Every finding on record at Life Care Center of Rochester

Based on observation and interview, the facility failed to ensure recipes were followed when preparing pureed meals. This deficient practice had the opportunity to affect 4 of 4 residents who received pureed meals from this kitchen. Finding includes:During an observation of the preparation of a pureed meal, on 9/16/2025 at 11:36 A.M., [NAME] 12 placed 10 scoops of green beans into a blender. She indicated she was making 10 servings of green beans. [NAME] 12 proceeded to add a 1/2 cup of vegetable broth to the blender. She indicated the puree was too watery and then added an additional three scoops of green beans to the blender. A recipe book was not used while [NAME] 12 prepared the pureed meal.During an interview, on 9/16/2025 at 11:51 A.M., [NAME] 12 indicated she should have used a recipe when preparing the pureed meals.On 9/16/2025 a policy was requested regarding the use of a recipe book when preparing pureed meals but one was not provided prior to the survey exit.1.3-20(i)(1)

Based on observation, record review, and interview, the facility failed to store food under sanitary conditions for 1 of 1 kitchen observed. This issue had the potential to affect 57 of 57 residents who received food from this kitchen. Findings include: On 9/15/2025 at 9:40 A.M. a kitchen tour was conducted with [NAME] 8. The following was observed in the walk in cooler:-An opened bag of mozzarella cheese with a use by date of 9/3/2025.-An opened bag of celery not sealed tightly.-An opened carton of grated parmesan cheese with no use by date.During an interview, on 9/15/2025 at 9:50 A.M., [NAME] 8 indicated the expired foods should have been thrown away, foods should have had a use by date and the celery should have been sealed tightly During a follow-up tour of the kitchen on 9/19/2025 at 10:00 A.M. with [NAME] 9 the following was observed in the kitchen drawer:-An ice-cream scoop put away as clean with dried food on it.-A ladle put away as clean with dried food on it.-A whisk put away as clean with dried food on it.During an interview, on 9/19/2025 at 10:05 A.M., [NAME] 9 indicated the utensils should have been clean before storing.On 9/18/2025 at 2:00 P.M., the DON provided the policy titled, Food Safety and Sanitation and indicated it was the policy currently being used by the facility. The policy indicated, .Use by date is noted on the label or product when applicable. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. All food is stored six inches off the floor and 18 inches from the ceiling. Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to follow infection control guidelines related to urinary drainage bag positioning on the floor for 1 of 4 residents reviewed for catheters.(Resident 41) Finding includes:During an observation, on 9/15/2025 at 11:31 A.M., Resident 41's urine drainage bag was on the floor. During an observation, on 9/15/2025 at 12:12 P.M., Resident 41's urine drainage bag was on the floor. During an observation, on 9/16/2025 at 3:58 P.M., Resident 41's urine drainage bag was touching the floor. The record for Resident 41 was reviewed on 9/16/2025 at 11:00 A.M. Diagnoses included but were not limited to: diabetes and retention of urine. An admission MDS (Minimum Data Set) assessment, dated 9/4/2025, indicated the resident had an indwelling urinary catheter, and was dependent on staff for toilet hygiene, and required substantial to maximum assist for transfers to bed/chair and received an antibiotic. A current Care Plan, initiated 7/25/2025, indicated the resident had an indwelling foley catheter due to urinary retention and was at risk of infection/UTI. Interventions included, but were not limited to: catheter care every shift; check tubing for kinks during daily care; medication as ordered; observed for signs/symptoms of dehydration. A new intervention was added to the care plan on 9/16/2025 for the foley catheter bag to be covered and off the floor. A current Care Plan, dated 8/5/2025 and revised on 9/10/2025, indicated the resident was antibiotic therapy related to a UTI and was at risk for adverse side effects. Physician Orders indicated Resident 41 had been treated with antibiotics for urinary tract infections on 8/25/2025 and again on 9/11/2025.Current Physician Orders included the following orders: Indwelling catheter to straight drainage; change for infection, obstruction or when the closed system was compromised.During an interview, on 9/16/2025 at 4:09 P.M., LPN 5 indicated the urinary drainage bag should not have been on the floor.On 9/18/2025 at 4:35 P.M., the Director of Nursing provided the policy titled, Indwelling Urinary Catheter (Foley) Management, revised on 6/27/2023, and reviewed on 9/4/2025, and indicated the policy was the one currently used by the facility. The policy indicated . 2 . Maintain unobstructed flow. b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure there were medical symptoms to support the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: The record for Resident 22 was reviewed on 9/16/2025 at 2:25 P.M. Diagnoses included, but were not limited to malnutrition, anemia, cirrhosis, diabetes, prostate cancer, and dysphagia. An admission MDS (Minimum Data Set) assessment, dated 8/28/2025, indicated the resident had clear speech, was able to make their own decisions and was able to make himself understood and understood others, exhibited no behaviors during the assessment period and received an antipsychotic medication.A Physician's Order, dated 8/28/2025, indicated the resident was to received the medication Quetiapine (antipsychotic) 25 mg (milligram) 1 tablet at bedtime and 50 mg 1 tablet at bedtime related to metabolic encephalopathy.A pharmacy recommendation, dated 8/29/2025, indicated Resident 22 received an antipsychotic medication and had no documented diagnoses and/or medical symptom to support the use of the medication. The MD responded, will have psychiatry evaluate for discontinuation -- was weaned off in 8/2025--will wean again, The form was signed by the physician on 9/2/2025.A current Care Plan, initiated on 8/29/2025, indicated the resident used an antipsychotic medication and was at risk for adverse side reactions. Interventions included, but were not limited to: administer antipsychotic medication as ordered; observe for side effects and effectiveness every shift; consult with pharmacy and MD to consider dosage reduction; and educate family/resident about the risks and benefits.During an interview, on 9/19/2025 at 9:57 A.M., the Director of Nursing indicated the current diagnosis for the antipsychotic medication was not appropriate. On 9/19/2025 at 10:55 A.M., the Director of Nursing provided a policy titled, Unnecessary Medication, with a revision date on 4/22/2025, and indicated the policy was the one currently used by the facility. The policy indicated . Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used --without adequate indications of it's use. Definitions- Adequate Indications for use- .means that the medication administered is consistent with manufacture's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references 3.1-3(w)

Based on record review and interview, the facility failed to ensure a PASRR (Preadmission Screening and Record Review) was completed after a change in psychiatric diagnoses and medications were made for 1 of 2 residents reviewed for PASRR. (Resident 7)Finding includes: The record for Resident 7 was reviewed was on 9/17/2025 at 9:37 A.M. Diagnoses included, but were not limited to: hypertension, non Alzheimer's dementia, depression and delusional disorder. A Notice of PASRR Level I Screen Outcome, dated June 21, 2022, indicated: Outcome Level 1 Outcome: No Level II Required. If changes occur or new information refutes these findings, a new screen must be submitted.Current Physician Orders, included: Cymbalta (antidepressant) 30 mg (milligram) 1capsule every morning ordered on 9/3/2024.Resident 7 received a new qualifying diagnosis of delusional disorder and subsequent medication changes on 9/4/2024 . A current Care Plan, initiated date unknown, indicated the resident had behavioral episodes related to cognitive deficit and delusional disorder. During an interview, on 9/19/2025 at 9:19 A.M., the Director of Nursing indicated, a new PASAAR level one should have been completed when the new diagnosis and medication changes were made.On 9/19/2025 at 10:55 A.M., the Director of Nursing provided the policy titled, Pre-admission Screening and Resident Review (PASARR), undated, and indicated this was the current policy used by the facility. The policy indicated .A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later . 13,. Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review

Based on observation, record review and interview, the facility failed to develop comprehensive care plans for 3 of 16 residents reviewed for care plans. (Residents 4, 25 & 12)Findings include: 1. During an interview, on 9/15/2025 at 2:41 P.M., Resident 4 indicated he smoked cigarettes. During an observation, on 9/17/2025 at 3:26 P.M., Resident 4 was observed seated in the courtyard smoking with a smoking apron over his body and supervised by an activity staff member. A record review for Resident 4 was completed, on 9/18/2025 at 9:07 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, chronic kidney disease stage 5 and peripheral vascular disease. An Annual Minimum Date Set (MDS) assessment, dated 7/14/2025, indicated Resident 4 was cognitively intact. A Smoking Safety Evaluation, dated 8/2/2025, indicated Resident 4 had not demonstrated the ability to safely smoke without supervision. A Care Plan for safe smoking could not be located in the medical record. During an interview, on 9/19/2025 at 12:52 P.M., the MDS Coordinator indicated Resident 4 was a cigarette smoker and did not have a care plan for safe smoking. She indicated a care plan for Resident 4 should have been completed for safe smoking. 2. During an interview and observation, on 9/16/2025 at 9:16 A.M., Resident 25 indicated he had had mouth pain from his teeth cutting his mouth up. He indicated he had gone to the dentist and was supposed to get dental work completed. Resident 25 was observed to have many missing upper teeth During an interview, on 9/18/2025 at 1:39 P.M., Resident 25 indicated he was to have his remaining upper teeth pulled for a full denture and some of his bottom teeth pulled for a partial denture. He again complained of his teeth cutting the heck out of his mouth. A record review for Resident 25 was completed on 9/17/2025 at 10:17 A.M. Diagnoses included, but were not limited to: injury of the cervical spinal cord and injury of a motor vehicle accident. An Annual MDS (minimum data set) assessment, dated 8/28/2025, indicated Resident 25 was cognitively intact and had no oral health issues. An Admission/readmission Collection Tool, on 2/5/2025 at 3:23 P.M., indicate Resident 25 had missing natural teeth. A Care Plan could not be located in the medical record for oral health or for oral pain related to the condition of Resident 25's natural teeth. During an interview, on 9/19/2025 at 12:52 P.M., the MDS Coordinator indicated Resident 25 was missing teeth and did not have a care plan for oral health. She indicated a care plan for Resident 25 should have been completed for oral health. 3. The record for Resident 12 was completed on 9/16/2025 3:03 P.M. Diagnoses included, but were not limited to dementia with mild mood disturbance, major depressive disorder, anxiety disorder and vertigo. An admission Minimum Data Set (MDS) assessment, dated 7/24/2025, indicated Resident 12 received an antipsychotic medication. Current Physicians Orders included Risperidone (an antipsychotic medication) 0.5 mg (milligram) one tablet at bedtime ordered on 7/18/2025. A current Care Plan, initiated 7/22/2025. indicated the resident had a behavior problem due to dementia and mood disorder and had episodes of undressing/naked in communal areas. Interventions included but were not limited to: Observe for behaviors. Document observed behavior and attempted interventions. Administer medications as ordered. Provide resident with privacy, with her own room for undressing/naked behavior. A current Care Plan, initiated 8/14/2025, indicated the resident was at risk for elopement related to the resident wandering without purpose and had had episodes of wandering without clothing in place. Interventions included but were not limited to: add resident to the elopement book, complete elopement risk assessment, personal safety alarm devices, and wander guard applied to left ankle. A current Care plan, initiated on 8/20/2025, indicated the resident had the potential to be physically aggressive related to dementia. The resident had episodes of hitting staff due to delusional thoughts that staff were stealing her clothes. Interventions include but are not limited to: Document observed behavior and attempted interventions, Psychiatric/Psychogeriatric consult as indicated. Observe and report any sign/symptoms of resident posing danger to self and others and give the resident as many choices as possible about care and activities. A Nurses Progress Note, dated 7/19/2025 at 4:13 P.M., indicated the resident had been found in the hallway without her shirt. The resident had entered a male resident's room covered with a pillow. Resident 12 was easily redirected to her room and redressed. The note indicated the resident had been wandering into other residents' rooms all shift and had been reminded of her room number. A Nurse's Progress Note, dated 8/3/2025 at 8:29 A.M., indicated the resident's clothing had been set out for her. Resident 12 had entered the hallway dressed only in her pants. The resident was carrying a trash can and been looking for a restroom. She had been assisted back to her room and was shown her restroom with a woman sign on the bathroom door. The resident stated, I'm not a woman I'm a boy. The resident indicated she was a boy due to her chest. Resident 12 had been made aware she had had to have her breast removed. The resident then stated Are you my mama? A nurse assisted the resident with finishing her activities of daily care (dressing, toileting and hygiene needs). The resident then ate her breakfast in her room. Resident 12 had then carried her breakfast tray to the hallway, when a staff member had attempted to take the tray, the resident had become demanding, wanting to go to the kitchen, indicating she wanted to make her own pancakes from now on. The staff had explained to the resident she could not go into the kitchen but she could go to the dining room. She had been redirected after a short time, and taken to the dining room for coffee. A laminated restroom sign had been placed on the resident's bathroom door to assist her with locating the restroom in her room. A Nurse's Progress Note, dated 8/15/2025 at 7:40 A.M., indicated the resident had been asking staff how to get out of this place because she had a doctor's appointment. The writer had informed the resident that is was night time and she did not have an appointment at this time. The resident started knocking everything off of the nurses station and had grabbed the arm of a staff member, and pushed another staff member in the back. Resident 12 had then sat on a couch in the lobby for awhile. Resident 12 later asked staff to help her find a jacket. She was then assisted to her room, took her medications and went to bed. A Nurse's Progress Note, dated 8/15/2025 at 12:28 P.M., indicated Resident 12 threw 3 glasses of water into the hallway. The resident had then removed all of her clothes from the closet and stacked the clothes on her bed. Next, Resident 12 had removed the call light from the wall. The note indicated the resident wandered the unit and continued to go into other resident rooms. The note also indicated Resident 12 had been redirected, but at times had become agitated with the redirection. A Nurse's Progress Note, dated 8/27/2025 at 8:30 P.M., indicated at 7:50 P.M., an aide had entered the resident's room to help get her ready for bed. The aide had removed the resident's clothing that had feces on it, which had caused the resident to get upset. The resident had started yelling at the aide that she was stealing her stuff, then had slapped the aide across the face. The aide had removed herself from the room. During an interview, on 9/18/2025 at 10:09 A.M., the Director of Nursing indicated Resident 12's care plans were not person-centered regarding interventions to address the resident's behaviors - including dementia, wandering, delusions and agitation. On 9/19/2025 at 10:55 A.M. the Director of nursing provided the policy titled, Comprehensive Care Plans and Revisions, dated 3/2/2022, and indicated the policy was the one currently used by the facility. The policy indicated .the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care 3.1-35(a)

