Every finding on record at Northwood Rehabilitation & Health Care Center

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for five Residents (#66, #47, #52, #12 and #79) out of a total sample of 27 residents. Specifically:For Resident #66 the facility failed to provide timely incontinence care.For Residents #47, #52 and #12, the facility failed to provide supervision with meals as indicated in the Resident's plan of care.For Resident #79, the facility failed to ensure facial hair was being shaved.Findings include: 1 Review of facility policy, titled Activities of Daily Living, dated April 2015 indicated the following: -A program of activities of daily living (ADL) is provided to residents to maintain or restore maximum functional independence. The ability for each resident to meet the demands of daily living is assessed by a licensed nurse and/or other members of the interdisciplinary team. A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is reviewed minimally quarterly. 1. Resident #66 was admitted to the facility in November 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, dementia and aphasia. Review of Resident #66's most recent Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff to be severely impaired with cognitive skills for daily decision making. The MDS further indicated that the Resident was always incontinent of bowel and bladder and is dependent on staff for toileting hygiene and activities of daily living (ADLS). On 8/13/25 the surveyor observed Resident #66 continuously from 7:42 A.M. to 1:15 P.M. At 7:42 A.M., Certified Nurse's Aide (CNA) #1 brought Resident #66 into the dining room before breakfast was served. Resident #66 was brought to the dining room in a high back wheelchair and remained in the chair for the duration of the observation. Beginning at 11:22 A.M., the surveyor observed a fecal and urine like odor in the day room around Resident #66. At 11:25 A.M., the surveyor observed Resident #66 attempting to stand up from his/her wheelchair with an uncomfortable look on his/her face. At 11:47 A.M., the surveyor observed Resident #66 attempting to stand up from his/her wheelchair again. CNA #1 approached the Resident and said, sit in your chair, where are you going? The CNA then covered the Resident with a blanket on his/her lap but did not attempt to provide any care to the Resident. During an interview on 8/13/25 at 12:05 P.M., CNA #1 said that incontinent residents should be checked and changed every two hours. When asked if the CNA could smell any fecal or urine odor in the dining room, she said that she usually wears a mask so hadn't noticed. CNA #1 said that Resident #66 is incontinent of bowel and bladder and the last time that he/she was checked and changed was when he/she was brought into the dining room this morning. CNA #1 said that usually hospice comes in to assist the Resident, but today, hospice has not been in. She said that Resident #66 had not received incontinence care since he/she was initially brought into the dining room. Resident #66 is unable to participate in an interview. At 1:15 P.M., CNA #1 brought Resident #66 from the dining room to his/her room. The surveyor observed incontinence care provided. The Resident had both feces and urine in his/ her brief. The Resident's skin was intact with mild redness noted around the peri area. Review of Resident #66's Bowel and Bladder Assessment, dated 4/7/25 indicated the following: -Bowel: incontinent/ complete evaluation in full. -Bladder- incontinent/ complete evaluation in full. -Factors related to incontinence: impaired mobility, confusion/ dementia. -cognitive status: confused always. -Resident is a check and change management program- Resident will be checked for incontinence and peri-care provided after each incontinent episode. Review of Resident #66's care card (a document that provides information about the level of assist a resident requires) indicated that Resident #66 was incontinent of bowel and bladder and was dependent for toileting hygiene. Review of Resident #66's active bowel and bladder care plan, dated 11/22/24, indicated that Resident #66 has an alteration in elimination related to incontinence, bladder incontinence, with interventions that include to Check resident regularly for incontinent episodes. Review of Resident #66's most recent Norton Assessment (an assessment completed to determine the risk for skin breakdown), dated 7/8/25, indicated a score of 6 which indicates high risk for skin breakdown. The Norton Assessment indicated, in part, that the Resident had poor physical condition and incontinence of bowel and bladder. During an interview on 8/13/25 at 12:17 P.M., Nurse #4 said that Residents who are incontinent of bowel and or bladder should be changed every two hours. She said that not doing so would place the Resident at risk for skin breakdown. She said that skin breakdown can occur within one day. Nurse #4 further said that Resident #66 is on her assignment today and has not been made aware of any refusals of care. During an interview on 8/14/25 at 6:55 A.M., Nurse #2 said that she expects CNAs to check change and reposition residents who are incontinent every two hours. Nurse #2 said that not providing this care every two hours places the residents at risk for skin breakdown. During an interview on 8/14/25 at 7:01 A.M., CNA #8 and CNA #9 said if a resident is incontinent of bowel and or bladder, they should be checked and changed every two to three hours. During an interview on 8/13/25 at 2:02 P.M., the Director of Nurses said that residents who are known to be incontinent of bowel and bladder should be checked every two hours and changed. She said that not performing this task could lead to skin breakdown and said that skin breakdown can happen very quickly. 2.2a. Resident #47 was admitted to the facility in September 2023 with diagnoses that included protein calorie malnutrition, dysphagia (difficulty swallowing) and weakness. Review of Resident #47's most recent Minimum Data Set (MDS) Assessment, dated 6/6/25, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated the need for supervision or touching assistance with eating meals. Review of Resident #47's active (activities of daily living (ADL) care plan, dated as revised 6/18/25, indicated: Eating: supervision or touching assistance. Review of Resident #47's CNA (Certified Nurse's Assistant) care card (a document that indicates the level of assistance required by a resident) indicated that Resident #47 required set up assistance for meals. On 8/12/25 at 8:35 A.M., the surveyor observed a staff member bring the breakfast meal to Resident #47's room, set up the Resident in bed with a tray table and leave the room. The Resident was left in the room alone eating breakfast. During a continuous observation on 8/13/25 from 8:32 A.M. to 8:43 A.M., the surveyor observed a staff member bring Resident #47 their breakfast meal, set the Resident up in bed with their meal and leave the room, leaving the Resident alone to eat in his/her room. On 8/13/25 at 12:30 P.M., the surveyor observed a staff member bringing the lunch meal into Resident #47's room, setting up the meal, and leaving the room. The Resident was left alone to eat in his/her room. On 8/14/25 at 9:04 A.M., Resident #47 was observed in bed, alone, eating breakfast in his/her room. During an interview on 8/14/25 at 11:32 A.M., Nurse #7 said that Resident #47 needs cues and reminders while eating because he/she tends to fall asleep during meals. Nurse #7 said that Resident #47 should not be eating alone in his/her room and staff should remain in the room with the Resident. Nurse #7 also said that Resident #47 has a diagnosis of dysphagia so is at an increased risk for choking. During an interview on 8/14/25 at 11:35 A.M. CNA #1 said that she was assigned to care for Resident #47 and that he/she does not need assistance with meals. During an interview on 8/14/25 at 10:12 A.M., the Director of Nursing said that the requirement of supervision or touching assistance in the care plan indicates that a resident should not be eating alone in their room. She further said that the CNA card should be accurate and up to date. She said it should match the care plan and MDS assessment, which would be the most up to date and accurate indication of the level of assistance required to care for a Resident. 2b. Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 requires supervision for meals. On 8/12/25 at 9:10 A.M., Resident #52 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #52 had spilled approximately 75% of his/her hot chocolate on his/her lap and there was food on his/her chest. When asked, the Resident said he/she spilled his/her drink but could not say more. On 8/13/25 at 8:41 A.M., Resident #52 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #52 had a significant amount of cheerios and milk on his/her chest and was attempting to scoop more cereal from the bowl and was unsuccessful. On 8/14/25 at 8:31 A.M., Resident #52 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #52 had a significant amount of cheerios and milk on his/her chest. Review of Resident #52's activity of daily living care plan last revised 3/6/25, indicated the following intervention: -Eating: supervision or touching assist. Review of Resident #52's care card (a form indicating the level of assistance a resident requires) indicated Resident #52 requires supervision or touching assistance with meals. During an interview on 8/15/25 at 8:07 A.M., Certified Nursing Assistant #5 said Resident #52 requires supervision with all meals. During an interview on 8/14/25 at 9:07 A.M., Nurse #1 said Resident #52 requires supervision with meals. During an interview on 8/14/25 at 11:33 A.M., the Director of Nursing said people who are supervised for meals should have staff repeatedly checking on them throughout the meal. The Director of nursing said that if a care plan also says touching assistance the staff should be with the resident for the entire meal. The Director of Nursing said Resident #52 requires supervision throughout his/her meal. 2c. Resident #12 was admitted to the facility in August 2023 with diagnoses including dysphagia and Alzheimer's Disease Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #12 requires supervision for self-feeding tasks. On 8/12/25 at 9:10 A.M., Resident #12 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #12 had a significant amount of food on his/her chest. On 8/13/25 at 8:38 A.M., Resident #12 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #12 had a significant amount of food on his/her chest. On 8/14/25 at 8:39 A.M., Resident #12 was observed lying in bed eating breakfast. There were no staff in his/her room or the hallway to provide supervision or assistance if needed. Resident #12 had a significant amount of food on his/her chest. Review of Resident #12's activity of daily living care plan last revised 7/30/25, indicated the following intervention: -Eating: supervision or touching assistance. Review of Resident #12's care card (a form indicating the level of assistance a resident requires) indicated Resident #12 requires supervision or touching assistance with meals. During an interview on 8/15/25 at 8:07 A.M., Certified Nursing Assistant #5 said Resident #12 requires supervision with all meals. During an interview on 8/14/25 at 9:07 A.M., Nurse #1 said Resident #12 requires supervision with meals. During an interview on 8/14/25 at 11:33 A.M., the Director of Nursing said people who are supervised for meals should have staff repeatedly checking on them throughout the meal. The Director of nursing said that if a care plan also says touching assistance the staff should be with the resident for the entire meal. The Director of Nursing said Resident #12 requires supervision throughout his/her meal. 3. Resident #79 was admitted to the facility in August 2024 with diagnoses including heart disease type 2 diabetes mellitus. Review of Resident #79's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that that the Resident requires partial/moderate assistance for personal hygiene (The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands). On 8/12/25 at 9:31 A.M., the surveyor observed Resident #79 sitting up in his/her chair, he/she had white facial hair on his/her chin, upper lip and cheeks. The Resident told the surveyor that he/she wants his/her face shaved and he/she cannot do it because his/her hands do not work well. The Resident then said he/she wishes staff would shave his/her face more often, but he/she feels like there are not enough staff on the unit to do it. On 8/13/25 at 12:10 P.M., Resident #79 was eating his/her lunch in the dining room, he/she had white facial hair on his/her chin, upper lip and cheeks. On 8/14/25 at 1:28 P.M., Resident #79 was sitting in his/her wheelchair on the first floor, he/she had white facial hair on his/her chin, upper lip and cheeks. Resident #79 told the surveyor that he/she really wants his/her face shaved weekly and it has not happened recently. Resident #79 then said he/she wants the Certified Nursing Assistants (CNA) to shave his/her face, but they are always too busy and do not have time to do it. Review of Resident #79's Kardex (a facility care card that indicates the level of a care a resident needs) indicated that the Resident requires partial/moderate assistance for personal hygiene (grooming). Review of Resident #79's ADL Deficit care plan dated 9/13/24, indicated the following intervention: Personal Hygiene – Partial assist. Review of Resident #79's Personal Hygiene CNA documentation for July 2025 indicated that the Resident required either substantial/maximum assistance or dependence on staff for 27 out of the 31 days. Review of Resident #79's Personal Hygiene CNA documentation on 8/14/25 for August 2025 indicated that the Resident required either substantial/maximum assistance or dependence on staff for 10 of the 14 elapsed days. During an interview on 8/14/25 at 1:31 P.M., CNA #10 said Resident #79 needs help from staff for ADLs and hygiene because his/her hands do not work so well. CNA #10 said he/she needs set-up assistance for using his/her electric razor to shave his/her face. CNA #10 then said if staff notices facial hair on a resident, they should ask the resident if they would like it removed. During an interview on 8/14/25 at 1:40 P.M., Nurse #6 said if a CNA observed facial hair on a resident they should ask if he/she wants it removed. During an interview on 8/14/25 at 1:54 P.M., the Director of Nursing (DON) said if staff notice facial hair on a resident they need to offer to shave it. The DON then said partial/moderate assistance means a resident needs help with that ADL task. The DON said Resident #79 should have been ask if he/she wants his/her facial hair shaved.

Based on observations and interview, the facility failed to provide each resident with an over the bed table on 1 out of 3 units. Specifically, the C unit had tray tables for only 19 of the 41 beds available on the floor. Findings include:On 8/12/25 at 7:35 A.M., Certified Nursing Assistant (CNA) #5 said he has worked at the facility for several years and has noticed that in recent months the over the bed tables on the C unit have been taken to other units for use, leaving the residents on the C unit without enough tables. CNA #5 said the residents on the C unit are forced to share tables from room to room, creating a wait time for passing out meals, inability to leave activity materials within reach for residents, and eliminating a place for residents to keep personal items. CNA #5 said he has taken this concern to the Administrator for several months without a response. The surveyor observed all rooms on the C unit and observed that the unit only has 19 tray tables for 41 available beds. On 8/12/25 at 12:15 P.M., the surveyor observed a family member exiting a room to come to the nurse's station to ask for a tray table so she could provide her mother with coffee and a snack. The staff took a table from the hallway that had been used by a resident for an activity task and gave it to the family member to take to her mother's room. On 8/13/25 at 8:32 A.M., the surveyor observed a staff member bringing a meal into a room for a resident's breakfast. The resident did not have a tray table in her room, and the staff member had to bring the meal back to the hallway and find a table to bring into the resident's room. On 8/13/25 at 9:49 A.M., a resident was brought into the hallway from their bedroom to sit for an activity task. There was no table available for the activity and a staff member had to retrieve a table from a different resident's room. On 8/13/25 at 12:30 P.M., the surveyor observed a staff member bringing a meal into a room for a resident's breakfast. The resident did not have a tray table in her room, and the staff member had to bring the meal back to the hallway and find a table to bring into the resident's room. During an interview on 8/13/25 at 9:53 A.M., CNA #1 said not every resident has an over bed table and they often have to bring them back and forth between residents and rooms. During an interview on 8/14/25 at 12:01 P.M., the Administrator said he was aware the C unit did not have enough tables for each resident. The Administrator said he thought his maintenance director had ordered 22 tables, but he was unable to provide an order history for the tables. The Maintenance Director was on vacation and unavailable for interview.

Based on record review and interview, the facility failed to ensure one Resident (#86) was seen by a physician at least once every 30 days for the first 90 days after admission. Findings include:Resident #86 was admitted to the facility in May 2025 with diagnoses that included hallucinations and chronic kidney disease. Review of Resident #86's most recent Minimum Data Set (MDS) Assessment, dated 5/14/25, indicated that the Resident could not participate in a Brief Interview for Mental Status Exam and was assessed by staff to have severe cognitive impairment. Review of the paper medical record and electronic medical record indicated one physician's progress note, dated 5/9/25. Further review of the entire medical record failed to indicate another physician's visit since 5/9/25. During an interview on 8/13/25 at 1:50 P.M., the Chief Nurse Specialist provided the requested physician's visit notes. She said that the only physician's note in the medical record for the Resident was from 5/9/25. During an interview on 8/14/25 at 10:02 A.M., The Director of Nurses said that she would expect a new Resident to be seen within 48 hours of admission and then at least every 30 days for the first 90 days after that. The Director of Nurses said that she would call the physician's office to see if there have been other visits with the Resident that are not in the medical record. The Director of Nurses also said that all notes should be put into the medical record timely so that the record is complete. During an interview on 8/14/25 at 11:06 A.M., the Medical Director (who is not the physician for this Resident) said that he would expect visits upon admission every 30 days for the first 90 days by a physician or a Nurse Practitioner. During a follow up interview on 8/15/25 at 7:57 A.M., the Director of Nurses said that Resident #86's physician is on vacation, and she has not heard back or received any other notes from the physician's office. During an interview on 8/15/25 at 8:59 A.M. the Administrator said he would expect physicians and Nurse Practitioners to see residents per the regulations, including every 30 days for the first 90 days after admission. On 8/19/25 the facility sent the surveyor more physician visit notes for Resident #86, dated 7/18/25 and 8/18/25, which were 72 and 103 days after the Resident's admission to the facility.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#131), out of a total sample of 27 residents. Specifically, for Resident #131, the facility failed to obtain weekly measurements for the external length of Resident #131's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line migration and dressing changes: Use a sterile measuring tape or incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated. Resident #131 was admitted to the facility in August 2025 with diagnoses that included bacteremia, methicillin resistant staphylococcus aureus (MRSA), and urinary tract infection (UTI).The most recent Minimum Data Set (MDS) assessment has not been completed. Review of Resident #131's active physician orders, failed to indicate orders to measure external length of the PICC line. Review of Resident #131's baseline plan of care, dated 8/7/25, failed to indicate care of PICC line and need for measurements with dressing changes. Review of Resident #131's nursing progress notes and assessments from 8/6/25 through 8/14/25 failed to indicate that nursing obtained PICC line measurements. During an interview on 8/14/25 at 1:07 P.M., the Director of Nursing and the Regional Clinical Manager/Chief Nurse Specialist said the PICC line measurements should be obtained weekly with the PICC line dressing change to monitor for catheter migration which could lead to complications including infection. The measurements should be documented in a nursing note.

Based on record review and interviews, the facility failed to notify the Registered Dietitian and Physician of a significant change in nutritional status for one Resident (#12) out of a total sample of 27 residents. Findings include:Review of the facility policy titled, Weights, undated, indicated the following:-If a significant weight loss gain is identified (> 5% in 30 days or > 10% in six months), the IDT (interdisciplinary team), dietitian, physician and family are notified.-All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Resident #12 was admitted to the facility in August 2023 with diagnoses including dysphagia, diabetes, and Alzheimer's Disease. Review of Resident #12's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #12 requires supervision for self-feeding tasks and is dependent on staff for all other self-care and mobility tasks. Review of Resident #12's weights indicated that on 7/14/25, the Resident weighed 257.2 lbs. (pounds) and on 8/6/25, the Resident weighed 240.4 lbs. which is a -6.53% significant weight loss. During an interview on 8/14/25 at 8:38 A.M., Resident #12 said he/she was unaware he/she had lost any weight, and no one had come to speak with him/her about it. Review of Resident #12's medical record failed to indicate the following:-The physician or Dietitian were notified of the weight loss.-The Dietitian reviewed Resident #12's weight loss and addressed the loss.-Resident #52 was followed by the risk management team. During an interview on 8/14/25 at 9:07 A.M., Nurse #1 said all residents are weighed according to the physician orders and if a significant change in weight occurs, the nursing staff should obtain a reweight within 24-48 hours to validate the significant change. Nurse #1 said if the significant weight change is validated, the dietitian, physician, and interdisciplinary team should be notified and an intervention put in place immediately to prevent further weight loss. Nurse #1 said she works full time on Resident #12's unit and was unaware the Resident had lost any weight and therefore did not notify the physician or dietitian of any weight loss. During an interview on 8/14/25 at 10:23 A.M., the Registered Dietitian (RD) said she works at the facility two days a week and reviews a weight report to follow all residents' weights and to identify any weight changes that occurred. The RD said the facility also has weekly risk management meetings and she is also notified of a resident's significant weight change during these meetings. The RD said if a resident were to have a significant weight loss, which would be over 5% in one month, the nursing staff should complete a reweight of the resident within 24-48 hours to validate the loss. The RD said if the weight loss is validated, she should be notified by the nursing staff, and a nutritional intervention should be put in place immediately. The RD said she often finds weight loss herself by looking at the report and the nursing staff does not always notify her of significant weight changes in the facility. When reviewing Resident #12's medical record with the surveyor, the RD confirmed the Resident's significant weight loss and said she was never notified of the loss, that the Resident was never discussed in risk meeting, that a reweight was never obtained as it should have been and that an intervention was never put in place as it should have been. The RD said she would have to assess Resident #12 because she felt the Resident would benefit from increased supplementation. During an interview on 8/14/25 at 11:03 A.M., Physician #1 said he was not aware of Resident #12's weight loss and had not been notified by the facility. During an interview on 8/14/25 at 11:33 A.M., the Director of Nursing said all residents are weighed monthly unless otherwise ordered and the facility monitors these weights to check for any significant weight changes. The Director of Nursing said if a significant weight change occurs, the facility must notify the physician and dietitian and put a new nutritional intervention in place immediately. The Director of Nursing said she was unaware the physician and dietitian were not notified of Resident #12's weight loss.

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#66) was free from neglect out of a total sample of 27 residents. Specifically, for Resident #66, the facility neglected to provide the necessary care for incontinence management. Findings include: Resident #66 was admitted to the facility in November 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, dementia and aphasia. Review of Resident #66's most recent Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff to be severely impaired with cognitive skills for daily decision making. The MDS further indicated that Resident #66 was always incontinent of bowel and bladder and is dependent on staff for toileting hygiene and activities of daily living (ADLS). On 8/13/25 the surveyor observed Resident #66 continuously from 7:42 A.M. to 1:15 P.M. At 7:42 A.M., Certified Nurse's Aide (CNA) #1 brought Resident #66 into the dining room before breakfast was served. Resident #66 was brought to the dining room in a high back wheelchair and placed at a dining table in the corner of the room. Resident #66 sat in this position in the dining room for the duration of the observation. Beginning at 11:22 A.M., the surveyor observed a fecal and urine like odor in the day room in the area Resident #66 was sitting. At 11:25 A.M., the surveyor observed Resident #66 attempting to stand up from his/her wheelchair with a grimace on his/her face. At 11:47 A.M., the surveyor observed Resident #66 attempting to stand up from his/her wheelchair again. CNA #1 approached the Resident and said, sit in your chair, where are you going? The CNA then covered the Resident with a blanket on his/her lap and did not attempt to provide any further care for the Resident. During an interview on 8/13/25 at 12:05 P.M., CNA #1 said incontinent residents should be checked and changed every two hours on a perfect day, meaning a day with enough staffing. CNA #1 said that the unit was staffed with four CNA's today, which was ideal staffing for all care to be provided to the residents. When asked if the CNA could smell any stool or urine in the dining room, she said that she usually wears a mask so hadn't noticed, and said there was one resident who was removed from the dining room earlier in the day because they had moved their bowels but didn't notice an odor at this time. CNA #1 said she was the primary CNA for Resident #66 today and said the Resident is incontinent of both bowel and bladder. CNA #1 said she provided incontinence care for Resident #66 this morning prior to bringing the Resident to the dining room before breakfast. CNA #1 said Resident #66 also receives care from hospice and that a hospice aide typically comes in to assist the Resident, but today, hospice has not been in, and Resident #66 has not received incontinence care since he/she was initially brought into the dining room. After discussing Resident #66's incontinence needs, CNA #1 did not attempt to provide care to the Resident. At 12:12 P.M., lunch was delivered to the unit and Resident #66 remained in the dining room. The odor of feces and urine was still present in the room in the area of the Resident. At 12:57 P.M., staff were observed assisting Resident #66 with the lunch meal. Resident #66 has continued to remain in the dining room and has not been provided with any incontinence care. The surveyor continued to observe fecal and urine like odors in the dining room during the lunch meal. During an interview on 8/13/25 at 12:59 P.M., Nurse #4 said that she is the nurse assigned to care for Resident #66 today and has not been made aware of any behaviors of refusal of care. The surveyor asked if she knew whether Resident #66 had been provided with incontinence care, and she said she would check with CNA #1. Nurse #4 immediately approached CNA #1 and asked if the Resident had received care. Nurse #4 said that the Resident had not received care and as soon as the Resident is done eating, CNA #1 would change the Resident. At 1:15 P.M., CNA #1 brought Resident #66 from the dining room to his/her bedroom. CNA #1 provided incontinence care, and the surveyor observed the care provided. The surveyor observed Resident #66 had both stool and urine in his/her brief and he/she had mild redness noted on the skin of the peri area (the region of skin in the genitals and anus). Resident #66 was unable to participate in an interview. Review of Resident #66's Bowel and Bladder Assessment, dated 4/7/25 indicated the following:-Bowel: incontinent/complete evaluation in full.-Bladder- incontinent/complete evaluation in full.-Factors related to incontinence: impaired mobility, confusion/ dementia.-Cognitive status: confused always.-Resident is a check and change management program- Resident will be checked for incontinence and peri-care provided after each incontinent episode. Review of Resident #66's care card (a document that provides information about the level of assistance a resident requires) indicated Resident #66 had incontinence of bowel and bladder and was dependent on staff for toileting hygiene. Review of Resident #66's active bowel and bladder care plan, dated 11/22/24, indicated that Resident #66 has an alteration in elimination related to incontinence, bladder incontinence, with interventions that include to Check resident regularly for incontinent episodes. Review of Resident #66's Mini Nutritional Assessment, date 11/11/24, assessed indicated that the Resident is malnourished. During an interview on 8/13/25 at 2:02 P.M., the Director of Nurses said that residents who are known to be incontinent of bowel and bladder should be checked every two hours and changed as needed. She said that not performing this task could lead to skin breakdown and said that skin breakdown can happen very quickly. She said that malnourishment in addition to incontinence increases the risk for skin breakdown. The Director of Nurses said that not providing incontinence care to an incontinent resident is both a dignity concern as well as a potential for neglect. During an interview on 8/14/25 at 6:55 A.M., Nurse #2 said that she expects CNAs to check change and reposition residents who are incontinent every two hours. Nurse #2 said that not providing this care every two hours places the residents at risk for skin breakdown. Nurse #2 said that not providing incontinence care to a resident who is known to be incontinence for five hours would be neglect. During an interview on 8/14/25 at 7:01 A.M., CNA #8 and CNA #9 said that neglect is a type of abuse that they have been educated about at the facility. They said that not checking and changing an incontinent resident every two to three hours is neglect. During an interview on 8/14/25 at 12:36 P.M., the Clinical Nurse Specialist said that not providing incontinence care to a resident with known incontinence could be considered neglect. During an interview on 8/15/25 at 9:02 A.M., the Administrator said, there is no excuse for what happened to this resident. He said that not providing incontinence care has the potential to be neglect.

Based on observations, record review and interviews, the facility failed to ensure one Resident (#52) was assessed for and free from restraints, out of a total sample of 27 residents. Findings include:Review of the facility policy titled, Restraint Management, dated August 2018, indicated the following: -It is the policy of the facility to utilize restraints only when clinically justifiable to treat the resident's medical condition while maintaining the resident's highest practicable level of physical and psychological wellbeing. Restraints will be utilized only after alternatives to restraints and/or least restrictive restraints have been attempted. The need for a restraint will be evaluated by the interdisciplinary team (IDT) and this recommendation will be reviewed with the residents and/or responsible party. The interdisciplinary team will evaluate the resident on admission, annually, quarterly and initiation of restraint with significant change of condition to determine the need for continued use of the restraint and to evaluate for opportunities to reduce or eliminate the restraint.-Physical restraints is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and repeated falls. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 has an impairment in range of motion in the left hand and requires supervision for eating. On 8/12/25 at 9:10 A.M., Resident #52 was observed lying in bed on a scoop mattress (a mattress with raised edges) with the bed at the lowest position. On 8/13/25 at 6:58 A.M. Resident #52 was observed lying in bed on a scoop mattress with the bed at the lowest position. The Resident was attempting to move both legs over the edge of the bed to climb out of bed. On 8/13/25 at 7:41 A.M., and 8:42 A.M., Resident #52 was observed lying in bed on the scoop mattress. A pillow had been placed under the sheet next to the Resident's right leg, preventing the Resident from moving his/her leg over the side of the bed. Review of the restraint assessment, dated 7/7/25, failed to indicate the facility assessed Resident #52's use of a low bed and a scoop mattress as potential restraints. Review of Resident #52's fall care plan, last revised 3/6/25, indicated the following intervention:-Provide environmental adaptations:(Specify) Low/platform bed. During an interview on 8/13/25 at 9:33 A.M., Certified Nursing Assistant (CNA) #5 said Resident #52 constantly attempts to climb out of bed and is able to get out of bed on his/her own. CNA #5 and the surveyor observed Resident #52 lying in bed, and CNA #5 said he had placed the pillow under Resident #52's sheet to prevent the Resident from being able to move his/her legs to the side of the bed and prevent him/her from getting up on his/her own. CNA #5 said the staff put the pillow like this every day or else the Resident would attempt to get up and potentially fall. During an interview on 8/13/25 at 9:46 A.M., Nurse #1 said the facility completes restraint assessments for every resident quarterly and a low bed and scoop mattress should be assessed as potential restraints. Nurse #1 said Resident #52 attempts to climb out of bed on his/her own and a scoop mattress was provided to the Resident as a way to slow his/her movement when attempting to get out of bed. Nurse #1 said a pillow under the sheet would limit a resident's movement intentionally and would be considered a restraint. During an interview on 8/13/25 at 9:53 A.M., the Assistant Director of Nursing (ADON) said restraint assessments are completed quarterly for every resident and that Resident #52 has a low bed and a scoop mattress and these would be considered two interventions that would need to be assessed as potential restraints. The ADON said a pillow under a sheet would be a restraint as it limits the movement of a resident intentionally. During an interview on 8/13/25 at 10:25 A.M., the Director of Nursing (DON) said residents have restraint assessments completed quarterly, and the assessments are to include any device or intervention that may be considered a restraint. The DON said Resident #52 has both a low bed and a scoop mattress and these are two interventions that are potential restraints and should be included in the restraint assessment. The DON said pillows are not to be put under sheets on the side of the mattress because this would be used to limit a resident's movement and would be a restraint.

Based on interview and record review, the facility failed to implement policies and procedures for neglect by a staff member for one Resident (#66), out of 27 residents. Specifically, the facility failed to implement written policies and procedures related to the timely reporting of neglect and removal of the alleged perpetrator from the unit.Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the following:-Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.- Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.-VI. Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:-A. Responding immediately to protect the alleged victim and integrity of the investigation.-D. Room or staffing changes, if necessary, to protect resident(s) from the alleged perpetrator.-VII. Reporting/Response: The facility will have written procedures that include:-1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #66 was admitted to the facility in November 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, dementia, and aphasia. Review of Resident #66's most recent Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff to be severely impaired with cognitive skills for daily decision making. The MDS further indicated that Resident #66 was always incontinent of bowel and bladder and is dependent on staff for toileting hygiene and activities of daily living (ADLs). On 8/13/25 the surveyor observed Resident #66 continuously from 7:42 A.M. to 1:15 P.M. During this period of 5 hours and 33 minutes, the facility staff failed to provide necessary incontinence care to the Resident, until the surveyor questioned whether the Resident had received care. When the Resident did receive care, he/she had been incontinent of bowel and bladder. During an interview on 8/13/25 at 12:05 P.M., Certified Nurse's Aide (CNA #1) said that she was assigned to care for Resident #66 on this day (on the C wing unit), and had not provided incontinence care to the Resident since bringing him/her into the dining room at 7:42 A.M. During an interview on 8/13/25 at 2:02 P.M., the Director of Nurses said that residents who are known to be incontinent of bowel and bladder should be checked every two hours and changed as needed. The Director of Nurses said that not providing incontinence care to an incontinent resident is both a dignity concern as well as a potential for neglect. Review of the State Agency Health Care Facility Reporting System (HCFRS) on 8/14/25 at 7:42 A.M., failed to indicate a report of abuse/ suspected abuse/neglect for Resident #66 was made by the facility. Review of the facility schedule for 8/14/25 indicated that CNA #1 was assigned to the C wing unit for the 7:00 A.M. to 3:00 P.M. shift and the surveyor observed CNA #1 working on the unit, providing care to residents, after the allegation had been brought to the attention of administration and during the facility's ongoing investigation. During an interview on 8/14/25 at 10:06 A.M., the Director of Nurses said that an investigation was started into the allegation of neglect that was brought to her attention yesterday, and that she started a grievance yesterday. She said that not providing necessary care to a resident is neglect. The Director of Nurses said that she did not report the allegation to the state agency, but she should have. She said it should have been reported to the state agency within two hours and then investigated to determine the outcome. She said that when there is an accused they should be removed from the schedule until the investigation is complete, and a conclusion is reached. The Director of Nurses further said that the accused CNA was educated and brought back onto the schedule. She said that the investigation is not completed at this time and is ongoing. During an interview on 8/14/25 at 12:36 P.M., the Clinical Nurse Specialist said that not providing incontinence care to a resident with known incontinence could be neglect, and that any allegation of abuse or neglect should be reported immediately within two hours to the state agency and a full investigation should be completed. During an interview on 8/15/25 at 9:02 A.M., the Administrator said that the allegation should have been reported yesterday when it was brought to the facility's attention. He was not sure if the investigation was complete or not at this time but said that if there was an accused staff member they should be removed from the schedule until the conclusion of the investigation

