Every finding on record at Park Villa

Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 31 residents who resided in the facility and received meals from the facility kitchen. Findings included: - 04/14/26, a review of the noon meal consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting. On 04/14/26 at 11:15 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 04/13/26 at 10:56 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled in the classes but had not completed them 04/15/26 at 11:45 AM, Administrative Nurse D verified DS BB had no dietary manager certification, but had enrolled and started the dietary certification classes. The facility's Nutritional Services Policy, revised 01/21/26, documented the certified dietary manager would oversee all kitchen procedures, including the following:1. Menu planning2. Diet and diet manual with nutritional evaluations3. Office procedures, including the process of nursing staff informing the Registered Dietitian, in writing, of the arrival of new elders.4, Food production5, Food service

Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen. The facility failed to label, seal, and date food stored in the refrigerator/freezer and dry storage area. The facility also failed to consistently log freezer/refrigerator temperatures. Findings included:- On 04/13/26 at 08:10 AM, observation in the kitchen revealed the following:A white upright freezer had approximately one-quarter inch (in) of ice built up along the inside of the freezer and the shelves.The refrigerator located in the kitchen had a plastic bag with unlabeled, undated sliced yellow cheese.The March 2026 Freezer/Refrigerator Temperature Logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:1. Chest freezer located in dry storage on 05,06,10,11,14,15,17,19,21, and 23-31.2. A white stand-up freezer on 7,8,14, 15,18, 21, and 25.3. A double door refrigerator on 7,8,15, 18, 21, 22.4. A single door refrigerator on 6, 7, 8, 21.The April freezer/refrigerator temperature logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:A double door freezer on 4, 5,The ice machine located in the area between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it.Eight 15.5-pound (lb.) plastic jugs of used cooking grease with numerous different sizes of grayish-black substances on their top.The dry storage area had the following:An approximately one-quarter full 5 lb. package of undated pasta Labello egg noodles.An approximately one-quarter full 4.5 lb. package of unlabeled, undated, unsealed [NAME] noodles. Approximately three-quarters of a full package of undated strawberry gelatin.An approximately three-quarters full bag of unsealed buttermilk pancake.On 04/13/26 at 08:20 AM, Dietary Staff (DS) CC verified the above findings and stated she would ask the dietary manager what to do with the findings when she arrived at the facility for her shift.On 04/14/26 at 01:30 PM, the Dietary Manager (DM) BB stated staff should label and date all food placed in dry storage, refrigerator, or freezer, when received, and if open, make sure they are sealed, labeled, and dated with the open date.The facility's Dietary Purchases, Receipt and Storage Policy, revised 01/21/26, documented all products would be labeled with the date received in the facility. Frozen foods stored in the freezer, and the temperature would be maintained at 0 to -10 degrees Fahrenheit (F). Produce is stored in the refrigerator, and the temperature would be maintained at 38-44 degrees F. Dairy products would be stored in the refrigerator, and the temperature would be maintained at 35 to 40 degrees F. The facility's Monitoring of Refrigerators and Freezers Policy, revised 01/21/26, documented all refrigerators/freezers would be cleaned on a weekly basis and as necessary for spills. Refrigerators that are accessible to elders and used by multiple elders and/ or families would contain only food that is sealed in an airtight container that had not been inside an elder's room. All food items would be labeled with the contents of the container and the date it was placed in the refrigerator. A temperature log would be completed. The Certified Dietary Manager/designee is responsible for monitoring temperatures and appropriate logging of temperatures, and appropriate discarding from refrigerators/freezers containing food items. All temperature logs will be maintained in the environmental services office for two weeks.

Based on observation, interview, and record review, the facility failed to discard expired stock medication from the North Hall medication cart. Findings included: - On 04/13/2026 at 08:10 AM, observation of the North Hall medication cart revealed the following:Acetaminophen suppositories 650 milligrams (mg), four suppositories, expiration 3/2026. On 04/13/2026 at 08:15 AM, Certified Medication Aide (CMA) R verified the medication aides or nurses were to discard expired medications. On 4/15/2026 at 02:30 PM, Administrative Nurse E verified the medication aides or nurses were to check the medication cart and discard expired medications. The facility's Medication Labeling and Storage policy, dated 01/22/2026, documented medications are labeled and stored in accordance with facility requirements and State and Federal laws. All drug containers would be labeled, and drug labels must be clear, consistent, legible, and in compliance with State and Federal requirements. Floor stock medications are labeled floor stock or house supply and kept in the original manufacturer's container with the expiration date and lot number clearly evident.

Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life), was developed and available for Resident (R)12 and R5. This placed R12 and R5 at risk for inappropriate end of life cares. Findings included:- R12's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), and atrial fibrillation (rapid, irregular heartbeat). R12's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R12 had severely impaired cognition. The MDS recorded he required extensive assistance of two staff with bed mobility and transfers. The MDS documented R12 received hospice services. R12's Care Plan, dated 01/19/26, recorded R12 required extensive assistance with most activities of daily living (ADL) care. R12's Care Plan documented R12 had a terminal prognosis due to Alzheimer's and directed staff to adjust provision of ADLs to compensate for R12's change in abilities and consult with the physician to have hospice care in the facility. The care plan directed the staff to observe R12 closely for signs of pain, administer pain medications ordered and notify the physician if there is breakthrough pain. The care plan lacked instruction on the services provided by hospice, including hospice staff visits, supplies, and medical equipment provided by hospice, and medications covered by hospice. Review of R12's medical records revealed the resident was admitted to hospice care on 12/29/25 but lacked evidence of coordination of care between hospice and the facility. On 04/14/26 at 09:30 AM, R12 was lying in a low bed and Certified Medication Aide (CMA) R knelt beside R12's bed and administered his eye drops. On 04/13/26 at 02:00 PM, Administrative Nurse F verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The Hospice Services policy, dated 01/22/26, documented the facility would provide continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdisciplinary care that would recognize spiritual needs and assist residents, family members, and friends to live as fully and completely as possible with meaning and dignity. An interdisciplinary care plan would integrate the care and services provided by the facility and the hospice provider to include residents, staff, and physician comfort with dealing with pain. The care plan would also include family expectations, resident and family knowledge of disease progression and eventual outcome, staff time required to provide care and services, cultural and ethnic diversity, and communication and/or coordination of participants and agencies providing aspects of palliative care. The facility would coordinate care planning with the hospice provider, including all services and supplies provided by the hospice provider. - R5s Electronic Health Record (EHR) revealed diagnosis of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin, hypertension (HTN-elevated blood pressure), atherosclerotic heart disease(a disease involving the buildup of fats, cholesterol, and other substances in artery walls, which narrows pathways and restricts blood flow). R5's Significant Change Minimum Data Set (MDS), revised 03/10/26, documented R5 had a Brief Interview of Mental Status (BIMS) score of two, which indicated severe cognitive impairment. The MDS document R5, dependent on staff with putting on and taking off footwear, required substantial, maximal staff assist with oral and toileting hygiene, bed mobility, transfers, upper and lower body dressing, and partial, moderate assist with personal hygiene. The MDS documented R5 received hospice care services. R's Care Plan, revised 07/09/25, documented R5 required moderate to extensive assistance with activities of daily living (ADLs). R5's Care Plan documented that the resident was admitted [hospice services] on 03/10/26. The plan directed the staff to adjust the provision of R5's activities of daily living to compensate for R5's changing abilities and encourage R5 to participate to the extent she wishes to participate. The plan directed staff to assess R5 for coping strategies, respect her wishes, and consult with the physician and services to have continuing hospice care for R5 in the facility. The plan directed staff to monitor R5 closely for signs of pain, administer pain medications as ordered, and notify the physician and hospice immediately if there is breakthrough pain. The care plan lacked a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, and what care they would provide. A review of R5's clinical record revealed the resident was admitted to hospice care on 03/10/26. On 04/15/26 at 08:10 AM, R5 rested in bed with eyes closed with no signs or symptoms of pain. 04/14/26 at 04:03 PM, Administrative Nurse F verified R5's Care Plan lacked information regarding hospice visits, phone numbers, and medical supplies that hospice services would provide. Administrative Nurse F stated the information should be on the resident's care plan. The facility's Hospice Services Policy, revised 01/22/26, documented an interdisciplinary care plan would be established, which integrates the care and services provided by the facility and the hospice provider, including : 1. Resident, staff, and physician comfort with dealing with death 2. Family expectations, 3. Resident and family knowledge of disease progression and eventual outcome 4. Staff time required to provide necessary care and services 5. Cultural and ethnic diversity 6. Communication and/or coordination of participants and agencies providing aspects of palliative care.

Based on observation, record review, and interview, the facility failed to implement acceptable infection control practices related to hand hygiene when staff failed to change gloves or wash hands between cares for Resident (R)6. Findings included: - On 04/15/26 at 10:21 AM, observation revealed R6 rested in bed with her eyes closed. Licensed Nurse (LN) H and Certified Nurse Aide (CNA) M donned gowns applied an N95 mask and gloves, then entered the resident's room and explained to R6 they were going to look at the wound on her bottom and provide catheter care. CNA M and LN H uncovered R6 to reveal the resident had no incontinent brief on. LN H assisted R6 in turning on her left side. CNA M separated the middle of R6's buttocks to reveal an open area approximately 0.3 centimeters (cm) long by 0.2 CM wide. CNA M provided catheter care on the tubing, starting from the insertion site down the tubing with a wet soapy washcloth, then used a dry one on the tubing. Further observation revealed LN H positioned R6 on her back, then separated R6's labia, then, with the same soiled gloves, pulled down the resident's front blouse, and placed her hands on the cloth bed pad to assist CNA M in pulling R6 up in bed. Further observation revealed that, with the same soiled gloves, LN H pulled the resident sheet and blanket over R6, placed the bed control in her right hand, and used the control to put R6's head of bed up, then removed and discarded the gloves, gown, and mask in a trash can. LN H verified she had not changed gloves after assessing R6's labia and stated she should have.On 04/15/26 at 12:08 PM, Administrative Nurse E stated she would expect staff to change gloves and wash hands when providing care, when going from dirty to clean.The facility's Infection Control Policy, revised 01/19/26, instructed staff to remove soiled gloves, wash hands, and change gloves after having contact with infectious material and before leaving the resident's environment, and wash hands immediately with antimicrobial soap.

Based on observation, record review, and interview, the facility failed to initiate timely interventions to prevent the development of a Stage 2 pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 27. Findings included:- R27's Electronic Health Record (EHR) revealed a diagnosis of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), heart failure, and muscle weakness. R27's Significant Change Minimum Date Set (MDS), dated [DATE], recorded R27 had a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The assessment revealed R27 required extensive staff assistance of two for bed mobility, personal hygiene, dressing, repositioning, and transfers. The resident was at risk for pressure ulcer development, had one or more unhealed pressure ulcers/injuries but did not document the number of Stage one, two, three or four pressure ulcers. The MDS documented that the resident had a moisture associated skin damage area with a pressure reducing device in her chair, was on a turning/repositioning program, with nutritional or hydration intervention to manage skin problems. R27's Care Plan dated 02/11/26, documented R27 had potential for skin impairment due to a history of refusal to lay down and get pressure off buttocks and had fragile skin. The CAA documented staff would encourage R27 to lay down in bed before and between meals and reposition at least every two hours and as necessary. R27's activities of daily living (ADL) Care Plan dated 02/11/26, recorded R27 required extensive assistance of one to two staff with most ADLs. R27's urinary incontinence Care Plan dated 02/11/26 recorded R27 had a urinary catheter due to constant urinary retention and incontinence. The Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE], documented a score of 16, which indicated the resident was at risk for pressure ulcer development.The Weekly Wound assessment dated [DATE], documented R27 had a lateral opening on her left buttocks with a measurement of 2.0 centimeters by 1.0 cm, and the area was cleansed, dried, and dressings were applied. The Plan of Care Note, dated 01/29/26 at 10:17 AM, documented R27 had a wound and weight loss; the note documented the resident had a catheter placed to aid in wound healing. The note documented that staff switched out R27's old recliner chair due to the seat being worn out and replaced the chair with a new recliner. The Weekly Wound Assessment dated 04/14/26, documented R27 had left inner buttocks wound with a measurement of 3.0 cm by 2.0 cm by 0.5 cm depth. The area was cleansed, dried and Prisma (a sterile wound dressing made of cellulose, collagen, and zinc promotes an antibacterial environment to promote wound healing) applied to the wound bed then covered with a dressing. No new skin concerns were noted at the time. Review of R27's medical record revealed a physician order dated 04/14/26 which directed staff to cleanse the open areas on R27's bottom with wound cleanser, apply saline moistened Prisma to the wound bed and cover with ABD daily. On 04/14/26 at 08:50 AM, observation revealed R27 lying on the left side of the bed and Certified Nurse Aide (CNA) N assisted Licensed Nurse (LN) G to keep R27 turned on her side while she performed wound care. LN G cleansed the buttocks wound on the left inner buttocks with soap and water, then wiped with saline solution and placed a cut to fit Prisma wound dressing and covered with an ABD pad, no drainage noted. LN G measured R27's wound at 2.0 cm x 3.5 cm by 0.8 cm depth. On 04/15/26 at 10:45 AM, Administrative Nurse E verified R27's pressure ulcer was facility acquired and stated she developed it after R27 sustained a left 5th metatarsal fracture and had to wear a walking boot. The resident is not as mobile and incontinent and did not want to sleep in her bed and sit in the recliner and wheelchair. The facility's Wound Assessment, Prevention and Treatment policy dated 01/19/26, documented all residents considered to have some risk of the development of pressure ulcers. A licensed nurse will perform a full body skin assessment on admission within two to four hours of entrance to the facility and again on the last day of the assessment period. A skin assessment utilizes the Braden scale and skin assessment criteria described in the skin assessment policy. A skin assessment would be performed on the day of return from a stay in another health care facility and seven days after that return, and each time a change in the resident's condition is noted. Braden Scale would be performed weekly for four weeks following an admission. After conducting an inspection of the resident's skin, the nurse would review the resident's assessment protocol for pressure ulcers to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a resident's risk of pressure ulcers or to treat an existing pressure ulcer would be implemented. The Certified Nurse Aide would perform a skin assessment at the time of each bathing experience document and report findings to the licensed nurse. Residents with lower extremities with ulcers would be assessed by a physician to determine the etiology of the ulcer. The physician's diagnosis would be recorded in the resident's clinical record.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 35 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/23/24, a review of the noon meal consisted of barbeque meatballs, red potato salad, creamy sweet corn, dinner roll, and chocolate pudding. On 07/23/24 at 11:30 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 07/22/24 at 12:30 PM, Dietary Staff BB verified he was not a certified dietary manager. Dietary Staff BB stated he had not started the certified dietary manager classes. On 07/24/24 at 10:58 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's undated Dietary Supervisor Certified Dietary Manager (CDM) Policy, documented the CDM qualifications and position requirements were the following: Successful completion of the state's CDM certification course. Ability to read and write English but not necessary for English primary language Ability to do simple math Ability to learn special diets Good personal hygiene ServSafe Certification required Membership in the state association of nutritional and food service professionals 2 years experience in food service in a healthcare setting preferred Exceptional interpersonal skills. Exceptional organizational skills. Ability to meet the dietary needs of the facility's diverse census. The facility failed to employ a full-time certified dietary manager for 35 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 07/22/24 at 07:50 AM, observation in the kitchen revealed the following: The refrigerator had an unlabeled, undated half-full plastic bag of chicken strips, an unlabeled and undated plastic bag with five hamburger patties, an uncovered metal pan of blueberry crisp, and an unsealed plastic bag of yellow cheese slices. The dry storage area had an unlabeled, undated five-pound plastic bag of white cake mix, half full, and an unlabeled, undated five-pound plastic bag of Devil's Food cake mix, half full. The chest-style deep freezer located in the dry storage area had approximately one-quarter to one-half inch (in) of ice buildup all around the inside of it. On 07/22/23 at 7:55 AM, Dietary Staff (DS) CC verified the issues in the kitchen. On 07/23/24 at 10:30 AM, observation in the kitchen revealed one-floor tile located in the dry storage room, in front of the white chest deep freezer, had a missing piece in the lower corner approximately one-quarter to one-half inch wide and five inches long; a piece was also missing in the upper right corner of the same tile approximately one-half inch wide by four inches long. On 07/23/24 at 01:15 PM, Dietary Manager (DM) BB verified the issue with the ice in the white chest deep freezer and the tile in the dry storage room and stated the deep freeze needed to be defrosted. DM BB stated staff should make sure food items are in a sealed container, labeled and dated before they place them in the refrigerator and dry storage area. The facility's Dietary Purchases, Receipt, and Storage Policy, revised 10/24/22, documented all products would be labeled with the date received in the facility. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 35 residents who received their meals from the facility's kitchen. This placed the 35 residents at risk for foodborne illness.

