Every finding on record at Mountain View Manor

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that a resident representative was notified of an accident involving the resident, which resulted in injury, to one of three sampled residents (#21). The deficient practice could result in harm to the resident without their representative being aware. Findings include:Resident #21 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, type 2 diabetes, chronic osteomyelitis, acute embolism and thrombosis, pulmonary hypertension, metabolic encephalopathy, pressure ulcer of the sacral region, mood affective disorder, iron deficiency anemia, hypothyroidism, benign prostatic hyperplasia, and chest pain. A power of attorney (POA) document uploaded into the resident record, signed and dated on October 14, 2025, revealed that Resident #21's son was his POA. A provider progress note dated January 13, 2026, revealed that the resident had a POA and that the resident elected his son, who was designated as his health care surrogate. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS also revealed one documented fall after admission. An incident progress note dated January 16, 2026, at 11:50 p.m. revealed that at 10:30 p.m., the resident was heard yelling for help and was found in his room on the floor. The note revealed that the resident stated he was attempting to get up to go to the bathroom when his legs buckled, and he slid to the floor. The note revealed that the resident was found with no injuries, and he stated that he did not bump his head. The note also revealed that the resident was barefoot, he did not use his call light for assistance, and that team health and the Director of Nursing (DON) were notified. There was no evidence in the note that the POA was notified of the incident. An order administration progress note dated January 17, 2026, at 3:19 a.m. revealed that oxycodone HCl Oral Tablet 10 MG was administered for pain in the resident's legs, feet, and lower back. An order administration progress note dated January 17, 2026, at 5:21 p.m. revealed that the resident refused wound care on his sacral wound because he stated he was in too much pain. An order administration progress note dated January 18, 2026, at 6:57 p.m. revealed that oxycodone HCl Oral Tablet 10 MG was administered for pain in the resident's hips, lower back, and knees. An order administration progress note dated January 19, 2026, at 2:51 a.m. revealed that oxycodone HCl Oral Tablet 10 MG was administered for pain on movement in the resident's thighs and knees. A health status progress note dated January 19, 2026, at 2:59 p.m. revealed that the resident reported increasing pain since he fell on Friday. January 16th, and that he was unable to bear weight on his right leg. The note revealed that the nurse practitioner (NP) was notified, and that the POA and resident wanted to be sent to the emergency room (ER). The note revealed that when emergency services (EMS) arrived, the resident was in too much pain to be moved, so EMS provided the resident with intravenous pain medication.An order administration progress note dated January 19, 2026, at 3:04 p.m. revealed that oxycodone HCl Oral Tablet 10 MG was administered for pain, and was ineffective with a follow-up pain scale of 9. An alert progress note dated January 19, 2026, at 8:46 p.m. revealed that the resident's son went to the facility to pick up the resident's belongings because he was being admitted to the hospital for a hip injury. A care plan focus initiated on January 19, 2026, revealed that the resident had an actual fall on January 16, 2026, with no injury, with interventions to continue interventions on the at-risk plan, determine and address causative factors of the fall, and to monitor, document, and report as needed for 72 hours to the provider. An interview was conducted on June 10, 2026, at 9:03 a.m. with a Licensed Practical Nurse (LPN/Staff #9) who stated that a POA was a legal document that could be used medically or financially when indicated, so that an individual could make decisions for a resident. The LPN stated that he would know if a resident had a POA because it would be listed in their medical chart under contacts and would be uploaded as a document. The LPN stated that when residents have a fall, their process was to check for injuries, help the resident to bed, start neuro checks, notify the doctor, the family or POA, and the DON right away. The LPN stated that he would notify the emergency contacts even if the resident did not have a POA, and he would ensure that a party was notified other than the resident. The LPN stated that there was a rule of notifying 3 people: one person from the contacts in the chart, the DON, and the doctor. The LPN stated that they would then be expected to document and chart who was notified of the fall. The LPN also stated that the risk of failing to notify a POA of a fall would include the resident's physical or mental well-being, as well as their inability to track a resident's fall history if the POA was never notified that a fall occurred. The LPN opened Resident #21's clinical record and stated that the resident had a signed POA document that listed his son as his POA. The LPN stated that on the contacts page, the resident's son was listed as an emergency contact, but should have been listed as the POA. The LPN stated that if the resident had a fall at the facility, they would be expected to notify his son. The LPN stated that on January 16, 2026, there was a progress note that revealed the resident was heard yelling for help and was found on the floor of his room, with details that he experienced a fall. The LPN stated that the health team and the DON were notified, but there was no evidence that the POA was notified, even though the POA should have been notified. The LPN stated that there was a progress note on January 19, 2026, that revealed the resident's son came to pick up the resident's belongings because he went to the hospital for a hip injury after complaining of increased pain since the fall, and was unable to bear weight. An interview was attempted on June 10, 2026, at 9:24 a.m. with Resident #21, with no success. An interview was conducted on June 10, 2026, at 9:51 a.m. with the DON, Staff #51, who stated that a POA was the person who could make decisions for a resident who could not make decisions for themselves. The DON stated that when a resident enters the facility with a designated POA, it would be uploaded into their chart, and the contact information would be listed under POA. The DON stated that there were times when a POA might be listed as an emergency contact #1, but the POA document would be uploaded as a way to communicate the designation in the medical record. The DON stated that staff would be expected to notify a POA of a change in condition, falls, new psychotropic medications, medication changes, a change in the plan of care, or any incident. The DON stated that the only time they would not notify the POA was if the resident specifically told them not to, but generally, staff were expected to always notify the emergency contact or POA of a fall or incident. The DON stated that a POA should be notified of a fall even if there was no injury because sometimes a resident could experience a fall and not know there was an injury. The DON also stated that the timeframe for reporting a fall to the POA was within an hour, unless they could not get in touch with them, then they would be expected to leave a message and make a progress note for the attempt to reach them. The DON stated that the risk of failing to notify a POA of a fall could be that the resident might not be able to articulate or communicate that they need the hospital, or if there was an injury. The DON further stated that there was a potential for harm to the resident if the facility failed to notify the POA. The DON opened the clinical record for resident #21 and stated that the resident had an emergency contact listed, which was his son, and that there was a POA document uploaded into the medical record. The DON stated that the POA document was in effect on January 12, 2026, and that the resident was admitted to the facility on [DATE], which indicated that the POA paperwork was in effect on admission. The DON stated that Resident #21 was cognitively intact, but that they still should have notified the son of the fall unless the resident specifically told them not to, and further stated that there was no documentation or evidence that the resident told them not to. The DON looked at the progress notes and stated that the fall occurred on January 16, 2026, and that team health and the DON were notified, but there was no evidence to show that the POA was notified of the fall. The DON stated that the handling of the fall incident with Resident #21 did not meet her expectations. An interview was attempted on June 10, 2026, at 10:12 a.m. with Resident #21's POA, with no success. An interview was attempted on June 10, 2026, at 10:14 a.m. with the Licensed Practical Nurse (LPN/Staff #25) who wrote the progress note regarding the fall, with no success. Review of policy titled, Change in a Resident's Condition or Status, dated February 2021, revealed that the facility would promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy revealed that, unless otherwise instructed by the patient, the nurse would notify the resident's representative when the resident was involved in an accident or incident or if there was a significant change in the resident's status.Review of a policy titled, Resident Rights, dated February 2021, revealed that federal and state laws guaranteed certain basic rights to all residents of the facility, including the resident's rights to be notified of his or her medical condition and of any changes in his or her condition.

Based on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to prevent one resident (#3) from wandering into other resident rooms. The deficient practice may result in higher liklihood of wandering and reduced safety for the residents. Findings include: -Resident #3 was admitted to the facility on [DATE] with diagnoses including Traumatic hemorrhage of left cerebrum, delirium due to known physiological condition, other symptoms and signs involving cognitive functions and awareness. A review of the minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 08, indicating that the resident had moderate cognitive impairment. A review of the resident's care plan initiated April 03, 2025 revealed a focus that the resident was an elopement risk/wanderer related to disoriented to place. History of attempts to leave facility unattended. Impaired safety awareness, entering other resident rooms. Interventions that were initiated on April 03, 2025 included distract resident from wandering by offering pleasant diversions, structed activities, food, conversation, television, book. Resident #3's triggers for wandering/eloping are wants to go to his car, the behaviors are de-escalated by redirection, snacks and TV (westerns). Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. The final intervention was added on April 04, 2025 and was monitor location every 15 minutes, document wandering behavior and attempted diversional interventions in behavior log. -Resident #1 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of first lumbar vertebra, low back pain, difficulty walking, and history of traumatic brain injury. A review of the minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 10, indicating that the resident had moderate cognitive impairment. A review of a progress note dated April 6, 2025 at 02:00 a.m. by Licensed Practical Nurse (LPN) Staff #3 revealed that a confused male resident entered Resident #1's room and approached her bed. This was witnessed by a staff member that responded to her room. Staff intercepted the male resident and directed that resident out of the room. No physical contact occurred and Resident #1 felt unsafe and called 911 to report an attempted sexual assault. Police Department arrived to file a report. Resident #1 stated she was emotionally distraught and in need of reassurance for her safety. Emotional support was provided by staff. A staff member was then posted outside her door and was visible to her. A progress note dated April 6, 2025 at 12:04 revealed that Licensed Practical Nurse (LPN) Staff #2 documented that she spoke to Resident #3's wife, face to face about the police report related to sexual assault. A psychological evaluation would be done, a care conference and 15 minute checks would be conducted. An interview was conducted on April 22, at 11:11 a.m. with Resident #1 who stated that a male resident (Resident #3) came into her room and had on a diaper brief with one hand in the brief and kept on touching her walker. Resident #1 stated that when you are flat on your back and can't sit up it is scary. Resident #1 also revealed that she was afraid that he was going to crawl up and get her. Resident #1 confirmed that she called the police. An interview was attempted on April 22 2025 at 11:56 a.m. with Licensed Practical Nurse (LPN) Staff #3, after the list of phone numbers was completed and returned. However, when attempting to call Staff #3, was told wrong number by the person who answered. An interview was attempted on April 22, 2025 at 12:27 p.m. with Licensed Practical Nurse (LPN) Staff #2. Staff #2 did not answer and a voicemail message was left, asking Staff #2 to return the call. An interview was conducted on April 22, 2025 at 12:35 p.m. with Certified Nursing Assistant (CNA) Staff #1 who revealed that when residents tend to wander into other resident rooms, you need to know their schedules and if the resident likes cartoons, turn on cartoons. Then bring the resident to the common areas to interact with other residents. An interview was conducted on April 22, 2025 at 12:37 p.m. with LPN Staff #5 who revealed that there are a couple residents in the building that like to go into other resident rooms. One of them is not mentally capable to understand not to go in. Sometimes rooms are changed and the resident might wander back to the old room. The best way to prevent them is to keep an eye on them, redirect them. Say why don't we watch T.V. An interview was conducted on April 22, 2025 at 12:41 p.m. with Director of Nursing (DON) Staff #4 who stated that she had heard of the incident; and that, a man went to Resident #1's door and did not actually enter the room. However, Staff #4 admitted was out of town when the incident happened. When asked how to prevent residents from going into other resident rooms, Staff #4 revealed that it's a challenge and depends on the resident's cognition. Educate and redirect, care plan, meet with family. Keep an eye on them. An interview was conducted April 22, 2025 at 12:57 p.m. with Staff #2 and revealed was the nurse to follow night LPN Staff #3. Staff #2 was the person who informed the family/wife and the Nurse Practitioner (NP), that Resident #3 went into resident #1's room. Resident #3 would wander and take off his pants. Resident #1 had been sexually assaulted in the past. Resident #1 called the police. While the police were there interviewing Resident #1, Resident #3 attempted to go into Resident #1's room again and the police observed the resident attempting to come back in. Review of the policy Abuse Prevention Program (revised September 2021) revealed that employees will be annually trained to recognize situations in which abuse is more likely to occur and how to intervene for prevention, such as characteristics of residents which have the potential to trigger an abusive incident like wandering into other resident rooms.

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#7) was free from an accident of elopement. The deficient practice could lead to accidents resulting in harm to residents. Findings include: Resident #7 was readmitted to the facility on [DATE], with diagnoses that included peripheral vascular disease, unspecified dementia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, alcohol abuse, tobacco use, and long-term use of anticoagulants. The clinical record was reviewed and there was no evidence of an elopement risk assessment upon re-admission in October 2023 for Resident #7. An Elopement Risk Tool dated January 13, 2024, revelealed, No the resident does not display cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision making skills. A quarterly MDS (minimum data set) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment score of 11, indicating the resident had a moderate cognitive impairment. An additional BIMS assessment dated [DATE], at 10:21 AM, revealed the resident had a score of 3, indicting the resident was severely cognitively impaired. There was no evidence of a re-assessment of the resident's elopement risk with the resident's decline in cognitive status. A progress note dated March 25, 2025, at 1:05 AM, revealed facility staff were, unable to locate resident, and a search was started by facility staff. The resident was found outside, on the opposite side of the parking lot, on the ground, away from his wheelchair. The resident stated that he went to smoke a cigarette. The resident was assessed, and was brought back in the facility. The resident had a new cut over the right eye and a small abrasion to the right ankle and foot. An Elopement Evaluation dated March 25, 2025, at 2:12 AM, revealed that the resident scored 1.0, indicating the resident was at risk of elopement. A care plan dated March 25, 2025, revealed Resident #7 was an elopement risk due to disorientation to place and impaired safety awareness, with an intervention to assess for fall risk, identify pattern of wandering, and monitor for fatigue and weight loss. There was no evidence of a care plan for elopement risk prior to March 25, 2025. On April 1, 2025, a formal request was made to the facility for any elopement risk assessments for Resident #7 prior to March 25, 2025. The administrator signed a statement that there were none. An observation was conducted with the Administrator (Staff #3) on April 1, 2025, at 2:56 PM, the administrator indicated the spot in the parking lot where Resident #7 was found during the elopement incident, and estimated that the distance the resident had traveled from the door to where he was found lying down was approximately 50 to 100 feet. An interview was conducted with a Certified Nursing Assistant (CNA / Staff #22) on April 1, 2025, at 12:31 PM who stated that the facility's process for monitoring residents for elopement or wandering is that if the staff know a resident is a wanderer, then closely monitor the resident or place an additional staff member with the resident. Staff #22 stated that this is usually communicated through verbal report. Staff #22 stated that she was notified after the incident of Resident #7's elopement that the 300 hall door was not locking, and that now it is locked. Staff #22 stated that she believed she saw repairs being done to the door today. Regarding Resident #7's elopement, Staff #22 states that she was informed that a resident had gotten out of the building, a couple minutes, and that she was instructed not to use the 300 hall door. Staff #22 stated that normally, that door is locked at all times and you need a code to open the door. After the incident, on March 25, 2025, there was a staff meeting, and Staff #22 was informed that whoever had used that door must not have shut it all the way, and all staff were instructed not to use that door. On April 1, 2025, at 12:40 PM, an interview was conducted with a Licensed Practical Nurse (LPN / Staff #51), who stated the facility's process for assessing a resident's risk for elopement is for nursing staff to complete an elopement assessment. Staff #51 stated that the facility does the elopement assessment for each resident on admission; and that, it is also triggered to complete periodically. Staff #51 stated that facility staff perform frequent checks on residents, and are alerted to which residents have wandering behaviors, and this is communicated during verbal report. Staff #51 stated that every exterior door in the facility is a locked door that requires a code to open. Staff #51 stated that about a week ago, Resident #7 had an incident of elopement. She stated that she was the day shift nurse on March 24, 2025; and that, the incident happened later that day after her shift was over. She stated that she noticed the resident was more active that day, and that he was up in his wheelchair. She stated that she came to work on March 25, 2025, and heard about the incident at the staff meeting that day; and that, she was informed Resident #7 had gotten out of the facility and fallen. She stated staff were instructed not to use the 300 hall door because a resident had gotten out, and that the staff were checking the door. An interview was conducted on April 1, 2025, at 1:33 PM, with the Assistant Director of Nursing (ADON / Staff #45) who stated that the facility had a screening process to assess resident's for elopement risk; and that, the assessment gives a score, and the resident's care plan is adjusted according to the risk score. The ADON stated that if a resident were to have an elopement incident, that the facility staff must locate the resident, notify the provider and responsible parties, the nurse reports to the director of nursing, and the interdisciplinary team would investigate the incident. Regarding Resident #7's elopement incident, Staff #45 stated that she received a text message at 12:33 AM from the floor nurse that the resident fell on pavement, during night shift between March 24-25, 2025. The ADON stated she did not receive a response, when she questioned the nurse further regarding the incident. The ADON stated she came to work the following morning around 8:30 AM, and was told that the resident had gotten out of the 300 hall coded door, and that staff found the resident approximately 30 minutes after they had last rounded on the resident. Staff #45 stated that the administrator was completing the investigation into the incident to see what happened with the door. Regarding Resident #7, the ADON stated she was told, he scratched his face when he fell in the parking lot. The clinical record was reviewed together and the ADON stated that she could not see any elopement risk assessments completed for Resident #7 prior to the incident. A telephonic interview was conducted with an LPN (Staff #29), on April 1, 2025, at 2:35 PM who stated that she was Resident #7's nurse on the night of the incident; and that, she noticed the resident had a cognitive decline over the past few months. Staff #29 stated that recently, Resident #7 had been spending more time in bed, however on the date of the incident, the resident had been more active and had been, going around the building, and walking around the halls by his bedroom. Staff #29 stated that night, the staff had noticed approximately 15 minutes after rounding on the resident, that he was unable to be located. Staff #29 sent the 100 hall nurse outside to search for the resident, and that is where the resident was found. Staff #29 stated that at the back of the facility parking lot, there is a space between the facility's parking lot and the apartment next door, where the resident was laying, and his wheelchair was still on the pavement. The resident had a laceration above his eye, and Staff #29 did an assessment and noted no other injuries. Staff #29 stated she informed the provider, the facility management, and the resident's responsible party. An interview was conducted with the Administrator (Staff #3) on April 1, 2025, at 3:00 PM who stated that he was informed of Resident #7's elopement incident on March 25, 2025, at approximately 7:00 AM, and that the resident had gotten out the 300 hall door. Since the incident, Staff #3 stated that the facility has ordered alarms for the doors, and that a door repairman had replaced the magnets on the door that were starting to give. The administrator also stated that a staff or visitor could have used the door and the wind could have kept it open. Additionally, since the incident, visitors and staff had been instructed to use an alternate door. Staff #3 stated that his expectation for staff is to look at things all the time to make sure accidents are preventable. Also, Staff #3 stated that he did an in-service with staff on reporting incidents right away. An interview was conducted with the Director of Nursing (DON / Staff #49) on April 1, 2025, at 3:58 PM. The DON stated her expectation for the facility preventing accidents is that staff do everything they can immediately to address items that are identified. The DON stated the facility screens residents for elopement risk to try to prevent incidents, on admission and quarterly on the MDS assessment. If there was a significant change in a resident, then staff would try to arrange a care plan to address the changes. The DON stated that regarding Resident #7's incident, that staff had rounded on the resident around 11:30 PM on March 24, 2025, and about 15 minutes later the resident was unable to be located. The DON stated the resident was located in the rear parking lot, and that the resident was assessed for injury and brought back inside the building with all responsible parties notified. The DON stated that she is aware the resident is cognitively impaired and has had a decline in his health recently. The DON stated that the door was assessed, and it was determined that the magnet holding the top of the door started to fail, and that likely somebody went through the door and failed to double check that the door closed properly. The DON stated that the facility replaced the magnet for the door. Review of the facility policy titled Elopement Precautions / Missing Resident, revised 2007, revealed the objective of the policy is the prevention of residents leaving facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing. All residents at the time of admission will be identified as an elopement risk if it is reported that there has been elopement incidents in the prior living arrangement. Any resident that demonstrates or verbalizes elopement will immediately be considered an elopement risk and immediate care interventions will be adopted to prevent unplanned elopement. If a resident is found to be an elopement risk and if the facility has a Special Care Unit, placement of the resident in the unit will be considered. If the resident demonstrates behaviors that cause the facility to believe the resident is at significant risk, the resident may be placed in the unit until further notification of physician, family, legal authority, and case worker, if applicable, can be made and a more permanent interdisciplinary team decision can be determined. For facilities that do not have a Special Care Unit, or for areas of the facility outside of the Special Care Unit in order to manage residents in the general facility population and assure the safe whereabouts of each resident at all times, the following physical plant features are to be in place: All exit doors from the facility that are not under direct observation shall be alarmed. In this facility, the following doors are alarmed: all exit doors are alarmed. Additionally, exit doors that are not alarmed are to remain under direct observation when there is any resident in the facility deemed to be an elopement risk in this facility, the following doors remain unsecured and without alarm with direct observation: Include which doors, how direct observation is provided, hours doors are unsecured and observed, and how periods of time when assigned individual is not available, the observation continues.

