Every finding on record at Meridian Meadows Transitional Care

Based on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided. Findings include: The National Academies of Sciences, Engineering, and Medicine (NASEM) website accessed on 4/8/26, article titled The National Imperative to Improve Nursing Home Quality (2022) documented, inadequate staffing contributes to delayed care, missed care tasks, and reduced resident safety. Staffing must be aligned with resident acuity, not just minimum numbers.A review of facility grievances dated 10/1/25 through 3/31/26, documented the following:-A Grievance Form dated 1/12/26, documented a resident reported not receiving incontinence care from 6:00 PM to 6:00 AM and was found wet the following morning. The Investigation outcome confirmed the allegation. The resident was not assisted overnight. Staff were re educated on consistent overnight checks and timely incontinence assistance.-A Grievance Form dated 2/11/26, documented a family member reported concerns about staffing levels, long wait times for medications and showers, and delays in assistance with meals and transfers. The Investigation outcome confirmed the allegation. CNA meal setup issues were identified and staff were educated. The investigation referenced a review of call light response times and medication administration but did not document the outcome of those reviews.-A Grievance Form dated 3/5/26, documented a resident expressed concern about long call light wait times and CNAs providing rushed care. The Investigation outcome confirmed the allegation. The resident was educated that call lights would be answered timely but not instantly. CNAs were instructed to answer call lights, provide a time estimate, and follow through.-A Grievance Form dated 3/14/26, documented a resident reported delayed care, stating his catheter bag reached 2,000 mL before a CNA arrived to empty it. The Investigation outcome confirmed the allegation. Staff were reminded to monitor and empty catheter bags during routine rounds.-A Grievance Form dated 3/22/26, documented a family member reported delayed care and concerns about the resident not getting out of bed in a timely manner. The Investigation outcome confirmed the allegation. The investigation identified call lights were answered timely, but care was delayed because the resident required two person assistance and staff were assisting others. Staff were reminded of the importance of timely follow through once needs are identified.A review of the three week facility staffing schedule, dated 3/8/26 through 3/28/26, as follows:Week 1-3/8/26 (Sunday): Census 37 | Staffing hours 110.6-3/9/26 (Monday): Census 38 | Staffing hours 125.1-3/10/26 (Tuesday): Census 38 | Staffing hours 130.5-3/11/26 (Wednesday): Census 37 | Staffing hours 143.7-3/12/26 (Thursday): Census 37 | Staffing hours 148.6-3/13/26 (Friday): Census 38 | Staffing hours 139.8-3/14/26 (Saturday): Census 38 | Staffing hours 139.6Week 2-3/15/26 (Sunday): Census 38 | Staffing hours 116.8-3/16/26 (Monday): Census 39 | Staffing hours 151.5-3/17/26 (Tuesday): Census 41 | Staffing hours 153.9-3/18/26 (Wednesday): Census 41 | Staffing hours 154.6-3/19/26 (Thursday): Census 41 | Staffing hours 132.3-3/20/26 (Friday): Census 42 | Staffing hours 143.1-3/21/26 (Saturday): Census 41 | Staffing hours 105.9Week 3-3/22/26 (Sunday): Census 41 | Staffing hours 119.3-3/23/26 (Monday): Census 40 | Staffing hours 138.5-3/24/26 (Tuesday): Census 40 | Staffing hours 131.1-3/25/26 (Wednesday): Census 41 | Staffing hours 141.7-3/26/26 (Thursday): Census 43 | Staffing hours 160.0-3/27/26 (Friday): Census 42 | Staffing hours 145.7-3/28/26 (Saturday): Census 42 | Staffing hours 108.0The three-week facility staffing schedule documented consistently lower staffing hours on weekends compared to weekdays. On 3/30/26 at 9:58 AM, Resident #5 stated she has had a low staffing concerns and has informed staff about it. She states a few weeks ago she submitted a grievance form with low staffing concerns but had not heard back.On 3/31/26 at 9:16 AM, Resident #40 stated that when the facility is short staffed, residents who normally eat in the independent dining room are required to eat in the assisted dining room due to lack of supervision. She stated this occurs primarily on weekends.On 3/31/26 at 10:32 AM, Resident #15 stated staff are not available to assist when needed throughout the day.On 3/30/26 at 11:55 AM, a family representative stated the facility has low staffing on the weekend and when she arrives to visit her mother, the room is often unorganized. She also stated she has made several attempts to coordinate with the facility staff to pick up her mother from the facility, but the resident is never ready on time.On 3/31/26 at 10:43 AM, a family representative stated the facility is short staffed on weekends and they are often unable to get assistance when needed.On 4/1/26 at 9:28 AM, the Resident Council meeting identified the following concerns:-Low weekend staffing has been repeatedly brought to administration without resolution.-Residents who normally eat in the independent dining room must eat in assisted dining room on weekends due to staffing shortages.-Staff are observed sitting at the nurses' station charting while call lights remain unanswered.On 4/1/26 at 11:34 AM, a whiteboard was observed in the kitchen stating the independent dining room is closed on Saturdays and Sundays, consistent with resident reports of low weekend staffing.Residents were observed eating in the independent dining room on the following dates and times:-3/30/26 (Monday) at 7:29 AM-3/30/26 (Monday) at 12:36 PM-4/1/26 (Wednesday) at 7:21 AM-4/1/26 (Wednesday) at 12:32 PM-4/2/26 (Thursday) at 7:20 AM-4/2/26 (Thursday) at 12:26 PMOn 4/2/26 at 5:27 AM, the night shift LN (Licensed Nurse) stated each wing has one CNA and one LN on duty. She stated the 6:00 PM-6:00 AM shift generally meets resident needs, but between 4:00 AM and 6:00 AM, residents may wait longer for assistance.On 4/2/26 at 5:35 AM, the second night shift LN stated that around 4:00 AM, residents begin calling for assistance and staff try to help each other out. She stated residents are understanding that they have to wait.On 4/2/26 at 6:19 AM, CNA #1 stated the facility is often low staffed on weekends and is not always appropriately staffed from 6:00 PM to 10:00 PM, resulting in longer wait times to meet resident needs.On 4/2/26 at 9:41 AM, the Staffing Coordinator stated staffing is based on census and confirmed the facility, does not have a lot of weekend staff. She stated she sometimes comes in to help cover shifts.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents and failed to securely store medications. This was true for 1 of 3 medication carts (West Wing Cart) inspected for expired medications and true for 1 of 1 residents (Resident #4) reviewed for storage of self-administered medications. These failures created the potential for residents to receive expired medications with decreased efficacy and created the potential for harm to residents if they were to obtain medications which were left unsecured. Findings include:The facility's Medication Storage policy, implemented 12/29/25 documented all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.1. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including dysphagia, disease of the esophagus, and gastrostomy. A review of Resident #4's care plan, revised 1/27/26, documented that he required supervision for self administration of nutrition and was able to self administer his medications. A review of Resident #4's Self Administration of Medication Assessment, dated 2/13/26, documented that he required assistance to store medications in a secure location. On 4/1/26 at 11:01 AM, Resident #4 was observed sitting at his desk in his room. During the observation, two cups were noted on his nightstand. One cup contained white powdered residue, and the second cup—labeled 7 PM—was approximately one quarter filled with white powder residue. Also on the nightstand were six containers of Jevity nutritional supplement. On 4/1/26 at 11:32 AM, Resident #4 stated that sometimes the licensed nurse brings his medications to his room and places them on the nightstand for him to take when he is ready. He further stated that at times he must go into the hallway at 4:00 AM to obtain his medications for the day. Resident #4 confirmed he placed the medications on his nightstand until he chooses to take them and stated the facility had not instructed him to store them elsewhere. Resident #4 also stated he self administers his nutritional supplements without staff assistance and confirmed that facility staff provide him with a case of Jevity to self-administer. On 4/2/26 at 11:28 AM, the CRN stated she had not been informed that medications were being left on Resident #4's bedside table. 2. On 4/1/26 at 3:55 PM, 19 packets of Bacitracin ointment was observed in a clear plastic cup in the bottom drawer of the medication cart on the [NAME] Wing with an expiration date of 02/2025. When asked what the expiration date was on the medication, LPN #2 confirmed the bacitracin ointment was expired. When asked about the process when expired medications were found, LPN #2 stated expired medication should be disposed of. On 4/3/26 at 10:43 AM, when asked how often nurses are supposed to check medication carts for expired medications, the DON stated there was not a designated schedule and further added nurses should be watching during medication pass for expired medications.