Based on record review and interview, the facility failed to follow a physician's order for insulin administration for 1 of 3 residents reviewed for insulin. (Resident 5)Finding includes:During an interview, on 9/16/2025 at 10:05 A.M., Resident 5 indicated he received insulin injections twice a day. A record review was completed for Resident 5, on 9/16/2025 at 1:35 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, gout and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 8/22/2025, indicated Resident 5 was cognitively intact and received insulin injections for 7 of 7 days of the look back period. A Physician's Order, dated 6/2/2025 and discontinued on 9/3/2025, indicated insulin glargine solution 100 units per milliliter inject 20 units subcutaneously every morning and at every bedtime. The order included the following parameters: hold the insulin if the blood sugar was less than 150 mm/dL (milligrams per deciliter). The order was revised on 9/3/2025 and indicated to hold the insulin glargine solution if the blood sugar was less then 150 mg/dL or greater than 400 mg/dL and to notify the physician or nurse practitioner. The September 2025 Medication Administration Record (MAR) indicated the insulin glargine solution was administered for the following blood sugars below 150 mg/dL. -9/12/2025 at 7:11 A.M. blood sugar was 138 mg/dL.-9/12/2025 at 8:15 P.M. blood sugar was 145 mg/dL.-9/13/2025 at 9:05 A.M. blood sugar was 123 mg/dL. The August 2025 Medication Administration Record (MAR) indicated the insulin glargine solution was administered for the following blood sugars below 150 mg/dL. -8/30/2025 at 7:51 A.M. the blood sugar was 148 mg/dL. The July 2025 Medication Administration Record (MAR) indicated the insulin glargine solution was administered for the following blood sugars below 150 mg/dL.-7/1/2025 at 9:57 P.M. the blood sugar was 90 mg/dL.-7/30/2025 at 9:11 A.M. the blood sugar was 136 mg/dL. A Care Plan, initiated on 10/22/2024 and revised on 8/29/2025, indicated Resident 5 had diabetes mellitus and was at risk for a hypoglycemic/hyperglycemic reactions. Interventions included, but were not limited to: accu checks [Accu-chek] (blood glucose monitoring system) as ordered and medication as ordered. During an interview, on 09/19/2025 at 11:04 AM, the Infection Preventionist indicated Resident 5's physician order indicated the insulin glargine solution should have been held for a blood sugar less than 150 mg/dL and he should not have received the medication when his blood sugar was less than 150 mg/dL. A current policy, dated 2/27/2025, was provided by the Director of Nursing (DON), on 9/19/2025 at 1:15 P.M. The policy titled, Physician Orders, indicated, .A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a meal or a snack prior to arrival for dialysis visits or after the dialysis treatment was offered for 1 of 3 residents reviewed for nutrition. (Resident 4)Finding includes:During an interview, on 9/15/2025 at 2:38 P.M., Resident 4 indicated he attended dialysis on Tuesdays, Thursdays and Saturdays with a transportation time of 6:00 A.M. to the dialysis center. He indicated he was not offered breakfast prior to leaving for dialysis appointments, nor did the facility pack a meal or a snack. A record review for Resident 4 was completed, on 9/18/2025 at 9:07 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, chronic kidney disease stage 5 and dependance on dialysis. An Annual MDS (minimum data set) assessment, dated 7/14/2025, indicated Resident 4 was cognitively intact, needed set-up assistance for eating and received dialysis treatments. A Physician's Order, dated 11/1/2024, indicated Resident 4 was to receive a regular diet with no salt packets and diet condiments with double protein. A Physician's Order, dated 11/1/2024, indicated to send Resident 4 to dialysis on Tuesdays, Thursdays and Saturdays. A record of Resident 4's eating consumption, from 8/19/2025-9/19/2025, indicated Resident 4 was not available for meals on: 8/192025 (Tuesday), 8/21/2025 (Thursday), 8/23/2025 (Saturday), 8/26/2025 (Tuesday), 8/28/2025 (Thursday), 8/30/2025 (Saturday), 9/2/2025 (Tuesday), 9/4/2025 (Thursday), 9/6/2025 (Saturday), 9/9/2025 (Tuesday) and 9/16/2025 (Tuesday). However, there was no documentation that indicated Resident 4 had refused a meal. A Care Plan, initiated on 8/26/2024 and revised on 9/18/2025, indicated Resident 4 had the potential for nutritional problems related to diabetes mellitus and renal complications, had a 7.5 percent weight loss from 6/14/2025-9/11/2025 and frequently refused meals. Interventions included, but were not limited to: the resident will comply with recommended diet for weight reduction daily (initiated 8/27/2024 and revised on 8/7/2025), provide and serve diet as ordered (initiated 8/27/2025 and revised on 8/26/2025) and observe and report to the physician as needed any signs or symptoms of malnutrition as emaciation, muscle wasting and significant weight loss ( revised and initiated on 8/27/2024). During an interview, on 9/18/2025 at 5:57 A.M., Resident 4 indicated he had not been given breakfast, a snack or lunch to take with him to dialysis. During an interview, on 9/18/2025 at 6:18 A.M., Resident 16, who was also attended the dialysis appointment, indicated she was not allowed to have any food or drink prior to her dialysis treatment. Resident 16 indicated she was not provided breakfast or a sack lunch to take to her dialysis appointment. During an interview, on 9/18/2025 at 2:16 P.M., the Clinical Manager for the dialysis center indicated residents should and were encouraged to eat prior to their dialysis treatment. She indicated that eating during a dialysis treatment was discouraged during the dialysis treatment due to the potential risk of choking and was written within the facility contract. She indicated the residents could eat prior to treatment and during their transportation to and from the dialysis center. During an interview, on 9/19/2025 at 10:01 A.M., [NAME] 9 indicated she was willing to pack a lunch for residents that attended dialysis or keep the resident's meal for later consumption. [NAME] 9 indicated she only worked on Fridays and every other weekend. During this interview, [NAME] 9 indicated they had two insulated lunch bags, but neither were in use during the interview (even though another dialysis patient was out that day). [NAME] 9 confirmed she had not prepared or sent a snack or meal with residents who were at dialysis treatments. There was no Dietary Manager employed by the facility during the survey to interview regarding providing meals and/or breakfast to residents scheduled for dialysis treatments on their dialysis appointment days. A current policy was provided, on 9/15/2025 at 10:45 A.M. the policy titled, Dialysis, indicated, .To provide care guidelines for the resident who receives dialysis at another facility .Day of Dialysis .6. Send sack/lunch with each resident 3.1-46(a)(2)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent an alert and oriented male resident (Resident B) from entering a severely cognitive impaired female resident's (Resident C) room and exposing himself, while kneeling on her bed. Finding includes: A self-reported incident #492, dated 10/12/24, indicated .Male resident found in female resident's room sitting on the foot of the bed with pants around ankles. Female resident lying on her back with her pants down around her ankles. No observation of any physical contact The report indicated Residents B (male) and Resident C (female) were placed on 1:1 observations by facility staff members. Family members, the facility physician and police were notified of the incident. The incident follow-up, dated 10/17/24, indicated Resident B was provided education and Resident C was evaluated by the psychiatric NP, on 10/15/24, with no new orders received. The 1:1 observations were continued for both Residents and a motion sensor had been in place at Resident C's doorway. The incident follow-up indicated after the completion of the investigation, it was determined neither resident had any negative outcomes and the facility concluded this was not an abusive situation. A typed statement, signed by the Social Service Director (SSD) indicated .On 10/12/24, SSD walked down to [name of Resident B] room to let him know it was time for a shower. [Name of Resident B] walked down with SSD to the shower room when it was occupied by another resident. [Name of Resident B] turned around and walked back down the hallway. SSD assisted the other resident out of the shower room. Walked back down the hallway to inform [name of Resident B] that the shower room was open. When SSD walked into [name of Resident B] room he was not in there. SSD turned around to walk down the hall looking for [name of Resident B] when [name of Resident C] door was noticed to be closed. SSD opened [name of Resident C] door, door alarm did not sound, SSD pulled back the privacy curtain. [Name of Resident B] was sitting at the end of [name of Resident C] bed with his pants down around his ankles and [name of Resident C] was laying down at the head of the bed with her pants down around her ankles as well. [Name of Resident B] got up and pulled his pants up and walked out of the room with SSD. While walking out of the room SSD checked door alarm, turned it back on and ensured it was working before walking [name of Resident B] to the shower room A typed interview, signed by the Administrator and SSD, dated 10/12/24, indicated .An interview was conducted with [name of Resident B] and Social Service Director (who had witnessed the incident). When asked what he was doing in room [ROOM NUMBER]. He stated just talking. When it was explained to [name of Resident B] what the staff witnessed, [name of Resident B] denied that he was sitting on the end of the bed with his pants down around his ankles. When explained to [name of Resident B] what the witness had stated, [name of Resident B] still denied his pants were not down and he was just talking 1. On 10/29/24 at 11:00 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to; peripheral vascular disease, hypertension, anxiety and a left metatarsal (toe) amputation. A Behavioral Care Plan, dated 8/19/24, indicated the resident had sexual inappropriateness. Interventions included but were not limited to; .discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident A Psychiatry Progress Note, dated 9/20/24, indicated . Patient is NOT currently a danger to self/others The note indicated Resident B's judgement and thought processes were intact and he had good insight. A Quarterly Minimum Data Set (MDS) assessment, dated 10/2/24, indicated the resident was cognitively intact, was independent with transfers, walked independently, required supervision/cues for lower body dressing/undressing, was able to sit to stand independently and able to lie flat in bed without any assistance. A Nursing Progress Note, dated 10/12/24 at 10:16 A.M., indicated the SSD had opened Resident C's door and found the privacy curtain pulled around Resident C's bed. After opening the curtain, Resident B had been found in Resident C's room, sitting at the end of the bed, with his pants down. Resident B was asked to leave the room. A Nursing Progress Note, dated 10/12/24 at 3:25 P.M., indicated Resident B remained on 1:1 observations and his room change, had been completed. A Psychiatry Progress Note, dated 10/14/24, indicated Resident B was seen due to sexually inappropriate behavior via telehealth by the Nurse Practitioner (NP). It was reported to the NP, Resident B had been found with another resident, who had dementia, with his pants down. Resident B .denied his intentions but then confessed to the social worker of his intentions. When discussing the incident with the patient via telehealth, he reported I do not remember anything and refuses to talk about the incident. He was calm and kept repeating that he did not remember anything, although he had good recall of recent events such as what he ate for breakfast. Discussed boundaries with female residents. Pt [patient] has Dx [diagnoses] (depression). Pt is currently on 1:1 observation. ASSESSMENT AND PLAN 1. Inappropriate sexual behavior: Pt attempted to have sexual contact with a dementia resident Continue 1:1, Care plan with patient on boundaries . A Psychiatry Progress Note, dated 10/18/24 indicated Resident B had been seen for a follow-up visit for sexually inappropriate behavior. Resident B continued to state he did not have any recollection of event. Resident B appeared to know and realize he would be transferred to another facility, per the plan of care. Resident B remained on 1:1 observations, from facility staff, until he was discharged to another facility on 10/18/24. 2. On 10/29/24 at 11:51 A.M., a review of the clinical record for Resident C was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to; cancer, dementia and anxiety. A Quarterly Minimum Data Set (MDS) assessment, dated 8/19/24, indicated the resident was severely cognitively impaired, required supervision/cues for lower body dressing/undressing, was able to sit to stand independently and able to lie flat in bed without any assistance. A Care Plan, dated 8/19/24, indicated Resident C had episodes of masturbating with inappropriate objects and was at risk for self harm. The interventions included, but were not limited to: maintain safety during masturbation, offer privacy and consult psychiatric services as needed. A Care Plan, dated 8/19/24, indicated the resident had a behavior problem related to dementia, poor impulse control and had become sexually inappropriate in social areas. The interventions included, but were not limited to: document inappropriate behaviors, intervene as necessary to protect the safety of others, divert attention, offer to return resident to her room for privacy and refer to psychiatric services as needed. A Psychiatric Progress note, dated 8/23/24, indicated Resident C was a poor historian due to cognitive/psychiatric impairment. Resident had been seen for a follow-up visit for sexual hyperactivity. Resident C had been going into male rooms and soliciting sex. Pt has dementia and staff report that she has been having orgasms. Resident appeared calm and did not appear anxious. The Note indicated the resident had severe impairment of judgement and insight with poor short-term and long term memory. A Nursing Skin Integrity form, dated 10/12/24 at 10:28 A.M., indicated a skin inspection was conducted and indicated Resident C's skin was normal. There was no documentation which indicated the resident's vaginal area had been examined for tears, reddness or bruising. A Nursing Progress Note, documented by LPN 2, dated 10/12/24 at 3:17 P.M., indicated Resident C had left the dining room after her breakfast meal and followed LPN 2 to the medication cart, had medications administered and then the resident proceeded to return to her room. The note indicated LPN 2 had continued to pass more medications and then returned to her medication cart, near the nurse's station. LPN 2 was contacted by the Social Service Director, who reported she had found Resident B in Resident C's room. Resident C had her knees bent with legs apart, with her pants around her ankles. Resident B was sitting at the foot of the bed, pulling up his pants. The residents were separated from one another. Resident C went out of the facility with her daughter and will be place on 1:1 supervision when she returned. A form titled, BIMS/Staff Assessment for Mental Status, dated 10/12/24, indicated Resident C had a cognitive x deficit and needs were anticipated by staff.Resident is able to make simple daily decisions, when presented with choices, such as what to wear, eat and activities to participate in A Nursing Progress Note, dated 10/12/24 at 10:08 P.M., indicated the resident returned from LOA (Leave Of Absence ) with her daughter. A Nursing Progress Note dated 10/13/24 at 1:06 A.M., indicated Resident C continued to have 1:1 staff observations and had received a head to toe skin assessment, with no new skin issues noted. A Nursing Progress Note, dated 10/13/24 at 12:32 P.M., indicated Resident C had stayed in her room, with the doorway alarm activated. Resident C had been observed walking in her room, walking to the bathroom and showed no interest in coming out of her room. The note indicated the resident had meal trays delivered to her room. A Psychiatric Progress Noted, dated 10/16/24, indicated Resident C required a teleheath visit due to sexual inappropriate behaviors. The resident was unable to follow the conversation due to dementia and memory loss and had no recollection of the incident. The Resident had a tendency to wander around and into other resident rooms. The note indicated Resident C had been found with a male resident. A Psychosocial Note, dated 10/21/24 at 9:44 A.M., indicated the resident had been discharged to another facility on 10/18/24. During an interview, on 10/29/24 at 1:38 P.M., the Social Service Director (SSD) indicated she had walked with Resident B, to the shower room. When they arrived, the shower was occupied, so Resident B was observed by the SSD heading back towards his room. She then assisted the resident who had completed their shower out of the area, then proceeded to return to Resident B's room to inform him the shower room was available, but he was not in his room. As she walked back down the hallway, she noticed Resident C's door was closed, which was not normal, as she always had her door opened. The SSD indicated she stepped into the room and noticed the alarm (to alarm staff of anyone entering or exiting the room) had been turned off and Resident C's curtain was pulled. She pulled the curtain back to observe Resident B, on the bed, on his knees, with his pants/underpants around his ankles, facing Resident C. Resident C was observed to be lying down, face up, with her legs near where Resident B had been kneeling. The SSD indicated she observed Resident C with her pants/underwear down around her ankles. Resident B was observed by SSD to immediately pull up his pants and walk out of the room. She walked with him, away from Resident C's room, to the shower room, after she reset the door alarm. Resident B was then moved to a different room on another hallway, after his shower. The police had been contacted, as well as Resident C's daughter. The SSD indicated the daughter came to the facility and took the resident out of the facility for awhile and then brought her back to the facility, later the same day. The SSD indicated she had not observed if the male resident had an erection when she entered the room. During an interview, on 10/29/24 at 2:38 P.M., LPN 2 indicated she had went to the dining room to ask Resident C to walk with her to the medication cart, so she could administer Resident's medication. LPN 2 indicated Resident C went down the hallway and into her room and LPN 2 followed her and turned the doorway alarm on. LPN proceeded to go into another resident's room, across the hallway, to administer medications. After she had completed the administration task she went back to the nurse's station. Then she heard SSD yelling for assistance. She heard the SSD tell a resident to get dressed and heard her ask Resident B what he had been doing. Resident B replied just talking and I'm sorry LPN 2 went into Resident C's room and observed her dressed and seated on the side of her bed. LPN 2 then did a full skin assessment of Resident C and then she assessed Resident B. She did not talk to the daughter or call the police, as supervisors were in the facility. However, LPN indicated the daughter came in around lunch time and took Resident C out of the facility for a few hours. During an interview, on 10/29/24 at 253 P.M., the Administrator indicated she had contacted the daughter and the police. The Administrator indicated she had suggested, to the daughter, to take her out of the facility for a while. She indicated the physician had been notified, of the incident, and did not direct the facility staff to send Resident C for an examination at the local hospital. On 10/29/24 at 10:46 A.M., the Administrator provided a policy titled, Abuse - Prevention, dated 6/17/24, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to prevent and prohibit all types of abuse .Procedure .4. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: a. Verbally aggressive behavior; b. Physically aggressive behavior; c. Sexually aggressive behavior; d. Taking, touching, or rummaging through other's property; e. Wandering into other's rooms/space This citation relates to Complaint IN00445259. 3.1-45(a)(2)

Based on observation and interview, the facility failed to store and serve food under sanitary conditions related to undated and unlabeled foods for 1 of 1 kitchen areas observed (Main kitchen) and serving of plates during meal service. This issue had the potential to affect all 53 residents who resided in the facility and received food from these dietary areas. Findings include: During the initial tour of the main kitchen on [DATE] at 9:4 A.M., with the Dietary Manager, the following items were observed: - in the walk-in cooler there was 1 plastic bag with shredded carrots with an expiration date of [DATE] and 1 opened plastic bag with cooked pork chops, undated and unlabeled. -In the dry pantry, there was an unlabeled and opened bag of brownie mix and powdered sugar, and stuffing mix with an expiration date of [DATE]. During an interview, on [DATE] at 9:40 A.M., the Dietary Manager indicated nothing should be expired in the kitchen and food should have labels and expiration dates. On [DATE], at 12:01 P.M., 33 residents were observed in main dining area. Two different staff were noted to have their thumbs on the eating portion of the dinner plates when serving 3 residents in the dining room. During an interview, on [DATE] at 9:51 A.M., the Dietary Manager indicated staff should not have had their thumbs on the eating portion of the dinner plates when serving meals and dishes should be handled by the outside at an angle. On [DATE], at 1:30 P.M., the Administrator provided the policy titled, Use By Date Guide, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated determine a use by date when labeling unopened and opened food .if uncertain of the appropriate date to place on an item, contact Director of Food Services all opened containers of food in dry storage area should be .labeled and dated with the open date and the use by date. On [DATE], at 10:55 A.M., the DON provided the policy titled, Resident Dining Services, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated, the facility has an established process to ensure food is served in accordance with professional standards for food safety service . 3XXX,d+[DATE](i)(3)

Based on observation, record review and interview, the facility failed to develop comprehensive person-centered care plans for a resident with edema (Resident 29) and a resident with a history of itching (Resident 34) for 2 of 20 residents reviewed. Findings include: 1. During an observation, on 9/16/2024 at 10:59 A.M., Resident 29 had +1 pitting edema (swelling with a slight indentation in the skin that was barely visible after pressure was applied) to his bilateral lower legs. During an observation, on 9/18/2024 at 10:59 A.M., Resident 29 was noted to have +1 pitting edema to his bilateral lower legs. The record for Resident 29 was reviewed on 9/18/2024 at 10:17 A.M. Diagnoses included but were not limited to: chronic venous idiopathic hypertension, congenital malformation syndrome, muscle weakness, sleep apnea, chronic obstructive pulmonary disease, hypertension and generalized edema. The record lacked a person-centered care plan for the resident's edema. During an interview, on 9/19/2024 at 11:17 A.M., the MDS Coordinator indicated she updated and completed the care plans along with other departments personnel. MDS Coordinator indicated there was a plan which indicated the resident was at risk for edema but there were no interventions regarding edema. During an interview, on 9/19/2024 at 11:36 A.M., the DON indicated edema should have been included in care plan for Resident 29. 2. During an observation, on 9/17/2024 at 9:47 A.M., Resident 34 was noted to have scabbed over scratches on his left leg shin. The record for Resident 34 was reviewed on 9/18/2024 at 11:05 A.M. Diagnoses included but were not limited to cerebral palsy, chronic obstructive pulmonary edema, epilepsy, cognitive communication deficit, muscle weakness, dysphagia, emphysema, hypertension and difficulty in walking. Resident 29's current medications included: Triamcinolone Acetonide External Cream 0.5 % to bilateral lower extremities topically one time a day for chronic red and irritated skin, ordered 7/16/2024, and N-Acetyl Cysteine (NAC) 600 mg (milligrams) one capsule by mouth two times a day for skin itching, ordered 2/10/2023. A psychiatric provider note, dated 7/29/2024, indicated Resident 34 took NAC for skin itching/picking. The record lacked a person-centered care plan for Resident 34's itching. During an interview, on 9/19/2024 at 9:48 A.M., LPN 4 indicated Resident 34 had scratched and itched his extremities for years. LPN 4 indicated staff applied medicated lotion as well as administered an oral medication for itching on a scheduled basis. During an interview, on 9/19/2024 at 11:23 A.M., MDS Coordinator, who completed and updated care plans along with other departments. The MDS Coordinator indicated she was not aware of Resident 34's itching as a continued issue and indicated itching was not care-planned. During an interview, on 9/19/2024 at 2:29 P.M., MDS Nurse and DON indicated Resident 34's itching/scratching should have been included on the resident's care plan. On 9/20/2024, at 10:00 A.M., requested a care plan policy and was policy was not provided. 3.1-35(a)

Based on record review and interview, the facility failed to provide a transfer and discharge form for 3 of 3 residents reviewed for hospitalization . (Residents 16, 2 and 44) Findings include: 1. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, neuromuscular dysfunction of bladder, unspecified psychosis and presence of urogenital implants. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact, and he received antipsychotic medication. He had four stage 4 pressure ulcers and had an indwelling bladder catheter. A Nursing Progress Note, dated 3/27/2024 at 1:09 P.M., indicated Resident 16 had exhibited an increase in delusional behavior and a referral was made to the neuropsychiatric hospital. Resident 16 agreed he needed more assistance with psychiatric services due to his mind was racing. Resident 16 was accepted for admission, and his guardian was informed of the pending admission. A Behavioral Health History and Physical Examination, dated 3/27/2024, indicated Resident 16 was admitted to the neuropsychiatric hospital on 3/27/2024. Resident 16 returned to the facility on [DATE]. A Nursing Progress Note, dated 6/27/2024 at 7:36 A.M., indicated Resident 16 left the facility for outpatient surgery for placement of a colostomy related to stage 4 wounds with a possible skin graft in the future. Resident 16 returned to the facility on [DATE]. A Nursing Progress Note, dated 7/7/2024 at 6:45 P.M., indicated Resident 16 had a significant amount of frank blood coming from his penis after a change of the suprapubic catheter. The nurse practitioner was contacted and advised to send Resident 16 to the emergency department for an evaluation. Resident 16 was transferred to the local hospital via emergency management services (EMS). A Nursing Progress Note, dated 7/8/2024 at 1:30 A.M., indicated Resident 16 returned from the emergency department During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated the transfer and discharge form could not be located for transfers from the facility on 3/27/2024, 6/27/2024, and 7/7/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a transfer and discharge form was to be sent for any transfer to the hospital. 2. During an interview with Resident 2, on 9/17/2024 at 10:34 A.M., she indicated she had been hospitalized four times for pneumonia recently. A record review for Resident 2 was completed on 9/18/2024 at 2:20 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 with neuropathy, emphysema, atrial fibrillation, and paranoid personality disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 7/31/2024, indicated Resident 2 was cognitively intact. The assessment indicated her primary medical categories were debility and cardiorespiratory conditions. She had a diagnosis of respiratory failure and chronic lung disease. A Nursing Progress Note, dated 2:55 P.M., indicated Resident 2 was lethargic, had oxygen saturations of 87 percent and lungs sounds were diminished with no air movement. New physician orders were obtained to treat Resident 2 in-house with the following: oxygen, a chest x-ray, Rocephin (antibiotic), Prednisone (steroid) and Mucinex (expectorant). A Nursing Progress Note, dated 6/16/2024 at 10:49 P.M., indicated the nurse practitioner gave an order to send Resident 2 to the emergency department for an evaluation and treatment. A Nursing Progress Note, dated 6/22/2024 at 10:55 A.M., indicated Resident 2 was readmitted to the facility after being placed in the Intensive Care Unit (ICU) at the hospital for altered mental status, acute respiratory failure, sepsis, urinary tract infection and bilateral lower extremity cellulitis. A Nursing Progress Note, dated 7/18/2024 at 2:17 P.M., indicated an order was received to send Resident 2 to the emergency department for an evaluation and treatment. A report was given to the emergency department nurse and indicated Resident 2 was confused, lethargic, responded to her name, but falls back asleep. A Nursing Progress Note, dated 7/22/2024 at 4:27 P.M., indicated Resident 2 returned to the facility from the hospital. A Nursing Progress Note, dated 7/24/2024 at 1:07 A.M., indicated the nurse noted Resident 2's left toes/foot had a purplish/blackish discoloration. Resident 2 complained of sharp pain to her left foot. There was no known injury to Resident 2's left foot/toes. Resident 2 was sent to the emergency department at 10:20 P.M. She arrived back to the facility, at 1:07 A.M., with no fracture, but edema noted. During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated a transfer and discharge form could not be found for Resident 2's transfers to the emergency department on 6/16/2024, 7/18/2024 and 7/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a transfer and discharge form should be sent for any transfer to the hospital. 3. During an interview with Resident 44, on 9/17/2024 at 11:22 A.M., she indicated she had been hospitalized with shortness of breath. A record review for Resident 44 was completed on 9/18/2024 at 1:33 P.M. Diagnoses included, but were limited to: chronic obstructive pulmonary disease (COPD), tracheostomy, chronic respiratory failure, and obstructive sleep apnea. A Quarterly Minimum Data Set (MDS) assessment, dated 8/3/2024, indicated Resident 44 was cognitively intact. and she received treatments of oxygen, suctioning, tracheostomy care, and non-invasive mechanical ventilation. A Nursing Progress Note, dated 7/14/2024 at 9:00 P.M., indicated Resident 44 had difficulty breathing with an oxygen saturation of 82 percent on three liters of oxygen. Resident 44's oxygenation levels continued to drop with oxygen saturations reading erratically between 36-46 percent with respirations of 28-34 per minute. EMS was called and Resident 44 was transported to the emergency department. A Nursing Progress Note, dated 7/29/2024 at 5:08 P.M., indicated Resident 44 was readmitted to the facility with respiratory failure due to pneumonia and fluid overload. During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated a transfer and discharge form could not be found for Resident 44's transfer to the emergency department on 7/14/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a transfer and discharge form should have been sent for any transfer to the hospital. A policy for a transfer and discharge form was requested on 9/20/24. A policy was not provided. 3.1-12(a)(6)(A)

