Every finding on record at Luna Wellness Rehabilitation, LLC

Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents reviewed for MDS timing. This deficient practice could likely result in residents' needs not being met. The findings are: R #1A. Record review of R #1's admission Record, no date, revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's MDS assessments revealed staff did not complete his admission MDS assessment until 02/04/26. R #3C. Record review of R #3's admission Record, no date, revealed R #3 was admitted to the facility on [DATE]. D. Record review of R #3's MDS assessments revealed staff did not complete his admission MDS assessment until 01/28/26. E. On 03/12/26 at 1:55 PM, during an interview, the MDS Coordinator stated staff did not complete R #1's and R #3's admission MDS assessments within 14 days of admission to the facility.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 2 (R #1 and R #2) of 3 (R #1, R #2 and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #1A. Record review of R #1's admission Record, no date, revealed he was admitted into the facility on [DATE]. B. Record review of R #1's baseline care plan, dated 01/18/26, revealed that it was not signed and locked (finalized by all authors) until 01/21/26. R #2C. Record review of R #2's admission Record, no date, revealed he was admitted into the facility on [DATE]. D. Record review of R #2's baseline care plan, dated 02/26/26, revealed that it was not signed and locked until 03/02/26. E. On 03/12/26 at 1:50 PM, during an interview, the MDS coordinator confirmed R #1 and R #2's baseline care plans were not completed within 48 hours of admission. The expectation was for baseline care plans to be completed within the first 48 hours of admission.

Based on record review and interview, the facility failed to ensure there was a pressure injury risk assessment completed to determine the risk of developing a pressure ulcer (Injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #10) of 1 (R #10) residents reviewed for pressure ulcers. This deficient practice could likely result in a delay in preventative measures and residents developing pressure ulcers. The findings are: A. Record review of R #10's progress note, dated 03/06/26, revealed that R #10 had a pressure ulcer to her coccyx (small bone at the bottom of the spine). B. Record review of R #10's assessments revealed that staff had not completed a Braden Scale (tool for predicting pressure ulcer risk) on R #10 since 01/07/25. C. On 03/12/26 at 4:39 PM, during an interview, the MDS coordinator confirmed that R #10 had not had a Braden Scale assessment since 01/07/25. The MDS coordinator confirmed that the assessment should be completed quarterly or when there is a change in the resident's condition. D. Record review of the Pressure Injury Prevention and Management Policy, no date, revealed that licensed nurses will conduct pressure injury risk assessments (Braden Scale) on all residents upon admission/re-admission, weekly for four weeks, and then quarterly or whenever the resident's condition changes.

Based on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 46 residents (residents were identified by the resident census list provided by the Administrator on 03/10/26). This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. On 03/11/26 at 12:00 PM, during an interview, CNA #8 stated that there are not enough CNA's scheduled. CNA #8 stated that she was not able to take her time providing resident care. She felt that she is always rushed. CNA #8 stated that there are three residents that need two-person assistance (two trained caregivers are required to safely move, transfer, or reposition a patient who is too weak, unsteady, or heavy to move on their own) of her assigned residents. CNA #8 stated that she has to wait for someone from another unit to assist her. It can take a while because the other CNA's are busy on their unit (CNA #8 was not specific on which two residents needed two-person assistance). B. On 03/11/26 at 2:32 PM, during an interview, CNA #9 stated that she is responsible for 15 residents. She has two to three residents that require two-person assistance. She stated that she has to wait for someone to help her with the residents needing the Hoyer lift (a mechanical, portable, or stationary patient lift designed to assist caregivers in transferring individuals with limited mobility between beds, wheelchairs, toilets, or the floor). Waiting can take a while. CNA #9 stated that there are not enough CNA's. CNA #9 stated when showering a resident, the call lights are on for up to 30 minutes sometimes. C. On 03/11/26 at 2:46 PM, during an interview, CNA #10 stated that staff complete showers during the day shift because there aren't enough staff on the night shift to do showers. CNA #10 stated that she has to rush to do resident showers. While she is showering the residents, there are not any other CNA's on her unit. CNA #10 stated they are all busy in the morning. They have to get the residents up and ready for the day, getting them changed, and providing ADL care. She is always rushing and moving. The nurses will watch the floor sometimes, but they are busy too. D. On 03/12/26 at 10:45 AM, during an interview, the Scheduler stated that they do 12-hour shifts. She stated that she schedules two to five CNA's per shift. It just depends on who is available. The Scheduler stated that staff had told her that they need more help. The Scheduler stated that she schedules staff by what she has available. They have a high turn around and can't keep people. The Scheduler stated she will try to schedule staff to cover call ins, but that she doesn't always have staff to fill it. E. Record review of R #9's care plan, revised on 04/09/25, revealed R #9 requires setup/clean-up assistance with eating and hydration. R #9 requires setup assistance with dressing both upper and lower body and toilet hygeine F. On 03/12/26 at 11:57 AM, during an interview, R #9 stated that sometimes there are not enough staff. R #9 stated that he has to wait to get assistance because staff get pretty busy. G. Record review of R #11's Quarterly MDS, dated [DATE], revealed that R #11 needs substantial/maximal assistance with sit to stand. R #11 is partial/moderate assistance with toilet transfer and sit to lying. R #11 is supervision or touching assistance for lying to sitting on the side of his bed. H. On 03/12/26 at 1:26 PM, during an observation of the [NAME] Unit revealed the following: 1. CNA #12 stated to the WCN that she was going to lunch. 2. R #11's call light was on. There were no available staff on the unit. I. On 03/12/26 at 1:42 PM, during an observation of the [NAME] Unit, the Scheduler came onto the unit. She answered R #11's call light. As the Scheduler was walking into R #11's room, R #11 was wheeling himself out of his room in his wheelchair. The Scheduler asked him Did you need help? He stated that he did it himself. J. On 03/12/26 at 1:59 PM, during an interview, LPN #8 (R #11's nurse) stated that at the time R #11's call light was on, that he was doing wound care. CNA #11 (R #11's CNA) was assisting him. K. On 03/12/26 at 2:18 PM, during an interview with R #11 and R #11's sister, R #11 stated that his call light was on because he wanted to get out of bed and needed help. R #11 stated that he got tired of waiting so he did it himself. R #11's sister stated that she had gone to find staff. She also stated that R #11 has to wait up to 30 minutes or more to get help. It is sometimes hard to find staff. L. On 03/12/26 at 2:26 PM, during an interview, the Administrator stated that staffing is a challenge due to staff calling in. The Administrator stated that he would like to have four to five CNA's on the floor. He doesn't have enough CNA's to schedule four to five CNAs per shift. The Administrator stated that for the night shift, he usually has two CNA's scheduled. The Administrator stated he has other staff that will help cover the units as needed. For R #11, if there wasn't coverage, it was a communication issue between the staff to cover lunch breaks. The Administrator stated that the units should have coverage at all times.

Based on observation and interview, the facility failed to secure medications in a medication cart for all 24 residents on North Hall (residents were identified by the census list provided by the DON on 05/12/26). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 05/13/26 at 10:26 AM, during an observation of the North Hall revealed the following: 1. A medication cart was in the hall unlocked. 2. There were no staff present at the medication cart. 3. Medications were in the unlocked drawers of the cart. B. On 05/13/26 at 10:31 AM, during an interview, the ADON confirmed the following: 1. The cart contained medications for residents. 2. There were no staff present at the medication cart. 3. The medication cart was unlocked. 4. Staff were expected to keep the cart locked when the cart was unattended.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #16, R #17, and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for pressure ulcers when staff failed to: 1. Document wound care for R #16 and R 24. 2. Document medication administration for R #17. This deficient could likely cause staff to not have the most accurate resident information if the records are inaccurate or missing adversely impact the care staff provides. The findings are: R #16 A. Record review of review of R #16's admission Record, no date, revealed resident was admitted on [DATE] and discharged on 02/23/26. B. Record review of R #16's Convalescent Care Orders (CCO's, specialized, short-term instructions designed to support a patient's recovery, often focused on rehabilitation, wound care, or medication management to prevent re-hospitalization), dated 02/11/26, revealed an order for wound vacuum (wound vac, a medical device that promotes healing by applying gentle suction to a wound) dressing changes to be performed on Monday, Wednesday, and Fridays. C. Record review of R #16's physician's orders, dated 02/13/26, revealed an order with a start date of 02/16/26, for wound care to R #16's pressure ulcer on her coccyx (lowest part of the spine). Wound vac settings at 125 millimeters of mercury (mmHg, negative pressure measurement) continuously. Change every three days PRN. One time a day every Monday, Wednesday, and Friday. D. Record review of R #16's nursing progress notes, dated 02/13/26, revealed the following: 1. Staff documented wound characteristics (the color of the tissue, the type and amount of drainage, the condition of the surrounding skin, and the presence of odor, pain, or tunneling) and measurements for R #16's wound on her coccyx (lowest part of the spine). 2. Staff did not document performing wound care or applying the wound vacuum to R #16's pressure ulcer on the coccyx. E. Record review of R #16's physician's progress note, dated 02/13/26, revealed the physician documented R #16 had a wound vacuum in place. F. Record review of R #16's Administration Record, dated February 2026, revealed staff did not document performing wound care on R #16's pressure ulcer on her coccyx on 02/13/26. G. On 05/13/26 at 1:04 PM, during a joint interview, the ADON and DON confirmed the following: 1. R #16's CCO dated 02/11/26, had orders for wound care for R #16's pressure wound on her coccyx every Monday, Wednesday, and Friday. 2. The wound care nurse took measurements of all of R #16's wounds on 02/13/26 and would have completed wound care at that time. 3. The wound care nurse did not document completing R #13's wound care or applying the wound vac to R #16's wounds on 02/13/26. 4. Staff were expected to document all wound care in the resident's medical record. R #17 H. Record review of R #17's admission Record, no date, revealed R #17 was admitted to the facility on [DATE]. I. Record review of R #17's physician's orders, dated 04/06/26, revealed an order to apply zinc barrier cream (highly effective, soothing topicals that form a protective physical shield over the skin) to R #17's coccyx twice a day. J. Record review of R #17's Administration Record, dated April 2026, revealed staff did not document applying zinc barrier cream to R #17's coccyx on the following dates and times: 1. 04/20/26 in the morning. 2. 04/22/26 in the morning. 3. 04/23/26 in the morning. 4. 04/30/26 in the evening. K. Record review of R #17's Administration Record, dated May 2026, revealed staff did not document applying zinc barrier cream to R #17's coccyx on the following dates and times: 1. 05/01/26 in the morning. 2. 05/06/26 in the morning. 3. 05/11/26 in the morning. 4. 05/12/26 in the morning. L. On 05/13/26 at 12:58 PM, during an interview, the ADON stated the following: 1. He was the nurse working with R #17 in the morning on 05/12/26. 2. He did apply zinc barrier cream in the morning on 05/12/26. 3. The nurses normally apply the cream when the CNA completes brief changes. 4. He confirmed he did not document applying barrier cream in the morning on 05/12/26. M. On 05/13/26 at 1:00 PM, during a joint interview, the ADON and the DON confirmed the following: 1. Staff did not document applying zinc barrier cream to R #17's coccyx multiple times in April 2026 and May 2026. 2. Staff were expected to document all medication administrations and treatments in the resident's medical record. R #24 N. Record review of R #24's admission Record, no date revealed R #24 was admitted to the facility on [DATE]. O. Record review of R #24's physician orders revealed the following: 1. 03/16/26 repositioning R #24 to reduce pressure on coccyx (is the small, triangular bone at the base of the spine, composed of three to five fused vertebrae, serving as a support for sitting and an attachment point for muscles and ligaments) as needed every shift. 2. 03/25/26 Clean wound to coccyx with normal saline (NS), pat dry, pack with calcium alginate rope (is an external wound dressing designed to absorb exudate and protect the wound from contamination) secure with gauze. Cover with mepilex (is a brand of advanced foam dressings designed to manage a variety of wound types, including chronic, acute, and post-surgical wounds) daily as needed (PRN) one time a day. 3. 04/30/26 Clean wound to coccyx with NS, pat dry, pack with puracol (is a collagen-based wound dressing made from purified bovine collagen, designed to mimic the body's extracellular matrix and provide structural support for healing tissue and cover with bordered foam dressing) daily (PRN) as needed one time a day. P. Record review of R #24's TAR (Treatment Administration Record) for March 2026 revealed staff did not document wound care for R #24 on 03/29/26. Q. Record review of R #24's TAR for April 2026 revealed staff did not document wound care for R #24 on the following dates: 1. 04/02/26. 2. 04/11/26. 3. 04/17/26. 4. 04/25/26. R. Record review of R #24's TAR for May 2026 revealed staff did not document the following: 1. Repositioning R #24 on 05/04/26. 2. Wound care on the following dates: a. 05/04/26. b. 05/09/26. S. On 05/13/26 at 1:00 PM during an interview with LPN #25 confirmed R #24 receives wound care daily. LPN #25 stated wound care documentation is to be done when care is completed in R #24's chart. LPN #24 stated staff reposition R #24 every two (2) hours or as needed. T. On 05/13/26 at 2:25 PM, during an interview with the DON confirmed staff did not document R #24's wound care for 03/29/26, 04/02/26, 04/11/26, 04/17/26, 04/25/26, and 05/09/26. Staff did not document repositioning R #24 for 05/04/26. The DON's expectation is for staff to document when they reposition and provide wound care for residents.