Based on observation, record review and interviews, the facility failed to develop and implement person centered care plans for two Residents (#52 and #45), out of a total sample of 27 residents. Specifically, the facility failed:1. For Resident #52, a. to develop a care plan for the use of a scoop mattress,b. to implement a personalized care plan for the use of two staff during activities of daily living, andc. to implement a personalized care plan for the use of a pressure relieving device; and2. For Resident #45, to develop and implement an individualized behavioral care plan. Findings include: 1. Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and repeated falls. Review of Resident #52's Minimum Data Set (MDS) assessment, dated 7/11/25, indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 requires substantial assistance from staff for activities of daily living. a. On 8/12/25 at 9:10 A.M., on 8/13/25 at 6:58 A.M. and 8:34 A.M., and on 8/14/25 at 8:31 A.M., the surveyor observed Resident #52 lying in bed on a scoop mattress (a mattress with raised edges). Resident #52 was unable to answer any questions about his/her mattress. Review of Resident #52's medical record indicated the Resident had sustained four falls within the last year. Review of Resident #52's fall prevention care plan failed to indicate a scoop mattress was included as a personalized intervention. During an interview on 8/13/25 at 9:53 A.M., the Assistant Director of Nursing (ADON) said Resident #52 was provided with a scoop mattress after a fall and this should have been added to the care plan for staff to be aware of its use. During an interview on 8/13/25 at 10:25 A.M., the Director of Nursing (DON) said Resident #52 has sustained several falls and had been provided with a scoop mattress as a fall intervention. The DON said all fall interventions should be included when developing the fall care plan. b. On 8/12/25 at approximately 10:00 A.M. and on 8/13/25 at 9:45 A.M., Resident was provided morning care by Certified Nursing Assistant (CNA) #5. Review of Resident #52's behavioral care plan, last revised 3/6/25, indicated the following intervention: -Two staff at all times with ADL (activities of daily living) care. Approach from ride side due to visual deficit. Review of Resident #52's care card (a form indicating the level of assistance a resident requires) indicated the following: -Resident is a two person assist for all ADLs (activities of daily living) due to accusatory (behavior). During an interview on 8/13/25 at 9:46 A.M., Nurse #1 said Resident #52 can become agitated with care and can refuse and requires two staff to assist with all personal care. During an interview on 8/15/25 at 8:07 A.M., CNA #5 said that Resident #52 requires two staff members for all care. During an interview on 8/13/25 at 9:43 A.M., the ADON said Resident #52 often refuses care, swears at staff and has the potential to hit staff so should have two staff members present when providing personal care. During an interview on 8/13/25 at 10:25 A.M., the DON said Resident #52 is care planned to have two staff present when care is being provided due to his/her behaviors and the potential of acting out towards staff. c. On 8/12/25 at 9:10 A.M., the surveyor observed Resident #52 lying in bed with both of his/her feet laying directly on the bed. There were no pillows by his/her feet on the bed or next to the bed, and there were no heel protective booties observed in the room. On 8/13/25 at 7:28 A.M., and 8:41 A.M., the surveyor observed Resident #52 lying in bed with both of his/her feet laying directly on the bed. There were no pillows by his/her feet on the bed or next to the bed, and there were no heel protective booties observed in the room. On 8/14/25 at 6:25 A.M., the surveyor observed Resident #52 lying in bed with both of his/her feet laying directly on the bed. There were no pillows by his/her feet on the bed or next to the bed, and there were no heel protective booties observed in the room. Review of Resident #52's physician orders indicated the following: -Offload heels every shift as tolerated, initiated on 7/18/25 -Left heel bootie apply at hs (night) and remove AM (in morning) check q (every) shift, initiated on 12/20/24. Review of Resident #52's skin integrity care plan last revised 3/6/25, indicated the following intervention: -Offload heels while in bed. Review of Resident #52's most recent Norton Assessment, dated 7/8/25, indicated the Resident scored a 7 and was at a high risk for pressure ulcer development. During an interview on 8/14/25 at 6:35 A.M., Nurse #2 said she did not place the heel protector booties on the Resident during this overnight shift while the Resident was in bed. During an interview on 8/13/25 at 9:07 A.M., Nurse #1 said Resident #52 should be offloading his/her heels while in bed. During an interview on 8/14/25 at 11:33 A.M., the DON said all plans of care should be implemented as written. The DON said Resident #52 had a previous pressure ulcer on his/her left heel and is at a high risk of the pressure ulcer redeveloping. The DON said the staff should be implementing the Resident's skin care plan and he/she should be wearing a protective heel bootie while in bed and offloading his/her heels. 2. Resident #45 was admitted to the facility in December 2024 with diagnoses including bipolar disorder and paraplegia. Review of the MDS assessment, dated 3/14/25, indicated Resident #45 is cognitively intact evidenced by a score of 15 out of 15 on the BIMS exam. The MDS also indicated Resident #45 had verbal and physical behaviors and behaviors of rejecting care. Review of the progress notes indicated Resident #45 had multiple instances of behaviors: -12/30/24: This writer has attempted to build rapport with Resident #45 due to difficulty dealing with this resident.Will continue to establish supportive therapeutic relationship. -1/4/25: Resident #45 was asked to use his/her cellphone appropriately and not take pictures of other patients or activate alarm noises. This writer discussed helping us to help him/her. Resident #45 stated I understand. -1/8/25: .Discussed rough start during his/her stay at [facility] and wishing to turn it around and be more positive an cooperative. [sic] -3/11/25: Discussion with Resident #45 about sharing his/her food with other residents. Resident #45 is attempting a nice gesture yet this writer explained that other patients may be on specific diet. -4/17/25: Multiple conversations with Resident #45 about treating all with respect. Resident #45 has been disrespectful with multiple patients and staff. -4/21/25: Redirected Resident #45 from angry outbursts due to flooded toilet by my next-door neighbors fault. Resident #45's perception was that my anger and yelling would be helpful -4/24/25: Multidisciplinary team meeting/intervention with Resident #45 to address how to best assist him/her medically, emotionally and spiritually. Resident #45 has been disrespectful and angry towards staff multiple times each day for a couple weeks. Resident #45 was allowed to share his/her emotional and physical needs and did so appropriately. Staff was attentive and supportive.Resident #45 understands that his/her negative and disruptive outbursts are not in the best interest of all concerned. -5/16/25: Late Entry for 5-15-25: Resident giving food again to another resident after being told multiple times to not give him/her food all the time due to [NAME] (sic) weight gain. Redirected without effect continued to give other resident more pizza. S.W. (Social Worker) has been notified of what has been going on. [sic] -5/18/25: PT (patient) continue (sic) with increased behaviors, provides another resident in the unit with sugary drinks and snacks despite multiple education from staff. -5/19/25: SW and SUDs (Substance Use Disorder) Counselor met with Resident #45 about giving food to another resident. He/she states he/she will stop. -5/22/25: Continued dialogue with Resident #45 about doing the right thing and treating all with respect. Continuous discussions with Resident #45 about not feeding [another resident] snacks.Resident #45 continues to forget discussion about treating all with respect. -5/25/25: 15 minute checks started. (The documentation failed to indicate the reason Resident #45 was placed on 15 minute checks.) -5/29/25: PT with increased disruptive behavior in the unit, verbally and socially inappropriate towards staff. PT continues to use abusive and demeaning language towards staff despite education. PT continues to provide another patient in the unit with sugary snacks and orders fast food MacDonalds to that patient. PT is always approached by two staff due to his/her increased verbal confrontation with staff, education and safety reinforced. PT reports I can do whatever I want, I don't need you people here. Continues on 15 minute checks. No unsafe behavior observed. -5/30/25: Resident #45 understands why he/she should not feed other residents ice-cream. Resident #45 states he/she will try to be better. Multiple conversations with Resident #45 about appropriate behaviors with all he/she comes into contact with. Resident #45 states he/she understands yet is incapable on following thru on healthy choices and appropriate/good actions. -6/1/25: Patient remains on 15 minute checks. Patient was observed using inappropriate language [with] kitchen staff and the aides. Redirection was attempted with minimal effect. -6/2/25: Resident #45 was accused by other female residents of inappropriate vernacular Resident states he/she will try to be better. Multiple conversations with Resident #45 about appropriate behaviors with all he/she comes into contact with. -6/5/25: Physiatry Note: Subjective: Nursing reports patient is frequently getting upset regarding the smoking and requesting for more cigarettes and also is offering outside food to other residents. He/she is alert and oriented x3, but impulsive and gets agitated with everyone. -6/7/25: At 9am Resident #45 was out in front of room [ROOM NUMBER] and refused to leave, stating I can go wherever I want. [Other Resident] stated I don't want you near my room. Patient removed from entrance 15 minute checks in place. -6/9/25: Discussed doing the next right thing with Resident #45. Resident #45's perception is that I am right, and everyone else is wrong. This writer will continue with therapeutic dialogue with Resident #45 in attempts to redirect him/her from alienating other residents and staff. -6/10/25: Resident #45 out to ER yesterday [on a section-12] after hitting a peer. -6/10/25: Discussed last night's interaction with another resident. Resident #45's perception is that I have zero fault! and I am right. This writer will continue therapeutic approach with Resident #45 yet it has been difficult to achieve positive results or redirection due to Resident #45's continued perceptions. -6/10/25: Administrator served Resident #45 a 30-day notice of intent to discharge due to incident last night in the presence of SW (social worker). Resident #45 was highly agitated, stating it wasn't true and everybody was lying. -6/13/25: Behavioral Health Services Note: Patient seen today for routine assessment and medication review. Mood is unstable with no acute distress. Nursing reports new concerns regarding pt irritability, impulsivity, aggression but his/her sleep is good. Pt reported on being aggressive toward another resident but denies and becomes agitated. Continue with supportive care. Start Depakote 250 mg by mouth once a day and patient continues to benefit from psychiatric medications. Monitor mood, document behaviors and contact [behavioral health services] if needed. Follow up: 1-4 weeks. -6/24/25: Refuses to leave door open to his room, refuses to have light on when roommate being attended by nurse. Yells and curses at staff. When door is opened, he/she gets oob (out of bed) and shuts door. Verbal redirection with no effect at all. -6/26/25: This writer has had multiple daily conversations with Resident #45 about doing the right thing and treating all with respect. Resident's intentions in conversation are good, yet his/her follow thru with staff and other residents continues to be demanding, righteous and confrontational.Resident #45 seems incapable to realize that his/her actions are not positive or appropriate. [sic] -6/27/25: Verbally abusive to a staff member times 3. Verbal redirection without effect. -6/27/25: Resident #45 went outside quickly got in van and would not get out even after driver told him/her that he was not able to take him/her. Driver had to take d/t (due to) he/she would not get out of the van. [sic] -6/30/25: Nurse Practitioner Note: PT was evaluated by psych on 6/13 due to altercation with another resident. Patient has had increased irritability as well. -7/1/25: Late note for 6/28/25: Resident was requesting for medication that was not on his/her medication list, when writer asked what was going on with him/her if he/she was having any discomfort, he/she got very upset and could not gave (sic) the nurse a chance to administer other resident medications. Redirected with negative effects. -7/10/25: Continues to give another resident food that he/she should not have. Resident #45 has been told this so many times but continues to give him/her food. -7/16/25: When Resident #45 was spoken to about feeding another resident he/she had very vulgar language i.e. go F yourself. I will effing do what I want. Verbally redirected without effect. -7/17/28: It has been reported by CNA and other residents that Resident #45 was non-compliant during cigarette breaks, grabbing and pocketing others' cigarettes. Resident #45 denies incident. He/she has been asked to check belongings but refused. Nursing will continue offering education as needed. -7/20/25: At approximately 11:30 AM, CNA called me to [Resident #45's room]. Upon arrival, I found Resident #45 cutting another resident's hair with scissors. On the table were a manual and electric shaver that belonged to his/her roommate. When asked to stop, Resident #45 continued cutting. The CNA and I relocated to other resident back to his/her room. We have asked Resident #45 to return the scissors for safety reasons but he/she refused. The lead CNA attempted to redirect him/her without success. NP (Nurse Practitioner) on call has been notified, ordering a Section 12. Resident #45 was transferred to [the hospital] via stretcher, 2 cops were present. DON (Director of Nursing) and Administrator made aware. -7/22/25: Nurse Practitioner Note: Over the weekend patient was seen by staff cutting another resident's hair. When asked to give the staff his/her scissors, patent refused and became agitated. Patient was sent out for further psych evaluation. Patient was cleared by psych to return back to [facility] the same day. On today's exam, patient agitated that he/she had to give his/her scissors to staff. Discussed importance of not cutting another patient's hair due to safety concerns. -7/24/25: PT noted to be intrusive into pt's rooms today. When asked to leave stated I can be wherever I want! Swearing at nursing staff. -7/31/25: Again after multiple times not to give extra food to another resident he/she gave him/her more ice cream and cookies. Verbal redirection without effect. -8/12/25: Using abusive words on staff, calling them liars. Distracting other residents from getting care stating, don't believe what they are saying to you. Review of Resident #45's behavior care plan on 8/13/25 indicated: Focus: Behavior Problem related to diagnosis of Bipolar Disorder. He/she can be verbally abusive: curses and screams at others. He/she is resistive to care and redirection and my wander, initiated 1/2/25, revised 7/16/25. Interventions: Explain care in advance, in terms resident understands. If reasonable, discuss behavior, explain/reinforce why behavior is unacceptable. Intervene as needed to promote the rights & safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed, dated 1/2/25. The behavioral care plan failed to include all of Resident #45's specific behaviors such as physical aggression to other residents, the need for 15- minute checks, moments of paranoia or continuously giving food to another resident. The care plan also failed to indicate individualized interventions for staff to utilize during his/her behaviors. Additionally, the care plan focus indicates that Resident #45 is resistive to redirection, but failed to include alternative methods or means for staff to utilize in lieu of redirection. During an interview on 8/13/25 at 10:09 A.M., the Administrator said that the facility had issued Resident #45 a 30-day notice after a resident-to-resident altercation, and after a female resident alleged that he/she had grabbed her buttocks inappropriately. The Administrator said that Resident #45 won the appeal and remained in the facility. During an interview on 8/13/25 at 10:51 A.M., Unit Secretary #1 said that Resident #45 was very behavioral. When asked why he/she was placed on 15-minute checks, Unit Secretary #1 said she was not sure, but it may have been related to him/her constantly giving food to another resident which had caused the other resident to gain a large amount of weight. During an interview on 8/13/25 at 10:56 A.M., CNA #7 said it was hard to keep track of Resident #45's incidents because he/she has had so many. CNA #7 said that Resident #45 is a very challenging resident on the unit. During an interview on 8/13/25 at 11:01 A.M., Unit Manager #1 said that Resident #45 does have a behavior care plan, but she didn't know if there was anything specific in there outlining his/her behaviors or interventions for staff to follow. During an interview on 8/13/25 at 1:03 P.M., Social Worker #1 said that she does not write behavioral care plans. Social Worker #1 said that behavioral care plans should be specific and individualized to address resident needs. During an interview on 8/14/25 at 8:06 A.M., Resident #45 appeared tired and agitated. Resident #45 said that he/she enjoyed seeing the SUD counselor and declined to continue the rest of the interview. During an interview on 8/13/25 at 8:08 A.M., CNA #6 said that Resident #45 can be rude and very challenging. During an interview on 8/14/25 at 12:51 P.M., the DON said that she would expect resident care plans to be individualized and address and resident specific behaviors and needs.

Based on observation, record review, and interview, the facility failed to ensure physician's orders were implemented for two Residents (#40, #10), out of a total of 27 sampled residents. Specifically, the facility failed:1. For Resident #40, to ensure he/she received two tablets of Lactaid as ordered by the physician; and2. For Resident #10, to ensure a wander guard (a bracelet and monitor placed on a resident who is at risk for elopement, that is part of an alarm system to alert staff if a Resident is attempting to exit a unit or facility) was in place per the physician's order. Review of the facility's policy titled Self-Administration of Medications Policy, dated July 2015, indicated: Evaluate the resident's cognitive, physical and visual ability to self-administer medications, update the care plan for self-administration to include where the medications will be stored, documentation of self-administration and location of the drug administration. [NAME] the MAR (Medication Administration Record) for each medication being self-administered for daily compliance monitoring purposes. (Indicate that the resident has self-administered). 1. Resident #40 was admitted to the facility in June 2021 with diagnoses including hypertension and heart failure. Review of the Minimum Data Set (MDS) Assessment, dated 6/6/25, indicated Resident #40 is cognitively intact evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #40 requires assistance with ambulation and bathing. During an interview on 8/12/25 at 8:22 A.M., Resident #40 was seated in the main dining room. Resident #40 pointed to a white pill on the dining room table and said it was his/her Lactaid tablet. Resident #40 said that staff give him/her the bottle which he/she keeps in his/her room and that he/she brings a tablet to meals. Resident #40 said that he/she used to take two tablets but the bottle goes quick and he/she started to take one tablet instead and it's been working. Review of the Resident #40's Physician's Orders indicated: -May self-administer Lactaid, ocean nasal spray, refresh eye drops and keep at bedside table locked draw (sic), dated 12/17/24. -Lactaid Tab give two tablets orally with meals for lactose intolerance; unsupervised self-administration. May keep in locked bedside table drawer and self-administer, dated 9/7/22. Review of the August 2025 MAR indicated Resident #40 self-administered two tablets of Lactaid three times a day from 8/1/25 through 8/13/25. On 8/13/25 at 8:06 A.M., Resident #40 was in the dining room waiting for his/her breakfast Resident #40 pointed to one white tablet and told the surveyor that was his/her Lactaid tablet. Resident #40 said that he/she had told a nurse that he/she was only taking one tablet instead of two but could not recall who it was. On 8/14/25 at 8:13 AM., the surveyor observed Resident #40 seated in the dining room, waiting for breakfast, with one Lactaid tablet on the table in front of him/her. During an interview on 8/14/25 at 8:59 A.M., Nurse #3 said that Resident #40 keeps his/her medications in a white container in his/her room. Nurse #3 said that Resident #40 takes two Lactaid tablets twice a day, (contrary to the Resident's self-report of taking one tablet and the physician's order indicating he/she should be taking two tablets three times a day). During an interview on 8/14/25 at 9:34 A.M., the Assistant Director of Nursing (ADON) said that residents should be assessed for self-administration of medications and that medications can be stored in their rooms or in the medication cart. The ADON said nursing staff should visualize residents self-administering their medications and then document on the MAR. The ADON was not aware that Resident #40 had been taking only one tablet of Lactaid instead of the ordered dosage, or that he/she had been bringing the tablet to the dining room and placing it on the table during the meal. During an interview on 8/14/25 at 12:48 P.M., the Director of Nursing (DON) said that for residents who want to self-administer medications, staff are expected to assess and educate the residents and obtain a physician's order. The DON said medications should be administered in the dosage amount ordered by the physician. 2. Resident #10 was admitted to the facility in November 2024 with diagnoses that included metabolic encephalopathy, chronic obstructive pulmonary disease and acute respiratory failure. Review of Resident #10's most recent MDS assessment, dated 5/30/25, indicated a BIMS score of 0 out of a possible 15, indicating severe cognitive impairment. The MDS also indicated that wandering occurred daily. Review of Resident #10's active Physician's Orders indicated the following: -Check Wander Guard Placement on Right Ankle. Code Alert: 9000-0434M. Expiration date 04-14-2026, every shift for safety, dated 4/22/25. [sic] -check wander guard functioning, dated 4/22/25. On 8/12/25 at 10:13 A.M., the surveyor observed Resident #10 in his/her wheelchair, there was no wander guard visible on his/her right ankle. On 8/13/25 at 9:37 A.M., the surveyor observed Resident #10 sitting in his/her wheelchair in his/her room. The surveyor asked the Certified Nurse's Assistant (CNA) if the Resident had a wander guard on his/her right ankle. The CNA lifted the Resident's pant leg, and there was no visible wander guard in place. Review of Resident #10's active behavior care plan, dated 4/22/25, indicated the following intervention: -[Resident] has a new wander guard placed to [his/her] right ankle. Review of the August 2025 Treatment Administration Record (TAR) indicated that the wander guard was checked and in place on 8/12 and 8/13 when the surveyor did not observe the wander guard as in place. Review of Resident #10's nursing progress notes indicated the following: -A progress note, dated 4/22/25, that indicated, Resident alert, continues to have increased behavior of exiting. New order for Wander guard placed to the right ankle for safety protection. [sic] During an interview and observation on 8/13/25 at 1:24 P.M., the surveyor and Nurse #4 observed Resident #10 in his/her room, there was no wander guard in place. Nurse #4 said that the Resident is unable to remove it him/herself, and that staff should be checking placement every shift as indicated in the physician's orders. During an interview on 8/13/25 at 1:59 P.M., the Director of Nurses said that nurses should be checking every shift that the wander guard is in place. She said she would expect that physician's orders are followed and carried out. During an interview on 8/14/25 at 11:05 A.M., the Medical Director said that he would expect physician's orders to be followed as written.

Based on record review and interview, the facility failed to ensure ongoing behavioral health services were provided for Resident #45. Specifically, the facility failed to ensure the behavioral health provider completed follow up services after the introduction of a new medication and failed to alert the provider when his/her behaviors continued and was sent out on a section-12 hospitalization, (an involuntary psychiatric hospitalization). Findings include: Review of the facility's Consultant Services policy, dated April 2015 indicated: [The Facility] will identify and facilitate consultant services to meet the resident's needs to ensure optimum care for each resident/patient through consultant services.The policy did not include information related to communication of resident status from the facility to the provider.Resident #45 was admitted to the facility in December 2024 with diagnoses including bipolar disorder and psychoactive substance abuse.Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #45 is cognitively intact evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #45 had verbal and physical behaviors and also behaviors of rejecting care. Review of Resident #45's care plans indicated:Focus: Resident #45 has a diagnosis of depression and bipolar disorder, initiated 12/23/24.Interventions: Provide individual support, listen, empathize. Encourage him/her to remain on topic. Encourage him/her to reach out to supportive people in his/her life. Talk about things he/she enjoys. Assess environment and suggest change if needed. Utilize SW (social worker) and psych services as needed. Focus: Behavior Problem related to diagnosis of Bipolar Disorder. He/she can be verbally abusive: curses and screams at others. He/she is resistive to care and redirection and may wander, initiated 1/2/25, revised 7/16/25. Interventions: Explain care in advance, in terms resident understands. If reasonable, discuss behavior, explain/reinforce why behavior is unacceptable. Intervene as needed to promote the rights & safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed, 1/2/25.Focus: Resident #45 has a diagnosis of psychoactive substance abuse, initiated 7/14/25. Interventions: Provide individual/group therapy/Psychoeducation groups. Provide community resources and referrals for aftercare as desired. 7/14/25Review of the Behavioral Health Nurse Practitioner (NP) note dated 6/13/25 indicated: Patient seen today for routine assessment and medication review. Mood is unstable with no acute distress. Nursing reports new concerns regarding pt irritability, impulsivity, aggression but his/her sleep is good. Pt reported being aggressive toward another resident but denies and becomes agitated. Continue with supportive care. Start Depakote (a medication used to treat mood disorders and seizures) 250 mg by mouth once a day and patient continues to benefit from psychiatric medications. Monitor mood, document behaviors and contact [behavioral health services] if needed. Follow up: 1-4 weeks. Review of the physician's orders indicated Depakote was initiated as recommended by the Behavioral Health Nurse Practitioner. The clinical record failed to indicate anyone from Behavioral Health Services completed a follow up visit in the 1-4 weeks as indicated in the 6/13/25 note or that Resident #45 declined or refused any visits. Review of Resident #45's progress notes indicated:-6/24/25: Refuses to leave door open to his/her room, refuses to have light on when roommate being attended by nurse. Yells and curses at staff. When door is opened, he/she gets oob (out of bed) and shuts door. Verbal redirection with no effect at all.-6/26/25: This writer has had multiple daily conversations with Resident #45 about doing the right thing and treating all with respect. Resident's intentions in conversation are good, yet his/her follow thru with staff and other residents continues to be demanding, righteous and confrontational.Resident #45 seems incapable to realize that his/her actions are not positive or appropriate. -6/27/25: Verbally abusive to a staff member times 3. Verbal redirection without effect. -6/27/25: Resident #45 went outside quickly got in van and would not get out even after driver told him/her that he was not able to take him/her. Driver had to take d/t (due to) he/she would not get out of the van. -6/30/25: Nurse Practitioner (NP) Note: PT was evaluated by psych on 6/13 due to altercation with another resident. Patient has had increased irritability as well.-7/1/25: Late note for 6/28/25: Resident was requesting for medication that was not on his/her medication list, when writer asked what was going on with him/her if he/she was having any discomfort, he/she got very upset and could not gave (sic) the nurse a chance to administer other resident medications. Redirected with negative effects. -7/10/25: Continues to give another resident food that he/she should not have. Resident #45 has been told this so many times but continues to give him/her food.-7/16/25: When Resident #45 was spoken to about feeding another resident he/she had very vulgar language i.e. go F yourself. I will effing do what I want. Verbally redirected without effect. -7/17/28: It has been reported by CNA and other residents that Resident #45 was non-compliant during cigarette breaks, grabbing and pocketing others' cigarettes. Resident #45 denies incident. He/she has been asked to check belongings but refused. Nursing will continue offering education as needed. -7/20/25: At approximately 11:30 AM, CNA called me to [Resident #45's room]. Upon arrival, I found Resident #45 cutting another resident's hair with scissors. On the table were a manual and electric shaver that belonged to his/her roommate. When asked to stop, Resident #45 continued cutting. The CNA and I relocated to other resident back to his/her room. We have asked Resident #45 to return the scissors for safety reasons but he/she refused. The lead CNA attempted to redirect him/her without success. NP on call has been notified, ordering a Section 12. Resident #45 was transferred to [the hospital] via stretcher, 2 cops were present. DON (Director of Nursing) and Administrator made aware. -7/22/25: Nurse Practitioner Note: Over the weekend patient was seen by staff cutting another resident's hair. When asked to give the staff his/her scissors, patent refused and became agitated. Patient was sent out for further psych evaluation. Patient was cleared by psych to return back to [facility] the same day. On today's exam, patient agitated that he/she had to give his/her scissors to staff. Discussed importance of not cutting another patient's hair due to safety concerns. -7/24/25: PT noted to be intrusive into pt's rooms today. When asked to leave stated I can be wherever I want! Swearing at nursing staff.-7/31/25: Again after multiple times not to give extra food to another resident he/she gave him/her more ice cream and cookies. Verbal redirection without effect. -8/12/25: Using abusive words on staff, calling them liars. Distracting other residents from getting care stating, don't believe what they are saying to you.The clinical record failed to indicate that Behavioral Health Services was notified of Resident #45's continued behaviors or section 12 hospitalization on 7/20/25.During an interview on 8/13/25 at 10:51 A.M., Unit Secretary #1 said that Resident #45 was very behavioral on the unit and could be difficult to manage. During an interview on 8/13/25 at 10:56 A.M., CNA #7 said it was hard to keep track of Resident #45 incidents because there has been so many. CNA #7 said that Resident #45 is a very challenging resident on the unit. During an interview on 8/13/25 at 11:01 A.M., Unit Manager #1 said that Resident #45 is very behavioral on the unit. Unit Manager #1 said that he/she had last been seen by psych services in June 2025 when he/she was put on Depakote. Unit Manager #1 said the Depakote doesn't seem to be working. Unit Manager #1 said that behavioral health services would only have been notified of the lack of progress with the psych medications or his/her section 12 hospitalization if the staff documented it in the referral book. When asked if staff should be communicating with behavioral health services regarding Resident #45's ongoing behaviors and July 2025 hospitalization, Unit Manager #1 said I can put it in now. Review of the unit's psychiatric referral book from June 2025 through August 2025 indicated no requests for Resident #45 to be seen until 8/13/25. During an interview on 8/13/25 at 1:03 P.M., Social Worker #1 said Resident #45 is very behavioral and said that behavioral health services is involved and was not aware he/she had not been seen by them since June 2025. Social Worker #1 said nursing staff should have communicated Resident #45's ongoing behaviors and section-12 hospitalization to behavioral health services by putting that information in the referral book. During an interview on 8/14/25 at 8:06 A.M., Resident #45 appeared tired and agitated. Resident #45 said that he/she enjoyed seeing the SUDS (Substance Use Disorder) Counselor and declined to continue the rest of the interview. During an interview on 8/13/25 at 8:08 A.M., CNA #6 said that Resident #45 can be rude and very challenging. The Behavioral Health Nurse Practitioner was unavailable for interview.During an interview on 8/14/25 at 11:18 A.M., the Behavioral Health Services Director (BHSD), she said that the Behavioral Health Services Nurse Practitioner (NP) was away, but comes out weekly to the facility. The BHSD said that the NP will have a schedule for residents on caseload and determine the frequency of follow up if needed. The BHSD said they also review the referral book for updates from staff. The BHSD was not aware that Resident #45 had not been seen by the Behavioral Health NP since 6/13/25 despite the 6/13/25 note indicating the need for follow up in 1-4 weeks. The BHSD said she would have expected facility staff to alert the NP and communicate ongoing behaviors and section-12 hospitalizations because there would be no other way for their staff to know unless they happened to find it in a progress note. During an interview on 8/14/25 at 12:51 P.M., The Director of Nursing (DON) was not aware that Resident #45 had not received any visits from Behavioral Health Services since 6/13/25. The DON said that she would expect nursing staff to communicate ongoing resident behaviors and psychiatric hospitalizations to behavioral health services.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically:1. The facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed.2. The facility failed to ensure medications were stored securely in a resident room for one Resident (#40) out of a total of 27 sampled residents. Findings include: Review of the Medication Storage Room/Medication Cart Policy, dated February 2018, indicated: Licensed personnel will be responsible to check expiration dates on ordered medications, house stock medications, and supplies. Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. Review of the Self-Administration of Medications Policy dated July 2015. indicated: Evaluate the resident's cognitive, physical and visual ability to self-administer medications, Update the care plan for self-medication to include where the medications will be stored, documentation of self-administration and location of the drug administration. 1. On 8/13/25 at 8:51 A.M., the surveyor and Unit Manager #2 observed the following in the B Wing side two medication cart: - One fluticasone propionate nasal spray, opened and undated. - One advair diskus inhaler, opened and undated. - One trelegy ellipta inhaler, opened and undated. During a follow up interview on 8/13/25 at 8:51 A.M., Unit Manager #2 said the fluticasone propionate nasal spray, advair diskus inhaler, and trellegy inhaler were all opened. Unit Manager 2 said these medications have shortened expiration dates once opened and should have been dated but were not. During an interview on 8/13/25 at 11:09 A.M., the Director of Nursing (DON) said the fluticasone propionate nasal spray advair diskus inhaler, and trellegy inhaler have shortened expiration dates once opened and should have been dated once opened. 2. Resident #40 was admitted to the facility in June 2021 with diagnoses including hypertension and heart failure. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #40 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #40 requires assistance with ambulation and bathing. During an interview on 8/12/25 at 8:22 A.M., Resident #40 was seated in the main dining room. Resident #40 pointed to a white pill on the dining room table and said it was his/her Lactaid tablet. Resident #40 said that staff give her the bottle which he/she keeps in his/her room and that she brings a tablet to meals. Resident #40 said that he/she used to take two tablets but the bottle goes quick and he/she started to take one tablet instead and it's been working. Review of the Resident #40's physician order dated 12/17/24 indicated: May self-administer Lactaid, ocean nasal spray, refresh eye drops and keep at bedside table locked draw. (sic) During an interview on 8/12/25 at 9:04 A.M., Resident #40 was seated in his/her room. Resident #40 showed the surveyor a small ceramic container which held a bottle labeled Dairy Relief; Lactase Enzyme Supplement and two bottles of refresh eye drops. On 8/13/25 at 7:54 A.M., the surveyor observed the bottle of Lactase, and two bottles of refresh eye drops in the container on Resident #40's overbed table and a bottle of saline nasal spray on top of plastic drawers next to his/her TV. Resident #40 was not present in his/her room. On 8/13/2025 at 8:06 A.M., Resident #40 was in the dining room waiting for his/her breakfast Resident #40 pointed to a white tablet and told the surveyor that was his/her Lactaid tablet. On 8/13/25 at 12:04 P.M., and 8/14/25 at 8:10 A.M., the surveyor observed Resident #40 was not in his/her room and the bottle of Lactase, eye drops, and nasal spray were unsecured in the room. Resident #40's roommate was present and eating his/her meals. On 8/14/25 at 8:13 AM., the surveyor observed Resident #40 seated in the dining room, waiting for breakfast, with a Lactaid tablet on the table in front of him/her. During an interview on 8/14/25 at 8:59 A.M., Nurse #3 said that Resident #40 keeps his/her medications in a white container in his/her room. During an interview on 8/14/25 at 9:34 A.M., the Assistant Director of Nursing (ADON) said that residents should be assessed for self-administration of medications and that medications can be stored in their rooms or in the medication cart. The ADON was not aware that Resident #40's medications were not secured while he/she was not in the room, and his/her roommate was present. During an interview on 8/14/2025 at 12:48 P.M., the Director of Nursing (DON) said staff are expected to assess and educate the residents, get a physician order for residents who want to self-administer medications. The DON said medications should be securely stored in Resident rooms when not in use.

Based on observation, record review and interviews, the facility failed to implement an activity program of choice for one Resident (#12) out of a total sample of 27 residents. Findings include:Resident #12 was admitted to the facility in August 2023 with diagnoses including Alzheimer's Disease. Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #12 requires supervision for self-feeding tasks and is dependent on staff for all other self-care and mobility tasks. During an interview on 8/1/2/25 at 8/12/25 8:13 A.M., Resident #12 said he/she does not get out of bed and does not participate in activities. The Resident's television was on and there were no activity materials observed in the Resident's room. On 8/12/25, Resident #12 was observed lying in bed with the television on throughout the 7:00 A.M. and 3:00 P.M. shift and did not get out of bed. At no point did the surveyor observe an activity staff member invite the Resident to a group activity. During this time, the activities listed on the activity calendar were:-9:00 A.M. - Morning Visits/mails. This activity did not occur for Resident #12.-10:00 A.M., [NAME] Cart (beverages and snacks). This activity was not observed occurring on the unit.-10:30 A.M., Morning Stretch. Resident #12 did not participate in this group activity, and an activity staff was not observed doing this activity with the Resident in his/her room. -11:00 A.M., Task Table/Patio Time. Resident #12 did not participate in this activity, and no activity materials were observed on the table in the Resident's room. -2:00 P.M. Bean Bag Toss - Resident #12 did not participate in this group activity, and an activity staff was not observed doing this activity with the Resident in his/her room. On 8/13/25 Resident #12 was observed lying in bed with the television on throughout the 7:00 A.M. and 3:00 P.M. shift and did not get out of bed. At no point did the surveyor observe an activity staff member invite the Resident to a group activity. During this time, the activities listed on the activity calendar were:-9:00 A.M. - Morning Visits/mails. This activity did not occur for Resident #12.-10:00 A.M., [NAME] Cart (beverages and snacks). This activity was not observed occurring on the unit.-10:30 A.M., Morning Stretch. Resident #12 did not participate in this group activity, and an activity staff was not observed doing this activity with the Resident in his/her room. -2:00 P.M. Arts and Crafts - Resident #12 did not participate in this group activity, and an activity staff was not observed doing this activity with the Resident in his/her room. Review of Resident #12's activity preferences in the MDS indicated it was somewhat important for the Resident to have books, newspapers, magazines to read, to listen to music, to be with groups of people, and to get fresh air and go outside. Review of Resident #12's activity care plan indicated the following interventions: -As needed, remind and assist resident to higher level activities of interest. -Continue to educate resident of group programs of assessed interest by inviting resident and by explaining details of the program. -Disclose time, location and brief description of these programs -Encourage resident to present ideas for activity programs -Encourage resident to visit peers of similar capabilities -Explain purpose and encourage participation in resident council -Offer materials of interest for independent leisure activity.-Offer to go with resident just to take a look -Provide a calendar of events to assure awareness Review of Resident #12's fall care last revised 7/30/25 indicated the following intervention:- Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs. Review of Resident #12's impaired cognition care plan last revised 7/30/25 indicated the following intervention:-Encourage socialization and recreation activity Review of the activity progress note dated 7/16/25 indicated the Resident:-enjoys social contact with staff on a daily basis and continues to enjoy 1:1 visit with staff, music, watching television, and visiting with family.-Requires reminders to attend activities. -Needs assistance to participate in activities.-Enjoys large groups.-Is dependent on others for transport to activities.-Activity preferences include: religious, music, sing-a-long, active games, outside, sensory groups, radio/music. -Television was not listed as a preferred activity. During an interview on 8/15/25 at 9:16 A.M., the Activities Director said the activity calendars are created based on resident preferences and abilities. The Activities Director said Resident #12 resides on a dementia unit and the activities on this unit are tailored to the cognitive abilities of the residents. The Activities Director said that for residents who are bed bound or do not get out of bed, the activities may include room visits, hand massages, exercises, activity materials that would leave in room, radio, magazines, and use of an iPAD for music. The Activities Director said Resident #12 loves to talk, likes to do light exercise with assistance, likes music and singing with or without music, magazines, picture books, and one-on-one. She said that Resident #12 has not gotten out of bed recently and that the activity staff should have gone into his/her room to do activities individually or to leave materials.

Based on observations, record review and interview, the facility failed to ensure that one Resident (#52) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Resident's choices out of a total sample of 27 residents. Specifically, the facility did not provide a left-hand splint for Resident #27 to use for contracture management. Findings include:Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and left hand contracture. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 has an impairment in range of motion in the left hand and requires supervision for eating. On 8/12/25 at 9:10 A.M., Resident #52 was observed lying in bed. His/her morning care had not yet been completed, and his/her left hand was observed lying on the bed without an orthotic (splint) on. There was no orthotic observed near the bed or in the room. On 8/13/25 at 7:28 A.M., Resident #52 was observed lying in bed. His/her morning care had not yet been completed, and his/her left hand was observed lying on the bed without an orthotic on. There was no orthotic observed near the bed or in the room. On 8/14/25 at 6:25 A.M., Resident #52 was observed lying in bed. His/her morning care had not yet been completed, and his/her left hand was observed lying on the bed without an orthotic on. There was an orthotic observed near on the bottom shelf of the bedside table. The straps on the orthotic were closed, indicating it had not been used. Review of the occupational therapy Discharge summary, dated [DATE], indicated the following:-Discharge recommendation: patient to wear (his/her) left hand orthotic overnight for management of dystonia and to reduce risk of contracture. -Patient response progress and response to treatment: patient exhibits positive response to interventions to alleviate dystonia for improved postural stability while seated. Reports good fit and comfort while using (his/her) left hand orthotic to manage dystonia and reduce risk of contracture. Review of Resident #52's physician orders indicated the following order initiated on 3/11/25:-Splint to be worn on left hand overnight. Apply with PM (night) care. Remove with AM (morning) care. Check skin each shift. Review of Resident #52's dystonia care plan, last revised 3/18/25, indicated the following intervention:-Patient to wear resting hand orthotic on (his/her) left hand overnight, Apply during PM care. Remove during AM care. Check skin daily each shift. [sic] During an interview on 8/14/25 at 6:40 A.M., Resident #52 said he/she is supposed to wear a splint at night and has not been wearing it. The Resident said he/she is agreeable to wearing the splint. During an interview on 8/14/25 at 6:35 A.M., Nurse #2 said she works the overnight shift and Resident #52 has an order to wear a left-hand splint while sleeping. Nurse #2 said she did not put the splint on Resident #52 last night. During an interview on 8/14/25 at 6:41 A.M., Certified Nursing Assistant #2 said Resident #52 has a hand splint that he/she is supposed to wear at night, and she did not see the Resident wearing the splint last night. During an interview on 8/14/2025 at 11:33 A.M., the Director of Nursing said Resident #52 has a left-hand contracture and was provided with a splint from the therapy department for contracture management. The Director of Nursing said Resident #52 should be wearing the splint at night as ordered.