The facility identified a census of 35 residents. The sample included 12 residents with five residents reviewed for immunizations, Resident (R)10, R2, R1, R3, and R18, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to evaluate for eligibility and offer or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R10, R2, R1, R3, and R18's clinical medical records lacked evidence the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. On 07/23/24 at 03:00 PM, Administrative Nurse F stated residents were offered the pneumonia vaccines on admission, and as indicated; the facility sent out the Centers for Disease Control and Prevention (CDC) vaccination sheets and a sheet the facility had formatted that included multiple vaccinations at the top of the form and the resident or the residents representative were to circle the one they authorize the resident to receive. The form had the choice of a pneumonia vaccine but did not specify if the resident should receive the PVC13, PVC20, or PVC23. On 07/23/24 at 03:00 PM, when asked for a list of residents who were eligible for the Prevnar 20 (PCV20) vaccination, Administrative Staff A verified they would have the consultant pharmacist provide them with the residents who would be eligible for the PVC20, which was all but two residents in the facility who already received the PVC20. The facility's Immunization Policy, undated, documented all residents would be offered the pneumococcal vaccination on admission and as approved by the primary care physician after investigating/inquiry related to current immunization status, The policy documented the CDC recommends two vaccines for all adults over [AGE] years or older. The policy documented the resident received the PVC 13 and the PVC 23 but lacked guidance on when to administer the PVC20. The facility failed to offer the PCV20 pneumococcal vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumonia.

The facility had a census of 35 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date or the required physician documentation and specified duration, for Resident (R)10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan lacked documentation for the resident's antianxiety medication and the indication for the use of the medication. The Physician's Order, dated 05/31/24, directed the staff to administer lorazepam (antianxiety) 0.5 milligram (mg). Give 0.5 mg every six hours as needed for anxiety. The order lacked a stop date. R10's EHR lacked evidence of a specified duration which included a physician's rationale for the extended use. R10's consultant pharmacist monthly reviews, completed on 06/30/24, lacked evidence that the CP had identified the PRN lorazepam with no stop date. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/22/24 at 03:00 PM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. Administrative Nurse D verified the pharmacist had sent monthly reviews to the facility for concerns that lacked a recommendation for a stop date for the lorazepam. The facility's Consult Pharmacist Services Provider Requirements dated 06/01/2023, documented that regular and reliable consult pharmacist services are provided to elders. The pharmacist would review the medication regimen (drug regimen review) of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documentation of the reviews and findings in the elders' clinical record. The facility failed to ensure the CP identified and reported the lack of a 14-day stop date for the use of PRN lorazepam for R10. This placed the resident at risk for unnecessary antipsychotic medication with side effects.

The facility had a census of 35 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for R10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan lacked documentation for the resident's antianxiety medication and the indication for the use of the medication. The Physician's Order, dated 05/31/24, directed the staff to administer lorazepam (antianxiety) 0.5 milligram (mg). Give 0.5 mg every six hours as needed for anxiety. The order lacked a stop date. R10's EHR lacked evidence of a specified duration which included a physician's rationale for the extended use. R10's consultant pharmacist monthly reviews, completed on 06/30/24, lacked evidence that the CP had identified the PRN lorazepam with no stop date. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/22/24 at 03:00 PM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. The facility's Unnecessary Drugs and Psychotropic Drug Use policy, dated 10/12/2-022, documented the resident would be administered psychotropic medication only when necessary to treat specific diagnoses and document conditions. The facility would limit the timeframe for PRN psychotropic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing Practitioner. Limiting PRN psychotropic medications, which are antipsychotic medications, to 14 days and not entering a new order without first evaluating the resident. The interdisciplinary team would identify and document the resident's indication for use. Orders for PRN psychotropic and or antipsychotic medications that are not prescribed to treat a diagnosis-specific condition or do not meet the PRN requirements for psychotropic and antipsychotic medications. The facility failed to ensure R10's PRN lorazepam had a 14-day stop date or specified duration placing R10 at risk for adverse side effects.

The facility had a census of 35 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)10. This placed R10 at risk for inappropriate end-of-life care. Findings included: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS documented the resident received hospice services. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan documented the resident received hospice services due to a terminal prognosis and directed staff to adjust the provision of ADLs to compensate for R10's change in needs and consult a physician and social services to have hospice care for the resident. The care plan directed the staff to observe the resident closely for signs of pain, administer pain medications ordered, and notify the physician if there is breakthrough pain. The care plan lacked instruction on the services provided by hospice including hospice staff visits, supplies and medical equipment provided by hospice, and medications covered by hospice. R10's medical records revealed the resident was admitted to hospice care on 05/31/24 but lacked evidence of coordination of care between the hospice and the facility. The facility had received a hospice plan of care dated 06/03/24. The review revealed there was no communication book or external document. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/24/24 at 12:00 PM, Administrative Nurse E verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The Hospice Policy and Procedure policy, dated 06/01/23, documented the facility's goal of palliative and end-of-life care is to prevent and relieve suffering and to support the best possible quality of life for residents and the resident's family members regardless of the stage of the disease or the need for other therapies. End-of-life care would be provided based on a comprehensive and systematic delivery of care and services. Quality end-of-life care would include medical treatment that is appropriate and evidenced-based, continuity of comprehensive care, care customized to the resident's and family member's preference, care adapted to serve the residents and families, and assisting the resident to live as fully as possible. The care plan is based on the ongoing assessment and reflects goals set by the resident's family or surrogate in collaboration with the interdisciplinary team (IDT) including the resident's physician. In collaboration with the resident, family, and other involved health care professionals, the IDT develops the care plan with additional input, when indicated, from other community providers such as community services, and spiritual leaders. Changes in the care plan are based on the evolving needs and preferences of the resident and family, with recognition of the complex, competing, and shifting priorities in the goals of care. The IDT provides services to the resident and family consistent with the care plan to include chaplains, nurses, physicians, social workers, and other therapeutic disciplines who provide palliative care services to residents and family members. The IDT communicates regularly -at least weekly or more often as required by the clinical situation to plan, review, evaluate, and update the care plan, with input from both the resident and the family. The facility failed to coordinate care between the facility and the hospice provider for R10, who received hospice services. This deficient practice placed her at risk for inappropriate end-of-life care.

The facility identified a census of 27 residents with three reviewed for privacy and confidentiality in regard to their care at the facility. Based on record review, observation, and interview, the facility failed to protect the privacy of Resident (R) 1 when in February of 2023 Certified Nurses Aide (CNA) M took a video which included Resident (R) 1's lower legs and feet, and posted it to a social media site. R1's representative saw the video on the social media site and recognized R1's pants and shoes. R1's representative notified the facility on 05/05/23 of the video posted by CNA M. CNA M's job had previously been terminated on 04/09/23 for other infractions. The video of R1 was taken off of the social media site. This deficient practice placed R1 at risk for impaired psycho-social wellbeing and impaired privacy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of senile degeneration of the brain, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarct (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting the left, non-dominant side, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated R1 was moderately cognitively impaired. The MDS further documented required extensive assistance of one to two staff for bed mobility, transfer, locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/21/22, documented R1 needed focuses to help her maintain as much cognition as possible as her cognitive decline was permanent and progressive, R1 was documented as being easily distractible. The Activities of Daily Living/Rehabilitation Potential CAA, dated 10/21/22, documented R1 needed extensive assistance with her activities of daily living. R1 had a history of a cerebral infarct affecting her left side and has a contracture (shortening of the muscle) of her left forearm. The Impaired Cognitive Function Care Plan, dated 04/20/23, directed staff to reduce any distractions, turn off television, radio, and close door the door, provide R1 with necessary cues. Staff were directed to communicate with R1 in a consistent, clear directive conversation. Staff were directed to cue, reorient, and supervise R1 as needed. The Facility Report of Concern, dated 05/05/23, documented R1's representative went to the facility and spoke with the charge nurse on duty and voiced a complaint that former employee, CNA M, posted a video on a social media site with R1's feet in it. The charge nurse on duty reported the complaint to Administrative Nurse D. The video was taken off the social media site. CNA M had been terminated previously on 04/09/23. The facility Cell Phone Policy was updated, audits of employee's cell phones being on their person were completed, and an in-service training was completed with all staff. The facility did not report the incident to the State Agency (SA). On 05/31/23 at 09:30 AM, observation revealed R1 sat in her recliner watching TV. On 05/31/23 at 09:30 AM, R1 stated that she liked living in the facility and received good care at the facility. On 05/31/23 at 10:00 AM, Administrative Nurse D stated that at the time of the incident in February of 2023, no one at the facility had any idea that a video had been taken. Administrative Nurse D stated she was unaware of the incident until R1's representative had made the facility aware of the incident. Administrative Nurse D stated the facility did not have a cell phone policy but a policy was put into place after this incident. Administrative Nurse D stated it was against the facility's policy to post any pictures or videos to social media sites. Administrative Nurse D stated that R1's representative told the facility that she was going to report the incident to the state so she and Administrative Staff A did not think they were required to report the incident. On 05/31/23 at 10:30 AM, Administrative Staff A stated that he was the interim administrator and he was not at the facility at the time of the incident. Administrative Staff A stated that he was the acting administrator of the facility on 05/05/23 when the incident was reported the facility. Administrative Staff A stated that posting pictures or videos of residents of the facility was against the social media policy. Administrative Staff A stated the facility did not report the incident to the state agency because R1's representative said she was going to report the incident. The facility's Personal Cell Phone Policy, dated 05/08/23, documented all personal cell phones are prohibited from resident rooms, bath houses, commons area, and facility halls. In an effort to provide for the privacy of the residents personal cell phones are not to be on staff's person in the facility. Personal cell phones are to be left in the car, in the break room, or left with the charge nurse on duty. The facility's Social Networking and Other Web-Based Communications Policy, dated 02/06/20, documented unless specifically instructed, employees are not authorized and therefore restricted to speak on the behalf of the facility. Employees may not publicly discuss residents, elders, family members, employees, vendors, volunteers or any work related matters, whether confidential or not, outside the facility authorized communications. Employees are expected to respect the privacy of the facility and its employees and elders and are prohibited from disclosing personal employee or non-employee information and any other proprietary and non-public information that employees have access to. Per the facility's social media policy, if a shared photograph or recording of an elder or the manner that the photo is used, demeans or humiliates an elder, regardless of whether the elder provided consent and regardless of elder's cognitive status, abuse includes and will be reported, investigated and resolved but not limited to: photographs, recordings containing nudity, sexual and intimate relations, bathing, showering, dressing, toileting, providing perineal care, agitating an elder to elicit a response, derogatory statements directed at an elder, showing a body part without the resident's face whether it is chest, limbs or back, or showing an elder in a compromising situation. The facility failed to protect R1's privacy which placed R1 at risk for R1's psycho-social well-being and privacy infringed.