Based on record review and interview, the facility failed to ensure the MDS was accurate for 1 (R #17) of 3 (R #16, R #17, and R #24) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #17's admission Record, no date, revealed R #17 was admitted to the facility on [DATE]. B. Record review of R #17's physician's orders, dated 02/04/26 and discontinued on 04/06/26, revealed an order to apply skin prep (a barrier film to protect skin from adhesive damage, moisture, and friction) to right heel daily for deep tissue injury (a serious, localized form of pressure sore). C. Record review of R #17's nursing progress note, dated 04/30/26, revealed the following:1. Staff documented that R #17's deep tissue injury healed on 03/10/26. 2. Staff continued to put skin prep as a preventative measure (proactive actions taken to stop adverse events, illnesses, or system failures before they occur). D. Record review of R #17's Quarterly MDS Assessment, dated 03/23/26, revealed staff documented R #17 had a pressure ulcer. E. On 05/13/26 at 1:44 PM, during an interview, the MDS coordinator confirmed the following:1. R #17's pressure wound healed on 03/10/26.2. R #17 did not have a pressure wound when her Quarterly MDS Assessment, dated 3. 03/23/26, was completed.4. Staff should not have documented that R #17 had a pressure wound on the Quarterly MDS Assessment.5. Staff were expected to ensure pressure wounds were accurately documented on the MDS Assessments.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #16) of 1 (R #16) residents reviewed for colostomy (a surgical procedure that creates an opening, called a stoma, in the abdominal wall. It connects the colon (large intestine) to the outside of your body, allowing stool to bypass a damaged or diseased part of the lower bowel and collect in an external, odor-proof pouch) care, when staff failed to: 1. Enter colostomy care orders upon admission for R #16's colostomy. 2. Provide colostomy care for R #16's colostomy.These deficient practices could likely lead to the residents not receiving the care needed and/or worsening of their medical conditions. The findings are:A. Record review of review of R #16's admission Record, no date, revealed R #16 was 1. admitted on [DATE]. 2. discharged on 02/23/26. B. Record review of R #16's nursing progress notes revealed the following:1. On 02/12/26, staff documented R #16 had a colostomy.2. On 02/17/26, staff documented R #16's colostomy bag was changed.3. Staff did not document any colostomy care between 02/12/26 and 02/16/26. C. Record review of R #16's physician's orders, dated 02/17/26 (5 days after admission on [DATE]), revealed the following orders;1. An order for colostomy care once a day every three (3) days to start on 02/18/26.2. An order for colostomy care as needed. D. Record review of R #16's Administration Record, dated February 2026, revealed staff did not document providing colostomy care prior to 02/18/26. E. On 05/13/26 at 1:04 PM, during a joint interview, the ADON and DON confirmed the following:1. Staff did not enter orders for colostomy care for R #16 prior to 02/17/26.2. Staff did not document providing colostomy care for R #16 prior to 02/17/26.3. The wound care nurse took pictures of the colostomy without the colostomy bag on 02/13/26 and would have completed colostomy care after taking the pictures.4. They were unable to determine if staff provided colostomy care for R #16 between 02/13/26 and 02/16/26.5. Staff were expected to obtain orders for colostomy care at admission.

Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment was accurate for 1 (R #24) of 3 (R #16, R #17, and R #24) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #24's admission record revealed he was admitted to facility on 05/16/25 with the following diagnoses: 1. Chronic Peripheral [NAME] Insufficiency (is a form of venous disease that occurs when veins in your legs are damaged). 2. Type 2 Diabetes with other skin complications (happens when the body cannot use insulin correctly and sugar builds up in the blood). 3. Unilateral primary osteoarthritis left knee (is a degenerative joint condition that primarily affects one side of the body, typically in the knees, hips, or hands). 4. Muscle weakness, generalized (occurs when your body is not able to contract your muscles properly, leading to reduced strength in one or more of your muscles). 5. Need assistance with personal care (refers to the support provided to individuals who require assistance with daily living activities). 6. Unspecified Dementia, unspecified severity, with agitation (is the loss of cognitive functioning and thinking). B. Record review of the facility's incident list, dated 05/13/25 through 08/27/25, revealed R #24 fell on the following date: 1. 05/30/25, 2. 05/20/25, 3. 07/22/25. C. Record review of R #24's physician's orders, dated 06/13/25, revealed R #24 may use 2 1/4 side rails (a type of bed rail that is typically used in medical settings to prevent patients from exiting their beds) for increased mobility and independence. D. Record review of R #24's care plan dated 06/13/25 revealed R #24 uses 2 1/4 side rails to assist in bed mobility and transfers to maximize independence. E. On 08/27/25 at 2:35 PM, during an interview, the MDS coordinator confirmed the fall with injury that occurred on 05/20/25 should have been documented in R #24's admission assessment dated [DATE] and should have included the use of side rails to assist in bed.

Based on observation, record review, and interview, the facility failed to ensure care plan revisions occurred for 2 (R #16 and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for falls, when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #16 A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had a diagnosis of repeated falls. B. Record review of the facility's incident list, dated 05/13/25 through 08/27/25, revealed R #16 fell on the following dates: 1. 07/13/25, 2. 07/27/25 at 3:35 PM, 3. 07/27/25 at 11:15 PM, 4. 08/15/25, 5. 08/19/25. C. On 08/27/25 at 1:38 PM, during an observation of R #16 in her bed, a fall mat was on the floor next to R #16's bed. D. Record review of R #16's Interdisciplinary Team Meeting for Falls spreadsheet (document with information that IDT team discussed regarding resident falls), no date, revealed after R #16's fall on 07/13/25, the IDT team added a fall mat as an intervention for R #16's falls. E. Record review of R #16's care plan, dated 07/08/25, revealed staff did not revise R #16's care plan to include a fall mat. R #24 F. Record review of R #24's admission record revealed he was admitted to facility on 05/16/25. G. Record review of the facility's incident list, dated 05/13/25 through 08/27/25, revealed R #24 fell on the following date: 1. 05/30/25, 2. 05/20/25, 3. 07/22/25. H. On 08/27/25 at 1:30 PM, during an observation of R #24's room, a fall mat was on the floor against the wall on R #24's side of the room, and 2-1/4 side rails up (a type of bed rail that is typically used in medical settings to prevent patients from exiting their beds) on top of R #24's bed. I. On 08/2725 at 1:36 PM, during an interview, CNA #25 stated R #24 had the following interventions in place to prevent falls: 1. R #24 uses side rails for mobility in bed and when he gets up R #24 side rails to assist with his balance. 2. R #24 call light within reach. 3. R #24 has a fall mat placed on the floor when laying in bed. 4. R #24 is placed in common area so staff can keep a close eye on R #24. J. Record review of R #24's care plan, dated 06/13/25, revealed the following: 1. Staff did not document R #24 call light within reach as an intervention. 2. Staff did not document the use of a fall mat as an intervention to prevent injury if R #24 falls. 3. Staff did not document that R #24 is placed in a common area as an intervention to prevent falls. K. On 08/27/25 at 2:29 PM during an interview LPN #28, she confirmed R #24's care plan does not indicate R #24's use for a fall mat, and interventions and it should be care planned. L. On 08/27/25 at 2:35 PM, during a joint interview, the MDS coordinator and DON confirmed the following: 1. R #16's and R # 24's care plan was not revised to include a fall mat next to bed. 2. Staff are expected to revise the care plan when a new intervention is added for falls.

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #16, and R #24) of 3 (R #16, R #17, and R #24) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #16 A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 08/27/25 at 1:38 PM, during an observation of R #16 in her bed, revealed the following: 1. A fall mat was on the floor next to R #16's bed. 2. Bed rails were in place at the top of both sides of R #16's bed. C. On 08/27/25 at 1:44 PM, during an interview with LPN #17, she stated the following: 1. About three (3) weeks before LPN #17's interview with the surveyor (she did not know specific dates), R #16 had several falls. 2. Prior to her falls, she used to use a walker but now required a wheelchair. 3. R #16 would try to get up without assistance. 4. R #16 was unaware that it was unsafe for her to get up without assistance. 5. She had a fall mat and bed rails to prevent falls. D. Record review of R #16's change of condition MDS (a significant decline or improvement in a resident's status, impacting two or more areas and requiring an Interdisciplinary Team (IDT) review and potential care plan revision), dated 07/15/25, revealed staff completed a change in condition MDS on 07/15/25. E. Record review of R #16's entire medical record, no date, revealed the following: 1. Staff completed a bed rail assessment for R #16 on 01/17/25. 2. Staff did not document a bed rail assessment after R #16's change in condition on 07/15/25. F. Record review of R #16's physician's orders, dated 04/21/25, revealed an order R #16 may utilize side rails to assist with repositioning. R #24 G. Record review of R #24's admission record revealed he was admitted to facility on 05/16/25. H. Record review of R #24's physician's orders, dated 06/13/2025, revealed R #24 may use 2 1/4 side rails for increased mobility and independence. I. Record review of R #24's progress notes no date, revealed the progress note did not contain any documentation of R #24 use of side rails on R #24's bed. J. Record review of R #24's entire medical record revealed a side rail assessment (carried out by a competent person considering the bed occupant, assessing the rail is suitable for use) was not completed. K. Record review of R #24's care plan dated 06/13/25 revealed R #24 uses 2 ¼ side rails to assist in bed mobility and transfers to maximize independence. L. On 08/27/25 at 1:30 PM, during an observation of R 24's bed, revealed bed rails were in place at the top of both sides of R #24's bed. M. On 08/27/25 at 2:15 PM during an interview with the Therapy Director, she stated that therapy did not do any assessments for R #24 regarding using side rails on his bed. She stated nursing is responsible for that. N. On 08/28/25 at 10:23 AM, during an interview with LPN #16, the following was revealed: 1. Upon admission the admitting nurse obtains consents for bed rails for all residents. 2. The only residents who did not get bed rails were residents who were immobile (unable to move without assistance) and residents who refused to sign the consent. 3. The admitting nurse did not complete an assessment for the safety of bed rails prior to the placement of bed rails on any residents. 4. She was not sure if therapy evaluated residents for the safety of bed rails. O. On 08/28/25 at 10:29 AM, during a joint interview, the MDS and the DON confirmed the following: 1. The IDT team determines the safety of bed rails prior to placing bed rails on resident's beds. 2. Residents should be assessed for the safety of bed rails prior to placing bed rails on the resident's bed. 3. They were unsure if a consent was required prior to placing bed rails on a resident's bed. 4. Residents should be reassessed for the continued safety of bed rail use at least every three (3) months and with any change in condition. 5. R #16 had not had an assessment for the safety of the use of bed rails since 01/17/25. 6. R #16 had a change in her condition in July 2025 (did not give specific date). 7. Staff should have completed a bed rail assessment on R #16 after her change in condition in July 2025. 8. Staff did not document a bed rail assessment prior to placing bed rails on R #24's bed. 9. Staff did not obtain a consent prior to placing bed rails on R #24's bed.