Based on observations, record reviews and interviews, the facility failed to implement fall interventions to potentially prevent falls for two Residents (#52 and #22) out of a total sample of 27 residents. Findings include: 1. Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and repeated falls. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 has an impairment in range of motion in the left hand and requires supervision for eating. Review of Resident #52's physician orders indicated the following orders: -bed alarm - check placement and function q (every) shift, every shift for preventative maintenance s/p (status post) fall, 3/13/24. -chair alarm - check placement and function q (every) shift, every shift for preventative maintenance s/p (status post) fall, 3/13/24. Review of Resident #52's medical record indicated the Resident had sustained 4 falls in the past year. a. A nursing note dated 9/21/24 indicated the following:-Resident had a witnessed fall, (he/she) slid off from (his/her) w/chair. (He/she) was observed sitting on the floor on (his/her) buttocks. resident was getting agitated and impulsive with redirection and insisted on standing up on (his/her) own. no injuries noted, ROM (range of motion) at baseline, denies pain, responsible parties notified. Review of the incident report for this fall failed to indicate the Resident's chair alarm was in place and functioning at the time of the fall. b. A nursing note dated 10/23/24 indicated the following: -Resident was observed on the floor in (his/her) room next to (his/her) roommate bed by a CNA (certified nursing assistant). (He/she) was lying down. It was unwitnessed fall. When asked what happened. Resident stated (he/she) was going to the bathroom when (he/she) lost balance and fell. Review of the incident report for this fall failed to indicate the Resident's bed alarm was in place and functioning at the time of the fall. c. A nursing note dated 10/26/25 indicated the following: -Resident was found sitting on the floor on (his/her) buttocks, resident alert and responsive, No signs of distress or SOB (shortness of breath), denies pain or hitting (his/her) head. Resident has intact bruise on (his/her) back. non skid socks on, chair alarm on, safety maintained. Review of the incident report for this fall indicated the Resident was found sitting on floor next to his/her bed as he/she was attempting to reach down to get his/her shoes. The incident report said a CNA was alerted of the fall due to a visitor seeing the Resident on the floor and failed to indicate the Resident's alarm was alerting the staff of his/her movement. d. A nursing note dated 7/12/25 indicated the following: -This writer was called into the resident's room by housekeeping staff who observed the resident on the floor. Resident was found lying supine on the bedside. Resident stated (he/she) slid off the bed. Review of the incident report for this fall indicated that at the time of this fall the Resident's alarm was not on and did not sound. On 8/12/2025 at 9:10 A.M., Resident #52 was observed lying in bed. A bed alarm was observed on the floor next to the Resident's bed and the light indicating it was functional was not on. On 8/12/2025 at 11:30 A.M., Resident #52 was observed sitting in his/her wheelchair in the dining room. The Resident's chair did not have a chair alarm on it. On 8/13/2025 at 6:58 A.M., 7:41 A.M., and 8:42 A.M., Resident #52 was observed lying in bed. A bed alarm was observed on the floor next to the Resident's bed and the light indicating it was functional was not on. On 8/13/2025 at 9:53 A.M., Resident #52 was observed sitting in his/her wheelchair in the dining room. The Resident's chair did not have a chair alarm on it. During an interview on 8/13/2025 at 9:53 A.M., the Assistant Director of Nursing (ADON) said Resident #52 has had numerous falls and was provided with both a chair and a bed alarm as a fall intervention. The Assistant Director of Nursing then observed Resident #52 in the dining room and confirmed the Resident did not have a chair alarm on his/her wheelchair. The surveyor and Assistant Director of Nursing then went to the Resident's room and observed the bed alarm which the Assistant Director of Nursing said was not functioning and possibly had a dead battery. The Assistant Director of Nursing said that these alarms should be checked for placement and functioning every shift. During an interview on 8/13/2025 at 1:53 P.M., the Director of Nursing said after a resident falls the facility implements a new fall intervention for the prevention of further falls and these interventions should be followed at all times. The Director of Nursing said that in reviewing the incident report for Resident #52's falls, the staff did not indicate the alarms were in place and functioning at the time of the falls and the alarms must not have been implemented as they should have been. She said that the witness statements in the incident reports are accurate so if the report says no alarm, then there was no alarm in place. The Director of Nursing said Resident #52's bed and chair alarms should be checked every shift for placement and function, and she was unaware Resident #52 did not have a chair alarm on his/her wheelchair or that the bed alarm was not functioning. 2. Resident #22 was admitted to the facility in May 2025 with diagnoses of falls resulting in left pubis fracture and bipolar disorder. Review of Resident #22's most recent Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS also indicated Resident #22 required substantial to moderate assistance with self-care and mobility tasks. Review of Resident #22's medical record indicated the Resident had sustained 4 falls in the past three months. Review of Resident #22's fall care plan indicated the following interventions: -Low bed, call light. Rehab/mental health screens, initiated 5/7/25. -Fall mats to both sides of bed, initiated 6/6/25. -15-minute checks x 48 hours, initiated 6/9/25. -Bed, chair, fall mat, and motion alarms, initiated 7/15/25. -Close observation, initiated 8/14/25. On 8/12/25 at 7:37 A.M., Resident #22 was observed lying in bed. A fall mat was observed on the floor next to the right side of bed. There were no alarms in the room. On 8/13/25 at 11:44 A.M., Resident #22 was observed lying in bed. A fall mat was observed on the floor next to the right side of bed. There were no alarms in the room. On 8/13/25 at 12:31 P.M., Resident #22 was observed sitting up in bed eating lunch. A fall mat to the right side of bed was pushed aside to accommodate the overbed table. There were no alarms in the room. On 8/14/25 at 7:35 A.M., Resident #22 was observed lying in bed. A fall mat was observed on the floor next to the right side of bed. There were no alarms in the room. Review of Resident #22's incident report dated 8/2/25 indicated the following: - 'Resident sitting at the dining table eating his/her breakfast, he/she was observed standing fast from the chair, lost balance, and landed on his/her left side'. Review of the incident report for this fall failed to indicate the Resident's chair alarm was in place and functioning at the time of the fall. The report failed to mention an alarm being in place on the chair or that it had sounded. Review of Resident #22's incident report dated 8/11/25 indicated the following: - 'Around 8 P.M., CNA on duty notified nurse that Resident was on the floor. As reported by CNA, Resident told me he/she fell, and I found him/her on his/her knees. On assessment by nurse Resident was found partly in bed with both his/her legs dangling out of bed.' Review of the incident report for this fall failed to indicate the Resident's chair alarm was in place and functioning at the time of the fall or that bilateral fall mats were in place. The report failed to mention an alarm being in place in the room or on the bed or that it had sounded. Review of Resident #22's Rehab Screen, dated 8/12/25, recommended bed at lowest level. Bilateral floor mats. Resident supervised in common areas when displaying increased agitation to reduce risk of falls. During an interview on 8/13/2025 at 1:53 P.M., the Director of Nursing said after a resident falls the facility implements a new fall intervention for the prevention of further falls and these interventions should be always followed. She said that the witness statements in the incident reports are accurate so if the report says no alarm, then there is no alarm in place. During an interview on 8/14/25 at 12:56 P.M., The Director of Nursing said that the care plan is reviewed after each fall and that she makes rounds to make sure interventions are in place. She said that she was not aware that Resident #22's plan of care indicated bilateral fall mats were to be used. She said that the fall interventions of bilateral fall mats in the care plan should be followed, but were not.

Based on observations, interviews and record review, the facility failed to maintain professional standards in the management and care for urinary catheter devices for one Resident (#81) out of a total sample of 27 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed in direct contact with the floor. Findings include:Review of facility policy, titled Urinary Catheter Care, dated April 2015, indicated the following:-Policy: Routine urinary catheter care will be provided by trained CNAs [Certified Nursing Assistants] as necessary, to keep the catheter insertion site clean in order to prevent infection and other complications. Resident #81 was admitted to the facility in September 2023 with diagnoses that included weakness and atrial fibrillation. Review of Resident #81's most recent Minimum Data Set (MDS) Assessment, dated 5/30/25, indicated that the Resident was unable to participate in a Brief Interview for Mental Status (BIMS) exam and was assessed by staff as being severely impaired with cognitive skills for daily decision making. The MDS further indicated the use of an indwelling urinary catheter. On 8/12/25 at 7:42 A.M., the surveyor observed Resident #81 awake in bed. The surveyor observed a urinary catheter drainage bag without a privacy bag present resting in direct contact with the floor On 8/13/25at 6:57 A.M., the surveyor observed Resident #81 sleeping in bed. The surveyor observed a urinary catheter drainage bag with a privacy bag present resting in direct contact with the floor. On 8/13/25 at 8:46 A.M., the surveyor observed a nurse assist the Resident with breakfast and then leave the Resident's room. The Resident remained in bed, and the urinary catheter drainage bag remained in direct contact with the floor. On 8/13/25 at 10:27 A.M., the surveyor observed the Resident in bed, dressed. The urinary catheter drainage bag remained without a privacy bag and remained resting in direct contact with the floor without any barrier between the drainage bag and the floor. Review of Resident #81's physician's orders indicated the following: -Foley catheter care every shift, dated 2/26/25.-Change foley catheter bag weekly every sun night, dated 6/15/25. During an interview on 8/14/25 at 6:55 A.M., Nurse #2 said that catheter drainage bags should not be resting on the floor. She said that if the drainage bag is resting on the floor, it would be an infection control concern. She further said that staff should check frequently that it isn't on the floor. During an interview on 8/14/25 at 7:01 A.M., Certified Nurse's Assistant (CNA) #8 and CNA #9: said that a resident's urinary drainage bag should have a privacy cover and not be resting directly on the floor. They said that if the drainage bag is touching floor would create a risk for infection. During an interview on 8/14/25 at 9:57 A.M., the Director of Nurses said that a urinary drainage bag should be hanging on the side of the bed, below the level of the bladder, but it should not be in contact with the floor due to infection control concerns and risk for infection.

Based on record review and interviews the facility failed to provide nutritional intervention for one Resident (#12) with a significant weight loss out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Weights, undated, indicated the following:-A weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present.-if a significant weight loss/gain is identified (> 5% in 30 days or > 10% in six months), the IDT (interdisciplinary team), dietitian, physician and family are notified.-All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Resident #12 was admitted to the facility in August 2023 with diagnoses that included dysphagia, diabetes, and Alzheimer's Disease. Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #12 required supervision for self-feeding tasks and was dependent on staff for all other self-care and mobility tasks. Review of Resident #12's weights indicated that on 7/14/25, the Resident weighed 257.2 lbs. (pounds) and on 8/6/25, the Resident weighed 240.4 lbs. which is a -6.53% significant weight loss. During an interview on 8/14/25 at 8:38 A.M., Resident #12 said he/she was unaware he/she had lost any weight, and no one had come to speak with him/her about it. Review of Resident #12's medical record failed to indicate the following:-A re-weight was obtained to validate the weight loss.-The physician or Dietitian were notified of the weight loss.-The Dietitian reviewed Resident #12's weight loss and addressed the loss. -A new intervention for further prevention of weight loss was initiated. -Resident #12 was followed by the risk management team. Review of Resident #12's nutritional care plan initiated on 8/7/25 indicated the following interventions:-Allow Resident sufficient time to eat.-Monitor and evaluate energy intake, food/beverage via food records and observation.-Monitor and evaluate weight changes.-Provide medical food supplements. Review of the Certified Nursing Assistant (CNA) documentation indicated the staff failed to monitor Resident #12's food intake for 4 meals (out of a possible 21) since the weight loss occurred. During an interview on 8/14/25 at 9:07 A.M., Nurse #1 said all residents are weighed according to the physician orders and if a significant change in weight occurs, the nursing staff should obtain a reweight within 24-48 hours to validate the significant change. Nurse #1 said if the significant weight change is validated, the dietitian, physician, and interdisciplinary team should be notified and an intervention put in place immediately to prevent further weight loss. Nurse #1 said she works full time on Resident #12's unit and was unaware the Resident had lost any weight. During an interview on 8/14/25 at 10:23 A.M., the Registered Dietitian (RD) said she works at the facility two days a week and reviews a weight report to follow all residents' weights and to identify any weight changes that occurred. The RD said the facility also has weekly risk management meetings and she is also notified of a resident's significant weight change during these meetings. The RD said if a resident were to have a significant weight loss, which would be over 5% in one month, the nursing staff should complete a reweight of the resident within 24-48 hours to validate the loss. The RD said if the weight loss is validated, she should be notified by the nursing staff, and a nutritional intervention should be put in place immediately and waiting a week to do so would be too long. The RD said she often finds weight loss herself by looking at the report and the nursing staff does not always notify her of significant weight changes in the facility. When reviewing Resident #12's medical record with the surveyor, the RD confirmed the Resident's significant weight loss and said she was never notified of the loss, that the Resident was never discussed in risk meeting, that a reweight was never obtained as it should have been and that an intervention was never put in place as it should have been. The RD said she would have to assess Resident #12 because she felt the Resident would benefit from increased supplementation. During an interview on 8/14/25 at 11:03 A.M., Physician #1 said he was not aware of Resident #12's weight loss and had not been notified by the facility. During an interview on 8/14/2025 at 11:33 A.M., the Director of Nursing said all residents are weighed monthly unless otherwise ordered, and the facility monitors these weights to check for any significant weight changes. The Director of Nursing said if a significant weight change occurs, the facility must complete a reweight of the resident, notify the physician and dietitian and put a new nutritional intervention in place immediately. The Director of Nursing said Resident #12 did have a significant weight loss and was unsure why a nutritional care plan was created but a new intervention not put in place. The Director of Nursing said she would have expected a new nutritional intervention to have been put in place for Resident #12 immediately and could not say why one was not.

Based on record review and interview, the facility failed to ensure Residents were assisted in making transportation arrangements to Radiology appointments for one Resident (#8) out of a total sample of 27 Residents. Specifically, the facility failed to ensure Resident #8 was provided assistance to obtain transportation for a brain Magnetic Resonance Imaging (MRI) appointment as recommended by a Neurologist. Findings include:Review of the facility policy titled Nursing Policy & Procedure Manual Transportation, dated 4/20/2021, indicated the following:- It is the policy of this facility to ensure that residents are transported safely to and from medical/clinical appointments. It is the goal to ensure residents are transferred to their scheduled appointments and/or events.- The facility may opt to obtain contract transportation for the resident.- If a contracted provider cancels scheduled transportation arrangements, parties will be notified as soon as possible. Resident #8 was admitted to the facility in July 2023 with diagnoses including paranoid schizophrenia and epilepsy. Review of Resident #8's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #8 requires assistance with activities of daily living and does not have a history of rejecting care. Review of Resident #8's Neurology visit from an outside General Neurology Clinic with a consultation date of 5/12/25 indicated the following:- Reason for the visit: Here for new evaluation and treatment of seizures and sensory impairment.- Patient was previously followed by neurology for multiple issues: Small Seizures- Plan: Imaging: Send for MRI brain for evaluation of parkinsonism Review of a nursing note dated 5/12/25 indicated the following: Resident returned from neurology appointment with n.n.o. (no new orders) at this time, f/u (follow-up) appt (appointment) given. Review of Resident #8's care plan, dated as revised 8/12/24, indicated that the Resident has a diagnosis of Seizure Disorder/history of seizure disorder. During an interview on 8/13/25 at 8:46 A.M., Resident #8 said he/she was waiting to go to his/her appointment a week ago and the facility told him/her it was at 2:00 P.M. and he got a phone call from the transport company that he/she missed his/her ride as it was at 1:30 P.M. Resident #8 said he/she has had seizures and he/she needs to get an MRI. The Resident then said he/she wishes the facility would provide an escort to go with him/her so he/she does not need to worry about things. During a telephone interview on 8/13/25 at 9:16 A.M., Resident #8's family member said he/she has not heard anything from the facility regarding the Resident's appointment. The family member then said Resident #8 has night seizures which started months ago, and he/she has banged his/her head against the wall. The family member then said that he/she only hears from Resident #8 and that he/she has not been to his/her MRI appointment and he/she thinks an escort is necessary for Resident #8. Review of a nurse practitioner progress note dated 2/4/25 at 3:54 P.M., indicated the following: HPI (history of present illness): Patient also had a questionable seizure in May (2024), it was unwitnessed, reported by the patient that when he/she woke up he/she was shaking. Patient was supposed to follow-up with neurology in September however transportation did not arrive. (sic) Review of a nursing progress note dated 6/28/25 at 8:54 P.M. indicated the following: Patient was scheduled for an MRI of the brain today but transportation did not show up. Appointment was rescheduled but pending discussion with U/M (Unit Manager) and U/S (Unit Secretary) as available times are either very early in the morning or very late at night. (sic) Review of a nurse practitioner note dated 6/30/25 at 1:43 P.M., indicated the following: Assessments/Plans: Referral to neurology for questions of seizures, appointment schedule for May 12 (2025), will need follow-up rescheduled. Was scheduled for MRI of the brain, although transportation did not arrive. Will need rescheduling. (sic) Review of a nurse practitioner note dated 7/26/25 at 1:36 P.M., indicated the following: Assessments/Plans: Referral to neurology for questions of seizures, appointment schedule for May 12 (2025), will need follow-up rescheduled. Was scheduled for MRI of the brain, although transportation did not arrive. Will need rescheduling. (sic) Review of a nursing progress note dated 8/6/25 at 3:52 P.M. indicated the following: Resident missed appt (appointment) today due to transportation communication. During an interview on 8/13/25 at 11:14 A.M., Unit Manager #2 said if residents have appointments, we (the facility) book the transportation, we then see if a family member wants to join and if not then we bring a staff member as an escort to the appointment. Unit Manager #2 then said she cannot remember if Resident #8 has missed any appointments lately as she is the Unit Manager for two units in the facility. Unit Manager #2 then said Resident #8 should have an escort to his/her appointments as a medical appointment would go over his/her head and it would be too much for him/her. On 8/13/25 at 11:35 A.M., Unit Secretary #1 informed the surveyor of the four transport companies that the facility typically uses to get residents to their appointments. On 8/13/25 at 11:54 A.M., 12:06 P.M., 12:25 P.M. and 12:35 P.M., the surveyor called the four transportation companies, none of which had any record of transportation requests for Resident #8. During an interview on 8/13/25 at 1:14 P.M., Nurse #3 said Resident #8 has had seizures before and he/she is followed by neurology. Nurse #3 said sometimes the Unit Secretary or a CNA (certified Nursing Assistant) will go with him/her. During a telephone interview on 8/13/25 at 2:20 P.M., the Nurse Practitioner said Resident #8 has questionable seizures and is being seen by Neurology, he/she was seen on May 12th and they requested an MRI. The Nurse Practitioner then said he/she was supposed to have one at the end of June and in August, but the resident did not go due to transportation issues. The Nurse Practitioner then said it would be optimal for Resident #8 to receive an MRI of his/her brain right away. During an interview on 8/14/25 at 8:27 A.M., the Assistant Director of Nursing (ADON) said she was unaware that Resident #8 had a history of seizures. The ADON said when a resident comes back from a medical appointment the nurse working will review the discharge paperwork and make note of any follow-ups that are needed. The ADON said transportation has been an issue due to insurance issues. The ADON then said she wishes that all residents could have an escort to their appointments. The ADON and the surveyor proceeded to review the appointment books on the B-Wing Nursing unit. Review of the appointment book at the B-Wing Nursing Station on Resident #8's unit indicated the following on 8/6/25: *Resident #8 @ 2:00 p/u (pick-up) MRI* Review of appointment binder on the B-Wing Nursing Station indicated the following:- A fax form from the MRI clinic for Resident #8 dated 6/27/25 with the title Screening Forms, the following fields were checked off: urgent, for review, please comment, please reply. MRI Appointment date: 6/28/25 6:20 P.M. arrival.- A document dated 7/30/25 in the B-Wing appointment book indicated a new appointment date for 8/6/25 at 2:00 P.M., on the document was a hand-written note indicating that the insurance company was emailed on 7/30/25.- A document titled Doctor's Appointments dated 8/6/25 indicated the following: Reason: MRI, Time: 2:00 P.M. arrival- A document titled Doctor's Appointments dated 9/11/25 for the MRI Center with the hand-written word brain on it. During an interview on 8/14/25 at 8:52 A.M., Unit Secretary #1 was reviewing the appointment books with the surveyor. Unit Secretary #1 said she handles appointments for another unit in the facility, but this floor's Unit Secretary was on vacation. Unit Secretary #1 told the surveyor the facility has issues with getting calls for pick up times on the appointment day, usually the transportation company will call the day of the appointment. Unit Secretary #1 said sometimes we do not know which company will be picking the residents up and sometimes they do not show up. Unit Secretary #1 reviewed the appointment paperwork for Resident #8 and she said the Resident should have been to his/her MRI appointment sooner. At 9:16 A.M., the Unit Secretary #1 called Resident #8's insurance company, the insurance company said transportation came to the facility for the Resident's 8/6/25 appointment but the Resident never came downstairs, so they left. The insurance company said they only had the Resident's phone number and not the facility's phone number. The insurance company then said there was no record of them arranging transportation on 6/28/25. Unit Secretary #1 told the surveyor the insurance company needs the facility's phone number and not Resident #8's so we can make sure he/she makes the appointment. Unit Secretary #1 and the ADON said their expectation is that the facility is responsible for ensuring Resident #8 gets to his/her appointments. During an interview on 8/14/25 at 11:48 A.M., the Director of Nursing (DON) said the facility needs to ensure the Resident is ready when an appointment is scheduled. The DON then said appointments need to be scheduled as soon as possible and then rescheduled as soon as possible if needed. The DON said if the facility is having transportation issues then another option needs to be utilized. The DON then said she expects Resident #8 to have his/her appointment made in a timely manner and he/she should have had his/her MRI sooner.

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#11) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 27 residents. Specifically, the facility failed to ensure nursing assessments, including the assessment of the dialysis access site were performed when Resident #11 returned from dialysis treatments. Findings include:Review of the facility policy titled 'Hemodialysis', dated April 2015, indicated care of arteriovenous (AV) fistula (how patients are connected to a dialysis machine):-Assess AV fistula every shift for the following and document:a. pain.b. signs and symptoms of infection (drainage, swelling, tenderness).c. scab formation.d. color, motion, and sensitivity of access arm.e. palpate fistula for a thrill (vibration felt over fistula).f. auscultate fistula for a bruit (whooshing heard over fistula).-Documentation of the assessment will be kept in the medical record. Resident #11 was admitted to the facility in July 2024 with diagnoses including End Stage Renal Disease (ESRD) and Diabetes. Review of the most recent Minimum Data Set (MDS) Assessment, dated 8/7/25, indicated that Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and that Resident #11 was on dialysis. Review of the August 2025 Physician's orders failed to indicate any orders to assess Resident #11's AV fistula every shift or upon return from dialysis. Review of the August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate any orders to assess Resident #11's AV fistula every shift or upon return from dialysis. Review of Resident #11's nursing progress notes from 7/16/25 through 8/14/25 failed to include every shift assessment of his/her AV fistula or an assessment upon Resident #11's return from dialysis. Review of the Renal Dialysis Care Plan, revised 8/6/24, indicated Resident #11 received hemodialysis on Mondays, Wednesdays and Fridays for End Stage Renal Disease. The plan of care included the following interventions:-after dialysis resident may have low blood pressure (BP), dehydration signs/symptoms, muscle cramps, nausea, vomiting, headache, or pain in the back or chest.-fever, abnormal heart rhythms, air embolism, bleeding, infections are potential complications of hemodialysis.-monitor thrill and bruit. [part of the assessment to check function of an AV fistula and ensure proper blood flow. During an interview on 8/12/25 at 7:41 A.M., Resident #11 pointed to his/her left lower arm fistula when the surveyor asked to view his/her access site. During an interview on 08/14/25 at 1:11 P.M., the Director of Nursing and Regional Clinical Manager/Chief Nurse Specialist said there should be an order for assessment of the dialysis access of Resident #11 upon return from dialysis and that should be documented in the medical record.

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for five of five sampled CNA's. Findings include:During the review of five CNA employee records on 8/14/25 at 11:05 A.M., the surveyor noted that five of five sampled CNAs did not receive annual performance reviews. During an interview on 8/14/25 at 11:33 A.M., the Human Resource representative said she provides the Unit Managers with the annual performance review paperwork, and once completed she files them in the employees' file. The Human Resource representative said annual performance reviews for this year have not been completed. During an interview with the Corporate Nurse on 8/14/25 at 12:31 P.M., the above concerns were reviewed. The Corporate Nurse said performance reviews should be completed on an annual basis. The Corporate Nurse said we are currently working on getting all performance reviews completed.

Based on observations, record review and interviews the facility failed to ensure two Residents (#108 and #100) with pressure ulcers receive care consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. Specifically, 1. For Resident #108 the facility failed to: 1a. Implement recommendations from the consultant wound physician and, 1b. Ensure air mattress settings were set according to the plan of care. 2. For Resident #100 the facility failed to implement recommendations from the consultant wound physician. Findings Include: Review of facility policy titled Consultant Services, dated as April 2015, indicated the following: -Policy: [The facility] will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/ patient through consultant services. - Procedure: The charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Review of facility policy titled Prevention and Management of Pressure Injuries, undated, indicated the following: -Standard: the facility is dedicated to preventing pressure injuries and to developing a preventive plan of care based on individual needs. Residents receive the care and services they need according to established practice guidelines, so that residents who enter the facility without a pressure injury do not develop one unless the individuals clinical condition demonstrates that they were unavoidable. The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. -Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage heeling and/or maintenance of skin integrity. Care plans are developed based on individual resident's goals and decisions for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. -Protocol -Assessment: 2. The resident is assessed for pressure injury risk factors. -The Resident's skin is observed daily with care 4. Residents will have a weekly body audit completed by the licensed staff. Review of facility policy titled Pressure Injury/ Non-Pressure Wound Risk Management, undated, indicated the following: -Those residents who score at risk on the Braden or Norton Scale, or those identified to be at risk through comprehensive assessment or who have actual skin impairment are provided with care to address their individual risk factors and goals of treatment. -Procedure: Determine cause of pressure and remove the causative agent if possible. Interventions may include: 2. Provide appropriate pressure redistributing devices to beds and wheelchairs. 3. Heels are extremely vulnerable and must be elevated completely off the bed and /or chair surface. Residents identified at risk will have an order in place to offload heels. 1. Resident #108 was admitted to the facility in May 2024 with diagnoses that include acute metabolic acidosis and protein- calorie malnutrition. Review of Resident #108's most recent Minimum Data Set (MDS) Assessment, dated 6/7/24, indicates a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating the Resident has moderate cognitive impairment. The MDS further indicates that the resident has no pressure ulcer or injuries but is at risk for developing pressure ulcers or injuries. The MDS indicates that Resident #108 has no diabetic foot ulcers or other open lesions on the foot. Further the MDS indicates that Resident #108 requires substantial/ maximal assistance for activities of daily living (ADLs) On 8/26/24 at 9:22 A.M., Resident #108 was observed lying in bed, an air mattress was in use. Resident #108 said he has a sore on his/her right heel that developed at the facility. His/her heels were directly on the mattress. Review of Weekly skin Audit, dated 6/1/24 indicated the following: -Indicate type of audit: Admission/ Readmission -Are there any skin impairments: No Review of Resident #108's Norton Assessment (an assessment tool used to determine risk for development of pressure ulcers), dated 6/1/24 indicated a score of 8, indicating that Resident #108 is at high risk of developing pressure ulcers. Review of the progress notes indicated the following: -A nursing progress note dated 6/30/24 indicated but was not limited to, Pt [patient] has blister on his/her right heel. -A second nursing progress note dated 6/30/24 indicated that the Resident was Noted to have a blister to right heel, area is blanchable. Measures 2.0 centimeters (cm) length, 3.0 cm, zero depth noted, no drainage. An Interim Skin Audit with an effective date of 6/30/24 indicated the following: -Are there pre-existing skin impairments? No. -Are there any new skin impairments? Yes. -If yes, indicate type(s): New suspected pressure ulcer/ deep tissue injury (DTI) indicated as being located on the right heel. A Pressure Injury Evaluation with an effective date of 6/30/24 indicated Resident #108 has an unstageable deep tissue injury (DTI)to the right heel with a date of origin of 6/30/24. Review of Resident #108's active care plan indicated the following: -A care plan dated as initiated on 7/10/24, ten days after the right heel ulcer was noted, which indicated the resident has potential alteration in skin integrity related to decreased/ impaired mobility or function, friction, nutrition, risk assessment, shearing (sic) with interventions including apply heel protectors posey Xlg Rx (extra-large prescribed) (sic) as ordered with skin prep. -A care plan dated as initiated on 8/13/24, forty-four days after the right heel ulcer was noted, which indicated actual alteration in skin integrity related to decreased mobility, DTI unstageable to right heel with interventions that included to follow physician's orders for skin care and treatments. 1a. On 8/26/24 at 9:22 A.M., Resident #108 was observed by the surveyor lying on his/her back in bed, an air mattress was in place, and the Resident's heels were noted to be directly on the mattress. On 8/27/24 at 10:13 A.M., the surveyor observed a nurse and a certified nurse's assistant (CNA) place a pillow under the Resident #108's knees, leaving bilateral heels to fall directly on the mattress. On 8/28/24 at 10:13 A.M., Resident #108 was observed lying in bed with his/her heels directly on the mattress. An off-loading boot was observed in the corner of the room in a chair, not in use. On 8/28/24 at 4:00 P.M., Resident #108 was observed lying in bed, sleeping with bilateral heels directly on the mattress. On 8/29/24 at 6:50 A.M., Resident #108 was observed lying in bed on his/her back with bilateral heels directly on the mattress. Review of Resident #108's medical record indicated that a consultant wound physician assessed the Resident on 7/9/24 for an initial evaluation. The progress note indicated that the resident presented with wounds on his/her left posterior heel, right posterior heel. Both areas were classified as unstageable DTIs. Recommendations for treatment included skin prep to bilateral heels every shift, off-load wound, float heels in bed: 2 pillows under the ankle; pressure off-loading boot. Review of Resident #108's July 2024 Treatment Administration Record (TAR) indicated that skin prep was initiated to bilateral heels once daily on 6/27/24 and failed to indicate that the frequency was increased to every shift as recommended by the consultant wound physician. The July 2024 TAR also indicated that an order to off load heels every shift was initiated on 6/26/24 but failed to indicate that a pressure off-loading boot was initiated as per the consultant wound physician's recommendations. Review of the consultant wound physician's progress note, dated 7/23/24, indicated that the left heel DTI had resolved, and that the right heel continues to be evaluated as an unstageable DTI. The recommendations for treatment of the right heel were skin prep to right heel every shift (3 times daily), off-load wound, float heels in bed; pressure off-loading boot. Review of Resident #108's July 2024 TAR indicated that skin prep was discontinued on 7/23/24 to bilateral heels, and an order was put into place for skin prep to the right heel daily on 7/24/24. Review of the July 2024 TAR failed to indicate that skin prep had been ordered as recommended every shift (3 times daily) or that a pressure- off loading boot was initiated. Review of the consultant wound physician progress note, dated 8/6/24, indicated that the right heel had a full thickness, stage 3 pressure wound. The wound size was documented as 0.5 cm x 0.5 cm with no measurable depth. Treatment recommendations made included Alginate Calcium, apply once daily for 30 days, cover with a gauze island dressing once daily, off-load wound, float heels in bed: pressure off-loading boot. Review of Resident #108's August 2024 TAR failed to indicate that the recommendations for Alginate Calcium and pressure off-loading boot were put into place. The treatment order for the right heel remained as skin prep once daily. Review of the consultant wound physician progress note, dated 8/13/24, indicated a right heel wound size of 1.0 cm x 1.0 cm with no measurable depth. Treatment recommendations made included hydrocolloid sheet (thin). apply three times per week for 30 days, off-load wound, float heels in bed: pressure off-loading boot. Review of Resident #108's August 2024 TAR indicated that until 8/16/24 the treatment to the right heel was skin prep once daily and that the treatment recommendations for hydrocolloid sheet were not put into place until 8/17/24, four days after the recommendation was made. The August 2024 TAR also failed to indicate that an off-loading boot was put into place. Review of the consultant wound physician progress note, dated 8/20/24 indicated a right heel wound size of 1.0 cm x 1.0 cm x 0.1 cm depth. Recommendations to continue the same treatment were made. Review of the consultant wound physician progress note, dated 8/30/24, indicated a right heel full thickness stage 3 pressure wound that measured 1.0 cm x 1.0 cm x 0.1 cm depth. Wound progress was documented as not at goal. Recommendations were made to change treatment to Alginate calcium once daily x 30 days, then wrap with gauze (kerlix). Recommendations remain to float heels in bed, pressure off- loading boot. During an interview on 8/27/24 at 12:47 P.M., Nurse #3 said that when recommendations are made from the consultant wound physician, they should be communicated to the Nurse Practitioner and put into place. During an interview on 8/29/24 at 10:46 A.M., the Director of Nurses (DON) said that a nurse from the facility rounds every week with the consultant wound physician, and that nurse is responsible for communicating and implementing those recommendations. The DON said that consultant wound physician recommendations should be implemented within 24 hours and not implementing recommendations could contribute to worsening of a pressure area. During an interview on 8/29/24 at 3:00 P.M., the consultant wound physician said that the facility should elevate heels with the use of an off-loading boot as recommended. He said there have been several times that he has noticed heels are not being off-loaded appropriately. The consultant wound physician said he would expect that his recommendations be put into place. 1b. On 8/26/24 at 9:22 A.M., Resident #108 was observed lying in bed on his/her back on an air mattress that was set at 250. On 8/28/24 at 10:13 A.M., and 2:07 P.M., Resident #108 was observed lying in bed on his/her back on an air mattress that was set at 250. On 8/29/24 at 6:50 A.M., Resident #108 was observed sleeping in bed on his/her back on an air mattress that was set at 250. On 8/29/24 at 10:27 A.M., a nurse was in Resident #108's room completing a wound dressing change. The nurse exited the room and the Resident remained in bed, lying on an air mattress that was set on 250. Review of physician's orders failed to indicate an order for an air mattress. Review of Resident #108's active care plan dated as initiated on 8/13/24 indicated that the Resident has a DTI unstageable to right heel with interventions that included specialty air mattress setting 140 (sic). Review of Resident #108's current weight indicated that on 8/1/24 he/she weighed 141.6 pounds. During an interview on 8/29/24 at 10:46 A.M., the Director of Nurses (DON) said there should be a physician's order for the air mattress, and that it should be set at or around the resident's weight. She said the air mattress should be set at around 140. If the mattress is set too high, it could be a safety issue, and would be ineffective as a pressure relieving mattress. During an interview on 8/29/24 at 3:00 P.M., the consultant wound physician said it is inappropriate to over inflate an air mattress, and it becomes more like a regular mattress. Overinflating the mattress has the potential to cause worsening of the wound. 41456 2. Resident #100 was admitted to the facility in August 2023 with diagnoses including heart failure and muscle weakness. Review of Resident #100's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she had intact cognition. The MDS also indicated Resident #100 required maximal assistance from staff for bed mobility tasks. Review of the Wound Evaluation & Summary Management note dated 8/20/24, indicated Resident #100 has a pressure wound to his/her left posterior heel for over 210 days and the wound is not at goal. On 8/26/24 at 9:55 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. During this observation, Resident #100 said he/she has a wound on his/her left heel. On 8/27/24 at 7:10 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. On 8/28/24 at 8:26 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. Review of Resident #100's physician orders indicated the following order: -Offload heels every shift as tolerated, initiated 7/28/24. Review of the Wound physician notes dated 7/23/24, 7/30/24, 8/6/24, 8/13/24 and 8/20/24 -Pressure off-loading boot, Prevalon (a pressure relieving positioning boot), float heels in bed, off-load wound. Review of Resident #100's skin integrity care plan, last revised 7/24/24, indicated the following interventions: -Follow MD (physician) orders for skin care and treatments, -Provide positioning intervention as indicated on impaired functional mobility care plan. During an interview on 8/27/24 at 10:55 A.M., Resident #100 said he/she used to have a boot for his/her left heel but has not had one in months. On 8/28/24 at 8:41 A.M., Resident #100 was observed lying in bed with both heels directly on the mattress and not offloaded from pressure. During an interview on 8/27/24 at 11:01 A.M., Certified Nursing Assistant #1 said Resident #100 has protective socks but does not need to elevate his/her heels while in bed. During an interview on 8/27/24 at 11:09 A.M., Nurse #2 said Resident #100 has a wound on his/her left heel and should be offloaded from pressure at all times when lying in bed. Nurse #2 said the Resident does not have a prevalon boot. During an interview on 8/28/4 at 8:54 A.M., Nurse #7 said Resident #100 has had a wound on his/her left heel for several months and is treated by the wound doctor every week. Nurse #7 said Resident #100 should be offloading his/her heels while in bed and his/her heels should never be directly on the bed. Nurse #7 said Resident #100 does not have a prevalon boot. During an interview on 8/28/24 at 9:56 A.M., the Director of Nursing said nursing is responsible for making sure all recommendations from the wound doctor are transcribed over and followed. The Director of Nursing said all wound recommendations are expected to be followed.

