Every finding on record at Living Center West

Based on observation, record review, resident and staff interview, and facility policy review the facility failed to provide a call light within reach of a resident, which resulted in a fall with a bruise to the hip for 1 of 1 resident reviewed with a fall (Resident #1). The facility identified a census of 74 residents. On March 6, 2026, the facility staff self-reported the incident to the Department of Inspections, Appeals, & Licensing. The facility staff fully corrected the deficient practice on March 17, 2026, by taking the following steps: -Head to toe assessment of Resident #1 completed on 3/06/26. -Resident #1 Care Plan updated 3/6/26 to ensure call lights within reach of the non affected extremity.-Interviews conducted with residents about treatment by staff, safety, and abuse reporting.-Interviews conducted with facility staff. -All staff in-service 3/17/2026 which included call light response and resident safety. -Abuse policy review. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Diagnoses per the resident's MDS assessment included stroke, arthritis, hemiplegia or hemiparesis, and anxiety disorder. The MDS indicated Resident #1 required partial to moderate assistance with toilet transfer, sit to stand transfer, and ambulation. The MDS assessment further revealed the resident had impairment on one side to the resident's upper extremity. Review of Resident #1's Care Plan, date initiated 2/12/25, revealed the resident was at risk for falling related to weakness, impaired mobility, and transient ischemic attack (TIA). The intervention initiated on 2/12/25 revealed, Keep personal items and frequently used items within reach. The intervention initiated 3/6/26 directed staff to ensure call lights are within reach of the non affected extremity. An Incident Report for Resident #1 dated 3/5/26 at 11:15 AM prepared by Staff B, Licensed Practical Nurse (LPN) revealed resident was found sitting on the floor with her back against the toilet seat. Resident #1 stated she was trying to reach for the call light cord when she slid from the toilet seat and sat on the floor. The Resident Description section revealed, I was trying to reach for the call light cord. The Immediate Action Taken section revealed, in part, We make sure the that the call light cord should always be within reach. The incident report failed to document where the call light was located at the time of the fall. A Progress Note from 3/5/26 at 4:20 PM revealed Resident #1 was found sitting on the floor with her back against the toilet seat. Resident stated to staff she was trying to reach for the call light cord when she slid from the toilet seat and sat on the floor. On 6/4/26 at 9:45 AM an interview with Resident #1, she revealed she was on the toilet and asked for the cord for the call light. Resident #1 stated Staff A tossed it to me (resident) in a [NAME]. Resident #1 reported Staff A was irritated with [Resident #1], and [Resident #1] could not catch it. [Resident #1] called to her to wait and she did not wait. Resident #1 reported they fell trying to reach the cord, yelled for help, and she came back to the room and told [Resident #1] to get up, get up, get up. Review of Resident #1's statement included as part of the facility investigation, dated 3/9/26 at 5:30 PM revealed the following: Resident #1 explained Staff A had assisted the resident to the toilet. Resident #1 asked her for the call cord, and she (Staff A) tossed it at [Resident #1] in a [NAME] like she didn't want to be bothered. [Resident #1] didn't catch it. Before she left the room [Resident #1] yelled, wait but she didn't come back. [Resident #1] tried to reach it herself and slipped off the toilet. [Resident #1] started to yell, help, help, [Resident #1] had to yell it multiple times before she came back into the room. A written statement from the facility investigation revealed, in part, the following from Staff B, LPN (statement dated 3/6/26 at 11:36 AM): He was called to Resident #1's room by Staff A, CNA on 3/5/26 approximately 11:25am, upon arrival resident was found sitting in front of the toilet on the floor. Head to toe assessment completed with no issues found, vital signs stable, resident denied pain. Resident #1 stated she was reaching for her call light when she slipped off the toilet. Per the statement, Staff B completed another skin assessment on resident on 3/6/26 as the CNA stated the resident had a bruise on her right hip. Per the statement, the bruise measured 12 centimeters (cm) x10 cm, and the resident continued to deny pain. On 6/4/26 at 10:43 AM during an interview with Staff B, Licensed Practical Nurse (LPN), he revealed did the assessment after Resident #1's fall on 3/5/26. Staff B explained the resident had a routine and couldn't move her right hand which was closer to the call light, so had to hand her the call light and place it in her left hand. Staff B stated Resident #1 reported Staff A just kind of tossed Resident #1 the call light. He reported Resident #1 could not move her right hand so staff had to place the call light in her left hand. A Progress Note dated 3/6/26 at 12:29 PM revealed Resident #1 had a 12 cm by 9 cm bruise noted to the right hip. Power of attorney and medical provider were notified. A Non-Pressure Skin Condition Report dated 3/6/26 revealed right hip bruise area measured 12 cm by 9 cm. The assessment of the area on 3/10/26 revealed tenderness with palpation, and dissolves quickly per self. A Progress Note dated 3/7/26 at 12:44 PM noted bruise to right hip reported previously. Resident #1 denied pain of right hip with passive or active range of motion, and still reported mild discomfort to touch the bruise. A Progress Note dated 3/8/26 at 1:06 PM noted Resident reported mild discomfort to touch the bruise to right hip. During an observation on 6/8/26 at 11:09 AM Staff C, CNA transferred Resident #1 from wheelchair to toilet without difficulty with gait belt and a stand pivot transfer. Once Staff C had Resident #1 on the toilet, she placed the call cord in her left hand and allowed privacy for Resident #1. On 6/8/26 at 12:04 PM Staff C revealed Resident #1 normally transferred with a cane outside of her room, and inside of her room she feels more comfortable with a gait belt and doing a pivot transfer. Per Staff C, normally the resident did transfer pretty well, explained the resident was very routine based, and she will explain her routine to you. Staff C explained if staff move too quick she can become anxious. Staff C further explained if take time with Resident #1 ,she will transfer pretty easily. Staff C explained they would put the call light to her left hand and she would ask for you to put it in her hand. Staff C further explained Resident #1 was pretty alert and oriented. On 6/8/26 at 12:15 PM Staff D, CNA explained when she put Resident #1 on the toilet, would hand her the call light. If you forgot it, she would repeat herself. Staff D explained it was very well known she wants her call light. She would repeat it until you did it for her. Staff D further explained would put it in her left hand because the right hand was restricted, she can't do anything with it. Staff D explained Resident #1 was alert and oriented; she knew what was going on and was able to let her needs be known.On 6/8/26 at 2:01 PM, Staff E, LPN, Assistant Director of Nursing (ADON) confirmed there was a bruise on Resident #1's left hip the next day after the fall on 3/5/26. She explained Resident #1 fell to the left and the bruise was related to the fall. After the fall the intervention we put in place was staff education. In this instance it was to make sure the call light was in reach of the non affected side. On 6/8/26 2:20 PM, the Director of Nursing (DON) stated they didn't know much about Resident #1's fall on 3/5/26 related to it was before they became DON. She was transferred on the toilet by Staff A, she made it onto the toilet but was reaching for call light when she lost her balance and fell off the toilet and landed on her hip. The DON stated staff should place the call light in the resident's hand. The DON confirmed the bruise on Resident #1 left hip was related to the fall on 3/5/26. On 6/8/26 at 2:45 PM the Administrator explained for the fall with Resident #1, the resident reported Staff A threw the call light and shoved it at Resident #1. The resident tried to get it into her left hand when she fell. She revealed the facility terminated Staff A related to her being disrespectful to residents. The facility provided a policy titled Fall Reduction and Response revised 2/17/25. The policy directed interventions to reduce the risk of falls will be implemented based on assessed risk. The procedure addressed to identify any factors that may predispose the resident for falls and/or activities that have helped prevent falls in the home environment. The policy directed staff to put call light within reach.

Based on clinical record review, staff interviews, and policy review the facility failed to provide written bed hold notices at the time of hospital transfer for 1 of 1 residents reviewed for hospitalization (Resident #68). The facility reported a census of 67 residents.Findings include:Resident #68's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 6/19/25. The MDS included diagnoses of heart failure, renal insufficiency (poor working kidneys), respiratory failure (lungs unable to work efficiently), and pneumonia (lung infection).The Clinical Census reviewed 8/27/25 listed a status of stop billing on 7/12/25.The Clinical - MDS list reviewed 8/28/25 listed a Discharge Return Anticipated (left the facility overnight but planned to return)/End of PPS Part A stay (end of Medicare Stay) MDS assessment dated [DATE].The Communication with Physician Note dated 7/12/25 at 9:49 AM indicated at 9:00 AM the facility notified Resident #68's provider of his change in condition of diminished lung sounds (difficult to hear air moving in the lungs) with difficulty breathing, confusion, weakness, pale, cool clammy skin, and slurred speech. The provider directed the facility to send Resident #68 to the hospital.On 8/27/25 at 10:49 AM when asked for Resident #68's bed hold and transfer documentation, Staff C, Nurse Consultant, responded they didn't have a completed bed hold form for his transfer to the hospital on 7/12/25. She stated his clinical health record included a note that the facility discussed a bed hold information with him or his family.On 8/28/25 at 9:11 AM the Director of Nursing (DON) indicated the facility didn't generate a bed hold form in the electronic health record. The DON described the Bed Hold form as a separate piece of paper the nurses needed to complete.The facility's admission Agreement, revised December 2024 documented when a resident is temporarily absent from the facility for medical treatment, the facility shall provide written information to the resident specifying (1) the duration of the bed hold policy under applicable governmental regulations, if any, during which the Resident shall be permitted to return and resume residence in the facility and (2) the facility's policies regarding bed hold periods. The facility shall then ask the resident or the resident's representative if he or she wishes the facility to hold open the bed. The facility shall document in the resident's records the fact that such information was given and the response of the resident or the resident's representative.

Based on observations, staff interviews, and facility policy review the facility failed to utilize Enhanced [NAME] Precaution (EBP) for high contact resident care for one of four residents reviewed (Resident #2). The facility reported a census of 67 residents. Findings includeResident #2's Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental States (BIMS) score of 5, indicating severe cognitive impairment. The MDS listed Resident #2 had an indwelling urinary catheter. The MDS identified Resident #2 had an unhealed pressure ulcer. Resident #2's Medical Diagnosis list reviewed 8/28/25 listed diagnoses dated 8/8/25 of retention of urine and a pressure ulcer of the right buttock.The Care Plan Focus dated 8/18/25 indicated Resident #2 dated needed EBP related to a pressure ulcer and catheter. The Goal listed precautions would reduce the spread of infectious agent and minimize the transmission of infection. The Interventions directed the following dated 8/18/25:a. Wear a gown and gloves for high contact activities.b. Have PPE available for staff near the entrance to the resident's room.c. Maintain signage on/outside resident's door regarding precautions needed, required PPE and high-contact resident care activities. Resident #2's August 2025's Treatment Administration Record (TAR) included an order dated 8/20/25 to apply wound paste two times a day and as needed to the left buttock.On 8/28/25 at 7:53 AM Staff B, Certified Nurse Aide (CNA), pushed the full body lift into Resident #2's room and stated she needed to check her care card for the transfer. Staff B reported she needed to get a sling to transfer Resident #2 and left the room. Observed Resident#2's urinary catheter bag hang on the left side of the bed.On 8/28/25 at 7:58 AM in Resident #2's room Staff B and Staff A, CNA, placed the full body sling under Resident #2 as she laid in her bed. Staff A picked up the catheter bag from the left side of the bed with her ungloved hands and placed it by the Resident #2's feet in the bed. The 2 CNAs hooked the sling under Resident #2 to the full body lift and moved her to the wheel chair (w/c). Staff A dropped the catheter bag on the floor then hooked it under the w/c. Staff A and Staff B failed to wear PPE during the transfer and moving of Resident #2's urinary catheter bag.On 8/28/25 at 9:35 AM Resident #2's husband sat in her room and reported the CNA's just helped her to the bed from the w/c. He reported they wore gloves during the transfer but failed to wear a gown. The blue PPE bag hung on the back of the door containing gloves and masks, but failed to have gowns. On 8/28/25 at 9:39AM, Staff A reported the facility had PPE on the back of the room doors. When the resident had a sign on the door that told them to use PPE and what PPE they needed. She didn't know why they failed to use PPE during Resident #2's transfer.On 8/28/25 at 11:50 AM, the Infection Preventionist (IP) reported she expected the CNAs to use the EBP with all hands on high contact cares including transfers. She confirmed she added the EBP sign to Resident#2's room on 8/27/25 after breakfast. She confirmed she expected the staff to wear gloves when handling the catheter bag.On 8/28/25 at 12:15 PM, the Director of Nursing (DON) confirmed she expected the staff to wear the EPB with transfers and cares.Resident #2's room door had a sign hanging that directed the following:a. Gloves and gown shall be donned (applied) prior to high-contact care activity.b. High-contact care activities include: i. Transferring in resident room and common shower room ii. Device care or use: central line, urinary catheter, feeding tube.The Transmission Based Precautions policy dated 6/5/24, defined Enhanced Barrier Precautions as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP is used in conjunction with standard precautions and expands the use of PPE to donning gowns and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms (MDRO)s to staff hands and clothing. EBP are indicated for resident with any of the following:Infection or colonization with a Centers for Disease Control (CDC)-targeted MDRO when contact precautions do not otherwise apply; or chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.a. Chronic wounds include, but are not limited to, pressure ulcers.b. Indwelling medical device include, but are not limited to, urinary catheters.

Based on interviews, clinical record review, facility investigation, and facility policy review, the facility failed to protect resident's right to privacy for 1 of 3 residents reviewed for resident rights when staff took video of a resident and posted it to social media (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The Care Plan, initiated 7/09/24, revealed Resident #1 had impaired cognition related to moderate intellectual disability, Schizophrenia, and Major Depressive Disorder. The facility submitted a self-reported incident on 11/12/24 at 10:58 to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of the facility internal investigation revealed a statement of incident, signed and dated on 11/12/24 by Staff A. Staff A wrote that on 11/11/24, they were joking with resident while eating an ice cream cone and had asked if it was good and how he was eating it. Staff A's statement informed the video was taken at approximately 4:30 PM and the resident was joking saying no as he smiled and showed his teeth. Staff A's statement revealed the video was posted to their private Snapchat story. Review of an 8 second video submitted by the facility showed Resident #1 holding an ice cream cone, he appeared to be sitting in a wheelchair in the hallway and was without dentures in place. A female voice said, let me see your teeth, Resident #1 responded no, and then smiled without teeth as a female voice laughed. Review of Staff A personnel file revealed a document titled Confidentiality Agreement, signed and dated by Staff A on 8/16/23 which agreed not to take any photographs or recordings of residents in any nature and not post any information resident's personal or health related information on any form of social media. Staff A personnel file additionally revealed a document titled, Dependent Adult Abuse Policy Review, which attested understanding of obligation to report to supervisor any potential abuse as defined in the Abuse Prevention, Identification, and Reporting Policy, signed by Staff A and dated 8/16/23. Disciplinary Report Form, dated 11/14/24, revealed termination of Staff A's employment due to video taken of resident and posted to Snapchat in violation of the facility's abuse policy for personal degradation signed by the Director of Nursing and Facility Administrator. On 1/08/25 at 3:50 PM, Staff B, former Director of Nursing (DON), stated that on 11/11/24 at approximately 8:00 PM she received a text message, with screen-shot of the video, from Staff C, former Assistant Director of Nursing (ADON) which informed her that Staff A had posted video of Resident #1 to their Snapchat story. Staff B stated that she showed this to the Facility Administrator the following day and that the facility decided to suspend Staff A while conducting an internal investigation. On 1/09/24 at 09:40 AM, Staff C, former ADON, stated she had witnessed the video of Resident #1 posted by Staff A on Staff A's Snapchat story and notified Staff B through a text message. Staff C informed that Staff A did not send video directly to Staff C, but posted it to a Snapchat story in which anyone on Staff A's friends list could have seen the video. On 1/09/25 at 10:45 AM, Facility Administrator stated she found out about video of Resident #1 posted by Staff A on 11/12/24 around 10:00 AM, when Staff B, notified her of the incident. Facility Administrator revealed she then reported incident to DIAL and began an internal investigation of the incident which included staff and resident interviews for potential abuse, disciplinary action of Staff A, and all staff education of the facility's abuse/personal degradation policy. The facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated July 2024, revealed the prohibition of staff from taking part in acts that result in personal degradation, including the taking or using any type of equipment to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. The policy defined personal degradation as a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm, the personal dignity of a reasonable person and includes the taking, transmission, or display of an electronic image of a dependent adult by a caretaker, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity or a reasonable person.