Based on observation and interview, the facility failed to store food under sanitary conditions for all 33 residents (residents were identified by the resident census provided by the Administrator on 03/31/25) when staff failed to: 1. Label and date all items in the kitchen refrigerator. 2. Cover food in the refrigerator. Failure to store food under safe and sanitary conditions could likely to lead to foodborne illnesses in residents. The findings are: A. On 03/31/25 at 1:10 PM, during an observation of the kitchen, revealed the following: 1. The walk-in refrigerator had four trays with 12 bowls of strawberry desserts on each tray. 2. The desserts did not have a cover over them. 3. The desserts did not have a date to indicate when they were prepared. B. On 03/31/25 at 1:20 PM, during an interview the Director of Dietary confirmed that the desserts should be covered with clear plastic wrap and each tray should be labeled with the date the desserts were prepared.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #8, R #23, and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure that antidepressant medication for R #8 was prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #23 and R #24. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #8 A. Record review of R #8's admission record, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 did not have a psychiatric diagnosis. B. Record review of R #8's [name of state] PASRR (Preadmission Screening and Resident Review) Level 1 Identification Screen form (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 03/13/25, revealed R #8 did not have a diagnosis or suspected mental illness (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior). C. Record review of R #8's [name of state] PASRR Level 1 Identification Screen form, dated 03/25/25, revealed R #8 did not have a diagnosis or suspected mental illness. D. Record review of R #8's physician's orders revealed the following: 1. An order dated 03/13/25, for bupropion (antidepressant medication) 100 mg once a day for depression. 2. An order dated 03/25/25, for bupropion 100 mg at bedtime for depression. E. Record review of R #8's MAR, dated March 2025, revealed R #8 received Bupropion 100 mg on the following dates: 1. 03/14/25, 2. 03/15/25, 3. 03/16/25, 4. 03/17/25, 5. 03/18/25, 6. 03/19/25, 7. 03/25/25, 8. 03/26/25, 9. 03/27/25, 10. 03/28/25, 11. 03/29/25, 12. 03/30/25. F. Record review of R #8's admission MDS, dated [DATE], revealed the following: 1. Section I- Active diagnoses: staff did not select depression. 2. Section N- Medications: staff documented that R #8 was taking an antidepressant. G. On 04/07/25 at 1:53 PM, during an interview, RN #16 confirmed the following: 1. R #8 had an order for bupropion 100 mg at bedtime for depression. 2. R #8 did not have a diagnosis of depression in her medical record. H. On 04/07/25 at 3:25 PM, during an interview, the DON confirmed that she would expect a resident to have a diagnosis of depression if the resident has an order for an antidepressant medication. Gradual Dose Reduction R #23 I. Record review of R #23's face sheet, revealed R #23 was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder, recurrent, mild (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). J. Record review of R #23's physician's orders revealed an order dated 03/03/25 for Sertraline HCL (Zoloft. An antidepressant medicine used to treat clinical depression) tab 25 mg, 1 tablet by mouth one time a day for depression. K. Record review of R #23's MAR dated March 2025 revealed staff documented that R #23 was given Zoloft as ordered daily. L. Record review of R #23 care plan dated 08/15/22, for the use of antidepressant medication related to Depression, and poor nutrition. M. Record review of R #23 of the pharmacy recommendation for R #23 dated 01/02/25, revealed the following: 1. R #23 is currently receiving antidepressant Sertraline since 01/12/24 consider gradual dose reduction (GRD). 2. R #23's physician did not provide ratrional with patient specific information as to why resident needed to remain on medication. 3. R #23's physician failed to document clinical rationale to continue R #23's use of Zoloft. N. Record review of R #23's entire medical record (no date) revealed no GDR documented from the provider in record. O. On 04/04/25 at 11:44 AM, during an interview, the DON confirmed that there was no rationale from the physician in R #23's medical record regarding the gradual drug reduction recommendation for R #23. R #24 P. Record review of R 24's admission record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE]. 2. Diagnosis of anxiety disorder (mental health conditions that cause excessive fear and worry in response to situations). Q. Record review of R #24's physician's orders revealed an order, dated 08/17/24, hydroxyzine (antihistamine medication used for short-term treatment of nervousness and tension which may occur with certain mood disorders such as anxiety) 25 mg give 1 tablet by mouth at bedtime for anxiety (feeling of worry, nervousness, or unease, typically about something with an uncertain outcome). R. Record review of R #24's pharmacy recommendation dated 02/03/25 revealed the following: 1. This resident (R #24) has been taking the anxiolytic (medication used to treat anxiety) hydroxyzine 25mg at bedtime for anxiety since 08/17/24. 2. Please evaluate the current dose and consider a dose reduction. 3. The form was marked: Previous dose reduction failed; date of failed GDR was left blank. 4. Important: please add resident specific documentation to support the above action or check below if information was added to physician progress notes: This area was left blank. 5. The form was not signed by the Doctor. S. Record review of R #24's Doctor's Progress Note dated 02/21/25 revealed the following: 1. History of present illness: minimal depression, cognitively intact patient 2. Assessment: Anxiety disorder 3. Plan: hydroxyzine 25 mg 1 tablet at bedtime for anxiety. 4. The resident's doctor did not document any rationale to continue the medication without a GDR. T. Record review of R #24's Electronic Medical Record (EMR) did not provide any additional information regarding the indication for continued use or rationale on why the pharmacist recommendation was not implemented. U. Record review of R #24's Medication Administration Records revealed the following: 1. R #24 received hydroxyzine 25 mg daily at bedtime February 1st through February 28th, 2025. 2. R #24 received hydroxyzine 25 mg daily at bedtime March 1st through March 31st, 2025. V. On 04/07/25 at 3:22 PM, during an interview with the DON, she confirmed that the GDR was not completed and there was no additional information provided in the physician progress notes.

Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #8 and R #13) of 2 (R #8 and R #12) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #8 A. On 04/01/25 at 10:55 AM, during an interview with R #8's family member, he stated the following: 1. R #8 was transferred to the hospital on [DATE], due to having high blood pressure. 2. The facility contacted him by phone (R #8's family member was not specific on when) to notify him that R #8 was being transferred to the hospital. 3. He was notified verbally that R #8 was being transferred to the hospital and that the facility would hold R #8's bed for her. 4. He did not receive a written notification of the bed hold policy and was not aware of how many days the facility would hold the bed for R #8. B. Record review of R #8's medical record revealed the following: 1. On 03/19/25, R #8 was sent to the hospital for high blood pressure. 2. Staff did not document a written bed hold notice for R #8's transfer to the hospital on [DATE]. C. On 04/04/25 at 11:16 AM, during an interview with the Business Office Manager (BOM), she confirmed the following: 1. She was the individual who was responsible for giving bed hold notices. 2. She did not give R #8 or her representative a bed hold notice for her transfer to the hospital on [DATE]. 3. She stated R #8's payer source allows for a 3 day interrupted stay. 4. She stated she thought the bed hold notice did not apply to her because of R #8's payer source. R #13 D. On 04/01/25 at 1:26 PM, during an interview with R #13's family member, he stated the following: 1. R #13 was sent to the hospital two months prior to the interview (did not remember the date) after R #13 fell. 2. The facility contacted him by phone (R #8's family member was not specific on when) to notify him that R #13 was being transferred to the hospital. 3. He was not told how long the facility would hold a bed for R #13. 4. He did not receive a written notification of the bed hold policy and was not aware of how many days the facility would hold the bed for R #13. E. Record review of R #13's medical record revealed the following: 1. On 01/04/25, R #13 was sent to the hospital for pain in her leg after she fell. 2. Staff did not document a written bed hold notice for R #13's transfer to the hospital on [DATE]. F. On 04/04/25 at 11:26 AM, during an interview with the BOM, she confirmed the following: 1. She does not give the bed hold notification to the residents or their representative at the time of transfer to the hospital. 2. If the resident does not return to the facility the same day, they will mail a bed hold notice to the family the next day. 3. She did not complete a bed hold notice for R #13's transfer to the hospital on [DATE], because she returned the same day.

Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 1 (R #24) of 4 (R #11, R #15, R #24 and R #25) residents reviewed for accurate MDS assessments. If staff do not document accurately on the MDS assessment then the facility may not be aware of the residents needs. The findings are: A. Record review of R 24's admission record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE]. 2. Diagnosis of anxiety disorder (mental health conditions that cause excessive fear and worry in response to situations). B. Record review of R #24's physician's orders dated 08/17/24, revealed the following, hydroxyzine (antihistamine medication used for short-term treatment of nervousness and tension which may occur with certain mood disorders such as anxiety) 25 mg give 1 tablet by mouth at bedtime for anxiety (feeling of worry, nervousness, or unease, typically about something with an uncertain outcome). C. Record review of R #24's Doctor's Progress Note dated 10/11/24 revealed the following: 1. Assessment: Anxiety disorder 2. Hydroxyzine 25 mg 1 tablet at bedtime for anxiety. D. Record review of R #24's Quarterly MDS, dated [DATE], revealed the staff did not document R #24's diagnosis of anxiety disorder. E. On 04/07/25 at 3:22 PM, during an interview with the DON, she confirmed that the diagnosis of anxiety disorder should have been included on R #24's quarterly MDS.

Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #35) of 3 (R #8, R #13, and R #35) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #35's admission record revealed R #35 was admitted to the facility on [DATE]. B. Record review of R #35's physician order, dated 03/07/25, revealed an order for a diabetic, consistent carbohydrate diet (a diet that aims to maintain stable blood sugar levels by consuming a similar amount of carbohydrates at each meal and snack to help prevent blood sugar spikes and crashes) with ground texture (foods that are soft, moist, and easily chewed, with solid pieces no larger than 1/4 inch, often recommended for individuals with difficulty swallowing or chewing) and thin consistency (liquids that flow like water) for fluids. B. Record review of R #35's Admission Minimum Data Set (MDS, federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) Assessment, dated 03/12/25, revealed the following: 1. Section K- Swallowing/Nutritional Status: a. K0200 Height and Weight; staff documented R #35 was 70 inches (5.8 feet) tall and weighed 149 pounds. b. K0300 Weight Loss; staff documented no or unknown weight loss. c. K0520 Weight Gain; staff documented no or unknown weight gain. C. Record review of R #35's care plan, dated 03/31/25, revealed staff documented the following: 1. R #35's goal was to comply with a recommended diet for weight reduction (weight loss). 2. Intervention was if unsuccessful at weight loss, or if the resident choose not to lose weight, refer me (R #35) to the physician. D. On 04/07/25 at 2:05 PM, during an interview with RN #16, she confirmed the following: 1. R #35 was not overweight. 2. R #35's care plan had a goal to lose weight and interventions in place for weight loss. 3. R #35's care plan was not appropriate for R #35 because he did not need to lose weight. E. On 04/07/25 at 3:23 PM, during an interview with the DON, she confirmed that the resident care plans should be specific for the resident and R #35's care plan should not have included a plan for weight loss.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #35) of 3 (R #24, R #25, and R #35) residents sampled for nutrition, when staff failed to follow protocols for identifying weight loss when R #35 had weight loss. This deficient practice could likely result in residents losing weight without the facility being aware of causing physical and mental health issues. The findings are: A. Record review of R #35's admission record revealed R #35 was admitted to the facility on [DATE]. B. Record review of R #35's hospital records, dated 03/01/25, revealed the following: 1. On 02/25/25 R #35 weighed 132.4 pounds. 2. On 03/02/25 R #35 weighed 145.11 pounds (12.71 pound weight gain). C. Record review of R #35's weights in the medical record revealed the following: 1. On 03/07/25, R #35 weighed 149 pounds. 2. On 03/10/25, R #35 weighed 142.6 pounds. 3. On 03/17/25, R #35 weighed 143 pounds. 4. On 03/31/25, R #35 weighed 126.2 pounds. D. Record review of R #35's physician order, dated 03/07/25, revealed the following: 1. An order for a diabetic consistent carbohydrate diet (a diet that aims to maintain stable blood sugar levels by consuming a similar amount of carbohydrates at each meal and snack to help prevent blood sugar spikes and crashes) with ground texture (foods that are soft, moist, and easily chewed, with solid pieces no larger than 1/4 inch, often recommended for individuals with difficulty swallowing or chewing) and thin consistency (liquids that flow like water) for fluids. 2. R #35's medical record did not contain any other diet orders or orders for nutritional supplements. E. Record review of R #35's dietitian note, dated 03/10/25, revealed the following: 1. R #35's was to continue on current diet order. 2. Staff were to monitor R #35's food intake for potential need to add a nutritional supplement (formulated to provide a concentrated source of essential nutrients, including vitamins, minerals, protein, and calories, to help meet nutritional needs when food intake is insufficient or when individuals struggle to eat or digest food). F. Record review of R #35's progress notes revealed the following: 1. On 03/08/25, R #35 had +1 pitting edema [a type of swelling where pressing on the skin leaves a temporary indentation or pit. It's often caused by fluid buildup in the tissues and can be a sign of underlying conditions. Grades severity from 0 (no edema) to +4 (very deep indentation with a slow rebound), and can cause rapid fluctuation in weight] in both legs and left arm. 2. On 03/09/24, R #35 had +2 pitting edema in both legs. 3. On 03/13/24, R #35 had +1 pitting edema in both legs. 4. On 03/17/25, R #35 had +2 pitting edema in both legs. 5. On 03/18/25, R #35 had +2 pitting edema to both legs. 6. On 03/19/25, R #35 had +2 pitting edema to both legs. 7. On 03/21/25, R #35 had +2 pitting edema to both legs. 8. On 03/22/25, R #35 had +2 pitting edema to both legs. 9. On 03/23/25, R #35 had +2 pitting edema to both legs. 10. On 03/26/25, R #35 had no edema. 11. On 03/27/25, R #35 had no edema. G. On 04/03/25 at 2:17 PM, during an interview, CNA #16 confirmed the following: 1. R #35 had weight loss (see finding C). 2. She weighed R #35 on 03/31/25 and noticed he had lost weight. 3. She thought she notified the nurse about the weight loss. 4. She couldn't remember which nurse she notified. H. Record review of R #35's entire medical record, no date, revealed the record did not contain any documentation that staff notified the physician or the dietitian about R #35's weight loss. I. On 04/03/25 at 2:22 PM, during an interview, the DON confirmed the following: 1. She was not aware that R #35 had weight loss (see finding C) 2. She would expect the person who weighed the resident to notify the nurse about the weight loss. 3. She would expect the nurse to notify the physician about weight loss right away. 4. She stated the facility has nutritional at risk meetings weekly to be able to identify anyone who has lost weight. 5. She confirmed that the facility had not had a nutritional at risk meeting for R #35. J. On 04/07/25 at 2:05 PM, during an interview, RN #16 confirmed the following: 1. R #35 had lost weight (see finding C). 2. R #35 had significant edema for a while after he arrived (was unable to state how long). 3. R #35's weight loss could have been due to his edema decreasing. 4. Staff should have notified the provider when R #35 lost weight.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and the physician provided a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation for 2 (R #23 and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), recurrent, mild. B. Record review of R #23's physician's orders revealed an order dated 03/03/25 for Zoloft (Sertraline. An antidepressant medicine used to treat clinical depression) oral tablet 25 mg, 1 tablet by mouth one time a day for depression. C. Record review of R #23's pharmacy recommendation summary report dated 01/02/25, revealed the following: 1. R #23 is currently receiving antidepressant Zoloft since 01/12/24, consider gradual dose reduction (GRD). 2. R #23's physician did not provide rationale with patient specific information as to why R #23 needed to remain on medication. D. On 04/04/25 at 11:44 am, during an interview, the DON confirmed that the provider did not provide a rationale for recommendation, follow up, or supporting information as to why the resident is still on medication Zoloft. R #24 E. Record review of R #24's physician's orders revealed the following: 1. Order, dated 08/17/24, hydroxyzine (antihistamine medication used for short-term treatment of nervousness and tension which may occur with certain mood disorders such as anxiety) 25 mg give 1 tablet by mouth at bedtime for anxiety (feeling of worry, nervousness, or unease, typically about something with an uncertain outcome). F. Record review of R #24's pharmacy recommendation dated 02/03/25, revealed the following: 1. This resident (R #24) has been taking the anxiolytic (medication used to treat anxiety) hydroxyzine 25 mg at bedtime for anxiety since 08/17/24. 2. Please evaluate the current dose and consider a dose reduction. 3. The form was marked: Previous dose reduction failed; date of failed GDR. was left blank. 4. Important: please add resident specific documentation to support the above action or check below if information was added to physician progress notes: This area was left blank. 5. The form was not signed by the Doctor. G. Record review of R #24's physician's orders revealed an order dated 08/17/24, hydroxyzine 25 mg give 1 tablet by mouth at bedtime for anxiety. H. Record review of R #24's Doctor's Progress Note dated 02/21/25 (most recent doctor's note) revealed the following: 1. History of present illness: minimal depression, cognitively intact patient 2. Assessment: Anxiety disorder 3. Plan: hydroxyzine 25 mg 1 tablet at bedtime for anxiety. 4. The resident's doctor did not document any rationale to continue the medication without a GDR. I. Record review of R #24's Electronic Medical Record (EMR) revealed the provider did not provide any additional information regarding the indication for continued use or rationale on why the pharmacist recommendation was not implemented. J. On 04/07/25 at 3:22 PM, during an interview, the DON confirmed that the GDR was not completed and there was no additional information provided in the physician progress notes.