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to investigate sexual contact between two residents (#7 and #9) who were not adequately assessed for capacity and consent. The deficient practice could allow for ongoing incidents of sexual abuse, which could lead to harm of a resident. Findings include: -Resident #7 was readmitted to the facility on [DATE], with diagnoses that included peripheral vascular disease, unspecified dementia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, alcohol abuse, tobacco use, and long-term use of anticoagulants. A brief interview for mental status (BIMS) assessment dated [DATE], revealed the resident had a score of 9, indicating the resident had a moderate cognitive impairment. A quarterly MDS (minimum data set) assessment dated [DATE], revealed the resident had a BIMS assessment score of 11, indicating the resident had a moderate cognitive impairment. A BIMS assessment dated [DATE], revealed the resident had a score of 3, indicating severe cognitive impairment. A care plan dated September 16, 2024, revealed Resident #7 had impaired cognitive function/dementia or impaired thought processes due to dementia. Interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs, and to ask yes/no questions. The clinical record was reviewed and there was no evidence of a capacity evaluation or a determination of decision-making ability from a physician. A Healthcare (Medical) Power of Attorney (POA) with Mental Health Authority document, dated May 17, 2023, revealed the resident appointed a friend to represent the resident's choices and healthcare decisions in the event that Resident #7 would be unable to communicate wishes and healthcare decisions due to incapacities, or if the resident's doctor determines the resident unable to make healthcare decisions. An Alert Note dated December 19, 2024, revealed Resident #7 was noted to be holding hands with a female resident in the TV room. The writer kept close eye on the residents, and noted that both residents are engaged in kissing. The writer redirected the residents multiple times. Residents are both still sitting in TV room conversating and holding hands. Will notify social services and Assistant Director of Nursing (ADON). A Health Status Note dated December 23, 2024, revealed upper management was notified of a possible romantic relationship with another resident. Social services will contact the resident's wife and set a time for a care plan meeting. The residents are being redirected when behavior is noticed and a possible move to another hall is being considered for one resident. A Behavior Note dated December 23, 2024, revealed Resident #7 was noted to be making out with a female resident. The writer tried redirecting the residents several times, but the behavior continued. Resident #7 was noted to have his hand down the female resident's pants and the other hand up her shirt. A call was placed to the ADON who stated to move the female resident to a different hallway and to keep the residents separated. The writer spoke to both residents. Resident #7 stated, ok, and the female resident, just gave a dirty look. A Communication with Resident Note dated December 23, 2024, revealed the ADON came into the building and sat with Resident #7, and spoke with the resident about the behaviors of his hands being inappropriate with a female resident. Resident #7 put his head down and said he agreed that he was not following the building's protocol and apologized for this behavior. The ADON also instructed the resident to not touch other residents while at the facility, and then notified administration of this occurrence as well. The ADON was instructed to separate the residents and have them not on the same hall moving forward. The female resident was moved to the other side of the building and both residents were placed on close monitoring. There was no evidence that the resident's physician was notified regarding the incidents, or to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. Regarding Resident #9: Resident #9 was admitted to the facility October 30, 2024, with diagnoses that included unspecified dementia, schizophrenia, anxiety disorder, major depressive disorder, drug induced subacute dyskinesia, unspecified disorder of adult personality and behavior, aphasia, and other seizures. An admission MDS assessment dated [DATE], revealed the resident was coded as having clear speech with distinct intelligible words, and the resident's ability to express ideas and wants was coded as understood. Additionally, the resident was coded as having clear comprehension in the ability to understand others. However, a discrepancy was noted, as the assessment revealed that no the BIMS assessment should not be conducted due to the resident being rarely/never understood. Additionally, in the Staff Assessment for Mental Status, the resident was coded as having moderately impaired decision-making regarding tasks of daily life, with decision poor; cues/supervision required. A care plan dated November 12, 2024, revealed the resident has impaired cognitive function/dementia or impaired thought processes due to dementia, and difficulty making decisions. Interventions included to ask yes/no questions to determine the resident's needs, and communicate with the resident/family regarding the resident's capabilities and needs. Additionally, an intervention was listed that the resident needs assistance with all decision making. An Alert Note dated December 19, 2024, revealed the resident was noted to be holding hands with a male resident (#7) in the TV room. The writer kept a close eye on the residents, and both residents are engaged in kissing. The staff redirected the residents multiple times, and the residents are both still sitting in the TV room conversating and holding hands. The ADON and social services will be notified. A BIMS evaluation dated December 19, 2024, revealed the resident had a score of 15, indicating intact cognition. There was no evidence of notification to the physician or the resident's POA/representative regarding the incident or to determine the resident's decision-making ability on December 19, 2024. A Health Status Note dated December 23, 2024, revealed the Resident #9's POA was notified of a romantic relationship with another resident. The POA was notified that the facility staff were redirecting the resident when the residents were observed together, but that Resident #9 might have to be moved to another hall. The note revealed the POA was fine with moving her if necessary. A Behavior Note dated December 23, 2024, revealed Resident #9 was noted to be making out with the male resident (#7). The writer tried to redirect several times, and the male resident was observed with his hands down the female's pants and up her shirt. The ADON was notified, who stated to move Resident #9 to a different hallway. The resident gave the writer a dirty look when escorted to her new room. There was no evidence of communication with the resident's physician regarding the sexual incident on December 23, 2025, to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. An Alert Note dated December 29, 2024 revealed Resident #9 has displayed inappropriate sexual behaviors towards and with other residents this shift, and was observed being physically and verbally inappropriate several times. Staff have attempted to separate patients several times, ineffectively. The resident was medicated for anxiety, which was ineffective. The physician and nursing management were made aware to follow up. No patients were injured and no patients complained about the behavior. The note indicated the writer will communicate with family. A Behavior Note dated December 31, 2024, revealed Resident #9 was caught by a certified nursing assistant (CNA) kissing the male resident (#7) by the nursing station. The resident had her hands down the male resident's pants. Resident #9 was encouraged to go to her side of the building but preferred to stay in the TV room. There was no evidence of physician notification, POA notification, administrative notification, or further assessment to determine decision-making ability or consent from both residents for this incident. On April 1, 2025, a formal request was made to the facility for a log of any reportable events occurring in 2024. The administrator signed a statement that there were none in 2024. On April 1, 2025, at 12:40 PM, an interview was conducted with a Licensed Practical Nurse (LPN / Staff #51), who stated she was aware that Resident #7 and Resident #9 had a relationship, and the residents were told by facility staff that they could not see each other anymore. Staff #51 stated that Resident #9 was behavioral and had a POA, and that Resident #7 was not cognitively intact. She stated that the residents were observed being sexually inappropriate in the dining room, and that Resident #9 was moved to another hall, and that staff were told to monitor the residents. An interview was conducted on April 1, 2025, at 1:33 PM, with the Assistant Director of Nursing (ADON / Staff #45) who stated if staff were to notice possible sexual abuse, to report it to the Director of Nursing, to the physician, and remove the resident from the situation. The ADON stated that Resident #7 was holding hands with another resident, and that staff didn't report anything else. Further, she stated that we did separate them. Additionally, the ADON stated Resident #9 was very hypersexual, and that she was not sure if the resident was able to make her own decisions, and that the resident's sister was her POA and decision maker. Also, the ADON stated that I don't know if any assessments were done on the residents at the time of the incidents, or if the facility investigated the incidents for possible sexual abuse. A telephonic interview was conducted with an LPN (Staff #65) on April 1, 2025, at 2:31 PM. Staff #65 stated that she was familiar with Resident #9 and that she was behavioral, and flirty with all the gentleman in the building. Staff #65 stated that Resident #9 was following a male resident around the building, and when asked for further details, Staff #65 stated I don't want to have to repeat myself and I'm not answering any more questions. The call was ended. A telephonic interview was conducted with an LPN (Staff #29), on April 1, 2025, at 2:35 PM. Staff #29 stated that Resident #7 has had a cognitive decline over the past several months. Staff #29 stated that she believed Resident #7 and Resident #9 liked each other and that they were caught by staff making out, and that facility staff took steps to keep them separated. Staff #29 stated that she reported the incident to management and that staff separated the residents. Staff #29 stated it was in everybody's best interest if we didn't allow that. An interview was conducted with the Administrator (Staff #3) on April 1, 2025, at 3:00 PM. Staff #3 stated that any allegation of sexual abuse needs to be investigated by the administrator, and the residents need to be protected from further abuse. Staff #3 stated it was his expectation that residents involved in allegations of abuse would not have access to each other during the investigation process, and that staff would keep them separated to protect them. Additionally, that the physician would be notified to assess the residents. Staff #3 stated he was not aware of any allegations of sexual abuse regarding Resident #7. He stated he was aware that Resident #7 was trying to be more than friends with another resident, and that she was fond of him, but that Staff #3 did not know who the female resident was. A telephonic interview was conducted with the Social Services Director (Staff #17) on April 1, 2025, at 3:27 PM. Staff #17 stated that the sexual contact between Resident #7 and #9 was consensual and that the residents were coherent enough to make their own decisions, and that is why the facility decided not to call it sexual abuse. An interview was conducted with the Director of Nursing (DON / Staff #49) on April 1, 2025, at 3:58 PM. The DON stated if an allegation of abuse occurred, that staff would be expected to report it, and the facility to investigate and determine whether it happened or not. Regarding Residents #7 and #9, the DON stated that there was sexual contact between the two residents, but never any allegations of sexual abuse. The DON stated that the resident' BIMS scores were appropriate and that they were cognitively intact and consenting adults, and that neither resident had a POA. The DON stated that she did not know if the physician was consulted to make a determination of whether the residents had capacity for decision making and could consent. The interview with the DON continued and the BIMS scores of Resident #7 were reviewed, and the DON stated that the resident had scores indicating moderate to severe cognitive impairment. Additionally, the DON reviewed the clinical record for Resident #7 and stated that a friend was listed as medical POA, and that the DON could not see any note that the POA was contacted for Resident #7 at the start of the incidents. Additionally, the DON stated she could not find any assessment determining ability for decision making from a physician for Resident #7. Further, the DON reviewed the clinical record for Resident #9, and stated that there was a POA listed, and that she did not see any note indicating that the physician or POA were consulted on December 19, 2024 regarding the sexual incidents. The DON stated that she did not know if the facility conducted an investigation on the incident. The DON stated that the incidents should have been investigated to determine the residents' decision-making ability and consent. Review of the facility policy titled Abuse Prevention Program, revised September 2021, revealed the facility will not tolerate verbal, sexual, physical and mental abuse. The objective of the policy is to develop and implement a system for identifying, investigating, preventing and reporting any incident, or suspected incident, of abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. All witnessed or suspected events as defined by this policy are to be reported regardless of who is involved or suspected. Abusive examples include various forms of sexual abuse including rape, forced sexual acts, fondling, and sexual harassment. If an incident occurs, or there is an allegation that an incident might have occurred of abuse, the Administrator, or designee will investigate. The person doing the investigation will complete a Resident Abuse/Neglect Investigation Report. The administrator will sign and maintain all reports, and findings will be reported according to state requirements. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in process. The results of all investigations must be reported to officials in accordance with State law within 5 working days of the incident.

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report to the state agency that two residents (#7 and #9) who were not adequately assessed for capacity and consent had sexual contact. The deficient practice could allow for ongoing incidents not being reported which could lead to harm. Findings include: -Resident #7 was readmitted to the facility on [DATE], with diagnoses that included peripheral vascular disease, unspecified dementia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, alcohol abuse, tobacco use, and long-term use of anticoagulants. A brief interview for mental status (BIMS) assessment dated [DATE], revealed the resident had a score of 9, indicating the resident had a moderate cognitive impairment. A quarterly MDS (minimum data set) assessment dated [DATE], revealed the resident had a BIMS assessment score of 11, indicating the resident had a moderate cognitive impairment. A BIMS assessment dated [DATE], revealed the resident had a score of 3, indicating severe cognitive impairment. A care plan dated September 16, 2024, revealed Resident #7 had impaired cognitive function/dementia or impaired thought processes due to dementia. Interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs, and to ask yes/no questions. The clinical record was reviewed and there was no evidence of a capacity evaluation or a determination of decision-making ability from a physician. A Healthcare (Medical) Power of Attorney (POA) with Mental Health Authority document, dated May 17, 2023, revealed the resident appointed a friend to represent the resident's choices and healthcare decisions in the event that Resident #7 would be unable to communicate wishes and healthcare decisions due to incapacities, or if the resident's doctor determines the resident unable to make healthcare decisions. An Alert Note dated December 19, 2024, revealed Resident #7 was noted to be holding hands with a female resident in the TV room. The writer kept close eye on the residents, and noted that both residents are engaged in kissing. The writer redirected the residents multiple times. Residents are both still sitting in TV room conversating and holding hands. Will notify social services and Assistant Director of Nursing (ADON). A Health Status Note dated December 23, 2024, revealed upper management was notified of a possible romantic relationship with another resident. Social services will contact the resident's wife and set a time for a care plan meeting. The residents are being redirected when behavior is noticed and a possible move to another hall is being considered for one resident. A Behavior Note dated December 23, 2024, revealed Resident #7 was noted to be making out with a female resident. The writer tried redirecting the residents several times, but the behavior continued. Resident #7 was noted to have his hand down the female resident's pants and the other hand up her shirt. A call was placed to the ADON who stated to move the female resident to a different hallway and to keep the residents separated. The writer spoke to both residents. Resident #7 stated, ok, and the female resident, just gave a dirty look. A Communication with Resident Note dated December 23, 2024, revealed the ADON came into the building and sat with Resident #7, and spoke with the resident about the behaviors of his hands being inappropriate with a female resident. Resident #7 put his head down and said he agreed that he was not following the building's protocol and apologized for this behavior. The ADON also instructed the resident to not touch other residents while at the facility, and then notified administration of this occurrence as well. The ADON was instructed to separate the residents and have them not on the same hall moving forward. The female resident was moved to the other side of the building and both residents were placed on close monitoring. There was no evidence that the resident's physician was notified regarding the incidents, or to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. -Resident #9 was admitted to the facility October 30, 2024, with diagnoses that included unspecified dementia, schizophrenia, anxiety disorder, major depressive disorder, drug induced subacute dyskinesia, unspecified disorder of adult personality and behavior, aphasia, and other seizures. An admission MDS assessment dated [DATE], revealed that the resident was coded as having clear speech with distinct intelligible words, and the resident's ability to express ideas and wants which was coded as understood. Additionally, the resident was coded as having clear comprehension in the ability to understand others. However, a discrepancy was noted, as the assessment revealed that no the BIMS assessment should not be conducted due to the resident being rarely/never understood. Additionally, in the Staff Assessment for Mental Status, the resident was coded as having, moderately impaired decision-making regarding tasks of daily life, with, decision poor; cues/supervision required. A care plan dated November 12, 2024, revealed that the resident had impaired cognitive function/dementia or impaired thought processes due to dementia, and difficulty making decisions. Interventions included to ask yes/no questions to determine the resident's needs, and communicate with the resident/family regarding the resident's capabilities and needs. Additionally, an intervention was listed that the resident needs assistance with all decision making. An Alert Note dated December 19, 2024, revealed that the resident was noted to be holding hands with a male resident (#7) in the TV room. The writer kept a close eye on the residents, and both residents are engaged in kissing. The staff redirected the residents multiple times, and the residents are both still sitting in the TV room conversating and holding hands. The ADON and social services will be notified. A BIMS evaluation dated December 19, 2024, revealed the resident had a score of 15, indicating intact cognition. There was no evidence of notification to the physician or the resident's POA/representative regarding the incident or to determine the resident's decision-making ability on December 19, 2024. A Health Status Note dated December 23, 2024, revealed the Resident #9's POA was notified of a romantic relationship with another resident. The POA was notified that the facility staff were redirecting the resident when the residents were observed together, but that Resident #9 might have to be moved to another hall. The note revealed the POA was fine with moving her if necessary. A Behavior Note dated December 23, 2024, revealed Resident #9 was noted to be, making out with the male resident (#7). The writer tried to redirect several times, and the male resident was observed with his hands down the female's pants and up her shirt. The ADON was notified, who stated to move Resident #9 to a different hallway. The resident gave the writer a dirty look when escorted to her new room. There was no evidence of communication with the resident's physician regarding the sexual incident on December 23, 2025, to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. An Alert Note dated December 29, 2024 revealed Resident #9 has displayed inappropriate sexual behaviors towards and with other residents this shift, and was observed being physically and verbally inappropriate several times. Staff have attempted to separate patients several times, ineffectively. The resident was medicated for anxiety, which was ineffective. The physician and nursing management were made aware to follow up. No patients were injured and no patients complained about the behavior. The note indicated the writer will communicate with family. A Behavior Note dated December 31, 2024, revealed Resident #9 was caught by a certified nursing assistant (CNA) kissing the male resident (#7) by the nursing station. The resident had her hands down the male resident's pants. Resident #9 was encouraged to go to her side of the building but preferred to stay in the TV room. There was no evidence of physician notification, POA notification, administrative notification, or further assessment to determine decision-making ability or consent from both residents for this incident. On April 1, 2025, a formal request was made to the facility for a log of any reportable events occurring in 2024. The administrator signed a statement that there were none in 2024. On April 1, 2025, at 12:40 PM, an interview was conducted with a Licensed Practical Nurse (LPN / Staff #51), who stated she was aware that Resident #7 and Resident #9 had a relationship, and the residents were told by facility staff that they could not see each other anymore. Staff #51 stated that Resident #9 was behavioral and had a POA, and that Resident #7 was not cognitively intact. She stated that the residents were observed being sexually inappropriate in the dining room, and that Resident #9 was moved to another hall, and that staff were told to monitor the residents. An interview was conducted on April 1, 2025, at 1:33 PM, with the Assistant Director of Nursing (ADON / Staff #45) who stated if staff were to notice possible sexual abuse, to report it to the Director of Nursing, to the physician, and remove the resident from the situation. The ADON stated that allegations of sexual abuse must be reported to mandatory sources within 2 hours. The ADON stated that Resident #7 was holding hands with another resident, and that, staff didn't report anything else. Further, she stated that, we did separate them. Additionally, the ADON stated Resident #9 was, very hypersexual, and that she was not sure if the resident was able to make her own decisions; and that, the resident's sister was her POA and decision maker. Also, the ADON stated that, I don't know if any assessments were done on the residents at the time of the incidents, or if the facility investigated the incidents for possible sexual abuse. A telephonic interview was conducted with an LPN (Staff #65) on April 1, 2025, at 2:31 PM who stated that she was familiar with Resident #9 and that, she was behavioral, and flirty with all the gentleman in the building. Staff #65 stated that Resident #9 was following a male resident around the building, and when asked for further details, Staff #65 stated, I don't want to have to repeat myself and, I'm not answering any more questions. The call was ended. A telephonic interview was conducted with an LPN (Staff #29), on April 1, 2025, at 2:35 PM who stated that Resident #7 has cognitively declined over the past several months. Staff #29 stated that she believed Resident #7 and Resident #9 liked each other; and that, they were caught by staff making out, and that facility staff took steps to keep them separated. Staff #29 stated that she reported the incident to management. Staff #29 stated it was in everybody's best interest if we didn't allow that. An interview was conducted with the Administrator (Staff #3) on April 1, 2025, at 3:00 PM who stated that any allegation of sexual abuse is to be reported within 2 hours and needs to be investigated by the administrator, and the residents need to be protected. Staff #3 stated it was his expectation that residents involved in allegations of abuse would not have access to each other during the investigation process; and that, staff would keep them separated to protect them. Additionally, Staff #3 stated that the physician would be notified to assess the residents. A telephonic interview was conducted with the Social Services Director (Staff #17) on April 1, 2025, at 3:27 PM. Staff #17 stated that she was not employed at the facility during the time frame of the sexual incidents between Residents #7 and #9, however she believed Resident #7's wife was his decision maker. She stated she was aware that Resident #7 had sexual behavior with Resident #9. Staff #17 stated that Resident #9 made her own decisions, and that Adult Protective Services (APS) was involved and stepping in to make decisions for the resident. An interview was conducted with the Director of Nursing (DON / Staff #49) on April 1, 2025, at 3:58 PM. The DON stated if a reportable incident occurs, that she would expect staff to notify leadership and notify the administrator, and report to mandatory sources within 2 hours. The DON stated that the importance of reporting is to have an outside unbiased source investigate the incident. Also, if an allegation of abuse occurred, that staff would be expected to report it, and the facility to investigate and determine whether it happened or not. Regarding Residents #7 and #9, the DON stated that there was sexual contact between the two residents, but never any allegations of sexual abuse. The DON stated that the resident' BIMS scores were appropriate and that they were cognitively intact and consenting adults, and that neither resident had a POA. The DON stated that her understanding was that the resident's had rights to have a relationship, but not to demonstrate their sexual behaviors in public places that would make other residents uncomfortable. The DON stated that she did not know if the physician was consulted to make a determination of whether the residents had capacity for decision making and could consent. The BIMS scores of Resident #7 were reviewed, and the DON stated that the resident had scores indicating moderate to severe cognitive impairment. Additionally, the DON reviewed the clinical record for Resident #7 and stated that a friend was listed as medical POA, and that the DON could not see any note that the POA was contacted for Resident #7 at the start of the incidents. Additionally, the DON stated she could not find any assessment determining ability for decision making from a physician for Resident #7. Further, the DON reviewed the clinical record for Resident #9, and stated that there was a POA listed, and that she did not see any note indicating that the physician or POA were consulted on December 19, 2024 regarding the sexual incidents. The DON stated that she did not believe the facility reported the incident as an allegation of possible sexual abuse, and that she did not know if the facility conducted an investigation. The DON stated that the incidents should have been investigated to determine the residents' decision-making ability and consent. Review of the facility policy titled Abuse Prevention Program, revised September 2021, revealed the facility will not tolerate verbal, sexual, physical and mental abuse. The objective of the policy is to develop and implement a system for identifying, investigating, preventing and reporting any incident, or suspected incident, of abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. All witnessed or suspected events as defined by this policy are to be reported regardless of who is involved or suspected. Abusive examples include various forms of sexual abuse including rape, forced sexual acts, fondling, and sexual harassment. If an incident occurs, or there is an allegation that an incident might have occurred of abuse, the Administrator, or designee will investigate. The person doing the investigation will complete a Resident Abuse/Neglect Investigation Report. The administrator will sign and maintain all reports, and findings will be reported according to state requirements. If the events that cause the allegation involve abuse, a report must be made to the state survey agency and local law enforcement, immediately and not later than 2 hours after receiving the allegation.