Based on interviews, facility investigation review, and facility policy review, the facility failed to report to the state agency within 2 hours of knowledge of an abuse allegation for 1 of 3 residents reviewed for resident's rights (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The facility submitted a self-reported incident on 11/12/24 at 10:58 AM to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of facility internal investigation revealed a statement of incident, signed and dated on 11/12/24 by Staff A. Staff A wrote that on 11/11/24, they were joking with a resident while eating an ice cream cone and had asked if it was good and how he was eating it. Staff A's statement informed the video was taken at approximately 4:30 PM and the resident was joking saying no as he smiled and showed his teeth. Staff A's statement revealed the video was posted to their private Snapchat story. Review of an 8 second video submitted by the facility showed Resident #1 holding an ice cream cone, he appeared to be sitting in a wheelchair in the hallway and was without dentures in place. A female voice said, let me see your teeth, Resident #1 responded no, and then smiled without teeth as a female voice laughed. On 1/08/25 at 3:50 PM, Staff B, former Director of Nursing (DON), stated that on 11/11/24 at approximately 8:00 PM she received a text message, with screen-shot of the video, from Staff C, former Assistant Director of Nursing (ADON) which informed her that Staff A had posted the video of Resident #1 to their Snapchat story. Staff B stated that she showed this to the Facility Administrator the following day and that the facility decided to suspend Staff A while conducting an internal investigation. On 1/09/24 at 09:40 AM, Staff C, former ADON, stated she had witnessed the video of Resident #1 posted by Staff A on Staff A's Snapchat story and notified Staff B through a text message. Staff C informed that Staff A did not send video directly to Staff C, but posted it to a Snapchat story in which anyone on Staff A's friends list could have seen the video. On 1/09/25 at 10:45 AM, Facility Administrator stated she found out about the video of Resident #1 posted by Staff A on 11/12/24 around 10:00 AM, when Staff B, notified her of the incident. Facility Administrator revealed she then reported incident to the state agency and began internal investigation of incident, which included staff and resident interviews for potential abuse, disciplinary action of Staff A, and all staff education of the facility ' s abuse/personal degradation policy. The facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated July 2024, revealed the prohibition of staff from taking part in acts that result in personal degradation, including the taking or using any type of equipment to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. The policy instructed that all allegations of resident abuse shall be reported to the Department of Inspections, Appeals, and Licensing (D.I.A.L), not later than 2 hours after the allegation is made.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 66 residents. Findings include: The CMS 2567, dated 1/18/24 listed, in part, the following concerns: F689, F698 The current survey, conducted 9/16/24-9/19/24 also identified the above concerns. In an interview on 9/19/24 at 12:27 PM the Administrator explained she did not know if the facility put plans in place to address the deficiencies from the previous survey. There was nothing handed off when the previous administrator left. A review of the facility QAPI Program Policies and Procedures, undated revealed the following: The QAA Committee functions under the facility's governing body and is responsible for developing and implementing appropriate plans of action to correct deficiencies identified, regularly review, and analyze data under QAPI and drug regimen review, and act on available data to make improvements. To ensure the planned changes/interventions are implemented and effective in achieving and sustaining improvements, our organization chooses indicators/measures that tie directly to the new action and conducts ongoing periodic measurement and review to ensure that the new action has been adopted and is performed consistently.

Based on record review, resident and staff interviews, and policy review the facility failed to address the resident's goals for discharge for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 8/08/24 for Resident #52 indicated a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The MDS further indicated diagnoses including: alcohol cirrhosis of the liver with ascites (scar and fluid buildup), non-Alzheimer's dementia, and Diabetes Mellitus. The Care Plan for Resident #52 updated 7/11/22 noted the resident needed 24-hour care related to cognitive loss. It instructed staff to arrange for care conferences and review discharge plans quarterly and as needed. It further encouraged the resident/family/POA to share concerns. A review of the clinical record and Electronic Health Record revealed they lacked documentation pertaining to Durable Power of Attorney or mental capacity documents to indicate the resident was unable to make his own medical decisions. The Discharge Planning Review- v2 dated 6/28/24 documented Resident #52's family goal was to have the resident stay in the facility long term. It further documented the resident had alcohol-induced dementia diagnosed which impairs judgment and safety awareness. It indicated the need for supervision for Activities of Daily Living along with medication management. It reported the resident was unable to meet basic and critical care needs in a lower level of care setting. The Nursing Communication note dated 7/22/24 documented the resident verbalized wanting to get out of here saying he's too young to be here, he wants to work, [NAME] the lawn, have a beer, and is too self-sufficient to be here. The Psychosocial Note dated 8/12/24 reported the resident went to the Social Services office and wanted to know about discharge. The social worker suggested the resident speak to his family as staff was not in the position to make that decision. The note dated 9/06/24 documented a case consultation with the Managed Care Organization caseworker in which discharge plans were reviewed and no changes were made. In an interview on 9/16/24 at 1:29 PM Resident #52 noted he wanted to go home and had not seen the social worker to discuss this. In an interview on 9/17/24 at 9:42 AM the Social Worker explained he encouraged the resident to speak to his family as they would need to have a big part in his leaving and they said he can't return home. He acknowledged the resident does not have a guardian or designated decision maker. Thus far he had only encouraged the resident to talk to family about this; he did not start any other discharge planning. He confirmed the resident was not evaluated for his mental capacity to make decisions. In an interview on 9/18/24 at 2:57 PM the Administrator explained Resident #52 had a BIMS of 12 and his family was involved with his Plan of Care but was now non-responsive. She noted the facility collaborated as a team to determine if a discharge plan was appropriate or not, and relied on the medical provider's input as well. If they think someone will eventually not be capable of making decisions they have the resident designate who they want to be DPOA. If they come in already compromised they work with family to try and get a guardian appointed. Non-relatives who are willing to take guardianship usually have a full caseload. She acknowledged she was not sure if guardianship was attempted for the resident, and that the Social Worker would know for sure. The facility policy titled Transfer/Discharge Criteria, revised 2/01/20 lacked any direction regarding discharge planning according to resident goals or determination of medial decision-making capacity as it relates to discharge planning.

Based on observation, clinical record review, policy review, and staff interview the facility failed to maintain accurate advance directive records based on resident preference for 1 of 8 residents reviewed (Resident #4). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated [DATE] documented the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. It further revealed diagnoses of coronary artery disease, chronic respiratory failure with hypoxia (not enough oxygen in the blood), and asthma. On [DATE] at 9:50 AM a document titled Policy for Resuscitative Services/Cardiopulmonary Resuscitation (CPR) dated [DATE] was located in front of the resident's chart. It documented that in the event respirations or pulse would cease for Resident #4, she requested CPR be performed. During the same chart review the resident's Iowa Physician's Orders for Scope of Treatment (IPOST), signed [DATE] and located in the resident's chart behind the Resuscitative Services document, indicated if the resident did not have a pulse and was not breathing, staff should not attempt CPR. An entry in the electronic health record (EHR) dated [DATE] at 17:43 titled Health Status Note revealed the care provider called Resident #4's daughter to update her about changing the IPOST to a code status of DNR, comfort measures only, with no feeding tube and she was in agreement with the change. On [DATE] at 2:00 PM when asked about code status Staff A, Licensed Practical Nurse (LPN) stated he would look for it in the front of the resident's chart. He reported there was not a code status book or other location for advance directive information. Observed Staff A look in the front of Resident #4's chart, where he pointed at the request for CPR to be performed. When showed the discrepancy between that document and the IPOST behind it, Staff A indicated he would have looked at the first form and was not aware they were different. At 12:11 PM on [DATE] a follow up with Staff A determined the facility was working to ensure the correct document was in the resident's file. A policy, titled Advanced Directives Policy and dated [DATE], documented the intent of the facility to implement the terms of resident Advanced Directives in accordance with the appropriate direction of the resident, Power of Attorney, or resident's physician. The procedure included information that revoked advance directives should be removed from the resident's medical record and placed in an administrative file to avoid any misunderstanding.

Based on record review, staff and resident interviews, and policy review the facility failed to implement its policy to ensure the safety of both smoking and non-smoking residents (Resident #65). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 6/26/24 for Resident #65 indicated a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment. The MDS further indicated diagnoses including: Wernicke's Encephalopathy (difficulty waking, abnormal eye movements, confusion), bipolar disorder, and tremor. The Smoking Safety Screen dated 8/27/24 documented Resident #65 was able to smoke without supervision off campus. It indicated the need for the facility to store his lighter and cigarettes for safety. In an interview on 9/16/24 at 10:40 AM the resident reported he buys and keeps his own cigarettes and lighter in his room. He confirmed he smokes by himself whenever he wants. In an interview on 9/17/24 at 11:08 AM Staff A, Licensed Practical Nurse (LPN) explained most times residents keep their smoking supplies with them, not at the nurse's station. He confirmed they do not keep Resident #65's smoking supplies. In an interview on 9/17/24 at 11:18 AM Staff B, LPN explained nurses don't really control resident smoking supplies. They are not kept on the medication carts or in the medication rooms. Residents keep the supplies in their rooms. In an interview on 9/17/24 at 11:10 AM the MDS coordinator explained the smoking safety screening is done quarterly. Nurses are to keep the lighters and cigarettes in their cart. There shouldn't be any residents keeping their own supplies. It be should either at the nurse's station or the locked medication room. In an interview on 9/18/24 at 2:53 PM the Administrator explained the smoking residents were told they needed to keep their materials with the nurse in the lock box. Safety risks for other confused residents were explained and education was provided to families as well. Residents have been non-compliant so they discussed getting lock boxes for resident rooms. They have not gotten them because the residents again agreed to keep their supplies with the nurses. It is technically a non-smoking facility but if they are alert and oriented, and have the assessment to be safe to do so, they are allowed to smoke off campus. The facility policy titled Smoking, revised 8/30/23 instructed residents choosing to leave the premises to smoke to store smoking materials in an area not easily accessible to others.

Based on interviews, clinical record review, and facility policy review the facility failed to complete pre and post dialysis assessments that included site assessment for 1 of 1 dialysis residents reviewed (Resident #16). The facility reported a census of 66 residents. Findings include: The Medication Administration Record (MAR) for Resident #16 dated 7/2024, listed a diagnosis of chronic kidney disease, stage 4 (SEVERE) end stage renal disease. The MAR directed vital signs (VS) before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after return from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 8/2024, directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after she returned from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 9/2024, the MAR directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after she returned from dialysis. The Care Plan dated 1/9/24, addressed Resident#16 needed hemodialysis related to end stage renal disease. The Care Plan directed assess access site (right upper extremity) as ordered. The Psychosocial Note dated 9/12/2024 at 2 PM, revealed a Brief Interview for Mental Status score of 11, mild cognitive impairments. The Nurses Progress Note dated 9/6/24, at 6:04 PM, 9/4/24 at 6:04 PM, 8/30/24 at 2:54 PM, 7/26/24 at 10:26 PM, 7/24/24 at 12:05 PM, and 7/17/24 at 12:39 PM, lacked an assessment of the dialysis site. The facility lacked documentation of the Hemodialysis Communication form's dated 7/10/24, 8/2/24, 8/12/24, 8/23/24, 8/26/24, 8/28/24, 9/2/24, 9/9/24, 9/11/24, 9/13/24, and 9/16/24. The Order Review dated 9/19/24, identified the location of dialysis every Monday, Wednesdays, Fridays with a Pick up time at 05:45 AM. The orders lacked direction to assess the site post dialysis. 09/18/24 01:44 PM Staff C, Registered Nurse (RN) revealed upon Resident#16's return from dialysis she checked her vitals and documents on the Dialysis Communication form and looked at the sheet they send with her to see if they changed anything. On 09/18/24 at 2:03 PM the Restorative Licensed Practical Nurse (LPN) reported when a resident comes back and before they go to dialysis the nurses check vitals and the bruit and thrill and doc in the MAR. On 9/18/24 at 2:27 PM the Assistant Director of Nursing (ADON) reported the nurses need to check the vitals when a resident comes back from dialysis and put them on the sheet or could be on the MAR. On 9/19/24 at 8:10 AM the Director of Nursing (DON) reported the nurses are expected to check residents vitals before and after dialysis and check the bruit and thrill before dialysis. She said the don't listen after dialysis due to the bandage. The DON reported they look at the dressing when they come back but the don't document that anywhere. 09/19/24 10:15 AM the ADON reported that staff are expected to document vitals pre and post dialysis in the MAR and on the sheet and some note in the Progress Note. The facility Dialysis Binder held a document titled Binder Expectations undated that directed: All Hemodialysis forms will remain inside the binder. All Hemodialysis forms will be completed in full (no blanks). Management team will audit binder for completion. Only management team will remove Hemodialysis forms to file in Pt chart. Process: The nurse: 1. Pre-treatment (Tx) VS assessment (Complete the entire facility section except post vitals, Print your name and date/time of completion) 2. Include appointment packet with facesheet and medication list. 3. Post Tx VS/assessment when resident returns 4. Enter VS assessment in MAR and chart in Progress notes. The facility policy titled Dialysis Care dated 2/2/17, directed nursing shall provide direct visual monitoring of the access site before and after dialysis. Nursing shall provide ongoing monitoring and care of the resident's vascular access site.