Based on record review and interview, the facility failed to ensure resident medical records contained documentation that residents received, or staff offered the pneumococcal (a bacteria that caused pneumonia infection of the respiratory tract) vaccination for 1 (R #35) of 5 (R #9, R #15, R #23, R #25, and R #35) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. Record review of R #35's admission record, revealed R #35 was admitted on [DATE]. B. Record review of R #35's pneumococcal vaccination consent, no date, revealed R #35 consented to the pneumococcal vaccination. C. Record review of R #35 medical record, revealed the record did not contain documentation that staff administered the pneumococcal vaccination. D. On 04/07/25 at 3:45 PM, during an interview, the Infection Preventionist (IP) confirmed the facility did not administer the pneumococcal vaccination to R #35.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis for access by the public and all 33 residents (residents were identified by the census list provided by the Administrator on 08/05/24), when staff failed to: 1. Post required staffing information. 2. Retain 18 months of posted staffing records. These deficient practices could likely prevent the public, as well as the residents from having access to accurate current and previous staffing records. The findings are: A. On 04/03/25 at 1:45 PM, during an observation of the facility, revealed staff did not post the daily staffing information. B. On 04/03/25 at 1:48 PM, during an interview, the Social Services Worker (SSW) confirmed that the daily staffing information was not posted. C. Record review of the daily staffing records provided by the DON, revealed the following: 1. The facility did not have posted daily staffing sheets from 04/01/25 through 04/03/25. 2. The facility did not retain posted daily staffing sheets prior to 03/14/25. D. On 04/03/25 at 2:40 PM, during an interview, the facility's Scheduler confirmed that she did not post the daily staffing information on 04/01/25, 04/02/25, or 04/03/25. E. On 04/03/25 at 1:53 PM, during an interview with the DON, she confirmed the following: 1. The daily staffing record was not posted on 04/01/25, 04/02/25, and 04/03/25. 2. Staff were expected to hang staffing information daily in the hall near the entrance common area. 3. The facility did not have the daily staffing records prior to 03/14/25.

