monitoring the resident's blood pressure twice daily. Further review of these MARs and corresponding progress notes, related to the insulin, revealed insulin was held once in May 2024. Further review revealed the nurses failed to administer PRN clonidine ten times in April 2024 and twice in May 2024. (Refer to F684 for specific dates and times.) During the continued phone interview on 06/20/24 beginning at 11:07 AM, the consultant pharmacist stated he looked at all the medications and parameters for the residents. When asked if he had identified the concerns with the insulin and clonidine, the consultant pharmacist stated he had not made any recommendations regarding the insulin or clonidine in the past 6 months. 33103 2) Review of Resident #26 Record review revealed Resident #26 was admitted to the facility on [DATE] with a diagnosis to include Hypertensive Chronic Kidney Disease, Anxiety Disorder, Atrial Fibrillation, Hyperlipidemia, Cardiac Pacemaker, Dementia, Cardiomyopathy, Type II Diabetes. A review of the Physicians Orders document Diltiazem HCl tablet 30 MG. Give 1 tablet by mouth two times a day (9:00 AM and 5:00 PM) for hypertension, to hold for SBP less than 130. start date 02/06/24. On the following dates the systolic blood pressure (SBP) was less than 130 and the nurse gave the resident the medication Diltiazem HCl tablet 30 MG. 06/01/24 9:00 AM: B/P 126/78 and 5:00 PM: B/P 120/67 06/02/24 9:00 AM: B/P 129/73 06/03/24 9:00 AM: B/P 125/66 06/08/24 9:00 AM: B/P 115/55 06/11/24 9:00 AM: B/P 128/80 and 5:00 PM: B/P 110/74 06/13/24 5:00 PM: B/P 119/60 06/14/24 9:00 AM: B/P 127/60 06/15/24 5:00 PM: B/P 127/81 06/17/24 9:00 AM: B/P 110/56 06/19/24 5:00 PM B/P 116/65 05/01/24 9:00 AM: B/P 129/79 and 5:00 PM: B/P 116/67 05/05/24 9:00 AM: B/P 129/78 05/07/24 5:00 PM B/P 122/78 05/09/24 9:00 AM: B/P 129/79 05/10/24 9:00 AM: B/P 128/69 and 5:00 PM: B/P 121/68 05/11/24 9:00 AM: B/P 101/74 05/12/24 5:00 PM: B/P 122/79 05/13/24 9:00 AM: B/P 124/68 and 5:00 PM B/P 127/76 05/14/24 5:00 PM B/P 119/68 05/15/24 9:00 AM: B/P 121/64 05/16/24 5:00 PM: B/P 129/73 05/17/24 9:00 AM: B/P 123/65 05/20/24 5:00 PM: B/P 128/76 05/25/24 9:00 AM: B/P 121/67 05/26/24 5:00 PM B/P 128/71 05/27/24 9:00 AM: B/P 124/62 05/30/24 5:00 PM: B/P 128/71 05/31/24 9:00 AM: B/P 107/57 04/02/24 5:00 PM: B/P 126/77 04/04/24 9:00 AM: B/P 112/67 and 5:00 PM: B/P 113/76 04/05/24 9:00 AM: B/P 117/76 and 5:00 PM: B/P 117/76 04/06/24 9:00 AM: B/P 122/67 and 5:00 PM: B/P 118/61 04/10/24 9:00 AM: B/P 116/85 and 5:00 PM: B/P 121/59 04/11/24 5:00 PM: B/P 128/73 04/12/24 9:00 AM: B/P 129/78 and 5:00 PM: B/P 113/54 04/13/24 5:00 PM: B/P 126/84 04/14/24 9:00 AM: B/P 124/84 04/15/24 5:00 PM: B/P 117/65 04/16/24 9:00 AM: B/P 117/65 and 5:00 PM: B/P 126/85 04/17/24 9:00 AM: B/P 118/67 and 5:00 PM: B/P 126/85 04/19/24 5:00 PM: B/P 121/67 04/21/24 9:00 AM: B/P 124/79 04/22/24 9:00 AM: B/P 125/89 04/26/24 5:00 PM: B/P 120/61 3) A review of Resident #53 record review revealed Resident #53 was admitted to the facility on [DATE] with a diagnosis to include Hypertension, Dementia, Alzheimer's Disease, Chronic Kidney Disease. A review of the Physician Orders reveal Resident #53 was on Amlodipine Besylate Tab 5 MG. hold SBP (Systolic Blood Pressure) is less than 110 or Heart Rate is less than 60. The start date is 07/04/22. Review of the MARS (Medication Administration Record) for April 2024, May 2024, and June 2024 reveal the Amlodipine Besylate Tab 5 MG 1 tablet twice daily with an order to hold if systolic blood pressure (SBP) is less than110 or Heart rate is less than 60 start date 07/04/22. The following dates show the medication was given outside parameters to hold: 04/07/24 5:00 PM: B/P 98/74 04/16/24 18:13: Heart rate 58 04/17/24 5:00 PM: Heart rate 54 05/11/24 9:00 AM: B/P 105/54 and Heart rate 58 05/16/24 9:00 AM: Heart rate 56 05/27/24 9:00 AM: Heart rate 56 06/15/24 9:00 AM: Heart rate 56 05/18/24 9:00 AM: Heart rate 55 Review of the Pharmacy Reviews for 12/24-05/24 by the Pharmacist does not mention anything that he had concerns with the nurse giving a medication when it should have been held. During an interview on 06/20/24 at 9:36 AM with the DON (Director of Nursing), she was asked to review the MARS (Medication Administration Record) for April 2024, May 2024 and June 2024 for Resident #26 and Resident #53. She reviewed the MARS for these residents and acknowledged the medications were given when it specifically documented to hold the medication. She stated I did in-service after pharmacist mentioned it on another resident. I did the Inservice on 04/29/24. During an interview on 06/20/24 at 10:02 AM with RN, Unit Manager, he was asked to review the physician orders vs the MARS for April 2024, May 2024 and June 2024. He acknowledged that the nurses did not hold the medication as per physician order. During an interview on 06/20/24 at 10:20 AM, with Staff G, LPN (Licensed Practical Nurse) she was asked to Review Resident #23 and Resident #53 orders and MAR for these residents. She was asked to look at the resident's B/P vs the medication order on the days she worked and gave the medication. She didn't understand what the concern was and was asked if she should have held the medications for when the systolic B/P was below 130 for Resident #26. She did not have an answer and why she gave it. During a telephone interview on 06/20/24 at 10:51 AM with the Pharmacist he stated that I look at all medications and parameters, but I don't make recommendations he then stated I would make a recommendation if I had a concern but had no concerns with these two residents.