Based on observation, interview and record review, the facility failed to ensure discontinued medications were removed from a medication room and failed to ensure a medication refrigerator was free from a large build up of ice for 1 of 2 medication rooms observed. (Skilled hall medication room) Finding includes: During an observation of the South/Skilled hall medication room, on 9/19/2024 at 9:23 A.M. with RN 2, the following was observed: a plastic bag with the following medications, along with a hand written list, dated 6/12/2024, of the following medications 30 Haldol 5 mg (milligram) tablets (antipsychotic); 70 Hydrocodone 10/325 mg tablets (narcotic); 45 Lorazepam 0.5 mg tablets; liquid Morphine Sulfate (narcotic); 2 Fentanyl 20 mcg (micrograms) and 3 25 mcg patches (narcotic). The freezer section of the medication refrigerator had a large build up of ice. During an interview, on 9/19/2024 at 9:25 A.M., RN 2 indicated the medications that had been discontinued ahsould have been desgtroyed and the medication refrigerator should not have had an ice build up. On 9/19/2024 at 10:00 A.M., the Regional Director of Clinical Services provided the policy titled, Controlled Substance Destruction Process, dated 5/6/2022, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Once an order has been received to discontinue a medication, facility staff should remove this medication from the resident's medication supply .4. Destruction of controlled substances should occur as soon as possible ON 9/19/2024 at 10:05 A.M., the Regional Director of Clinical Services provided the policy titled, Medication Storage in Refrigerator/Freezer, dated 8/24/2023, and indicated the policy was the one currently used by the facility. The policy indicated .8. If there is excessive ice build-up in the freezer, the maintenance department should be notified to defrost the unit to ensure proper functioning 3.1-25(o) 3.1-25(r)

Based on observation, interview and record review, the facility failed to ensure staff change gloves and complete hand hygiene when providing perineal care for 1 of 1 residents reviewed for incontinence needs. (Resident 7) Finding includes: During an observation on, 9/17/2024 at 9:06 A.M., CNA 3 was observed to provide incontinence care for Resident 7. She donned gloves and removed the dirty brief from the resident. CNA 3 put the dirty brief and the dirty wipes she had used on the floor mat next to the resident. With her dirty gloves still on, she went into the bathroom to obtain a trash bag. She placed the wet brief and the wipes into the trash bag. CNA 3 then went to the closet and got a pair of clean pants without changing her contaminated gloves. CNA 3 then put the residents pants on, and repositioned the resident on the floor mat. CNA 3 rubbed the residents back and then moved a pillow under her head. During an interview, on 9/17/2024 at 9:13 A.M., CNA 3 indicated she should have removed her gloves and washed her hands after cleaning the resident's perineal area. On 9/19/2024 at 9:43 A.M., the Regional Director of Clinical Services provided the policy titled, Hand Hygiene, dated 6/3/2024, and indicated the policy was the one currently use by the facility, The policy indicated .2. Associated perform hand hygiene (even if gloves are uses) in the following situations: . b. After contact with blood, body fluids .d. after removing personal protective equipment) e.g., gloves 3.1-18(a)

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted timely for 2 of 2 resident assessments reviewed. (Resident 20 & 47) Findings include: 1. The record for Resident 47 was reviewed on 9/19/2024. Resident 47 was admitted on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, was not locked and transmitted until 9/17/2024, which was over 120 days from the admission MDS assessment that was transmitted. 2. The record for Resident 20 was reviewed on 9/19/2024. Resident 20 was admitted on [DATE]. A Quarterly MDS assessment, dated 5/12/2024, was not transmitted and accepted until 9/17/2024. The accepted date was over 120 days from the last assessment that was transmitted. During an interview, on 9/19/2024 at 11:20 A.M., the MDS Coordinator indicated the next assessments due were listed on her schedule and that the MDS assessment in question had been transmitted. She indicated she completed the schedule for the MDS assessments and it did not trigger on the report . She indicated she had not gone back far enough and would begin reviewing for the previous 120 days. She indicated the facility used the Resident Assessment Instrument (RAI).

Based on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manor for 3 of 3 residents reviewed for oxygen therapy. (Resident 36, 44 & 154) Findings include: 1. During an observation, on 9/16/2024 at 2:48 P.M., Resident 36's equalizer tubing was dated 8/2020/24 and unbagged. Resident 36's current Physician's Orders included: change and date nebulizer tubing weekly every day shift on Tuesdays. During an interview, on 9/18/2024 at 2:17 P.M., Resident 36 indicated the nebulizer tubing was never in a bag. 45120 2. During an observation, on 9/16/2024 at 10:13 A.M., Resident 44's nebulizer mask was lying on a bedside table with the respiratory bag, dated 8/20/2024, and the tracheostomy suction tip was observed with the outer wrapper, undated, with the suction tip outside the wrapper. During an observation, on 9/16/2024 at 1:58 P.M., the suction tip was missing from the suctioning tubing, but the suctioning tubing was open to air. During an observation, on 9/17/1024 at 9:30 A.M., the suctioning Yankauer (tonsil tip suctioning device to remove secretions) was opened, placed in the opened packaging, undated and the sterile water was opened and not dated. During an interview with Resident 44, on 9/17/2024 at 11:23 A.M., she indicated her tracheostomy was cleaned everyday with suctioning and she preferred for daily cleaning or twice daily cleaning with suctioning. She indicated the tubing was changed once weekly. During an observation, on 9/20/2024 at 10:14 A.M., the nebulizer mask was observed on the bed. A record review for Resident 44 was completed on 9/18/2024 at 1:33 P.M. Diagnoses included, but were limited to: chronic obstructive pulmonary disease (COPD), tracheostomy, chronic respiratory failure, and obstructive sleep apnea. A Quarterly MDS assessment, dated 8/3/2024, indicated Resident 44 was cognitively intact and received treatments of oxygen, suctioning, tracheostomy care and non-invasive mechanical ventilation. A current Care Plan, initiated on 6/12/2024, and revised on 9/5/2024, indicated Resident 44 had a tracheostomy and was at risk for infection and/or complications. Interventions included to suction as needed. A Physician's Order, dated 7/29/2024, indicated to change nebulizer tubing every Friday. A Physician's Order dated 9/12/2024 indicated to change the nebulizer circuit every Tuesday on the day shift. During an interview, on 9/20/2024 at 10:15 A.M., LPN 4 indicated nebulizer equipment should have a respiratory bag placed by the nebulizer equipment and the bag was to be changed out weekly on Fridays or as needed. The nebulizer equipment should be placed in the respiratory bag when not in use. She indicated the suctioning tips should be thrown away after an initial use and not reused. LPN 4 indicated the Yankauers were used for a 24-hour period and stored in the packaging they were removed from for use. A policy was provided on 9/20/2024 at 12:33 P.M., by the Director of Nursing. The policy was titled, Small Volume Nebulizer Therapy. The policy indicated, .Policy .The facility will provide Small Volume Nebulizer Treatments in accordance with professional standards of practice, as outlined in [NAME] through the procedure linked below .Federal Regulation .The services provided or arranged by the facility, as outlined by the comprehensive care plan, must---(i) Meet professional standards of quality [NAME]'s procedure titled, Nebulizer treatment, small volume, indicated, .Nebulizer circuit should be stored in a patient-care set-up bag. Labeled with the patient's name and dated A policy was provided, on 9/20/2024 at 12:33 P.M., by the Director of Nursing. The policy titled, Oral Suctioning, indicated, .The facility will provide oral suctioning in accordance with professional standards of practice and physicians order, to clear secretions from the mouth in the event a resident is unable to remove secretions or foreign matter by effective coughing .4. Yankauer and tubing should be stored in a patient setup bag when not in use 3.1-47(a)(6)

Based on record review and interview, the facility failed to provide a bed hold form for 3 of 3 residents reviewed for hospitalization . (Residents 16, 2, and 44) Findings include: 1. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, neuromuscular dysfunction of bladder, unspecified psychosis, and presence of urogenital implants. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact, and he received antipsychotic medication. He had four stage 4 pressure ulcers and had an indwelling bladder catheter. A Nursing Progress Note, dated 3/27/2024 at 1:09 P.M., indicated Resident 16 had exhibited an increase in delusional behavior and a referral was made to the neuropsychiatric hospital. Resident 16 agreed he needed more assistance with psychiatric services due to his mind was racing. Resident 16 was accepted for admission, and his guardian was informed of the pending admission. A Behavioral Health History and Physical Examination, dated 3/27/2024, indicated Resident 16 was admitted to the neuropsychiatric hospital on 3/27/2024. Resident 16 returned to the facility on [DATE]. A Nursing Progress Note, dated 6/27/2024 at 7:36 A.M., indicated Resident 16 left the facility for outpatient surgery for placement of a colostomy related to stage 4 wounds with a possible skin graft in the future. Resident 16 returned to the facility on [DATE]. A Nursing Progress Note, dated 7/7/2024 at 6:45 P.M., indicated Resident 16 had a significant amount of frank blood coming from his penis after a change of the suprapubic catheter. The nurse practitioner was contacted and advised to send Resident 16 to the emergency department for an evaluation. Resident 16 was transferred to the local hospital via emergency management services (EMS). A Nursing Progress Note, dated 7/8/2024 at 1:30 A.M., indicated Resident 16 returned from the emergency department During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated a bed hold form could not be located for Resident 16's transfers from the facility on 3/27/2024, 6/27/2024, and 7/7/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a bed hold policy should have been sent for any transfer to the hospital. 2. During an interview with Resident 2, on 9/17/2024 at 10:34 A.M., she indicated she had been hospitalized four times for pneumonia recently. A record review for Resident 2 was completed on 9/18/2024 at 2:20 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 with neuropathy, emphysema, atrial fibrillation, and paranoid personality disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 7/31/2024, indicated Resident 2 was cognitively intact. The assessment indicated her primary medical categories were debility and cardiorespiratory conditions. She had a diagnosis of respiratory failure and chronic lung disease. A Nursing Progress Note, dated 2:55 P.M., indicated Resident 2 was lethargic, had oxygen saturations of 87 percent and lungs sounds were diminished with no air movement. New physician orders were obtained to treat Resident 2 in-house with the following: oxygen, a chest x-ray, Rocephin (antibiotic), Prednisone (steroid) and Mucinex (expectorant). A Nursing Progress Note, dated 6/16/2024 at 10:49 P.M., indicated the nurse practitioner gave an order to send Resident 2 to the emergency department for an evaluation and treatment. A Nursing Progress Note, dated 6/22/2024 at 10:55 A.M., indicated Resident 2 was readmitted to the facility after being placed in the Intensive Care Unit (ICU) at the hospital for altered mental status, acute respiratory failure, sepsis, urinary tract infection and bilateral lower extremity cellulitis. A Nursing Progress Note, dated 7/18/2024 at 2:17 P.M., indicated an order was received to send Resident 2 to the emergency department for an evaluation and treatment. A report was given to the emergency department nurse and indicated Resident 2 was confused, lethargic, responded to her name, but falls back asleep. A Nursing Progress Note, dated 7/22/2024 at 4:27 P.M., indicated Resident 2 returned to the facility from the hospital. A Nursing Progress Note, dated 7/24/2024 at 1:07 A.M., indicated the nurse noted Resident 2's left toes/foot had a purplish/blackish discoloration. Resident 2 complained of sharp pain to her left foot. There was no known injury to Resident 2's left foot/toes. Resident 2 was sent to the emergency department at 10:20 P.M. She arrived back to the facility, at 1:07 A.M., with no fracture, but edema noted. During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated a bed hold form could not be found for the transfers to the emergency department on 6/16/2024, 7/18/2024 and 7/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a bed hold policy should have been sent for any transfer to the hospital. 3. During an interview with Resident 44, on 9/17/2024 at 11:22 A.M., she indicated she had been hospitalized with shortness of breath. A record review for Resident 44 was completed on 9/18/2024 at 1:33 P.M. Diagnoses included, but were limited to: chronic obstructive pulmonary disease (COPD), tracheostomy, chronic respiratory failure, and obstructive sleep apnea. A Quarterly Minimum Data Set (MDS) assessment, dated 8/3/2024, indicated Resident 44 was cognitively intact. and she received treatments of oxygen, suctioning, tracheostomy care, and non-invasive mechanical ventilation. A Nursing Progress Note, dated 7/14/2024 at 9:00 P.M., indicated Resident 44 had difficulty breathing with an oxygen saturation of 82 percent on three liters of oxygen. Resident 44's oxygenation levels continued to drop with oxygen saturations reading erratically between 36-46 percent with respirations of 28-34 per minute. EMS was called and Resident 44 was transported to the emergency department. A Nursing Progress Note, dated 7/29/2024 at 5:08 P.M., indicated Resident 44 was readmitted to the facility with respiratory failure due to pneumonia and fluid overload. During an interview, on 9/19/2024 at 2:26 P.M., the Social Service Director indicated a bed hold form could not be found for Resident 44's transfer to the emergency department on 7/14/2024. During an interview, on 9/20/2024 at 10:26 A.M., LPN 4 indicated a bed hold form would be sent for any transfer to the hospital. A policy for the bed hold policy was requested on 9/20/24. A policy was not provided. 3.1-12(a)(25)(A)

Based on interview and record review, the facility failed to provide timely notification of a change in condition and provide timely treatment for 2 of 3 residents reviewed for hospitalization and insulin usage. (Resident 2 and 16) Findings include: 1. During an interview with Resident 2, on 9/17/2024 at 10:34 A.M., she indicated she had been hospitalized four times for pneumonia recently. A record review for Resident 2 was completed on 9/18/2024 at 2:20 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 with neuropathy, emphysema, atrial fibrillation, and paranoid personality disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 7/31/2024, indicated Resident 2 was cognitively intact and had a diagnosis of respiratory failure and chronic lung disease. The assessment indicated her primary medical categories were debility and cardiorespiratory conditions. A Nursing Progress Note, dated 7/10/2024 at 8:48 A.M., indicated Resident 2's vital signs included a blood pressure of 96/43, an irregular heart rate of 94-97 beats per minute and oxygen saturations levels of 87 percent on room air. The oxygen saturation levels increased to 94 percent with two liters of oxygen. Resident 2 was noncompliant with oxygen therapy during breakfast. Lungs sounds were diminished with no air movement in the lower lobes, diminished in the middle lobes, and rhonchi was heard in the upper lobes. A cough was present. The nurse practitioner was to be notified of the findings. A Nursing Progress Note, dated 7/11/2024 at 9:41 A.M., indicated Resident 2 fell asleep at the dining room table during breakfast and her oxygen saturation level on room air was 87 percent, which was consistent with the resident's levels without oxygen therapy. A Nursing Progress Note, dated 7/12/2024 at 12:05 P.M., indicated Resident 2 on antibiotic therapy for pneumonia with oxygen therapy at three liters per nasal cannula. Resident 2's oxygen saturation levels ranged from 78-93 percent depending on whether Resident 2 held her head up. A Nursing Progress Note, dated 7/12/2024 at 12:07 P.M., indicated Resident 2 started the day awake, but fell asleep in the dining room at breakfast. Three staff members assisted her back to bed. She continued to be treated with an antibiotic for pneumonia. A Nursing Progress Note, dated 7/12/2024 at 2:34 P.M., indicated Resident 2 was up and awake after sleeping most of the day. A Nursing Progress Note, dated 7/13/2024 at 9:53 A.M., indicated Resident 2 continued antibiotic therapy for pneumonia, but was very lethargic with diminished lung sounds. Resident 2 dropped food from her mouth during breakfast and continued to fall asleep during the meal. A Nursing Progress Note, dated 7/13/2024 at 1:57 P.M., indicated Resident 2 was not following simple directions, was unable to remember to use her call light for assistance, was throwing items in the trash can and was unable to lock her wheelchair brake, which she has done with ease in the past. Resident 2 seemed more confused on this day. A Nursing Progress Note, dated 7/14/2024 at 11:33 A.M., indicated Resident 2 was not following directions. She dropped a carton of milk on the floor due to falling asleep during breakfast. She was very disheveled and unaware of her surroundings. Her vital signs were within normal limits. Her lung sounds were diminished throughout the lung and there were spaces with no air movement in the upper, middle, and lower lung bases. A Nursing Progress Note, dated 7/16/2024 at 2:40 P.M., indicated Resident 2 needed two staff members for maximum assistance with transfers, and dependent for bed mobility. She finished her antibiotic therapy for pneumonia. She had been lethargic in the afternoon and required additional assistance with ADLs (activities of daily living). A Nursing Progress Note, dated 7/16/2024 at 11:21 P.M., indicated Resident 2 was lethargic, needed extra staff for care and needed fed dinner. A Nurse Practitioner Note, dated 7/16/2024, indicated a post-acute visit was provided due to recent hospitalization for decreased level of consciousness, lethargy, and pneumonia. The note indicated Resident 2 was compliant with oxygen therapy, was on antibiotics for pneumonia, now required 1-2 staff assistance due to not using her legs. The staff denied any acute issues related to Resident 2 today. A Nursing Progress Note, dated 7/17/2024 at 10:54 A.M., indicated Resident 2's blood pressure was 98/54. She was very lethargic and unable to feed herself her breakfast without assistance. She had more garbled speech. The nurse practitioner was aware of these symptoms. A Nurse Practitioner Note, dated 7/17/2024, indicated a post-acute visit day 2 was provided due to recent hospitalization and the last visit was on 7/16/2024 with the resident being monitored for oxygen saturation levels. The note indicted staff denied any acute issues related to the resident on that date. A Nursing Progress Note, dated 7/17/2024 at 5:48 P.M., indicated Resident 2 was not eating on her own as she had in the past. Her food continued to drop on the floor and her chest. A Nursing Progress Note, dated 7/18/2024 at 8:58 A.M., indicated Resident 2 was not able to follow simple directions, was having problems eating her food, was dropping drinks on her chest, was falling asleep with her meal and was needing assistance of 2-3 staff members for transfers due to weakness in the lower extremities. She had no air movement in all her lung fields with an irregular heartbeat. A Nursing Progress Note, dated 7/18/2024 at 11:27 A.M., indicated Resident 2 was placed on the list to be seen by the primary medical practitioner. A Medical Physician Note, dated 7/18/2024, resident had indicated an altered mental status with no obvious signs and to send to the emergency department. A Nursing Progress Note, dated 7/18/2024 at 2:17 P.M., indicated an order was obtained to send Resident 2 to the emergency department for an evaluation and treatment. During an interview, on 9/24/2024 at 10:20 A.M., LPN 4 indicated the nurse practitioner and/or physician should be notified immediately of any change of condition after vital signs were obtained. The record lacked documentation the Nurse Practitioner evaluated the resident when she initially displayed a change in condition on 7/11/2024. Although the resident was evaluated by the Nurse Practitioner on 7/17/2024, the resident's significant change in condition was not communicated and addressed. The documentation indicated the resident continued to decline and her change in condition was not addressed until 7/18/2024 when the physician noted the resident's altered level of consciousness and gave an order to send her to an acute care facility for an evaluation. 2. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, neuromuscular dysfunction of bladder, unspecified psychosis and presence of urogenital implants. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact, received antipsychotic medication. He had four stage 4 pressure ulcers and had an indwelling bladder catheter. A Nursing Progress Note, dated 7/7/2024 at 2:51 P.M., indicated Resident 16 had no urinary output since the suprapubic catheter had last been changed. The bulb was of the catheter was deflated and the catheter was pulled back. Blood-tinged urine was noted in the catheter tubing, and active bleeding was noted coming from his penis. A Nursing Progress Note, dated 7/7/2024 at 6:45 P.M., indicated there continued to be significant frank blood coming from Resident 16's penis. The nurse practitioner was notified, and an order was obtained to send the resident to the emergency department. An Care Triage Note, dated 7/7/2024, indicated blood was coming out of Resident 16's penis. The blood had saturated Resident 16's brief and had saturated another brief immediately when changed. An order was given to send Resident 16 to the emergency department due to possible trauma caused when the the suprapubic catheter was changed and bleeding had occurred for 3.5 hours. During an interview, on 9/24/2024 at 10:20 A.M., LPN 4 indicated the nurse practitioner and/or physician should be notified immediately of any change of condition after vital signs were obtained. 3. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, and diabetes mellitus type 2. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact and received insulin medication. A Physician's Order, dated 4/4/2024, indicated to notify the physician for a blood sugar less than 60 mg/dL (milligrams per deciliter) or greater than 400 mg/dL. A blood sugar of 489 mg/dL was recorded on 8/24/2023, and a blood sugar of 410 mg/dL was recorded on 9/4/2024. There was no documentation the physician was notified. A current Care Plan, initiated 9/5/2023, and revised on 12/7/2023, indicated Resident 16 had diabetes mellitus and was at risk for hypo/hyperglycemic reactions. Interventions included to obtain blood sugars as ordered. During an interview, on 9/20/2024 at 12:34 P.M., the DON indicated the physician should have been notified of the blood sugars greater than 400. A policy was provided, on 9/20/2024 at 12:33 P.M., by the Director of Nursing (DON). The policy titled, Changes in Resident's Condition or Status, indicated .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is .(B) A significant change in the resident's physical, mental, or psychosocial status 3.1-37(a)