Based on interview and record review, the facility failed to keep residents free from abuse for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse when staff failed to: 1. Implement interventions to prevent R #24 from touching R #21, R #23, R #25, and R #26 without consent. 2. Ensure R #24 did not enter R #25's room and R #27's personal space without permission while not fully clothed. 3. Ensure R #24 did not use sexually inappropriate comments when speaking to R #22. These deficient practices could likely result in physical harm to residents with inappropriate behaviors, physical harm and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions for the residents who were subject to this behavior. The findings are: R #24 A. Record review of R #24's medical record revealed R #24 was admitted to the facility on [DATE]. B. Record review of R #24's medical record no date revealed he had the following diagnoses: 1. Vascular Dementia (problems, with reasoning, planning, judgment, memory and other though processes caused by brain damage from impaired blood flow to the brain), unspecified severity, with agitation. 2. Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). 3. Other Age-related cataract (cloudy area in the lens of the eye). 4. Dry eye syndrome (tears aren't able to provide adequate lubrication of the eye) of bilateral lacrimal glands (tear-shaped gland that secretes tears). C. Record review of R #24's care plan, dated [DATE], revealed R #24 had a history of making sexually inappropriate comments, gestures and would flash his private areas (added to care plan on [DATE]). On [DATE], this behavior was identified as resolved and removed from R #24's care plan. D. Record review of R #24's current care plan, multiple dates, revealed the following: 1. On [DATE], R #24 had severely impaired cognitive function and becomes restless, agitated, or more confused at times throughout the day. a. On [DATE], staff revised the cognitive status section of R #24's care plan to include an intervention for staff to provide one-to-one observation as practicable (based on staff availability). 2. On [DATE], staff added noncompliance/preferences to R #24's care plan, with the goal to redirect R #24 when he overestimates his abilities (believe his abilities are more than they are), refuses care, and respect his preferences. a. On [DATE], staff revised the noncompliance/preference section of R #24's care plan to include that R #24 attempts to engage in explicit/sexual language. b. On [DATE], staff revised the noncompliance/preference section of R #24's care plan to include that R #24 prefers to be nude and prefers to be naked from the waist down. The intervention is for staff to encourage R #24 to cover himself when in a common area. 3. Staff did not document the behavior that R #24, which included entering other residents rooms without consent or interventions aimed to prevent this behavior. 4. Staff did not document the behavior that R #24 touched residents without consent or interventions aimed to prevent this behavior. E. Record review of R #24's medical record revealed that safety checks were completed every 15 minutes from [DATE] to [DATE] and every 30 minutes from [DATE] to [DATE] (unclear why safety checks stopped). F. Record review of R #24's physician orders, multiple dates, revealed the following orders: 1. Start date [DATE], discontinue date [DATE], Risperidone (antipsychotic medication used to treat schizophrenia, bipolar, or irritability associated with autistic disorder), 1 milligram (mg, unit of measure indicating ,d+[DATE] of a gram), every 12 hours as needed (PRN) for agitation related to vascular dementia. 2. Start date [DATE], discontinue date [DATE], Risperidone 1 mg, two times a day for dementia with behaviors related to restlessness and agitation. 3. Start date [DATE], Remeron (antidepressant used to treat depression) 15 mg at bedtime for depression. 4. Start date [DATE], discontinue date [DATE], Risperidone 0.5 mg at bedtime for vascular dementia with agitation. 5. Start date [DATE], discontinue date [DATE], Risperidone 0.5 mg at bedtime for vascular dementia with agitation. 6. Start date [DATE], discontinue date [DATE]: Depakote (anticonvulsant medication used to treat seizure disorders and certain psychiatric conditions) 125 mg, one tablet, two times a day, for restlessness and agitation. 7. Start date [DATE], Depakote 125 mg, two tablets, two times a day for restlessness and agitation. G. Record review of R #24's [DATE] Medication Administration Record revealed the following: 1. On [DATE], PRN Risperidone administered. 2. On [DATE], PRN Risperidone not administered. 3. On [DATE], PRN Risperidone not administered. 4. On [DATE], PRN Risperidone not administered. 5. On [DATE], PRN Risperidone not administered. 6. On [DATE], PRN Risperidone not administered. 7. From [DATE] through [DATE] all scheduled doses of Risperidone were received. H. Record review of R #24's [DATE] Treatment Administration Record (TAR), revealed that a one-to-one safety observation every hour for Safety monitoring was added to R #24's TAR on [DATE] and discontinued on [DATE]. I. Record review of R #24's [DATE] Activities of Daily Living (ADL) sheet revealed the following: 1. On [DATE], staff documented that R #24 had sexually inappropriate behaviors. 2. On [DATE], staff documented that R #24 had sexually inappropriate behaviors. J. Record review of R #24's medical record revealed that R #24 was on 15-minute safety checks from [DATE] to [DATE]. R #23 K. Record review of R #23's medical record revealed R #23 was admitted on [DATE]. L. Record review of R #23's medical record no date revealed she had the following diagnoses: 1. Post-traumatic stress disorder (PTSD, a disorder in some people who have experienced a shocking, scary, or dangerous event). 2. Delusional Disorders (a mental illness in which the individual has one or more firmly held false beliefs that persist for at least one month). 3. Visual hallucinations (a false perception of an external visual stimulus where none exists). 4. Major depressive disorder (MDD,a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily life). M. Record review of R #23's quarterly MDS, dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 15 (13 to 15 cognitively intact). N. Record review of R #23's nursing progress note, dated [DATE], revealed the following: 1. R #23 reported that R #24 had touched her leg and made her feel unsafe. 2. R #23 sat in her wheelchair, having a conversation in front of R #24's doorway. 3. R #23 was unable to propel herself from R #24's doorway. 4. R #24 tried to assist R #23 in moving and touched her leg. 5. Staff were placed outside R #23 and R #24's rooms to closely observe for any behaviors. 6. R #23 and R #24 were placed on 15-minute safety checks, which included observing the residents every 15 minutes. O. Record review of CNA #21 witness statement, dated [DATE], revealed the following: 1. R #23 was sitting in front of R #24's room having a conversation. 2. CNA #21 heard R #23 tell R #24 to get away from her. 3. CNA #21 observed R #24 trying to help R #23 move because she was stuck between his wheelchair and the wall. 4. R #23 told CNA #21 that R #24 did not hurt her, but he touched her left leg up close to her groin. 5. R #23 told CNA #21 that she didn't feel safe anymore. 6. R #23 said that she was afraid R #24 would try to come into her room. P. Record review of R #23's progress note, dated [DATE], revealed the following: 1. R #23 was up all-night having hallucinations that R #24 was coming into her room (two days after the incident with R #24). 2. R #23 did not feel safe. 3. Recommended moving R #23 to another hall. Q. Record review of R #23's social services note, dated [DATE], revealed that R #23 was moved to another room. R. Record review of R #23's progress note, dated [DATE], revealed that R #23 did not feel safe. S. On [DATE] at 1:01 PM, during an interview with R #23, she revealed that the incident happened not too long ago (did not provide date) and stated, The black guy tried to touch me inappropriately (did not describe how). T. Record review of R #23's Resident Safety Survey (survey used by the facility to identify resident safety concerns), dated [DATE], revealed the following: 1. R #23 told staff that she feels uncomfortable with R #24 in the nursing home. 2. States that he touched her thigh. 3. Staff told R #23 that R #24 is nearly blind and asked if she new that, to which she replied that she did not know (unable to determine staff purpose for line of questioning). 4. R #23 stated that she feels safer since her room change. U. Record review of R #23's care plan, dated [DATE], revealed the following: 1. R #23 had a history of hallucinations. 2. R #23 had a history of PTSD due to a history of sexual abuse. 3. R #23 had accused a male peer of being in her room, (did not specify who R #23 accused or the date of the accusation). R #22: V. Record review of R #22's medical record revealed R #22 was admitted on [DATE]. W. Record review of R #22's medical record revealed she had the following diagnoses: 1. Major depressive disorder (MDD). 2. Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) with mood disturbance. 3. Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) with early onset. X. Record review of R #22's quarterly MDS, dated [DATE], revealed she had a BIMS score of 12 (moderately cognitively impaired). Y. Record review of CNA #21's witness statement, dated [DATE], revealed the following: 1. CNA #21 overheard R #24 ask R #22 if she likes having sex. 2. R #22 told R #24 she could not hear him. 3. CNA #21 told R #24 to get away from R #22 and that it was inappropriate for him to speak to R #22 that way. Z. On [DATE] at 12:24 PM, during an interview with LPN #21, the following was revealed: 1. She was told by CNA #21 that R #24 told R #22 that he wanted to do something sexual to her but, R #22 didn't hear him. 2. Staff moved R #22 away and kept an eye on R #24. 3. CNA's had told her about R #24 touching female residents (did not provide dates). 4. The facility never indicated that staff were supposed to keep an eye on R #24 due to sexually inappropriate language or touching others without consent. 5. R #24 had said something of a sexual nature to one of the CNAs, and she told the CNA to report it to the administration (she was unsure of the date). R #21 AA. Record review of R #21's medical record revealed R #21 was admitted on [DATE]. BB. Record review of R #21's medical record revealed R #21 had the following diagnoses: 1. Vascular Dementia with other behavioral disturbances. 2. Adjustment disorder (a group of symptoms such as stress, feeling sad or hopeless, and physical symptoms that can occur after stressful life events) with depressed mood. CC. Record review of R #21's quarterly MDS, dated [DATE], revealed she had a BIMS score of 3 (0 to 7 severe cognitive impairment). DD. On [DATE] at 2:01 PM, during an interview with R #21's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters), the following was revealed: 1. The ADON called her on [DATE] and notified her that another resident touched R #21's thigh (did not know who the other resident was) on [DATE]. 2. The facility handled the situation internally, and she was not aware of what had been done. 3. She declined counseling for R #21 because R #21 did not remember the event due to her dementia. EE. Record review of CNA #22's witness statement, dated [DATE], revealed the following: 1. CNA #22 witnessed R #24 rubbing R #21's thigh and was trying to take her to his room. 2. CNA #22 removed R #21 away from R #24 and notified the nurse. FF. On [DATE] at 1:32 PM, during an interview with CNA #22, the following was revealed: 1. She witnessed R #24 rubbing R #21's thigh, but she was unsure what the date was. 2. She removed R #21 from the situation. 3. She reported that R #24 touched R #21's thigh to RN #21 after she moved R #21 away from R #24. 4. She completed a witness statement. 5. RN #21 instructed her to keep a close eye on R #24 for the rest of the shift to make sure he didn't try to touch R #21 or any other residents. 6. R #24 had a behavior of coming out of his room naked, and staff were instructed to encourage him to cover himself. 7. There was a time (no date provided), that R #24 came out of his room naked. CNA #22 assisted R #24 back to his room to get dressed, and R #24 tried to touch her in an inappropriate area (area not specified). CNA #22 reported it to the nurse. 8. R #24 had interventions in place regarding behaviors related to aggression, refusing care, and mood. 9. There are no interventions in place for R #24 touching others without consent. 10. She has not been instructed to continue to keep a close eye (monitor) on R #24 after that day. 11. She was not aware of any inappropriate behaviors from R #24 in the last couple months (no date provided). GG. On [DATE] at 3:50 PM, during an interview with RN #21, she revealed the following: 1. She was notified by CNA #22 that R #24 was touching R #21 on the upper thigh. 2. R #21 told her that R #24 touched her leg. 3. She instructed CNA #22 to stay in the common area to keep an eye on R #24 that shift. 4. She was not aware of any time before this incident that R #24 had said or done anything of a sexual nature. 5. R #24 was not on close observation or 15-minute safety checks at the time he touched R #21's upper thigh. 6. One time (no date provided) R #26 came out of her room and said that R #24 went into her room. 7. R #26 said that she was scared of R #24 because he went into her room. 8. She notified the ADON about R #24 going into R #26's room. 9. RN #21 said that R #23 got moved to another hall because R #23 was scared of R #24. 10. R #24 was placed on frequent checks for a few days after R #23 was moved. 11. The facility did not implement any changes to continue to monitor for this behavior for R #24. 12. R #24's medications were changed, and that seemed to help. R #26 HH. Record review of R #26's medical record no date revealed R #26 was admitted to the facility on [DATE]. II. Record review of R #26's diagnoses, revealed she has the following diagnoses: 1. MDD. 2. Memory Deficit following nontraumatic Intracerebral Hemorrhage. 3. Adjustment Disorder with Mixed Anxiety and Depressed Mood. 4. PTSD. JJ. Record review of R #26's quarterly MDS, dated [DATE], revealed she had a BIMS score of 3. KK. Record review of R #26's social service progress note, dated [DATE], revealed the following: 1. R #26's daughter told staff that R #26 didn't want to take a shower because a black man went in the shower when staff left R #26 alone, and he touched her bottom [Identified in facility initial report as R #24]. 2. R #26 told staff she didn't want to shower because it is cold. 3. R #26 told the social worker that she didn't feel safe because of R #24. She told staff that R #24 asked her how she was doing. She had asked R #24 what he wanted? R #24 responded that he wanted her. 4. R #26 told staff that R #24 didn't touch her (contradicting family members initial statement #1 above). LL. Record review of the facility Complaint Narrative Investigation Follow-Up Report (5 day), dated [DATE], revealed the facility identified R #24 as the other resident involved in R #26's allegation. R #27 MM. Record review of R #27's medical record revealed R #27 was admitted to the facility on [DATE]. NN. Record review of R #27's medical diagnoses revealed she had the following diagnoses: 1. MDD. 2. Dementia 3. Hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness). OO. Record review of R #27's Resident Safety Survey dated [DATE], revealed the following: 1. R #27 reported that she did not feel safe at the facility because of R #24. 2. R #27 told staff that the man next door [R #24] goes around touching other women and he did that to me the other night and he touched my chair. He was completely naked. PP. Record review of the ADON's interview with R #27, no date, revealed that R #27 told staff that R #24 did not touch her but attempted to take her bag (interview was a follow-up interview after R #27 told staff that R #24 did that to her and was completely naked). QQ. On [DATE] at 3:15 PM, during an interview with R #27, the following was revealed: 1. R #24 had come up behind her in the common area and pulled her wheelchair. 2. When R #27 turned around to see what was happening, R #24 was sitting right next to her, completely naked, so she yelled at him to put some clothes on. 3. R #27 was unsure of the date of this event. 4. R #27 had witnessed R #24 go into other people's rooms. 5. R #23's family told her that R #24 touched R #23 and that is why she was moved to another hall. 6. R #24 touched another lady but she couldn't remember her name. 7. R #24 goes into people's rooms and takes things while they are sleeping. 8. On [DATE] in the evening (two days before this interview), R #24 went into the common area without pants or a covering on his lap while R #27 was sitting in the common area. R #24 looked at her and went back to his room. Staff were not present and there were no other residents present (See finding J, R #24 was supposed to be on Q15 minute checks during this time). 9. R #24 usually has a blanket on his lap, but it doesn't always cover everything. 10. It makes her uncomfortable when R #24 comes out of his room naked or when his blanket doesn't cover his private parts. 11. She was scared and afraid that R #24 would come into her room, but now she feels safe because she is a fighter and R #24 seemed to get scared when she yelled at him. R #25 RR. Record review of R #25's medical record revealed R #25 was admitted to the facility on [DATE]. SS. Record review of R #25's medical diagnoses revealed she had the following diagnoses: 1. Neurocognitive Disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function). 2. Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). 3. MDD. 4. Borderline Personality Disorder (a mental disorder characterized by unstable moods, behavior, and relationships). TT. Record review of R #25's quarterly MDS, dated [DATE], revealed she had a BIMS score of 12. UU. Record review of R #24's progress note, dated [DATE], revealed the following: 1. R #24 went into R #25's room wearing no pants or covering and proceeded to touch R #25's leg (See finding H, R #24 was reportedly on hourly one-to-one observations between [DATE] to [DATE]). 2. R #25 was able to tell the staff member that R #24 put his hands on her leg. 3. R #25 thought R #24 was only trying to wake her up and didn't think he meant any harm. 4. The nurse asked the CNAs to keep their eyes on R #24 for the rest of the shift 5. The nurse notified management and the doctor about R #24 going into R #25's room and touching her leg. VV. On [DATE] at 2:14 PM, during an interview with R #25, she stated that she did not recall a male resident entering her room and touching her leg. WW. On [DATE] at 10:36 AM, during an interview with CNA #23, revealed the following: 1. She did not have any male residents who had talked to or touched female residents inappropriately. 2. Staff had reported to her that R #24 had tried to touch someone in the night. 3. At one time, they were supposed to check on R #24 every 15 minutes and document on a sheet (no dates provided for when it was started or ended). 4. There are currently no instructions to keep an eye on R #24. XX. On [DATE] at 10:43 AM, during an interview with RN #22, the following was revealed: 1. She had worked at the facility for three weeks 2. She was the nurse working with R #24. 3. She did not have any male residents who had talked to other residents inappropriately or touched them without their consent. 4. She had not heard about any resident's with sexual behaviors. 5. She had not been told to watch out for any residents regarding this type of behavior. YY. On [DATE] at 10:45 AM, during an interview with RN #23, the following was revealed: 1. She had worked at the facility since the end of [DATE]. 2. She provided care for R #24 when assigned. 3. She was not aware of any male residents talking to or touching female residents without consent. 4. She stated that staff were supposed to watch R #24 closely for agitation behaviors and yelling out. 5. She had never been told to keep a close eye on R #24 regarding touching residents without consent. 6. She confirmed that R #24's Care plan did not indicate that R #24 was to be monitored for touching residents without consent. ZZ. On [DATE] at 11:01 AM, during a joint interview with the interim DON and the ADON, they revealed the following: 1. R #24 was trying to help R #23 because R #23 was stuck. It wasn't sexual in nature when R #24 touched R #23's leg. 2. Since R #22 did not hear R #24 ask her if she liked to have sex, they didn't think it was abuse. 3. They did not think that R #24 touching R #21's leg was sexual in nature. 4. Some staff members have had sexual things happen to them in their past, so they get uncomfortable with certain situations, which made the staff more sensitive to resident's behaviors. 5. The interim DON and ADON did not think that R #24's behaviors were sexual in nature. 6. The interim DON stated that R #24 did not have the cognitive ability to have sexual behaviors. 7. R #24 had been doing well so they resolved the issue regarding sexual behaviors on his care plan (See finding C, review of R #24's care plan revealed the interventions related to sexual behaviors were discontinued on [DATE], the same day as the incident with R #23). AAA. On [DATE] at 9:50 AM, during an interview with the interim administrator, he revealed the following: 1. He reviewed each of the incidents and determined them unsubstantiated. 2. He determined that each event was not sexual in nature (did not elaborate). BBB. On [DATE] at 1:08 PM, during an interview with R #24's physician, the following was revealed: 1. He did not recall being notified that R #24 asked a female resident if she liked having sex or that he touched other residents without their consent. 2. R #24 used to be very aggressive with staff and would isolate himself in his room. 3. They changed R #24's medications and he became more mellow. 4. The medication changes were intended to improve R #24's behaviors with, refusing showers, isolation, and aggression with staff. 5. He was unsure which medications were adjusted. 6. R #24 has made improvements and started coming out of his room and having conversations with other residents about ,d+[DATE] months ago. CCC. On [DATE] at 1:02 PM, during a joint interview with the interim DON and the interim Administrator, they revealed the following: 1. They watched video footage and determined that R #24 did not touch R #21's leg. 2. They watched video footage and determined that R #24 did not go into the shower with R #26. 3. R #24 did not have sexual intentions with R #27; he was just trying to grab her bag. 4. R #24 did not have sexual intentions when he went into R #25's room naked in the middle of the night. R #25 thought he was only trying to wake her up. Since she or her family didn't think it was abuse, it wasn't abuse. DDD. On [DATE] at 2:58 PM, during an interview with R #24's physician, the following was revealed: 1. Around [DATE], R #24 started becoming vulgar and having sexual behaviors like touching others and making sexual comments. 2. The facility contacted mental health services and together they decided to adjust R #24's medications. 3. They started R #24 on Risperidone, but he became lethargic (a state of weariness that involves diminished energy, mental capacity, and motivation) so they adjusted his Risperidone and started R #24 on Depakote. 4. R #24 started having appropriate interactions with residents and staff after the medication changes. 5. They have not seen any issues since the medication changes. EEE. On [DATE] at 3:35 PM, during an interview with the interim DON, the following was revealed: 1. R #24 was placed on one-to-one monitoring as practicable (as staffing allows). 2. The facility is not staffed to be able to have a staff member monitoring a resident around the clock. 3. One-to-one monitoring means more frequent rounding and checks, no specific timing of rounding. 3. Staff do not document one-to-one monitoring. 4. Staff only document if something occurs. The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 3:37 PM. The facility was verified to have fully implemented this approved plan on [DATE] at 4:39 PM. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on [DATE]. Plan of Removal A. How facility will ensure harm will not occur or recur: The attending physician, medical director, and Ombudsman were notified of the Immediate Jeopardy issued to the facility on [DATE]. The facility implemented the immediate actions and implemented the following to ensure harm will not occur or recur. There have been no events of sexual inappropriate comments and/or gestures from Resident #24 in over 70 days. 1. The current care plan was revised to observe/monitor behaviors of touching. Resident #24 was immediately placed on 15-minute observations. The 15-minute observations will remain in effect for seventy-two (72) hours and will end on [DATE]. Then, every shift thereafter, when behavior resolves 15-minute safety check will resolve. Date Completed: On-going process 2. Safety Surveys were conducted to ask all residents and nursing staff employees if they felt unsafe around Resident # 24. Date Completed: [DATE] 3. Education has been provided to staff: a. To increase staff awareness of when an event occurs related to inappropriate sexual comments and /or behavior; the staff will communicate during daily huddles. b. Additional education provided include: i. Abuse and Neglect; ii. 15-minute Safety Checks for 72 hours during a new event; then every shift for residents identified to have a pattern of inappropriate behaviors until resolved. iii. Know your Resident - which includes the process for reviewing the pattern of current and past behaviors, and interventions in the Care Plan with all staff and new employees iv. Shift huddle handoff will include not only medical report but also behavior changes and or concerns Date Completed: On-going 4. On-Going Monitoring: a. New events will require 15-minute checks for inappropriate behaviors b. After 15 minutes checks have concluded, checks will be every shift for those residents that have a pattern of inappropriate behavior or show signs of behavioral escalation. 5. CNA's making the 15-minute observation checks will immediately report to the charge nurse any changes in behavior or inappropriate sexual remarks or actions. This will remain in effect for seventy-two (72) hours and will end on [DATE]. For residents that have a history of behavioral issues, after the 15 minute checks have expired, the behavioral monitoring will occur every shift. Any changes and or escalation in behavioral will be reported. Date Completed: on-going 6. Attempts are made to provide education on care plan and current interventions to Resident #24. However, due to BIMS score of 3.0, the resident does not comprehend the education. Date Completed: [DATE] 7. The Charge nurse is to verify every shift (12 hours) with the CNA assigned of the 15-minute observations. This will remain in effect for seventy-two (72) hours and will end on [DATE], then every shift thereafter. Date Completed: [DATE] 8. All resident care plans have been updated to address observation and monitoring of the encouraging all residents on the reporting of any unwanted pilfering/physical contact, including verbalizations that maybe offensive from any other resident. Date Completed: On-going process 9. If an event occurs going forward that involves inappropriate sexual comments and/or gestures, the resident will immediately be placed on 15-minute observation checks for seventy -two (72) hours and the observation checks are documented for the established timeframe. The care plan will be updated to reflect the interventions put in place. Date completed: On-going process.