Based on observations, record review and interviews, the facility failed to provide behavioral health services by a) ensuring recommendations from the Psychiatric Nurse Practitioner were implemented and b) psychotropic medications were provided as ordered for one Resident (#80) out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Psychotropic Medication Management, dated April 2015, indicated the following: -Administer medications as directed by the physician and manufacturer. -Monitor target behaviors daily for antipsychotics, antidepressants and anxiolytics using behavior monitoring tool. -Review the care plan with IDT (interdisciplinary team) when a resident is admitted on psychoactive medications, quarterly, annually and as needed for changes in resident status and revise as necessary. -Review should include verification that adequate indications for use of the psychotropic medication exist, the medications are note being used for extended duration, and residents are free from duplicate therapy and being monitored for adverse consequences, per current professional standards of practice and in accordance with Federal and State guidelines. Review of the policy titled, Consultant Services, sated April 2015, indicated the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident/patient at the request of the MD of family. The consultant should document findings and recommendations on this form. -The charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Resident #80 was admitted to the facility in June 2024 with diagnoses including Alzheimer's Disease, major depression, unspecified dementia with other behavioral disturbance. Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had severe cognitive impairment with a score of 0 out of a possible 15 on the Brief Interview for Mental Status. The MDS also indicated Resident #80 required partial assistance with all functional daily tasks. Throughout the survey, Resident #80 was observed pacing throughout the C Unit and was unable to be redirected by staff. During the survey period, Resident #80 sustained two falls and was involved in a resident-to-resident altercation. Review of the Documentation Survey Report for the months of June, July and August, indicated Resident #80 displayed behaviors daily, however, did not specify the type of behaviors. Review of the admitting Nurse Practitioner note written on 6/5/24 indicated the following: -Resident #80 was admitted to the facility with a preexisting prescription for Risperidone (an antipsychotic medication) and Trazadone (a mood stabilizer) and the plan was to continue both medications. -Resident #80 was cooperative with exam upon admission. At time of admission, the following orders were initiated for Resident #80: -Psych consult as indicated. -Risperidone 0.25 mg (milligrams) oral tablet, every 24 hours PRN (as needed). -Risperidone 0.25 mg BID (twice a day). -Trazadone 50 mg at bedtime. a. Review of Resident #80's nursing notes, six weeks after admission indicated the following: -6/23/24: Patient had episodes of increased agitation with physical aggression towards staff. Banging on the table and throwing stuff off the nurse's station counter, redirected multiple times and Risperidone utilized as needed with no effect. -6/28/24: Patient is having increased behaviors, agitation, intrusive yelling and aggression. -6/30/24: Resident walked through halls all day and had to be redirected. -7/3/24: resident continue with increased agitation and aggressive behavior towards staff and other residents. Resident not redirectable, PRN risperidone administered in the AM with no effects. -7/3/24: Patient continued to exhibit increased behaviors, with physical aggression towards staff and attempting to hit other residents. New order to increased risperidone. 7/4/24: patient has not slept in days. Increased confusion, restlessness, agitation and aggression towards staff and residents. Patient refusing to take medications. The nurse received doctor ordered to send resident out to ER, nurse complied. 7/4/24: patient returned from (hospital) with recommendations to increase Risperdal to 1 mg (milligram) at HS (night) and .5 mg in am and .5 mg as needed for agitation. 7/6/24: Resident alert, (he/she) has been up all night and refused to take medication. (He/she Was very aggressive and agitated, going from room to room uncovering residents who are sleeping this shift. (He/she) Was very difficult to redirect. Roommate was very upset and not happy because (he/she) kept going to her, screaming, yelling at her and calling her names. 7/6/24: Resident #80 had hit his/her roommate and was being sent out to the hospital for a psychiatric evaluation. 7/8/24: a psych consult was requested for Resident #80. Review of Resident #80's medical record indicated he/she was first evaluated by the behavioral health team on 7/11/24, six weeks after the Resident's admission, over two weeks after his/her first behaviors presented and over a week after the Resident had been aggressive towards staff and residents. Review of the behavioral health note indicated the following: - Problem: 86 YO (year old) new to this clinician, here for LTC (long term care) as family was no longer able to care for (him/her) at home. (He/she) has a psych hx (history) of dementia with ETOH (alcohol) abuse, MDD (major depressive disorder), agitation, aggression, and psychosis. Seen per staff request for initial assessment and due to significant mood and behavioral disturbance. Staff report resident has been highly irritable, agitated, restless, delusional and aggressive at times since admission and has had to be sent out on multiple occasions. (He/she) Has had multiple evaluations by the crisis team in the ER and they have been upward titrating (his/ her) Risperdal with some benefit. Staff report (he/she) is now being less aggressive but remains highly restless and intrusive and can be difficult to redirect at times. -Plan/recommendations: Remeron (a mood stabilizer), recommend trialing resident on Remeron 7.5 MG (milligrams) PO (by mouth) daily at bedtime to help with mood and appetite. Review of the nursing note from 7/11/24 indicated Resident #80 was seen by the Psychiatric Nurse Practitioner, however, failed to indicate the recommendation for the initiation of Remeron was relayed to the Physician. Review of the Medication Administration Record for July and August 2024 failed to indicate Remeron was initiated. Review of the Physician note dated 7/26/24, failed to indicate the physician was aware of this recommendation. Review of the nursing notes from July and August 2024 indicated the following: -7/15/24: Continues to have increased anxiety and aggression. (He/she) was wandering the hallway at about 7PM, (he/she) slapped a staff's hand who was sitting there documenting. -7/20/24: Resident #80 refused all day time medications. -8/2/24: Resident was observed pulling on another resident's hair by staff .Social worker made aware and working on section 12 (involuntary transportation to hospital for evaluation of mental health). Resident #80 returned to the facility the same day, on 8/2/24. Resident #80 was seen by the Psychiatric Nurse Practitioner again on 8/16/24, 2 weeks after the Resident was sectioned 12'd to the hospital for being a danger to self or others. Review of the Psychiatric Nurse Practitioner indicated the following: -Chief complaint: Pt (patient) pacing around unit, agitation, aggression, and refusing medications. Target symptoms: aggression. agitation, anxiety and paranoia. -Clinical assessment: Patient pacing in (his/her) room and unit, patient with agitation, and at times moving fast, restless, having racing thoughts, and refusing medications. Aggressive, poor concentration, poor judgement, aggressive behaviors. No s/sx (signs or symptoms) of SI (Suicide Ideation). Recommending to start Ativan (an anti-anxiety medication) 0.5mg as follows: give 1 tab by mouth twice a day prn for anxiety/agitation. -Plan/recommendation: Notify of any changes or concerns. Continue to monitor. Recommendation to start new medication(s). Recommending start Ativan as follows: 0.5mg as follows: give 1 tab by mouth twice a day prn for anxiety/agitation. Recommending to start Depakote (mood stabilizer) 125 mg twice a day r/t (due to) psychotic disorder with delusions due to known physiological condition. Review of the nursing note on 8/16/24 failed to indicate these recommendations were reported to the physician. Review of the Medication Administration Record for August 2024, failed to indicate Ativan or Depakote were ever initiated. Review of the Physician note dated 8/20/24 failed to indicate the physician was made aware of these recommendations. The surveyor attempted to call the physician and his office said he was unavailable for the week. Review of Resident #80's psychotropic medication care plan, last revised 7/2/24, indicated the following intervention: -investigate/monitor need for psychological/psychiatric support provide services as ordered by the physician. During an interview on 8/29/24 at 9:37 A.M., Nurse Practitioner #1 said all recommendations from behavioral health are sent to her by nursing for her to approve. Nurse Practitioner #1 said she was not aware of the Remeron recommendation in July and approved the recommendation for Ativan and Depakote in August but was never aware the medications had not been given. During an interview on 8/29/24 at 9:45 A.M., Nurse #6 said Resident #80 displays a lot of behaviors. Nurse #6 said behavioral health services are at the facility weekly, however, Resident #80 has only been seen twice since admission. Nurse #6 said she feels Resident #80 would have benefitted from being seen more often. Nurse #6 said recommendations from behavioral health are given to nurse who then sends them over to the physician. Nurse #6 said Resident #80's family was never contacted to sign the consent for use of Remeron which is why the Resident was never started on that medication. Nurse #6 said she was also aware of the recommendation to start Ativan and Depakote, however, never followed up to see if the doctor approved and should start them. During an interview on 8/29/24 at 9:55 A.M., Social Worker #1 and the Director of Social Services both said Resident #80 exhibits behaviors often and his/her behavior is pretty significant. Both said behavioral health is in the building weekly but Resident #80 was only seen once a month because of billing and should have been seen more frequently. During an interview on 8/29/24 at 10:59 A.M., Corporate Nurse #1 said she would expect Resident #80 to have been seen by behavioral services after every resident-to-resident incident and when the Resident presented with increased behaviors. During an interview on 8/29/24 at 10:23 A.M., the Director of Nursing (DON) said behavioral services are in the building at least once a week and residents are seen on an as needed basis. The DON said behavioral health services should evaluate/treat a resident who is experiencing increased behaviors and who are involved in resident-to-resident incidents with each increase of behavior or incident. The DON said Resident #80 should have been seen more regularly by the behavioral health team. The DON said if the Psychiatric Nurse Practitioner makes recommendations, the nurses are expected to notify the physician so they can be implemented if he agrees. The DON was unaware of the recommendations made and that they were never followed through. During an interview on 8/29/24 at 2:14 P.M., the Psychiatric Nurse Practitioner said all recommendations are given to nursing and it is expected that the nursing staff report these recommendations to the physician and follow through with them. The Psychiatric Nurse said she was unaware that the three recommendations made were never followed up with and that Resident #80 should have been seen more frequently due to his/her behaviors/presentation. b. Review of the Medication Administration Report for June, indicated Resident #80 was prescribed the following psychotropic medications: -Trazadone oral tablet, 50mg. Give one tablet at bedtime related to major depressive disorder, initiated on 6/5/24 -Risperidone oral tablet 0.5mg. Give 1 tablet by mouth two times a day related to major depressive disorder, initiated on 6/5/24. --Risperidone oral tablet .25mg. Give one tablet by mouth every 24 hours as needed for anxiety, initiated on 6/5/24 Review of the Medication Administration Report for July, indicated Resident #80 was prescribed the following psychotropic medications: -Risperidone oral tablet 0.5 mg. Give 1 tablet two times a day related to major depressive disorder, initiated on 6/5/24 and discontinued on 7/4/24. -Risperidone oral tablet. Give .5mg by mouth three times a day related to Alzheimer's Disease, initiated, and discontinued on 7/4/24. -Risperidone oral tablet 0.5 mg by mouth one time a day related to Alzheimer's Disease, initiated on 7/5/24 and discontinued on 7/8/24. -Risperidone oral tablet 1 mg. Give 1 tablet by mouth in the evening related to unspecified dementia, initiated on 7/5/24 and discontinued on 7/16/24. -Risperidone oral tablet 0.5 mg. Give 1 tablet by mouth at bedtime for increased behavior, initiated 7/15/24 and discontinued 7/24/24. -Risperidone oral tablet 1 mg. Give 1 mg by mouth one time a day for increased behavior, initiated 7/16/24 and discontinued 7/24/24. -Risperidone oral tablet 0.5 mg. Give 1 tablet at bedtime for increased behavior, initiated on 7/24/24 -Risperidone oral tablet 1 mg. Give 1mg by mouth one time a day for increased behavior, initiated 7/25/24. -Risperidone oral tablet 0.25mg. Give one tablet by mouth every 24 hours as needed for anxiety, initiated on 6/5/24 and discontinued on 7/5/24. -Risperidone oral tablet 0.5mg. Give one tablet by mouth every 8 hours as needed for behaviors related to unspecified dementia, initiated 7/5/24. -Risperidone oral tablet. Give 0.5mg by mouth every 8 hours as needed for increased agitation related to major depressive disorder, initiated 7/3/24 and discontinued 7/9/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated 6/5/24 and discontinued on 7/4/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated on 7/25/24. -Trazadone 50 mg. Give 1 tablet by mouth in the afternoon related to major depressive disorder, initiated on 7/23/24. Review of the Psychiatric Nurse Practitioner and Physician notes failed to indicate a recommendation to stop Resident #80's Trazadone on 7/4/24, and he/she was without the mood stabilizer for 20 days. Throughout this time period, there were several nursing notes indicating Resident #80 had increased anxiety and agitation and had several occasions of refusing his/her medications. In addition, there was no indication for a recommendation to start the second dose of Trazadone on 7/25/24 when the medication was reintroduced on 7/23/24. Further review indicated that Resident #80's went 6 days (from 7/9/24 to 7/14/24) with only a one-time dose of the antipsychotic Risperidone, with no indication of that dose reduction being recommended by the Physician or nurse Practitioner. On 7/15/24, after 6 days without the second dose of antipsychotic medication, Resident #80 was physically aggressive towards a staff member. Review of the Medication Administration Report for August, indicated Resident #80 was prescribed the following psychotropic medications: -Risperidone oral tablet 0.5 mg. Give one tablet by mouth at bedtime for increased behavior, initiated on 7/24/24 and discontinued on 8/6/24. -Risperidone oral tablet 1 mg. Give 1 mg by mouth one time a day for increased behavior, initiated on 7/25/24 and discontinued on 8/6/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated 7/25/24 and discontinued 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth in the afternoon related to major depressive disorder, initiated 7/23/24 and discontinued 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth three times a day for increased agitation related to dementia, initiated on 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth every 8 hours as needed for increased agitation, initiated on 8/20/24 and discontinued on 8/21/24. -Trazadone 50 mg. Give 1 tablet by mouth every 8 hours as needed for increased agitation for 14 days, initiated on 8/21/24. Review of the Psychiatric Nurse Practitioner and Physician notes failed to indicate a recommendation to stop Resident #80's Risperidone on 8/6/24 and he/she has been without the antipsychotic medication since, a total of 23 days. Review of the physician note dated 8/20/24 indicated the following: -The patient does have a history of dementia with behavioral disturbance. The patient is currntly on Risperdal 1 mg p.o.q.a.m. (by mouth every morning) and .5mg p.o.h.s.p.r.n. (by mouth every day as needed), although this was scheduled through 8/6/24. It is unclear if this has been continued. Review of Resident #80's psychotropic medication care plan, last revised 7/2/24, indicated the following intervention: -Administer medication as prescribed by the physician. Review of Resident #80's behavioral care plan, last revised 7/19/24, indicated the following intervention: -Administer medications as ordered and monitor for effectiveness. Document resident's medication effects and notify MD/NP if behavior escalates. The surveyor attempted to call the physician and his office said he was unavailable for the week. During an interview on 8/29/24 at 9:37 A.M., Nurse Practitioner #1 said she was unaware Resident #80's Trazadone and Risperidone had been stopped and did not know why that would have happened. Nurse Practitioner said all medication changes should be approved by the physician. During a follow-up interview on 8/29/24 at 1:07 P.M., Nurse Practitioner #1 said the side effects of stopping an antipsychotic abruptly without tapering would be increased behaviors which Resident #80 has been exhibiting. Nurse Practitioner said the abrupt stopping without authorization from the medical team can be harmful to the Resident. During an interview on 8/29/24 at 9:45 A.M., Nurse #6 said she was aware there was a period Resident #80 was not on any psychotropic medication and was unsure of the reason. During an interview on 8/29/24 at 10:23 A.M., the Director of Nursing (DON) said she was unaware of both the Trazadone and Risperidone being discontinued and could not explain how or why this occurred. The DON said there are possible side effects of stopping psychotropic medications without a taper, which would include instability, shakes, increased agitation and confusion, and general symptoms of withdrawal. During an interview on 8/29/24 at 10:59 A.M., Corporate Nurse #1 said she would expect Resident #80 to have been seen by behavioral services after every resident-to-resident incident and when the Resident presented with increased behaviors. Corporate Nurse #1 said she would expect the interdisciplinary team to discuss every incident, including a medication review and the stopping of Resident #80's Risperidone and Trazadone should have been caught by the team. Corporate Nurse #1 said stopping antipsychotic medications abruptly would create increased symptoms. Corporate Nurse #1 said the facility had recently completed education on psychotropic medications and she believes a nurse put an end date on all psychotropic medications without speaking with the doctor. Corporate Nurse #1 said the facility went through all the medication orders to ensure this end date was deleted, however the end date of Resident #80's Risperidone must have been missed. During an interview on 8/29/24 at 2:14 P.M., the Psychiatric Nurse Practitioner said she was unaware that Resident #80's medication had been stopped and said this could have caused harm to the Resident causing increased behaviors, instability and a fast increasing of symptoms.

Based on observation, record review , policy review and interview the facility failed to ensure two Residents (#71 and #73) were provided effective interventions and supervision to prevent falls, out of a total sample of 36 residents. Specifically, the facility failed to 1) ensure for Resident #71 that effective interventions were in place to prevent further falls after sustaining multiple falls which then resulted in Resident #71 sustaining a hip fracture, and 2) ensure for Resident #73 was provided effective supervision and interventions to prevent a fall. Findings include: Review of the facility policy titled Falls Management last revised August 2018 indicated that a fall risk evaluation will be conducted after each fall and the interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. Review of the facility policy titled Comprehensive Care Plans dated last revised November 2017 indicated the care plan is revised as needed. 1. Resident #71 was admitted to the facility in February 2019 with diagnoses including dementia with behavioral disturbance, weakness and history of transient ischemic attacks (mini strokes). Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was an extensive assist of two staff members for transfers in and out of chairs and bed. Further review indicated that Resident #71 scored four out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Review of the medical record indicated that Resident #71 fell out of bed on 1/5/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 1/6/23, indicated that Resident #71 scored a 13 (above a score of 10 is considered high risk) indicating a high risk for falls. Review of the medical record indicated that Resident #71 fell in her/his room on 3/16/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 3/16/23, indicated that Resident #71 scored a 16 indicating a high risk for falls. Review of the medical record indicated that Resident #71 in her/his room on 4/6/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 4/6/23, indicated that Resident #71 scored a 20 indicating a high risk for falls. Further review of the three documents ( Nur- Fall Risk Assessment -V2 dated 1/6/23, 3/16/23 and 4/6/23)indicated an increasing rate of risk for falls with each fall. Review of the medical record indicated that Resident #71 fell in the lounge on 5/2/23. Further review indicated that Resident #71 sustained a fracture of the left femoral neck ( a type of hip fracture) requiring hospitalization and surgical intervention. Review of Resident #71's care plan with the focus on falls, dated as initiated 4/27/22, indicated that the interventions in place to prevent falls included the following: a) Invite, encourage, remind, escort to activity programs consistent with the Resident's interests to enhance physical strengthening needs. b) Provide, monitor use of adaptive devices: walker, wheelchair c) Referral for screen an treatment as needed: PT (physical therapy), OT (occupational therapy) and mental health. d) Remind Resident #71 and reinforce safety awareness: a) when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. b) Educate/remind Resident to request assistance prior to ambulation. c) appropriate footwear. Further review failed to indicate that the care plan was reviewed or updated until 5/23/23, after Resident #71 sustained a hip fracture from falling out of a chair. Review of the Nurse's note dated 5/2/23, indicated that Resident #71 was in the lounge room when a certified Nurse's aide found the Resident on the floor and yelled for the nurse to help. Further review indicated that Resident #71 stated that she/he was attempting to get the walker but her/his feet got all tangled up. Review of the facility document titled #268 Fall, dated 5/2/23, indicated that Resident #71 was wearing improper footwear at the time of the fall. During an interview on 8/9/23, at 2:16 P.M., the SDC (Staff Development Coordinator) said that he was not able to locate any documentation in the medical record that indicated the care plan was reviewed or updated after the falls that occurred on 1/5/23, 3/16/23 and 4/6/23, for if effectiveness of the current interventions were adequate to prevent further falls. The SDC then said that the care plan should have been reviewed and updated to determine if the current interventions were adequate to prevent further falls. 36431 2. For Resident #73 the facility failed to implement effective interventions including adequate supervision to prevent Resident #73 from falling. The most recent fall on 8/7/23 resulted in a hematoma and abrasion on his/her forehead. Resident #73 was transferred to the hospital emergency department for further evaluation and returned to the facility. Resident #73 was admitted to the facility in May 2019 with diagnoses including heart disease, unspecified dementia, and repeated falls. Review of Resident #73's Minimum Data Set assessment with an assessment reference date of 5/31/23 indicated Resident #73 scored an eight out of 15 on the Brief Interview for Mental Status, indicating moderately intact cognition, and required extensive assistance from staff for transfers and toileting. Review of Resident #73's medical record indicated Fall Risk Assessments dated 3/24/23, 5/24/23 and 6/19/23 indicated Resident #73 was assessed as a high risk for falls. On 8/9/23 at 9:17 A.M., Resident #73 was in his/her room, sitting in a wheelchair. The right side of Resident #73's forehead was reddened and bruised. Resident #73 said he/she fell skipping down the stairs to see his/her sister. A CNA was in the room assisting the resident in the other bed. On 8/9/23 at 9:23 A.M., the CNA left the room. Resident #73 remained in the room without staff present, a chair alarm box was attached to his/her wheelchair. At 9:27 A.M., the chair alarm sounded when Resident #73 leaned forward in his/her chair, it turned off when he/she leaned back after approximately one minute. No staff were observed to respond during the time the alarm sounded. Review of Resident #73's incident reports indicated the following: -On 2/15/23 at 14:48 (2:48 P.M.) Resident #73 sustained a fall on 2/15/23 in his/her room. Resident #73 was trying to transfer from the toilet to his/her wheelchair. The staff statements indicated it was an unwitnessed fall. No injury. -On 2/24/23 Resident #73 was on the floor in his/her room at about 5:15 P.M. during mealtime. Resident stated he/she was trying to pick up ice from the floor and fell from his/her wheelchair. Resident was assessed for a bump on his/her upper forehead. The fall was unwitnessed. -On 3/24/23 Resident #73 fell in his/her bathroom at 12:05 P.M., the incident description indicated the Resident said he/she (had) gone into the bathroom by him/herself and tripped and hit his/her head three times. He/she is complaining of having pain in the forehead. The incident report indicated the Resident did not call for assistance when ambulating from his/her wheelchair. The fall was unwitnessed. -On 6/19/23 at 11:11 A.M., Resident was found sitting on his/her bathroom floor. Resident said he/she propelled him/herself and put him/herself on the toilet then tried to use the bar to pull him/herself up and fell to the floor on his/her buttocks. The fall was unwitnessed. -On 8/7/23 at 17:52 (5:52 P.M.) Patient (Resident #73) had an unwitnessed fall in his/her room from his/her wheelchair. He/she stated that he/she was trying to go downstairs to see his/her friend. Upon assessment, the patient was observed to sustain a hematoma on his/her forehead, and he/she complained of pain on his/her left side. MD (medical doctor) notified and advised to send patient to the ED (emergency department) for evaluation. Patient has a history of falls due to poor safety awareness. A nursing progress note dated 8/7/23 indicated a call was made to the hospital, spoke to the nurse who confirmed that the patient did not sustain any fracture and will be returning to the facility. Review of the incident reports indicated all five of Resident #73's falls reviewed were unwitnessed, three were while Resident #73 was in the bathroom alone, and two falls were when Resident #73 was alone in his/her room. On 8/9/23 at 10:09 A.M., Review of Resident #73 care plan dated as revised 7/17/23 indicated the following: At risk for fall related injury related to disease process/condition (dementia, diabetes, PVD (peripheral vascular disease) CVD (coronary artery disease) .) fall history 6/19/23, fall in last month, fall in the last 2-6 months, medication usage antidepressant, use of assistive devices walker/wheelchair. Interventions included: *Call bell in reach. Give reminders to use the call bell, dated 10/24/22. *Encourage Resident to go to day room after A.M. care, 6/19/23. *Fall mats on either side of bed when resident in bed, 11/17/22. *Invite encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs 5/11/22 *Keep bed in the lowest position 11/17/22. *Padded side rails 6/14/23 * Provide/monitor use of adaptive devices: walker/wheelchair 4/27/22 *Referral for screen and treatment as needed: PT (physical therapy) *Report falls to physician and responsible party 4/27/22. *Use fall risk screen to identify risk factors 4/27/23. At the time of the care plan review, the care plan did not indicate the use of a chair alarm and indicated canceled as potential preventative measure in place is/are bed alarm, floor mat alarm, other alarm, canceled date 4/27/22. Review of the physician's orders indicated an order dated 8/9/23, two days after the 8/7/23 fall, for a chair alarm, check placement and function every shift. Review of the Resident Care Card (a reference card which breaks down a resident's daily needs), dated 3/2020 indicated the following under additional information, staff to be with the pt (patient) at all times during toileting, dated 9/16. 15-minute checks dated 10/17. Toilet after meals and before sleep. Staff being with Resident #73 during toileting did not occur in three falls. The care plan and Resident Care card had conflicting information regarding Resident #73 implemented safety interventions to prevent falls. During an interview on 8/9/23 at 12:47 P.M., CNA #4 said Resident #73 is a high risk for falling and you must keep your eye on him/her because he/she will sneak away and go back to his/her room. CNA #4 said Resident #73 believes his/her roommate is a sibling and that is why he/she wants to go back to his/her room. CNA #4 said he always tries to know where Resident #73 is. During an interview on 8/9/23 at 4:18 P.M., CNA #5 said she was working with Resident #73 the evening of his/her last fall (8/7/23) CNA #5 said Resident #73 is at risk for falls, needs frequent checks and they (staff) try to keep him/her out of his/her room. CNA #5 said Resident #73 would not have dinner in the dining room and was left in his/her room during the dinner meal. CNA #5 said staff were passing trays and helping other residents when Resident #73 fell in his/her room. During an interview on 8/10/23 at 11:03 A.M. Unit Manager #1 said Resident #73 is not on 15-minute safety checks and said she just reinstated the chair alarm after this last fall. Unit Manager #1 said Resident #73 is mostly continent and that is why he/she tries to go into the bathroom him/herself. Unit Manager #1 reviewed the fall care plan and said interventions were related to bed safety and could be updated to address Resident #73's safety when in his/her room for using the bathroom or when in his/her room alone. Aside from encouraging Resident #73 to go to the day room after morning care the care plan failed to have effective person-centered interventions to prevent the risk of falling for Resident #73, who is a known high risk for falls, who has known falls during bathroom use, or when in the room without supervision.

Based on observation, record review and interview, the facility failed to identify and address significant weight loss and failed to implement interventions to prevent weight loss for 6 residents (#7, #28, #105, #60, #102 and #46) out of a total of 32 sampled Residents. Findings include: Suggested parameters for evaluating significance of unplanned and undesired weight loss are: Interval Significant loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of the facility's Weights policy, dated 2015 indicated: *All weight loss/gain of 3 lbs or more on a resident weighing 100 lbs or less and weight loss/gain of 5 pounds or more on a resident weighing 100 lbs or more requires a reweigh for verification. A Reweigh is done on the same scale, with a licensed nurse present. *If a significant weight loss/gain is identified (< 5% in 30 days or > 10% in six months, the IDT, Dietitian, physician and family are notified. *All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions are implemented as appropriate and are monitored weekly. 1. For Resident #28, the facility failed to identify and address a significant weight loss. Resident #28 was admitted to the facility in July 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and eating. On 9/21/22 at 8:54 A.M., the surveyor observed Resident #28 resting in bed. He/she appeared frail. Review of Resident #28's care plans indicated: Resident #28 at risk for nutritional decline, revised 6/29/22. Interventions: Provide diet as ordered. Provide snacks as desired and in compliance with diet order. Monitor weight as needed. Dietitian to evaluate and make diet change recommendations as needed. Allow the resident adequate time to consume meals. Encourage resident to attend food related activities. Assist with intake as needed. Adaptive equipment as ordered. Provide medical food supplement. Review of Resident #28's weights indicated: 7/1/22: 153.4 lbs (pounds) 8/2/22: 143 lbs a severe loss of 6.78 % of his/her total body weight in 1 month. 9/2/22: 140.4 lbs a severe loss of 8.47% of his/her total body weight in 2 months. Review of the clinical record indicated that Resident #28 had most recently been evaluated by a Dietitian on 6/29/22; previous to the severe weight loss. The clinical record failed to indicate any progress notes or evaluations completed by nursing or the Physician regarding Resident #28's weight loss. During an interview with Unit Manager #3 on 9/22/22 at 10:50 A.M., she said that Certified Nurses Aides (CNAS) obtain weights and give them to the nursing staff who then put them in the computers. Unit Manager #3 said that if there is a 3 lb difference a re-weigh should be done within a couple days to verify and if its a verified change, then the Dietitian and the Physician is notified to assess the Resident. Unit Manager #3 said staff did not tell her that Resident #28 had a weight loss. During an interview with the Nurse Practitioner on 9/22/22 at 11:35 A.M., she said that she was not aware that Resident #28 had lost weight. She said that the expectation is for staff to notify her when a Resident has a significant weight loss. During an interview with the Dietitian on 9/23/22 at 8:24 A.M., she said that she had not been made aware of Resident #28's weight loss. She said she would have asked for a re-weigh to confirm the weight loss and then looked at possible interventions to address Resident #28's weight loss. 2. For Resident #105 the facility failed to identify and address a significant weight loss. Resident #105 was admitted to the facility in January 2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #105's most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #105 weights indicated: 12/2/21: 144.8 lbs (pounds) 2/1/22: 143 lbs 3/2/22: 141 lbs 4/1/22 131 lbs; a severe weight loss of 7% of his/her total body weight in 1 month. 5/1/22: 125.6 lbs; 6/2/22: 123.8 lbs; a severe weight loss of 14.5% of his/her total body weight in 6 months. 7/1/22: 124.6 lbs 8/9/22: 131.2 lbs 9/1/22: 126.5 lbs Review of Resident #105's clinical record indicated that Resident #105 had been evaluated by a Dietitian on 5/24/22; 54 days after his/her severe weight loss was first documented on 4/1/22. The evaluation indicated that Resident #105 was hospitalized and should be evaluated upon his/her return. (Resident #105 had sustained the weight loss prior to his/her hospitalization .) Resident #105's clinical record failed to indicate he/she was re-evaluated by a Dietitian upon his/her return from the hospital on 5/25/22 and was not assessed again by a Dietitian until 9/1/22. The evaluation dated 9/1/22 indicated that Resident #105 had sustained a previous weight loss and the evaluation indicated his/her current weight was based on the 8/9/22 weight. During an interview on 9/23/22 at 12:07 P.M., the Dietitian said she was not employed at the facility at the time of Resident #105's weight loss. She said that Resident #105 should have been evaluated upon his/her return from the hospital. 3. For Resident #7, the facility failed to provide fortified foods as recommended by the Dietitian to address a significant weight loss. Resident #7 was admitted to the facility in June 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is cognitively intact and requires assistance with bathing, dressing and eating. On 9/21/22 at 10:41 A.M., the surveyor observed Resident #7 resting in bed. He/she appeared frail and thin. On 9/22/22 at approximately 10:00 A.M., the surveyor observed staff assisting Resident #7 with eating his/her breakfast. Review of Resident #7's weights indicated: 6/2/22: 125.5 lbs (pounds) 7/6/22: 119 lbs; a significant loss of 5% of his/her total body weight in 1 month. 8/9/22: 109.2 lbs 8/24/22: 114.4 lbs 9/2/22: 117 lbs Review of the clinical record indicated that the Dietitian evaluated Resident #7 and recommended he/she receive fortified foods at all meals as an intervention to address the weight loss. On 9/22/22 at 11:10 A.M. the surveyor and the Food Service Director reviewed Resident #7's meal tickets. The Food Service Director said that although Resident #7 was receiving fortified cereal with breakfast, he/she was not receiving fortified foods with lunch or dinner as recommended by the Dietitian. Review of the Nurse Practitioner Note dated 9/7/22 indicated that Resident #7's current weight is 117 lbs, but his/her weight in June 2022 was 125 lbs. Last September 2021, the patient was 133 lbs. Resident #7 is on a regular textured thin liquid diet and his/her food is fortified. During an interview with the Nurse Practitioner on 9/22/22 at 11:35 A.M., she said she was not aware that Resident #7 was not receiving fortified foods with all his/her meals. 4. For Resident #60, the facility failed to identify and address a significant weight loss. Resident #60 was admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record indicated Resident #60 has an invoked health care proxy (HCP) with an invocation date 2/17/22. During an observation on 9/21/22 at 8:53 A.M., Resident #60 was observed wandering in and out of rooms. Resident #60 appeared thin and frail. Review of Resident #60's medical record indicated the following weights: *10/22/21-159.2 lbs. (pounds) (Standing) *11/2/21-160.2 Ibs. *11/19/21-128.0 lbs. (Standing) *12/1/21-126.0 Ibs. *12/8/21-125.2 lbs. *1/25/22-123.8 lbs. *2/1/22-123.8 lbs. *2/17/22-124.4 lbs *3/1/22-127.0 lbs. *4/1/22-121.0 lbs. (Standing) *5/1/22-121.8 lbs. *6/2/22-120.2 lbs *7/1/22-122.0 lbs *8/2/22-122.2 lbs *9/1/22-127.6 lbs *9/23/22-129.8 lbs In the 91-day period between 11/2/21 and 2/1/22, Resident #60 had a weight change of 22.72 % lbs indicating a severe weight loss. Review of the nutrition assessment completed on 11/2/21 indicated that Resident #60's Body Mass Index (BMI) indicated he/she was overweight and that the weight loss was desired. However, there was no indication in the medical record that the responsible party (HCP) was notified of the weight changes and if he/she was aware and in agreement that the weight loss between 11/2/21 and 2/1/22 being desired. During an interview with the Dietician on 9/23/22 at 9:38 A.M., she said she was not employed at the facility at the time of Resident #60's weigh loss and was not the Dietitian that completed the evaluation on 11/2/21. The Dietitian said the expectation is for the facility to re-weigh the Resident within 24-48 hours to confirm the weight change, notify the responsible party, confer with the interdisciplinary team (IDT) and come up with interventions. The Dietician also said she considers the 22.72% weight change in that 90-day period (11/2/21-2/1/22) to be significant. During a follow up interview with the Dietician on 9/23/22 at 9:46 A.M., she said to confirm if the weight change was desirable, the responsible party should have been made aware (since the Resident is not able to make his/her own decisions) so that the responsible party could make the decision whether the weight changes were desirable or not. She said it would be hard to determine if the Resident desired the weight loss since no one communicated with the responsible party to determine that. During an interview with the Director of Nurses on 9/26/22 at 8:08 A.M., she said she expects re-weighs to be completed if the weight is in question, notify the responsible party to find out if the weight change is desired or not, if it is not desired, work with the interdisciplinary team (IDT) to come up with interventions. 5. For Resident #102, the facility failed to identify and address a significant weight loss. Resident #102 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the minimum data set (MDS) completed on 8/31/22 indicated that Resident #102 had a brief interview for mental status (BIMS) score of 99 indicating severe impairment. Further review of the medical record indicated that Resident #102 has an invoked health care proxy (HCP) invoked 2/17/22. During an observation on 9/21/22 at 8:38 A.M., Resident #102 was observed in the dining room waiting for breakfast. Review of Resident #102's medical record indicated the following weights: *6/7/21-189 lbs-Standing *9/2/21-186.2 lbs *10/1/21-183.8 lbs *10/12/21-185.0 lbs *11/1/21-182.6 lbs *12/1/21-183.2 lbs *1/25/22-174.4 lbs *2/1/22-175.9 lbs *3/1/22-175.0 lbs *4/1/22-186.8 lbs-Wheelchair *6/29/22-166.2 lbs *7/1/22-160.6 lbs *8/2/22-160.0 lbs *9/1/22-165.2 lbs *9/1/22-164.8 lbs For the 91-day period between 4/1/22 and 7/1/22, Resident #102 had a severe weight loss of 14.03%. Review of the nutritional assessment completed on 6/1/22 indicated that Resident #102 is in the weight class 1 obesity, yet not appropriate for a weight reduction diet due to age and diagnosis, the progress note continued to state that weight loss is anticipated as the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the medical record did not include any documentation from the physician indicating that weight loss is anticipated due to Resident # 102's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the dietician on 9/23/22 at 9:50 A.M., she said she was not employed at the facility at the time of Resident #102's weight loss and did not complete the nutritional assessment dated [DATE]. The Dietitian said a reweigh should have been done to confirm the actual weight on 4/1/22, then notify the responsible party of the weight change, wait for the responsible party to determine if the weight change is desirable or not, if not desirable, work with the interdisciplinary team to put in interventions. The dietician also stated that the weight loss between 4/1/22 and 7/1/22 was a significant weight loss. During an interview with the dietician on 9/23/22 at 9:54 A.M., she said to determine if the weight loss is anticipated due to a diagnosis, there should be documentation from the physician indicating that, and more documentation indicating the responsible party being notified of the physician's expectations. During an interview with the Director of Nurses on 9/26/22 at 8:19 A.M., she said that if a weight appears to be off, a reweigh needs to be done immediately, to confirm the correct weight, if a weight change is noted, the interdisciplinary team (IDT) should be notified so they can come up with interventions, she also said that responsible parties should be notified of weight changes or expected weight changes due to diagnoses. 6. For Resident #46, the facility failed to identify and address a significant weight loss. Resident #46 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the minimum data set (MDS) completed on 7/7/22 indicated that Resident #46 was not able to complete a brief interview for mental status (BIMS) score because he/she is rarely or never understood. Further review of the medical record indicated that Resident #46's health care proxy (HCP) is invoked. During an observation on 09/21/22 at 8:46 A.M., a staff member was observed feeding Resident #46, the Resident appeared thin and frail. Further review of the medical record indicated the following weights: *7/1/22-110.2 lbs *8/2/22-102.0 lbs *9/2/22-98.7 lbs For the 32-day period between 7/1/22 and 8/2/22, Resident #46 had a severe weight loss of 7.44%. During an interview with the dietician on 9/21/22 at 11:44 A.M., she said that a weight change was missed between 7/1/22 and 8/2/22. The Dietician said a re-weigh should have been done to confirm the weight change, and if confirmed, the responsible party should have been notified of the weight change, work with him/her to come up with ideas on an intervention that would assist the Resident in a weight gain. The Dietician also said the interdisciplinary team (IDT) should be notified to include other interventions. The Dietician stated that the weight loss between 7/1/22 and 8/2/22 was a significant weight loss. During an interview with the Director of nurses on 9/26/22 at 8:12 A.M., she said the Resident #46 should have been re-weighed, when weight change was confirmed, the responsible party should have been notified and the interdisciplinary team (IDT) should have been notified as well.