Based on observation, record review, and interviews, the facility failed to ensure the menu was followed for 54 of 54 residents who consumed food in the facility. Finding includes: During an observation of the noon meal service in the kitchen and dining and resident halls, conducted on 2/19/2024 between 11:30 A.M. - 12:55 P.M., the following was observed: Cook 4 utilized a 3 ounce scoop to serve all the residents Dijon potatoes, except for two residents receiving pureed food. Cook 4 served two residents a pureed diet. There were only pureed hamburger steak and gravy and pureed Dijon potatoes on the plate. In addition, the two residents received a container of chocolate ice cream and beverages. The residents did not receive a dinner roll or a vegetable. Cook 4 served eight residents a mechanical soft diet, but they did not receive any dinner roll. Review of the facility menu for the day, provided by the Food Service Supervisor on 2/19/2024 at 1:00 P.M., indicated staff should have utilized a #8 (4 ounce) scoop for the Dijon potatoes for all residents, a #16 (2 ounce scoop) for pureed bread for those residents receiving a pureed and mechanical soft diet, and a #8 scoop (4 ounce) of pureed spinach for those residents receiving a pureed diet. During an interview with the Food Service Supervisor, on 2/19/2024 at 2:38 P.M., she indicated the wrong size scoop was used by Cook 4 for the potatoes. She also indicated the pureed and mechanical soft diet residents should have received pureed bread and the pureed residents should have received a pureed serving of vegetable. The facility policy and procedure, titled, Menus, Substitutions, and Alternatives provided by the Administrator on 2/19/2024 at 3:27 P.M. included the following: Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines 1.3-20(i)(1)

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment was maintained in 1 of 4 halls observed for environment. (Central Hall) Findings include: During an initial tour, on 2/19/2024 from 9:20 A.M. to 9:34 A.M., the following items were observed on the Central Hall: - room [ROOM NUMBER] had brown and yellow stains in the bathroom with a strong urine smell. - Rooms 203-204's shared bathroom had stained flooring, and a strong urine smell. - room [ROOM NUMBER]-212's shared bathroom had stained flooring with a slimy black substance along the wooden cove wall base. The wooden cove wall base had black stains. A liquid substance was seen around the toilet to the cove wall base. The drywall above the cove wall base was wavy in appearance. - Rooms 216-217's shared bathroom had stained flooring, debris on floor and a strong urine odor. - Rooms 220-221's shared bathroom had stained flooring, and odor of urine. - Rooms 222-223's shared bathroom had stained flooring, and odor of urine. During an observation and interview, on 2/19/2024 at 2:26 P.M., the Maintenance Director observed the black slimy substance in the shared bathroom of rooms 211-212. He indicated the black slimy substance was from the wood cove wall base giving away. The Maintenance Director moved the trash can, and gnats were observed flying from the black slimy substance. He indicated the facility had been repairing rooms and bathrooms when a room became available for repair. He provided a map of the facility, titled Refresh Rooms, that indicated rooms 213-225 had been completed. During an interview, on 2/19/2024 at 2:38 P.M., the Housekeeping Supervisor indicated the housekeeping staff were assigned to a hall daily, and daily residents' rooms responsibilities included, sweeping, and mopping of the residents' rooms and mopping the entirety of the residents' bathrooms. During an observation, on 2/19/2024 at 2:41 P.M., the Executive Director and the Housekeeping Supervisor observed the condition of the shared bathroom of rooms 211-212. They could not identify the black slimy substance, but agreed the bathroom had a strong urine odor. On 2/19/2024 at 2:45 P.M., the Executive Director indicated a plan was put in place after the last annual recertification in June 2023 for room renovations. She provided a form titled, Floor Care Plan, Started January 2024, Monday-Friday. The form had all rooms from Central East, Central West, Skilled, and South Halls listed. The form indicated on the Skilled Hall, room [ROOM NUMBER] had the walls completed, room [ROOM NUMBER] had the floors completed and bathroom completed, and the South Hall had room [ROOM NUMBER] with the floors completed and the completed. The Executive Director, the renovation or refresh of the rooms was not part of the Quality Assurance/Quality Improvement Plan of the facility. On 2/19/2024 at 3:36 P.M., the Executive Director provided the policy titled, Preventative Maintenance Program, dated 1/11/2023, and indicated the policy was the one currently used by the facility. The policy indicated, .The Plan Operations/Maintenance Department will respond to and correct identified problems within the scope of their operations or arrange for the correction by a qualified individual in a timely manner. Corrective actions will be recorded in TELS [a building management platform system] This Federal tag relates to complaint IN00428075. 3.1-19 (f)

Based on record review and interview, the facility failed to report the allegations of verbal and sexual abuse from Resident 38 targeting 5 out of 7 residents reviewed for abuse. (Resident 34, 49, 31, 5 and 48) The immediate jeopardy began on 3/25/18 when the facility staff failed to immediately report an allegation of verbal and sexual abuse to the Executive Director and the state agency. The Director of Nursing, the Executive Director and the Corporate Nurse were notified of the immediate jeopardy at 5:30 P.M. at 4/24/18. The immediate jeopardy was removed on 4/30/18, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not at immediate jeopardy. Findings include: 1. The clinical record for Resident 38 was reviewed on 4/24/18 at 12:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/9/18, indicated Resident 38 had a BIMS (Brief Interview of Mental Status) score of 12, moderately impaired, and he used a wheelchair for locomotion in the facility with supervision. There was no care plan for behaviors. The Nursing Notes, dated 3/25/18 at 5:52 A.M., indicated Resident 38 was up at 4:30 A.M. sitting by the nurses station. He had made several sexual comments to staff about another resident. The nurse had spoken to him about his inappropriate behavior, she told him he should not say things like that to staff or other residents. The Nursing Notes, dated 3/25/18 at 3:24 P.M., indicated Resident 38 was noted getting close to 2 other residents and 2 staff members, saying inappropriate words and touching arms and hands. He was educated at that time to not touch anyone. A message was left for SSD (Social Service Director) regarding his behaviors. During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident from 3/25/18 and no report to the local State agency had been completed. During an interview, on 4/24/18 at 3:06 P.M., the DON (Director of Nursing) indicated she had requested Resident 38 to be evaluated by psych services for sexual inappropriate behavior towards staff. She indicated she was not aware of the nursing note from 3/25/18 or that the incident had been reported to the ED. She indicated no report was completed to the local State agency. The Rounding Providers Initial Assessment Form Behavior/Psychiatric, dated 3/28/18, indicated Resident 38 was evaluated for mood and effectiveness of [MEDICAL CONDITION] medication due to staff reporting inappropriate sexual behavior. The Nurse Practitioner indicated Resident 38 admitted to flirting with staff and had discussed how staff was offended. The treating [DIAGNOSES REDACTED]. 2. During an interview, on 4/23/18 at 2:48 P.M., Resident 34 indicated Resident 38 made obnoxious comments that were sexual. She indicated he told suggestive stories during a movie, telling her how he could please a woman with his fingers. She indicated other women had complained about Resident 38 and she had reported the allegations to Activity Assistant 5, the Director of Activities, the Executive Director and the Director of Nursing. The clinical record for Resident 34 was reviewed on 4/24/18 at 12:00 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/6/18, indicated Resident 34 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. During an interview during the Resident Council Meeting, on 4/24/18 at 10:06 A.M., Resident 34 indicated that nobody from administration had gotten back to her in regards to an important question about behavior issues from Resident 38. She wondered how many issues had to be reported before something would be done. She indicated Resident 38 made her feel intimidated and like he was backing me in a corner (figuratively) when he starts his business. Do I have to leave an activity I enjoy? She indicated it should not be up to other residents to protect her. She indicated when staff were not present he would start getting verbal, say something sexual and at the last movie he just sat and stared at her, she looked at him he made a suggestive wink at her. She indicated he targeted Resident 5 and harassed Resident 31. During an interview, on 4/24/18 at 10:25 P.M., Resident 34 indicated Resident 38 enjoyed verbal sparing and would make fun of Resident 49 during the Coffee and Chat activity that seemed to upset Resident 49. She indicated he said mean spirited remarks to Resident 5 during meals and activities, to the point that Activity Assistant 5 moved her away from him. She indicated his behaviors seemed to be getting worse lately. During an interview, on 4/24/18 at 3:02 P.M., Resident 34 indicated during a Butch Cassidy movie and the Sun Dance Kid, Resident 38 approached her and indicated to her he could please her with his fingers. A few weeks later, during the Stars Wars movie, she felt Resident 38 was trying to wheel up to her and that it bothered her when he was in an activity with her because she did not know when he is going to attack. She indicated 2 weeks ago, she decided to say something because she felt his behaviors were becoming a pattern and she had reported the incidents to the Activity Director and the Executive Director. The Social Service Investigation Notes, dated 4/5/18 at 11:30 A.M., indicated the SSD had spoken with Resident 34. It was reported that Resident 38 asked Resident 34 if he could sit by her, but instead sat facing her. He was talking about past relationships and expressed he had erectile dysfunction but a former girlfriend taught him how to satisfy a female in other ways. She reported that she had a verbal altercation with him in the dining area earlier this same week. Resident 34 reported that Resident 38 was forcing himself on to Resident 31 to hold her hand. He had made comments to Resident 49 in regards to her feet being too small and was approaching Resident 5 in the dining room. Resident 34 reported she refused to do many activities anymore to avoid Resident 38 and the situation. During an interview, on 4/24/18 at 3:33 P.M., the SSD indicated she had spoken to Resident 34 about an incident with Resident 38 regarding him inappropriately touching an applicant that had been blacked out on the Social Service Investigation Notes. She indicated it said, (employee name) and (employee name) maybe were talking in the dining room and Resident 38 had his hands all over an applicant (person here for a job interview) from the waist up. During an interview, on 4/24/18 at 11:17 A.M., the SSD indicated she was aware of the allegations that were reported by Resident 34 because she had done the interviews and it was her hand writing. She indicated she reported the information to the ED (Executive Director). During an interview, on 4/24/18 at 11:20 A.M., the ED indicated she was not aware of any other allegations in the SSD's notes, except for what was on the reportable from 4/5/18. The Reportable Incident, dated 4/5/18, indicated Resident 38 had made verbal sexual comments to Resident 34 and the immediate action taken was SSD interviewed other residents and Resident 38 was separated from Resident 34 during activities and meal services. The preventative measures included investigations of residents and separation of residents involved during activities and meal services. The Follow up indicated to continue to separate residents during activities and meal services, redirect Resident 38 when he was demonstrating behaviors. The facility would continue to in-service all staff in the handling of these types of behaviors. There was no report filed on other allegations reported in the SSD report dated 4/5/18. During an interview, on 4/24/18 at 2:45 P.M., the DON indicated she was not aware of the reportable incident filed on 4/5/18 or the allegations in the SSD's report. 3. The clinical record for Resident 31 was reviewed on 4/14/17 at 4:30 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 2/28/18, indicated Resident 31 had a BIMS (Brief Interview of Mental Status) score of 13, cognitively intact. The Social Service Investigation Notes, dated 4/5/18 at 1:00 P.M., indicated Resident 31 had spoken with the SSD and indicated the man sitting next to her kept trying to hold her hand. Resident 31 indicated she kept her distance from Resident 38, if he was sitting somewhere she would leave and sit somewhere else. During an interview, on 4/24/18 at 11:17 A.M., the SSD (Social Service Director) indicated she was aware that Resident 31 had concerns with Resident 38 grabbing her hand and wanting to hold it during Bingo. She indicated that Resident 31 would leave activities if she saw Resident 38 in one. She indicated she was not sure what staff was doing to protect other residents from Resident 38. During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident and no report had been completed to local State agency. During an interview, on 4/24/18 at 2:44 P.M., Resident 31 indicated Resident 38 wanted to hold her hand and she told him no, indicating she had been married for [AGE] years. Resident 38 indicated that was okay and persisted in trying to hold her hold. She indicated she was uncomfortable with it. During an interview, on 4/24/17 at 3:06 P.M., the DON (Director of Nursing) indicated she was not aware to the incident and no report had been completed to the local State Agency. 4. During an interview in the Resident Council Meeting, on 4/24/17 at 10:25 A.M., Resident 49 indicated that Resident 38 had made fun of her feet, stating they were too small a few times. She indicated this made her sad and upset. The clinical record for Resident 49 was reviewed on 4/24/18 at 5:00 P.M. The diagnoses, included but were not limited to, Dow[DIAGNOSES REDACTED] and depression. The annual MDS (Minimum Data Set) assessment, dated 3/21/18, indicated Resident 49 had a BIMS (Brief Interview of Mental Status) score of 11, moderate cognitive impairment. The Social Service Investigation Notes, dated 4/5/18 at 12:10 P.M., indicated the SSD (Social Service Director) had spoken with Resident 49 and the resident reported that Resident 38 had made a comment about her feet being too small. During an interview, on 4/24/18 at 10:25 A.M., Resident 34 indicated she witnessed Resident 38 making fun to Resident 49's feet during Coffee and Chat. During an interview, on 4/24/18 at 11:17 A.M., the SSD (Social Service Director) indicated she was aware of the incident when Resident 38 told Resident 49, your feet are too small for your body, how can you even walk on those. She indicated this statement made Resident 49 not feel very good and she did consider it verbal abuse and reported it to the ED (Executive Director). During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident and no report had been completed to the local State agency. During an interview, on 4/23/18 at 2:40 P.M., with Resident 49 indicated the incident with Resident 38 happened about 3 weeks ago in the dining room. He stated my feet were small and looked funny. She indicated she had reported the incident to the SSD (Social Service Director) about a week after it happened. Resident indicated that social service was going to talk to him and that social service never followed up with her to indicate what she had said to him, or to see how she was doing. During an interview, on 4/24/17 at 3:06 P.M., the DON (Director of Nursing) indicated she was not aware of the incident and no report had been filed with the local State agency. 5. The clinical review for Resident 48 was reviewed on 4/24/18 at 5:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/16/18, indicated Resident 48 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. During an interview, on 4/24/18 at 12:11 P.M., CNA (Certified Nurse Aide) 2 indicated she had heard loud commotion going on in the dining room and she had to get Resident 38 and bring him back to his room after an incident with another resident. During an interview, on 4/24/18 at 12:28 P.M. CNA 6 indicated she was aware Resident 48 had a verbal altercation with Resident 38 in the dining room last week. During an interview, on 4/24/18 at 2:50 P.M., the DM (dietary manager) indicated Resident 48 and Resident 38 were getting loud with each other in the dining room and she went and the Director of Nursing out of morning meeting to handle the situation. During an interview, on 4/24/18 at 3:00 P.M., Resident 48 indicated he had a verbal altercation with Resident 38 in the dining room because Resident 38 was saying inappropriate things to the females present about females' bodies. Resident 48 indicated he wanted to hit Resident 38. He indicated Resident 38 had said, You're an old man with one leg, there isn't much you can do. He indicated he had reported the incident to the SSD and DON was present immediately following the situation. During an interview, on 4/24/18 at 3:45 P.M., the SSD indicated Resident 48 had reported Resident 38 was talking about female body parts and was upset about the incident. She indicated the incident should have been reported for resident to resident altercation. No report was filed with the local State agency for allegation of resident to resident verbal altercation. 6. During an interview, on 4/24/18 at 10:28 A.M., Resident 34 indicated she felt like Resident 38 targeted Resident 5 viciously and he said mean spirited things to her. She indicated he would move across the dining room to say things to her face and Resident 5 was not capable of saying anything back to him related to her cognitive state. The clinical record for Resident 5 was reviewed on 4/24/18 at 5:25 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 1/9/18, indicated Resident 5 has a BIMS (Brief Interview of Mental Status) score of 7, cognitively impaired. During an interview, on 4/24/18 at 5:14 P.M., the ED (Executive Director) indicated the policy for reporting allegations of abuse should have been followed. During an interview, on 4/25/18 at 10:02 A.M., the AD (Activity Director) indicated Resident 34 had reported the allegations of Resident 38 saying inappropriate sexual comments to her, was attempting to hold the hand of Resident 31, and he made comments that were not very nice to Resident 5 about her not being very smart. She indicated Activity Assistant 5 had reported to her that Resident 38 had been mean to Resident 5, and that she was to fill out behavior sheet. The AD indicated she and Resident 34 had gone and reported the allegations directly to the ED. She had indicated she was aware of Resident 38's allegations and the increased tensions between Resident 38 and Resident 34 and it had been discussed in the facility regarding what to do about behaviors. On 4/23/18 at 12:00 P.M., the ED provided the Protection of Residents: Reducing the Threat of Abuse & Neglect policy, dated 2/2018, and indicated this was the policy currently being used by the facility. The policy indicated 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, were reported immediately, but not later than 2 hours after the allegation was 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 or do not result in in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. Report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken. The immediate jeopardy that began on 3/25/18 was removed on 4/30/18 when the facility completed education with the Executive Director and other staff members in regards to immediately reporting allegation of abuse, but noncompliance remained at the the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring and in-servicing. 3.1-28(c)