Based on record review, SOM Appendix PP, and staff interview, it was determined the facility failed to keep complete hospice records on file at the facility for residents receiving hospice services. This was true for 1 of 3 residents (Resident #18) whose record was reviewed for accuracy and completeness. This deficient practice created the potential for harm if hospice paperwork did not confirm Resident #18 agreed to receive hospice services. Findings include:SOM Appendix PP: Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.A. The designated interdisciplinary team member is responsible for the following:Obtaining the following information from the hospice: a. The most recent hospice plan of care specific to each patient. b. Hospice election form. c. Physician certification and recertification of the terminal illness specific to each patient. d. Names and contact information for hospice personnel involved in hospice care of each patient. e. Instructions on how to access the hospice's 24-hour on-call system. f. Hospice medication information specific to each patient. g. Hospice physician and attending physician (if any) orders specific to each patient.2. Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. The facility's Hospice Services Facility Agreement, dated 12/2/25, documented the facility would provide or arrange for hospice services which includes a designated facility member who would obtain information relating to the residents' hospice coordination of care and physician certification, and other documentation to include, but is not limited to, the Hospice Election Form. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including leukemia, dementia, anxiety, and depression.A review of Resident #18's medical record and hospice documentation did not include a Hospice Election form.On 4/2/26 at 11:46 AM, the CRN stated Resident #18's Hospice Election form was not on record at the facility prior to requesting a copy from the Hospice company earlier that morning.On 4/6/26 at 2:15 PM, the CRN clarified via email she did not believe the election form needed to be included in the Hospice documentation kept at the facility level.

Based on record review and staff interview, it was determined the facility failed to ensure residents were free from duplicate medication orders and side effect monitors were in place. This was true for 2 of 6 residents (#2 and #5) whose records were reviewed for unnecessary medications. This failure placed Resident #2 at risk for overmedication and Resident #5 at risk for their needs to go unmet when they were not monitored for side effects of their medications. Findings include: 1. According to the Food and Drug Administration (FDA) Ativan (lorazepam) prescribing information, accessed 4/7/26, patients receiving lorazepam must be monitored for the following potential adverse effects: -Sedation -Respiratory depression -Cognitive impairment -Paradoxical reactions (such as agitation or hyperactivity) -Dependence and withdrawal symptoms Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. Resident #5's medical record included the following physician orders: -Lorazepam Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for anxiety. -Lorazepam Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for terminal agitation for 180 days. A review of Resident #5's care plan and physician orders showed no documentation of monitoring interventions for the use of lorazepam, including monitoring for sedation, respiratory status, cognitive changes, or other adverse effects identified in the FDA prescribing information. On 4/2/26 at 11:16 AM, the DON confirmed that Resident #5's record did not include monitoring parameters for lorazepam. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, congestive heart failure, and a mild cognitive impairment. Resident #2's physician orders documented the following: -Bisacodyl Suppository, Insert 10 mg rectally as needed for constipation If no results within 24 hours from bisacodyl tablet -Start Date- 12/2/2024 -Bisacodyl Rectal Suppository 10 mg, Insert 10 mg rectally every 24 hours as needed for, No BM [bowel movement] after prior bowel protocol regimen -Start Date- 11/29/2024 On 4/3/26 at 12:13 PM, the CRN stated Resident #2 had two orders for bisacodyl suppositories in error.

Based on record and policy review, and staff interview, it was determined the facility failed to implement a performance improvement plan (PIP) for a systemic concern related to staffing. This deficient practice created the potential for harm if residents received substandard quality of care if staffing concerns were not identified and responded to accordingly. Findings include:The facility's QAPI Facility Plan, dated January 2026, documented the QAPI plan for the facility was to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. Objectives of the QAPI plan include:-Establish a facility-wide process to identify opportunities for improvement through continuous attention to quality of care, quality of life and resident safety.-Address gaps in the systems or processes.-Ensure adequate provision of staffing time, equipment and technical training resources.-Establish clear expectations around safety, quality, rights, choices and respect.-Continually improve the quality of care and services provided to [the] residents.The facility's self-reported [NAME] PBJ Staff Data Report for the first quarter of 2026 documented the facility had concerns with low weekend staffing.On 3/30/26 at 1:07 PM, Resident #15 stated he was concerned with the low weekend and night staffing and at resident council had complained about it with the other residents. He stated the residents stopped complaining about staffing around December 2025 when the facility had failed to respond to their earlier concerns.Resident Council Meeting Minutes were reviewed for staffing related concerns from October 2025 through March 2026 with the following results:-November 2025: Residents were concerned that the facility is often short staffed on the weekends.-December 2025: Residents were concerned about staffing on the weekends as they were not receiving their medications until 9:30 AM to 10:00 AM. Staffing concerns were noted as being in progress for a resolution.-January 2026: Residents were informed new staff have been trained and were working regularly, and residents stated the short staffing had significantly improved. The concerns were noted as resolved.-March 2026: Residents were concerned about not getting their snacks when the facility is short staffed.On 3/30/26 at 9:00 AM, the SA team met with facility residents who voiced concerns about low weekend staffing and poor staff response time during the night shift. The facility residents who were independent diners complained they could not eat in the independent dining hall when there were not enough staff on the weekend.On 4/3/26 at 12:20 PM, the Administrator confirmed independent dining had to be closed when there were not enough staff, so residents could safely dine with the available staff in the dependent dining hall.The Administrator provided two open performance plans which included: 1. Consistently offering snacks (opened December 2025); and 2. Tracking falls (opened 2/19/26).He stated there had been a staffing PIP opened in October 2025, but it closed in December 2025 when the residents stopped complaining about staffing. The Administrator did not identify any specific gaps in the staff systems or metrics related to how staffing was evaluated for effectiveness prior to closing the concern.Cross Reference F725, F727

Based on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention. Findings include:Review of the facility's three-week nursing schedule, dated 3/8/26 through 3/28/26, documented the facility did not provide 8 consecutive hours of registered professional nursing coverage on the following dates:-3/14/26 - No consecutive 8 hours-3/15/26 - No consecutive 8 hours-3/28/26 - No consecutive 8 hoursOn 4/2/26 at 9:47 AM, the Staffing Coordinator stated she was unaware the registered professional nursing hours must be consecutive.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders. This was true for 1 of 1 residents (Resident #1) reviewed for oxygen therapy. This deficient practice created the potential for adverse outcomes if residents' did not receive the proper amount of oxygen. Findings include:The facility's Oxygen Administration policy, implemented 12/30/25 documented, Oxygen is administered under orders of a physician, except in the case of an emergency.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure with hypoxia and congestive heart failure.Resident #1's care plan revised on 3/7/26, documented Resident #1 used oxygen per physician order.A physician order dated 3/26/26, documented oxygen at 0-2 LPM via nasal cannula as needed to keep oxygen saturations equal to or greater than 88% and to check oxygen saturation every shift.Resident #1's March and April 2026 MAR/TAR documented Resident #1's oxygen saturations ranged from 90-95% and was occasionally receiving 3 LPM of oxygen as needed.On 3/30/26 at 1:00 PM, Resident #1 was observed resting in bed with the head of the bed elevated. His oxygen concentrator was running but he was not wearing his nasal cannula. Resident #1's oxygen concentrator was set at 2.5 LPM. When asked about the oxygen, Resident #1 stated he uses his oxygen at night and when he is napping.On 4/3/26 at 9:26 AM, Resident #1 was observed lying in bed with oxygen on via nasal cannula.On 4/3/26 at 10:43 AM, the DON accompanied the surveyor to Resident #1's room. Resident #1 was observed still lying in bed with oxygen on via nasal cannula. When asked what Resident #1's oxygen concentrator was set at, the DON stated the oxygen concentrator was set at 3 LPM.On 4/3/26 at 10:45 AM, the DON reviewed Resident #1's record and was asked to verify Resident #1's oxygen order. The DON stated Resident #1's oxygen order was for 0-2 LPM via nasal cannula. When asked what Resident #1's oxygen concentrator should have been set at, the DON reviewed Resident #1's record and stated she was looking for any changes in Resident #1's condition that would indicate a need for more oxygen. The DON confirmed that Resident #1's oxygen concentrator should have been set between 0-2 LPM.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure wound care was provided according to physician orders and acceptable standards of practice. This was true for 1 of 1 residents (Resident #5) observed for wound treatment. This failure created the potential for delayed healing and wound deterioration. Findings include:a.Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease.A physician order directed staff to cleanse Resident #5's left heel with wound cleanser, apply normal saline-moistened gauze, and cover with a dry dressing every shift.On 4/3/26 at 10:01 AM, RN #1 was observed performing wound care for Resident #5. RN #1 removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing.The treatment provided did not include the ordered normal saline-moistened gauze.On 4/3/26 at 10:16 AM, RN #1 confirmed she performed the wrong treatment.On 4/3/26 at 10:46 AM, the ADON confirmed the wound care provided was not consistent with the physician's order.b.Resident #5's care plan, revised 3/30/26, documented she was at risk for skin impairment and pressure ulcers.A review of Resident #5's record documented the following physician order dated 3/27/26:-Discontinue wound vac (a negative pressure device) and apply wet to dry dressing until further orders are received.A Nursing Progress Note dated 3/27/26 at 3:15 PM, documented the following wound care orders had been discontinued:-Right lateral foot and left medial foot: Cleanse with wound cleanser and cover with Mepilex border or similar bandage once daily every Monday and Thursday.-Left heel: Check wound vac dressing and ensure pump is functioning every morning and at bedtime.-Charge wound vac at bedtime.-Wound vac procedure including cleansing, skin prep, black foam application, transparent dressing, and negative pressure at -125 mmHg continuously, changed twice weekly.-Instruction to remove wound vac and apply wet to dry dressing if the device was nonfunctional for more than 2 hours and notify provider.The Nursing Progress Note did not include documentation that a new wound treatment was implemented following the discontinuation of the wound vac.A review of Resident #5's Treatment Administration Record showed that a new wound care order for the left heel-cleanse with wound cleanser, apply normal saline-moistened gauze, and cover with a dry dressing every shift-was not implemented until 3/31/26, four days after the wound vac was discontinued.On 4/3/26 at 10:46 AM, the ADON stated the facility had difficulty communicating with the hospice agency to clarify the wound care order and acknowledged he did not think to obtain a temporary order from the facility's medical director.