Based on record review and interview, the facility failed to 1. protect residents from ongoing verbal abuse after 1 Resident (#76) alleged abuse to staff and 2.) failed to protect 1 Resident (#88) who does not have the ability to consent to physical touch with another resident out of a total of 32 sampled Residents. Findings include: Review of the facility policy titled Abuse prohibition policy revised September 2020 indicated the following: *Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation. *The procedure includes screening of personnel for a history of abuse. *Identifying events, occurrences, patterns, and trends of potential abuse for residents. *Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities. *Protecting residents from harm during an investigation of alleged abuse. *It will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur. 1. Resident #76 was admitted to the facility in September, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #76's Minimum Data Set (MDS) assessment completed 8/10/22 indicated that Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15, indicating intact cognition. During review of the facility's incident report titled Abuse by Staff-Verbal dated 8/23/22, a witness statement written by the Assistant director of nurses(ADON) indicated that she came in to work on the morning of 8/23/22 and read a note from the 24-hour report regarding an alleged incident of abuse the night before during the 3:00 P.M.-11:00 P.M. shift regarding certified nurse's assistant (CNA #2) toward Resident #76. The witness statement indicated Resident #76 alleged that CNA #2 had been treating him/her poorly. It had been happening since CNA #2 was assigned to his/her unit. Resident #76 said that CNA #2's demeanor toward him/her makes him/her feel like a burden. CNA #2 told Resident #76 she/he used the call light too often. CNA #2 also became angry at the sound of Resident #76's chair alarm and when Resident #76 requested to be changed after a bowel movement, CNA #2 made it clear she did not want to change him/ her. During an interview with the ADON on 9/30/22 at 9:54 A.M., she said the incident happened during the 3:00P.M. -11:00 P.M. shift, Resident #76 reported the incident at the end of the shift to Nurse #6, Nurse #6 wrote the incident progress note at midnight. Nurse #6 failed to alert administration of Resident #76's allegation of abuse, therefore, CNA #2 returned to work on 8/23/22 and began working on the 7:00 A.M. -3:00P.M. shift putting Resident #76 and other Residents at risk for continued abuse. During an interview with the Director of Nurses (DON) at 3:15 P.M., on 9/30/22, she said CNA #2 who was already in the building and providing care to the Residents was walked out of the building at 9:15 A.M., on 8/23/22.The investigation concluded it was in the best interest of the facility terminate CNA #2 based on neglect and verbal abuse. During an interview with both the ADON and the DON on 9/26/22 at 8:57 A.M., they both stated that the above incident was abusive towards Resident #76 and substantiated that CNA #2 was abusive towards Resident #76. 2. For Resident #88, the facility failed to prevent physical contact between him/her and Resident #39. Resident #88 is unable to consent to physical intimacy and expressed relief when he/she was separated from Resident #39. Review of the Facility's Abuse Prohibition Policy dated 2020 indicated: *Sexual Abuse includes but is not limited to: sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non consensual sexual contact of any type with a resident. Resident #88 was admitted to the facility in August 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired and he/she requires assistance with transfers, dressing and toileting. Review of Resident #88's clinical record included a letter from Resident #88's family physician dated 8/20/21, regarding his/her cognitive status: The patient suffers from mental [CONDITION(S)]. His/Her cognitive ability is lacking and he/she requires constant supervision which to date has been provided by his/her sister. Resident #88 is illiterate and lacks insight and any learning capacity due to cognitive dysfunction. The clinical record also indicated that Resident #88 became Resident #39's roommate in August 2022. Resident #39 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 15 out of 15 on the Brief interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact and he/she requires assistance with toileting and dressing. Review of Resident #39's clinical record indicated he/she has an activated health care proxy, (meaning he/she cannot make medical decisions for himself/herself due to his/her traumatic [CONDITION(S)]) Review of Resident #39's clinical record indicated a nurse progress Note dated 9/2/22, that staff had observed Resident #39 holding hands with his/her roommate (Resident #88) during an activity. Later that afternoon staff opened the door to their room and observed Resident #88 sitting on Resident #39's lap fully clothed but jumped up nervous. The note indicated that staff then placed the residents on 15 minute checks. Review of Resident #88's nursing progress note dated 9/2/22, indicated that Resident #88's sister was notified of the incident and she was upset and concerned about Resident #88's safety. She said that Resident #88 was never involved in that lifestyle. The clinical record failed to indicate an evaluation of Resident #88's ability or willingness to participate in touching or being with Resident #39, or methods for staff to monitor the interactions between Resident #88 or Resident #39 other than 15 minute checks. Review of Resident #88's nursing progress note dated 9/4/22, indicated Resident #88 said he/she was scared because Resident #39 was being loud and throwing things. Resident #88's sister reported that in the night, Resident #39 had removed Resident #88's blanket off the bed and an immediate room change then took place, (2 days after the 15 minute checks had been initiated and after Resident #88 had been observed on Resident #39's lap). Review of Resident #88's social service progress note dated 9/6/22, indicated that Resident #88 met with the Social Worker and told her about what happened and was scared, but is now happy in his/her new room. Review of Resident #39's Psychiatric Nurse Practitioner Note dated 9/13/22, indicated: Resident and his/her roommate (Resident #88), who has a developmental disorder became very close and he/she thinks they were in a relationship. Per the nursing staff he/she was inappropriate at times with touching him/her, lying in his/her bed and holding hands with him/her throughout the day. [Resident #39] asked him/her to sit on his/her lap to stop his/her legs from shaking which was very inappropriate. Resident #39 was told that they had to break up and the roommate had to change rooms as the family was very upset and they demanded an immediate room change for safety. During an interview with Resident #39 on 9/26/22, at 11:05 A.M., when asked how long he/she and Resident #88 were together he/she responded 3 weeks. When asked if they were physically romantic, Resident #39 said that they held hands and kissed. Resident #39 said that staff at the facility were not supportive of their relationship and that they had to break up when Resident #88's family found out. Resident #39 said that Resident #88 acts afraid when he/she sees him/her now and that it is upsetting for Resident #39. During an interview with Unit Manager #1 on 9/22/22, at 8:46 A.M., she said that Resident #88 could not cognitively consent to being in a physical or romantic relationship. During an interview with Nurse #3 on 9/22/22, at 8:32 A,M. he said that Resident #88 could not consent to being physical or in a relationship with another resident. During an interview with the Psychiatric Social Worker on 9/22/22, at 11:39 A.M., she said that during her visit with Resident #39 on 9/7/22, he/she had disclosed that Resident #39 and Resident #88 had been kissing previous to 9/2/22, and that Resident #39 had said that they were attracted to each other. The Psychiatric Social Worker said that she did not share this information with staff at the facility. During interview an on 9/22/22, at 12:32 P.M., and 9/23/22 at 1:03 P.M. the Director of Nursing (DON) said that she thought Resident #88 was moved out of the room on 9/2/22, and not placed on 15 minute checks. The DON acknowledged that physical incidents could still have occurred with both residents sharing the room while on 15 minute checks. The DON said that the ideal intervention for safety would have been an immediate room change off of the unit. During a follow up interview with the Social Worker and the Director of Nursing on 9/26/22, at 11:26 A.M. the Social Worker said that after they were informed of Resident #39's disclosure of kissing Resident #88 on 9/22/22, but they did not consider it to be assault even though Resident #88 is not able to consent, because they did not feel Resident #39 was malicious, and Resident #88 seemed to be a willing participant. The facility failed to prevent physical contact between Resident #88 and Resident #39. Using the reasonable person concept, a person who is unable to understand or consent to physical contact or romantic involvement with another, would suffer emotional distress.

Based on observation, interview and record review, the facility 1). failed to assess a relationship between 2 Residents (#39 and #88), 2). failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . administered insulin without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. For Resident #88, the facility failed to assess the relationship between him/her and his/her roommate (Resident #39). Resident #88 does not have the capacity to consent to a romantic relationship or physical intimacy. Resident #88 expressed relief when he/she was separated from Resident #39. American Nursing Associations Scope and Standards of Nursing Practice, 2010, pg 32,: Standard 1. Assessment: The Registered Nurse (RN) collects comprehensive data pertinent to the consumer's health and/or the situation. Competencies: Collects comprehensive data including but not limited to physical functional, psychosocial, cognitive and ongoing process while honoring the uniqueness of the person. Resident #88 was admitted to the facility in August 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired and he/she requires assistance with transfers, dressing and toileting. Review of Resident #88's clinical record included a letter from Resident #88's family physician dated 8/20/21, regarding his/her cognitive status: The patient suffers from mental [CONDITION(S)]. His/Her cognitive ability is lacking and he/she requires constant supervision which to date has been provided by his/her sister. Resident #88 is illiterate and lacks insight and any learning capacity due to cognitive dysfunction. The clinical record also indicated that Resident #88 became Resident #39's roommate in August 2022. Resident #39 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 15 out of 15 on the Brief interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact and he/she requires assistance with toileting and dressing. Review of Resident #39's clinical record indicated he/she has an activated health care proxy, (meaning he/she cannot make medical decisions for himself/herself due to his/her traumatic [CONDITION(S)]). Review of Resident #39's clinical record indicated a nurse progress note dated 9/2/22, that staff had observed Resident #39 holding hands with his/her roommate (Resident #88) during an activity. Later that afternoon staff opened the door to their room and observed Resident #88 sitting on Resident #39's lap fully clothed but jumped up nervous. The note indicated that staff then placed the residents on 15 minute checks. On 9/23/22, the surveyor was informed that the facility does not have a policy regarding resident interpersonal relationships or ability to consent to physical or romantic relationships. The clinical record failed to indicate assessments for either Resident #88 or Resident #39 identifying a possible relationship, Resident #88's ability or willingness to participate in touching or being with Resident #39, or methods for staff to monitor the interactions between Resident #88 and Resident #39. During an interview with Resident #39 on 9/26/22, at 11:05 A.M., when asked how long he/she and Resident #88 were together he/she responded 3 weeks. When asked if they were physically romantic, Resident #39 said that they held hands and kissed. Resident #39 said that staff at the facility were not supportive of their relationship and that they had to break up when Resident #88's family found out. Resident #39 said that Resident #88 acts afraid when he/she sees him/her now and that it is upsetting for Resident #39. Review of Resident #39's Psychiatric Nurse Practitioner Note dated 9/13/22, indicated: Resident and his/her roommate (Resident #88), who has a developmental disorder became very close and he/she thinks they were in a relationship. Per the nursing staff he/she was inappropriate at times with touching him/her, lying in his/her bed and holding hands with him/her throughout the day. [Resident #39] asked him/her to sit on his/her lap to stop his/her legs from shaking which was very inappropriate. Resident #39 was told that they had to break up and the roommate had to change rooms as the family was very upset and they demanded an immediate room change for safety. The Psychiatric Nurse Practitioner note indicated that staff had knowledge of Resident #39's involvement with Resident #88 including touching, lying in bed with him/her and holding hands. During an interview with the Psychiatric Nurse Practitioner on 9/23/22, at 10:55 A.M., she said that she had been informed of Resident #39's inappropriate behavior by nursing staff. During an interview with Activities Assistant #1 on 9/22/22, at 8:41 A.M. she said that it was common to see Resident #88 and Resident #39 together. She said that she had seen them holding hands on 9/2/22, and alerted the Activities Director. She also said that in the weeks before that, she had seen them sitting on a bed together and had heard staff talking about how close the two of them were getting. During an interview with Unit Manager #1 on 9/22/22, at 8:46 A.M., she said that she had been alerted by Activities on 9/2/22, that Resident #39 and Resident #88 had held hands during a movie. She said previous to 9/2/22, that she was not aware that Resident #39 or Resident #88 had been involved with one another, but that they were often seen seated together during activities or meals. Unit Manager #1 said that Resident #88 could not cognitively consent to being in a physical or romantic relationship. During an interview with Nurse #3 on 9/22/22, at 8:32 A.M. he said that staff were not really aware of the relationship between Resident #39 and Resident #88 because they always kept the door shut. Nurse #3 said that Resident #88 could not consent to being physical or in a relationship with another resident. During an interview with the Social Worker on 9/22/22, at 9:02 A.M. she said that if two residents in the facility were to begin a romantic relationship, the expectation would be for them to be assessed for the ability to consent to engage in the relationship. The Social Worker said that Resident #39 had been known to act in a caregiver role to his/her roommates. She said that Resident #39 had been seen holding hands with Resident #88, bringing him/her to activities, and sitting together for meals. She said previous to 9/2/22, she had not believed these behaviors to be indicative of romantic or physical in nature between Resident #39 and Resident #88. During an interview with the Psychiatric Social Worker on 9/22/22, at 11:39 A.M., she said that during her visit with Resident #39 on 9/7/22, he/she had disclosed that Resident #39 and Resident #88 had been kissing previous to 9/2/22, and that Resident #39 had said that they were attracted to each other. The Psychiatric Social Worker said that she did not share this information with staff at the facility. During interviews on 9/22/22, at 12:32 P.M., and 9/23/22, at 1:03 P.M. the Director of Nursing (DON) said that if Residents wish to engage in relationships, they should be assessed for the capacity to consent. She said that she had been aware of Resident #39 frequently being seen holding hands with Resident #88 but she thought that they were just friends. The DON said that Resident #39 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged that physical incidents could still have occurred with both Residents' sharing the room while on 15 minute checks. The DON said that the ideal intervention for safety would have been an immediate room change off of the unit. Review of Resident #88's nursing progress note dated 9/4/22, indicated that Resident #88 said he/she was scared because Resident #39 was being loud and throwing things. Resident #88's sister reported that in the night, Resident #39 had removed Resident #88's blanket off the bed and an immediate room change then took place, (2 days after the 15 minute checks had been initiated and after Resident #88 had been observed on Resident #39's lap) Review of Resident #88's social service progress note dated 9/6/22, indicated that Resident #88 met with the Social Worker and told her about what happened and was scared, but is now happy in his/her new room. The facility failed to assess the relationship between Resident #88's and Resident #39 despite multiple staff observations and reports of behaviors indicative of intimacy like hand holding. Using the reasonable person concept, a person who is unable to understand or consent to physical contact or romantic involvement with another, would suffer emotional distress. 2. For Resident #42, the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #42 scored a 13 out of 15 on the Brief Interview for Mental Status exam, which indicated Resident #42 is cognitively intact. On 9/21/22, at 7:53 A.M. and 4:31 P.M., the surveyor observed Resident #42 with oxygen via nasal cannula running at 3 liters (L) per minute. During an interview on 9/21/22, at 7:53 A.M. Resident #42 said that he/she had been using oxygen for quite some time. Review of the Resident's medical record failed to indicate a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/22/22, at 12:53 P.M. Unit Manager (UM) #2 said that all oxygen use requires a doctor's order and should be reflected on the treatment record. UM #2 also said that the evaluation and monitoring of the use of oxygen should include oxygen saturations both on and off of the oxygen at least every shift. During an interview on 9/22/22, at 1:47 P.M., the Director of Nursing (DON) said that all oxygen use requires a doctor's order. The DON also said that she could not find a policy that indicated the need for a doctor's order for oxygen or how to assess the use of oxygen. 3. For Resident #39, the facility administered insulin without an order. Review of the Code of Massachusetts Regulations Section 9.03- Standards of Conduct for Nurses, current through 8/5/22, indicated a nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. Review of facility policy titled 'Medication Administration by Route or Dosage', revised March 2017, indicated the following: Procedure: Verify medication order on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #39 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #39 was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with care activities and received insulin (an injectable medicine used to treat blood sugar). On 9/21/22, at 9:42 A.M., Resident #39 was observed sitting in his/her room. The Resident said he/she had a concern with his/her insulin administration this morning. Resident #39 said no one had ordered his/her insulin and he/she did not get the correct dose this morning. Resident #39 said this morning after breakfast he/she was given 45 units of insulin instead of the 72 units he/she is supposed to receive. Resident #39 said the nurse told him/her that maybe he/she would get the rest of the dose this afternoon. Review of Resident #39's medical record indicated the following: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 72 units subcutaneously every morning. Rotate sites. -September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/21/22, at 10:02 A.M., Nurse #1 said that she only gave the Resident 45 units of insulin as that was all she had on hand. Nurse #1 said there were no other vials of the insulin in the medication fridge. Nurse #1 said she had not notified the physician or Nurse Practitioner of the incorrect dose of insulin being administered and had not gotten an order to administer 45 units only prior to administration. During an interview on 9/21/22, at 10:14 A.M., the Assistant Director of Nursing said the nurse should not have administered a partial dose of the insulin. The Assistant Director of Nursing said that the nurse should have notified the provider that there wasn't enough for a full dose and then gotten a new order. The Assistant Director of Nursing said the nurse can't just administer what is left. During an interview on 9/21/22, at 2:44 P.M., the Director of Nursing said she was aware of the incorrect dose of insulin being given to Resident #39. She said the nurse should have obtained an order prior to administration and said it was serious.

Based on observation, record review and interview, the facility failed to provide necessary treatment to prevent the worsening of pressure ulcers for 1 Resident (#43) out of a total of 32 sampled residents. Findings include: Review of the facility's Prevention and Management of Pressure Injuries policy, dated July 2017 indicated: Wound treatments are done per physician order. Stage 3 and Stage 4 pressure injuries should be covered. Resident #43 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of his/her most recent Minimum Data Set assessment dated [DATE], indicated he/she was severely cognitively impaired and requires assistance with bathing, dressing and toileting. On 9/21/22, at 8:16 A.M., the surveyor observed Resident #43 asleep in bed. One foot was flat on the mattress and the other foot was resting on the floor. Review of Resident #43's care plans indicated: Actual skin alteration in skin integrity, dated 7/31/22; Goal: Resident will show evidence of healing. Interventions: Medicate per orders, complete skin condition check, heels offloaded while in bed, provide positioning intervention as indicated on impaired functional mobility care plan, follow MD orders for skin care and treatments. Review of Resident #43's clinical record indicated he/she developed a deep tissue injury (a kind of pressure injury with localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device) on his/her left heel. Review of Resident #43's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Offload heels at all times when in bed. Review of the Wound Physician's progress note dated 8/2/22, indicated: Unstageable Deep Tissue Injury (DTI), 2 CM (centimeters) X 2 CM Exudate (drainage): None Surface Area: 4.00 CM Objective: Control Infection treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's August Treatment Administration Record indicated his/her wound treatments were not completed on the 7:00 A.M.- 3:00 P.M. shift on 8/2/22, 8/3/22, 8/9/22, 8/17/22, 8/26/22; and also not completed on the 3:00 P.M. -11:00 P.M. shift on 8/3/22, 8/11/22, 8/14/22, 8/23/22, 8/26/22. Review of the Wound Physician's progress note dated 8/23/22, indicated: Stage III Left Heel Ulcer: 4 centimeters (CM) X 4 CM X. 01 CM (which indicated the wound opened) Surface area: 16 CM Slough (dead tissue separating from the ulcer): 50% Granulation tissue (new connective tissue): 50% Exudate: None Periwound (surrounding skin) radius: Odor Treatment Recommendations: Leptospermum honey, apply once daily for 30 days; [MEDICATION(S)] (an antibiotic) gel, apply once daily for 30 days. Gauze island with BDR (border) apply once daily for 30 days. Objective: Control infection Required surgical Debridement. (A surgical procedure to remove dead tissue from the wound) Review of the nursing progress note dated 8/26/22, indicated: This writer called Nurse Practitioner to report that patient's treatment [MEDICATION(S)] ([MEDICATION(S)]) gel hasn't been delivered due to order faxed had no strength in it, new order given to d/c [MEDICATION(S)] gel and continue with med honey. The nursing progress note indicated that Resident #43 did not receive an ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 8/29/22: Resident with left heel wound getting worse. Seen today by nurse practitioner. X-Ray to left heel to evaluate for [CONDITION(S)], Start [MEDICATION(S)] 100 mg by mouth BID x 7 days, [MEDICATION(S)] 875/125 mg by mouth BID x 7 days. (Antibiotics to treat infections) Review of the Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Stage III Left heel wound: 4 CM X 4 CM X .1 CM Surface area: 16 CM Exudate: Moderate serous (Fluid draining from the wound; there had been none at the previous visit) Slough: 100% (an increase of dead tissue from the previous visit by 50%.) Required Debridement During an interview with the Wound Physician on 9/23/22, at 3:06 P.M., he said that he was not aware that Resident #43 went 3 days without having a treatment as ordered. During an interview with the Director of Nursing and the Assistant Director of Nursing on 9/26/22, at 8:42 A.M., they said that they were not aware about treatments not being completed as ordered for Resident #43.

Based on records reviewed and interviews, for one of 22 sampled residents (Resident #22), who required the use of continuous oxygen, which was only removed when he/she went outside to smoke, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety. On 11/27/21 at approximately 6:30 P.M., Resident #22, along with several other residents, was assisted outside to the smoking area by a receptionist. While Resident #22 finished his/her cigarette, other smokers were assisted back into the Facility, however no one checked on Resident #22 or assisted him/her back inside the Facility when he/she was finished smoking. Resident #22 was left alone, outside without his/her oxygen for approximately 1.5 hours, in the dark, and temperature condition was approximately thirty-seven degrees. As a result, Resident #22 said he/she was worried and felt dizzy, was becoming short of breath, and felt like he/she was going to pass out, while he/she waited for someone to come for him/her and assist him/her back into the Facility. Findings Include: Review of the Facility Policy titled Smoking, dated as revised 11/2020, indicated that smoking would take place under the supervision of a staff member. Review of the Grievance Sheet, dated 11/30/21, indicated that, on Saturday 11/27/21, Resident #22 went out for the 6:30 P.M. cigarette break. The Grievance Sheet indicated that the girl at the front desk let the smokers outside and periodically checked on them to see who was ready to come in. The Grievance Sheet indicated that Resident #22 was left outside until 8:50 P.M. The Grievance Sheet indicated that the receptionist was to receive education about the smoking protocol. During an interview on 01/26/22 at 3:15 P.M., the Social Worker said Resident #22 told her that on the night of 11/27/21, he/she was left outside alone after everyone else went in from smoking break and said Resident #22 told her that he/she wanted to get back into the Facility but could not get in. The Social Worker said the smoking area is accessed through a door in the dayroom (which is not within sight of the reception area), that there's a code for the door, and it leads to the patio. The Social Worker said that staff must oversee the smokers while on the patio, that staff must be able to see the residents at all times. The Social Worker said Resident #22 told her he/she was very tired by the time he/she got back to his/her room and said Resident #22 was very upset about the situation and asked her to file a formal complaint for him/her. During an interview on 01/26/22 at 3:45 P.M., the Human Resource (HR) Manager said she spoke with the Receptionist who told her that she had paged nursing staff to take the group of smokers outside and nobody came so she let the group outside to smoke. The HR Manager said the Receptionist told her that, after she let the smokers outside, she left the smoking area and went back to the front lobby of the Facility (reception area) and later went back to the door to the smoking area to let the smokers back inside. The HR Manager said the Receptionist told her that she did not remember leaving anyone outside. The HR Manager said resident smoking break is never supposed to be overseen by the Receptionist and said it was supposed to be a Certified Nurse Aide (CNA) that does smoking breaks. The HR Manager said that the Receptionist should not have let the residents outside to smoke if she was not going to be there watching them at all times. During an interview on 02/01/22 at 12:00 P.M., the Receptionist said that the nurses usually bring residents outside to smoke and said, on 11/27/21, when she called the unit, nobody came. The Receptionist said although she could not recall who told her, she was told that she could let the smokers outside and then check on them. The Receptionist said she was a new employee and said she had never taken the smokers outside in the past. The Receptionist said she was never told to stay there to watch the smokers and said she was told she could go back to the front desk. The Receptionist said she was unsure how the door opened from outside, but said that when the door opens, an alarm goes off. The Receptionist said she recalled that one of the residents had a breathing thing (oxygen tank) but did not know what it was and said when she let the smokers back inside, she thought she saw everyone come in. During an interview on 02/01/22 at 12:15 P.M., Resident #22 said, on 11/27/21, one of the receptionists took everyone, approximately 4 or 5 people, out to have a cigarette and said the Receptionist did not stay with them or come outside. Resident #22 said the Receptionist came back to check on people and when the other residents finished their cigarettes they went inside. Resident #22 said after he/she finished his/her cigarette, he/she rang the door bell from outside to let someone know he/she was ready to come in. Resident #22 said at some point he/she saw the Receptionist come from the front of the building into the lobby and tried to get her attention. Resident #22 said the Receptionist looked at the door to the smoking area, and said even though he/she waved at the Receptionist to get her attention, she walked away and back up to the front lobby. Resident #22 said the outside door had a handle, that there was something that looked like it needed a security code and if the button is pressed, he/she thought it would ring and said he/she kept ringing it. Resident #22 said he/she was outside in the smoking area for approximately 1.5 hours and said he/she required continuous oxygen which he/she did not have because he/she has to leave it inside the Facility when going out to smoke. Resident #22 said he/she was worried because he/she felt dizzy, was getting short of breath, and felt like he/she was going to pass out because he/she was outside for so long. Resident #22 said although he/she was wearing a sweater, said it was chilly outside. Resident #22 said the same girl that let him/her outside finally came back and let him/her in but did not ask if he/she was ok or if he/she needed anything. Review of the Accuweather temperature recorded for the Facility's location for 11/27/21 was thirty-seven degrees. During an interview on 01/26/22 at 4:50 P.M., the Director of Nursing (DON) said CNAs are typically responsible for taking residents outside to smoke during their designated smoking times. The DON said a staff member should be outside with residents who are smoking at all times, because too much can happen too quickly and said the Receptionist should not have assisted the smokers outside and or left the area to go up front.