The facility identified a census of 27 residents with three reviewed for privacy and confidentiality in regard to their care at the facility. Based on record review, observation, and interview, the facility failed to report an incident to the State Agency as required when in February of 2023, the facility received an allegation of abuse concerning Certified Nurse's Aide (CNA) M and Resident (R)1. This deficient practice placed R1 at risk for ongoing and/or unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of senile degeneration of the brain, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarct (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting the left, non-dominant side, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated R1 was moderately cognitively impaired. The MDS further documented required extensive assistance of one to two staff for bed mobility, transfer, locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/21/22, documented R1 needed focuses to help her maintain as much cognition as possible as her cognitive decline was permanent and progressive, R1 was documented as being easily distractible. The Activities of Daily Living/Rehabilitation Potential CAA, dated 10/21/22, documented R1 needed extensive assistance with her activities of daily living. R1 had a history of a cerebral infarct affecting her left side and has a contracture (shortening of the muscle) of her left forearm. The Impaired Cognitive Function Care Plan, dated 04/20/23, directed staff to reduce any distractions, turn off television, radio, and close door the door. Provide R1 with necessary cues. Staff directed to communicate with R1 in a consistent, clear directive conversation. Staff were directed to cue, reorient, and supervise R1 as needed. The Facility Report of Concern, dated 05/05/23, documented R1's representative went to the facility and spoke with the charge nurse on duty and voiced a complaint that a former employee, CNA M, posted a video on a social media site with R1's feet visible in it. The charge nurse on duty reported the complaint to Administrative Nurse D. The video was taken off of the social media site. CNA M had been terminated previously on 04/09/23. The facility Cell Phone Policy was updated, audits of employees' cell phones being on their person were completed, and an in-service training was completed with all staff. The facility did not report the incident to the SA. On 05/31/23 at 09:30 AM, observation revealed R1 sat in her recliner watching TV. On 05/31/23 at 09:30 AM, R1 stated that she liked living in the facility and received good care at the facility. On 05/31/23 at 10:00 AM, Administrative Nurse D stated that at the time of the incident in February of 2023 no one at the facility had any idea that a video had been taken. Administrative Nurse D stated she was unaware of the incident until R1's representative had made the facility aware of the incident. Administrative Nurse D stated the facility did not have a cell phone policy but a policy was put into place after this incident. Administrative Nurse D stated it was against the facility's policy to post any pictures or videos to social media sites. Administrative Nurse D stated that R1's representative had told the facility that she was going to report the incident to the state so she and Administrative Staff A did not think they were required to report the incident. On 05/31/23 at 10:30 AM, Administrative Staff A stated that he was the interim administrator and he was not at the facility at the time of the incident. Administrative Staff A stated that he was the acting administrator of the facility on 05/05/23 when the incident was reported the facility. Administrative Staff A stated that posting pictures or videos of residents of the facility was against the social media policy. Administrative Staff A stated the facility did not report the incident to the state agency because R1's representative said she was going to report the incident. The facility's undated Reporting Abuse, Neglect or Misappropriation of a Resident, documented that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported per Federal and State law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency and adult protective services in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility per agreement with th3e local law enforcement agency. The facility's Personal Cell Phone Policy, dated 05/08/23, documented all personal cell phones are prohibited from resident rooms, bath houses, commons area, and facility halls. In an effort to provide for the privacy of the residents personal cell phones are not to be on staff's person in the facility. Personal cell phones are to be left in the car, in the break room, or left with the charge nurse on duty. The facility's Social Networking and Other Web-Based Communications Policy, dated 02/06/20, documented unless specifically instructed, employees are not authorized and therefore restricted to speak on the behalf of the facility. Employees may not publicly discuss residents, elders, family members, employees, vendors, volunteers or any work-related matters, whether confidential or not, outside the facility authorized communications. Employees are expected to respect the privacy of the facility and its employees and elders and are prohibited from disclosing personal employee or non-employee information and any other proprietary and non-public information that employees have access to. Per the facility's social media policy, if a shared photograph or recording of an elder or the manner that the photo is used, demeans or humiliates an elder, regardless of whether the elder provided consent and regardless of elder's cognitive status, abuse includes and will be reported, investigated and resolved but not limited to: photographs, recordings containing nudity, sexual and intimate relations, bathing, showering, dressing, toileting, providing perineal care, agitating an elder to elicit a response, derogatory statements directed at an elder, showing a body part without the resident's face whether it is chest, limbs or back, or showing an elder in a compromising situation. The facility failed to report an incident where R1's privacy was infringed upon which placed R1 at risk for ongoing abuse and/or mistreatment.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to monitor and adhere to cleaning and disinfecting shared equipment which consisted of a digital thermometer and oxygen saturation clip, (a device used to monitor oxygen in the blood) placing the residents at risk for infection. Findings included: - On 06/29/22 at 08:00AM, upon entrance into the facility observation revealed a sign in sheet to document entrance into the facility, a small brown wooden box which contained a digital thermometer and a oxygen saturation clip. Further observation revealed no supplies for disinfecting or cleaning the thermometer or oxygen clip after use. On 07/05/22 at 7:30AM, observation continued to reveal no supplies were available to clean the digital thermometer or oxygen clip used by all who entered the facility. On 07/05/22 at 08:10AM, Administrative Staff A verified no supplies were available at the sign in area of the facility to clean the digital thermometer or oxygen clip. Administrative Staff A stated she did not realize there were no supplies available at the sign in station. The facility's Infection Control policy, dated 03/16/2022, stated equipment is to be cleaned and disinfected after each use. The facility failed to ensure shared equipment was cleaned and disnfected between uses, placing the residents at risk for infection.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances, placing the residents at risk for unresolved concerns. Findings included: - On 06/30/22 at 01:30PM, during private discussion with the residents of the resident council, residents verbalized an ongoing unpleasant dining experience due to a resident who hollered and was disruptive during meals. Council members verbalized no resolution from the facility regarding the council's grievance. Review of the resident council meeting minutes for March, April, May and June 2022, revealed grievances by council members regarding a resident who hollered loudly during meals. The council minutes lacked documentation of the facility's action to resolve the grievance. Review of the facility's grievance log lacked documentation of any grievances in the facility. On 07/05/22 at 12:05PM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly while other residents seated at dining table ate the noon meal. On 06/30/22 at 01:30PM, Certified Nurse Aide (CNA) M verified R1 was disruptive during dining, and other residents complained about the noise when they were eating meals. On 07/05/22 at 10:10AM, Administrative Staff A verified R1 was disruptive and hollered during meals and stated it had been going on for several months. On 07/06/22 at 9:50AM, Social Service/Activity Staff verified R1 was disruptive and loud during meals. Social Service/Activity Staff stated residents had complained for several months about it being too loud when they were eating. The facility's Grievance Policy, dated 03/2022, stated Residents may present any concerns they have through a grievance resolution procedure. This facility attempts to resolve promptly all concerns. Residents have the right to receive prompt efforts by management. Grievances are to be followed up on and response provided to the individual or group with the resolution of the concern. The facility's Resident Council, policy dated 10/2003, stated the residents shall meet once a month to discuss any problems they may had and the facility will work towards alleviating these grievances. The facility failed to respond to resident council grievances, placing the residents in the facility at risk for unresolved issues.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide comfortable sound levels promoting a homelike dining environment. This placed the residents at risk for an unpleasant dining experience. Findings included: - On 06/29/22 at 11:33AM, observation in the dining room revealed Resident (R) 1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly, made hooting noises, growled and was disruptive. On 06/29/22 at 12:10PM, observation revealed R16 sat on a dining chair across the table from R1. Further observation revealed R1 continued to holler loudly. R16 stood up and moved to a different dining table. R1 became louder, and made hooting type noises. R16 then stood up again and stated, I am going back to my room to eat, I just can't stand this anymore. On 06/30/22 at 11:50AM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly and made growling and hooting noises while other residents were being served and ate the noon meal. On 07/05/22 at 12:05PM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly while other residents seated at dining table ate the noon meal. On 06/30/22 at 01:30PM, Certified Nurse Aide (CNA) M verified R1 was disruptive during dining, and other residents complained about the noise when they were eating meals. On 07/05/22 at 10:10AM, Administrative Staff A verified R1 was disruptive and hollered during meals and stated it had been going on for several months. On 07/06/22 at 9:50AM, Social Service/Activity Staff verified R1 was disruptive and loud during meals. Social Service/Activity Staff stated residents had complained for several months about it being too loud when they were eating. The facility's undated, Dining Room Standards policy, stated the community will ensure and maintain a cheerful dining experience with comfortable sound levels. The facility failed to provide a homelike dining environment for the residents who ate meals in the dining room, placing them at risk for an unpleasant dining experience.

The facility had a census of 26 residents. The sample included 13 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with the use of the power lift recliner for Resident (R)25, placing the resident at risk for accidents and injury related to the power lift chair. Findings included: - R25's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R25 had unsteady balance, functional impairment on both upper extremities, and had no falls during the look-back period. Review of the Electronic Medical Record lacked documentation an Electric Recliner Assessment was completed for the resident. The Fall Risk Assessments, dated 03/11/22, 06/03/22, 06/11/22, and 06/28/22, documented the resident a high fall risk. The Fall Care Plan, dated 06/13/22, directed staff to ensure R25's had a safe environment with the floors free from spills or clutter, a reachable call light, bed in the lowest position, and personal items withing reach. The fall care plan documented the resident did not have any safety awareness and to continue with interventions already in place, ensure the resident used the electronic personal safety alarm and keep the resident in line of sight. The Fall Investigation, dated 06/11/22, documented at 03:20 PM, staff heard R25's personal alarm sounding, and the resident was observed on the floor in front of a recliner in the living room. Staff assisted the resident to her wheelchair and obtained vital signs. R25 was noted to have skin tears to her right eyebrow 0.6 centimeters (cm) and right pinky finger 0.6 cm. The areas were cleaned, band aides applied, and ice packs to the areas. The fall investigation further documented the resident had been in the power lift recliner in the living room. The Fall Investigation, dated 06/28/22, documented at 09:45AM, R25 was seated in a power lift chair in the living room, the control to her recliner was in the chair. Staff observed R25 moving and pushing the electric control which caused her to fall forward on the floor. R25 was noted to have two small lacerations to the bridge of her nose, a bloody nose and bleeding from her mouth on top of the gum line. Staff assisted the resident back into the recliner, then to the wheelchair and transported her to bed and noted she was incontinent of bowel. Staff assessed the resident, provide cares, and started neurological checks. The investigation further documented staff would not place R25 in a power lift chair and keep the resident in line of sight. On 06/30/22 at 01:00 PM, observation revealed R25 sat in a regular (no power lift chair) recliner in the living room. Further observation revealed the resident the resident had her eyes closed and the footrest was elevated. On 07/05/22 at 09:00 AM, Administrative Nurse E verified the resident had two falls from a power lift chair with injury and the facility had not completed a power lift chair assessment for the resident. Administrative Nurse E verified the resident could not use the power lift chair controls safely and verified the care plan was not updated with the falls. The facility's Plan of Care Conference policy, dated November 2003, documented to provide optimal, holistic care to each resident on an individual basis, an interdisciplinary care plan would be established on admission and reviewed and revised on a regular schedule. The care plan is initiated on the date of admission by the assessment process by all disciplines and is completed in 21 days. All care plans will be reviewed and update by the team every 90 days and will revise regularly as changes occur. The facility's Goals and Objectives, Care Plan policy, dated 2001, documented care plans would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan and objectives are defined as the desired outcome for a specific resident's problem and are derived from information contained in the resident's comprehensive assessment and are resident oriented, are behaviorally stated, are measurable, and contain timetables to meet the resident's needs in accordance with the comprehensive assessment. The policy documented the goals and objectives are reviewed and/or revised; when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly. The facility failed to revise R25's care plan with interventions for safe use of the power lift recliner or the regular recliner. This placed the resident at risk for complications and future injuries.

The facility had a census of 26 residents. The sample included 13 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent accidents for Resident (R) 25 who had two falls from a recliner and sustained a laceration and injury on her nose and face. This placed the resident at risk for further injury. Findings included: - R25's diagnosis included dementia (progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and [CONDITION(S)] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R25 had unsteady balance, functional impairment on both upper extremities, and had no falls during the look-back period. Review of the Electronic Medical Record lacked documentation an Electric Recliner Assessment was completed for the resident. The Fall Risk Assessments, dated 03/11/22, 06/03/22, 06/11/22, and 06/28/22, documented the resident a high fall risk. The Fall Care Plan, dated 06/13/22, directed staff to ensure R25's had a safe environment with the floors free from spills or clutter, a reachable call light, bed in the lowest position, and personal items withing reach. The fall care plan documented the resident did not have any safety awareness and to continue with interventions already in place, ensure the resident used the electronic personal safety alarm and keep the resident in line of sight. The Fall Investigation, dated 06/11/22, documented at 03:20 PM, staff heard R25's personal alarm sounding, and the resident was observed on the floor in front of a recliner in the living room. Staff assisted the resident to her wheelchair and obtained vital signs. R25 was noted to have skin tears to her right eyebrow 0.6 centimeters (cm) and right pinky finger 0.6 cm. The areas were cleaned, band aides applied, and ice packs to the areas. The fall investigation further documented the resident had been in the power lift recliner in the living room. The Fall Investigation, dated 06/28/22, documented at 09:45AM, R25 was seated in a power lift chair in the living room, the control to her recliner was in the chair. Staff observed R25 moving and pushing the electric control which caused her to fall forward on the floor. R25 was noted to have two small lacerations to the bridge of her nose, a bloody nose and bleeding from her mouth on top of the gum line. Staff assisted the resident back into the recliner, then to the wheelchair and transported her to bed and noted she was incontinent of bowel. Staff assessed the resident, provide cares, and started neurological checks. The investigation further documented staff would not place R25 in a power lift chair and keep the resident in line of sight. On 06/30/22 at 01:00 PM, observation revealed R25 sat in a regular (non powered) recliner in the living room. Further observation revealed the resident had her eyes closed and the footrest was elevated. On 07/05/22 at 09:00 AM, Administrative Nurse E verified the resident had two falls from a power lift chair with injury and the facility had not completed a power lift chair assessment for the resident. Administrative Nurse E verified the resident could not use the power lift chair controls safely. The facility's Fall Management policy, dated July 2022, documented staff would assure the facility provided the highest possible level of care for the resident safety and comfort with minimal fall occurrence. With every fall, a fall management assessment and fall care plan will be completed by the charge nurse, and the primary care physician and responsible party would be notified. The fall management assessment would be routed to the director of nursing for review, and the DON or the charge nurse will contact physical therapy or occupational therapy for evaluation. A fall follow up form would be initiated along with the Fall Management Assessment and completed by the charge nurse for each shift for 72 hours after the fall. The facility failed to prevent falls for R25, who had two falls with minor injury from a power lift recliner. This placed the resident at risk for further falls and injury

The facility had a census of 26 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess Resident (R)11's side rails for safe use. This placed the resident at risk for injury. Findings included: - R11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R11 required extensive assistance of one staff with bed mobility and transfers. The MDS lacked documentation the resident had bed side rails. The Activities of Daily Living (ADLs) Care Plan, dated 11/08/21, indicated R11 required extensive staff assistance with most ADLs due to muscle weakness and impaired balance. The Care Plan lacked indication of the use of a side rail to assist with repositioning in bed. R11's electronic medical record lacked a side rail assessment. On 06/30/22 at 08:30 AM, observation revealed R11 seated in a recliner in room with his feet elevated and eyes closed. On 7/05/22 at 08:35 AM, observation revealed an upper one-third side rail on the outer right side of the bed. The upper opening measured 15.5inches long by 14.5 inches wide on the bottom of the rail to the top of the mattress. The side rail was attached to the bed with wire ties and was able to move back and forth out of the bed frame. On 07/05/22 at 0:45 AM, Administrative Staff A verified the bed rails should not be on R11's bed and verified the rails had too large of openings. On 07/05/22 at 09:00AM, Administrative Nurse Staff E verified the residents medical record lacked a side rail assessment for safety of the rails. The facility's Restraint Use Policy and Procedures policy, undated, recorded the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraints use is to enhance resident quality of life by assuring safety while promote an optimal level of function. The facility failed to adequately assess R11 for the appropriate side rail, placing him at risk for accident or injury.

The facility had a census of 34 residents. The sample included three residents reviewed for elopement risk. Based on observation, record review, and interview, the facility failed to adequately monitor and supervise cognitively impaired Resident (R) 1, when she exited the facility through the unlocked, unalarmed front entrance door without staff's knowledge and was outside for approximately 25 minutes before staff located her. This deficient practice placed R1 in immediate jeopardy and had the potential to affect the other 13 residents at risk for elopement. Findings included: - R1's Physician Order Sheet, dated 02/03/21, documented diagnoses of altered mental status, [CONDITION(S)] (hardening and thickening of the wall of the arteries), chronic kidney disease, and Alzheimer's disease with late onset (progressive mental deterioration characterized by confusion and memory failure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment and continuous inattention and disorganized thinking. The MDS documented the resident required limited assistance of one staff with bed mobility, transfers, locomotion off the unit, dressing, toilet use, and personal hygiene. The MDS documented the resident had unsteady balance, able to stabilize without staff assistance, and required no mobility assistance devices. The Cognition Care Plan, dated 02/19/21, directed staff to cue, reorient and supervise R1 as needed and present just one thought, idea, question or command at a time. The Wandering Care Plan, dated 02/19/21, directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. The care plan directed staff to monitor the resident's location every 60 minutes, document wandering behavior and attempted diversional interventions in behavior log, and respond to sounding door alarms immediately. The Elopement Risk Assessment, dated 02/23/21 documented R1 had a high risk for elopement. The Nurse's Note, dated 03/04/21 at 03:35 AM, documented the resident seemed very confused and got up several times throughout the night wanting to exit the facility with a bag of her belongings and go home. The note documented the resident was pleasant with staff and easily redirected. The Nurse's Note, dated 03/08/21 at 04:50 AM, documented resident up three different times through the night and wandered trying to go into wrong rooms. The Nurse's Note, dated 03/08/21 at 03:21 PM, documented resident very pleasantly confused today and staff redirected her out of other resident rooms this afternoon. The Nurse's Note, dated 03/12/21 at 04:59 AM, documented the resident awake, ready to leave and go home, and staff convinced her to sit in the lobby. The Nurse's Note, dated 03/14/21 at 04:09 PM, documented at 07:15 AM LN I went to R1's room to check her temperature and oxygen (O2) saturation per COVID (highly contagious respiratory infection) protocol and noted the resident was not in her room. At 07:30 AM, LN I returned to the lobby to check R1's temperature and O2 saturation and she was noted not to be in the lobby or dining room. LN I asked another staff member if they knew where the resident was, and all staff denied seeing her since they had gotten her up between 06:00 - 06:45 AM and assisted the resident to sit in her chair in her room. Staff searched the entire facility including all other residents' rooms and bathrooms, both shower rooms, all utility rooms, activity room, rehabilitation room and laundry room. R1 was not found in any of these places. Staff members went outside and walked around the facility premises without being able to locate resident. At 07:45 AM, staff members got into their vehicles to search for the resident. One staff member went about three blocks while the other staff member went driving around town. When the first staff member returned to the facility, he noted R1 sat in the passenger seat of a staff members vehicle. At 08:00 AM, staff assisted R1 back into the facility, no injuries were noted, and vital signs were stable. After the incident was resolved, administration watched the video and noted the resident left the facility through the front door at 06:57 AM and staff notified the Administrator at 07:58 AM of resident leaving the facility. On 03/17/21 at 12:40 PM, review of the facility's surveillance video of nurse's desk and front door revealed on 03/14/21 at 05:45 AM, Licensed Nurse (LN) G sat on a wheeled office chair at the nurse's desk, wheeled over to the alarm box on the wall, and pressed the buttons to disengage the front door alarm to allow a gentleman to walk through. The video surveillance revealed nothing appeared to be propped in front of the door and the resident ambulated out the front door at 06:55 AM. On 03/17/21 at 09:40 AM, observation revealed R1 ambulated independently out of her room to the living room area with a slow steady gait and sat down on a recliner chair. On 03/16/21 at 02:05 PM, Administrative Nurse D stated the facility conducted wandering assessments and quarterly nursing reviews that addressed elopement and stated R1 was not at risk for elopement because Administrative Nurse D had R1 try to open the door and R1 could not open it, so the assessment was coded as not at risk for elopement. On 03/16/21 at 04:46 PM, Maintenance Staff (MS) U stated he did not check the alarms on the doors daily, he checked if the doors were locked when he came to work. On 03/17/21 at 01:00 PM, Dietary Staff (DS) BB stated he worked on 03/14/21, and when he came into work at about 05:50 AM, LN G did not have to let me into the facility as the door alarm was already off. DS BB stated LN G always just shut the door alarm off and he could just walk in without the alarm sounding. On 03/18/21 at 02:01 PM, Administrative Nurse D verified if LN G did not turn off the door alarm on 03/14/21, the elopement could have been avoided. The facility's 3/5/20 Wandering Resident/Elopement policy, directed staff that residents identified as being at risk for elopement are accounted for with a visual check by staff every 30 minutes. The time most likely for elopements to occur are after family visits and after 04:00 PM. If our population of residents includes a potential wanderer, staff should be more alert to listen for door alarms. The policy documented all doors are locked at all times with the magnetic system connected to the fire alarm system panel. Doors can be disabled but only at the discretion of the administrator. the person who disables the alarm panel is responsible for resetting the system. The facility failed to provide adequate supervision for cognitively impaired R1, who eloped from the facility without staff knowledge due to LN G deactivating the door alarm and remained outside for approximately one hour before staff located her. This deficient practice placed R1 in immediate jeopardy. The facility removed the immediacy when Administration placed a lock box on the door alarm unlock/lock panel and implemented a door alarm check twice a day on 03/17/21. The facility completed wandering assessments on all of the residents and educated staff on Wandering Elopement Resident on 03/18/21. This deficient practice remained at a scope and severity of a G.