Based on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure residents had an active physician's order. This was true for 1 of 16 residents (Resident #15) whose record was reviewed for quality of care. This deficient practice created the potential for adverse outcomes when Resident #15 self-administered a medication not ordered by a physician. Findings include: Resident #15 was readmitted to the facility on [DATE] with multiple diagnoses including type 1 diabetes, partial paralysis of left side, and ataxia after a stroke.On 3/30/26 at 1:07 PM, it was observed Resident #15 had a bottle of glucose tablets on his desk. When asked why there were glucose tablets on his desk, Resident #15 stated he took glucose tablets whenever he felt his blood sugar going low.A physician's note dated 2/13/26, documented the physician had seen Resident #15 for low blood sugars, and referenced Resident #15 was taking glucose tablets whenever his blood sugar was in the 60's.A review of physician's orders, dated 3/1/26 through 4/1/26, did not include an order for glucose tablets.On 4/2/26 at 9:10 AM, the CRN and DON confirmed there were no current physician orders related to glucose tablets.Cross reference F554.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were dependent on staff for activities of daily living assistance received services for their fingernails. This was true for 1 of 1 residents (Resident #50) reviewed for nail care. This placed Resident #50 at risk of embarrassment which could affect him socially due to the appearance of his fingernails. Findings include: The facility's Nail Care policy, implemented 12/20/24 and revised 12/31/25 documented:The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Policy Explanation and Compliance Guidelines:Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible.Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.)Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke.Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.Principles of nail care:Nails should be kept smooth to avoid skin injury.Only licensed nurses shall trim or file fingernails of residents with diabetes.Residents without complicating disease processes, may have their toenails clipped by staff who have received education and training to provide this service within professional standards of practice and as per facility policy.Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including muscle wasting and atrophy (the loss of muscle tissue, causing reduced strength and muscle thinning) and diabetes.Resident #50's ADL care plan, revised on 3/30/26, documented Resident #50 required partial to moderate assistance with ADLs.On 3/31/26 at 11:18 AM, Resident #50's fingernails were observed to be long, thick and yellow in color. When asked if Resident #50 preferred long fingernails, he stated he preferred his fingernails shorter. When asked if Resident #50 had asked the staff to cut his nails, Resident #50 stated he was unaware he could ask staff to cut his fingernails.On 4/1/26 at 11:45 AM, Resident #50's fingernails were observed to be long, thick and yellow in color. When asked if Resident #50 had asked staff to cut his nails, he stated he asked for his nails to be cut. On 4/2/26 at 1:37 PM, Resident #50's fingernails were observed with LPN #1. LPN #1 stated Resident #50's thumbnails were long and needed to be cut. LPN #1 further stated that the nails were yellow in color and were dirty and needed to be soaked. When asked who performs nailcare for Resident #50, LPN #1 stated nurses perform nail care. When asked how often nail care is performed, LPN #1 stated she would have to check Resident #50's order.On 4/2/26 at 1:45 PM, LPN #1 reviewed Resident #50's records and stated she didn't see an order for Resident #50's nail care. When asked if a physician order is needed for diabetic nail care, the ADON stated yes. When asked to show the surveyor Resident #50's order for diabetic nail care, the ADON stated when Resident #50 was admitted to the facility, the order would be in the physician notes. The ADON reviewed Resident #50's record and confirmed there was no order for Resident #50's diabetic nail care and would clarify with the provider.

Based on record review and staff interview, it was determined the facility failed to ensure physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 16 residents (Resident #4) reviewed for professional standards of practice. This failure created the potential for harm if Resident #4 were to receive oral medications despite having difficulty swallowing. Findings include:According to the National Council of State Boards of Nursing (NCSBN) website, accessed 4/6/26, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it.Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including dysphagia, disease of the esophagus, and gastrostomy.Resident #4's nutritional care plan, revised 4/3/26, documented the resident was NPO (nothing by mouth).A review of Resident #4's physician orders showed the following medications were ordered to be administered by mouth:-Prednisone 5 mg: Give 1 tablet by mouth daily for renal insufficiency-Magnesium glycinate 100 mg: Give 1 capsule by mouth at bedtime for insomniaOn 4/2/26 at 11:32 AM, the DON and the CRN confirmed that Resident #4 does not take anything by mouth and stated the providers orders should have been clarified prior to implementation.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident care plans accurately reflected the use of assistive devices. This was true for 1 of 16 residents (Resident #18) reviewed for comprehensive person-centered care plans. This failure had the potential to result in unmet care needs and increased risk to resident safety. Findings include:Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including leukemia, dementia, anxiety, and depression.On 3/30/26 at 10:52 AM, Resident #18 was observed in her bed with a transfer pole on the left side of her bed, and a 1/4 bed rail on the right side of her bed.A review of Resident #18's care plan did not document the use of a transfer pole or 1/4 bed rail on her bed.On 4/3/26 at 10:28 AM, the CRN stated Resident #18 did not have a care plan implemented related to the 1/4 bed rail and transfer pole, and there should have been.

Based on observation, policy review, and staff interview it was determined the facility failed to assess a resident for safety related to bed rail use or informed consent was obtained prior to use of the bed rail. This was true for 1 of 1 resident (Resident #18) reviewed for restraint assessment. This deficient practice had the potential for physical and psychosocial harm if Resident #18 were injured, trapped, or felt she was being restrained unnecessarily. Findings include:The facility's Use of Assistive Devices policy, dated 12/29/25, documented the facility's process for the proper and consistent use of assistive devices for residents requiring equipment to maintain or improve function and/or dignity is based on the residents' comprehensive assessment, in accordance with the residents' plan of care. The facility's Restraint Free Environment policy, reviewed 12/31/25, defined the use of bed rails as one type of physical restraint.Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including leukemia, dementia, anxiety, and depression.On 3/30/26 at 10:52 AM, Resident #18 was observed in her bed with a transfer pole on the left side of her bed, and a 1/4 bed rail on the right side of her bed.A review of Resident #18's record did not document a restraint assessment or consent form had been completed for use of the 1/4 bed rail. On 4/3/26 at 10:27 AM, the CRN stated Resident #18 did not have any restraint assessments for the 1/4 bed rail and there should have been.Cross reference F656.

Based on observation, policy review, resident interview, and staff interviews, it was determined the facility failed to ensure an interdisciplinary team assessment, physician orders, or care plan documentation were in place for self administration of glucose tablets. This was true for 1 of 3 residents (Resident #15), whose record was reviewed for medication administration. This failure created the potential for harm when unsafe medication practices and unmonitored treatment of hypoglycemia were identified. Findings include:The facility's Resident Self-Administration of Medication policy reviewed 12/30/25, documented residents may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. The results of the IDT assessment are recorded on the Medication Self-Administration Safety Screen. The care plan must reflect resident self-administration and storage arrangements for such medications. A re-assessment of safety at minimum should be considered by the IDT for the following: a. a significant change in resident's status, b. quarterly, c. annually, or d. medication error.Resident #15 was admitted , 2/3/20, and readmitted to the facility on [DATE] with multiple diagnoses including type 1 diabetes, partial paralysis of left side, and ataxia (loss of full control of bodily movements) after a stroke.On 3/30/26 at 1:07 PM, it was observed Resident #15 had a bottle of glucose tablets on his desk. When asked why there were glucose tablets on his desk, Resident #15 stated he took glucose tablets whenever he felt his blood sugar going low.A Medication Self-Administration Safety Screen assessment dated [DATE], documented Resident #15 required supervision to take medication, and glucose tablets were not listed as a medication he could store and take independently. Resident #15's record did not include documentation of Medication Self-Administration Safety Screen assessments had been conducted since 2023. A physician's progress note dated 2/13/26, documented the physician had seen Resident #15 for low blood sugars, and referenced Resident #15 was taking glucose tablets whenever his blood sugar was in the 60's.On 4/2/26 at 9:10 AM, the CRN and DON confirmed there were no Medication Self-Administration Safety Screen assessments related to Resident #15 being able to self-administer glucose tablets. Cross reference F684.

Based on record review and staff interview, it was determined the facility failed to ensure residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of that treatment. This was true for 1 of 6 residents (Resident #5) whose records were reviewed for informed consent. This failure created the potential for miscommunication and adverse effects when Resident #5 was not informed in advance of the risks and benefits of the ordered medication. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease.Resident #5's medical record included the following physician orders:-Lorazepam (a controlled substance anti-anxiety medication) Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for anxiety.-Lorazepam Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for terminal agitation for 180 days.A review of Resident #5's record showed no documentation that Resident #5 or her representative were informed of the risks and benefits or consent for the initiation of lorazepam use.On 4/2/26 at 12:08 PM, the CRN confirmed Resident #5 or their representative had not signed a consent documenting their understanding of the risks and benefits of lorazepam treatment prior to adding lorazepam as an active order for Resident #5.