Based on observation, record review, and interview, the facility failed to: 1) ensure residents identified as high risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for two Residents (#26 and #68) and 2) failed to prevent an elopement from the facility for one Resident (#77) out of a total sample of 25 residents. Findings include: Review of the Facility's Fall Management Policy, revised August 2018, indicated the following: -A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly MDS cycle, when a significant change in status occurs, annually and following a fall. -The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. -Residents/patients who are identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with information made available at the time of admission to implement a safety related care plan. Residents/patients who are identified to be at risk on subsequent fall evaluations will be evaluated in accordance with nursing, medical and rehabilitation needs. -A fall risk will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological checks, range of motion and evaluation of cognitive status will be documented. -The interdisciplinary team will meet at the next morning meeting to review any falls. The falls policy did not include any procedures or methodology for facility staff to follow regarding assessment of resident status for patterns or updating resident interventions to prevent further potential falls. 1) A. Resident #26 was admitted to the facility in March 2020 with diagnoses that included [CONDITION(S)] and muscle weakness. Review of Resident #26's most recent Minimum Data Set (MDS) dated , 1/1/21, indicated that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 10, indicating that he/she has severe cognitive impairment. The MDS also indicated that Resident #26 requires extensive assistance for all mobility tasks. Review of Resident #26's Nursing notes indicated that Resident #26 had sustained falls on 5/22/20, 5/26/20, 6/28/20, 7/14/20, 7/27/20, and 8/7/20. Review of the incident report for the fall that occurred on 5/22/20 indicated that Resident #26 sustained a fall sliding out of his/her wheelchair. The investigation concluded with an intervention to be supervised when out of bed. Review of Resident #26's fall care plan failed to indicate that this intervention was added to the care plan. An intervention was added on 5/26/20 for Resident #26 to be seated in common areas. Review of an incident report dated 7/14/20, indicated that Resident #26 sustained a fall in his/her room while transferring him/herself out of bed. Review of the subsequent nursing noted dated 7/14/21 indicated that Resident #26 sustained a zygomatic arch (jaw) fracture secondary to the fall. During an interview on 3/18/21 at 10:41 A.M., Certified Nursing Assistant (CNA) #2 said that Resident #26 is able to be in his/her room alone and does not require supervision for basic mobility tasks. CNA #2 said that Resident #26 is most comfortable in his/her room and even if Resident #26's care plan had an intervention for him/her to be in common areas while awake, the staff let him/her stay in his/her room. CNA #2 said that Resident #26 has a bed alarm and floor mat which should keep him/her safe from falls. During an interview on 3/18/21 at 10:13 A.M., Nurse #1 said that she was unaware that Resident #26's fall care plan included an intervention for him/her to be supervised in the day room while awake. Nurse #1 said that she feels the interventions of an alarm and fall mat are enough to keep the resident safe from falls. 1) B. For resident #68 the facility failed to identify and implement interventions to address his/her falls. Subsequently, Resident #68 sustained 6 falls in 6 months, including 1 fall with major injury. Resident #68 was admitted ,d+[DATE] diagnosis including diabetes, chronic pulmonary obstructive disease and depression. Review of Resident #68's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that he/she is moderately cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #68's care card, (a form utilized to inform staff on how to care for a resident), indicated that Resident #68 requires 1 person assistance with toileting, transfers, bed mobility and ambulation. During an interview with Resident #68 on 3/16/21 at approximately 8:45 A.M., the surveyor observed the resident to be wearing an alarmed seatbelt. Resident #68 said that he/she has the alarmed Velcro seatbelt because he/she had fallen a few times recently. Review of Resident #68's clinical record revealed 4 different fall care plans with differing dates of interventions. Review of the Facility's Fall Management Policy, revised August 2018, indicated the following: *A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly MDS cycle, when a significant change in status occurs, annually and following a fall. *The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. *Residents/patients who are identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with information made available at the time of admission to implement a safety related care plan. Residents/patients who are identified to be at risk on subsequent fall evaluations will be evaluated in accordance with nursing, medical and rehabilitation needs. *A fall risk will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological checks, range of motion and evaluation of cognitive status will be documented. *The interdisciplinary team will meet at the next morning meeting to review any falls. The falls policy did not include any procedures or methodology for facility staff to follow regarding assessment of resident status for patterns or updating resident interventions to prevent further potential falls. a. Review of Resident #68's Fall Incident Report and Investigation dated 10/28/20 indicated that at 1:00 P.M., Resident #68 turned off his/her alarmed Velcro seatbelt and toileted him/herself. Resident #68 then fell on his/her way back to bed. Resident #68 sustained a small skin tear to his/her right arm. The incident report indicated that Resident #68's care card and care plan were not updated with new interventions and that despite being assessed as having moderate cognitive impairment staff re-educated Resident #68 on the importance of the use of alarms and his/her call light. The facility failed to develop a plan of care related to Resident #68 turning off the alarms. There were no updates to Resident #68's care card, falls or behavior care plan to address Resident #68 turning off his/her alarms. b. Review of Resident #68's Fall Incident Report and Investigation dated 11/6/20 indicated that at 10:45 P.M., Resident #68 fell while getting out of bed attempting to go to the bathroom. A written Certified Nurses Aid (CNA) witness statement indicated that Resident #68's alarms were off. The incident report indicated that Resident #68 sustained lacerations to his/her left hip and was sent to the hospital. Review of the Hospital Report indicated that Resident #68 sustained one 8 centimeters X 1 centimeter laceration requiring 6 sutures and one 1.5-centimeter laceration requiring 2 sutures. Interventions implemented to prevent re-occurrence was re-education provided to the resident on safety and use of the call button for assistance; interventions which had been previously in place for Resident #68 and had not been effective. There were no updates to Resident #68's care card or care plan to address Resident #68's behavior of turning off his/her alarms. c. Review of Resident #68's Fall Incident Report and Investigation dated 11/16/20 indicated that he/she fell out of bed at 9:30 P.M. The report indicates that Resident #68 stated he/she slid out of bed. The investigation did not indicate if Resident #68's alarms were on or functioning. The report failed to indicate any new interventions were implemented to prevent further occurrence of falls. d. Review of Resident #68's Fall Incident Report and Investigation dated 12/25/20 indicated that at 9:00 P.M., Resident #68 fell out of his/her wheelchair. The incident report indicated that Resident #68 told staff that he/she slid out of his/her wheelchair. Interventions implemented to prevent further occurrence were 15 minute checks and placing the call light and frequently needed objects in reach. The investigation did not indicate if Resident #68's alarms were on or functioning. Review of Resident #68's clinical record failed to indicate that 15 minute checks were implemented after the fall. No staff could confirm if Resident #68 had been placed on 15 minute checks after he/she fell on [DATE]. Review of Resident #68's Fall Care Plans included keeping Resident #68's call light within reach, and for the use of a reacher for items objects dated 11/6/20. e. Review of Resident #68's Fall Incident Report and Investigation dated 1/11/21 indicated that at 2:45 P.M., Resident #68 fell while attempting to transfer himself/herself from the bed to the wheelchair. A rehab staff witness statement indicated that Resident #68's call light was in reach and that he/she was re-educated to call for help. The investigation did not indicate if Resident #68's alarms were on or functioning. The incident report failed to indicate any new interventions to prevent further occurrences of falls were implemented. f. Review of Resident #68's Fall Incident Report and Investigation indicated that on 3/17/21 Resident #68 fell at 6:00 P.M., after trying to get up from his/her bed to go to the bathroom. The incident report did not include if Resident #68's alarms were on or functioning. Interventions implemented to prevent re-occurrence was the use of fall mats. During an interview with CNA #6 on 3/17/21 at 9:58 A.M., she said that Resident #68 falls frequently and that his/her alarm belt is used to prevent the resident's falls. CNA #6 said that Resident #68 is alert and oriented x 3 and staff always reminds Resident #68 to use his/her call light to call for assistance. CNA #6 said that Resident #68 turns off his/her bed and chair alarm frequently. CNA #6 also said that Resident #68 also places himself/herself on the floor for attention. CNA #6 was unable to articulate other interventions staff have utilized to address Resident #68's falls or his/her behavior of turning off his/her alarms. During an interview with Nurse #5 on 3/27/21 at 10:10 A.M., she said that Resident #68 has had a number of falls. Nurse #5 said that staff frequently check on Resident #68 and that he/she has alarms as interventions to prevent falls, but that Resident #68 does turn off his/her alarms. Nurse #5 said that she was told that Resident #68 will put himself/herself on the floor as a behavior. Nurse #5 was not sure of other interventions that may have been utilized to address Resident #68's falls or his/her behaviors of turning off his/her alarms. Review of Resident #68's behavior care plan indicated a behavior of placing himself/herself on the floor, but did not include interventions or a means to address the behavior. Resident #68's behavior care plan did not include Resident #68's behavior of turning off his/her alarms or interventions on how to address this. Review of Resident #68's behavior monitoring sheets indicated that the behavior of placing himself/herself on the floor, or turning off his/her alarms had not been tracked from October 2020 - March 2021. None of the fall investigations indicated that Resident #68 had placed himself/herself on the floor instead of falling. Review of Resident #68's available psychiatric counseling notes from 12/2020 - 2/2021 indicated that he/she was being seen by psychiatric services for supportive counseling, but his/her behaviors were not being discussed during therapy. During an interview with the Director of Nursing and the Regional Nurse on 3/19/21 at 11:30 A.M., the surveyor reviewed Resident #68's falls. The Director of Nursing said that the expectation is for all residents to be assessed after falls to determine if there were any patterns to follow regarding falls. She said that resident care plans should be updated with new interventions after falls in an effort to prevent further falls. 2. For Resident #77, the facility failed to conduct an Elopement Risk Screen after a change of condition. Resident #77 was admitted to the facility in June 2020 with diagnoses including dementia, depression, [CONDITION(S)] and intracranial abscess. Review of Resident #77's Minimum Data Set, dated dated dated [DATE] indicated Resident #77 was cognitively intact with a 14 out of 15 on the Brief Interview for Mental Status. Review of Resident #77's medical record included a nursing progress note dated 7/4/2020 at 7:48 A.M. which indicated: - Patient continues to exit seek and was found near break room. Patient was redirected to his/her room but was put on 1:1 (supervision within arms reach) until the next shift. Safety maintained. Upon tour of the facility, the Surveyor observed that the break room was on the opposite side of the building from where Resident #77's bedroom/unit was located. Further review of Resident #77's medical record included a nursing progress note dated 7/05/20 at 7:18 A.M. which indicated the following: - Resident was extremely confused and difficult in redirection during sundown. He/she was combative and refused to settle while cued by staff. Change in mental status was noted. When staff were busy attending to other needy patients in the unit, this resident was later found outside the building wandering around. He/she was brought in by three staff, but with resistance from the resident. He/she was then kept 1:1 for continuous supervision to prevent elopement. Further review of Resident #77's medical record included a Social Service Progress Note dated 7/6/22 which indicated that Resident #77 eloped from building over the weekend. Review of Resident #77's medical record failed to indicate that an elopement assessment was completed after Resident #77 was found near the employee break room on 7/4/2020. During an interview on 3/19/21 at 10:12 A.M., the Director of Nursing (DON) said that an elopement risk screen assessment should be completed upon admission, quarterly and with a change in condition. The DON further said that if a resident begins to exhibit impulsive behaviors, exit seeking behaviors, begins wandering, or is found off of his/her unit an elopement assessment should be completed. The DON said she was unaware that Resident #77 had been found by staff outside of the building. The DON was unable to say why Resident #77's did not have an elopement risk assessment completed after he/she began to exhibit exit seeking behaviors prior to eloping from the building and that it should have been done. Review of facility policy titled Elopement July 2015 indicated that an Elopement Risk Screen will be completed on admission, re-admission, annually, quarterly, and upon change of condition.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively impaired, had a [DIAGNOSES REDACTED]. On 01/26/21, Resident #1 who was seated at the nursing station in a wheelchair, was served a hot beverage in a Styrofoam cup without a lid, he/she spilled the hot beverage onto his/her lap, and [MEDICAL CONDITION] both upper thighs, the areas were immediately assessed by nursing, and were red and blistered. Resident #1's burn areas were evaluated and treated by the Wound Physician, he/she required treatments to the burn areas until 3/03/21, when the treatments were discontinued. Findings include: Review of Resident #1 medical record indicated he/she was admitted to the Facility in January 2021, with [DIAGNOSES REDACTED]. The record indicated Resident #1 was cognitively impaired, unable to make his/her own health care decisions, and indicated that he/she was very hard of hearing. Review of Resident #1's Admission Nursing Summary, dated 01/25/21, indicated that he/she was forgetful, confused, disoriented, and he/she had poor hearing. Review of Resident #1's Nurse Progress Note, dated 01/26/21, indicated that during the day shift (7:00 A.M. to 3:00 P.M.), he/she was confused and required a lot of redirection to maintain his/her safety. The Note indicated Resident #1 had tremors and required assistance while eating. Review of Resident #1's Occupational Therapy (OT) Evaluation and Plan of treatment, dated 01/26/21, indicated that he/she had impaired fine motor skills and impaired gross motor coordination. During an interview on 03/09/21 at 11:00 A.M., the Occupational Therapist (OT) said she met with Resident #1 and found that he/she had impairments with hand eye coordination, fine motor skills, and upper body strength. The OT said that Resident #1 was confused, thinking he/she was at home during the evaluation and required reorientation. The Therapist said that she would not recommend residents, especially resident's with cognitive impairments, to be served hot beverages out of styrofoam cups, due to safety concerns. The Facility's Investigation, dated 02/01/21, indicated that on 01/26/21, the kitchen staff prepared hot beverages for residents during dinner, but did not take the temperature of the hot beverages at any time before being served to the residents. The Investigation indicated that the Administrator helped staff serve residents dinner around 5:30 P.M., and she gave Resident #1 a cup of hot tea in a styrofoam cup. The Investigation indicated that Resident #1, who was sitting in a wheelchair near the nursing station, spilled the hot tea onto his/her thighs, which resulted [MEDICAL CONDITION] his/her upper thighs which required wound care treatment. Review of Resident #1's Skin Assessment, undated (later identified as 01/26/21), indicated that he/she had bilateral broken blisters on his/her upper thighs. Review of Resident #1's Pain Evaluation, dated 01/26/21, indicated that he/she complained of mild pain due to his/her new burns. The Evaluation indicated that staff applied a cold pack to Resident #1's burns. The Evaluation indicated that Resident #1's facial expression was noted as sad, frightened, frown and his/her body language was noted as tense, distressed, fidgeting. During an interview on 03/09/21 at 5:00 P.M., the Nurse Supervisor said that she had Resident #1 on her assignment when he/she spilled the hot tea on him/herself. The Nurse Supervisor said Resident #1 was sitting near the nursing station for supervision because she (Nurse Supervisor) had safety concerns with Resident #1 being impulsive as he/she appeared to be sun-downing (state of confusion occurring in the late afternoon and spanning into the night). During an interview on 03/09/21 at 10:24 A.M., the Regional Clinical Specialist said she was helping on Resident #1's care unit on 01/26/21. The Specialist said she was sitting at the nursing station and heard Resident #1 yell out, Oh, oh, oh so she went to see what was going on. The Specialist said that she brought Resident #1 into his/her room to complete an assessment and attended to his/her burns. Review of Certified Nurse Aide's (CNA) #1's Written Statement, dated 01/27/21, indicated that she was in the hallway and she heard Resident #1 yell, I spilled hot tea on my legs. The Statement indicated that a nurse asked CNA #1 to assist with changing Resident #1, which was when she saw that Resident #1's knees and thighs were bright red with blisters, and that the blisters had started to peel. Review of Resident #1's Treatment Administration Record (TAR), dated 1/26/21, indicated that his/her physician's orders [REDACTED]. The TAR indicated nursing to cover his/[MEDICAL CONDITION] a foam dressing (a highly absorbent dressing which is permeable to gases and water vapors) and monitor. Review of Resident #1's Initial Wound Evaluation and Management Summary, dated 02/10/21, indicated that he/she had a burn wound which measured 6 centimeters (cm) long, 2.5 cm wide, and 0.1 cm in depth, on his/her right lower medial thigh. The Evaluation indicated that Resident #1 had a burn wound which measured 1.5 cm long, 3 cm wide, and 0.1 cm depth, on his/her left upper medial thigh. The Evaluation indicated that Resident #1 had a surgical excisional debridement procedure (debridement is the removal of dead or infected skin tissue to help a wound heal) at the Facility to treat his/her burns. Review of Resident #1's medical record indicated he/she continued to be followed by the Wound Care Physician and was evaluated again by the Wound Physician on 02/24/21 and 03/02/21 to treat and monitor his/her burns. Review of Resident #1's Physician's Interim / Telephone orders, dated 3/03/21, indicated to discontinue treatments to his/her left and right upper [MEDICAL CONDITION], however he/she had a new physician's orders [REDACTED]. During an interview on 03/09/21 at 12:45 P.M., the Food Service Manager (FSM) said that prior to the incident on 1/26/21, kitchen staff did not take the temperatures of the hot beverages coming out of the kitchen that was served to the residents. The FSM said kitchen staff started checking the temperatures of the hot beverages coming out of the kitchen in response to Resident #1's incident. The FSM said the Facility does not have a Policy regarding hot beverages or the use of styrofoam cups. During an interview on 03/09/21 at 10:00 A.M., the Administrator said that on 01/26/21, the Facility used styrofoam cups and other single use dinnerware on one unit due to infection control concerns. The Administrator said that on 01/26/21 she assisted staff with serving dinner on Resident #1's care unit. The Administrator said she saw Resident #1, who had been upset and wanting to go home, sitting near the nursing station in a wheelchair and said he/she had refused to eat dinner. The Administrator said she poured hot water for tea from the holding container into a styrofoam cup for Resident #1. The Administrator said she placed the hot cup of tea on a side table near Resident #1 and she told him/her to wait a few minutes before drinking it. The Administrator said she did not see Resident #1 spill the beverage but heard him/her yell out, Ah, I spilled it, it's hot. The Administrator said she responded to Resident #1 and saw his/her pants/thighs were wet, so she pulled her clothes away from his/her skin and other staff came to help.

Based on interviews and records reviewed, for one of three sampled residents (Resident #2), the Facility failed to ensure he/she was free from unwanted sexual contact and verbal abuse, when Resident #1 who had a known history of exhibiting sexually inappropriate behaviors in the Facility, grabbed Resident #2, attempted to put his/her tongue in Resident #2's mouth, and made a lewd and indecent comment to Resident #2. Resident #2 was visibly upset and shaken by the incident and told staff it triggered his/her [MEDICAL CONDITION]. Findings include: The Facility policy titled, Abuse Prohibition, dated 12/2016, indicated sexual abuse was defined as sexual harassment, sexual coercion, or sexual assault. Sexual abuse was non-consensual sexual contact of any type with a resident. The Facility policy titled, Resident to Resident Altercation, dated 4/2015, indicated an altercation free culture would be promoted through appropriate staff and resident screening, training, education, supervision, and support. The policy indicated a system to follow up on altercations, with an emphasis to prevent future altercations, would be in place such as updated care plans. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Review of Resident #1's medical record indicated he/she had been involved in at least one previous resident to resident altercation related to unwanted sexual contact in (MONTH) (YEAR), that was reported to and investigated by the Department of Public Health. The Care Plan, dated, 11/16/18, indicated Resident #1 was to be supervised by staff at all times when out and about on the unit, and was only allowed to visit female residents in common areas, due to known sexually inappropriate behaviors toward other residents. Resident #2 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Facility's Investigation, dated 3/25/19, indicated that on 3/25/19, Resident #2 reported to the Director of Social Services that Resident #1 had reached behind his/her neck, pulled him/her close, and kissed him/her on the lips with his/her tongue. The Investigation indicated Resident #2 said he/she did not consent to this contact, and said it was unwanted. The Investigation indicated Resident #2 said Resident #1 said to meet him/her in the bathroom later for oral sex, or words to that effect. The Surveyor interviewed Resident #2 at 2:00 P.M. on 4/17/19. Resident #2 said that on 3/25/19, just after breakfast, he/she was in the family room located on the first floor of the Facility, when Resident #1 approached him/her from the side, reached around his/her neck, pulled him/her (Resident #2) to his/her (Resident #1's) face. Resident #2 said Resident #1 kissed him/her on the lips, and then tried to put his/her (Resident #1's) tongue in his/her (Resident #2's) mouth. Resident #2 said he/she pulled back away from Resident #1. Resident #2 said Resident #1 then said for him/her to meet Resident #1 in the bathroom later and I'll eat you out or words to that effect. Resident #2 said there were no staff in the family room when the incident occurred. Resident #2 said he/she went out to the hallway, and was shaken and upset. Resident #2 said a staff member was walking by and asked him/her what was wrong, and the staff member told Resident #2 to report it immediately to the Director of Social Services. Resident #2 said that Resident #1's actions caused him/her to think of memories of when he/she was raped many years ago, and said it caused him/her to experience [MEDICAL CONDITIONS] from that experience. Resident #2 said he/she felt devastated from the incident with Resident #1, and said the sight of (Resident #1) makes me feel sick to my stomach or words to that effect. The Surveyor interviewed Resident #1 at 1:34 P.M. on 4/17/19. Resident #1 said he/she had a high libido and could not help him/herself or words to that effect. Resident #1 said he/she had pulled Resident #2 close to him/her and just gave him/her a kiss or words to that effect. Resident #1 said he/she did not have permission from Resident #2 to kiss him/her, and said Resident #2 was angry after the kiss. The Surveyor interviewed the Director of Nurses at 10:52 A.M. and throughout the course of the survey. The Director of Nurses said Resident #1 had a known history of sexually inappropriate behaviors and an incident of sexual abuse while in the Facility that had occurred with another resident. The Director of Nurses said Resident #1 was supposed to be supervised at all times by staff, but said that on 3/25/19, Resident #1 was not supervised by staff, was in the family room with Resident #2, and the incident of resident to resident sexual abuse occurred as a result.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure staff implemented interventions identified in Resident #1's comprehensive Plan of Care, which indicated he/she required distant supervision at all times. Resident #1 had a known history of sexually inappropriate behaviors and, while unsupervised by staff, made unwanted sexual contact with Resident #2. Findings include: The Facility policy titled, Resident to Resident Altercation, dated 4/2015, indicated an altercation free culture would be promoted through appropriate staff and resident screening, training, education, supervision, and support. The policy indicated a system to follow up on altercations, with an emphasis to prevent future altercations, would be in place such as updated care plans. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Care Plan, dated, 11/16/18, indicated staff were to provide distant supervision for Resident #1 at all times when out and about on the unit, and was only allowed to visit residents of the opposite gender in common areas, due to known sexually inappropriate behaviors toward other residents. Resident #2 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Facility's Investigation, dated 3/25/19, indicated that on 3/25/19, Resident #2 reported to the Director of Social Services that Resident #1 had reached behind his/her neck, pulled him/her close, and kissed him/her on the lips with his/her tongue. The Investigation indicated Resident #2 said he/she did not consent to this contact, and said it was unwanted. The Investigation indicated Resident #2 said Resident #1 said to meet him/her in the bathroom later for oral sex, or words to that effect. The Surveyor interviewed Resident #2 at 2:00 P.M. on 4/17/19. Resident #2 said that on 3/25/19, just after breakfast, he/she was in the family room located on the first floor of the Facility, when Resident #1 approached him/her from the side, reached around his/her neck, pulled him/her (Resident #2) to his/her (Resident #1's) face. Resident #2 said Resident #1 kissed him/her on the lips, and then tried to put his/her (Resident #1's) tongue in his/her (Resident #2's) mouth. Resident #2 said he/she pulled back away from Resident #1. Resident #2 said Resident #1 then said for him/her to meet Resident #1 in the bathroom later and I'll eat you out or words to that effect. Resident #2 said there were no staff in the family room when the incident occurred. The Surveyor interviewed the Director of Nurses at 10:52 A.M. and throughout the course of the survey. The Director of Nurses said Resident #1 had a known history of sexual inappropriateness and sexual abuse of at least one other resident (Resident #3). The Director of Nurses said Resident #1 was supposed to be supervised at all times by staff, but on 3/25/19, Resident #1 was not supervised by staff, was in the family room with Resident #2, and the incident of resident to resident sexual abuse occurred as a result.

Based on records reviewed, observations and interviews, for two of six sampled residents (Resident #1 and Resident #4), the facility failed to ensure that the residents were free from alleged incidents of sexual abuse. - On 10/06/18 at approximately 12:00 P.M., Certified Nurse Aide (CNA) #1 observed an unknown male (Visitor #1) with his mouth on Resident #1's exposed nipple. During a sexual assault examination at the hospital approximately nine hours later, multiple abrasions, tears and bleeding of Resident #1's genital area, and the presence of a thick, slippery fluid were observed in/on Resident #1's internal and external genital area. A full sexual assault examination of Resident #1's genital area could not be completed due to Resident #1's verbal and physical expressions of pain during the examination. Nurse #1 said the extent and location of Resident #1's genital injuries were consistent with a sexual assault. - On 09/05/18, Resident #5 unbuttoned and unzipped Resident #4's pants while he/she was asleep in bed and unable to consent to the physical contact, and touched Resident #4's inner thighs and genital area. Nurse #6 completed a skin assessment following the report of Resident #5's sexual abuse of Resident #4 and observed a bruise on Resident #4's inner left thigh. Resident #5 remained in the room across the hall from Resident #4 until approximately seven days later, when he/she was moved five rooms away from Resident #4 but remained on the same resident care unit. From the time of the alleged incident through to the time of survey, Resident #4 expressed emotional distress due to the alleged incident and the ongoing daily interactions with Resident #5. Findings include: The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that definitions of abuse included that sexual abuse was the non-consensual sexual contact of any type with a resident and included, but was not limited to, sexual harassment, sexual coercion or sexual assault. 1. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and his/her primary language was not English. Review of Resident #1's clinical record indicated that it did not include an assessment or evaluation of his/her cognitive capacity to consent to a sexual relationship. The Record also indicated that Resident #1's Health Care Proxy had been invoked (indicates the person is no longer able to make health care related decisions for themselves) in 2014 because of his/her dementia. The Record did not indicate that Resident #1 had known self-injurious behaviors, or behaviors including masturbation, inserting foreign objects into himself/herself or his/her incontinence brief, or manipulating his/her genitals. - Review of the Sexual Crime Report, dated 10/06/18 and 10/07/18 and completed by Nurse #1, who was specially trained to conduct sexual assault exams, indicated that Resident #1 sustained multiple abrasions and/or tears of his/her genital area, and that bright red blood was present at the sites of the tears. The Report indicated that the presence of a thick, slippery fluid was observed in Resident #1's genital area, and an abundant amount of a thick, slippery fluid was pooled internally. Surveyor #1 interviewed Nurse #1 at 1:46 P.M. on 10/10/18, and at multiple times throughout the dates of survey. Nurse #1 said she conducted the sexual assault examination of Resident #1 on 10/06/18. Nurse #1 said Resident #1's observed injuries were confined to his/her genital area, and included abrasions, tears, and bleeding. Nurse #1 said Resident #1 also had a thick, slippery fluid in/on his/her internal and external genital area. Nurse #1 said a complete sexual assault examination of Resident #1's genital area could not be conducted due to Resident #1's verbal and physical expressions of pain, especially with attempts to conduct an internal exam. Nurse #1 said the extent and placement of Resident #1's genital injuries were consistent with a sexual assault. Nurse #1 said she could not interview Resident #1 about his/her injuries due to his/her dementia and language barrier. Review of the Facility's Internal Investigation, dated 10/10/18, indicated that the alleged unknown male observed with his mouth on Resident #1's exposed breast was identified as Visitor #1 by CNA #1 and Nurse #2 using photographs provided by the Facility. Surveyor #1 interviewed Visitor #1 at 10:30 A.M. on 10/17/18. Visitor #1 said he had visited residents at the Facility for approximately [AGE] years, and could not recall ever signing in or out of the Facility, or of being asked by staff to sign in or out of the Facility. Visitor #1 said staff often provided visitors with the alarm codes, instead of entering the codes for the visitors when needed. Visitor #1 said that if the Facility had a sign in policy for visitors, they did not enforce it. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 3:33 P.M. on 10/11/18, and at multiple times throughout the dates of survey. Nurse #2 said she recognized Visitor #1 from prior passing encounters, but did not know his name. Nurse #2 said she identified Visitor #1 through a review of photographs during the Facility's Internal Investigation. Nurse #2 said she did not know who Visitor #1 visited with at the Facility, but said she had observed him visit with Resident #1, Resident #2 and Resident #3 on prior dates. Nurse #2 said she observed Visitor #1 on Resident #1's unit at approximately 11:30 A.M. on 10/06/18. Surveyor #1 interviewed CNA #1 at 2:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. CNA #1 said that on 10/06/18 at approximately 12:00 P.M., she went to Resident #1's room to deliver his/her lunch tray and observed Resident #1's privacy curtain partially pulled around his/her bed. CNA #1 said that when she was able to see around the curtain, she observed a male sitting on Resident #1's bed. CNA #1 said she did not recognize the man, but identified him as Visitor #1 through a review of photographs during the Facility's Internal Investigation. CNA #1 said Visitor #1 was seated next to and leaning on Resident #1's person on his/her bed. CNA #1 said Visitor #1 had his arms around Resident #1 and his mouth covered the nipple of Resident #1's left breast. CNA #1 said that when Visitor #1 saw her, he got up off the bed slowly like he was trying to keep CNA #1 from seeing Resident #1's exposed breast, and then hurried out of the room. CNA #1 said Visitor #1 tried to keep his head turned from her, as if he did not want CNA #1 to identify him. CNA #1 said Resident #1 was known to her, and said that she and Resident #1 spoke a similar language and were able to communicate in simple phrases. CNA #1 said she asked Resident #1 if he/she had a significant other or if he/she knew who the man was, and said Resident #1 answered no to both questions. CNA #1 said she stayed with Resident #1 to make sure he/she was safe, and then left the room. CNA #1 said that as she approached the nurses' station, she observed Visitor #1 attempt to enter the alarm code at the main entrance to the unit in order to exit the unit. CNA #1 said Visitor #1 asked her for the alarm code, which she provided. CNA #1 said said she knew she should not have given Visitor #1 the code. CNA #1 said Visitor #1 left the unit, and she went into a resident room to see if she could identify what kind of a vehicle Visitor #1 drove, but said she never saw him leave the Facility. CNA #1 said she then notified Nurse #2 of the incident that she observed between Resident #1 and Visitor #1, and said that approximately 10 minutes later, also notified Nurse #3. Nurse #2 said that at approximately lunchtime on 10/06/18, CNA #1 reported seeing a man hovering over Resident #1, or words to that effect. Nurse #2 said she went to check on Resident #1, and did not observe any apparent emotional distress, physical pain, or trauma. Nurse #2 said she went to find Nurse #3, who was Resident #1's assigned nurse, to notify her of CNA #1's report. Nurse #2 said she asked Nurse #3 to talk to her when she (Nurse #3) was done because she was busy with another resident. Nurse #2 said she then observed CNA #1 talking to Nurse #3, and said she overheard CNA #1 tell Nurse #3 that his mouth was on Resident #1's breast, or words to that effect. Nurse #2 said she told Nurse #3 to notify the DON of the report. Nurse #2 said she got busy after that and did not follow up to find out what Nurse #3 did in response to the alleged incident. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 9:47 A.M. on 10/12/18. Nurse #3 said that prior to 12:30 P.M. on 10/06/18, Nurse #2 said she needed to speak with Nurse #3 when they were done feeding residents lunch. Nurse #3 said CNA #1 then reported to her that when CNA #1 went to give Resident #1 his/her lunch tray, she observed a man on top of Resident #1 and that Resident #1's breast was exposed. Nurse #3 said CNA #1 reported that the man got up and left. Nurse #3 said she checked on Resident #1 after speaking with CNA #1, and said she did not observe any visible injuries and did not observe Resident #1's breast exposed. Nurse #3 said she only looked Resident #1 over from his/her head to just below the breasts, and said she did not do a full assessment of Resident #1's skin. Nurse #3 said she did not assess Resident #1's genital area because his/her incontinence brief appeared to be in place. Nurse #3 said Resident #1 seemed to be fine, or words to that effect. CNA #1 said that at approximately 1:00 P.M., she saw Resident #1's family arrive on the unit. CNA #1 said she saw Nurse #3 go into Resident #1's room with the family, and so she assumed that Nurse #3 notified them of what CNA #1 observed between Resident #1 and Visitor #1. CNA #1 said she approached Resident #1's family after Nurse #3 left Resident #1's room, and through conversation, learned that Nurse #3 did not notify Resident #1's family of the alleged incident. CNA #1 said Resident #1's family said Resident #1 did not have a spouse or a significant other. CNA #1 said that not long after Resident #1's family arrived, exact time unknown, they asked her to assist Resident #1 with care because Resident #1 said he/she was full of blood, or words to that effect, and had urinated. CNA #1 said that when she walked Resident #1 to the bathroom, she observed that Resident #1's incontinence brief was not secured at the sides. CNA #1 said she observed blood clots and clear discharge while cleaning Resident #1's genital area, and said she notified Nurse #3 of her observations. CNA #1 said she disposed of Resident #1's incontinence brief in the trash and placed Resident #1's clothing into the dirty laundry. CNA #1 said she notified Nurse #3 of the blood clots and clear discharge she observed while providing care to Resident #1. Nurse #3 said CNA #1 reported seeing blood when she provided care to Resident #1. Nurse #3 said she did not think anything of CNA #1's report at the time as Resident #1 had known prior episodes of genital bleeding. Nurse #3 said that at approximately 1:30 P.M., she, Nurse #2 and CNA #1 spoke about the alleged incident. Nurse #3 said that about that same time, Resident #1's family came in to visit. Nurse #3 said she did not notify Resident #1's family that CNA #1 reported observing a man on top of Resident #1 and that his/her breast was exposed because she was administering medications at the time. Surveyor #1 interviewed the Assistant Director of Nurses (ADON) at 12:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. The ADON said CNA #1 reported that the unknown male (Visitor #1) left Resident #1's room, and said she (the ADON) assumed that the unknown male (Visitor #1) had left the Facility. The ADON said she later learned from a person, who's identity she could not recall, that the unknown male reportedly visited with someone on another resident care unit in the Facility after leaving Resident #1's unit. Review of the Police Incident Report, dated 10/06/18, indicated that the Police were notified by Resident #1's family, and not by a Facility representative, of the alleged sexual assault of Resident #1. - Review of Resident #1's clinical record indicated that he/she had bleeding from his/her genital area on 01/28/18, 05/25/18, and 07/28/18. The Record also indicated that on 07/28/18, Nurse #4 observed a laceration to Resident #1's genital area, in addition to the bleeding. There was no documentation to indicate that the physician or a Nurse Practitioner (NP) conducted a medical evaluation of Resident #1 following the three documented episodes of genital bleeding, to determine a cause of his/her bleeding and genital laceration. Surveyor #1 interviewed Nurse Practitioner (NP) #1 at 12:06 P.M. on 10/18/18 and by telephone at 8:56 A.M. on 10/19/18. NP #1 said she began providing care to Resident #1 in approximately (MONTH) (YEAR). NP #1 said she did not recall ever being notified of Resident #1's episodes of genital bleeding on 05/25/18 or 07/28/18, and said that if she had been notified, she would have conducted a physical assessment of Resident #1 as soon as possible. NP #1 said she would have documented any assessment she conducted of Resident #1 in his/her clinical record. - Review of Resident #1's Weekly Skin Audit, dated 01/29/18 (the day after he/she had an episode of genital bleeding), indicated that he/she had a bruise on the back of his/her left shoulder. Review of Resident #1's Nursing Progress Note, dated 01/29/18, indicated that he/she had a bruise on the back of his/her right shoulder, which was not consistent with the Weekly Skin Audit conducted on the same day. Surveyor #1 interviewed the Director of Nurses (DON) at 10:33 A.M. on 10/18/18. The DON said she was unable to locate an incident report or investigation regarding the bruise observed on Resident #1's shoulder on 01/29/18. The DON said that the expectation was for staff to notify the DON and complete an incident report whenever they observed a bruise on a resident. There was no documentation to support, and staff interviews confirmed, that Facility staff ensured that the alleged perpetrator (Visitor #1) did not continue to have access to residents throughout the Facility after Resident #1's alleged sexual assault; or, that the Facility investigated Resident #1's prior episodes of genital bleeding and/or laceration(s), a potential indicator of sexual abuse, on 01/28/18, 05/25/18, and 07/28/18 to determine a cause of the bleeding and to ensure the prevention of abuse. 2. Resident #4 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #4's MDS Assessment, dated 07/13/18, indicated that he/she was cognitively intact. Review of the Facility's Communication/Grievance Sheet, dated 09/07/18, indicated that Resident #5 said he/she unzipped Resident #4's pants and tried to get down his/her pants, or words to that effect. The Sheet indicated that the Director of Social Services discussed with Resident #5 that he/she did not have Resident #4's consent to touch him/her. Review of the Facility's Incident Report Form, dated 09/11/18, indicated that on 09/05/18 while Resident #4 was sleeping, and therefore unable to provide consent, Resident #5 unbuttoned and unzipped Resident #4's pants and touched Resident #4's inner thighs and perineal area. Surveyor #2 interviewed Nurse #6 at 10:20 A.M. on 10/11/18. Nurse #6 said that on 09/07/18, Resident #4 reported that Resident #5 told him/her that he/she tried to undo Resident #4's pants, and that Resident #4 said he/she now had a bruise on his/her inner thigh. Nurse #6 said Resident #4 told her that he/she felt stupid, or words to that effect, following the incident with Resident #5. Review of Resident #4's Nursing Progress Note, dated 09/07/18, indicated that Nurse #6 completed a skin assessment following the report of sexual abuse and observed a bruise on Resident #4's inner left thigh. Surveyor #2 interviewed Resident #4 at 1:40 P.M. on 10/12/18. Resident #4 said Resident #5 told him/her that Resident #5 unzipped Resident #4's pants while he/she was asleep. Resident #4 said he/she thought that Resident #5 waited until he/she was asleep because Resident #5 knew Resident #4 would not have allowed Resident #5 to unzip his/her pants or touch him/her. Resident #4 said he/she felt disgusted with Resident #5 and felt sick to his/her stomach since the incident occurred. Resident # 5 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #5's MDS Assessment, dated 07/20/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Resident #5 at 11:30 A.M. on 10/11/18. Resident #5 said he/she touched Resident #4's inner thigh/perineal area over his/her clothes while Resident #4 was asleep in bed. Review of Resident #5's Therapy Assessment Note from the Facility's mental health provider, dated 09/17/18, indicated that Resident #5 said that Resident #4 was asleep when he/she put his/her hands down Resident #4's pants, and that he/she could not get Resident #4's pants off. The Note indicated that Resident #5 said he/she later told Resident #4 what he/she had done to him/her. - Observations on 10/11/18 and 10/12/18, and review of the Facility's interior floor plan indicated that at the time of the alleged incident on 09/05/18, Resident #5's room was located across the hallway from Resident #4's room. Review of Resident #4's Social Service Progress Note, dated 09/13/18, indicated that Resident #4 reported that he/she felt violated by the incident that occurred on 09/05/18. The Note indicated that the Director of Social Services informed Resident #4 of a plan to move Resident #5 to another room on the same resident care unit, but did not include documentation for when the plan to move Resident #5 would be implemented. Resident #4 said Resident #5 resided in the room across the hall from him/her prior to Resident #5's room change nine days after the incident. Resident #4 said that after the alleged incident, he/she would shut his/her door so Resident #5 could not see inside or enter his/her room because Resident #5 made him/her feel anxious and afraid. Review of the Facility's interior floor plan, and observations of Resident #5's room on 10/11/18 and 10/12/18, indicated that his/her room remained on the same resident care unit as Resident #4. Resident #4 said he/she felt anxious and uncomfortable because Resident #5 still resided on the same unit and Resident #4 saw Resident #5 on a daily basis. - Review of Resident #4's Nursing Progress Notes, dated 09/08/18 through 09/20/18, indicated that Resident #4 expressed feelings of increased anxiety and [MEDICATION NAME] (an anti-anxiety medication) was administered approximately nine times for complaints of anxiety following the incident. Review of Resident #4's Physician's Interim/Telephone Orders, dated 10/01/18 and 10/05/18, indicated that his/her dosage of [MEDICATION NAME] was increased following the incident due to unrelieved anxiety. Surveyor #2 interviewed Resident #7 at 12:20 P.M. on 10/12/18. Resident #7 said Resident #4 was upset about the sexual assault by Resident #5 and avoided Resident #5 following the incident. There was no documentation to support that the Facility ensured that Resident #4 did not suffer ongoing mental abuse following his/her report of sexual assault as a result of daily interactions with Resident #5, who continued to reside on Resident #4's unit.