Based on policy review, record review, and interview, the facility failed to ensure psychotropic medications for 1 of 7 residents reviewed for medication use, were limited to 14 days or extended only with an indicated duration for use. Resident #22 had a PRN (as needed) order for lorazepam, a psychotropic medication, initiated on 02/29/24, with no indication for the duration of use. The findings included: 1) Review of the policy 3.8 Psychotropic Medication Use, revised 10/24/22 documented, 9. For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days in appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record. This policy lacked that the PRN order needed to indicate a duration for use, as per regulatory compliance. Review of the record revealed Resident #22 was admitted to the facility on [DATE], with an admission to Hospice services as of 10/05/23. Admitting diagnoses included anxiety disorder. Review of the current order dated 02/29/24 documented the use of 0.5 milligrams of Lorazepam (an anti-anxiety medication that is also a psychotropic medication), every four hours, as needed for anxiety. Further review of this order lacked any end date or duration for the medication. Review of the most current psychiatric progress note dated 03/12/24 documented Resident #22 was prescribed the Lorazepam 0.5 mg every four hours PRN (as needed), but lacked any duration of use. During a phone interview on 06/20/24 at 11:07 AM, when asked about the PRN Lorazepam use greater than 14 days, the consultant pharmacist stated there should be a re-evaluation for use to continue the medication more than 14 days, and agreed the medication should have a specific duration of time. The consultant pharmacist stated his last recommendation related to the Lorazepam was on 02/28/24, as it was ordered every two hour as needed, and the order was changed to every four hours, as needed.

Based on policy review, record review, and interview, the facility failed to ensure complete and accurate clinical records for 1 of 7 sampled residents reviewed for medication use, as evidenced by contradictions in psychotropic medication doses for Resident #37; and for 1 of 1 sampled resident on transmission based precautions (TBPs) as evidenced by the lack of timely orders for contact precautions for Resident #61. The findings included: Review of the policy Nursing Documentation reviewed 08/10/2023 documented, Medical Records: . The medical record must also reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident' progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. 1) Review of the record revealed Resident #37 was admitted to the facility on [DATE], had a short hospitalization as of 05/27/23 with readmission to the facility on [DATE]. Resident diagnoses included anxiety disorder, depression, and psychotic disorder with delusions. Review of the current physician orders revealed the following: a) As of 03/19/24 the resident was prescribed clonazepam (an antianxiety medication) 0.5 mg (milligrams) once daily. b) As of 01/18/24 the resident was prescribed seroquel (an antipsychotic medication) 100 mg in the morning and 50 mg at bedtime. c) As of 12/08/23 the resident was prescribed trazodone (an antidepressant medication) 25 mg at bedtime. Review of the most current physician progress note dated 06/10/24, by the physician who ordered the above three medications, documented Resident #37 was on clonazepam 1 mg, seroquel 50 mg and 25 mg, and trazodone 50 mg. These doses contradicted the current active orders. Review of the previous physician progress note dated 02/15/24, by the nurse practitioner, documented Resident #37 was on trazodone 50 mg at bedtime, which contradicted the order. During a side-by-side review of the record and interview on 06/20/24 at 2:19 PM, the Director of Nursing (DON) agreed with the inaccurate physician documentation related to the medication usage for Resident #37. 38212 2) The policy titled, Contact Precautions and reviewed by the facility on 06/03/24 documents in part: 2. The licensed professional independent practitioner orders isolation for suspected or diagnosed infections. During a review of the residents on Enhanced Barrier Precautions and Contact Precautions it was noted that Resident #61 did not have an order written for contact precaution until 2 days after the results were reviewed by the facility. The laboratory results of the stool sample collected on Resident #61 indicated her stool was positive for Clostridium difficile (C. Difficile) on 06/14/24 and documented as reviewed by the facility on 06/15/24. The chart was reviewed for Resident #61 and the order for contact precautions were written on 06/17/24. On 06/20/24 at 10:05 AM, an interview was conducted with the Infection Preventionist. She was asked about the order for the contact precautions on Resident #61 and why they were written 2 days post confirmation of the facilities review of the laboratory results. She stated she always does her audits of the Isolation and Enhanced Barrier Precautions on Mondays and she realized she hadn't written the order for Resident #61's contact isolation. She stated she does not ever back date anything, so the order was written after the diagnosis and precautions were instituted.