Based on record review and interview, the facility failed to investigate the allegations of verbal and sexual abuse from Resident 38 targeting 5 out of 7 residents reviewed for abuse. (Resident 34, 49, 31, 5 and 48) The immediate jeopardy began on 3/25/18 when the facility failed to investigate allegations of verbal and sexual abuse. The Director of Nursing, the Executive Director and the Corporate Nurse were notified of the immediate jeopardy at 5:30 P.M. at 4/24/18. The immediate jeopardy was removed on 4/30/18, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not at immediate jeopardy. Findings include: 1. The clinical record for Resident 38 was reviewed on 4/24/18 at 12:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/9/18, indicated Resident 38 had a BIMS (Brief Interview of Mental Status) score of 12, moderately impaired, and he used a wheelchair for locomotion in the facility with supervision. There was no care plan for behaviors. The Nursing Notes, dated 3/25/18 at 5:52 A.M., indicated Resident 38 was up at 4:30 A.M. He was sitting by the nurses station and had made several sexual comments to staff about another residents. The nurse had spoken to him about his inappropriate behavior told him should not say things like that to staff or other residents. The Nursing Notes, dated 3/25/18 at 3:24 P.M., indicated Resident 38 was getting close to 2 other residents and 2 staff members, saying inappropriate words and touching arms and hands. He was educated at that time to not touch anyone. A message was left for SSD (Social Service Director) regarding his behaviors. During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident from 3/25/18 and no investigation had been completed. During an interview, on 4/24/18 at 3:06 P.M., the DON (Director of Nursing) indicated she had requested Resident 38 to be evaluated by psych services for sexual inappropriate behavior towards staff. She indicated she was not aware to the nursing note from 3/25/18 or if the incident had been reported to the ED (Executive Director). She was unaware if the incident had been investigated. The Rounding Providers Initial Assessment Form Behavior/Psychiatric, dated 3/28/18, indicated Resident 38 was evaluated for mood and effectiveness of [MEDICAL CONDITION] medication due to staff reporting inappropriate sexual behavior. The Nurse Practitioner indicated Resident 38 admitted to flirting with staff and had discussed how staff was offended. The treating [DIAGNOSES REDACTED]. 2. During an interview, on 4/23/18 at 2:48 P.M., Resident 34 indicated Resident 38 made obnoxious comments that were sexual. She indicated he told suggestive stories during a movie, telling her how he could please a woman with his fingers. She indicated other women had complained about Resident 38 and she had reported the allegations to Activity Assist 5, the Director of Activities, the Executive Director and the Director of Nursing. The clinical record for Resident 34 was reviewed on 4/24/18 at 12:00 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/6/18, indicated Resident 34 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. During an interview during the Resident Council Meeting, on 4/24/18 at 10:06 A.M., Resident 34 indicated that nobody from administration had gotten back to her in regards to an important question about behavior issues from Resident 38. She wondered how many issues had to be reported before something would be done. She indicated Resident 38 made her feel intimidated and like he was backing me in a corner (figuratively) when he starts his business. Do I have to leave an activity I enjoy? She indicated it should not be up to other residents to protect her. She indicated when staff were not present he would start getting verbal, say something sexual and at the last movie he just sat and stared at her, she looked at him he mad a suggestive wink at her. She indicated he targeted Resident 5 and harassed Resident 31. During an interview, on 4/24/18 at 10:25 P.M., Resident 34 indicated Resident 38 enjoyed verbal sparing and would make fun of Resident 49 during the Coffee and Chat activity that seemed to upset Resident 49. She indicated he said mean spirited remarks to Resident 5 during meals and activities, to the point that Activity Assistant 5 moved her away from him. She indicated his behaviors seemed to be getting worse lately. During an interview, on 4/24/18 at 3:02 P.M., Resident 34 indicated during a Butch Cassidy movie and the Sun Dance Kid, Resident 38 approached her and indicated to her he could please her with his fingers. A few weeks later, during the Stars Wars movie, she felt Resident 38 was trying to wheel up to her and that it bothered her when he was in an activity with her because she did not know when he was going to attack. She indicated that about 2 weeks ago, she decided to say something because she felt his behaviors were becoming a pattern and she had reported the incidents to the Activity Director and the Executive Director. The Social Service Investigation Notes, dated 4/5/18 at 11:30 A.M., indicated the SSD had spoken with Resident 34 and it was reported that Resident 38 asked Resident 34 if he could sit by her, but instead sat facing her. He was talking about past relationships and expressed he had erectile dysfunction but a former girlfriend taught him how to satisfy a female in other ways. She reported that she had a verbal altercation with him in the dining area earlier this same week. Resident 34 reported that Resident 38 was forcing himself on to Resident 31 to hold her hand. He had made comments to Resident 49 in regards to her feet being too small, and that he was approaching Resident 5 in the dining room. Resident 34 reported she refused to do many activities anymore to avoid Resident 38 and the situation. During an interview, on 4/24/18 at 3:33 P.M., the SSD indicated she had spoken to Resident 34 about an incident with Resident 38 regarding him inappropriately touching an applicant that had been blacked out on the Social Service Investigation Notes. She indicated it said, (employee name) and (employee name) maybe were talking in the dining room and Resident 38 had his hands all over an applicant (person here for a job interview) from the waist up. During an interview, on 4/24/18 at 11:17 A.M., the SSD indicated she was aware of the allegations that were reported by Resident 34 because she had done the interviews and it was her hand writing. She indicated she reported the information to the ED (Executive Director). During an interview, on 4/24/18 at 11:20 A.M., the ED indicated she was not aware of any other allegations in the SSD's notes, except for what was on the reportable from 4/5/18. The Reportable Incident, dated 4/5/18 indicated Resident 38 had made verbal sexual comments to Resident 34 and the immediate action taken was SSD interviewed other residents and Resident 38 was separated from Resident 34 during activities and meal services. The preventative measures included investigations of residents and separation of residents involved during activities and meal services. The Follow up indicated to continue to separate residents during activities and meal services, redirect Resident 38 when he was demonstrating behaviors. The facility would continue to in-service all staff in the handling of these types of behaviors. There was no investigation available of the allegations reported in the SSD report. During an interview, on 4/24/18 at 2:45 P.M., the DON indicated she was not aware of the reportable incident filed on 4/5/18 or the allegations in the SSD's report. 3. The clinical record for Resident 31 was reviewed on 4/14/17 at 4:30 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 2/28/18, indicated Resident 31 had a BIMS (Brief Interview of Mental Status) score of 13, cognitively intact. The Social Service Investigation Notes, dated 4/5/18 at 1:00 P.M., indicated Resident 31 had spoken with the SSD and indicated the man sitting next to her kept trying to hold her hand. Resident 31 indicated she kept her distance from Resident 38, if he was sitting somewhere she would sit somewhere else. During an interview, on 4/24/18 at 11:17 A.M., the SSD (Social Service Director) indicated she was aware that Resident 31 had concerns with Resident 12 grabbing her hand and wanting to hold it during Bingo. She indicated that Resident 31 would leave activities if she saw Resident 38 in one. She indicated she was not sure what staff was doing to protect other residents from Resident 38. During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident and no investigation had been completed. During an interview, on 4/24/18 at 2:44 P.M., Resident 31 indicated Resident 38 wanted to hold her hand and she told him no, indicating she had been married for [AGE] years. Resident 38 indicated that was okay and persisted in trying to hold her hand. She indicated she was uncomfortable with it. During an interview, on 4/24/17 at 3:06 P.M., the DON (Director of Nursing) indicated she was not aware to the incident and no investigation had been completed. 4. During an interview in the Resident Council Meeting, on 4/24/17 at 10:25 A.M., Resident 49 indicated that Resident 38 had made fun of her feet, stating they were too small a few times. She indicated this made her sad and upset. The clinical record for Resident 49 was reviewed on 4/24/18 at 5:00 P.M. The diagnoses, included but were not limited to, Dow[DIAGNOSES REDACTED] and depression. The annual MDS (Minimum Data Set) assessment, dated 3/21/18, indicated Resident 49 had a BIMS (Brief Interview of Mental Status) score of 11, moderate cognitive impairment. The Social Service Investigation Notes, dated 4/5/18 at 12:10 P.M., indicated the SSD (Social Service Director) had spoken with Resident 49 and the resident reported that Resident 38 had made a comment about her feet being too small. During an interview, on 4/24/18 at 10:25 A.M., Resident 34 indicated she witnessed Resident 38 making fun to Resident 49's feet during Coffee and Chat. During an interview, on 4/24/18 at 11:17 A.M., the SSD (Social Service Director) indicated she was aware of the incident when Resident 38 told Resident 49, your feet are too small for your body, how can you even walk on those. She indicated this statement made Resident 49 not feel very good and she did consider it verbal abuse and reported it to the ED (Executive Director). During an interview, on 4/24/18 at 11:40 A.M., the ED (Executive Director) indicated she was not aware of the incident and no investigation had been completed. During an interview, on 4/23/18 at 2:40 P.M., Resident 49 indicated the incident with Resident 38 happened about 3 weeks ago in the dining room. He stated my feet were small and looked funny. She indicated she had reported the incident to the SSD (Social Service Director) about a week after it happened. Resident indicated that social service was going to talk to him and that social service never followed up with her to indicate what she had said to him, or to see how she was doing. During an interview, on 4/24/17 at 3:06 P.M., the DON (Director of Nursing) indicated she was not aware to the incident and no investigation had been completed. 5. The clinical review for Resident 48 was reviewed on 4/24/18 at 5:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/16/18, indicated Resident 48 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. During an interview, on 4/24/18 at 12:11 P.M., CNA (Certified Nurse Aide) 2 indicated she had heard loud commotion going on in the dining room and she had to get Resident 38 and bring him back to his room after an incident with another resident. During an interview, on 4/24/18 at 12:28 P.M. CNA 6 indicated she was aware Resident 48 had a verbal altercation with Resident 38 in the dining room last week. During an interview, on 4/24/18 at 2:50 P.M., the DM (Dietary Manager) indicated Resident 48 and Resident 38 were getting loud with each other in the dining room and she went and the Director of Nursing out of morning meeting to handle the situation. During an interview, on 4/24/18 at 3:00 P.M., Resident 48 indicated he had a verbal altercation with Resident 38 in the dining room because Resident 38 was saying inappropriate things to the females present about females' bodies, especially Resident 34. Resident 48 indicated he wanted to hit Resident 38. He indicated Resident 38 had said, You're an old man with one leg, there isn't much you can do. He indicated he had reported the incident to the SSD and DON was present immediately following the situation. During an interview, on 4/24/18 at 3:45 P.M., the SSD indicated Resident 48 had reported Resident 38 was talking about female body parts and was upset about the incident. She indicated the incident should have been reported for resident to resident altercation. No investigation was available for allegation for resident to resident verbal altercation. 6. During an interview, on 4/24/18 at 10:28 A.M., Resident 34 indicated she felt like Resident 38 targeted Resident 5 viciously and he said mean spirited things to her. She indicated he would move across the dining room to say things to her face and Resident 5 was not capable of saying anything back to him related to her cognitive state. The clinical record for Resident 5 was reviewed on 4/24/18 at 5:25 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 1/9/18, indicated Resident 5 has a BIMS (Brief Interview of Mental Status) score of 7, severe impairment. During an interview, on 4/24/18 at 5:14 P.M., the ED (Executive Director) indicated the policy for investigating allegations of abuse should have been followed. During an interview, on 4/25/18 at 10:02 A.M., the AD (Activity Director) indicated Resident 34 had reported the allegations of Resident 38 saying inappropriate sexual comments to her, was attempting to hold the hand of Resident 31, and he made comments that were not very nice to Resident 5 about her not being very smart. She indicated Activity Assistant 5 had reported to her that Resident 38 had been mean to Resident 5, and that she was to fill out behavior sheet. The AD indicated she and Resident 34 had gone and reported the allegations directly to the ED. She had indicated she was aware of Resident 38 allegations and the increased tensions between Resident 38 and Resident 34 and it had been discussed in the facility regarding what to do about behaviors. On 4/23/18 at 12:00 P.M., the ED provided the Protection of Residents: Reducing the Threat of Abuse & Neglect policy, dated 2/2018, and indicated this was the policy currently being used by the facility. The policy indicated in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process, and report results of all investigations to the administrator and to other officials in accordance with State law with in 5 working days of the incident. The immediate jeopardy that began on 3/25/18 was removed 4/30/18 when the facility completed education with the Executive Director and other staff members in regards to investigating an allegation of abuse, but noncompliance remained at the the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring and in-servicing. 3.1-28(d) 3.1-28(e)

Based on record review and interview, the facility failed to allow a resident to remain in the facility, when a resident was transferred to a sister facility without thorough determination of this resident's threat to other residents in the facility in 1 of 4 residents reviewed for discharges. (Resident 38) The immediate jeopardy began on 4/24/18 when the facility discharged Resident 38 to a sister facility that was 60 miles away. The Director of Nursing, the Executive Director, the Corporate Nurse and Regional Vice President were notified of the immediate jeopardy at 2:15 P.M. at 4/25/18. The immediate jeopardy was removed on 4/30/18, noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not at immediate jeopardy. Finding includes: The clinical record for Resident 38 was reviewed on 4/25/18 at 12:30 P.M., indicated resident was discharged to another facility on 4/24/18. The Telephone Order from the physician, dated 4/24/18, indicated Resident 38 may transfer to another facility with medications. A Progress Note, dated 4/24/18 at 7:38 P.M., indicated, . writer was informed that the ED (Executive Director) had spoken to Resident 38's wife in regards to inappropriate comments being made to other residents in the facility. The wife replied Wow, OMG (oh my god), has anyone came and talked to him? I wish I would have been told sooner. (Resident 38's name) thinks he is a lot funnier than he is. This crap upsets me. Can I admit him to another facility in the area? The ED responded, yes, wife replied, Can you give me a couple of days? This is not fair. Wife was crying on the phone with ED. ED apologized and told wife we would be looking for alternative placement for the resident. ED told wife please do not be upset, I will let you know when we figure out where we will be moving him. Wife replied, This is so unfair The Discharge/Transfer Order, dated 4/24/18 at 8:30 P.M., indicated Resident 38's discharge was necessary for the safety of other individuals in the facility. Other residents were endangered due to the clinical or behavior status of the resident. Resident 38 was displaying aggression toward other residents. The Progress Note, dated 4/24/18 at 10:19 A.M., indicated Resident 38 was discharged to another facility at 10:00 P.M. by facility bus. During an interview, on 4/25/18 at 12:50 P.M., the ED indicated she was not sure why the facility discharged Resident 38. The facility had a meeting on the evening of 4/24/18 with 7 or 8 members to discuss discharge. During an interview, on 4/25/18 1:09 P.M., the ED indicated Resident 38 was discharged because the facility felt he required one on one assistance and they could not provide that service. She indicated by immediately discharging Resident 38, the facility would have ensured the safety of other residents. The clinical record for Resident 38 was reviewed on 4/24/18 at 12:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/9/18, indicated Resident 38 had a BIMS (Brief Interview of Mental Status) score of 12, moderately impaired, and he used a wheelchair for locomotion in the facility with supervision. The Nursing Notes, dated 3/25/18 at 5:52 A.M., indicated Resident 38 was up at 4:30 A.M., and was sitting by the nurses station and made several sexual comments to staff and about another residents and the nurse had spoken to the him about his inappropriate behavior and he should not say things like that to staff or other residents. The Nursing Notes, dated 3/25/18 at 3:24 P.M., indicated Resident 38 was noted in the afternoon to be getting close to 2 other residents and 2 staff members, saying inappropriate words and touching arms and hands. He was educated at that time to not touch anyone and a message was left for SSD. The Rounding Providers Initial Assessment Form Behavior/Psychiatric, dated 3/28/18, indicated Resident 38 was evaluated for mood and effectiveness of [MEDICAL CONDITION] medication due to staff reporting inappropriate sexual behavior. The Nurse Practitioner indicated Resident 38 admitted to flirting with staff and had discussed how staff was offended. The treating [DIAGNOSES REDACTED]. No documentation of assessment for resident behaviors were available for review and no updates were noted to the plan of care to address the needs and behaviors of Resident 38. During an interview, on 4/25/18 at 1:15 P.M., the POA (Power of Attorney) indicated Resident 38 had recently become more forgetful and was known to be crude and inappropriate at times. He indicated he had been notified by the facility previously about Resident 38 being offensive to another resident. He indicated the ED had called to notify him that the facility was discharging Resident 38 to another facility that day because he was a threat to females in the facility. The POA felt this was very sudden. He indicated the ED had told him things had been going that .the facility has let slide ., but this time he had to be transferred due to sexual harassment laws. The POA indicated the wife of Resident 38 was really upset about the transfer. During an interview, on 4/26/18 at 12:12 P.M., the ED indicated the facility discharged Resident 38 due to his history and patterns of being verbally and sexually abusive with residents. On 4/25/18 at 4:30 P.M., the DON (Director of Nursing) provided the Transfers and Discharges policy, dated 9/1/17, and indicated this was the policy currently being used by the facility. The policy indicated transfers and discharges would be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations. Transfers and discharges may occur for the following reasons: The transfer or discharge is necessary for the resident's welfare and the resident's needs can not be met in their current place in the facility and when the health of safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. In the event that the resident requires transfer or discharge due to one of the above stated reasons documentation will be in the medical record to include: The basis for the transfer, the specific resident need that cannot be met. Facility attempts to meet the resident needs, and the service available at the receiving facility to the meet the needs. Documentation from the resident's physician is needed when transfer is necessary because the safety of individuals in the facility is endangered due to the clinical behavior status of the resident. Documentation from the physician for reasons stated above will be recorded on the Discharge/Transfer order form and a discharge summary must be completed for all discharges. The immediate jeopardy that began on 4/24/18 was removed 4/30/18 when the facility readmitted Resident 38 and had him assessed by a physician and the interdisciplinary team, and developed a plan to ensure he could safely remain in the facility, but noncompliance remained at the the lower scope and severity of isolation, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring and in-servicing. 3.1-12(a)(4)