The facility had a census of 27 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to administer medications in accordance with professional standards of practice for Resident (R) 1 who received R4's medication, which caused severe sedation, and resulted in R1's hospitalization , placing R1 in immediate jeopardy. This deficient practice had the potential to affect the other 26 residents in the facility who received medications. Findings included: - R1's 14 day Minimum Data Set (MDS) assessment, dated 06/05/19, documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment, with no behaviors. The MDS documented the resident was independent with most Activities of Daily Living (ADLs), and received antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) and diuretic (medication to promote the formation and excretion of urine) medications seven of seven days during the lookback period. The 11/16/18 [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA) documented the resident had long standing [MEDICAL CONDITION] ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and depression requiring medication. The CAA documented the resident required focuses to monitor effectiveness, benefit versus risks for use of medication, and the need to include potential for gradual dose reduction. The 06/06/19 care plan directed staff to administer R1's medications as physician ordered. The 07/25/19 at 9:35 PM, fax to the hospital emergency room (ER) documented R1 was given R4's Atorvastatin (cholesterol medication) 20 milligrams (mg), [MEDICATION NAME] (antipsychotic) 150 mg, [MEDICATION NAME] (anticonvulsant) Extended Release 500 mg, and [MEDICATION NAME] (anxiety medication) 15 mg in error. The on-call Nurse Practitioner (NP) HH directed facility staff to perform neurological (assessment of sensory and motor responses especially reflexes to see if nervous system impaired) and vital sign checks every hour for 6 hours then every 2 hours until the morning. The NP also directed facility staff to call or bring the resident to the ER if any adverse reactions were noted, and hold all of R1 7/25/19 evening medications except his breathing treatment. The 07/25/19 at 11:51 PM, nurse's note recorded when performing the 11:00 PM neurological check, R1 was unresponsive, opened his eyes briefly to pain, pulse 48 beats per minute (bpm) (normal 60)and blood pressure 98/52 millimeters of Mercury (mmHg) (normal 120/80). The note documented facility staff called the ER at 11:05 PM to notify them the facility would be sending R1. The note documented facility staff called Emergency Medical Services (EMS) at 11:15 PM, and the resident left the facility per EMS at 11:25 PM. The 07/26/19 at 03:24 AM, nurse's note documented facility staff called the ER and were told the resident was admitted to the hospital for observation, on a heart monitor, oxygen, and a nurse was in the room with the resident at all times to keep him stimulated. The 07/27/19 at 12:10 PM, nurse's note documented R1 returned to the facility, gait unsteady and stated he became light headed and dizzy when walking. The note documented the resident's pulse was 90 bpm and blood pressure 128/79 mmHg. Manufacturer guidelines document the recommended initial dosage for [MEDICATION NAME] of 12.5 mg once or twice a day. The symptoms of an overdose include drowsiness, [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness), coma (a state of prolonged unconsciousness, including a lack of response to stimuli, from which it is impossible to rouse a person), rapid or irregular heartbeat, low blood pressure, difficulty breathing, and loss of life. On 07/30/19 at 07:50 AM, observation revealed R1 ambulated independently down the hallway to his room with a slow, steady gait, smiled, and talked freely with staff. On 07/30/19 at 09:49 AM, Administrative Nurse D stated staff notified her on 07/25/19 when R1 was taken to the hospital, and the morning of 07/26/19 discussed with Licensed Nurse (LN) G the need for education and medication administration competency check to be completed with Certified Medication Aide (CMA) R before she passed medications to residents. Administrative Nurse D stated she did not feel the facility was understaffed the evening of 07/25/19 when the medication error occurred. On 07/30/19 at 10:08 AM, LN G stated he talked with the charge nurse on 07/25/19 after the medication error occurred. LN G talked to CMA R on 07/26/19 about the medication error and instructed CMA R that if she was interrupted while passing medications, she needed to start back over with the 5 rights of medication administration. LN G also instructed CMA R to only pass 1 resident's medications at a time and verified CMA R did not follow the facility's policy regarding the 5 rights of medication administration. On 07/30/19 at 1:47 PM, Consultant (C) GG stated when R1 arrived at the ER he was sleepy, aroused to pain, sedated from incorrect medications he received, and needed to be admitted to be monitored for respiratory depression. R1 required supplemental oxygen with a nasal cannula, telemetry (transmission of cardiac signals to a display monitor) and respiratory support. C GG stated the resident was given a high dose of [MEDICATION NAME] and was not used to this medication which caused respiratory depression. C GG stated if the resident had been given a lower dose of [MEDICATION NAME], the resident would not have needed to be closely monitored. C GG stated he admitted R1 to the hospital to be monitored because the resident was in the ER for several hours and it did not appear the sedation effect was going to wear off quickly. C GG stated when a person started on [MEDICATION NAME], they have to start at a low dose and slowly add higher doses, if needed, because of the sedation affect of the medication. On 07/30/19 at 02:03 PM, CMA R stated she worked the 02:00 PM -10:00 PM shift on 07/25/19 and was late passing medications due to assisting with a high volume of call lights. R1 came to the nurse's station and the charge nurse checked his blood sugar. CMA R stated she placed R1's medications into a medication cup with his name written on the cup and placed the cup into the top drawer of the medication cart to administer after R1 finished getting his blood sugar checked. CMA R stated she started placing R4's medications into a cup with her name written on the cup, had to stop to assist another resident, and placed the medication cup into the top drawer of the medication cart. CMA R stated she came back to the medication cart and picked up R4's medication cup and gave it to R1, who swallowed the medications. CMA R stated she turned back to the medication cart and realized she had given R1 the wrong medications. CMA R stated she immediately reported the medication error to the charge nurse who called the ER. CMA R was told by the charge nurse to hold R1's evening medications and check R1's vital signs, which were normal. CMA R stated she worked the next day, 07/26/19, from 06:00 AM -12:00 PM as a nurse's aide and LN G completed a medication administration competency form with her before she returned to passing medications to residents. The facility's Administering Medications policy, dated (MONTH) 2010, documented the individual administering medications must verify the resident's identity before giving the resident their medications. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Medications must not be prepared in advance. The facility failed to administer medications in accordance with professional standards of practice for Resident (R)1 who received R4's medication, caused severe sedation, and resulted in R1's hospitalization , placing R1 in immediate jeopardy. The facility removed the immediate jeopardy on 07/30/19 at 06:10 PM, when the facility implemented medication administration competency checklists with all staff who administered medications, implemented a new facility policy for medication errors, and implemented a new mediation error analysis tool. The deficient practice remained at a scope and severity of a G.