Based on record review and interview, the facility failed to report the findings of 4 of 4 allegations of misappropriation of property to the State Survey Agency within five working days of the incident, involving Resident #1, #2, #3, and #4. The findings included: Record review revealed allegations of misappropriation of resident property (narcotics) from Resident #1, #2, #3, and #4, were reported to the State Survey Agency on 04/10/23 and 04/11/23. The details include the following: Staff A, Licensed Practical Nurse (LPN) who worked the East Unit Medication Cart #2 on 04/09/23 on the 7 AM - 3 PM shift, and Staff B, LPN who worked the East Unit Medication Cart #1 on 04/08/23 on the 11 PM - 7 AM shift and again on 04/09/23 on the 3 PM - 11 PM shift, identified a possible concern with the controlled medications on 04/09/23 at approximately 4 PM. These two direct care nurses notified their Director of Nursing (DON) and attempted to resolve an issue with missing narcotic cards (bubble packs with individual pills in each section, with up to 30 pills possible per card). On 04/10/23 the DON was able to locate the missing narcotic cards, that had been emptied and discarded into the shredder box along with blank narcotic sheets. The nursing staff and managerial staff were able to determine Staff C, LPN, had forged initials and names as witnesses in order to remove five narcotic medication cards from the above mentioned four residents, that included 122 pills. The pills were never found but the empty narcotic cards and blank corresponding narcotic sheets were found in the shredder box. During the entrance conference on 05/11/23 at 11:33 AM, the DON was asked to locate and provide evidence of the investigation of misappropriation of resident medication by Staff C. Evidence and interviews revealed a thorough investigation was completed by the facility. The Nursing Home Administrator (NHA) had completed four individual reports of misappropriation of resident medications, one for each resident involved. Review of the requested Summary Log for each report revealed the following: The State Survey Agency immediate report for Resident #1 was submitted on 04/11/23, and the five-day report was submitted on 04/26/23, eleven business days after the event. The State Survey Agency immediate report for Resident #2 was submitted on 04/11/23, and the five-day report was submitted on 04/25/23, ten business days after the event. The State Survey Agency immediate report for Resident #3 was submitted on 04/11/23, and the five-day report was submitted on 04/25/23, ten business days after the event. The State Survey Agency immediate report for Resident #4 was submitted on 04/10/23, and the five-day report was submitted on 04/25/23, eleven business days after the event. During an interview on 05/12/23 at 1:32 PM, when asked why the five-day reports were submitted late for the above four residents, the NHA stated, There is no good reason. The NHA stated they had an accreditation survey, followed by their annual recertification survey, and then the drug diversion incident, and it just got missed.

Based on observation, interview and record review, the facility failed to notify the Physician of an elevated blood sugar for 1 of 1 residents sampled for glucose monitoring during medication administration (Resident #37). The findings included: On 04/05/23 at 4:45 PM, observations of medication administration were conducted with Staff B, a Licensed Practical Nurse (LPN). Staff B was observed taking Resident #37's blood sugar with a glucometer. The blood sugar result was 474 milligrams per deciliter (mg/dL). Normal values for blood sugar can range between 70 mg/dL and 130 mg/dL. Staff B proceeded to inject Resident #37 with 6 units of Insulin Lispro 100 UNIT/ML (milliliter) per physician order. Staff B did not call the physician per order that reads contact physician every 8 hours as needed for blood sugar greater that 400 call MD and recheck in one hour. She also did not recheck the blood sugar. Review of the Medication Administration Record (MAR) for Resident #37 revealed on 04/01/23 the blood sugar was 396 mg/dL, on 04/02/23 the blood sugar was 404 mg/dL and on 04/03/23 the blood sugar was 404 mg/dL. These were all recorded by Staff B. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Chronic obstructive pulmonary disease, Type 2 diabetes mellitus and Hypertension. The resident's Brief Interview for Mental Status was 15 on the quarterly assessment with an assessment reference date of 02/22/23. This indicated the resident was cognitively intact. During interview, it was discussed with the Director of Nurses (DON) on 04/05/23 at 1:00 PM that Staff B did not call the physician per order when Resident #37's blood sugar was 474 ml/dL. Progress notes were reviewed and no call was made to the physician on 04/04/23 or previous days when the blood sugars were greater than 400 mg/dL. The DON agreed that the physician should have been notified per order and will discuss with Staff B.