Based on observation, clinical record review, policy review, staff, and resident interviews, the facility failed to report an allegation of sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). On 5/7/24 a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until 6/10/24. The facility suspended Staff A on 6/10/24 and terminated her on 6/17/24. The deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/25/24 at 9:30 AM The IJ began on 2/29/24. The facility staff removed the immediacy on 6/10/24 through the following actions: a. Previous Administrator employment at Living Center [NAME] ended 3/18/24. b. The facility suspended Staff A on 6/10/24. c. The facility terminated Staff A's employment on 6/17/24. b. The facility carried out abuse prevention education for all staff on 6/10/24. d. The facility sent the nurse home immediately on 6/10/24. e. The facility notified the agency the nurse couldn't return to the facility on [DATE]. f. The facility retrained all of the staff on the Abuse Policy and Procedures (including reporting, prevention, etc.)specifically highlighting sexual exploitation completed by Administrator and Clinical Leadership on 6/10/24. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #10 required supervision or touching assistance with showering/bathing. The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, stated all residents had the right to be free from abuse and defined abuse to include sexual exploitation. The policy stated sexual exploitation was consensual or nonconsensual sexual conduct with a dependent adult by a caretaker and stated it included but not limited to kissing. The policy stated the facility would report all allegations of abuse immediately to the State Agency not later than 2 hours after receiving the report of the allegation. The Care Plan Focus dated 8/4/23 reflected Resident #10 required 24 hour care related to the inability to care for himself in the community. The Care Plan Focus dated 8/21/23 indicated Resident #10 had impaired cognitive function, dementia, or impaired thought processes related to his diagnoses of dementia, Wernicke's encephalopathy (a disease of the brain which caused symptoms which included confusion), and psychotropic drug use. The Interventions directed the staff to keep Resident #10's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Care Plan Focus initiated 9/29/23 and revised 6/12/24 identified Resident #10 had signs and symptoms of mood distress as evidenced by verbalizing feeling down, depressed, or hopeless related to diagnoses for depression, anxiety, and dementia. In email correspondence, sent to Staff D, former Administrator, on 2/29/24 at 2:47 PM, Resident #10's Guardian (RR #10) stated Resident #10 declared his love for Staff A. RR #10 explained Resident #10 told him, they tried to figure out how to go out on dates together. Resident #10 told RR #10 they kissed each other and Staff A locked the activity room door so they could have privacy. Resident #10 said Staff A talked about her husband and reported problems in their relationship. Resident #10 stated he intended to protect Staff A and asked RR #10 for help facilitating the relationship so they could spend more time alone. Resident #10 stated they had to hide their relationship because of Staff A's employment. Resident #10 declared his love for Staff A. He never had this in his life before and he wanted to nurture it. He explained he would like to get married. In email correspondence, sent to RR #10 on 3/1/24 at 10:37 AM, Staff D responded they would address it immediately. The facility lacked documentation into the concerns reported in the 2/29/24 email from RR #10 indicating they reported the concerns to the State Agency. A statement dated 6/10/24, written by Staff B, Certified Medication Aide, (CMA), indicated on 5/7/24, when she looked for Resident #10 to give his medication, she noticed the activity room door slightly cracked. As Staff B looked in, she saw Resident #10 and Staff A kissing each other on the mouth. Staff B gave Resident #10 his medication and quickly left the room. Staff A found Staff B and asked her not to say anything, adding it would not happen again. Staff B reported the situation to Staff C, Registered Nurse (RN), after Staff A left the building. A statement dated 6/10/24, written by Staff C stated at the end of April or Early May (2024) Staff B told her she saw Resident #10 and Staff A making out. Staff C said she directed Staff B to report it to the Director of Nursing (DON). On or around 5/31/24, Staff C observed Resident #10 talking on the phone to Staff A around 7:00 PM. A statement dated 6/10/24, written by the DON, stated she notified RR #10 of the alleged incident. RR #10 explained while hospitalized in December 2023, the hospital staff saw text messages between Resident #10 and Staff A where he declared his love for her. RR #10 added Resident #10 told her about his relationship with Staff A. They would close the activity room door, kiss, and Staff A would tell him about her marital problems. RR #10 stated she emailed Staff D regarding the concerns on 3/1/24. In a written interview on 6/10/24, Resident #10 denied kissing Staff A. A statement dated 6/10/24, written by the DON, stated Resident #10 called her and said he lied about what they talked about earlier because he didn't want to get Staff A or himself in trouble. Resident #10 explained Staff A called him that evening and told him to be honest about things. A statement dated 6/10/24, written by Staff A, stated she had a relationship with Resident #10 for over 6 months now and it still continued. The note stated when Staff A left to go home, she gave Resident #10 a hug and just a smack on his cheek. The note stated no other staff or residents knew about the relationship. They started to become close around the end of November when he spent time with her in the activity room. The Health Status Note dated 6/10/24 at 7:05 PM indicated the facility had a report of someone witnessing Resident #10 and a staff member kissing in the activity room. Resident #10 denied any sexual contact or intimate relationship and stated they were just friends. Upon interview, the staff member admitted to the allegations and walked out of the facility. The Psychosocial Note dated 6/14/24 at 3:14 PM identified He was open to discussing his relationship with staff member Staff A and named them by name. He voiced frustration over the many questions over the matter and feeling that no one believed him that this incident is making a mountain out of a mole hill. He said he spent a lot of time with Staff A helping in the activity office. He said they became friends and that he liked them, even felt love for them but stated nothing sexually happened. He said he is okay with the questions, but worried about the impact of the situation on Staff A. Resident #10 said he is open to further visits to help with processing. Post-Traumatic Stress Disorder (PTSD) form completed with positive results for PTSD but related to a situation in his past. Staff A's Personnel Record listed a termination date of 6/17/24. The Psychosocial Note dated 6/20/24 at 3:18 PM described Resident #10 as tearful about the facility firing Staff A. He stated if he didn't come to the facility, she would still have her job. He stated he didn't go to the activity room to color because of the sadness it brought him, so he colored in the lounge. He felt coloring helped him cope with the grief and guilt over the situation. He reported still having contact with Staff A via phone and text. He stated Staff A's spouse didn't care for her so he thought that led to his relationship with her. He stated he feared the facility would kick him out of the facility due to the situation. The Psychosocial Note dated 6/25/24 at 11:44 AM reflected Resident #10 had a meeting with staff for support, and reported he had a difficult morning. He still felt some blame but also anger over the situation. He said he had nightmares about the issue. He reported crying a lot, and trying to forget Staff A but he didn't really want. He has removed Staff A name and number from his phone. Resident #10 also shared that he is angry at Staff A spouse because he didn't care for Staff A and Staff A didn't love the spouse. Resident #10 said he didn't think the meeting helped him, but thought it gave him an opportunity to talk out some of his thoughts. On 7/22/24 at 2:35 PM watched Resident #10 propel himself down the hall in his wheelchair. On 7/23/24 at 2:48 PM, Resident #10 stated Staff A became pregnant and couldn't work at the facility anymore. He said they had a close relationship, but said they had no kissing involved. He stated they would text and call each other on the phone. He added they each had problems, so that was what friends did. He said they hugged as friends, kissed as friends, and had a light kiss on the cheek. He didn't think of that as an affair. He stated she closed the door to keep other people out, so they could work on projects. On 7/23/24 at 3:35 PM the Administrator stated Resident #10 struggled with the situation between him and Staff A. She described him as all over the map and his mood could go from a low to a high. She stated he had a time with her out of the picture. She indicated she had a hard time watching him as started to accept it and struggle. She described him as a lot quieter. She stated Staff B reported to Staff C that she saw Resident #10 and Staff A kissing on the lips in the activity room. Staff B stated Staff C told her not to worry about it. The Administrator stated she found out when Staff C told Staff F, CNA, about it a couple of weeks later. The Administrator stated when she met with Staff A, she told her she had a relationship with Resident #10 for 6 months, they loved each other, and had a kiss. She stated they had Staff A leave the building, then they talked to residents and staff. She stated initially Resident #10 denied it but then later that day he admitted to it. The Administrator stated RR #10 stated she reported it before and sent an email to Staff D. The Administrator said she couldn't find a follow up to the email. On 7/24/24 at 11:59 AM via phone, Staff B stated she tried to find Resident #10 to give him his medications and saw the activity room door cracked. When she looked in the room she saw Resident #10 in his wheelchair with Staff A sitting on his knee in the middle of a long kiss on the mouth. She said when Staff A looked up, she went in and gave Resident #10 his medications. She quickly left because she (Staff B) felt embarrassed. Staff B stated a few minutes later when Staff A found her, she asked her not to tell anyone, and added they wouldn't do that anymore. Staff B stated she waited for Staff A to leave the building, then told Staff C. Staff C told her not to tell anyone. She explained she didn't hear anything else about it until she got a call about a month later. On 7/24/24 at 3:00 PM Resident #15, Resident #10's roommate, stated he told the Social Worker that morning he did a bad thing. He said he saw Staff A on Sunday at a picnic and she gave him some pictures to give to Resident #10. Resident #15 stated he gave the items to Resident #10. Resident #10 told him that he loved Staff A in a romantic way, he saw them hold hands but not kiss. Resident #15 said Resident #10 use to get up early and go to the activity room, but he no longer did that since Staff A left. He stated Resident #10 talked about her all of the time. During the conversation, Resident #15's phone rang and he said the call came from Staff A. Resident #10 said the number of the person calling, and it matched Staff A's phone number in her personnel record. On 7/24/24 at 4:44 PM, the Social Worker reported the situation with Staff A had a lot of impact on Resident #10. He stated he felt guilty and didn't feel like going to the activity room anymore. He talked to him about mental health counseling and he agreed to go. He stated Resident #10's cognition fluctuated and he didn't know if he could consent (for the kiss). On 7/24/24 at 4:53 PM, the Assistant Director of Nursing (ADON) said she noted a difference in Resident #10 since the situation with Staff A. She described him as more withdrawn, tearful, and didn't engage in activities as he did in the past. On 7/25/24 at 8:19 AM via phone, Staff D denied that someone reported to her that Resident #10 stated he kissed Staff A and she locked the door of the activity room for them to be alone. She didn't recall receiving an email on 2/29/24 about the situation and stated such allegations would be reportable. She stated the only thing that someone reported to her was that Resident #10 sent Staff A heart emojis and that isn't reportable. On 7/25/24 at 10:05 AM, the Administrator stated she suspended Staff A on 6/10/24 and she didn't return to the building. The facility terminated her on 6/17/24. On 7/25/24 at 10:18 AM, via phone, Staff C explained Staff B reported that she saw Staff A kissing a resident. Staff B told her Staff A took care of it, so Staff C thought that Staff A turned herself in. On 7/25/24 at 11:54 AM via phone, RR #10 stated when hospitalized last November, the hospital nursing staff saw him texting things like heart emojis to Staff A. RR #10 explained they reported it to Staff D. They told RR #10 the facility brought in Staff A, looked at her phone, and talked to her about boundaries. In February (2024), RR #10 went with Resident #10 when he had a procedure. He reported they gave him sedatives and described him as loopy. RR #10 stated Resident #10 told her that he had a romantic relationship with Staff A and they kissed. RR #10 reported this to the Administrator via email at the time, the Administrator told her she would address it. RR #10 didn't hear anything else about it. RR #10 said after the alleged witnessed kiss, Resident #10 became very anxious and upset that someone accused him of things. Resident #10 didn't understand what they accused him of. Resident #10 only had one other girlfriend in his life and he felt like he would never have a relationship. RR #10 stated she felt it was more meaningful for him than for Staff A. The facility lacked documentation of an investigation into the alleged text messages sent from Resident #10 to Staff A in November 2023. On 7/29/24 at 9:05 AM Staff A stated they became close because as Activity Director, she made sure the residents came to activities and participated. When she first met him, he expressed confusion about being in the facility and they didn't have activities for him to do. She stated he began activities and spent most of those days in the activity room. She stated they became close probably around November of 2023. They shared information with each other about their family and they became close. They ended up being close friends and gave each other advice. She stated their relationship became too close. She stated she worked at the facility for [AGE] years and never abused anyone. She stated a kiss happened once. It was 4:45 PM, as she left for the day, she gave everyone a hug. When she told Resident #10 about her leaving, she gave him a hug, he held onto her a little longer, pulled her in, and kissed her. She stated Resident #10 kissed her on the mouth and pulled her back again. She described it as just one kiss, a couple of quick smacks on the mouth. She reported standing during the kiss and as he sat in his wheelchair. She stated the CMA walked in and saw this. After, Staff A stated she found the CMA and apologized to her for having seen that. The CMA said not to worry about it and she wouldn't say anything. Staff A denied asking the CMA not to say anything. She stated she held hands with Resident #10 before this, as a friend, but stated she held hands with other residents too. She stated Resident #10 told her he loved her a while ago. He knew about her about her being married. He told her he wanted to be with her. She told him that nothing was going to happen (between them). She said when she first met Resident #10, he thought they met prior to him being at the facility. Staff A stated that she never met him before though. She stated when he didn't sleep, he became very confused. Sometimes he thought he was her husband. She stated she sometimes sent him heart emojis and he sent her heart emojis but in friendship and not romantically. She texted him hearts when she thought he was down. She told him she loved him as a friend, her best friend. When he told her, he needed more than that, she tried to block him from her phone a couple of times. She stated he left voicemails and would become crying mad, asking why she hid from him. She stated this occurred prior to when someone observed them kiss. She denied shutting the door to the activity room. She denied having contact with Resident #10 or calling Resident #15 the previous week. She did meet Resident #15 at a picnic last week and gave him books on anxiety to give to Resident #10. She felt Resident #10 had more depression. She stated she didn't want Resident #10 to feel she turned her back on him. She stated she hadn't communicated with him for a couple of months since they suspended her. When she told him that she wasn't coming back, he got very mad, apologized, and blamed himself. On 7/29/24 at 1:14 PM Staff G, Licensed Practical Nurse (LPN), reported Resident #10 expressed he missed Staff A. On 7/29/24 at 1:30 PM, the DON stated Staff F reported the alleged kiss to the ADON. She said the incident happened weeks prior and the agency nurse didn't report it until later. She explained since the incident, staff have reported him as more depressed, not himself, and changed his routine. She said he didn't participate in activities as much and liked his solitude. She stated Resident #10 stayed in his room more. On 7/29/24 at 4:09 PM, the Administrator stated she expected residents to be free from abuse and staff should treat them like their own loved one. After an allegation of abuse, the facility would remove the alleged perpetrator from all residents and report it to the State Agency.