The facility had a census of 31 residents. The sample included 7 residents, of which 4 were reviewed for abuse. Based on observation, record review, and interview, the facility failed to report and investigate allegations of abuse to the state agency in a timely manner, for 3 of the 4 sampled residents, when Nurse Aide B sexually abused Resident #1, and physically abused Resident #3 and Resident #7. The facility also failed to protect the residents in the facility from potential abuse when Nurse Aide B continued to work the remainder of his/her shift, which placed the residents in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/28/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. The MDS documented the resident was rarely or never understood, but sometimes could understand others, had inattention, and disorganized thinking. The MDS documented the resident required extensive assistance of 2 staff for all (ADLs) Activities of Daily Living, with exception of extensive assistance of 1 staff for eating and bathing. The MDS documented the resident received antipsychotic (class of medications used to treat [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions)), and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications. The 7/28/17 care plan for ADLs directed staff to provide extensive assistance of 1-2 staff for toileting, assist and encourage the resident to use the toilet before and after meals, in the afternoon, at bed time, monitor the resident for restlessness at night time, and assist him/her to the toilet as indicated. The care plan for medications directed staff to administer antianxiety and antipsychotic medications as ordered by the physician, and monitor for side effects and effectiveness. The 7/31/17 signed physician orders [REDACTED]. The nurse's note on 7/31/17 at 9:15 PM, documented a staff member reported he/she witnessed a possible sexual abuse incident, by another staff member, to Resident #1 at approximately 9:00 PM that evening. The note documented staff immediately assessed the resident, who was asleep on his/her bed, with no noted injuries on the inside or outside of the resident's mouth. The note documented the resident appeared calm, and was resting without signs or symptoms of discomfort. The facility's investigation report, dated 8/2/17, documented on 7/31/17, at approximately 9:00 PM, Nurse Aide A reported he/she entered the resident's room and witnessed Nurse Aide B take his/her genitalia (male or female reproductive organs), out of the resident's mouth, while the resident sat on the toilet in his/her bathroom, while Nurse Aide B stood next to the resident. The investigation report documented the facility notified the resident's family on 8/2/17 at 9:07 AM (approximately 36 hours after the incident) and the resident's physician on 8/2/17 at 10:30 AM (approximate 37.5 hours after the incident) The 8/2/17 at 2:10 PM, nurse's note documented at 10:30 AM (approximately 37.5 hours after the abuse) staff notified the physician's office and reported the allegation of sexual abuse to Resident #1. The note documented staff requested the resident be seen that day, and documented the resident had no bruising, redness or injury. The note documented law enforcement arrived at the facility to investigate the incident. The note lacked documentation of when law enforcement was notified, and when they arrived at the facility. The 8/2/17 physician's progress note, documented staff transported the resident to the physician to be examined for possible sexual abuse that occurred on the evening of 7/31/17. The staff member who accompanied the resident to the appointment, stated he/she recently noticed when staff toileted the resident in his/her bathroom, the resident became more agitated but when toileted in the bath house, he/she was fine. The physician's note documented on his/her assessment, suspected sexual abuse, with possible exposure to (STD) [MEDICAL CONDITION]. The 8/2/17 at 5:13 PM, nurse's note documented the physician ordered staff to collect a urine sample from the resident to test for chlamydia (an infection spread through sexual contact). The 8/9/17 at 11:58 AM, nurse's note documented the laboratory results from the urine specimen on 8/3/17 were negative. In a notarized witness statement, dated 8/2/17, Nurse D, documented Medication Aide C and Nurse Aide A, summoned him/her to speak to them in private. Nurse Aide A reported he/she witnessed a sexual abuse incident to Resident #1 by Nurse Aide B. The statement documented Nurse Aide A checked on the resident and noticed his/her door closed, and he/she went in to see if the resident needed help. Nurse Aide A stated he/she saw the resident, seated on the toilet, Nurse Aide B stood next to the resident, with his/her genitalia in the resident's mouth, and then he/she saw Nurse Aide B remove it. The statement documented Nurse D notified Administrative Nurse J and was told to keep an eye on Nurse Aide B and the incident would be investigated the next morning. In a notarized witness statement, dated 8/2/17, Nurse Aide A documented on 7/31/17, at approximately 9:00 PM, he/she took a laundry basket back to the bath house and noticed Resident #1's room door was closed. Nurse Aide A documented he/she opened the door to see if the resident was in bed, the lights were on, and he/she looked over to see the resident, seated on the toilet, dressed in a nightgown. Nurse Aide A documented Nurse Aide B had his/her genitalia in the resident's mouth, and then saw him/her remove it. Nurse Aide A documented he/she immediately left the room, reported what he/she witnessed to Medication Aide C, and they both reported the incident to Nurse D. In a notarized witness statement, dated 8/2/17, Nurse I documented on 7/31/17 at 9:32 PM, he/she was notified by Administrative Nurse H of an incident that involved Resident #1 and Nurse Aide B. Nurse I documented he/she was advised by Administrative Nurse H to not allow Nurse Aide B to be left unattended with any of the residents for the remainder of the shift. Nurse I documented Nurse Aide B was in his/her sight at all times. In a notarized witness statement, dated 8/3/17, Medication Aide C documented on 7/31/17, at approximately 9:00 PM, Nurse Aide A approached him/her after leaving Resident #1's room. Nurse Aide A reported he/she went into the resident's room to see if Nurse Aide B needed help putting the resident to bed. Nurse Aide A reported he/she saw the resident on the toilet, and Nurse Aide B had his/her genitalia in the resident's mouth. Medication Aide C documented he/she asked Nurse Aide A to confirm what he/she witnessed before they told Nurse D. On 8/10/17 at 9:00 AM, observation revealed two staff assisted the resident to toilet in the shower room. Staff transferred the resident from his/her wheelchair, to the toilet with a gait belt. The resident was calm and talked to staff during the care, and he/she displayed no behaviors. On 8/7/17 at 12:42 PM, Administrative Nurse H stated he/she had not reported the sexual abuse incident to the state agency, and made a conscious decision to not report it until 8/2/17. On 8/3/17 at 5:13 PM, Nurse Aide A, stated he/she noticed the resident's door was partly closed, and he/she went into the resident's room to see if the resident needed help. Nurse Aide A stated he/she stated the room lights were on, he/she did not see the resident, but the bathroom light was also on. Nurse Aide A stated he/she looked into the bathroom, and saw the resident seated on the toilet, as Nurse Aide B, stood next to the resident, and removed his/her genitalia from the resident's mouth. Nurse Aide A stated he/she reported to Medication Aide C, and together they reported to Nurse D. Nurse Aide A stated Nurse Aide B usually worked alone, and never asked other staff for assistance when he/she provided cares to the residents. On 8/8/17 at 10:31 AM, Nurse Aide E stated he/she worked with Nurse Aide B. Nurse Aide E stated Nurse Aide B became angry easily, threw things, and used inappropriate language, but he/she had no knowledge of Nurse Aide B sexually abusing any of the residents. On 8/8/17 at 3:42 PM, Administrative Nurse J stated Administrative Nurse H notified him/her of the sexual abuse incident on the evening of 7/31/17, and he/she planned to have Nurse I monitor Nurse Aide B for the remainder of their shift (approximately 9 hours), and he/she would handle the sexual abuse allegation in the morning. Administrative Nurse J stated he/she then received a call from Nurse D asking for advice on what to do about the incident. Administrative Nurse J stated he/she told Nurse D that Administrative Nurse H had been notified of the incident and would handle it. Administrative Nurse J stated he/she did not work the next day (8/1/17) and he/she received no calls from anyone from the facility about the incident. When he/she came to work on 8/2/17, Administrative Nurse H called him/her into the office and said the incident had not been reported to the state agency, local law enforcement, physician, or the resident's family because he/she was busy with another incident. Administrative Nurse J verified he/she notified local law enforcement and Resident #1's family (approximately 36 hours after the incident). Administrative Nurse J stated he/she should have contacted law enforcement on 7/31/17, when he/she was notified of the sexual abuse incident, had Nurse Aide B removed from the facility, and started an investigation. On 8/9/17 at 1:07 PM, Nurse Aide F stated he/she worked the night shift with Nurse Aide B, and Nurse Aide B always wanted to work the north hall, with the dementia and confused residents. Nurse Aide F stated Nurse Aide B always wanted to provide cares to the residents by himself/herself. Nurse Aide F stated he/she did not like to work with Nurse Aide B because he/she was rough with some of the residents. On 8/9/17 at 1:55 PM, (CMA) Certified Medication Aide G stated he/she went with the resident to his/her physician's appointment on 8/2/17. CMA G stated he/she noticed the resident acted more agitated than normal when toileted in his/her bathroom, but displayed no behaviors when toileted in the shower room. CMA G stated Nurse Aide B became angry at times, and yelled at the residents and staff. On 8/8/17 at 2:32 PM, Administrative Staff O stated he/she was notified of the 7/31/17 sexual abuse incident by Administrative Nurse H on 8/2/17, while he/she was driving to the facility (approximately 37 hours after the incident was reported to Administrative Nursing Staff H). Administrative Staff O verified he/she expected staff to send Nurse Aide B home immediately, to protect the other residents not allow him/her to continue his/her shift, call local law enforcement, and start the investigation. On 8/9/17 at 10:50 AM, Physician T stated on 8/2/17 at approximately 10:30 AM, Administrative Nurse H notified him/her of the resident's sexual abuse by a staff member at the facility (approximately 37 hours after the incident occurred). Physician T stated he/she expected staff to notify him/her immediately after the sexual abuse occurred, and the resident should have been transported to the hospital emergency room for examination. On 8/10/17 at 3:16 PM, Consultant Staff U stated he/she was notified of the sexual abuse incident by Physician T after Physician T examined the resident on 8/2/17. Consultant Staff U verified the resident's sexual abuse should have been reported to a health care professional immediately after the incident occurred. The facility's undated Resident Rights documented residents have the right to be free from verbal, sexual, physical or mental abuse. The Resident Rights documented in the event of an alleged violation involving treatment, the facility is required to report it to the appropriate officials, and all alleged violations must be promptly and thoroughly investigated, results reported to the appropriate agencies, and corrective actions must be taken. The facility's abuse, neglect and exploitation policy, dated 2/11/02, documented all alleged violations and substantiated incidents would be reported to the state agency, and all other required agencies as required by law. The administrator will notify the police, ombudsman, state agency and the abuse hotline of the results of the investigation if warranted. The facility failed to investigate and report to the state agency, in a timely manner, an allegation of sexual abuse, when Nurse Aide B sexually abused Resident #1. The facility abated the immediate jeopardy on 8/10/17, when an all staff in-service was presented on the facility's revised policy on abuse, neglect and exploitation. The deficient practice remained at a scope and severity of a F. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 7/7/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 0, severe cognitive impairment, physical and verbal behaviors toward others. The MDS documented the resident was totally dependent on staff for all (ADLs) activities of daily living, including bed mobility, transfers, eating, dressing, personal hygiene, and bathing. The MDS documented the resident had a [MEDICAL CONDITION] on one side, did not walk, and used a wheelchair for mobility. The annual cognitive (CAAs) care area assessment, dated 1/6/17, documented the resident had a BIMS score of 0, and did not participate in the assessments. The CAA documented the resident did not talk at all, tightly pursing his/her lips, and very clearly shouted to get out, or shut up. The 7/7/17 care plan for cognitive loss/dementia directed staff to ask yes or no questions to determine the resident's needs, keep the resident's routine consistent, provide consistent care givers as much as possible to decrease confusion, listen to the resident's elaborate stories that he/she believes, and try not to encourage or crush his/her delusions. The care plan for ADLs documented the resident was unable to use the toilet, and totally dependent on 1 to 2 staff for urinary catheter (tube inserted into the bladder to drain urine into a collection bag) and [MEDICAL CONDITION] (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) care. The care plan directed 2-3 staff to use the mechanical full body lift to transfer the resident. The 7/29/17 signed physician orders [REDACTED]. The 7/2/2017 at 4:00 AM, nurse's note documented the resident continued to resist care by screaming and scratching, staff during repositioning and dressing changes. On 8/10/17 at 10:00 AM, observation revealed Nurse Aide E and Nurse Aide F repositioned and provided care to the resident. Observation revealed the resident in bed, while staff changed the resident's disposable brief, provided hygiene care, applied a new disposable brief, then repositioned the resident on his/her left side, with pillows placed behind him/her for support. Further observation revealed the resident yelled out, and he/she was hard to understand, and told staff to leave him/her alone, and get out of his/her room. On 8/7/17 at 1:55 PM, Nurse D stated approximately one month ago, he/she heard Nurse Aide E and Nurse Aide S talking about Nurse Aide B, and how he/she tried to smother the resident by placing a pillow over the resident's face. Nurse D stated he/she heard Nurse Aide E say he/she may have to change shifts so he/she would not work with Nurse Aide B. Nurse D verified he/she did not take action, or report the incident to any one at the facility. On 8/8/17 at 10:31 AM, Nurse Aide E stated he/she worked with Nurse Aide B had no knowledge of Nurse Aide B trying to suffocate the resident. Nurse Aide E stated he/she does not remember the conversation with Nurse Aide S about the incident. On 8/7/17 at 11:50 AM, Nurse Aide S stated he/she heard about the incident when Nurse Aide B placed a pillow over the resident's face, could not remember who told him/her, but it could have been Nurse Aide E. Nurse Aide S stated Nurse Aide B must have been angry at the resident, and stated he/she should have reported what he/she heard to the nurse or administrator. On 8/8/17 at 3:42 PM, Administrative Nurse J verified he/she heard speculation from staff Nurse Aide B placed a pillow over the resident's face, but he/she could not get any staff to talk about the incident or tell him/her the specifics. Administrative Nurse J stated he/she asked staff a few questions, but without any information, there was nothing he/she could do. Administrative Nurse J stated he/she was aware that he/she was mandated to report abuse, and stated he/she should have reported this incident. On 8/22/17 at 2:35 PM, Nurse Aide V stated he/she had worked with Nurse Aide B many times on the 6:00 PM-6:00 AM shift. Nurse Aide V could not remember the date, but stated one night he/she and Nurse Aide B went into the resident's room to provide cares and Nurse Aide V stated he/she witnessed Nurse Aide B place a pillow over the resident's face. Nurse Aide V stated it was done in a joking manner, and was on the resident's face for a few seconds, until Nurse Aide V removed it. Nurse Aide V stated he/she told Nurse Aide B not to do that, Nurse Aide B snickered at Nurse Aide V and walked out of the room. Nurse Aide V stated he/she may have reported to a nurse, but could not remember the nurse's name. Nurse Aide V stated he/she reported the incident to the day shift nurse aides during report at 6:00 AM. On 8/22/17 at 5:36 PM, Nurse Aide W stated he/she worked with Nurse Aide B on the 6:00 AM-6:00 PM shift. Nurse Aide W stated he/she could not remember the exact date, but it was approximately 3 or 4 months ago, he/she helped Nurse Aide B with the resident's cares about 8:30 PM. Nurse Aide W stated Nurse Aide B became frustrated with the resident when the resident began hollering out, and Nurse Aide B told the resident to stop in an aggressive and stern voice. Nurse Aide W stated the resident pinched Nurse Aide B, and he/she responded by placing a pillow over the resident's face. Nurse Aide W stated he/she did not confront Nurse Aide B because he/she is a little scary and Nurse Aide W did not want Nurse Aide B to get angry with him/her. Nurse Aide W stated he/she left the room to get clean linens, and when he/she returned to the resident's room (approximately 2 minutes or less) the pillow had been removed from the resident's face. Nurse Aide W stated he/she had not reported the incident to anyone. The facility's undated Resident Rights documented residents have the right to be free from verbal, sexual, physical or mental abuse. The Resident Rights documented in the event of an alleged violation involving treatment, the facility is required to report it to the appropriate officials, and all alleged violations must be promptly and thoroughly investigated, results reported to the appropriate agencies, and corrective actions must be taken. The facility's abuse, neglect and exploitation policy, dated 2/11/02, documented all alleged violations and substantiated incidents would be reported to the state agency, and all other required agencies as required by law. The administrator will notify the police, ombudsman, state agency and the abuse hotline of the results of the investigation if warranted. The facility failed to investigate and report to the state agency, an allegation of abuse, when Nurse Aide B placed a pillow over Resident #3's face. - Resident #7's quarterly (MDS) Minimum Data Set assessment, dated 6/9/17, documented the resident had short and long term memory problems, severely impaired cognition, inattention, disorganized thinking, hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), physical and verbal behavior toward others, wandering, and rejection of cares. The MDS documented the resident required staff supervision for all (ADLs) activities of daily living, with the exception of totally dependent on staff for bathing. The MDS documented the resident received antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications. The 6/19/17 care plan directed staff to administer medications as ordered by the physician and monitor/document side effects and effectiveness. The care plan directed staff to intervene before agitation escalates, guide the resident away from the source of distress, calmly engage in conversation, and if the resident's response is aggressive, staff should walk away and approach later. The care plan for ADLs documented the resident was independent with bed mobility, dressing, eating, personal hygiene, toileting, and required extensive to total assistance of 2 staff for bathing. The 6/14/17 signed physician orders [REDACTED]. (progressive mental deterioration characterized by confusion and memory failure), restlessness and agitation. The 7/18/17 at 3:53 PM, nurse's note documented staff attempted to assist the resident with a shower, and the resident became combative and lightly shoved staff. The note documented there was no harm to the resident or staff, and staff re-directed the resident away from the situation without need for further intervention. The 8/2/17 at 9:33 PM, nurse's note documented the resident wandered throughout the facility, with staff interventions of one on one, activities, and re-directing, with no change in the resident's behavior. The 8/11/17 at 2:39 PM, nurse's note documented the resident wandered around the facility. The note documented staff easily re-directed the resident with toileting, and he/she then sat in the living room and watched television. On 8/7/17 at 3:00 PM, observation revealed the resident assisted the activity staff, was thanked by staff and he/she offered to help out the next day. Observation revealed staff was patient, kind, and respectful to the resident. On 8/7/17 at 1:55 PM, Nurse D stated Nurse Aide B had been rough with the resident, pulled on the resident's arm while they walked down the hall, and Nurse D told Nurse Aide B to be nice. Nurse D stated he/she heard Nurse Aide B pushed the resident into his/her room, and the resident fell backward onto his/her bed. Nurse D stated he/she should have reported the incident to Administrative Nurse H or Administrative Nurse J. On 8/8/17 at 3:42 PM, Administrative Nurse J stated staff reported Nurse Aide B would get vocal with the resident, used a loud voice, and held the resident's arms too tight when assisting the resident with cares. Administrative Nurse J verified he/she heard Nurse Aide B had been rough with the resident when Nurse Aide B grabbed the resident's arm harder than needed. Administrative Nurse J stated he/she could not remember which staff member told him/her of the incident. Administrative Nurse J stated he/she should have reported and investigated the allegation. On 8/8/17 at 4:51 PM, Nurse P stated he/she heard about 4-5 month's ago, Nurse Aide B shoved the resident into his/her room, and the resident fell backward on his/her bed. Nurse P stated the incident was not reported to him/her, but heard it had been reported to someone, but he/she could not remember who it was reported to. On 8/9/17 at 1:20 PM, Administrative Nurse H stated he/she heard Nurse Aide B had been rough with the resident, but he/she had no details about the incident. Administrative Nurse H verified he/she had not investigated or reported the allegations of abuse. The facility's undated Resident Rights documented residents have the right to be free from verbal, sexual, physical or mental abuse. The Resident Rights documented in the event of an alleged violation involving treatment, the facility is required to report it to the appropriate officials, and all alleged violations must be promptly and thoroughly investigated, results reported to the appropriate agencies, and corrective actions must be taken. The facility's abuse, neglect and exploitation policy, dated 2/11/02, documented all alleged violations and substantiated incidents would be reported to the state agency, and all other required agencies as required by law. The administrator will notify the police, ombudsman, state agency and the abuse hotline of the results of the investigation if warranted. The facility failed to investigate and report an allegation of abuse to the state agency, when Nurse Aide B treated Resident #7 in a rough manner.