Based on record and policy review, and staff interview, it was determined the facility failed to document if the COVID-19 vaccine was offered to residents. This was true for 2 of 5 residents (#4 and #8) reviewed for COVID-19 vaccination. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination. Findings include:The facility's COVID-19 Vaccination policy dated 12/11/25, documented the resident's medical record will include documentation of the following:-Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine.-Each dose of the vaccine administered to the resident, or,-If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal.1. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including muscle wasting and osteonecrosis.A review of Resident #4's record did not document if he was offered the opportunity to decline or accept the COVID-19 vaccination.On 4/1/26 at 11:07 AM, the CRN stated there were no records on file related to educating or offering the COVID-19 vaccine for Resident #4. 2. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including osteoarthritis, protein-calorie malnutrition, and dementia.A review of Resident #8's record did not document if she was offered the opportunity to decline or accept the COVID-19 vaccination.On 4/1/26 at 11:08 AM, the CRN stated there were no records on file related to educating or offering the COVID-19 vaccine for Resident #8.

Based on observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene during medication administration or wound care, did not follow proper wound care protocol, and did not sanitize reusable medical equipment. This was true for 2 of 5 residents (#10 and #27) observed for medication administration and for 1 of 1 residents (Resident #5) observed for wound care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. On 4/1/26 at 7:38 AM: LPN #2 was observed for morning medication pass. LPN #2 prepared medications for Resident #27, poured water into a clear plastic cup, locked the medication cart and went to Resident #27's room. LPN #2 knocked and entered Resident #27's room and handed resident #27 a medication cup and a cup of water. No hand hygiene was performed upon entering resident #27's room or prior to administering her medications. Resident #27 took her medications, LPN #2 performed hand hygiene upon exit of Resident #27's room and returned to the medication cart. On 4/1/26 at 7:48 AM: LPN #2 prepared medications for Resident #10, locked the medication cart and went to Resident #10's room. LPN #2 knocked and entered Resident #10's room. No hand hygiene was performed upon entering Resident #10's room. LPN #2 administered medications to Resident #10 with a spoon and applesauce. LPN #2 performed hand hygiene, exited Resident #10's room and returned to the medication cart. On 4/1/26 at 8:07 AM, when asked when hand hygiene is performed, LPN #2 stated hand hygiene is performed before entering and exiting resident's rooms. On 4/3/26 at 10:34 AM, observations were discussed with the DON and CRN. When asked if staff should perform hand hygiene before entering resident rooms, the DON confirmed staff should be performing hand hygiene upon entering resident's rooms. 2. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. Resident #5's care plan, revised 3/30/26, documented she was at risk for developing a multidrug resistant organism (MDRO) through silent transmission related to her medical condition, chronic wounds, and history of MDRO to her left heel. A review of Resident #5's physician order dated 2/6/26 directed staff to maintain Enhanced Barrier Precautions every shift due to her wounds. An Enhanced Barrier Precautions sign was posted outside Resident #5's room directed all individuals to sanitize hands before entering and after leaving the room, and directed health care providers to wear gloves and gowns when performing high contact resident care activities, including: -Dressing/bathing -Transferring -Changing linens -Providing hygiene assistance -Changing briefs or assisting with toileting -Device care or use (central line, urinary catheter, feeding tube, tracheostomy) -Wound-care (any skin opening requiring a dressing) On 4/3/26 at 10:01 AM, RN #1 was observed performing wound care for Resident #5. The following infection control concerns were observed: -Upon entering the room, RN #1 performed hand hygiene and applied gloves; however, no gown was worn, as required under Enhanced Barrier Precautions for wound care. -RN #1 placed a barrier cover on the bed and placed supplies on top of it, then grabbed the bed remote and adjusted the bed while wearing the same gloves, contaminating them. -RN #1 removed Resident #5's sock and placed her foot on the barrier while her wound-care supplies were directly placed on Resident #5's bed. -RN #1 reached into her pocket, removed a pair of scissors, and used them to cut the dressing without sanitizing the scissors. -After removing the soiled dressing, RN #1 removed her gloves, performed hand hygiene, and applied clean gloves. She then placed her gloved hand on the footboard of the bed while reaching across the bed to obtain wound cleanser. -After completing the treatment, RN #1 disposed of contaminated supplies, removed her gloves, and reapplied gloves without performing hand hygiene. On 4/3/26 at 10:14 AM, RN #1 confirmed she should have applied proper PPE, sanitized her scissors before use, and performed appropriate hand hygiene.

Based on record and policy review, SOM Appendix PP, and staff interview, it was determined the facility failed to educate residents on the risks and benefits of pneumococcal and influenza immunizations. This was true for 3 of 5 residents (#4, #8, and #36) whose records were reviewed for current immunizations. This deficient practice created the potential for harm if residents were not educated about the risk and benefits of receiving or declining the pneumococcal and influenza immunizations. Findings include:The facility's Pneumococcal Vaccine and Influenza Immunization policies, reviewed 12/22/25 documented:-Prior to administration of the influenza or pneumococcal vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of the CDC's current vaccine information statement relative to the vaccinations.-The vaccine information statements will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza or pneumococcal vaccines.-Individuals receiving the influenza or pneumococcal vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record.-The resident's medical record will include documentation that the resident and/or the resident's representative were provided education regarding the benefits and potential side-effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal.1. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including muscle wasting and osteonecrosis (the death of bone tissue due to a temporary or permanent loss of blood supply, often leading to bone collapse and severe arthritis).A review of Resident #4's record did not document whether he was offered the opportunity to decline or accept the pneumococcal immunization based on education from staff discussing the risks and benefits.On 4/1/26 at 11:03 AM, the CRN stated there were no records on file related to educating Resident #4 on the risks or benefits of receiving the pneumococcal immunization.2. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including cancer and coronary artery disease (a heart condition caused by plaque buildup in the arteries that supply blood to the heart, restricting blood flow).A review of Resident #36's record did not document whether he was offered the opportunity to decline or accept the pneumococcal immunization based on education from staff discussing the risks and benefits.On 4/1/26 at 11:04 AM, the CRN stated there were no records on file related to educating Resident #36 on the risks or benefits of receiving the pneumococcal immunization.3. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including osteoarthritis (the most common chronic joint disease, characterized by the breakdown of cartilage, bone changes, and inflammation), protein-calorie malnutrition, and dementia.A review of Resident #8's record did not document she or her representative was offered the opportunity to decline or accept the influenza and pneumococcal immunizations based on education from staff discussing the risks and benefits.On 4/1/26 at 11:05 AM, the CRN stated there were no records on file related to educating Resident #8 on the risks or benefits of receiving the influenza and pneumococcal immunizations.

Based on record review, staff interviews, and review of the Long-Term Care Reporting Portal, it was determined that the facility failed to ensure residents were free from neglect. This was true for 3 of 6 residents ( #3, #10, and #20) whose records were reviewed for abuse and neglect. This failure resulted in harm when Resident #3 was injured during a transfer and created the potential for embarrassment and psychosocial harm when Resident #10 and Resident #20 were not provided timely incontinence care. Findings include:The facility's Abuse and Neglect policy, dated 12/2/24, documented that the facility will identify events, occurrences, patterns, and trends that may constitute neglect-defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.The facility's Safe Resident Handling/Transfer policy, dated 12/20/24, documented that two staff members must be utilized when transferring residents with a full mechanical lift.1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (a condition that occurs when the blood flow to part of the brain is obstructed), hemiplegia (paralysis or weakness on one side of the body), and major depressive disorder. Resident #3's care plan, dated 5/15/23, directed staff to perform two-person transfers using the mechanical lift. An MDS quarterly assessment, dated 3/30/25, documented that Resident #3 was unable to go from a sitting to standing position and was dependent on staff for transfers (meaning all efforts were done by staff). Review of the Long-Term Care Reporting Portal revealed an incident dated 3/31/25, documenting that Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell, landing on her left arm. A progress note dated 3/31/25 at 7:20 PM, documented CMA #1 entered Resident #3's room to administer medications and noted she was ready to be transferred with the sling underneath her. CMA #1 left the room to obtain the mechanical lift and request help, but no one was available. The note documented CMA #1 hooked the sling to the mechanical lift and initiated the transfer on his own. He documented during the transfer the sling became unhooked, and the mechanical lift began to tilt to the right side. CMA #1 documented Resident #3 fell landing on her left arm. Resident #3 was assessed for injuries, and a small bruise was located on her right hand. During the initial assessment Resident #3 verbalized an 8 out of 10 pain level. The note concluded all appropriate parties were notified of the incident and Resident #3 was being monitored by the nursing staff. A review of the facility's Incidents and Accidents (I&A) record dated 3/31/25 documented that Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell, landing on her left arm. The I&A documented that X-ray services were provided on 4/1/25, revealing that Resident #3 sustained a comminuted fracture (a bone broken in at least two places). Pain management and orthopedic services were provided. The report also included notification of all appropriate parties, as well as staff education and disciplinary actions taken. The facility's I&A report documented that the investigation determined the allegation of neglect was confirmed due to CMA #1 deviating from Resident #3's plan of care by attempting to transfer her alone. On 9/3/25 at 2:47 PM, the Administrator confirmed that the incident involving Resident #3 was substantiated as neglect. 2. Resident #10 was admitted on [DATE] with multiple diagnoses including non-dominant sided hemiplegia and dysphagia (difficulty swallowing) after a stroke, and insomnia. The facility's Grievance Log documented Resident #10 filed a grievance against CNA #2 on 4/8/25. The grievance documented “Resident [#10] states that whenever [CNA #2] works; the resident does not get [incontinence care]. The grievance report documented this allegation was verified when staff watched the camera footage from the night in question, 4/6-4/7/25, and [CNA #2] had “only attended to Resident #10 once throughout their shift from 10 PM to 6 AM.” On 9/4/25 at 10:04 AM, the Administrator stated, Resident #10's allegation of neglect was likely verified based on the evidence documented on the grievance report and Resident #10 was assessed and there was no evidence of physical or psychosocial harm following the incident. 3. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses including severe vascular dementia (cognitive decline caused by damaged blood vessels in the brain, chronic kidney disease, and diabetes. Review of the Long-Term Care Reporting Portal revealed an incident dated 4/10/25 which documented Resident #20 was identified to have been left soiled by CNA #2 on 4/7 when the oncoming staff took over their assignments. The facility's Investigation Report documented in a chronological summary, review of facility camera footage on the night of 4/6-4/7/25, CNA #2 had extended absences from the floor and minimal resident care provided. On 9/4/25 at 10:04 AM, the Administrator stated, the investigation confirmed CNA #2 failed to perform care for Resident #20, and Resident #20 was assessed and there was no evidence of physical or psychosocial harm following the incident. Corrective actions taken by the facility on 4/8/25 to prevent incident from reoccurrence included: CMA received formal written counseling and education on safe transfers, and two persons assist required for total lifts. Nursing staff education on transfer protocols and resident neglect, including supervisor follow-up and observations to ensure compliance with transfers and resident care. Facility reinforced the two-person Hoyer lift policy and emphasized expectations for staff to use facility radios for additional assistance. Facility has taken appropriate measures to ensure further compliance with the incident as of 4/8/25 and is cited at past non-compliance at F600.