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to implement their policy on sexual contact between two residents (#7 and #9) who were not adequately assessed for capacity and consent. The deficient practice could allow for ongoing incidents which could lead to harm of a resident. Findings include: -Resident #7 was readmitted to the facility on [DATE], with diagnoses that included peripheral vascular disease, unspecified dementia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, alcohol abuse, tobacco use, and long-term use of anticoagulants. A brief interview for mental status (BIMS) assessment dated [DATE], revealed the resident had a score of 9, indicating the resident had a moderate cognitive impairment. A quarterly MDS (minimum data set) assessment dated [DATE], revealed the resident had a BIMS assessment score of 11, indicating the resident had a moderate cognitive impairment. A BIMS assessment dated [DATE], revealed the resident had a score of 3, indicating severe cognitive impairment. A care plan dated September 16, 2024, revealed Resident #7 had impaired cognitive function/dementia or impaired thought processes due to dementia. Interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs, and to ask yes/no questions. The clinical record was reviewed and there was no evidence of a capacity evaluation or a determination of decision-making ability from a physician. A Healthcare (Medical) Power of Attorney (POA) with Mental Health Authority document, dated May 17, 2023, revealed the resident appointed a friend to represent the resident's choices and healthcare decisions in the event that Resident #7 would be unable to communicate wishes and healthcare decisions due to incapacities, or if the resident's doctor determines the resident unable to make healthcare decisions. An Alert Note dated December 19, 2024, revealed Resident #7 was noted to be holding hands with a female resident in the TV room. The writer kept close eye on the residents, and noted that both residents are engaged in kissing. The writer redirected the residents multiple times. Residents are both still sitting in TV room conversating and holding hands. Will notify social services and Assistant Director of Nursing (ADON). A Health Status Note dated December 23, 2024, revealed upper management was notified of a possible romantic relationship with another resident. Social services will contact the resident's wife and set a time for a care plan meeting. The residents are being redirected when behavior is noticed and a possible move to another hall is being considered for one resident. A Behavior Note dated December 23, 2024, revealed Resident #7 was noted to be making out with a female resident. The writer tried redirecting the residents several times, but the behavior continued. Resident #7 was noted to have his hand down the female resident's pants and the other hand up her shirt. A call was placed to the ADON who stated to move the female resident to a different hallway and to keep the residents separated. The writer spoke to both residents. Resident #7 stated, ok, and the female resident, just gave a dirty look. A Communication with Resident Note dated December 23, 2024, revealed the ADON came into the building and sat with Resident #7, and spoke with the resident about the behaviors of his hands being inappropriate with a female resident. Resident #7 put his head down and said he agreed that he was not following the building's protocol and apologized for this behavior. The ADON also instructed the resident to not touch other residents while at the facility, and then notified administration of this occurrence as well. The ADON was instructed to separate the residents and have them not on the same hall moving forward. The female resident was moved to the other side of the building and both residents were placed on close monitoring. There was no evidence that the resident's physician was notified regarding the incidents, or to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. -Resident #9 was admitted to the facility October 30, 2024, with diagnoses that included unspecified dementia, schizophrenia, anxiety disorder, major depressive disorder, drug induced subacute dyskinesia, unspecified disorder of adult personality and behavior, aphasia, and other seizures. An admission MDS assessment dated [DATE], revealed that the resident was coded as having clear speech with distinct intelligible words, and the resident's ability to express ideas and wants which was coded as understood. Additionally, the resident was coded as having clear comprehension in the ability to understand others. However, a discrepancy was noted, as the assessment revealed that no the BIMS assessment should not be conducted due to the resident being rarely/never understood. Additionally, in the Staff Assessment for Mental Status, the resident was coded as having, moderately impaired decision-making regarding tasks of daily life, with, decision poor; cues/supervision required. A care plan dated November 12, 2024, revealed that the resident had impaired cognitive function/dementia or impaired thought processes due to dementia, and difficulty making decisions. Interventions included to ask yes/no questions to determine the resident's needs, and communicate with the resident/family regarding the resident's capabilities and needs. Additionally, an intervention was listed that the resident needs assistance with all decision making. An Alert Note dated December 19, 2024, revealed that the resident was noted to be holding hands with a male resident (#7) in the TV room. The writer kept a close eye on the residents, and both residents are engaged in kissing. The staff redirected the residents multiple times, and the residents are both still sitting in the TV room conversating and holding hands. The ADON and social services will be notified. A BIMS evaluation dated December 19, 2024, revealed the resident had a score of 15, indicating intact cognition. There was no evidence of notification to the physician or the resident's POA/representative regarding the incident or to determine the resident's decision-making ability on December 19, 2024. A Health Status Note dated December 23, 2024, revealed the Resident #9's POA was notified of a romantic relationship with another resident. The POA was notified that the facility staff were redirecting the resident when the residents were observed together, but that Resident #9 might have to be moved to another hall. The note revealed the POA was fine with moving her if necessary. A Behavior Note dated December 23, 2024, revealed Resident #9 was noted to be, making out with the male resident (#7). The writer tried to redirect several times, and the male resident was observed with his hands down the female's pants and up her shirt. The ADON was notified, who stated to move Resident #9 to a different hallway. The resident gave the writer a dirty look when escorted to her new room. There was no evidence of communication with the resident's physician regarding the sexual incident on December 23, 2025, to determine the resident's decision-making ability, or that assessment was conducted to determine that the sexual contact was consensual. An Alert Note dated December 29, 2024 revealed Resident #9 has displayed inappropriate sexual behaviors towards and with other residents this shift, and was observed being physically and verbally inappropriate several times. Staff have attempted to separate patients several times, ineffectively. The resident was medicated for anxiety, which was ineffective. The physician and nursing management were made aware to follow up. No patients were injured and no patients complained about the behavior. The note indicated the writer will communicate with family. A Behavior Note dated December 31, 2024, revealed Resident #9 was caught by a certified nursing assistant (CNA) kissing the male resident (#7) by the nursing station. The resident had her hands down the male resident's pants. Resident #9 was encouraged to go to her side of the building but preferred to stay in the TV room. There was no evidence of physician notification, POA notification, administrative notification, or further assessment to determine decision-making ability or consent from both residents for this incident. On April 1, 2025, a formal request was made to the facility for a log of any reportable events occurring in 2024. The administrator signed a statement that there were none in 2024. On April 1, 2025, at 12:40 PM, an interview was conducted with a Licensed Practical Nurse (LPN / Staff #51), who stated she was aware that Resident #7 and Resident #9 had a relationship, and the residents were told by facility staff that they could not see each other anymore. Staff #51 stated that Resident #9 was behavioral and had a POA, and that Resident #7 was not cognitively intact. She stated that the residents were observed being sexually inappropriate in the dining room, and that Resident #9 was moved to another hall, and that staff were told to monitor the residents. An interview was conducted on April 1, 2025, at 1:33 PM, with the Assistant Director of Nursing (ADON / Staff #45) who stated if staff were to notice possible sexual abuse, to report it to the Director of Nursing, to the physician, and remove the resident from the situation. The ADON stated that allegations of sexual abuse must be reported to mandatory sources within 2 hours. The ADON stated that Resident #7 was holding hands with another resident, and that, staff didn't report anything else. Further, she stated that, we did separate them. Additionally, the ADON stated Resident #9 was, very hypersexual, and that she was not sure if the resident was able to make her own decisions; and that, the resident's sister was her POA and decision maker. Also, the ADON stated that, I don't know if any assessments were done on the residents at the time of the incidents, or if the facility investigated the incidents for possible sexual abuse. A telephonic interview was conducted with an LPN (Staff #65) on April 1, 2025, at 2:31 PM who stated that she was familiar with Resident #9 and that, she was behavioral, and flirty with all the gentleman in the building. Staff #65 stated that Resident #9 was following a male resident around the building, and when asked for further details, Staff #65 stated, I don't want to have to repeat myself and, I'm not answering any more questions. The call was ended. A telephonic interview was conducted with an LPN (Staff #29), on April 1, 2025, at 2:35 PM who stated that Resident #7 has cognitively declined over the past several months. Staff #29 stated that she believed Resident #7 and Resident #9 liked each other; and that, they were caught by staff making out, and that facility staff took steps to keep them separated. Staff #29 stated that she reported the incident to management. Staff #29 stated it was in everybody's best interest if we didn't allow that. An interview was conducted with the Administrator (Staff #3) on April 1, 2025, at 3:00 PM who stated that any allegation of sexual abuse is to be reported within 2 hours and needs to be investigated by the administrator, and the residents need to be protected. Staff #3 stated it was his expectation that residents involved in allegations of abuse would not have access to each other during the investigation process; and that, staff would keep them separated to protect them. Additionally, Staff #3 stated that the physician would be notified to assess the residents. A telephonic interview was conducted with the Social Services Director (Staff #17) on April 1, 2025, at 3:27 PM. Staff #17 stated that she was not employed at the facility during the time frame of the sexual incidents between Residents #7 and #9, however she believed Resident #7's wife was his decision maker. She stated she was aware that Resident #7 had sexual behavior with Resident #9. Staff #17 stated that Resident #9 made her own decisions, and that Adult Protective Services (APS) was involved and stepping in to make decisions for the resident. An interview was conducted with the Director of Nursing (DON / Staff #49) on April 1, 2025, at 3:58 PM. The DON stated if a reportable incident occurs, that she would expect staff to notify leadership and notify the administrator, and report to mandatory sources within 2 hours. The DON stated that the importance of reporting is to have an outside unbiased source investigate the incident. Also, if an allegation of abuse occurred, that staff would be expected to report it, and the facility to investigate and determine whether it happened or not. Regarding Residents #7 and #9, the DON stated that there was sexual contact between the two residents, but never any allegations of sexual abuse. The DON stated that the resident' BIMS scores were appropriate and that they were cognitively intact and consenting adults, and that neither resident had a POA. The DON stated that her understanding was that the resident's had rights to have a relationship, but not to demonstrate their sexual behaviors in public places that would make other residents uncomfortable. The DON stated that she did not know if the physician was consulted to make a determination of whether the residents had capacity for decision making and could consent. The BIMS scores of Resident #7 were reviewed, and the DON stated that the resident had scores indicating moderate to severe cognitive impairment. Additionally, the DON reviewed the clinical record for Resident #7 and stated that a friend was listed as medical POA, and that the DON could not see any note that the POA was contacted for Resident #7 at the start of the incidents. Additionally, the DON stated she could not find any assessment determining ability for decision making from a physician for Resident #7. Further, the DON reviewed the clinical record for Resident #9, and stated that there was a POA listed, and that she did not see any note indicating that the physician or POA were consulted on December 19, 2024 regarding the sexual incidents. The DON stated that she did not believe the facility reported the incident as an allegation of possible sexual abuse, and that she did not know if the facility conducted an investigation. The DON stated that the incidents should have been investigated to determine the residents' decision-making ability and consent. Review of the facility policy titled Abuse Prevention Program, revised September 2021, revealed the facility will not tolerate verbal, sexual, physical and mental abuse. The objective of the policy is to develop and implement a system for identifying, investigating, preventing and reporting any incident, or suspected incident, of abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. All witnessed or suspected events as defined by this policy are to be reported regardless of who is involved or suspected. Abusive examples include various forms of sexual abuse including rape, forced sexual acts, fondling, and sexual harassment. If an incident occurs, or there is an allegation that an incident might have occurred of abuse, the Administrator, or designee will investigate. The person doing the investigation will complete a Resident Abuse/Neglect Investigation Report. The administrator will sign and maintain all reports, and findings will be reported according to state requirements.

Based on clinical record review, interviews and facility policy review, the facility failed to ensure medical records were completed and accurately documented for three residents (#49, #36, and #223). The deficient practice may result in the incompletely kept medical records and not being accurate. -Findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. The MDS further revealed no indicators for mood or behaviors and that the resident had upper extremity impairment on both sides and lower extremity impairment on one side; required partial/moderate assistance with toileting hygiene, personal hygiene and substantial/maximal assistance rolling left and right. The MDS further revealed the resident has frequent urinary incontinence and is incontinent of bowel. Review of the care plan-initiated February 24, 2025 revealed a focus on assistance with activities of daily living (ADL) related to right femur fracture, COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking and weakness. Interventions included max assist with bed mobility, and moderate assist with toileting and personal hygiene. Further review of the care plan revealed a focus for risk for skin breakdown related to right femur fracture COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking, weakness and incontinence of bladder. Interventions included using a draw sheet or lifting device to move resident and caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on February 25, 2025 at 01:38 PM with resident #223. Resident #223 reported that certified nursing assistant (CNA/Staff #23) had inflicted pain and belittled both roommate and resident #223; and that, the CNA's behavior was, abusive. Resident #223 could not recall to whom she had reported the CNA's behavior to, but recalled that she did report it. Resident #223 stated that the CNA had recently passed by her room, and made a childish gesture putting her hand to her nose and making a noise. Resident #223 stated it was, childish and immature. On February 25, 2025 at 1:49 PM the allegation of abuse was reported to facility administrator (Admin/Staff #85). On February 25, 2025 at approximately 3:00pm Administrator (Staff #85) provided an interview statement regarding resident #223. The statement revealed, Asisstant Direcctor of Nursing (ADON/Staff #37) and Director of Nursing (DON/Staff #80) interviewed resident #22 regarding concerns with the CNA/Staff #23. Resident #223 stated, CNA doesn't listen and when she changed the resident, the resident felt as if they were up against the table and could have fallen. On February 27, 2025 at 02:34 PM an interview was conducted with alleged perpetrator, certified Nursing Assistant (CNA/Staff #23) who stated she had been employed with the facility for approximately three weeks and her last shift was February 24, 2025. Staff #23 stated she arrived to the facility at 9pm, but worked the 6pm- 6am shift. Staff #23 stated she was assigned the 200 unit and had only worked the 200 unit. Staff #23 stated she did not assist resident #223 during her sift on February 24, 2025, and was unsure why she was suspended. Staff #23 stated she had informed the Director of Nursing (DON/Staff #80) of her interactions with resident #36. Staff #23 stated she had not received abuse training while an employee at the facility, and her last abuse training was October 2024. A review of the facility staff sign-in sheets dated Monday, February 24, 2025 revealed CNA/Staff#23 was assigned to units 100/200 hall and units 300/400 hall. Resident #223 resided on the 100 halls. Staff #23 signed her signature for both areas. An interview was conducted on February 27, 2025 at 03:26 PM with Administrator (Staff #85) who stated that when he was informed of the allegations of abuse he checked on the resident. Then DON (Staff#80) and ADON (Staff#37) interviewed resident #223. Staff #85 stated immediately following the report of abuse that resident interviews were conducted, CNA/Staff #23 was interviewed over the phone regarding both residents #223 and #36 and was suspended during the investigation. Staff #85 stated that the CNA provided care to both residents on night shift February 24, 2025. Staff #85 stated safety interviews were conducted for the 100 and 200 halls to ensure the residents felt safe and for any issues. Staff #85 stated all the residents reported feeling safe and no further interviews were conducted. Staff #85 stated the results of the investigations were, basically CNA/#23 was in a rush and a little abrupt with the residents #223 and #36. According to the CNA #23, they were both messy and was in a rush, to get them cleaned. Staff #85 stated he did not consider the events as abuse and would unsubstantiated the report however, are terminating the employee tomorrow. Staff #85 stated social services met with residents #223 and #36 and have been monitoring the residents daily. Further record review revealed no progress note in resident #223's clinical record regarding the alleged abuse incident. An interview with licensed practical nurse (LPN/staff #48) was conducted on February 28, 2025 at 10:07 AM who stated that if an allegation of verbal or physical abuse occurs, that the resident should be separated from the alleged perpetrator and the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would investigate. An interview was conducted on with DON/staff #80 on February 27, 2025 at 03:42 PM who stated the process for any abuse allegations involves conducting investigations, interviewing the resident, gathering statements, reaching out to the person it was alleged against, and conduct additional staff interviews. Staff #80 stated the night nurse was supposed to email her, but had not. Staff #80 stated the process also involves a safe sweep by asking the residents if there are any concerns and are safe; once all put together, if there is an allegation for abuse to do a self- report. Staff #80 stated the investigation for resident #223 was completed. Staff #80 stated, I feel that the investigation was complete, spoke to staff, resident, employee and do not feel that there was any actual abuse- it was the manner in which the care was given to both residents, she could have been kinder in her delivery of care and her manner in which she delivered her care. Staff #80 stated CNA #23 is currently suspended due to the allegations, but would have a conversation, informing her that the facility does not feel that she is a good fit for the facility. 50862 -Resident #36 was admitted on [DATE] with diagnoses that included atrial fibrillation, sequelae of cerebral infarction (stroke), aphasia, dysphagia, anxiety disorder, major depressive disorder, and right hip pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was independent in cognitive skills for daily decision making, and her decisions are consistent and reasonable with no behavioral concerns. A care plan revised on February 19, 2025, revealed the following areas of focus ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, musculoskeletal impairment, and that bed mobility required substantial assistance by one staff to reposition in bed; communication problem related to slurring and stroke, with interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, respond to the feeling resident is trying to express; chronic pain related to right hip dislocation. An interview was conducted on February 25, 2025 at 10:36 AM with Resident #36, who stated that at 4:00 AM this morning she was awakened for a brief-change by a Certified Nursing Assistant (CNA/staff #23), who called her a fat lady. The resident stated that the CNA was new to her, and was not wearing a name badge. The resident also stated that staff #23 would not listen to her and was rough when the staff member, quickly rolled her over and, threw the resident against the wall. The resident relayed that when she expressed her pain -- the CNA called her a cry baby. The resident continued, stating that as the CNA pulled her over onto the other side of bed, the resident grabbed the bed frame to keep from falling off the bed and onto the floor. The resident further relayed that the CNA grabbed the resident's legs and threw them over the edge of bed, and her feet could not touch the floor. The resident stated to surveyor, I do not feel safe here! The Resident also stated that this interaction made her feel afraid of falling. An observation of the room revealed that the resident's bed was placed against the wall having one-side to exit from, and there was no evidence of a half-rail grab bar. Following the initial interview with Resident #36, the allegation of abuse was reported to facility's Administrator (staff #100) at 11:01 AM. Review of resident #36's progress notes revealed no evidence that the incident was reported on February 25, 2025. Review of facility reported incident form dated February 25, 2025, revealed that the complaint of abuse was unsubstantiated, despite reporting that the care was being done abruptly. The report included a written e-mail statement from the CNA (staff #23) that revealed the resident was messy, and as she was cleaning the resident the resident stated that she was uncomfortable. The CNA wrote that she apologized, explained the procedure and tried to be gently. The CNA further wrote that the resident sounded like she was in pain, and that she told the nurse that the resident needed some pain pills. A telephonic interview was conducted on February 27, 2025 at 2:34 PM with CNA (staff #23), who confirmed that she went to change Resident #36 during the last rounds. The CNA further stated that the resident is a larger woman, and she is strong and felt confident in changing the resident. The CNA continued stating that when she rolled the resident, the resident complained of pain. The CNA stated that she apologized to the resident for making her uncomfortable, but told the resident that she needed to change the resident. The CNA further stated that when she had completed the brief change she told the resident she would let the nurse know about the resident's pain. She further stated that she reported to a Licensed Practical Nurse (LPN/staff #34) that the resident was having pain. An interview was conducted February 27, 2025 at 02:35 PM with a CNA (staff #16), who stated that she had recently taken training classes on abuse and neglect, and knows that all new bruises or skin tears are reported to a nurse or anything related to possible signs of abuse, and that any allegation of physical abuse is reported immediately. An interview was conducted February 27, 2025 at 02:43 PM with an LPN (Staff #48), who stated that staff are educated monthly regarding the abuse allegations process and procedures. She also stated that when abuse is suspected, the process is to separate those that are doing the behavior or remove the perpetrator, then contact the DON. If it is a staff to resident -- remove the staff, and call the Director of Nursing (DON/staff #105) and the Administrator. Staff #48 stated that physical abuse is reported right away within two-hours. Staff #48 stated that the risk of not reported abuse could result in additional residents being harmed. Staff #16 stated that the focus of reporting abuse is to protect the residents. An interview was conducted February 28, 2025 at 09:39 AM with LPN Staff #41 who explained the process and procedure for abuse was to make sure the residents are safe, report incident right away, and document per verbatim. Staff #41 stated, if there is injury, the State has to be reported within two hours. The nurse stated the charting task process requires creating an incident report within electronic medical records under risk management. Within risk management site, the nurse will document that the DON and Administrator have been notified, chart all calls made, and write an incident report note that will populate into electronic medical records as a progress note. The nurse responsibilities are to update the care plan's goals and interventions for patient safety and ensure communication with staff on how resident wants their care performed. Staff #41 stated staff should not to be in a rush during the care process because it can lead to being rough. An interview was conducted on February 28, 2025 at 09:51 AM with Licensed Practical Nurse (Staff #171) who stated had received updated education on abuse. Staff #171 stated that the process involves abuse reporting and safety of the patients, then notifying supervisor, reporting to the abuse coordinator, documenting the incident within risk management assessment that will include a note on whom was notified. Staff #171 stated that if the situation was physical abuse, the nurse calls 911 and documents the police report number. The nurse will notify the doctor, and doctor makes the decision to send the patient to the hospital. If unable to contact the doctor, the nurse would send patient to the hospital, and document. The nurse stated, if I received a report that abuse had occurred and I do not see a risk management documentation, I would start the process as being a new incident. The risk management document is within the electronic medical records, and once the incident data is entered and saved, the risk management note populates into electronic medical records progress note section. My expectation is that the allegation would be documented in the risk management section, reported to management, and completed in the way I was trained to process an abuse allegation. The risk of not documenting abuse is the risk of losing my job. I am required to report. The risk of not reporting the abuse, is that abuse will continue. The risk management person or abuse coordinator does the reporting or makes sure that the incident was reported to the State surveyors, State board, doctor, family, APS, and Ombudsman. The Medical Records staff would then update the care plan. Staff #171 confirmed no updated care plan at this facility for this resident. 51928 -Resident #49 was admitted to the facility on [DATE] with diagnoses that included myelodysplastic syndrome, unspecified and anemia, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS further revealed that the resident needed partial to moderate assistance rolling left and right, and the helper does less than half of the effort in the process. During an interview with resident #49 on February 28, 2025 at 9:26 AM it was revealed that on the night of Monday, February 24, 2025 at 11:02 PM the resident pushed her call light button and the Certified Nursing Assistant (CNA/staff #23) responded ten minutes later. Upon entering the room, staff #23 opened the door and turned on the light. Resident #49 stated that they introduced themselves to staff #23; and that, and staff #23 expressed frustration and stated that they were unhappy about the workload in this hall having to deal with fifteen incontinent and senile people. Resident #49 stated that then they had requested a brief change, after a bowel movement, and staff #23 proceeded to use both hands - she aggressively pushed resident to her side. This caused resident #49 to knock the items off the bedside table with her left arm and grab ahold of the bed frame with their right hand. Resident #49 stated, don't be so rough with me. Resident #49 was then cleaned on her backside and asked staff #23 to clean her genital area. Resident #49 stated that she had just recovered from a urinary tract infection and did not want to go through that again. Staff #23 stated that the cleaning and wiping was good enough and left the room. Resident #49 stated that on February 25, 2025 at 3:38 AM, she was awakened by staff #23 who opened the door without knocking, turned on the lights, and said, wake up grandma. Resident #49 replied, Please don't call me that. I told you my name. Resident stated she felt extremely uncomfortable with the physical and verbal interactions with staff #23. Resident #49 stated that at 8:00 AM, on the same morning, resident #49 was visited by another CNA (staff #13). Resident #49 expressed her concerns and told staff #13 about what happened with staff #23. Resident #49 then asked staff #13 to check her body for visible injuries and no physical injuries were observed. Staff #13 then wiped and cleaned the areas of concern to the resident and told resident #49 that the allegations would be reported. Resident #49 stated that the director of nursing (DON/staff #80) and assistant director of nursing (ADON/staff #37) came to the room for an interview at 11:30 AM on February 25, 2025. Record review regarding other abuse allegations revealed a statement signed by ADON/staff #37 and dated February 25, 2025. The document stated that the resident was upset with staff and that the resident was turned abruptly and felt as if she may fall. The document stated that staff #80 and facility administrator (Staff #100) notified this staff #23 about these concerns and that staff #23 would be immediately taken off the schedule, pending an investigation and the outcomes. Further record review revealed no progress note in resident #49's clinical record or facility reported incident to the state agency until March 4, 2025 at 5:48 PM. An interview with licensed practical nurse (LPN/staff #48) on February 28, 2025 at 10:07 AM revealed the process of responding to an abuse allegation that that whether verbal or physical abuse the resident should be separated from the alleged perpetrator; and that, the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would conduct an investigation. An interview with DON/staff #80 on February 28, 2025 at 10:34 AM revealed that staff #80 had been alerted to visit with resident #49 because of abuse allegations and issues regarding other residents and the care that they had received by staff #23 during the prior shift. She went with staff #37 to visit with all residents, but stated that the concerns reported by resident #49, were not consistent with her definition of abuse. The DON stated that in her opinion rough treatment by staff and calling the resident grandma did not meet her definition of abuse, but that a resident's perception would ultimately dictate if abuse had occurred. In the interview, staff #80 stated that the actions of staff #23 did not meet facility standards for care at the facility. Staff #80 further explained the investigation process. She stated that once an allegation was made it was reported to the leadership team. Reports must be made to the state agencies. All allegations are to be entered into the clinical record by nursing staff. Staff #80 then stated that staff #23 would be terminated from the facility on February 28, 2025 for not meeting the expectations of the facility. The facility policy titled Abuse Prevention Program, revised September 2021, revealed: - The facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident ' s property, by employees, family members, visitors or other residents. -The Administrator, or a person designated by the Administrator, shall be responsible for transmitting reports concerning residents in this facility to ensure timely reporting to the various government agencies that receive such reports. -If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after receiving the allegations, If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the report must be made within 24 hours of receiving the allegation. The facility must report the allegation and not wait until confirmed with an investigative process. -Reports shall be made to the State Survey Agency and at least one law enforcement entity. -The charge nurse will immediately assess the resident and determine and provide for any care needs. Any findings from the assessment of the resident are to be recorded in the nurse's notes in the medical record. -Auditing should be done on a regular basis to track the quality and accuracy of incident follow up charting. A facility policy titled, Documentation (undated), revealed documentation auditing should be done on a regular basis to track the quality and accuracy of incident follow up charting.