The facility had a census of 31 residents. The sample included 7 residents, of which 4 were reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure residents remained free from staff to resident sexual abuse, when Resident #1 was sexually abused by a staff member, and the alleged perpetrator continued to work and provide care to the residents. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/28/17, documented the resident had a (BIMS) Brief Interview for Mental status score of 1, which indicated severe cognitive impairment. The MDS documented the resident was rarely or never understood, but sometimes could understand others, had inattention, and disorganized thinking. The MDS documented the resident required extensive assistance of 2 staff for all (ADLs) Activities of Daily Living, with exception of extensive assistance of 1 staff for eating and bathing. The MDS documented the resident received antipsychotic (class of medications used to treat [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions)), and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications. The 7/28/17 care plan for ADLs directed staff to provide extensive assistance of 1-2 staff for toileting, assist and encourage the resident to use the toilet before and after meals, in the afternoon, at bed time, monitor the resident for restlessness at night time, and assist him/her to the toilet as indicated. The care plan for medications directed staff to administer antianxiety and antipsychotic medications as ordered by the physician, and monitor for side effects and effectiveness. The 7/31/17 signed physician orders [REDACTED]. The nurse's note on 7/31/17 at 9:15 PM, documented a staff member reported he/she witnessed a possible sexual abuse incident, by another staff member, to Resident #1 at approximately 9:00 PM that evening. The note documented staff immediately assessed the resident, who was asleep on his/her bed, with no noted injuries on the inside or outside of the resident's mouth. The note documented the resident appeared calm, and was resting without signs or symptoms of discomfort. The 8/2/17 at 2:10 PM, nurse's note documented at 10:30 AM (approximately 37.5 hours after the abuse) staff notified the physician's office and reported the allegation of sexual abuse to Resident #1. The note documented staff requested the resident be seen that day, and documented the resident had no bruising, redness or injury. The note documented law enforcement arrived at the facility to investigate the incident. The note lacked documentation of when law enforcement was notified, and when they arrived at the facility. The 8/2/17 physician's progress note, documented staff transported the resident to the physician to be examined for possible sexual abuse that occurred on the evening of 7/31/17. The staff member who accompanied the resident to the appointment, stated he/she recently noticed when staff toileted the resident in his/her bathroom, the resident became more agitated but when toileted in the bath house, he/she was fine. The physician's note documented on his/her assessment, suspected sexual abuse, with possible exposure to (STD) [MEDICAL CONDITION]. The facility's investigation report, dated 8/2/17, documented on 7/31/17, at approximately 9:00 PM, Nurse Aide A reported he/she entered the resident's room and witnessed Nurse Aide B take his/her genitalia (male or female reproductive organs), out of the resident's mouth, while the resident sat on the toilet in his/her bathroom, while Nurse Aide B stood next to the resident. The 8/2/17 at 5:13 PM, nurse's note documented the physician ordered staff to collect a urine sample from the resident to test for chlamydia (an infection spread through sexual contact). The 8/9/17 at 11:58 AM, nurse's note documented the laboratory results from the urine specimen on 8/3/17 were negative. In a notarized witness statement, dated 8/2/17, Nurse D, documented Medication Aide C and Nurse Aide A, summoned him/her to speak to them in private. Nurse Aide A reported he/she witnessed a sexual abuse incident to Resident #1 by Nurse Aide B. The statement documented Nurse Aide A checked on the resident and noticed his/her door closed, and he/she went in to see if the resident needed help. Nurse Aide A stated he/she saw the resident, seated on the toilet, Nurse Aide B stood next to the resident, with his/her genitalia in the resident's mouth, and then he/she saw Nurse Aide B remove it. The statement documented Nurse D notified Administrative Nurse J and was told to keep an eye on Nurse Aide B and the incident would be investigated the next morning. In a notarized witness statement, dated 8/2/17, Nurse Aide A documented on 7/31/17, at approximately 9:00 PM, he/she took a laundry basket back to the bath house and noticed Resident #1's room door was closed. Nurse Aide A documented he/she opened the door to see if the resident was in bed, the lights were on, and he/she looked over to see the resident, seated on the toilet, dressed in a nightgown. Nurse Aide A documented Nurse Aide B had his/her genitalia in the resident's mouth, and then saw him/her remove it. Nurse Aide A documented he/she immediately left the room, reported what he/she witnessed to Medication Aide C, and they both reported the incident to Nurse D. In a notarized witness statement, dated 8/2/17, Nurse I documented on 7/31/17 at 9:32 PM, he/she was notified by Administrative Nurse H of an incident that involved Resident #1 and Nurse Aide B. Nurse I documented he/she was advised by Administrative Nurse H to not allow Nurse Aide B to be left unattended with any of the residents for the remainder of the shift. Nurse I documented Nurse Aide B was in his/her sight at all times. In a notarized witness statement, dated 8/3/17, Medication Aide C documented on 7/31/17, at approximately 9:00 PM, Nurse Aide A approached him/her after leaving Resident #1's room. Nurse Aide A reported he/she went into the resident's room to see if Nurse Aide B needed help putting the resident to bed. Nurse Aide A reported he/she saw the resident on the toilet, and Nurse Aide B had his/her genitalia in the resident's mouth. Medication Aide C documented he/she asked Nurse Aide A to confirm what he/she witnessed before they told Nurse D. On 8/10/17 at 9:00 AM, observation revealed two staff assisted the resident to toilet in the shower house. Staff transferred the resident from his/her wheelchair, to the toilet with a gait belt. The resident was calm and talked to staff during the care, and he/she displayed no behaviors. On 8/7/17 at 12:42 PM, Administrative Nurse H stated he/she received a call on 7/31/17 at approximately 9:27 PM from Nurse Aide A, who reported he/she saw Nurse Aide B in the resident's bathroom, the resident seated on the toilet, and Nurse Aide B removed his/her genitalia from the resident's mouth. Administrative Nurse H stated he/she called the facility and spoke to Nurse I (charge nurse) and told him/her to watch Nurse Aide B closely, not to let him/her out of his/her sight, and to not let Nurse Aide B know that he/she was aware of the incident. Administrative Nurse H verified he/she did not direct staff to send Nurse Aide B home, and Nurse Aide B was allowed to complete his/her shift (approximately 9 hours). Administrative Nurse H verified there were 2 staff working in the facility from 11:00 PM on 7/31/17 to 6:00 AM on 8/1/17. Administrative Nurse H verified he/she should have handled the incident differently by having Nurse I send Nurse Aide B home, and call the police. Administrative Nurse H stated he/she should have come to the facility when he/she was notified of the incident. On 8/3/17 at 5:13 PM, Nurse Aide A, stated he/she noticed the resident's door was partly closed, and he/she went into the resident's room to see if the resident needed help. Nurse Aide A stated he/she stated the lights were on, he/she did not see the resident, but the bathroom light was on. Nurse Aide A stated he/she looked into the bathroom, and saw the resident seated on the toilet, as Nurse Aide B, stood next to the resident, as he/she removed his/her genitalia from the resident's mouth. Nurse Aide A stated he/she reported to Medication Aide C, and together they reported to Nurse D. Nurse Aide A stated Nurse Aide B usually worked alone, and never asked other staff for assistance when he/she provided cares to the residents. On 8/8/17 at 10:31 AM, Nurse Aide E stated he/she worked with Nurse Aide B. Nurse Aide E stated Nurse Aide B became angry easily, threw things, and used inappropriate language, but he/she had no knowledge of Nurse Aide B sexually abusing any of the residents. On 8/8/17 at 3:42 PM, Administrative Nurse J stated Administrative Nurse H notified him/her of the incident on the evening of 7/31/17, and he/she planned to have Nurse I monitor Nurse Aide B for the remainder of their shift (approximately 9 hours), and he/she would handle it in the morning. Assistant Administrative Nurse J stated he/she then received a call from Nurse D asking for advice on what to do about the incident. Administrative Nurse J stated he/she told Nurse D that Administrative Nurse H had been notified of the incident and would handle it. Administrative Nurse J stated he/she did not work the next day (8/1/17) and he/she received no calls from anyone from the facility about the incident. When he/she came to work on 8/2/17, Administrative Nurse H called him/her into the office and said the incident had not been reported to the state agency, local law enforcement, the physician, or the resident's family because he/she was busy with another incident. Administrative Nurse J verified he/she notified local law enforcement and Resident #1's family (approximately 36 hours after the incident). Administrative Nurse J stated he/she should have contacted law enforcement on 7/31/17, when he/she was notified of the incident, had Nurse Aide B removed from the facility, and started an investigation. On 8/9/17 at 10:50 AM, Physician T stated he/she was notified on 8/2/17 at approximately 10:30 AM, by Administrative Nurse H, that Resident #1 had been sexually abused by a staff member the evening of 7/31/17 (approximately 36 hours after the incident). Physician T verified he/she would have expected staff to notified him/her immediately after the incident was reported to them. On 8/9/17 at 1:07 PM, Nurse Aide F stated he/she worked the night shift with Nurse Aide B, and Nurse Aide B always wanted to work the north hall, with the dementia and confused residents. Nurse Aide F stated Nurse Aide B always wanted to provide cares to the residents by himself/herself. Nurse Aide F stated he/she did not like to work with Nurse Aide B because he/she was rough with some of the residents. On 8/9/17 at 1:55 PM, (CMA) Certified Medication Aide G stated he/she went with the resident to his/her physician's appointment on 8/2/17. CMA G stated he/she noticed the resident acted more agitated than normal when toileted in his/her bathroom, but displayed no behaviors when toileted in the shower room. CMA G stated Nurse Aide B became angry at times, and yelled at the residents and staff. On 8/8/17 at 2:32 PM, Administrative Staff O stated he/she was notified of the 7/31/17 incident by Administrative Nurse H on 8/2/17, while he/she was driving to the facility (approximately 37 hours after the incident was reported to Administrative Nursing Staff H). Administrative Staff O verified he/she expected staff to send Nurse Aide B home immediately, not allow him/her to continue his/her shift, call local law enforcement, and start the investigation. The facility's abuse, neglect and exploitation policy, dated 2/11/02, documented to protect the residents, if an employee to resident abuse occurred the employee was sent home immediately. The policy documented to protect the residents from further possible abuse, the employee was removed immediately from duty, pending an investigation, and disciplinary action would be taken, up to and including dismissal as appropriate. The policy documented all alleged violations and substantiated incidents would be reported to the state agency, and all other required agencies as required by law. The administrator will notify the police, ombudsman, state agency and the abuse hotline of the results of the investigation if warranted. The facility staff failed to provide an environment free from abuse, when Nurse Aide B sexually abused Resident #1, and continued working in the facility for approximately 9 hours after the incident. This deficient practice placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 8/10/17, when an all staff in-service was presented on the facility's revised policy on abuse, neglect and exploitation. The deficient practice remained at a scope and severity of a G.