Based on record review and staff interview, it was determined the facility failed to ensure allegations of neglect were reported to the State Agency within the regulated time period. This was true for 2 of 6 residents, (#3, and #10) who were reviewed for abuse and neglect. This failure had the potential to affect all residents in the facility and placed them at risk for harm related to neglect. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (a condition that occurs when the blood flow to part of the brain is obstructed), hemiplegia (paralysis or weakness on one side of the body), and major depressive disorder. A review of the facility's Incidents and Accidents (I&A) record dated 3/31/25 documented that Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell, landing on her left arm. The I&A documented that X-ray services were provided on 4/1/25, revealing that Resident #3 sustained a comminuted fracture (a bone broken in at least two places). Pain management and orthopedic services were provided. The report also included notification of all appropriate parties, as well as staff education and disciplinary actions taken. The facility's I&A report documented that the investigation determined the allegation of neglect was confirmed due to CMA #1 deviating from Resident #3's plan of care by attempting to transfer her alone. On review of the Long-Term Care Reporting Portal an incident reported on 4/2/25, documented that on 3/31/25, Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell landing on her left arm. On 9/3/25 at 2:47 PM, the Administrator stated if the incident triggered an investigation for neglect my reporting date of 4/2/25 would be considered late reporting however, we did not identify the incident as neglect until the injury was confirmed on 4/1/25. 2. Resident #10 was admitted on [DATE] with multiple diagnoses including non-dominant sided hemiplegia and dysphagia (difficulty swallowing) after a stroke, and insomnia. Review of the facility's Grievance Logs, Resident #10 made an allegation of neglect on 4/8/25. Review of the State Agency's Long Term Care Reporting Portal, Resident #10's grievance was included in another investigation initiated on 4/10/25, however, Resident #10's name was not associated with the other investigation. On 9/3/25 at 3:24 PM, the Administrator stated Resident #10's allegation of neglect should have been reported to the State Agency when he received it.