Based on observation, clinical record review, policy review, staff, and resident interviews, the facility failed to investigate an allegation of sexual exploitation and separate an alleged perpetrator of sexual exploitation from other residents for 1 of 1 resident reviewed for abuse (Resident #10). When a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until several weeks later. At that time, the facility suspended Staff A and then terminated her employment on 6/17/24. In addition, the facility learned Resident #10 reported on 2/29/24 he and Staff A kissed and she locked the door of the activity room so they could be alone. In addition, the facility learned on 2/29/24 that Resident #10 stated he and Staff A kissed and she locked the door of the activity room so they could be alone. After learning of either incident, the facility failed to report the incident to the Department of Inspections, Appeals, and Licensing (DIAL or State Agency) until 6/10/24. In addition, the facility failed to separate Staff A from Resident #10 or other residents after 2/29/24. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/25/24 at 9:30 AM The IJ began on 2/29/24. Facility staff removed the Immediate Jeopardy on 6/14/24 through the following actions: a. Previous Administrator employment at Living Center [NAME] ended 3/18/24. b. The facility suspended Staff A on 6/10/24. c. The facility terminated Staff A's employment on 6/17/24. b. The facility carried out abuse prevention education for all staff on 6/10/24. d. The facility sent the nurse home immediately on 6/10/24. e. The facility notified the agency the nurse couldn't return to the facility on [DATE] f. The facility retrained all of the staff on the Abuse Policy and Procedures (including reporting, prevention, etc.) specifically highlighting sexual exploitation completed by Administrator and Clinical Leadership on 6/10/24. g. Interviewed all cognitively intact residents to verify they facility didn't have other affected residents on 6/11/24. h. The facility notified Resident #10's provider and responsible party on 6/10/24. i. Grievance procedures implemented 5/21/24 and continued education provided at June and July in services and resident council. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #10 required supervision or touching assistance with showering/bathing. The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, stated all residents had the right to be free from abuse and defined abuse to include sexual exploitation. The policy stated sexual exploitation was consensual or nonconsensual sexual conduct with a dependent adult by a caretaker and stated it included but not limited to kissing. The facility would investigate the alleged incident and implement measures to prevent further potential abuse of residents during the investigation by suspending the employee, removing the employee from a resident contact area, or in rare instances, separating the employee from Resident #10 alleged to have been abused, but allowing the employee to care for and have contact with other residents if there was a second employee who remained with and accompanied the employee accused of abuse at all times. The Care Plan Focus dated 8/4/23 reflected Resident #10 required 24 hour care related to the inability to care for himself in the community. The Care Plan Focus dated 8/21/23 indicated Resident #10 had impaired cognitive function, dementia, or impaired thought processes related to his diagnoses of dementia, Wernicke's encephalopathy (a disease of the brain which caused symptoms which included confusion), and psychotropic drug use. The Interventions directed the staff to keep Resident #10's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. In email correspondence, sent to Staff D, former Administrator, on 2/29/24 at 2:47 PM, Resident #10's Guardian (RR #10) stated Resident #10 declared his love for Staff A. RR #10 explained Resident #10 told him, they tried to figure out how to go out on dates together. Resident #10 told RR #10 they kissed each other and Staff A locked the activity room door so they could have privacy. Resident #10 said Staff A talked about her husband and reported problems in their relationship. Resident #10 stated he intended to protect Staff A and asked RR #10 for help facilitating the relationship so they could spend more time alone. Resident #10 stated they had to hide their relationship because of Staff A's employment. Resident #10 declared his love for Staff A. He never had this in his life before and he wanted to nurture it. He explained he would like to get married. In email correspondence, sent to RR #10 on 3/1/24 at 10:37 AM, Staff D responded they would address it immediately. The facility lacked documentation of an investigation into the concerns reported in the 2/29/24 email from RR #10. A statement dated 6/10/24, written by Staff B, Certified Medication Aide, (CMA), indicated on 5/7/24, when she looked for Resident #10 to give his medication, she noticed the activity room door slightly cracked. As Staff B looked in, she saw Resident #10 and Staff A kissing each other on the mouth. Staff B gave Resident #10 his medication and quickly left the room. Staff A found Staff B and asked her not to say anything, adding it would not happen again. Staff B reported the situation to Staff C, Registered Nurse (RN), after Staff A left the building. A statement dated 6/10/24, written by Staff C stated at the end of April or Early May (2024) Staff B told her she saw Resident #10 and Staff A making out. Staff C said she directed Staff B to report it to the Director of Nursing (DON). On or around 5/31/24, Staff C observed Resident #10 talking on the phone to Staff A around 7:00 PM. A statement dated 6/10/24, written by the DON, stated she notified RR #10 of the alleged incident. RR #10 explained while hospitalized in December 2023, the hospital staff saw text messages between Resident #10 and Staff A where he declared his love for her. RR #10 added Resident #10 told her about his relationship with Staff A. They would close the activity room door, kiss, and Staff A would tell him about her marital problems. RR #10 stated she emailed Staff D regarding the concerns on 3/1/24. A statement dated 6/10/24, written by Staff A, stated she had a relationship with Resident #10 for over 6 months now and it still continued. The note stated when Staff A left to go home, she gave Resident #10 a hug and just a smack on his cheek. The note stated no other staff or residents knew about the relationship. They started to become close around the end of November when he spent time with her in the activity room. The Health Status Note dated 6/10/24 at 7:05 PM indicated the facility had a report of someone witnessing Resident #10 and a staff member kissing in the activity room. Resident #10 denied any sexual contact or intimate relationship and stated they were just friends. Upon interview, the staff member admitted to the allegations and walked out of the facility. The Psychosocial Note dated 6/14/24 at 3:14 PM identified he felt comfortable discussing his relationship with Staff A. He voiced frustration over the many questions over the matter and feeling that no one believed him that this incident is making a mountain out of a mole hill. He said he spent a lot of time helping in the activity office. He said they became friends and that he liked them, even felt love for them but stated nothing sexually happened. He said he is okay with the questions, but worried about the impact of the situation on Staff A. Resident #10 said he is open to further visits to help with processing. Post-Traumatic Stress Disorder (PTSD) form completed with positive results for PTSD but related to a situation in his past. Staff A's Personnel Record listed a termination date of 6/17/24. The Psychosocial Note dated 6/20/24 at 3:18 PM described Resident #10 as tearful about the facility firing Staff A. He stated if he didn't come to the facility, she would still have her job. He stated he didn't go to the activity room to color because it brought him sadness, so he colored in the lounge. He felt coloring helped him cope with the grief and guilt over the situation. He reported still having contact with Staff A via phone and text. On 7/22/24 at 2:35 PM watched Resident #10 propel himself down the hall in his wheelchair. On 7/23/24 at 2:48 PM, Resident #10 stated Staff A became pregnant and couldn't work at the facility anymore. He said they had a close relationship, but said they had no kissing involved. He stated they would text and call each other on the phone. He added they each had problems, so that was what friends did. He said they hugged as friends, kissed as friends, and had a light kiss on the cheek. He didn't think of that as an affair. He stated she closed the door to keep other people out, so they could work on projects. On 7/23/24 at 3:35 PM the Administrator stated Staff B reported to Staff C that she saw Resident #10 and Staff A kissing on the lips in the activity room. Staff B stated Staff C told her not to worry about it. The Administrator stated she found out when Staff C told Staff F, CNA, about it a couple of weeks later. The Administrator stated when she met with Staff A, she told her she had a relationship with Resident #10 for 6 months, they loved each other, and had a kiss. She stated they had Staff A leave the building, then they talked to residents and staff. She stated initially Resident #10 denied it but then later that day he admitted to it. The Administrator stated RR #10 stated she reported it before and sent an email to Staff D. The Administrator said she couldn't find a follow up to the email. On 7/24/24 at 11:59 AM via phone, Staff B stated she tried to find Resident #10 to give him his medications and saw the activity room door cracked. When she looked in the room she saw Resident #10 in his wheelchair with Staff A sitting on his knee in the middle of a long kiss on the mouth. She said when Staff A looked up, she went in and gave Resident #10 his medications. She quickly left because she (Staff B) felt embarrassed. Staff B stated a few minutes later when Staff A found her, she asked her not to tell anyone, and added they wouldn't do that anymore. Staff B stated she waited for Staff A to leave the building, then told Staff C. Staff C told her not to tell anyone. She explained she didn't hear anything else about it until she got a call about a month later. On 7/25/24 at 8:19 AM via phone, Staff D denied that someone reported to her that Resident #10 stated he kissed Staff A and she locked the door of the activity room for them to be alone. She didn't recall receiving an email on 2/29/24 about the situation and stated such allegations would be reportable. She stated the only thing that someone reported to her was that Resident #10 sent Staff A heart emojis and that isn't reportable. On 7/25/24 at 10:05 AM, the Administrator stated she suspended Staff A on 6/10/24 and she didn't return to the building. The facility terminated her on 6/17/24. On 7/25/24 at 10:18 AM, via phone, Staff C explained Staff B reported that she saw Staff A kissing a resident. Staff B told her Staff A took care of it, so Staff C thought that Staff A turned herself in. On 7/25/24 at 11:54 AM via phone, RR #10 stated when hospitalized last November, the hospital nursing staff saw him texting things like heart emojis to Staff A. RR #10 explained they reported it to Staff D. They told RR #10 the facility brought in Staff A, looked at her phone, and talked to her about boundaries. In February (2024), RR #10 went with Resident #10 when he had a procedure. He reported they gave him sedatives and described him as loopy. RR #10 stated Resident #10 told her that he had a romantic relationship with Staff A and they kissed. RR #10 reported this to the Administrator via email at the time, the Administrator told her she would address it. RR #10 didn't hear anything else about it. RR #10 said after the alleged witnessed kiss, Resident #10 became very anxious and upset that someone accused him of things. Resident #10 didn't understand what they accused him of. Resident #10 only had one other girlfriend in his life and he felt like he would never have a relationship. RR #10 stated she felt it was more meaningful for him than for Staff A. The facility lacked documentation of an investigation into the alleged text messages sent from Resident #10 to Staff A in November 2023. On 7/29/24 at 1:30 PM, the DON stated Staff F reported the alleged kiss to the ADON. She said the incident happened weeks before and the agency nurse didn't report it until later. On 7/29/24 at 4:09 PM, the Administrator stated she expected residents to be free from abuse and staff should treat them like their own loved one. After an allegation of abuse, the facility would remove the alleged perpetrator from all residents and report it to the State Agency.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to prevent sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). After a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room, they left the room leaving the two of them alone in the room. No one reported the witnessed event to members of administration until several weeks later and the facility didn't terminate Staff A until 6/17/24. In addition, the facility learned on 2/29/24 that Resident #10 stated he and Staff A kissed and she locked the door of the activity room so they could be alone. The facility failed to have documentation of an investigation into the situation, nor did they separate Staff A from Resident #10 or the other residents after 2/29/24. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/25/24 at 9:30 AM The IJ began on 2/29/24. The facility staff removed the immediacy on 6/14/24 through the following actions: a. Previous Administrator employment at Living Center [NAME] ended 3/18/24. b. The facility suspended Staff A on 6/10/24. c. The facility terminated Staff A's employment on 6/17/24. b. The facility carried out abuse prevention education for all staff on 6/10/24. d. The facility sent the nurse home immediately on 6/10/24. e. The facility notified the agency the nurse couldn't return to the facility on [DATE] f. The facility retrained all of the staff on the Abuse Policy and Procedures (including reporting, prevention, etc.). specifically highlighting sexual exploitation completed by Administrator and Clinical Leadership on 6/10/24. g. Mental Health counseling offered to Resident #10. h. Weekly visits with Resident #10 and Social Worker initiated 6/14/24. i. Interviewed all cognitively intact residents to verify they facility didn't have other affected residents on 6/11/24. j. The facility notified Resident #10's provider and responsible party on 6/10/24. k. The facility reviewed and updated Resident #10's Care Plan l. Monthly Staff In-services to occur to provide education and retraining as needed. m. Grievance procedures implemented 5/21/24 and continued education provided at June and July in services and resident council. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #10 required supervision or touching assistance with showering/bathing. The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, stated all residents had the right to be free from abuse and defined abuse to include sexual exploitation. The policy stated sexual exploitation was consensual or nonconsensual sexual conduct with a dependent adult by a caretaker and stated it included but not limited to kissing. The Care Plan Focus dated 8/4/23 reflected Resident #10 required 24 hour care related to the inability to care for himself in the community. The Care Plan Focus dated 8/21/23 indicated Resident #10 had impaired cognitive function, dementia, or impaired thought processes related to his diagnoses of dementia, [NAME]'s encephalopathy (a disease of the brain which caused symptoms which included confusion), and psychotropic drug use. The Interventions directed the staff to keep Resident #10's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Care Plan Focus initiated 9/29/23 and revised 6/12/24 identified Resident #10 had signs and symptoms of mood distress as evidenced by verbalizing feeling down, depressed, or hopeless related to diagnoses for depression, anxiety, and dementia. In email correspondence, sent to Staff D, former Administrator, on 2/29/24 at 2:47 PM, Resident #10's Guardian (RR #10) stated Resident #10 declared his love for Staff A. RR #10 explained Resident #10 told him, they tried to figure out how to go out on dates together. Resident #10 told RR #10 they kissed each other and Staff A locked the activity room door so they could have privacy. Resident #10 said Staff A talked about her husband and reported problems in their relationship. Resident #10 stated he intended to protect Staff A and asked RR #10 for help facilitating the relationship so they could spend more time alone. Resident #10 stated they had to hide their relationship because of Staff A's employment. Resident #10 declared his love for Staff A. He never had this in his life before and he wanted to nurture it. He explained he would like to get married. In email correspondence, sent to RR #10 on 3/1/24 at 10:37 AM, Staff D responded they would address it immediately. The facility lacked documentation of an investigation into the concerns reported in the 2/29/24 email from RR #10 and lacked documentation they reported the concerns to the State Agency. The History and Physical, dated 5/1/24 reflected the hospital staff received limited history from Resident #10 due to his cognitive impairment. The report listed Resident #10 had [NAME] Korsakoff Syndrome (a condition which caused impaired memory). A statement dated 6/10/24, written by Staff B, Certified Medication Aide, (CMA), indicated on 5/7/24, when she looked for Resident #10 to give his medication, she noticed the activity room door slightly cracked. As Staff B looked in, she saw Resident #10 and Staff A kissing each other on the mouth. Staff B gave Resident #10 his medication and quickly left the room. Staff A found Staff B and asked her not to say anything, adding it would not happen again. Staff B reported the situation to Staff C, Registered Nurse (RN), after Staff A left the building. A statement dated 6/10/24, written by Staff C stated at the end of April or Early May (2024) Staff B told her she saw Resident #10 and Staff A making out. Staff C said she directed Staff B to report it to the Director of Nursing (DON). On or around 5/31/24, Staff C observed Resident #10 talking on the phone to Staff A around 7:00 PM. A statement dated 6/10/24, written by the DON, stated she notified RR #10 of the alleged incident. RR #10 explained while hospitalized in December 2023, the hospital staff saw text messages between Resident #10 and Staff A where he declared his love for her. RR #10 added Resident #10 told her about his relationship with Staff A. They would close the activity room door, kiss, and Staff A would tell him about her marital problems. RR #10 stated she emailed Staff D regarding the concerns on 3/1/24. In a written interview on 6/10/24, Resident #10 denied kissing Staff A. A statement dated 6/10/24, written by the DON, stated Resident #10 called her and said he lied about what they talked about earlier because he didn't want to get Staff A or himself in trouble. Resident #10 explained Staff A called him that evening and told him to be honest about things. A statement dated 6/10/24, written by Staff A, stated she had a relationship with Resident #10 for over 6 months now and it still continued. The note stated when Staff A left to go home, she gave Resident #10 a hug and just a smack on his cheek. The note stated no other staff or residents knew about the relationship. They started to become close around the end of November when he spent time with her in the activity room. The Health Status Note dated 6/10/24 at 7:05 PM indicated the facility had a report of someone witnessing Resident #10 and a staff member kissing in the activity room. Resident #10 denied any sexual contact or intimate relationship and stated they were just friends. Upon interview, the staff member admitted to the allegations and walked out of the facility. The Psychosocial Note dated 6/14/24 at 3:14 PM identified He was open to discussing his relationship with staff member Staff A and named them by name. He voiced frustration over the many questions over the matter and feeling that no one believed him that this incident is making a mountain out of a mole hill. He said he spent a lot of time with Staff A helping in the activity office. He said they became friends and that he liked them, even felt love for them but stated nothing sexually happened. He said he is okay with the questions, but worried about the impact of the situation on Staff A. Resident #10 said he is open to further visits to help with processing. Post-Traumatic Stress Disorder (PTSD) form completed with positive results for PTSD but related to a situation in his past. Staff A's Personnel Record listed a termination date of 6/17/24. The Psychosocial Note dated 6/20/24 at 3:18 PM described Resident #10 as tearful about the facility firing Staff A. He stated if he didn't come to the facility, she would still have her job. He stated he didn't go to the activity room to color because of the sadness it brought him, so he colored in the lounge. He felt coloring helped him cope with the grief and guilt over the situation. He reported still having contact with Staff A via phone and text. He stated Staff A's spouse didn't care for her so he thought that led to his relationship with her. He stated he feared the facility would kick him out of the facility due to the situation. The Psychosocial Note dated 6/25/24 at 11:44 AM reflected Resident #10 had a meeting with staff for support, and reported he had a difficult morning. He still felt some blame but also anger over the situation. He said he had nightmares about the issue. He reported crying a lot, and trying to forget Staff A but he didn't really want. He has removed Staff A name and number from his phone. Resident #10 also shared that he is angry at Staff A spouse because he didn't care for Staff A and Staff A didn't love the spouse. Resident #10 said he didn't think the meeting helped him, but thought it gave him an opportunity to talk out some of his thoughts. On 7/22/24 at 2:35 PM watched Resident #10 propel himself down the hall in his wheelchair. On 7/23/24 at 2:48 PM, Resident #10 stated Staff A became pregnant and couldn't work at the facility anymore. He said they had a close relationship, but said they had no kissing involved. He stated they would text and call each other on the phone. He added they each had problems, so that was what friends did. He said they hugged as friends, kissed as friends, and had a light kiss on the cheek. He didn't think of that as an affair. He stated she closed the door to keep other people out, so they could work on projects. On 7/23/24 at 3:35 PM the Administrator stated Resident #10 struggled with the situation between him and Staff A. She described him as all over the map and his mood could go from a low to a high. She stated he had a time with her out of the picture. She indicated she had a hard time watching him as started to accept it and struggle. She described him as a lot quieter. She stated Staff B reported to Staff C that she saw Resident #10 and Staff A kissing on the lips in the activity room. Staff B stated Staff C told her not to worry about it. The Administrator stated she found out when Staff C told Staff F, CNA, about it a couple of weeks later. The Administrator stated when she met with Staff A, she told her she had a relationship with Resident #10 for 6 months, they loved each other, and had a kiss. She stated they had Staff A leave the building, then they talked to residents and staff. She stated initially Resident #10 denied it but then later that day he admitted to it. The Administrator stated RR #10 stated she reported it before and sent an email to Staff D. The Administrator said she couldn't find a follow up to the email. On 7/24/24 at 11:59 AM via phone, Staff B stated she tried to find Resident #10 to give him his medications and saw the activity room door cracked. When she looked in the room she saw Resident #10 in his wheelchair with Staff A sitting on his knee in the middle of a long kiss on the mouth. She said when Staff A looked up, she went in and gave Resident #10 his medications. She quickly left because she (Staff B) felt embarrassed. Staff B stated a few minutes later when Staff A found her, she asked her not to tell anyone, and added they wouldn't do that anymore. Staff B stated she waited for Staff A to leave the building, then told Staff C. Staff C told her not to tell anyone. She explained she didn't hear anything else about it until she got a call about a month later. On 7/24/24 at 3:00 PM Resident #15, Resident #10's roommate, stated he told the Social Worker that morning he did a bad thing. He said he saw Staff A on Sunday at a picnic and she gave him some pictures to give to Resident #10. Resident #15 stated he gave the items to Resident #10. Resident #10 told him that he loved Staff A in a romantic way, he saw them hold hands but not kiss. Resident #15 said Resident #10 use to get up early and go to the activity room, but he no longer did that since Staff A left. He stated Resident #10 talked about her all of the time. During the conversation, Resident #15's phone rang and he said the call came from Staff A. Resident #10 said the number of the person calling, and it matched Staff A's phone number in her personnel record. On 7/24/24 at 4:44 PM, the Social Worker reported the situation with Staff A had a lot of impact on Resident #10. He stated he felt guilty and didn't feel like going to the activity room anymore. He talked to him about mental health counseling and he agreed to go. He stated Resident #10's cognition fluctuated and he didn't know if he could consent (for the kiss). On 7/24/24 at 4:53 PM, the Assistant Director of Nursing (ADON) said she noted a difference in Resident #10 since the situation with Staff A. She described him as more withdrawn, tearful, and didn't engage in activities as he did in the past. On 7/25/24 at 8:19 AM via phone, Staff D denied that someone reported to her that Resident #10 stated he kissed Staff A and she locked the door of the activity room for them to be alone. She didn't recall receiving an email on 2/29/24 about the situation and stated such allegations would be reportable. She stated the only thing that someone reported to her was that Resident #10 sent Staff A heart emojis and that isn't reportable. On 7/25/24 at 10:05 AM, the Administrator stated she suspended Staff A on 6/10/24 and she didn't return to the building. The facility terminated her on 6/17/24. On 7/25/24 at 10:18 AM, via phone, Staff C explained Staff B reported that she saw Staff A kissing a resident. Staff B told her Staff A took care of it, so Staff C thought that Staff A turned herself in. On 7/25/24 at 11:54 AM via phone, RR #10 stated when hospitalized last November, the hospital nursing staff saw him texting things like heart emojis to Staff A. RR #10 explained they reported it to Staff D. They told RR #10 the facility brought in Staff A, looked at her phone, and talked to her about boundaries. In February (2024), RR #10 went with Resident #10 when he had a procedure. He reported they gave him sedatives and described him as loopy. RR #10 stated Resident #10 told her that he had a romantic relationship with Staff A and they kissed. RR #10 reported this to the Administrator via email at the time, the Administrator told her she would address it. RR #10 didn't hear anything else about it. RR #10 said after the alleged witnessed kiss, Resident #10 became very anxious and upset that someone accused him of things. Resident #10 didn't understand what they accused him of. Resident #10 only had one other girlfriend in his life and he felt like he would never have a relationship. RR #10 stated she felt it was more meaningful for him than for Staff A. The facility lacked documentation of an investigation into the alleged text messages sent from Resident #10 to Staff A in November 2023. On 7/29/24 at 1:30 PM, the DON stated Staff F reported the alleged kiss to the ADON. She said the incident happened weeks prior and the agency nurse didn't report it until later. She explained since the incident, staff have reported him as more depressed, not himself, and changed his routine. She said he didn't participate in activities as much and liked his solitude. She stated Resident #10 stayed in his room more. On 7/29/24 at 4:09 PM, the Administrator stated she expected residents to be free from abuse and staff should treat them like their own loved one. After an allegation of abuse, the facility would remove the alleged perpetrator from all residents and report it to the State Agency.