Based on observation, interview, record review and policy review, the facility failed to provide anchors for catheter tubing for 2 of 3 sampled residents observed for catheter care (Residents # 54 and #66). The findings included: The policy of the facility titled Indwelling Urinary Catheter (Foley) Management issued 04/01/22 and reviewed 08/22/22 states Additional care practices related to catheterization Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter, and securing the catheter to facilitate flow of urine, preventing kinking of the tubing. On 04/06/23 at 9:24 AM, catheter care was observed on Resident #54 with Staff A, a Certified Nursing Assistant (CNA). The resident was in a wheelchair with a leg bag and transferred to the bed for Foley catheter care. Staff A cleansed the area around the tubing on the Foley catheter and cleansed the tubing with soap and water. She dried the tubing with a towel, applied a new leg bag after cleaning the connection with alcohol. During the observation of catheter care, there was no anchor for the tubing either before the bag was changed or after the new bag was applied. An interview was conducted with Staff A immediately after catheter care was completed asking where the anchor was for the catheter. Staff A replied they do not do that here. Resident #54 was admitted to the facility on [DATE] with diagnoses that included Neuromuscular dysfunction of the bladder, Chronic kidney disease, and Unspecified dementia. His Brief Interview for Mental Status (BIMS) assessment was 8 which indicated he was moderately impaired on the quarterly Minimum Data Set (MDS) with an assessment reference date of 03/29/23. During an interview, it was discussed with the Director of Nursing (DON) on 04/06/23 at 11:36 AM, regarding the observation of catheter care without the anchor present. The DON stated the residents have anchors on their catheter tubing. An observation was conducted subsequent to the interview of Resident #66 on 04/06/23 at 11:40 AM, who was in bed with a Foley catheter to bedside drainage. She did not have an anchor on her catheter tubing and no care plan that stated that she refused an anchor. Resident #66 was admitted to the facility on [DATE] with diagnoses that included Colostomy, Diabetes type 2 and Depression. She had a catheter for a Stage 4 wound. An additional interview was conducted with the DON after the observations were made of the residents with Foley catheters. She stated that the anchors are in the facility and all CNAs will be educated to use them.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 6.41 percent, 2 medication errors were identified while observing a total of 31 opportunities, affecting Resident #27. The findings included: On 04/05/23 at 10:08 AM, a medication pass observation was conducted with Licensed Practical Nurse (LPN) Staff C for Resident #27. Staff C was observed preparing the resident's medications to include eye drops and 7 oral medications. One of the medications prepared and given was Aspirin EC (enteric coated) 81mg (milligrams) 1 by mouth. The medication ordered was Aspirin Tablet Chewable give 81mg by mouth one time a day for CAD (Coronary Artery Disease). On 04/05/23 at 10:45 AM the medications for Resident # 27 were reconciled to the Medication Administration Record (MAR). A additional error was discovered at this time. Staff C omitted administering Carvedilol Tablet 25mg 1 tablet by mouth. Carvedilol is used to treat heart failure and hypertension. Resident #27 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Hemiparesis and Hemiplegia following Cerebral Vascular Accident and Type 2 Diabetes Mellitus. On 04/05/23 at 11:45 AM, an interview was conducted with the Director of Nurses (DON) apprising her of the medication pass observation and the reconciliation of the medications administered by Staff C. The DON stated that she will be educating the nurse.