Based on policy review, record review, review of facility grievance reports, review of the State Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from physical, verbal, and mental abuse. This was true for 7 of 13 residents (#3, #5, #6 #10, #11, #12, and #13) reviewed for abuse. This placed Resident #3 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect Resident #3 from abuse by LPN #1. Residents #5, #6, #10, #11, #12, and #13 experienced mental harm when Resident #7 verbally abused them. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and anxiety disorder. Resident #3's care plan for daily preferences, initiated 5/5/23, stated she preferred female caregivers for personal cares. Resident #3's MAR for May 2023, documented to administer Valium medication to treat anxiety, muscle spasms, and seizures) 10 mg to her vagina at bedtime every Monday, Wednesday, and Saturday for bladder spasms, beginning 5/6/23. Resident #3's MAR, dated 5/13/23, documented LPN #1, (a male nurse) administered the Valium vaginally at bedtime. On 5/23/23 at 9:00 AM, when asked if staff in the facility treated her well and provided good care, Resident #3 stated she liked the facility, and everyone was nice except one nurse. Resident #3 stated LPN #1 was rough and hurt her approximately a week ago when he forcefully inserted a medication into her vagina. She stated LPN #1 pushed so high [into the vagina] it hurt. Resident #3 said she yelled, Ow that hurts! She stated LPN #1 replied, that should not hurt you that much. Resident #3 stated LPN #1 was rude to her and made her feel bad. She said she had vaginal bleeding for 3 days after the medication was inserted and continued to have some vaginal bleeding. Resident #3 stated she filled out a grievance after the incident. She said the SSD talked to her about the grievance and Resident #3 told her what happened. She said the SSD and DON then came and talked to her together and asked her if she would give LPN #1 a second chance to care for her if he apologized. Resident #3 stated she told them she preferred not to have him in her room again. When asked if Resident #3 felt LPN #1 was abusive, she answered quickly in a forceful tone, Yes! The facility's grievance reports were reviewed, dated March 2023, April 2023, and May 2023. There were no grievances related to the incident Resident #3 described. Resident #3's record did not include documentation of the incident she described. There was no documentation in her record of vaginal bleeding. On 5/23/23 at 10:15 AM, LPN #3 was asked if she was aware Resident #3 had bleeding from her vagina after a medication was inserted into her vagina. LPN #3 said she was aware, and the facility was monitoring the bleeding. On 5/23/23 at 10:35 AM, LPN #3 reviewed Resident #3's record and said she could not find documentation of the vaginal bleeding. LPN #1's personnel file, including disciplinary actions, was requested from the facility. The facility provided a type-written document titled, Conversation with [LPN #1] - Summary of Important Facts, dated 5/19/23. The purpose of the document stated, Counseling session in response to formal grievance filed by a resident. The incident review section stated the grievance was regarding an allegation of the insertion of a narcotic pill vaginally, and the patient experiencing significant pain as a result. The grievance report referred to in LPN #1's personnel file was not included with the May 2023 grievances requested by the surveyors. On 5/23/23 at 10:30 AM, the grievance report referenced in LPN #1's personnel file was requested and provided by the Administrator. Resident #3's grievance dated 5/16/23, documented [LPN #1] had to insert a pill vaginaly [sic] he had a bad attitude and argued with me. The report documented [LPN #1] was so rough that I am still bleeding. The resolution on the grievance form stated, SSD and I [DON] talked with resident about [LPN #1], she was satisfied with resolution. [Resident #3] aware she may let IDT know if she requests alternative nurse. The grievance investigation was documented as initiated on 5/18/23, resolved on 5/18/23, and was signed by risk management on 5/19/23. An attachment to the grievance dated 5/16/23, documented the following: 1. Narcotic Pill Inserted Vaginally and Causing Pain: This presents a serious risk as it may indicate incorrect medication administration or inappropriate behavior. It directly affects patient safety and comfort. It also raises legal and ethical questions. 2. Poor Social Engagement and Rude Behavior: While not directly a physical safety issue, poor social engagement and rude behavior can have a serious impact on patient mental wellbeing. It can also be indicative of larger problems with staff professionalism and training. It's also a risk to the reputation of the facility. 3. Argumentative and Verbal Behavior: This presents risk to the mental wellbeing of patients, and to the harmony of the work environment. Such behavior can lead to distress for the patient and a negative perception of the facility. 4. Schedule of Nurse [LPN #1] - Works Friday to Sunday: This is potentially a lower risk issue. However, if the patient's discomfort or complaints are specifically associated with [LPN #1], and he is consistently scheduled on certain days, this might inadvertently result in a predictable, recurring issue. The facility could also be seen as not responding to patient preferences and needs. The facility's policy, Abuse, Neglect and Exploitation, dated 8/26/22, stated the following: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. - Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. - An immediate investigation is warranted when instances of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. - The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Resident #3's grievance was not identified as an allegation of abuse and investigated per facility policy. On 5/23/23 at 2:07 PM, the SSD and Administrator were interviewed. The SSD said she received a grievance from Resident #3 on 5/16/23. She said they treated Resident #3's allegations as a grievance due to Resident #3 not liking how the medication was administered. She said the IDT met and discussed the administration of the medication and education with LPN #1. The Administrator stated he saw it as an incorrect medication administration procedure. On 5/23/23 at 2:30 PM, the DON said she received a grievance regarding Resident #3 on 5/16/23. She stated she and the SSD asked Resident #3 if she was willing to work with LPN #1 again. The DON said Resident #3 stated she did not feel like she had a choice. The DON said she told Resident #3 she did have a choice, but there would be times when she would need a nurse and he would be the only one available. On 5/23/23 at 2:45 PM, the Administrator reviewed the facility's policy for abuse and neglect. He stated he felt the vaginal medication administration was a procedural issue. When the surveyors reviewed Resident #3's grievance with the Administrator regarding LPN #1's roughness resulting in vaginal bleeding, the disciplinary discussion with LPN #1 regarding poor social engagement and argumentative and verbal behavior, Resident #3's subsequent statements to the SSD and DON about not having a choice to have LPN #1 care for her, the Administrator agreed the grievance should have been reported as potential abuse. The Administrator also said there was no documentation of the allegation in Resident #3's record or documentation of the conversations with the SSD and DON. When asked why Resident #3's grievance was not included in the grievances requested by the surveyors, he stated it was not provided as it was still in progress. On 5/23/23 at 5:18 PM, the Administrator, DON, and CNO were notified verbally and in writing of an Immediate Jeopardy (IJ) determination at F600 related to the facility's failure to ensure residents were free from abuse. This failure placed Resident #3 at increased likelihood for serious harm. On 5/23/23 at 5:23 PM, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: - An abuse allegation investigation was initiated per facility policy. - Interview of all appropriate residents to determine scope of potential harm to other residents. - Suspend accused staff member pending investigation and substantiation/un-substantiation of accusations to prevent the potential for further harm to residents. On 5/23/23 at 5:23 PM, the Administrator, DON, and CNO were verbally notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at a scope and severity of G, constituting actual harm that is not immediate jeopardy. From 6/12/23 to 6/14/23, the survey was extended after review of the facility's investigation uploaded to the State Agency's Long-Term Care Reporting Portal on 5/26/23 with the facility's documented determination the abuse to Resident #3 was unsubstantiated and LPN #1's potential continued access to Resident #3. Additionally, another investigation was uploaded to the State Agency's Long-Term Care Reporting Portal on 5/30/23 by the facility relating to Resident-to-Resident verbal abuse that occurred on 5/23/23 and upon receipt and review of these reports, it was determined further investigation was necessitated to rule out further immediate jeopardy in the facility. Additional findings include: On 5/26/23, the facility uploaded the investigation of Resident #3's allegation of abuse by LPN #1 to the State Agency's Long-Term Care Reporting Portal, after it was identified on survey. The investigation included the following documentation: a. Interview questions conducted by the Administrator with Resident #3 documented the following: - Administrator: Do you feel safe here at [the facility]? - Resident #3: Yes, except for [LPN #1]. - Administrator: Have you been abused by another resident or staff member? - Resident #3: Only him (referring to [LPN #1]). - Administrator: Do you feel like what occurred was abuse? - Resident #3: Yes, it was painful. He shoved it [the medication] up there [in the vagina] so high. That had never happened before. I yelled out in pain, and he said, 'that shouldn't be painful.' b. Interview questions conducted by the Administrator and DON with CNA #1 who LPN #1 said was in the room with him and Resident #3 at the time of the administration of her vaginal medication, documented the following: - Administrator/DON: Are you aware of an incident on 5/13/23 involving [LPN #1] and [Resident #3]? - CNA #1: Yes. - Administrator/DON: Did you witness the incident? - CNA #1: Yes - Administrator/DON: In your own words, describe the incident in question. - CNA #1: I went to answer [Resident #3's] call light and he [LPN #1] came in behind me to give her her [sic] pill in her vagina. I stayed to change her brief after he's done. He [LPN #1] told her [Resident #3] he was going to put the pill in. Tried once and couldn't, and tried a second time. She started saying 'it's hurting'. - Administrator/DON: Was she yelling out in pain or telling him? - CNA #1: No yelling, telling him 'it hurts, it hurts'. He was telling her 'It's okay, it's normal to be hurting'. - Administrator/DON: What did you think about what was happening? Did anything about the situation seem different than normal? - CNA #1: I saw that he wasn't gentle like I've seen others do it, and they are more gentle. - Administrator/DON: Can you say more about what you mean? - CNA #1: When he inserted two fingers to try again, she said it was hurting, and he kept going. On 6/13/23 at 5:15 AM, CNA #1 was asked by the state surveyors if she witnessed the vaginal medication administration on 5/13/23 to Resident #3 by LPN #1. CNA #1 said she was present to assist with Resident #3's positioning and stayed after the procedure to help her with her adult briefs. CNA #1 stated Resident #3 screamed several times that it [insertion of the medication] hurt. She stated LPN #1 did not pause and kept going. She said Resident #3 had an indwelling urinary catheter at the time. CNA #1 stated she did not observe bleeding in Resident #3's vaginal area prior to insertion of the vaginal medication by LPN #1. She said when she changed Resident #3's brief after the procedure there was bleeding in the vaginal area. On 6/13/23 at 1:30 PM, Resident #3 stated she did not want LPN #1 ever coming into her room and another nurse administered her medications when she needed them when LPN #1 was present on night shift. On 6/14/23 at 8:38 AM, LPN #1 was interviewed by the surveyors via phone. When asked if Resident #3 complained of pain during the procedure, LPN #1 stated if someone was yelling out during a procedure he would stop and assess the situation. LPN #1 said he did not recall Resident #3 yelling out but that he was very focused on completing the procedure. The facility failed to ensure Resident #3 was protected from physical and mental abuse. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Guillain-Barre Syndrome (a rare disorder in which the body's immune system attacks the nerves which can result in lasting effects, such as weakness, numbness, or fatigue), Myelopathy (injury to the spinal cord which can cause nerve dysfunction along the spinal cord resulting in pain, loss of balance and coordination and numbness in the area around the compression point). Resident #7's care plan, initiated 2/11/22, stated Resident #7 had a history of aggressive symptoms of being antagonistic to other residents. Interventions included: - Resident #7 utilized counseling services and was practicing tools on how to be respectful to others and staff were to remind him to be respectful of others, initiated on 2/18/22, and revised on 3/6/23. - If Resident #7 was observed to initiate any potential form of abuse such as taunting, belittling, hitting, or badgering to another resident staff were to immediately ensure the safety of Resident #7 and all residents and directly notify the facility abuse coordinator, initiated 2/11/22, and revised on 5/12/22. These interventions were not followed. a. An investigative summary uploaded to the State's Long-Term Care Reporting Portal, dated 5/30/23, documented an investigation of a verbal altercation between Resident #7 and Resident #6. The investigative summary documented Resident #7 was the alleged initiator of the verbal altercation and Resident #6 was the alleged receiver of the verbal altercation. The summary documented Resident #7 and #6 had attended a facility activity of going shopping and it was alleged Resident #6 requested the country music be turned off [on the facility bus] as it made him tearful. Resident #7 allegedly became upset stating the music should not be turned off for one individual. The summary documented per witness statements and Resident #7 and Resident #6's recollection of the event, a verbal altercation then took place and ended with Resident #6 calling the police. The investigative summary, dated 5/30/23, further documented, On this day, the facility implemented an all-resident interview process to assure the safety, emotional, and psychosocial wellbeing of all residents. In doing so it was identified that [Resident #7] has unfortunately recently had negative, verbal interactions with other residents. These findings warranted the facility to take further immediate action by placing a staff member to be in direct line of sight of [Resident #7] to observe verbal interactions with others to ensure resident safety and well-being. The all-resident interviews, dated 5/24/23, included the following additional allegations of verbal abuse from Resident #7: i. Resident #6 stated he did not feel safe in the facility and said another resident harrassed him verbally. On 6/14/23 at 10:08 AM, Resident #6 was interviewed about his interaction with Resident #7 on the bus after the field trip to the store on 5/23/23. Resident #6 stated country music was a trigger for sadness to him related to his ex-wife. He stated he very nicely asked the bus driver to turn the music off. He stated Resident #7 said it shouldn't be turned off for one person and called him a cry baby. Resident #6 stated Resident #7 was constantly badgering him, calling him names and bullying. He stated Resident #7 called him whiny and always made derogatory remarks to him whenever he encountered him. Resident #6 said he usually says nothing in response, but because Resident #7 kept calling him names on the bus and continued when they got off the bus back at the facility, he couldn't take it anymore and told Resident #7 he was going to call the police if he didn't stop. Resident #6 said Resident #7 did not stop so he called the police. Resident #6 said he told the Administrator when he saw Resident #7, he went the othr way and avoided activities Resident #7 attended. Resident #6 further stated Resident #7 bullies everybody and never has anything nice to say. ii. Resident #11 stated [Resident #7] called me a bitch and fat pig when passing by him. An incident, dated 5/24/23, uploaded to the State's Long Term Care Reporting Portal, documented Resident #11 reported Resident #7 addressed her with an inappropriate epithet upon entering through the front doors [of the facility]. Resident #11 reported she was verbally insulted, leading to feelings of anger, frustration, rejection, and awkwardness. The investigation summary of the incident documented: Post-incident, Social Services conducted an interview with [Resident #11]. She expressed her preference to avoid socializing with [Resident #7] and continue her interactions with other residents and staff. The investigation summary further documented, A subsequent follow-up was done with each resident to ensure their safety. [Resident #11] reported feeling safe at [the facility], knowing exactly who to report any safety concerns to. However, she did express feeling verbally harassed by [Resident #7], citing instances of him addressing her with derogatory remarks . The investigation's final verdict stated, Upon completing our investigation, it was found that the incident resulted from a mutual state of annoyance between the residents involved. [Resident #7], in particular, demonstrated a lack of restraint in expressing his annoyance, resorting to offensive language when agitated. Interviews conducted with other residents further substantiated this behavior, revealing a pattern that led to several residents perceiving [Resident #7] as a bully. iii. Resident #6 stated he did not feel safe in the facility. He stated he had been abused by another resident verbally. iv. Resident #10 stated she had not currently been abused by another resident or staff member but stated When I first got here [Resident #7] was very mean to me, said the worst swear words I have ever heard. I just avoid him because I don't want him to say anything else to me. v. Resident #5 stated he did not feel safe in the facility. He stated he was verbally harassed by another resident. On 6/13/23 at 11:16 AM, Resident #5 was interviewed by the state surveyors. Resident #5 stated he felt angry when he saw Resident # 7. He stated he made noises and comments to get a rise from him. Resident #5 said Resident #7 bothers other residents and they were scared of him. Resident #5 further stated Resident #7 intimidated residents. vi. Resident #12 stated he was abused by another resident and stated, That guy [Resident #7], he calls me names .Big Baby On 6/12/23 at 4:41 PM, the Administrator stated he did not feel Resident #7 was abusive, but more annoying. He stated Resident #7 said things to get a reaction, but residents said it was not abuse. When the facility's policy with the definitions of abuse and willfulness were reviewed with the Administrator, he agreed the allegations for Resident #7 should be reported and investigated and stated he had learned a lot since these incidents. The Administrator agreed Resident #7's comments fit the definition of abuse based on review of the facility policy. b. A progress note, dated 1/3/23 at 7:00 PM, documented Resident #13 [unidentified in the note] from room [ROOM NUMBER] was next to RN #1 at the nurse's station keeping her company as they waited for the CNA to get her to bed. The note documented Resident #7 came over and told Resident #13 to get out of the way in a mean, loud tone. The note documented before Resident #7 came closer to them, Resident #13 told RN #1 she didn't want to be here if he was coming over. The note documented Resident #13 acted scared of Resident #7. When RN #1 asked Resident #13 about it, she stated he says mean things to me. During an interview on 6/12/23 at 4:41 PM, when asked about the progress note and the incident between Resident #7 and Resident #13, the Administrator said there was no grievance or reportable about the altercation, and he was unaware of the incident. The facility failed to ensure Residents #5, #6, #10, #11, #12, and #13 were free from verbal and mental abuse.