The facility had a census of 31 residents. The sample included 7 residents, of which 3 were reviewed for behaviors. Based on record review and interview, the facility failed to provide mental and psychosocial care and services for 2 of 3 sampled residents, who had suicidal thoughts, to assist them to attain the highest practicable mental and psychosocial well-being. (#4, #5) Findings included: - The medical record revealed the facility admitted Resident #5 on 7/14/17. The (POS) Physician order [REDACTED]. glucose, the body cannot make enough insulin or the body can't respond to the insulin), hypertension (high blood pressure), [MEDICAL CONDITION] disorder (a condition that includes aspects of both [MEDICAL CONDITION] and a mood disorder), and [MEDICAL CONDITION] (major mental illness that causes people to have episodes of severe high and low moods). The admission (MDS) Minimum Data Set assessment, dated 7/20/17, documented the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status of 12, and moderately severe depression with a mood score of 18. The MDS documented the resident had no thoughts he/she would be better off dead or of hurting him/herself in some way. The MDS documented the resident required staff supervision with eating, limited staff assistance with all other (ADL) activities of daily living, received scheduled and (PRN) as needed pain medications, and reported frequent severe pain. The MDS documented the resident received insulin, antipsychotic, antidepressant, and anticoagulant medications. The 14 day MDS, dated [DATE], documented the same except the resident had no thoughts he/she would be better off dead or of hurting him/herself in some way and the safety notification was checked, and the resident had verbal and wandering behaviors. The 7/20/17 (CAA) Care Area Assessment summary for psychosocial well-being documented the resident had depression, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], and moderately severe depression. The summary documented the resident had chronic back pain, wore glasses, spoke clearly, and responded to conversation appropriately. The resident had significant signs of moderately severe depression, needed to focus to help his/her mood to improve to highest practicable levels, and a mental health practitioner continued to follow the resident closely. The 7/14/17 initial care plan documented the resident was cognitively impaired, communicated easily, and required staff assistance with bed mobility, transfers, dressing, and hygiene. The 7/27/17 care plan for [MEDICAL CONDITION] medication directed staff to administer medications as ordered, monitor side effects and effectiveness of the medications every shift, report adverse reactions including suicidal ideation (thoughts about how to kill oneself, which can range from a detailed plan to a fleeting thought), social isolation and behavior not usual to the resident. The care plan documented the resident was on a behavior management program including one to one supervision, and staff were to encourage the resident to attend exercise and activities. The 7/31/17 care plan update directed staff to provide behavioral health consults as needed, monitor/document/report any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness, impaired judgement, and/or safety awareness. The 8/3/17 care plan update for psychosocial well-being directed staff to allow the resident time to answer questions and to verbalize feelings/perceptions and fears as he/she expressed them, consult with social services, and psychiatric services as needed. The care plan directed staff to monitor and document the resident's feelings relative to unhappiness, anger, loss, and provide support to identify problems that cannot be controlled and identification of potential solutions. The 7/14/17 physician's orders [REDACTED]. The black box warning (A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug.) for [MEDICATION NAME], recorded increased suicide risk and directed staff to observe for clinical worsening, suicidality, or unusual behavior changes. The 7/23/17 at 8:30 AM, nurse's note, late entry, documented the housekeeper observed the resident attempting to cut his/her wrist with a butter knife, and a nurse aide notified the nurse of the incident. The note documented staff removed the butter knife from the resident's room. The note further documented a medication aide reported the resident told him/her, 15 minutes prior to this incident, if he/she had a gun, he/she would kill him/herself. The 7/23/17 at 9:30 AM, nurse's note documented the resident went to the nurse's station with complaints of chest pain, and his/her vital signs were assessed with [REDACTED]. The 7/23/17 at 9:30 AM, facility fax to the physician documented the resident had attempted to cut his/her wrist with a butter knife. Staff documented in the nurse's notes, on 7/23/17, visual checks at 2:35 PM, 3:24 PM, 3:55 PM, and at 4:10 PM. The nurse's notes documented staff called the physician at 4:10 PM regarding the resident had a low blood sugar, but did not follow up the earlier fax information regarding the resident's attempt to cut his/her wrists or the statements that he/she wanted to die. The 7/24/17 at 4:53 PM, nurse's note stated the facility received a call from the physician's nurse regarding the facility's fax (Saturday 7/23/17 at 9:30 AM) which reported the resident attempted to cut him/herself and he/she wanted to kill him/herself. The note stated the facility nurse reported the resident had no behaviors today and the physician would see the resident on Wednesday, 7/27/17. The 8/5/17 at 6:30 AM, nurse's note documented the resident was at the nurse's station and stated he/she was going to commit suicide. The note documented the resident was very anxious this morning, and repeatedly requested pain medication after the nurse already administered pain medication to the resident. The 8/5/17 at 7:00 AM, nurse's note documented staff observed the resident attempting to break a mirror he/she removed from the wall, inside the shower room. The 8/5/17 at 7:30 AM, nurse's note documented staff observed the resident out to the dining room for breakfast, with no further mention of committing suicide. The 8/5/17 (Saturday) at 2:35 PM, facility fax to the physician documented the resident was at the nurse's station early this morning and stated I'm going to commit suicide. The fax also documented staff observed the resident trying to break a mirror in his/her room to use as a weapon. The physician replied on Monday, 8/7/17 at 10:42 AM, (after the resident had been transferred to the emergency room ) and ordered staff to set up an appointment for the resident. The 8/6/17 at 7:00 AM, nurse's note documented the resident stated I cut my wrist and staff observed several cuts on his/her wrist. The note documented staff asked the resident how he/she did it, and the resident stated my glasses. The note documented staff called the hospital ER and received orders to transfer the resident to the hospital for evaluation. The 8/6/17 emergency department report documented the resident was agitated, anxious, and had multiple abrasions on his/her left forearm with no open areas. On 8/10/17 at 1:23 PM, Nurse Aide E stated on Sunday, 8/6/17, the resident broke his/her glasses and used the plastic to dig at his/her arm. Nurse Aide E stated the day before, Saturday, 8/5/17, the resident removed the shower room mirror off the wall and staff noted the mirror had chips in the corner but no large, broken pieces. Nurse Aide E stated staff found the resident taking the mirror down and stopped him/her. Nurse Aide E stated he/she sat with the resident for a few minutes and the resident made statements about ending his/her life. Nurse Aide E stated the nurse, immediately came to the bathroom to assess the resident, and sat with the resident at breakfast. Nurse Aide E stated occasionally the resident told staff he/she wanted a gun to kill him/herself and staff talked to the resident for a while to calm him/her down and try to figure out what was actually bothering the resident. Nurse Aide E stated the resident appeared agitated with thoughts of self harm 2-3 times per week, since admission to the facility, about 3 weeks earlier. On 8/10/17 at 1:53 PM, Administrative Nurse J stated the resident made verbal comments about suicide, broke his/her radio, and broke his/her glasses. Administrative Nurse J stated he/she visited with the psychiatric nurse about the resident's behavior and occasional statements of wanting to kill him/herself. Administrative Nurse J stated the psychiatric nurse told him/her when the resident became anxious about pain medication, the behavior triggered. Administrative Nurse J stated staff attempted to ensure the resident had his/her pain medications on time, but the resident's behavior remained the same. On 8/10/17 at 3:17 PM, Social Services Designee N stated he/she had not been involved with resident's care plans until this past week, and was unaware the resident made suicidal statements. Social Services Designee N stated he/she had not been informed he/she was to provide social services for the residents. On 8/10/17 at 4:02 PM, Administrative Nurse J verified the staff had not followed the facility's suicide prevention policy. On 8/14/17 at 2:00 PM, Nurse Practitioner L stated the facility notified him/her by phone, on 7/24/17, of the resident's attempt to cut his/her wrists on 7/23/17. Nurse Practitioner L stated the resident had suicidal ideation, but did not normally act on it. Nurse Practitioner L stated he/she visited with the resident on 7/26/17. Nurse Practitioner L stated the resident started having anxiety, and then had depressive thoughts, but no suicidal plans, and he/she increased the resident's [MEDICATION NAME] (antipsychotic medication). Nurse Practitioner L verified the facility had not notified him/her of the resident's attempts to hurt him/herself on 8/5 and 8/6/17, and stated he/she expected facility staff to notify the physician or call 911 on the weekends. On 8/14/17 at 4:15 PM, Physician K verified staff had not reported the resident's attempt to cut his/her wrist on 7/23/17, and had not sent a fax with that information. Physician K stated he/she expected staff to notify him/her or the on call provider, by telephone, of suicide attempts. Physician K verified staff sent his/her office a fax on Saturday, 8/5/17, regarding the resident's statement that he/she was going to commit suicide, and reported the resident took the mirror off the bathroom wall and tried to break it. Physician K stated the clinic office was not staffed on weekends and the fax regarding the resident's suicidal behaviors was not read until the following Monday. (after the resident had been admitted to the ER, early Monday morning with several cuts on his/her wrists) On 8/15/17 at 10:25 AM, Administrative Nurse M verified staff should have notified the physician in a timely manner, by telephone, of the resident's suicidal comments and attempts to harm him/herself on 8/5/17. Administrative Nurse M verified staff should have notified the physician of the resident's 7/23/17 attempts to harm him/herself and should have provided the resident with one on one supervision after the suicidal attempts. Administrative Nurse M verified the facility had not provided adequate social services for the resident after the resident attempted to cut his/her wrists on 7/23/17. Administrative Nurse M stated the staff person covering for the SSD had not been aware of the incident and was unaware he/she was to provide those services. The facility's 4/2007 policy for Behavior Assessment and Monitoring recorded, as part of the initial assessment, nursing will identify residents with a problematic behavior or mental illness, document and inform the physician about a resident's mental status, behavior, and any relevant factors. The nursing staff would monitor for side effects and complications related to psychoactive medications and the physician would periodically reconsider the indication of continued usage. The facility's 12/2007 Suicide Threats policy documented all suicide threats would be taken seriously and addressed appropriately. Staff would report any resident threats of suicide immediately to the charge nurse. The charge nurse would immediately assess the situation and notify the (DON) Director of Nursing of such threats. The policy directed staff to remain with the resident until the charge nurse arrived to evaluate the resident. After evaluation of the resident, the charge nurse would notify the resident's physician and responsible party, and seek further direction from the physician. All nursing staff and other staff involved in caring for the resident would be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. If the resident remained in the facility, staff will monitor the resident's mood and behavior, and update the care plan, until a physician has determined the risk of suicide does not appear to be present. The 8/10/17 update for suicide precautions documented if the resident is considered at risk for suicidal behavior or ideation, a psychiatric consult would be obtained and completed within 24 hours of suicide precautions being ordered, unless the resident was transferred to an inpatient psychiatric setting. The policy documented all residents on suicide precautions would be transferred by ambulance. The facility failed to provide adequate services for mental health and psychosocial well-being for Resident #5, who made verbal statements of suicidal intentions and had displayed suicidal behaviors, culminating in actual harm to him/her, and the resident required hospitalization . - The medical record revealed the facility admitted Resident #4 on 11/2/16. The (POS) Physician order [REDACTED]. glucose, the body cannot make enough insulin or the body can't respond to the insulin), [MEDICAL CONDITION] of liver (condition in which the liver does not function properly due to long-term damage), [MEDICAL CONDITION] (An infection caused by [MEDICAL CONDITION] that attacks the liver), pancytopenia (condition in which a person's body has too few red blood cells, white blood cells, and platelets), [MEDICAL CONDITION] (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks). The admission (MDS) Minimum Data Set assessment, dated 2/3/17, documented the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 14, no mood issues, and no behaviors. The assessment documented the resident was independent with transfers, locomotion, walking, dressing, required supervision with eating, hygiene, and limited staff assistance with bed mobility. The resident received (PRN) as needed, pain medication, reported frequent, moderate pain, and received insulin, antipsychotic, and antidepressant medications 7 of 7 days. The re-admission MDS, dated [DATE], documented the same except the resident had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), which placed the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, and significantly interfered with the resident's participation in activities or social interactions. The MDS documented the resident's behaviors significantly intruded on the privacy or activity of others, and significantly disrupted the care or living environment. The MDS documented the resident required supervision with all (ADLs) activities of daily living, except bed mobility, received scheduled pain medications, and received antianxiety medication 7 of 7 days. The 2/3/17 (CAA) Care Area Assessment summary for [MEDICAL CONDITION] drug use documented the resident received antidepressant and antipsychotic medications, and the resident frequently requested PRN, antipsychotic medication. The summary documented the lesser restrictive environment of the facility was new for the resident, and he/she was easily angered when staff attempted to educate him/her on the risks of medications. The behavior and mood CAA had not triggered. The 5/5/17 CAA for behaviors documented, during the past week, the resident had one episode of concerning behavior, when he/she hollered out, disrupted the environment, and intruded on the privacy of others. The summary documented this behavior interfered with his/her care and participation, causing a potential physical risk to the resident, and no triggers or reactions were identified. The summary documented the resident had long standing psychiatric conditions, but had not given staff any reason to believe he/she may place others in danger. The resident needed [MEDICAL CONDITION] medications for the best quality of life for him/her and continued to need focus to help him/her continue to limit behavioral episodes. The 5/5/17 care plan for mood documented the resident was dependent for meeting emotional, intellectual, physical, and social needs related to psychiatric disorders, and directed staff to provide the resident with materials for individual activities as desired, such as watching TV, and walking. The care plan for behavior documented the resident had behavior problems including: wandering, rummaging, taking other's belongings, and wanting to eat constantly during the active phase of his/her [MEDICAL CONDITION] type disorder. The care plan directed staff to administer medications as ordered, monitor/document for side effects and effectiveness, provide opportunity for positive interaction, and attention. The care plan directed staff to stop and talk with the resident when passing by, explain all procedures to the resident before starting, and allow the resident a few moments to adjust to changes. Discuss the resident's behavior, explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, divert attention, and remove from the situation and take to an alternate location as needed. The care plan documented the resident had the potential to be verbally aggressive, hollers at others, had poor impulse control, and directed staff to monitor behaviors every shift and as needed. The care plan directed staff to monitor/document/report any adverse reactions related to the use of [MEDICAL CONDITION] medications, including depression, and [MEDICAL CONDITION]. The medical record contained numerous nurse's notes which documented the resident stole other residents' food or candy, made inappropriate sexual remarks, urinated in inappropriate places, and made threats of harm to him/herself since 11/11/16, shortly after admission to the facility. The 5/27/17 at 4:10 PM, nurse's note documented the resident came to the nurse's station and stated I have 11 scars from cutting myself and I might harm myself or harm someone. The note documented staff assisted the resident to his/her room, and visited with him/her about harming him/herself or others. The note documented staff explained to the resident that he/she needed to stay in his/her room and take a nap. The note documented staff explained to the resident if he/she harmed anyone at this facility or him/herself, the nurse would call the cops and he/she would be put in jail. The resident stated that he/she understood and layed down to take a nap. The 6/5/17 at 10:30 AM, nurse's note documented the resident took another resident's snack and staff asked the resident to give it back. The resident stated he/she was just going to take a few pieces of the snack, the nurse told the resident he/she needed to give it back, and the resident threw the snack toward the other resident. The note documented the resident yelled at another resident, he/she refused to go back to his/her room, and sat in the dining room. The 6/18/17 at 3:42 PM, nurse's note documented the resident defecated (had a bowel movement) in his/her pants, then smeared feces on the bed and recliner and came out into the hallway, undressed. The note documented when aides redirected the resident to his/her room to get cleaned up the resident attempted to smear feces on them and stated I did it on purpose - It turns me on! The 6/29/17 at 1:46 AM, nurse's note documented the resident had been to the ice machine approximately 20 times this evening to get ice, was redirected by staff to return to bed and the resident cursed at staff and spit on the floor. The 6/29/17 at 11:30 AM, nurse's note documented the resident stated that he/she will have to go to mental health appointments and live in a nursing home for the rest of his/her life, and stated he/she might as well kill him/herself and his/her family. The note documented the resident stated he/she did not have anything to look forward to, I might as well just die. The note documented staff attempted to reassure the resident of all the good things the resident had in life, but the resident stated, I don't care about any of that, and I just want to die. The 7/3/17 at 9:32 PM, nurse's note documented the resident was confused and kept asking to be sent to the mental hospital, stating something is wrong with me. The note documented staff assisted the resident to the bathroom then to bed. The 7/11/17 at 3:02 PM, nurse's note documented the resident verbalized to staff he/she was going to put him/herself on the floor until he/she was admitted to the state hospital. The note documented staff educated the resident putting him/herself on the floor would not assist him/her to return to the state hospital. The note documented the resident stated he/she would quit eating and taking medications, and staff educated the resident of the importance of taking meals and medications. The 7/28/17 at 5:34 PM, nurse's note documented the resident threw his/her meal at the table, nearly hitting table mates with food and silverware. The note documented staff removed the resident from the table and placed him/her in a recliner in the living room. The note documented the resident started to yell at staff. The 7/29/17 at 10:17 PM, nurse's notes documented the resident refused to go to the dining room and refused to eat a meal. The note documented the resident pulled his/her pants down, and made nonsensical statements with words about sexual assault and jacking off. The note documented the resident told the nurse staff had sex with him/her. The note documented the resident had urinated on the floor, two times, and staff were unable to redirect the resident. The 7/31/17 at 11:10 AM, nurse's note documented the resident told staff I want to go to jail and stated nobody wants me here so I just as well be in jail. The note documented the administrator had visited with resident about his/her behaviors over the past week. The 8/1/17 at 9:00 AM, nurse's note documented the resident urinated on a recliner in his/her room and stated staff can clean him/her up. The 8/1/17 at 9:25 AM, nurse's note documented the resident walked to the administrator's office and stated I want the cops called, I have been looking at the opposite sex inappropriately. The note documented the administrator and director of nursing visited with the resident regarding his/her behavior. The 8/1/17 at 10:30 AM, nurse's note documented the resident stated he/she tried to cut his/her wrist with a comb and staff noted a scrape mark on the resident's left wrist. The 8/1/17 at 10:37 AM, nurse's note documented staff called and updated Nurse Practitioner L and received a telephone order to transfer the resident to the hospital emergency room for a psychiatric evaluation. The 8/1/17 at 11:12 AM, nurse's note documented the administrator and one staff member transported the resident to the emergency room . The 8/1/17 at 9:20 PM, nurse's note documented the hospital emergency room sent the resident to another hospital after the psychiatric evaluation. On 8/9/17 at 10:20 AM, Nurse Practitioner L stated the resident had been doing well when he/she first came to the facility, attended a lot of activities, voiced he/she liked it here, and seemed to be happy. Nurse Practitioner L stated the resident never thought he/she would like living in a nursing home, but he/she did. Nurse Practitioner L stated the resident's behavior seemed to change drastically around May, and he/she was unsure why. Nurse Practitioner L stated the resident had no medication changes other than pain medication related to his/her surgery in January. Nurse Practitioner L stated he/she became increasingly concerned about the resident's behaviors and talked to staff because he/she was very concerned the resident might hurt him/herself or someone else. Nurse Practitioner L stated he/she saw the resident about every 90 days, unless there was a need sooner. On 8/8/17 at 4:51 PM, Nurse P stated the resident's behaviors changed in May, and the resident started saying inappropriate things to staff. Nurse P stated the resident reported he/she wanted to smear (BM) bowel movement on staff because it turned him/her on sexually. Nurse P stated the resident reported a staff person had sex with him/her, and the resident urinated on the floor so staff could clean it. On 8/8/17 at 2:32 PM, Administrative Staff O stated on 7/31/17, he/she printed behaviors the resident had with staff, and noted the behaviors had escalated. Administrative Staff O stated on Tuesday, 8/1/17, he/she checked on the resident, who was still upset and agitated. Administrative Staff O stated about 10:00 AM, Administrative Nurse H informed him/her the facility needed to send the resident to the hospital because the resident tried to cut his/her wrist with a comb. Administrative Staff O stated he/she and another staff member transported the resident to the emergency room and the resident continued to have behaviors there, and was transferred to a psychiatric hospital. On 8/8/17 at 3:42 PM, Administrative Nurse J stated the resident laughed, joked, and got along with others when he/she was first admitted to the facility. Administrative Nurse J stated he/she took the resident to a mental health appointment, in June, at which mental health staff told the resident he/she would never get out of the nursing home. Administrative Nurse J stated after the appointment, the resident had behaviors which included: he/she broke his/her dentures in half, seemed angry, withdrawn, and came to less activities, made sexual comments to staff, intentionally had a bowel movement in his/her pants and then smeared feces all over him/herself so staff would have to come in and clean him/her up. On 8/9/17 at 5:15 PM, Administrative Nurse H verified the facility had not reported to the state, the 8/1/17 incident regarding Resident #4, in which the resident told staff he/she wanted to cut his/her wrists and had made marks across his/her wrist with a comb. (reported to state 8/9/17) On 8/10/17 at 1:38 PM, Nurse Aide E stated the resident frequently made sexually inappropriate comments towards staff, and staff would get the nurse to assist with the resident's cares when he/she talked like that. Nurse Aide E stated the resident would get mad and brush against them when passing by, would throw things, and other times he/she would just lay there and not do a thing for him/herself while staff provided cares. Nurse Aide E stated during the past month the resident's behaviors escalated, he/she stole food out of other resident's rooms, emptied cups into the top of the ice machine, and took food from facility staff and refrigerators. Nurse Aide E stated interventions did not prevent the behaviors from occurring again. On 8/10/17 at 2:10 PM, Administrative Nurse H verified the resident reported he/she might as well be dead, and after that, his/her behavior got worse. Administrative Nurse H stated he/she talked with the resident and reported the statements to the mental health staff. Administrative Nurse H verified he/she notified Nurse Practitioner L, not the physician, of the resident's statements and behaviors. On 8/10/17 at 3:17 PM, Social Services Designee N stated he/she had not been involved with the resident's care plan until this past week, and he/she had not been informed, prior to this week, he/she was to provide social services. Social Services Designee N stated staff told him/her the resident stated he/she would slit somebody's throat. Social Services Designee N stated he/she was unaware of the resident's suicide statement in June. Social Services Designee N stated staff redirected the resident, and when confronted, the resident did not become upset, and would either apologize or staff would give him/her the food. Social Services Designee N stated, in March, the resident became vocal about wanting to go to prison or to a stricter environment. On 8/10/17 at 4:15 PM, Nurse Aide Q stated the resident would use his/her call light and when staff responded the resident would have his/her clothes down around the ankles. Nurse Aide Q stated the resident made sexual comments, yelled at the aides, threw his/her food, took other resident's food off their plates, but he/she never threatened other residents. On 8/10/17 at 4:45 PM, Nurse R stated interventions to prevent the resident's behaviors had not worked. Nurse Aide R stated he/she did not recall the social services staff providing one on one counseling, or helping with the resident's behaviors. On 8/15/17 at 10:25 AM, Administrative Nurse M verified the facility had not provided adequate social services for the resident. The facility's 4/2007 policy for Behavior Assessment and Monitoring recorded, as part of the initial assessment, nursing will identify residents with a problematic behavior or mental illness, document and inform the physician about a resident's mental status, behavior, and any relevant factors. The nursing staff would monitor for side effects and complications related to psychoactive medications and the physician would periodically reconsider the indication of continued usage. The facility's 12/2007 Suicide Threats policy documented all suicide threats would be taken seriously and addressed appropriately. Staff would report any resident threats of suicide immediately to the charge nurse. The charge nurse would immediately assess the situation and notify the (DON) Director of Nursing of such threats. The policy directed staff to remain with the resident until the c(TRUNCATED)