Based on staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database, the facility failed to implement their policy to effectively prevent abuse for three residents (#223, #36, and #49). The deficient practice could result in abuse continuing and not being prevented. Findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. The MDS further revealed no indicators for mood or behaviors and that the resident had upper extremity impairment on both sides and lower extremity impairment on one side; required partial/moderate assistance with toileting hygiene, personal hygiene and substantial/maximal assistance rolling left and right. The MDS further revealed the resident has frequent urinary incontinence and is incontinent of bowel. Review of the care plan-initiated February 24, 2025 revealed a focus on assistance with activities of daily living (ADL) related to right femur fracture, COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking and weakness. Interventions included max assist with bed mobility, and moderate assist with toileting and personal hygiene. Further review of the care plan revealed a focus for risk for skin breakdown related to right femur fracture COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking, weakness and incontinence of bladder. Interventions included using a draw sheet or lifting device to move resident and caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on February 25, 2025 at 01:38 PM with resident #223. Resident #223 reported that certified nursing assistant (CNA/Staff #23) had inflicted pain and belittled both roommate and resident #223; and that, the CNA's behavior was, abusive. Resident #223 could not recall to whom she had reported the CNA's behavior to, but recalled that she did report it. Resident #223 stated that the CNA had recently passed by her room, and made a childish gesture putting her hand to her nose and making a noise. Resident #223 stated it was, childish and immature. On February 25, 2025 at 1:49 PM the allegation of abuse was reported to facility administrator (Admin/Staff #85). On February 25, 2025 at approximately 3:00pm Administrator (Staff #85) provided an interview statement regarding resident #223. The statement revealed, Asisstant Direcctor of Nursing (ADON/Staff #37) and Director of Nursing (DON/Staff #80) interviewed resident #22 regarding concerns with the CNA/Staff #23. Resident #223 stated, CNA doesn't listen and when she changed the resident, the resident felt as if they were up against the table and could have fallen. On February 27, 2025 at 02:34 PM an interview was conducted with alleged perpetrator, certified Nursing Assistant (CNA/Staff #23) who stated she had been employed with the facility for approximately three weeks and her last shift was February 24, 2025. Staff #23 stated she arrived to the facility at 9pm, but worked the 6pm- 6am shift. Staff #23 stated she was assigned the 200 unit and had only worked the 200 unit. Staff #23 stated she did not assist resident #223 during her sift on February 24, 2025, and was unsure why she was suspended. Staff #23 stated she had informed the Director of Nursing (DON/Staff #80) of her interactions with resident #36. Staff #23 stated she had not received abuse training while an employee at the facility, and her last abuse training was October 2024. A review of the facility staff sign-in sheets dated Monday, February 24, 2025 revealed CNA/Staff#23 was assigned to units 100/200 hall and units 300/400 hall. Resident #223 resided on the 100 halls. Staff #23 signed her signature for both areas. An interview was conducted on February 27, 2025 at 03:26 PM with Administrator (Staff #85) who stated that when he was informed of the allegations of abuse he checked on the resident. Then DON (Staff#80) and ADON (Staff#37) interviewed resident #223. Staff #85 stated immediately following the report of abuse that resident interviews were conducted, CNA/Staff #23 was interviewed over the phone regarding both residents #223 and #36 and was suspended during the investigation. Staff #85 stated that the CNA provided care to both residents on night shift February 24, 2025. Staff #85 stated safety interviews were conducted for the 100 and 200 halls to ensure the residents felt safe and for any issues. Staff #85 stated all the residents reported feeling safe and no further interviews were conducted. Staff #85 stated the results of the investigations were, basically CNA/#23 was in a rush and a little abrupt with the residents #223 and #36. According to the CNA #23, they were both messy and was in a rush, to get them cleaned. Staff #85 stated he did not consider the events as abuse and would unsubstantiated the report however, are terminating the employee tomorrow. Staff #85 stated social services met with residents #223 and #36 and have been monitoring the residents daily. Further record review revealed no progress note in resident #223's clinical record regarding the alleged abuse incident. An interview with licensed practical nurse (LPN/staff #48) was conducted on February 28, 2025 at 10:07 AM who stated that if an allegation of verbal or physical abuse occurs, that the resident should be separated from the alleged perpetrator and the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would investigate. An interview was conducted on with DON/staff #80 on February 27, 2025 at 03:42 PM who stated the process for any abuse allegations involves conducting investigations, interviewing the resident, gathering statements, reaching out to the person it was alleged against, and conduct additional staff interviews. Staff #80 stated the night nurse was supposed to email her, but had not. Staff #80 stated the process also involves a safe sweep by asking the residents if there are any concerns and are safe; once all put together, if there is an allegation for abuse to do a self- report. Staff #80 stated the investigation for resident #223 was completed. Staff #80 stated, I feel that the investigation was complete, spoke to staff, resident, employee and do not feel that there was any actual abuse- it was the manner in which the care was given to both residents, she could have been kinder in her delivery of care and her manner in which she delivered her care. Staff #80 stated CNA #23 is currently suspended due to the allegations, but would have a conversation, informing her that the facility does not feel that she is a good fit for the facility. 50862 Resident #36 was admitted on [DATE] with diagnoses that included atrial fibrillation, sequelae of cerebral infarction (stroke), aphasia, dysphagia, anxiety disorder, major depressive disorder, and right hip pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was independent in cognitive skills for daily decision making, and her decisions are consistent and reasonable with no behavioral concerns. A care plan revised on February 19, 2025, revealed the following areas of focus ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, musculoskeletal impairment, and that bed mobility required substantial assistance by one staff to reposition in bed; communication problem related to slurring and stroke, with interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, respond to the feeling resident is trying to express; chronic pain related to right hip dislocation. An interview was conducted on February 25, 2025 at 10:36 AM with Resident #36, who stated that at 4:00 AM this morning she was awakened for a brief-change by a Certified Nursing Assistant (CNA/staff #23), who called her a fat lady. The resident stated that the CNA was new to her, and was not wearing a name badge. The resident also stated that staff #23 would not listen to her and was rough when the staff member, quickly rolled her over and, threw the resident against the wall. The resident relayed that when she expressed her pain -- the CNA called her a cry baby. The resident continued, stating that as the CNA pulled her over onto the other side of bed, the resident grabbed the bed frame to keep from falling off the bed and onto the floor. The resident further relayed that the CNA grabbed the resident's legs and threw them over the edge of bed, and her feet could not touch the floor. The resident stated to surveyor, I do not feel safe here! The Resident also stated that this interaction made her feel afraid of falling. An observation of the room revealed that the resident's bed was placed against the wall having one-side to exit from, and there was no evidence of a half-rail grab bar. Following the initial interview with Resident #36, the allegation of abuse was reported to facility's Administrator (staff #100) at 11:01 AM. Review of resident #36's progress notes revealed no evidence that the incident was reported on February 25, 2025. Review of facility reported incident form dated February 25, 2025, revealed that the complaint of abuse was unsubstantiated, despite reporting that the care was being done abruptly. The report included a written e-mail statement from the CNA (staff #23) that revealed the resident was messy, and as she was cleaning the resident the resident stated that she was uncomfortable. The CNA wrote that she apologized, explained the procedure and tried to be gently. The CNA further wrote that the resident sounded like she was in pain, and that she told the nurse that the resident needed some pain pills. A telephonic interview was conducted on February 27, 2025 at 2:34 PM with CNA (staff #23), who confirmed that she went to change Resident #36 during the last rounds. The CNA further stated that the resident is a larger woman, and she is strong and felt confident in changing the resident. The CNA continued stating that when she rolled the resident, the resident complained of pain. The CNA stated that she apologized to the resident for making her uncomfortable, but told the resident that she needed to change the resident. The CNA further stated that when she had completed the brief change she told the resident she would let the nurse know about the resident's pain. She further stated that she reported to a Licensed Practical Nurse (LPN/staff #34) that the resident was having pain. An interview was conducted February 27, 2025 at 02:35 PM with a CNA (staff #16), who stated that she had recently taken training classes on abuse and neglect, and knows that all new bruises or skin tears are reported to a nurse or anything related to possible signs of abuse, and that any allegation of physical abuse is reported immediately. An interview was conducted February 27, 2025 at 02:43 PM with an LPN (Staff #48), who stated that staff are educated monthly regarding the abuse allegations process and procedures. She also stated that when abuse is suspected, the process is to separate those that are doing the behavior or remove the perpetrator, then contact the DON. If it is a staff to resident -- remove the staff, and call the Director of Nursing (DON/staff #105) and the Administrator. Staff #48 stated that physical abuse is reported right away within two-hours. Staff #48 stated that the risk of not reported abuse could result in additional residents being harmed. Staff #16 stated that the focus of reporting abuse is to protect the residents. An interview was conducted February 28, 2025 at 09:39 AM with LPN Staff #41 who explained the process and procedure for abuse was to make sure the residents are safe, report incident right away, and document per verbatim. Staff #41 stated, if there is injury, the State has to be reported within two hours. The nurse stated the charting task process requires creating an incident report within electronic medical records under risk management. Within risk management site, the nurse will document that the DON and Administrator have been notified, chart all calls made, and write an incident report note that will populate into electronic medical records as a progress note. The nurse responsibilities are to update the care plan's goals and interventions for patient safety and ensure communication with staff on how resident wants their care performed. Staff #41 stated staff should not to be in a rush during the care process because it can lead to being rough. An interview was conducted on February 28, 2025 at 09:51 AM with Licensed Practical Nurse (Staff #171) who stated had received updated education on abuse. Staff #171 stated that the process involves abuse reporting and safety of the patients, then notifying supervisor, reporting to the abuse coordinator, documenting the incident within risk management assessment that will include a note on whom was notified. Staff #171 stated that if the situation was physical abuse, the nurse calls 911 and documents the police report number. The nurse will notify the doctor, and doctor makes the decision to send the patient to the hospital. If unable to contact the doctor, the nurse would send patient to the hospital, and document. The nurse stated, if I received a report that abuse had occurred and I do not see a risk management documentation, I would start the process as being a new incident. The risk management document is within the electronic medical records, and once the incident data is entered and saved, the risk management note populates into electronic medical records progress note section. My expectation is that the allegation would be documented in the risk management section, reported to management, and completed in the way I was trained to process an abuse allegation. The risk of not documenting abuse is the risk of losing my job. I am required to report. The risk of not reporting the abuse, is that abuse will continue. The risk management person or abuse coordinator does the reporting or makes sure that the incident was reported to the State surveyors, State board, doctor, family, APS, and Ombudsman. The Medical Records staff would update the care plan. Staff #171 confirmed no updated care plan at this facility for this resident. An interview was conducted on February 27, 2025 at 02:55 PM with the DON (staff #105), who stated that abuse policy and procedure and education are conducted at monthly staff meetings, during unit huddles, one-on-one with staff that missed the all-staff meetings, and through monthly computer training. The DON further stated that they spoke with Resident #36, and even though the resident is difficult to understand and comes up with several stories, they were able to identify what happened. The DON stated that the resident expressed her main concern was the violation of her right to be heard, and that the CNA (staff #23) was not listening when the resident asked her to slow down during the care, and that there are no bed-rails to grab. The DON also relayed that the resident stated she was afraid of falling out of bed, expressed feeling vulnerable, and that the resident did not know the staff member that was performing the care. The DON stated that they found through the investigation that the CNA was new, and did not listen to the resident's concerns about her care, and that the CNA (staff #23) had been terminated. On February 27, 2025 at 04:16 PM the Assistant Director of Nursing (ADON/staff #37) stated that CNA (staff #23) had multiple residents upset with her because the CNA was a little rough and rushed with their care. 51928 -Resident #49 was admitted to the facility on [DATE] with diagnoses that included myelodysplastic syndrome, unspecified and anemia, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS further revealed that the resident needed partial to moderate assistance rolling left and right, and the helper does less than half of the effort in the process. During an interview with resident #49 on February 28, 2025 at 9:26 AM it was revealed that on the night of Monday, February 24, 2025 at 11:02 PM the resident pushed her call light button and the Certified Nursing Assistant (CNA/staff #23) responded ten minutes later. Upon entering the room, staff #23 opened the door and turned on the light. Resident #49 stated that they introduced themselves to staff #23; and that, and staff #23 expressed frustration and stated that they were unhappy about the workload in this hall having to deal with fifteen incontinent and senile people. Resident #49 stated that then they had requested a brief change, after a bowel movement, and staff #23 proceeded to use both hands - she aggressively pushed resident to her side. This caused resident #49 to knock the items off the bedside table with her left arm and grab ahold of the bed frame with their right hand. Resident #49 stated, don't be so rough with me. Resident #49 was then cleaned on her backside and asked staff #23 to clean her genital area. Resident #49 stated that she had just recovered from a urinary tract infection and did not want to go through that again. Staff #23 stated that the cleaning and wiping was good enough and left the room. Resident #49 stated that on February 25, 2025 at 3:38 AM, she was awakened by staff #23 who opened the door without knocking, turned on the lights, and said, wake up grandma. Resident #49 replied, Please don't call me that. I told you my name. Resident stated she felt extremely uncomfortable with the physical and verbal interactions with staff #23. Resident #49 stated that at 8:00 AM, on the same morning, resident #49 was visited by another CNA (staff #13). Resident #49 expressed her concerns and told staff #13 about what happened with staff #23. Resident #49 then asked staff #13 to check her body for visible injuries and no physical injuries were observed. Staff #13 then wiped and cleaned the areas of concern to the resident and told resident #49 that the allegations would be reported. Resident #49 stated that the director of nursing (DON/staff #80) and assistant director of nursing (ADON/staff #37) came to the room for an interview at 11:30 AM on February 25, 2025. Record review regarding other abuse allegations revealed a statement signed by ADON/staff #37 and dated February 25, 2025. The document stated that the resident was upset with staff and that the resident was turned abruptly and felt as if she may fall. The document stated that staff #80 and facility administrator (Staff #100) notified this staff #23 about these concerns and that staff #23 would be immediately taken off the schedule, pending an investigation and the outcomes. Further record review revealed no progress note in resident #49's clinical record or facility reported incident to the state agency until March 4, 2025 at 5:48 PM. An interview with licensed practical nurse (LPN/staff #48) on February 28, 2025 at 10:07 AM revealed the process of responding to an abuse allegation that that whether verbal or physical abuse the resident should be separated from the alleged perpetrator; and that, the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would conduct an investigation. An interview with DON/staff #80 on February 28, 2025 at 10:34 AM revealed that staff #80 had been alerted to visit with resident #49 because of abuse allegations and issues regarding other residents and the care that they had received by staff #23 during the prior shift. She went with staff #37 to visit with all residents, but stated that the concerns reported by resident #49, were not consistent with her definition of abuse. The DON stated that in her opinion rough treatment by staff and calling the resident grandma did not meet her definition of abuse, but that a resident's perception would ultimately dictate if abuse had occurred. In the interview, staff #80 stated that the actions of staff #23 did not meet facility standards for care at the facility. Staff #80 further explained the investigation process. She stated that once an allegation was made it was reported to the leadership team. Reports must be made to the state agencies. All allegations are to be entered into the clinical record by nursing staff. Staff #80 then stated that staff #23 would be terminated from the facility on February 28, 2025 for not meeting the expectations of the facility. The facility policy titled Abuse Prevention Program, revised September 2021, revealed: - The facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident ' s property, by employees, family members, visitors or other residents. -Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident. -The Administrator, or a person designated by the Administrator, shall be responsible for transmitting reports concerning residents in this facility to ensure timely reporting to the various government agencies that receive such reports. -If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after receiving the allegations, If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the report must be made within 24 hours of receiving the allegation. The facility must report the allegation and not wait until confirmed with an investigative process. -Reports shall be made to the State Survey Agency and at least one law enforcement entity. -The charge nurse will immediately assess the resident and determine and provide for any care needs. Any findings from the assessment of the resident are to be recorded in the nurse's notes in the medical record. -Auditing should be done on a regular basis to track the quality and accuracy of incident follow up charting.