Based on policy review, record review, Incidents and Accidents (I&A) report review, review of grievances, and staff and resident interviews, it was determined the facility failed to ensure residents were free from abuse by other residents and staff. This was true for 4 of 5 residents (Residents #3, #4, #5, and #6) reviewed for abuse. This failure resulted in mental harm to Resident #4 when he was repeatedly taunted by Resident #3 to point of physical aggression toward Resident #3. Resident #3 was physically abused when Resident #4 hit him on the jaw with a cane. Resident #5 and Resident #6 were at risk of harm when verbally abused by RN #1. Findings include: The facility's Abuse policy, revised 1/14/21, documented the facility implemented policies and procedures that prevented all types of abuse, neglect and exploitation. The policy defined the following: * Physical Abuse - including but not limited to hitting, slapping, punching, biting, and kicking. * Verbal Abuse - use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. This policy was not followed. 1. Physical abuse of Resident #3 by Resident #4 and Resident #3's mental abuse of Resident #4. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 3/9/22, documented Resident #3 was cognitively intact. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 1/21/22, documented Resident #4 was cognitively intact. An I&A report, dated 2/11/22, documented Resident #3 was hit by Resident #4 with a cane and sustained a hematoma (injury resulting in blood pooling outside a blood vessel) on his left jaw. The facility's abuse investigation report, dated 2/11/22, documented Resident #3 was sitting in the dining room when Resident #4 entered the dining room. When Resident #3 saw Resident #4, Resident #3 started making baby noises directed to Resident #4. Resident #4 turned around and went back to his room and grabbed his cane. Resident #4 returned to the dining room and hit Resident #3 with his cane. A CNA saw Resident #4 about to hit Resident #3 with his cane and tried to stop Resident #4 but was too late. The nursing staff separated the two residents. Resident #4 was asked to go to his room and nursing staff placed ice on Resident #3's face. The investigative report documented Resident #4 stated he could not take it anymore, he went back to his room, grabbed his cane and hit Resident #3 to shut him up. A nurse's note, dated 2/11/22 at 2:00 PM, documented Resident #3 had a raised area on his left lower jaw. Resident #3 denied pain, but said it was a little sore. The nurse's note also documented Resident #3 had made many antagonistic comments in the past to Resident #4. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An x-ray report, dated 2/21/22, documented Resident #3 had no obvious mandible fracture. On 4/14/22 at 8:45 AM, Resident #4 stated Resident #3 kept calling him a cry baby and said wawa to him so many times. When asked what wawa meant, Resident #4 stated it meant a cry baby. Resident #4 stated the staff had heard Resident #3 calling him names and they had asked him to stop but Resident #3 did it again. Resident #4 stated Resident #3 was constantly picking on him, calling him names, sometimes loudly, and he could not take it anymore, so he took his cane and hit Resident #3 on his face. On 4/14/22 at 1:07 PM, Resident #3 stated Resident #4 hit him with his cane. When asked why Resident #4 hit him, Resident #3 stated it was because Resident #4 was a cry baby. On 4/13/22 at 9:30 AM, the Social Services Director (SSD) stated the staff had reported to her a couple of times Resident #3 made unnecessary remarks to Resident #4. The SSD stated she spoke to Resident #3 about his comments to Resident #4 and advised him to avoid making those unnecessary comments. The SSD stated she asked the staff to put Resident #3 and Resident #4 in different areas in the dining room. The SSD stated she had not received any further report from the staff after Resident #3 and Resident #4 were placed in different areas in the dining room, until the morning on 2/11/22, when Resident #4 hit Resident #3 with his cane. The facility failed to ensure Resident #3 was protected from physical abuse by Resident #4 and Resident #4 was protected from Resident #3's repeated antagonistic comments culminating in mental abuse. 2. Verbal abuse by RN #1 directed at Resident #5 and Resident #6: a. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 12/21/21, documented Resident #5 was cognitively intact and required extensive assistance of two persons for bed mobility, transfers, toileting, and personal hygiene. Resident #5's representative filed a grievance, dated 12/22/21 at 10:02 PM, documenting RN # 1 told Resident #5 he was being transferred to the bathroom too many times and those transfers were hurting his staff. Resident #5's representative stated RN #1 then counted how many times Resident #5 had to go to the bathroom and said it was 19 transfers a night. Resident #5's representative documented RN #1 stated We can't be doing this. Resident #5's representative documented RN #1 made her feel bad and she could only imagine how Resident #5 felt. Resident #5's representative also documented RN #1 was Degrading my [Resident #5] and making him feel bad for having needs that he can't fulfill. A facility's investigative report, dated 12/22/21, documented RN #1 was suspended from work pending the outcome of the investigation. The report documented several attempts were made to educate RN #1 and discuss ways to improve his customer service and bedside manner, but it was clear to the facility that RN #1 was not open to it. The facility did not substantiate RN #1 verbally abused Resident #5. The facility determined RN #1 demonstrated poor customer service. The facility terminated RN #1's employment at the facility. b. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 12/22/21, documented Resident #6 was cognitively intact. A grievance form completed by PTA #1 on behalf of Resident #6, dated 12/23/21 at 3:00 PM, documented RN #1 got angry at her, yelled at her, and ripped off the internal tie of her robe. Resident #6 reported RN #1 got mad at her when she asked RN #1 what medications RN #1 was giving to her. Resident #6 also reported RN #1 wanted to take her blood pressure and Resident #6 asked RN #1 if he would like her to take her arm out of the sleeve of her robe and RN #1 said yes. Resident #6 reported she asked RN #1 to pull the sleeve gently as her arm was tender, but RN #1 was rough and in the process ripped off the internal ties of her robe. An interview with Resident #6 conducted by the SSD, dated 12/23/21, documented Resident #6 had trouble with RN #1 the night of 12/21/21, so on 12/22/21, sje tried to be nice to RN #1 when he came to her room to take her blood pressure. Resident #6 reported she had her robe on and when she asked RN #1 if he wanted her to take her arm out, RN #1 said yes. Resident #6 reported she asked RN #1 if he could pull her robe gently on the cuff, so she could get her arm out of the sleeve. Resident #6 reported RN #1 pulled so hard it ripped off the internal ties of her robe. Resident #6 reported she apologized to RN #1 and told RN #1 just hold on to it and she would pull her arm out. Resident #6 reported RN #1 was mad and said to her I'm not touching your robe again and walked out of the room. When asked what happened the night of 12/21/21, Resident #6 reported RN #1 got upset when she asked him if he could ask her neighbor to turn his television down because it was too loud. Resident #6 also reported RN #1 got angry when she asked him what the medications were he was giving to her. The facility's investigative report, dated 12/23/21, documented RN #1 was already suspended from work due to an allegation from another resident at the time this incident was reported. The report documented several attempts were made to educate RN #1 and discuss ways to improve his customer service and bedside manner, but it was clear to the facility that RN #1 was not open to it. The facility terminated RN #1's employment at the facility. On 4/15/22 at 10:22 AM, the Administrator reviewed the Investigative reports, dated 12/22/21, regarding verbal abuse by RN #1 directed at Resident #5 and 12/23/21, regarding verbal abuse by RN #1 directed to Resident #6. The Administrator stated he started in the facility in March, 2022, and he was the abuse coordinator. The Administrator stated he informed the facility staff he should be informed of any alleged abuse incidents in the facility. The Administrator stated the investigative report documented RN #1 was not open for discussion with the previous administrator regarding the incidents and was terminated from his employment.