Based on observation and record review, it was determined that the facility to follow the lunch menu on 04/03/23. 1) During the review of the facility's approved menu for the lunch meal of 04/03/23, it was noted that a 3 ounce portion of Sliced Ham was to be served to residents with a physician ordered regular diet. Further review of the weeks Cycle Menu noted that all other lunch and dinner meals documented only a 2 ounce protein portion to be served. During the observation of the tray assembly line in the Main Kitchen on 04/03/23 at 11:45 AM, the surveyor requested that an averaged portion of Sliced Ham that was going to be served to the residents be weighed on the facility's calibrated portion scale. Following the weighing of 2 sliced ham portions noted only 2 ounces recorded and being served as a standard resident portion for regular diets.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that effected potentially 89 of the facility's 91 residents. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 4/3/23 at 9 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted: (a) A food delivery cart was noted to be located in the main Dining Room by the entrance exit door to the kitchen. Further observation noted that the open cart contained 5 resident breakfast trays. The CDM informed the surveyor that the trays were waiting to be distributed to resident rooms and that the trays had been sitting for some time. At the request of the surveyor the temperature of the milk (8 ounce cartons) were taken with the facility's calibrated thermometer. The 5 cartons of milk were recorded at 56 degrees F. The surveyor informed the CDM that the milk must be held at the minimum requirement of 41 degrees F or below. Photographic evidence obtained. (b) During the tour it was noted a pan of what appeared to be hamburger patties on top of the grill. The cook on duty (Staff D) stated that the patties were Salisbury Steaks (SS) that had been cooked earlier and were left out to be pureed. At the request of the surveyor the temperature of the SS were taken with the facility's calibrated thermometer and were recorded at 96 degrees F. The surveyor informed the CDM that hot foods must be kept at the regulatory minimum temperature of 135 degrees F, The CDM stated that the SS would be discarded and remade and held at required temperatures. Photographic evidence obtained. (c) Observation of the dietary rest room located within the dietary department was noted that the internal walls and door were dust laden. The hand sink and toilet were noted to be heavily soiled. Photographic evidence obtained. (d) The wall vents located at the West end of the kitchen and at the entrance to the dry/canned room storage were noted to have a heavy build-up of dust and dirt. It was discussed with the CDM that there was a potential for food contamination due to the blowing dust and dirt. Photographic evidence obtained. (e) The exterior of the ceiling air-conditioning vent located at the entrance to the dish machine area was noted to be full of condensation that was dripping heavily into a basin located underneath the vent. Further observation noted the basin to be full of condensation. It was discussed with the CDM that the condensation could result in contamination of clean resident dishes moving underneath the vent. Photographic evidence obtained. (f) Observation of the wall mounted hand-washing sink was noted to be clogged and a build-up of soiled water was in the sink. Photographic evidence obtained. (g) Observation of Reach-in refrigerator #1 noted a leftover contained of Tuna Fish. Further investigation noted the contained to be labeled with a preparation date of 3/29/23 and a discard/use by date of 3/31/23. The surveyor informed the CDM that today's date of 04/03/23 was 3 days after the documented discard date. The CD stated that the tuna fish should have been discarded on 03/01/23. Photographic evidence obtained. 2) During a second observation of the tray line assembly in the main kitchen on 04/03/23 at 11:55 AM, the surveyor requested a temperature check of foods on the tray line. Temperatures of foods were taken by the CDM with the use of the facility's calibrated thermometer. The temperature testing revealed that cold foods were not being held at the regulatory temperature of 41 degree F as evidenced by the following: * Bologna Sandwich (3) = 56 degrees F * Tuna Sandwich (2) = 47 degrees F

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary , orderly and comfortable interior for 3 of 3 residential wings (100, 200 and 300 unit), patio area, and dining room. The findings included: During the initial environment tour conducted 12/1421 - 12/16/21; and 12/17/21 at 9:50 AM, accompanied by the Director of Maintenance/Housekeeping, the following was noted: 1) 100 Unit: Room #100 - Exterior damage and black scuff marking to the room entry door and bathroom entry door. Rooms #101, #108, #109, #110, #111, #112, #113, #114, #115, #116, #120, #122, #124, and #128 - The exteriors to the room entry doors were noted damaged and numerous areas of black scuff marking. Hallway/Corridors (Rooms #101-#130) - Handrails on both sides of hallway noted to have numerous areas off missing and peeling paint. 2) 200 Unit: Room #216 - Ceiling damage throughout the room area, and wall discoloration above window area. Room #220 - Ceiling damage throughout the room area, dresser drawers (2) missing pull knobs (screws had been placed in knob holes). Hallway/Corridors (Rooms# 201-#227) - Handrails on both sides of hallway noted to have numerous areas off missing and peeling paint. 3) 300 Unit: Room #303 - Numerous holes in walls near door (D) and window (W) beds, room floor numerous large black scrapings, and bathroom floor covered with black stains. Room #305 - Over-bed table exterior heavily worn and in need of replacement, 1 of 2 bathroom lights not working, bathroom wall with large hole and base boards coming away from the wall. Room #307 - Large hole in wall near room window, and room base boards coming off of walls. Room# 309 - Bathroom base boars coming off of walls, and rooms walls with large black stains. Hallway/Corridors (Rooms #301-#309) - Handrails on both sides of hallway noted to have numerous areas off missing and peeling paint. Resident Outdoor Patio: Patio Lighting Pole Fixtures (5) - The glass covers were noted to be heavily soiled with unknown matter. South Entrance/Exit Door - The bottom of the door had a large (1 foot) piece of metal protruding and was a resident hazard. North Entrance Door - The entire front of the door exterior was covered in a black dust type substance, and the fan motor above the door noted to be soiled and rust laden. Dining/Activity Room - Walls - The wall and base board area near the patio entrance door were soiled, numerous holes, and in disrepair. Hand-washing Sink - The wall area around the sink was in disrepair, soiled and peeling paint area. Dining Room Chairs- - The exteriors of 20 dining room chairs were noted to be heavily worn and stained throughout. Following the tour it was noted that that staff are responsible for filling out a maintenance/housekeeping request form located at the nurses station for all repair issues. The findings of the observation tour were also reviewed and confirmed with the Administrator on 12/17/21 at 2 PM.