Based on clinical record review, facility documentation, observation, staff interviews, and policy review, the facility failed to ensure that three residents (#36, #223, and #49) were free from abuse. The deficient practice may result in further staff to resident abuse. Findings Include: Resident #36 was admitted on [DATE] with diagnoses that included atrial fibrillation, sequelae of cerebral infarction (stroke), aphasia, dysphagia, anxiety disorder, major depressive disorder, and right hip pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was independent in cognitive skills for daily decision making, and her decisions are consistent and reasonable with no behavioral concerns. A care plan revised on February 19, 2025, revealed the following areas of focus ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, musculoskeletal impairment, and that bed mobility required substantial assistance by one staff to reposition in bed; communication problem related to slurring and stroke, with interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, respond to the feeling resident is trying to express; chronic pain related to right hip dislocation. An interview was conducted on February 25, 2025 at 10:36 AM with Resident #36, who stated that at 4:00 AM this morning she was awakened for a brief-change by a Certified Nursing Assistant (CNA/staff #23), who called her a fat lady. The resident stated that the CNA was new to her, and was not wearing a name badge. The resident also stated that staff #23 would not listen to her and was rough when the staff member, quickly rolled her over and, threw the resident against the wall. The resident relayed that when she expressed her pain -- the CNA called her a cry baby. The resident continued, stating that as the CNA pulled her over onto the other side of bed, the resident grabbed the bed frame to keep from falling off the bed and onto the floor. The resident further relayed that the CNA grabbed the resident's legs and threw them over the edge of bed, and her feet could not touch the floor. The resident stated to surveyor, I do not feel safe here! The Resident also stated that this interaction made her feel afraid of falling. An observation of the room revealed that the resident's bed was placed against the wall having one-side to exit from, and there was no evidence of a half-rail grab bar. Following the initial interview with Resident #36, the allegation of abuse was reported to facility's Administrator (staff #100) at 11:01 AM. Review of resident #36's progress notes revealed no evidence that the incident was reported on February 25, 2025. Review of facility reported incident form dated February 25, 2025, revealed that the complaint of abuse was unsubstantiated, despite reporting that the care was being done abruptly. The report included a written e-mail statement from the CNA (staff #23) that revealed the resident was messy, and as she was cleaning the resident the resident stated that she was uncomfortable. The CNA wrote that she apologized, explained the procedure and tried to be gently. The CNA further wrote that the resident sounded like she was in pain, and that she told the nurse that the resident needed some pain pills. A telephonic interview was conducted on February 27, 2025 at 2:34 PM with CNA (staff #23), who confirmed that she went to change Resident #36 during the last rounds. The CNA further stated that the resident is a larger woman, and she is strong and felt confident in changing the resident. The CNA continued stating that when she rolled the resident, the resident complained of pain. The CNA stated that she apologized to the resident for making her uncomfortable, but told the resident that she needed to change the resident. The CNA further stated that when she had completed the brief change she told the resident she would let the nurse know about the resident's pain. She further stated that she reported to a Licensed Practical Nurse (LPN/staff #34) that the resident was having pain. An interview was conducted February 27, 2025 at 02:35 PM with a CNA (staff #16), who stated that she had recently taken training classes on abuse and neglect, and knows that all new bruises or skin tears are reported to a nurse or anything related to possible signs of abuse, and that any allegation of physical abuse is reported immediately. An interview was conducted February 27, 2025 at 02:43 PM with an LPN (Staff #48), who stated that staff are educated monthly regarding the abuse allegations process and procedures. She also stated that when abuse is suspected, the process is to separate those that are doing the behavior or remove the perpetrator, then contact the DON. If it is a staff to resident -- remove the staff, and call the Director of Nursing (DON/staff #105) and the Administrator. Staff #48 stated that physical abuse is reported right away within two-hours. Staff #48 stated that the risk of not reported abuse could result in additional residents being harmed. Staff #16 stated that the focus of reporting abuse is to protect the residents. An interview was conducted on February 27, 2025 at 02:55 PM with the DON (staff #105), who stated that abuse policy and procedure and education are conducted at monthly staff meetings, during unit huddles, one-on-one with staff that missed the all-staff meetings, and through monthly computer training. The DON further stated that they spoke with Resident #36, and even though the resident is difficult to understand and has several stories, they were able to identify what happened. The DON stated that the resident expressed her main concern was the violation of her right to be heard, and that the CNA (staff #23) was not listening when the resident asked her to slow down during the care, and that there are no bed rails to grab. The DON also relayed that the resident stated she was afraid of falling out of bed, expressed feeling vulnerable, and that the resident did not know the staff member that was performing the care. The DON stated that they found through the investigation that the CNA was new, and did not listen to the resident's concerns about her care, and that the CNA (staff #23) had been terminated. On February 27, 2025 at 04:16 PM the Assistant Director of Nursing (ADON/staff #37) stated that CNA (staff #23) had multiple residents upset with her because the CNA was a little rough and rushed with their care. 47910 -Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. The MDS further revealed no indicators for mood or behaviors and that the resident had upper extremity impairment on both sides and lower extremity impairment on one side; required partial/moderate assistance with toileting hygiene, personal hygiene and substantial/maximal assistance rolling left and right. The MDS further revealed the resident has frequent urinary incontinence and is incontinent of bowel. Review of the care plan-initiated February 24, 2025 revealed a focus on assistance with activities of daily living (ADL) related to right femur fracture, COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking and weakness. Interventions included max assist with bed mobility, and moderate assist with toileting and personal hygiene. Further review of the care plan revealed a focus for risk for skin breakdown related to right femur fracture COPD, chronic respiratory failure, neuropathy, foot drop, difficulty in walking, weakness and incontinence of bladder. Interventions included using a draw sheet or lifting device to move resident and caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on February 25, 2025 at 01:38 PM with resident #223. Resident #223 reported that certified nursing assistant (CNA/Staff #23) had inflicted pain and belittled both roommate and resident #223; and that, the CNA's behavior was, abusive. Resident #223 could not recall to whom she had reported the CNA's behavior to, but recalled that she did report it. Resident #223 stated that the CNA had recently passed by her room, and made a childish gesture putting her hand to her nose and making a noise. Resident #223 stated it was, childish and immature. On February 25, 2025 at 1:49 PM the allegation of abuse was reported to facility administrator (Admin/Staff #85). On February 25, 2025 at approximately 3:00pm Administrator (Staff #85) provided an interview statement regarding resident #223. The statement revealed, Asisstant Direcctor of Nursing (ADON/Staff #37) and Director of Nursing (DON/Staff #80) interviewed resident #22 regarding concerns with the CNA/Staff #23. Resident #223 stated, CNA doesn't listen and when she changed the resident, the resident felt as if they were up against the table and could have fallen. On February 27, 2025 at 02:34 PM an interview was conducted with alleged perpetrator, certified Nursing Assistant (CNA/Staff #23) who stated she had been employed with the facility for approximately three weeks and her last shift was February 24, 2025. Staff #23 stated she arrived to the facility at 9pm, but worked the 6pm- 6am shift. Staff #23 stated she was assigned the 200 unit and had only worked the 200 unit. Staff #23 stated she did not assist resident #223 during her sift on February 24, 2025, and was unsure why she was suspended. Staff #23 stated she had informed the Director of Nursing (DON/Staff #80) of her interactions with resident #36. Staff #23 stated she had not received abuse training while an employee at the facility, and her last abuse training was October 2024. A review of the facility staff sign-in sheets dated Monday, February 24, 2025 revealed CNA/Staff#23 was assigned to units 100/200 hall and units 300/400 hall. Resident #223 resided on the 100 halls. Staff #23 signed her signature for both areas. An interview was conducted on February 27, 2025 at 03:26 PM with Administrator (Staff #85) who stated that when he was informed of the allegations of abuse he checked on the resident. Then DON (Staff#80) and ADON (Staff#37) interviewed resident #223. Staff #85 stated immediately following the report of abuse that resident interviews were conducted, CNA/Staff #23 was interviewed over the phone regarding both residents #223 and #36 and was suspended during the investigation. Staff #85 stated that the CNA provided care to both residents on night shift February 24, 2025. Staff #85 stated safety interviews were conducted for the 100 and 200 halls to ensure the residents felt safe and for any issues. Staff #85 stated all the residents reported feeling safe and no further interviews were conducted. Staff #85 stated the results of the investigations were, basically CNA/#23 was in a rush and a little abrupt with the residents #223 and #36. According to the CNA #23, they were both messy and was in a rush, to get them cleaned. Staff #85 stated he did not consider the events as abuse and would unsubstantiated the report however, are terminating the employee tomorrow. Staff #85 stated social services met with residents #223 and #36 and have been monitoring the residents daily. Further record review revealed no progress note in resident #223's clinical record regarding the alleged abuse incident. An interview with licensed practical nurse (LPN/staff #48) was conducted on February 28, 2025 at 10:07 AM who stated that if an allegation of verbal or physical abuse occurs, that the resident should be separated from the alleged perpetrator and the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would investigate. An interview was conducted on with DON/staff #80 on February 27, 2025 at 03:42 PM who stated the process for any abuse allegations involves conducting investigations, interviewing the resident, gathering statements, reaching out to the person it was alleged against, and conduct additional staff interviews. Staff #80 stated the night nurse was supposed to email her, but had not. Staff #80 stated the process also involves a safe sweep by asking the residents if there are any concerns and are safe; once all put together, if there is an allegation for abuse to do a self- report. Staff #80 stated the investigation for resident #223 was completed. Staff #80 stated, I feel that the investigation was complete, spoke to staff, resident, employee and do not feel that there was any actual abuse- it was the manner in which the care was given to both residents, she could have been kinder in her delivery of care and her manner in which she delivered her care. Staff #80 stated CNA #23 is currently suspended due to the allegations, but would have a conversation, informing her that the facility does not feel that she is a good fit for the facility. 51928 -Resident #49 was admitted to the facility on [DATE] with diagnoses that included myelodysplastic syndrome, unspecified and anemia, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS further revealed that the resident needed partial to moderate assistance rolling left and right, and the helper does less than half of the effort in the process. During an interview with resident #49 on February 28, 2025 at 9:26 AM it was revealed that on the night of Monday, February 24, 2025 at 11:02 PM the resident pushed her call light button and the Certified Nursing Assistant (CNA/staff #23) responded ten minutes later. Upon entering the room, staff #23 opened the door and turned on the light. Resident #49 stated that they introduced themselves to staff #23; and that, and staff #23 expressed frustration and stated that they were unhappy about the workload in this hall having to deal with fifteen incontinent and senile people. Resident #49 stated that then they had requested a brief change, after a bowel movement, and staff #23 proceeded to use both hands - she aggressively pushed resident to her side. This caused resident #49 to knock the items off the bedside table with her left arm and grab ahold of the bed frame with their right hand. Resident #49 stated, don't be so rough with me. Resident #49 was then cleaned on her backside and asked staff #23 to clean her genital area. Resident #49 stated that she had just recovered from a urinary tract infection and did not want to go through that again. Staff #23 stated that the cleaning and wiping was good enough and left the room. Resident #49 stated that on February 25, 2025 at 3:38 AM, she was awakened by staff #23 who opened the door without knocking, turned on the lights, and said, wake up grandma. Resident #49 replied, Please don't call me that. I told you my name. Resident stated she felt extremely uncomfortable with the physical and verbal interactions with staff #23. Resident #49 stated that at 8:00 AM, on the same morning, resident #49 was visited by another CNA (staff #13). Resident #49 expressed her concerns and told staff #13 about what happened with staff #23. Resident #49 then asked staff #13 to check her body for visible injuries and no physical injuries were observed. Staff #13 then wiped and cleaned the areas of concern to the resident and told resident #49 that the allegations would be reported. Resident #49 stated that the director of nursing (DON/staff #80) and assistant director of nursing (ADON/staff #37) came to the room for an interview at 11:30 AM on February 25, 2025. Record review regarding other abuse allegations revealed a statement signed by ADON/staff #37 and dated February 25, 2025. The document stated that the resident was upset with staff and that the resident was turned abruptly and felt as if she may fall. The document stated that staff #80 and facility administrator (Staff #100) notified this staff #23 about these concerns and that staff #23 would be immediately taken off the schedule, pending an investigation and the outcomes. Further record review revealed no progress note in resident #49's clinical record or facility reported incident to the state agency until March 4, 2025 at 5:48 PM. An interview with licensed practical nurse (LPN/staff #48) on February 28, 2025 at 10:07 AM revealed the process of responding to an abuse allegation that that whether verbal or physical abuse the resident should be separated from the alleged perpetrator; and that, the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would conduct an investigation. An interview with DON/staff #80 on February 28, 2025 at 10:34 AM revealed that staff #80 had been alerted to visit with resident #49 because of abuse allegations and issues regarding other residents and the care that they had received by staff #23 during the prior shift. She went with staff #37 to visit with all residents, but stated that the concerns reported by resident #49, were not consistent with her definition of abuse. The DON stated that in her opinion rough treatment by staff and calling the resident grandma did not meet her definition of abuse, but that a resident's perception would ultimately dictate if abuse had occurred. In the interview, staff #80 stated that the actions of staff #23 did not meet facility standards for care at the facility. Staff #80 further explained the investigation process. She stated that once an allegation was made it was reported to the leadership team. Reports must be made to the state agencies. All allegations are to be entered into the clinical record by nursing staff. Staff #80 then stated that staff #23 would be terminated from the facility on February 28, 2025 for not meeting the expectations of the facility. The facility policy titled Abuse Prevention Program, revised September 2021, defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the state mental health authority was notified of a resident's change in mental condition for one resident of two sampled residents (#31). The deficient practice could result in residents not receiving the proper level of care to meet their needs. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included heart failure, unspecified dementia, hypertension, and chronic obstructive pulmonary disorder. A Level 1 Pre-Admission Screening and Resident Review (PASRR) dated July 24, 2023 was completed with no referral necessary for a PASRR Level 2. An Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated that the resident was moderately cognitively impaired, and no evidence of an active diagnosis for schizoaffective disorder. An MDS assessment dated [DATE] revealed an active diagnosis for schizoaffective disorder. There was no evidence in Resident #31's clinical record of psychiatric services provided after February 13, 2024. A new medical diagnosis of schizoaffective disorder was initiated on February 14, 2024. An MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. A care plan initiated on September 18, 2024 revealed that Resident #31 had a communication deficit related to schizoaffective disorder. An order for Depakote 250 milligram to treat schizoaffective disorder was initiated on November 13, 2024. There was no evidence in the resident's clinical records of an updated Level 1 PASRR Screening following a new diagnosis for serious mental illness. An interview was conducted on February 27, 2025 at 9:54 a.m. with the Social Services Director (SSD/Staff#14) who stated that she did not complete PASRRs and that it was the responsibility of the MDS coordinator because she had not been trained to do them. An interview was conducted on February 27, 2025 at 10:06 a.m. with the MDS Coordinator (Staff#99), who stated that he was not responsible for completing PASRRs, and that it was the social service director's job to send the paperwork to the state when a resident received a new diagnosis. He stated that the only part of his job that plays a role in the PASRR was the entry of a new diagnosis into the system. An interview was conducted on February 27, 2025 at 10:19 a.m. with the Administrator (Staff#100) who stated that he did not have anyone in the building who was trained to do PASRRs. The Administrator stated that he did not know who was responsible for the PASRRs but usually it was social services, and he stated that his explanation was confusing and unclear. The administrator stated that he would hope that the Director of Nursing (DON) would be able to complete PASRRs if there were a change in a resident's diagnoses; and that, she would work with the regional nurse to send the paperwork to the state agency. An interview was conducted on February 27, 2025 at 10:40 a.m. with the DON (Staff #105) who stated that she had very limited knowledge regarding PASRR; and that, they only would come through her office, and she did not look through them. The DON stated that she had only been trained once regarding PASRRs and did not know who was responsible for handling the PASRR if a resident received a new diagnosis, stating, I won't pretend to know. The DON also stated that her expectation would be that the new diagnosis would start with the physician, go to the MDS coordinator, and from there, the facility, does not do PASRR Level 2. The DON further stated that she was not handling PASRRs, she would not work with the regional nurse to do PASRRs, and she had not been told it was her responsibility because she did not remember reading that in her job description. The DON opened her job description and stated that she could not find anything in her job description relating to PASRRs being her responsibility, and from her understanding, PASRRs were supposed to be done in a timely manner. The DON stated that the risk of not appropriately completing the PASRR paperwork could result in a patient not being treated appropriately as per their diagnosis. An interview was conducted on February 27, 2025 at 12:35 p.m. with the Medical Director (MD/Staff#165), who confirmed that Resident #31 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and neuralgia. The MD stated that Resident #31 received a diagnosis for bipolar type schizoaffective disorder on February 14, 2024 and delusional disorder on September 13, 2024. The MD stated that Resident #31 probably fit the criteria for a PASRR Level 2 if a diagnosis of schizoaffective bipolar fit the criteria, and that he had no concern regarding paperwork being sent to the state because his only concern was that residents were being treated properly and receiving the appropriate level of care. Review of a policy titled, Admission Criteria, revealed that if a Level 1 Screening indicated that the individual might meet the criteria for a MD, ID, or RD, he or she would be referred to the state PASRR representative for a Level 2 Screening process, and that the social worker was responsible for making referrals to the appropriate state-designated authority. The policy revealed that the state PASRR representative would provide a copy of the report to the facility. Review of a policy titled, AHCCCS Medical Policy Manual - Pre-Admission Screening and Resident Review (PASRR), revealed that the facility was required to request Resident Reviews for individuals experiencing a Significant Change in condition as specified in Section 1919(e)(7)(B)(iii) of the Social Security Act. The policy revealed that the facility was required to submit a new Level 1 Screening to AHCCCS or DES/DDD within 14 calendar days after the facility determined through the MDS assessment that there had been a Significant Change in the resident ' s mental condition (42 CFR 483.20). The policy revealed that the submitted documentation would be reviewed to determine if another PASRR Level 2 evaluation was needed.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one of three sampled residents (#10). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation, anterograde amnesia, hypertension, and white matter disease. A physician's order dated December 19, 2024 was written for DNR (Do Not Resuscitate). An Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 08, which indicated moderately impaired cognition. Resident #10's clinical record review revealed no electronic or physical evidence of a signed advance directive or acknowledgement. An interview was conducted on February 27, 2025 at 8:29 a.m. with Licensed Practical Nurse (LPN/Staff#36) who stated that either the resident or power of attorney should sign the paperwork that confirm their advance directives upon admission to the facility. Staff #36 stated that it was the facility's expectation that there's a hard copy of the advance directive in the building, but that the facility was still getting used to the electronic charting system so it might not be in the electronic medical record (EMR). Staff #36 further stated that a signed copy of the advance directive paperwork was needed prior to placing the order in the EMR. Staff #36 reviewed the clinical record and stated that there was no evidence of an advance directive in the EMR, or of a paper chart with a paper copy of the advance directive. The LPN looked for the paper chart in the hall where the resident had lived previously, and could not locate a hard copy of the advance directive paperwork. Staff #36 stated that the chart should have been moved to the new hall when he moved rooms. Staff #36 also stated that she felt it was a problem and the risk of not having a resident's advance directives accessible could result in conflicting direction in the event that the resident coded, and without paperwork the facility considers the resident a full code. At this time, the resident's POA (Power of Attorney) walked by and Staff #36 asked if he had ever signed the advance directives paperwork to which he stated, I don't know what advanced directives are, so no. Staff #36 then asked the POA to sign the advance directives paperwork on February 27, 2025 at 8:47 a.m. An interview was conducted on February 27, 2025 at 8:41 a.m. with the Medical Records Director (MRD/Staff#29), who stated that she could not find any evidence of the resident's advance directives in the EMR. Staff #29 also stated that the facility's expectation is to maintain a hard copy and scanned version of consents obtained from nursing on admission. Staff #29 further stated that the risk of not maintaining the advance directive records could result in a delay of care in an emergency because you only have a few seconds to retrieve the information, and it would be a problem. An interview was conducted on February 27, 2025 at 8:55 a.m. with the Director of Nursing (DON/Staff#105), who stated that the facility's advance directives process included the POA and resident signing the form upon admission, medical records would then scan them into the EMR, and maintaining a hard copy at the nurses station. The DON stated that the facility had weekly audits for advance directives. She stated that the risk of not properly conducting procedures, or maintaining advance directives, could result in residents having, or not having, life saving measures performed that meet their wishes. The DON also stated that residents come to the facility with an established code status, however regardless must address the consents because their wishes may have changed. Staff #105 further stated that in the event that the code status order was wrong they would refer to the paper copy upon admission and scan it into the EMR. Staff #105 stated that Resident #10 did not have advance directives paperwork but he had an order for DNR on December 19, 2024; and that, should have advance directive paperwork. Review of a policy titled, Advance Directives, revealed that the social services director or designee inquire about the existence of a written advance directive prior to, or upon admission; the resident or representative would have to be provided with written information concerning the right to refuse or accept treatment in a way that was easily understood and to formulate an advance directive; if a resident did have an advance directive, a copy of the document would have to be obtained and maintained in the same section of the resident's medical record and readily retrievable by any facility staff. The policy also revealed that the residents wishes were to be communicated to direct care staff and physicians by placing the advance directive documents in a prominent, accessible location in the medical record.

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that an allegation of abuse was reported to mandatory reporting agencies within the required timeframe for one resident (#49). The deficient practice could result in abuse allegations not being reported. Findings include: -Resident #49 was admitted to the facility on [DATE] with diagnoses that included myelodysplastic syndrome, unspecified and anemia, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS further revealed that the resident needed partial to moderate assistance rolling left and right, and the helper does less than half of the effort in the process. During an interview with resident #49 on February 28, 2025 at 9:26 AM it was revealed that on the night of Monday, February 24, 2025 at 11:02 PM the resident pushed her call light button and the Certified Nursing Assistant (CNA/staff #23) responded ten minutes later. Upon entering the room, staff #23 opened the door and turned on the light. Resident #49 stated that they introduced themselves to staff #23; and that, and staff #23 expressed frustration and stated that they were unhappy about the workload in this hall having to deal with fifteen incontinent and senile people. Resident #49 stated that then they had requested a brief change, after a bowel movement, and staff #23 proceeded to use both hands - she aggressively pushed resident to her side. This caused resident #49 to knock the items off the bedside table with her left arm and grab ahold of the bed frame with their right hand. Resident #49 stated, don't be so rough with me. Resident #49 was then cleaned on her backside and asked staff #23 to clean her genital area. Resident #49 stated that she had just recovered from a urinary tract infection and did not want to go through that again. Staff #23 stated that the cleaning and wiping was good enough and left the room. Resident #49 stated that on February 25, 2025 at 3:38 AM, she was awakened by staff #23 who opened the door without knocking, turned on the lights, and said, wake up grandma. Resident #49 replied, Please don't call me that. I told you my name. Resident stated she felt extremely uncomfortable with the physical and verbal interactions with staff #23. Resident #49 stated that at 8:00 AM, on the same morning, resident #49 was visited by another CNA (staff #13). Resident #49 expressed her concerns and told staff #13 about what happened with staff #23. Resident #49 then asked staff #13 to check her body for visible injuries and no physical injuries were observed. Staff #13 then wiped and cleaned the areas of concern to the resident and told resident #49 that the allegations would be reported. Resident #49 stated that the director of nursing (DON/staff #80) and assistant director of nursing (ADON/staff #37) came to the room for an interview at 11:30 AM on February 25, 2025. Record review regarding other abuse allegations revealed a statement signed by ADON/staff #37 and dated February 25, 2025. The document stated that the resident was upset with staff and that the resident was turned abruptly and felt as if she may fall. The document stated that staff #80 and facility administrator (Staff #100) notified this staff #23 about these concerns and that staff #23 would be immediately taken off the schedule, pending an investigation and the outcomes. Further record review revealed no progress note in resident #49's clinical record or facility reported incident to the state agency until March 4, 2025 at 5:48 PM. An interview with licensed practical nurse (LPN/staff #48) on February 28, 2025 at 10:07 AM revealed the process of responding to an abuse allegation that that whether verbal or physical abuse the resident should be separated from the alleged perpetrator; and that, the DON and facility administrator should be notified immediately. The incident would then be documented in the clinical record by the nurse, and the administrator and DON would conduct an investigation. An interview with DON/staff #80 on February 28, 2025 at 10:34 AM revealed that staff #80 had been alerted to visit with resident #49 because of abuse allegations and issues regarding other residents and the care that they had received by staff #23 during the prior shift. She went with staff #37 to visit with all residents, but stated that the concerns reported by resident #49, were not consistent with her definition of abuse. The DON stated that in her opinion rough treatment by staff and calling the resident grandma did not meet her definition of abuse, but that a resident's perception would ultimately dictate if abuse had occurred. In the interview, staff #80 stated that the actions of staff #23 did not meet facility standards for care at the facility. Staff #80 further explained the investigation process. She stated that once an allegation was made it was reported to the leadership team. Reports must be made to the state agencies. All allegations are to be entered into the clinical record by nursing staff. Staff #80 then stated that staff #23 would be terminated from the facility on February 28, 2025 for not meeting the expectations of the facility. The facility policy titled Abuse Prevention Program, revised September 2021, revealed: - The facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident ' s property, by employees, family members, visitors or other residents. -The Administrator, or a person designated by the Administrator, shall be responsible for transmitting reports concerning residents in this facility to ensure timely reporting to the various government agencies that receive such reports. -If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after receiving the allegations, If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the report must be made within 24 hours of receiving the allegation. The facility must report the allegation and not wait until confirmed with an investigative process. -Reports shall be made to the State Survey Agency and at least one law enforcement entity. -The charge nurse will immediately assess the resident and determine and provide for any care needs. Any findings from the assessment of the resident are to be recorded in the nurse's notes in the medical record. -Auditing should be done on a regular basis to track the quality and accuracy of incident follow up charting.