Based on records reviewed and interviews, for three of six sampled residents (Resident #1, Resident #4, and Resident #6), the facility failed to ensure that allegations of sexual abuse or of residents being found exposed were immediately and thoroughly investigated, including interviews with the alleged victim and any other potential victims; the identification of, and interviews with or written statements obtained from any potential witnesses; and, the completion of a physical assessment of the alleged victim. - On 10/06/18 at approximately 12:00 P.M., Certified Nurse Aide (CNA) #1 observed an unknown male (Visitor #1) with his mouth on Resident #1's exposed nipple. During a sexual assault examination at the hospital approximately nine hours later, multiple abrasions, tears and bleeding of Resident #1's genital area (genital area between the vulva and anus in a woman, and between the scrotum and anus in a man), and the presence of a thick, slippery fluid were observed in/on Resident #1's internal and external genital area. A full sexual assault examination of Resident #1's genital area could not be completed due to Resident #1's verbal and physical expressions of pain during the examination. Nurse #1 said the extent and location of Resident #1's genital injuries were consistent with a sexual assault. - On 09/07/18, Resident #5 unbuttoned and unzipped Resident #4's pants while he/she was sleeping in bed and unable to consent to the physical contact, and touched Resident #4's inner thighs and genital area. Nurse #6 completed a skin assessment following the report of Resident #5's sexual abuse of Resident #4 and observed a bruise on Resident #4's inner left thigh. Resident #5 remained in the room across the hall from Resident #4 until approximately seven days later, when he/she was moved five rooms away from Resident #4 but remained on the same resident care unit. From the time of the alleged incident through to the time of survey, Resident #4 expressed emotional distress due to the alleged incident and the ongoing daily interactions with Resident #5. - On 03/10/18, Resident #6, who required extensive physical assistance with Activities of Daily Living (ADLs; daily self-care activities), was found with his/her johnny (a shirt-sleeved, collarless gown that is open in the back) lifted up and his/her breasts exposed. Findings include: The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that: - Supervisory personnel or their designee would perform a physical assessment of the resident if physical abuse was suspected, interview the resident when possible, and obtain written statements from witnesses of incidents. - The investigative process included, but was not limited to: interviewing the resident; interviewing staff witnesses or other available witnesses; and, interviewing the resident's family if appropriate. 1. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and his/her primary language was not English. Review of the Sexual Crime Report, dated 10/06/18 and 10/07/18 and completed by Nurse #1, who was specially trained to conduct sexual assault exams, indicated that Resident #1 sustained multiple abrasions and/or tears of his/her genital area, and that bright red blood was present at the sites of the tears. The Report indicated that the presence of a thick, slippery fluid was observed in Resident #1's genital area, and an abundant amount of a thick, slippery fluid was pooled internally. Surveyor #1 interviewed Nurse #1 at 1:46 P.M. on 10/10/18, and at multiple times throughout the dates of survey. Nurse #1 said she conducted the sexual assault examination of Resident #1 on 10/06/18, and said the extent and placement of Resident #1's genital injuries were consistent with a sexual assault. The Facility's Internal Investigation, dated 10/10/18, indicated that the alleged unknown male observed with his mouth on Resident #1's breast was identified as Visitor #1 by CNA #1 and Nurse #2 using photographs provided by the Facility. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 3:33 P.M. on 10/11/18, and at multiple times throughout the dates of survey. Nurse #2 said she observed Visitor #1 on Resident #1's unit at approximately 11:30 A.M. on 10/06/18. Nurse #2 said she recognized Visitor #1 from prior passing encounters, but did not know his name or who he visited with at the Facility. Nurse #2 said she had observed Visitor #1 visit with multiple other residents on prior dates. Surveyor #1 interviewed CNA #1 at 2:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. CNA #1 said that on 10/06/18 at approximately 12:00 P.M., she went to Resident #1's room to deliver his/her lunch tray and observed that Resident #1's privacy curtain was partially pulled around his/her bed. CNA #1 said that when she was able to see around the curtain, she observed a male (Visitor #1) sitting on Resident #1's bed, with his arms around him/her, and that he was leaned over onto Resident #1 with his mouth covering the nipple of Resident #1's left breast. CNA #1 said Visitor #1 left Resident #1's room, and she stayed with Resident #1 to make sure she was safe. CNA #1 said Resident #1 was known to her, and said that she and Resident #1 spoke a similar language and were able to communicate in simple phrases. CNA #1 said she asked Resident #1 if he/she had a significant other or if he/she knew who the man was, and said Resident #1 answered no to both questions. CNA #1 said that after she left Resident #1's room, she saw Visitor #1 at the exit door of the resident care unit. CNA #1 said Visitor #1 asked her for the door alarm code, which she provided. CNA #1 said she knew she should not have given Visitor #1 the door alarm code. CNA #1 said Visitor #1 left the resident care unit, and she went into a resident room to see if she could identify what kind of a vehicle Visitor #1 drove, but said she never saw him leave the Facility. CNA #1 said she notified Nurse #2 and then Nurse #3 of what she saw occur between Resident #1 and Visitor #1. Nurse #2 said that at approximately lunchtime on 10/06/18, CNA #1 reported seeing a man hovering over Resident #1. Nurse #2 said she went to check on Resident #1, and did not observe any apparent emotional distress, physical pain, or trauma. Nurse #2 said she then observed CNA #1 talking to Nurse #3, and said she heard CNA #1 tell Nurse #3 that his mouth was on Resident #1's breast, or words to that effect. Nurse #2 said she told Nurse #3 to notify the DON of CNA #1's report. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 9:47 A.M. on 10/12/18. Nurse #3 said that prior to 12:30 P.M. on 10/06/18, Nurse #2 said she needed to speak with Nurse #3 when they were done feeding residents lunch. Nurse #3 said that before she could speak with Nurse #2, CNA #1 reported that when she went to give Resident #1 his/her lunch tray, she observed a man on top of Resident #1 and observed that Resident #1's breast was exposed. Nurse #3 said CNA #1 reported that the man got up and left. Nurse #3 said she checked on Resident #1 after speaking with CNA #1, and said she did not observe any visible injuries and did not observe Resident #1's breast exposed. Nurse #3 said she only looked Resident #1 over from his/her head to just below the breasts, and did not do a full assessment of Resident #1's skin, including his/her genital area. CNA #1 said that shortly after 1:00 P.M., exact time unknown, she spoke with Resident #1's family, who reported that Resident #1 did not have a spouse or a significant other. CNA #1 said Resident #1's family asked her to assist Resident #1 with care because Resident #1 said he/she was full of blood, or words to that effect, and had urinated. CNA #1 said that when she walked Resident #1 to the bathroom, she observed that Resident #1's incontinence brief was not secured at the sides. CNA #1 said she observed blood clots and clear discharge while cleaning Resident #1's genital area, and said she notified Nurse #3 of her observations. CNA #1 said she disposed of Resident #1's incontinence brief in the trash and placed Resident #1's clothing into the dirty laundry. Nurse #3 said CNA #1 reported seeing blood when she provided care to Resident #1. Nurse #3 said she did not think anything of CNA #1's report at the time because Resident #1 had known prior episodes of genital bleeding. Nurse #2 said Nurse #3 did not conduct an assessment of Resident #1 until approximately 3:00 P.M. on 10/06/18, two and a half hours after the initial allegation of sexual abuse. Nurse #2 said a thorough skin assessment should have included a check of Resident #1's genital area. Nurse #2 said she did not initiate an investigation into the allegation that Visitor #1 was observed with his mouth on Resident #1's exposed breast. Nurse #3 said she did not interview Resident #1 about the alleged incident because Resident #1's primary language was not English, did not interview CNA #1 to determine what she meant when she reported that the man was lying on top of Resident #1, if there was any physical contact between the man and Resident #1 or which one of Resident #1's breasts was exposed, and did not initiate an investigation into the allegation that Visitor #1 was observed with his mouth on Resident #1's exposed breast. There was no documentation to support, and staff interviews failed to confirm, that the Facility conducted a physical assessment of Resident #1 to determine what injuries he/she may have sustained as a result of the physical interaction between him/her and Visitor #1; that the Facility interviewed Resident #1 regarding the alleged incident; or, that the Facility interviewed Resident #1's family to gather any information Resident #1 may have reported to his/her family. 2. Resident #4 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #4's MDS Assessment, dated 07/13/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Nurse #6 at 10:20 A.M. on 10/11/18. Nurse #6 said that on 09/07/18, Resident #4 reported that Resident #5 told him/her that he/she tried to undo Resident #4's pants, and that Resident #4 said he/she now had a bruise on his/her inner thigh. Nurse #6 said Resident #4 told her that he/she felt stupid, or words to that effect, following the incident with Resident #5. Review of Resident #4's Nursing Progress Note, dated 09/07/18, indicated that Nurse #6 completed a skin assessment following the report of sexual abuse and observed a bruise on Resident #4's inner left thigh. Surveyor #2 interviewed Resident #4 at 1:40 P.M. on 10/12/18. Resident #4 said Resident #5 told him/her that Resident #5 unzipped Resident #4's pants while he/she was asleep. Resident #4 said he/she thought that Resident #5 waited until he/she was asleep because Resident #5 knew Resident #4 would not have allowed Resident #5 to unzip his/her pants or touch him/her. Resident #4 said he/she felt disgusted with Resident #5 and felt sick to his/her stomach since the incident occurred. Resident # 5 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #5's MDS Assessment, dated 07/20/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Resident #5 at 11:30 A.M. on 10/11/18. Resident #5 said he/she touched Resident #4's inner thigh/perineal area over his/her clothes while Resident #4 was asleep in bed. - The Director of Nurses (DON) provided Surveyor #2 with a Communication/Grievance Sheet, dated 09/07/18, in response to Surveyor #2's request to review the Facility's internal investigation into the alleged sexual assault of Resident #4 by Resident #5 on 09/05/18. Review of the Facility's Communication/Grievance Sheet, dated 09/07/18, indicated that it included interviews with Resident #4 and Resident #5 regarding the sexual assault of Resident #4 by Resident #5 that occurred on 09/05/18. The Sheet did not include interviews with, or written statements obtained from, staff, other residents, or any potential witnesses to the alleged incident. There was no documentation to support that the Facility identified, interviewed or obtained written statements from all potential witnesses to the alleged sexual assault of Resident #4 by Resident #5. 3. Resident #6 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #6's MDS, dated [DATE] indicated that he/she was severely cognitively impaired, required extensive physical assistance for ADLs, and that his/her primary language was not English. Review of the Facility's Grievance Log Book included a grievance, dated 03/12/18, filed on the behalf of Resident #6. The Grievance indicated that Resident #6's family member observed Resident #6 in bed at 11:30 A.M. on 03/10/18 with his/her johnny pulled up from the bottom, and his/her breasts exposed. The Grievance indicated that the unit nurse was unaware Resident #6 was still in bed. The Grievance indicated that Facility's response was to provide ongoing education of Facility staff to avoid customer service issues. Review of Resident #6's Behavioral Care Plan indicated that it included a focus that Resident #6 refused to wear a nightgown, but did not indicate when the behavior was added to the care plan. Review of Resident #6's clinical record indicated that it did not include documentation that he/she had a history of [REDACTED]. Surveyor #1 interviewed the Director of Nurses (DON) at 10:27 A.M. on 10/12/18, and at multiple times throughout the dates of survey. The DON said she could not locate an incident report or internal investigation completed in response to a grievance that Resident #6's family reported that he/she was found exposed on 03/10/18. The DON said she was not the DON at the time of the incident, and did not know why an incident report or internal investigation was not completed. There was no documentation to support that the Facility thoroughly investigated a report that Resident #6, a cognitively impaired resident who required physical assistance for all of his/her care needs, was found in bed with his/her johnny pulled up and his/her breasts exposed.

Based on records reviewed, observations and interviews, for two of six sampled residents (Resident #1 and Resident #4), the facility failed to develop and implement comprehensive abuse policies and procedures which included: the timely notification of the Department of Public Health (DPH) and other required parties as applicable of incidents of alleged sexual abuse; failed to protect a resident from further mental harm following a report of sexual assault, the assessment of a resident for physical or psychosocial injury following an alleged incident of sexual assault; and, the procedure for staff to follow after an allegation of sexual abuse, including the preservation of potential physical evidence, and the procedure for staff to follow in the event of alleged incidents of abuse by a visitor. - On 10/06/18 at approximately 12:00 P.M., Certified Nurse Aide (CNA) #1 observed an unknown male (Visitor #1) with his mouth on Resident #1's exposed nipple. During a sexual assault examination at the hospital approximately nine hours later, the extent and location of Resident #1's genital injuries were determined to be consistent with a sexual assault. - On 09/05/18, Resident #5 touched Resident #4's inner thighs and genital area while he/she was asleep in bed and unable to consent to the physical contact. Resident #5 remained in the room across the hall from Resident #4 until approximately seven days later, when he/she was moved five rooms away from Resident #4 but remained on the same resident care unit. From the time of the alleged incident through to the time of survey, Resident #4 expressed emotional distress due to the alleged incident and the ongoing daily interactions with Resident #5. Findings include: The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that: - Definitions of abuse indicated that sexual abuse was the non-consensual sexual contact of any type with a resident and included, but was not limited to, sexual harassment, sexual coercion or sexual assault. - Procedures included the reporting of all alleged violations of resident abuse to appropriate state agencies with the simultaneous development of corrective actions determined as part of the internal facility investigation to prevent further occurrences of abuse. - Abuse prevention included that it would be the Facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur. - Protection of residents from harm indicated that immediate actions included, but were not limited to: removing the resident from the alleged abuser or removing the alleged abuser from the resident; separate residents if it was a resident-to-resident altercation; notification of the nursing supervisor; performance of a physical assessment of the resident if physical abuse was suspected; and, to provide any necessary interventions to insure the resident's safety and well-being. - The supervisor or designee would notify the Administrator and/or DNS (Director of Nursing Services); and, interview the resident when possible. - Any allegation of abuse would be thoroughly investigated. The investigative process included, but was not limited to: interviewing the resident further if needed; interviewing staff witnesses or other available witnesses; interviewing the resident's family, if appropriate; and, reviewing the resident's medical record. - Reporting/Documentation Requirements indicated that the Administrator, Director of Nurses (DON) or their designee assumed responsibility for the immediate notification of the incident to persons including, but not limited to, the resident or his/her responsible party, and the physician of record and/or the Facility medical director if the physician of record is not available. - Immediate notification to the Department of Public Health (DPH) via electronically transmitted report, with a written report due 48 hours after the immediate notification. - The Administrator, DON or their designee responsibilities included, but were not limited to: ensuring that there was documentation in the resident's medical record of the incident, any interventions, physician and family notification at the time of the incident; have evidence that all alleged violations were thoroughly investigated; and, the prevention of further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress. There was no documentation to support that the Facility's Abuse Prohibition Policy included a procedure regarding the preservation of potential evidence in the event of suspected sexual abuse or assault. There also was no documentation to support that the Policy included actions to be taken in the event of an allegation of abuse by a person other than a staff person or another resident. The Facility's policy, titled A&I (Accident & Incident) Specific Reporting DPH/DOH (Department of Health) Reportable Event, dated (MONTH) (YEAR), indicated that reporting/documentation requirements included that the Administrator, Director of Nursing (DON) or their designee responsibilities included, but were not limited to, the immediate verbal notification of the local police department in all alleged or confirmed cases of physical abuse and misappropriation of resident property. The Facility's policy, titled Visitor Sign-In, reviewed 2/10, indicated that all visitors must register their name and time of day as they enter the Facility. The Policy indicated that the guest register was located at the reception desk. 1. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and his/her primary language was not English. Review of the Sexual Crime Report, dated 10/06/18 and 10/07/18 and completed by Nurse #1, who was specially trained to conduct sexual assault exams, indicated that Resident #1 sustained multiple abrasions and/or tears of his/her genital area, and that bright red blood was present at the sites of the tears. The Report indicated that the presence of a thick, slippery fluid was observed in Resident #1's genital area, and an abundant amount of a thick, slippery fluid was pooled internally. Surveyor #1 interviewed Nurse #1 at 1:46 P.M. on 10/10/18, and at multiple times throughout the dates of survey. Nurse #1 said she conducted the sexual assault examination of Resident #1 on 10/06/18, and said the extent and placement of Resident #1's genital injuries were consistent with a sexual assault. The Facility's Internal Investigation, dated 10/10/18, indicated that the alleged unknown male observed with his mouth on Resident #1's exposed breast was identified as Visitor #1 by CNA #1 and Nurse #2 using photographs provided by the Facility. The Investigation indicated that Resident #1's physician was notified, but did not include the date and time of the notification, and did not include the name of the responsible person that was reportedly notified. The Surveyors observed that the reception desk was located in a lobby of the Facility, directly accessible from the Facility's main entrance; and, that any person who accessed the Facility through the main entrance would have to pass by the reception desk in order to access resident care floors. Surveyor #1 interviewed the Administrator at 8:19 A.M. on 10/11/18. The Administrator said the Facility's visitor sign-in book was located at the receptionist desk, but that it although it was Facility policy for visitors to sign in and out, it was common for visitors not to sign in or out of the Facility. The Administrator also said that not all visitors entered or exited through the Facility's main entrance where the sign-in book was kept. The Administrator said Facility staff often gave visitors the door alarm codes to deactivate the alarms within the Facility. The Administrator said the Facility's visitor sign-in books were reviewed after the alleged incident and it was determined that Visitor #1 had not signed in on the date of the alleged incident. The Administrator also said that at the time of the alleged incident, the Facility's main entrance was monitored by a receptionist who worked until 5:00 P.M., and the front entrance was not alarmed until at 8:00 P.M., which left the Facility's front entrance unmonitored for approximately three hours every day. Review of the Facility's interior floor plan indicated that there were nine first floor entrance and/or exit doors. Surveyor #1 interviewed Visitor #1 at 10:30 A.M. on 10/17/18. Visitor #1 said he had visited residents at the Facility for approximately [AGE] years, and could not recall ever signing in or out of the Facility, or of being asked by staff to sign in or out of the Facility. Visitor #1 said staff often provided visitors with the door alarm codes. Visitor #1 said that if the Facility had a sign in policy for visitors, they did not enforce it. Surveyor #1 interviewed CNA #1 at 2:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. CNA #1 said that on 10/06/18 at approximately 12:00 P.M., she went to Resident #1's room to deliver his/her lunch tray and observed Resident #1's privacy curtain partially pulled around his/her bed. CNA #1 said that when she was able to see around the curtain, she observed a male sitting next to Resident #1 on the bed with his arms around him/her, and his mouth covered Resident #1's left nipple. CNA #1 said Visitor #1 got up off of the bed slowly and then hurried out of the room. CNA #1 said Resident #1 was known to her, and said that she and Resident #1 spoke a similar language and were able to communicate in simple phrases. CNA #1 said she asked Resident #1 if he/she had a significant other or if he/she knew who the man was, and said Resident #1 answered no to both questions. CNA #1 said she stayed with Resident #1 to make sure he/she was safe, and then left the room. CNA #1 said that as she approached the nurses' station, she observed Visitor #1 attempt to enter the alarm code at the main entrance to the unit in order to exit the unit. CNA #1 said Visitor #1 asked her for the alarm code, which she provided. CNA #1 said she knew she should not have given Visitor #1 the door alarm code. CNA #1 said that after Visitor #1 left the unit, she notified Nurse #2 of the incident she observed between Resident #1 and Visitor #1. CNA #1 said that approximately 10 minutes after notifying Nurse #2 of the alleged incident, she also notified Nurse #3. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 3:33 P.M. on 10/11/18, and at multiple times throughout the dates of survey. Nurse #2 said that at approximately lunchtime on 10/06/18, CNA #1 reported seeing a man hovering over Resident #1. Nurse #2 said she went to check on Resident #1, and did not observe any apparent emotional distress, physical pain, or trauma. Nurse #2 said she observed CNA #1 talking to Nurse #3, who was Resident #1's primary nurse, and heard CNA #1 tell Nurse #3 that his mouth was on Resident #1's breast, or words to that effect. Nurse #2 said she told Nurse #3 to notify the DON of the report. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 9:47 A.M. on 10/12/18. Nurse #3 said that prior to 12:30 P.M. on 10/06/18, CNA #1 reported that when she went to give Resident #1 his/her lunch tray, she observed a man on top of Resident #1 and that Resident #1's breast was exposed. Nurse #3 said she checked on Resident #1 after speaking with CNA #1, and said she did not observe any visible injuries and did not observe Resident #1's breast exposed. Nurse #3 said she only looked Resident #1 over from his/her head to just below the breasts, and did not do a full assessment of Resident #1's skin. Nurse #3 said she did not assess Resident #1's genital area because his/her incontinence brief appeared to be in place. Nurse #3 said Resident #1 seemed to be fine, or words to that effect. CNA #1 said that at approximately 1:00 P.M., she saw Resident #1's family arrive on the unit. CNA #1 said she saw Nurse #3 go into Resident #1's room with the family, and so she assumed that Nurse #3 notified them of the incident. CNA #1 said she approached Resident #1's family after Nurse #3 left Resident #1's room, and through conversation, learned that Nurse #3 did not notify Resident #1's family of the alleged incident. CNA #1 said that not long after Resident #1's family arrived, exact time unknown, they asked her to assist Resident #1 with care because Resident #1 said he/she was full of blood, or words to that effect, and had urinated. CNA #1 said that when she walked Resident #1 to the bathroom, she observed that Resident #1's incontinence brief was not secured at the sides. CNA #1 said she observed blood clots and clear discharge while cleaning Resident #1's genital area, and said she notified Nurse #3 of her observations. CNA #1 said she disposed of Resident #1's incontinence brief in the trash and placed Resident #1's clothing into the dirty laundry. Nurse #3 said CNA #1 reported seeing blood when she provided care to Resident #1. Nurse #3 said she did not think anything of CNA #1's report at the time and did not assess Resident #1 because he/she had known prior episodes of genital bleeding. Nurse #3 said that at approximately 1:30 P.M., Resident #1's family came in to visit. Nurse #3 said she did not notify Resident #1's family of the incident CNA #1 observed between Resident #1 and Visitor #1 because she was administering medications at the time. Nurse #2 said she later heard Resident #1's family asking Nurse #3 questions about the alleged incident, and said she assumed that Nurse #3 had notified the family, DON, and the police. Nurse #2 said she was not aware until after 3:00 P.M. that Nurse #3 had not notified anyone of the alleged incident, including Resident #1's family, the DON, and law enforcement. Nurse #2 said Nurse #3 did not conduct an assessment of Resident #1 until approximately 3:00 P.M. on 10/06/18. Nurse #2 said a thorough assessment of a resident's skin condition should include a check of the resident's genital area. Nurse #3 said she did not call the the DON or the Assistant Director of Nurses (ADON) until after approximately 3:00 P.M. Nurse #3 said she should have called the DON, ADON, and law enforcement right after she received report of the alleged incident from CNA #1. Nurse #3 said it did not occur to her to tell CNA #1 not to provide care to Resident #1 after the alleged incident in case there was evidence. Nurse #3 said she did not initiate an investigation into the alleged incident between Resident #1 and Visitor #1, including interviews with Resident #1 and CNA #1. Surveyor #1 interviewed the Assistant Director of Nurses (ADON) at 12:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. The ADON said that approximately 3:30 P.M. on 10/06/18, she received a telephone call from Nurse #3, who said she received a report from CNA #1 approximately two and a half hours prior that she observed an unknown male (Visitor #1) lying on top of Resident #1. The ADON said Nurse #3 did not say she had attempted to notify anyone in Facility administration prior to the telephone call to the ADON. The ADON said that when she arrived at the Facility, the Police Department and Resident #1's family were present. Review of the Police Incident Report, dated 10/06/18, indicated that the Police were notified by Resident #1's family, and not by a Facility representative, of the alleged sexual assault of Resident #1. The ADON said CNA #1 reported that Visitor #1, an unknown male, left Resident #1's room and said she assumed that meant Visitor #1 left the Facility. The ADON said she later learned, from a person who's identity she could not recall, that Visitor #1 reportedly visited with someone on another resident care unit in the Facility after leaving Resident #1's unit. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not report the alleged sexual assault of Resident #1 until 10/09/18, three days after the alleged incident occurred, which was not consistent with Facility policy. There was no documentation to support that the Facility staff implemented the Facility's Abuse Prohibition Policy regarding: the immediate notification of the DPH, law enforcement, Resident #1's physician and responsible person, of Resident #1's alleged sexual assault; the completion of a physical assessment of Resident #1 to determine what injuries Resident #1 may have sustained as a result of the alleged sexual abuse; interviews with Resident #1 and/or his/her family; or, that that Facility staff ensured that the alleged perpetrator did not have continued access to residents throughout the Facility after the alleged incident reportedly occurred. There was no documentation to support that the Facility developed a policy and procedure regarding the preservation of potential evidence in the event of suspected sexual abuse or assault; or, that the Facility's current Abuse Prohibition Policy included actions to be taken in the event of an allegation of abuse by a person other than a staff person or another resident. 2. Resident #4 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #4's MDS Assessment, dated 07/13/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Nurse #6 at 10:20 A.M. on 10/11/18. Nurse #6 said that on 09/07/18, Resident #4 reported that Resident #5 told him/her that he/she tried to undo Resident #4's pants, and that Resident #4 said he/she now had a bruise on his/her inner thigh. Review of Resident #4's Nursing Progress Note, dated 09/07/18, indicated that Nurse #6 observed a bruise on Resident #4's inner left thigh following his/her report of sexual abuse. Surveyor #2 interviewed Resident #4 at 1:40 P.M. on 10/12/18. Resident #4 said Resident #5 told him/her that Resident #5 unzipped Resident #4's pants while he/she was asleep, but that Resident #4's pants were too tight so he/she could not do anything, or words to that effect. Resident # 5 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #5's MDS Assessment, dated 07/20/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Resident #5 at 11:30 A.M. on 10/11/18. Resident #5 said he/she touched Resident #4's inner thigh/perineal area over his/her clothes while Resident #4 was asleep in bed. Review of the Facility's Incident Report Forms, dated 09/11/18 and 09/14/18, indicated that on 09/05/18 while Resident #4 was sleeping, and therefore unable to provide consent, Resident #5 unbuttoned and unzipped Resident #4's pants and touched Resident #4's inner thighs and perineal area. The Forms indicated that Resident #5 was educated that his/her behavior was not consensual, or words to that effect. - Resident #4 said Resident #5 resided in the room across the hall from him/her prior to Resident #5's room change nine days after the incident. Resident #4 said that after the alleged incident, he/she would shut his/her door so Resident #5 could not see inside or enter his/her room because Resident #5 made him/her feel anxious and afraid. Observations on 10/11/18 and 10/12/18, and review of the Facility's interior floor plan indicated that at the time of Resident #4's alleged incident on 09/05/18, Resident #5's room was located across the hallway from Resident #4's room. Review of Resident #4's Social Service Progress Note, dated 09/13/18, indicated that the Director of Social Services informed Resident #4 of a plan to move Resident #5 to another room on the same unit, but did not include documentation for when the plan to move Resident #5 would be implemented. Observations of Resident #5's room on 10/11/18 and 10/12/18, and review of the Facility's interior floor plan indicated that he/she was moved to a room that was on the same resident care unit as Resident #4. Resident #4 said he/she felt anxious and uncomfortable because Resident #5 still resided on the same resident care unit and Resident #4 saw Resident #5 on a daily basis. Although the Facility implemented 15 minute checks for Resident #4 and Resident #5 following the allegation of sexual abuse, there was no documentation to indicate the 15 minute checks were consistently completed by staff. Surveyor #2 interviewed the Staff Development Coordinator (SDC) at 10:00 A.M. on 10/18/18. The SDC said the documentation for the 15 minute checks implemented for Resident #4 and Resident #5 following the allegation of sexual abuse was incomplete. The SDC said staff did not follow the Facility's policy regarding the implementation of interventions to ensure resident safety following an alleged incident of abuse. There was no documentation to support that the Facility separated Resident #4 and Resident #5 following an allegation of sexual assault, in accordance with Facility policy, which caused ongoing mental harm to Resident #4; or, that staff consistently documented the completion of 15 minute checks, which were implemented in response to Resident #4's allegation of sexual assault by Resident #5, this was not consistent with Facility policy.

Based on records reviewed and interviews, for two of six sampled records (Resident #1 and Resident #4), the facility failed to ensure that reports of sexual assault and/or abuse were immediately reported to the Department of Public Health (DPH) in accordance with regulatory requirements and facility policies and procedures. - On 10/06/18 at approximately 12:00 P.M., Certified Nurse Aide (CNA) #1 observed an unknown male (Visitor #1) with his mouth on Resident #1's exposed nipple. During a sexual assault examination at the hospital approximately nine hours later, the extent and location of Resident #1's genital injuries were determined to be consistent with a sexual assault. - On 09/05/18, Resident #5 unbuttoned and unzipped Resident #4's pants while he/she was asleep in bed and unable to consent to the physical contact, and touched Resident #4's inner thighs and genital area. From the time of the alleged incident through to the time of survey, Resident #4 expressed emotional distress due to the alleged incident and the ongoing daily interactions with Resident #5. Findings include: The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that the Administrator, Director of Nurses (DON) or their designee assumed responsibility for the immediate notification to the DPH via electronically transmitted report, with a written report due 48 hours after the immediate notification. 1. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and his/her primary language was not English. Review of the Sexual Crime Report, dated 10/06/18 and 10/07/18 and completed by Nurse #1, who was specially trained to conduct sexual assault exams, indicated that Resident #1 sustained multiple abrasions and/or tears of his/her genital area, and that bright red blood was present at the sites of the tears. The Report indicated that the presence of a thick, slippery fluid was observed in Resident #1's genital area, and an abundant amount of a thick, slippery fluid was pooled internally. Surveyor #1 interviewed Nurse #1 at 1:46 P.M. on 10/10/18, and at multiple times throughout the dates of survey. Nurse #1 said she conducted the sexual assault examination of Resident #1 on 10/06/18, and said that the extent and placement of Resident #1's genital injuries were consistent with a sexual assault. Review of the Facility's Internal Investigation, dated 10/10/18, indicated that the alleged unknown male perpetrator was identified as Visitor #1 by CNA #1 and Nurse #2 using photographs provided by the Facility. Surveyor #1 interviewed CNA #1 at 2:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. CNA #1 said that on 10/06/18 at approximately 12:00 P.M., she observed a male (Visitor #1) sitting on Resident #1's bed with his arms around him/her, leaning over onto Resident #1, and with his mouth covered the nipple of Resident #1's left breast. CNA #1 said she notified Nurse #2 and Nurse #3 of what she observed between Resident #1 and Visitor #1. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 3:33 P.M. on 10/11/18, and at multiple times throughout the dates of survey. Nurse #2 said that at approximately lunchtime on 10/06/18, exact time unknown CNA #1 reported seeing a man hovering over Resident #1. Nurse #2 said she then heard CNA #1 tell Nurse #3 that his mouth was on Resident #1's breast, or words to that effect. Nurse #2 said she told Nurse #3 to notify the DON of the report. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 9:47 A.M. on 10/12/18. Nurse #3 said that prior to 12:30 P.M. on 10/06/18, CNA #1 reported that when she went to give Resident #1 his/her lunch tray, she observed a man on top of Resident #1 and that Resident #1's breast was exposed. CNA #1 said Resident #1's family arrived at approximately 1:00 P.M., and shortly after that, exact time unknown, they asked her to assist Resident #1 with care because Resident #1 said he/she was full of blood, or words to that effect, and had urinated. CNA #1 said that when she walked Resident #1 to the bathroom, she observed that Resident #1's incontinence brief was not secured at the sides. CNA #1 said she observed blood clots and clear discharge while cleaning Resident #1's genital area, and said she notified Nurse #3 of her observations. Nurse #3 said CNA #1 reported seeing blood when she provided care to Resident #1. Nurse #3 said she did not think anything of it at the time as Resident #1 had known prior episodes of genital bleeding. Nurse #2 said she was not aware until after 3:00 P.M. that Nurse #3 had not notified anyone of the alleged incident, including the DON. Nurse #3 said she called the DON at approximately 3:00 P.M., and then called the Assistant Director of Nurses (ADON) when she could not reach the DON. Nurse #3 said she should have called the DON and ADON right after receiving report of the alleged incident from CNA #1. Surveyor #1 interviewed the Assistant Director of Nurses (ADON) at 12:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. The ADON said that at approximately 3:30 P.M. on 10/06/18, she received a telephone call from Nurse #3, who said that CNA #1 reported she observed an unknown male (Visitor #1) lying on top of Resident #1. The ADON said Nurse #3 did not say she had attempted to notify anyone in Facility administration prior to the telephone call to the ADON. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not submit a report of the alleged sexual assault of Resident #1 until 10/09/18, three days after the alleged incident occurred. There was no documentation to support that the Facility reported the alleged sexual assault of Resident #1 to the DPH within two hours, in accordance with Facility policy. 2. Resident #4 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #4's MDS Assessment, dated 07/13/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Nurse #6 at 10:20 A.M. on 10/11/18. Nurse #6 said that on 09/07/18, Resident #4 reported that Resident #5 told him/her that he/she tried to undo Resident #4's pants, and that Resident #4 said he/she now had a bruise on his/her inner thigh. Review of Resident #4's Nursing Progress Note, dated 09/07/18, indicated that Nurse #6 observed a bruise on Resident #4's inner left thigh following his/her report of sexual abuse. Surveyor #2 interviewed Resident #4 at 1:40 P.M. on 10/12/18. Resident #4 said Resident #5 told him/her that Resident #5 unzipped Resident #4's pants while he/she was asleep. Resident #4 said he/she thought that Resident #5 waited until he/she was asleep because Resident #5 knew Resident #4 would not have allowed Resident #5 to unzip his/her pants or touch him/her. Resident # 5 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #5's MDS Assessment, dated 07/20/18, indicated that he/she was cognitively intact. Surveyor #2 interviewed Resident #5 at 11:30 A.M. on 10/11/18. Resident #5 said he/she touched Resident #4's inner thigh/perineal area over his/her clothes while Resident #4 was asleep in bed. Review of the Facility's Communication/Grievance Sheet, dated 09/07/18, indicated that Resident #5 said he/she unzipped Resident #4's pants and tried to get down his/her pants, or words to that effect. The Sheet indicated that the Director of Social Services and Resident #5 discussed that Resident #5 did not have Resident #4's consent to touch him/her. Review of the Facility's Incident Report Forms, dated 09/11/18 and 09/14/18, indicated that on 09/05/18 while Resident #4 was sleeping, and therefore unable to provide consent, Resident #5 unbuttoned and unzipped Resident #4's pants and touched Resident #4's inner thighs and perineal area. The Forms indicated that Resident #5 was educated that his/her behavior was not consensual, or words to that effect. Review of the DPH's Health Care Facility Reporting System (HCFRS) indicated that the Facility did not submit a report of the alleged sexual assault of Resident #4 on 09/05/18 until 09/11/18, six days after the alleged incident occurred and four days after the alleged incident was reported to Facility staff. There was no documentation to support that the Facility reported the alleged sexual assault of Resident #4 to the DPH within two hours, in accordance with Facility policy.