Based on record review and interview, the facility failed to protect a resident from sexual and verbal abuse that resulted in psychosocial harm as evidenced by a decrease in participation in activities and an increase of fear for her well-being in 1 of 7 residents reviewed for abuse. (Resident 34) Finding includes: During an interview, on 4/23/18 at 2:48 P.M., Resident 34 indicated Resident 38 made obnoxious comments that were sexual. She indicated he told suggestive stories during a movie, telling her how he could please a woman. She indicated other women had complained about Resident 38 and she had reported the allegations to Activity Assistant 5, the Director of Activities, the Executive Director and the Director of Nursing. The clinical record for Resident 34 was reviewed on 4/24/18 at 12:00 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/6/18, indicated Resident 34 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. During an interview during the Resident Council Meeting, on 4/24/18 at 10:06 A.M., Resident 34 indicated that nobody from administration had gotten back to her in regards to an important question about behavior issues from Resident 38. She wondered how many issues had to be reported before some thing would be done. She indicated Resident 38 made her feel intimidated and like he was backing me in a corner (figuratively) when he starts his business. Do I have to leave an activity I enjoy? She indicated it should not be up to other residents to protect her. She indicated when staff were not present he would start getting verbal, say something sexual and at the last movie he just sat and stared at her, when she looked at him he made a suggestive wink at her. During an interview, on 4/24/18 at 10:25 P.M., Resident 34 indicated Resident 38 enjoyed verbal sparing and his behaviors seemed to be getting worse lately. During an interview, on 4/24/18 at 3:02 P.M., Resident 34 indicated during a Butch Cassidy movie and the Sun Dance Kid, Resident 38 approached her and indicated to her he could please her with his fingers. A few weeks later, during the Stars Wars movie, she felt Resident 38 was trying to wheel up to her and that it bothered her when he was in an activity with her because she did not know when he was going to attack. She indicated 2 weeks ago, she decided to say something because she felt his behaviors were becoming a pattern and she had reported the incidents to the Activity Director and the Executive Director. The Social Service Investigation Notes, dated 4/5/18 at 11:30 A.M., indicated the SSD had spoken with Resident 34 and it was reported that Resident 38 asked Resident 34 if he could sit by her, but instead sat facing her. He was talking about past relationships and expressed he had erectile dysfunction but a former girlfriend taught him how to satisfy a female in other ways. She reported that she had a verbal altercation with him in the dining area earlier this same week. A Reportable Incident, dated 4/5/18, indicated Resident 38 had made verbal sexual comments to Resident 34 and the immediate action taken was SSD interviewed other residents and Resident 38 was separated from Resident 34 during activities and meal services. The preventative measures included investigations of residents and separation of residents involved during activities and meal services. The Follow up indicated to continue to separate residents during activities and meal services, redirect Resident 38 when he was demonstrating behaviors. The facility would continue to in-service all staff in the handling of these types of behaviors. During an interview, on 4/30/18 at 11:18 A.M., the local Ombudsman indicated he had spoken with Resident 34. She had indicated she was fearful of the environment around her in regards to Resident 38. During an interview, on 5/1/18 at 1:57 P.M., Resident 34 indicated she felt like Resident 38 targeted her and she felt uncomfortable in his presence. She indicated he made her feel like activities would be an unpleasant event if he was present. She indicated she feared he would say something insulting and the more comfortable he became with his sexual remarks with her the worse they would become. She felt he would potentially do something sexual to her, like touch her in an unwelcome way. She indicated she was afraid of him and that nobody from the facility had come to discuss her fears with her in regards to Resident 38. On 4/23/18 at 12:00 P.M., the ED provided the Protection of Residents: Reducing the Threat of Abuse & Neglect policy, dated 2/2018, and indicated this was the policy currently being used by the facility. The policy indicated each resident had the right to be free from abuse. Residents must not be subjected to abuse by anyone. This included, but was not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, the resident representative, friends, or any other individual. It was policy and practice that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility must have established a safe environment that supports a resident's consensual relationship. The facility was required to protect a resident from non-consensual sexual relations anytime the facility had a reason to suspect that the resident did not wish to engage. Verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Sexual abuse was defined as non-consensual sexual contact of any type with residents that included, but was not limited to, sexual harassment, sexual coercion or sexual assault. 3.1-27(a)(1) 3.1-27(b)

Based on record review, interview and observation, the facility failed to ensure that a resident admitted with an unstageable pressure ulcer on their coccyx was placed on an appropriate sized bed and speciality mattress resulting in the worsening of the pressure ulcer to a Stage 4. (Resident 77) Findings include: The clinical record for Resident 77 was reviewed on 4/25/18 at 3:29 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 4/28/18, indicated Resident 77 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, and he required extensive assist with ADLs (activities od daily living). The Ostomy/Wound Progress Note from the hospital, dated 1/10/18, indicated Resident 77 had multiple open areas and suspected deep tissue injury areas related to a recent 4 day stint where he had fallen and laid on his floor at home. The coccyx unstageable pressure ulcer measured 10 cm (centimeter) x 5.5 cm x 0.3 cm and he was using a low loss air mattress. The Final Report Progress Notes from hospital, dated 1/14/18, indicated Resident 77 presented to the hospital with multiple decubitus ulcers at the time of admission including midline back, left lower back, left ischial tuberosity, right heel, left heel, left lateral foot, coccygeal left upper leg and right posterior leg, he was essentially bedridden/wheelchair bound, [MEDICAL CONDITION] with BMI (Body Mass Index) of approximately 39-40 which contributes to difficulty with mobilizing the patient. The care plan for pressure ulcers, dated 1/16/18, indicated Resident 77 had a pressure ulcers and interventions included, but were not limited to, observe effectiveness of/response to treatments as ordered, provide pressure relieving or reduction device (speciality mattress), turn and reposition every two hours and wound care ordered by physician. The Progress Note, dated 1/17/18 at 12:08 A.M., indicated Resident 77 was a 2-3 assist for turning and repositioning and he had multiple pressure wounds that were bandaged on his left back, left hip and coccyx as well as both heels. Abrasion to left hip measured 5.5 cm x 2.5 cm, his right heel was non blanchable area that measured 3 cm x 3 cm, his left heel there was black necrotic area with yellow slough that measured 1.5 cm x 1.5 cm, the left lateral ankle measured 1.5 cm x 2 cm, the left lateral foot measures 1 cm x 0.7 cm, his upper mid back measure had a pressure area that measured 3.5 cm x 0.8 cm, his left wasit/hip had an area that measured 2 x 2 cm, his left upper hip measures 1.5 cm x 2 cm, the large area to left buttocks was 5 cm x 3 cm, the area surrounding the coccyx measures 5.5 cm x 3 cm and consisted mostly of yellow slough. Resident 77 was proped with many pillows and floated both heels. Resident 77 was going to need a bariatric bed due to his large size. The Pressure Ulcer Status Record, dated 1/16/18 to 1/29/18, indicated Resident 77 had an unstageable pressure ulcer to his coccyx that measured 5.5 cm x 3.0 cm that was 80% eschar, 10 % slough and 10% granulation tissue and it had merged with left buttock wound as of 1/22/18. The Progress Note, dated 1/22/18 at 3:34 P.M., indicated left buttocks.coccyx was now one wound that measured 3.0 cm x 3.0 cm with unstable wound bed that was 10 % granulation and 90% slough and left buttock wound measured 5.0 cm x 5.0 cm with unstable wound bed with 20% slough and 80% eschar. Resident had follow up appointment at wound clinic on 1/24/18. The Progress Note, dated 1/23/18 at 11:29 A.M., indicated the wound clinic had cancelled that appointment for 1/24/18. No documentation of follow up with appointment with wound clinic available. The Pressure Ulcer Status Record, dated 1/16/18 to 2/5/18, indicated Resident 77 had an unstageable pressure ulcer to left buttock measuring 5.0 cm x 5.0 cm, measured 5.0 cm x 5.0 cm on 1/22/18, measured 5.0 x 5.5 cm on 1/29/18 and had merged with coccyx wound and other left buttock wound on 2/5/18. The Pressure Ulcer Status Record, dated 1/16/18 to 2/26/18, indicated Resident 77 had an unstageable pressure ulcer to left buttocks that measured 1.5 cm x 1.0 cm on 1/16/18, measured 3.0 cm x 3.0 cm on 1/22/18 (merged with coccyx wound), measured 2.8 cm x 3.4 cm on 1/29/18, measured 7.0 cm x 7.0 cm x <0.2 cm (merged with another left buttock wound), measured 7.5 cm x 6.5 cm x < 0.2 cm on 2/12/18, measured 7.0 cm x 6.0 cm x 2.0 cm as a Stage 4 pressure ulcer with 1 cm tunneling at 9 o'clock on 2/19/18, and measured 7.0 cm x 4.0 cm x 4.0 cm with 3.0 cm tunneling at 9 o'clock. The Progress Note, dated 1/27/18 at 2:34 A.M., indicated Resident 77 required full care with positioning with 3 person assist and his wounds were all healing except the area to the coccyx as resident lies in supine position most of the time, difficulty with repositioning with narrow bed. The Progress Note, dated 1/29/18 at 11:33 P.M., indicated coccyx wound had some bleeding and light yellow drainage. No physician notification present for change in drainage or increase in size of wounds. The Progress Note, dated 2/3/18 at 4:03 A.M., indicated Resident 77 had complained that his bed was not big enough to reposition off buttocks and move side to side. The Progress Note, dated 2/4/18 at 2:48 A.M., indicated Resident 77 stated his bed was too small and it was hard to reposition him due to lack of space. The Progress Note, dated 2/5/18 at 2:18 A.M., indicated all pressure areas except coccyx and buttocks are healing well and that coccyx and buttocks were affected by constant [MEDICAL CONDITION] diarrhea. The Progress Note, dated 2/5/18 at 4:50 P.M., indicated the areas to the left buttock and coccyx were now one wound measuring 7.0 cm x 7.0 cm x 0.2 cm with 70% yellow slough and 30% granulation. No physician notification noted for wound changes. The Progress Note, dated 2/10/18 at 2:49 A.M., indicated Resident 77 rested quietly through out night except for when medication were passed and treatments were completed. Resident indicated much easier to rest in bariatric bed. The Progress Note, dated 2/14/18 at 5:46 A.M., indicated the drainage from the coccyx/buttocks was moderate. The Progress Note, dated 2/16/18 at 4:59 A.M., indicated treatment to areas was being done and the area to coccyx appeared to be tunneling and appeared wider and resident voiced pain during treatment. The Progress Note, dated 2/16/18 at 9:30 A.M., indicated Resident 77 complained of pain to coccyx and pain medication was administered. The Progress Note, dated 2/19/18 at 4:49 P.M., indicated the unstageable pressure area to buttocks was now concerned a Stage 4 wound that measured 7.0 cm x 6.0 cm x 2.0 cm with wound bed 60 % granular and 40% yellow slough with tunneling of 1.0 cm noted at 9 o'clock. The Progress Note, dated 2/26/18 at 4:21 A.M., indicated Stage 4 to left buttock/coccyx measured 7.0 cm x 4.0 cm x 4.0 cm with 3.0 cm tunneling noted at 9 o'clock with wound bed 60% granular tissue and 40% thick yellow slough. Moderate amount of bloody drainage noted. Resident intended to be followed by the local wound clinic however appointment has been cancelled twice. A new Stage 2 pressure ulcer was noted to left buttock that measured 4.0 cm x 3.0 cm. Resident was currently on a bariatric bed with a pressure relieving bariatric bed ordered. The Progress Note, dated 3/4/18 at 4:18 A.M., indicated the pressure area on coccyx was larger and deeper that when seen 4 days ago and a moderate amount of bloody drainage was noted. The Wound Healing Center Progress Notes, dated 3/5/18, indicated Resident 77 was .referred for Stage 4 pressure ulcer to sacrum, unstageable pressure ulcers to left foot and heel and superficial Stage 2 to mid back. The facility had been doing the wound care but apparently felt that the sacral wound in particular had gotten to the point that further evaluation in wound clinic was required. The main and the most concerning wound was the sacral coccygeal wound. This wound measured 10 cm x 3.5 cm x 6.5 cm with foul smelling brown and black drainage and several wads of necrotic tissue which were debrided. It was clear that there was cancellous bone from his sacral palpable in the depths of the wound. The difficulty in exposing this wound for debridement, the size of the wound and issues related to pain control led to the discontinuation of further debridement. It was felt that inpatient management including intravenous antibiotics for the clinical sacral osteo[DIAGNOSES REDACTED] as well as probable need to perform a more through debridement in the operating room, Resident 77 was admitted to the local hospital. The post debridement measurements were 10.1 cm x 3.6 cm x 6.5 cm The History and Physical, dated 3/7/18, indicated Resident 77 was a direct admit to the hospital from the wound clinic for osteo[DIAGNOSES REDACTED] of his Stage 4 pressure ulcer and was receiving intravenous antibiotics and was required surgical debridement. The Pressure Ulcer Status Record, dated 3/9/18 to 4/30/17, indicated Resident 77 was admitted back to facility on 3/9/18 with Stage 4 pressure ulcer to coccyx measuring 12.0 cm x 16.0 cm x 5.0 cm. The Wound Healing Center Porgress Note, dated 3/23/18, indicated Resident 77 had a significant large pressure wound to coccyx area that measures 12.5 cm x 15.5 cm x 5 cm that extends done to exposed sacral bone. The wound was in the lower midline coccyx area and extended very close to anus and reached across both sides, but prodominantly the left. It was recommended to continue frequent dressing changes of wet-to-dry dressing, as it forced the nurses to have to turn him from side to side. The Wound Healing Center Progress Note, dated 4/6/18, indicated Resident 77 was .unable to be brought to the wound clinic as previously scheduled due to problems with transportation from the facility. This was not the first time this had happened. The physician had called to speak with the facility Medical Director to express his concern about needing to see the resident in the wound clinic weekly and he had expressed the faciltiy was having some troubles with transportation The Wound Healing Center Procedure Note, dated 4/9/18, indicated Resident 77 had underwent a significant debribement in the operating room on 3/8/18 by surgeon and subsequently has had conservative managemant, unforunately, he has not had regular appointments in the Wound Healing Center. During on observation, on 4/30/18 from 2:55 P.M. to 3:15 P.M., LPN (Licensed Practical Nurse) 8 was observed completing the dressing changes for Resident 77. The following was observed: LPN 8 brought into room supplies for dressing change and placed on clean table that was covered with a clean towel. She opened up some of the wound dressings and initialed dressings with marker. She removed her gloves and was observed to wash her hands (soap and hand contact) for 10 seconds. She applied new gloves, removed the dressing from upper back, the outer dressing from the coccyx, the dressing from the left hip and then removed the packing from the coccyx wound. She removed her gloves, applied alcohol gel and reapplied new gloves. LPN 8 indicated Resident 77 had two new wound to upper back, she measured all three wound with same package. She removed her gloves, applied alcohol gel, and reapplied new gloves. She removed the packing from the left hip wound and then sprayed wound cleansed in the coccyx wound and proceeded to clean wound. No glove change noted. She indicated the coccyx wound was a Stage IV with exposed bone that measured 16 cm x 4.5 cm x 4.2 cm. She removed gloves, applied alcohol gel, and applied new gloves. She reapplied dressing to left hip. She removed her gloves and washed hands for 10 seconds (soap and hand contact) and applied new gloves. She cleaned all three wound to upper back with same moistened 4 x 4 gauze pad and reapplied new dressings. No glove changes or handwashing noted. She then opened Kerlix package and opened cotton tip package. She then changed gloves, used alcohol gel and applied new gloves. She then completed the dressing change to coccyx by filling space in wound with moistened kerlix and applying ABD (abdominal pads). During an interview, 5/01/18 11:06 A.M., the DON (Director of Nursing) indicated Resident 77 was on low air mattress on regular size bed on admission of 1/16/18, was then placed on bariatric bed with regular mattress on 2/10/18 because no air loss mattress was available that would fit, and now is on bariatriac low air loss mattress that was delivered on 3/9/18. The DON indicated they clarified with the hospital regarding the order for a sand bed to prevent further breakdown to coccyx and the hospital had stated the air mattress would be fine. There was no documentation available regarding the clarification of the sand bed. During an interview, on 5/01/18 at 12:49 P.M., the DON indicated she did not know Resident 77 required a bariataric bed until February. She indicated the facility had a bariatric bed in the facility but did not place the resident in one until February. She indicated she was not aware of the progress notes indicating resident required a bariatric bed and was unable to reposition off buttocks to relieve pressure due to size of bed. During an interview, on 5/1/18 at 2:44 P.M., the Front Office Clerk at the wound clinic, indicated the appointment that was cancelled on 1/24/18 was cancelled by the facility and not the clinic. She indicated resident was not seen in the office until 3/5/18. During an interview, on 5/1/18 at 2:50 P.M., the DON indicated she thought the wound clinic had cancelled the appointment from 1/24/18 and she was unsure of why another appointment was not made. On 4/27/18 at 10:24 A.M., the Divisional Director of Clinical Services provided the Pressure Ulcer/Injury Prevention policy, dated 11/2017, and indicated this was the policy currently being used by the facility. The policy indicated measures to maintain and improve the patient's tissue tolerance to pressure woould be implemented in the plan of care . measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear would be implemented in the plan of care: a) reposition at least every 2-4 hours, itilize positioning devices to keep bony prominences from direct contact, ensure proper body alignment when side-lying . g) a pressure reduction mattress replacement was placed under the patient. 3.1-40(a)(2) 3.1-40(a)(3)