Based on staff interviews and policy review, the facility failed to ensure a list of monthly resident discharges was submitted to a representative of the Office of the State Long-Term Ombudsman. The deficient practice resulted in the ombudsman not being notified of transfers or discharges. Findings include: An interview was conducted with the administrator (Staff #100) on February 26, 2025, at 09:00 AM who stated that the discharge report is submitted to the ombudsman quarterly instead of monthly. Additionally, if any problems arise, such as resident insurance concerns during discharge, the facility promptly informs the ombudsman. An interview was conducted with the Social Service (Staff #160) on February 27, 2025 at 8:42 AM who stated that the facility provides written notification to the resident and their family or legal representative. This notice must be given at least thirty days before discharge. However, she also noted that she does not prepare the monthly status report for the ombudsman. Instead, her role involves developing the discharge plan each month and submitting it accordingly to the administrator. An interview was conducted with the admission Manager (Staff #9) on February 27, 2025 who confirmed had a role in receiving and reviewing discharge referral packets. Staff #9 added that social service staff completed resident referrals, and submits them to admissions to be reviewed for completion. Admissions then uploads completed packet to the resident's chart so they are able to be reviewed by nurses and nurse practitioner. However, she added that she doesn't participation in sending the discharge report to the ombudsman, which is a social service and administrator task. A review of the facility's policy titled Admissions, Transfers, and Discharges, revealed the facility must send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman.

Based on clinical record review, staff interviews and policy review and AHCCCS Medical Policy Manual, the facility failed to ensure that a staff member was responsible to complete the required assessments for PASRR to meet the residents' needs. The deficient practice could result in residents not receiving appropriate care and treatment related to Serious Mental Illness (SMI) and Mental Illness (MI). Findings include: Review of a policy titled, Admission Criteria, revealed that if a Level 1 Screening indicated that the individual might meet the criteria for a MD, ID, or RD, he or she would be referred to the state PASRR representative for a Level 2 Screening process, and that the social worker was responsible for making referrals to the appropriate state-designated authority. The policy revealed that the state PASRR representative would provide a copy of the report to the facility. Review of a policy titled, AHCCCS Medical Policy Manual - Pre-Admission Screening and Resident Review (PASRR), revealed that the facility was required to request Resident Reviews for individuals experiencing a Significant Change in condition as specified in Section 1919(e)(7)(B)(iii) of the Social Security Act. The policy revealed that the facility was required to submit a new Level 1 Screening to AHCCCS or DES/DDD within 14 calendar days after the facility determined through the MDS assessment that there had been a Significant Change in the resident ' s mental condition (42 CFR 483.20). The policy revealed that the submitted documentation would be reviewed to determine if another PASRR Level 2 evaluation was needed. During clinical record review of PASRR for one resident there was no evidence that a PASRR assessment had been updated to reflect a new psychiatric diagnosis. An interview was conducted on February 27, 2025 at 9:54 a.m. with the Social Services Director (SSD/Staff#14) who stated that she did not complete PASRRs and that it was the responsibility of the MDS coordinator because she had not been trained to do them. An interview was conducted on February 27, 2025 at 10:06 a.m. with the MDS Coordinator (Staff#99), who stated that he was not responsible for completing PASRRs, and that it was the social service director's job to send the paperwork to the state when a resident received a new diagnosis. He stated that the only part of his job that plays a role in the PASRR was the entry of a new diagnosis into the system. An interview was conducted on February 27, 2025 at 10:19 a.m. with the Administrator (Staff#100) who stated that he did not have anyone in the building who was trained to do PASRRs. The Administrator stated that he did not know who was responsible for completing/reviewing PASRRs but usually it was social services, and he stated that his explanation was confusing and unclear. The administrator stated that he would hope that the Director of Nursing (DON) would be able to complete PASRRs if there were a change in a resident ' s diagnoses and that she would work with the regional nurse to send the paperwork to the state agency. An interview was conducted on February 27, 2025 at 10:40 a.m. with the DON (Staff #105) who stated that she had very limited knowledge regarding PASRRs, they only would come through her office, and she did not look through them. The DON stated that she had only been trained once regarding PASRRs and she did not know who was responsible for handling the PASRR if a resident received a new diagnosis, stating I won ' t pretend to know. The DON also stated that her expectation would be that the new diagnosis would start with the physician, go to the MDS coordinator, and from there, the facility does not do PASRR Level 2 ' s. The DON further stated that she was not handling PASRRs at all, she would not work with the regional nurse to do PASRRs, and she had not been told it was her responsibility because she did not remember reading that in her job description. The DON opened her job description and stated that she could not find anything in her job description relating to PASRRs being her responsibility, and from her understanding, PASRRs were supposed to be done in a timely manner. The DON stated that risk of not appropriately completing the PASRR paperwork could result in a patient not being treated appropriately as per their diagnosis. An interview was conducted on February 27, 2025 at 12:35 p.m. with the Medical Director (MD/Staff#165), who stated Resident #31 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and neuralgia. The MD stated that one resident received a diagnosis for bipolar type schizoaffective disorder on February 14, 2024 and delusional disorder on September 13, 2024. The MD stated that the resident probably fit the criteria for a PASRR Level 2 if a diagnosis of schizoaffective bipolar fit the criteria, and that he had no concern regarding paperwork being sent to the state because his only concern was that residents were being treated properly and receiving the appropriate level of care. Review of S483.21(b)(3) Comprehensive Care Plans in the State Operations Manual, Appendix PP, revealed the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality. The regulation also revealed that standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.

Based on clinical record review, staff and resident interviews, and policy and procedure, the facility failed to ensure that pain medication was administered according to physician orders for two of seventeen sampled residents (#224 and #12). The deficient practice could result in overmedication for residents. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included unspecified systolic (congestive) heart failure, unspecified sequelae of unspecified cerebrovascular disease, and fibromyalgia. Resident #12's most recent care plan dated August 27, 2024 revealed that the facility must anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During every shift, the facility is expected to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the physician's order dated September 7, 2024 revealed that Hydrocodone-Acetaminophen Oral Tablet 5-325 milligram, should be administered as needed, every six hours for pain levels of seven to ten, and not to exceed three doses in a twenty-four-hour period. Review of the Medication Administration Record (MAR) dated December 2024, January 2025 and February 2025 revealed that thirteen times, Hydrocodone was administered at a pain level below seven. Those dates and reported pain levels included: December 2, 2024 - Pain level 5 - Hydrocodone administered December 10, 2024 - Pain level 6 - Hydrocodone administered December 12, 2024 - Pain level 5 - Hydrocodone administered December 18, 2024- Pain level 5 - Hydrocodone administered December 19, 2024- Pain level 5 - Hydrocodone administered December 22, 2024 - Pain level 6 - Hydrocodone administered December 23, 2024 - Pain level 5 - Hydrocodone administered January 1, 2025 - Pain level 5 - Hydrocodone administered January 7, 2025 - Pain level 6 - Hydrocodone administered January 23, 2025 - Pain level 5 - Hydrocodone administered January 27, 2025 - Pain level 5 - Hydrocodone administered February 15, 2025 - Pain level 5 - Hydrocodone administered February 22, 2025 - Pain level 4 - Hydrocodone administered An interview with Licensed Practical Nurse (LPN/staff #48) on February 26, 2025 at 9:12 am revealed that the process for administration of Hydrocodone to the resident included the nurse asking the resident to rate their level of pain on a scale of one to ten and administering the proper medication based on the resident's response. Upon review of the MAR for resident #12, staff #48 stated that the hydrocodone was administered outside of the pain level parameters. The Director of Nursing (DON/staff #80) stated during an interview on February 26, 2025 at 9:31 am that the expectation of the facility is to administer medication as ordered by the physician. Upon review of the MAR for resident #12, the administration of Hydrocodone did not meet the expectation. DON #80 stated that this risks oversedation to the resident. 47910 -Resident #224 was admitted to the facility on [DATE] and discharged to the hospital February 25, 2025 with diagnoses of acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, other supraventricular tachycardia, atherosclerotic heart disease of native coronary artery without angina pectoris. human metapneumovirus pneumonia. Review of physician orders revealed a physician order dated February 13, 2025 for oxygen administration 54 liters per minute (LPM) via nasal cannula every shift related to acute respiratory failure with hypoxia. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had severe cognitive impairment. The MDS assessment also included the resident received oxygen therapy. A care plan initiated on February 24, 2025 revealed the resident had congestive heart failure and Acute respiratory failure with hypoxia, PNA and that oxygen was in use. The interventions included oxygen settings via nasal cannula at 4 LPM continuous. Review of the Oxygen (O2) Saturation (Sats) Summary documentation revealed the following: 2/24/2025 23:35 92.0% @ 3 L/Min Oxygen via Nasal Cannula 2/18/2025 23:22 97.0% @ 2 L/Min Oxygen via Nasal Cannula 2/17/2025 23:20 100.0% @ 5 L/Min Oxygen via Nasal Cannula 2/13/2025 19:00 91.0% @ 5 L/Min Oxygen via Nasal Cannula 2/12/2025 23:24 95.0% @ 5 L/Min Oxygen via Nasal Cannula Review of the Medication Administration Records (MAR) for February 2025, revealed the resident was administered oxygen at 4 LPM via nasal cannula February 13, 2025 , February 17, 2025 , February 18, 2025 and February 24, 2025 . However, continued review of the clinical record did not reveal orders for oxygen titration for resident #224. During an observation conducted on February 25, 2025 at 12:42 PM, the resident was observed receiving oxygen via NC at 2 LPM. There was no date on the oxygen tubing. An interview was conducted on February 25, 2025 at 12:42 PM with family member who stated the facility was not refilling the resident's humidifier and runs dry, the family member stated resident #224 was on 5LPM for two weeks and was supposed to be on 2-3 LPM which was her baseline. An interview was conducted on February 26, 2025 at 12:25 PM with Certified Nursing Assistant (CNA/Staff#16). Staff #16 stated as a CNA she allowed to set up the oxygen for the resident, but is not allowed to open or administer the oxygen because it is considered a drug and are not allowed to carry the portable tanks. An interview was conducted on February 26, 2025 at 12:12 PM with a Licensed Practical Nurse (LPN/staff #48), who stated physician orders are needed to administer and titrate oxygen. Staff #48 stated resident #224 had orders for 4LPM continuous via nasal cannula. Staff #48 review the O2 Saturations Summary stating, on 2/18/25 resident #224 received 2 LPM's and order reads 4 LPM continuous, on 2/17/25 resident #224 received 5LPM, order reads 4 L; on 2/13/25 resident #224 received 5 LPM, orders reads 4 L continuous; on 2/12/25 resident #224 received 5LPM, order reads 4 LPM. Staff #48 stated the nurses are responsible for ensuring the residents oxygen is per the physician's orders and that CAN's can place the tubing in a resident's nose, but cannot adjust the LPM. Staff #48 stated the risks of not administering oxygen per physicians' orders can increase the residents Co2 levels leading to confusion, nausea and vomiting. In an interview conducted with the Director of Nursing (DON/staff #80) on February 26, 2025 at 12:29 PM, the DON stated oxygen tubing should be changed by the facility nurses and that facility practice is that the tubing should be changed every Sunday and as needed. The DON reviewed the treatment order for resident #224 revealing no orders for changing of the residents tubing. She stated the expectation is that there would be a physician order for oxygen tubing changes and that the order would be on the Medication Administration Record (MAR). The DON stated it would be impossible to know if the tubing had been changed if the order was not on the MAR and if the tubing was not tagged with a date. The DON also stated there would be a risk of infection if the oxygen tubing was not changed. The DON reviewed the resident's clinical record and stated that she did not see any order to change the oxygen tubing in the clinical record. The DON further reviewed the resident clinical record stating that resident #224 orders are for oxygen at 4LPM via nasal cannula and per the documentation resident was receiving oxygen outside of the physician's ordered parameters. DON reviewed orders and revealed no orders were found to titrate and that the nurse should have contacted the physician to see what the physician wanted to do. The DON stated that the risks of administering oxygen outside of the ordered rate can cause carbon dioxide (CO2) retention or air hunger. Review of the facility policy titled Administering Medication, dated April 2019 states the medications are administered in a safe and timely manner, and as prescribed. Also, the individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, right documentation and right method (route) of administration before giving the medication.