Based on records reviewed and interviews, for one of six sampled residents (Resident #1), the facility failed to ensure that Nurse #3 reported an alleged incident of sexual assault to law enforcement and administration, in accordance with facility policy and regulations. The Facility also failed to ensure that policies and procedures included examples of situations that would be considered crimes. - On 10/06/18 at approximately 12:00 P.M., Certified Nurse Aide (CNA) #1 observed an unknown male (Visitor #1) with his mouth on Resident #1's exposed nipple. During a sexual assault examination at the hospital approximately nine hours later, the extent and location of Resident #1's genital injuries were determined to be consistent with a sexual assault. Findings include: Review of the Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that it did not include a procedure for the handling of materials that may be used for evidence or for a criminal investigation. The Facility's policy, titled A&I (Accident & Incident) Specific Reporting DPH (Department of Public Health)/DOH (Department of Health) Reportable Event, dated (MONTH) (YEAR), indicated that reporting/documentation requirements included that the Administrator, Director of Nursing (DON) or their designee responsibilities included, but were not limited to, the immediate verbal notification of the local police department in all alleged or confirmed cases of physical abuse and misappropriation of resident property. The Policy did not include examples of situations that would be considered crimes. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, was over the age of 60, and his/her primary language was not English. Review of the Sexual Crime Report, dated 10/06/18 and 10/07/18 and completed by Nurse #1, who was specially trained to conduct sexual assault exams, indicated that Resident #1 sustained multiple abrasions and/or tears of his/her genital area, and that bright red blood was present at the sites of the tears. The Report indicated that the presence of a thick, slippery fluid was observed in Resident #1's genital area, and an abundant amount of a thick, slippery fluid was pooled internally. Surveyor #1 interviewed Nurse #1 at 1:46 P.M. on 10/10/18, and at multiple times throughout the dates of survey. Nurse #1 said she conducted the sexual assault examination of Resident #1 at the hospital on [DATE], and said that the extent and placement of Resident #1's genital injuries were consistent with a sexual assault. The Facility's Internal Investigation, dated 10/10/18, indicated that the alleged unknown male observed with his mouth on Resident #1's breast was identified as Visitor #1 by CNA #1 and Nurse #2 using photographs provided by the Facility. Surveyor #1 interviewed CNA #1 at 2:18 P.M. on 10/11/18, and at multiple times throughout the dates of survey. CNA #1 said that on 10/06/18 at approximately 12:00 P.M., she observed Visitor #1 sitting next to Resident #1 on the bed with his arms around him/her, and his mouth covered Resident #1's left nipple. CNA #1 said Visitor #1 got up off of the bed slowly and then hurried out of the room. CNA #1 said Resident #1 was known to her, and said that she and Resident #1 spoke a similar language and were able to communicate in simple phrases. CNA #1 said she asked Resident #1 if he/she had a significant other or if he/she knew who the man was, and said Resident #1 answered no to both questions. CNA #1 said she stayed with Resident #1 to make sure he/she was safe, and then left the room. CNA #1 said she notified Nurse #2 of what she saw occur between Resident #1 and Visitor #1, and then notified Nurse #3 of the incident approximately 10 minutes later. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 3:33 P.M. on 10/11/18, and at multiple times throughout the dates of survey. Nurse #2 said that at approximately lunchtime on 10/06/18, CNA #1 reported seeing a man hovering over Resident #1. Nurse #2 said she then heard CNA #1 tell Nurse #3 that his mouth was on Resident #1's breast, or words to that effect. Nurse #2 said she told Nurse #3 to notify the DON of the report. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 9:47 A.M. on 10/12/18. Nurse #3 said that prior to 12:30 P.M. on 10/06/18, exact time unknown, CNA #1 reported that when she went to give Resident #1 his/her lunch tray, she observed a man on top of Resident #1 and that Resident #1's breast was exposed. CNA #1 said that shortly after 1:00 P.M., exact time unknown, she saw Resident #1's family arrive on Resident #1's unit. CNA #1 said Resident #1's family asked her to assist Resident #1 with care because Resident #1 said he/she was full of blood, or words to that effect, and had urinated. CNA #1 said that when she walked Resident #1 to the bathroom, she observed that Resident #1's incontinence brief was not secured at the sides. CNA #1 said she observed blood clots and clear discharge while cleaning Resident #1's genital area, and notified Nurse #3 of her observations. CNA #1 said she disposed of Resident #1's incontinence brief in the trash and placed Resident #1's clothing into the dirty laundry. Nurse #3 said CNA #1 reported seeing blood when she provided care to Resident #1. Nurse #3 said she did not think anything of it at the time as Resident #1 had known prior episodes of genital bleeding. Nurse #2 said she later heard Resident #1's family asking Nurse #3 questions about the alleged incident, and assumed that Nurse #3 had notified the family, DON, and law enforcement. Nurse #2 said she was not aware until after 3:00 P.M. that Nurse #3 had not notified anyone of the alleged incident, including law enforcement. Nurse #3 said she called the DON at approximately 3:00 P.M., and called the Assistant Director of Nurses (ADON) when she could not reach the DON. Nurse #3 said she should have called the DON, ADON, and law enforcement right after receiving report of the alleged incident from CNA #1. Nurse #3 said it did not occur to her to tell CNA #1 not to provide care to Resident #1 after the alleged incident in case there was evidence. Review of the Police Incident Report, dated 10/06/18, indicated that the Police were notified by Resident #1's family, and not a Facility representative, of the alleged sexual assault of Resident #1. There was no documentation to support that the Facility staff notified law enforcement of Resident #1's alleged sexual assault; or, that Facility policies and procedures included examples of situations that would be considered crimes.

Based on record review, observation and staff interview, for two of 22 sampled residents (Resident # 101 and Resident #80) the facility failed to ensure precautions were in place to prevent accidents and injuries. Findings include: 1. For Resident #101, the facility failed to to ensure the resident was transferred in a manner to prevent injury during transfers, which resulted in the resident sustaining extensive bruising to his/her left upper extremity and to the resident's right breast, extending to his/her right flank and right arm. Resident #101 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the most recent significant change Minimum Data Set (MDS) assessment, dated 11/17/17 indicated that the resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated that she/he was moderately cognitively impaired. The resident required extensive assistance with two staff members for bed mobility and transfer. She/he was non ambulatory and had worsening physically and verbally abusive behaviors. Review of the Resident Plan of Care for activities of daily living, dated 12/16/16 and revised 9/2017 indicated that the resident was totally dependent for dressing, toilet use, grooming, bathing and mouth care. The care plan did not indicate the resident's ability to transfer or the safest mode of transfer. Review of the Resident Care Card, last updated 10/2017, indicated that the resident's transfer status was dependant with two staff, mechanical lift, stand device. Review of the facility policy entitled, Gait Belt Use, dated 4/2015, indicated that gait belts must be used when physically transferring or ambulating residents. Review of the clinical record indicated a form, titled, Investigation of a Bruise/Skin Tear/Abrasion, dated 12/3/17, which indicated that Resident #101 sustained an 11 centimeter (cm) by 5 cm bruise on her/his left arm, from the armpit down to her/his elbow. Staff indicated on the form that they thought it may have happened during transfer with the stand-lift and because the patient was not able to bear weight on his/her feet. Attached to the Bruise/Skin Tear/Abrasion form were employee statements which included statements from Certified Nursing Assistants (CNAs) who cared for Resident #101 from 12/2/17 7:00 A.M. through 12/3/17 11:00 P.M. CNA #1 indicated on her statement (written 12/3/17) that she identified a bruise under the resident's left arm. There was no size or description. CNA #1 indicated that she cared for Resident #101 on 12/2/17 7:00 A.M. - 3:00 P.M. and then again on 12/3/17 7:00 A.M. through 4:00 P.M. The section of the statement that asked for documentation to assist staff to determine how/when the resident sustained [REDACTED]. On 12/05/17 at 10:03 AM, during observation of the resident, revealed a bruised area, deep purple in color, beginning under the left armpit and extending down to the inner elbow of the left arm. The bruising extended across the top of the left arm approximately 1/2 way around the arm. Nurse #1 and the resident's daughter were present at the time of the observation. The daughter said that although she was notified by staff on 12/3/17, she said they did not say it was as large as it was. Nurse #1 measured the bruising and said that the bruising was not 11 cm x 7 cm, but rather 11 inches (27.9 cm) x 7 inches (17.7 cm). Nurse #1 said that she cared for the resident on 12/1/17 and the bruising was not present. During interview on 12/05/17 at 10:50 A.M., CNA #1 said that she worked primarily in the activity department, but had been a CNA since September 2016 and picked up shifts as a CNA on her days off. She said she works all units of the facility, but knows the residents because of her role as an activity assistant. CNA #1 said that on 12/2/17, she wasn't sure of the time, she was getting Resident #101 up for the day. She said that Nurse #2 assisted her with the transfer. CNA #1 said she and Nurse #2 got on either side of Resident #101 and placed their arms under the residents arms in an attempt to transfer her/him to the chair. CNA #1 said the resident did not bear his/her own weight and would not put his/her feet on floor. CNA #1 said the resident was dead weight. CNA #1 said that they held on to the resident's pants and quickly transferred him/her to the wheelchair. The surveyor asked if she ever used a mechanical transfer device with this resident. She said that although they are supposed to use the sit to stand mechanical lift for Resident #101, she said she doesn't use it because it is dangerous when the resident refuses to participate. CNA #1 said the resident really should be a hoyer lift, but staff did not have a physician's order for that so staff had to lift the resident to the chair. The surveyor asked CNA #1 if there was a facility policy in regard to the use of gaitbelts when a resident is physically transferred by staff. CNA #1 said staff use gait belts, but CNA #1 didn't think that would help with Resident #101. She said that staff usually transfer him/her by holding on to his/her pants. Staff all have gait belts, staff are supposed to use them. CNA #1 said she didn't use it because she thought it would hurt the resident's back. CNA #1 said that staff had been complaining to the nurses that Resident #101 hasn't wanted to use the sit to stand mechanical device for a few months. (The surveyor was unable to verify this). CNA #1 continued to say that on 12/3/17 at 3:30 P.M., she got Resident #101 out of bed and that is when she noticed the bruise and called the nurse to look at the bruising. CNA #1 said it was time to get Resident #101 out of bed and she asked another CNA to assist her and they used the hoyer mechanical lift to get Resident #101 out of bed. The surveyor asked CNA #1 if the resident had been assessed by any other staff (nurses, rehab) in order to use the hoyer lift and CNA #1 said no, but she had to get the resident out of bed and she didn't feel like she had another option. During interview on 12/05/17 at 12:25 PM, Nurse #2, said he began work at the facility in 9/2017. He said he didn't work on the side of the unit where Resident #101 lived, and was not familiar with Resident #101. He said that on 12/2/17, it was the weekend, and it was busy. Nurse #2 said CNA #1 asked for a quick hand. He said he entered Resident #101's room and he put his left arm under the resident's left arm and grabbed hold of his/her pants. He said when he and CNA #1 went to stand the resident, Resident #101 did not bear weight, so they quickly sat the resident in the wheelchair. The surveyor asked Nurse #2 if he was aware of the Resident #101's transfer status. Nurse #2 said he was not. The surveyor asked if the facility had a policy in regard to gait belt use. He said maybe he should have used a gait belt, but he was not sure of the policy on that, and said again, he was just trying to help. During interview on 12/05/17 at 12:15 PM, Nurse #1 said she was a new nurse and began work in 6/2017. She said that sometimes the CNAs use the sit to stand mechanical device and sometimes it takes two people to transfer the resident out of bed. She said she sees some gait belt use but not sure what the policy is. Nurse #1 said that the CNAs know the resident well so they determine how they will transfer the resident. The surveyor asked if a licensed Nurse was involved in the assessment of which mode of transfer was appropriate and Nurse #1 said again that the CNAs know her and she is not usually there when the CNAs transfer the resident from bed to chair. During interview on 12/05/17 at 01:43 PM, Nurse #1 said that she observed Hospice Aide #1 and CNA #4 transfer the resident from bed to chair. Nurse #1 said that they performed a two person transfer without using the sit-to- stand mechanical device or a gait belt (neither Hospice Aide #1 or CNA #4 were available for interview). The surveyor asked Nurse #1 how should Resident #101 be transferred from bed to chair and she said that because of the bruising from the weekend, the resident should be transferred using a hoyer mechanical lift. She said we have haven't gotten the order for the hoyer lift yet, and said she was waiting for therapy to get back to her with the referral, or words to that effect. The surveyor asked who was responsible to determine the safest mode of transfer for Resident #101. Nurse #1 said that nursing sends a request for screening to the Rehab Department and together nursing and rehab will determine which mode of transfer is safest. Despite the Resident Care Card, which indicated that the resident should utilize a sit to stand mechanical device for transfer, the resident was known to be physically transferred with two staff members on two occasions between 12/2/17 through 12/5/17 involving 4 staff members (CNA #1, Nurse #2, Hospice Aide #1 and CNA #4). The staff also did not use a gait belt per facility policy. During interview on 12/05/17 at 1:40 P.M., CNA #2 said she was caring for Resident #101 today but she did not get her up today. She said she usually uses a sit to stand because the resident is usually so sleepy. CNA #2 said she was not Resident #101's regular CNA, but does care for him/her from time to time. During interview on 12/07/17 at 10:15 A.M., CNA #3, who was Resident #101's primary CNA, said she works full time day shift and takes care of the resident each day she works. She said that because the resident had not been able to stand for at least a month and a half or so, CNA #3 had been using the sit-to-stand machine. CNA #3 said she wouldn't try doing a 2 person transfer because the resident would not stand. During interview on 12/05/17 at 1:45 P.M., the Rehab Director said that a rehab screen was done on 12/5/17. He said that rehab staff had no awareness that the screen was needed because the resident sustained [REDACTED]. There were no observations of nursing staff performing this new mode of transfer (despite the resident's cognitive impairment and history of being physically and verbally abusive with staff during care, which can put both resident and staff at risk for injury). The Rehab Director said the last time the resident was screened specifically to assess her/his transfer status was in 10/2016 and at that time rehab recommended to use the easy stand (a sit to stand device) when the resident had increased confusion or fatigue. Review of the Therapy Referral Request, dated 12/4/17 indicated Areas of Concern-Transfers and Patient needs a hoyer lift for transfers. There was no indication the resident sustained [REDACTED]. On 12/7/17 at 7:15 A.M., during interview, the Director of Nursing said the resident had sustained another bruise to the right breast and arm. She said that they think it possibly could be from the hoyer mechanical lift hook pressing against his/her right flank and breast area but they could not be sure and she was just in the beginning process of investigating. The surveyor asked if the resident had been assessed to determine the safest mode of transfer. She said that rehab was involved and she believed an evaluation had been completed. During interview on 12/07/17 at 7:38 A.M., Resident #101's daughter said Did you see the new bruise I discovered yesterday (12/6/17)? The surveyor observed deep purple bruising which began at the right breast areola and extended to the resident's right flank. The width of the bruising was approximately 12.7 cm wide. There was also bruising to the upper right arm which measured approximately 15.24 cm by 10.1 cm. Review of the investigation statements in regard to the bruising identified on 12/6/17 indicated that the resident was transferred using the hoyer lift on 12/4/17- 7:00 A.M.- 3:00 P.M. by Hospice Aide #1 and CNA #3 and again on 12/5/17 3:00- 11:00 P.M. by CNA #5 and CNA #2. However, the facility had not yet determined if the hoyer mechanical lift was the safest mode of transfer nor had they observed staff to ensure they could safely transfer Resident #101 with the hoyer mechanical lift due to the resident's history of combativeness during care. During interview on 12/07/17 at 1:30 P.M. with the Director of Nursing, Rehab Director and Regional Nurse, the Rehab Director said that the decision to put someone on a hoyer lift is an Interdisciplinary Team (IDT) decision. He said the IDT team did not discuss the hoyer lift together until after an evaluation was completed by rehab staff yesterday (12/6/17) and nursing staff were not observed using the hoyer mechanical lift with Resident #101 to determine that staff could safely transfer Resident #101 until 12/6/17. 2. For Resident #80, the facility failed to consistently implement pressure sensitive safety alarms to prevent falls, as ordered by the physician and indicated in the comprehensive plan of care. The policy, titled Personal Alarms, dated 4/2015, indicated alarm integrity would be maintained. Resident #80 was admitted to the Facility 10/21/17, his/her [DIAGNOSES REDACTED]. The Admission Nursing assessment, dated 10/21/17, indicated Resident #80 had an unsteady gait, and required assistance from staff for transfers. The Falls Care Plan, dated 10/21/17, indicated bed and chair alarm (an alarm used to alert staff when a person at risk for falls self-transfers) for Resident #80. The Physician's order, dated 10/23/17, indicated bed and chair alarm at all times for Resident #80. The B-Wing Report Sheet, undated, indicated chair and bed pressure sensitive alarm for Resident #80. The Surveyor observed Resident #80 at 9:50 A.M. on 11/28/17 walking independently in his/her room using a walker, without a pressure sensitive alarm in place, and without staff present. The Surveyor observed Resident #80 at 9:24 A.M. on 12/4/17. Resident #1 was in his/her room, sitting on the edge of the bed, without a pressure sensitive alarm in place. The Pressure Alarm in Bed and Chair flowsheet, dated 12/2017, indicated staff would check for functioning and placement of Resident #80's pressure sensitive alarm every shift, and that the placement and functioning of the pressure sensitive alarm had been checked on the morning of 12/4/17. The Surveyor interviewed Nurse #3 at 9:52 A.M. on 12/4/17. Nurse #3 said Resident #80 should have a bed and chair alarm in place at all times. It was observed, by the Surveyor and Nurse #3 at that time, an alarm box was secured to the side of Resident #80's bed, however the alarm box was not attached to a pressure sensitive pad, and there was no pressure sensitive pad on Resident #80's bed.

Based on observations, interview and record review, the facility failed to accurately assess and develop a plan of care for safe transfers for 1 resident (#101), the facility also failed to implement the plan of care in regard to falls prevention for 2 residents (#11 and #80) out of a total sample of 22 sampled residents. 1. For Resident #101, the facility failed to ensure that an accurate assessment and care plan were developed which resulted in the resident sustaining extensive hematomas (bruising) to his/her left upper extremity and to the resident's right breast, extending to his/her right flank and right arm. Resident #101 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the most recent significant change Minimum Data Set (MDS) assessment, dated 11/17/17 indicated that the resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated that she/he was moderately cognitively impaired. The resident required extensive assistance with two staff members for bed mobility and transfer. She/he was non ambulatory and had worsening physically and verbally abusive behaviors. Review of the Resident Plan of Care for activities of daily living, dated 12/16/16 and revised 9/2017 indicated that the resident was totally dependent for dressing, toilet use, grooming, bathing and mouth care. The care plan did not indicate the resident's ability to transfer or the safest mode of transfer. Review of the Resident Care Card, last updated 10/2017, indicated that the resident's transfer status was dependant with two staff, mechanical lift, stand device. Review of the facility policy entitled, Gait Belt Use, dated 4/2015, indicated that gait belts must be used when physically transferring or ambulating residents. Review of the clinical record indicated a form, titled, Investigation of a Bruise/Skin Tear/Abrasion, dated 12/3/17, which indicated that Resident #101 sustained an 11 centimeter (cm) by 5 cm bruise on her/his left arm, from the armpit down to her/his elbow. Staff indicated on the form that they thought it may have happened during transfer with the stand-lift and because the patient was not able to bear weight on his/her feet. On 12/05/17 at 10:03 AM, observation of the resident, revealed a bruised area, deep purple in color, beginning under the left armpit and extending down to the inner elbow of the left arm. The bruising extended across the top of the left arm approximately 1/2 way around the arm. Nurse #1 and the resident's daughter were present at the time of the observation. Nurse #1 measured the bruising and said that the bruising was not 11 cm x 7 cm, but rather 11 inches (27.9 cm) x 7 inches (17.7 cm). Nurse #1 said that she cared for the resident on 12/1/17 and the bruising was not present. During interview on 12/05/17 at 10:50 A.M., CNA #1 said that she worked primarily in the activity department, but had been a CNA since September 2016 and picked up shifts as a CNA on her days off. She said she works all units of the facility, but knows the residents because of her role as an activity assistant. CNA #1 said that on 12/2/17, she wasn't sure of the time, she was getting Resident #101 up for the day. She said that Nurse #2 assisted her with the transfer. CNA #1 said she and Nurse #2 got on either side of Resident #101 and placed their arms under the residents arms in an attempt to transfer her/him to the chair. CNA #1 said the resident did not bear his/her own weight and would not put his/her feet on floor. CNA #1 said the resident was dead weight. CNA #1 said that they held on to the resident's pants and quickly transferred him/her to the wheelchair. The surveyor asked if she ever used a mechanical transfer device with this resident. She said that although they are supposed to use the sit to stand mechanical lift for Resident #101, she said she doesn't use it because it is dangerous when the resident refuses to participate. CNA #1 said the resident really should be a hoyer lift, but staff did not have a physician's order for that so staff had to lift the resident to the chair. The surveyor asked CNA #1 if there was a facility policy in regard to the use of gaitbelts when a resident is physically transferred by staff. CNA #1 said staff use gait belts, but CNA #1 didn't think that would help with Resident #101. She said that staff usually transfer him/her by holding on to his/her pants. Staff all have gait belts, staff are supposed to use them. CNA #1 said she didn't use it because she thought it would hurt the resident's back. CNA #1 continued to say that on 12/3/17 at 3:30 P.M., she got Resident #101 out of bed and that is when she noticed the bruise and called the nurse to look at the bruising. CNA #1 said it was time to get Resident #101 out of bed and she asked another CNA to assist her and they used the hoyer mechanical lift to get Resident #101 out of bed. The surveyor asked CNA #1 if the resident had been assessed by any other staff (nurses, rehab) in order to use the hoyer lift and CNA #1 said no, but she had to get the resident out of bed and she didn't feel like she had another option. During interview on 12/05/17 at 12:25 PM, Nurse #2, said he began work at the facility in 9/2017. He said he didn't work on the side of the unit where Resident #101 lived, and was not familiar with Resident #101. He said that on 12/2/17, it was the weekend, and it was busy. Nurse #2 said CNA #1 asked for a quick hand. He said he entered Resident #101's room and he put his left arm under the resident's left arm and grabbed hold of his/her pants. He said when he and CNA #1 went to stand the resident, Resident #101 did not bear weight, so they quickly sat the resident in the wheelchair. The surveyor asked Nurse #2 if he was aware of the Resident #101's transfer status. Nurse #2 said he was not. The surveyor asked if the facility had a policy in regard to gait belt use. He said maybe he should have used a gait belt, but he was not sure of the policy on that, and said again, he was just trying to help. During interview on 12/05/17 at 12:15 PM, Nurse #1 said she was a new nurse and began work in 6/2017. She said that sometimes the CNAs use the sit to stand mechanical device and sometimes it takes two people to transfer the resident out of bed. She said she sees some gait belt use but not sure what the policy is. Nurse #1 said that the CNAs know the resident well so they determine how they will transfer the resident. The surveyor asked if a licensed Nurse was involved in the assessment of which mode of transfer was appropriate and Nurse #1 said again that the CNAs know her and she is not usually there when the CNAs transfer the resident from bed to chair. During interview on 12/05/17 at 01:43 PM, Nurse #1 said that she observed Hospice Aide #1 and CNA #4 transfer the resident from bed to chair. Nurse #1 said that they performed a two person transfer without using the sit-to-stand mechanical device or a gait belt (neither Hospice Aide #1 or CNA #4 were available for interview). The surveyor asked Nurse #1 how should Resident #101 be transferred from bed to chair and she said that because of the bruising from the weekend, the resident should be transferred using a hoyer mechanical lift. She said we have haven't gotten the order for the hoyer lift yet, and said she was waiting for therapy to get back to her with the referral, or words to that effect. The surveyor asked who was responsible to determine the safest mode of transfer for Resident #101. Nurse #1 said that nursing sends a request for screening to the Rehab Department and together nursing and rehab will determine which mode of transfer is safest. Despite the Resident Care Card, which indicated that the resident should utilize a sit to stand mechanical device for transfer, the resident was known to be physically transferred with two staff members on two occasions between 12/2/17 through 12/5/17 involving 4 staff members (CNA #1, Nurse #2, Hospice Aide #1 and CNA #4). The staff also did not use a gait belt per facility policy. During interview on 12/5/17 at 1:45 PM, the Rehab Director said the last time the resident was screened specifically to assess her/his transfer status was in 10/2016 and at that time rehab recommended to use the easy stand (a sit to stand device) when the resident had increased confusion or fatigue. On 12/7/17 at 7:15 A.M., during interview, the Director of Nursing said the resident had sustained another bruise to the right breast and arm. She said that they think it possibly could be from the hoyer mechanical lift hook pressing against his/her right flank and breast area but they could not be sure and she was just in the beginning process of investigating. The surveyor asked if the resident had been assessed to determine the safest mode of transfer. She said that rehab was involved and she believed an evaluation had been completed. During interview on 12/07/17 at 7:38 A.M., Resident #101's daughter said Did you see the new bruise I discovered yesterday (12/6/17)? The surveyor observed deep purple bruising which began at the right breast areola and extended to the resident's right flank. The width of the bruising was approximately 12.7 cm wide. There was also bruising to the upper right arm which measured approximately 15.24 cm by 10.1 cm. Review of the investigation statements in regard to the bruising identified on 12/6/17 indicated that the resident was transferred using the hoyer lift on 12/4/17- 7:00 A.M.- 3:00 P.M. by Hospice Aide #1 and CNA #3 and again on 12/5/17 3:00- 11:00 P.M. by CNA #5 and CNA # 2. However, the facility had not yet determined if the hoyer mechanical lift was the safest mode of transfer nor had they observed staff to ensure they could safely transfer Resident #101 with the hoyer mechanical lift due to the resident's history of combativeness during care. During interview on 12/07/17 at 1:30 P.M. with the Director of Nursing, Rehab Director and Regional Nurse, the Rehab Director said that the decision to put someone on a hoyer lift is an Interdisciplinary Team (IDT) decision. He said the IDT team did not discuss the hoyer lift together until after an evaluation was completed by rehab staff yesterday (12/6/17) and nursing staff were not observed using the hoyer mechanical lift with Resident #101 to determine that staff could safely transfer Resident #101 until 12/6/17. 2. For Resident #11, the facility failed to keep the resident's bed in the low position while the resident was in bed per the plan of care. Resident #11 was admitted to the facility 5/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment, dated 9/8/17, indicated that the resident was severely cognitively impaired and was dependent for bed mobility, transfer and dressing. Review of a Fall Investigation form, dated 7/13/17, indicated that Resident #11 had fallen from bed. Review of the interventions put into place to prevent further occurrences indicated to place the resident's bed in the low position all the time. Review of the Physician's Order form, dated 11/2017, indicated an order to have the bed in low position at all times, falls out of bed. The following was observed by the surveyor: * 11/28/17 at 11:29 A.M., The resident was in bed, the bed was in the high position. * 12/01/17 at 8:49 A.M., The resident was in bed, the bed was in the high position. * 12/01/17 at 2:40 P.M., The resident was in bed, the bed was in the high position. * 12/4/17 at 9:20 A.M., The resident was in bed, the bed was in the high position. During interview on 12/1/17 at 9:30 A.M., Nurse #2 said that Resident #11's bed should be in the low position because he/she has a history of falls. 3. For Resident #80, the facility failed to ensure that personal safety alarms were utilized per the plan of care. The policy titled Personal Alarms, dated 4/2015, indicated alarm integrity would be maintained. Resident #80 was admitted to the Facility 10/17, his/her [DIAGNOSES REDACTED]. The Admission Nursing assessment, dated 10/21/17, indicated Resident #80 had an unsteady gait, and required assistance from staff for transfers. The Falls Care Plan, dated 10/21/17, indicated bed and chair alarm (an alarm used to alert staff when a person at risk for falls self-transfers) for Resident #80. The Physician's order, dated 10/23/17, indicated bed and chair alarm at all times for Resident #80. The B-Wing Report Sheet, undated, indicated chair and bed pressure sensitive alarm for Resident #80. The Surveyor observed Resident #80 at 9:50 A.M. on 11/28/17 walking independently in his/her room using a walker, without a pressure sensitive alarm in place, and without staff present. The Surveyor observed Resident #80 at 12:00 P.M. on 11/28/17 in his/her wheelchair, with a pressure sensitive alarm in place in the wheelchair. The Surveyor observed Resident #80 at 9:24 A.M. on 12/4/17. Resident #1 was in his/her room, sitting on the edge of the bed, without a pressure sensitive alarm in place. The Pressure Alarm in Bed and Chair flowsheet, dated 12/2017, indicated staff would check for functioning and placement of Resident #80's pressure sensitive alarm every shift, and that the placement and functioning of the pressure sensitive alarm had been checked on the morning of 12/4/17. The Surveyor interviewed Nurse #3 at 9:52 A.M. on 12/4/17. Nurse #3 said Resident #80 should have a bed and chair alarm in place at all times. It was observed, by the Surveyor and Nurse #3 at that time, an alarm box was secured to the side of Resident #80's bed, however the alarm box was not attached to a pressure sensitive pad, and there was no pressure sensitive pad on Resident #80's bed. Refer to F689.

Based on record review, observation and staff interview, the facility failed to ensure that 1 of 5 applicable residents (#2) in a total sample of 23, received proper care and treatment to prevent the development and worsening of a pressure sore. Findings include: For Resident #2, the facility failed to properly apply a Hoyer pad (mechanical lift pad), and the resident developed a stage two pressure ulcer (1.3 centimeter (cm) by 1 cm, with 0.2 cm depth) which worsened to an unable to stage pressure ulcer (4 cm by 2 cm, unable to determine depth) to his/her left posterior thigh. Resident #2 was admitted to the facility 4/2009, with [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly Minimum Data Set (MDS) Assessment, dated 1/11/13, indicated that the resident's cognition was moderately impaired and he/she was totally dependent for transfers, bathing, dressing, grooming, and eating. The resident was non-ambulatory and required the use of a mechanical lift to be moved from the bed to a chair. The MDS coded "0" for the presence of pressure sores. During the initial tour of the facility on 2/27/13 at 9:15 A.M., Unit Manager(UM) #3 said that Resident #2 developed a pressure ulcer on his/her posterior left thigh, and they think it was because the Hoyer pad was placed inappropriately. She continued to say that the Certified Nursing Assistants (CNAs) have been inserviced in the proper application of the Hoyer lift pad. During review of the resident's clinical record on 2/27/13 at 10:00 A.M., a Pressure Ulcer care plan, dated 2/18/13, indicated the following- "resident noted, 1.3 cm by 1 cm area to back of his/her thigh. Location of area is approx. to Hoyer pad. Staff educated to use caution with transfers". Review of the resident's Pressure Ulcer Record indicated the following: * 2/18/13- Stage two, 1.3 cm by 1 cm, 0.2 cm depth, scant sero-sanguinous drainage, no odor- treatment- Allevyn Adhesive dressing, change every 3 days * 2/26/13- Unable to stage, 2 cm by 1.4 cm, ? depth, sero-sanguinous drainage with a slight odor, treatment- [MEDICATION NAME] and dimethicone BID, Resident started on an antibiotic- [MEDICATION NAME] 100 mg(milligram) by mouth, twice a day * 3/4/13- Unable to stage, 4 cm by 2 cm, ? depth, odor present, antibiotic was changed to Keflex Review of the Skin/Wound Management Focus Notes indicated the following: *2/18/13- Stage two to the left thigh, Hoyer pad-Staff reeducated on transfers with resident and lambs wool for protection with transfers. Continue weekly reviews. The next review should have occurred on 2/25/13. Surveyor was unable to obtain any further focus notes. Review of the In-Service Training Report, dated 2/18/13, indicated the following: Hoyer pad placement- CNAs/Nursing-ensure pad is in proper placement and not rolled underneath thighs and bottom. During observation on 3/5/13 at 4:20 P.M., the resident was observed sitting in a wheelchair, restrained with a velcro seatbelt. The seamed portion of the Hoyer lift pad was curled and twisted under the resident's left thigh. The velcro seatbelt was secured very snug across the resident's thighs, which created a pulling force, pushing the curled and twisted Hoyer pad, towards the unable to stage pressure ulcer. The Hoyer pad was positioned improperly despite recent education on 2/18/13 with CNA/Nursing staff in regard to proper placement of a Hoyer pad. During interview on 3/5/13 at 4:30 P.M., UM#3 said that the placement of the Hoyer pad as well as the snug fit of the velcro seatbelt was inappropriate. Um #3 said "It's(Hoyer pad) pressing right up against the wound we are trying to heal."

Based on observations, interviews, and record review, the facility failed to prevent the development of blisters on both heels for 1 resident (Resident #27) in a sample of 14 residents. Findings include: Review of the clinical record on 4/25/13 indicated that the Resident #27 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. Review of the Norton Plus Scale for determining the risk for potential skin breakdown, dated 4/8/13, indicated a score of 5 which meant the resident was at high risk for skin breakdown. Review of the Admission Nursing Assessment, dated 4/8/13, indicated that the resident had 4 plus [MEDICAL CONDITION] (If pressing on the extremity caused an indentation that persisted for some time after the release of the pressure, the [MEDICAL CONDITION] was referred to as [MEDICAL CONDITION].) on both lower extremities. There were also scabs noted on both lower extremities. The assessment indicated that the resident's skin was intact. The assessment indicated that the resident was to have preventative/protective foot care to his/her bilateral heels every shift using skin prep. Review of the resident's physician orders, dated 4/8/13, indicated that there was no order for skin prep to be completed on the resident's heels as indicated on the nursing assessment. The physician orders [REDACTED]. During an interview with the Director of Nurses (DON) on 4/25/13 at 1:15 P.M., she said the resident's bed had a pressure redistribution mattress (Panacea). Manufacturer guidelines regarding the mattress stated that the heel area was ultra-soft, high resiliency foam which cradled the vulnerable heel area. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 4/13/13, indicated that the resident's Brief Interview for Mental Status (BIMS) was 9 which showed a decline in the resident's cognition. The MDS indicated that the resident was usually understood and was able to understand. The MDS further indicated that the resident required the physical assistance of two staff members for bed mobility, transfers, toileting, bathing, and personal hygiene. The MDS did not identify any open areas on the resident's skin. The plan of care for the prevention of skin breakdown, dated 4/8/13, due to poor mobility included: *Certified Nurse's Assistant (CNA) assess condition with daily care and report results to charge nurse. *Total Body checks with all showers and complete baths. *Turn and redistribute weight every two hours. *Ensure pressure relieving mattress was in place and functional each day. During interview with the Rehabilitation Manager on 4/25/13 at 5:10 P.M., he said that during Physical Therapist (PT) #1's evaluation of the resident, she requested via a Rehabilitation Telephone Order (TO) Request Form that the resident's heels be elevated. The Rehabilitation Manager said he was told that the resident's heels were red and the resident was at high risk for skin breakdown due to the [MEDICAL CONDITION] present in his/her feet and legs. Review of the Rehabiltiation TO Request Form, dated 4/10/13, indicated that "pt will use heels up when positioned in bed". On the Form there was a notation dated 4/11/13 indicating "No Need Heels Not Red". During an interview with PT #1 on 4/26/13 at 11:40 A.M., she said that on 4/10/13 when she spoke to the resident, the resident complained of pain in both heels that kept him/her up most of the night. She said she examined the resident's heels and found them red. She said she wrote a Rehabilitation TO Request Form to elevate his/her feet in bed and left the request with nursing. Review of the Skin Management Program, revised 10/2012, indicated that the purpose of the program was to minimize the development of pressure ulcers through the systematic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. Policy indicated that each resident undergo a weekly body check by the licensed nurses utilizing the "weekly body check form". Review of the Weekly Body Check Form indicated that the entire body was to be examined and any redness,open areas, bruises, dry or oily skin, skin tears, or podiatry needs were to be noted. Review of the Weekly Body Check, dated 4/11/13 Thursday 3:00 P.M. to 11:00 P.M., indicated that the resident's skin was intact and signed by the licensed nurse. Review of the Weekly Body Check, dated 4/18/13 Thursday 3:00 P.M. to 11:00 P.M., indicated that there was no documentation and/or signature of the licensed nurse. Review of the resident's Treatment Administration Record (TAR), dated 4/18/13 Thursday from 3:00 P.M. to 11:00 P.M., indicated that the skin check was completed and initialed by the licensed nurse. Review of the nurse's note, dated 4/23/13, indicated that the resident had bilateral 2 plus [MEDICAL CONDITION] in the lower extremities and both heels had fluid filled blisters. The note indicated that the left heel blister was broken with clear drainage and redness and measured 10 centimeters (cm) by 8 cm by 0.1 cm and the right heel blister was intact and measured 8 cm by 6 cm. The note indicated that the physician was notified and the physician ordered a different treatment for [REDACTED]. The physician orders, dated 4/23/13, included: *Left heel - normal saline wash, followed by an Allevyn Adhesive dressing every 3 days. *Right heel - skin prep, followed by a dry clean dressing. *Heel Protectors at all times. Documentation on the reverse side of the Treatment Administration Record (TAR), dated 4/23/13 3:00 P.M. - 11:00 P.M., indicated: right heel blister intact; left heel red with hanging skin. Resident removed all dressings and heel protector. Heels redressed and resident remained non-compliant with dressings and heel protectors. The physician orders, dated 4/24/13, indicated that the treatment to the left heel was changed to normal saline wash, apply Dimethicone (protective agent) cream with a dry clean dressing every shift. Documentation on the reverse side of the TAR, dated 4/24/13 from 7:00 A.M. - 3:00 P.M., indicated that the right heel blister was intact and left heel dressing was intact. Observation on 4/25/13 at 9:45 A.M. of the resident's bilateral heels revealed a large intact fluid filled blister on the right heel. An open reddened area on the left heel was observed extending across the bottom of the heel to the base of the Achilles tendon. The resident was observed prior to the dressing change in his/her wheelchair with heel protectors in place.