Based on observation, record review, and interview, the facility failed to provide metal health services for 1 (R #1) of 2 (R #1 and R #2) residents sampled for abuse, when they failed to provide metal health services for R #1 after she alleged sexual abuse by a staff member providing care to her. This deficiency caused R #1 to have severe psycho-social distress having to deal with sexual abuse and past trauma brought on by the sexual abuse without mental health service. The findings are: A. Record review of R #1's medical record revealed R #1 was admitted on [DATE]. B. Record review of R #1's nursing progress notes revealed the following: 1. 02/01/24 R #1 was admitted for therapy due to a right hip fracture with repair due to a fall. R #1 is alert and oriented, and able to make her needs known. 2. 02/01/24 R #1 is alert and oriented to herself. R #1 is able to express her needs. R #1 does require staff assistance for her ADLs. R #1 is nonweight bearing to the right lower extremity. R #1 is incontinent on both bowel and bladder. D. Record review of the facility complaint investigation file, no date, revealed the following: 1. The facility initial incident report, dated 02/18/24, revealed: a. R #1 alleged CNA #1 was helping her in the shower when CNA #1 put his fingers inside of her. b. R #1 stated the incident occurred one or two weeks ago [prior to 02/18/24]. E. Record review of R #1's nursing progress notes revealed the following: 1. On 02/18/24, a CNA reported R #1 had a complaint that needed to go to facility management. Administrator was notified and came into the facility to speak with R #1. 2. On 02/18/24, the nurse for R #1 was notified by the Administrator that R #1 reported she was sexually abused by a male CNA staff two weeks before 02/18/24. 3. On 02/29/24, Note Text: Resident met with Interim ADON, Interim DON, Interim Administrator, Social Worker, and BOM for care conference regarding notification by the Ombudsman that the Resident feels that she would like therapy s/t (secondary to) alleged event which occurred on 02/18/2024. Resident confirmed she would like mental health and/or therapy services and was notified that appointment and transportation will be made to a local mental health clinic by SW and/or designee for the earliest available appointment. F. On 03/07/24 at 11:26 am, during an interview R #1 stated she was not sure of the day, but CNA #1 was assisting her during a shower. When CNA #1 washed her backside, his fingers went in her vaginal area. R #1 stated I did not tell him anything. I froze. What do I tell him? That never happened to me . I was in shock . It took a week to tell someone. I did not know what to say . R #1 also stated she was previously in an abusive relationship. R #1 stated it took her [AGE] years to run away from that relationship. R #1 stated the incident was hard, I have not been this depressed for years . I have not got therapy they keep changing the date. R #1 was unsure when her appointment was scheduled for. G. On 03/07/24 at 11:26 am, during an observation, R #1 was visibly in distress. R #1 was crying, voice shaky, with periods of pause in speech when she discussed the incident with CNA #1. R #1 was also in distress when she discussed how the incident brought up the trauma from a previous relationship. H. On 03/07/24 at 12:18 pm during an interview, the Administrator stated on 02/18/24 she received a call that R #1 had a complaint for management. The Administrator stated she had gone home for the evening but came back to talk to R #1. The Administrator confirmed R #1 reported CNA #1 had sexually abused her during a shower a few weeks before, but R #1 did not know the date. The Administrator confirmed she started her investigation and reported it to the appropriate agencies immediately. The Administrator confirmed R #1 had an appointment for behavioral health services scheduled for 03/07/24 (the first appointment since the allegation of sexual abuse was made). The Administrator stated the Ombudsman brought up behavioral health services, and they held a meeting with the resident on 02/29/24. The Administrator confirmed the facility did not schedule or consider behavioral health services [prior to the Ombudsman], because the resident did not request it. The Administrator confirmed R #1 did get emotional when she discussed the sexual abuse. There were different subsequent conversations about the sexual abuse with staff during conferences and law enforcement personal for investigative purposes. The Administrator stated [after the incident] they offered to transfer R #1 to a different facility or home with home health, but the resident wanted to stay on 02/29/24. I. Record review of the Facility Abuse, Neglect and Exploitation Reporting & Prevention policy procedure review date 02/13/20 revealed, Prevent Further Abuse the Administrator or designee in his or her absence will implement corrective action based on the course/outcome of the investigation to prevent any further abuse from that could include . f. Follow up counseling for the resident(s) deemed to be in need will be initiated by social service.

Based on record review and staff interview, the facility failed to ensure that a resident that entered into the facility with an indwelling Foley catheter (a tube that is placed into the bladder) was assessed for the removal and provided a clinical reason for the catheter for 1 (R #19) of 1 (R #19) sampled residents with an indwelling urinary catheter. This failed practice could lead to the resident not having bladder control and could further lead to a bacteria colonization (a permanent infection). The findings are: A. Record review of the resident's care plan dated 07/11/17 revealed the resident has an urinary catheter for obstruction of urinary tract. Further review of the face sheet revealed the resident recently had a right sided hemicolectomy (removal of the ascending large intestine). B. Record review of the resident's face sheet indicated that the resident has [MEDICAL CONDITION], dated 07/14/17. C. Record review of the resident's clinical record revealed no assessment to remove the urinary catheter and see if he was able to drain his bladder or to see if he had any bladder control. The clinical record further failed to contain any clinical reason for the continued use of the urinary catheter. D. Record review of R #19's physician's orders [REDACTED]. 1. 11/22/19 - UA (urinalysis, to check for an urinary tract infection [MEDICAL CONDITION]) 2. 11/23/17 -[MEDICATION NAME](antibiotic) 500 mg twice a day for 7 days for UTI 3. 12/25/17 -[MEDICATION NAME] mg twice a day for 10 day for UTI 4. 12/28/27 - Discontinue Cipro. Bactrim DS (antibiotic) twice a day for 10 days for UTI 5. 01/30/18 - UA 6. 02/02/18 -[MEDICATION NAME] mg twice a day for 10 days for UTI E. During an interview on 03/01/18 at 9:15 am, LPN # 2 was asked if she knew the reason R #19 had an urinary catheter. She stated, [MEDICAL CONDITION]. When asked, she could not provide a more specific reason for the [MEDICAL CONDITION]. Further, she was asked if any attempt had been made to remove the catheter and she could not provide a date when this might have been done. F. During an interview on 03/01/18 at 9:30 am, RN #1 was asked if he knew the reason R #19 had an urinary catheter. He stated, [MEDICAL CONDITION]. When asked, he could not provide a more specific reason for the [MEDICAL CONDITION]. Further, he was asked if any attempt had been made to remove the catheter and he could not provide a date when this might have been done. G. During an interview on 03/01/18 at 2:10 pm, the DON was asked for the reason for the urinary catheter. She stated, [MEDICAL CONDITION] and some acute [MEDICAL CONDITION]. When asked if there was a more specific reason for the [MEDICAL CONDITION], she could not find one. Further, she was asked if any attempt had been made to remove the catheter. She did not know of one and that the urinary catheter should have been pulled out. H. During an interview on 03/01/18 at 3:15 pm, R #19 spoke through LPN #4 about the reason for the urinary catheter. He stated that the catheter was placed for the abdominal/intestinal removal surgery and has not been removed. When asked, he stated that he has not asked for it to be removed because he is lazy and it is just easier for him not to have to get up to urinate. When asked, he stated that he did not have any trouble urinating before the surgery.

Based on interview and record review, the facility failed to revise care plans for 5 (R #9, R #17, R #22, R #39, and R #43) of 5 (R #9, R #17, R #22, R #39, and R #43) residents sampled with care plans not revised, when they failed to 1) update R #9's care plan for Psychoactive medication, 2) update R #17's care plan for nutrition and falls, 3) update R #22's care plan for hydration and falls, 4) update R #39's care plan for self care, falls, skin, pain, psychoactive, Hypertension, aspiration, and [MEDICAL CONDITION], and 5) R #43's pressure ulcers (bed sore). This deficient practice could likely result in residents not receiving the care and assistance they need to maintain their high practicable well being. The findings are: R #17 Findings related to nutrition A. Record review of the care plan dated 04/13/17 revealed: Problem: Resident is at nutritional risk as evidenced by missing teeth, dementia (a disorder of mental process marked by memory disorder and impaired reasoning), Current Diet Regular Goal: resident will be free of significant weight loss thru NRP (next reporting period) 07/13/17 Intervention: Weight per schedule, notify NP (nurse practitioner)/MD (Medical Doctor) of weight concerns, Diet per Order . Last reviewed 06/22/17. B. Record review of the physician's order dated 08/10/17 for R #17 revealed: Add double portions with all meals, all food groups. C. Record review of the progress note dated 02/13/17 revealed: Pt (patient) has experienced weight loss. Writer recommended in (MONTH) (YEAR), to add double portions, was ordered by MD but not communicated to dietary/kitchen staff for her diet ticket. D. Record review of the weights for R #17 revealed: 1. 02/05/18 - 80 lbs 2. 01/05/18 - 88 lbs (This indicates a 9.9% weight loss in one month - a significant weight loss) E. On 03/02/18 at 10:35 am, during an interview with the Dietician, he confirmed that R #17 was supposed to receive double portions as of (MONTH) (YEAR), but it was not done until 02/13/18 when he noticed she was not on double portions as ordered. The Dietician stated, I write a recommendation, the doctor signs it, the nurses puts in a dietary communication. The kitchen never got a communication about the (MONTH) (YEAR) order. This could have caused the significant weight loss. F. Record review of the medical record R #17 revealed she was admitted on [DATE] with Diagnoses: [REDACTED]. Findings related to falls G. Record review of the progress notes for R #17 revealed the resident had falls on: 01/29/18, 02/22/18 H. Record review of the care plan, dated 04/13/17 for R #17 revealed: Problem: At risk to fall Goal: Resident will have minimum fall risk through 07/13/17, continue through 12/12/17 Interventions: Assist with toileting as needed, Provide WC (wheelchair) . Last dated review of these interventions was 09/26/17 Findings related to R #9's PRN (as needed) medication I. Record review of R #9's Physician's Orders dated 07/06/17 revealed [MEDICATION NAME] (anti-anxiety) 0.25 mg tablet take 1 tablet by mouth 2 times daily as needed for anxiety. No rational for extended PRN use (longer than 14 days) of [MEDICATION NAME] provided by R #9's Physician could be found in R #9's medical chart. J. Record review of R #9's Care Plan dated 09/03/17 revealed Psychoactive medication and at risk for side effects. Antidepressant - [MEDICATION NAME]. Antianxiety - [MEDICATION NAME]: Goal resident will receive the least dosage possible of the psychoactive med(s) to ensure the maximum functional ability both physically and mentally . cont (continue) thru 12/03/17 (handwritten) . K. On 03/02/18 at 11:00 am, during an interview the DON and MDSC confirmed that R #9's care plan was not updated. They should be writing whether the goal was effective or not. The DON also confirmed that there was no rational from R #9's Physician to extended PRN use (longer than 14 days) of R #9's [MEDICATION NAME]. R #22 Findings related to falls L. Record review of the admission record dated 06/23/17 for R #22 showed admission on 06/23/17 with Diagnoses: [REDACTED]. M. Record review of the progress notes for R #22 revealed: 1.12/31/18 found on floor 2. 01/15/18 found on floor 3. 02/20/18 witnessed fall, healed area on knee reopened 4. 02/22/18 found on floor 5. 02/26/18 found on the floor with skin tears N. Record review of care plan, dated 07/14/17 and 10/06/17, for R #22 revealed: Problem: At risk to fall AEB (as evidenced by) cognitive impairment, physical impairment, unsteady gait, recent fall, uses w/c (wheelchair) Goal: Resident will have minimal fall risk thru NRP (next reporting period) continue thru (sic) 12/04/17. Interventions: Assist with toileting as needed, provide assist to use assistive devices, bed alarm, chair alarm, floor mat when in bed, antiroll back on w/c. 8/14/17 Findings related to hydration for # 22 O. Record review of a physician's order for R #22, dated 02/12/18, revealed: Puree diet thin with extra gravy on meat. Honey thicken liquids, spoon fed by staff P. Record review of the care plan for R #22, dated 07/13/17 and 12/23/17, revealed: Problem: At risk for dehydration R/T (related to) [MEDICAL CONDITION] Goal: Resident will have adequate fluid intake AEB (as evidenced by) pink, moist mucous membrane (a membrane that lines body passages) and sufficient fluid intake thru 03/28/18. Intervention: Fresh water at bedside, Assess for S/S (signs and symptoms) of dehydration and report to charge nurse. (There is no mention of giving honey thickened liquids given by spoon). Q. On 02/26/18 at 01:17 pm, during an interview with the family member of R #22, she stated, He (her family member) has to spoon fed thickened liquids. I have not seen staff doing it, but they might be. R. On 02/28/18 at 11:29 am, during an interview with the Restorative Aide, she stated, I him took to breakfast, made him (R #22) his coffee--I put coffee in and add 2 tablespoons of thickener-if the spoon can stand straight it is called honey consistency. (Name of R #22) uses a regular coffee cup, he can give himself the drinks from a cup. He can do his cup (drink directly from a cup), but it is hard for him, sometimes I need to guide his hand. S. On 03/01/18 at 08:46 am, during an interview, CNA #4 stated, I help everyone in dining. He (R #22) is on a puree diet. I do assist with feeding. I have helped him with his drinking; I held the glass for him and he drank and another time he helped himself. He takes honey thickened liquids. CNA #4 stated she was not aware of any requirement for spooned liquids. T. On 03/01/18 at 11:53 am, during an interview, CNA #1 stated, I offer him drink and he takes the drinks. We give him nectar thickened liquids-he can drink it himself. CNA #1 stated he was not aware of any requirement for spooned liquids. U. On 03/01/18 at 11:59 AM, during an interview, the MDS Coordinator confirmed the care plans for R # 17 and R #22 are outdated and should have been updated for falls, nutrition and hydration. V. On 03/02/18 on 09:55 am, during an interview, DON stated, for both (Name of R #17 and Name of R #22) the care plan should have updated for any falls. They should have been evaluated and new interventions tired. (Name of #17)'s double portions were missed, if she was not getting what she needed it could have contributed to her weight loss. The double portions should have been on the care plan. (Name of #22)'s order for liquids by spoon should have gone on the care plan and been told to the staff. It got missed. W. Record review of the facility policy, undated, Falls-Clinical Protocol revealed: Follow-up: 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. X. Record review of the facility policy Falls and Fall Risk, Managing revealed: 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. R #39 Y. Record review of R #39 Care Plan revealed 1. Dated 11/09/17 - Problem: Resident has (sic) Self Care Goal: Resident will maintain a sense of dignity by being clean dry, neat, odor free thru Next Reporting Period (NRP) 11/09/17 continue thru 02/09/18 2. Dated 11/09/17 - Problem: Resident at risk to Fall Goal: Resident will have minimal fall risk thru Next Reporting Period (NRP) 02/09/18 3. Dated 11/09/17 - Problem: At risk for Skin Breakdown Goal: Skin will be clean, dry and intact without evidence of breakdown thru NRP 11/09/17 4. Dated 08/09/17 - Problem: Resident at risk for increase Pain Goal: Will have minimal pain level continue thru NRP 02/09/18 5. Dated 11/09/17 - Problem: Resident is taking Psychoactive medication and at risk for side effects Goal: Resident will receive the least dosage possible for the psychoactive med(s) to ensure the maximum functional ability both physically and mentally thru NRP 02/09/18 6. Dated 11/09/17 - Problem: DX (Diagnosis) [MEDICAL CONDITION]( Hypertension: abnormally high blood pressure) Goal: Resident will have BP (Blood Pressure) within acceptable range as determined by NP/MD/thru NRP 02/09/18 7. Dated 11/09/17 - Problem: Aspiration R/T difficulty swallowing AEB Goal: Resident will minimal risk of aspiration thru NRP 11/09/17 8. Dated 11/09/17 - Problem: Secure exits in my living environment Goals: I want to be in a secure and safe environment thru NRP 11/09/17 9. Dated 11/09/17 - Problem: DX of [MEDICAL CONDITION] Goals: Resident will remain free from injury during [MEDICAL CONDITION] activity thru NRP 02/09/18 Z. On 03/05/18 at 01:03 pm, during an interview, the MDS Coordinator confirmed that R #39's care plan were not reviewed since 11/09/17 in the areas of: Self Care, Falls, Skin, Pain, Psychoactive medications, Dx of HTN, Aspiration, and [MEDICAL CONDITION]. The next care plan meeting is scheduled for (MONTH) (YEAR). Findings related to R #43's pressure ulcer AA. Record review of R #43's Wound Care Notes revealed the following: 1. Dated 01/19/18 - the resident had a Stage III pressure ulcer (an open wound due to pressure that is not quite as deep and the bone) at the tail bone that was surgically closed at a hospital out of state. R #43 had a fall on 01/17/18 and the wound opened up and had orders to treat. 2. Dated 02/16/18 - the resident now has a second wound that was found below the first wound. BB. Record review of the resident's wound care plan, updated last on 02/14/18, revealed nothing about the first pressure wound on the tail bone being repaired in a hospital out of state, the fall that reopened it, nor the new pressure ulcer. CC. During an interview on 02/28/18 at 1:00 pm, the DON confirmed the care plan was not updated regarding the status of the wound of the tail bone nor the newer ulcer below that one. DD. Record review of the Care Planning Policy and Procedure no date revealed the following: . Care plans are revised as changes in the resident's condition dictate. Care Plans are reviewed at least quarterly . Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome had not been achieved; c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. At least quarterly.