Based on clinical record review, staff interviews, observations, and policy review, the facility failed to ensure that medications were not left unattended on a bedside table for one of 22 sampled residents (#423); and failed to ensure that medications were stored in a secure manner that would prevent accident hazards. The deficient practice may result in accidental self-administration and/or undesirable medication induced harm. Findings include: Resident #423 was admitted on [DATE] with diagnoses that included pneumonia, acute chronic respiratory failure with hypoxia, Sjogren syndrome and anxiety disorder. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. During an observation conducted on February 23, 2025 at 1:39 p.m. of the resident #423's room, a dry mouth spray, a tube of Triamcinolone Acetonide Cream, Systane ultra dry eye drops and an Albuterol Sulfate Inhaler were observed on top of the resident #423's bedside table. The resident stated she liked her inhaler right next to her just in case she felt the need for it. The resident stated that her husband brought the medications in on Friday, February 21, 2025, and that none of the staff commented about the medications being on her bedside table. Review of clinical records dated February 21, 2025 through February 28, 2025 revealed no evidence of a medication self-administration assessment. Review of progress notes dated February 21, 2025 through February 28, 2025, revealed no evidence of an Interdisciplinary Team Meeting (IDT) regarding the resident's ability to safely self-administer medications. A care plan initiated on February 21, 2025 revealed no evidence of a focus or interventions regarding self-administration of medications. A physician order dated February 22, 2025 revealed the following: Albuterol Sulfate Hydrofluoroalkane Inhalation Aerosol solution 108 micrograms/ACT- inhale two puffs orally every 6 hours as needed for wheezing; may use house stock medications and start medications when available. Further review of physicians orders revealed no evidence of orders for Triamcinolone Acetonide Cream. Further review of physician orders dated on February 23, 2025, revealed that a new order had been initiated relaying that, The patient has displayed understanding of albuterol inhaler and may have it at the bedside. This order was placed in the clinical records after the unattended medications were brought to the Director of Nursing's (DON staff# 105) attention. An interview was conducted on February 23, 2025 at 11:28 a.m with a Licensed Practical Nurse (LPN /staff #6) immediately after the observation. The LPN (staff #6) also stated the resident cannot have medications unattended in her room, and stated that all self-administration medicines should be kept in a lockbox to prevent other residents from ingesting the medication. An interview was conducted on February 23, 2025, at 11:47 a.m with a Registered Nurse (RN/Staff #11), who stated that the risk of medications being left unattended at the bedside could result in other residents taking the medications, and staff not being aware. An interview was conducted on February 27, 2025 at 12:10 p.m with the DON (staff #105), who stated that when a nurse observes medication unattended on a resident's bedside table, she would expect the nurse to identify the medication, report the occurrence to the DON, and offer the resident training and education to the staff. The DON further stated that the risk of leaving medications unattended in resident rooms could result in a risk to the resident. 50595 -Regarding medication found on floor On February 27, 2025, at 09:15 AM, a medication was observed laying on the carpet floor at the nursing station between hallways three hundred and four hundred. Following the observation, the Licensed Practical Nurse (staff#36) was interviewed who stated if the residents saw the medication on the carpet and picked it up the risk could be that one of the residents might pick it up from the carpet and take it. The nurse added that she could not identify the type of medication and that it was hard to know which resident had that medication. An interview was conducted on February 27, 2025, at 11:53 AM, with CNA (staff#13) who stated if he sees medication on the resident's bedside or the floor, he will take it to the nurse to identify it. The CNA added thatthe risk of the resident finding medication at the bedside or on the floor isthat the resident might mistake it for candy and eat it. An interview was conducted on February 27, 2025, at 11:59 AM, with CNA (Staff#16) who stated, I never saw it on the floor, but I observed the medication in the resident's room. Staff #16 stated that she had seen medication on the resident's bedside table two or three times; and that, this could put many residents at risk - potentially the resident might take a double dose of drugs or accidentally take a medication that they are allergic to. An interview was conducted on February 27, 2025, at 12:10 PM, with DON (staff#105) who stated that there was a previous report regarding medication found at the resident's bedside. Staff #105 stated that if the resident finds a medication on the floor or at the bedside, it poses a lot of risks to the resident; and that, if the nurse finds medication at the resident's bedside or on the floor, she would expect the nurse to identify it, report the incident to her, and offer training and education to the staff. Review of facility policy titled Storage of Medications indicated that compartments (including carts) containing drugs and biologicals shall be locked when not in use, and trays and carts used to transport such items shall not be left unattended if open or otherwise available to others. Review of a facility policy titled, Self-Administration of Medications, revealed that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. As part of the comprehensive assessment, the interdisciplinary team (IDT) assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Based on observations, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure 2 residents (#36, #7) were treated with dignity and respect. The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect. Findings include: -Regarding Resident #36 Resident #36 was admitted on [DATE] with diagnoses that included atrial fibrillation, sequelae of cerebral infarction (stroke), aphasia, dysphagia, anxiety disorder, major depressive disorder, and right hip pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was independent in cognitive skills for daily decision making, and her decisions are consistent and reasonable with no behavioral concerns. A care plan revised on February 19, 2025, revealed the following areas of focus ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, musculoskeletal impairment, and that bed mobility required substantial assistance by one staff to reposition in bed; communication problem related to slurring and stroke, with interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, respond to the feeling resident is trying to express; chronic pain related to right hip dislocation. An interview was conducted on February 25, 2025 at 10:36 AM with Resident #36, who stated that at 4:00 AM this morning she was awakened for a brief-change by a Certified Nursing Assistant (CNA/staff #23), who called her a fat lady. The resident stated that the CNA was new to her, and was not wearing a name badge. The resident also stated that staff #23 would not listen to her and was rough when the staff member, quickly rolled her over and, threw the resident against the wall. The resident relayed that when she expressed her pain -- the CNA called her a cry baby. The resident continued, stating that as the CNA pulled her over onto the other side of bed, the resident grabbed the bed frame to keep from falling off the bed and onto the floor. The resident further relayed that the CNA grabbed the resident's legs and threw them over the edge of bed, and her feet could not touch the floor. The resident stated to surveyor, I do not feel safe here! The Resident also stated that this interaction made her feel afraid of falling. An observation of the room revealed that the resident's bed was placed against the wall having one-side to exit from, and there was no evidence of a half-rail grab bar. Following the initial interview with Resident #36, the allegation of abuse was reported to facility's Administrator (staff #100) at 11:01 AM. -Regarding Resident #7: Resident #7 was admitted on [DATE] with diagnoses of multiple sclerosis, functional quadriplegia, and adult failure to thrive. A quarterly MDS assessment dated [DATE], included a Brief Interview of Mental Status (BIMS) score of 11/15 which indicated moderately impaired cognition. The assessment also included that there were no behaviors identified. A care plan initiated on September 13, 2024 revealed Resident #7 a dining experience focus that included that the resident was going to the dining room for meal service and have the other assisted residents fed first, so he can have his meal served hot, receive more direct care, and will have time to enjoy his meal without feeling rushed. During an initial facility observation conducted on February 25, 2025 at 11:17 AM, while in dining area, a surveyor heard a CNA (CNA/staff #10) called Resident #7 a feeder. The CNA was observed walking around dining room directing other staff and stated four more times we have a feeder over there while pointing at Resident #7. An interview was conducted with the CNA (staff #10) who proceeded to point towards resident #7 and stated, he is a feeder and called him a feeder 3 more times. An interview was conducted on February 26, 2025 at 11:49 AM with a Certified Nursing Assistant (CNA/ staff #7), who stated that there were two people in the building that required feeding assistance with meals which included Resident #7, who required feeding assistance for all meals. Staff #7 stated that residents who require assistance with meals will have on the meal ticket the words, Assisted Dining so all new staff will know which resident will need assistance with meal intake. The CNA stated that the facility's expectations are that staff call residents by their preferred name, and said we do not allow staff to use the word feeder. An interview was conducted on February 27, 2025 at 12:31 PM with a Licensed Practical Nurse (LPN staff #36) who stated that residents that require assistance with feeding should not be called a feeder. She stated that nurses are trained to identify a resident as, needing assistance with feeding, and that she would correct or educate a staff member if they used the word, feeder, and report the concern to the DON. The LPN stated that the risk of calling a resident a, feeder could result in harm to the resident's self-esteem and dignity, and it could hurt the facility's reputation. An interview was conducted on February 27, 2025 at 02:16 PM with the Director of Nursing (DON staff #105), who stated the facility's computer trainings include a dignity or communication-courtesy education, and it is unacceptable to call a person by anything but their preferred name. She stated that her expectation is that staff will use the resident's preferred name; and that, calling a resident a feeder could result in making the resident feel insulted or angry. The DON also stated that the CNA (CNA/staff #10) was educated by management regarding calling residents, a feeder. A facility policy titled, Dignity, revised February 2021, revealed that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident (#224) was provided respiratory care consistent with professional standards. The deficient practice could result in respiratory complications. Findings include: Resident #224 was admitted to the facility on [DATE] and discharged to the hospital February 25, 2025 with diagnoses of acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, other supraventricular tachycardia, atherosclerotic heart disease of native coronary artery without angina pectoris. human metapneumovirus pneumonia. Review of physician orders revealed a physician order dated February 13, 2025 for oxygen administration 54 liters per minute (LPM) via nasal cannula every shift related to acute respiratory failure with hypoxia. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had severe cognitive impairment. The MDS assessment also included the resident received oxygen therapy. A care plan initiated on February 24, 2025 revealed the resident had congestive heart failure and Acute respiratory failure with hypoxia, PNA and that oxygen was in use. The interventions included oxygen settings via nasal cannula at 4 LPM continuous. Review of the Oxygen (O2) Saturation (Sats) Summary documentation revealed the following: 2/24/2025 23:35 92.0% @ 3 L/Min Oxygen via Nasal Cannula 2/18/2025 23:22 97.0% @ 2 L/Min Oxygen via Nasal Cannula 2/17/2025 23:20 100.0% @ 5 L/Min Oxygen via Nasal Cannula 2/13/2025 19:00 91.0% @ 5 L/Min Oxygen via Nasal Cannula 2/12/2025 23:24 95.0% @ 5 L/Min Oxygen via Nasal Cannula Review of the Medication Administration Records (MAR) for February 2025, revealed the resident was administered oxygen at 4 LPM via nasal cannula February 13, 2025 , February 17, 2025 , February 18, 2025 and February 24, 2025 . However, continued review of the clinical record did not reveal orders for oxygen titration for resident #224. During an observation conducted on February 25, 2025 at 12:42 PM, the resident was observed receiving oxygen via NC at 2 LPM. There was no date on the oxygen tubing. An interview was conducted on February 25, 2025 at 12:42 PM with family member who stated the facility was not refilling the resident's humidifier and runs dry, the family member stated resident #224 was on 5LPM for two weeks and was supposed to be on 2-3 LPM which was her baseline. An interview was conducted on February 26, 2025 at 12:25 PM with Certified Nursing Assistant (CNA/Staff#16). Staff #16 stated as a CNA she allowed to set up the oxygen for the resident, but is not allowed to open or administer the oxygen because it is considered a drug and are not allowed to carry the portable tanks. An interview was conducted on February 26, 2025 at 12:12 PM with a Licensed Practical Nurse (LPN/staff #48), who stated physician orders are needed to administer and titrate oxygen. Staff #48 stated resident #224 had orders for 4LPM continuous via nasal cannula. Staff #48 review the O2 Saturations Summary stating, on 2/18/25 resident #224 received 2 LPM's and order reads 4 LPM continuous, on 2/17/25 resident #224 received 5LPM, order reads 4 L; on 2/13/25 resident #224 received 5 LPM, orders reads 4 L continuous; on 2/12/25 resident #224 received 5LPM, order reads 4 LPM. Staff #48 stated the nurses are responsible for ensuring the residents oxygen is per the physician's orders and that CAN's can place the tubing in a resident's nose, but cannot adjust the LPM. Staff #48 stated the risks of not administering oxygen per physicians' orders can increase the residents Co2 levels leading to confusion, nausea and vomiting. In an interview conducted with the Director of Nursing (DON/staff #80) on February 26, 2025 at 12:29 PM, the DON stated oxygen tubing should be changed by the facility nurses and that facility practice is that the tubing should be changed every Sunday and as needed. The DON reviewed the treatment order for resident #224 revealing no orders for changing of the residents tubing. She stated the expectation is that there would be a physician order for oxygen tubing changes and that the order would be on the Medication Administration Record (MAR). The DON stated it would be impossible to know if the tubing had been changed if the order was not on the MAR and if the tubing was not tagged with a date. The DON also stated there would be a risk of infection if the oxygen tubing was not changed. The DON reviewed the resident's clinical record and stated that she did not see any order to change the oxygen tubing in the clinical record. The DON further reviewed the resident clinical record stating that resident #224 orders are for oxygen at 4LPM via nasal cannula and per the documentation resident was receiving oxygen outside of the physician's ordered parameters. DON reviewed orders and revealed no orders were found to titrate and that the nurse should have contacted the physician to see what the physician wanted to do. The DON stated that the risks of administering oxygen outside of the ordered rate can cause carbon dioxide (CO2) retention or air hunger. Review of the facility policy titled Administering Medication, dated April 2019 states the medications are administered in a safe and timely manner, and as prescribed. Also, the individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, right documentation and right method (route) of administration before giving the medication.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that care and services related to pressure ulcer was provided for 1 of 3 sampled residents (#1). The deficient practice could result in developing and/or worsening of the pressure ulcer. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included cerebrovascular disease, congestive heart failure, severe protein-calorie malnutrition, and type II diabetes. A skin/wound observation dated February 23, 2023 included the skin was intact. A Braden Scale Risk assessment dated [DATE] revealed the resident's sensory perception was slightly limited, the skin was often moist and the resident's activity level was bedfast with very limited mobility. The assessment also included that nutrition was very poor; and, the resident was at high risk for developing pressure ulcers. The clinical record revealed the resident was admitted to hospice care on February 23, 2023. An MDS (Minimum Data Set) assessment dated [DATE] included the resident had no unhealed pressure injuries. Another Braden Scale Risk assessment dated [DATE] revealed sensory perception was slightly limited, the skin was often moist, the activity level was bedfast with very limited mobility, nutrition was very poor; and, the resident was at high risk for developing pressure ulcers. A nursing progress note dated [DATE] included that the nurse requested from hospice documentation on assessments, measurements, wound orders for the resident's wound to the coccyx. Per the documentation, the nurse was informed that hospice does not measure wounds as they do not treat wounds, they just do care/orders to help protect the wounds . A physician order dated [DATE] included to cleanse the unstageable wound to the sacrum with normal saline and cover with foam dressing daily and as needed if soiled. The progress note dated [DATE] included that the nurse did the wound care on the coccyx area which had a lot of sloughing noted. Per the documentation, hospice came in about 10 minutes after and assessed the wound to the coccyx and heels. It also included that hospice said that there was no change to the wound just that the wound bed was basically debriding itself. Per the documentation, hospice will be coming daily to do wound care and to change dressing as needed when soiled. Despite documentation that the resident had an unstageable pressure ulcer to the coccyx/sacral area, there was no evidence found in the clinical record that the wound was assessed to include measurement, description of the wound bed, wound edges, presence of exudate, odor, tunneling or undermining and surrounding area From [DATE] through 15, 2023. A Weekly Skin Report dated [DATE] through [DATE] included an unstageable coccyx/sacral wound that measured 9 cm (centimeters) by 7 cm by 2.8 cm.; had 2 cm undermining at 11 o'clock, 3.5 cm at 12 o'clock, and 4 cm at 2 o'clock. Per the documentation, the wound had an onset date of February 22, 2023. The report did not include documentation on the appearance of the wound bed, surrounding skin, and drainage/exudate. A care plan initiated on [DATE] revealed the resident was high risk for pressure ulcers and had a stage 4 pressure injury to the sacrum. The goals were that the resident would have optimum skin management and that the pressure injury would improve. Interventions included to provide pressure reducing surfaces on bed and chair, provide pillows or other supportive/protective devices to assist with positioning, repositioning every two hours, pressure reducing device, and two-person assist to avoid friction/sheering. Review of the TAR (treatment administration record) for [DATE] revealed a treatment order for the unstageable wound to the sacrum was transcribed. Further review of the TAR revealed that the treatment was not documented as administered on [DATE],12, 17, 18 and 21, 2023. There was no documentation on the clinical record of reason why treatment was not completed on dates not marked in the TAR; and that, the physician was notified. Continued review of the clinical record revealed that the resident #1 expired on [DATE] at approximately 3:30 pm. During an interview conducted with a Certified Nursing Assistant (CNA/staff #13) on [DATE] at approximately 10:00 a.m., the CNA stated that residents on hospice are turned every two hours if they have bed sores; and that, anytime she assists a resident on hospice she looks them over. Staff #13 stated that hospice staff does the showers or bed baths and wound care; and, hospice will tell the facility staff if there were any skin issues and what care hospice had provided. Regarding resident #1, The CNA stated that the resident had a sore on the coccyx on admission that kept getting larger and it was smelly. Staff #13 stated they assisted the hospice nurse with wound care twice; and that, the last time she assisted with wound care was one week before the resident expired. An interview was conducted on [DATE] at approximately 10:15 a.m. with another CNA (staff #22) who stated that resident #1 arrived with a gnarly sore and needed to be repositioned every two hours. Staff #22 stated the wound would constantly leak requiring a full bed linen change regularly. Staff #22 stated the wound did not grow in size because the skin was dying and nothing can be done for a dying skin. Staff #22 stated the odor got better for a while but there were days when the wound would drain and leak. During an interview conducted with the Director of Nursing (DON/staff #31) on [DATE] at approximately 10:20 a.m., the DON stated that hospice residents are provided care in collaboration with the facility. The DON stated that the residents on hospice were still the facility's resident; and that, the facility should make sure skin care was provided and assessed. The DON stated that hospice would provide wound care supplies for the staff who should be assessing and documenting care. The DON stated that wounds should be care planned, should have provider orders for care and assessments documented. The DON further stated that wound care provided should be documented in the clinical record. An interview was conducted on [DATE] at approximately 10:30 am with a Registered Nurse/Wound Nurse (RN/staff #40) who stated that even if a resident was on hospice, it is their responsibility to provide wound care. Staff #40 stated that hospice will order treatments and if there are changes to treatment they will let the facility know. Staff #40 stated that any assessments that hospice does should be given to the facility including measurements. Regarding resident #1, the RN stated that they were not notified on admission that the resident had a wound on the coccyx area; and that, hospice had something documented on [DATE] or 6, 2023 about the resident's wound. Staff #40 stated they attempted to reach out to hospice on the [DATE] for the assessment or information about the coccyx wound. Further, staff #40 stated that the first time she assessed the coccyx wound was on [DATE]; however, she did not get measurements. Staff #40 said that this was because she was told by hospice that they (hospice) do not measure or treat pressure wounds on hospice residents, only protect them. Staff #40 stated that the first documented measurements by the facility was on [DATE] (one day before the resident passed); and that, the staff was providing wound care with saline cleanser and a foam dressing. Staff #40 stated they saw additional wound care supplies in the room from hospice; but, the facility did not have orders for it so they did not use it. Staff #40 stated they just had orders to protect it and that the idea was that hospice was managing (the resident's) skin and we were waiting on instructions. A facility Wound and Skin Care Protocols and Procedures (revised ,d+[DATE]) included that the purpose was to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. This included that the Director of Nursing will be responsible for reviewing weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practices. The protocol included that a complete wound assessment and documentation will be done weekly on all pressure ulcers untiled healed. The criteria include site/location, stage, size, appearance of wound bed, undermining/tunneling, surrounding skin, and drainage.

Based on clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to ensure target behavior and adverse side effects related to psychotropic medication use were monitored for 7 of 9 sampled residents (#6, #24, #29, #38, #40, #109 and #110). The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #24 was admitted on [DATE] with diagnoses of bipolar disorder, insomnia, major depressive disorder, panic disorder, mild cognitive impairment and dementia. A review of the comprehensive care plan dated June 22, 2022, revealed a focus of antianxiety, antidepressant and antipsychotic medication usage. Intervention included monitoring target behaviors. A review of the active physician orders revealed the following information: -Ativan (antianxiety) 0.5mg (milligram) tablet take 1 tablet every 2 hours as needed for panic, anxiety and shortness of breath (order date was November 2022); -Buspirone (antianxiety) 10mg one tablet twice daily (order date: January 25, 2023); -Remeron (antidepressant) 15mg one tablet every evening (order date: January 25, 2023); -Abilify (antipsychotic) 15mg one tablet daily for depression and psychotic features (order date: January 25, 2023); and, -Sertraline (antidepressant) 50mg one tablet daily (order date: January 25, 2023). However, these medications did not have associated diagnosis/indication for its use. Review of a quarterly MDS (minimum data set) dated February 6, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. On February 9, 2022, the order for Ativan increased to 1mg tablet take 1 tab every 6 hours as needed (Terminal Restlessness Anxiety). The clinical record revealed no evidence that specific target behaviors and adverse effects related to the use of each psychotropic medications prescribed was monitored and documented. An interview was conducted on February 22, 2023 at 4:00 p.m. with a certified nurse assistant (CNA/staff #16) who stated that she monitors residents for all behaviors, what they are eating and bowel movements when a resident is on psychotropic medications. An interview was conducted on February 22, 2023 at 3:22 p.m. with a registered nurse (RN/staff #1)who stated that orders should always be in place for all medications and should specifically state what the medication was for. The RN stated that the diagnosis as it relates to psychotropic medications should also be documented in the care plan; and that, medications, per order, should be monitored. She stated that targeted behaviors and side effects should be tracked and any noted concerns for vital signs or changes in condition need to be brought to the attention of the medical provider. An interview was conducted on February 22, 2023 at 9:33 a.m. with the administrator (staff # 46) who stated that if monitoring for targeted behaviors was not documented in the MAR, then staff were not doing it. She stated that the potential risk for residents includes the inappropriate administration of medications. 45311 -Resident #6 was admitted on [DATE] with diagnoses of opioid dependence, long-term use of anticoagulant, and unspecified depression. A psychoactive drug use authorization form signed by resident and dated July 10, 2022 included for Celexa (antidepressant) for signs and symptoms of sad affect and self-isolation. A physician order dated July 8, 2022 for Celexa 20 milligrams orally daily. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident had intact cognition. A physician order dated February 20, 2023 for Celexa 20 milligrams orally for 7 days. A care plan for the antidepressant was initiated on February 21, 2023. Interventions included to monitor patterns of target behaviors and assess, document, and report adverse side effects The MAR for February 2023 revealed that Celexa was administered as ordered. However, review of the clinical record revealed no evidence that adverse side-effects or target behavior related to the medication use were monitored. -Resident #38 admitted on [DATE] with diagnoses of dementia with behavioral disturbances, major depressive disorder, anxiety disorder, and senile degeneration of the brain. A physician order dated August 10, 2021 for Lexapro (antidepressant) 20 milligrams via tube daily. A care plan initiated on March 30, 2022 included resident was at risk for side effects related to use of antipsychotic drug. Interventions included to monitor patients of target behaviors and assess/document/report adverse side effects. The physician order dated August 9, 2022 included for the following: -Haldol (antipsychotic) 2 milligrams/cubic centimeter, give 0.5 milliliter every 6 hours as needed for nausea, vomiting, agitation, and/or hallucination; -Seroquel (antipsychotic) 100 milligrams per tube twice daily; and, -Ativan (antianxiety) 0.5 milligrams via tube every 4 hours as needed. The care plan dated August 22, 2022 included the resident had a problem for psychosocial well being due to a history of dementia with behavioral disturbances. Interventions included to assess the effectiveness of antipsychotic, antidepressant and anti-anxiety medication therapy; and to monitor adverse effects of psychoactive medication. However, review of the clinical record revealed no evidence that the adverse side-effects or target behavior related to the use of psychotropic medications were monitored. 41020 -Resident #40 readmitted on [DATE] with diagnoses of primary hypertension, type 2 diabetes mellitus with hyperglycemia and bipolar disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The assessment also included that the resident displayed no behaviors. The psychoactive drug use authorization form dated November 14, 2022 revealed Depakote (brand name for divalproex sodium-anticonvulsant/mood stabilizer) for history of bipolar disorder as evidenced by sexual inappropriateness. Potential risks and benefits to the medication were noted, as well as the resident's signature, indicating that she had been informed. A physician's order dated November 14, 2022 included for divalproex sodium 500 milligrams (mg) every evening. Review of the November 2022 Medication Administration Record (MAR) revealed medications were administered as ordered. However, the clinical record revealed no evidence that the behavior and adverse side-effect related to the use of Depakote was monitored and documented. -Resident #110 admitted on [DATE] with diagnoses of unspecified convulsions, pressure ulcer of the sacral region and primary hypertension. The physician order dated February 14, 2023 revealed an order for mirtazapine (antidepressant) 15 mg daily. Review of the February 2023 MAR revealed mirtazapine was documented as administered as ordered. A Psychoactive Drug Use Authorization dated February 21, 2023 related to Remeron (mirtazapine) for depression as evidenced by decreased appetite revealed the resident's signature, indicating he had received education regarding the potential risks and benefits of the medication. However, the clinical record revealed no evidence that the behavior and adverse side-effect related to the use of Mirtazapine was monitored and documented. -Resident #109 admitted on [DATE] with diagnoses of type 2 diabetes mellitus, primary hypertension and major depressive disorder. A Psychoactive Drug Use Authorization dated January 25, 2023 included sertraline (antidepressant). No behaviors were identified on the authorization. The resident acknowledged the risks and benefits of the medication and provided her signature as indication that she had been fully informed. A physician order dated January 25, 2023 included for sertraline (antidepressant) 100 mg daily. The January 2023 MAR revealed that sertraline was documented as administered as ordered by the physician. However, the clinical record revealed no evidence that the behavior and adverse side-effect related to the use of sertraline was monitored and documented. -Resident #29 admitted with diagnoses including primary hypertension, insomnia and anxiety disorder. Review of the physician's orders dated July 24, 2022 included for the following: -Temazepam (sedative/hypnotic) 15 mg at bedtime; -Haloperidol (antipsychotic) 2 mg/milliliter (mL) oral concentrate; give 1/4 mL every 6 hours; and, -Lorazepam (anxiolytic) 0.5 mg every 4 hours as needed for anxiety. The MAR from July 25 - August 28, 2022 revealed the resident received these medications as ordered by the physician. A physician's order dated August 29, 2023 revealed an order for Seroquel (quetiapine fumarate/antipsychotic) 25 mg daily. The MAR from August 29 through October 23, 2022 revealed the resident received medications as ordered. The quarterly MDS assessment date October 24, 2023 included that the resident displayed no behaviors. However, further review of the clinical record revealed no evidence that adverse side-effects or target behaviors related to the psychotropic medication use were monitored. On February 22, 2023 at 9:32 a.m. an interview was conducted with the Executive Director (staff #46) who stated that if behavior and adverse side-effect monitoring were not documented on the MAR, then the staf were not doing it. An interview was conducted on February 22, 2023 at 10:35 a.m. with a registered nurse (RN/staff #3) who stated that she ensures that psychotropic medications are prescribed for a specific diagnosis; and that, the residents' mood and behaviors were monitored and she would document anything abnormal in the progress notes. The RN further stated that adverse side-effects are monitored and documented in the MAR or the skilled/progress note. In an interview with the a licensed practical nurse (LPN/staff #6) conducted on February 22, 2023, the LPN stated that she was told by the MDS nurse and/or her nurse trainer not to put a diagnosis in when she enters psychotropic medication orders. She stated that she would enter behavior monitoring, but that she could not think of anything specific - such as agitation or yelling. She stated that she thought there was a fixed order for behavior monitoring that may apply to the resident's behaviors; or, it may not. She stated that she would know if the medication was working by observing the resident for behaviors. An interview was conducted on February 22, 2023 at 11:02 a.m. with an LPN (staff #5) who stated that she transcribes the physician orders into the clinical record and would document the diagnosis in the order as it relates to the medication. She stated that she does not always document the target behaviors related to the medication; and that, she documents by exception in the progress notes. She stated that adverse side-effects are documented in the progress notes by exception, then she will notify the provider. During an interview with the Director of Nursing (DON/staff #67) conducted on February 22, 2023 at 1:19 p.m., the DON stated that her expectation was that the psychotropic medication orders would have an associated diagnosis, specific target behaviors and adverse side-effect monitoring. She stated that monitoring would be included in the progress or skilled nursing notes. She stated that the risks of not providing adequate monitoring would include not meeting the resident's needs or treating the behavior effectively and/or missing adverse effects. A review of the Psychotropic Medication Use policy dated July 2022, revealed that residents will not receive medications that are not clinically indicated to treat a specific condition; and that, the use of psychotropic medications is based on a comprehensive review, including signs and symptoms. The facility policy on Medication Orders with revision date of November 2020 included that recording of PRN (as needed) medication orders are to specify type, route, dosage, frequency, strength and reason for administration.

Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that care and services were provided to prevent the worsening of pressure sores for one resident (#17). The deficient practices resulted in pressure ulcers not being thoroughly assessed and monitored, delays in treatment and worsening of pressure ulcers. Findings include: Resident #17 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice services. Regarding the pressure ulcer to the right heel: According to an untitled and undated transfer note, the resident had blisters on the right heel, which was protected with an ace bandage. The admission nursing evaluation dated (MONTH) 15, 2019 included the resident was admitted on hospice services. The evaluation included the resident had stage 2 pressure ulcers to both heels and that treatment orders were received. The evaluation did not include any further description of the right heel. A hospice nurse start of care visit note (MONTH) 15, 2019 included the resident was alert and oriented to place and was forgetful. It also included a Braden Risk Assessment, which identified that the resident was at moderate risk for pressure ulcer development. The note did not include any documentation regarding a right heel stage 2 pressure ulcer. Review of the admission physician orders revealed for weekly skin checks and for heel protectors while in bed. The orders did not include for any treatment for [REDACTED]. Hospice physician orders dated (MONTH) 15, 2019 included for heel protectors while in bed. The orders did not include any treatment for [REDACTED]. According to an initial Individual Resident Care Plan dated (MONTH) 19, 2019, the resident had actual alteration in skin integrity. The documentation included the resident had wounds to both heels. The goal was that the resident would show improvement in skin areas. Interventions included for skin assessments every week and as needed, assist to reposition resident when in bed and chair, treat per physician's order, measure open area weekly and document, and refer to wound consultant as needed. Review of the (MONTH) 2019 TAR (treatment administration record) revealed the orders for heel protectors to be on while in bed. However, there was no documentation this was done from (MONTH) 16 through 20, on the 6:00 a.m. to 2:00 p.m. shift. An admission MDS (Minimum Data Set) assessment dated (MONTH) 22, 2019 included the resident had short and long term memory problems, had moderate cognitive impairment with daily decision making skills and required extensive assistance with Activities of Daily Living. Per the MDS, the resident was also assessed to have three unhealed pressure ulcers, which included a pressure ulcer to the right heel, unspecified stage. A hospice nurse supervisory visit note dated (MONTH) 25, 2019 revealed under integumentary assessment that the resident had wounds. However, the documentation did not include the type of wounds, location, number and a description of the wounds. There was no mention that the resident had a pressure ulcer to the right heel. An initial dietary review dated (MONTH) 27, 2019 included the resident had stage 2 pressure injuries to bilateral heels. Further review of the hospice visit notes dated (MONTH) 16, 17, 21, 23, 24, 25, 27, 28 and 29, 2019, revealed documentation that the resident had wounds. However, the notes did not include any documentation regarding a right heel pressure ulcer. Review of the Daily Skilled Nurse's notes from (MONTH) 16 through 31, 2019 included the resident had pressure ulcer on the heels. However, the documentation did not include a description of the heel wounds, staging or any measurements. Despite documentation upon admission that the resident had blisters/stage 2 pressure ulcer to the right heel, there were no physician orders for any treatment, and there was no evidence that a thorough assessment of the right heel pressure ulcer was done upon admission through (MONTH) 31, 2019, which included a description of the wound bed and surrounding skin, measurements and if any drainage was present. Daily skilled nurse's notes from (MONTH) 1 through (MONTH) 5, 2019 included documentation that the resident had pressure ulcers on the heels. However, the documentation did not reflect a description of the right heel wound, staging or any measurements. A hospice nurse visit note dated (MONTH) 5, 2019 included the resident had wounds. However, the documentation did not include the resident had a pressure ulcer to the right heel. A pressure ulcer care plan dated (MONTH) 5, 2019 revealed the resident had multiple stage 2 pressure injuries, including a stage 2 pressure ulcer to the right heel. Interventions included floating the heels, use of heel protectors, reposition every 2 hours, pressure reducing mattress, wound care as directed and as needed and report changes to doctor as needed. Continue review of the clinical record revealed no physician orders for any treatment to the right heel pressure ulcer, nor was there documentation that a thorough assessment of the pressure ulcer was completed from (MONTH) 1 through 5, which included a description of the wound bed and surrounding skin, measurements and if any drainage was present. Hospice physician orders dated (MONTH) 7, 2019 now included to cleanse the right heel wound with wound cleanser, pat dry, leave open to air and to float heels. The orders also included for the hospice nurse to assess the wound every nurse visit, and for the facility nurse to do daily checks and notify hospice for wound changes, increase in size, pain, swelling, redness, bleeding, drainage or foul odor. The [DIAGNOSES REDACTED]. Despite wound care orders for a SDTI to the right heel, there was no documentation that a thorough assessment of the right heel had been done from (MONTH) 7 through 10, 2019, which included a description of the wound bed and surrounding skin and any measurements. A hospice visit note dated (MONTH) 11, 2019 now included the resident had an unstageable deep tissue injury (DTI) to the right mid-heel with an onset date of (MONTH) 7, 2019. The pressure ulcer measured 2.4 cm (centimeters) x 2.3 cm, with intact granulation tissue, 100% [MEDICATION NAME] and 0-25% necrotic tissue with slough/eschar, with indistinct edges and no odor or exudate was present. The note included that wound care was provided. A hospice visit note dated (MONTH) 13, 2019 included an unstageable DTI to the right mid-heel, with intact granulation tissue, indistinct edges, 100% [MEDICATION NAME], and 0-25% necrotic tissue slough/eschar, with no odor or exudate. The note also included that wound care was provided. A hospice visit note dated (MONTH) 14, 2019 included the fluid filled blister to the right heel had subsided, with a black discoloration on the edge. The right heel was described as an unstageable DTI with 0-25% necrotic tissue/slough/eschar and 100% [MEDICATION NAME]. No measurements were documented. The note further included that the order for the right heel was not on the treatment record. Review of a hospice visit note dated (MONTH) 18, 2019 revealed documentation that the right heel unstageable SDTI was assessed, however, there were no measurements or any description of the wound bed. Review of the (MONTH) 2019 TAR revealed the physician ordered wound treatment to the right heel from (MONTH) 7, was not initiated until (MONTH) 20. There was no documentation that wound care was provided to the right heal from (MONTH) 7 through 19. Additional hospice visits notes dated (MONTH) 20, 21, 24, 26 and 28, 2019 did not include any documentation regarding the right heel unstageable pressure ulcer. Review of the physician order recapitulation for (MONTH) 2019 revealed the following treatment orders: cleanse the wound on the right heel with wound cleanser, pat dry, leave open to air and to float heels. The orders also included for the hospice nurse to assess the wound every nurse visit, and for the facility nurse to do daily checks and notify hospice for wound changes, increase in size, pain, swelling, redness, bleeding, drainage or foul odor. The [DIAGNOSES REDACTED]. According to the (MONTH) 2019 TAR, the above orders were included. However, on (MONTH) 25, 29 and 30, there was no documentation that the treatment was provided. Review of the hospice notes for (MONTH) 1, 3, 5, 8, 11, 16, 19, 23 and 30, 2019 revealed no documentation regarding the right heel pressure ulcer. Further review of the clinical record revealed there was no documentation that a thorough assessment of the right heel pressure ulcer had been completed at least weekly, which included a description of the wound bed and surrounding skin, any measurements and if any drainage was present, since (MONTH) 11 and 13, 2019, when the pressure ulcer was described as having 0-25% necrotic tissue slough/eschar. During a wound observation conducted with a registered nurse (staff #37) on (MONTH) 6, 2019 at 12:55 p.m., the resident's right heel was observed and no open areas were noted. Staff #37 stated the resident has no open wounds. She said the hospice nurse does the treatments, but the facility nurse can do dressing changes on an as needed basis. She described the wound to the right heel as closed, with blanchable areas. Regarding the pressure ulcer to the right posterior ear: A physician's order dated (MONTH) 15, 2019 included for oxygen 2-5 liters per minute continuously via nasal cannula. A nursing note dated (MONTH) 11, 2019 included that a message was left with hospice related to a report made by a CNA (certified nursing assistant) that there was an odor present during resident care. The location of the odor was not documented. The hospice visit note dated (MONTH) 11, 2019 revealed that a new abrasion was noted above the resident's right ear and that the oxygen tubing cannot sit above the ear, as it causes pain. The note included that foam was ordered for the oxygen tubing. The note did not incude a description of the wound or any measurements. Despite documentation that foam was ordered for the oxygen tubing, there was no physician's order for this and there were no orders for any treatment to the right ear on (MONTH) 11, 2019. The hospice visit notes dated (MONTH) 13, 14 and 18, 2019 did not include the resident had a wound to the right ear. A nurse's note dated (MONTH) 19, 2019 included that a CNA reported finding 2 new wounds on the resident's ear. Per the documentation, treatment was provided and hospice was notified. The note did not include a description of the 2 wounds, nor were there any measurements. Further review of the physician orders revealed there were no treatment orders for the right ear pressure ulcers from (MONTH) 11-18, 2019. A physician's order dated (MONTH) 19, 2019 now included to cleanse the right posterior ear wound with normal saline or wound cleanser, apply antibiotic ointment twice daily and as needed for two weeks and then re-evaluate. A care plan dated (MONTH) 19, 2019 included the resident had impaired skin integrity, with two pressure ulcers to the right posterior ear. The goal was for the wounds to heal within 2 weeks. Interventions included treatment as ordered and to measure and record weekly. The hospice visit note dated (MONTH) 20, 2019 revealed no documentation regarding the right ear wound. Review of the (MONTH) 2019 TAR revealed the wound care order for the right posterior ear. However, there was no documentation that the wound treatment was provided on (MONTH) 22, 26, 27, 29 and 30, on the second shift. The (MONTH) 2019 TAR also included the orders for the right ear wound, however, it was not marked as administered on (MONTH) 1. Review of the hospice notes dated (MONTH) 1, 3, 5, 8, 11, 16, 19, 23 and 30, 2019, revealed no documentation regarding the right ear pressure ulcer. Continued review of the clinical record revealed no evidence that the pressure ulcers to the right posterior ear were thoroughly assessed from (MONTH) 11 through (MONTH) 31, 2019., which included a description of the wound beds and surrounding skin, staging of the wounds and if any drainage was present. During a wound observation conducted with a registered nurse (staff #37) on (MONTH) 6, 2019 at 12:55 p.m., the resident had a scabbed area, which reached behind the ear and under the right ear lobe, and was approximately 2 cm in length. Regarding the sacral/coccyx area: Review of the untitled and undated transfer note revealed the resident had a healing stage 2 pressure ulcer to the coccyx. The hospice physician orders dated (MONTH) 15, 2019 included for the application of zinc to the stage 2 pressure ulcer to the coccyx with each brief change. The admission nursing evaluation dated (MONTH) 15, 2019 included the resident was admitted on hospice and had a stage 2 pressure ulcer to the coccyx. The evaluation did not include a description of the wound bed and surrounding skin, any measurements, if any tunneling/undermining were present and if there was any drainage. It also included that treatment orders were received. A hospice nurse start of care visit note (MONTH) 15, 2019 included the resident was alert and oriented to place and was forgetful. The note included that a Braden Risk assessment indicated the resident was at moderate risk for developing pressure ulcers. Under the integumentary assessment, the resident was noted to be bedbound, but was able to adjust slightly in bed. It also included the resident had a stage 2 pressure injury to the coccyx and that zinc ointment was applied. However, the documentation did not include a description of the wound bed and surrounding skin, any measurements or if any drainage was present. Review of the physician order recapitulation for (MONTH) 2019 included to apply zinc with each brief change to the stage 2 pressure ulcer on the coccyx and for weekly skin checks. This order was transcribed onto the (MONTH) 2019 TAR and showed that the treatment was not marked as administered on (MONTH) 16 and 19, on the 6:00 a.m. to 2:00 p.m. shift. The Individual Resident Care Plan dated (MONTH) 19, 2019 included the resident had actual alteration in skin integrity, as the resident had a wound to the coccyx, which was present prior to admission. Interventions included treatment per physician's order, skin assessment every week and as needed and measuring/documenting open area weekly. The admission MDS assessment dated (MONTH) 22, 2019 included the resident had a pressure ulcer to the sacral region, unspecified stage. Review of the hospice visit notes dated (MONTH) 21 and 23, 2019 revealed documentation that the resident's skin was assessed, however, there was no assessment documentation regarding the coccyx pressure ulcer, which included measurements, a description of the wound bed and surrounding skin and if any drainage was present. The daily skilled nurse's notes from (MONTH) 16 through (MONTH) 24, 2019 also documented the resident had a pressure ulcer to the coccyx. However, the documentation did not include a thorough assessment of the wound. A hospice visit note dated (MONTH) 25, 2019 revealed the resident was lethargic, bedbound and had wounds. However, the assessment did not include any description of the coccyx pressure ulcer or any measurements. A hospice visit note dated (MONTH) 26, 2019 revealed the resident was alert and oriented to person, forgetful, had pale skin with poor turgor and had wounds. The note included the resident had a stage 2 pressure ulcer to the coccyx, with an onset date of (MONTH) 26, 2019. However, previous documentation showed that the coccyx pressure ulcer was identified on admission. Per the note, measurements were unable to be taken, but no explanation was given. The wound bed was described as having intact granulation tissue, distinct edges with 75-<100% [MEDICATION NAME] and had 0-25% total necrotic tissue slough/eschar present. This is the first assessment documentation of the coccyx wound bed, since it was identified upon admission. This hospice visit note also stated that wound care was ordered and included the following treatment: wound cleanser, pat dry with 4 x 4 and cover with foam dressing, which was to be removed every 3 days and as needed. The wound care was to be done by facility staff or the hospice nurse. Review of a hospice physician's order dated (MONTH) 26, 2019 revealed to cleanse the coccyx area with soap and water or wound cleanser, pat dry with 4 x 4, cover with foam dressing every 3 days or as needed by facility or hospice nurse. The orders also included to monitor for increase in redness or drainage. According to the (MONTH) 2019 TAR, this order was not transcribed onto the TAR. A hospice visit note dated (MONTH) 31, 2019 included a stage 2 pressure ulcer to the coccyx, which measured 8 cm x 6 cm. This is the first documentation of the measurements of the coccyx pressure ulcer. The note further included the coccyx wound bed had <75 and >25% of granulation tissue, 50-<75% [MEDICATION NAME] and had necrotic tissue slough/eschar of 0-25%, and the surrounding skin was dark red. Per the note, the resident's sacral pressure injury was worsening and that a sacral dressing to the resident's spine for pressure injury prevention was applied, because it was very red and facility was not keeping up with frequent repositioning. Further, the note stated that orders for turning the resident every 2 hours were written. Review of a hospice physician order dated (MONTH) 31, 2019 included for wound care to be performed by hospice nurse weekly and as needed, and the facility nurse was to perform wound care as needed if dressing is soiled. The order further included to cleanse with soap and water or wound cleanser, pat dry, then apply 7 x 7 sacral foam dressing and to notify hospice if wound worsens or shows signs of infection. The order also included to turn resident every 2 hours for pressure relief. This order was transcribed onto the TAR for (MONTH) 2019 and provided as ordered. Further review of the clinical record revealed documentation that the coccyx pressure ulcer was assessed at least weekly in (MONTH) 2019 and healed by (MONTH) 19, 2019. A wound observation was conducted on (MONTH) 6, 2019 at 12:55 p.m., with a registered nurse (staff #37). At this time, staff #37 provided wound care to the sacral area. The sacral area appeared red, with no open areas. Staff #37 described the wound as a sacral, non-open, reddened, blanchable area, with no drainage and measured 12 cm x 9 cm. In an interview with a registered nurse (RN/staff #55) conducted on (MONTH) 7, 2019 at 1:57 p.m., she stated when a resident is admitted with or develops a pressure ulcer, a skin assessment is conducted and the Weekly Pressure Ulcer Healing Assessment form is completed for each pressure ulcer identified. She stated the pressure ulcer assessment included staging, measurements and a description of the wound such as; presence/absence of eschar or drainage. She stated the wound should be monitored every shift for signs and symptoms of infection, and that weekly wound assessments should be done and documented. An interview with a licensed practical nurse (LPN/staff #32) was conducted on (MONTH) 7, 2019 at 2:17 p.m. Staff #32 stated when a resident is admitted with or develops a pressure ulcer, she will conduct an assessment of the wound which includes measurements, staging and a description of the depth of the wound or presence/absence of drainage. She stated that treatment will then be initiated and administered based on the facility's standing orders for pressure ulcers. She said succeeding assessments of the pressure ulcer will be done weekly and as needed, and that findings will be documented in the pressure ulcer form, which is maintained in the resident's clinical record. Regarding resident's receiving hospice services and who have pressure ulcers/injuries, staff #32 stated that if hospice provides the treatment for [REDACTED]. She stated the facility nurse will conduct an assessment of the resident's wound as needed, if the wound dressing gets loose. She further stated that if there is no documentation found in the resident's chart from the facility nurse regarding the pressure ulcer/wound, it means the facility nurse did not do the dressing change or assessment. During an interview with the assistant Director of Nursing (ADON/staff #29) conducted on (MONTH) 7, 2019 at 2:29 p.m., she stated the floor nurses are expected to conduct an assessment and stage the pressure ulcer when they find it. She stated the floor nurses are expected to note the size, depth, description and measurement of the pressure ulcer, and that succeeding assessments of the wound should be done weekly or as needed when there are changes. She said if the resident is on hospice, the hospice nurse is expected to assess and document the wound on a weekly basis. An interview with the Director of Nursing (DON/staff #28) was conducted on (MONTH) 7, 2019 at 3:47 p.m. Staff #28 stated that pressure ulcer wounds are assessed by the nurses, and that assessments are done on a weekly basis, which includes staging, measurements and a description of the wound. She stated if the hospice nurse is providing the treatment for [REDACTED]. She said the facility nurse will conduct an assessment on an as needed basis, when the facility nurse changes the dressing. She further stated that all assessments including pressure ulcers are maintained in the resident's clinical record. Review of the Wound and Skin Care Protocols and Procedures revealed the purpose was to promote a systematic approach and monitoring process for the care of the residents with existing wounds and for those who are at risk for skin breakdown; and to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. The objective was to maintain skin integrity and promote wound healing. The policy further included that a complete wound assessment and documentation will be done weekly on all pressure ulcers until healed. The criteria included site/location, stage, size, appearance of wound bed, undermining/tunneling, surrounding skin and drainage/exudate. The policy also stated to provide ongoing documentation by the charge/treatment nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to provide interventions and adequate supervision for one resident (#81), with drug seeking behaviors. Findings include: Resident #81 was admitted to the facility on [DATE], readmitted to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. An admission nursing evaluation dated [DATE], included the resident frequently had severe pain. The evaluation also noted that the resident had a PICC (peripherally inserted central catheter) line to the left upper arm (single lumen) for antibiotics. Physician orders dated [DATE] included for Oxycodone (narcotic pain medication) 15 milligrams (mg) 2 tablets by mouth every 4 hours as needed for moderate to severe pain (pain level of ,[DATE]) and Oxycontin (narcotic pain medication) 10 mg by mouth every 12 hours. The orders also included for PICC line care, per facility policy. Review of the resident's clinical record revealed a yellow note in the chart which included the resident's name and was dated [DATE]. This note stated the following: A couple dirty laundry things 1.) Do not leave any IV supplies in his room or within his reach. Take all sharps to another room or the medication cart. 2.) Watch him take his medication and that he is not cheeking them. I guess he was taking medications/IV syringes from here and pushing them through the PICC line. Despite the above concerns, there was no clinical record documentation that the physician was notified. In addition, there was no clinical record documentation of any interventions that were implemented upon admission to address the resident's drug seeking behavior. A nurse's note dated [DATE] included that the resident requested pain medication and when the nurse entered the room, the resident was sweaty, agitated, and his eyes were wide open. Also noted was the resident acted surprised and his hands were shaking. A Certified Nursing Assistant (CNA) later reported that the room smelled of smoke and when she went to the door, there were jeans packed under the door. Nurse's notes dated [DATE] included that at 2:30 a.m., the nurse went into the resident's room, which smelled of smoke and the trash can was blocking the door. The resident denied smoking and refused a room search. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident was assessed to be cognitively intact and was independent with all levels of his care. Review of the resident's care plans revealed the resident was alert and oriented x 4, and was independent with ADLs (activities of daily living). The care plans did not address the concern that the resident had drug seeking behaviors. Review of a nurse's note dated [DATE], revealed the nurse was unable to flush the resident's PICC line. She noted that the clamp on the PICC line was unclamped and the resident was agitated and jumpy, when the nurse had entered the room. A nurse's note on [DATE] documented that the resident was moved to a room closer to the nursing station for closer monitoring. Further review of the clinical record revealed there was no documentation of any interventions that were implemented to address the resident's drug seeking behaviors, such as providing increased monitoring or supervision, other than moving the resident closer to the nurse's station on [DATE]. Review of the nurse's notes dated [DATE], revealed the resident was not feeling well, his color was pale and vital signs were obtained. The resident had requested pain medication and to have his door shut. Approximately 10 -15 minutes later, the bathroom call light went off and the nurse responded and found the resident unresponsive. The nurse started cardiopulmonary resuscitation (CPR) and 911 was called. Emergency Medical Technicians arrived, however, the time of death was called at 5 p.m. Per the note, after the resident left the facility, the CNA and nurse gathered the resident's belongings and found syringes. A nurse's note dated [DATE] revealed that on [DATE], the nurse accepting the resident to the facility received report from the hospital nurse who stated that hospital staff found a luer-lock syringe in one of the resident's pockets, and the syringe was tested and came back positive for Oxycodone. The hospital nurse advised the receiving nurse to check his mouth for cheeking medication. The note further included that All facility staff was aware of precautions and each shift did mouth checks and discarded leur-lock syringes into sharps. According to the Medical Examiner report, the date of death was [DATE], and the Immediate cause of death was toxic effects of oxycodone. Significant finding: femoral blood levels-399 ng/ml (normal levels ,[DATE]). An interview was conducted on [DATE], with a registered nurse (RN) who had cared for the resident on [DATE]. She stated the resident had asked for pain medication and that she had checked his mouth after giving the medications. She said she had also discontinued the IV antibiotics and took the leur-lock syringe and placed it in the sharps container, then closed his door, per his request. She stated after the resident had been removed from the facility, the CNA was cleaning the room and found a leur-lock syringe in the resident's bed and in the top drawer of the bedside dresser. An interview was conducted on [DATE] with the Director of Nursing, who stated that she was the one who had placed the yellow note in the resident's record regarding the cheeking of medication and the syringes. An interview with a different RN was conducted on [DATE]. The RN stated that if a resident comes into the facility with special needs such as alcoholism or drug abuse, she would chart the information in the nurses's notes and pass it along in report and include any special needs on the care plan. Review of facility policy for Disposal of Contaminated Sharps revealed that whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated container. Review of the facility policy for Duties and Responsibilities of the nurse revealed that the nurse should consult with the resident's physician in providing the resident's care and treatment as necessary and notify the resident's attending physician, when the resident is involved in a accident or incident. The policy included to participate in the development and implementation of procedures for the safe operation of all nursing service equipment. In addition, the policy noted to review resident care plans for appropriate goals, problems, approaches, and revisions based on nursing needs.