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and act to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 74 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 1/18/24, listed, in part, the following concerns: F550, F600 The CMS 2567, dated 6/6/24, listed, in part, the following concerns: F550 The current survey, conducted 7/22/24 7/29/24, also identified the above concerns. A 1/17/24 Performance Improvement Project (PIP) Inventory document stated all staff would complete abuse prevention training and the current phase of the PIP was monitoring. The document listed the indicators and measures tracked to show improvement to include better treatment noted to residents by family, staff, and residents. The facility In Service Agenda for 5/21/24 included the topics of resident rights and the abuse policy/procedures. The QA Committee Meeting Sign in, dated 6/19/24, listed a PIP Team Report for Abuse. The facility lacked further documentation of QAPI/QA program activities related to resident treatment or abuse prevention. The facility lacked evidence of an ongoing QAPI program related to the above areas including a process of addressing how the committee would conduct the activities necessary to identify and correct quality deficiencies. The facility lacked do documentation of monitoring or evaluating the effectiveness of corrective action/ performance improvement activities and revision as needed. On 7/29/24 at 4:09 PM, when queried about QA activities from January to June 2024 which addressed dignity or abuse prevention, the Administrator stated they all had staff abuse training which had a completion deadline of 2/1/24. In February 2024, they educated all staff regarding de escalation techniques and resident rights. She stated in May, they talked to staff regarding resident rights, grievances, and conducted abuse education on 6/10/24. The Administrator stated she would email all QA activities related to dignity and abuse prevention to the survey team. The facility's QAPI Plan, updated 7/19/18, indicated the plan provided guidance for the overall quality improvement program . The plan reflected the facility utilized a systematic approach to determine when they needed an in depth analysis to fully understand identified problems, causes of the problems, and implications of a change. The facility would implement the plan, evaluate the results, and analyze the outcome.

Based on observation, clinical record review, and staff interview, the facility failed to follow the care plan to provide a pressure reducing cushion for 1 of 3 residents reviewed with a pressure ulcer (Resident #11). The facility reported a census of 74 residents. Findings: 1. Resident #11 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of arthritis, non Alzheimer's dementia, and weakness. The MDS stated Resident #10 required partial to moderate assistance for rolling right to left, substantial to maximum assistance for showering and transfers, and was dependent of staff for toileting hygiene. The MDS listed a Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. The Care Plan Focus dated 6/27/23, reflected Resident #11 had a risk for skin breakdown related to impaired mobility, incontinence, and weakness. The Care Plan Focus, dated 6/12/24, indicated Resident #11 had a pressure reducing cushion to the chair. The Braden Scale for Predicting Pressure Sore Risk, dated 7/18/24, identified Resident #11 at risk for the development of pressure sores. The Wound/Skin Healing Records revealed Resident #11 had a Stage 2 (partial thickness loss of skin) pressure ulcer on the coccyx (tailbone) with an onset date of 6/11/24 which measured 0.5 centimeters (cm) x 0.2 cm x 0.1 cm. (length x width x depth). The Subsequent Wound/Skin Health Record measurements included: a. 6/17/24 0.8 cm x 0.5 cm x 0.1 cm b. 6/24/24 0.5 cm x 0.4 cm x 0.1 cm c. 7/1/24 0.8 cm x 0.4 cm x 0.2 cm d. 7/8/24 0.6 cm x 0.3 cm x 0.2 cm e. 7/15/24 0.5 cm x 0.3 cm x 0.1 cm f. 7/22/24 0.5 cm x 0.2 cm x 0.1 cm Observations on the following dates/times revealed Resident #11 in her wheelchair with no cushion under her: 7/23/24 at 8:44 AM, 12:16 PM and 12:41 PM 7/24/24 at 8:10 AM On 7/24/24 at 2:38 PM, Staff G, Licensed Practical Nurse (LPN), measured a wound on Resident #11's coccyx as 0.5 cm x 0.3 cm x 0.2 cm. The wound had a yellow center and red edges. On 7/29/24 at 1:14 PM Staff G stated Resident #11 should always have a cushion in her chair, she had an incontinent episode and they had to switch it out. She stated the staff should replace the cushion in the chair in a timely manner. On 7/29/24 at 1:30 PM the Director of Nursing (DON) stated Resident #11 had a cushion in her wheelchair but stated she didn't know why she didn't have it the week before. She stated they could be cleaning it or the staff could have failed to place it in the chair. She stated they had extra cushions (if one became soiled). The facility policy Pressure Ulcer Prevention Program, effective 6/7/17, directed the facility would provide care to promote the prevention and healing of pressure ulcers. The policy indicated the most effective means of preventing skin breakdown included relief of pressure on the skin and directed staff to utilize pressure redistribution devices.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure privacy by leaving a resident exposed for several minutes during incontinence cares for 1 of 7 residents reviewed for dignity (Resident #6). The facility reported a census of 74 residents. Findings: Resident #6 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total assistance from staff for toileting hygiene. The MDS included diagnoses of anxiety disorder, depression, and weakness. The Care Plan Focus, dated 4/8/24, indicated Resident #6 experienced bladder incontinence related to impaired mobility, obesity, and overactive bladder. The Interventions directed the staff to use incontinence products to promote hygiene and dignity. On 7/23/24 at 1:25 PM, Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA, transferred Resident #6 to the bed with a mechanical lift, as the Director of Nursing (DON) observed. Staff E and Staff F pulled down Resident #6's pants. Staff E unfastened her incontinent brief and pulled the brief down in front, exposing Resident #6's frontal perineal area (referring to the frontal genital area). Staff F stated she would go and find a large sized brief. Staff F and the DON left the room. Staff E waited for approximately 2 minutes and then proceeded to clean Resident #6's frontal perineal area. Approximately 2 minutes later, the DON returned to the room, and reported Staff F would be back with a few more items. Approximately 2 minutes later, Staff F returned with a pan of water on a rolling bedside table. Staff E utilized the pan of water and the cloths to complete Resident #6's perineal cleansing. Several minutes elapsed from the time Staff F and the DON left the room until Staff E completed the remainder of Resident #6's perineal cares. During this time, Resident #10 laid in bed without a drape with her frontal perineal area exposed. The facility policy Residents' [NAME] of Rights revised December 2023, stated residents had the right to personal privacy during personal care. On 7/29/24 at 1:14 PM Staff G, Licensed Practical Nurse (LPN), stated if staff stepped away from a resident for a few moments they should drape them for privacy. On 7/29/24 at 1:30 PM the Director of Nursing (DON) stated if staff stepped away from an exposed resident, they should cover the resident up. She stated she thought the staff member waited to perform cares because the facility directed staff when the facility had State Surveyors in the building, the needed to wait for a member of administration to proceed with cares. She stated if the staff waited, they should cover the resident.

Based on observation, record review, and interviews the facility failed to maintain an adequate number of supplies to provide for the daily needs of all residents in the facility. The facility reported a census of 83 residents. Findings include: The Treatment Administration Record for Resident #2 lacked documentation of completion of 12 treatments between 5/1/24 and 5/6/24. During an interview with Staff L, Licensed Practical Nurse (LPN) on 5/28/24 at 4:34 PM she stated sometimes she didn't have the supplies she needed for catheter care. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA) stated 3 different residents complained of missed wound care treatments. She provided that information to the nurse on duty. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN) stated there were not enough supplies to complete care. She gave the example of a need the week before to use pudding cups instead of medication cups because they ran out. At 6:25 AM on 5/29/24 Staff C, RN, stated supplies were an issue in the facility. She felt they didn't keep track of the used items and the acuity of the residents admitted . Staff C mentioned running out of medication cups, cups used to measure 30 cc when flushing catheters, blood glucose test strips when there were 11 diabetic residents on one floor, alcohol squares which required them to order some from the pharmacy to ensure they could continue to provide care, tissues, and gloves. She also reported the facility had to ask a family member to bring in colostomy supplies from home for a new resident because they were not properly prepared for her arrival. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated the Director of Nursing (DON) ordered supplies. She would order once a month and could ask for emergency orders if needed. The ADON stated she had heard multiple instances of running out of supplies including medication cups. She stated she put multiple notes under the DON's door and added that the Administrator had to come in on a Saturday to help get supplies so staff could complete their work. On 5/29/24 at 1:55 PM the DON confirmed she was responsible for supplies and ordered them once per month. She stated she tried her best to figure out the supplies needed and noted high acuity put a strain on their supply. The DON stated she started ordering more stock supplies because insurance only allowed specific amounts. On 6/4/24 at 11:50 AM observed the lower level storage room. A white plastic organizer held drawers labeled with different sizes of Mepilex wound dressings. All of the drawers were empty except the one labeled with the 6 inch by 6 inch size which held two of the dressings. The Director of Nursing (DON) stated she was placing an order that day. On 6/4/24 at 12:00 PM observed a second floor medication cart. There was one 2 inch by 2 inch Mepilex in the second drawer, with 3 more in a box in the 3rd drawer. The double-locked bottom drawer of the cart contained approximately 3, 6x6 Mepilex. Staff H reported they locked those dressings so they didn't disappear when he needed them to provide treatment. He stated people took them and didn't tell anyone so he would run out when he needed to complete treatments.

Based on observation, staff interview, resident interview, clinical record review, and policy review the facility failed to treat residents with dignity and respect while providing cares for 5 of 7 residents reviewed for resident rights (Residents #3, #6, #7, #8, #9). The facility reported a census of 83 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #3 required total assistance with toilet use, transfers, and sitting up in bed. The MDS reflected diagnoses of anxiety and depression, obesity, and respiratory failure. The Care Plan Focus dated 2/27/23 reflected Resident #3 had a decline in activities of daily living (ADL). The Intervention directed to not rush the resident and allow extra time for ADLs. On 5/23/24 at 2:36 PM observed Resident #3 laying on her left side in bed with her right arm over her forehead. As she slowly rolled to her right to lay on her back, her face reflected a slight grimace. She stated she had a leg that didn't work very well anymore. Resident #3 described Staff A, Certified Nurse Aide (CNA), as rough when providing care on the overnight shift from 5/21/24 to 5/22/24. Resident #3 elaborated rough meant rushed and maybe angry. In addition, if she didn't move fast enough Staff A pulled on her leg to position her. Resident #3 said she couldn't report the CNA as mean, but just in a hurry. She shouldn't have to fear putting the call light on at night because she didn't know who was going to answer. Resident #3 stated the CNA 'runs hot and cold' and she never knew what she was going to get. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA), stated that some CNAs can be 'stern.' She reported resident needs were extensive and the CNAs had to do their work to move on to assist other residents. Staff D stated Resident #3 reported Staff A rolled her too hard or too rough. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN), stated she observed some CNAs work in a way resident might feel is too fast. She stated residents had complained to her about 3rd shift working with them too fast. On 5/29/24 at 5:24 AM Staff B, CNA, stated maybe some staff do work too fast. Residents want staff to spend a lot of time with them, but they had to get to the next resident to provide care. Staff B stated some staff approaches were hard for residents. She heard residents complain about rude attitudes. That included Staff A. On 5/29/24 at 6:25 AM Staff C, RN, said the facility staffed by budget, not acuity, and some residents didn't sleep through the night. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated residents at night reported they didn't get the care they deserved. On 6/4/24 at 9:50 AM Staff G, CNA, reported Resident #3 told her she tried to be nice to Staff A because she knew she got upset. An interview with Staff A, CNA, on 6/4/24 at 1:09 PM revealed she would go to the nurse if Resident #3 reported pain. She said she didn't think she was rough providing cares. Staff A thought residents might view rough as carelessness, moving too fast, or rushed cares. She stated she could tell maybe by the look on their face or what they said. Staff A confirmed she told other CNAs not to go in the resident's room unless her call light was on. She thought Resident #3 didn't want anyone in there because she was upset when she first arrived that they woke her up multiple times at night. Staff A didn't ask the resident if this was what she wanted. A document titled Resident's [NAME] of Rights, revised 12/2023, documented the resident had a right to a dignified existence and self determination. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of quality of life. The facility must protect and promote the rights of the resident. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, indicated the facility would provide a supportive and safe environment for all residents. 2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total staff assistance with sitting up in bed and all transfers. The MDS reflected diagnoses of morbid obesity, anxiety and depression, and need for assistance with personal care. The Care Plan Focus dated 4/8/24 indicated Resident #6 had chronic pain and ADL deterioration. The Interventions directed the following: a. Assess the effects of pain b. Monitor for complaints and non verbal signs of pain c. Don't rush the resident allowing for extra time to complete ADLs. An interview with Resident #6 on 5/23/24 at 2:50 PM stated on or around the week of 5/19/24 Staff A was going too fast and grabbed her arm to turn her. Resident #6 further stated there have been other times Staff A has been rude or rushed during care. That included: 1. Yelling from the doorway when the call light was on 'what do you want' even though she had to come in to turn the light off 2. Ignoring her when coming in to assist her roommate 3. Making her feel like a nuisance if she needed her, like she shouldn't be here 4. Moving her too fast and rolling her on her arm 5. Making rough, growling sounds while turning her, 'bullish like a drill sergeant ' 6. Telling other CNAs not to come in her room unless the call light was on An interview with Resident #6's roommate on 6/3/24 at 10:00 AM revealed that Staff A is 'hard on' Resident #6. She was 'pretty rough' on her, she heard it. She explained she heard Resident #6 groan and Staff A said she had to roll over and just moved her fast. The resident asked for pillows and Staff A dropped them on the bed without helping her use them as support. Resident #6's roommate added Staff A regularly worked 16 hour shifts, it affected her mood and the way she treated them. On 6/5/24 at 10:19 AM Staff H, Licensed Practical Nurse (LPN), stated he couldn't deny if residents described Staff A as rushed or frustrated, she had a routine and didn't want it messed with. It wouldn't surprise him if there was a complaint; if they called her and she helped. Then they called again, changing her routine and she didn't like that. On 6/5/24 at 2:23 Staff I, CNA, stated residents can misinterpret Staff A and she can misinterpret them. She didn't think that happened with the other staff. Staff A could get anxious and was matter of fact. She had a routine that she stuck to. Some of the residents missed that when she was not there, some didn't. 3. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #7 required substantial to maximal assistance with bed mobility and total assistance from staff to stand from sitting and chair to bed transfers. The MDS reflected diagnoses of chronic pain, obesity, and polyneuropathy. On 5/28/24 at 4:14 PM Resident #7 revealed he felt some of the staff on the overnight shift were 'not so good.' He stated around 9:00 PM or 10:00 PM he didn't like to put his call light on because of who might walk through the door. He said there were 7nights a week that he lived there and he knew all of them were not going to be good because of certain staff. 'It isn't right.' He mentioned his medications needed to be on time and staff should not talk down to residents. He should not have to worry about who was coming to take care of him. Resident #7 explained joking back and forth with two CNAs who told him he was the boss because he was the resident. When he shared that visit with a nurse and another CNA who came in, he said the nurse told him she was the boss around here and he felt she wasn't joking. This made him feel more anxious. 4. Resident #8's Care Plan listed an admitted [DATE] and diagnoses of diabetes mellitus, Parkinson's disease, and unsteadiness on feet. The Care Plan Focus dated 5/30/24 reflected Resident #8 had a deterioration in ability to complete ADLs. The Interventions instructed to not rush Resident #8, allow extra time, help with morning and evening cares. The Admission Record listed Resident #8 as his own responsible party. A progress note dated 5/29/24 at 13:04 documented Resident #8 reported to the facility's nurse practitioner about a CNA being rough with him last night. On 5/30/24 at 1:50 PM observed Resident #8 resting on his back in bed, on the top of his sheets. Resident #8 described himself as tired due to having difficulty sleeping the night before. He couldn't find his call light and had to get up to use the bathroom. He stated one of the facility's staff came into his room and told him to get back in bed. Resident #8 demonstrated how the CNA put her hands on his back, pushed him, and then he indicated he stumbled. He said he felt helpless and scared because it was dark, and he didn't know who it as he was new to the facility. He asked me to leave the door open so someone could see him. A document titled interview with (Staff J, RN) on 5/29/24 described Resident #8 got up and down a lot that night, used his call light a lot, and that she didn't have concerns with his care. An interview with Staff J on 6/4/24 at 11:39 AM revealed that she didn't know who the CNA was and therefore not able to discuss the care provided. On 6/4/24 at 8:12 AM Staff B recalled working with Resident #8. That night she checked in on the residents at least every 2 hours, completed check and change as needed, and assisted with toileting. She stated this resident was up and down all night and she redirected him to bed, offered the recliner, offered the common area, and took him to the bathroom or provided his urinal at least 4 times. She believed a resident who was being very vocal that night triggered and upset him. She denied physical contact other than putting her hand on his shoulder to guide him back to bed. Staff B indicated he also needed assistance with pivoting and that could be what he was thinking of. She stated there were no other staff in the room while she provided redirection, and they could have prevented this situation if they had enough staff at night to calm the other resident and Resident #8 at the same time. A follow up interview with Resident #8 on 6/3/24 at 10:20 AM determined the resident didn't have concerns over the weekend other than help being slow to come Sunday night. He reported that he remained worried, and watched the hallway outside of his room during the interview. 5. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #9 required partial to moderate assistance with bed mobility and needed total assistance from staff for transfers. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic pain, and a fracture. A progress note dated 4/26/24 at 14:31 labeled Behavior Note documented Resident #9 complained 3 times that week of staff rolling him too rough during cares and being rude. He didn't think they were trying to hurt him but did say they needed to be gentler. The Progress Notes lacked follow-up documentation with Resident #9 about the status of the situation. On 6/3/24 at 3:12 PM Resident #9 reported he didn't think staff were rough any more, but mostly too fast. They could still slow down a little and talk to him. He said some staff are more respectful than others.