Based on observations, interviews and record review, the facility failed to ensure adequate interventions, including increased supervision, were developed and implement to prevent falls for 1 of 3 who fell resulting in a head injury and subsequant death. (Resident D) The facility also failed to ensure interventions were implemented for 2 of 3 residents reviewed for falls. (Resident's E and F) Findings include: 1. On 5/11/16 at 10:15 A.M., a review of the clinical record for Resident D was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. An Initial Data Collection Tool/Nursing Service form, dated 4/29/16 at 2:00 P.M., indicated resident was unable/unwilling to recognize need to wait for assistance to get out of bed and was unable to wait for assistance before transferring. A Fall Risk Evaluation, dated 4/29/16, indicated the resident scored a 22. The form indicated a score of over 10 or more indicated the resident was at risk for a fall and interventions should promptly be put into place. A Minimum Data Set (MDS) Admission Assessment, dated 5/6/16, indicated a Brief Interview Mental Status (BIMS) score of 4, which indicated the resident's cognitive status was severely impaired. An Interim Care Plan, dated 4/29/16, indicated resident was at risk for a physical injury from falls related to fall risk score of 22, unsteady ambulation, unable to understand safety strategies and recent falls. The interventions included to educated resident on call light, independent for transfers/ambulation, monitor & encourage use of proper foot wear and glasses on prior to getting out of bed. A Nursing Note, dated 4/29/16 at 7:30 P.M., indicated the resident was admitted to the secure unit. The Nursing Note indicated the resident was alert, confused, and ambulated with a walker with 1 assist. The note indicated the resident had been taking hydrocodone (opiod pain medication) for the past 2 months for pain. A Progress Note, dated 4/30/16 at 4:24 P.M., indicated the resident required assistance of one with transfers, a scheduled toileting plan was in place, and resident complained of right knee pain. The note indicated the resident was to have an evaluation by PT (physical therapy) and OT (occupational therapy). A Plan of treatment for [REDACTED]. The plan indicated the resident was admitted due to complex partial seizures with exacerbation, mental status changes and generalized weakness. The Plan of Treatment indicated the resident was able to transfer to toilet requiring contact guard assist (contact with patient due to unsteadiness) and was utilizing a rolling walker. A Plan of treatment for [REDACTED]. fall category. The Plan further indicated the resident ambulates 50 feet on level surfaces and required contact guard assist (contact with resident due to unsteadiness) with a rolling walker with 75% (percent) tactile and verbal instruction/cues for safety. A Nursing Note, dated 5/1/16 at 10:21 A.M., indicated the resident was noted to be leaning sideways on the bathroom sink and told nurse she felt dizzy. The note indicated the resident walked with a rolling walker, from room to dining room, approximately 100 feet with PT. An Activities of Daily Living (ADL's) care plan, dated 5/2/16, indicated resident was self-care deficit. Interventions included but were not limited to: explain all procedures prior to performing task, and provide the amount of assistance/supervision that was needed. A Nursing Note, dated 5/4/16 at 8:49 A.M., indicated resident was incontinent of urine most of the time, wears a pull up, and was ambulating independently with rolling walker. An Incident/Accident Data Entry Questionnaire form, dated 5/5/516 at 1:30 A.M., indicated the resident had an unwitnessed fall while attempting to ambulate to the restroom and received a laceration to the forehead. The form indicated the resident was found in a sitting position on the floor, no head injury was suspected. The the resident's pulse, temperature and respirations were recorded. The area for the resident's blood pressure was left blank. The questionnaire indicated it was unknown if resident was using an assistive device. The form indicated interventions were in place at time of the fall and resident was to be checked on, routinely throughout the night and the new intervention put into place was to request a medication change. The form noted a family member was notified at 2:00 A.M. and physician was notified at 8:00 A.M. A Nurse's Note, dated 5/5/16 at 1:30 A.M., indicated the resident fell tonight and daughter was notified. The note indicated the daughter wanted resident tapered off the ativan and a fax was sent to the physician. A Non-pressure Skin Condition Record, dated 5/5//16, indicated resident had a non-surgical cut on the left temple area which measured 1.2 x 0.1 centimeters (cm) and a left temple bruise which measured 1.2 x 0.5 cm. Both injuries were first observed on 5/5/16. A Neurological Assessment Flow Sheet was started 5/5/16 at 1:30 A.M. The form was completed every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every hour, then every 4 hours for 16 hours, then every shift until 5/7/16 (night shift). The form indicated with each observation resident had no neurological problems. A physician's orders [REDACTED].M., indicated an order for [REDACTED]. A care plan, dated 5/5/16, indicated the resident was at risk for a fall related injury as evidenced by previous fall, functional problem, medication usage, poor safety awareness, poor cognition and weakness. The interventions included by were not limited to: call light within reach, provide/observed use of adaptive devices, referral for PT/OT, educated/remind resident to request assistance prior to ambulation, appropriate footwear, report falls to physician & responsible party, obtain Urine (5/5), request decrease of ativan (5/5) and scheduled toileting (upon rising, before/after meals at bedtime and as needed) (5/9). A Nursing Note, dated 5/5/16 at 9:42 P.M., indicated resident was alert to self with confusion, does not call when she needs help going to the bathroom, the left temple had a small goose egg with cut due to fall earlier, resident using a rolling walker to ambulate. A urinalysis (U/A) report, dated 5/6/16, indicated the resident had no urine infection. A Nursing Note, dated 5/7/16 at 1:14 P.M., indicated resident continued to be unsteady on her feet, off balance with ambulation, difficulty noted with pivoting as if her feet became crossed, required one assist with transfers/ambulation, having much difficulty with simple conversation and replies with confused words. A Nursing Note, dated 5/8/16 at 8:39 P.M., indicated the neuro checks were completed, resident was confused with disoriented speech, incoherent and had mild anxiety. The Nursing Note indicated the daughter thought the resident might be having little seizures however no involuntary movement was noted by nurse after observing the resident for 15 minutes. The nursing note also indicated she contacted the DON (Director of Nursing) with the above findings and will continue to monitor closely. An Incident/Accident Data Entry Questionnaire form, dated 5/9/16 at 5:30 A.M., indicated Resident D had an unwitnessed fall and received a laceration to her head with no loss of consciousness. The form indicated the resident was found by QMA (Qualified Medication Aide) #3 lying on her back with her head slightly under her bed. The form indicated the physician was called at 5:40 A.M., however a family member wasn't contacted until 8:00 A.M. The resident's head laceration was cleansed, vital signs were taken and neurological assessments were started. The form indicated the interventions in place at the time of the accident was for the resident to have non-skid socks on and no new interventions were in place due to resident in the emergency room . The resident's vital signs were: pulse 69, respirations 18, temperature 96.2 and blood pressure was 120/82 A Nursing Note, dated 5/9/16 at 6:23 A.M., indicated resident was lying on her backside with head slightly under the bed and the resident's walker was beside her. The note indicated the resident had 2 lacerations to her left side of her hand and to see skin sheets. A Non-Pressure Skin Condition Record, dated 5/9/16, indicated the resident had two lacerations to left side of her head, one measured 1.0 x 0.1 x < (less than) 0.1 centimeters (cm) and the other measured 1.0 x 0.3 x <0.1 cm. A Nursing Note, dated 5/9/16 at 8:32 A.M., indicated at approximately 8:00 A.M., Resident D put her hand to her head and said my head hurts so bad then the resident acted very tired. The Assistant Director of Nursing (ADON) was notified and the ADON and a CNA (not identified) took the resident to her room and laid her down in her bed, while LPN #4 called physician, daughter and a ambulance. The resident became unresponsive and 911 was called again. An ER (emergency room ) Report, dated 5/9/16, indicated the resident had arrived to the ER due to a fall at the nursing home and received a minimal laceration to the left temporal area and her right pupil was poorly reactive. The report indicated the resident was in an unresponsive state with a left temporal contusion and huge contrecoup to her right subdural hematoma. (Mosby's Medical Dictionary 4th Edition, 2009, defined the contrecoup injury as follows: an injury, usually involving the brain, in which the tissue damage in on the side opposite the trauma site, as when a blow to the left side of head results in brain damage on the right side.) The Report indicated a head CT (Computerized Tomography) scan showed a massive cerebral subdural hematoma. Arrangements were made for comfort measures and hospice level care at the hospital. A radiology report, date 5/9/16, indicated the resident had an acute subdural hemorrhage overlying the right cerebral convexity with a right to midline shift. The report indicated brain swelling in the right cerebral hemisphere of the brain. A Patient Progress Note-Nursing Activities & Physical Assessment, dated 5/11/16 at 5:03 A.M., indicated time of death 4:30 A.M., the patient was a Do Not Resuscitate and the family was at the bedside. During an interview, on 5/11/16 at 1:45 P.M., the Director of Nursing (DON) indicated the interventions to prevent a fall for Resident D, after her fall on 5/5/16, were to obtain a U/A and decrease the resident's ativan, staff were to be rounding every 15 minutes and station themselves in the hallway. The DON further indicated the root cause of Resident D's fall were: taking herself to the bathroom, and ativan causing more confusion. During an interview, on 5/11/16 at 3:40 P.M., LPN (Licensed Practical Nurse) #4 indicated she was working the day shift on the dementia unit the morning of 5/9/16. She received report a little after 6:00 A.M. and was told Resident D had a fall with a laceration to her head and her vital signs were all ok. LPN #4 indicated the nurse giving her report did not say if the family had been notified of the fall. LPN #4 indicated the resident was observed to be in the Day room getting her blood drawn and complained of no pain. LPN#4 indicated she started her morning medication pass and gave the Resident D her morning medications and took the residents vitals sometime after 7:00 A.M. and Resident's vitals were ok. LPN #4 indicated the resident had no problems with taking her medications. LPN #4 indicated she assisted the resident to her table to eat breakfast sometime near 8:00 A.M. LPN #4 indicated while the resident was eating she put her hand to her head and told LPN #4 my head hurts so bad. LPN #4 called the ADON over to the unit, so she could call the physician, physician said to send to ER, 911 was called and then a family member was notified. LPN #4 indicated the resident started to lean so the ADON took the resident to her room to wait for the ambulance to arrive. While the resident was in her room the resident became unresponsive, with her pupils fixed and 911 was called again. The ambulance arrived and took the resident to the ER. During an interview, on 5/12/16 at 10:00 A.M., CNA #5 indicated she was working the morning shift of 5/9/16 and when she arrived to the unit Resident D was observed at the nursing station. CNA #5 indicated the resident was smiling, talking and had dried blood on the left side of her head. CNA #5 indicated she had taken care of the resident before 5/9 and resident was a stand by assist with toileting and transfers. She indicated she had caught the resident trying to get out of bed on her own several times. CNA #5 indicated during breakfast the resident complained of nausea and a headache. She remembered the nurse contacting the ADON when the resident complained about her head pain. During an interview, on 5/12/16 at 10:20 A.M., the ADON indicated LPN #4 contacted her on the morning of 5/9/16 regarding concerns with Resident D. The ADON indicated when she arrived on the unit the resident was sitting in the dining area and looked tired. The ADON indicated the resident laid her head on the ADON's shoulder. She then transferred the resident to a wheelchair and took the resident to her room and assisted her to bed while LPN #4 made phone calls. During an interview, on 5/13/16 at 1:30 P.M., QMA #3 indicated she worked the secure dementia unit from 2:00 A.M. thru 6:00 A.M. on 5/9/16 by herself. QMA #3 indicated she rounded the unit every 15 minutes to check on the residents and at approximately 5:15 A.M., Resident D was observed to be in bed under her covers. QMA #3 indicated the resident had a 6:00 A.M. pain medication and entered the resident's room and found the resident lying on her back, with head at foot of the bed. The QMA #3 indicated the resident's walker was located on the other side of a recliner that sat beside the resident's bed. QMA#3 indicated the resident was crying and trying to sit up on her own. QMA #3 indicated the resident had non-skid socks on and resident's call light was clipped to her bed. The QMA called the manager on duty and she assessed the resident, cleansed her wound and called the doctor. QMA #4 got a wheelchair and assisted the resident to the restroom then resident transferred herself to the toilet with stand by assist and was taken by wheelchair to the nurse's desk to be monitored. The QMA indicated the resident was talking and sitting in the wheelchair when she left the unit. On 5/13/16 at 12:05 P.M., the DON provided a policy titled, Falls Management, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions A Staffing Schedule, dated 5/8/16, and provided by the DON on 5/16/16, indicated a RN (Registered Nurse) worked the night shift till 2:00 A.M. on 5/9/16, then QMA #3 worked from 2:00 A.M. until 6:00 A.M. There were no other staff members to work the secure dementia unit on the morning of 5/9/16. During an interview, on 5/16/16 at 12:45 P.M., the DON indicated on the morning of 5/9/16 there were 13 residents on the secure dementia unit, 10 of those residents required 1 assist for transfers and toileting and one resident was a stand by assist for transfers and toileting. The DON indicated there was one staff member on the unit working the night shift. When the DON was asked who was supervising the rest of the residents while the one staff member was assisting a resident to the restroom she indicated no one. 2. The clinical record for Resident F was reviewed on 05/12/2016 at 9:07 A.M. Resident F was admitted to the facility, on 12/29/15, with diagnoses, including but not limited to: fracture of the pelvis, chronic obstructive pulmonary disease, enlarged prostate, atherosclerotic heart disease, emphysema, heart failure, hypertension, and history of fracture of the left humerus. The history and physical assessment, completed at an acute care facility prior to the resident's admission to the facility, on 12/25/15, indicated Resident F tripped over his oxygen tubing in his home and fell , fracturing his pelvis and humerous. A fall risk evaluation, completed on 12/29/15, indicated the resident had a history of [REDACTED]. The intervention put in place, on 12/29/15, to prevent falls was call light within reach. The initial admission Minimum Data Set (MDS) assessment, completed on 01/05/16, indicated the resident scored a 14 of 15 on the (Brief Interview of Mental Status) BIMS, required extensive staff assistance for transfers, was non ambulatory, and required extensive staff assistance for wheelchair locomotion and toileting needs. The resident had an indwelling urinary catheter and was frequently incontinent of his bowels. A nursing progress note, dated 03/07/16 at 12:00 A.M., indicated the resident was found on the floor in his room. The resident was confused and had been attempting to ambulate by himself. Another fall risk evaluation, completed on 03/07/16, indicated the resident was still a high risk for falls and the interventions in place were call light in reach and education provided. An Incident/Accident Data Entry Questionnaire (sic), completed on 03/07/16 at 12:00 A.M., indicated Resident F was found on the floor by a nurse. The resident had been attempting to ambulate without any assistive devices and was alert but confused. The follow up portion of the investigative form indicated the resident was unable to balance himself independently and had no barriers which might have contributed to his fall. The resident had not utilized his call light and he had a low bed in place. The resident had previously refused hip protectors as an intervention. The interventions implemented were to continue the bed in low position and call light in reach and education regarding the call light was provided to the resident. A Nursing progress note, dated 04/22/16 at 3:54 P.M., indicated the resident slid out of his wheelchair and was found on the floor in front of his wheelchair. The most recent Fall Risk Evaluation, completed on 04/22/16, indicated the resident was still a high risk for falls and the intervention implemented was dysem (a non slip thin material) to wheelchair. A care plan related to the resident's risk for falls, initiated on 01/04/16 and current through 07/06/16, indicated the resident was at risk for a fall as evidence by previous falls. The interventions included a fall risk assessment, invite and escort to activity programs, provide environmental adaptations- call light in reach and adequate glare free lighting, and area free of clutter, provide resident teaching for safety measures, provide wheelchair, refer to PT (physical therapy), OT (occupational therapy) and Mental health, remind to lock brakes on bed and chair before transferring, when rising from a lying position sit on side of bed for a few minutes before transferring/standing, educate to request assistance prior to ambulation, report falls to physician and responsible party. Non-skid strips next to bed was added as an intervention on 03/07/16 and a dysom (sic) to wheelchair was added on 04/22/16. A Nursing progress note, dated 05/02/16 at 3:39 P.M., indicated the resident was attempting to transfer himself and had not utilized the call light or requested assistance. On 05/13/2016 at 10:54 A.M., Resident F's room observed and there were no non-skid strips observed on either side of his bed or in the bathroom. On 05/13/2016 at 10:59 A.M., Resident F was observed in the front lobby seated in his wheelchair. There was a thick cushion visible underneath the resident in the wheelchair seat. The cushion was wider than the wheelchair seat and was slightly creased in the middle and extended past the end of the wheelchair seat by approximately 1 1/2 inches. There was no dycem material visible underneath the resident. Resident F was queried regarding any thin non slip type material on the chair cushion and he indicated he did not recall any such material being applied, just the cushion. On 05/13/2016 at 2:55 P.M., Resident F was transferred with the assistance of LPN #22 and QMA #23 from his wheelchair to his bed. His wheelchair cushion was noted to be in his wheelchair but there was no dycem type material anywhere in his wheelchair. Both staff confirmed there was no dycem in his wheelchair and no non-skid strips on either side of his bed. QMA #23 looked in his closets and she could not locate any dycem material. On 05/16/2016 at 9:09 A.M., there were still no nonslip strips on either side of Resident F's bed. 3. The clinical record for Resident E was reviewed on 05/13/2016 at 8:59 A.M. Resident E was admitted to the facility on [DATE], with diagnosis, including but not limited to: dementia with behavioral disturbance, depression, anxiety disorder and shortness of breath. A nursing progress note, dated 04/29/16 at 2:24 A.M., indicated a noise was heard in the resident's room and the resident was found laying on his backside with his feet extended towards the bathroom. Resident E indicated he was trying to go to the bathroom. When the resident was asked why he did not use call light, he indicated because he could not find his call light. The call light was located on the resident's bed. Resident E was reeducated on the use of call light and need for assistance. The resident had incurred skin tears to both his elbows and the top of his left hand and to his left wrist. A nursing progress note, dated 04/29/16 at 7:52 A.M., indicated the IDT (interdisciplinary team) meeting had met in regards to Resident E's fall that occurred early this (04/29/16) A.M. and an appropriate intervention was to place a clip to the resident's call light cord and have staff attach it to the resident's shirt/gown while he was in bed. A fall risk care plan, initiated on 04/29/16, indicated the resident was to be invited and escorted to activities, provided call light in reach and glare free lighting and area free of clutter, provide resident teaching for safety measures, provide walker/cane and wheelchair, remind resident to lock brake on bed, chair etc before transferring, when rising from lying position to sit on side of bed for a few minute, educated and reminded to request assistance prior to ambulation, report falls to physician and responsible party, report any side effects of medication, and clip to call light cord and keep cord attached to shirt or gown while in bed. A nursing progress note, dated 05/30/16 at 1:47 A.M., indicated the resident required standby by assistance for transfers and ambulation and he utilized a walker. A nursing progress note, dated 05/10/16 at 10:30 A.M., indicated the resident had poor safety awareness. On 05/13/2016 at 10:57 A.M., Resident E was observed sleeping in his bed on his back. His call light was lying on the floor and there was no clip noted on the cord. On 05/16/2016 at 9:38 A.M., Resident E was observed in his room in bed asleep. The resident had a low bed but his call light cord was on the floor and there was no clip on the cord. The resident's call light cord remained on the floor and the resident remained sleeping in his bed from 9:38 A.M. to 11:00 A.M. His shoes were off and he was wearing non-skid socks on both feet. At 10:37 A.M., two staff members, LPN #25 and CNA #26 had assisted Resident E's roommate but had not noticed the call light on the floor. On 05/16/2016 at 12:45 P.M., Resident E was observed being supervised by an unnamed staff as he ambulated from the dining room back to his room with his walker. He then was noted to be supervised by the staff member while he got into bed. The unnamed staff member left and Resident E was observed, at 1:02 P.M., in his room asleep with his shoes on and his call light cord was on the floor. He was observed again, at 2:07 P.M., in his bed asleep and his call light was on the floor. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure adequate interventions, including increased supervision, were developed and implement to prevent falls for 1 of 3 who fell resulting in a head injury and subsequant death. (Resident D) The facility also failed to ensure interventions were implemented for 2 of 3 residents reviewed for falls. (Resident's E and F) Findings include: 1. On 5/11/16 at 10:15 A.M., a review of the clinical record for Resident D was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. An Initial Data Collection Tool/Nursing Service form, dated 4/29/16 at 2:00 P.M., indicated resident was unable/unwilling to recognize need to wait for assistance to get out of bed and was unable to wait for assistance before transferring. A Fall Risk Evaluation, dated 4/29/16, indicated the resident scored a 22. The form indicated a score of over 10 or more indicated the resident was at risk for a fall and interventions should promptly be put into place. A Minimum Data Set (MDS) Admission Assessment, dated 5/6/16, indicated a Brief Interview Mental Status (BIMS) score of 4, which indicated the resident's cognitive status was severely impaired. An Interim Care Plan, dated 4/29/16, indicated resident was at risk for a physical injury from falls related to fall risk score of 22, unsteady ambulation, unable to understand safety strategies and recent falls. The interventions included to educated resident on call light, independent for transfers/ambulation, monitor & encourage use of proper foot wear and glasses on prior to getting out of bed. A Nursing Note, dated 4/29/16 at 7:30 P.M., indicated the resident was admitted to the secure unit. The Nursing Note indicated the resident was alert, confused, and ambulated with a walker with 1 assist. The note indicated the resident had been taking hydrocodone (opiod pain medication) for the past 2 months for pain. A Progress Note, dated 4/30/16 at 4:24 P.M., indicated the resident required assistance of one with transfers, a scheduled toileting plan was in place, and resident complained of right knee pain. The note indicated the resident was to have an evaluation by PT (physical therapy) and OT (occupational therapy). A Plan of treatment for [REDACTED]. The plan indicated the resident was admitted due to complex partial seizures with exacerbation, mental status changes and generalized weakness. The Plan of Treatment indicated the resident was able to transfer to toilet requiring contact guard assist (contact with patient due to unsteadiness) and was utilizing a rolling walker. A Plan of treatment for [REDACTED]. fall category. The Plan further indicated the resident ambulates 50 feet on level surfaces and required contact guard assist (contact with resident due to unsteadiness) with a rolling walker with 75% (percent) tactile and verbal instruction/cues for safety. A Nursing Note, dated 5/1/16 at 10:21 A.M., indicated the resident was noted to be leaning sideways on the bathroom sink and told nurse she felt dizzy. The note indicated the resident walked with a rolling walker, from room to dining room, approximately 100 feet with PT. An Activities of Daily Living (ADL's) care plan, dated 5/2/16, indicated resident was self-care deficit. Interventions included but were not limited to: explain all procedures prior to performing task, and provide the amount of assistance/supervision that was needed. A Nursing Note, dated 5/4/16 at 8:49 A.M., indicated resident was incontinent of urine most of the time, wears a pull up, and was ambulating independently with rolling walker. An Incident/Accident Data Entry Questionnaire form, dated 5/5/516 at 1:30 A.M., indicated the resident had an unwitnessed fall while attempting to ambulate to the restroom and received a laceration to the forehead. The form indicated the resident was found in a sitting position on the floor, no head injury was suspected. The the resident's pulse, temperature and respirations were recorded. The area for the resident's blood pressure was left blank. The questionnaire indicated it was unknown if resident was using an assistive device. The form indicated interventions were in place at time of the fall and resident was to be checked on, routinely throughout the night and the new intervention put into place was to request a medication change. The form noted a family member was notified at 2:00 A.M. and physician was notified at 8:00 A.M. A Nurse's Note, dated 5/5/16 at 1:30 A.M., indicated the resident fell tonight and daughter was notified. The note indicated the daughter wanted resident tapered off the ativan and a fax was sent to the physician. A Non-pressure Skin Condition Record, dated 5/5//16, indicated resident had a non-surgical cut on the left temple area which measured 1.2 x 0.1 centimeters (cm) and a left temple bruise which measured 1.2 x 0.5 cm. Both injuries were first observed on 5/5/16. A Neurological Assessment Flow Sheet was started 5/5/16 at 1:30 A.M. The form was completed every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every hour, then every 4 hours for 16 hours, then every shift until 5/7/16 (night shift). The form indicated with each observation resident had no neurological problems. A physician's orders [REDACTED].M., indicated an order for [REDACTED]. A care plan, dated 5/5/16, indicated the resident was at risk for a fall related injury as evidenced by previous fall, functional problem, medication usage, poor safety awareness, poor cognition and weakness. The interventions included by were not limited to: call light within reach, provide/observed use of adaptive devices, referral for PT/OT, educated/remind resident to request assistance prior to ambulation, appropriate footwear, report falls to physician & responsible party, obtain Urine (5/5), request decrease of ativan (5/5) and scheduled toileting (upon rising, before/after meals at bedtime and as needed) (5/9). A Nursing Note, dated 5/5/16 at 9:42 P.M., indicated resident was alert to self with confusion, does not call when she needs help going to the bathroom, the left temple had a small goose egg with cut due to fall earlier, resident using a rolling walker to ambulate. A urinalysis (U/A) report, dated 5/6/16, indicated the resident had no urine infection. A Nursing Note, dated 5/7/16 at 1:14 P.M., indicated resident continued to be unsteady on her feet, off balance with ambulation, difficulty noted with pivoting as if her feet became crossed, required one assist with transfers/ambulation, having much difficulty with simple conversation and replies with confused words. A Nursing Note, dated 5/8/16 at 8:39 P.M., indicated the neuro checks were completed, resident was confused with disoriented speech, incoherent and had mild anxiety. The Nursing Note indicated the daughter thought the resident might be having little seizures however no involuntary movement was noted by nurse after observing the resident for 15 minutes. The nursing note also indicated she contacted the DON (Director of Nursing) with the above findings and will continue to monitor closely. An Incident/Accident Data Entry Questionnaire form, dated 5/9/16 at 5:30 A.M., indicated Resident D had an unwitnessed fall and received a laceration to her head with no loss of consciousness. The form indicated the resident was found by QMA (Qualified Medication Aide) #3 lying on her back with her head slightly under her bed. The form indicated the physician was called at 5:40 A.M., however a family member wasn't contacted until 8:00 A.M. The resident's head laceration was cleansed, vital signs were taken and neurological assessments were started. The form indicated the interventions in place at the time of the accident was for the resident to have non-skid socks on and no new interventions were in place due to resident in the emergency room . The resident's vital signs were: pulse 69, respirations 18, temperature 96.2 and blood pressure was 120/82 A Nursing Note, dated 5/9/16 at 6:23 A.M., indicated resident was lying on her backside with head slightly under the bed and the resident's walker was beside her. The note indicated the resident had 2 lacerations to her left side of her hand and to see skin sheets. A Non-Pressure Skin Condition Record, dated 5/9/16, indicated the resident had two lacerations to left side of her head, one measured 1.0 x 0.1 x < (less than) 0.1 centimeters (cm) and the other measured 1.0 x 0.3 x <0.1 cm. A Nursing Note, dated 5/9/16 at 8:32 A.M., indicated at approximately 8:00 A.M., Resident D put her hand to her head and said my head hurts so bad then the resident acted very tired. The Assistant Director of Nursing (ADON) was notified and the ADON and a CNA (not identified) took the resident to her room and laid her down in her bed, while LPN #4 called physician, daughter and a ambulance. The resident became unresponsive and 911 was called again. An ER (emergency room ) Report, dated 5/9/16, indicated the resident had arrived to the ER due to a fall at the nursing home and received a minimal laceration to the left temporal area and her right pupil was poorly reactive. The report indicated the resident was in an unresponsive state with a left temporal contusion and huge contrecoup to her right subdural hematoma. (Mosby's Medical Dictionary 4th Edition, 2009, defined the contrecoup injury as follows: an injury, usually involving the brain, in which the tissue damage in on the side opposite the trauma site, as when a blow to the left side of head results in brain damage on the right side.) The Report indicated a head CT (Computerized Tomography) scan showed a massive cerebral subdural hematoma. Arrangements were made for comfort measures and hospice level care at the hospital. A radiology report, date 5/9/16, indicated the resident had an acute subdural hemorrhage overlying the right cerebral convexity with a right to midline shift. The report indicated brain swelling in the right cerebral hemisphere of the brain. A Patient Progress Note-Nursing Activities & Physical Assessment, dated 5/11/16 at 5:03 A.M., indicated time of death 4:30 A.M., the patient was a Do Not Resuscitate and the family was at the bedside. During an interview, on 5/11/16 at 1:45 P.M., the Director of Nursing (DON) indicated the interventions to prevent a fall for Resident D, after her fall on 5/5/16, were to obtain a U/A and decrease the resident's ativan, staff were to be rounding every 15 minutes and station themselves in the hallway. The DON further indicated the root cause of Resident D's fall were: taking herself to the bathroom, and ativan causing more confusion. During an interview, on 5/11/16 at 3:40 P.M., LPN (Licensed Practical Nurse) #4 indicated she was working the day shift on the dementia unit the morning of 5/9/16. She received report a little after 6:00 A.M. and was told Resident D had a fall with a laceration to her head and her vital signs were all ok. LPN #4 indicated the nurse giving her report did not say if the family had been notified of the fall. LPN #4 indicated the resident was observed to be in the Day room getting her blood drawn and complained of no pain. LPN #4 indicated she started her morning medication pass and gave the Resident D her morning medications and took the residents vitals sometime after 7:00 A.M. and Resident's vitals were ok. LPN #4 indicated the resident had no problems with taking her medications. LPN #4 indicated she assisted the resident to her table to eat breakfast sometime near 8:00 A.M. LPN #4 indicated while the resident was eating she put her hand to her head and told LPN #4 my head hurts so bad. LPN #4 called the ADON over to the unit, so she could call the physician, physician said to send to ER, 911 was called and then a family member was notified. LPN #4 indicated the resident started to lean so the ADON took the resident to her room to wait for the ambulance to arrive. While the resident was in her room the resident became unresponsive, with her pupils fixed and 911 was called again. The ambulance arrived and took the resident to the ER. During an interview, on 5/12/16 at 10:00 A.M., CNA #5 indicated she was working the morning shift of 5/9/16 and when she arrived to the unit Resident D was observed at the nursing station. CNA #5 indicated the resident was smiling, talking and had dried blood on the left side of her head. CNA #5 indicated she had taken care of the resident before 5/9 and resident was a stand by assist with toileting and transfers. She indicated she had caught the resident trying to get out of bed on her own several times. CNA #5 indicated during breakfast the resident complained of nausea and a headache. She remembered the nurse contacting the ADON when the resident complained about her head pain. During an interview, on 5/12/16 at 10:20 A.M., the ADON indicated LPN #4 contacted her on the morning of 5/9/16 regarding concerns with Resident D. The ADON indicated when she arrived on the unit the resident was sitting in the dining area and looked tired. The ADON indicated the resident laid her head on the ADON's shoulder. She then transferred the resident to a wheelchair and took the resident to her room and assisted her to bed while LPN #4 made phone calls. During an interview, on 5/13/16 at 1:30 P.M., QMA #3 indicated she worked the secure dementia unit from 2:00 A.M. thru 6:00 A.M. on 5/9/16 by herself. QMA #3 indicated she rounded the unit every 15 minutes to check on the residents and at approximately 5:15 A.M., Resident D was observed to be in bed under her covers. QMA #3 indicated the resident had a 6:00 A.M. pain medication and entered the resident's room and found the resident lying on her back, with head at foot of the bed. The QMA #3 indicated the resident's walker was located on the other side of a recliner that sat beside the resident's bed. QMA#3 indicated the resident was crying and trying to sit up on her own. QMA #3 indicated the resident had non-skid socks on and resident's call light was clipped to her bed. The QMA called the manager on duty and she assessed the resident, cleansed her wound and called the doctor. QMA #4 got a wheelchair and assisted the resident to the restroom then resident transferred herself to the toilet with stand by assist and was taken by wheelchair to the nurse's desk to be monitored. The QMA indicated the resident was talking and sitting in the wheelchair when she left the unit. On 5/13/16 at 12:05 P.M., the DON provided a policy titled, Falls Management, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions A Staffing Schedule, dated 5/8/16, and provided by the DON on 5/16/16, indicated a RN (Registered Nurse) worked the night shift till 2:00 A.M. on 5/9/16, then QMA #3 worked from 2:00 A.M. until 6:00 A.M. There were no other staff members to work the secure dementia unit on the morning of 5/9/16. During an interview, on 5/16/16 at 12:45 P.M., the DON indicated on the morning of 5/9/16 there were 13 residents on the secure dementia unit, 10 of those residents required 1 assist for transfers and toileting and one resident was a stand by assist for transfers and toileting. The DON indicated there was one staff member on the unit working the night shift. When the DON was asked who was supervising the rest of the residents while the one staff member was assisting a resident to the restroom she indicated no one. 2. The clinical record for Resident F was reviewed on 05/12/2016 at 9:07 A.M. Resident F was admitted to the facility, on 12/29/15, with diagnoses, including but not limited to: fracture of the pelvis, chronic obstructive pulmonary disease, enlarged prostate, atherosclerotic heart disease, emphysema, heart failure, hypertension, and history of fracture of the left humerus. The history and physical assessment, completed at an acute care facility prior to the resident's admission to the facility, on 12/25/15, indicated Resident F tripped over his oxygen tubing in his home and fell , fracturing his pelvis and humerous. A fall risk evaluation, completed on 12/29/15, indicated the resident had a history of [REDACTED]. The intervention put in place on 12/29/15 to prevent falls was call light within reach. The initial admission Minimum Data Set (MDS) assessment, completed on 01/05/16, indicated the resident scored a 14 of 15 on the (Brief Interview of Mental Status) BIMS, required extensive staff assistance for transfers, was non ambulatory, and required extensive staff assistance for wheelchair locomotion and toileting needs. The resident had an indwelling urinary catheter and was frequently incontinent of his bowels. A nursing progress note, dated 03/07/16 at 12:00 A.M., indicated the resident was found on the floor in his room. The resident was confused and had been attempting to ambulate by himself. Another fall risk evaluation, completed on 03/07/16, indicated the resident was still a high risk for falls and the interventions in place were call light in reach and education provided. An Incident/Accident Data Entry Questionnaire (sic), completed on 03/07/16 at 12:00 A.M., indicated Resident F was found on the floor by a nurse. The resident had been attempting to ambulate without any assistive devices and was alert but confused. The follow up portion of the investigative form indicated the resident was unable to balance himself independently and had no barriers which might have contributed to his fall. The resident had not utilized his call light and he had a low bed in place. The resident had previously refused hip protectors as an intervention. The interventions implemented were to continue the bed in low position and call light in reach and education regarding the call light was provided to the resident. A Nursing progress note, dated 04/22/16 at 3:54 P.M., indicated the resident slid out of his wheelchair and was found on the floor in front of his wheelchair. The most recent Fall Risk Evaluation, completed on 04/22/16, indicated the resident was still a high risk for falls and the intervention implemented was dysem (a non slip thin material) to wheelchair. A care plan related to the resident's risk for falls, initiated on 01/04/16 and current through 07/06/16, indicated the resident was at risk for a fall as evidence by previous falls. The interventions included a fall risk assessment, invite and escort to activity programs, provide environmental adaptations- call light in reach and adequate glare free lighting, and area free of clutter, provide resident teaching for safety measures, provide wheelchair, refer to PT (physical therapy), OT (occupational therapy) and Mental health, remind to lock brakes on bed and chair before transferring, when rising from a lying position sit on side of bed for a few minutes before transferring/standing, educate to request assistance prior to ambulation, report falls to physician and responsible party. Non-skid strips next to bed was added as an intervention on 03/07/16 and a dysom (sic) to wheelchair was added on 04/22/16. A Nursing progress note, dated 05/02/16 at 3:39 P.M., indicated the resident was attempting to transfer himself and had not utilized the call light or requested assistance. On 05/13/2016 at 10:54 A.M., Resident F's room observed and there were no non-skid strips observed on either side of his bed or in the bathroom. On 05/13/2016 at 10:59 A.M., Resident F was observed in the front lobby seated in his wheelchair. There was a thick cushion visible underneath the resident in the wheelchair seat. The cushion was wider than the wheelchair seat and was slightly creased in the middle and extended past the end of the wheelchair seat by approximately 1 1/2 inches. There was no dycem material visible underneath the resident. Resident F was queried regarding any thin non slip type material on the chair cushion and he indicated he did not recall any such material being applied, just the cushion. On 05/13/2016 at 2:55 P.M., Resident F was transferred with the assistance of LPN #22 and QMA #23 from his wheelchair to his bed. His wheelchair cushion was noted to be in his wheelchair but there was no dycem type material anywhere in his wheelchair. Both staff confirmed there was no dycem in his wheelchair and no non-skid strips on either side of his bed. QMA #23 looked in his closets and she could not locate any dycem material. On 05/16/2016 at 9:09 A.M., there were still no nonslip strips on either side of Resident F's bed. 3. The clinical record for Resident E was reviewed on 05/13/2016 at 8:59 A.M. Resident E was admitted to the facility on [DATE], with diagnosis, including but not limited to: dementia with behavioral disturbance, depression, anxiety disorder and shortness of breath. A nursing progress note, dated 04/29/16 at 2:24 A.M., indicated a noise was heard in the resident's room and the resident was found laying on his backside with his feet extended towards the bathroom. Resident E indicated he was trying to go to the bathroom. When the resident was asked why he did not use call light, he indicated because he could not find his call light. The call light was located on the resident's bed. Resident E was reeducated on the use of call light and need for assistance. The resident had incurred skin tears to both his elbows and the top of his left hand and to his left wrist. A nursing progress note, dated 04/29/16 at 7:52 A.M., indicated the IDT (interdisciplinary team) meeting had met in regards to Resident E's fall that occurred early this (04/29/16) A.M. and an appropriate intervention was to place a clip to the resident's call light cord and have staff attach it to the resident's shirt/gown while he was in bed. A fall risk care plan, initiated on 04/29/16, indicated the resident was to be invited and escorted to activities, provided call light in reach and glare free lighting and area free of clutter, provide resident teaching for safety measures, provide walker/cane and wheelchair, remind resident to lock brake on bed, chair etc before transferring, when rising from lying position to sit on side of bed for a few minute, educated and reminded to request assistance prior to ambulation, report falls to physician and responsible party, report any side effects of medication, and clip to call light cord and keep cord attached to shirt or gown while in bed. A nursing progress note, dated 05/30/16 at 1:47 A.M., indicated the resident required standby by assistance for transfers and ambulation and he utilized a walker. A nursing progress note, dated 05/10/16 at 10:30 A.M., indicated the resident had poor safety awareness. On 05/13/2016 at 10:57 A.M., Resident E was observed sleeping in his bed on his back. His call light was lying on the floor and there was no clip noted on the cord. On 05/16/2016 at 9:38 A.M., Resident E was observed in his room in bed asleep. The resident had a low bed but his call light cord was on the floor and there was no clip on the cord. The resident's call light cord remained on the floor and the resident remained sleeping in his bed from 9:38 A.M. to 11:00 A.M. His shoes were off and he was wearing non-skid socks on both feet. At 10:37 A.M., two staff members, LPN #25 and CNA #26 had assisted Resident E's roommate but had not noticed the call light on the floor. On 05/16/2016 at 12:45 P.M., Resident E was observed being supervised by an unnamed staff as he ambulated from the dining room back to his room with his walker. He then was noted to be supervised by the staff member while he got into bed. The unnamed staff member left and Resident E was observed, at 1:02 P.M., in his room asleep with his shoes on and his call light cord was on the floor. He was observed again, at 2:07 P.M., in his bed asleep and his call light was on the floor. This Federal tag relates to Complaint IN 103. 3.1-45(a)(2)