Based on observation, interview, and record review, it was determined that the approved facility menu was not followed for 5 of 5 sampled residents (Resident's #24, #34, #37, #42, and #54.) with physician ordered Pureed Diet and 2 of 2 sampled residents (Resident's #90 and #145) with physician ordered Renal Diet. The findings included: During the observation of the tray line in the main kitchen on 12/15/21 at 7:30 AM, it was noted that the approved menu for the breakfast meal of 12/15/21 documented that pureed hot cereal be served to residents receiving a pureed diet. Observation of the tray line noted that only regular oatmeal was prepared and being served. Interview with the Dietary Manager and Breakfast Cook (Staff B) at the time of the observation revealed that they were unaware that the menu documented pureed hot cereal and that regular hot cereal (Oatmeal) was being served to residents receiving a pureed diet . A review of the facility's diet census for 12/15/21 noted that there were 5 residents with physician ordered Pureed Diet that included; Resident #24, #34, #37, #42, and #54. Observation of the lunch meal on 12/16/21 at 11:50 AM noted that the approved menu for Liberal Renal diet documented that a 4 ounce serving of Salt Free Corn be served in place of the Sweet Potato Casserole due to high Potassium content . Observation of the tray assembly line noted that the salt free corn was not prepared and that Sweet Potato Casserole would be served to the resident's receiving Renal Diets. The surveyor requested that the corn be prepared and served to the resident's receiving Renal Diets. The Dietary Manager confirmed to the surveyor the the approved Renal Diet was not followed for there lunch meal. Review of the facility's Diet Census noted that the were were 2 residents with physician ordered Renal Diets that included; Residents #90 and #145).

Based on record review, policy review and interview, the facility failed to complete the required five day report for 3 of 5 allegations of abuse. The incidents affected Residents #76, #346 and #72. The findings included: Facility policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect, last revised 08/10/21 documents Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with state law, including the the State Agency, within five working days of the incident, and if the alleged allegation is verified appropriate corrective action must be taken. 1) Review of the facility abuse log conducted on 10/15/21 revealed one allegation of sexual abuse on 10/14/21 involving Resident #76 and a staff member. Clinical record review conducted on 12/16/21 revealed Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set, quarterly assessment with reference date 11/16/21 documents the resident was assessed as moderately impaired for skills of decision making, required limited assistance with activity of daily living and is receiving antipyscotic and antidepressant medications. A Care Plan revised on 11/15/21 documented the resident uses [CONDITION(S)] medications to manage mood & behaviors associated with [CONDITION(S)], [CONDITION(S)] Depression and Anxiety. The interventions included observe for occurrence of target behavior symptoms: inappropriate response to verbal communication, talking to self, responding to internal stimuli, and document per facility protocol. Review of Progress notes dated 10/14/21 documented Resident in bed resting with eyes closed respirations 18. Resident expresses no complaint of pain and shows no signs or symptoms of distress at this time. Able to make all needs known. Resident rounded on frequently by assigned staff. Call light within reach. Will continue to monitor throughout shift. Social Service notified resident of room change .Resident agreed to room change. Staff will continue to assist resident as needed. Review of the facility documents related to the incident involving Resident #76 and a Licensed Nurse revealed the resident reported an allegation of sexual misconduct to the alleged perpetrator on 10/14/21 and the nurse involved reported the incident to the Director of Nursing. Further review of the documents provided by the facility, failed to include the completion and reporting of the five day report summarizing the findings of their investigation. 2) Review of the facility abuse log conducted on 10/15/21 revealed two allegations of resident to resident abuse on 10/15/21 involving Resident #346. Clinical record review conducted on 12/15/21 revealed Resident #346 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set, significant change assessment with reference date 09/28/21 documents the resident was assessed as severely impaired for skills of decision making, required extensive assistance with activity of daily living and is receiving antidepressant and antianxiety medications. A Care Plan revised on 10/15/21 documented the resident has potential to be physically and verbally aggressive. Yelling and screaming related to Dementia with behavioral disturbances, wanders, combative with staff and other residents. Review of a Behavior Note dated 10/15/21 documented Resident was wandering the halls and also having to be redirected and scream was noted from room [ROOM NUMBER] by that resident of that room. When entering the room, Resident #346 and the other resident were both sitting on the floor. Other resident stated that Resident #346 had come into her room, took a clean gown off her bed, and when she tried to get it back from her, she hit her across the face. The other resident stated that she then hit her back and they both fell to the floor. Resident #346 was removed from the room, and monitored for further activity. Review of the facility documents related to the incident involving Resident #346 revealed the resident had a physical altercation with the roommate on 10/15/21. Further review of the documents provided by the facility, failed to include the completion and reporting of the five day report summarizing the findings of their investigation. Interview with the Administrator and the Director of Nursing conducted on 12/16/21 at 1:15 PM revealed the Administrator stated the facility had no lapse on Administrator on duty; the previous Administrator left on 10/18/21 , morning hours and she started later that afternoon. The Administrator confirmed she did not complete the five day report, for the incidents involving Resident #76 and Resident #346, it was an oversight and as the Risk Manager it is her responsibility to ensure the reporting and completion of abuse investigations. 