The facility had a census of 34 residents. The sample included 17 residents. Based on record review and interview, the facility failed to adequately assess and seek physician involvement for 1 of 1 sampled resident, who had a change in condition which required hospitalization . (#23) Findings included: - Resident #23's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 10/31/16, documented the resident had long and short term memory problems with severely impaired decision making skills. The assessment revealed the resident dependent upon 2 staff for bed mobility, transfers, dressing and personal hygiene. The assessment further revealed the resident did not experience any shortness of breath, was not on oxygen, and received 4 days of antibiotics (medication that inhibits the growth of or destroys microorganisms). The 10/26/16 care plan directed staff to monitor, document, and report to the physician any signs and symptoms of fever, coughing, aspiration, (inhaling liquid or food into the lungs) or dysphasia (swallowing difficulty). The 11/23/16, physician order's directed staff to administer Tylenol (mild pain medication), 650 (mg) milligrams, by mouth, twice a day, for pain (initiated on 10/17/16), [MEDICATION NAME] Nebulizer Solution (breathing treatment) 2.5 mg/3 ml (milliliters), 0.083%, 1 inhalation via nebulizer, (device which changes liquid medication into a mist easily inhaled into the lungs), every 4 hours, as needed (initiated 11/9/16) and [MEDICATION NAME] (an antianxiety medication), 1 mg, by mouth, every 4 hours, as needed for anxiety (initiated 10/17/16). The 11/9/17 at 3:22 PM, nurse's note indicated the resident had a productive cough, was lethargic (less alert and less interested in their surroundings), had coarse lung sounds with wheezes (breathe with a [MEDICATION NAME] or rattling sound in the chest), and crackles (clicking sound heard in the lungs) in the resident's upper lung fields, and oxygen saturation (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) of 85% (normal is 95-100) on room air. The note further indicated the physician directed the staff to administer [MEDICATION NAME] (an antibiotic), 500 mg, 1 tablet, by mouth, for 10 days due to an upper respiratory infection. Review of the medical record revealed no documentation staff administered supplemental oxygen for low oxygen saturation. The 11/12/16 at 11:07 AM, nurse's note stated the resident's family member requested staff administer a nebulizer breathing treatment and further stated the resident had a coarse cough. The note stated the resident's lungs had crackles throughout all lung fields which indicated infection, airway irritation and inflammation. The 12/6/16 at 9:43 AM, nurse's note stated the resident's blood pressure was 78/42 (normal 120/80), pulse 66 (within normal limits), respirations 16 (within normal limits) and oxygen saturation was 98% (withing normal limits) on room air. The note further stated the resident had crackles in all lobes of his/her lungs. The note further stated staff notified the physician and staff administered a breathing treatment. The 12/7/16 at 11:58 AM, nurse's note stated the physician directed staff to monitor the resident's lung sounds and notify the physician if lung sounds worsen. The 12/19/16 at 5:11 PM, nurse's note stated the resident had an axillary (of or relating to the armpit) temperature of 103 degrees (normal is 98.6 degrees Fahrenheit) and staff administered Tylenol and monitor the resident. (Review of the medical record revealed no documentation staff notified the physician) The 12/19/16 at 6:15 PM, nurse's note stated the resident had a body temperature of 101.4, he/she refused supper, had increased cough, lung sounds moist and diminished, and respirations of 14.(Review of the medical record revealed no documentation staff notified the physician) The 12/20/16 at 9:57 AM, nurse's note stated the resident was coughing at breakfast, staff checked the resident's lungs and revealed no abnormal lung sounds. The 12/24/16 at 3:44 PM, nurse's note stated staff administered Tylenol, 650 mg, by mouth to the resident for fever. The 12/24/16 at 5:37 PM, nurse's note stated staff administered a Albuteral Nebulizer breathing treatment to the resident. (Review of the medical record revealed no documentation staff assessed the resident's respiratory status) The 12/24/16 at 8:50 PM, nurse's note stated the resident had a body temperature of 101.2 degrees and staff administered Tylenol, 650 mg, by mouth. (Review of the medical record revealed no documentation staff assessed the resident's respiratory status or notified the physician of the resident's elevated temperature) The 12/24/16 at 9:23 PM, nurse's note stated the resident was congested, had a non productive cough, and staff would continue to monitor. The note further stated the Tylenol administered at 8:50 PM was effective. The 12/25/16 at 1:57 PM, nurse's note stated the resident's family member requested the staff administer a breathing treatment to the resident. The note further stated the resident had wheezing throughout all lung fields, and his/her oxygen saturation was 84% on room air and no documentation supplemental oxygen was given. (Review of the medical record further revealed no documentation staff notified the physician the resident's decline) The 12/25/16 at 2:15 PM, nurse's note stated the resident continued to have wheezing throughout his/her lung fields. The 12/25/16 medical record revealed staff administered the following medication: 3:07 PM, Tylenol, 650 mg, by mouth and no documentation of effectiveness of medication. 5:56 PM, [MEDICATION NAME], 1 mg, by mouth for anxiety and agitation and assessed as effective. 9:35 PM, Tylenol 650 mg, by mouth and no documentation of effectiveness of medication. 11:02 PM, [MEDICATION NAME] Nebulizer breathing treatment and no documentation of effectiveness of medication. The 12/26/16 medical record revealed staff administered the following medication: 12:02 AM, [MEDICATION NAME] Nebulizer breathing treatment and assessed as effective. 3:04 AM, Tylenol 650 mg, by mouth and assessed as effective. 3:04 AM, [MEDICATION NAME] Nebulizer breathing treatment and assessed as effective. The 12/26/16 at 7:10 AM, nurse's note stated the resident was wheezing, and had a 101 degree axillary body temperature. The note further indicated staff administered an [MEDICATION NAME] Nebulizer breathing treatment, and assessed no change in the resident's lung sounds. The note stated staff repositioned the resident at which time he/she was incontinent of bowel. The staff administered Tylenol 650 mg, by mouth, for his/her elevated body temperature. (Review of the medical record revealed no documentation staff notified the physician of the resident's condition) The 12/26/16 at 9:30 AM, nurse's note stated the resident remained lethargic with an axillary body temperature of 99 degrees. The resident's family member contacted the facility for an update on his/her condition and requested the resident see the physician. The note stated the clinic was closed and staff contacted the local hospital for orders to transport the resident. The 12/26/16 at 12:00 PM, nurse's note stated the resident admitted to the hospital for left lower lobe pneumonia (lung inflammation caused by bacterial or [MEDICAL CONDITION] infection, in which the air sacs fill with pus and may become solid affecting the lower left lobe of the lung). The 12/26/16 hospital emergency room report documented the resident presented with fever, cough, shortness of breath, and anxiety. The report further documented the resident had pneumonia, a urinary tract infection (an infection of the kidney, ureter, bladder, or urethra), [MEDICAL CONDITION] (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes),[MEDICAL CONDITION] (the presence in tissues of harmful bacteria and their toxins), dementia, and [MEDICAL CONDITION]. The 12/26/16 X-ray report indicated the resident had left lower lobe pneumonia. The 12/2816 at 10:28 AM, nurse's note stated the physician reported the resident was not doing well, his/her kidneys were shutting down and was skeptical the resident would return to the facility. The 1/5/17 hospital discharge summary stated the resident had pneumonia, resolved urinary tract infection,[MEDICAL CONDITIONS], and [MEDICAL CONDITION] (a high sodium level). The report indicated the resident was started on IV (intravenous fluids), [MEDICATION NAME] (an antibiotic), 3.375 grams, 1/2 dose due to [MEDICAL CONDITION]. The physician changed the antibiotic to Rocephen (an antibiotic for bacterial infections), 2 grams, IV, daily and 500 mg [MEDICATION NAME] (an antibiotic) for pneumonia and urinary tract infection. On 2/8/17 at 9:01 AM, Administrative Nurse B stated he/she would notify the physician promptly when a resident had a change in condition and verified lack of documentation in the medical record that staff notified the physician when the resident declined. On 2/8/17 at 12:11 PM, Administrative Nurse A verified lack of documentation in the medical record that the staff failed to seek physician involvement. On 2/9/17 at 10:00 AM, Physician O stated staff should have notified him/her of the resident's change in condition and he/she would have placed him/her on oral antibiotics, along with the breathing treatment. The facility's October 2010 Acute Condition Changes Clinical Protocol stated the nurse would assess, document, and report vital signs, neurological status, level of pain, level of consciousness, emotional status, active diagnoses, and current medications. The protocol further stated the nurse should be adequately prepared with pertinent information, including the residents current symptoms and status. The nurse would contact the physician based upon the urgency of the situation. The facility failed to adequately assess and seek physician involvement for Resident #23's, who had a change in condition, which resulted in hospitalization and treatment of [REDACTED].

The facility had a census of 33 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to ensure a safe transfer for the use of the sit to stand mechanical lift, which resulted in a fracture for 1 of 3 sampled residents. (#1) Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 5/8/15, indicated the resident had severe cognitive impairment with short and long term memory problems, severely impaired cognitive skills for decision making, and had inattention, disorganized thinking, and psychomotor retardation behaviors. The MDS further indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident had unsteady balance only able to stabilize with assistance from staff, and had a lower extremity range of motion impairment on 1 side. The 5/8/15 fall (CAA) Care Area Assessment indicated the resident had a history of [REDACTED]. The 5/8/15 urinary CAA informed staff the resident required extensive assistance from staff for his/her (ADLs) Activities of Daily Living, and used an easy stand (a mechanical lift) for transfers. The 5/14/15 care plan instructed staff to use an easy stand (mechanical lift), with assistance for transfers. The 8/16/15 care plan update informed staff to provide a full body mechanical lift, and 2 staff for transfers. The 8/5/15 at 8:00 AM, nurse's note indicated staff noted a bruise on the resident's left bicep. The note indicated the resident's bruise was dark purple at the base of the bicep and had faint bruising around the entire bicep, and staff would continue to monitor. The 8/5/15 facility investigation indicated the resident had appeared with a bruise of unknown origin, which had gotten larger, and eventually indicated a fracture. The facility investigation determined that it appeared the resident was pinched on his/her left arm with the lift jacket during a transfer. The investigation stated the bruise was found on the 6:00 AM to 2:00 PM shift while staff was getting the resident up for breakfast, staff who worked the previous shift from 10:00 PM to 6:00 AM, had not seen any bruising, or staff who worked the 2:00 PM to 10:00 PM shift the pervious day. The 8/6/15 physician order [REDACTED]. The 8/6/15 at 11:00 PM, nurse's note indicated staff iced the resident's bruise as directed, the bruise appeared dark purple, and his/her arm was swollen. The note further indicated the ice and elevation did decrease the swelling, but the resident grimaced and moaned when staff touched the area. The 8/7/15 at 7:05 PM, nurse's note indicated staff applied ice to the resident's left bicep, which remained bruised and swollen. The note further indicated the resident grimaced and pulled away when staff touched his/her arm. The 8/8/15 at 11:47 PM, nurse's note indicated the resident's arm continued to be bruised and swollen, and staff noted bruising on his/her left breast. The 8/10/15 at 3:13 AM, nurse's note indicated the resident's left arm remained swollen and bruised, and his/her left bruise continued to have bruising. The 8/10/15 at 11:11 PM, nurse's note indicated the resident's arm remained swollen from the shoulder to the mid fingers, and the bruise involved the entire arm now. The note indicated staff had elevated his/her arm above the heart level while in bed, and continued the physician ordered ice treatment. The note further indicated the resident displayed a decrease in nonverbal signs of pain, the staff had assessed the resident as severely cognitive impairment and unable to verbalize pain, his/her needs were anticipated by the staff. (This was the 1st documentation of swelling into the fingers) The 8/11/5 at 7:15 AM, nurse's note indicated the resident's left arm remained swollen, bruised, and slightly cooler to touch then the right arm. The note further indicated the resident cried and indicated pain when staff touched his/her arm to move it, and the bruise continued to be dark purple. The 8/11/15 at 7:45 AM, nurse's note indicated the resident's family expressed concern about the resident's left arm bruising, his/her pain, and requested the resident to be evaluated by the physician. The 8/12/15 physician orders [REDACTED]. The physician's orders [REDACTED]. The 8/12/15 radiology report indicated the resident sustained [REDACTED]. (the two ends of the broken bone are separated from one another) The 8/12/15 at 4:47 PM, nurse's note indicated the resident returned to the facility with his/her left arm immobile in a sling. The 8/21/15 at 12:04 AM, nurse's note indicated the resident returned from an appointment with an orthopedic physician who stated the arm was inoperable. The note stated the physician directed the staff to continue to provide the sling and swath for 6 weeks, and not to lift under the resident's arm for 12 weeks. The 8/21/15 physician's progress note indicated the resident had sustained a fracture when the resident was pinched by the lift. The progress note indicated the resident appeared comfortable in a sling and a swathe, and there was no skin breakdown. The note indicated the resident's fracture as non surgical due to his/her current health condition, chronic dementia, and limited health function. The note further indicated the physician recommended no manual lifting underneath the arm pit for 3 months. On 9/14/15 at 3:01 PM, observation revealed the resident lying in bed, with a foam immobilize in place across the resident's chest, which assisted in preventing movement of his/her arms. Further observation revealed 2 staff in his/her room, with a full mechanical lift to transfer the resident from his/her bed to his/her wheelchair. Observation revealed staff rolled the resident side to side to get the lift sling under the resident, and connected the lift sling to the mechanical lift with hooks. Continued observation revealed the staff raised the resident up off the bed with the mechanical lift, positioned him/her over the wheelchair, and lowered the resident to the sitting position in his/her wheelchair. On 9/14/15 at 3:25 PM, Nurse Aide D stated he/she did not notice any difference in the resident's transfer ability the night before the staff noted the bruise. Nurse Aide D stated the resident had arthritis in 1 hand, and would not hold on to the lift, and was not sure how well he/she would hold on with the other due to the resident would sometimes dangle when lifted. Nurse Aide D verified the resident did not assist with the transfer when using the easy stand mechanical lift, which he/she had reported to the charge nurse a couple times in the past. On 9/15/15 at 9:38 AM, Nurse Aide C stated there were times when the resident did not do well with the easy stand, there were times when you would know he/she was uncomfortable. Nurse Aide C stated when staff used the easy stand for transferring the resident, his/her legs sometimes would appear stiff, he/she would not hold on well, and there were a couple times he/she noticed the resident's total weight was held up by the straps under his/her arms and not by bearing weight on his/her feet. Nurse Aide C verified staff used the full lift after the resident sustained [REDACTED]. On 9/15/15 at 9:57 AM, Nurse E verified the resident had not been re-evaluated for the use of the easy stand for transfers. Nurse E further verified the resident had a decline since admission, and had a decreased ability to hold him/herself up to participate in the transfer with the easy stand mechanical lift. On 9/15/15 at 10:30 AM, Nurse Aide A stated the resident was not able to hold on to the easy stand lift, because his/her arms were too contracted. On 9/15/15 at 10:48 AM, Administrative Nurse F stated staff were expected to notify the charge nurse if a resident had a decline with transfers. Administrative Nurse F further verified unless staff reported there was a decline with transferring status, the nurses would not know, unless the facility had done a quarterly evaluation. On 9/15/15 at 4:13 PM, Administrative Nurse F verified the facility had no policy for assessment for use of the mechanical lift. The facility failed to ensure a safe transfer for Resident #1's use of a mechanical lift, which resulted in a fracture.