Based on clinical record review, observations, interviews, and policy review the facility failed to accurately and thoroughly assess patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use for 3 of 3 residents reviewed for catheters and for 12 of 12 residents in the facility using catheters as part of their care. The facility reported a census of 83 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required supervision or touch assistance with transfers, standing up from bed, and mobility. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic kidney disease, and respiratory failure. Resident #1's Care Plan included a focus area dated 4/29/24 documenting the use of the indwelling catheter related to urinary retention and a failed voiding trial. Interventions included catheter care BID and PRN (twice a day and as needed), reporting urinary tract infection symptoms, labs as ordered, and assessing for continued need of the catheter quarterly. The Care Plan lacked interventions regarding resident specific catheter site cleaning and care, changing the catheter bag, changing the catheter, fluid intake or urinary output guidelines, or symptoms to monitor for a change in condition. The MDS Observation Tasks documented continence for 29 of 41 possible shifts from 5/1/24 to 5/14/24 with 12 shifts not documented. 2 of 29 reflected Resident as continent, 11 of 29 as incontinent, 2 of 29 not rated due to a condom catheter, and the remaining 14 identified Resident #1's indwelling catheter. The document lacked evidence the staff provided catheter or catheter bag care on any shift. Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required substantial to maximal assistance with rolling in bed, they required total assistance with sitting up and transfers. The MDS included diagnoses of diabetes mellitus, paraplegia (inability to move from the waist down), stage IV (4) pressure ulcer of unspecified buttock, and non-pressure chronic ulcer of skin of sites with fat layer exposed. Resident #2's Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. 3. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #9 required partial to moderate assistance with bed mobility and needed total assistance from staff for transfers. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic pain, and a fracture. Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. Observation of catheter bag care for Resident #9 on 6/3/24 at 1:49 PM revealed staff pulled the curtain, practiced hand hygiene, wore appropriate PPE, and cleaned the tubing. Staff didn't discuss fluid intake with the resident, ask about catheter associated pain, or document urine output. An interview with Staff L, Licensed Practical Nurse (LPN) on 5/28/24 at 4:34 PM revealed orders for changing bags and the catheter should be in the electronic health record. She stated sometimes she doesn't have the right supplies for catheter care. She didn't think the facility measured fluid intake or urine output for any residents unless there was a specific order. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA) stated they have never had to document catheter care, input, or output for. They told the nurse what they observed and the nurse documented. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN), stated they didn't document outputs at the facility. The CNAs emptied catheter bags at the end of every shift, but, didn't document either. She indicated there were residents currently in the facility on fluid restrictions and dialysis who should have this monitored. She thought it should be in the electronic health record under the task section. During an interview at 5:59 PM on 5/28/24 the Administrator stated the only time the facility monitored intake and output for catheters was if the doctor wrote an order for it. During an interview on 5/29/24 at 6:25 AM Staff C, RN stated she experienced poor communication in the facility. She indicated there was information she felt she should have about residents that she didn't get. She didn't know about documenting urine output, as the CNAs didn't have a place to record quantity or quality. She said notifying the providers of decreased output is difficult, because they don't have data to report. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated the facility didn't currently document fluid intake or urine output unless they had an order from the provider. The order from the provider only included fluid restriction, not how much input to allow or to monitor for output. She reported she expected the staff to document the information. On 5/29/24 at 1:55 PM the DON explained they didn't have catheter care documentation. A follow up interview on 6/6/24 at 12:01 verified catheter care didn't get documented. The DON couldn't report how they verified the completion of catheter care. A policy titled Comprehensive Assessment and Reassessment, effective 5/10/17, documented the assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's stay, with the assessment process individualized to meet the needs of the resident population. It listed symptoms that might be associated with a disease, condition, or treatment, continence, and special treatments and procedures as factors in this process. A policy titled Catheter Care, effective 10/1/18, provided the procedure for emptying the catheter bag. It didn't address the other components of catheter care, assessments, monitoring, communication with providers, patterns in fluid intake, voiding patterns, interventions, cleaning care, or symptoms associated with short or long term catheter use.

Based on clinical record review, interviews, and policy review the facility failed to ensure catheter care orders were in place for 1 of 3 residents reviewed for catheter care (Resident #1). The facility reported a census of 83 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required supervision or touch assistance with transfers, standing up from bed, and mobility. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic kidney disease, and respiratory failure. The Care Plan Focus dated 4/29/24 indicated Resident #1 had a urinary catheter. The Focus lacked interventions for cleaning the catheter site, changing the catheter bag, or changing the catheter. Neither the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) documented an order to change the indwelling urinary catheter on a schedule or as needed before 5/13/24, (27 days after admission). The MAR and TAR printed at 9:58 AM on 5/28/24 lacked documentation of orders to change the catheter bag. The Order Note dated 5/13/24 at 2:42 PM indicated Resident #1 didn't have orders entered for care of the indwelling urinary catheter. The nurse contacted the Nurse Practitioner for orders at that time. On 5/28/24 at 5:59 PM the Administrator stated the only time the facility monitored fluid intake or urine output for residents with a catheter was if there was a provider's order. On 5/29/24 at 1:55 PM the Director of Nursing stated the facility entered orders at admission and found an RN to do the admission assessment. Sometimes that was her or the Assistant Director of Nursing, or the charge nurse. She further stated that there was no documentation of emptying the bags, tracking fluid intake, or measuring urine output that might have caught missing orders. An interview with Staff K, Licensed Practical Nurse (LPN) on 5/30/24 at 10:18 AM revealed there were no orders in place for catheter care or maintenance when the resident began complaining of pain on 5/13/24, so he had to call the nurse practitioner to establish care. He had to find supplies, put together a makeshift catheter kit, and was able to get it changed later that day. He stated someone dropped the ball on making sure the orders were in place at admission. A policy titled Catheter Care effective 10/1/18 documented the procedure for catheter site care. It lacked policy or procedure regarding catheter orders, bag replacement, catheter replacement, assessment for care or removal, or documentation of input/output.

Based on clinical record review, staff and resident interviews, observations, and facility policy review, the facility failed to identify impaired skin for residents at high risk to develop pressure sores for 2 of 6 resident's reviewed (Residents #5 and #6). The facility reported a census of 85 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had diagnoses which included Non-traumatic brain dysfunction, heart failure, diabetes, and dementia. The MDS revealed the resident required extensive assistance for personal hygiene and had total dependence on staff for toileting, moving about the facility via wheelchair, did not ambulate, and had incontinence of bowel and bladder. The MDS indicted the resident had moisture related damage due to incontinence and required treatments of ointments and creams. The resident had a Brief Interview for Mental Status score of 3 which indicated severe cognitive impairment. Review of the Care Plan dated 5/9/2023, informed staff the resident had a risk for skin breakdown due to diabetes and dementia. The Care Plan directed staff to monitor the resident's skin condition with cares, report redness and break down, and to provide skin treatments as ordered. Review of the yearly Braden Scale for Predicting Pressure Sore Risks dated 4/10/24 revealed Resident #5 had a score of 15 which indicated they were at risk for developing pressure sores. Review of Resident #5's Wound/Skin Healing Record dated 5/3/24 indicated the resident had 2-Stage 2 pressure injuries identified on this date in the coccyx region and the right buttock. The coccyx wound measured 2 cm x 0.5 cm x 0.1 cm depth without drainage and the right buttock measure 2.5 cm x 1 cm x 0.1 cm depth without drainage. The staff indicated the pressure areas were a Stage 2 which means the resident had partial thickness loss of the skin with exposed dermis. Observation on 5/8/24 at 9:30 AM revealed the resident in bed on her right side, propped up with a bed pillow. The pressure sore to the right buttock approximately the size of a quarter was non-reddened. The previously opened area to the coccyx appeared closed. Staff D/LPN indicated the areas appeared healed on this date. Staff E/LPN applied the prescribed treatments to both areas. Review of the Physician's Order Sheet dated 5/6/24 revealed the Primary Care Provider order Resinol External Ointment 55-2% to the buttock and coccyx area twice daily and as needed. Review of the nursing Progress Notes from 3/7/24 - 5/3/24 failed to reveal skin assessments completed by nursing staff. Review of the New skins found on Skin Sweep 5/1 - 5/3/2024 form provided to survey team on 5/6/24 included Resident #5 with pressure sores to her coccyx and right buttock. 2. According to the MDS dated [DATE] Resident #6 had diagnoses which included heart failure, malnutrition, and schizophrenia. The MDS indicated the resident had a risk to develop pressure sores and had moisture associated skin damage due to incontinence. The resident had occasional urinary incontinence and frequent bowel incontinence. The MDS revealed the resident had a BIMS score of 12 which indicated moderately impaired cognition, exhibited disorganized speech and had verbal and physical behaviors towards others. The resident required total assistant to move from bed to chair, did not walk, and needed substantial assistance with toileting. Review of Resident #6's Care Plan dated 4/5/23 and revised on 10/3/23 indicated the resident had a Stage 2 pressure ulcer on the right buttock due to impaired mobility and incontinence. The Care Plan directed the staff to assess the pressure ulcer for location, stage, size, presence of granulation tissue and epithelization, and condition of surrounding skin weekly. To monitor skin during cares and report any signs of further breakdown (sore, tender, red or broken areas) and to provide skin treatments as ordered. Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated [DATE] revealed the resident had a score of 15 which indicated the resident at high risk to develop pressure sores. At the time of the assessment the resident did not have a pressure sore. Review of Resident #6's nursing Progress Notes fail to contain skin assessments or documentation of skin condition from 3/1/24 - 5/2/2024. Review of a Physician's Order dated 9/8/2023 directed the staff to apply Phytoplex Z-guard External Paste 57-17% to the residents buttocks topically every evening and night shift for redness to the buttocks. Review of a Wound/Healing Record dated 3/25/24 indicated the resident acquired a Stage 2 pressure ulcer to the right buttock on 6/3/2023. On 3/25/24 the staff considered the pressure sore healed but failed to continue to assess the resident's skin weekly as per policy. Review of a Wound/Skin Healing Record dated 5/2/24 revealed the resident acquired a Stage 3 pressure sore to the left buttock which measures 1 cm x 1.5 cm x 0.1 cm depth. During an interview with Staff E/LPN on 5/8/24 at 9:17 AM, Staff E stated Resident #6 had known skin impairments, she did not assess the resident's skin weekly and stated she should have had weekly skin checks completed. During an interview with Staff D/LPN on 5/6/24 at 1:00 PM, Staff D stated Resident #6 had a history of pressure wound to the buttocks. She stated it comes and goes, it is a chronic wound. Staff D stated the resident was resistive to cares and will not always allow staff to provide cares including wound cares. Observation attempted on 5/8/24 at 9:40 AM of the resident's pressure ulcer to his buttock. The resident became extremely agitated and refused to allow the Surveyor to view the pressure area. During an interview with Staff B/Director of Nurses on 5/8/24 at 10:00 AM. Staff B stated the aides are to observe the resident's skin with cares and report areas of concern to the charge nurse. She stated with each bath, the aides are to report areas of skin concerns by placing their findings on a bath sheet and handing it off to the resident's charge nurse. Staff B was asked for copies of bath sheets for Resident #5 but failed to provide them, stating she couldn't find any. The expectation for residents with healed pressure sores is for the nursing staff to measure and assess a residents pressure site for an additional 2 weeks after the staff determined the area is healed. The nurses are expected to complete the skin assessments every week as per the policy. During an interview with Staff F/Administrator on 5/6/24 at 12:45 PM, Staff F stated the nursing staff failed to perform weekly skin assessments as per facility policy and directed the nursing staff to examine every resident's skin condition on 5/1/24 - 5/3/2024. As a result of the completion of the facility wide mandated resident skin assessments the nursing staff identified an additional 15 residents with impaired skin, 3 of the 15 were labeled as pressure sore. Review of the New skins found on Skin Sweep 5/1/24 - 5/3/2024 form provided to the survey team on 5/6/24 included Resident #6 with a pressure related pressure sore to his bilateral buttocks. The facility Skin Care: Management of Wounds and Pressure Injuries policy effective 6/20/2023 included: Policy: Wound management involves assessment and proper treatment of wounds to promote healing, minimize pain, and prevent infection. PROCEDURE: Assessment: The purpose is to evaluate wounds to determine appropriate treatment and response to the treatment. Visual assessment with every dressing change. Documented assessment at least weekly. Documented assessment includes: Date of onset/date updated Location, size, depth, stage, condition of surrounding skin, condition of wound bed, current treatment, and response, family notification, physician notification, and dietary notification.