3) Record review for Resident #72 revealed a care plan dated 07/04/19 with a focus on Resident #72 has a behavior problem: Potential to be socially inappropriate as evidenced by; Potential for gossiping or fabricating stories that relate to staff or other residents. Making accusatory and untrue statements about staff & others, cursing at staff. A goal of Resident #72 will not experience behaviors, that are harmful to self and others through next review date. Interventions included Administer medications as ordered. Anticipate and meet the resident's needs. If reasonable, discuss the residents behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Notify MD and Psychiatrist as needed. Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Review of an Immediate Report dated 10/15/21, it was noted that there was no 5-day report filed and no documentation of an investigation into the allegation, on behalf of the facility. Record review for Resident #72 lacked any documentation including progress notes for 10/15/21 or resident to resident altercation. On 12/16/21 at 3:00 PM, a review of employee statement by DON (Director of Nursing), not dated and residents full names not used revealed, I was sitting at my desk in my office when Resident #72 approached me and stated, Resident #346 hit me in the head! I asked her what exactly had happened, and she stated that she was in the dining room, and the activities assistant had asked Resident #346 to sit down. When Resident #346 refused to sit down, Resident #72 then also asked her to sit down. When Resident #72 asked her, Resident #346 came over with a newspaper and hit her on the top of her head with it. Resident #72 then said that Resident #346 slapped her across the face. She then called out for the Activities Assistant to come and help her, which she quickly did to put a stop to the situation. She currently denies any pain or discomfort. During an interview conducted on 12/16/21 at 1:13 PM with the Administrator and Director of Nursing, the Administrator stated she was new to the facility and only had 1 day with the previous Administrator, and the lack of reporting a five-day report of the incident between Resident #346 and Resident #72 was just an oversight that it was not completed. The DON stated that Resident#72 had initially come to the DON to report the incident with Resident #346 and told her that Resident #346 had hit her. During an interview on 12/16/21 at 3:10 PM, the DON stated she and the Regional Clinical Director looked and could not locate any documentation, including an investigation, statement summary or incident report for the incident. She stated the Administrator also tried to find documentation, but was not able to, that was the Administrator's transition period. During an interview conducted on 12/16/21 at 3:20 PM with Staff C, Registered Nurse, Unit Manager when asked about the altercation between the two residents on 10/15/21, she stated she honestly did not remember. During an interview conducted on 12/17/21 at 11:10 AM with Staff D, Activities Assistant, when asked if she recalled an altercation between two residents on 10/15/21 during activities, she stated she did not remember.

Based on record review, policy review and interview, it was determined, the facility failed to complete a thorough investigation of 3 of 5 allegations of abuse. The incidents affected Residents #76, #346 and #72. The findings included: Facility policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect, last revised 08/10/21 documents Investigation and Protection, It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. Complaints and grievances will be investigated as outlined in the Concern & Comment (Grievance) Program Policy and will be repotted immediately if the investigation reveals any alleged violations involving neglect, abuse (including injuries of unknown source), and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law. Procedure 1. Following identification ofalleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. 2. Alleged victim will be examined forany sign of injury, including a physical examination or psychosocial assessment, if needed. Caution must be used in handling evidence that could be used in a criminal investigation. 3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, Or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the residents. 4. The administrator/designee will complete an Incident Report. 5. The administrator/designee will review the Incident Report for completeness and assure that the physician and resident representatives have been notified of the circumstance. 6. If it is determined that alleged abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws (i.e. state licensing and certification agencies, law enforcement, and the ombudsman). 7. The written summary of the investigation should include, but is not limited to: a. A review of the Incident Report. b. An interview with the person(s) reporting the incident. c. Interviews with any witnesses to the incident. d. An interview with the resident, if appropriate. e. A review of the resident's medical record. f. An interview with the employee(s), as needed. g. A review of the employee's file, as needed. h. Interviews with staff members on all shifts having contact with the resident at the time of the incident. i. Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. j. Interviews other residents who received care or services from the alleged perpetrator. k. A review all circumstances surrounding the incident. 8. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited. 9. If the accused abuser is another resident, the residents must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents. 10. If the accused individual is a family member, visitor or another person in the facility who is neither an employee nor another resident, the person will be denied unsupervised access to the resident or other residents pending the results of the investigation. I l. Any investigation of alleged resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. 12. If the investigation is being conducted by the designee, the adminstrator will be consulted daily concerning the progress of the investigation. 13. The administrator or designee will keep the resident and representative informed of the progress of the investigation. the alleged victim will be protected from retaliation. 13. The administrator or designee will inform the resident. representative and physician of the results of the investigation and corrective action taken. 