Based on record review, observation, and interview, the facility failed to ensure safe use of a mechanical lift for a resident who had stiffness and impaired range of motion. The resident was dropped from the lift to the floor. The facility failed to thoroughly investigate the cause of the fall to plan for prevention of other falls. This deficient practice affected 1 of 5 residents reviewed for falls in a sample of 20. (Resident #18) Resident #18 fell from the lift and received a laceration to the head requiring sutures. Finding includes: The clinical record for Resident #18 was reviewed on 04/12/11 at 10:25 A.M. An acute care center history and physical, dated 09/15/10, indicated the resident had been treated for [REDACTED]. The most recent Minimum Data Set (MDS) assessment for Resident #18, completed on 01/20/11, indicated she required total staff assistance for transferring needs and had impaired upper and lower extremity range of motion. Interview with LPN #8, during the initial tour of the facility, completed on 04/11/11 between 10:30 - 11:45 A.M. indicated the resident required transferring assistance from two staff and utilized a mechanical lift. Review of the Incident Follow-Up and Recommendation Form, completed on 09/15 and 09/16/10, regarding the fall for Resident #18 on 09/15/10, indicated the following: "Resident slid out of Hoyer while being transferred. Rec'd (received) laceration to head...Res transferred to ER (emergency room ) for eval rec'd 12 sutures to head. CNA's to be re-educated of proper use of Hoyer. will have maint (maintenance) check function of Hoyer lift." Interview with the Director of Nursing, on 04/13/11 at 9:30 A.M. indicated the maintenance had checked all the lifts in the facility and found no mechanical issues. When queried regarding whether the proper type of lift pad was being utilized at the time of the fall, wether the pad had been placed on the proper or same "loop", if the condition of the lift pad was checked, and how the resident and pad were noted when the nurse was called to the room, as well as statements from the two CNA staff, she indicated there were statements from the CNA's which did not indicate anymore information except that the resident had a tendency to roll to her left side and was "stiff." She indicated there had been no documentation regarding the position or condition of the lift pad because the resident's injuries had taken precedence when the nurse had entered the room. Observation of a transfer from bed to chair for Resident #18, conducted on 04/15/11 at 10:55 A.M. by CNA #10 and CNA #11, indicated a "full body" lift pad was utilized and the Hoyer mechanical lift was also utilized. The resident was noted to be thin, kept her arms contracted, and did tend to lean or list to her left side. Interviews with both CNA's indicated the "full body" lift pad was designated for Resident #18 due to her "stiffness." They indicated it was not "written" but both CNA's had been shown which lift pad to utilize when they were trained. 3.1-45(a)(2)