Based on clinical record review, staff, resident, family member and Medical Director interviews, and facility policy review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed for abuse, when a direct care worker indicated they intentionally pressed on a resident's knee to cause pain and to avoid providing the resident care (Resident #32). The facility reported a census of 73 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed Resident #32 with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicative of moderate cognitive impairment. Resident #32 dependent on staff for transfers, toileting, and toileting hygiene and required substantial/maximal assistance of staff for bed mobility. Resident #32 utilized antipsychotic, antidepressant, and opioid (pain) medications. Diagnoses included: Alzheimer's Disease, Schizophrenia, and adult failure to thrive. The Care Plan, initiated 8/25/23, revealed a Focus Area that indicated Resident #32's ability to complete Activities of Daily Living (ADLs) had deteriorated and an intervention for staff to assist with morning and evening cares. The Care Plan included a Focus Area identifying Resident #32 with both behavioral symptoms directed at others and not directed at others. Behavioral interventions included: avoid power struggles with resident, avoid over stimulation, convey an attitude of acceptance toward the resident, maintain a calm environment and approach to resident. The Medication Administration Record (MAR), dated January 2024, revealed orders for extra-strength Tylenol 1000 milligrams (mg) three times a day and Tramadol 50 mg three times a day, both scheduled for pain. The MAR also revealed an order for Tramadol 50 mg to be given once a day, as needed (PRN), in addition to the scheduled dose for left knee pain. On 1/06/24 at 1:40 AM, Resident #32 required a dose of the PRN Tramadol 50 mg for left knee pain, as Resident #32 rated 10 out of 10 painful, on a pain scale of 1 to 10. The Social Service Assessment, dated 11/24/23, revealed Resident #32 compliant and cooperative with medications and treatments, cooperative with staff, and accepting of assistance. On 1/05/24, the facility self-reported an allegation of Dependent Adult Abuse to the Department of Inspections, Appeals, and Licensing in response of a report to Administrator, that Staff I, Certified Nursing Assistant (CNA), had stated they would press on Resident #32's knees to cause her pain so that Resident #32 would refuse care from Staff I. Review of the facility's investigation of alleged abuse included: a. CNA Staff F's, written statement, dated 1/05/24, documented Staff I worked on 1/04/24 until 2:00 PM, Staff F arrived to the hallway at 1:30 PM and heard Resident #32 screaming and crying from her room. Staff I told Staff F not to go into Resident #32's room as Staff I was sick of her attitude and letting her deal with her attitude by herself. Staff F went into Resident #32's room shortly after and informed by Resident #32's husband (roommate) that the CNA's who came into room were rough with Resident #32 and had shoved/pushed on his wife's knee. Staff F's statement also reported on 1/05/24 around 10:00 AM, Staff F had been partners with Staff I on the hallway in which Resident #32 resided. Staff F notified Staff I of Nurse request for Resident #32 to lay in bed after lunch, Staff I responded that Staff F was too nice to Resident #32 and that Staff I leaned on Resident #32's leg as often as they could because the more she hurts, the more she screamed, and would refuse to lay down or be changed, and the less they had to deal with her fat ass. b. The Administrator's summary of events, dated 1/05/24, documented the Administrator received report of alleged abuse at 3:30 PM. The Administrator went and visited with both Resident #32 and her husband (roommate), then notified Staff I of suspension for allegation for Dependent Adult Abuse until investigation concluded. Administrator indicated an assessment had been completed with Resident #32, no injuries noted, and Resident #32's Guardian notified of incident and investigation. Additional entry, dated 1/10/24, documented a call placed two times with messages for Staff I to call or come in for an interview regarding her suspension, no return call or answer received from Staff I. c. A hand written document of interviews with victim and victim's husband, dated and signed by Facility Administrator on 1/05/24, revealed that both Resident #32 and husband (roommate) stated Staff I had been rough with Resident #32 and informed that if Staff I needed to move her in wheelchair or mechanical lift, Staff I would do so at times by pushing on Resident #32's legs, which caused her pain. Resident #32 stated her leg would hurt for the rest of the day if staff had hurt it once. Resident #32 and husband had both reported that if Staff I hurt Resident #32, she would refuse Staff I to care for her the rest of the day. Resident #32 and husband stated they felt safe with all other staff, with the exception of Staff I. On 1/07/24 at 10:29 AM, Resident #32 stated staff had been rough when providing cares, unable to offer specific instance or identify staff she had referenced. 1/16/24 at 9:30 AM, the Medical Director explained Resident #32 had a frozen and swollen left knee joint which would cause pain when touched. On 1/17/24 at 11:00 AM, Staff J, Licensed Practical Nurse (LPN), reported Staff I had a bit of a rough attitude, but had not heard her verbally abuse anyone. On 1/17/24 at 12:15 PM Staff A, CNA, stated Resident #32 often had behaviors during cares, reported the resident had hit or kicked staff. Staff A explained Resident #32 had pain in leg/knee and would scream related to knee pain. On 1/17/24 at 2:33 PM, Staff F, CNA, stated they had not been partnered with Staff I prior to 1/05/24. Staff F reported concerns of abuse directly to Staff D, LPN, on 1/05/24 at approximately 2:00 PM. On 1/17/24 at 4:20 PM, Staff K, CNA, reported they had worked with Staff I approximately five times and stated Staff I had been a little short with residents at times, but mostly had been short or defensive with the Nursing Staff. On 1/18/24 at 8:50 AM, Staff D, LPN, reported Resident #32 had yelling or screaming behaviors at times, but also had times being pleasant and agreeable, often depended on staff approach. Staff D reported Staff I moody at times but had not observed any mistreatment of residents. Staff D explained Staff F had been very matter of fact and concerned when she reported the allegation of abuse to her and Staff D confirmed this had been reported on 1/05/24 around the beginning of second shift (approximately 2:00 PM). Staff D notified the Facility Administrator of allegation immediately after report received. On 1/18/24 at 11:30 AM, Resident #32's husband informed that he had told one staff not to touch Resident #32's knee but they continued to do so. Husband unable to identify the staff member by name, however, informed that he hadn't heard the torture since the facility had their [NAME] wow and the staff they had now were very good. On 1/18/24 at 1:30 PM, Staff E, Registered Nurse (RN), stated they had reported Staff I three weeks prior for unprofessional behavior, which included loud tone of voice and insubordination. Review of the personnel file for Staff I included background check with no prior history of abuse, a certificate of Dependent Adult Abuse Training, completed by Staff I on 6/02/23, and Staff I's signature to indicate understanding of the Dependent Adult Abuse facility policy. Staff I also signed and dated, on 6/01/23, the employee expectations for appropriate speech to residents and co-workers and actions to be kind, considerate, and respectful to all families and residents. The Facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, documented residents must not be subjected to abuse by anyone, including but not limited to facility staff. Policy instructed Administrator or designee to complete documentation of the allegation of Resident Abuse and collect any supporting documents relative to the alleged incident including an attempt to obtain witness statements (oral and/or written) from all known witnesses.

Based on clinical record review, staff and Physician interviews, observations, and facility policy review, the facility failed to assess 1 of 7 residents who had reports of pain (Resident #3). The facility reported a census of 81. Findings Include: According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had diagnoses which included dementia, vascular dementia, stroke, diabetes type 2, kidney disease, above the knee left leg amputation and osteoarthritis. The resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated the resident had moderate cognitive ability. The resident required extensive assistance of 2 staff for transfers, dressing, toileting and total dependence on staff for hygiene needs. The resident did not walk or bear weight. According to the Care Plan dated 7/1/2023, Resident #3 identified with a self-care deficit related to decreased mobility, diabetes, depression, anxiety, dementia and a left above the knee amputation. The Care Plan directed the staff to assist the resident with grooming, dressing, personal hygiene and repositioning. The Care Plan informed the staff the resident requires a full body mechanical lift with the assistance of 2 staff. The staff are to use the amputee and/or universal sling during transfers with the mechanical lift. Review of Resident #3's Progress Notes revealed the following entries: a. A Progress Note by Staff B-Licensed Practical Nurse (LPN)/Restorative Nurse regarding communication to the physician dated 9/16/23 at 4:28 pm, revealed notification to the physician that the resident is complaining of pain to the low back and the right lower extremity. The resident is yelling out with cares and transfers. b. A Progress Note by Staff D-Registered Nurse (RN) on 9/17/2023 at 11:00 pm, revealed Staff D noted a 9.5-centimeter (cm) x 2 cm bruise to the resident's groin area, the origin of the bruise is unknown. c. A Progress Note by Staff C-LPN on 9/19/2023 at 3:12 pm, revealed during cares this morning, staff noted some bruises from the right groin on to the right side of the external vulva measuring about 9.5 cm x 2 cm. d. A Progress Note by Staff A-RN/Administrator on 10/4/2023 at 1:18 pm, revealed the resident had a bruised area noted to right hip measuring 9 cm circular area. Provider made aware of bruising and ordered x-rays of pelvis. e. A Progress Note by Staff C-LPN dated 10/4/2023 at 2:49 pm, x-ray results indicated a fracture in the proximal right femur. The care provider has updated and the Power of Attorney (POA) who preferred comfort care rather than sending the resident to the hospital. The care provider ordered Roxanol 0.25 millimeters by mouth every hour as needed for pain. f. A Restorative Program Note written on 10/5/2023 at 3:44 pm, by Staff B-LPN/Restorative Nurse revealed the resident refused to participate with range of motion exercises to lower extremities due to discomfort. The resident only allowed Staff B-LPN/Restorative Nurse to perform range one time this past week. g. A late entry by Staff A-RN/Administrator on 10/6/23 at 5:27 pm, revealed the resident had bruising and not able to tolerate her range of motion exercises due to pain. The roommate shared that a few weeks ago she remembered the staff transferred the resident into her wheelchair with the Hoyer lift and the wheelchair began to tip back. The staff quickly lifted the resident into her wheelchair to prevent a fall to the floor. The Progress Notes revealed the Primary Care Physician ordered X-rays of the pelvis and right femur, a fracture of the right femur identified. The physician ordered pain medications. Review of the Medication Administration Record (MAR) dated September 2023 revealed the Physician directed the staff to administer a one dose of Advil 600 milligrams by mouth for reports of the resident yelling in pain with cares and transfers. Review of the MAR dated October 2023 revealed on 10/4/23 the Physician gave the resident an order for morphine 0.25 milligrams every hour as needed for pain. The MAR indicated the staff administered 2 doses of morphine on 10/4/23 and 1 dose of morphine on 10/7/23 and 10/8/23 for complaints of pain. During an interview with Staff B-LPN on 10/10/23 at 10:15 am, Staff B stated up until 9/12/23 Resident #3 participated in her restorative exercise program but on 9/12/23, the resident refused to participate in the passive excessive program related to pain. Staff B stated she did not assess the resident for abnormalities to extremities. Staff B indicated she reported the increase in pain to the resident's charge nurse. During an interview with Staff C-LPN on 10/10/23 at 12:50 pm, the staff stated he was first made aware of the resident's bruise to her right flank and right hip area on 9/18/23 by Staff K-Certified Nursing Assistant (CNA). Staff K reported to the LPN the resident had bruising and severe pain when they attempted to roll her over for cares. The LPN stated he assessed the bruises but failed to complete a thorough assessment with included range of motion and assessing for a fracture. Staff C contacted the primary care provider regarding the bruises, the physician ordered a portable x-ray. During an interview with Staff N-LPN on 10/10/23 at 2:25 pm, Staff N- LPN stated today at the beginning of her shift at 2:00 pm she received disciplinary action for failure to assess Resident #3 after she had complaints of pain. On 9/18/23 Staff G-CNA reported to her Resident #3 crying each time they would transfer her with a mechanical lift and when they rolled her for cares. Staff L- Social Worker (SW) indicated she did go in and assess but didn't chart anything. Staff N indicated on 9/18/23 the resident did not have any noted bruising to her right hip area. During an interview with Staff A-RN/Administrator on 10/10/23 at 8:45 am, Staff A stated Resident #3 had bruising noted on 9/19/23 and she initiated an investigation to determine the cause. On 10/4/23 Resident #3 had a portable x-ray which revealed an acute comminuted fracture proximal right femur. During an interview with Staff K-CNA on 10/10/23 at 11:25 am, the staff stated when she returned back to work on 9/18/23 the resident yelled out in pain with cares and transfers. Staff K stated during cares she noticed a dark purple bruise to the resident's right hip area. Staff K reported the bruise and increase in pain to Staff C-LPN. She noted she provided cares for the resident on 9/15/23 and is confident the bruises she saw on 9/18/23 were not present on 9/15/23 and the resident did not have severe pain as she did on 9/18/23. During an interview with Staff O-Director of Nursing (DON) on 10/10/23 at 2:00 pm, the staff stated she became aware of the bruises to the right groin and perineal area on 9/18/23. Staff O stated she thought the bruises were caused from the staff using a wrong sling. Staff O stated the staff failed to assess the resident thoroughly as they thought the bruises were from the staff using the wrong sling. Review of an Incident Report dated 9/19/23 revealed during morning cares on this day the staff noticed bruises from the right groin on to the right side of the external vulva measuring 9.5 cm by 2 cm. Review of an Incident Report dated 9/19/23 revealed the resident had bruising noted. Review of a second Incident Report filed on 9/19/23 indicated on 10/5/23 it was noted the resident was not tolerating range of motion exercises to the right hip and had additional bruising. The provider ordered x-rays and the resident went to the emergency room the next day. Review of an x-ray report of the right pelvis dated 10/4/23 revealed the resident had an acute comminuted angulated proximal right femur fracture in the subtrochanteric region. There is underlying generalized osteopenia and degenerative changes of the spine and hip. During an interview on 10/12/23 at 11:10 am with the resident's Primary Care Physician (PCP), revealed the provider group initially became aware of the bruising and pain on 10/4/23. The Advanced Registered Nurse Practioner (ARNP) saw the resident on that day and ordered x-rays to be done. The PCP stated he saw the resident again yesterday (10/11/23) and increased her pain medications to twice daily along with hourly as needed morphine for pain, in attempts to get control of the resident's pain. Observation on 10/10/23 at 9:15 am, Staff P-CNA and Staff K-CNA entered the resident's room with the Hoyer lift. When the staff began to lift the resident from the wheelchair into bed, the resident screamed out in pain. The resident complained of right leg/hip pain and began to cry. Review of an Assessment Policy dated 5/10/17 directed the staff to re-assess the resident when a resident experiences a significant change in their condition. The significant change shall require a change in the resident's Care Plan reflecting the change in condition.