Based on nursing professional standards of practice review, policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development of and worsening of a pressure ulcer. This was true for 1 of 2 residents (Resident #1) reviewed for quality of care related to pressure ulcers. This deficient practice resulted in harm to Resident #1 when she developed an avoidable pressure ulcer. Findings include: The National Pressure Injury Advisory Panel website, accessed on 9/15/21, defined a Stage 2 pressure ulcer as follows: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. The Potter and Perry Fundamentals of Nursing, tenth edition, page 1255, guidance to prevent pressure ulcer development included establishing and posting [documenting] an individualized turning schedule, and turn patient off at risk areas often, provide a pressure-redistribution surface, protect pressure points from medical devices such as oxygen tubing, feeding tubes and casts, clean the peri area with a no-rinse perineal cleanser and protect skin with a moisture-barrier ointment after each incontinent episode, and to keep skin dry and free of maceration (softening and break down of skin resulting from prolonged exposure to moisture). The Lippincott Manual of Nursing Practice, 10th edition, pages 183-184, directed nurses to reposition residents every 2 hours to relieve pressure. Risk factors for pressure ulcers included malnourishment and immobility. The facility's policy for Pressure Injury Prevention and Management, revised on 5/11/21, stated the facility was committed to preventing avoidable pressure injuries (also referred to as ulcers) and the promotion of healing of existing pressure injuries. * The guidelines for assessment of pressure injury risk included a licensed nurse conducted a full-body assessment on all residents upon admission, readmission, weekly, and after newly identified pressure injury, and findings were documented in the medical record. * The guidelines for interventions for prevention and to promote healing included evidence-based treatments in accordance with current standards of practice were provided for all residents who had a pressure injury present. The policy and professional standards of practice were not followed. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's quarterly MDS assessment, dated 8/14/21, documented Resident #1's hearing and vision were adequate, and she was able to understand and comprehend speech, and her cognition was intact. The MDS assessment also stated she needed two people to assist her with bed transferring, turning, repositioning, dressing, toilet use, and one person to assist her with all other personal care areas. The assessment documented Resident #1 was at risk of developing pressure ulcers. Resident #1's skin care plan, initiated on 2/7/20, revised on 2/10/20 and 12/18/20, stated she had the potential for skin impairment related to being bed-bound for many years and having contractures on upper and lower extremities. The care plan interventions were documented as follows: * Float heels with pillows and place the pillows between legs to minimize skin on skin contact while in bed. * Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * Keep skin clean and dry. * Observe skin daily with care and notify the nurse of any skin issues. * Use pressure relieving cushion when in bed or on the wheelchair. * Use a draw sheet and lift device to move Resident #1 while in bed. * Weekly skin checks to be performed by a license nurse. A quarterly Braden Scale pressure ulcer risk assessment, dated 8/3/21, documented Resident #1 was at moderate risk of developing pressure ulcers related to required moderate to maximum assistance in moving and was not able to complete lifting without sliding against sheets. The assessment documented Resident #1 required frequent repositioning with maximum assistance. A nursing progress note, dated 8/19/21 at 2:24 PM, documented a charge nurse observed a small open area with a red tissue base over Resident #1's sacrum (tailbone). It was identified as a Stage 2 pressure ulcer and wound care was initiated. a. Resident #1's weekly pressure ulcer assessment documented the pressure ulcer worsened in size as follows: * On 8/19/21, the pressure ulcer size was 1.2 cm x 1.3 cm x 0.1 cm. * On 8/26/21, the pressure ulcer size was 5 cm x 7 cm x 0.1 cm. Resident #1's pressure ulcer increased in size by 3.8 cm in length and by 5.7 cm in width in 7 days b. Resident #1's TAR for August and September 2021, documented Resident #1 received pressure ulcer wound care ordered by the physician once every other day, started on 8/20/21, as follows: * Clean Stage 2 pressure ulcer injury to sacrum with wound cleanser, apply Venelex ointment (medication to promote wound healing), cover with protective dressing. Resident #1's TAR for July, August, and September 2021 documented Resident #1 received pressure ulcer prevention and related care ordered by the physician. It documented non-completion or blank as follows: * Weekly skin assessment every Tuesday day shift, document Y if skin intact or no signs and symptoms of skin break down, otherwise document N, start date 10/6/2020. Documentation indicated non-completion or blank on 8/10/21, 8/17/21 and 9/7/21. * Float bilateral heels on pillows while in bed every day and night shift, start date 12/17/20. Documentation indicated non-completion or blank on day shift on 7/3/21, 7/9/21, 7/10/21,7/24/21, 8/6/21, 8/7/21, 8/8/21, 8/10/21, 8/13/21, 8/17/21, 8/20/21, 8/21/21, 8/22/21, 8/27/21, 8/29/21 and 9/7/21. * Low air loss mattress with bolsters with setting at 5-8, check every shift to make sure airbed is inflated functioning with appropriate setting 5-8, start date 5/29/20. Documentation indicated non-completion or blank on day shift on 7/3/21, 7/9/21, 7/10/21, 7/24/21, 8/6/21, 8/7/21, 8/8/21, 8/10/21, 8/13/21, 8/17/21, 8/20/21, 8/21/21, 8/22/21, 8/27/21, and 9/7/21. * Monitor pressure ulcer for dressing, pain, and skin one time a day, documented with a + with no issue, and - with an issue, start date 8/20/21. Documentation indicated non-completion or blank on 8/20/21, 8/21/21, 8/22/21, 8/27/21, and 9/7/21. On 9/9/21 at 11:37 AM, the DON said the facility's requirement for skin assessment and pressure ulcer wound measurement was weekly. She stated nurses should document it in the TAR and the Weekly Pressure Ulcer Assessment.

Based on record review, policy review, review of the State Survey Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from abuse for 1 of 12 residents (Resident #1) reviewed for abuse. Resident #1 experienced psychosocial harm and sexual abuse when she was asked by CNA #5 to touch his exposed penis. This failure to prevent abuse placed Resident #1 at risk for continued abuse and had the potential for other residents to be subjected to abuse and neglect. Findings include: The facility's Abuse policy, revised 1/14/21, documented the facility implemented policies and procedures that prevented all types of abuse and exploitation. This policy defined sexual abuse as non-consensual sexual contact of any type with a resident. This policy was not followed. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's annual MDS assessment documented Resident #1's hearing and vision were adequate, and she was able to understand and comprehend speech. Her cognition was moderately impaired. The MDS assessment stated she needed two people to assist her with transferring and turning in bed and one-person assistance for all other personal care areas. The facility submitted an investigation to the State Agency Long Term Care Reporting Portal on 5/6/21 which documented Resident #1 was sexually abused. The investigation documented CNA #5 stated he exposed his genitals to Resident #1. A Meridian Police Department report, dated 5/5/21, reference # 2021-2934, with the incident topic adult-sexual abuse of a vulnerable adult, documented an interview with CNA #5 in which he stated, I pulled myself out (referring to genital), ok, I did ask her if she wanted to help adjust me. A facility abuse investigation report, dated 5/6/21, documented Resident #1 stated she touched CNA #5's penis. It also documented CNA #5's employment was terminated on 5/6/21. On 6/29/21 at 8:55 AM, Resident #1 stated she remembered CNA #5 and he usually took the carrots (a physical therapy contracture preventative device that is shaped like a carrot) out of her hands at night. Resident #1 stated she touched CNA #5's penis because he asked her to, and she did not want do it. Resident #1 had tears in her eyes and looked away from the surveyor when she made this statement. On 6/29/21 at 2:10 PM, The Administrator stated CNA #5 was in jail, related to his admission of sexual abuse, and awaiting trial. He stated the facility had initiated emotional support and monitoring of Resident #1 for any signs of anxiety or distress.