Based on record review and staff interview, the facility failed to ensure that at resident that came in with an indwelling Foley catheter (a tube placed into the bladder through the urethra opening) was assessed for the removal and provided a clinical reason for the urinary catheter for 1 (R #19) of 1 (R #19) sampled residents with an indwelling urinary catheter. This failed practice could lead to the resident not having bladder control and could further lead to a bacteria colonization (a permanent infection). The findings are: A. Record review of the resident's care plan dated 07/11/17 revealed the resident has an urinary catheter for obstruction of urinary tract. Further review of the face sheet revealed the resident recently had a right sided hemicolectomy (removal of the ascending large intestine). B. Record review of the resident's face sheet indicated that the resident has [MEDICAL CONDITION], dated 07/14/17. C. Record review of the resident's clinical record revealed no assessment to remove the urinary catheter and see if he was able to drain his bladder or to see if he had any bladder control. The clinical record further failed to contain any clinical reason for the continued use of the urinary catheter. D. Record review of R #19's physician's orders [REDACTED]. 1. 11/22/19 - UA (urinalysis, to check for an urinary tract infection [MEDICAL CONDITION]) 2. 11/23/17 -[MEDICATION NAME](antibiotic) 500 mg twice a day for 7 days for UTI 3. 12/25/17 -[MEDICATION NAME] mg twice a day for 10 day for UTI 4. 12/28/27 - Discontinue Cipro. Bactrim DS (antibiotic) twice a day for 10 days for UTI 5. 01/30/18 - UA 6. 02/02/18 -[MEDICATION NAME] mg twice a day for 10 days for UTI E. During an interview on 03/01/18 at 9:15 am, LPN #2 was asked if she knew the reason R #19 had an urinary catheter. She stated, [MEDICAL CONDITION]. When asked, she could not provide a more specific reason for the [MEDICAL CONDITION]. Further, she was asked if any attempt had been made to remove the catheter and she could not provide a date when this might have been done. F. During an interview on 03/01/18 at 9:30 am, RN #1 was asked if he knew the reason R #19 had an urinary catheter. He stated, [MEDICAL CONDITION]. When asked, he could not provide a more specific reason for the [MEDICAL CONDITION]. Further, he was asked if any attempt had been made to remove the catheter and he could not provide a date when this might have been done. G. During an interview on 03/01/18 at 2:10 pm, the DON was asked for the reason for the urinary catheter. She stated, [MEDICAL CONDITION] and some acute [MEDICAL CONDITION]. When asked if there was a more specific reason for the [MEDICAL CONDITION], she could not find one. Further, she was asked if any attempt had been made to remove the catheter. She did not know of one and that the urinary catheter should have been pulled out. H. Record review of R #19's [DIAGNOSES REDACTED]. I. During an interview on 03/01/18 at 3:15 pm, R #19 spoke through LPN #4 about the reason for the urinary catheter. He stated that the catheter was placed for the abdominal/intestinal removal surgery and has not been removed. When asked, he stated that he has not asked for it to be removed because he is lazy and it is just easier for him not to have to get up to urinate. When asked, he stated that he did not have any trouble urinating before the surgery.

Based on interview, record review, and observation, the facility failed to follow physician's orders regarding a therapeutic diet for 2 (R #17 and R #22) of 2 ( R #17 and R #22) residents sampled for nutrition and hydration. This deficient practice likely results in resident's not receiving food and fluid by the prescribed method to meet the resident needs. The findings are: R #17 A. Record review of the medical record R #17 revealed she was admitted on [DATE] with Diagnoses: [REDACTED]. B. Record review of the care plan dated 04/13/17 revealed: Problem: Resident is at nutritional risk as evidenced by missing teeth, dementia, Current Diet Regular Goal: resident will be free of significant weight loss thru NRP (next reporting period) 07/13/17 Intervention: Weight per schedule, notify NP (nurse practitioner)/MD (Medical Doctor) of weight concerns, Diet per Order .last reviewed 06/22/17. C. Record review of the physician's order dated 08/10/17 for R #17 revealed: Add double portions with all meals, all food groups. D. Record review of the progress note, written by the dietician, dated 02/13/17 revealed: Pt (patient) has experienced weight loss. Writer recommended in (MONTH) (YEAR), to add double portions, was ordered by MD but not communicated to dietary/kitchen staff for her diet ticket. E. Record review of the weights for R #17 revealed: 1. 02/05/18 - 80 lbs 2. 01/05/18 - 88 lbs (This indicates a 9.9% weight loss in one month-a significant weight loss.) F. On 03/02/18 at 10:35 am, during an interview with the Dietician, he confirmed that R #17 was supposed to receive double portions as of (MONTH) (YEAR), but it was not done until 02/13/18 when he noticed she was not on double portions as ordered. The Dietician stated, I write a recommendation. The doctor signs it. The nurses puts in a dietary communication. The kitchen never got a communication about the (MONTH) order. This could have caused the significant weight loss. R #22 G. Record review of the admission record dated 06/23/17 for R #22 showed admission on 06/23/17 with Diagnoses: [REDACTED]. H. Record review of a physician's order for R #22, dated 02/12/18, revealed: Puree diet thin with extra gravy on meat. Honey thicken liquids spoon fed by staff. I. Record review of the care plan for R #22, dated 07/13/17 and 12/23/17, revealed: Problem: At risk for dehydration R/T (related to) [MEDICAL CONDITION] Goal: Resident will have adequate fluid intake AEB (as evidenced by) pink, moist mucous membrane (a membrane that lines body passages) and sufficient fluid intake thru 03/28/18. Intervention: Fresh water at bedside, Assess for S/S (signs and symptoms) of dehydration and report to charge nurse. (There is no mention of giving honey thickened liquids given by spoon). J. On 02/26/18 at 01:17 pm, during an interview with the family member of R #22, she stated, He (her family member) has to spoon fed thickened liquids. I have not seen staff doing it, but they might be. K. On 02/28/18 at 11:29 am, during an interview with the Restorative Aide, she stated, I him took to breakfast, made him (R #22) his coffee--I put coffee in and add 2 tablespoons of thickener-if the spoon can stand straight it is called honey consistency. (Name of R #22) uses a regular coffee cup, he can give himself the drinks from a cup. He can do his cup (drink directly from a cup), but it is hard for him, sometimes I need to guide his hand. L. On 03/01/18 at 08:46 am, during an interview, CNA #4 stated, I help everyone in dining. He (R #22) is on a puree diet. I do assist with feeding. I have helped him with his drinking; I held the glass for him and he drank and another time he helped himself. He takes honey thickened liquids. CNA #4 stated she was not aware of any requirement for spooned liquids. M. On 03/01/18 at 11:53 am, during an interview, CNA #1 stated, I offer him drink and he takes the drinks. We give him nectar thickened liquids-he can drink it himself. CNA #1 stated he was not aware of any requirement for spooned liquids. N. On 03/01/18 11:59 am, during an interview with the MDS(Minimum Data Set Coordinator, she confirmed the care plans for R # 17 and R #22 are outdated and should have been updated for nutrition for R #17 and hydration for R #22. O. On 03/02/18 on 09:55 am, during an interview, the DON stated, They should have been evaluated and new interventions tried. (Name of #17)'s double portions were missed; if she was not getting what she needed it could have contributed to her weight loss. The double portions should have been on the care plan. We should have known. (Name of #22)'s order for liquids by spoon should have gone on the care plan and been told to the staff. It got missed.