Based on clinical record review, observations, staff and resident interviews, and facility policy review, the facility failed to provide appropriate supervision to keep residents safe during a transfer for two of seven residents reviewed. (Residents #1 and #3). The facility reported a census of 81 residents. Findings Include: 1. According to the MDS (Minimum Data Set) dated 8/16/2023, Resident #1 had no cognitive impairment, transferred from one surface to another with extensive assistance of two staff, had a fall with a major injury since the prior assessment and diagnoses including end stage renal disease, diabetes, and heart failure. The Care Card dated 6/9/2023 revealed the resident required the assistance of two staff and a gait belt to stand pivot transfer. The Care Card dated 8/9/2023 revealed the resident required a full body lift with a large sling to transfer from one surface to another. The Emergency Department (ED) Note dated 8/7/2023 revealed resident #1 had a closed fracture of the left ankle. The resident had a fall at the nursing home on 8/6/2023. The resident stated she had bad neuropathy and cannot feel her feet. The August Treatment Administration Record (TAR), included an order dated 12/22/2022. It directed staff to apply a left ankle brace during the day, and off at bedtime. The order discontinued on 8/25/2023. In the facility Incident Report dated 8/6/2023 at 11:50 A.M., Staff H documented two CNA's lowered the resident to the floor due to the resident unable to stand. The resident indicated staff did not know how to transfer her, and they lowered her to the floor. Staff H indicated she educated staff after the incident occurred. In the resident's Progress Notes dated 8/6/2023 at noon, Staff H, Licensed Practical Nurse (LPN) documented staff summoned her to the resident's bathroom where the resident sat on the floor. The Certified Nurse's Aides (CNA's) attempted to pivot transfer the resident from the toilet, but the resident unable to stand well enough to pivot. On 10/10/2023 at 10:10 A.M., Staff M, Registered Nurse (RN)/MDS Coordinator, reported at the time the resident fell on [DATE], she required assistance of two staff to stand pivot transfer. Staff refer to the Care Cards in the resident rooms or the Care Plans for direction regarding how to transfer a resident. On 10/10/2023 at 10:12 A.M., Staff A, Administrator reported Staff F and Staff J, CNA's would have received education regarding transfers when they were hired. Staff H re-educated them after the resident fell on [DATE]. On 10/10/2023 at 10:20 A.M., Staff B, LPN/Restorative Nurse, reported working on 8/7/2023. Staff were assisting the resident to the dining room for breakfast and they reported the resident had pain. Staff B informed Staff C and they notified the physician and received an order for an x-ray. On 10/10/2023 at 11:30 A.M., Staff K. CNA reported working on 8/7/2023. When Staff K assisted Resident #1 to get up from the bed, the resident reported pain and swelling in the ankle. The resident indicated staff were trying to transfer her and when they turned her, she felt something. On 10/10/2023 at 12:20 P.M., Staff J, CNA reported working on 8/6/2023. She was a new hire and it was her first day working without her mentor. Staff J indicated Resident #1 transferred with the assistance of one staff when Staff J lowered the resident to the floor. The resident had the call light on, Staff J answered the light, attempted to stand, pivot transfer the resident from the toilet to the wheel chair and the resident's legs gave out. The wheel chair sat behind the resident, however the resident asked her to lower her to the floor. Staff H entered the room and assessed the resident. Staff F entered the room and they assisted the resident off the floor and to the wheel chair. The resident never complained of pain at the time. On 10/10/2023 at 1:10 P.M., Staff C, LPN reported working on 8/7/2023 on the day shift. In report, he heard the resident had a fall without injury. That morning, an aide reported the resident had pain, could not stand, and the ankle appeared swollen. The resident indicated staff were new. On 10/10/2023 at 7:55 P.M., Staff I, CNA reported working on the day shift on 8/7/2023. She heard staff lowered the resident to the floor. Typically, the resident transferred with an E-Z stand up lift. That morning, the resident complained of pain in her left foot and it appeared somewhat swollen. Staff I reported the concern to Staff C, LPN. On 10/10/2023 at 8:00 P.M., Staff H, LPN reported working on 8/6/2023 from 6 A.M. until 6 P.M. There were 2 new CNA's working on Resident #1's hall. Staff H was in the next room and one of the staff came and said they lowered the resident to the floor. The resident reported staff did not know how to transfer her. Staff H saw in the TAR that the resident had an order for a brace on the left leg. The resident informed Staff H that she did not want to wear it and had not worn it in a while. Staff H completed the Incident Report and assumed there were two staff present at the time of the fall. The resident never complained of pain the remainder of the shift. The resident did receive a scheduled narcotic pain pill. On 10/12/2023 at 8:23 A.M., Staff F, CNA reported working on 8/6/2023 along with Staff J, CNA and Staff H, LPN on Resident #1's hall. Staff F assisted a resident in a nearby room and Staff J called for help. Staff F and Staff H observed the resident on the bathroom floor. Staff J reported the wheel chair had been placed near the resident but the resident said sit me on the floor. Staff F indicated the resident required the assistance of one staff at the time of the fall. The resident never complained of pain and said she was sorry. Care Cards in the resident's rooms include instructions on how to transfer each resident. Staff F revealed the resident did not have a brace on her left leg at the time of the fall. On 10/12/2023 at 11:00 A.M., Staff E, RN reported working on 8/6/2023 from 6:00 P.M. until 6:00 A.M. on 8/7/2023. Staff E heard in report at the change of shift from Staff H that the resident had a fall. Resident #1 routinely took a pain pill around 7:00 P.M., that was her normal pattern. Staff E would ask her during medication administration if she wanted a pain pill, and she would say yes. The resident never complained of pain in that leg and the aides never reported it. Staff E had no knowledge that the resident had an order for a foot brace. On 10/12/2023 at 11:20 A.M., the resident's physician reported Resident #1 had very frail and itchy skin due to her end stage renal disease. The resident had been in and out of Skilled Care prior to coming to the facility. The resident became more fatigued and declined mentally during her stay. 19126 2. According to the MDS dated [DATE], Resident #3 had diagnoses which included dementia, vascular dementia, stroke, diabetes type 2, kidney disease, above the knee left leg amputation and osteoarthritis. The resident had a BIMS score of 9 out of 15 which indicated the resident had moderate cognitive ability. The resident required extensive assistance of 2 staff for transfers, dressing, toileting and total dependence on staff for hygiene needs. The resident did not walk or bear weight. According to the Care Plan dated 7/1/2023, Resident #3 identified with a self-care deficit related to decreased mobility, diabetes, depression, anxiety, dementia and a left above the knee amputation. The care plan directs the staff to assist the resident with grooming, dressing, personal hygiene and repositioning. The care plan informs the staff the resident requires a full body mechanical lift with the assistance of 2 staff. The staff are to use the amputee and/or universal sling during transfers with the mechanical lift. During an interview with Staff C-Licensed Practical Nurse (LPN) on 10/10/23 at 12:50 pm, Staff C stated the resident has bruises to her right flank area radiating into the groin area and a purple bruise to the resident's right hip which measures 9.5 centimeters (cm) x 2 cm. Staff C stated they think the staff were using the wrong sling to move the resident from surface to surface and should have used an amputee sling. Staff C stated he spoke to the resident's room mate who reported several weeks ago the staff were transferring the resident from the bed to the wheelchair with the Hoyer lift. When they were just ready to sit her in the wheelchair the back of the wheelchair fell backwards. The staff quickly grabbed her away from the wheelchair so she wouldn't land on the floor. During an interview with Staff Q-Certified Nursing Assistant (CNA) on 10/10/23 at 2:30 pm, revealed she was helping a peer transfer Resident #3 with a Hoyer lift. The 2 aides had the resident up in the Hoyer lift just getting ready to seat her when all of a sudden the wheelchair began to tip backwards. The aides quickly grabbed the resident to avoid her falling on the floor. The staff repositioned the wheelchair properly and continued to place the resident in the wheelchair. The resident then went out to the dining room for her evening meal. During an interview with Staff G-CNA on 10/10/23 at 2:40 pm, the staff member stated they were transferring Resident #3, they almost had her in the wheelchair when the chair began to tip back. The aide stated everything happened so fast but they were able to prevent the resident from falling on the floor. Staff G reported the incident to Staff N-LPN at the time of the incident, the aide reported this was the resident's first complaints of pain after the incident. During an interview with Staff D-Registered Nurse (RN) on 10/11/23 at 12:50 pm, the staff stated she reported the bruising on a recent weekend she worked but cannot remember the date, she stated she made out a skin sheet regarding the bruises. Staff D watched the aides do a transfer with the resident using the Hoyer lift on 9/17/23 and felt the resident just didn't seem to be sitting in her chair correctly, she appeared to not be sitting comfortably. At the time of the observations she stated she believes the staff were using a sling that criss-crosses at the resident's legs but then stated she may be wrong about that. Staff D indicated the bruising between the resident's legs did not appear to be causing the resident pain. Review of an Incident Report dated 9/19/23 prepared by Staff A-RN/Administrator, revealed the resident's roommate shared with her that several weeks ago they remembered the staff were transferring the resident into the wheelchair with a Hoyer lift and the resident's wheelchair tipped backwards causing the staff to quickly lift the resident with the sling to prevent a fall to the floor. During an interview with Staff O-RN/Director of Nurses on 10/10/23 at 2:00 pm, revealed she believes the staff used the wrong sling during a transfer on 9/19/23 and she put corrective measures into place. They obtained a new wheelchair for the resident due to the tipper bar on the back of wheel turned to the side. Review of a Primary Care Physician visit note dated 10/4/23 revealed the nursing staff informed her on this day the resident is experiencing acute right hip pain with right hip hematoma. After the facility investigation, the facility aides informed the administration that the resident had an incident on 9/19/23 with a Hoyer lift transfer, where anti-tipper bar on her wheelchair malfunctioned and patient tipped backwards partially, the aides recovered the resident with the Hoyer lift sling and placed the resident into the wheelchair. Review of a Lift and Transfer policy dated 11/17/2018 states all nursing staff shall be oriented to facility lifting and transferring techniques upon hire. The Restorative Nurse or designee shall monitor and provide education on lifting and transferring techniques on an ongoing basis. Training shall cover: all mechanical lifts is use by the facility; all transfer techniques for resident population, use of gait belt; review of body mechanics; care signs, assisting with falls; foot rest safety, alarms and injury prevention.

Based on observation, record review, and staff and family member interviews, the facility failed to assess, implement the care plan and provide an [MEDICATION NAME] as directed to Resident #9 for pain before performing debridement of an ulcer and before restorative care services. Resident #9 displayed facial grimacing with moans and gripped the restorative person ' s hand while the staff person performed restorative services (passive range of motion exercises) and attempted to grab the knife during debridement of a wound. The medication record revealed the staff did not administer an [MEDICATION NAME] before the planned services as directed per the resident ' s plan of care. The medication record revealed the resident had not received an [MEDICATION NAME] since admission into the facility. The sample consisted of 9 residents and the facility reported a census of 82 residents. Findings Include: 1. An admission Minimum Data Set (MDS) Assessment tool, with a reference date of 10/5/2011, revealed Resident #9 had [DIAGNOSES REDACTED]. The MDS identified the resident as severely cognitively impaired but able to make needs known and understand others. The resident required extensive assistance by 2 or 3 staff members for activities of daily living skills. The assessment indicated the resident had bilateral functional limitation in range of motion of both upper and lower extremities. The admission MDS identified the resident as unable to answer questions for a pain assessment but had observed indicators of pain 3 to 4 of the last 5 days. The MDS indicated the resident had shown facial expression such as grimaces, protective body movements such as guarding or holding a body part during movement. The resident had not received any medication or non-medication interventions for pain. The Care Area Assessment (CAA) dated 10/5/11 revealed problem areas with psychosocial well-being, pressure ulcers and pain which then required care plan development. A CAA Summary for pain completed by the facility's MDS nurse on 10/11/11 revealed the following summary: 1. The resident exhibits signs and symptoms of pain such as facial expressions and protective body movements especially when repositioned. 2. The resident has multiple [DIAGNOSES REDACTED]. Facility admission orders [REDACTED] 1. [MEDICATION NAME] (Tylenol) 325 milligrams (mg) 2 tablets (650 mg) administered oral every 4 hours as needed for pain. 2. [MEDICATION NAME] 650 mg administered rectal (suppository) every 4 hours as needed for pain. 3. Physical Therapy to provide pressure ulcer wound debridement. The admission pain assessment completed by Staff O on 9/28/11 revealed Resident #9 had pain in the left hip, right knee and bilateral foot pressure ulcers. The resident had a facial expression pain scale of "3" on a 0 to 5 scale, with 5 as the most severe pain. The pain was identified as sharp and observed with sudden onset with movement. The resident ' s care plan dated 10/18/2011 identified a problem with pain related to multiple decubitus ulcers and directed staff to perform the following: a) Assess pain frequency, intensity, response, and notify physician if needed, performed by nursing staff. b) Confer 1 to 1 to allow expressions of feelings performed by all staff. c) Educate resident to report pain, performed by nursing staff. d) Encourage frequent rest period, performed by all staff. e) Give pain medication as ordered and monitor effectiveness, performed by nursing staff. f) Monitor for nonverbal evidence of pain such as facial grimacing and report, performed by nursing and certified nursing assistant (CNA) staff. The Nurse ' s Notes entries indicated the following: On 9/28/2011, Staff O identified left ankle and right great toe with sudden pain at wound with movement, described as a "4" level on a 0 - 10 pain scale with 10 identified as the worst pain and the resident unable to communicate. At 10:40 p.m. Staff O transcribed the resident as unable to communicate coherently with others secondary to dementia. The family member informed the nurse that the resident had pain in the pressure ulcers of the feet and left side. The September 2011 PRN Medication Sheet indicated the resident did not receive an [MEDICATION NAME] for the pain. 9/30/11 at 4:15 a.m. by Staff K, asked resident questions and received no verbal response, then asked if in pain and no response from the resident. 10/1/11 at 2:25 p.m. transcribed by Staff P, resident does grimace and moan when repositioned to right side and when perineal hygiene performed. The October 2011 PRN Medication Sheet indicated the resident had not been provided an [MEDICATION NAME]. Review of all Resident #9's PRN Medication Administration Records (MAR's) from September-December 2011 revealed the resident did not receive the as needed [MEDICATION NAME] for pain. Observation of restorative range of motion exercises on 12/8/11 at 11:10 a.m. revealed Resident #9 positioned in bed by Staff A. Staff A initiated the exercise as he/she attempted to fully extend the resident's left leg as he/she pulled the foot and leg towards the foot of the bed from a resting position with the knee bent at an approximate 80 degree angle and left hip flexed at an approximate 45 degree angle. The resident's face revealed grimacing of the mouth and forehead during the activity, the resident made a short moaning sound as he/she lifted his/her back up from the bed slightly and attempted to extend his/her left arm and hand towards Staff A's hands positioned on the resident's left leg. Resident #9 squeezed his/her legs together with Staff A's left hand positioned at the inner aspect of the resident's left knee, and restrained Staff A's ability to effectively perform the exercises. The resident did not release Staff A's hand when requested and Staff A used his/her left hand to separate the resident's knees enough to remove his/her left hand and continue the exercises. Resident #9 placed his/her left hand tightly around Staff A's right forearm as he/she performed the leg exercises, the resident did not release Staff A's arm when requested, and Staff A had to use his/her left hand to manually remove the resident's fingers and thumb from his/her forearm as the resident resisted Staff A's attempts to remove his/her grip around his/her forearm. Resident #9's left leg demonstrated some relaxation and extension when Staff A performed flexion/extension of each of the resident's toes and gentle rotation of the resident's ankle as Staff A supported the resident's foot. On 12/7/11 at 12:50 p.m., a family member stated Resident #9 had lived with him/her approximately 5 years prior to placement at the facility. The family member stated he/she knew the resident's needs and could interpret the resident's non-verbal behaviors. The family member stated had observed Staff A perform ROM (Range of Motion) exercises to the resident on a few occasions and the resident had pain during the exercises as demonstrated by her facial expression, body stiffening and resistance to the activity. The family member acknowledged the resident had advanced dementia with limited remaining life expectancy but did not want the resident to experience needless pain, and he/she had planned to contact the physician about the restorative exercises and the resident's pain. On 12/8/11 at 11:06 a.m., Staff A stated that he/she thought Resident #9 could identify him/her by the color of the uniform, as other staff did not wear that color. Staff A stated the resident would "tense up" when he/she went into the resident's room, and "it would look like the resident was in pain but the resident had never said was in pain and hadn ' t cried " . The text book, Clinical Nursing Skills Basic to Advanced Skills fifth edition by Smith Duell and Martin, Page 275 Unit 1, provides direction to discontinue exercises during passive range of motion if client complains of pain or discomfort. On Page 280, the critical thinking options provides direction to assess amount and type of pain and report findings to the physician and to check with physician about premedicating the client before exercises are initiated. On 12/8/11 at 3:00 p.m., the Director of Nursing (DON) indicated he/she was not aware Resident #9 had not received [MEDICATION NAME] or [MEDICATION NAME] since admission to the facility and concerns that the resident had experienced pain during ROM exercises and wound treatments. Both the DON and facility nurse consultant Staff Q indicated they would investigate the matter and place the resident on a scheduled [MEDICATION NAME] regimen if appropriate. On 12/9/11 at 10:40 p.m., Staff E (Restorative Nurse) stated she supervised Staff A and coordinated the restorative program for facility residents. Staff E stated she expected Staff A to communicate any difficulties encountered during performance of the resident's exercise program. Staff E stated she observed Staff A perform each resident's exercise program approximately every 3 months when quarterly MDS assessments were due and did not routinely make random or unplanned observations for the job performance evaluation. Staff A had not informed her of any difficulties with Resident #9. On 12/9/11 at 12:15 p.m., Staff N, staff nurse and Assistant Director of Nursing (ADON) stated he/she had cared for Resident #9 a few times and agreed that the resident would have had pain from the multiple pressure sores and would/could have experienced pain during wound debridement. On12/9/11 at 11:50 a.m., Staff M, facility Physical Therapist, stated he used a sharp blade similar to a scalpel as he cut and removed black eschar and yellow/white slough tissue from Resident #9's pressure sore wounds. Staff M stated not certain if the resident was on a scheduled pain medication or if staff had administered [MEDICATION NAME] before the procedures. Staff M stated the resident did not tell him that he/she had pain during the procedures. Staff M also stated that during the procedures, Resident #9 had attempted to grab his hand and thought the resident would grab the knife. Staff M stated the resident also attempted to grab the blankets to cover self during the procedures. Staff M stated that he had been a Physical Therapist for 7 years and had performed sharp wound debridement to approximately 10 to 15 patients. Staff M stated some people experienced pain during the procedure and agreed Resident #9's attempts to grab his hand or knife could have been the resident's attempt to resist the procedure due to pain. The text Wound Care, A Collaborative Practice Manual for Health Professionals, ( third edition) by Lippincott Williams & Wilkins indicated on page 203 the procedure to follow for Sharp Debridement. The procedure directed to verify the physician orders, explain procedure to patient and premedicate the patient for pain.