1) Review of the Facility abuse log conducted on 10/15/21 revealed one allegation of sexual abuse on 10/14/21 involving Resident #76 and a staff member. Clinical record review conducted on 12/16/21 revealed Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set, quarterly assessment with reference date 11/16/21 documents the resident was assessed as moderately impaired for skills of decision making, required limited assistance with activity of daily living and is receiving antipyscotic and antidepressant medications. A Care Plan revised on 11/15/21 document the resident uses [CONDITION(S)] medications to manage mood & behaviors associated with [CONDITION(S)], [CONDITION(S)] Depression and Anxiety. The interventions included observe for occurrence of target behavior symptoms: inappropriate response to verbal communication, talking to self, responding to internal stimuli, and document per facility protocol. Review of Progress notes dated 10/14/21 documented Resident in bed resting with eyes closed respirations 18. Resident expresses no complaint of pain and shows no signs or symptoms of distress at this time. Able to make all needs known. Resident rounded on frequently by assigned staff. Call light within reach. Will continue to monitor throughout shift. Social Service notified resident of room change .Resident agreed to room change. Staff will continue to assist resident as needed. Review of the facility documents related to the incident involving Resident #76 and the Licensed Nurse revealed the resident reported an allegation of sexual misconduct to the alleged perpetrator on 10/14/21 and the nurse involved reported the incident to the director of nursing. Further review of the documents provided by the facility, failed to include the thorough investigation of the allegation. The facility provided a statement from the nurse involved and a note from the director of nursing, not dated, documenting the allegation. The documents provided including the event report, provided no evidence the facility address or interview other residents assigned to the alleged perpetrator, or evidence of interviews with the staff members on duty on the date of the alleged incident. Interview with Director of Nursing (DON) conducted on 12/16/21 at 12:55 PM revealed the staff was having a meeting on 10/14/21 and the nurse involved reported to her that Resident #76 had made allegations of sexual abuse. The DON interviewed the resident and then called the police. The DON was asked how the incident was investigated and replied the previous administrator conducted the investigation and most likely she relied on the police investigation. The DON confirmed the facility does not have the police report for this event or written evidence of residents interviews, staff interviews or evidence the psychiatric consult was conducted after the event. The DON also explained the social worker had contacted the assisted living facility, in which the resident previously resided and she was told the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse was suspended for a day, 10/14/21 and returned to work on 10/15/21. 2) Review of the facility abuse log conducted on 10/15/21 revealed two allegations of resident to resident abuse on 10/15/21 involving Resident #346. Clinical record review conducted on 12/15/21 revealed Resident #346 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Minimum Data Set, significant change assessment with reference date 09/28/21 documents the resident was assessed as severely impaired for skills of decision making, required extensive assistance with activity of daily living and is receiving antidepressant and antianxiety medications. Care Plan revised on 10/15/21 document the resident has potential to be physically and verbally aggressive. Yelling and screaming related to Dementia with behavioral disturbances, wanders, combative with staff and other residents. Behavior Note dated 10/15/21 document Resident was wandering the halls and also having to be redirected and scream was noted from room [ROOM NUMBER] by that resident of that room. When entering the room, Resident #346 and the other resident were both sitting on the floor. Other resident stated that Resident #346 had come into her room, took a clean gown off her bed, and when she tried to get it back from her, she hit her across the face. The other resident stated that she then hit her back and they both fell to the floor. Resident #346 was removed from the room, and monitored for further activity. Interview with the DON conducted on 12/17/21 at 10:50 AM revealed the previous Administrator conducted the investigation and provided a copy of a statement from the aide, stating she did not see anything, only heard the resident screaming. The DON was not able to locate a thorough investigation of the event, including triggers that may have cause the resident's behaviors, timeline documenting the level of supervision provided to Resident #346, who had a previous altercation with another resident earlier during the day and evidence the facility had identified anti-anxiety medication omission on 10/14/21 and 10/15/21. Based on the reviews, the facility did not conduct thorough investigations of the events involving Resident #76 and #346. The facility was not able to provide evidence of interviews, reviews, analysis of the events to substantiate or unsubstantiate the allegations. 3) Review of the Immediate Report dated 10/15/21 revealed there was no 5-day report filed and no documentation of an investigation into the allegation, on behalf of the facility. Record review for Resident #72 lacked any documentation including progress notes for 10/15/21 or resident to resident altercation. During an interview conducted on 12/16/21 at 1:13 PM with the Administrator and Director of Nursing. The administrator stated she was new to the facility and only had 1 day with previous Administrator, and the lack of reporting a five-day report of the incident between Resident Resident #346 and Resident #72 was just an oversight that it was not completed. The DON stated that Resident Resident #72 had initially come to the DON to report the incident with Resident #346 and told her that Resident #346 had hit her. During an interview on 12/16/21 at 3:10 PM, the DON stated she and the Regional Clinical Director looked and cannot locate any documentation, including an investigation, statement summary or incident report for the incident. She stated the Administrator also tried to find documentation, but was not able to, that was the administrator's transition period. During an interview conducted on 12/16/21 at 3:20 PM with Staff C, Registered Nurse, Unit Manager when asked about the altercation between two residents on 10/15/21, she stated she honestly did not remember. During an interview conducted on 12/17/21 at 11:10 AM with Staff D, Activities Assistant when asked if she recalled an altercation between two residents on 10/15/21 during activities, she stated she did not remember.