Based on observation, interview, and record review it was determined that: 1) R #22 was at risk for wandering and required a wanderguard (departure alert system). 2) Facility administration was aware that the wanderguard system was working only intermittently. 3) R #22's wanderguard did not alarm when R #22 left the faciity on [DATE]. R #22 was out of the building for an unknown amount of time and found on the ground outside of the facility. 4) Two other residents were at risk for wandering, R #18 and R #65. 5) The facility ordered a new departure alert system, however the intermittent working wanderguard system remained in place without any additional safeguards. 6) The facility did not care plan R #22 and R #18 for their wanderguards. This resulted in an Immediate Jeopardy with a starting date of 05/17/17. The facility was notified on 05/25/17 at 10:52 am. A plan of removal was received on 05/25/17 at 4:45 pm and rejected. A second Plan of Removal was received and approved on 05/25/17 at 5:30 pm. Upon implementation of a plan to safeguard wandering residents the IJ was lifted on 05/25/17 at 7:45 pm. This dropped the scope and severity down to E. Based on observation, interview, and record review, the facility failed develop Care Plans for 2 (R #22, and R #65) of 3 (R #18, R #22, and R #65) residents at risk for wandering, when they failed to 1) develop a Care Plan for R #22's wanderguard, 2) develop a Care Plan for R #65's wandergaurd, and 3) develop a care plan for psychoactive medications for 1 (R #86) of 5 (R #6, R #29, R #55, R #65, R #86) residents sampled for unnecessary medications. This deficient practice lead to R #22 leaving the building unknowingly by staff and falling outside on 05/25/17. The findings are: R #22 IJ A. Record review of the facility investigation dated 05/18/17 revealed At 10:15 (pm), code was called for possible elopement as staff could not locate resident (R #22); at 10:22 (pm), resident was observed outside of the helipad exit door to the left of the patio lying in the sand on his right side with his w/c (wheelchair) facing him; w/c was upright, resident was lying on right side and denies falling but cannot verbalize how he got on the ground. Full body assessment completed and resident has no injuries, moves all extremities voluntarily. Assisted up to w/c with gait belt and x 2 (2 person) assist, returned to room and assisted resident to get ready for bed. Wander guard was present to resident's rt (right) ankle but alarm did not sound when resident crossed threshold to exit building . wander guard in place but not sounding. B. Record review of R #22's Care Plan date 03/15/17 revealed no care plan for wanderguard. C. Record review of R #22's physician's orders [REDACTED]. D. Record review of R #22's Convalescent Care /Physician order [REDACTED]. E. Record review of R #22's Referral Request dated 11/10/16 revealed, Concerns: EXIT SEEKING! Wander Bracelet (wanderguard) on. F. Record review of R #22's MAR for January 2017 revealed documentation for staff to check R #22's wanderguard. No other checks for subsequent months were found. G. On 05/25/17 at 9:40 am, during an interview, the DON stated, The door to the helipad and the door to the hospital is not consistently reporting. We have a new system coming in. You never know when it is not going to work and it is on multiple residents. The DON also stated that staff should be checking on residents frequently in intervals of 30 minutes to an hour. The nurse has to check they are in the building per shift. H. On 05/25/17 at 10:08 am, during an observation of the wanderguard system with the DON, the exit door to the helipad and front door did sound with wanderguard pendant. The exit door leading into the hospital on the hallway with rooms 1-8 did not alarm when wanderguard pendant passed the sensor. The exit door leading to the hospital on the hallway with rooms 9-16 did not alarm when leaving the facility to the hospital, but alarmed when coming back into the facility from the hospital. I. On 05/25/17 at 2:49 pm, during an interview, CNA #9 stated she was not assigned to R #22, but helps out everyone. CNA #9 had just come back from break. R #22 was missing, so we called the code (resident missing). I checked every room on north hall. We needed to go check out side. I know that door (the helipad exit door) can be kind of funky. It may not work (the alarm). I went out looked to left he was laying on the floor. I don't know how long he was out there. His skin was cold to the touch. It looked like he had slid off the chair and it slid away. Just the fact that we did not know how long he had been out there was really worrying. It was dark and there are no lights out there on the side of the building. J. On 05/25/17 at 3:05 pm, during an interview, CNA #10 stated she was assigned to R #22's hallway. I was doing a shower. After, I came to get him (R #22) to go to bed. We could not find him, and called a code. The nurses found him outside. When asked when the last time CNA #10 saw R #22 before she noticed he was missing, CNA #10 stated, It was about an hour before (she noticed R #22 was missing). Some residents take a lot of care and require 2 people for showers. K. On 06/06/17 at 3:30 pm, during an interview the DON confirmed there was no Care Plan for R #22's wanderguard. R #18 L. Record review of R #18's physician's orders [REDACTED]. risk for elopement. M. Record review of R #18's Care Plan dated 03/24/17 revealed no Care Plan for R #18's wanderguard. N. On 06/06/17 at 3:30 pm, during an interview, the DON confirmed there was no Care Plan for R #18's wanderguard. R #65 O. Record review of R #65's physician's orders [REDACTED]. P. Record review of R #65's Care Plan dated 08/29/16 revealed Care Plan for their wanderguard. R #86 Q. Record review of R #86's Physician order [REDACTED]. 1. 03/24/17 [MEDICATION NAME] (antidepressant) take one tablet by mouth once daily dx (diagnosis): depression 2. 03/24/17 [MEDICATION NAME] (anxiety medication) take one tablet by mouth three times daily as needed dx: anxiety R. Record review of R #86's MAR for May 2017 revealed the following: 1. [MEDICATION NAME] given every day 2. [MEDICATION NAME] prn was given 05/1, 05/02, 05/04, 05/08, 05/09 S. Record review of R#86 medical record revealed no care plan for psychoactive medications. T. On 05/25/17 at 3:27 pm, during an interview, the DON confirmed that the facility did not develop a care plan for R #86's psychoactive medications.

Based on observation, interview, and record review it was determined that: 1) R #22 was at risk for wandering and required a wanderguard (departure alert system). 2) Facility administration were aware that the wanderguard system was working only intermittently. 3) R #22's wanderguard did not alarm when R #22 left the facility. R #22 was out of the building for an unknown amount of time and found on the ground outside of the facility. 4) Two other residents were at risk for wandering R #18 and R #65. 5) The facility ordered a new departure alert system, however the intermittent working wanderguard system remained in place without any additional safeguards. 6) The facility failed to Care Plan R #22's and R #18's wanderguard. This resulted in an Immediate Jeopardy with a starting date of 05/17/17. The facility was notified on 05/25/17 at 10:52 am. A plan of removal was received on 05/25/17 at 4:45 pm and rejected. A second Plan of Removal was received and approved on 05/25/17 at 5:30 pm. Upon implementation of a plan to safeguard wandering residents the IJ was lifted on 05/25/17 at 7:45 pm. This dropped the scope and severity down to E. Based on observation, interview and record review, the facility failed to keep residents free from accidents for 3 (R #22, R #18, and R #65) of 3 (R #22, R #18, and R #65) residents at risk for wandering, when they failed to 1) safeguard against residents unknowingly leaving the facility, 2) develop a Care Plan for R #22's and 18's wanderguards, 3) failed to have Physicians Orders for R #22's wanderguard, 4) maintain proper working function of R #65's personal alarms to prevent falls, further 5) the facility failed to secure a medication cart, secure a storage room, secure a fire alarm panel, secure the oxygen room, and secure the maintenance room. This deficient practice led to R #22 leaving the building unknowingly by staff and falling outside and could also allow residents into normally locked rooms and hurt themselves. The findings are: R #22 IJ A. Record review of the facility investigation dated 05/18/17 revealed At 10:15 (pm), code was called for possible elopement as staff could not locate resident (R #22); at 10:22 (pm), resident was observed outside of the helipad exit door to the left of the patio lying in the sand on his right side with his w/c (wheelchair) facing him; w/c was upright, resident was lying on right side and denies falling but cannot verbalize how he got on the ground. Full body assessment completed and resident has no injuries, moves all extremities voluntarily. Assisted up to w/c with gait belt and x 2 (2 person) assist, returned to room and assisted resident to get ready for bed. Wander guard (sic) was present to resident's rt (right) ankle but alarm did not sound when resident crossed threshold to exit building . wander guard (sic) in place but not sounding. B. Record review of R #22's Care Plan date 03/15/17 revealed no care plan for wanderguard. C. Record review of R #22's physician's orders [REDACTED]. D. Record review of R #22's Convalescent Care /Physician order [REDACTED]. E. Record review of R #22's Referral Request dated 11/10/16 revealed Concerns: EXIT SEEKING! Wander Bracelet (wanderguard) on. F. Record review of R #22's MAR for January 2017 revealed documentation for staff to check R #22's wanderguard. No other checks for subsequent months were found. G. On 05/25/17 at 9:40 am, during an interview, the DON stated The door to the helipad and the door to the hospital is not consistently reporting. We have a new system coming in. You never know when it is not going to work and it is on multiple residents. The DON also stated that staff should be checking on residents frequently in intervals of 30 minutes to an hour. The nurse has to check they are in the building per shift. H. On 05/25/17 at 10:08 am, during an observation of the wanderguard system with the DON, the exit door to the helipad and front door did sound with wanderguard pendant. The exit door leading into the hospital on the hallway with rooms 1-8 did not alarm when wanderguard pendant past the sensor. The exit door leading to the hospital on the hallway with rooms 9-16 did not alarm when leaving the facility to the hospital, but alarmed when coming back into the facility from the hospital. I. On 05/25/17 at 2:49 pm, during an interview, CNA #9 stated she was not assigned to R #22 but helps out everyone. CNA #9 had just come back from break. R #22 was missing, so we called the code (resident missing). I checked every room on north hall. We needed to go check out side. I know that door (the helipad exit door) can be kind of funky; it may not work (the alarm). I went out looked to the left. He was laying on the floor. I don't know how long he was out there. His skin was cold to the touch. It looked like he had slid off the chair and it slid away. Just the fact that we did not know how long he had been out there was really worrying. It was dark and there are no lights out there on the side of the building. J. On 05/25/17 at 3:05 pm, during an interview, CNA #10 stated she was assigned to R #22's hallway. I was doing a shower. After, I came to get him (R #22) to go to bed. We could not find him, and called a code. The nurses found him outside. When asked when the last time CNA #10 saw R #22 before she noticed he was missing, CNA #10 stated It was about an hour before (she notice R #22 was missing). Some residents take a lot of care and require 2 people for showers. K. On 06/06/17 at 3:30 pm, during an interview, the DON confirmed there was no Care Plan for R #22's wanderguard. R #18 L. Record review of R #18's physician's orders [REDACTED]. risk for elopement. M. Record review of R #18's Care Plan dated 03/24/17 revealed no Care Plan for R #65's wanderguard. N. On 06/06/17 at 3:30 pm, during an interview the DON confirmed there was no Care Plan for R #18's wanderguard. R #65 O. Record review of R #65's physician's orders [REDACTED]. P. Record review of R #65's Care Plan revealed Care Plan for R #18's wanderguard. Q. Record review of the confidential patient safety work product document for R #65 dated 05/18/17 revealed the resident had a fall on that date at 0245 (2:45 am) during the night shift. The physician was not notified. R. On 05/30/17 at 11:45 am, during an interview, LPN #2 was asked if R #65 had a fall. LPN #2 reported that on 05/18/17, while shadowing the ADON, it was reported to them that the resident fell about 4:30 am and the bed alarm did not go off. LPN #2 observed the bed alarm and discovered that alarm was not plugged in correctly, He replaced the alarm and made sure it was plugged in correctly. At about 6:10 am, during shift change, R #65 fell again but this time the alarm did go off. When asked how do you know what interventions or assistance is needed to prevent falls, LPN #2 stated that the information is in the care plan and passed on during shift change report. When asked what the circumstances around the accident, LPN# 2 reported that it was an unwitnessed fall when R #65 was attempting to transfer himself from the bed to the wheelchair. The fall resulted in a small abrasion 2 cm by 3 cm on right side of his forehead. S. Record review of the Care Plan for R#65 dated 8/29/16 revealed: 1. PROBLEM: (Name R#64) is at risk for falling with repeated falls. AEB (As Evidence By: Cognitive impairment, Physical impairment, Unsteady gait, Recent fall, Uses assistive devices. 2. GOAL: .will have minimal fall risk thru 11-29-16, Risk Score 77 High. 3. INTERVENTION: 1. Assist with toileting as needed, 2. provide/assist to use assistive devices 3. Remind resident . 4. Complete Fall Risk . 5. Report falls 6. Assist resident to wear nonskid, 7. Observe 8. Administer medication as ordered 9. Therapy per order 10. Bed alarm, clip chair alarm 11.Wander Bracelet at all times. There are no new Fall interventions since 08/29/16, last reviewed 2/27/17. T. During an interview on 05/31/2017 at 12:42 pm with ADON, she confirmed that the bed alarm for R #65 did not sound during the first fall, the information was given during shift change report. ADON also confirmed that she and LPN #2 replaced the alarm. The ADON reported that R #65 received a scrape and egg size bump on the right side of his forehead. U. On 05/31/17 at 1:39 pm, during an interview the DON confirmed R #65's bed alarm should not have been unplugged. Medication cart V. On 05/22/17 at 10:30 am, observation of the medication cart for North Hall revealed medication cart was unlocked with the keys on top of the cart. LPN #5 was behind the nurses station at the computer. W. On 05/22/17 at 10:31 am, during an interview, LPN #5 was asked which nurse was assigned the medication, LPN #5 stated she was. Is it unlocked? LPN #5 then went around the nurses station to the medication cart and confirmed that the medication cart was unlocked. Storage room X. On 05/22/17 at 10:40 am, the storage room closest to the hospital on the hallway with rooms 9-16 was not secure. Surveyors opened the door to confirm. Room was filled with equipment and furniture stacked for storage. Drill holes on the door frame and door indicated that there was a hinge and pad lock that had been removed. Fire Panel Y. On 05/25/17 at 7:34 pm, observation of the maintenance hall (hall with breaker boxes and fire alarm panel) next to the administrator's office revealed the fire alarm panel door open. The key lock was in the locked position, but panel was open. Inside the fire alarm panel were wires and two batteries connected to the some of the wires. Z. On 05/25/17 at 7:36 pm, during an interview, the Maintenance Director and the Administrator both confirmed that the panel is supposed to be closed and locked. Oxygen room AA. On 05/30/17 at 2:06 pm, during an observation, the oxygen room door was left ajar so the lock was not engaged. During an interview at that time, the DON confirmed that the door should be closed and locked. Maintenance room BB. On 05/31/17 at 10:45 am, during an observation of the maintenance room (next to the storage room on the hallway with rooms 9-16), revealed the door wide open. Inside the room were miscellaneous chemicals, tools, and equipment throughout. CC. On 05/31/17 at 10:51 am, during an interview, the Administrator confirmed that the maintenance room door was open and it should be secure. DD. On 05/31/17 at 2:39 pm, during an interview, the DON confirmed: 1) Yes, cart should have been locked. 2) Yes, the storage room should have been secured. Someone on the weekend shift took off the lock. 3) Yes, I would think it (the fire alarm panel) should be locked. 4) Yes, the oxygen room should have been secured. 5) Yes, the maintenance door should be closed if they (maintenance) are not there.